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1.4 Perioperative Management

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• Recommendation 11: For patients with asymptomatic carotid stenosis who are undergoing CEA, lower-dose aspirin (75–325mg daily) rather than higher-dose aspirin (> 325mg daily) is recommended. (Class I; Level B).

• Recommendation 12: For patients with asymptomatic carotid stenosis undergoing carotid stenting, combination antiplatelet therapy with aspirin (75–325mg daily) and clopidogrel (75mg daily) is recommended. Clopidogrel (75mg daily) should be started at least 3 days before stenting or as a single 300mg loading dose given in urgent cases. Aspirin and clopidogrel should be continued for at least 4 weeks after stenting and then antiplatelet monotherapy should be continued indenitely. (Class I; Level B).

• Recommendation 26: For recently symptomatic carotid stenosis patients scheduled to undergo carotid endarterectomy, it is recommended that all be prescribed antiplatelet therapy throughout the peri-operative period and in the long term. (Class I; Level A).

• Recommendation 27: For recently symptomatic patients with a 50–99% carotid stenosis who are to undergo carotid endarterectomy, peri-operative combination antiplatelet therapy should be considered, and should be started after imaging has excluded intracranial haemorrhage. (Class IIA; Level C).

• Recommendation 28: In recently symptomatic patients with a 50–99% carotid stenosis who are to undergo carotid endarterectomy where antiplatelet monotherapy is preferred to combination therapy, aspirin (300–325 mg daily for 14 days, followed by 75–162 mg daily) should be considered. (Class IIA; Level B).

• Recommendation 29: For recently symptomatic patients undergoing carotid endarterectomy on aspirin monotherapy, lower dose aspirin (75–325 mg daily) rather than higher dose (>325mg daily) is recommended. (Class I; Level B).

• Recommendation 30: For recently symptomatic carotid stenosis patients undergoing carotid endarterectomy who are intolerant of, or allergic to, aspirin and clopidogrel, dipyridamole modied release monotherapy (200mg twice daily) is recommended. (Class I; Level C).

• Recommendation 31: For recently symptomatic patients undergoing carotid stenting, combination antiplatelet therapy with aspirin (75–325mg daily) and clopidogrel is recommended. Clopidogrel (75mg daily) should be started at least 3 days prior to stenting or as a single 300 mg loading dose in urgent cases. Aspirin and clopidogrel should be continued for at least 4 weeks after stenting and then long term antiplatelet monotherapy (preferably clopidogrel 75 mg daily) should be continued indenitely. (Class I; Level C).

• Recommendation 32: For patients who have undergone carotid endarterectomy or carotid stenting, long term aspirin + clopidogrel therapy is not recommended unless required for cardiac or other vascular disease indications. (Class III; Level A).

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1.4.10 Patients withAtrial Fibrillation: Combination Therapy

withOral Anticoagulants andAntiplatelets

1.4.10.1 Studies

In an analysis of the National Inpatient Sample (NIS) from 2005 to 2009 (n=672,074 patients), 8.8% of patients who underwent CEA or CAS had atrial brillation (AF). Atrial brillation was associated with an increased rate of postoperative stroke in patients undergoing CEA but not in patients undergoing CAS [40]. The relative risk of the composite end point of postoperative stroke, cardiac complications, and mortality was increased in patients with atrial brillation undergoing CAS (OR, 1.43; 95% CI, 1.18–1.74) and in those undergoing CEA (OR, 3.18; 95% CI, 2.89–3.49). After adjustment for potential confounders, the odds of the composite end point of postoperative stroke, cardiac complications, and mortality in atrial brillation patients were signicantly higher among patients who underwent CEA (compared with those who underwent CAS). An opposite relationship was seen in patients without atrial brillation, in whom the composite end point was signicantly lower in patients undergoing CEA.This analysis suggests that almost 10% of CAS and CEA is performed in patients with atrial brillation in general practice, and higher rates of adverse events are observed among these patients, particularly those undergoing CEA.

1.4.10.2 Guidelines

The question of the extent to which patients with atrial brillation who underwent CEA or CAS should receive a comedication of antiplatelet therapy and anticoagulants is not denitively answered in the ESVS guideline. The 2016 European Society of Cardiology (ESC) guidelines for the management of atrial brillation [41] recommend:

• After TIA or stroke, combination therapy of oral anticoagulation and an antiplatelet is not recommended. (harm; recommendation grade III/evidence level B).

• This means that patients with atrial brillation should receive long-term monotherapy with oral anticoagulants. There is no indication for additional antiplatelet therapy in patients with atrial brillation who underwent CEA.

