Comparative Results for the Carotid Artery Stenting Versus Carotid Endarterectomy with Regional Anesthesia: Retrospective Analysis and Review of the Literature

Öz

Introduction: Carotid artery endarterectomy has already gained acceptance as the standard method for treating extracranial carotid artery stenosis. The last 2 decades have witnessed the increasing popularity of minimally invasive endovascular techniques.Patients and Methods: This study involved a retrospective analysis of 41 patients undergoing stent placement in carotid artery and carotid artery endarterectomy between January 2005 and January 2012 due to carotid artery stenosis. The patients were divided into two groups, group 1 (surgery, n=20) and group 2 (stenting, n=21). The two groups were compared with respect to complications, length of hospitalization, and costs.Results: The mean age was 68.35±8.21 years in group 1 and 66.76±9.16 years in group 2. The mean total cost was 2158.00±801.30 TL (Turkish Lira) for group 1 and 6927.86±2884.72 TL for group 2. The mean length of follow-up was 560.05±232.94/ days in the stenting group and was 933.85±505.45 /days in the surgery group. No statistically significant difference was found between the two groups in terms of age, gender, diabetes mellitus, restenosis, mean duration of hospitalization, and mortality (p>0.05). The only difference was observed in the average cost, which turned out to be lower in group 1 than in group 2 (p

Anahtar Kelimeler

• Stents, carotid endarterectomy; anesthesia; regional

Anestezi Altında Karotis Endarterektomi ile Karotis Arter Stentin Karşılaştırmalı Sonuçları: Retrospektif Analiz ve Litaratürün Gözden Geçirilmesi

Öz

Giriş: Karotis arter endarterektomi ekstrakranial karotis arter stenozunun standart tedavisinde kabul edilmiş bir yöntemdir. Son iki dekatta, minimal invaziv endovasküler teknikler daha popüler hale gelmiştir. Hastalar ve Yöntem: Çalışmamızda Ocak 2005-Ocak 2012 yılları arasında karotis arter tıkanıklığı nedeniyle karotis arter endarterktomi ve karotis artere stent yerleştirilmesi yapılan 41 hasta retrospektif olarak analiz edildi. Hastalar grup 1 (cerrahi, n=20) ve grup 2 (stent, n=21) olarak iki gruba ayrıldı. Hastalar postoperatif komplikasyon, hastane kalış ve maliyet açısından karşılaştırıldı.Bulgular: Ortalama yaş grup 1'de 68,35±8,21 yıl, grup 2'de ise 66,76±9,16 yıl idi. Ortalama toplam maliyet grup 1'de 2158,00±801,30 TL (Türk lirası), grup 2'de 6927,86±2884,72 TL idi. Ortalama takip süresi stent grubu için 560,05±232,94/gün ve cerrahi grup için 933,85±505,45/gün idi. Yaş, cinsiyet, diabetes mellitus, restenoz, ortalama hastanede kalış süresi ve mortalite açısından iki grup arasında fark yoktu. Sadece maliyet grup 1'de grup 2'den daha düşüktü (p>0,05). Sonuç: Son zamanlarda yeni stent ve filtre tipleri rekürren internal karotis arter stenozu olan ve boyuna radyoterapi alan hastalarda tercih edilebilir. Ancak bölgesel anestezi altında karotis endarterektomi stent ile karşılaştırıldığında stent kadar güvenli olup üstelik stentden daha ucuzdur.

Anahtar Kelimeler

• Stent, karotis endarterektomisi; bölgesel anestezi

Kaynakça

1. Powell RJ, Schermerhorn M, Nolan B, Lenz J, Rzuidlo E, Fillinger M, et al. Early results of carotid stent placement for treatment of extracranial carotid bifurcation occlusive disease. J Vasc Surg 2004;39:1193-9.
2. Bockenheimer SA, Mathias K. Percutaneous transluminal angioplasty in arteriosclerotic internal carotid artery stenosis. AJNR Am J Neuroradiol 1983;4:791-2.
3. Marks MP, Dake MD, Steinberg GK, Norbash AM, Lane B. Stent placement for arterial and venous cerebrovascular disease: preliminary experience. Radiology 1994;191:441-6.
4. Gurm HS, Yadav JS, Fayad P, Katzen BT, Mishkel GJ, Bajwa TK, et al. Long-term results of carotid stenting versus endarterectomy in high-risk patients. N Engl J Med 2008;358:1572-9.
5. Van der Vaart MG, Meerwaldt R, Reijnen MM, Tio RA, Zeebregts CJ. Endarterectomy or carotid artery stenting: the quest continues. Am J Surg 2008;195:259-69.
6. Liu ZJ, Fu WG, Guo ZY, Shen LG, Shi ZY, Li JH. Updated systematic review and meta-analysis of randomized clinical trials comparing carotid artery stenting and carotid endarterectomy in the treatment of carotid stenosis. Ann Vasc Surg 2012;26:576-90.
7. Misra BK, Purandare HR, Ved R, Ashok PP. Carotid endarterectomy: results and long-term follow-up of a single institution Neurol India 2011;59:390-6.
8. Anastasian ZH, Gaudet JG, Connolly ES Jr, Arunajadai S, Heyer EJ. The effect of antihypertensive class on intraoperative pressor requirements during carotid endarterectomy. Anesth Analg 2011;112:1452-60.

