Accepted Manuscript Feasibility and Safety of Simultaneous Carotid Endarterectomy and Carotid Stenting for Bilateral Carotid Stenosis: A Single-Center Experience using a Hybrid Procedure Rong-wei Xu, MD, Peng Liu, MD, PhD, Xue-qiang Fan, MD, Qian Wang, MD, Jian-bin Zhang, MD, Zhi-dong Ye, MD PII:
S0890-5096(16)30051-6
DOI:
10.1016/j.avsg.2015.11.017
Reference:
AVSG 2690
To appear in:
Annals of Vascular Surgery
Received Date: 3 December 2014 Revised Date:
1 November 2015
Accepted Date: 13 November 2015
Please cite this article as: Xu Rw, Liu P, Fan Xq, Wang Q, Zhang Jb, Ye Zd, Feasibility and Safety of Simultaneous Carotid Endarterectomy and Carotid Stenting for Bilateral Carotid Stenosis: A SingleCenter Experience using a Hybrid Procedure, Annals of Vascular Surgery (2016), doi: 10.1016/ j.avsg.2015.11.017. This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
ACCEPTED MANUSCRIPT
Feasibility and Safety of Simultaneous Carotid Endarterectomy and
2
Carotid Stenting for Bilateral Carotid Stenosis: A Single-Center
3
Experience using a Hybrid Procedure
4 5 6 7 8
Rong-wei Xu,MD,Peng Liu,MD,PhD,Xue-qiang Fan,MD,Qian Wang,MD,Jian-bin Zhang,MD Zhi-dong Ye,MD Department of Cardiovascular surgery,China-Japan Friendship Hospital,No.2 Yinghua East Road,Chaoyang District, Beijing 100029,China Correspondence to: Zhidong Ye,MD,E-mail:[email protected]
RI PT
1
SC
9 10
M AN U
11 12 13 14
18 19 20 21
TE EP
17
AC C
16
D
15
22 23 24 25 1
ACCEPTED MANUSCRIPT
ABSTRACT
27
Objective: Treatment for bilateral carotid stenosis (BCS) is challenging and the
28
optimal treatment strategy is not clear. We report our experience of treating 8 patients
29
with BCS by simultaneous carotid endarterectomy (CEA) and carotid stenting (CAS),
30
thereby providing an alternative for vascular surgeons.
31
Materials and Methods: Between October 2010 and August 2014, 8 patients (5
32
males and 3 females; range, 53–82 years; mean, 69±8.8 years) underwent
33
simultaneous CEA and CAS in our hospital. CEA before CAS was done in 5 patients,
34
CAS before CEA was done in 3 patients. One patient also underwent simultaneous
35
coronary artery bypass grafting (CABG) due to unstable angina. Intraoperative
36
transcranial Doppler ultrasonography, carotid shunts, patches and embolic protection
37
devices were used in all patients. Instances of hyperperfusion syndrome (HPS),
38
hemodynamic depression (HD), stroke, myocardial infarction (MI) and death were
39
recorded.
40
Results: All patients completed the procedure. One patient developed post-procedural
41
HPS. After systemic treatment, he recovered completely. There were no deaths,
42
major/minor strokes, or MI, nor did any patient exhibit lower palsy in cranial nerves
43
in the perioperative period (100%, then we aborted the second
143
procedure to avoid severe postoperative hyperperfusion syndrome.
SC
M AN U
D
TE
EP
AC C
144
RI PT
122
For CEA, an incision was made along the anterior border of the
145
sternocleidomastoid muscle. After opening the carotid sheath, the common carotid
146
artery, internal carotid artery and external carotid artery were exposed and isolated.
147
Heparin (1 mg/kg) was administered before clamping the carotid artery. Next, a
148
carotid shunt was used to maintain cerebral blood flow and endarterectomy was
149
carried out. After the atherosclerotic plaque was stripped, the arterial wall was sutured
150
with a polytetrafluoroethylene patch.
