Dissertations / Theses: 'Carotid endarterectomy'

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Gaunt, Michael E. "Assessment of carotid endarterectomy." Thesis, University of Leicester, 1995. http://hdl.handle.net/2381/34353.

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A major cause of perioperative strokes during carotid endarterectomy is intraoperative embolisation. Previous studies have identified that intraoperative embolisation can be detected by monitoring with transcranial Doppler sonography (TCD). However, these studies were unable to demonstrate a convincing link between embolisation and the development of neurological deficits and therefore, the clinical relevance of these TCD detected emboli remained uncertain. This study aimed to accurately determine the incidence and clinical relevance of TCD detected intraoperative embolisation during carotid endarterectomy. To do this 100 consecutive patients undergoing carotid endarterectomy were monitored with TCD. To assess the clinical impact of intraoperative embolisation all patients underwent the following pre- and postoperative assessments; neurological and cognitive function; retinal fundoscopy and automated visual fields; CT and MRI brain scans. During analysis of the intraoperative TCD recordings the operation was divided into its constituent stages and for each stage the number and character of emboli were determined. It was found that the majority of intraoperative emboli were characteristic of air and not associated with an adverse clinical outcome. However, emboli occurring during the dissection and recovery stages of the operation were characteristic of particulate emboli and associated with the development of neurological and cognitive deficits. In particular, gross, persistent particulate embolisation during the recovery phase of the operation heralded early carotid artery thrombosis and was associated with the development of major neurological deficits. The TCD detection of particulate emboli occurred before the development of neurological signs and with early operative intervention to correct the defect, neurological deficit could be avoided. This finding represents an important new clinical application of TCD monitoring and provides direct clinical evidence for the role of platelet emboli in the aetiology of stroke. The second part of the study was concerned with comparing methods of quality control to detect technical defects which may lead to embolisation. The techniques compared were Angioscopy, B-mode ultrasound, continuous wave Doppler and TCD. Angioscopy detected major technical errors in 12 patients (4 intimal flaps, thrombus in 8). TCD detected shunt malfunction in 13 patients (2 potentially serious) in addition to particulate embolisation detected during dissection and recovery. Continuous wave Doppler and B-mode ultrasound images were technically inadequate in 9 and 24 patients respectively and neither technique altered clinical management. Therefore it was concluded, that a combination of TCD monitoring and completion angioscopy provided the maximum yield in terms of diagnosing technical error and establishing the cause of perioperative morbidity and mortality.

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Lennard, Nicola S. "Quality control for carotid endarterectomy." Thesis, University of Leicester, 2004. http://hdl.handle.net/2381/29469.

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The aims of this study are to assess whether the introduction of a rigorous quality control method could produce a sustained reduction in the intraoperative stroke rate in this unit and whether it was feasible and practical to implement such a programme. The second part of this study will assess the incidence of sustained embolisation in the early post-operative period and investigate whether the antiplatelet agent Dextran 40 can help stop this embolisation, potentially preventing carotid artery thrombosis.;A prospective audit of all patients undergoing carotid endarterectomy was performed. The ability to monitor intraoperatively with TCD and perform completion angioscopy was assessed, as was the impact that these quality control techniques had on influencing the surgery. Patients were monitored postoperatively with TCD and any patient who developed sustained embolisation was commenced on an infusion of Dextran 40.;91% had continuous intraoperative TCD monitoring and 94% underwent successful completion angioscopy, a technical error was identified in 5% of angioscopic assessments. The intraoperative stroke rate was 0% during this study. Postoperative monitoring revealed that 5% of patients develop significant embolisation following CEA, Dextran 40 appeared to stop this embolisation. The overall 30-day stroke or death rate following CEA has fallen from 6% prior to 1992 to 2.2% in 1998.;It is possible to implement a quality control programme for CEA and this has been associated with a fall in the overall 30-day death and any stroke rate.

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Wong, John Hoi-Ying. "A regional performance of carotid endarterectomy." Thesis, National Library of Canada = Bibliothèque nationale du Canada, 1997. http://www.collectionscanada.ca/obj/s4/f2/dsk2/ftp04/mq21224.pdf.

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Webster, Sally E. "Asprin's effectiveness decreases during carotid endarterectomy." Thesis, University of Leicester, 2007. http://hdl.handle.net/2381/29538.

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Carotid Endarterectomy (CEA) is a well-established operation which reduces the risk of stroke in patients with atherosclerotic stenosis of the internal carotid artery. Paradoxically, the operation itself carries a risk of peri-operative stroke. This thesis comprises four sections: 1. Intravenous Dextran 40 solution has been shown to reduce the risk of post-operative stroke in patients with high numbers of post-operative emboli. It was hypothesised that Dextran applied locally to the operative field would be as effective as preventing emboli, but have a lower incidence of systemic complications. A randomised trial was carried out comparing Dextran 40 irrigation with conventional Heparinised Saline solution. Post-operative emboli were quantified and compared. 2. Previous work on platelet function during CEA showed an incidental significant increase in aggregation in response to arachidonic acid (the substrate for the Cyclo-oxygenase (COX) pathway) by the end of the operation. Aggregometry performed during CEA showed that the anti-platelet effect of aspirin was significantly reduced during and after surgery. This effect occurred within three minutes of the administration of intravenous unfractionated heparin (UFH) and had never previously been described. It contradicted all knowledge of aspirin's mechanism of action (irreversible acetylation of the Ser-529 residue of COX). 3. Further in vitro, ex vivo and ELISA studies were performed to determine the mechanisms behind the changes in platelet aggregation. 4. Evidence suggests that Low Molecular Weight Heparin (LMWH) causes less platelet activation than UFH. The final part of this thesis describes a pilot randomised trial comparing the effects of LMWH and UFH on the anti-platelet effect of aspirin. This reduction in aspirin's efficacy may be important, not just for patients undergoing CEA, but also may contribute to risk of thrombo-embolic complications in patients undergoing other vascular interventional procedures (surgery, angioplasty, stenting).

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Newman, Jeremy Edward. "Incidence and mechanism of post carotid endarterectomy hypertension." Thesis, University of Leicester, 2014. http://hdl.handle.net/2381/37193.

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Post-endarterectomy hypertension (PEH) is associated with intracranial haemorrhage (ICH), hyperperfusion syndrome stroke and cardiac complications. Whilst well recognised, its pathophysiology is poorly understood. It was hypothesised that pre-operative poorly controlled blood pressure, baroreceptor dysfunction and impairment of cerebral autoregulation might be associated with PEH. Our aim was to investigate these and other pre-operative clinical variables which may be predictive of those who suffer PEH. 106 patients undergoing carotid endarterectomy (CEA) underwent investigations to evaluate the pathophysiology of PEH including; 24-hour ambulatory BP, central aortic BP, baroreceptor sensitivity (BRS), cerebral autoregulation and transcranial Doppler (TCD) measurement of middle cerebral artery blood flow velocity (MCAV); Clinical details, BP readings from the ward, induction of anaesthesia and during surgery, mode of anaesthesia, vasoactive medications and MCAV changes following flow restoration. Patients with PEH (defined as systolic pressure (SBP) > 170mmHg + no symptoms or > 160mmHg with headache/seizure/deficit) were treated according to Unit guidelines. 40/106 required treatment for PEH (26 in recovery, 27 on the ward), while 7 had surges in SBP > 200mmHg on the ward. PEH (recovery/ward) was not associated with pre-operative patient characteristics or TCD variables and was not associated with impaired autoregulation (autoregulation was better preserved in PEH patients (ARI 4.3 +/-1.4 vs. ARI 3.5 +/-1.6 (p=0.03)). PEH was significantly associated with; (i) higher pre-operative BP (peak SBP > 170mmHg = 59% prevalence); (ii) peak SBP > 170mmHg before induction of anaesthesia (61% prevalence) and (iii) impaired BRS (3.4 +/- 1.7ms/mmHg vs. 5.3 +/-2.8ms/mmHg, p=0.001). Length of stay was significantly increased in PEH patients (p < 0.001), while three patients with temporary headache/seizure/deficit and one with delayed ICH required treatment for PEH (p=0.02). PEH was associated with pre-operative poorly controlled BP and impairment of baroreceptor sensitivity. Cerebral autoregulation was better preserved in those who suffered PEH. Within the time constraints of carrying out surgery in the hyper acute period, it is neither achievable nor advisable to aggressively optimise blood pressure prior to surgery. For now the optimal management remains an uncompromising approach to treating PEH.

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Zierler, Brenda Kaye. "Utilization of carotid endarterectomy before and after the North American symptomatic carotid endarterectomy trial (NASCET) report : effects of clinical research results on the care of patients with carotid artery disease /." Thesis, Connect to this title online; UW restricted, 1996. http://hdl.handle.net/1773/7289.

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McMahon, Gregory Scott. "The role of heparin in thromboembolic complications following carotid endarterectomy." Thesis, University of Leicester, 2011. http://hdl.handle.net/2381/9638.

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The importance of platelets emerged from a local research programme, which aimed to reduce the stroke risk associated with carotid endarterectomy (CEA). It had been demonstrated that intra-operative heparinisation induced a transient reversal of aspirin inhibition; platelets were able to aggregate in response to arachidonic acid (AA). It was hypothesized that intra-operative anticoagulation with intravenous low molecular weight heparin (LMWH) instead of unfractionated heparin (UFH) might be associated with a reduction in pleiotropic platelet effects, and that this would result in a reduction of post-CEA embolization, a surrogate marker for stroke risk. A randomized controlled trial recruited 183 patients; 91 randomized to receive standard intra-operative anticoagulation with 5000IU UFH, and; 92 who received 2500IU LMWH intravenously. Studies conducted in sub-populations aimed to investigate the platelet aggregatory responses to AA and adenosine diphosphate (ADP) and the platelet pathways that were active (plasma and serum were assayed for the stable products of platelet metabolism; thromboxane (TXB2) from the cyclo-oxygenase-1 (COX-1) pathway and 12- hydroxyeicosatretraenoic acid (12-HETE) from the 12-lipoxygenase (12-LOX) pathway). To determine how heparin might interact with the platelet, lipase activity, the presence of heparin antibodies and anti-factorXa (FXa) activity were studied. Increases in platelet aggregation to AA and ADP were observed 3 minutes after heparinisation. In response to AA, these increases were similar for both UFH and LMWH, but patients who received UFH demonstrated significantly greater aggregation in response to ADP. Whilst there was no increase in the production of TXB2, there was a significant increase in the generation of 12-HETE. The increase in platelet response was associated with anti-FXa activity, but not with lipase or heparin antibody activity. The intra-operative substitution of LMWH for UFH was associated with a significant reduction in the risk of patients experiencing high-rate embolization post-operatively, and there is an argument for the re-evaluation of anticoagulation during CEA.

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Magee, Timothy Raymond. "The role of bilateral transcranial doppler sonography in carotid endarterectomy." Thesis, University of Bristol, 1996. http://ethos.bl.uk/OrderDetails.do?uin=uk.bl.ethos.322523.

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Senaratne, Jawaharlal W. B. "An investigation into genetic and environmental influences on and treatment of end-stage atherosclerotic arterial disease." Thesis, University of Oxford, 2000. http://ethos.bl.uk/OrderDetails.do?uin=uk.bl.ethos.365465.

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Chapman, Gordon. "Feasibility of early cerebral haemodynamic testing in patients undergoing carotid endarterectomy." Thesis, University of Leeds, 2007. http://ethos.bl.uk/OrderDetails.do?uin=uk.bl.ethos.446439.

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Marrocco, Trischitta Massimiliano Maria <1969&gt. "Longterm peripheral baroreflex and chemoreflex function after bilateral eversion carotid endarterectomy." Doctoral thesis, Alma Mater Studiorum - Università di Bologna, 2008. http://amsdottorato.unibo.it/977/.

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Introduction The “eversion” technique for carotid endarterectomy (e-CEA), that involves the transection of the internal carotid artery at the carotid bulb and its eversion over the atherosclerotic plaque, has been associated with an increased risk of postoperative hypertension possibly due to a direct iatrogenic damage to the carotid sinus fibers. The aim of this study is to assess the long-term effect of the e-CEA on arterial baroreflex and peripheral chemoreflex function in humans. Methods A retrospective review was conducted on a prospectively compiled computerized database of 3128 CEAs performed on 2617 patients at our Center between January 2001 and March 2006. During this period, a total of 292 patients who had bilateral carotid stenosis ≥70% at the time of the first admission underwent staged bilateral CEAs. Of these, 93 patients had staged bilateral e-CEAs, 126 staged bilateral s- CEAs and 73 had different procedures on each carotid. CEAs were performed with either the eversion or the standard technique with routine Dacron patching in all cases. The study inclusion criteria were bilateral CEA with the same technique on both sides and an uneventful postoperative course after both procedures. We decided to enroll patients submitted to bilateral e-CEA to eliminate the background noise from contralateral carotid sinus fibers. Exclusion criteria were: age >70 years, diabetes mellitus, chronic pulmonary disease, symptomatic ischemic cardiac disease or medical therapy with b-blockers, cardiac arrhythmia, permanent neurologic deficits or an abnormal preoperative cerebral CT scan, carotid restenosis and previous neck or chest surgery or irradiation. Young and aged-matched healthy subjects were also recruited as controls. Patients were assessed by the 4 standard cardiovascular reflex tests, including Lying-to-standing, Orthostatic hypotension, Deep breathing, and Valsalva Maneuver. Indirect autonomic parameters were assessed with a non-invasive approach based on spectral analysis of EKG RR interval, systolic arterial pressure, and respiration variability, performed with an ad hoc software. From the analysis of these parameters the software provides the estimates of spontaneous baroreflex sensitivity (BRS). The ventilatory response to hypoxia was assessed in patients and controls by means of classic rebreathing tests. Results A total of 29 patients (16 males, age 62.4±8.0 years) were enrolled. Overall, 13 patients had undergone bilateral e-CEA (44.8%) and 16 bilateral s-CEA (55.2%) with a mean interval between the procedures of 62±56 days. No patient showed signs or symptoms of autonomic dysfunction, including labile hypertension, tachycardia, palpitations, headache, inappropriate diaphoresis, pallor or flushing. The results of standard cardiovascular autonomic tests showed no evidence of autonomic dysfunction in any of the enrolled patients. At spectral analysis, a residual baroreflex performance was shown in both patient groups, though reduced, as expected, compared to young controls. Notably, baroreflex function was better maintained in e-CEA, compared to standard CEA. (BRS at rest: young controls 19.93 ± 2.45 msec/mmHg; age-matched controls 7.75 ± 1.24; e-CEA 13.85 ± 5.14; s-CEA 4.93 ± 1.15; ANOVA P=0.001; BRS at stand: young controls 7.83 ± 0.66; age-matched controls 3.71 ± 0.35; e-CEA 7.04 ± 1.99; s-CEA 3.57 ± 1.20; ANOVA P=0.001). In all subjects ventilation (VÝ E) and oximetry data fitted a linear regression model with r values > 0.8. Oneway analysis of variance showed a significantly higher slope both for ΔVE/ΔSaO2 in controls compared with both patient groups which were not different from each other (-1.37 ± 0.33 compared with -0.33±0.08 and -0.29 ±0.13 l/min/%SaO2, p<0.05, Fig.). Similar results were observed for and ΔVE/ΔPetO2 (-0.20 ± 0.1 versus -0.01 ± 0.0 and -0.07 ± 0.02 l/min/mmHg, p<0.05). A regression model using treatment, age, baseline FiCO2 and minimum SaO2 achieved showed only treatment as a significant factor in explaining the variance in minute ventilation (R2= 25%). Conclusions Overall, we demonstrated that bilateral e-CEA does not imply a carotid sinus denervation. As a result of some expected degree of iatrogenic damage, such performance was lower than that of controls. Interestingly though, baroreflex performance appeared better maintained in e-CEA than in s-CEA. This may be related to the changes in the elastic properties of the carotid sinus vascular wall, as the patch is more rigid than the endarterectomized carotid wall that remains in the e-CEA. These data confirmed the safety of CEA irrespective of the surgical technique and have relevant clinical implication in the assessment of the frequent hemodynamic disturbances associated with carotid angioplasty stenting.