9. North American Symptomatic Carotid Endarterectomy Trial (NASCET) Collaborators. Beneficial effects of carotid endarterectomy in symptomatic patients with high-grade carotid stenosis. N Engl J Med 1991;325:445-53.
10. Barnett HJ, Taylor DW, Eliasziw M, Fox AJ, Ferguson GG, Haynes RB, et al. Benefit of carotid endarterectomy in patients with symptomatic moderate or severe stenosis: North American Symptomatic Carotid Endarterectomy Trial Collaborators. N Engl J Med 1998;339:1415-25.
11. Goldstein LB, Samsa GP. Reliability of the National Institutes of Health Stroke Scale: extension to non-neurologists in the context of a clinical trial. Stroke 1997;28:307-10.
12. CAVATAS Investigators. Endovascular versus surgical treatment in patients with carotid stenosis in the Carotid and Vertebral Artery Transluminal Angioplasty Study (CAVATAS): a randomized trial. Lancet 2001;357:1729- 37.
13. Space Collaborative Group, Ringleb PA, Allenberg J, Bru¨ckmann H, Eckstein HH, Fraedrich G, et al. 30 day results from the SPACE trial of stent-protected angioplasty versus carotid endarterectomy in symptomatic patients: a randomized noninferiority trial. Lancet 2006;368:1239-47.
14. Randomised trial of endarterectomy for recently symptomatic carotid stenosis: final results of the MRC European Carotid Surgery Trial (ECST). Lancet 1998;351:1379-87.
15. Rowed DW, Houlden DA, Burkholder LM, Taylor AB. Comparison of monitoring techniques for intraoperative cerebral ischemia. Can J Neurol Sci 2004;31:347-56.
16. Lewis SC, Warlow CP, Bodenham AR, Colam B, Rothwell PM, Torgerson D, et al. General anaesthesia versus local anaesthesia for carotid surgery (GALA): a multicentre, randomised controlled trial. Lancet 2008;372:2132- 42.
17. Kim TY, Choi JB, Kim KH, Kim MH, Shin BS, Park HK. Routine Shunting is Safe and Reliable for Cerebral Perfusion during Carotid Endarterectomy in Symptomatic Carotid Stenosis. Korean J Thorac Cardiovasc Surg 2012;45:95-100.
18. Woodworth GF, McGirt MJ, Than KD, Huang J, Perler BA, Tamargo RJ. Selective versus routine intraoperative shunting during carotid endarterectomy: a multivariate outcome analysis. Neurosurgery 2007;61:1170-6.
19. Kalko Y, Aydin U, Bayrak Y, Kafa U, Kösker T, Basaran M, et al. Carotid endarterectomy under local anesthesia: single institutional experience. Interact Cardiovasc Thorac Surg 2006;5:570-3.
20. Mayer RC, Bingley J, Westcott MJ, Deshpande A, Davies MJ, Lovelock ME, et al. Intraoperative neurological changes in 1665 regional anaesthetic carotid endarterectomies predicts postoperative stroke. ANZ J Surg 2007;77:49-53.
21. Rantner B, Goebel G, Bonati LH, Ringleb PA, Mas JL, Fraedrich G; Carotid Stenting Trialists’ Collaboration. The risk of carotid artery stenting compared with carotid endarterectomy is greatest in patients treated within 7 days of symptoms. J Vasc Surg 2013;57:619-26.
22. Park B, Mavanur A, Dahn M, Menzoian J. Clinical outcomes and cost comparison of carotid artery angioplasty with stenting versus carotid endarterectomy. J Vasc Surg 2006;44:270-6.
23. Doig D, Brown MM. Carotid stenting versus endarterectomy. Annu Rev Med 2012;63:259-76.
24. Vilain KR, Magnuson EA, Li H, Clark WM, Begg RJ, Sam AD 2nd, et al; CREST Investigators. Costs and cost-effectiveness of carotid stenting versus endarterectomy for patients at standard surgical risk: results from the Carotid Revascularization Endarterectomy Versus Stenting Trial (CREST). Stroke 2012;43:2408-16.