Current Literature

30-Day Perioperative Clinical Outcomes of Transcarotid Artery Revascularization versus Carotid Endarterectomy

AbuRahma AF, Santini A, AbuRahma ZT, et al. Thirty-Day Perioperative Clinical Outcomes of Transcarotid Artery Revascularization vs Carotid Endarterectomy in a Single-Center Experience. J Am Coll Surg. 2023, in press.

Transcarotid artery revascularization (TCAR) is a minimally invasive procedure that utilizes flow reversal followed by carotid artery stenting to reduce the risk of plaque embolization. The features of the procedure are clearly described on the Society for Vascular Surgery website.

TCAR has been proposed as an alternative to carotid endarterectomy (CEA) and conventional carotid artery stenting. This study presented short-term results of TCAR compared to CEA using prospectively collected data from a single center. The main outcomes of interest were 30-day rates of stroke and/or death; other outcomes analyzed were rates of complications such as cranial nerve injury and bleeding. Propensity matching was used to compare risk-adjusted patients (n = 501: 347 CEA, 154 TCAR). Preoperative symptoms were equivalent in the two groups, with TCAR patients having higher rates of preoperative hypertension.

The data analysis showed that observed outcomes were similar in the two groups and this remained true following propensity matching. The authors concluded that TCAR and CEA produced similar results.

Data from other published studies are presented in the discussion section of the article; these data suggested that TCAR is associated with a lower risk of perioperative myocardial infarction compared with CEA. The authors also noted that other published research has suggested a higher risk of long-term need for reintervention in patients treated with stenting and they recommended additional studies to gather long-term outcomes data.

Indocyanine Green Dosing in Biliary Anatomy Identification

Ladd AD, Rodriguez JZ, Lewis D, et al. Low vs Standard-Dose Indocyanine Green in the Identification of Biliary Anatomy Using Near-Infrared Fluorescence Imaging: A Multicenter Randomized Controlled Trial. J Am Coll Surg. 2023, in press.

Near-infrared fluorescence (NIRF) imaging using indocyanine green (ICG) is used to facilitate identification of biliary anatomy during procedures such as laparoscopic cholecystectomy. A disadvantage of standard dose ICG (2.5 mg) is hepatic and background fluorescence that may reduce the accuracy of biliary anatomy identification. This article reported data from a randomized, prospective study that assessed the potential advantages of using a lower dose of ICG (0.05 mg); the study cohort consisted of 55 patients who underwent laparoscopic cholecystectomy.

Surgeons were blinded as to the dose of ICG; anatomic visualization was graded using video recordings of the procedures and NIRF was compared to standard visible light imaging using a standard scale. The data showed that NIRF using the lower dose of ICG was associated with significantly improved bile duct-to-liver and bile duct-to-background fat fluorescence ratios. In addition, low-dose ICG had slightly better mean standard scores, but this did not reach statistical significance. The authors concluded that reduced background fluorescence was a potentially valuable characteristic of low-dose ICG usage.

Postoperative VTE Chemoprophylaxis Associated with Reduced Bleeding Complications versus Dosing Prior to Skin Closure

Klonis C, Ashraf H, Cabalag CS, Wong DJ, Stevens SG, Liu DS. Optimal Timing of Perioperative Chemical Thromboprophylaxis in Elective Major Abdominal Surgery: A Systematic Review and Meta-Analysis. Ann Surg. 2022.

The optimal timing of administration of anticoagulant drugs for prevention of postoperative venous thromboembolism (VTE) in patients undergoing major abdominal surgical procedures is not known. Surgeon dosing practices are variable with anticoagulants administered preoperatively, prior to skin closure, and postoperatively.

Available systematic reviews of the literature have suggested that outcomes are similar for all dosing times, but these reviews analyzed data from heterogeneous study cohorts that included orthopedic, neurosurgical, urologic, and general surgery patients; thus, evidence to support one dosing time over another for patients undergoing major abdominal operations is needed. This systematic review used data from 14 studies that supplied data from 24,922 patients. Patients undergoing bariatric surgery, anti-reflux procedures, colorectal surgery, ventral hernia repair, and miscellaneous major abdominal procedures were included.

Chemoprophylaxis was initiated before skin closure in 10,403 patients and postoperatively in 14,519 patients. The data analysis showed that risk for postoperative VTE was equivalent for both dosing times, but the risks of significant bleeding events (all bleeding events, major bleeding, need for transfusion, and need for reintervention) were significantly increased in patients receiving chemoprophylaxis prior to skin closure. The authors concluded that administration of VTE chemoprophylaxis postoperatively was associated with reduced risk of bleeding complications compared with dosing prior to skin closure.