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Chen KS, Khawaja A, Xu E, Mekary RA, Vaitkevicius H, Aziz-Sultan A, Du R, Patel NJ. Changes in inpatient brain arteriovenous malformation management in the United States following the ARUBA trial: analysis of an interrupted time series design. Clin Neurol Neurosurg 2024; 242:108293. [PMID: 38728853 DOI: 10.1016/j.clineuro.2024.108293] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2023] [Revised: 01/31/2024] [Accepted: 04/18/2024] [Indexed: 05/12/2024]
Abstract
The November 2013 online publication of ARUBA, the first multi-institutional randomized controlled trial for unruptured brain arteriovenous malformations (AVMs), has sparked over 100 publications in protracted debates METHODS: This study sought to examine inpatient management patterns of brain AVMs from 2009 to 2016 and observe if changes in U.S. inpatient management were attributable to the ARUBA publication using interrupted time series of brain AVM studies from the National Inpatient Sample data 2009-2016. Outcomes of interest were use of embolization, surgery, combined embolization and microsurgery, radiotherapy, and observation during that admission. An interrupted time series design compared management trends before and after ARUBA. Segmented linear regression analysis tested for immediate and long-term impacts of ARUBA on management. RESULTS: Elective and asymptomatic patient admissions declined 2009-2016. In keeping with the ARUBA findings, observation for unruptured brain AVMs increased and microsurgery decreased. However, embolization, radiosurgery, and combined embolization and microsurgery also increased. For ruptured brain AVMs, treatment modality trends remained positive with even greater rates of observation, embolization, and combined embolization and microsurgery occurring after ARUBA (data on radiosurgery were scarce). None of the estimates for the change in trends were statistically significant. CONCLUSIONS: The publication of ARUBA was associated with a decrease in microsurgery and increase in observation for unruptured brain AVMs in the US. However, inpatient radiotherapy, embolization, and combined embolization and surgery also increased, suggesting trends moved counter to ARUBA's conclusions. This analysis suggested that ARUBA had a small impact as clinicians rejected ARUBA's findings in managing unruptured brain AVMs.
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Affiliation(s)
- Karen S Chen
- Department of Radiology and Neurosurgery, Texas Children's Hospital, Baylor College of Medicine, 6701 Fannin St, Suite 470, Houston, TX 77030, USA
| | - Ayaz Khawaja
- Department of Neurology, New York University Health and Hospitals, Bellevue, 462 First Ave, New York, NY 10016, USA
| | - Edward Xu
- Department of Radiology and Neurosurgery, Texas Children's Hospital, Baylor College of Medicine, 6701 Fannin St, Suite 470, Houston, TX 77030, USA
| | - Rania A Mekary
- Department of Social and Administrative Sciences, School of Pharmacy, MCPHS University, 179 Longwood Ave, Boston, MA 02115, USA; Computational Neuroscience Outcomes Center at Harvard, Department of Neurosurgery, Brigham and Women's Hospital, 75 Francis St, Boston, MA 02115, USA
| | - Henri Vaitkevicius
- Marinus Pharmaceuticals, 5 Radnor Corporate Center, 100 Matsonford Rd, Suite 500, Radnor, PA 19087, USA
| | - Ali Aziz-Sultan
- Department of Neurosurgery, Brigham and Women's Hospital, Harvard Medical School, 75 Francis St, Boston, MA 02115, USA
| | - Rose Du
- Department of Neurosurgery, Brigham and Women's Hospital, Harvard Medical School, 75 Francis St, Boston, MA 02115, USA
| | - Nirav J Patel
- Department of Neurosurgery, Brigham and Women's Hospital, Harvard Medical School, 75 Francis St, Boston, MA 02115, USA.
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Rantner B, Bellmunt-Montoya S. Beyond Successful Carotid Interventions: A Broader Assessment for Long Term Results in Asymptomatic Patients. Eur J Vasc Endovasc Surg 2024; 67:538-539. [PMID: 38224865 DOI: 10.1016/j.ejvs.2024.01.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2023] [Revised: 01/03/2024] [Accepted: 01/09/2024] [Indexed: 01/17/2024]
Affiliation(s)
- Barbara Rantner
- Department of Vascular and Endovascular Surgery, Ludwig Maximillian University Hospitals Munich, Munich, Germany.
| | - Sergi Bellmunt-Montoya
- Department of Vascular, Endovascular Surgery and Angiology, Hospital Universitari Vall d'Hebron, Barcelona, Spain; Universitat Autònoma de Barcelona, Barcelona, Spain
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3
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Saba L, Scicolone R, Johansson E, Nardi V, Lanzino G, Kakkos SK, Pontone G, Annoni AD, Paraskevas KI, Fox AJ. Quantifying Carotid Stenosis: History, Current Applications, Limitations, and Potential: How Imaging Is Changing the Scenario. Life (Basel) 2024; 14:73. [PMID: 38255688 PMCID: PMC10821425 DOI: 10.3390/life14010073] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2023] [Revised: 12/24/2023] [Accepted: 12/29/2023] [Indexed: 01/24/2024] Open
Abstract
Carotid artery stenosis is a major cause of morbidity and mortality. The journey to understanding carotid disease has developed over time and radiology has a pivotal role in diagnosis, risk stratification and therapeutic management. This paper reviews the history of diagnostic imaging in carotid disease, its evolution towards its current applications in the clinical and research fields, and the potential of new technologies to aid clinicians in identifying the disease and tailoring medical and surgical treatment.
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Affiliation(s)
- Luca Saba
- Department of Radiology, University of Cagliari, 09042 Cagliari, Italy;
| | - Roberta Scicolone
- Department of Radiology, University of Cagliari, 09042 Cagliari, Italy;
| | - Elias Johansson
- Neuroscience and Physiology, Sahlgrenska Academy, 41390 Gothenburg, Sweden;
| | - Valentina Nardi
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN 55905, USA;
| | - Giuseppe Lanzino
- Department of Neurologic Surgery, Mayo Clinic, Rochester, MN 55905, USA;
| | - Stavros K. Kakkos
- Department of Vascular Surgery, University of Patras, 26504 Patras, Greece;
| | - Gianluca Pontone
- Centro Cardiologico Monzino IRCCS, Via C. Parea 4, 20138 Milan, Italy; (G.P.); (A.D.A.)
- Department of Biomedical, Surgical and Dental Sciences, University of Milan, 20122 Milan, Italy
| | - Andrea D. Annoni
- Centro Cardiologico Monzino IRCCS, Via C. Parea 4, 20138 Milan, Italy; (G.P.); (A.D.A.)
| | | | - Allan J. Fox
- Department of Medical Imaging, Neuroradiology Section, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, ON M4N 3M5, Canada;
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Elshikhawoda MSM, Jararaa S, Tan SHS, Mohamed AHA, Abdalaziz DAS, Roble AA, Okaz M, Ahmad W, Elsanosi A, Jararah H. Indications and Outcome of Carotid Endarterectomy (CEA): A Single Centre Experience. Cureus 2023; 15:e50930. [PMID: 38249276 PMCID: PMC10800008 DOI: 10.7759/cureus.50930] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/21/2023] [Indexed: 01/23/2024] Open
Abstract
Background Stroke is a prevalent ailment that impacts a substantial number of individuals globally, resulting in both physical impairment and mortality. One of its major causes is carotid artery stenosis. The symptoms and degree of stenosis are key indications for carotid endarterectomy (CEA). In this study, we highlight the indications and outcomes of carotid endarterectomy in our center. Methods This is a descriptive, retrospective, observational study. Data of patients who underwent CEA at Glan Clwyd Hospital from January 2018 to January 2023 was retrieved. The study sample consisted of patients diagnosed with symptomatic carotid artery stenosis who had CEA at Glan Clwyd Hospital. The data was analyzed using statistical software SPSS (IBM Corp. Released 2012. IBM SPSS Statistics for Windows, Version 21.0. Armonk, NY: IBM Corp). Results A total of 150 patients were enrolled in the study. A majority of the patients were male, accounting for 69.3% (n = 104), and had a mean age of 71.1 ± 9.9 standard deviation. A majority of the patients were smokers (48.7%) and had additional medical conditions, including hypertension (34%), ischemic heart disease (17.3%), chronic obstructive pulmonary disease (73.3%), and diabetes (46.7%). Nevertheless, the remaining comorbidities were less common. The outcome of the CEA among the patients was cardiac event 3.3% (n = 5); transient ischemic attack (TIA) 3.3% (n = 5); stroke 0.6% (n = 1); hemorrhage 2.6% (n = 4); surgical site infection 2% (n = 3); perioperative mortality 1.3% (n = 2); and cranial nerve injury 1.3% (n = 2). However, no complications were reported in most of the patients, 85.6% (n = 128). Conclusion An endarterectomy is quite advantageous for treating symptomatic stenosis. The findings can be applied to patients who are physically suitable for surgery. The efficacy of endarterectomy is contingent upon not only the severity of carotid stenosis but also various other parameters, such as the time elapsed between the presenting event and the surgical intervention, as well as the patient's overall medical condition. However, the CEA is the gold standard in surgical management for symptomatic carotid disease.
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Affiliation(s)
| | | | | | | | | | | | - Mahmoud Okaz
- Vascular Surgery, Glan Clwyd Hospital, Rhyl, GBR
| | - Waseem Ahmad
- Vascular Surgery, Glan Clwyd Hospital, Rhyl, GBR
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Zimmermann M, Larena-Avellaneda A, Rother U, Lareyre F, Søgaard M, Tulamo R, Venermo M, Behrendt CA. Editor's Choice - Long Term Outcomes After Invasive Treatment of Carotid Artery Stenosis: a Longitudinal Study of German Health Insurance Claims. Eur J Vasc Endovasc Surg 2023; 66:493-500. [PMID: 37490978 DOI: 10.1016/j.ejvs.2023.07.030] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2023] [Revised: 06/23/2023] [Accepted: 07/19/2023] [Indexed: 07/27/2023]
Abstract
OBJECTIVE There is a paucity of observational data including long term outcomes after invasive treatment for carotid artery stenosis. METHODS This retrospective study used nationwide insurance claims from the third largest provider in Germany, DAK-Gesundheit. Patients who underwent inpatient carotid endarterectomy (CEA) or carotid artery stenting (CAS) between 1 January 2008 and 31 May 2017 were included. The Elixhauser comorbidity scores from longitudinally linked hospital episodes were used. Kaplan-Meier analysis and the log rank test were used to determine long term stroke free survival. Multivariable regression models were developed to adjust for confounding. RESULTS A total of 22 637 individual patients (41.6% female, median age 72.5 years) were included, of whom 15 005 (66.3%) were asymptomatic and 17 955 (79.3%) underwent CEA. After a median of 48 months, 5 504 any stroke or death events were registered. The mortality rate varied between 0.4% (CEA for asymptomatic stenosis) and 2.1% (urgent CAS for acute stroke patients) at 30 days, and between 4.1% and 8.4% at one year, respectively. The rate for any stroke varied between 0.6% (CEA for asymptomatic stenosis) and 2.5% (CAS for symptomatic patients) at 30 days, and between 2.5% and 6.4% at one year, respectively. The combined rate for any stroke and mortality at one year was 6.3% (CEA for asymptomatic stenosis), 8.7% (CAS for asymptomatic stenosis), and 12.5% (urgent CAS for acute stroke patients). After five years, the overall stroke rate was 7.4% after CEA and 9.0% after CAS. In adjusted analyses, both older age and van Walraven comorbidity score were associated with events, while treatment of asymptomatic stenosis was associated with lower event rates. CONCLUSION The current study revealed striking differences between previous landmark trials and real world practice. It further suggested excess deaths among invasively treated asymptomatic patients.