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Benade-Treadwell, Maria M. "The cost-effectiveness of carotid endarterectomy as a stroke prevention strategy." Thesis, University of Edinburgh, 2000. http://hdl.handle.net/1842/22577.

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Following the publication of two large-scale randomised controlled trials in the early 1990s, little doubt remains about the efficacy of carotid endarterectomy as a means of preventing stroke in selected sub-groups of patients. However, the effectiveness and cost-effectiveness of this intervention as a stroke prevention strategy are uncertain, as are the public health implications when this strategy is applied to a population. This thesis focuses on the effectiveness and cost-effectiveness of carotid endarterectomy as a stroke prevention strategy in the Scottish population. The variation in uptake of carotid endarterectomy by hospital and region between 1981 - 1996 is described by analysing a unique set of patient linked data on hospital use and outcome following carotid surgery for 2892 patients. Stroke-free survival and overall survival before and after the publication of the trial results for this cohort are also assessed. A systematic overview of studies addressing the costs and benefits of carotid endarterectomy is conducted by critically appraising the methodology and interpretation of previous cost and cost-effectiveness estimates. Unlike previous studies, this thesis considers the resource implications of carotid endarterectomy by estimating not only the procedure cost of carotid endarterectomy but also the overall NHS work-up costs for a large cohort of patients with transient ischaemic attack referred to a Scottish teaching hospital for carotid endarterectomy assessment, investigation and surgery. Finally, as part of the analysis of cost-effectiveness estimates for Scottish patients, a novel use of the European Carotid Surgery Trial data has enabled assessment of the transferability of efficacy results obtained in a randomised controlled trial to a setting outside trial conditions.

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Kragsterman, Björn. "Carotid Artery Stenosis : Surgical Aspects." Doctoral thesis, Uppsala University, Department of Surgical Sciences, 2006. http://urn.kb.se/resolve?urn=urn:nbn:se:uu:diva-6834.

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Randomised controlled trials (RCT) have demonstrated a net benefit of carotid endarterectomy (CEA) in stroke prevention for patients with severe carotid artery stenosis as compared to best medical treatment. Results in routine clinical practice must not be inferior to those in the RCTs. The carotid arteries are clamped during CEA which may impair the cerebral perfusion.

The aim of this thesis was to assess population-based outcomes from CEA, investigate risk factors for perioperative complications/late mortality and to evaluate effects of carotid clamping during CEA. In the Swedish vascular registry 6182 CEAs were registered during 1994-2003. Data on all CEAs were retrieved, analysed and validated. In the validation process no death or disabling stroke was unreported. The perioperative stroke or death rate was 4.3% for those with symptomatic and 2.1% for asymptomatic stenosis (the latter decreasing over time). Risk factors for perioperative complications were age, indication, diabetes, cardiac disease and contralateral occlusion. Median survival time was 10.8 years for the symptomatic and 10.2 years for the asymptomatic group.

Tolerance to carotid clamping during CEA under general anaesthesia was evaluated in 62 patients measuring cerebral oximetry, transit time volume flowmetry and stump pressure. High internal carotid artery flow before clamping and low stump pressure was associated with decreased oxygenation after clamping suggesting shunt indication.

In 18 patients undergoing CEA, jugular bulb blood samples demonstrated significantly altered levels of marker for inflammatory activation (IL-6) and fibrinolytic activity (D-dimer and PAI-1) during carotid clamping as compared to radial artery levels. This indicates a cerebral ischaemia due to clamping although clinically well tolerated.

In conclusion, the perioperative outcome after CEA in Sweden compared well with the RCTs results. Tolerance to carotid clamping may be evaluated by combining stump pressure and volume flow measurements. Although clinically tolerated clamping may induce a cerebral ischaemic response.

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Anderson, Sarah. "The neuropsychological and magnetic resonance imaging assessment of patients undergoing carotid endarterectomy /." Adelaide, 2000. http://web4.library.adelaide.edu.au/theses/09ARPS/09arpsa5492.pdf.

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Olech, Tony. "Neuropsychological functioning and protein S-100ℓ levels before and after carotid endarterectomy /." Adelaide, 2000. http://web4.library.adelaide.edu.au/theses/09AR.PS/09ar.pso449.pdf.

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Dellagrammaticas, Demosthenes. "Cerebral haemodynamic control and carotid endarterectomy : comparison of general and locoregional anaesthesia." Thesis, University of Manchester, 2012. https://www.research.manchester.ac.uk/portal/en/theses/cerebral-haemodynamic-control-and-carotid-endarterectomy-comparison-of-general-and-locoregional-anaesthesia(a7b50cfa-d56d-40ff-b8d8-dbc1a2ff105e).html.

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The role of CEA for stroke prevention in the presence of symptomatic carotid artery stenosis is well established. In order to maximize the benefit of surgery, several perioperative processes of care have been under scrutiny, of which one is the choice of anaesthetic method. The differing effects of GA vs. LA on the cerebral circulation after CEA may be of significance, since changes in the cerebral circulation post-CEA may give rise to cerebral hyperperfusion and intracerebral haemorrhage. This work assessed the effect of GA vs. LA on cerebral haemodynamic control after CEA using transcranial Doppler (TCD) techniques, and correlated these changes with serum markers of cerebral injury. Subjects undergoing CEA had perioperative TCD monitoring of middle cerebral artery blood flow velocity (MCAV). Pre- and postoperative (within 48 hours of surgery) testing of cerebral autoregulation [CA] (tilt-testing) and cerebral vasoreactivity to CO2 [CVR] (rebreathing expired air) was conducted. Cerebral haemodynamic parameters and clinical outcome were correlated with changes in jugular venous and peripheral levels of protein S100β and neurone-specific enolase (NSE).The change in CA and CVR was not different between GA (n=16) and LA (n=20). Overall, CA and CVR improved significantly within 48 hours of CEA for patients with preoperative impairment of these parameters, although some patients with normal baseline CA and CVR exhibited postoperative impairment. Increase of MCAV >100% from baseline after restoration of carotid blood flow was observed in patients with impaired CVR, but resolved by the first postoperative day. Transient elevation in jugular venous (but not peripheral) S100β during surgery was seen. Both jugular and peripheral NSE levels dropped during surgery. Neither anaesthetic method nor CA or CVR status had any effect on changes in serum S100β or NSE. Cerebral autoregulatory parameters thus improve rapidly after CEA, but appear unaffected by anaesthetic technique. This supports the concept that cerebral hyperperfusion is dependent on factors in addition to impaired CA or CVR. Changes in serum S100β or NSE do not reflect cerebral haemodynamic changes. However, the variability encountered between patients warrants further investigation. The implications for clinical practice and directions for further research are discussed.

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Johansson, Elias. "Carotid stenosis." Doctoral thesis, Umeå universitet, Institutionen för folkhälsa och klinisk medicin, 2011. http://urn.kb.se/resolve?urn=urn:nbn:se:umu:diva-46396.

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Carotid stenosis is one of several causes of ischemic stroke and entails a high risk of ischemic stroke recurrence. Removal of a carotid stenosis by carotid endarterectomy results in a risk reduction for ischemic stroke, but the magnitude of risk reduction depends on several factors. If the delay between the last symptom and carotid endarterectomy is less than 2 weeks, the absolute risk reduction is >10%, regardless of age, sex, or if the degree of carotid stenosis is 50–69% or 70–99%. Thus, speed is the key. However, if many patients suffers an ischemic stroke recurrence within the first 2 weeks of the presenting event, an additional benefit is likely be obtained if carotid endarterectomy is performed even earlier than within 2 week after the presenting event. Carotid endarterectomy for asymptomatic carotid stenoses carries a small risk reduction for stroke. Screening for asymptomatic carotid stenosis requires a prevalence of >5% in the examined population, i.e., higher than in the general population; however, directed screening in groups with a prevalence of >5% is beneficial. The aims of this thesis were to investigate the length of the delay to carotid endarterectomy, determine the risk of recurrent stroke before carotid endarterectomy, and determine if a calcification in the area of the carotid arteries seen on dental panoramic radiographs is a valid selection method for directed ultrasound screening to detect asymptomatic carotid stenosis. Consecutive patients with a symptomatic carotid stenosis who underwent a preoperative evaluation aimed at carotid endarterectomy at Umeå Stroke Centre between January 1, 2004–March 31, 2006 (n=275) were collected retrospectively and between August 1, 2007–December 31, 2009 (n=230) prospectively. In addition, 117 consecutive persons, all preliminarily eligible for asymptomatic carotid endarterectomy and with a calcification in the area of the carotid arteries seen on panoramic radiographs, were prospectively examined with carotid ultrasound. The median delay between the presenting event and carotid endarterectomy was 11.7 weeks in the first half year of 2004, dropped to 6.9 weeks in the first quarter year of 2006, and had dropped to 3.6 weeks in the second half year of 2009. The risk of ipsilateral ischemic stroke recurrence was 4.8% within 2 days, 7.9% within 1 week, and 11.2% within 2 weeks of the presenting event. For patients with a stroke or transient ischemic attack as the presenting event, this risk was 6.0% within 2 days, 9.7% within 1 week, and 14.3% within 2 weeks of the presenting event. For the 10 patients with a near-occlusion, the risk of ipsilateral ischemic stroke recurrence was 50% at 4 weeks after the presenting event. Among the 117 persons with a calcification in the area of the carotid arteries seen on panoramic radiographs, eight had a 50–99% carotid stenosis, equalling a prevalence of 6.8% (not statistically significantly over the pre-specified 5% threshold). Among men, the prevalence of 50–99% carotid stenosis was 12.5%, which was statistically significantly over the pre-specified 5% threshold. In conclusion: The delay to carotid endarterectomy was longer than 2 weeks. Additional benefit is likely to be gained by performing carotid endarterectomy within a few days of the presenting event instead of at 2 weeks because many patients suffer a stroke recurrence within a few days; speed is indeed the key. The finding that near-occlusion entails an early high risk of stroke recurrence stands in sharp contrast to previous studies; one possible explaination is that this was a high-risk period missed in previous studies. The incidental finding of a calcification in the area of the carotid arteries on a panoramic radiograph is a valid indication for carotid ultrasound screening in men who are otherwise eligible for asymptomatic carotid endarterectomy.

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Kragsterman, Björn. "Carotid artery stenosis : surgical aspects /." Uppsala : Acta Universitatis Upsaliensis : Univ.bibl. [distributör], 2006. http://urn.kb.se/resolve?urn=urn:nbn:se:uu:diva-6834.

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Irshad, Kashif. "The carotid endarterectomy (CEA) in Quebec : a study of the last three years." Thesis, McGill University, 2002. http://digitool.Library.McGill.CA:80/R/?func=dbin-jump-full&object_id=78386.

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Introduction. The Carotid Endarterectomy (CEA) is used for stroke prophylaxis in asymptomatic carotid stenosis and in patients with previous strokes or transient ischemic attacks.
Objective. To audit the operative results of the CEA in the province of Quebec between 1996 and 1999.
Methods. The Quebec Medical Discharge Summary Database provided demographics and surgical complications following all CEAs performed between 1996--1999.
Results. The CEA was performed at a rate of 42 procedures/100 000 persons aged greater than 40 however this rate appears to be declining over the study span. Being operated on by a neurosurgeon was an independent risk factor for peri-operative stroke (OR 1.55, 95%CI 1.12--2.12). There was no difference in outcomes between teaching and non-teaching centres.
Conclusion. The CEA is being used less frequently recently and is being performed fewer times than in the United States. Neurosurgeons have poorer outcomes which might be due to surgeon factors or poorly controlled counfounders.

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Siqueira, Letícia Cristina Dalledone 1981. "Avaliação da resposta hemodinâmica cerebral através da monitorização com a espectroscopia próxima ao infravermelho (NIRS) em pacientes com doença aterosclerótica submetidos à endarterectomia de carótida = Evaluation of the brain hemodynamic response by means of near-infrared spectroscopy (NIRS) monitoring in atherosclerotic patients who underwent carotid endarterectomy." [s.n.], 2015. http://repositorio.unicamp.br/jspui/handle/REPOSIP/312479.

