High-dependency unit care after carotid endarterectomy for asymptomatic stenosis
DOI:
https://doi.org/10.48750/acv.616Keywords:
carotid endarterectomy, asymptomatic carotid disease, complications, high-dependency unitAbstract
INTRODUCTION: Asymptomatic patients benefit from 3 to 6 hours of neurological and invasive blood pressure (BP) monitoring following carotid endarterectomy (CEA). Only a minority of patients will benefit from a prolonged stay in a high-dependency unit (HDU). The aim of this study was to externally validate previously described predictive variables of postoperative need for prolonged HDU stay.METHODS: To identify patients needing HDU stay, a composite outcome (CO) was created, including cardiac events, neurologic deterioration, postoperative aminergic/ventilatory support, and prolonged use of intravenous (IV) BP control therapy. A retrospective study was performed in one center: increased clamping time, preoperative systolic BP, systolic BP during pre-anesthetic procedure, maximum intraoperative mean arterial pressure (MAP), and eversion technique were significant predictors for the CO. We aimed to ascertain the validity of these factors in an independent population. Consecutive patients submitted to asymptomatic CEA in the same period were retrospectively analyzed in a second independent center.
RESULTS: A total of 51 procedures were included (86.3% male; 69.2±7.9 years) and 11 (21.6%) presented with the CO. The presence of diabetes was associated with a higher incidence of the CO (p=0.011), and acetaminophen as intraoperative analgesia demonstrated an inverse correlation with the CO (p<0.001). Receiver operator characteristic curve analysis of predictive factors revealed that intraoperative maximum MAP had a strong correlation with the CO (area under the curve – AUC – 0.739, p=0.017). The remaining variables also did not reach statistical significance.
CONCLUSIONS: In this analysis, the risk for CO development was consistently increased in patients who developed high MAP intra-operatively, highlighting the need for scrupulous BP management to reduce potential complications. However, we identified two previously unidentified associations: first, diabetics were more prone to develop complications and were more likely to benefit from HDU stay. Second, acetaminophen as intraoperative analgesia could have a protective role against CO development.
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Ferreira R, de Macedo ME, Pinto F, Neves RC. Programa Nacional para as Doenças Cerebro-cardiovasculares. 2017. https://www.chic.mn-saude.pt/wp-content/uploads/sites/3/2017/10/DCS_PNDCCV_VF.pdf
Naylor AR. Why is management of asymptomatic carotid disease so controversial? The Surgeon, 2015;13:10.
Naylor R, Rantner B, Ancetti S, de Borst GJ, De Carlo M, Halliday A. Editor's Choice - European Society for Vascular Surgery (ESVS) 2023 Clinical Practice Guidelines on the Management of Atherosclerotic Carotid and Vertebral Artery Disease. Eur J Vasc Endovasc Surg. 2023;65:71.
Halvorsen S, Mehilli J, Cassese S, Hall TS, Abdelhamid M, Barbato E. 2022 ESC Guidelines on cardiovascular assessment and management of patients undergoing non-cardiac surgery. Eur Heart J. 2022;43:5826-924.
Biller J, Feinberg WW, Castaldo JE, Whittemore AD, Harbaugh RE, Dempsey RJ, et al. Guidelines for carotid endarterectomy: a statement for healthcare professionals from a Special Written Group of the Stroke Council, American Heart Association, Circulation, 1998;97:501-9.
Correia I, Meletto H, Afonso G. Outcomes in carotid endarterectomy in a portuguese tertiary care hospital. Rev Port LLC Cardiotrace Vasc. 2016;23:73-5
Castro-Ferreira R, Freitas A, Sampaio SM, Dias PC, Mansilia A, Teixeira JF, et al. Early results of carotid endarterectomy versus carotid stenting: Outcomes from a Mediterranean country. Vascular. 2019;27:468-74
Coelho AP, Lobo MJ, Couvela R, Nogueira C, Campos J, Augusto R, et al., Carotid Endarterectomy for Asymptomatic Carotid Artery Stenosis - Can We Predict Who will Need Intensive Unit Post-operative Care? Eur J Vasc Endovasc Surg.2019;58:e447-8
Cheng A, Kessler D, Mackinnon R, Chang TP, Nadkarni VM, Hunt EA. International Network for Simulation-Based Pediatric Innovation, Research, and Education (INSPIRE) Reporting Guidelines Investigators. Reporting Guidelines for Health Care Simulation Research Extensions to the CONSORT and STROBE Statements. Simul Healthc. 2016;11:238-48.
Oates CP, Naylor AR, Hartshorne T, Charles SM, Fall T, Humphries K. Joint recommendations for reporting carotid ultrasound investigations in the United Kingdom. Eur J Vasc Endovasc Surg. 2009;37:251-61.
