Mycotic Abdominal Aortic Aneurysms—A Tertiary Centre Experience and Formulation of a Management Protocol

Abstract

Of 58,423 patients who had undergone carotid revascularization, 8% had had contralateral carotid occlusion (CCO). Of the patients with CCO, 69% underwent transfemoral carotid artery stenting (TF-CAS) and 31%, carotid endarterectomy (CEA). Before adjustment, the patients with CCO who had undergone TF-CAS showed no differences in the rate of the combined endpoint of in-hospital death, myocardial infarction, or stroke compared with the patients without CCO (2.1% vs 2.3%; P ¼ .33). The patients with CCO who had undergone CEA had experienced a significantly greater rate of the combined adverse outcomes compared with the patients without CCO (3.6% vs 2.0%). The unadjusted rates of the adverse outcomes were significantly greater for the patients with CCO who had undergone CEA than for the patients without CCO who had undergone CEA (3.6% vs 2.1%). After adjustment, CCO was associated with a 71% increase in the odds of an adverse outcome after CEA (P < .001) compared with no increase after TF-CAS (P ¼ .64).Conclusions: CCO remains an important predictor of increased risk for patients undergoing CEA but not for those undergoing TF-CAS.Commentary: I have two issues with their report. First, although the authors stated that patients with CCO who had undergone TF-CAS had had more comorbidities than the patients who had undergone CEA, they did not emphasize that 2283 patients who had required general anesthesia for CAS had been excluded from the study. Would that not mean that potentially higher risk patients were excluded from the CAS arm? Why did the authors not exclude the patients who had undergone CEA under general anesthesia? Second, cardiologists performed 45% of the TF-CAS procedures, vascular surgeons, 23%, and other specialists, the remaining cases. However, vascular surgeons performed only 40% of the CEAs, with "other surgeons" performing 38%, cardiologists, 2%, and others, 20%. Comparing TF-CAS and CEA for patients with CCO would have been more valid if the vast majority of CEAs had been performed by board-certified vascular surgeons and not by "other surgeons," cardiologists, or radiologists (I did not know cardiologists and radiologists were trained to perform CEA).Despite the weaknesses of their report, I tend to agree that CAS might be preferred over CEA in the setting of CCOdbut not TF-CAS. Even before I read the next article, I think most of us would agree that the preferred technique for patients with CCO would be transcarotid artery revascularization (TCAR). I always wondered how flow reversal during TCAR would not cause diminished cerebral blood flow, especially in the setting of CCO; however, the vast majority of patients tolerate it well. I performed TCAR last week in one patient with CCO, with the patient under local anesthesia so I could monitor the patient after we initiated flow reversal.