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III Divisione di Chirurgia Vascolare (Primario: G. Bandiera)

13th Congress of Mediterranean League of Angiology and Vascular Surgery Syracuse - May 21-25, 2003. G.Bandiera, C.Cirielli, F.M. Di Paola, G.Dompè, L. Mascellari, F. Serino. Carotid Revascularization Surgery: Our Experience. III Divisione di Chirurgia Vascolare (Primario: G. Bandiera).

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III Divisione di Chirurgia Vascolare (Primario: G. Bandiera)

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  1. 13th Congress of Mediterranean League of Angiology and Vascular Surgery Syracuse - May 21-25, 2003 G.Bandiera, C.Cirielli, F.M. Di Paola, G.Dompè, L. Mascellari, F. Serino Carotid Revascularization Surgery: Our Experience III Divisione di Chirurgia Vascolare (Primario: G. Bandiera)

  2. Carotid Endarterectomy(CE) III Divisione di Chirurgia Vascolare (Primario: G. Bandiera)

  3. Carotid Endarterectomy (CE) III Divisione di Chirurgia Vascolare (Primario: G. Bandiera)

  4. Carotid Endarterectomy (CE) III Divisione di Chirurgia Vascolare (Primario: G. Bandiera)

  5. Carotid Endarterectomy (CE) III Divisione di Chirurgia Vascolare (Primario: G. Bandiera)

  6. The “symptomatic” carotid • T.I.A. = Transient Ischaemic Attack (<24 hours) • R.I.N.D. = Reversible Ischaemic Neurological Deficit (>24 hours and <3 weeks) • P.R.I.N.D. = idem, “Partially” Reversible • Stroke =Mortal, Severe or Persistent Neurological Deficit III Divisione di Chirurgia Vascolare (Primario: G. Bandiera)

  7. Symptomatic patients selection • ECST (European Carotid Surgery Trial): the “threshold” limit for the surgical treatment of a carotid stenosis is 70-80% • NASCET (North American Symptomatic Carotid Endarterectomy): EC in patients with stenosis between 50 and 69% offers a slight but significant advantage III Divisione di Chirurgia Vascolare (Primario: G. Bandiera)

  8. III Divisione di Chirurgia Vascolare (Primario: G. Bandiera)

  9. Apparent discrepancy due to the different methods used to measure the grade of stenosis III Divisione di Chirurgia Vascolare (Primario: G. Bandiera)

  10. NASCET ECST 30 65 40 70 50 75 60 80 70 85 80 91 90 97 external carotid internal carotid hypothetic position of the carotid wall Comparison of the grade of stenosis of the I.C. evaluated according to NASCET and ECST A-B NASCET A common carotid C-B ECST C

  11. Symptomatic p.ts, 30 days follow up: ECST NASCET deaths 1.0% 1.1% invalidating strokes 2.5% 1.8% (1/3 intraop.) non-invalidating strokes 3.5% 4.5% (2/3 postop.) ECST (European Carotid Surgery Trial)Lancet, 1998;351:1379 NASCET (North American Symptomatic Carotid Endarterectomy Trial)Ferguson GG et al., Stroke, 1999;30:1751 III Divisione di Chirurgia Vascolare (Primario: G. Bandiera)

  12. NASCET (North American Symptomatic Carotid Endarterectomy Trial)Ferguson GG et al., Stroke, 1999;30:1751 Other complications in 1415 symptomatic operated patients wound:9.1% (3% severe) haematomas: 7.0% infections: 2.0% others: 0.1% cranial nerve lesions : 8.6% (none severe) facial: 2.2% vagus: 2.5% access. spinal: 0.2% hypoglox: 3.7% Stroke at 2 years: operated: 9% non-operated controls: 26% III Divisione di Chirurgia Vascolare (Primario: G. Bandiera)

  13. The “asymptomatic” carotid III Divisione di Chirurgia Vascolare (Primario: G. Bandiera)

  14. Asymptomatic patients selection • AHA (American Heart Association) • SICVE (Società Italiana di Chirurgia Vascolare ed Endovascolare) III Divisione di Chirurgia Vascolare (Primario: G. Bandiera)

  15. ACAS (American Carotid Asymptomatic Study)Jama, 1995;273:1421 • Stroke and/or correlated death at 2.7 years in 1662 pt.s: • 5.1% in operated pt.s • 11.0% in non-operated controls • (= risk reduction: 53%) III Divisione di Chirurgia Vascolare (Primario: G. Bandiera)

  16. carotid revascularization surgery • CE alone • CE + angioplasty (vein or PTFE patch) • Eversion CE • Bypass (vein or PTFE or Dacron) • Graft interposition (vein or PTFE or Dacron) III Divisione di Chirurgia Vascolare (Primario: G. Bandiera)