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Affiliation(s)
| | - Axel Larena-Avellaneda
- Department of Vascular and Endovascular Surgery, Asklepios Clinic Altona, Asklepios Medical School, Hamburg, Germany
| | - Ulrich Rother
- Department of Vascular Surgery, University Hospital Erlangen, Friedrich Alexander Universität Erlangen-Nürnberg (FAU), Erlangen, Germany
| | - Fabien Lareyre
- Department of Vascular Surgery, Hospital of Antibes-Juan-les-Pins, Antibes, Institut National de la Santé et de la Recherche Médicale (INSERM), Centre Méditerranéen de Médecine Moléculaire (C3M), Université Côte d'Azur, Nice, France
| | - Mette Søgaard
- Aalborg Thrombosis Research Unit, Department of Clinical Medicine, Faculty of Medicine, Aalborg University, Aalborg, Denmark; Department of Cardiology, Aalborg University Hospital, Aalborg, Denmark
| | - Riikka Tulamo
- Department of Vascular Surgery, Helsinki University Hospital, University of Helsinki, Helsinki, Finland
| | - Maarit Venermo
- Department of Vascular Surgery, Helsinki University Hospital, University of Helsinki, Helsinki, Finland
| | - Christian-Alexander Behrendt
- Department of Vascular and Endovascular Surgery, Asklepios Clinic Wandsbek, Asklepios Medical School, Hamburg, Germany; Brandenburg Medical School Theodor Fontane, Neuruppin, Germany.
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Gonçalves VA, Geiger MA, Sarti DA, Guillaumon AT. Association between platelet lymphocyte ratio and neutrophil lymphocyte ratio and clinical outcomes following carotid endarterectomy. J Vasc Bras 2023; 22:e20220122. [PMID: 37790888 PMCID: PMC10545233 DOI: 10.1590/1677-5449.202201222] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2022] [Accepted: 06/06/2023] [Indexed: 10/05/2023] Open
Abstract
Background Approximately 30% of stroke cases result from carotid disease. Although several risk factors for complications after carotid endarterectomy have been identified, the existence of a biomarker that can estimate postoperative risk in these patients has not yet been proven. Objectives This study aimed to investigate correlations between the platelet-lymphocyte ratio (PLR) and the neutrophil-lymphocyte ratio (NLR) and postoperative clinical outcomes in patients undergoing carotid endarterectomy. Methods A retrospective study was conducted, including 374 patients who underwent carotid endarterectomy between 2002 and 2019 due to moderate to high extracranial internal carotid artery stenosis. Their platelet-lymphocyte ratio and neutrophil-lymphocyte ratios were obtained from the same blood samples. Results There was a statistically significant correlation between the PLR and the occurrence of restenosis (p < 0.01) and acute myocardial infarction (AMI) after endarterectomy (p = 0.03). Additionally, there was a statistically significant correlation between the PLR and the combined outcomes stroke and/or AMI and/or death (p = 0.03) and stroke and/or AMI and/or death and/or restenosis (p < 0.01). However, there were no significant correlations between NLR and these outcomes (p = 0.05, p = 0.16). Conclusions The platelet-lymphocyte ratio proved to be a useful test for predicting occurrence of strokes, acute myocardial infarctions, and deaths during the postoperative period after carotid endarterectomy. It was also associated with the risk of postoperative restenosis.
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Affiliation(s)
- Vinicius Adorno Gonçalves
- Universidade Estadual de Campinas – UNICAMP, Faculdade de Ciências Médicas, Hospital de Clínicas, Campinas, SP, Brasil.
| | - Martin Andreas Geiger
- Universidade Estadual de Campinas – UNICAMP, Faculdade de Ciências Médicas, Hospital de Clínicas, Campinas, SP, Brasil.
| | | | - Ana Terezinha Guillaumon
- Universidade Estadual de Campinas – UNICAMP, Faculdade de Ciências Médicas, Hospital de Clínicas, Campinas, SP, Brasil.
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7
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Venermo M, Mani K, Boyle JR, Eldrup N, Setacci C, Jonsson M, Menyhei G, Beiles B, Lattmann T, Cassar K, Altreuther M, Thomson I, Settembre N, Laxdal E, Behrendt CA, deBorst GJ. Editor's Choice - Sex Related Differences in Indication and Procedural Outcomes of Carotid interventions in VASCUNET. Eur J Vasc Endovasc Surg 2023; 66:7-14. [PMID: 37105268 DOI: 10.1016/j.ejvs.2023.04.022] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2022] [Revised: 03/01/2023] [Accepted: 04/19/2023] [Indexed: 04/29/2023]
Abstract
OBJECTIVE It has been suggested that peri-operative complications after carotid surgery may be higher in women than in men. This assumption may affect the treatment patterns, and it is thus possible that carotid endarterectomy (CEA) is provided to women less often. The aim of the current VASCUNET study was to determine sex related differences in operative risk in routine clinical practice among non-selected patients undergoing carotid revascularisation. METHODS Data on CEA and carotid artery stenting (CAS) from 14 vascular registries were collected and amalgamated. Comprehensive data were available for 223 626 carotid artery procedures; these were analysed overall and by country. The primary outcome was any stroke and or death within 30 days of carotid revascularisation. Secondary outcomes were stroke, death, or any major cardiac event or haemorrhage leading to re-operation. RESULTS Of the procedures, 34.8% were done in women. The proportion of CEA for asymptomatic stenosis compared with symptomatic stenosis was significantly higher among women than men (38.4% vs. 36.9%, p < .001). The proportion of octogenarians was higher among women than men who underwent CEA in both asymptomatic (21.2% vs. 19.9%) and symptomatic patients (24.3% vs. 21.4%). In the unadjusted analysis of symptomatic and asymptomatic patients, there were no significant differences between men and women in the rate of post-operative combined stroke and or death, any major cardiac event, or combined death, stroke, and any major cardiac event after CEA. Also, after stenting for asymptomatic or symptomatic carotid stenosis, there were no significant differences between men and women in the rate of post-operative complications. In adjusted analyses, sex was not significantly associated with any of the end points. Higher age and CAS vs. CEA were independently associated with all four end points. CONCLUSION This study confirmed that, in a large registry among non-selected patients, no significant sex related differences were found in peri-operative complication rates after interventions for carotid stenosis.
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Affiliation(s)
- Maarit Venermo
- Department of Vascular Surgery, University of Helsinki and Helsinki University Hospital, Helsinki, Finland.
| | - Kevin Mani
- Department of Surgical Sciences, Uppsala University, Sweden
| | - Jonathan R Boyle
- Division of Vascular and Endovascular Surgery, Addenbrooke's Hospital, Cambridge University Hospital Trust, Cambridge, UK
| | - Nikolaj Eldrup
- Department of Vascular Surgery, Rigshospitalet, Copenhagen
| | | | - Magnus Jonsson
- Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden, and Department of Vascular Surgery, Karolinska University Hospital, Stockholm, Sweden
| | - Gabor Menyhei
- Department of Vascular Surgery, Pecs University Medical Centre, Pecs, Hungary
| | - Barry Beiles
- Australasian Vascular Audit, Australasian Society for Vascular Surgery, Melbourne, Australia
| | - Thomas Lattmann
- Clinic of Vascular Surgery, Cantonal Hospital, Winterthur, Switzerland
| | - Kevin Cassar
- Department of Surgery, Faculty of Medicine and Surgery, University of Malta
| | - Martin Altreuther
- Department of Vascular Surgery, St Olavs Hospital, Trondheim, Norway
| | - Ian Thomson
- Department of Surgical Sciences, Otago University, Dunedin, New Zealand
| | - Nicla Settembre
- CHRU-Nancy, Inserm 1116, Virtual Hospital of Lorraine, University of Lorraine, Nancy, France
| | - Elin Laxdal
- Department of Vascular Surgery, Landspitalinn University Hospital, Reykjavik, Iceland
| | - Christian-Alexander Behrendt
- Department of Vascular and Endovascular Surgery, Asklepios Clinic Wandsbek, Asklepios Medical School, Hamburg, Germany
| | - Gert J deBorst
- Department of Vascular Surgery G04.129, University Medical Centre Utrecht, The Netherlands
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Abbott AL. Extra-Cranial Carotid Artery Stenosis: An Objective Analysis of the Available Evidence. Front Neurol 2022; 13:739999. [PMID: 35800089 PMCID: PMC9253595 DOI: 10.3389/fneur.2022.739999] [Citation(s) in RCA: 13] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2021] [Accepted: 01/24/2022] [Indexed: 12/26/2022] Open
Abstract
Background and Purpose Carotid stenosis is arterial disease narrowing of the origin of the internal carotid artery (main brain artery). Knowing how to best manage this is imperative because it is common in older people and an important cause of stroke. Inappropriately high expectations have grown regarding the value of carotid artery procedures, such as surgery (endarterectomy) and stenting, for lowering the stroke risk associated with carotid stenosis. Meanwhile, the improving and predominant value of medical intervention (lifestyle coaching and medication) continues to be underappreciated. Methods and Results This article aims to be an objective presentation and discussion of the scientific literature critical for decision making when the primary goal is to optimize patient outcome. This compilation follows from many years of author scrutiny to separate fact from fiction. Common sense conclusions are drawn from factual statements backed by original citations. Detailed research methodology is given in cited papers. This article has been written in plain language given the importance of the general public understanding this topic. Issues covered include key terminology and the economic impact of carotid stenosis. There is a summary of the evidence-base regarding the efficacy and safety of procedural and medical (non-invasive) interventions for both asymptomatic and symptomatic patients. Conclusions are drawn with respect to current best management and research priorities. Several "furphies" (misconceptions) are exposed that are commonly used to make carotid stenting and endarterectomy outcomes appear similar. Ongoing randomized trials are mentioned and why they are unlikely to identify a routine practice indication for carotid artery procedures. There is a discussion of relevant worldwide guidelines regarding carotid artery procedures, including how they should be improved. There is an outline of systematic changes that are resulting in better application of the evidence-base. Conclusion The cornerstone of stroke prevention is medical intervention given it is non-invasive and protects against all arterial disease complications in all at risk. The "big" question is, does a carotid artery procedure add patient benefit in the modern era and, if so, for whom?