As far as patients with atrial brillation who underwent CAS are concerned, the ESC guideline leaves this question unanswered. However, analogous to coronary stent implantation in patients with atrial brillation, it has been common practice up to now to administer antiplatelets (monotherapy with either ASA, 75–325mg daily, or clopidogrel, 75mg daily, or a combination of both drugs) for 4 weeks in addition to concomitant anticoagulation for reasons of fear of early thrombotic occlusion. Whether this therapy should be continued for longer is unclear.

1.4 Perioperative Management

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For the coronary stent, the ESC guidelines [41] recommend:

• After elective coronary stenting for stable coronary artery disease in atrial brillation (AF) patients at risk of stroke, combination triple therapy with aspirin, clopidogrel and an oral anticoagulant should be considered for 1month to prevent recurrent coronary and cerebral ischaemic events. (Recommendation class IIa/evidence level B).

• After an ACS (acute coronary syndrome) with stent implantation in AF patients at risk of stroke, combination triple therapy with aspirin, clopidogrel and an oral anticoagulant should be considered for 1–6months to prevent recurrent coronary and cerebral ischaemic events. (Recommendation class IIa/evidence level C).

• The duration of combination antithrombotic therapy, especially triple therapy, should be kept to a limited period, balancing the estimated risk of recurrent coronary events and bleeding. (Recommendation class IIa/evidence level B).

• Dual therapy with any oral anticoagulant plus clopidogrel 75mg/day may be considered as an alternative to initial triple therapy in selected patients. (Recommendation class IIb/evidence level C).

1.4.11 Lipid-Lowering Therapy (Statins)

1.4.11.1 European Society forVascular Surgery (ESVS) [1]

• Recommendation 13: For patients with asymptomatic carotid stenosis, lipid lowering therapy with statins (with or without ezetimibe) is recommended for the long-term prevention of stroke, myocardial infarction, and other cardiovascular events. (Class I; Level B).

• Recommendation 34: For patients with a symptomatic carotid stenosis, statin therapy is recommended for the long term prevention of stroke, myocardial infarction and other cardiovascular events. (Class I; Level B).

• Recommendation 35: For symptomatic carotid stenosis patients who do not reach their lipid targets on maximum doses or maximum tolerated doses of statins, ezetimibe (10mg daily) is recommended. (Class I; Level B).

• Recommendation 36: For symptomatic carotid stenosis patients who are intolerant of, or not achieving target low density lipoprotein levels on statins, with or without ezetimibe, additional or alternative treatment with PCSK9 inhibitors should be considered. (Class IIA; Level B).

• Recommendation 37: For patients scheduled to undergo endarterectomy or stenting, it is recommended to commence statin therapy pre-operatively. (Class I; Level A).

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1.4.11.2 European Society ofCardiology (ESC) andtheEuropean Society

ofAnaesthesiology (ESA)- Guideline [30]

• Peri-operative continuation of statins is recommended, favouring statins with a long half-life or extended-release formulation.

• Preoperative initiation of statin treatment should be considered in patients undergoing vascular surgery, ideally at least 2weeks prior to surgery.

1 Extracranial Carotid Stenosis

1.4.12 Diabetes Mellitus

1.4.12.1 European Society forVascular Surgery (ESVS) [1]

• No. 16: For diabetic patients with asymptomatic carotid stenoses, optimal glycaemic control is recommended. (Class I; Level B).

1.4.12.2 Studies

The importance of well controlled diabetes in patients with CEA was highlighted by Parr etal. [42] based on 614,190 patients from the 2006–2013 National Inpatient Sample. Patients with uncontrolled diabetes had signicantly higher rates of stroke (3.27% vs. 0.93%), myocardial infarction (3.35% vs. 1.10%) and higher hospital mortality (1.43% vs. 0.25%) than patients with well-controlled diabetes. In patients without diabetes, the comparative gures were 0.94% (stroke), 0.87% (myocardial infarction) and 0.27% (hospital mortality). In addition to the less favourable outcome, higher treatment cost and a longer hospital stay were also observed in patients with uncontrolled diabetes. This nding highlights the importance of considering the state of control of a patient’s disease rather than just whether they carry a diagnosis of diabetes when weighing the benets and costs of CEA.

1.4.13 Wound Drainage After CEA

1.4.13.1 European Society forVascular Surgery (ESVS) [1]

• No. 79: For patients undergoing carotid endarterectomy, selective wound drainage should be considered. (Class IIA; Level B).

