Aortoenteric Fistula: A Late Complication of Endovascular Repair of an Inflammatory Abdominal Aortic Aneurysm

Endovascular repair provides a reasonable alternative to open repair for the treatment of abdominal aortic aneurysms in select cases. Although the endovascular approach may be preferable for inflammatory aneurysms, aggressive surveillance is needed to monitor for long-term complications. A 61-year-old man underwent endovascular exclusion of a symptomatic inflammatory abdominal aortic aneurysm with an AneuRx bifurcated aortic prosthesis. He presented with gastrointestinal bleeding 51/2 months later and was found to have an aortoenteric fistula involving the third portion of the duodenum. The aneurysm had expanded significantly at the proximal neck. The patient underwent successful removal of the device, aortic ligation, and extraanatomic bypass. Aortoenteric fistula is a rare but now established complication of endovascular aneurysm repair. The pathophysiology in these cases remains unclear. The presence of inflammation and endoleak may predispose to further aneurysmal degeneration.

Mycotic Carotid Artery Pseudoaneurysm Following Stenting

Carotid stenting is assuming an important role in the management of carotid disease. Surgeons although hesitant to embrace catheter treatment for the management of primary carotid artery disease, are more enthusiastic regarding it's use in the treatment of recurrent stenoses. This report suggests that caution should be exercised in the selection of patients to be treated with carotid stenting for recurrent disease.

Factors Affecting Recurrent Carotid Stenosis

Recurrent carotid stenosis is an ongoing process that may develop at or near the site of an operational or interventional procedure to treat an atheromatous stenosis. Although such a restenosis is most often initially without symptoms, as the disease progresses it may become symptomatic, and thus endanger the patient's life. Such patients are therefore candidates for revisional surgery. Extensive research investigation and numerous studies have incriminated several risk factors as predisposing conditions for recurrent carotid stenosis. The definite role of each predisposing factor, however, is still widely debated. Clarifying the extent of involvement of each factor in the pathogenesis of carotid restenosis is indeed demanding, as it would contribute enormously to the identification of the group of high-risk patients, and, therefore, determine the therapeutic approach in these patients.

Carotid artery stenting versus carotid endarterectomy: updated meta-analysis, metaregression and trial sequential analysis of short-term and intermediate-to long-term outcomes of randomized trials

INTRODUCTION

To compare carotid artery stenting (CAS) versus carotid endarterectomy (CEA) in the treatment of carotid stenosis, including two recently published, prospective, randomized trials of these therapies.

EVIDENCE ACQUISITION

A multiple electronic health database search on all randomized trials describing CAS compared with CEA in patients with symptomatic or asymptomatic carotid artery stenosis was performed. Primary outcomes were death, stroke, and myocardial infarction.

EVIDENCE SYNTHESIS

Carotid artery stenting as compared with CEA was associated with a 61% increase in the risk of periprocedural death or stroke (Peto OR, 1.609; 95% confidence interval [CI]: 1.193-2.170; P=0.002). The trial sequential monitoring boundary was crossed by the cumulative Z-curve, suggesting firm evidence for at least a 20% relative risk increase of periprocedural death or stroke and any stroke compared with CEA. Carotid artery stenting as compared with CEA was associated with a 42% increase in the risk for the composite of periprocedural stroke or death plus ipsilateral stroke thereafter (Peto OR, 1.417; 95% CI: 1.074-1.870; P=0.0014).

CONCLUSIONS

In this largest and most comprehensive meta-analysis to date using outcomes that are standard in contemporary studies, CAS was associated with an increased risk of both periprocedural and intermediate- to long-term outcomes.

Conventional carotid endarterectomy versus stenting: comparison of restenosis rates in arteries with identical predisposing factors

BACKGROUND

The aim of the study was to investigate the possible role of individual predisposition in the pathogenesis of carotid restenosis.

METHODS

Over 1700 patients have undergone carotid endarterectomy (CEA) in our institute over the past 15 years. We retrospectively reviewed the charts of those who also had contralateral carotid stenting (CAS) for primary atherosclerotic stenosis and recorded the rates of post-CEA and post-CAS restenosis ≥50%.