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Affiliation(s)
- Anne L. Abbott
- Department of Neuroscience, Central Clinical School, Monash University, Melbourne, VIC, Australia
- Neurology Private Practice, Knox Private Hospital, Wantirna, VIC, Australia
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Storck M. Struktur- und Qualitätsempfehlungen zur invasiven Behandlung der extrakraniellen Karotisstenose. AKTUELLE KARDIOLOGIE 2022. [DOI: 10.1055/a-1693-2139] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
ZusammenfassungDie Versorgungsqualität bei Eingriffen an der extrakraniellen A. carotis wird von der
Expertise des Operateurs, indirekt somit auch von Mindestmengen und außerdem von
Strukturmerkmalen der behandelnden Einrichtungen beeinflusst. In einer kurzen Übersicht werden
aktuelle Analysen aus dem Bereich der Versorgungsforschung sowie die aktuellen
Leitlinien-Empfehlungen dargelegt. Die Mindestmenge von 20 Eingriffen pro Jahr bei Operationen
(CEA) und 10 Eingriffen bei Stentangioplastien (CAS) sollte nach derzeitiger Empfehlung nicht
unterschritten werden. Eine 24-Stunden-Verfügbarkeit von Fachärzten sowie der
Bildgebungsverfahren (CT, MRA) wird empfohlen, optimalerweise auch eine organisierte enge
Kooperation mit Neuro-Interventionalisten sowie einer Stroke Unit.
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Affiliation(s)
- Martin Storck
- Klinik für Gefäß- und Thoraxchirurgie, Städtisches Klinikum Karlsruhe gGmbH, Karlsruhe, Deutschland
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Coelho A, Peixoto J, Mansilha A, Naylor AR, de Borst GJ. Timing of Carotid Intervention in Symptomatic Carotid Artery Stenosis: A Systematic Review and Meta-Analysis. Eur J Vasc Endovasc Surg 2021; 63:3-23. [PMID: 34953681 DOI: 10.1016/j.ejvs.2021.08.021] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2021] [Revised: 07/05/2021] [Accepted: 08/13/2021] [Indexed: 12/29/2022]
Abstract
OBJECTIVE This review aimed to analyse the timing of carotid endarterectomy (CEA) and carotid artery stenting (CAS) after the index event as well as 30 day outcomes at varying time periods within 14 days of symptom onset. METHODS A systematic review was performed according to the Preferred Reporting Items for Systematic reviews and Meta-analysis statement, comprising an online search of the Medline and Cochrane databases. Methodical quality assessment of the included studies was performed. Endpoints included procedural stroke and/or death stratified by delay from the index event and surgical technique (CEA/CAS). RESULTS Seventy-one studies with 232 952 symptomatic patients were included. Overall, 34 retrospective analyses of prospective databases, nine prospective, three RCT, three case control, and 22 retrospective studies were included. Compared with CEA, CAS was associated with higher 30 day stroke (OR 0.70; 95% CI 0.58 - 0.85) and mortality rates (OR 0.41; 95% CI 0.31 - 0.53) when performed ≤ 2 days of symptom onset. Patients undergoing CEA/CAS were analysed in different time frames (≤ 2 vs. 3 - 14 and ≤ 7 vs. 8 - 14 days). Expedited CEA (vs. 3 - 14 days) presented a sampled 30 day stroke rate of 1.4%; 95% CI 0.9 - 1.8 vs. 1.8%; 95% CI 1.8 - 2.0, with no statistically significant difference. Expedited CAS (vs. 3 - 14 days) was associated with no difference in stroke rate but statistically significantly higher mortality rate (OR 2.76; 95% CI 1.39 - 5.50). CONCLUSION At present, CEA is safer than transfemoral CAS within 2/7 days of symptom onset. Also, considering absolute rates, expedited CEA complies with the accepted thresholds in international guidelines. The ideal timing for performing CAS (when indicated against CEA) is not yet defined. Additional granular data and standard reporting of timing of intervention will facilitate future monitoring.
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Affiliation(s)
- Andreia Coelho
- Department of Angiology and Vascular Surgery, Centro Hospitalar Universitário do Porto, Portugal; Department of Surgery and Physiology, Faculdade Medicina da Universidade do Porto, Portugal
| | - João Peixoto
- Department of Surgery and Physiology, Faculdade Medicina da Universidade do Porto, Portugal; Department of Angiology and Vascular Surgery, Centro Hospitalar Vila Nova de Gaia/Espinho, Portugal
| | - Armando Mansilha
- Department of Surgery and Physiology, Faculdade Medicina da Universidade do Porto, Portugal
| | | | - Gert J de Borst
- Department of Vascular Surgery, University Medical Centre Utrecht, the Netherlands.
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Halliday A, Bulbulia R, Bonati LH, Chester J, Cradduck-Bamford A, Peto R, Pan H. Second asymptomatic carotid surgery trial (ACST-2): a randomised comparison of carotid artery stenting versus carotid endarterectomy. Lancet 2021; 398:1065-1073. [PMID: 34469763 PMCID: PMC8473558 DOI: 10.1016/s0140-6736(21)01910-3] [Citation(s) in RCA: 106] [Impact Index Per Article: 35.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/22/2021] [Revised: 08/09/2021] [Accepted: 08/11/2021] [Indexed: 01/16/2023]
Abstract
BACKGROUND Among asymptomatic patients with severe carotid artery stenosis but no recent stroke or transient cerebral ischaemia, either carotid artery stenting (CAS) or carotid endarterectomy (CEA) can restore patency and reduce long-term stroke risks. However, from recent national registry data, each option causes about 1% procedural risk of disabling stroke or death. Comparison of their long-term protective effects requires large-scale randomised evidence. METHODS ACST-2 is an international multicentre randomised trial of CAS versus CEA among asymptomatic patients with severe stenosis thought to require intervention, interpreted with all other relevant trials. Patients were eligible if they had severe unilateral or bilateral carotid artery stenosis and both doctor and patient agreed that a carotid procedure should be undertaken, but they were substantially uncertain which one to choose. Patients were randomly allocated to CAS or CEA and followed up at 1 month and then annually, for a mean 5 years. Procedural events were those within 30 days of the intervention. Intention-to-treat analyses are provided. Analyses including procedural hazards use tabular methods. Analyses and meta-analyses of non-procedural strokes use Kaplan-Meier and log-rank methods. The trial is registered with the ISRCTN registry, ISRCTN21144362. FINDINGS Between Jan 15, 2008, and Dec 31, 2020, 3625 patients in 130 centres were randomly allocated, 1811 to CAS and 1814 to CEA, with good compliance, good medical therapy and a mean 5 years of follow-up. Overall, 1% had disabling stroke or death procedurally (15 allocated to CAS and 18 to CEA) and 2% had non-disabling procedural stroke (48 allocated to CAS and 29 to CEA). Kaplan-Meier estimates of 5-year non-procedural stroke were 2·5% in each group for fatal or disabling stroke, and 5·3% with CAS versus 4·5% with CEA for any stroke (rate ratio [RR] 1·16, 95% CI 0·86-1·57; p=0·33). Combining RRs for any non-procedural stroke in all CAS versus CEA trials, the RR was similar in symptomatic and asymptomatic patients (overall RR 1·11, 95% CI 0·91-1·32; p=0·21). INTERPRETATION Serious complications are similarly uncommon after competent CAS and CEA, and the long-term effects of these two carotid artery procedures on fatal or disabling stroke are comparable. FUNDING UK Medical Research Council and Health Technology Assessment Programme.
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Affiliation(s)
- Alison Halliday
- Nuffield Department of Population Health, University of Oxford, Oxford, UK; Nuffield Department of Surgery, University of Oxford, Oxford, UK.
| | - Richard Bulbulia
- Nuffield Department of Population Health, University of Oxford, Oxford, UK; Medical Research Council Population Health Research Unit, Nuffield Department of Population Health, University of Oxford, Oxford, UK
| | - Leo H Bonati
- Department of Neurology, University Hospital, Basel, Switzerland
| | - Johanna Chester
- Nuffield Department of Population Health, University of Oxford, Oxford, UK
| | | | - Richard Peto
- Nuffield Department of Population Health, University of Oxford, Oxford, UK
| | - Hongchao Pan
- Nuffield Department of Population Health, University of Oxford, Oxford, UK; Medical Research Council Population Health Research Unit, Nuffield Department of Population Health, University of Oxford, Oxford, UK
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12
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Sastry RA, Pertsch NJ, Sagaityte E, Poggi JA, Toms SA, Weil RJ. Early Outcomes After Carotid Endarterectomy and Carotid Artery Stenting: A Propensity-Matched Cohort Analysis. Neurosurgery 2021; 89:653-663. [PMID: 34320217 DOI: 10.1093/neuros/nyab250] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2020] [Accepted: 06/17/2021] [Indexed: 01/22/2023] Open
Abstract
BACKGROUND Carotid endarterectomy (CEA) and carotid artery stenting (CAS) represent options to treat many patients with carotid stenosis. Although randomized trial data are plentiful, estimated rates of morbidity and mortality for both CEA and CAS have varied substantially. OBJECTIVE To evaluate rates of adverse outcomes after CAS and CEA in a large national database. METHODS We analyzed 84 191 adult patients undergoing elective, nonemergent CAS (n = 81 361) or CEA (n = 2830), from 2011 to 2018, in the American College of Surgeons' National Surgical Quality Improvement Program database. Odds of adverse outcomes (30-d rates of stroke, myocardial infarction (MI), cardiac arrest, prolonged length of stay (LOS), readmission, reoperation, and mortality) were evaluated in propensity-matched (n = 2821) cohorts through logistic regression. RESULTS In the propensity-matched cohorts, CAS had increased odds of periprocedural stroke (odds ratio [OR] 1.97, 95% CI 1.32-2.95) and decreased odds of cardiac arrest (OR 0.33, 95% CI 0.13-0.84) and 30-d reoperation (OR 0.59, 95% CI 0.44-0.80) compared to CEA. Relative odds of MI, prolonged LOS, discharge to destination other than home, 30-d readmission, or 30-d mortality were statistically similar. In the unmatched patient population, rates of adverse outcomes with CEA were constant over time; however, for CAS, rates of stroke increased over time. In both the matched and unmatched patient cohorts, patients 70 yr and older had lower rates of post-procedural stroke with CEA, but not with CAS, compared to younger patients. CONCLUSION In a propensity-matched analysis of a large, prospectively collected, national, surgical database, CAS was associated with increased odds of periprocedural stroke, which increased over time. Rates of MI and death were not significantly different between the 2 procedures.