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Orientador: Ana Terezinha Guillaumon
Dissertação (mestrado) - Universidade Estadual de Campinas, Faculdade de Ciências Médicas
Made available in DSpace on 2018-08-28T09:17:18Z (GMT). No. of bitstreams: 1 Siqueira_LeticiaCristinaDalledone_M.pdf: 5041737 bytes, checksum: 615b5b4269f2f46490565662d28dfb21 (MD5) Previous issue date: 2015
Resumo: Introdução: A espectroscopia próxima ao infra-vermelho (NIRS) é uma técnica não invasiva e de baixo custo que detecta as alterações hemodinâmicas teciduais. O NIRS pode monitorar de forma contínua as informações fisiológicas vasculares intracranianas. Por ser portátil, ele pode ser utilizado a beira do leito e no centro cirúrgico. Objetivo: Avaliar o comportamento das possíveis alterações hemodinâmicas cerebrais, durante a endarterectomia, em pacientes com estenoses maiores que 70%, utilizando NIRS. Casuística e métodos: Foram avaliados 10 voluntários portadores de doença carotídea aterosclerótica com indicação de endarterectomia. Após a seleção dos pacientes que responderam um questionário com dados epidemiológicos e informações referentes a presença de comorbidades, a doença foi confirmada por métodos diagnósticos. No procedimento cirúrgico utilizou-se o NIRS para monitorização. Foram avaliadas as variáveis saturação de oxigênio (Sat O2) hemoglobina total (HbT), hemoglobina reduzida (HbR) e hemoglobina oxigenada (HbO) nos três tempos cirúrgicos pré, trans e pós-clampeamento carotídeo. Resultados: Utilizou-se p<0,05 como nivel de significância. A avaliação dos resultados obtidos através das medidas registradas pelo NIRS permite afirmar que as etapas da cirurgia diferem quanto ás variável HbR e SatO2. Durante a etapa do clampeamento, a variável HbR mostra valores mais elevados que nas outras duas etapas da cirurgia. De outra parte, a variável SatO2 mostra redução durante o clampeamento. Conclusão: O NIRS é um método viável e aplicável de monitorização intracerebral, não-invasivo e em tempo real, durante a endarterectomia carotídea, capaz de medir de forma precisa as mudanças das condições hemodinâmicas capilares intra-cerebrais
Abstract: Introduction: Near-infrared spectroscopy (NIRS) is a low-cost, non-invasive technique that detects tissue hemodynamic alterations. It enables continuous monitoring of the intracerebral vascular physiologic information. Due to its portable nature, NIRS may be used beside a bed or in the operating room. Objective: To evaluate the use of NIRS for intra-surgical monitoring of the brain hemodynamic response, during an endarterectomy procedure of the atherosclerotic carotid artery. Casuistry and Methods: 10 patients with atherosclerotic carotid disease and recommended endarterectomy were evaluated. They were identified in a survey which provided epidemiologic data and the presence of comorbidities. Disease was confirmed by diagnostic methods. NRIS monitoring was used during the surgical procedure. Oxygen saturation (O2 Sat), total hemoglobin (THb), reduced hemoglobin (RHb), and oxyhemoglobin (OHb) were the variables analyzed at the three carotid clamp stages: pre-, trans- and post-. Results: A p<0.05 value was considered statistically significant. The results obtained from the NIRS data reveal that the surgical stages differ in relation to the RHb and O2Sat variables. RHb presents higher levels during clamping when compared with the other two surgical stages. On the other hand, O2Sat is decreased during clamping. Conclusion: NIRS is a feasible, realtime and non-invasive intracranial monitoring method, during carotid endarterectomy, which measures accurately and reliably the changes of the intracerebral capillary hemodynamic conditions
Mestrado
Cirurgia
Mestra em Ciências

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21

Fittipaldi, Silvia <1982&gt. "Evaluation of cardiovascular disease markers in patients submitted to carotid artery stenting or endarterectomy." Doctoral thesis, Alma Mater Studiorum - Università di Bologna, 2012. http://amsdottorato.unibo.it/4501/.

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Introduction. Microembolization during the carotid artery revascularization procedure may cause cerebral lesions. Elevated C-Reactive Protein (hsCRP), Vascular endothelial growth factor (VEGF) and serum amyloid A protein (SAA) exert inflammatory activities thus promoting carotid plaque instability. Neuron specific enolase (NSE) is considered a marker of cerebral injury. Neoangiogenesis represents a crucial step in atherosclerosis, since neovessels density correlates with plaque destabilization. However their clinical significance on the outcome of revascularization is unknown. This study aims to establish the correlation between palque vulnerabilty, embolization and histological or serological markers of inflammation and neoangiogenesis. Methods. Serum hsCRP, SAA, VEGF, NSE mRNA, PAPP-A mRNA levels were evaluated in patients with symptomatic carotid stenosis who underwent filter-protected CAS or CEA procedure. Cerebral embolization, presence of neurologicals symptoms, plaque neovascularization were evaluated testing imaging, serological and histological methods. Results were compared by Fisher’s, Student T test and Mann-Whitney U test. Results. Patients with hsCRP<5 mg/l, SAA<10mg/L and VEGF<500pg/ml had a mean PO of 21.5% versus 35.3% (p<0.05). In either group, embolic material captured by the filter was identified as atherosclerotic plaque fragments. Cerebral lesions increased significantly in all patients with hsCRP>5mg/l and SAA>10mg/l (16.5 vs 2.8 mean number, 3564.6 vs 417.6 mm3 mean volume). Discussion. High hsCRP, SAA and VEGF levels are associated with significantly greater embolization during CAS and to the vulnerabiliy of the plaque. This data suggest CAS might not be indicated as a method of revascularization in this specific group of patients.

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Oliveira, Germano da Paz 1982. "Análise comparativa dos parâmetros adquiridos com o US doppler transcraniano durante a endarterectomia carotídea por semi-eversão e a angioplastia carotídea." [s.n.], 2014. http://repositorio.unicamp.br/jspui/handle/REPOSIP/312480.

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Orientador: Ana Terezinha Guillaumon
Dissertação (mestrado) - Universidade Estadual de Campinas, Faculdade de Ciências Médicas
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Resumo: Objetivos: Analisar a distribuição temporal de sinais de microembolias (SM) ao longo de diferentes estágios da endarterectomia carotídea (EC) e da angioplastia carotídea (AC) e as variáveis associadas com a ocorrência destes sinais, além de avaliar as mudanças na velocidade média aferida na artéria cerebral média (ACM) durante os dois tipos de intervenção. Material e métodos: Trinta e três pacientes com estenose carotídea foram submetidos ou a EC (17) ou a AC (16). Os SM bem como as velocidades médias na ACM foram adquiridas utilizando o US doppler transcraniano (DTC) e esses dados então analisados e associados a diferentes estágios cirúrgicos (pré-proteção, durante a proteção e pós-proteção), tipos de intervenção (EC ou AC) e diferentes variáveis para encontrar potenciais fatores de risco para embolização. Para análise estatística, foram usados os testes de Qui-quadrado, de Fisher e de Mann-Whitney, além de análise por medidas repetidas das variâncias com transformação por postos (ANOVA), seguido de teste de perfil por contrastes e análise de regressão linear múltipla ajustada para o grupo. Resultados: Uma diferença significativa foi encontrada para o número de SM em ambos os grupos. Houve, em média, 89,8 (± 171,4) sinais por procedimento no grupo EC, enquanto a média no grupo AC foi de 597,5 (± 343,3) sinais por procedimento. A média da velocidade média na ACM foi, em ambos os grupos, significantemente menor no estágio durante a proteção. Anestesia local correlacionou-se positivamente (p=0,003) com aumento dos SM, e, associado a isso, o histórico de tabagismo importante (desde que houvesse a cessação do vício há mais de um ano) correlacionou-se negativamente (0,014) com a ocorrência de SM. Conclusão: EC por semi-eversão, à luz do DTC, provocou uma menor incidência de SM por procedimento do que AC com filtro distal, em todos os estágios cirúrgicos. A média da velocidade média na ACM se comportou de maneira similar em ambos os grupos (EC e AC). Anestesia geral e histórico de tabagismo importante (desde que o paciente houvesse cessado por menos um anos antes da intervenção) foram as únicas duas variáveis no estudo que se correlacionaram significativamente (negativamente) com a ocorrência de SM
Abstract: Objectives: To analyze the temporal distribution of microembolic signals throughout the different stages of both the semi-eversion carotid endarterectomy (CEA) and the carotid artery stenting (CAS) procedures and the variables associated with occurrence of them and to evaluate changes in mean blood flow velocity, for both CAS and CEA, within the ipsilateral middle cerebral artery (MCA). Methods: Thirty three patients with carotid stenosis underwent either a CEA (17) or a CAS (16). Microembolic signals, as well as mean blood flow velocity, were acquired using a Transcranial Doppler scan (TCD) and these data were then analyzed and associated to different surgical stages (pre-protection, during protection, and post-protection), types of procedure (CAS or CEA) and different variables to find potential risk factors. To statistical analysis, chi-squared test, Fisher test, Mann-Whitney test, repeated measures analysis of variance with rank transformation (ANOVA) followed by contrast test and multiple linear regression analysis were used. Results: A significant difference was found for the number of microembolic signals in both groups. There were, on average, 89.8 (± 171.4) signals per procedure in the CEA group, while the average in the CAS group was 597.5 (± 343.3) signals per procedure. The average blood flow in the MCA was, in both groups, significantly lower during the stage of protection. Local anesthesia correlated positively (p= .003) with increase in microembolic signals and history of prolonged tobacco use having dropped the addiction for over a year correlated negatively (p= -.014) with the frequency of microembolic signals. Conclusion: Semi-eversion CEA, in light of our TCD findings, evoked a smaller incidence of hyperintense microemboli per procedure than CAS with a distal filter in all the protection stages. The average of the mean blood flow velocity within the MCA has behaved similarly between both groups (CAS and CEA). General anesthesia and the history of tobacco use (as long as the patient had quit for a year or more prior to surgery) were the only two variables in the study that correlated significantly (negatively) with the frequency of microembolic signals
Mestrado
Fisiopatologia Cirúrgica
Mestre em Ciências

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Minuzzi, Rosângela da Rosa. "Proteína S-100ß do bulbo da jugular interna : um marcador de dano neuronal isquêmico em endarterectomia de carótida com clampeamento temporário." reponame:Biblioteca Digital de Teses e Dissertações da UFRGS, 2009. http://hdl.handle.net/10183/17757.

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A endarterectomia de carótida tem um papel bem estabelecido na prevenção de AVC ipsilateral em pacientes com mais de 50% de estenose sintomática da artéria carótida interna. No entanto, o dano cerebral isquêmico contribui significativamente para a morbidade e mortalidade perioperatórias aumentadas na endarterectomia de carótida com clampeamento intra-operatório temporário. Portanto a relação entre a gravidade do dano isquêmico neuronal durante o procedimento e o sistema de auto-regulação do funcionamento da relação oferta/consumo de oxigênio cerebral precisa ser explorado. Esta avaliação poderia ser feita usando-se um marcador sensível de estresse hipóxico, tal como a proteína S-100ß, que é liberada das células da astroglia que sofreram dano estrutural, para o interior da circulação sangüínea quando a permeabilidade da barreira hemato-encefálica está alterada. Isto é especialmente verdadeiro porque uma baixa pressão no coto distal ao clampeamento continua a ser o critério principal para shunt, embora ela possa estar normal em 6% a 30% dos pacientes que subseqüentemente desenvolvem sinais neurológicos, e anormal em 3% a 11% daqueles que não desenvolvem sinais de isquemia. Então, faz sentido investigar outros métodos para detectar dano cerebral isquêmico em endarterectomia de carótida, tais como a taxa de extração de oxigênio cerebral (ECO2) para permitir a otimização de variáveis acessíveis à intervenção médica, como: shunt, parâmetros ventilatórios e parâmetros hemodinâmicos. O objetivo deste trabalho foi avaliar a correlação entre um marcador de dano cerebral isquêmico, a proteína S-100ß sérica, com a fração de extração de oxigênio cerebral (ECO2) e com a pressão arterial de dióxido de carbono (PaCO2) em pacientes submetidos à endarterectomia de carótida para estenose sintomática, com clampeamento temporário. Este estudo transversal avaliou 33 pacientes, estado físico II e III e média de idade de 70 ± 8 anos que foram submetidos à anestesia geral endovenosa e inalatória . PaCO2 (mmHg) e % ECO2 foram medidas antes do clampeamento da carótida (T1), 5 minutos após o clampeamento (T2) e 5 minutos após o desclampeamento (T3) a partir de amostras sangüíneas retiradas da veia jugular interna. S-100ß foi determinada nos seguintes momentos: antes do clampeamento da carótida (T1), imediatamente antes do desclampeamento (T2) e 6 horas após o desclampeamento (T3). O tempo médio de isquemia cerebral foi de 16 minutos [(IQ25-75) 11,05 a 19,00]. Os coeficientes de correlação de Spearman (rs) para a relação entre os níveis de S-100β em 6 horas após a cirurgia e os níveis de ECO2 e PaCO2 durante o período do estudo foram rs = 0,59 (P = 0,00) e rs = -0,36 (P = 0,00) respectivamente. Em conclusão, os presentes achados sugerem que o dano neuronal isquêmico avaliado pela ECO2 durante o período isquêmico podem predizer um aumento de S-100ß. Contudo, futuros estudos são necessários para determinar o impacto clínico de tais achados.
Carotid endarterectomy (CED) is a well established procedure to prevent ipsilateral stroke in patients with more than 50% symptomatic internal carotid artery (ICA) stenosis. However, ischemic brain injury persists as a significant contributing factor to increased perioperative morbidity and mortality in carotid endarterectomy with temporary intraoperative clamping. Hence, the relationship between the severity of neuronal ischemic damage during carotid endarterectomy (CED) and the autoregulation system of the functioning brain oxygen supply/consumption ratio needs to be further explored. This appraisal could be made using a sensitive marker of hypoxic stress, such as S-100ß released into de bloodstream when structural damage to astroglial cells alter the permeability of the blood-brain barrier. This methodological resource can be valuable since a low stump pressure is generally the main criterion for shunting, although normal in about 6-30% of patients who subsequently develop neurological signs and abnormal in 3-11% in those without signs of ischemia. Thus, it makes sense to search for additional subsidies to detect ischemic brain damage during carotid endarterectomy, such as the rate of brain oxygen extraction (ECO2). This earlier accessible variable at low cost could help medical decision-making such as shunt or changes in hemodynamic and ventilatory parameters. The aim of this study was, therefore, assess the correlation between a marker of neuronal ischemic damage, serum S-100ß, and brain oxygen extraction fraction (ECO2) and PaCO2 (arterial carbon dioxide tension) in patients undergoing carotid endarterectomy for symptomatic stenosis with temporary clamping. This cross-sectional study assessed 33 patients, physical status II-III, and mean age of 70 ± 8 years, who undergoing intravenous general anesthesia. PaCO2 (mmHg) and %ECO2 were measured prior to carotid clamping (T1), 5 min after carotid clamping (T2) and 5 min after carotid unclamping (T3) with blood drawn from the internal jugular vein. Serum S-100β was determined at T1 - prior to carotid clamping, T2 - immediately before carotid unclamping, and T3 - 6 h after carotid unclamping. The median time of brain ischemia was 16 min [(IQ25-75) 11.05 to 19.00]. Spearman correlation coefficients (rs) for the relationship between S-100ß level at 6 h after surgery and PaCO2 and ECO2 levels during the study period were rs = -0.36 (P < 0.01) and rs = 0.59 (P < 0.01), respectively. To conclude, the present findings suggest that brain ischemic neural damage monitored by ECO2 during the ischemic time may predict an increase in S-100ß. Further studies are warranted to assess the clinical impact of these results.