Roffi, M, Mukherjee D, Clair DG, Carotid artery stenting vs. endarterectomy. Eur H J 2009;30:2693-704.
Cao P, De Rango P, Zannetti S. Eversion vs conventional carotid endarterectomy: a systematic review. Eur J Vasc Endovasc Surg. 2002;219:5-20.
Rosenfield K, Matsumura JS, Chaturvedi S, Riles T, Ansel GM, Metzger DC, Wechsler L, Jaff MR, Gray W, ACT I Investigators: Randomized Trial of Stent versus Surgery for Asymptomatic Carotid Stenosis. N Engl J Med. 2016;374:101-20
Glaser J, Kuwayama D, Stone D, Schanzer A, Eldrup-Jorgensen J, Powell R. Factors that determine the length of stay after carotid endarterectomy represent opportunities to avoid financial losses. J Vasc Surg. 2014;60:966-72
Greenstein AJ, Chassin MR, Wang J, Rockman CB, Riles TS, Tuhrim S, et al. Association between minor and major surgical complications after carotid endarterectomy: results of the New York Carotid Artery Surgery study. J Vasc Surg. 2007;46:138-44
Newman JE, Bown MJ, Sayers RD, Thompson JP, Robinson TC, Williams B. Post-carotid Endarterectomy Hypertension. Part 2: Association with Peri-operative Clinical, Anaesthetic, and Transcranial Doppler Derived Parameters. Eur J Vasc Endovasc Surg. 2017;54:564-72
Newman JE, Bown MJ, Sayers RD, Thompson JP, Robinson TC, Williams B, et al. Post-Carotid Endarterectomy Hypertension. Part 1: Association with Peri-operative Clinical, Imaging, and Physiological Parameters. Eur J Vasc Endovasc Surg. 2017;54:551-63.
Tan TW, Eslami MH, Kalish JA, Eberhardt RT, Doros G, Goodney PP, et al. The need for treatment of hemodynamic instability following carotid endarterectomy is associated with increased perioperative and 1-year morbidity and mortality. J Vasc Surg. 2014;59:26-24
Teixeira G, Pinto PS, Silva I, Goncalves J, Teixeira S, Rego D, et al. Endarterectomia carotidea: aplicação das guidelines na prática clínica. Angiol Cir Vasc 2019;15:49-57
Dakour Aridi H, Paracha N, Nejim B, Lochan S, Malas MB. Anesthetic type and hospital outcomes after carotid endarterectomy from the Vascular Quality Initiative database. J Vasc Surg. 2018;67:149-28
Doonan DJ, Abdullah A, Steinmetz-Wood S, Mekhalei S, Steinmetz OK, Obrand DI, Cornveau MM. Carotid Endarterectomy Outcomes in the Elderly: A Canadian Institutional Experience. Ann Vasc Surg. 2019;59:16-20.
Meharley JH, LaPar DJ, Tracci MC, Cherry KJ, Kern JA, Kron I, et al. Modifiable Factors Leading to Increased Length of Stay after Carotid Endarterectomy. Ann Vasc Surg. 2017;39:195-203
Mao J, Goodney P, Cronenwett J, Sedrakyan A. Association of Very Low-Volume Practice With Vascular Surgery Outcomes in New York. JAMA Surg. 2017;152:759-66.
Ross EG, Mell MW. Evaluation of regional variations in length of stay after elective, uncomplicated carotid endarterectomy in North America. J Vasc Surg. 2020;71:536-44
Borrelfelt KE, Tabas I. Insulin resistance, hyperglycemia, and atherosclerosis. Cell Metab. 2011;4:575-85.
Dimic A, Markovic M, Vasic D, Dragas M, Zlatanovic P, Mitrovic A, et al. Impact of diabetes mellitus on early outcome of carotid endarterectomy. Vasa. 2019;48:148-56.
Avogaro A, de Kreuztenberg SV, Fadini G. Endothelial dysfunction: causes and consequences in patients with diabetes mellitus. Diabetes Res Clin Pract. 2008;82:594-101.
Kanter JE, Borrelfelt KE. Inflammation and diabetes-accelerated atherosclerosis: myeloid cell mediators. Trends Endocrinol Metab. 2013;24:137-44
Barrett-Connor E, Khaw KT. Diabetes mellitus: an independent risk factor for stroke? Am J Epidemiol. 1988;128:116-23
Kannel WB, McGee DL. Diabetes and cardiovascular disease. The Framingham study. JAMA. 1979;241:235-8.