RESULTS

In the 29 cases analyzed (21 men/8 women), CEA was performed with conventional technique and direct suturing in most cases. Mean ages at the time of CEA and CAS were 69.2±6.6 and 73±6.7 yrs, respectively, and risk profiles at the 2 time points were similar: hypertension (96.5%), dyslipidemia (55.2%), smoking (51.7%), diabetes (31%), coronary artery disease (48.3%), chronic obstructive pulmonary disease (37.9%), and chronic renal failure (13.8%). Antiplatelet therapy protocols were identical for the two procedures. During follow-up (mean: 67.25±51.6 months after CEA, 24.6±16.9 months after CAS), Duplex scans revealed restenosis in 12 patients (9 arteries treated with CEA, 6 managed with CAS). In three patients, restenosis was bilateral. Restenosis-free survival rates at five years were 85% after CEA and 66% after CAS (P=NS).

CONCLUSIONS

In this selected group of patients, CEA and CAS were associated with a similar incidence of restenosis. Only 25% of the patients who developed restenosis did so after both procedures. These preliminary findings indicate that individual predisposition does not play a crucial role in the pathogenesis of restenosis. To confirm this conclusion, an analysis of a much larger, multicenter cohort is essential.

Drug-Coated Balloons for Infrainguinal Peripheral Artery Disease

Revascularization of infrainguinal peripheral artery disease has traditionally been accomplished via percutaneous transluminal angioplasty. However, long-term results have been hampered by high rates of restenosis. Along with the advent of stents, paclitaxel-coated balloons are an emerging therapeutic option for the invasive management of infrainguinal peripheral artery disease. Paclitaxel has been successful in inhibiting neointimal hyperplasia, the main mechanism for in-stent restenosis. Technological advances have facilitated the development of paclitaxel-coated balloons, which show promise in early trials for femoropopliteal stenosis relative to uncoated balloons. For infrapopliteal stenoses, the data remain scant and conflicted. Therefore, large-scale randomized clinical trials with long-term follow-up evaluating safety and effectiveness between various strategies need to be performed to determine the optimal invasive management strategy for infrainguinal peripheral artery disease.

Risk Factors for Developing Postprocedural Microemboli following Carotid Interventions

Purpose:

To determine risk factors predictive of microemboli found on diffusion-weighted magnetic resonance imaging (DW-MRI) following carotid angioplasty and stenting (CAS) with distal protection and carotid endarterectomy (CEA).

Methods:

A retrospective review was conducted of all carotid interventions at a single institution between 2004 and 2006. In that time frame, 64 carotid interventions (34 CAS, 30 CEA) were performed in 63 male patients (mean age 69.5 years, range 52 to 91) with DW-MRI scans available for review. Patient characteristics, including age, gender, smoking history, diabetes mellitus, hypertension, hyperlipidemia, obesity (body mass index >30), coronary artery disease (CAD), chronic obstructive pulmonary disease, peripheral vascular disease, and atrial fibrillation, were documented. For the CAS patients, anatomical and procedural characteristics, including fluoroscopy time, contrast volume, performance of an arch angiogram, and lesion anatomy, were recorded. Bivariate analyses were performed to determine which parameters were associated with the occurrence of acute postprocedural microemboli found on DW-MRI by 2 blinded neuroradiologists.

Results:

Twenty-four (71%) of the 34 CAS patients and 1 (3%) of the 30 CEA patients demonstrated new cerebral microemboli postoperatively. In the bivariate analyses of all patient, anatomical, and procedural characteristics, only a history of CAD was associated with an increased risk of microemboli; 20 (80%) of the 25 patients who had postprocedure microemboli had CAD compared to 18 (46%) of 39 patients without microemboli (p=0.007). Twenty (53%) of the 38 (59%) patients with CAD developed microemboli compared to 5 (19%) of the 26 patients without CAD (p=0.007). All other patient, procedural, and anatomical characteristics were not found to be independent risk factors predictive of postprocedure microemboli.