1.4.13.2 Studies

The rationale behind the use of drains is to prevent uid collections, which in the neck might cause respiratory complications or become secondarily infected. In the only (small) randomised study with a total of 70 patients with CEA and 106 groin

References

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dissections, in which the volume of uid was accurately measured postoperatively, the placement of a drain failed to signicantly decrease the risk of haematoma requiring surgical evacuation or amount of uid collections [43]. Most haematomas were small, with or without drainage. Wound complications were not signicantly affected by drainage and were not related to the presence of uid collections. If signicant uid collections occurred, they could not be prevented by drainage. The study argued against the routine placement of a drain after CEA.

Recently, Smolock etal. [44] analysed data from 47,752 patients in the Vascular

Quality Initiative (VQI) registry who underwent CEA between 2011 and 2015. Drains were placed in 19,425 patients and no drains were placed in 28,327. Patients with drain placement were more likely to be taking a preoperative P2Y12 (p>0.001), to have prior CEA or carotid artery stenting (P<.001), to use dextran (P<.001), and to have a concomitant procedure or coronary artery bypass graft (P<.001) and less likely to use protamine (P<.001) compared with those without drain placement. Drain placement did not prevent return to the OR for bleeding (P< .22). Re-exploration of the carotid artery after closure in the OR (P<.001), preoperative P2Y12 antagonist use (P<.001), and no protamine use (P<.001) were predictors for return to the OR for bleeding among those with drain placement. Of patients requiring return to the OR for bleeding, drain placement did not inuence 30-day stroke (P= .82), 30-day mortality (P=.43), or 30-day combined stroke/mortality (P=.42) compared with those without drain placement. Drain placement did not inuence postoperative wound infection (P < .3). Hospital length of stay was increased in patients with drain placement (P<.001). In conclusion, drain placement after CEA did not reduce return to the OR for bleeding, nor did it reduce perioperative stroke or death, but drain placement was associated with increased length of stay.

References

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10. Qi W, Lai Z, Shao J, Li K, Fang L, Xu L, Zhang X, Liu B. A systematic review and metaanalysis of combined carotid endarterectomy with ipsilateral proximal intervention (hybrid approach) for tandem carotid artery lesions. J Vasc Surg. 2021;73:2168–77.

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12. Giannopoulos S, Texakalidis P, Charisis N, Jonnalagadda AK, Chaitidis N, Giannopoulos S, Kaskoutis C, Machinis T, Koullias GJ. Synchronous carotid endarterectomy and coronary artery bypass graft versus staged carotid artery stenting and coronary artery bypass graft for patients with concomitant severe coronary and carotid stenosis: a systematic review and metaanalysis. Ann Vasc Surg. 2020;62:463–73.

13. Kakkos SK, Vega de Ceniga M, Naylor R.A systematic review and meta-analysis of periprocedural outcomes in patients undergoing carotid interventions following thrombolysis. Eur J Vasc Endovasc Surg. 2021;62:340–9.

14. Khan JM, McInnis CL, Ross-White A, Day AG, Norman PA, Boyd JG.Overview and diagnostic accuracy of near infrared spectroscopy in carotid endarterectomy: a systematic review and meta-analysis. Eur J Vasc Endovasc Surg. 2021;62:695–704.

15. Lazarides MK, Christaina E, Argyriou C, Georgakarakos E, Tripsianis G, Georgiadis GS.Editor’s choice-network meta-analysis of carotid endarterectomy closure techniques. Eur J Vasc Endovasc Surg. 2021;61:181–90.

16. Sridharan ND, Chaer RA, Smith K, Eslami MH.Carotid endarterectomy remains cost- effective for the surgical management of carotid stenosis. J Vasc Surg. 2022;75:1304–10.

17. Chang RW, Tucker LY, Rothenberg KA, Lancaster E, Faruqi RM, Kuang HC, Flint AC, Avins AL, Nguyen-Huynh MN.Incidence of ischemic stroke in patients with asymptomatic severe carotid stenosis without surgical intervention. JAMA. 2022;327:1974–82.

18. Keyhani S, Cheng EM, Hoggatt K, Austin PC, Madden E, Hebert PL, Halm EA, Naseri A, Johanning J, Abraham A, Bravata DM.Comparative effectiveness of carotid stenting to medical therapy among patients with asymptomatic carotid stenosis. Stroke. 2022;53:1157–66.

19. Keyhani S, Cheng EM, Hoggatt KJ, Austin PC, Madden E, Hebert PL, Halm EA, Naseri A, Johanning JM, Mowery D, Chapman WW, Bravata DM.Comparative effectiveness of carotid endarterectomy vs initial medical therapy in patients with asymptomatic carotid stenosis. JAMA Neurol. 2020;77:1110–21.

