Carotid artery disease: stenting vs endarterectomy

Abstract

Several multicentre, randomized trials have validated the efficacy of carotid endarterectomy (CEA). Comparative randomized trials are also currently developing insight into the role of carotid angioplasty and stenting (CAS), and identifying factors for optimal patient selection. Although these interventions are aimed at embolic stroke prevention, anaesthetic management might prevent the subset of strokes that are haemodynamic in nature by maintaining tight physiological control. The perioperative risk of myocardial events is increased in this population. Hence, preoperative attention to cardiovascular disease, hypertension, renal insufficiency, and diabetes mellitus might reduce neurological and cardiovascular complications. During carotid artery cross-clamping, the risk of cerebral ischaemia can be decreased by maintaining normal to high perfusion pressure. Although there is no demonstrable advantage of a specific anaesthetic technique for patients undergoing CEA, it is imperative that cerebral blood flow is optimized, that there is minimal cardiac stress, and that anaesthetic recovery is rapid. Carotid angioplasty and stenting is performed under light sedation with antithrombotic therapy and vigilance for bradycardia and hypotension. Tight haemodynamic control remains a priority in the immediate postoperative period for both interventions.

Preoperative Protective Stenting of the Internal Carotid Artery in the Management of Complex Head and Neck Paragangliomas: Long-Term Results

“…None of the patients reported on experienced any problem associated with daily aspirin use (gastritis/ulcer, mucosal bleeding). Feared complications from ICA stenting during a vascular procedure for atherosclerosis are distal embolization and strokes, vessel dissection, and early or late thrombosis [Erickson and Cole, 2010]. No early, intraoperative or late complications related to the endovascular procedures (angiography, stent positioning and embolization) have been reported to date in this series of patients.…”

Épidémiologie des accidents vasculaires cérébraux périopératoires

“…Tout cela souligne l'importance de l'AVCI dans le processus de dé cision chirurgicale et le choix des é quipes chirurgicales. L'incidence de l'AVCI pé riopé ratoire en chirurgie carotidienne est bien é valué e. Elle est trè s variable pouvant aller de 1 à 20 %, soulignant donc l'importance de l'expé rience des opé rateurs [9,108]. Les ré sultats de l'é tude CREST comparant l'endarté riectomie carotidienne à l'angioplastie avec stenting donne les fré quences actuelles d'AVCI pé riopé ratoire pour des é quipes entraîné es pour les deux techniques (Tableau 4) [109].…”

“…Depuis plus de deux dé cennies, l'AVCI est une complication pé riopé ratoire trè s é tudié e en chirurgie carotidienne [8,9] et cardiaque [10][11][12][13][14][15][16]. En revanche, pour l'AVCI en dehors de ces chirurgies, bien qu'abordé dans les anné es 1990 [8,17], ce n'est que dans ces cinq derniè res anné es que l'inté rêt a é té relancé sur le sujet [18][19][20][21][22].…”

Anaesthesiology and intensive care Does the optimization of intra-operative cerebral regional oxygen saturation have an effect on neurological function in elderly patients undergoing cardiac surgery?

“…Carotid artery stenoses, which are often observed in patients qualified for cardiac surgery procedures, are responsible for 20% of strokes in the population of adult patients. Atherosclerotic changes in the carotid arteries not only constitute a risk factor of central nervous system (CNS) stroke but are also a manifestation of generalized arterial atherosclerosis [5].…”