Conclusion:

CAS with distal protection carries a significantly greater risk for developing new microemboli compared to CEA. Of all the risk factors analyzed, only a history of CAD emerged as an independent risk factor for the development of microemboli following carotid intervention. This finding may influence the decision to perform CAS in patients deemed high risk solely due to the presence of CAD.

Predictors and Prognostic Significance of Troponin-I Release following Elective Coronary Angioplasty

The objective of this study was to investigate the predictors and prognostic significance of post-procedural cardiac troponin (cTn)-I elevations in a consecutive series of patients who underwent elective percutaneous coronary intervention (PCI). cTn-I was measured in 100 patients immediately before and within 24 h after the elective PCI. Post-procedural cTn-I elevation was observed in 27 of the 100 patients. In multivariate analysis, basal haemoglobin values and the number of repeated balloon dilatations were found to be independent predictors of cTn-I elevation. During the follow-up period of 12 ± 1.2 months, the cTn-I-positive group had more major adverse cardiovascular events than the cTn-I-negative group (33.3% versus 16.4%, respectively), but the difference was not significant. An increase in cTn-I levels following elective PCI procedures was frequent but did not predict a poor long-term outcome.

Brain Injury Secondary to Carotid Intervention

Causes of brain injury during endovascular carotid intervention are protean. Mechanisms of injury include embolic and hemodynamic events, acute carotid occlusions occurring through a variety of means, and the relatively rare contrast-induced encephalopathy.

Embolic injury may result from micro- and macroembolization and most commonly causes ischemic stroke when sufficiently severe. Hemodynamic injury may proceed from hemodynamic depression and hypoperfusion (which may result in watershed infarction) or the hyperperfusion syndrome, which may, if severe, result in hemorrhagic stroke.

Embolic and dynamic causes of stroke may either occur intraprocedurally or at a variable time after stent placement and may be co-related. Impaired clearance of emboli due to relative hypoperfusion may exacerbate their clinical relevance. Other causes of stroke include acute carotid occlusions, which most commonly occur procedurally due to flow-limiting spasm, acute dissection, and, if a filter-type cerebral protection device has been used, filter occlusion due to a large trapped embolic load. These scenarios may result in stroke if not recognized and dealt with appropriately. Acute stent thrombosis may occur within 24 hours of the procedure as a result of adverse hemodynamic factors or suboptimal patient response to procedural heparin and antiplatelet agents, or it may occur after the procedure, again perhaps as a result of suboptimal response to antiaggregate drugs.

Technological Advances in the Design of Catheters and Devices Used in Renal Artery Interventions: Impact on Complications

Purpose:

To analyze the impact of technical improvements in stent devices and guiding catheters (e.g., reduced device diameter, increased flexibility) on the complication rates associated with percutaneous renal artery interventions.

Methods:

During a 5-year period (1997–2001), 268 consecutive patients (178 men; mean age 67±9 years) had 370 atherosclerotic renal artery stenoses (RAS) ≥70% treated with angioplasty/stenting in 320 procedures. The guiding catheter technique was used routinely until 2000; in 2001, a guiding sheath was used in 29% of cases. From 1997 to 2000, sealing devices were frequently used for sheath removal; during the last year, the sheaths were removed using the Femostop device.

Results:

In 320 interventions, 32 (10%) complications occurred, with a decreasing frequency during the last 2 years (1996/97: 13% [7/53]; 1998: 16% [9/57]; 1999: 15% [11/74]; 2000: 4% [3/70]; 2001: 3% [2/66]). There were 21 (6.6%) local complications, including 4 cases requiring permanent hemodialysis after the intervention and 11 (3.4%) access site complications. No procedure-related death occurred. During the study period, the average sheath diameter was reduced from 8.15±0.76 F to 6.15±0.63 F (p<0.05). Mean procedural time was reduced from 42±13 minutes to 23±11 minutes (p<0.05). The initial heparin dose was reduced from 10,000 to 5000 units.