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Diaz, Duran Carles. "Història natural dels pacients intervinguts d’endoarteriectomia carotídia en una població mediterrània amb baixa incidència de malaltia coronària." Doctoral thesis, Universitat Autònoma de Barcelona, 2020. http://hdl.handle.net/10803/670480.

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Aquesta tesi doctoral és el fruit d’un projecte de recerca sobre la història natural del pacient sotmès a una EA carotídia. D’una banda, l’estudi de la supervivència a llarg termini del pacient intervingut en una població mediterrània caracteritzada per la baixa incidència de malaltia cardiovascular pot ajudar a determinar quins pacients tenen una esperança de vida major i influir en la presa de decisions terapèutiques, especialment en el pacient asimptomàtic. D’altra banda, l’anàlisi de la taxa de progressió de l’estenosi carotídia contralateral a una caròtida ja intervinguda proporcionarà una descripció més precisa d’aquestes lesions en el moment actual i podria determinar-ne nous esquemes de seguiment. Qualsevol estratègia terapèutica encaminada a millorar la història natural dels nostres pacients passa per un coneixement acurat d’aquesta, tant en el temps com en el lloc on hem de decidir .
Esta tesis doctoral es fruto de un proyecto de investigación sobre la historia natural del paciente sometido a una endarterectomia carotídea. Por un lado, el estudio de la supervivencia a largo plazo del paciente intervenido en una población mediterránea caracterizada por la baja incidencia de enfermedad cardiovascular puede ayudar a determinar los pacientes con esperanza de vida mayor e influir en la toma de decisiones terapéuticas, especialmente en los pacientes asintomáticos.Por otro lado, el análisis de la tasa de progresión de la estenosis carotídea contralateral a una carótida ya intervenida proporcionará una descripción más precisa d'estas lesiones en el momento actual y podría determinar nuevos esquemas de seguimiento. Cualquier estrategia terapéutica encaminada a mejorar la historia natural de nuestros pacientes pasa por un conocimiento preciso de ésta, tanto en el tiempo como en el lugar donde decidir.
This doctoral thesis is the result of a research project on the natural history of the patients submitted to a carotid endarterectomy. Firstly, the study of the long-term survival of patients intervened in a Mediterranean population characterized by a low incidence of cardiovascular disease can help to identify patients with longer life expectancy and influence therapeutic decision-making, especially in asymtomatic patients. On the other hand, determining the rate of disease progression in the contralateral carotid artery in patients already submitted to a carotid endarterecromy, will provide a more accurate description of these lesions at the present time and could determine new follow-up regimens. Any therapeutic strategy aimed to describe the natural history of our patients requires a precise knowledge of it, both at the time and in the place where to decide.

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Rothwell, Peter M. "The aetiology and prevention of ischaemic stroke associated with recently symptomatic atherothrombotic carotid artery stenosis : lessons from a randomised controlled trial of carotid endarterectomy." Thesis, University of Edinburgh, 1999. http://hdl.handle.net/1842/22604.

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The cost-effectiveness of carotid surgery, which is questioned by many, would be increased considerably if it was possible to predict the risks and likely benefits for individual patients. This was the main aim of the work described in this thesis. This was achieved in five stages. Firstly, using carotid angiograms from 3007 patients randomised in the European Carotid Surgery Trial (ECST), I determined the equivalence, reproducibility and pathological correlation of the assessment of plaque surface morphology on angiograms. Secondly, using data on patients randomised to no-surgery in the ECST, I studied the relationship between the degree of carotid stenosis, plaque surface morphology and other clinical and angiographic characteristics and the risk of ipsilateral carotid territory ischaemic stroke on medical treatment. Using both a simple univariate approach and a multivariate Cox's proportional hazards approach, I was able to develop a number of prognostic models. Thirdly, I studied the risk of stroke and death due to carotid endarterectomy using a systematic review of the published literature. The absolute risk of stroke and death due to surgery was defined with narrow confidence limits and the relationship between various clinical and angiographic characteristics and the operative risk was determined. The validity of the risk factors for operative stroke and death were derived from the systematic review and the interaction with surgical and anaesthetic technique was assessed using data on patients randomised to surgery in the ECST. Fourthly, the potential benefit of selecting patients for carotid endarterectomy on the basis of the balance between their predicted individual risks of stroke on medical treatment and stroke and death due to surgery was assessed by stratifying the results of the ECST by baseline risk and by applying the same prognostic models to data from the North American Symptomatic Carotid Endarterectomy Trial. Finally, I designed and set up two large international collaborative studies which aim to further define the prognostic factors for major ischaemic stroke and other vascular outcomes in patients presenting with transient ischaemic attacks and minor ischaemic stroke and increase the cost-effectiveness of stroke prevention using carotid endarterectomy.

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Ramponi, Fabio. "Operative strategies to prevent cerebrovascular complications in patients presenting with concomitant critical coronary and carotid artery disease: the role of combined anaortic off-pump coronary bypass and carotid endarterectomy." Thesis, The University of Sydney, 2022. https://hdl.handle.net/2123/28613.

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Permanent neurologic injury following coronary revascularization is among the most feared complication, as it bears disastrous consequences for the immediate and long-term patient recovery. Depending on the patient population and the diagnostic criteria utilized, isolated coronary artery bypass grafting carries a risk of postoperative neurologic events (including stroke, transient ischemic attack and neurocognitive decline) of 1 to 5%. Older age and increased atherosclerotic burden, progressively common features of the population referred for coronary surgery, are the main risk factors for perioperative ischemic stroke most commonly due to atheroembolic events secondary to aortic instrumentation (ie. cannulation, clamping and proximal anastomosis). Avoiding aortic manipulation with “anaortic” techniques (anaortic off-pump coronary bypass grafting) significantly reduces the risk of cerebrovascular events, a concept that has been fully embraced by the latest International coronary revascularization guidelines. A sub-group of patients at higher risk of perioperative neurologic morbidity are those with multilevel extra-cardiac atherosclerotic disease, in particular subjects presenting with concomitant severe carotid and coronary pathology. The management of this specific cohort is still controversial due to the lack of adequately powered randomized controlled trials. This Master of Philosophy research aims to: (i) describe the mechanisms of neurologic injury following isolated coronary artery bypass surgery (ii) explore the evidence related to surgical techniques aimed to reduce neurologic morbidity, in particular in the context of severe atherosclerotic burden; (iii) investigate the safety and efficacy of different surgical strategies for patients affected by concomitant severe carotid and coronary disease, with particular focus on the role of synchronous anaortic off-pump coronary bypass and carotid endarterectomy.

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Fiebig, Marnie. "Chlamydia pneumoniae as an etiological agent in atherosclerosis from patients undergoing carotid endarterectomy or abdominal aortic aneurysm repair." Thesis, National Library of Canada = Bibliothèque nationale du Canada, 2001. http://www.collectionscanada.ca/obj/s4/f2/dsk3/ftp04/MQ55902.pdf.

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Andrés, Navarro Omar. "Indicació selectiva de "shunt" en l'endoarteriectomia carotídia, un nou mètode." Doctoral thesis, Universitat de Girona, 2020. http://hdl.handle.net/10803/671393.

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The protocol followed in this thesis is to indicate the EAC according to the NASCET criteria. Closure of the arteriotomy with patch. The criteria to indicate this have been based on an original method, which takes into account the decrease in the mean pressure of the internal carotid artery, in the measure before and after the clamping of the common and external carotid arteries in EAC. In general, if it exceeds 20mmHg, it indicates the shunt, except in cases where the mean pressure of the internal carotid after the clamping of the common and external carotid arteries exceeds 60mmHg. 150 consecutive EAC have been analysed in 150 patients. The proposed method retains the conceptual criterion for shunt indication by lowering the internal carotid pressure during carotid clamping, with good results in morbidity and mortality and is a simple method to apply with conventional technology
El protocol seguit en aquesta tesi és indicar la EAC segons els criteris NASCET. Tancament de l’arteriotomia amb patch. Els criteris per indicar-lo s’han basat en un mètode original, que té en compte la davallada de la pressió mitjana de l’arteria caròtida interna, en la mesura prèvia i posterior al pinçament de les artèries caròtida comú i externa en l’EAC. De forma general, si aquesta supera els 20mmHg, s’indica el shunt, excepte en els casos on la pressió mitjana de la caròtida interna posterior al pinçament de les artèries caròtida comú i externa supera els 60mmHg. S’han analitzat 150 EAC consecutives en 150 pacients. El mètode proposat conserva el criteri conceptual d’indicació de shunt per davallada de la pressió de la caròtida interna durant el pinçament carotidi, amb bons resultats de morbiditat i mortalitat i és un mètode senzill d’aplicar amb tecnologia convencional

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Misonis, Nerijus. "Miego arterijų angioplastikos ir stentavimo ankstyvųjų bei vėlyvųjų rezultatų ir jiems poveikį darančių veiksnių tyrimas." Doctoral thesis, Lithuanian Academic Libraries Network (LABT), 2013. http://vddb.laba.lt/obj/LT-eLABa-0001:E.02~2013~D_20131004_095250-29569.

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Darbo tikslas – įvertinti miego arterijų angioplastikos ir stentavimo ankstyvuosius ir vėlyvuosius rezultatus bei poveikį darančius veiksnius. Metodai. Tyrimo metu vertintos VMAS procedūros atliktos 2006-2013 metais. Iš viso buvo atliktos 227 procedūros 211 pacientų; iš jų 156 (75,3 proc.) vyrams ir 55 (24,7 proc.) moterims. Rezultatai. Tyrimas atskleidė, kad esant 3 aortos lanko tipui VMAS procedūros trukmė buvo reikšmingai ilgesnė, o mikroembolai apsaugos sistemose buvo nustatyti dažniau. Mikroembolai apsaugos sistemose buvo nustatyti dažniau kai VMAS procedūra truko ilgiau. Apsaugos sistemos atliekant VMAS procedūrą buvo naudotos 70,9 proc. pacientų. Vyrams ir jaunesnio amžiaus pacientams VMAS procedūros metu apsauga buvo taikyta dažniau. Mikroembolai apsaugos sistemose buvo nustatyti 17,6 proc. pacientų ir dažniau buvo nustatyti naudojant FilterWire EZ ir Embo-shield-NAV apsaugos sistemas. Didesnė dešinės VMA stenozė buvo dažnesnė rūkantiems pacientams, o kairės VMA sirgusiems miokardo infarktu bei rūkantiems. Apsauga dažniau buvo taikyta pacientams kurie turėjo didelio laipsnio kairės VMA stenozę. Ankstyvuoju po procedūriniu periodu vyrų ir moterų mirštamumas atitinkamai buvo 1,2 proc. ir 1,8 proc., o 2 metų laikotarpyje buvo 18,7 proc. ir 28,6 proc. Pacientų mirštamumas 2 metų laikotarpyje, kuriems buvo naudotos apsaugos sistemos buvo mažesnis. Galimybę patirti komplikacijas (GSI ar PSIP) didino 3 aortos lanko tipas ir dešinės bendrosios miego arterijos stenozė, mažino... [toliau žr. visą tekstą]
The aim - to assess the carotid artery angioplasty and stenting early and late results and influencing factors. Methods. The study assessed CAS procedures performed in 2006-2013. A total of 227 procedures performed in 211 patients, of which 156 (75.3%) males and 55 (24.7%) females. Results. The study revealed that CAS procedure duration among patient with 3 aortic arch type was significantly longer and the microemboli protection systems were used more frequently. Protection systems were used more frequently when the CAS procedure lasted longer. Protection systems in CAS procedure was used in 70.9% patients. In men and younger patients protection system has been used more frequently. Microemboli in the protection systems have been identified by 17.6% patients and were more determined using the EZ FilterWire and Emboshield-NAV protection system. Increased right ICA stenosis was more common in patients who smoke, and left ICA with a history of myocardial infarction and smoking. Protection system was often used in patients who have had severe left ICA stenosis. The lethality rate in the early post procedural period among men and women was 1.2% and 1.8%, and in 2-year period was 18.7% and 28.6%, respectively. The lethality rate during 2-year period, which have been used for protective systems have been lower. The possibility to experience complications (stroke or TIA) increased 3 aortic arch type and the right common carotid artery stenosis, reduced protection systems using. Focal... [to full text]

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Misonis, Nerijus. "Evaluation of early and late results and predetermining factors after carotid artery angioplasty and stenting." Doctoral thesis, Lithuanian Academic Libraries Network (LABT), 2013. http://vddb.laba.lt/obj/LT-eLABa-0001:E.02~2013~D_20131004_095338-94074.

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The aim - to assess the carotid artery angioplasty and stenting early and late results and influencing factors. Methods. The study assessed CAS procedures performed in 2006-2013. A total of 227 procedures performed in 211 patients, of which 156 (75.3%) males and 55 (24.7%) females. Results. The study revealed that CAS procedure duration among patient with 3 aortic arch type was significantly longer and the microemboli protection systems were used more frequently. Protection systems were used more frequently when the CAS procedure lasted longer. Protection systems in CAS procedure was used in 70.9% patients. In men and younger patients protection system has been used more frequently. Microemboli in the protection systems have been identified by 17.6% patients and were more determined using the EZ FilterWire and Emboshield-NAV protection system. Increased right ICA stenosis was more common in patients who smoke, and left ICA with a history of myocardial infarction and smoking. Protection system was often used in patients who have had severe left ICA stenosis. The lethality rate in the early post procedural period among men and women was 1.2% and 1.8%, and in 2-year period was 18.7% and 28.6%, respectively. The lethality rate during 2-year period, which have been used for protective systems have been lower. The possibility to experience complications (stroke or TIA) increased 3 aortic arch type and the right common carotid artery stenosis, reduced protection systems using. Focal... [to full text]
Darbo tikslas – įvertinti miego arterijų angioplastikos ir stentavimo ankstyvuosius ir vėlyvuosius rezultatus bei poveikį darančius veiksnius. Metodai. Tyrimo metu vertintos VMAS procedūros atliktos 2006-2013 metais. Iš viso buvo atliktos 227 procedūros 211 pacientų; iš jų 156 (75,3 proc.) vyrams ir 55 (24,7 proc.) moterims. Rezultatai. Tyrimas atskleidė, kad esant 3 aortos lanko tipui VMAS procedūros trukmė buvo reikšmingai ilgesnė, o mikroembolai apsaugos sistemose buvo nustatyti dažniau. Mikroembolai apsaugos sistemose buvo nustatyti dažniau kai VMAS procedūra truko ilgiau. Apsaugos sistemos atliekant VMAS procedūrą buvo naudotos 70,9 proc. pacientų. Vyrams ir jaunesnio amžiaus pacientams VMAS procedūros metu apsauga buvo taikyta dažniau. Mikroembolai apsaugos sistemose buvo nustatyti 17,6 proc. pacientų ir dažniau buvo nustatyti naudojant FilterWire EZ ir Embo-shield-NAV apsaugos sistemas. Didesnė dešinės VMA stenozė buvo dažnesnė rūkantiems pacientams, o kairės VMA sirgusiems miokardo infarktu bei rūkantiems. Apsauga dažniau buvo taikyta pacientams kurie turėjo didelio laipsnio kairės VMA stenozę. Ankstyvuoju po procedūriniu periodu vyrų ir moterų mirštamumas atitinkamai buvo 1,2 proc. ir 1,8 proc., o 2 metų laikotarpyje buvo 18,7 proc. ir 28,6 proc. Pacientų mirštamumas 2 metų laikotarpyje, kuriems buvo naudotos apsaugos sistemos buvo mažesnis. Galimybę patirti komplikacijas (GSI ar PSIP) didino 3 aortos lanko tipas ir dešinės bendrosios miego arterijos stenozė, mažino... [toliau žr. visą tekstą]

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Bond, Richard. "Monitoring and audit of the performance of surgeons : the effect of case mix and surgical technique on the operative risk of carotid endarterectomy." Thesis, University of Oxford, 2003. http://ethos.bl.uk/OrderDetails.do?uin=uk.bl.ethos.289349.