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Affiliation(s)
- Rahul A Sastry
- Department of Neurosurgery, Warren Alpert School of Medicine, Brown University, Providence, Rhode Island, USA
| | - Nathan J Pertsch
- Department of Neurosurgery, Warren Alpert School of Medicine, Brown University, Providence, Rhode Island, USA
| | - Emilija Sagaityte
- Department of Neurosurgery, Warren Alpert School of Medicine, Brown University, Providence, Rhode Island, USA
| | - Jonathan A Poggi
- Department of Neurosurgery, Warren Alpert School of Medicine, Brown University, Providence, Rhode Island, USA
| | - Steven A Toms
- Department of Neurosurgery, Warren Alpert School of Medicine, Brown University, Providence, Rhode Island, USA.,Department of Neurosurgery, Rhode Island Hospital, Lifespan Health System, Providence, Rhode Island, USA
| | - Robert J Weil
- Department of Neurosurgery, Rhode Island Hospital, Lifespan Health System, Providence, Rhode Island, USA
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Aziz F, Behrendt CA, Sullivan K, Beck AW, Beiles CB, Boyle JR, Mani K, Benson RA, Wohlauer MV, Khashram M, Jorgensen JE, Lemmon GW. The impact of COVID-19 pandemic on vascular registries and clinical trials. Semin Vasc Surg 2021; 34:28-36. [PMID: 34144744 PMCID: PMC8137351 DOI: 10.1053/j.semvascsurg.2021.04.001] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2021] [Revised: 04/26/2021] [Accepted: 04/30/2021] [Indexed: 02/06/2023]
Abstract
Quality improvement programs and clinical trial research experienced disruption due to the coronavirus disease 2019 (COVID-19) pandemic. Vascular registries showed an immediate impact with significant declines in second-quarter vascular procedure volumes witnessed across Europe and the United States. To better understand the magnitude and impact of the pandemic, organizations and study groups sent grass roots surveys to vascular specialists for needs assessment. Several vascular registries responded quickly by insertion of COVID-19 variables into their data collection forms. More than 80% of clinical trials have been reported delayed or not started due to factors that included loss of enrollment from patient concerns or mandated institutional shutdowns, weighing the risk of trial participation on patient safety. Preliminary data of patients undergoing vascular surgery with active COVID-19 infection show inferior outcomes (morbidity) and increased mortality. Disease-specific vascular surgery study collaboratives about COVID-19 were created for the desire to study the disease in a more focused manner than possible through registry outcomes. This review describes the pandemic effect on multiple VASCUNET registries including Germany (GermanVasc), Sweden (SwedVasc), United Kingdom (UK National Vascular Registry), Australia and New Zealand (bi-national Australasian Vascular Audit), as well as the United States (Society for Vascular Surgery Vascular Quality Initiative). We will highlight the continued collaboration of VASCUNET with the Vascular Quality Initiative in the International Consortium of Vascular Registries as part of the Medical Device Epidemiology Network coordinated registry network. Vascular registries must remain flexible and responsive to new and future real-world problems affecting vascular patients.
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Affiliation(s)
- Faisal Aziz
- Integrated Vascular Surgery Program, Penn State Health Heart and Vascular Institute, Hershey, PA
| | | | | | - Adam W Beck
- Division of Vascular Surgery and Endovascular Therapy, University of Alabama at Birmingham, Birmingham, AL
| | - C Barry Beiles
- Australian and New Zealand Society for Vascular Surgery, Australasian Vascular Audit, Melbourne, Victoria, Australia
| | - Jon R Boyle
- University of Cambridge, Cambridge, Cambridgeshire, UK; Vascular Society of Great Britain and Ireland, Staffordshire, UK
| | - Kevin Mani
- Department of Surgical Sciences, Uppsala University, Uppsala, Sweden
| | - Ruth A Benson
- University Hospital Coventry and Warwickshire, West Midlands, UK
| | - Max V Wohlauer
- Vascular Surgery, University of Colorado, Denver, CO; Vascular Surgery COVID-19 Collaborative
| | - Manar Khashram
- Department of Surgery, University of Auckland, Auckland, NZ
| | - Jens Eldrup Jorgensen
- Tufts University School of Medicine, Boston, MA; Patient Safety Organization, Society for Vascular Surgery, Rosemont, IL
| | - Gary W Lemmon
- Patient Safety Organization, Society for Vascular Surgery, Rosemont, IL; Indiana University, 1801 N Senate Boulevard, D-3500, Indianapolis, IN 46202.
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Björses K, Blomgren L, Holsti M, Jonsson M, Smidfelt K, Mani K. Editor's Choice - The Impact of Covid-19 on Vascular Procedures in Sweden 2020. Eur J Vasc Endovasc Surg 2021; 62:136-137. [PMID: 34053841 PMCID: PMC8098046 DOI: 10.1016/j.ejvs.2021.04.027] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2021] [Revised: 04/27/2021] [Accepted: 04/28/2021] [Indexed: 11/29/2022]
Affiliation(s)
- Katarina Björses
- Vascular Centre Malmö, Skåne University Hospital, Lund University, Sweden.
| | - Lena Blomgren
- Karlskoga Vein Centre, Department of Cardiovascular Surgery, Faculty of Medicine and Health, Örebro University Hospital, Sweden
| | - Mari Holsti
- Department of Surgical and Peri-operative Sciences/Surgery, Umeå University, Umeå, Sweden
| | - Magnus Jonsson
- Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden
| | - Kristian Smidfelt
- Department of Vascular Surgery, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Kevin Mani
- Department of Surgical Sciences, Uppsala University, Uppsala, Sweden
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Behrendt CA, Sigvant B, Kuchenbecker J, Grima MJ, Schermerhorn M, Thomson IA, Altreuther M, Setacci C, Svetlikov A, Laxdal EH, Goncalves FB, Secemsky EA, Debus ES, Cassar K, Beiles B, Beck AW, Mani K, Bertges D. Editor's Choice - International Variations and Sex Disparities in the Treatment of Peripheral Arterial Occlusive Disease: A Report from VASCUNET and the International Consortium of Vascular Registries. Eur J Vasc Endovasc Surg 2020; 60:873-880. [PMID: 33004283 PMCID: PMC8080993 DOI: 10.1016/j.ejvs.2020.08.027] [Citation(s) in RCA: 44] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2020] [Revised: 06/30/2020] [Accepted: 08/17/2020] [Indexed: 01/17/2023]
Abstract
OBJECTIVE The aim of this study was to determine sex specific differences in the invasive treatment of symptomatic peripheral arterial occlusive disease (PAOD) between member states participating in the VASCUNET and International Consortium of Vascular Registries. METHODS Data on open surgical revascularisation and peripheral vascular intervention (PVI) of symptomatic PAOD from 2010 to 2017 were collected from population based administrative and registry data from 11 countries. Differences in age, sex, indication, and invasive treatment modality were analysed. RESULTS Data from 11 countries covering 671 million inhabitants and 1 164 497 hospitalisations (40% women, mean age 72 years, 49% with intermittent claudication, 54% treated with PVI) in Europe (including Russia), North America, Australia, and New Zealand were included. Patient selection and treatment modality varied widely for the proportion of female patients (23% in Portugal and 46% in Sweden), the proportion of patients with claudication (6% in Italy and 69% in Russia), patients' mean age (70 years in the USA and 76 years in Italy), the proportion of octogenarians (8% in Russia and 33% in Sweden), and the proportion of PVI (24% in Russia and 88% in Italy). Numerous differences between females and males were observed in regard to patient age (72 vs. 70 years), the proportion of octogenarians (28% vs. 15%), proportion of patients with claudication (45% vs. 51%), proportion of PVI (57% vs. 51%), and length of hospital stay (7 days vs. 6 days). CONCLUSION Remarkable differences regarding the proportion of peripheral vascular interventions, patients with claudication, and octogenarians were seen across countries and sexes. Future studies should address the underlying reasons for this, including the impact of national societal guidelines, reimbursement, and differences in health maintenance.
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Affiliation(s)
- Christian-Alexander Behrendt
- Department of Vascular Medicine, Research Group GermanVasc, University Medical Centre Hamburg-Eppendorf, Hamburg, Germany.
| | - Birgitta Sigvant
- Department of Surgical Sciences, Uppsala University, Uppsala, Sweden
| | - Jenny Kuchenbecker
- Department of Vascular Medicine, Research Group GermanVasc, University Medical Centre Hamburg-Eppendorf, Hamburg, Germany
| | - Matthew J Grima
- Department of Surgery, Vascular Unit, Mater Dei Hospital, Faculty of Medicine and Surgery, University of Malta, Msida, Malta
| | - Marc Schermerhorn
- Division of Vascular and Endovascular Surgery, Beth Israel Deaconess Medical Centre, Boston, MA, USA
| | - Ian A Thomson
- Department of Surgical Sciences, University of Otago, Dunedin, New Zealand
| | - Martin Altreuther
- Department of Vascular Surgery, St. Olavs Hospital, Trondheim, Norway
| | - Carlo Setacci
- Università degli Studi di Siena, Vascular and Endovascular Surgery, Siena, Italy
| | - Alexei Svetlikov
- Department of Cardiovascular Surgery, The I.I. Mechnikov North-Western State Medical University, St. Petersburg, Russia
| | - Elin H Laxdal
- Department of Vascular Surgery, Landspitali University Hospital, Reykjavik, Iceland
| | | | - Eric A Secemsky
- Division of Cardiology, Beth Israel Deaconess Medical Centre, Boston, MA, USA
| | - E Sebastian Debus
- Department of Vascular Medicine, Research Group GermanVasc, University Medical Centre Hamburg-Eppendorf, Hamburg, Germany
| | - Kevin Cassar
- Department of Surgery, Vascular Unit, Mater Dei Hospital, Faculty of Medicine and Surgery, University of Malta, Msida, Malta
| | - Barry Beiles
- Australian and New Zealand Society for Vascular Surgery, Melbourne, Australia
| | - Adam W Beck
- Division of Vascular Surgery and Endovascular Therapy, University of Alabama at Birmingham, AB, USA
| | - Kevin Mani
- Department of Surgical Sciences, Uppsala University, Uppsala, Sweden
| | - Daniel Bertges
- Division of Vascular Surgery, University of Vermont Medical Centre, Burlington, VT, USA
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16
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Sorber R, Clemens MS, Wang P, Makary MA, Hicks CW. Contemporary Trends in Physician Utilization Rates of CEA and CAS for Asymptomatic Carotid Stenosis among Medicare Beneficiaries. Ann Vasc Surg 2020; 71:132-144. [PMID: 32890650 DOI: 10.1016/j.avsg.2020.08.118] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2019] [Revised: 06/10/2020] [Accepted: 08/09/2020] [Indexed: 01/14/2023]
Abstract
BACKGROUND Carotid revascularization for asymptomatic carotid artery stenosis (ACAS) has become increasingly controversial in the past few decades as the best medical therapy has improved. The aim of this study was to assess and define contemporary trends in the rate of carotid revascularization procedures for ACAS in the United States and to characterize outlier physicians performing a higher rate of asymptomatic revascularization compared to their peers. METHODS We used 100% Medicare fee-for-service claims to identify all patients who were newly diagnosed with ACAS between 01/2011-06/2018. Patients with symptomatic carotid artery stenosis, those with prior carotid revascularization, and surgeons who performed ≤10 CEAs during the study period were excluded. We used a hierarchical multivariable logistic regression model to evaluate patient and physician characteristics associated with undergoing a carotid endarterectomy or carotid artery stent procedure within 3 months after the initial diagnosis of ACAS. We also assessed temporal trends in carotid revascularization rates over time using the Cochran-Armitage Trend Test. RESULTS Overall, 795,512 patients (median age 73.9 years, 50.9% male, 87.6% white) had a first-time diagnosis of ACAS during the study period, of which 23,481 (3.0%) underwent carotid revascularization within 3 months. There was a significant decline in overall carotid artery revascularization rates over time (2011: 3.2% vs. 2018: 2.1%; P < 0.001). The median and mean physician-specific carotid revascularization rates were 2.0% (IQR 0.0%-6.3%) and 4.7% ± 7.1%, respectively. Three-hundred and fifty physicians (5.2%) had carotid revascularization rates ≥19%, which was more than 2 standard deviations above the mean. After adjusting for patient-level characteristics, physician-level variables associated with carotid revascularization for newly diagnosed ACAS included male sex (adjusted OR 1.59, 95% CI 1.35-1.89), more years in practice (≥31 vs. <10 years, aOR 1.64, 95% CI 1.32-2.04), rural practice location (aOR 1.34, 95% CI 1.18-1.52), Southern region practice location (versus Northeast, aOR 1.54, 95% CI 1.39-1.69), and lower volume of ACAS patients (lower versus upper tertile, aOR 2.62, 95% CI 2.39-2.89). Cardiothoracic surgeons had a 1.52-fold higher odds of carotid revascularization compared to vascular surgeons (95% CI 1.36-1.68), whereas cardiologists and radiologists had lower intervention rates (both, P < 0.05). CONCLUSIONS The current early revascularization rate for newly diagnosed ACAS is <5% among proceduralists in the United States, and has been decreasing steadily since 2014. There are particular physician-level characteristics that are associated with higher rates of carotid revascularization that cannot be fully contextualized without high-level contemporary outcomes data to guide decision making in ACAS.