Conclusions:

In parallel with the use of more flexible catheters and premounted stents of lower profile, the complication rate of renal angioplasty/stenting of atherosclerotic RAS has been reduced significantly during a 5-year period.

Early Failure of Surgical Angioplasty with Tissue Glue: A Word of Caution

A 43-year-old woman with critical stenosis of the left main stem was managed with saphenous vein angioplasty using BioGlue. She developed severe myocardial ischemia postoperatively, probably due to external compression exerted on the patch by the adhesive material, and required emergency coronary artery bypass grafting.

Total Laparoscopic Aortic Surgery Versus Minimal Access Techniques: Review Of More Than 600 Patients

In the following paper we describe our experience with a large number of patients in which either a laparoscopic assisted procedure or a total laparoscopic operation was performed.

From 1996 until 2005 a total number of 638 aortic patients were operated on using a total laparoscopic or a laparoscopic assisted approach. A total laparoscopic operation was accomplished in 236 cases. A laparoscopic assisted aortic operation was performed in 402 patients. In aneurysm patients a tube graft was more frequently implanted.

Thirty-day mortality was significantly higher in patients with a total laparoscopic abdominal aortic aneurysm repair (3.0%) compared to a laparoscopic assisted procedure (1.8%). There was no significant difference in mortality in patients with occlusive disease and a total laparoscopic aortofemoral bypass versus a laparoscopically assisted operation.

The same tendency could be observed when analyzing the incidence of major perioperative complications. Again we found no significant difference in patients with occlusive disease yet more severe complications directly related to the operation in patients with a total laparoscopic aneurysm repair.

There was a significantly increased complication rate in total laparoscopic aortoiliac repair with a bifurcated prosthesis compared to a tube graft repair: a tendency we could not observe in aneurysm patients with a laparoscopic assisted operation.

Our data also show that there is a lot of room for technical improvements such as stapling devices or special grafts to reduce total operating times as well as the period of aortic crossclamping. The routine use of a minilaparotomy can hardly be a solution considering the technical drawbacks such as impaired vision and long term complications like ventral hernias. Compared to open surgery the midterm results of laparoscopic aortic procedures are promising. The time has come to prove that good results can be obtained in more than a few specialized centers.

Randomized Trial of Stent versus Surgery for Asymptomatic Carotid Stenosis

BACKGROUND

Previous clinical trials have suggested that carotid-artery stenting with a device to capture and remove emboli ("embolic protection") is an effective alternative to carotid endarterectomy in patients at average or high risk for surgical complications.

METHODS

In this trial, we compared carotid-artery stenting with embolic protection and carotid endarterectomy in patients 79 years of age or younger who had severe carotid stenosis and were asymptomatic (i.e., had not had a stroke, transient ischemic attack, or amaurosis fugax in the 180 days before enrollment) and were not considered to be at high risk for surgical complications. The trial was designed to enroll 1658 patients but was halted early, after 1453 patients underwent randomization, because of slow enrollment. Patients were followed for up to 5 years. The primary composite end point of death, stroke, or myocardial infarction within 30 days after the procedure or ipsilateral stroke within 1 year was tested at a noninferiority margin of 3 percentage points.

RESULTS

Stenting was noninferior to endarterectomy with regard to the primary composite end point (event rate, 3.8% and 3.4%, respectively; P=0.01 for noninferiority). The rate of stroke or death within 30 days was 2.9% in the stenting group and 1.7% in the endarterectomy group (P=0.33). From 30 days to 5 years after the procedure, the rate of freedom from ipsilateral stroke was 97.8% in the stenting group and 97.3% in the endarterectomy group (P=0.51), and the overall survival rates were 87.1% and 89.4%, respectively (P=0.21). The cumulative 5-year rate of stroke-free survival was 93.1% in the stenting group and 94.7% in the endarterectomy group (P=0.44).