151
For CAS, percutaneous access was achieved through the femoral artery in all 6
ACCEPTED MANUSCRIPT patients. Guiding catheters were positioned in the common carotid artery using a
153
0.035′′ guidewire. An embolic protection device (EPD) was then advanced employing
154
dedicated catheters or sheaths for deployment and retrieval. The EPD was utilized in
155
all patients. Atropine (0.5 mg) and/or dopamine (3–10 μg/kg/min, i.v.) was given
156
routinely to avoid or attenuate hemodynamic depression (HD) during balloon
157
pre-dilatation and stent placement. Pre-dilatation was based on the degree of stenosis
158
and was undertaken if the stenosis was >90%. Subsequently, a self‑expanding stent
159
was deployed across the lesion. After stent implantation, angiography was carried out
160
to evaluate blood flow across the stented segment. After post-dilatation, if needed, the
161
EPD was retrieved and the puncture site on the femoral artery was closed using a
162
vascular closure device. Representative pre-procedure and post-procedure DSA
163
images are shown in Figure 1.
M AN U
SC
RI PT
152
After the procedure, patients were monitored in the intensive care unit for an
165
additional 24 h. Careful hemodynamic monitoring and strict control of blood pressure
166
was initiated. Mannitol and dexamethasone were used to avoid hyperperfusion
167
syndrome (HPS). We were very careful about HD caused by a carotid sinus reflex
168
after CAS. Antiplatelet treatment began on the first postoperative day when surgical
169
bleeding had stopped. Patients received aspirin (100 mg) once daily as permanent
170
medication and clopidogrel (75 mg) once daily for ≥3 months after the procedure.
AC C
EP
TE
D
164
171 172
A
B
C
D
173
Figure 1. DSA of the carotid artery of a representative case. Pre-procedure: (A)
174
and (B) ICA angiography shows bilateral severe stenosis of the carotid bulb and 7
ACCEPTED MANUSCRIPT 175
proximal ICA; Post-procedure: (C) ICA angiography shows no stenosis after CEA;
176
(D) ICA angiography shows good blood flow across the stented segment and residual
177
stenosis 60% is noted in patients with a life expectancy of having 3–5 years.
226
Unfortunately, there are insufficient data to recommend CAS as primary therapy for
227
neurologically asymptomatic patients.23 In the present study, mean stenosis for CAS
228
as an adjunctive procedure was 68% using 60% as the cutoff, with the only exception
229
being the patient who had a >50% stenotic unstable ulcerative plaque. SVS guidelines
230
support >60% stenosis for intervention, but many practitioners reserve this
231
intervention for “high grade” stenosis in patients with asymptomatic carotid stenosis.
M AN U
SC
RI PT
218
Patients with BCS can present with unilateral symptoms or bilateral symptoms, and
233
some patients may be asymptomatic. Deciding which side to treat first is an important
234
factor to be considered. In our institution, for patients presenting with unilateral
235
symptoms, the culprit artery undergoes surgical treatment. If patients present with
236
bilateral symptoms, we treat the more obvious symptomatic side or the more severely
237
stenotic side. For patients who have bilateral asymptomatic or equally severe stenotic
238
lesions, the dominant cerebral hemispheric side undergoes surgical treatment. The
239
contralateral lesion, if needed, is treated in a second stage. However, if the
240
contralateral carotid plaque is unstable and/or the contralateral carotid anatomic
241
situation is suitable for interventional treatment, we undertake CEA and CAS
242
simultaneously. If patients refuse to undergo a simultaneous procedure, or due to other
243
medical risk factors cannot tolerate a simultaneous procedure, or the contralateral
244
lesion is unsuitable for CAS, we treat the contralateral lesion in a second stage. For
245
simultaneous treatment using CEA and CAS, the order of treatment is another
246
important factor to be considered. In general, we carry out CEA first unless high
247
hemodynamic risk is anticipated during CEA. In such patients, CAS is carried out
AC C
EP
TE
D
232
10
ACCEPTED MANUSCRIPT first. In the present study, CEA before CAS was done in 5 patients, and CAS before
249
CEA in 3 patients. One patient with coronary artery disease also underwent
250
simultaneous CABG due to unstable angina. In our institution, if patients with severe
251
stenosis of carotid and coronary arteries present with unstable angina and left
252
main-stem or multi-vessel disease, we tend to carry out simultaneous CEA and CABG.