20. Krawisz AK, Roseneld K, White CJ, Jaff MR, Campbell J, Kennedy K, Tsai T, Hawkins B, Jones S, Secemsky EA.Clinical impact of contralateral carotid occlusion in patients undergoing carotid artery revascularization. J Am Coll Cardiol. 2021;77:835–44.

21. Cole TS, Mezher AW, Catapano JS, Godzik J, Baranoski JF, Nakaji P, Albuquerque FC, Lawton MT, Little AS, Ducruet AF.Nationwide trends in carotid endarterectomy and carotid artery stenting in the post-CREST era. Stroke. 2020;51:579–87.

1 Extracranial Carotid Stenosis

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22. Hammar K, Laska AC, Wester P, Mani K, Lundström A, Jonsson M.Low incidence of late ipsilateral ischaemic stroke after treatment for symptomatic carotid stenosis in Sweden 2008-2017: increased risk in the elderly and after carotid stenting. Eur J Vasc Endovasc Surg. 2022;63:24–32.

23. Sagris M, Giannopoulos S, Giannopoulos S, Tzoumas A, Texakalidis P, Charisis N, Kokkinidis DG, Malgor RD, Mouawad NJ, Bakoyiannis C.Transcervical carotid artery revascularization: a systematic review and meta-analysis of outcomes. J Vasc Surg. 2021;74:657–65.

24. Galyfos GC, Tsoutsas I, Konstantopoulos T, Galanopoulos G, Sigala F, Filis K, Papavassiliou V. Editor’s choice-early and late outcomes after transcarotid revascularisation for internal carotid artery stenosis: a systematic review and meta-analysis. Eur J Vasc Endovasc Surg. 2021;61:725–38.

25. Columbo JA, Martinez-Camblor P, O’Malley AJ, Stone DH, Kashyap VS, Powell RJ, Schermerhorn ML, Malas M, Nolan BW, Goodney PP.Association of adoption of transcarotid artery revascularization with center-level perioperative outcomes. JAMA Netw Open. 2021;4(2):e2037885.

26. Mehta A, Patel PB, Bajakian D, Schutzer R, Morrissey N, Malas M, Schermerhorn M, Patel VI. Transcarotid artery revascularization versus carotid endarterectomy and transfemoral stenting in octogenarians. J Vasc Surg. 2021;74:1602–8.

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29. Martin C, Auboyer C, Boisson M, Dupont H, Gauzit R, Kitzis M, Leone M, Lepape A, Mimoz O, Montravers P, Pourriat JL, Steering Committee of the French Society of Anaesthesia and Intensive Care Medicine (SFAR) responsible for the establishment of the guidelines. Antibioprophylaxis in surgery and interventional medicine (adult patients). Update 2017. Anaesth Crit Care Pain Med. 2019;38:549–62.

30. Kristensen SD, Knuuti J, Saraste A, etal. 2014 ESC/ESA guidelines on non-cardiac surgery: cardiovascular assessment and management: the joint task force on non-cardiac surgery: cardiovascular assessment and management of the European Society of Cardiology (ESC) and the European Society of Anaesthesiology (ESA). Eur Heart J. 2014;35:2383–431.

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32. Tsujikawa S, Ikeshita K.Low-dose dexmedetomidine provides hemodynamics stabilization during emergence and recovery from general anesthesia in patients undergoing carotid endarterectomy: a randomized double-blind, placebo-controlled trial. J Anesth. 2019;33:266–72.

33. Bouri S, Thapar A, Shalhoub J, Jayasooriya G, Fernando A, Franklin IJ, Davies AH. Hypertension and the post-carotid endarterectomy cerebral hyperperfusion syndrome. Eur J Vasc Endovasc Surg. 2011;41:229–37.

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37. Stone DH, Giles KA, Kubilis P, Suckow BD, Goodney PP, Huber TS, Powell RJ, Cronenwett JL, Scali ST.Editor’s choice-protamine reduces serious bleeding complications associated with carotid endarterectomy in asymptomatic patients without increasing the risk of stroke, myocardial infarction, or death in a large National analysis. Eur J Vasc Endovasc Surg. 2020;60:800–7.

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44. Smolock CJ, Morrow KL, Kang J, Kelso RL, Bena JF, Clair DG. Drain placement confers no benet after carotid endarterectomy in the vascular quality initiative. J Vasc Surg. 2020;72:204–8.