CONCLUSIONS

In this trial involving asymptomatic patients with severe carotid stenosis who were not at high risk for surgical complications, stenting was noninferior to endarterectomy with regard to the rate of the primary composite end point at 1 year. In analyses that included up to 5 years of follow-up, there were no significant differences between the study groups in the rates of non-procedure-related stroke, all stroke, and survival. (Funded by Abbott Vascular; ACT I ClinicalTrials.gov number, NCT00106938.).

Current management of renal artery stenosis

Severe renal artery stenosis may cause renovascular hypertension; in case of bilateral narrowing or in a stenotic solitary kidney, renal insufficiency (e.g. ischemic kidney disease) or pulmonary flash edema may ensue. Renal artery stenosis can be treated by revasularization, using either percutaneous angioplasty (with or without stenting) or less common open surgical procedures, both with excellent primary patency rates. However, several randomized trials of renal artery angioplasty or stenting in patients with arteriosclerotic disease have failed to demonstrate a longer-term benefit with regard to blood pressure control and renal function over medical management. It has not yet been demonstrated that renal revascularization leads to a prolongation of event-free survival. Furthermore, endovascular procedures are associated with substantial risks. If revascularization is envisaged careful patient selection, e.g. patients with refractory hypertension or progressive renal failure, is important to maximize the potential benefit.

Effectiveness of revascularization of the ulcerated foot in patients with diabetes and peripheral artery disease: a systematic review

Symptoms or signs of peripheral artery disease (PAD) can be observed in up to 50% of the patients with a diabetic foot ulcer and is a risk factor for poor healing and amputation. In 2012, a multidisciplinary working group of the International Working Group on the Diabetic Foot published a systematic review on the effectiveness of revascularization of the ulcerated foot in patients with diabetes and PAD. This publication is an update of this review and now includes the results of a systematic search for therapies to revascularize the ulcerated foot in patients with diabetes and PAD from 1980 to June 2014. Only clinically relevant outcomes were assessed. The research conformed to the Preferred Reporting Items for Systematic Reviews and Meta-analyses guidelines, and Scottish Intercollegiate Guidelines Network methodological scores were assigned. A total of 56 articles were eligible for full-text review. There were no randomized controlled trials, but there were four nonrandomized studies with a control group. The major outcomes following endovascular or open bypass surgery were broadly similar among the studies. Following open surgery, the 1-year limb salvage rates were a median of 85% (interquartile range of 80-90%), and following endovascular revascularization, these rates were 78% (70-89%). At 1-year follow-up, 60% or more of ulcers had healed following revascularization with either open bypass surgery or endovascular techniques. Studies appeared to demonstrate improved rates of limb salvage associated with revascularization compared with the results of conservatively treated patients in the literature. There were insufficient data to recommend one method of revascularization over another. There is a real need for standardized reporting of baseline demographic data, severity of disease and outcome reporting in this group of patients.

Carotid Anatomy Does Not Predict the Risk of New Ischaemic Brain Lesions on Diffusion-Weighted Imaging after Carotid Artery Stenting in the ICSS-MRI Substudy

INTRODUCTION

The International Carotid Stenting Study (ICSS, ISRCTN25337470) randomized patients with recently symptomatic carotid artery stenosis > 50% to carotid artery stenting (CAS) or endarterectomy. CAS increased the risk of new brain lesions visible on diffusion-weighted magnetic resonance imaging (DWI-MRI) more than endarterectomy in the ICSS-MRI Substudy. The predictors of new post-stenting DWI lesions were assessed in these patients.

METHODS

ICSS-MRI Substudy patients allocated to CAS were studied. Baseline or pre-stenting catheter angiograms were rated to determine carotid anatomy. Baseline patient demographics and the influence of plaque length, plaque morphology, internal carotid angulation, and external or common carotid atheroma were examined in negative binomial regression models.