253
This patient had BCS: we immediately implanted a carotid stent after CEA followed
254
by CABG and achieved a successful outcome, but this is not routine practice.
RI PT
248
Theoretically, the complications of CEA and CAS are likely to occur in the
256
simultaneous procedure. The most potentially devastating complication of this
257
procedure is HPS. The prevalence of HPS was not high after the procedure, but it is
258
very dangerous. For BCS patients, cerebral arteries are maximally vasodilated due to
259
chronic brain ischemia and disordered autoregulation. Successful revascularization of
260
bilateral carotid arteries simultaneously can cause cerebral perfusion to increase
261
markedly. In this situation, if intracranial hemorrhage occurs, the prognosis is poor.24
262
Cerebral autoregulation needs several days to normalize after revascularization, so
263
patients are advised regarding immediate reporting of the onset of new symptoms
264
suggesting hyperperfusion (headache, vomiting, seizures) after the procedure. In our
265
series, one patient developed post-procedural HPS. This patient underwent bilateral
266
carotid
267
hemodynamics are hard to maintain. This may induce the occurrence of HPS. We
268
administered glycerol fructose (i.v.) and controlled blood pressure strictly, and he
269
recovered completely. HD (hypotension and/or bradycardia) is another important
270
concern caused by a carotid sinus reflex after CAS. In general, patients with HD can
271
recover spontaneously or after administration of additional fluids, anticholinergics
272
and/or vasopressors.21 No patient presented with post-procedural HD in our study, but
273
we should be alert to this complication. To prevent complications, we took the
274
following measures: (i) controlled blood pressure meticulously; (ii) monitored
275
hemodynamics carefully; (iii) applied TCDU, carotid shunts and EPD during
276
procedures; (iv) administered dehydrating and vasoactive drugs after the procedure.
277
and
cardiac
surgery
simultaneously;
stable
postoperative
AC C
EP
surgery
TE
D
M AN U
SC
255
Our results showed that, with thorough evaluation, careful preparation, and strict 11
ACCEPTED MANUSCRIPT management, simultaneous CEA and CAS for high-grade BCS may be considered as
279
an alternative management strategy in appropriately selected patients. However, there
280
were several limitations to the present study. First, it was a retrospective study with a
281
relatively small study cohort. Second, some patients with several risk factors
282
underwent simultaneous CEA and CAS. Therefore, our results should be interpreted
283
with caution. Multicenter, randomized, controlled studies with larger cohorts are
284
warranted to further explore the feasibility and safety of this simultaneous hybrid
285
procedure.
286
REFERENCES
287
1.Brott TG,Halperin JL,Abbara S,et al.2011 ASA /ACCF /AHA/ AANN/ AANS
288
/ACR/CNS/ SAIP/SCAI/SIR/SNIS/SVM/SVS guideline on the management of
289
patients with extracranial carotid and vertebral artery disease.Stroke 2011;42
290
(8):e464–540.
M AN U
SC
RI PT
278
2.EASTCOTT HH,PICKERING GW,ROB CG.Reconstruction of internal carotid
292
artery in a patient with intermittent attacks of hemiplegia.The Lancet 1954;267
293
(6846):994-996.
D
291
3.Barnett HJ, Taylor DW,Eliasziw M,et al. Benefit of carotid endarterectomy in
295
patients with symptomatic moderate or severe stenosis. North American
296
Symptomatic Carotid Endarterectomy Trial Collaborators.N Engl J Med 1998;339
297
(20):1415-1425.
EP
TE
294
4.North American Symptomatic Carotid Endarterectomy Trial Collaborators.
299
Beneficial effect of carotid endarterectomy in symptomatic patients with high-grade
300
carotid stenosis.N Engl J Med 1991;325(7):445-453.
