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Endovascular-First Approach for Symptomatic Carotid Artery Stenosis in a COVID-19 Positive Patient: Expected and Unexpected Advantages

Published:March 02, 2022DOI:https://doi.org/10.1016/j.avsg.2022.01.018
      Although carotid endarterectomy (CEA) remains the mainstay of treatment of symptomatic carotid artery stenosis, some authors have proposed to shift to a Carotid Artery Stent (CAS)-first approach during the most acute phases of the Coronavirus Disease 2019 (COVID-19) pandemic, in order to spare anesthesiology staff and facilities employment, and preserve Intensive Care Unit capacity.
      • Hellegering J.
      • van der Laan M.J.
      • Heide E.J.
      • et al.
      Preventing stroke in symptomatic carotid artery disease during the COVID-19 pandemic.
      In 2020, as the first COVID-19 outbreak overwhelmed the Hospitals in Europe and the United States, Hellegering et al. advocated CAS-first to be safe and effective in symptomatic patients, based on their previous experience of a tertiary referral center, but they have not reported the outcomes of their new approach yet.
      • Hellegering J.
      • van der Laan M.J.
      • Heide E.J.
      • et al.
      Preventing stroke in symptomatic carotid artery disease during the COVID-19 pandemic.
      Moreover, they made no mention of the expected results of CAS in symptomatic patients affected by concomitant COVID-19, an aspect worthy of attention not only due to the high prevalence of asymptomatic or undetected COVID-19 among the general population as the Omicron variant is increasingly spreading, but also because of the widely reported higher risk of ischemic stroke and Transient Ischemic Attack (TIA) in those patients.
      • Esenwa C.
      • Cheng N.T.
      • Lipsitz E.
      • et al.
      COVID-19-associated carotid atherothrombosis and stroke.
      We seek to contribute to the current knowledge on these matters by reporting on a case of a symptomatic patient with recurrent TIAs and concomitant paucisymptomatic COVID-19 successfully treated with CAS.
      An 81-year-old male affected by hypertension, chronic ischemic heart disease, atrial fibrillation under novel anticoagulant therapy (Edoxaban 30 mg/day), and previous prostate cancer treated with radiotherapy presented in the Emergency Room of our Center with numbness, paresthesia, and transient motor impairment of the left arm, subsiding within 30 minutes. He underwent neurological evaluation, brain CT scan, Computed Tomography Angiography (CTA) of the supra-aortic vessels, and carotid artery Duplex scan, which revealed a severe stenosis of the right internal carotid artery (>90%) due to a soft plaque located at its origin.
      At first, we interrupted the anticoagulant therapy and scheduled urgent carotid endarterectomy (CEA) after at least 48 hours, but routine preadmission pharyngeal swab resulted positive for SARS-CoV2, although the patient had no fever, cough, dyspnea, or fatigue, and oxygen saturation of hemoglobin was steadily above 95%. The patient was therefore admitted in the COVID-19-dedicated ward under close observation, and considering the high thrombotic risk that comes with the infection, the anticoagulant treatment was immediately resumed. We thought of delaying CEA waiting for the COVID-19 test to turn negative, albeit not beyond the recommended period of 14 days, but four days after admission, the patient had a relapse of paresthesia to the left arm. Magnetic resonance was negative for acute ischemic foci or cerebral hemorrhage, but the recurrence of the neurologic symptoms clearly indicated that treatment could not be further delayed.
      With the anticoagulant treatment still ongoing, we switched our operative strategy to urgent CAS, for which we obtained fully informed consent from the patient and his family. The procedure was performed under local anesthesia, with right transfemoral percutaneous access. A Carotid Wallstent® (Boston Scientific, Santa Clara, CA) 9 × 40 mm was deployed at the origin of the internal right carotid artery and postdilated with a balloon Ultrasoft SV® (Boston Scientific, Santa Clara, CA) 4.5 × 20 mm. Completion angiogram showed optimal patency of the right carotid axis in the absence of residual stenosis. No neurological deficits occurred during the procedure. The postoperative course was uneventful, without any relapse of sensory-motor impairment of the left arm, and 75 mg of clopidogrel was added to the chronic daily therapy for 30 days. The patient was discharged on postoperative day II, observing home quarantine until his follow-up swab turned negative.
      As a renewed interest toward extending CAS to symptomatic carotid artery stenosis is arising in the setting of the last pandemic wave caused by the Omicron variant, this experience completes the one reported by Hellegering et al., showing that a CAS-first approach in symptomatic carotid artery stenosis is useful not only to avoid intensive care facility and staff overload, but also to manage COVID-19 patients requiring urgent interventions.
      • Hellegering J.
      • van der Laan M.J.
      • Heide E.J.
      • et al.
      Preventing stroke in symptomatic carotid artery disease during the COVID-19 pandemic.
      In fact, although no specific literature exists regarding the perioperative risk related to CEA for these patients, current anesthesiology guidelines and consensus documents acknowledge that active COVID-19 increases surgical risk and advise, when feasible that any surgery should be delayed >6 weeks after infection resolution.
      • Connors J.M.
      • Levy J.H.
      Thrombo inflammation and the hypercoagulability of COVID-19.
      Moreover, the well-known COVID-19-related hypercoagulability dictates a suitable antithrombotic prophylaxis or even, according to some authors, systemic anticoagulation, which makes the management of chronic anticoagulant and antiplatelet therapy extremely complex and a reason for concern.
      • Zhang S.
      • Zhang J.
      • Wang C.
      • et al.
      COVID-19 and ischemic stroke: mechanisms of hypercoagulability (review).
      • Marone E.M.
      • Rinaldi L.F.
      Upsurge of deep venous thrombosis in patients affected by COVID-19: preliminary data and possible explanations.
      • Rico-Mesa J.S.
      • Rosas D.
      • Ahmadian-Tehrani A.
      • et al.
      The role of anticoagulation in COVID-19-induced hypercoagulability.
      • Marone E.M.
      • Bonalumi G.
      • Curci R.
      • et al.
      Characteristics of venous thromboembolism in COVID-19 patients: a multicenter experience from Northern Italy.
      On the one hand, in fact, anticoagulant therapy, if continued in the perioperative period, increases the risk of bleeding complications and neck hematoma, compromising the success of CEA (but not CAS).
      • Faggioli G.
      • Pini R.
      • Rapezzi C.
      • et al.
      Carotid revascularization in patients with ongoing oral anticoagulant therapy: the advantages of stent placement.
      On the other hand, its discontinuation exposes patients with active SARS-CoV2 infections to both arterial and venous thrombotic events, with catastrophic consequences in the setting of carotid surgery for cerebral ischemia.
      • Roussopoulou A.
      • Lazaris A.
      • Tsivgoulis G.
      • et al.
      Risk of perioperative neck hematoma in TIA and non-disabling stroke patients with symptomatic carotid artery stenosis undergoing endarterectomy within 14 days from cerebrovascular event.
      For these reasons, in patients taking chronic anticoagulant therapy, we found that endovascular treatment offers the ideal solution to this problem, allowing its maintenance throughout the perioperative and postoperative course. Other advantages of an endovascular approach in COVID-19 patients include local anesthesia and shorter in-hospital stay, as already highlighted for aortic surgery in previous publications.
      • Rinaldi L.F.
      • Marazzi G.
      • Marone E.M.
      Endovascular treatment of a ruptured pararenal abdominal aortic aneurysm in a patient with coronavirus disease-2019: suggestions and case report.
      In conclusion, we support the view that a CAS-first approach in symptomatic carotid artery stenosis is safe and effective in the pandemic setting, particularly for patients affected by concomitant COVID-19.

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