Hypothermia during Carotid Endarterectomy: A Safety Study
Serena Candela, Raffaele Dito, Barbara Casolla, Emanuele Silvestri, Giuliano Sette, Federico Filippi, Maurizio Taurino, Domitilla Brancadoro, Francesco Orzi, Serena Candela, Raffaele Dito, Barbara Casolla, Emanuele Silvestri, Giuliano Sette, Federico Filippi, Maurizio Taurino, Domitilla Brancadoro, Francesco Orzi
Abstract
Background: CEA is associated with peri-operative risk of brain ischemia, due both to emboli production caused by manipulation of the plaque and to potentially noxious reduction of cerebral blood flow by carotid clamping. Mild hypothermia (34-35°C) is probably the most effective approach to protect brain from ischemic insult. It is therefore a substantial hypothesis that hypothermia lowers the risk of ischemic brain damage potentially associated with CEA. Purpose of the study is to test whether systemic endovascular cooling to a target of 34.5-35°C, initiated before and maintained during CEA, is feasible and safe.
Methods: The study was carried out in 7 consecutive patients referred to the Vascular Surgery Unit and judged eligible for CEA. Cooling was initiated 60-90 min before CEA, by endovascular approach (Zoll system). The target temperature was maintained during CEA, followed by passive, controlled rewarming (0.4°C/h). The whole procedure was carried out under anesthesia.
Results: All the patients enrolled had no adverse events. Two patients exhibited a transient bradycardia (heart rate 30 beats/min). There were no significant differences in the clinical status, laboratory and physiological data measured before and after CEA.
Conclusions: Systemic cooling to 34.5-35.0°C, initiated before and maintained during carotid clamping, is feasible and safe.
Trial registration: ClinicalTrials.gov NCT02629653.
Conflict of interest statement
Competing Interests: The authors have declared that no competing interests exist.
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References
- Grotta JC. Clinical practice. Carotid stenosis. N Engl J Med 2013; 369(12):1143–50. 10.1056/NEJMcp1214999
- Kang J, Conrad MF, Patel V I, Mukhopadhyay S, Garg A, Cambria MR, et al. Clinical and anatomic outcomes after carotid endarterectomy. J Vasc Surg 2014; 59:944–949. 10.1016/j.jvs.2013.10.059
- Lee JH, Suh BY. Risk factor analysis of new brain lesions associated with carotid endarterectmy. Ann Surg Treat Res 2014; 86(1):39–44. 10.4174/astr.2014.86.1.39
- Barnett HJM, Taylor DW, Eliasziw M, Fox AJ, Ferguson GG, Haynes RB, et al. Benefit of carotid endarterectomy in patients with symptomatic moderate or severe stenosis. N Engl J Med 1998; 339:1415–25.
- North American Symptomatic Carotid Endarterectomy Trial Collaborators: Beneficial effect of carotid endarterectomy in symptomatic patients with high-grade carotid stenosis. N Engl J Med 1991; 325(7):445–53.
- Executive Committee for the Asymptomatic Carotid Atherosclerosis Study: Endarterectomy for asymptomatic carotid artery stenosis. JAMA 1995; 273:1421–8.
- Go C, Avgerinos ED, Chaer RA, Ling J, Wazen J, Marone L, et al. Long term clinical outcomes and cardiovascular events following carotid endarterectomy. Ann Vasc Surg 2015; 29(6):1265–71. 10.1016/j.avsg.2015.03.031
- Gupta PK, Ramanan B, MacTaggart JN, Sundaram A, Fang X, Gupta H, et al. Risk index for predicting perioperative stroke, myocardial infarction, or death risk in asymptomatic patients undergoing carotid endarterectomy. J Vasc Surg 2013; 57(2):318–26. 10.1016/j.jvs.2012.08.116
- Yenari M A, Soo Han H. Neuroprotective mechanisms of hypothermia in brain ischaemia. Nat Rev Neurosci. 2012; 13(4):267–78. 10.1038/nrn3174
- Steen PA, Newberg L, Milde JH, Michenfelder JD. Hypothermia and barbiturates: Individual and combined effects on canine cerebral oxygen consumption. Anesthesiology 1983; 58(6):527–532.
- Erecinska M, Thoresen M, Silver IA: Effects of hypothermia on energy metabolism in mammalian central nervous system. J Cereb Blood Flow Metab 2003; 23:513–530.
- Yenari M, Kitagawa K, Lyden P, Perez-Pinzon M: Metabolic Downregulation: A Key to Successful Neuroprotection?. Stroke 2008; 39(10):2910–7. 10.1161/STROKEAHA.108.514471
- Wu TC, Grotta JC. Hypothermia for acute ischaemic stroke. Lancet Neurol 2013; 12(3):275–84. 10.1016/S1474-4422(13)70013-9
- Van Der Worp HB, Macleod MR, Kollmar R. Therapeutic hypothermia for acute ischemic stroke: ready to start large randomized trials? for the European Stroke Research Network for Hypothermia (EuroHYP). J Cereb Blood Flow Metab 2010; 30(10):1079–1093.
- Busto R, Globus MY, Dietrich WD, Martinez E, Valdés I, Ginsberg MD. Effect of mild hypothermia on ischemia induced release of neurotransmitters and free fatty acids in rat brain. Stroke 1989; 20(7):904–910.
- Kil HY, Zhang J, Piantadosi CA. Brain temperature alters hydroxyl radical production during cerebral ischemia/reperfusion in rats. J Cereb Blood Flow Metab 1996; 16(1):100–106.
- Xu L, Yenari MA, Steinberg GK, Giffard RG. Mild hypothermia reduces apoptosis of mouse neurons in vitro early in the cascade. J Cereb Blood Flow Metab 2002; 22(1):21–28.
- Li J, Benashski S, McCullough LD. Post-stroke hypothermia provides neuroprotection through inhibition of AMP-activated protein kinase. J Neurotrauma 2011; 28(7):1281–1288. 10.1089/neu.2011.1751
- Kamme F, Campbell K, Wieloch T. Biphasic expression of the fos and jun families of transcription factors following transient forebrain ischaemia in the rat. Effect of hypothermia. Eur J Neurosci 1995, 7(10):2007–2016.
- Lotocki G, de Rivero Vaccari JP, Perez ER, Sanchez-Molano J, Furones-Alonso O, Bramlett HM, et al. Alterations in blood-brain barrier permeability to large and small molecules and leukocyte accumulation after traumatic brain injury: Effects of post-traumatic hypothermia. J Neurotrauma 2009; 26(7):1123–1134. 10.1089/neu.2008.0802
Source: PubMed