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Affiliation(s)
- Rebecca Sorber
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD
| | | | - Peiqi Wang
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Martin A Makary
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD; Department of Health Policy & Management, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD
| | - Caitlin W Hicks
- Division of Vascular Surgery and Endovascular Therapy, Johns Hopkins University School of Medicine, Baltimore, MD.
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Bouayed NM, Sekkal A. The management of asymptomatic carotid stenosis: Is there a benefit to operate elderly patients? Transl Med UniSa 2020; 23:79-81. [PMID: 34447720 PMCID: PMC8370528 DOI: 10.37825/2239-9747.1017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
Abstract
BACKGROUND We present a retrospective study of a series of 40 patients over the age of 75 operated for an asymptomatic carotid stenosis. The results were evaluated during an average of 3 years of follow-up. MATERIAL AND METHOD The study is retrospective and monocentric. The series includes 40 patients aged over 75 years and with an average age of 78.5 years (range 75-82). Patients underwent surgery for an asymptomatic carotid stenosis of more than 80%. The technique in all case was a carotid endarterectomy. RESULTS There have been no postoperative deaths or neurological adverse events. During an average follow-up of 3 years, there was one death secondary to colon cancer. However, 5 patients were lost to follow-up. CONCLUSION Carotid surgery in elderly patients may have a benefit. However, our study has shortcomings. It is retrospective and the patient cohort is reduced. A randomized, prospective study, comparing surgery or angioplasty with the best medical treatment, is necessary to choose the most effective and safest treatment to offer to an elderly patient with asymptomatic carotid stenosis.
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Affiliation(s)
- N M Bouayed
- University hospital Hai Sabah 31000 - Oran Algeria
| | - A Sekkal
- University hospital Hai Sabah 31000 - Oran Algeria
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Ferrah N, Walker SR. Weekend Carotid Endarterectomies are Not Associated with a Greater Risk of Stroke and/or Death in Australia and New Zealand. Ann Vasc Surg 2020; 71:145-156. [PMID: 32800885 DOI: 10.1016/j.avsg.2020.07.055] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2020] [Revised: 07/23/2020] [Accepted: 07/29/2020] [Indexed: 11/29/2022]
Abstract
BACKGROUND Data from multiple surgical studies and settings have reported an increase in adverse events in patients admitted or treated on weekends. The aim of this study was to investigate short-term outcomes for patients undergoing carotid endarterectomy (CEA) in Australia and New Zealand based on the day of surgery. METHODS This is a retrospective observational cohort study. Analysis of 7,857 CEAs recorded for more than 4 years in the Australasian Vascular Audit database was performed. Multivariate logistic regression was used to compare the following outcomes between CEAs performed during the week and on the weekend: (1) in-hospital stroke and/or death; (2) other postoperative complications; and (3) shorter (2 days or less) length of stay (LOS). RESULTS A total of 7,857 CEAs were recorded, with significantly more procedures performed during the week (n = 7,333, P < 0.001). There was no statistically significant difference in the frequency of stroke and/or death or other complications between CEAs performed during the week or on the weekend (P = 0.294 and P = 0.806, respectively). However, there was a significant difference in LOS for procedures performed during the weekend, with more of these patients being discharged within 2 days compared with procedures performed during the week (56.8% vs. 51.5%; P = 0.003). Multivariable logistic regression found no effect of day of the week on the odds of postoperative stroke and/or death (P = 0.685). Day of surgery was also not associated with greater odds of other complications (P = 0.925). However, CEAs performed by nonconsultants had significantly lower adjusted odds of other complications (3.1% vs. 4.1%; P = 0.033). The adjusted odds of having a shorter LOS were significantly greater for operations taking place on the weekend (P = 0.003). CONCLUSIONS In Australia and New Zealand, there appears to be no disadvantage to performing CEA on the weekend, in terms of stroke and/or death. Level of experience of the primary operator does not affect rates of stroke and/or death after CEA. Weekend CEA is associated with a shorter hospital LOS.
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Affiliation(s)
- Noha Ferrah
- Department of Vascular and Endovascular Surgery, Royal Hobart Hospital, Hobart, Tasmania, Australia; School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia.
| | - Stuart R Walker
- Department of Vascular and Endovascular Surgery, Royal Hobart Hospital, Hobart, Tasmania, Australia; Clinical School, University of Tasmania, Hobart, Tasmania, Australia
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Quality of care in surgical/interventional vascular medicine: what can routinely collected data from the insurance companies achieve? GEFASSCHIRURGIE 2020. [DOI: 10.1007/s00772-020-00679-4] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
AbstractThe complexity and diversity of surgical/interventional vascular medicine necessitate innovative and pragmatic solutions for the valid measurement of the quality of care in the long term. The secondary utilization of routinely collected data from social insurance institutions has increasingly become the focus of interdisciplinary medicine over the years. Owing to their longitudinal linkage and pan-sector generation, routinely collected data make it possible to answer important questions and can complement quality development projects with primary registry data. Various guidelines exist for their usage, linkage, and reporting. Studies have shown good validity, especially for endpoints with major clinical relevance. The numerous advantages of routinely collected data face several challenges that require thorough plausibility and validity procedures and distinctive methodological expertise. This review presents a discussion of these advantages and challenges and provides recommendations for starting to use this increasingly important source of data.
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Natural History of Non-operative Management in Asymptomatic Patients with 70%-80% Internal Carotid Artery Stenosis by Duplex Criteria. Eur J Vasc Endovasc Surg 2020; 60:339-346. [PMID: 32660806 DOI: 10.1016/j.ejvs.2020.05.039] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2019] [Revised: 05/04/2020] [Accepted: 05/27/2020] [Indexed: 11/20/2022]
Abstract
OBJECTIVE Treatment of asymptomatic internal carotid artery (ICA) stenosis, particularly for moderate to severe (70%-80%) disease, is controversial. The goal was to assess the clinical course of patients with moderate to severe carotid stenosis. METHODS A single institution retrospective analysis of patients with asymptomatic ICA stenosis identified on duplex ultrasound as moderate to severe (70%-80%) from 2003 to 2018 were analysed. Duplex criteria for 70%-80% stenosis was a systolic velocity of ≥325 cm/s or an ICA:common carotid artery ratio of ≥4, and an end diastolic velocity of <140 cm/s. Asymptomatic status was defined as no stroke/transient ischaemic attack (TIA) within six months of index duplex. Primary outcomes were progression of stenosis to >80%, ipsilateral stroke/TIA without documented progression, and death. RESULTS In total, 206 carotid arteries were identified in 182 patients meeting the inclusion criteria. Mean patient age was 71.5 years, 57.7% were male, and 67% were white. There were 19 stenoses removed from analysis except for survival analysis as they initially underwent carotid endarterectomy or carotid artery stent based on surgeon/patient preference. Documented progression occurred in 24.1% of stenoses. There were 5.3% of stenoses associated with an ipsilateral stroke/TIA without documented progression, which occurred at a mean of 26.4 months. Kaplan-Meier analysis demonstrated a 60.3% five year freedom from stenosis progression, 92.5% five year freedom from stroke/TIA without documented progression, and 83.7% five year survival. Risk factors associated with stroke/TIA without documented progression at five years were atrial fibrillation (hazard ratio [HR] 14.87, 95% confidence interval [CI] 2.72-81.16; p = .002) and clopidogrel use at index duplex (HR 6.19, 95% CI 1.33-28.83; p = .020). Risk factors associated with death at five years were end stage renal disease (HR 9.67, 95% CI 2.05-45.6; p = .004), atrial fibrillation (HR 7.55, 95% CI 2.48-23; p < .001), prior head/neck radiation (HR 6.37, 95% CI 1.39-29.31; p = .017), non-obese patients (HR 5.49, 95% CI 1.52-20; p = .009), and non-aspirin use at index duplex (HR 3.05, 95% CI 1.12-8.33; p = .030). CONCLUSION Patients with asymptomatic moderate to severe carotid stenosis had a low rate of stroke/TIA without documented progression. However, there was a high rate of stenosis progression reinforcing the need to follow these patients closely.