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32

Kretz, Benjamin. "Sténoses carotidiennes athéromateuses : causes fondamentales et conséquences cliniques." Thesis, Dijon, 2014. http://www.theses.fr/2014DIJOMU04/document.

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Le traitement de référence des lésions sténosantes carotidiennes de haut grade est la chirurgie associée à un traitement médical. Nous avons mis en place depuis 2003 une base de données prospective colligeant l’ensemble des patients hospitalisés dans notre service pour prise en charge d’une lésion sténosante carotidienne d’indication chirurgicale. Depuis 2012, cette base de données cliniques s’est vue complétée par la mise en place d’une tissuthèque et d’une plasmathèque. Nous présentons ici la méthode de mise en place d’une telle base, puis les résultats de quatre études originales sur la thématique du « patient à risque » en chirurgie carotidienne, portant sur l’influence de la fonction rénale, du délai entre les symptômes et la chirurgie et du statut de l’artère carotide controlatérale sur les résultats de cette chirurgie, ainsi que la proposition d’un score pronostic d’intolérance au clampage carotidien. Nous avons montré que l’insuffisance rénale influait sur les résultats de la chirurgie carotidienne de manière différente en fonction de la méthode d’appréciation de la fonction rénale (créatinine plasmatique, clearance de la créatinine calculée selon Cockcroft-Gault ou selon la formule MDRD) ; que le statut hémodynamique de la carotide controlatérale influait sur le taux de shunt sans modifier la morbidité ; que la chirurgie précoce des sténoses carotidiennes symptomatiques n’était pas grevée d’une surmortalité ; et qu’il était possible dans une certaine mesure de prédire la nécessité de mise en place d’un shunt carotidien. Nous abordons enfin les projets à venir utilisant la collection biologique pour tenter d’identifier les plaques athéromateuses à risque
The treatment of high-grade carotid stenosis is surgery combined with best medical treatment. We established since 2003, a prospective database including all patients hospitalized in our vascular surgery department for management of carotid stenosis. Since 2012, the clinical database was completed for the establishment of a biological database. We present here the method of setting up such a database, and the results of four original studies on the theme of "high-risk patient" for carotid surgery: the influence of renal function, of the delay between symptoms and surgery and of the contralateral carotid artery on outcome and the proposal of a prognostic score of intolerance to carotid clamping. We have shown that renal failure influenced outcome of carotid surgery in different ways depending on the method of assessment of renal function (serum creatinine, creatinine clearance calculated by Cockcroft-Gault or MDRD formula) ; the hemodynamic status of the contralateral carotid affected the rate of shunt without changing morbidity; that early surgery for symptomatic carotid stenosis was not burdened with excess mortality; and that it is possible to predict the need for establishment of a carotid shunt. Finally, we discuss future projects using biological collection to try to identify atherosclerotic plaques at risk

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Ramió, Iglesias Laura. "Anestèsia regional per a endarterectomia carotídia. 6 anys d’experiència." Doctoral thesis, Universitat Autònoma de Barcelona, 2019. http://hdl.handle.net/10803/667897.

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Introducció: L’estenosi carotídia causa el 20-25% dels accidents cerebrals vasculars d’origen isquèmic. L’endarterectomia carotídia (EC) es manté com a gold standard en els pacients amb alt grau d’estenosi en l’artèria caròtida interna per a la revascularització carotídia i la prevenció de l’infart cerebral subseqüent. La qüestió de l’anestèsia ideal per la EC ha estat un debat continu des de la primera intervenció. Hi ha evidència científica que les diferents tècniques anestèsiques no són equiparables ni en seguretat ni en qualitat. Així les coses i amb la presumpció que els millor resultats es podien obtenir de l’anestèsia peridural cervical associada a l’anestèsia del plexe cervical superficial, un nou protocol multidisciplinar s’instaura al nostre centre. La nostra opció es basa en la màxima cobertura analgèsica-anestèsica de la combinació de les dues tècniques (anestèsia peridural més plexe cervical superficial), en la major estabilitat hemodinàmica i en la reducció d’estada hospitalària de l’anestèsia regional vs general. El nostre objectiu principal és descriure la qualitat analgèsica-anestèsica de la tècnica. Material i mètodes: Es tracta d’un estudi observacional, descriptiu i retrospectiu. Es van estudiar de forma retrospectiva durant 6 anys (2009-2015) tots els pacients sotmesos a endarterectomia carotídia (EC). Per comparar l’estada hospitalària es van analitzar de forma restrospectiva les dades dels pacients intervinguts entre el 2003 i el 2008, quan la EC es realitzava mitjançant una anestèsia general. Resultats: Es va incloure un total de 88 pacients realitzats sota anestèsia regional i 30 pacients realitzats sota anestèsia general. En les variables principals relacionades amb la qualitat anestèsica es va trobar que un 4,5 % de pacients va requerir complementar amb anestèsic local i 11,2% amb opioids. Cap pacient va desenvolupar un IAM als 30 dies. En un 3,4 % dels casos va ser necessària una conversió a una anestèsia general. Pel que fa a la seguretat de la tècnica anestèsica, no es va trobar cap complicació vital. Es va observar una reducció de l’estada hospitalària de 2 dies en el grup d’anestèsia regional. El cost d’aquests dos dies sumat a l’estalvi en material va representar un estalvi entre 1.688,16 i 2.978,26 euros/pacient. Conclusions: Es va trobar una bona qualitat anestèsica-analgèsica amb l’anestèsia regional, donada la baixa necessitat de infiltració per part del cirurgià, la baixa necessitat d’opioid intraoperatori, la nul·la incidència d’IAM postoperatori i la baixa conversió a una anestèsia general. Hi va haver poques complicacions derivades de la tècnica anestèsica i aquestes van ser lleus. També es va observar una reducció del cost del procediment en el grup regional derivat de la reducció en l’estada hospitalària i de la reducció del consum de material.
Introduction: Carotid stenosis is the cause of 20-25% of all vascular cerebral accidents of ischemic origin. Carotid endarterectomy (CE) is still the gold standard in patients with a high degree stenosis of the internal carotid artery for carotid revascularization and subsequent cerebral stroke prevention. Looking for the ideal anaesthetic technique for CE procedures has been a continuous debate since the first intervention. Scientific evidences show that different anaesthetic techniques are not comparable neither in safety nor in quality . Thus, and with the presumption that the best results could be obtained from one cervical epidural anaesthesia combined with anaesthesia of the superficial cervical plexus, a new multidisciplinary protocol was implemented in our setting. Our choice was based on the maximum anaesthetic-analgesic coverage of the combination of the two techniques (peridural anesthesia plus superficial cervical plexus), on a greater hemodynamic stability and on the reduction of hospital stay of the regional vs. general anaesthesia. Our main objective is to describe the analgesic-anesthetic quality of the tecnical. Material and methods: It is an observational, descriptive and retrospective study. We retrospectively analysed during a period of 6 years (2009-2015) all patients undergoing carotid endarterectomy (CE). In order to compare hospital stay, data from patients who underwent the same procedure under general anaesthesia between 2003 and 2008 were analysed retrospectively. Results: A total of 88 patients in the regional anaesthesia group and 30 patients in the general anaesthesia group were included. In terms of anaesthetic quality variables, we observed that 4.5% of patients required complementary local anaesthetic dosage and 11.2% complementary opioids. No patient developed MI at 30 days. In 3.4% of cases, one conversion to general anaesthesia was required. Regarding to anaesthetic technique safety, no vital complications were observed. There was a reduction of hospital length of stay of 2 days in the regional anaesthesia group. The cost of these two days plus material savings represented a saving between 1688.16 and 2978.26 euros per patient. Conclusions: A good anaesthetic-analgesic quality of the regional anesthesia technique was observed due to the following findings: less intraoperative infiltration requirements by the surgeon, less use of intraoperative opioids, no incidence of postoperative MI and less conversion into general anaesthesia. There were only a few complications related to the regional anaesthetic technique without severity. We observed savings in procedure costs due to a shorter hospital stay and to reduced material use in the regional group.

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Aleksandra, Lučić Prokin. "Procena cerebralne autoregulacije primenom apnea testa kod simptomatske karotidne stenoze pre i posle karotidne endarterektomije." Phd thesis, Univerzitet u Novom Sadu, Medicinski fakultet u Novom Sadu, 2015. http://www.cris.uns.ac.rs/record.jsf?recordId=94905&source=NDLTD&language=en.

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TCD apnea test kao neinvazivna i bezbedna neuroultrasonografska metoda pruža korisne informacije o vazomotornoj reaktivnosti (VMR) u procesu indirektnog sagledavanja funkcionisanja moždane autoregulacije. Vazomotorna reaktivnosti podrazumeva sposobnost dilatacije ili konstrikcije moždanih arteriola nastale kao odgovor na određeni vazoaktivni stimulus, najčešće ugljen dioksid. Cilj ove doktorske disertacije bio je ispitivanje i analiziranje promene karotidne hemodinamike kod bolesnika sa ishemijskim moždanim udarom (IMU) ili tranzitornim ishemijskim atakom (TIA) i simptomatskom karotidnom stenozom u preoperativnom i tromesečnom postoperativnom periodu, kao i procena revaskularizacionog efekta karotidne endarterektomije (KEA).U istraživanje je uključeno 60 hospitalizovanih bolesnika koji su doživeli prvi IMU i TIA u zoni vaskularizacije arterije cerebri anterior (ACA) i arterije cerebri medije (ACM), svi sa karotidnom stenozom, ACI ≥70%. Bolesnici su bili hospitalizovani na Klinici za neurologiju, Kliničkog Centra Vojvodine, Klinici za kardiovaskularnu hirurgiju, Instituta za kardiovaskularne bolesti Vojvodine i Klinici za vaskularnu hirurgiju, u Novom Sadu. U odnosu na kliničke manifestacije bolesni i su podeljeni u tri grupe: bolesnici sa TIA i amaurosis fugax, sa parcijalnim infarktom u zoni ACA ili ACM i sa lakunarnim infarktom. Istraživanje je analiziralo uticaj promenljivih i nepromenljivih vaskularnih faktora rizika na pojavu IMU i TIA, ali i na VMR, procenjivanu kroz indeks zadržavanja daha (Breath Holding Index, BHI) ipsilateralno i kontralateralno u odnosu na karotidnu stenozu. Analizirana je povezanost stepena karotidne stenoze sa vrednostima BHI preoperativno, povezanost BHI sa težinom kliničke slike, uticaj kolateralnog krvotoka na VMR, distribucija BHI u pojedinim tipovima IMU i TIA kao i komparacija BHI u pre i u postoperativnom periodu od 30 i 90 dana. Na osnovu sprovedenog istraživanja, došlo se do zaključaka da je redukovana VMR preoperativna karakteristika karotidne stenoze ipsilateralno kao i karakteristika različitih tipova IMU i TIA ipsilateralno; postoji negativna korela ija izmeĐu stepena karotidne stenoze i BHI vrednosti. Nije potvrđena hipoteza da veći roj razvijenih kolateralnih puteva uslovljava očuvanu VMR; utvrđena je pozitivna korelacija između BHI vrednosti u preoperativnom i postoperativnom periodu; redukovana VMR ima negativan uticaj na težinu kliničke slike. Prepoznavanje vrednosti TCD apnea testa, koji se može koristiti kao komplementarna metoda drugim vazoaktivnim testovima u praćenju karotidne hemodinamike, od posebne je važnosti neurologu i vaskularnom hirurgu. Time bi se doprinelo daljoj evaluaciji mehanizma nastanka IMU, planiranju terapijskog pristupa i determinisanju prognoze operisanih bolesnika. Činjenica da većina neuroloških odeljenja poseduje TCD aparat, apnea test postaje dostupan svakom neurologu u kliničkom radu, posebno u našim uslovima, kada se do drugih drugih, skupljih metoda, teško stiže ili nam ostaju nedostižne.
TCD apnea test, as a noninvasive and safe neuroultrasonographic method, provides useful information about vasomotor reactivity (VMR) in the indirect evaluation of cerebral autoregulation. Vasomotor reactivity is the ability of cerebral arterioles to constrict or to dilate in response to a vasoactive stimulus, mainly carbon dioxide. The aim of this doctoral thesis was to investigate and analyze changes in carotid hemodynamics in patients with ischemic stroke (IS) or transient ischemic attack (TIA) and symptomatic carotid stenosis in the preoperative and three-month postoperative period as well as the assessment of revascularisation effect of carotid endarterectomy (CEA). The study included 60 hospitalized patients who experienced a first ischemic stroke or TIA in the vasularisation area of anterior cerebral artery (ACA) and middle cerebral artery (MCA), all with carotid stenosis ≥70% ACI. Patients were hospitalized at the Clinic of Neurology, Clinical Center of Vojvodina, Department of Cardiovascular Surgery, Institute of Cardiovascular Diseases and the Department of Vascular Surgery in Novi Sad. Considering clinical manifestations of stroke, the patients were divided into three groups: patients with TIA and amaurosis fugax, with partial infarction in area ACA or ACM and with lacunar infarct. The study analyzed the impact of variabile and unvariable vascular risk factors on the incidence of ischemic stroke and TIA, but also on VMR, evaluated through Breath Holding Index (Breath Holding Index, BHI) on the ipsilateral and contralateral side from carotid stenosis. We analysed the correlation between the degree of carotid stenosis with preoperative values of BHI, BHI correlation to the severity of clinical findings, the impact of collateral circulation to the VMR, distribution of BHI in certain types of ischemic stroke and TIA as well as comparison of BHI in the pre and postoperative period of 30 and 90 days. On the basis of this research came the conclusion that reduced VMR is characteristic of ipsilateral carotid stenosis in preoperative period as well as number of developed collateral characteristics of different types of ipsilateral ischemic stroke and TIA; there is a negative correlation between the degree of carotid stenosis and BHI values. The hypothesis that the greater pathways causes preservation of VMR was not confirmed, while the positive correlation between BHI values in the preoperative and postoperative period was established. Reduced VMR has a negative impact on the degree of clinical picture severity. Recognizing the importance of TCD apnea test method, that can be used as a complementary method to other vasoactive tests in monitoring of carotid hemodynamics, is of special importance to the neurologists and vascular surgeons. This would contribute to the further evaluation of mechanism of ischemic stroke, planning of therapeutic approach and determining the prognosis of treated patients. The fact that most of neurological department has TCD device, apnea test becomes available to every neurologist in clinical work, specially in our conditions, when other methods remain unattainable.