RESULTS

A total of 115 patients (70% male, average age 70.4) were included; 50.4% had at least one new DWI-MRI-positive lesion following CAS. Independent risk factors increasing the number of new lesions were a left-sided stenosis (incidence risk ratio [IRR] 1.59, 95% CI 1.04-2.44, p = .03), age (IRR 2.10 per 10-year increase in age, 95% CI 1.61-2.74, p < .01), male sex (IRR 2.83, 95% CI 1.72-4.67, p < .01), hypertension (IRR 2.04, 95% CI 1.25-3.33, p < .01) and absence of cardiac failure (IRR 6.58, 95% CI 1.23-35.07, p = .03). None of the carotid anatomical features significantly influenced the number of post-procedure lesions.

CONCLUSION

Carotid anatomy seen on pre-stenting catheter angiography did not predict of the number of ischaemic brain lesions following CAS.

Percutaneous Repair of Aortic Pseudoaneurysms: A Case Series

BACKGROUND

Aortic pseudoaneurysms (APSAs) are an uncommon but serious complication of aortic surgery with potentially fatal complications if left untreated. Operative repair is associated with significant morbidity and mortality. Percutaneous APSA repair may reduce the risk of these complications and represents an alternative option for patients. We report our experience with percutaneous intervention for the treatment of APSAs.

METHODS AND RESULTS

We retrospectively reviewed all patients at our institution who underwent percutaneous APSA repair with Amplatzer septal occluders and vascular plugs between January 2004 and September 2014. Ten patients are included in this study, representing our first cases of percutaneous APSA repair. Follow-up was performed with serial computed tomographic angiography. The primary outcome was the success rate of device deployment. Secondary outcomes included success rate of complete APSA exclusion, postprocedural symptoms, and periprocedural and postprocedural complications. Mean clinical follow-up time was 12 months (range, 5-30 months) and mean imaging follow-up time was 29 months (range, 14-52 months). Device deployment was successful in all patients, although 2 patients required reintervention due to device malposition and the discovery of additional defects on postprocedure CT angiography. There were no periprocedural or postprocedure complications. Long-term follow-up imaging was available for 7 patients and revealed complete APSA exclusion in 4 patients. One out of the remaining 3 patients ultimately required operative intervention.

CONCLUSIONS

Percutaneous APSA repair can be performed safely with a good procedural success, albeit with variable long-term results. This procedure may be considered as an alternative to surgical repair in select patients.

New technologies for CAS that might overcome the burden of microembolization

Microembolization during carotid artery stenting (CAS) is the result of embolic events shown by intraprocedural transcranial Doppler (TCD) or postprocedure diffusion-weighted MRI that do not lead to acute neurological deficit. Although the long term clinical outcome of these silent infarcts is not yet well established, there is increasing evidence that these events could be associated with neurological impairments, such as cognitive decline. In order to prevent microembolization due to excessive catheter manipulation at the time of guiding catheter placement in patients with challenging anatomy, a cervical access system with flow reversal protection was developed. Other embolic events are often seen as the result of plaque protrusion through stent struts. A new type of stent, so-called "hybrid" stent, incorporates the flexibility and conformability of an open-cell stent as well as plaque coverage seen with a close-cell stent, with the goal of achieving better plaque stabilization reducing macro and microembolization, while maintaining original vessel anatomy and flow hemodynamic. At the present time there are three different stents under investigation or this application.

How safe are carotid endarterectomy and carotid artery stenting in the early period after carotid-related cerebral ischemia?

Timing of treatment in carotid artery disease is still a matter of debate. So far there is controversial literature available concerning the safety of rapid treatment after a qualifying neurological event. Carotid endarterectomy turned out to be more effective in stroke prevention when carried out closer after the onset of symptoms. The initial "two weeks" cut off for surgery meanwhile turned into a "as soon as possible" treatment policy. In case of a cerebral infarction it seems reasonable, however, to delay surgery. Less evidence exists about the ideal timing of carotid artery stenting. Data analysis from the Carotid Stenosis Trialists' Collaboration showed that the early days after plaque rupture carry a high risk for periprocedural complications after carotid artery stenting. The analysis of a large register series showed, that carotid artery stenting carried a significantly higher risk for complications in patients with and without cerebral infarction when performed within 48 hours after the onset of symptoms.