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Peters F, Kreutzburg T, Kuchenbecker J, Marschall U, Remmel M, Dankhoff M, Trute HH, Repgen T, Debus ES, Behrendt CA. Behandlungsqualität in der operativ-interventionellen Gefäßmedizin – was können Routinedaten der Krankenkassen leisten? GEFÄSSCHIRURGIE 2020. [DOI: 10.1007/s00772-020-00664-x] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
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Registries, Research, and Quality Improvement. Eur J Vasc Endovasc Surg 2020; 59:503-509. [DOI: 10.1016/j.ejvs.2020.02.014] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2019] [Revised: 01/04/2020] [Accepted: 02/18/2020] [Indexed: 12/28/2022]
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Lim ETA, Laws PE, Beresford TP, Khanafer AMA, Roake JA. Timeliness and outcomes of carotid endarterectomy for symptomatic carotid artery stenosis: a single centre audit. ANZ J Surg 2020; 90:345-349. [PMID: 32080950 DOI: 10.1111/ans.15757] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2019] [Revised: 01/14/2020] [Accepted: 01/21/2020] [Indexed: 11/28/2022]
Abstract
BACKGROUND For patients presenting with symptomatic internal carotid artery stenosis, carotid endarterectomy (CEA) surgery is recommended to be performed generally within a 48-hr to 14-day window. This study aimed to assess timeliness of delivery, and outcomes, of CEA surgery in a tertiary vascular centre. METHOD Patients with symptomatic internal carotid artery stenosis who underwent CEA between 1 June 2014 and 31 June 2017 were identified and data were obtained from hospital records. The timeline of their journey from presentation to surgery was then mapped together with their outcomes. RESULTS One hundred and seventy-two cases were included in the study. Overall, the median time from development of presenting symptoms to surgery was 9 days and 119 (69%) cases were operated on within 14 days. The median time from development of presenting symptoms to ultrasound imaging was 2 days and the median time from symptoms to vascular referral was also 2 days. There were no deaths, strokes or transient ischaemic attacks within 30 days of CEA. At 1 year, survival was 100% but 15 (8.7%) had experienced at least one transient ischaemic attack or stroke. In the 53 cases operated upon beyond 14 days the dominant cause of delay in 32 (60%) was accessing surgery after review by the vascular service. CONCLUSION The aim of delivering CEA within 14 days of developing relevant symptoms was achieved in most cases with good outcomes. Nevertheless, points of delay in the patient journey that could be targeted for future quality improvement were identified.
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Affiliation(s)
- Eric T A Lim
- Department of Vascular, Endovascular and Transplant Surgery, Christchurch Hospital, Christchurch, New Zealand
| | - Peter E Laws
- Department of Vascular, Endovascular and Transplant Surgery, Christchurch Hospital, Christchurch, New Zealand
| | - Timothy P Beresford
- Department of Vascular, Endovascular and Transplant Surgery, Christchurch Hospital, Christchurch, New Zealand
| | - Adib M A Khanafer
- Department of Vascular, Endovascular and Transplant Surgery, Christchurch Hospital, Christchurch, New Zealand
| | - Justin A Roake
- Department of Vascular, Endovascular and Transplant Surgery, Christchurch Hospital, Christchurch, New Zealand
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Cronenwett JL. Why should I join the Vascular Quality Initiative? J Vasc Surg 2020; 71:364-373. [DOI: 10.1016/j.jvs.2019.10.011] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2019] [Accepted: 10/04/2019] [Indexed: 01/12/2023]
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Abbott AL, Brunser AM, Giannoukas A, Harbaugh RE, Kleinig T, Lattanzi S, Poppert H, Rundek T, Shahidi S, Silvestrini M, Topakian R. Misconceptions regarding the adequacy of best medical intervention alone for asymptomatic carotid stenosis. J Vasc Surg 2020; 71:257-269. [PMID: 31564585 DOI: 10.1016/j.jvs.2019.04.490] [Citation(s) in RCA: 46] [Impact Index Per Article: 11.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2018] [Accepted: 04/11/2019] [Indexed: 10/25/2022]
Abstract
BACKGROUND Medical intervention (risk factor identification, lifestyle coaching, and medication) for stroke prevention has improved significantly. It is likely that no more than 5.5% of persons with advanced asymptomatic carotid stenosis (ACS) will now benefit from a carotid procedure during their lifetime. However, some question the adequacy of medical intervention alone for such persons and propose using markers of high stroke risk to intervene with carotid endarterectomy (CEA) and/or carotid angioplasty/stenting (CAS). Our aim was to examine the scientific validity and implications of this proposal. METHODS We reviewed the evidence for using medical intervention alone or with additional CEA or CAS in persons with ACS. We also reviewed the evidence regarding the validity of using commonly cited makers of high stroke risk to select such persons for CEA or CAS, including markers proposed by the European Society for Vascular Surgery in 2017. RESULTS Randomized trials of medical intervention alone versus additional CEA showed a definite statistically significant CEA stroke prevention benefit for ACS only for selected average surgical risk men aged less than 75 to 80 years with 60% or greater stenosis using the North American Symptomatic Carotid Endarterectomy Trial criteria. However, the most recent measurements of stroke rate with ACS using medical intervention alone are overall lower than for those who had CEA or CAS in randomized trials. Randomized trials of CEA versus CAS in persons with ACS were underpowered. However, the trend was for higher stroke and death rates with CAS. There are no randomized trial results related to comparing current optimal medical intervention with CEA or CAS. Commonly cited markers of high stroke risk in relation to ACS lack specificity, have not been assessed in conjunction with current optimal medical intervention, and have not been shown in randomized trials to identify those who benefit from a carotid procedure in addition to current optimal medical intervention. CONCLUSIONS Medical intervention has an established role in the current routine management of persons with ACS. Stroke risk stratification studies using current optimal medical intervention alone are the highest research priority for identifying persons likely to benefit from adding a carotid procedure.
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Affiliation(s)
- Anne L Abbott
- Department of Neuroscience, Central Clinical School, Monash University, Melbourne, Victoria, Australia.
| | - Alejandro M Brunser
- Department of Neurology, Clínica Alemana de Santiago, Facultad de Medicina Clínica Alemana, Universidad del Desarrollo, Santiago, Chile
| | - Athanasios Giannoukas
- University Hospital of Larissa, Faculty of Medicine, School of Health Sciences, University of Thessaly, Larissa, Greece
| | - Robert E Harbaugh
- Department of Neurosurgery, Penn State University, State College, Pa
| | - Timothy Kleinig
- Neurology Department, Royal Adelaide Hospital, Department of Medicine, University of Adelaide, Adelaide, South Australia, Australia
| | - Simona Lattanzi
- Department of Experimental and Clinical Medicine, Marche Polytechnic University, Ancona, Italy
| | - Holger Poppert
- Neurology Department, Helios Dr Horst-Schmidt-Kliniken, Wiesbaden, Germany
| | - Tatjana Rundek
- Department of Neurology, University of Miami Miller School of Medicine, Miami, Fla
| | - Saeid Shahidi
- Department of Vascular and Endovascular Surgery, Acute Regional Hospital Slagelse, Copenhagen & South Denmark University, Copenhagen, Denmark
| | | | - Raffi Topakian
- Department of Neurology, Academic Teaching Hospital Wels-Grieskirchen, Wels, Austria
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Kubátová H, Poledne R, Piťha J. Immune cells in carotid artery plaques: what can we learn from endarterectomy specimens? INT ANGIOL 2019; 39:37-49. [PMID: 31782285 DOI: 10.23736/s0392-9590.19.04250-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
Abstract
INTRODUCTION Endarterectomy specimens represent a unique opportunity to study atherosclerosis. This review aims to summarize the recent knowledge of atherogenesis from studies characterizing a cellular composition of carotid endarterectomy specimens. EVIDENCE ACQUISITION A non-systematic literature review was carried out to summarize recent knowledge regarding ex vivo analysis of carotid artery plaque composition. Upon evaluation of their relevance, and elaborate forward and backward search, 95 articles were included in the review. EVIDENCE SYNTHESIS Despite the significant advancement of in vivo imaging techniques, the stroke prediction based on carotid artery plaque morphology is not reliable. Besides analyses of plaque morphology, present studies focus on precise characterization of the different immune cell types and elucidation of their role in plaque development. Plaque content analyses revealed the presence of various immune cells in carotid artery plaques. Presence of different immune cells subpopulations can be connected to some undesirable changes in plaque stability. CONCLUSIONS Since the destabilization of the atherosclerotic plaque is a multifactorial process, a combination of various methods should be used to characterize the unstable plaques more accurately. In this context, studies characterizing plaque content from a cellular point of view could elucidate some processes underlying the plaque progression. Together with morphological evaluation, these analyses could enable more precise assessment of plaque stability.
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Affiliation(s)
- Hana Kubátová
- Atherosclerosis Research Laboratory, Experimental Medicine Center, Institute for Clinical and Experimental Medicine, Prague, Czech Republic - .,Department of Physiology, Faculty of Science, Charles University, Prague, Czech Republic -
| | - Rudolf Poledne
- Atherosclerosis Research Laboratory, Experimental Medicine Center, Institute for Clinical and Experimental Medicine, Prague, Czech Republic
| | - Jan Piťha
- Atherosclerosis Research Laboratory, Experimental Medicine Center, Institute for Clinical and Experimental Medicine, Prague, Czech Republic.,Department of Internal Medicine, Second Medical Faculty, Charles University in Prague and Motol University Hospital, Prague, Czech Republic
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Aboyans V, Braekkan S, Mazzolai L, Sillesen H, Venermo M, De Carlo M. The year 2017 in cardiology: aorta and peripheral circulation. Eur Heart J 2019; 39:730-738. [PMID: 29300868 DOI: 10.1093/eurheartj/ehx800] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/27/2017] [Accepted: 12/22/2017] [Indexed: 12/30/2022] Open
Affiliation(s)
- Victor Aboyans
- Department of Cardiology, Dupuytren University Hospital, 2, Martin Luther King Ave., Limoges, France.,Inserm 1094, Limoges School of Medicine, Ave Dr. Marcland, 87025 Limoges, France
| | - Sigrid Braekkan
- K.G. Jebsen Thrombosis Research and Expertise Center (TREC), Department of Clinical Medicine, UiT - The Arctic University of Norway, Hansine Hansens veg 18, 9037, Tromsø, Norway
| | - Lucia Mazzolai
- Division of Angiology, Department of Heart and Vessel, Lausanne University Hospital, Ch du Mont-Paisible 18, Lausanne, 1011, Switzerland
| | - Henrik Sillesen
- Department of Vascular Surgery, Rigshospitalet, University of Copenhagen, Blegdamsvej 9, Copenhagen, 2100, Denmark
| | - Maarit Venermo
- Department of Vascular Surgery, Helsinki University Hospital, Haartmaninkatu 4, FI-00290 Helsinki, Finland
| | - Marco De Carlo
- Cardiac Catheterization Laboratory, Cardiothoracic and Vascular Department, Azienda Ospealiero-Universitaria Pisana, via Paradisa, Pisa, Italy
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Johal AS, Loftus IM, Boyle JR, Naylor AR, Waton S, Heikkila K, Cromwell DA. Changing Patterns of Carotid Endarterectomy Between 2011 and 2017 in England. Stroke 2019; 50:2461-2468. [DOI: 10.1161/strokeaha.119.025231] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background and Purpose—
Carotid endarterectomy (CEA) reduces the risk of stroke in recently symptomatic patients and less so in asymptomatic patients. Recent evidence suggests that the number of CEAs may be declining. The aim of this study was to investigate annual patterns of CEA in asymptomatic and symptomatic patients in England from 2011 to 2017.