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Ehrensperger, Eric 1966. "Predictors of cerebral ischemic events in patients with asymptomatic carotid artery stenosis : systematic review." Thesis, McGill University, 2008. http://digitool.Library.McGill.CA:80/R/?func=dbin-jump-full&object_id=111568.

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Background. Carotid stenosis is an important cause of stroke. Carotid endarterectomy is a means of reducing the burden of stroke but is of marginal benefit in individuals with asymptomatic carotid stenosis. The identification of factors associated with increased risk of cerebral ischemic events would help select individuals who may obtain a greater benefit.
Methods. A comprehensive search was performed to identify studies examining risk factors for cerebral ischemic events in patients with asymptomatic carotid stenosis. Inclusion criteria were defined a priori. Relevant studies were reviewed, assessed for quality, and data were extracted.
Results. Thirty-four studies met the inclusion criteria. There was a suggestion of increasing neurological events with increasing severity and progression of carotid stenosis. There was some evidence for an association with carotid plaque morphology. No consistent association was found with clinical factors, impaired cerebral vasoreactivity, or cerebral embolic signals.
Conclusions. The evidence is insufficient to reliably identify individuals with asymptomatic carotid stenosis who are at a higher risk of cerebral ischemic events.

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Vladimir, Manojlović. "Značaj karotidne endarterektomije kod asimptomatskih pacijenata sa nekompletnom kolateralizacijom unutar Vilisovog poligona." Phd thesis, Univerzitet u Novom Sadu, Medicinski fakultet u Novom Sadu, 2015. http://www.cris.uns.ac.rs/record.jsf?recordId=95440&source=NDLTD&language=en.

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UVOD: Vilisov poligon predstavlja najznačajniju rezervu kolateralnog protoka između ekstrakranijalnih arterija koje vaskularizuju mozak i ima sposobnost razvoja kolateranih puteva kod ekstrakranijalne karotidne bolesti. Ova anatomska struktura podložna je varijacijama koje uključuju i prekid kontinuiteta i nekompletnost kolateralizacije. CILJEVI: Cilj je bio da se utvrdi da li nekompletnost Vilisovog poligona utiče na češće pojavljivanje neurološke simptomatologije i ishemijske moždane lezije kod pacijenata sa ekstrakranijalnom karotidnom bolesti. Takođe cilj je bio i da se utvrdi da li cerebrovaskularna reaktivnost kod pacijenata sa asimptomatskom ekstrakranijalnom karotidnom bolesti zavisi od kompletosti Vilisovog poligona i na koji način hirurški tretman utiče na parametre cerebrovaskularne rezerve kod pacijenata sa kompletnim i nekompletnim Vilisovim poligonom. METOD: U retrospektivnoj studiji analiziran je nalaz MRA kod 211 pacijenata sa ekstrakranijalnom karotidnom bolesti i 102 pacijenta iz kontrolne grupe. U prospektivnoj studiji je kod 98 pacijenata sa asimptomatskom karotidnom bolesti pored MRA nalaza određivana cerebrovaskularna reaktivnost putem određivanja „breath hold index“-a (BHI) pre i nakon operativnog tretmana. REZULTATI: Nekompletan Vilisov poligon nađen je kod 25% asimptomatskih, 47,5% simptomatskih pacijenata sa karotidnom bolesti i kod 59% kontrolne grupe pacijenata, pri čemu su se razlike pokazale kao statistički značajne. Kod asimptomatskih pacijenata sa nekompletnim Vilisovim poligonom BHI preoperativno iznostio je 0,62 a postoperativno 1,01 na strani lezije. U slučaju nekompletnog Vilisovog poligona preoperativna vrednost BHI iznostila je 0,88 a postoperativna 1,09 na strani lezije. Razlike su se pokazale kao statistički značajne između grupa i pre i posle operativnog tretmana. Porast je bio statistički značajno izraženiji u grupi asimptomatskih pacijenata sa nekompletnim Vilisovim poligonom. Nisu zabeležene major operativne komplikacije (perioeprativni moždani udar,smrtni ishod) a na pojavu hiperperfuzionog sindroma najviše su uticali kompletnost Vilisovog poligona, vrednost BHI i preoperativni tretman hipertenzije. ZAKLJUČCI: Nekompletan Vilisov poligon predstavlja faktor rizika za pojavu neurološke simptomatologije ili ishemijske moždane lezije kod pacijenata sa ekstrakranijalnom karotidnom bolesti. Kod asimptomatskih pacijenata nekompletan Vilisov pologon utiče na smanjenu cerebrovaskularnu reaktivnost i veći rizik od moždanog udara. Parametri cerebrovaskularne reaktivnosti signifikantno se poboljšavaju nakon operativnog tretmana.
INTRODUCTION: Circle of Willis is the most important reserve of collateral flow between the extracranial arteries that supply the brain and has the ability to develop collateral pathways in extracranial carotid disease. This anatomical structure is subject to variations which include a disruption in the continuity and incompleteness of collateralisation. OBJECTIVES: was to determine whether the incompleteness of the Circle of Willis is more often associated with neurological symptoms and ishemic cerebral lesions in patients with extracranial carotid artery disease. Also, the objective was to determine whether cerebrovascular reactivity in patients with asymptomatic extracranial carotid artery disease depends on the completeness Circle of Willis and how surgical treatment affects the parameters of cerebrovascular reserve in patients with complete and incomplete Circle of Willis. METHODS: This study analyzed the findings of MRA in 211 patients with extracranial carotid artery disease and 102 patients in the control group. In prospective study in 98 patients with asymptomatic carotid artery disease in addition to the MRA findings cerebrovascular reactivity was determined by determining the "breath hold index" -a (BHI) before and after surgical treatment. RESULTS: Incomplete Circle of Willis was found in 25% of asymptomatic, 47.5% of symptomatic patients with carotid artery disease, and 59% of the control group patients, where the difference proved to be statistically significant. In asymptomatic patients with incomplete Circle of Willis BHI values were 0.62 preoperatively and 1.01 postoperatively on the side of the lesion. In the case of incomplete Circle of Willis preoperative BHI values were 0.88 preopertively and 1.09 postoperatively in asymptomatic patients. The differences are shown to be statistically significant between the groups before and after surgical treatment. The increase was significantly more pronounced in the group of asymptomatic patients with incomplete Circle of Willis. There were not recorded major operative complications (perioeprativni stroke, mortality) and the occurrence hyperperfusion syndrome was most affected by completeness of the Circle of Willis, a value BHI and preoperative treatment of hypertension. CONCLUSIONS: Incomplete Circle of Willis is a risk factor for the occurrence of neurological symptoms or ischemic brain lesions in patients with extracranial carotid artery disease. In asymptomatic patients incomplete Circle of Willis affects the reduced cerebrovascular reactivity and a higher risk of stroke. The parameters of cerebrovascular reactivity significantly improved after surgical treatment.

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Kuster, Gustavo Wruck. "Tomografia computadorizada de placa carotídea: uma comparação com a histologia." Universidade de São Paulo, 2015. http://www.teses.usp.br/teses/disponiveis/5/5138/tde-12012016-084705/.

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As características morfológicas da placa aterosclerótica têm sido sugeridas como componentes auxiliares à estenose, na avaliação de risco de acidente vascular cerebral (AVC), em pacientes com doença aterosclerótica carotídea sintomática. O objetivo desse estudo foi comparar as características da placa aterosclerótica de carótida pelo método de tomografia computadorizada com a análise histológica. Foram incluídos 19 pacientes com doença carotídea sintomática submetidos à TC de placa carotídea antes da realização de endarterectomia carotídea. Uma comparação sistemática entre a TC e a histologia foi realizada para determinar a correspondência entre os componentes da placa seguindo a classificação da \"American Heart Association\". Foi considerada placa vulnerável o tipo VI. A histologia foi realizada 5 (±2) dias após a TC. Os laudos (radiologia e patologia) foram comparados pelo investigador principal. Foi dosada a proteína C-Reativa (PCR) sérica e realizada avaliação do desempenho do PCR para detectar placa vulnerável, considerando como padrão-ouro o resultado da avaliação histológica. Foi avaliada a relação entre PCR e o tempo entre o evento e a cirurgia. Para tipo de placa aterosclerótica, foi encontrada uma acurácia de 84,2% (IC 95%: 82,8% a 85,6%), da tomografia em relação à histologia. A concordância para identificar ruptura de capa fibrosa com acurácia 94,7% (IC 95%: 94,2% a 95,3%), e, para calcificação, com acurácia 89.5% (IC 95%: 88,5% a 90,5%), foi considerada alta, e moderada para identificar hemorragia (68% acurácia). A concordância é moderada entre PCR de alto risco e placa vulnerável, e não há relação entre PCR, placa vulnerável e tempo de cirurgia. A tomografia de placa carotídea é um bom método não invasivo para detecção de vulnerabilidade da placa, identificação de ruptura de capa fibrosa e calcificação. Na nossa amostra, a concordância entre PCR alto risco e vulnerabilidade foi moderada, e não observamos relação entre vulnerabilidade, PCR e tempo entre o evento e a endarterectomia
Plaque morphologic characteristics have been suggested as an auxiliary component to luminal narrowing for assessing the risk of stroke associated with carotid atherosclerotic disease (CAD). The purpose of this study was to evaluate the ability of CT angiography (CTA) to categorize carotid artery atherosclerotic plaques (CAP) features in symptomatic patients submitted to endarterectomy according to the AHA histological classification. Nineteen patients with symptomatic CAD who underwent carotid CTA before endarterectomy were enrolled in a prospective study. A systematic comparison of CTA images with histological sections was performed to determine the CT attenuation associated with each component of the CAP. Histologic examination was performed 5 ± 2 days after the CTA. The neuroradiologist\'s reading of these analyses was compared with the histological slides interpretation performed by the same pathologist according to the CAP features following the AHA classification. The type VI plaque was considered as complicated. The two experts were blinded to each other\"s assessments. We performed C reactive Protein (CRP) and the CRP capacity to detect plaque vulnerability, considering histologic features as gold standard and the relation between CRP and time (event-surgery). There was an overall 84.2% (CI 95%: 82.8% a 85.6%), accuracy agreement in CAP classification between CTA and histological analysis. (Tab.1) The agreement between these two methods for the presence of calcification (Tab.2) in the CAP (accuracy 89.5%), and for categorizing the rupture of fibrous cap (accuracy 94,7), was excellent. (Tab. 3). CTA is not a good method to detect hemorrhage (Tab.4). High-risk CRP had moderate power to predict \"complicated plaque\" (Tab. 4) even as high risk CRP + CTA (Tab.5), There are No relation between CRP, complicated plaque and event to surgery delay. (Tab.6) CTA is a non-invasive tool that may help neurologists to categorize CAP features and potentially predict the risk of ischemic stroke in symptomatic CAD patients, and CRP could not be a good marker to complicated carotid plaque

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Aleksandar, Milosavljević. "Prediktori ishoda operativnog lečenja pacijenata sa koronarnom i karotidnom arteriosklerozom." Phd thesis, Univerzitet u Novom Sadu, Medicinski fakultet u Novom Sadu, 2016. http://www.cris.uns.ac.rs/record.jsf?recordId=101257&source=NDLTD&language=en.