301 302 303 304 305 306
AC C
298
5.Endarterectomy for asymptomatic carotid artery stenosis. Executive Committee for the Asymptomatic Carotid Atherosclerosis Study.JAMA 1995;273(18):1421-1428. 6.Ting AC, Cheng SW,Cheung J,et al. Early and late outcomes in Hong Kong Chinese patients undergoing carotid endarterectomy.Chin Med J 2002;115 (4):536-539. 7.Rothwell PM.Medical and surgical management of symptomatic carotid stenosis.Int J Stroke 2006;1(3):140-149. 12
ACCEPTED MANUSCRIPT 307
8.Halliday A,Mansfield A,Marro J,et al.Prevention of disabling and fatal strokes by
308
successful carotid endarterectomy in patients without recent neurological symptoms:
309
randomised controlled trial.Lancet 2004;363(9420):1491-1502. 9.Hobson RW 2nd,Weiss DG,Field WS,et al.Efficacy of carotid endarterectomy for
311
asymptomatic carotid stenosis.The Veterans Affairs Cooperative Study Group.N
312
Engl J Med 1993;328(4):221-227.
314 315 316
10.Tsukahara T,Hatano T,Ogino E,et al.Surgical treatment for bilateral carotid arterial stenosis.Acta Neurochir Suppl 2005;94:133-136.
11.Henry M,Gopalakrishnan L,Rajagopal S,et al.Bilateral carotid angioplasty and
SC
313
RI PT
310
stenting.Catheter Cardiovasc Interv 2005;64(3):275-82.
12.Portinos A,Kefaloyannis E,Philippakis G,et al.Simultaneous Bilateral Carotid
318
Endarterectomy Under Local Anesthesia.Asian Cardiovascular and Thoracic Annals
319
2008;16(4):327-328.
320 321
M AN U
317
13.Farsak B, Oç M,Boke E.Simultaneous bilateral carotid endarterectomy: our first experience.Ann Thorac Cardiovas Surg 2001;7(5):292-296.
14.Dimakakos P B,Kotsis T E,Tsiligiris B,et al.Comparative results of staged and
323
simultaneous bilateral carotid endarterectomy: a clinical study and surgical
324
treatment.Cardiovascular Surgery 2000;8(1):10-17.
TE
D
322
15.Toung TJ,Sieber FE,Grayson RF,et al.Chemoreceptor injury as probable cause of
326
respiratory depression after a simultaneous, bilateral carotid endarterectomy.Crit
327
Care Med 1990;18(11):1290-1291.
329 330 331 332 333
AC C
328
EP
325
16.Chen MS,Bhatt DL,Mukherjee D,et al.Feasibility of simultaneous bilateral carotid stenting.Catheter Cardiovasc Interv 2004;61 (4):437–442.
17.Wang YH, Hsieh HJ, Lee CW,et al.Simultaneous Bilateral Carotid Stenting in One Session in High-Risk Patients.J Neuroimaging 2008;18(3):252–255.
18.Liu S,Jung JK,Kim SM,et al.Simultaneous bilateral carotid stenting in high-risk patients.AJNR Am J Neuroradiol 2010;31(6):1113-1117.
334
19.Dong H,Jiang XJ,Peng M,et al.Comparison of the safety of simultaneous bilateral
335
carotid stenting versus unilateral carotid stenting:30-day and 6-month results.Chin 13
ACCEPTED MANUSCRIPT 336
Med J 2012;125(6):1010-1015.
337
20.Alurkar A,Karanam LS,Nayak S,et al.Simultaneous bilateral carotid stenting in a
338
series of 9 patients: a single-center experience with review of literature.J Clin
339
Imaging Sci 2012;2:72.
341
21.Li Y,Sun W,Yin Q,et al.Safety and efficacy of simultaneous bilateral carotid
RI PT
340
angioplasty and stenting.J Thromb Thrombolysis 2014;37(2):202-209.
22.Qureshi AI,Luft AR,Sharma M,et al.Frequency and determinants of postprocedural
343
hemodynamic instability after carotid angioplasty and stenting.Stroke 1999;30(10):
344
2086-2093.