Methods—
Data from the National Vascular Registry were used to describe (1) the number of CEA procedures in England and its 9 geographic regions from 2011 to 2017, (2) the characteristics of patients undergoing CEA, and (3) whether rates of CEA correlated with the number of vascular arterial units within each region. Annual stroke incidence for each region was derived from official population figures and the number of index stroke admissions per year.
Results—
The overall number of CEAs performed in England fell from 4992 in 2011 to 3482 in 2017, a 30% decline. Among symptomatic patients, there was a 25% decline, the number of CEAs falling from 4270 to 3217. In asymptomatic patients, there were 722 CEAs performed in 2011 and 265 in 2017, a 63% decline. CEAs per 100 000 adults within all regions declined over time but the size of change varied across the regions (range, 1.7–5.5 per 100 000). The regional numbers of CEAs per year were associated with changes in the regional stroke incidence, the proportion of CEAs performed in asymptomatic patients, and the number of hospitals performing CEA.
Conclusions—
This population-based study revealed a 63% decline in CEAs among asymptomatic patients between 2011 and 2017, possibly because of changing attitudes in the role of CEA. Reasons for the 25% decline in CEAs among symptomatic patients are unclear as UK guidelines on CEA have not changed for these patients. Whether the proportion of symptomatic patients with 50% to 99% ipsilateral stenosis has changed requires investigation.
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Affiliation(s)
- Amundeep S. Johal
- From the Clinical Effectiveness Unit, The Royal College of Surgeons of England, London, United Kingdom (A.S.J., S.W., K.H., D.A.C.)
| | - Ian M. Loftus
- St George’s University Hospitals NHS Foundation Trust, London, United Kingdom (I.M.L.)
| | - Jonathan R. Boyle
- Division of Vascular and Endovascular Surgery, Addenbrooke’s Hospital, Cambridge University Hospital Trust, United Kingdom (J.R.B.)
| | - A. Ross Naylor
- The Leicester Vascular Institute, Glenfield Hospital, United Kingdom (A.R.N.)
| | - Sam Waton
- From the Clinical Effectiveness Unit, The Royal College of Surgeons of England, London, United Kingdom (A.S.J., S.W., K.H., D.A.C.)
| | - Katriina Heikkila
- From the Clinical Effectiveness Unit, The Royal College of Surgeons of England, London, United Kingdom (A.S.J., S.W., K.H., D.A.C.)
- Department of Health Services Research and Policy, London School of Hygiene and Tropical Medicine (K.H., D.A.C.)
| | - David A. Cromwell
- From the Clinical Effectiveness Unit, The Royal College of Surgeons of England, London, United Kingdom (A.S.J., S.W., K.H., D.A.C.)
- Department of Health Services Research and Policy, London School of Hygiene and Tropical Medicine (K.H., D.A.C.)
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Rao V, Liang P, Swerdlow N, Li C, Solomon Y, Wyers M, Schermerhorn M. Contemporary outcomes after carotid endarterectomy in high-risk anatomic and physiologic patients. J Vasc Surg 2019; 71:104-110. [PMID: 31443978 DOI: 10.1016/j.jvs.2019.05.041] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2019] [Accepted: 05/08/2019] [Indexed: 11/17/2022]
Abstract
OBJECTIVE Current guidelines state that the acceptable 30-day postoperative stroke/death rate after carotid endarterectomy (CEA) is <3% for asymptomatic patients and <6% for symptomatic patients. The Centers for Medicare and Medicaid Services has identified certain high-risk characteristics used to define patients at highest risk for CEA for whom carotid artery stenting would be reimbursed. We evaluated the impact of the Centers for Medicare and Medicaid Services physiologic and anatomic high-risk criteria on major adverse event rates after CEA in asymptomatic and symptomatic patients. METHODS We retrospectively reviewed all patients undergoing CEA from 2011 to 2017 in the American College of Surgeons National Surgical Quality Improvement Program vascular targeted database. Patients with high-risk anatomic or physiologic characteristics were identified by a predefined variable and were compared with normal-risk patients. The primary outcome was 30-day stroke/death, stratified by symptom status. RESULTS We identified 25,788 patients undergoing CEA, of whom 60% were treated for asymptomatic carotid disease. Among all patients, high-risk physiology or anatomy was associated with higher rates of 30-day stroke/death compared with normal-risk patients (physiologic risk, 4.6% vs 2.3% [P < .001]; anatomic risk, 3.6% vs 2.3% [P < .001]). Patients who met criteria for high-risk physiology or anatomy also had higher rates of cardiac events (physiologic risk, 3.1% vs 1.6% [P < .001]; anatomic risk, 2.3% vs 1.6% [P < .01]), but only patients with high-risk anatomy had higher rates of cranial nerve injury (physiologic risk, 2.4% vs 2.5% [P = .81]; anatomic risk, 4.3% vs 2.5% [P < .001]). Asymptomatic patients with high-risk physiology or anatomy had higher rates of 30-day stroke/death, especially in the physiologic high-risk group (physiologic risk, 4.7% vs 1.5% [P < .001]; anatomic risk, 2.6% vs 1.5% [P < .01]), compared with normal-risk patients. However, among symptomatic patients, differences in stroke/death were seen only with high-risk anatomic patients and not with high-risk physiologic patients (physiologic risk, 4.6% vs 3.4% [P = .12]; anatomic risk, 4.8% vs 3.4% [P = .01]). CONCLUSIONS As currently selected, contemporary real-world outcomes after CEA in asymptomatic carotid disease patients meeting high-risk physiologic criteria show an unacceptably high 30-day stroke/death rate, well above the 3% threshold. These results suggest the need for better selection of patients and preoperative optimization before elective CEA.
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Affiliation(s)
- Vaishnavi Rao
- Stanford University School of Medicine, Stanford, Calif; Department of Vascular and Endovascular Surgery, Beth Israel Deaconess Medical Center, Boston, Mass
| | - Patric Liang
- Department of Vascular and Endovascular Surgery, Beth Israel Deaconess Medical Center, Boston, Mass
| | - Nicholas Swerdlow
- Department of Vascular and Endovascular Surgery, Beth Israel Deaconess Medical Center, Boston, Mass
| | - Chun Li
- Department of Vascular and Endovascular Surgery, Beth Israel Deaconess Medical Center, Boston, Mass
| | - Yoel Solomon
- Department of Vascular and Endovascular Surgery, Beth Israel Deaconess Medical Center, Boston, Mass
| | - Mark Wyers
- Department of Vascular and Endovascular Surgery, Beth Israel Deaconess Medical Center, Boston, Mass
| | - Marc Schermerhorn
- Department of Vascular and Endovascular Surgery, Beth Israel Deaconess Medical Center, Boston, Mass.
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Vikatmaa P. Carotid Stenting versus Endarterectomy: The Evidence is Evident. Or is it? Eur J Vasc Endovasc Surg 2019; 58:494. [PMID: 31377006 DOI: 10.1016/j.ejvs.2019.07.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2019] [Accepted: 07/04/2019] [Indexed: 10/26/2022]
Affiliation(s)
- Pirkka Vikatmaa
- Helsinki University Hospital, Department of Vascular Surgery, Helsinki, Finland.
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Aro E, Ijäs P, Vikatmaa L, Soinne L, Sund R, Venermo M, Vikatmaa P. The Efficacy of Carotid Surgery by Subgroups: The Concept of Stroke Prevention Potential. Eur J Vasc Endovasc Surg 2019; 58:5-12. [PMID: 31182335 DOI: 10.1016/j.ejvs.2019.04.003] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2018] [Revised: 03/27/2019] [Accepted: 04/07/2019] [Indexed: 10/26/2022]
Abstract
OBJECTIVE Considering carotid endarterectomy (CEA), reporting treatment delay, symptom status, and surgical complication rates separately gives an incomplete picture of efficacy; therefore, the aim was to combine these factors and develop a reporting standard that better describes the number of potentially prevented strokes. With a real life cohort and theoretical inclusion scenarios, the aim was to explore the stroke prevention potential of different carotid practices. METHODS Landmark studies for symptomatic and asymptomatic patients were revisited. By using published estimates of treatment effect, a simplified calculator was designed to assess the five year stroke prevention rate per 1000 CEAs (stroke prevention potential [SPP], range 0-478), including the presence and recentness of symptoms, sex, increasing stenosis severity, and complication rates. Patients operated on for carotid stenosis at Helsinki University Hospital (HUH) between 2008 and 2016 were collected from a vascular registry (HUSVASC) and categorised according to the model. The local annual complication rate was re-evaluated and added to the model. The HUH patient cohort was incorporated into the SPP model, and changes over time analysed. Finally, theoretical changes in patient selection were compared in order to explore the theoretical impact of patient selection and shortening of the delay. RESULTS Fifteen hundred and five symptomatic and 356 asymptomatic carotid stenoses were operated on with stroke plus death rates of 3.6% and 0.3%, respectively. The proportion of CEAs performed within two weeks of the index event increased over the follow up period, being 77% in 2016. The SPP increased from 123 in 2008 to 229 in 2016. Theoretically, 350 ischaemic strokes were prevented in the period 2008-16, with 1861 CEAs. CONCLUSIONS National and international comparison of different CEA series is irrelevant if the inclusion criteria are not considered. A calculator that is easy to apply to large scale high quality registered data was developed and tested. SPP was found to increase over time, which is a probable sign of improved patient selection and an increased number of strokes prevented by the CEAs performed.
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Affiliation(s)
- Ellinoora Aro
- Department of Vascular Surgery, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Petra Ijäs
- Department of Neurology, University of Helsinki and Helsinki University Hospital, Helsinki, Finland; Department of Neurosciences, University of Helsinki, Helsinki, Finland
| | - Leena Vikatmaa
- Department of Anaesthesiology, Intensive Care and Pain Medicine, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Lauri Soinne
- Department of Neurology, University of Helsinki and Helsinki University Hospital, Helsinki, Finland; Department of Neurosciences, University of Helsinki, Helsinki, Finland
| | - Reijo Sund
- Institute of Clinical Medicine, University of Eastern Finland, Kuopio, Finland; Centre for Research Methods, Faculty of Social Sciences, University of Helsinki, Helsinki, Finland
| | - Maarit Venermo
- Department of Vascular Surgery, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Pirkka Vikatmaa
- Department of Vascular Surgery, University of Helsinki and Helsinki University Hospital, Helsinki, Finland.