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Boljom prevencijom aterosklerotskih bolesti i uvođenjem invazivnih procedura endoluminalnim pristupom u lečenju koronarne bolesti i karotidne bolesti, hirurške procedure u poslednje dve decenije postaju sve kompleksnije i teže. Profil pacijenata podvrgnutih revaskularizaciji miokarda postaje sve rizičniji i procentualno se povećava broj polivaskularnih pacijenata za koje je neophodno uraditi dodatne procedure na karotidnim arterijama, bilo da su one urađene simultano, u dva ili tri akta. To su pacijenati koji imaju značajne aterosklerotske lezije na jednoj ili obe karotidne arterije zajedno sa značajnim suženjima koronarnih arterija. Algoritmi koji se nude u projektovanju operativne taktike ni danas nisu strogo definisani i vrlo često zavise od individualne procene i stava hirurga koji izvode ove procedure. Ishod operativnog lečenja ovih pacijenata često zavisi od hirurške taktike i ustanove u kojoj se oni operativno leče. Prediktori ishoda operativnog lečenja bi mogli biti važan faktor u selekcioniranju pacijenata u preporuci taktike operativnog lečenja. U tezi su analizirani klinički aspekti preoperativno i postoperativno, postoperativni mortalitet - 30 dana posle operacije i jednu godinu posle operacije. Analiziran je uticaj faktora: starost, pol, neurološka disfunkcija, infarkt miokarda do 90 dana pre operacije, nestabilna angina, diabetes mellitus, bilateralna stenoza karotidnih arterija kod 94 pacijenta koji su operisani u Klinici za kardiohirurgiju Instituta za kardiovaskularne bolesti Vojvodine u Sremskoj Kamenici u periodu 2007-2012g. Kod svih je, preoperativno, nađeno da imaju značajne promene na koronarnim i karotidnim arterijama. Pacijenti su podeljeni u dve grupe po tipu izvršene operacije. Prvu grupu su sačinjavali pacijenti koji su operisani u odvojenim operacijama karotidnih arterija i revakularizacije miokarda, a drugi su operisani simultano operacijom karotidnih arterija i revaskularizacijom miokarda. U metodologiji su korišćene metode retrospektivnog i prospektivnog istraživanja. Korišćena je elektronska baza podataka Instituta za kardiovaskularne bolesti Vojvodine, vođen je intervju sa pacijentima. Korišćeni su i pregledi doppler sonografije karotidnih arterija koji su rađeni u drugim ustanovama. Mortalitet-30 dana i jednu godinu posle operacije je bio prihvatljivo nizak, pacijenti su poboljšani u posmatranim parametrima. Neurološki morbiditet na 30 dana i jednu godinu posle je bio prihvatljivo nizak. Prediktori mortaliteta su bili pušenje 30 dana i godinu dana posle operacije u obe grupe. Prediktor morbiditeta 30 dana i jednu godinu nakon operacije bila je hiperlipoproteinemija. Ženski pol je bio nezavisni prediktor mortaliteta u grupi pacijenata operisanih u više aktova. Pacijenti operisini simultano su bili teži po simptomima ( NYHAklasi) i u većem riziku (EU2 score), ali nisu imali statistički značajno veću smrtnost u odnosu na grupu operisanu u više aktova.
Surgical procedures have become more complex and difficult in the past two decades due to the better prevention of atherosclerotic diseases and the introduction of invasive procedures with endoluminal approach to treating coronary and carotid artery diseases. The profile of patients undergoing myocardial revascularization is becoming riskier. There is also increase in the percentage of patients with polyvascular disease who need additional procedures on the carotid arteries, whether they are done simultaneously or in two or three acts. These are the patients who have significant atherosclerotic lesions in one or both of the carotid arteries along with the significant narrowing of the coronary arteries. Algorithms that are offered to plan operative tactics are still not strictly defined and often depend on the individual assessment of surgeons and the attitude of certain institutions that perform the procedure. The outcome of surgical treatment of these patients often depends on surgical tactics and the institution in which they are treated. Predictors of surgical treatment outcome could be an important factor for the selection of patients and the recommendation of operative treatment tactics. The thesis analyzed pre- and postoperative clinical aspect as well as 30-day and one-year postoperative mortality. The influence of the following factors was analyzed: age, sex, neurologic dysfunction, myocardial infarction occurring 90 days after surgery, unstable angina, diabetes mellitus, and bilateral carotid artery stenosis in 94 patients that underwent cardiac surgery at the Clinic of Cardiovascular Surgery of the Institute of Cardiovascular Diseases of Vojvodina in Sremska Kamenica in the period from 2007 to 2012. All patients had significant changes on the coronary and carotid arteries. The patients were divided into two groups according to the type of surgery. The first group consisted of the patients who underwent carotid artery surgery and myocardial revascularization separately. The second group of patients underwent carotid artery surgery and myocardial revascularization at the same time. Methods of retrospective and prospective research were used in the methodology. Electronic data base of the Institute of Cardiovascular Diseases of Vojvodina was also used and the patients were interviewed. Doppler of carotid arteries performed both in our institution and in other institutions was used. Mortality, 30-day and one-year post surgery, was acceptably low. The patients were improved in the observed parameters. Neurologic morbidity 30 days and one year after surgery was acceptably low. Smoking 30 days and one year after surgery was predictor of mortality in both groups. Hyperlipoproteinemia 30 days and one year after surgery was predictor of morbidity. Female sex was independent predictor of mortality for the first group of patients. The second group of patients were more complex according to the symptoms (NYHA class) and with greater risk (EU2 score), but their mortality rate was not statistically significant in relation to the first group of patients.

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Mourad, Jamil Jorge Abou. "Uso do remendo em cirurgia de carotida." [s.n.], 1996. http://repositorio.unicamp.br/jspui/handle/REPOSIP/308476.

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Orientadores: Bonno Van Bellen, John Cook Lane
Dissertação (mestrado) - Universidade Estadual de Campinas, Faculdade de Ciencias Medicas
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Resumo: A reestenose, que ocorre após a endarterectomia de carótida, não está bem defmida em todos os seus aspectos. O uso do remendo, para prevenção desta reestenose, é controvertido. A revisão da literatura, realizada neste trabalho, mostra que o remendo deve ser indicado quando a artéria carótida interna possuir um diâmetro menor que 3,5 mm. Acima deste índice, não há vantagem do remendo sobre a sutura primária, visando a prevenção da reestenose no fechamento da arteriotomia. Observa-se que a taxa de reestenose é maior quando se utiliza a sutura primária, porém, o emprego do remendo leva à complicação, embora de incidência extremamente baixa, tais como hemorragia, infecção, dilatação e rotura
Abstract: The incidence of reestenoses after carotid endarectomy is not well definido The use of a carotid patch during endarectomy of the carotid artery remains controversial. The review of the literature, demonstrate that a carotid patch is indicated when the diameter of internal carotid is less than 3.5 mm. Where the diameter of the carotid is larger than this, the patch is not necessary. Despiste the fact that the incidence of reestenosis of the carotid artery after endarectomy is larger when primary suture of the vessel is done, the use of a patch does have a small but higher incidence of complications such as hemorrage, infection, dilatation and rupture
Mestrado
Mestre em Cirurgia

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Black, Stephen Alan. "Simulated carotoid endarterectomy is a valid means of training and assessment in vascular surgery." Thesis, Imperial College London, 2009. http://ethos.bl.uk/OrderDetails.do?uin=uk.bl.ethos.501458.

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Radenko, Koprivica. "Rana karotidna endarterektomija nakon akutnog neurološkog deficita." Phd thesis, Univerzitet u Novom Sadu, Medicinski fakultet u Novom Sadu, 2016. http://www.cris.uns.ac.rs/record.jsf?recordId=100762&source=NDLTD&language=en.

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Ciljevi: Cilj ove studije je da ispita bezbednost rane karotidne endarterektomije (CEA) u odnosu na odložene CEA nakon akutnog ishemijskog neurološkog deficita (TIA/CVI). Drugi cilj je da istražimo da li postoji razlika u brzini neurološkog oporavka između navedenih grupa. Metode: Ukupno 157 ispitanika u prospektivnoj studiji je praćeno 30 dana postoperativno. Grupa I ili rana CEA, je imala 50 ispitanika operisanih od 3. do 14. dana po TIA/CVI događaju. Grupa II ili odložena CEA, je imala 107 ispitanika operisanih od 15. do 180. dana nakon TIA/CVI. Praćen je proceduralni opšti i specifični morbiditet i mortalitet u 30-dnevnom postoperativnom periodu. Rankin skor (mRS) smo koristili za procenu neurološkog invaliditeta. U odnosu na vrednost mRS skora smo formirali dve podgrupe mRS<3 i mRS3. U statističkoj analizi koristili smo Pirsonov hi test, Studentov test, ANOVU analizu varijanse, Boniferonijev test i multiplu analizu varijanse za ponovljena merenja (GLM- general line model), kao i parametarsku i neparametarsku korelaciju i regresiju. Nivo značajnosti je bio 0,05. Rezultati: Prosečna starost ispitanika je bila 66,72 godine uz 66,2% osoba muškog pola. U grupi I je prosečno vreme do intervencije bilo 9,5 dana, a u grupi II 72,22 dana. Grupe su homogene u odnosu na faktore rizika i komorbiditet. Grupa I je imala 54% nestabilnih aterosklerotskih plakova u poređenju sa grupom II gde ih je bilo 31,8% (χ2 = 7.084; p < 0.01). U grupi I TIA je imalo 50% ispitanika, a u grupi II CVI nalaza je bilo 68,2% (χ2 =4.825; p <0.05). CVI do 1 cm veličine je statistički značajno više zastupljen u grupi I , a CVI do 2 cm u grupi II (χ2 = 6.913; p <0.05). Stopa CVI je u grupi I bila 2.0% a u grupi II je 2.8% (F = 0.083; p > 0.05). Stopa postoperativnog infarkta miokarda (IM) je u grupi I je 2.0% a u grupi II je 1.9%. Stopa specifičnog hirurškog morbiditeta je u grupi I 4.0% a u grupi II 3.7%. U grupi I ukupni morbiditet bio 6.0% a u grupi II 7.5%, razlika nije bila statistički značajna (F =0.921; p > 0.05). Mortaliteta u obe grupe nije bilo. CVI/IM/smrt stopa je u grupi I bio 4.0% a u grupi II je bio 4.7% (F = 0.122; p >0.05). Hiperlipidemija je signifikantan faktor rizika za CVI/IM/smrt (χ2 = 4.083; p < 0.05). Poboljšanje mRS je u grupi I imalo 52%, a u grupi II 31,8% pacijenata (χ2 = 5.903; p <0.01). Relativni rizik je 2,4 odnosno toliko puta je veća šansa da kod bolesnika dođe do promene mRS ako je bolesnik u grupi I. Pad mRS koji nastupa između trećeg i desetog dana nakon CEA je statistički visoko značajno izraženiji u grupi ranih CEA ( F 3,701 df 1 p=0,029). Kod bolesnika sa TIA u preko 60% slučajeva došlo je do pada mRS, a kod onih koji su imali CVI u oko 25.5% (χ2 = 18.050; p < 0.01). Kod Rankin skora podgrupe mRS<3 i mRS3 je pad bio značajan i po vremenu (F 18,774; df 6; p=0,000) i po podgrupi ali je daleko brži pad zapažen u podgrupi mRS<3(F 6,010; df 1; p=0,003). Zaključak: Rana CEA je jednako bezbedna kao i odložena CEA u pogledu incidence perioperativnog morbiditeta i mortaliteta. Ranom CEA se postiže znatno brži neurološki oporavak pacijenata, naročito onih sa TIA i mRS<3 skorom.
Objectives: The aim of this study was to investigate the safety of early carotid endarterectomy (CEA) in relation to the delayed CEA after acute ischemic neurological events (TIA / CVI). The second objective was to investigate whether there is a difference in speed of neurological recovery between these groups. Methods: A total of 157 patients in the prospective study followed 30 days postoperatively. Group I or early CEA, had 50 patients operated from 3 to 14 days after TIA / CVI event. Group II or delayed CEA, had 107 patients operated from 15 to 180 days after the TIA / CVI. Accompanied by the general and specific procedural morbidity and mortality in 30-day postoperative folow up. Rankin score (mRS) were used for evaluation of neurologic disability. In relation to the value of mRS score we formed two subgroups mRS <3 i mRS3. In the statistical analysis we used the Pearson chi test, Student's test, ANOVA analysis of variance, Boniferony test and multiple analysis of variance for repeated measures (GLM- general line model), as well parametric and nonparametric correlation and regression. The significance level was 0.05. Results: The mean age was 66.72 years with 66.2% of males. In Group I is the average time to intervention was 9.5 days, and in group II 72.22 days. The groups were homogeneous in relation to risk factors and comorbidities. Group I had 54% of unstable atherosclerotic plaques compared with group II, where it was 31.8% (χ2 = 7.084; p <0.01). In the group I TIA had 50% of respondents, while in group II CVI was 68.2% (χ2 = 4.825; p <0.05). CVI to 1 cm in size were significantly more frequent in the group I, a CVI to 2 cm in group II (χ2 = 6.913; p <0.05). CVI rate in the group I was 2.0%, and in group II was 2.8% (F = 0.083, p> 0.05). Postoperative myocardial infarction (MI) in the group I is 2.0%, and in group II was 1.9%. Specific surgical morbidity rate in the group I and 4.0% in the group II 3.7%. In group I total morbidity was 6.0% in group II 7.5%, the difference was not statistically significant (F = 0.921; p> 0.05). Mortality in both groups was not. CVI/IM/death rate in group I was 4.0% in group II was 4.7% (F = 0.122; p> 0.05). Hyperlipidemia is a significant risk factor for CVI/IM/death (χ2 = 4.083; p<0.05). Improving mRS in the group I had 52% and in group II 31.8% of patients (χ2 = 5.903; p <0.01). The relative risk was 2.4 times as much and is more likely to occur in patients mRS changes if the patient in group I. Improving mRS that occurs between the third and tenth days after CEA was highly statistically significantly greater in the group of early CEA (F 3,701 df 1 p = 0.029). In patients with TIA in 60% of cases there was a decline mRS, and those had CVI in about 25.5% (χ2 = 18.050; p <0.01). In Rankin score subgroups mRS <3 i mRS 3 the decline was significant and time (F 18,774; df 6; p =0.000) and in the subgroup but it is far more rapid decline observed in the subgroup mRS <3 (F 6.010; df 1; p = 0.003). Conclusions: Early CEA is as safe as the delayed CEA in respect incidence of perioperative morbidity and mortality. Early CEA is achieved significantly faster recovery of neurological patients, especially those with TIA and mRS <3 compared with delayed CEA.

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Crusius, Marcelo Ughini. "Endarterectomia versus angioplastia carot?dea com stent : an?lise neurofuncional e neuropsicol?gica." Pontif?cia Universidade Cat?lica do Rio Grande do Sul, 2016. http://tede2.pucrs.br/tede2/handle/tede/7147.