Patient characteristics and outcomes of carotid endarterectomy and carotid artery stenting: analysis of the German mandatory national quality assurance registry - 2003 to 2014

AIM

In Germany, every surgical or endovascular procedure on the extracranial carotid artery is documented in a mandatory quality assurance registry. The purpose of this study is to describe the patient characteristics, the indications for treatment, and the short-term outcomes as well as to analyse the corresponding trends from 2003 to 2014.

METHODS

Data on demographics, peri-procedural measures, and outcomes were extracted from the annual quality reports published by the Federal Agency for Quality Assurance and the Institute for Applied Quality Improvement and Research in Health Care. Data were available from 2003 to 2014 for carotid endarterectomy (CEA) and from 2012 to 2014 for carotid artery stenting (CAS). The primary outcome event of this study is any stroke or death until discharge from hospital. Temporal trends of categorical variables were statistically analysed using the Cochran-Armitage test for trend.

RESULTS

Between 2003 and 2014, 309,405 CEAs and 18,047 CAS procedures were documented in the database; 68.1% of all patients were male. The mean age of patients treated with CEA increased from 68.9 years in 2003 to 70.9 years in 2014. The proportion of patients with ASA stages III to V increased from 65% to 71% in CEA, whereas it decreased from 44% to 41% in CAS patients. 53.1% of all CEAs were performed for asymptomatic patients (group A), 34.4% for symptomatic patients treated electively (group B), and 11.2% a in a collective group including other indications for CEA or CAS (such as recurrent stenosis, carotid aneurysms, emergency treatment due to stroke-in-evolution). The corresponding data for CAS are 49.3%, 26.1% and 26.3% respectively. In group B, the interval between the neurological index event and CEA decreased from 28 to 8 days (P<0.001). In patients treated with CAS, this interval was 9 days in 2012 (no further data available). On average, 67.1% and 48.2% of surgically treated patients as well as 77.8% and 69.8% of CAS patients were neurologically assessed before and after the procedure, respectively. From 2003 to 2014, CEA procedures were performed more frequently in locoregional anesthesia (10.1% to 29.1%, P<0.001). The same trend was observed for the application of the eversion technique (37.0% to 41.6%, P<0.001), the neurophysiological monitoring (49.8% to 61.8%, P<0.001), and the intra-procedural assessment of the treated artery (44.5% to 69.7%, P<0.001). In contrast, shunting was used less frequently (48.1% to 43.0%, P<0.001). Averagely 95.7% of all endovascular procedures were performed using stent-angioplasty. In 54.2% a protection device was used. Nitinol and bare metal stents were used in 74.1% and 21.4% of cases, respectively. The in-hospital rate of any stroke or death decreased from 2.0% to 1.1% in asymptomatic patients treated with CEA without a contralateral stenosis ≥75% or occlusion, P<0.001). In patients treated with CAS this rate did not increase (1.7% to 1.8%, p=0.909). The corresponding rates in CEA and CAS patients with severe contralateral stenosis or occlusion varied between 1.9%-3.1% and 2.2%-2.6%, respectively. In symptomatic patients (group B) with a stenosis of 50 percent or more, the rate of any stroke or death decreased significantly after CEA from 4.2% to 2.4% (P<0.001) and remained stable after CAS (3.9% to 3.5%, P=0.577).

CONCLUSION

This report on 327,452 carotid procedures analysed one of the largest quality registries on CEA and CAS worldwide. Data indicate that treated patients became older and sicker, whereas in contrast, the in-hospital rates of stroke or death are decreasing over time.

Recruiting RCTs comparing CAS, CEA and best medical treatment for asymptomatic carotid stenosis

The present paper summarizes the similarities and differences between recent and ongoing randomized controlled trials on optimal treatment of patients with severe but asymptomatic carotid stenosis. Protocol details will be discussed as well as needs for outcome and especially differentiation between patients with a low versus high risk for future events.