SC
342
23. Ricotta JJ, Abu Rahma A, Ascher E, et al. Updated Society for Vascular Surgery
346
Guidelines for management of extracranial carotid artery disease. J Vasc Surg 2011;
347
54:e1-e31.
M AN U
345
348
24.Ogasawara K,Sakai N,Kuroiwa T,et al.Intracranial hemorrhage associated with
349
cerebral hyperperfusion syndrome following carotid endarterectomy and carotid
350
stenting:
351
(6):1130-1136.
review
of
4494
AC C
EP
TE
D
retrospective
14
patients.J
Neurosurg
2007;107
S0890-5096(16)30051-6
DOI:
10.1016/j.avsg.2015.11.017
Reference:
AVSG 2690
To appear in:
Annals of Vascular Surgery
Received Date: 3 December 2014 Revised Date:
1 November 2015
Accepted Date: 13 November 2015
Please cite this article as: Xu Rw, Liu P, Fan Xq, Wang Q, Zhang Jb, Ye Zd, Feasibility and Safety of Simultaneous Carotid Endarterectomy and Carotid Stenting for Bilateral Carotid Stenosis: A SingleCenter Experience using a Hybrid Procedure, Annals of Vascular Surgery (2016), doi: 10.1016/ j.avsg.2015.11.017. This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
ACCEPTED MANUSCRIPT
Feasibility and Safety of Simultaneous Carotid Endarterectomy and
2
Carotid Stenting for Bilateral Carotid Stenosis: A Single-Center
3
Experience using a Hybrid Procedure
4 5 6 7 8
Rong-wei Xu,MD,Peng Liu,MD,PhD,Xue-qiang Fan,MD,Qian Wang,MD,Jian-bin Zhang,MD Zhi-dong Ye,MD Department of Cardiovascular surgery,China-Japan Friendship Hospital,No.2 Yinghua East Road,Chaoyang District, Beijing 100029,China Correspondence to: Zhidong Ye,MD,E-mail:[email protected]
RI PT
1
SC
9 10
M AN U
11 12 13 14
18 19 20 21
TE EP
17
AC C
16
D
15
22 23 24 25 1
ACCEPTED MANUSCRIPT
ABSTRACT
27
Objective: Treatment for bilateral carotid stenosis (BCS) is challenging and the
28
optimal treatment strategy is not clear. We report our experience of treating 8 patients
29
with BCS by simultaneous carotid endarterectomy (CEA) and carotid stenting (CAS),
30
thereby providing an alternative for vascular surgeons.
31
Materials and Methods: Between October 2010 and August 2014, 8 patients (5
32
males and 3 females; range, 53–82 years; mean, 69±8.8 years) underwent
33
simultaneous CEA and CAS in our hospital. CEA before CAS was done in 5 patients,
34
CAS before CEA was done in 3 patients. One patient also underwent simultaneous
35
coronary artery bypass grafting (CABG) due to unstable angina. Intraoperative
36
transcranial Doppler ultrasonography, carotid shunts, patches and embolic protection
37
devices were used in all patients. Instances of hyperperfusion syndrome (HPS),
38
hemodynamic depression (HD), stroke, myocardial infarction (MI) and death were
39
recorded.
40
Results: All patients completed the procedure. One patient developed post-procedural
41
HPS. After systemic treatment, he recovered completely. There were no deaths,
42
major/minor strokes, or MI, nor did any patient exhibit lower palsy in cranial nerves
43
in the perioperative period (100%, then we aborted the second
143
procedure to avoid severe postoperative hyperperfusion syndrome.
SC
M AN U
D
TE
EP
AC C
144
RI PT
122
For CEA, an incision was made along the anterior border of the
145
sternocleidomastoid muscle. After opening the carotid sheath, the common carotid
146
artery, internal carotid artery and external carotid artery were exposed and isolated.
147
Heparin (1 mg/kg) was administered before clamping the carotid artery. Next, a
148
carotid shunt was used to maintain cerebral blood flow and endarterectomy was
149
carried out. After the atherosclerotic plaque was stripped, the arterial wall was sutured
150
with a polytetrafluoroethylene patch.