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Background: Carotid disease has a high prevalence as a cause of ischemic stroke. The decision between the types of treatment for carotid stenosis has been the subject of discussion on what is most benefit for patients. The procedures performed to treat this disease are Carotid Endarterectomy (CEA) and Carotid Artery Stenting (CAS). Basically, in the literature, these two methods are almost equivalent procedures on the benefit caused for the patients analyzed in many ways, including the efficacy of revascularization, the complications of the procedures and the prevention of stroke. However, up to date, no research presented the analysis of functional brain connectivity networks with functional resting state MRI (rs-MRI) in patients that performed a CEA or CAS. We conducted neuropsychological tests to relate them with data from neuroimaging. This research aims to contribute in a pioneering way for knowledge in this field. Aims: Evaluate which type of procedure can bring more benefit to the patients with carotid artery disease in neuropsychological and functional brain connectivity. Method: Open randomized clinical trial with partial blinding; involving 33 subjects with cervical carotid artery stenosis with treatment indication and acceptable to both methods (CEA or CAS). At this time, the randomization was employed to patients who were dichotomized with the application of neuropsychological tests and clinical neurological examination. Group 1 represented the patients who underwent CEA with regional anesthesia loco (n = 18) and Group 2 patients underwent CAS (n = 15). Before the procedure all patients underwent rs-MRI and 4 to 8 weeks after the procedure, and were submitted again to an rs-MRI and also to a carotid ECO Doppler. The new assessment with neuropsychological tests and neurological clinical examination was performed three months after the procedure. Statistical analysis was performed using Student's t-test and analysis of variance (ANOVA). The results were considered significant when p ? 0.05. Results: Among the neuropsychological results, the CEA group in Boston naming test scores obtained 12.13 / 15 (?3.09) before procedure versus 13.44 / 15 (?1.63) in the post op, with p = 0.03. Visual memories (mv) tests 1 and 2 after the procedure, compared between groups showed higher values for the angioplasty group, with values of p = 0.02 for mv 1 and p = 0.007 for mv 2. Neuroimaging results showed, when the rs-RMI was analyzed with Regional Homogeneity (ReHo), three clusters in the Default Mode Network (DMN) in the CAS group; demonstrating an increase in functional connectivity post procedure. With the implementation of Independent Component Analysis (ICA) at rs-MRI, found in right frontal parietal (RFP) network 4 clusters an increased in connectivity in the post procedure for Group 2. Conclusion: There was improvement with statistical difference in two networks after angioplasty and worsening functional connectivity in these same networks with no statistical difference in the endarterectomy group postoperatively. Within the endarterectomy group had improved after the procedure in the Boston Naming Test.
Introdu??o: A doen?a carot?dea possui alta preval?ncia como causa de acidente vascular isqu?mico (AVCi). A decis?o entre os tipos de tratamento para a estenose carot?dea tem sido alvo de discuss?o, visando aos benef?cios trazidos aos pacientes. Os procedimentos realizados para tratar essa doen?a s?o a endarterectomia (CEA, do ingl?s carotid endarterectomy) e a angioplastia com implante de stent (CAS, do ingl?s carotid artery stenting). Na literatura, esses dois procedimentos praticamente equivalem-se quanto ao benef?cio aos pacientes sob v?rios aspectos, incluindo a efic?cia da revasculariza??o, as complica??es dos procedimentos e a preven??o do AVCi. O presente estudo original mostra uma an?lise da conectividade funcional cerebral com resson?ncia funcional em estado de repouso (rs-MRI, do ingl?s resting state MRI) em pacientes que realizaram a CEA e a CAS. Foram realizados, ainda, testes neuropsicol?gicos para compreens?o e rela??o com os dados da neuroimagem. Este estudo visa contribuir de forma pioneira para a busca de conhecimentos nesse aspecto. Objetivo: Avaliar qual tipo de procedimento (CEA ou CAS) pode trazer mais benef?cio ao paciente com doen?a carot?dea sob os pontos de vista neuropsicol?gico e da conectividade funcional cerebral. M?todo: Ensaio cl?nico aberto randomizado com cegamento parcial, envolvendo 33 pacientes possuidores de estenose de art?ria car?tida cervical com indica??o de tratamento admiss?vel aos dois m?todos (CEA ou CAS). Antes da realiza??o dos exames, a randomiza??o foi empregada aos pacientes, que foram dicotomizados com a aplica??o de testes neuropsicol?gicos e exame cl?nico neurol?gico. O Grupo 1 representou os pacientes que foram submetidos ? CEA com anestesia locorregional (n=18) e o Grupo 2, os pacientes submetidos ? CAS (n=15). Antes do procedimento, todos os pacientes foram submetidos ? rs-MRI e, quatro a oito semanas ap?s o procedimento, foram submetidos novamente a um exame de rs-MRI e, tamb?m, a um ECO doppler carot?deo. A nova avalia??o com testes neuropsicol?gicos e exame cl?nico neurol?gico foi realizada tr?s meses ap?s o procedimento. A an?lise estat?stica foi realizada com o teste t de Student e a an?lise de vari?ncia (ANOVA). Os resultados foram considerados significativos quando p? 0,05. Resultados: Dentre os resultados neuropsicol?gicos, o grupo da CEA, no teste de nomea??o de Boston, obteve escores de 12,13/15 (?3,09) no pr?-procedimento versus 13,44/15 (?1,63) no p?s, com signific?ncia p=0,03. Os testes de mem?rias visuais (mv) 1 e 2 ap?s o procedimento, quando comparados entre os grupos, obtiveram valores maiores para o grupo da angioplastia, com valores de signific?ncia de p=0,02 para mv 1 e de p=0,007 para mv 2. Nos resultados de neuroimagem, quando a rs-RMI foi analisada com ReHo (do ingl?s regional homogeneity), encontraram-se tr?s clusters na rede DMN (do ingl?s default mode network) no grupo CAS, demonstrando aumento de conectividade funcional no p?s-procedimento em rela??o ao pr?-procedimento. Com a aplica??o do ICA (do ingl?s independent component analysis) na rs-MRI, encontraram-se, na rede FPD (frontoparietal direita), quatro clusters, mostrando um aumento do valor na conectividade no p?s-procedimento para o Grupo 2. Conclus?o: Houve um aumento de conectividade, com diferen?a estat?stica, em duas redes (DMN e PDF) de conectividade funcional p?s-angioplastia e redu??o nessas mesmas redes, sem diferen?a estat?stica para o grupo da endarterectomia no p?s-operat?rio. Dentro do grupo da endarterectomia, houve melhora ap?s o procedimento no teste de nomea??o de Boston.

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Henriksson, Martin. "Cost-effectiveness and Value of Further Research of Treatment Strategies for Cardiovascular Disease." Doctoral thesis, Linköping : Univ, 2007. http://urn.kb.se/resolve?urn=urn:nbn:se:liu:diva-9788.

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Rodríguez, Cabeza Patricia. "Relación entre el flujo de la arteria cerebral media y la presión en la arteria carótida interna durante la endarterectomía carotídea." Doctoral thesis, Universitat de Girona, 2017. http://hdl.handle.net/10803/456481.

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Risk of cerebral hypoperfusion during carotid endarterectomy arterial is the main limiting factor of this technique. Shunt allows partial maintenance of cerebral perfusion during clamping. We analyze the hemodynamic behavior of ipsilateral middle cerebral artery and internal carotid artery during surgery. For this purpose, a preoperative intracerebral hemodynamics study using transcranial colour-coded duplex has been performed along with continuous transcranial ultrasound monitoring of intraoperative middle cerebral artery and measurement of invasive pressure in common carotid and internal carotid arteries during carotid endarterectomy. We have observed a significant positive relationship between presence or absence of collateral circulation in the preoperative study by transcranial doppler and maintenance of both carotid pressures and velocities in middle cerebral artery during the intervention. The analysis of collateral circulation patterns allows us to identify patients with the highest risk of presenting intraoperative cerebral ischemia and to require the use of shunt during clamping.
El riesgo de hipoperfusión cerebral durante la endarterectomía carotídea es el principal factor limitante de esta técnica. El shunt permite mantener parcialmente la perfusión cerebral durante el clampaje. Analizamos el comportamiento hemodinámico de las arterias cerebral media y carótida interna ipsilaterales durante la intervención. Se ha realizado un estudio preoperatorio de la hemodinámica intracerebral mediante dúplex transcraneal junto con una monitorización ecográfica de la arteria cerebral media intraoperatoria y una medición de la presión cruenta en carótida común e interna durante la cirugía. Hemos observado una relación positiva significativa entre la presencia o ausencia de circulación colateral en el estudio prequirúrgico y el mantenimiento tanto de presiones carotídeas como de velocidades en la arteria cerebral media durante la intervención. El análisis de los patrones de circulación colateral nos permite identificar a los pacientes con mayor riesgo de presentar isquemia cerebral intraoperatoria y de requerir la utilización de shunt.

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45

Guimarães, Beatriz Carvalho Branco de Torres. "High-dependency unit care after carotid endarterectomy for asymptomatic stenosis." Master's thesis, 2020. https://hdl.handle.net/10216/128811.

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Introdução: A Sociedade Europeia de Cirurgia Vascular recomenda 3-6 horas de monitorização clínica de deterioração neurológica e tensional invasiva após endarterectomia em doentes assintomáticos. Na realidade, apenas uma minoria irá beneficiar de monitorização invasiva após este período e a transferência precoce para a enfermaria permite um melhor cuidado do doente e gestão de recursos hospitalares. Objetivo: Identificar os doentes que beneficiarão mais de estadia prolongada (>6 horas) na unidade pós-anestésica. Métodos: Todos os doentes submetidos a endarterectomia assintomática em 2016 e 2017 foram analisados retrospetivamente. Foi criado um outcome composto para identificar os doentes que poderiam beneficiar mais de estadia prolongada na unidade pós-anestésica. Este inclui eventos cardíacos, deterioração neurológica, suporte vasopressor ou ventilatório no pós-operatório e terapia anti-hipertensiva prolongada. As co-morbilidades, técnicas anestésicas e cirúrgicas e variáveis de monitorização foram comparadas entre os dois grupos. Resultados: Cinquenta e oito procedimentos foram incluídos no estudo (84,5% homens; 70±8 anos), sendo que 11 (19%) manifestaram o outcome composto, a maioria devido a terapia anti-hipertensora intravenosa prolongada (n=6). A diabetes associou-se ao aumento da incidência do outcome composto (p=0,04) e o uso de paracetamol na analgesia intraoperatória correlacionou-se inversamente com a ocorrência deste conjunto de eventos (p<0,001). Não foram encontradas associações com outras variáveis. Conclusões: Doentes diabéticos têm maior propensão para desenvolver o outcome composto e, portanto, constituem o grupo que poderá beneficiar mais de estadia prolongada numa unidade diferenciada. O estudo não tem poder suficiente para avaliar as outras variáveis e, logo, é pertinente investigar mais sobre o tema.
Introduction: The European Society for Vascular Surgery recommends 3-6 hours of neurological and intra-arterial blood pressure monitoring following asymptomatic carotid endarterectomy. However, only a minority of patients will benefit from prolonged monitoring in a high-dependency unit and early patient transfer to the ward could lead to significant improvement in resource management without compromising the best patient care. Aim: The main goal of the study was to identify which patients benefit the most from prolonged high-dependency unit stay. Methods: Consecutive patients submitted to carotid endarterectomy, from 2016-2017, with asymptomatic stenosis were retrospectively reviewed. To better identify patients in need of prolonged high-dependency unit stay, a composite outcome was created including cardiac events, neurologic deterioration, postoperative adrenergic/ventilatory support and prolonged use of intravenous antihypertensive therapy. Co-morbidities, anesthetic and surgical technique and monitoring variables were compared between groups. Results: A total of 58 procedures were included (84.5% male; 70±8 years) and 11 (19%) presented the composite outcome, mostly due to the need for prolonged intravenous antihypertensive therapy (n=6). The presence of diabetes was associated with higher incidence of the compositive outcome (p=0.04) and the use of acetaminophen as intraoperative analgesia demonstrated an inverse correlation with the occurrence of these events (p<0.001). Other co-morbidities, the anesthetic and surgical technique and tensional fluctuations showed no further associations. Conclusions: Diabetics are more prone to develop the composite outcome and, therefore, are the most likely to benefit from a prolonged high-dependency unit stay. The study lacks power to address other covariates. Additional studies are necessary.

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46

Guimarães, Beatriz Carvalho Branco de Torres. "High-dependency unit care after carotid endarterectomy for asymptomatic stenosis." Dissertação, 2020. https://hdl.handle.net/10216/128811.

Full text

Abstract:

Introdução: A Sociedade Europeia de Cirurgia Vascular recomenda 3-6 horas de monitorização clínica de deterioração neurológica e tensional invasiva após endarterectomia em doentes assintomáticos. Na realidade, apenas uma minoria irá beneficiar de monitorização invasiva após este período e a transferência precoce para a enfermaria permite um melhor cuidado do doente e gestão de recursos hospitalares. Objetivo: Identificar os doentes que beneficiarão mais de estadia prolongada (>6 horas) na unidade pós-anestésica. Métodos: Todos os doentes submetidos a endarterectomia assintomática em 2016 e 2017 foram analisados retrospetivamente. Foi criado um outcome composto para identificar os doentes que poderiam beneficiar mais de estadia prolongada na unidade pós-anestésica. Este inclui eventos cardíacos, deterioração neurológica, suporte vasopressor ou ventilatório no pós-operatório e terapia anti-hipertensiva prolongada. As co-morbilidades, técnicas anestésicas e cirúrgicas e variáveis de monitorização foram comparadas entre os dois grupos. Resultados: Cinquenta e oito procedimentos foram incluídos no estudo (84,5% homens; 70±8 anos), sendo que 11 (19%) manifestaram o outcome composto, a maioria devido a terapia anti-hipertensora intravenosa prolongada (n=6). A diabetes associou-se ao aumento da incidência do outcome composto (p=0,04) e o uso de paracetamol na analgesia intraoperatória correlacionou-se inversamente com a ocorrência deste conjunto de eventos (p<0,001). Não foram encontradas associações com outras variáveis. Conclusões: Doentes diabéticos têm maior propensão para desenvolver o outcome composto e, portanto, constituem o grupo que poderá beneficiar mais de estadia prolongada numa unidade diferenciada. O estudo não tem poder suficiente para avaliar as outras variáveis e, logo, é pertinente investigar mais sobre o tema.
Introduction: The European Society for Vascular Surgery recommends 3-6 hours of neurological and intra-arterial blood pressure monitoring following asymptomatic carotid endarterectomy. However, only a minority of patients will benefit from prolonged monitoring in a high-dependency unit and early patient transfer to the ward could lead to significant improvement in resource management without compromising the best patient care. Aim: The main goal of the study was to identify which patients benefit the most from prolonged high-dependency unit stay. Methods: Consecutive patients submitted to carotid endarterectomy, from 2016-2017, with asymptomatic stenosis were retrospectively reviewed. To better identify patients in need of prolonged high-dependency unit stay, a composite outcome was created including cardiac events, neurologic deterioration, postoperative adrenergic/ventilatory support and prolonged use of intravenous antihypertensive therapy. Co-morbidities, anesthetic and surgical technique and monitoring variables were compared between groups. Results: A total of 58 procedures were included (84.5% male; 70±8 years) and 11 (19%) presented the composite outcome, mostly due to the need for prolonged intravenous antihypertensive therapy (n=6). The presence of diabetes was associated with higher incidence of the compositive outcome (p=0.04) and the use of acetaminophen as intraoperative analgesia demonstrated an inverse correlation with the occurrence of these events (p<0.001). Other co-morbidities, the anesthetic and surgical technique and tensional fluctuations showed no further associations. Conclusions: Diabetics are more prone to develop the composite outcome and, therefore, are the most likely to benefit from a prolonged high-dependency unit stay. The study lacks power to address other covariates. Additional studies are necessary.

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47

Andrade, José Diogo Guimarães Carneiro Vieira de. "Onset of nerological deficit during carotid clamping with carotid endarterectomy under local anesthesia is not a predictor of carotid restenosis." Master's thesis, 2019. https://hdl.handle.net/10216/120555.

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48

Andrade, José Diogo Guimarães Carneiro Vieira de. "Onset of nerological deficit during carotid clamping with carotid endarterectomy under local anesthesia is not a predictor of carotid restenosis." Dissertação, 2019. https://hdl.handle.net/10216/120555.

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49

Santos, Luís Daniel Veloso dos. "Carotid endarterectomy under locoregional anesthesia - review of current practices and results." Master's thesis, 2019. https://hdl.handle.net/10216/120587.

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50

Ministro, Andreia Rocha. "Carotid revascularization: endarterectomy versus stenting. A systematic review and meta-analysis." Master's thesis, 2020. https://hdl.handle.net/10216/128221.

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