  17. Anatomic features

  18. Nerve lesions ipoglosso r. buccale faciale r. mandibolare vago r. discendente

  19. III Divisione di Chirurgia Vascolare (Primario: G. Bandiera)

  20. III Divisione di Chirurgia Vascolare (Primario: G. Bandiera)

  21. by Cao P.G et al., 2002

  22. Shunt or no shunt? • NO Shunt Shunt • Total 73 (62%) 44 (38%) • NO Emboli 54 10 • Emboli 19 (26%) 34 (77%) • Gordon JK, 1996 cons: major risk of microembolies, major duration of the surgery III Divisione di Chirurgia Vascolare (Primario: G. Bandiera)

  23. III Divisione di Chirurgia Vascolare (Primario: G. Bandiera)

  24. common c.- internal c. bypass (vein)

  25. End to end anastomosis graft (or vein) interposition

  26. III Divisione di Chirurgia Vascolare (Primario: G. Bandiera)

  27. Resection-anastomosis of the internal carotid

  28. III Divisione di Chirurgia Vascolare (Primario: G. Bandiera)

  29. III Divisione di Chirurgia Vascolare IRCCS - IDI (Primario: G. Bandiera)5/1997 - 4/2003

  30. III Divisione di Chirurgia Vascolare IRCCS - IDI (Primario: G. Bandiera)5/1997 - 4/2003

  31. III Divisione di Chirurgia Vascolare IRCCS - IDI (Primario: G. Bandiera)5/1997 - 4/2003

  32. III Divisione di Chirurgia Vascolare IRCCS - IDI (Primario: G. Bandiera)5/1997 - 4/2003 Peri-operative results ECST NASCET Personal deaths 1.0% 1.1% 2 (0.6%) invalidating stroke 2.5% 1.8% (1/3 intraop.) 2 (0.6%) non-invalidat. stroke 3.5% 4.5% (2/3 postop.) 6 (1.8%)

  33. III Divisione di Chirurgia Vascolare IRCCS - IDI (Primario: G. Bandiera)5/1997 - 4/2003 Peri-operative results NASCET Personal wound: 9,1% 15 (4.5%) haematomas: 7.0% 15 (4.5%) infections: 2,0% 0 others: 0.1% 0 cranial nerve lesions: 8,6% 4 (1.2%) facial: 2.2% 1 (0,3%) vagus: 2.5% 0 access. spinal: 0.2% 0 hypoglossus: 3.7% 3 (0,9%)

  34. III Divisione di Chirurgia Vascolare IRCCS - IDI (Primario: G. Bandiera)5/1997 - 4/2003 Follow-up results (75-1 months - mean: 32 months) • occlusions restenosis • sympt. asympt. signif. non-sign. • symptomatic p.ts 1 0 1 0 • asymptomatic p.ts 2 1 5 3 • CE alone 3 1(10m.) 4(6,15,20,39m.) 3(24,26,36m.) • CE + patch 0 0 0 0 • CE eversion 0 0 1 0 • CC-IC bypass (saph.) 0 0 1(6m.) 0

  35. CE in GENERAL ANAESTHESIA • general anaesthesia: 303 (91%) • anaesthesia of the glomus: lidocain 1%: 1-2 ml • systemic heparin : 1 mg/kg b.w. (2 mg if shunt) • stump pressure: always • shunt in: if stump press.<30 mmHg • vessel cloud: always (rarely clamps) • heparinized solution: intravasal and for cleaning • if direct suture : polypropilen 5 or 6.0 • if patch: PTFE and PTFE suture 6.0 • aspirating drainage : always (removed in I-II p.o.) • Intensive Care: 24 hours III Divisione di Chirurgia Vascolare (Primario: G. Bandiera)

  36. if stump press.<30 mmHg: always shunt III Divisione di Chirurgia Vascolare (Primario: G. Bandiera) CE in GENERAL ANAESTHESIA

  37. CE in LOCAL ANAESTHESIA • local anaesthesia : 54 (13%) • anaesthesia of the glomus: lidocain 1%: 1-2 ml • sistemic heparin : 1 mg/kg b.w. (2 mg if shunt) • patient monitoring : verbal-motory (squeezing) • shunt: if clamping intolerance • vessel cloud: always (rarely clamps) • heparinized solution: intravasal and for cleaning • if direct suture : polypropilen 5 o 6.0 • if patch: PTFE and PTFE suture 6.0 • aspirating drainage : always (removed in I-II p.o.) • Intensive Care: 0-24 hours III Divisione di Chirurgia Vascolare (Primario: G. Bandiera)

  38. III Divisione di Chirurgia Vascolare (Primario: G. Bandiera) CE in LOCAL ANAESTHESIA • premedication: meperidina 100mg+atropina 0.5mg+deidrobenzoperidolo 1.25mg • sedation: remifentanil 0.04microg/Kg/min in infusione continua • anaesthetic:ropivacaina • superficial cervical block:12 ml(0.5%) • deep cervical block: 21 ml(0.7%) Moore Technique: 3 injections at C2,C3.C4 levels

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