151
For CAS, percutaneous access was achieved through the femoral artery in all 6
ACCEPTED MANUSCRIPT patients. Guiding catheters were positioned in the common carotid artery using a
153
0.035′′ guidewire. An embolic protection device (EPD) was then advanced employing
154
dedicated catheters or sheaths for deployment and retrieval. The EPD was utilized in
155
all patients. Atropine (0.5 mg) and/or dopamine (3–10 μg/kg/min, i.v.) was given
156
routinely to avoid or attenuate hemodynamic depression (HD) during balloon
157
pre-dilatation and stent placement. Pre-dilatation was based on the degree of stenosis
158
and was undertaken if the stenosis was >90%. Subsequently, a self‑expanding stent
159
was deployed across the lesion. After stent implantation, angiography was carried out
160
to evaluate blood flow across the stented segment. After post-dilatation, if needed, the
161
EPD was retrieved and the puncture site on the femoral artery was closed using a
162
vascular closure device. Representative pre-procedure and post-procedure DSA
163
images are shown in Figure 1.
M AN U
SC
RI PT
152
After the procedure, patients were monitored in the intensive care unit for an
165
additional 24 h. Careful hemodynamic monitoring and strict control of blood pressure
166
was initiated. Mannitol and dexamethasone were used to avoid hyperperfusion
167
syndrome (HPS). We were very careful about HD caused by a carotid sinus reflex
168
after CAS. Antiplatelet treatment began on the first postoperative day when surgical
169
bleeding had stopped. Patients received aspirin (100 mg) once daily as permanent
170
medication and clopidogrel (75 mg) once daily for ≥3 months after the procedure.
AC C
EP
TE
D
164
171 172
A
B
C
D
173
Figure 1. DSA of the carotid artery of a representative case. Pre-procedure: (A)
174
and (B) ICA angiography shows bilateral severe stenosis of the carotid bulb and 7
ACCEPTED MANUSCRIPT 175
proximal ICA; Post-procedure: (C) ICA angiography shows no stenosis after CEA;
176
(D) ICA angiography shows good blood flow across the stented segment and residual
177
stenosis 60% is noted in patients with a life expectancy of having 3–5 years.
226
Unfortunately, there are insufficient data to recommend CAS as primary therapy for
227
neurologically asymptomatic patients.23 In the present study, mean stenosis for CAS
228
as an adjunctive procedure was 68% using 60% as the cutoff, with the only exception
229
being the patient who had a >50% stenotic unstable ulcerative plaque. SVS guidelines
230
support >60% stenosis for intervention, but many practitioners reserve this
231
intervention for “high grade” stenosis in patients with asymptomatic carotid stenosis.
M AN U
SC
RI PT
218
Patients with BCS can present with unilateral symptoms or bilateral symptoms, and
233
some patients may be asymptomatic. Deciding which side to treat first is an important
234
factor to be considered. In our institution, for patients presenting with unilateral
235
symptoms, the culprit artery undergoes surgical treatment. If patients present with
236
bilateral symptoms, we treat the more obvious symptomatic side or the more severely
237
stenotic side. For patients who have bilateral asymptomatic or equally severe stenotic
238
lesions, the dominant cerebral hemispheric side undergoes surgical treatment. The
239
contralateral lesion, if needed, is treated in a second stage. However, if the
240
contralateral carotid plaque is unstable and/or the contralateral carotid anatomic
241
situation is suitable for interventional treatment, we undertake CEA and CAS
242
simultaneously. If patients refuse to undergo a simultaneous procedure, or due to other
243
medical risk factors cannot tolerate a simultaneous procedure, or the contralateral
244
lesion is unsuitable for CAS, we treat the contralateral lesion in a second stage. For
245
simultaneous treatment using CEA and CAS, the order of treatment is another
246
important factor to be considered. In general, we carry out CEA first unless high
247
hemodynamic risk is anticipated during CEA. In such patients, CAS is carried out
AC C
EP
TE
D
232
10
ACCEPTED MANUSCRIPT first. In the present study, CEA before CAS was done in 5 patients, and CAS before
249
CEA in 3 patients. One patient with coronary artery disease also underwent
250
simultaneous CABG due to unstable angina. In our institution, if patients with severe
251
stenosis of carotid and coronary arteries present with unstable angina and left
252
main-stem or multi-vessel disease, we tend to carry out simultaneous CEA and CABG.