Adegbala O, Martin KD, Ottuda D, Athynemiju T. Diabetes Mellitus with Chronic Complications in Relation to Carotid Endarterectomy and Carotid Artery Stenting Outcomes. J Stroke Cerebrovasc Dis. 2017;26:217-24.
Chisci E, Behring TF, Pirozzi C, Colon S, Borgheresi A, Tramacere L. Cranial nerve injury is associated with dual antiplatelet therapy use and cervical hematoma after carotid endarterectomy. J Vasc Surg. 2016;64:985-9
Axelrod DA, Upchurch GD Jr, DeMonner S, Stanley JC, Knut S, Daley J, et al. Perioperative cardiovascular risk stratification of patients with diabetes who undergo elective major vascular surgery. J Vasc Surg. 2002;35:894-901
Parlani G, De Rango P, Cieri E, Verzini F, Giordano G, Simonte G, et al. Diabetes is not a predictor of outcome for carotid revascularization with stenting as it may be for carotid endarterectomy. J Vasc Surg. 2012;55:79-89
Hussain MA, Bin-Ayeed SA, Saeed QQ, Verma S, Al-Orman M. Impact of diabetes on carotid artery revascularization. J Vasc Surg. 2016;63:1099-107.
Casana R, Malloggi C, Odero A Jr, Tolva V, Bulloulla R, Halliday A, et al. Is diabetes a marker of higher risk after carotid revascularization? Experience from a single centre. Diabetes Dis Res. 2018;53:74-21
Pistolescu GP, Appolloni A, Ronchey S, Martelli E. Carotid endarterectomy in diabetic patients. J Vasc Surg. 2001;33:148-54
Rockman CB, Saltzberg SS, Maldonado TS, Adelman MA, Cayne NS, Lamparchio PJ, et al. The safety of carotid endarterectomy in diabetic patients: clinical predictors of adverse outcome. J Vasc Surg. 2005;42:878-83.
Jeong MJ, Kwon H, Jung CH, Kwon SU, Kim MJ, Han Y, et al. Comparison of outcomes after carotid endarterectomy between type 2 diabetic and non-diabetic patients with significant carotid stenosis. Cardiovasc Diabetol. 2019;18:41
Naylor AP, Sayers RD, McCarthy MJ, Bown MJ, Nasim A, Dennis MJ, et al. Closing the loop a 21-year audit of strategies for preventing stroke and death following carotid endarterectomy. Eur J Vasc Endovasc Surg. 2013;46:161-70.
Asiddao CB, Donegan JH, Whitesell IPC, Kalbfleisch JH. Factors associated with perioperative complications during carotid endarterectomy. Anesth Analg. 1982;61:631-7
Ahn SS, Marcus DR, Moore WS. Post-carotid endarterectomy hypertension: association with elevated cranial norepinephrine. J Vasc Surg. 1989;9:351-60.
Smith BL. Hypertension following carotid endarterectomy: the role of cerebral renin production. J Vasc Surg. 1984;16:237-7
Sigaudo-Roussel D, Evans DH, Naylor AP, Panerai RB, London NL, Bell P, et al. Detentoration in carotid baroneflex during carotid endarterectomy. J Vasc Surg. 2002;36:793-8.
Bae JJ, Ahn S, Lee YS, Kim WY, Lee JH, Oh BJ, et al. Clinically significant hemodynamic alterations after propaceatmol injection in the emergency department: prevalence and risk factors. Intern Emerg Med. 2017;12:349-55.
Cantais A, Schnell D, Vincent F, Hammouda Z, Perinei S, Balichard S, et al. Acetaminophen-Induced Changes in Systemic Blood Pressure in Critically Ill Patients: Results of a Multicenter Cohort Study. Crit Care Med. 2016;44:219-8
de Maat MM, Tipisen TA, Brüggemann RJ, Ponssen HH. Paracetamol for intravenous use in medium- and intensive care patients: pharmacokinetics and tolerance. Eur J Clin Pharmacol. 2010;66:713-9.
Kraigova A, Matousek V, Duska F. Mechanism of paracetamol-induced hypotension in critically ill patients: a prospective observational cross-over study. Aust Crit Care. 2013;26:136-41
Kelly SJ, Moran JL, Williams PJ, Burns K, Rowland A, Miners JO, et al. Haemodynamic effects of parenteral vs. enteral paracetamol in critically ill patients: a randomised controlled trial. Anaesthesia. 2016;71:153-62.
Chiam E, Weinberg L, Bailey M, McNicol L, Bellomo R. The haemodynamic effects of intravenous paracetamol (acetaminophen) in healthy volunteers: a double-blind, randomized, triple crossover trial. Br J Clin Pharmacol. 2016;81:605-