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Chapter 2

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Thoracic-Outlet-Syndrome

2.1 Guidelines

2.1.1 Society forVascular Surgery

There are no guidelines for thoracic outlet syndrome (TOS); only the Society for Vascular Surgery has dened reporting standards [1, 2]. They focus on the description of ndings, diagnosis, treatment and presentation of results, including follow up. These excellent explanations are very comprehensive and can therefore not be referred to in detail here. In the following, we will limit ourselves to the classication and anatomy, and reporting standards.

2.1.1.1 Classication

• TOS is commonly referred to as one clinical entity. However, there are three

distinct types of TOS, depending on the principal anatomic structures involved and the clinical syndromes that result. Diagnosis, treatment, and outcomes vary, and these must be reported as separate entities.

• Neurogenic TOS (NTOS): Neurogenic symptoms are most common, caused by

brachial plexus compression or irritation at the scalene triangle or pectoralis minor space. Patients have symptoms caused by compression and irritation of the brachial plexus.

• Venous TOS (VTOS): Venous symptoms are caused by subclavian vein com-

pression at the costoclavicular junction or occasionally the pectoralis minor space and present as acute or chronic upper extremity deep venous thrombosis (Paget-Schroetter syndrome, effort thrombosis) or positional swelling (McCleery syndrome). Patients have signs and symptoms caused by intermittent compres-

Switzerland AG 2023 E. S. Debus, R. T. Grundmann, Evidence-based Therapy in Vascular Surgery,

https://doi.org/10.1007/978-3-031-47397-5_2

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2 Thoracic-Outlet-Syndrome

sion or partial or complete thrombosis of the subclavian vein at the costoclavicular junction.

• Arterial TOS (ATOS): ATOS occurs when the subclavian artery is compressed at

the scalene triangle, often by an anomalous bone structure, and presents as either symptomatic ischemia with the arm elevated or xed arterial damage (stenosis, occlusion, or aneurysmal degeneration resulting in upper extremity ischemia, commonly due to embolization). Note that to diagnose ATOS, the limb must be objectively ischemic with stress maneuvers; pulse obliteration and asymptomatic hemodynamic or anatomic changes with provocative maneuvers in the absence of such changes do not meet the denition of ATOS.

2.1.1.2 Reporting Standards: Treatment

NTOS

• Ergonomic modications at work and home or workplace.

• Physical therapy.

• Any other therapy attempted (massage, chiropractic) and results thereof.

• Medications.

• Therapeutic muscular, perineural, epidural or other injections (steroids, botuli-

num toxin).

• Operative decompression of the thoracic outlet, potentially including brachial

plexus neurolysis.

– Surgical approach and structures removed or altered, with precise attention

paid to terminology [as described in this guideline] (including extent of rib resection, anomalous anatomy observed, pectoralis minor tenotomy, neuroly-

sis, and any wrapping or other treatment of the nerves). – Pleural entry, use of chest drainage. – Intraoperative complications. – Postoperative pain control methods used. – Length of hospital stay. – Any postoperative complications or readmissions within 30days.

VTOS

• Axillosubclavian venous thrombolysis.

– Duration of symptoms in days and classication as before. – Successful or unsuccessful wire passage. – Technique: conventional (infusion during 6 to 48h) or pharmacomechanical

(immediate mechanically assisted thrombus removal). – Any adjunctive measures used (e.g., balloon venoplasty; note that stenting is

contraindicated in this situation).

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Соседние файлы в папке Библиотека им академика М.И. Перельмана

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15.09.202611 Мб0Книга_3870_Библиотеки_им_академика_М_И_Перельмана.pdf
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15.09.202611 Мб0Книга_3871_Библиотеки_им_академика_М_И_Перельмана.pdf
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15.09.202611 Мб0Книга_3872_Библиотеки_им_академика_М_И_Перельмана.pdf
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15.09.202611 Мб0Книга_3873_Библиотеки_им_академика_М_И_Перельмана.pdf
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15.09.202610 Мб0Книга_3874_Библиотеки_им_академика_М_И_Перельмана.pdf
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15.09.202610 Мб0Книга_3876_Библиотеки_им_академика_М_И_Перельмана.pdf
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15.09.202610 Мб0Книга_3879_Библиотеки_им_академика_М_И_Перельмана.pdf
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10.10.202610 Мб0Книга_3881_Библиотеки_им_академика_М_И_Перельмана.pdf
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10.10.202610 Мб0Книга_3882_Библиотеки_им_академика_М_И_Перельмана.pdf
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10.10.202610 Мб0Книга_3883_Библиотеки_им_академика_М_И_Перельмана.pdf
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10.10.202610 Мб0Книга_3884_Библиотеки_им_академика_М_И_Перельмана.pdf