253
This patient had BCS: we immediately implanted a carotid stent after CEA followed
254
by CABG and achieved a successful outcome, but this is not routine practice.
RI PT
248
Theoretically, the complications of CEA and CAS are likely to occur in the
256
simultaneous procedure. The most potentially devastating complication of this
257
procedure is HPS. The prevalence of HPS was not high after the procedure, but it is
258
very dangerous. For BCS patients, cerebral arteries are maximally vasodilated due to
259
chronic brain ischemia and disordered autoregulation. Successful revascularization of
260
bilateral carotid arteries simultaneously can cause cerebral perfusion to increase
261
markedly. In this situation, if intracranial hemorrhage occurs, the prognosis is poor.24
262
Cerebral autoregulation needs several days to normalize after revascularization, so
263
patients are advised regarding immediate reporting of the onset of new symptoms
264
suggesting hyperperfusion (headache, vomiting, seizures) after the procedure. In our
265
series, one patient developed post-procedural HPS. This patient underwent bilateral
266
carotid
267
hemodynamics are hard to maintain. This may induce the occurrence of HPS. We
268
administered glycerol fructose (i.v.) and controlled blood pressure strictly, and he
269
recovered completely. HD (hypotension and/or bradycardia) is another important
270
concern caused by a carotid sinus reflex after CAS. In general, patients with HD can
271
recover spontaneously or after administration of additional fluids, anticholinergics
272
and/or vasopressors.21 No patient presented with post-procedural HD in our study, but
273
we should be alert to this complication. To prevent complications, we took the
274
following measures: (i) controlled blood pressure meticulously; (ii) monitored
275
hemodynamics carefully; (iii) applied TCDU, carotid shunts and EPD during
276
procedures; (iv) administered dehydrating and vasoactive drugs after the procedure.
277
and
cardiac
surgery
simultaneously;
stable
postoperative
AC C
EP
surgery
TE
D
M AN U
SC
255
Our results showed that, with thorough evaluation, careful preparation, and strict 11
ACCEPTED MANUSCRIPT management, simultaneous CEA and CAS for high-grade BCS may be considered as
279
an alternative management strategy in appropriately selected patients. However, there
280
were several limitations to the present study. First, it was a retrospective study with a
281
relatively small study cohort. Second, some patients with several risk factors
282
underwent simultaneous CEA and CAS. Therefore, our results should be interpreted
283
with caution. Multicenter, randomized, controlled studies with larger cohorts are
284
warranted to further explore the feasibility and safety of this simultaneous hybrid
285
procedure.
286
REFERENCES
287
1.Brott TG,Halperin JL,Abbara S,et al.2011 ASA /ACCF /AHA/ AANN/ AANS
288
/ACR/CNS/ SAIP/SCAI/SIR/SNIS/SVM/SVS guideline on the management of
289
patients with extracranial carotid and vertebral artery disease.Stroke 2011;42
290
(8):e464–540.
M AN U
SC
RI PT
278
2.EASTCOTT HH,PICKERING GW,ROB CG.Reconstruction of internal carotid
292
artery in a patient with intermittent attacks of hemiplegia.The Lancet 1954;267
293
(6846):994-996.
D
291
3.Barnett HJ, Taylor DW,Eliasziw M,et al. Benefit of carotid endarterectomy in
295
patients with symptomatic moderate or severe stenosis. North American
296
Symptomatic Carotid Endarterectomy Trial Collaborators.N Engl J Med 1998;339
297
(20):1415-1425.
EP
TE
294
4.North American Symptomatic Carotid Endarterectomy Trial Collaborators.
299
Beneficial effect of carotid endarterectomy in symptomatic patients with high-grade
300
carotid stenosis.N Engl J Med 1991;325(7):445-453.
301 302 303 304 305 306
AC C
298
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