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Editor's Choice – Recommendations for Registry Data Collection for Revascularisations of Acute Limb Ischaemia: A Delphi Consensus from the International Consortium of Vascular Registries. Eur J Vasc Endovasc Surg 2019; 57:816-821. [DOI: 10.1016/j.ejvs.2019.02.023] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2018] [Accepted: 02/23/2019] [Indexed: 11/23/2022]
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Högberg D, Björck M, Mani K, Svensjö S, Wanhainen A. Five Year Outcomes in Men Screened for Carotid Artery Stenosis at 65 Years of Age: A Population Based Cohort Study. Eur J Vasc Endovasc Surg 2019; 57:759-766. [PMID: 31142437 DOI: 10.1016/j.ejvs.2019.02.005] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2018] [Accepted: 02/07/2019] [Indexed: 10/26/2022]
Abstract
OBJECTIVE This study aimed to determine the outcome of 65 year old men five years after carotid ultrasound screening, as well as risk factors for disease progression. METHODS All 65 year old men living in the county of Uppsala 2007-2009 were invited to an ultrasound examination of both carotid arteries and re-invited at age 70. The cohort was grouped into normal carotids, plaque without significant stenosis, moderate stenosis (50-79%), and severe stenosis (80-99%). The rate of disease progression was assessed from ultrasound data. Data on mortality, ipsilateral neurological events, risk factors, and medication were obtained from patient records and population registries. RESULTS Among men participating in carotid screening at age 65, 3,057 were re-screened at age 70. In those with normal carotids (n = 2,318), 23 (1.0%) progressed to a moderate stenosis, and four (0.2%) to a symptomatic severe stenosis. Among those with plaque (n = 696), 25 (3.6%) progressed to moderate stenosis, and eight (1.1%) to severe stenosis, of whom four (0.6%) had symptoms. Of 31 men with 50-79% stenosis, four (12.9%) had progressed to a severe stenosis, of whom two (6.5%) developed symptoms. Five of twelve subjects (42%) with 80-99% stenosis developed symptoms. Disease regression was present among 289/692 plaque (41.7%) and 16/33 stenosis (48.4%). In multivariable analysis, smoking, coronary artery disease and hypercholesterolemia were associated with disease progression. The proportions of antiplatelet, statin, and antihypertensive treatment in the population at age 70 were 22%, 29%, and 55%, respectively. CONCLUSION Men with plaques and moderate stenosis have a good prognosis, but in those with severe stenosis there is a high risk of neurological events.
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Affiliation(s)
- Dominika Högberg
- Department of Surgical Sciences, Section of Vascular Surgery, Uppsala University, Uppsala, Sweden; Department of Hybrid and Interventional Surgery, Sahlgrenska University Hospital, Gothenburg, Sweden.
| | - Martin Björck
- Department of Surgical Sciences, Section of Vascular Surgery, Uppsala University, Uppsala, Sweden
| | - Kevin Mani
- Department of Surgical Sciences, Section of Vascular Surgery, Uppsala University, Uppsala, Sweden
| | - Sverker Svensjö
- Department of Surgical Sciences, Section of Vascular Surgery, Uppsala University, Uppsala, Sweden; Department of Surgery, Falun County Hospital, Falun, Sweden
| | - Anders Wanhainen
- Department of Surgical Sciences, Section of Vascular Surgery, Uppsala University, Uppsala, Sweden
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Naylor R. When two worlds collide. ANZ J Surg 2019; 89:279-280. [PMID: 30942547 DOI: 10.1111/ans.14965] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2018] [Revised: 09/17/2018] [Accepted: 10/16/2018] [Indexed: 11/30/2022]
Affiliation(s)
- Ross Naylor
- Leicester Vascular Institute, Glenfield Hospital, Leicester, UK
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Castro-Ferreira R, Freitas A, Sampaio SM, Dias PG, Mansilha A, Teixeira JF, Leite-Moreira A. Early results of carotid endarterectomy versus carotid stenting: Outcomes from a Mediterranean country. Vascular 2019; 27:468-474. [PMID: 30940003 DOI: 10.1177/1708538119841451] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Introduction and objectives Which is the best carotid stenosis treatment remains a controversial issue. To present day, no study has compared the results of carotid artery stenting versus carotid endarterectomy in Portugal. We aim to provide real life numbers regarding the outcomes of both procedures in Portuguese public hospitals. Methods Every patient registered between 2005 and 2015 with the main diagnosis of carotid stenosis and submitted to carotid endarterectomy or carotid artery stenting was included. The information was obtained through the Central National Healthcare Administrative database, a mandatory registry for hospital refunding. Primary outcomes were hospital mortality and stroke. Patient demographics, comorbidities and hospital length of stay were also evaluated. Results The study included 6094 patients: 1399 were symptomatic (mention of prior stroke) and 4695 asymptomatic. Carotid artery stenting was performed on 22% of the symptomatic and 18% of the asymptomatic patients. In the symptomatic patients, the in-hospital mortality was significantly higher in those submitted to stenting (3.6% vs. 1.6% in carotid endarterectomy, p = 0.025). No significant differences in outcomes were observed in the asymptomatic group (mortality 0.9% vs. 0.8%, p = 0.852; stroke rate of 2.6% vs. 2.3%, p = 0.652 – carotid artery stenting vs. carotid endarterectomy). In both groups, there was an important increase in the proportion of stenting between 2005 and 2012, followed by a gradual decline until 2015. Conclusion Despite its increasing frequency, a higher early mortality was documented for CAS in symptomatic patients. No worse outcome was observed in asymptomatic patients.
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Affiliation(s)
- Ricardo Castro-Ferreira
- Departamento de Cirurgia e Fisiologia, Unidade de Investigação Cardiovascular, Faculdade de Medicina da Universidade do Porto, Portugal.,Serviço de Angiologia e Cirurgia Vascular, Centro Hospitalar São João, São João, Portugal
| | - Alberto Freitas
- Departamento de Ciências da Informação e da Decisão em Saúde, Centro de Investigação e Tecnologia de Informação em Sistemas de Saúde (CINTESIS) Faculdade de Medicina, Universidade do Porto, Portugal
| | - Sérgio M Sampaio
- Serviço de Angiologia e Cirurgia Vascular, Centro Hospitalar São João, São João, Portugal.,Departamento de Ciências da Informação e da Decisão em Saúde, Centro de Investigação e Tecnologia de Informação em Sistemas de Saúde (CINTESIS) Faculdade de Medicina, Universidade do Porto, Portugal
| | - Paulo G Dias
- Serviço de Angiologia e Cirurgia Vascular, Centro Hospitalar São João, São João, Portugal
| | - Armando Mansilha
- Departamento de Cirurgia e Fisiologia, Unidade de Investigação Cardiovascular, Faculdade de Medicina da Universidade do Porto, Portugal.,Serviço de Angiologia e Cirurgia Vascular, Centro Hospitalar São João, São João, Portugal
| | - José F Teixeira
- Serviço de Angiologia e Cirurgia Vascular, Centro Hospitalar São João, São João, Portugal
| | - Adelino Leite-Moreira
- Departamento de Cirurgia e Fisiologia, Unidade de Investigação Cardiovascular, Faculdade de Medicina da Universidade do Porto, Portugal
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Reiff T, Eckstein HH, Mansmann U, Jansen O, Fraedrich G, Mudra H, Böckler D, Böhm M, Brückmann H, Debus ES, Fiehler J, Lang W, Mathias K, Ringelstein EB, Schmidli J, Stingele R, Zahn R, Zeller T, Hetzel A, Bodechtel U, Binder A, Glahn J, Hacke W, Ringleb PA. Angioplasty in asymptomatic carotid artery stenosis vs. endarterectomy compared to best medical treatment: One-year interim results of SPACE-2. Int J Stroke 2019; 15:1747493019833017. [PMID: 30873912 PMCID: PMC7416333 DOI: 10.1177/1747493019833017] [Citation(s) in RCA: 30] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2018] [Accepted: 12/10/2018] [Indexed: 12/11/2022]
Abstract
BACKGROUND Treatment of individuals with asymptomatic carotid artery stenosis is still handled controversially. Recommendations for treatment of asymptomatic carotid stenosis with carotid endarterectomy (CEA) are based on trials having recruited patients more than 15 years ago. Registry data indicate that advances in best medical treatment (BMT) may lead to a markedly decreasing risk of stroke in asymptomatic carotid stenosis. The aim of the SPACE-2 trial (ISRCTN78592017) was to compare the stroke preventive effects of BMT alone with that of BMT in combination with CEA or carotid artery stenting (CAS), respectively, in patients with asymptomatic carotid artery stenosis of ≥70% European Carotid Surgery Trial (ECST) criteria. METHODS SPACE-2 is a randomized, controlled, multicenter, open study. A major secondary endpoint was the cumulative rate of any stroke (ischemic or hemorrhagic) or death from any cause within 30 days plus an ipsilateral ischemic stroke within one year of follow-up. Safety was assessed as the rate of any stroke and death from any cause within 30 days after CEA or CAS. Protocol changes had to be implemented. The results on the one-year period after treatment are reported. FINDINGS It was planned to enroll 3550 patients. Due to low recruitment, the enrollment of patients was stopped prematurely after randomization of 513 patients in 36 centers to CEA (n = 203), CAS (n = 197), or BMT (n = 113). The one-year rate of the major secondary endpoint did not significantly differ between groups (CEA 2.5%, CAS 3.0%, BMT 0.9%; p = 0.530) as well as rates of any stroke (CEA 3.9%, CAS 4.1%, BMT 0.9%; p = 0.256) and all-cause mortality (CEA 2.5%, CAS 1.0%, BMT 3.5%; p = 0.304). About half of all strokes occurred in the peri-interventional period. Higher albeit statistically non-significant rates of restenosis occurred in the stenting group (CEA 2.0% vs. CAS 5.6%; p = 0.068) without evidence of increased stroke rates. INTERPRETATION The low sample size of this prematurely stopped trial of 513 patients implies that its power is not sufficient to show that CEA or CAS is superior to a modern medical therapy (BMT) in the primary prevention of ischemic stroke in patients with an asymptomatic carotid stenosis up to one year after treatment. Also, no evidence for differences in safety between CAS and CEA during the first year after treatment could be derived. Follow-up will be performed up to five years. Data may be used for pooled analysis with ongoing trials.
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Affiliation(s)
- T Reiff
- Department of Neurology, University
Hospital of Heidelberg, Heidelberg, Germany
| | - HH Eckstein
- Department for Vascular and
Endovascular Surgery, Technical University of Munich, Munich, Germany
| | - U Mansmann
- Institute of Medical Informatics,
Biometry and Epidemiology, Ludwig Maximilian University Munich, Munich,
Germany
| | - O Jansen
- Department of Radiology and
Neuroradiology, UKSH Campus Kiel, Kiel, Germany
| | - G Fraedrich
- Department of Vascular Surgery,
University Hospital of Innsbruck, Innsbruck, Austria
| | - H Mudra
- Department of Internal Medicine,
Städtisches Klinikum München-Neuperlach, Munich, Germany
| | - D Böckler
- Department of Vascular Surgery,
University Hospital of Heidelberg, Heidelberg, Germany
| | - M Böhm
- Department of Internal Medicine,
University Hospital of Homburg/Saar, Homburg, Germany
| | - H Brückmann
- Department of Neuroradiology,
Ludwig-Maximilians-Universität, Munich, Germany
| | - ES Debus
- Department of Vascular Surgery,
University Hospital of Hamburg, Hamburg, Germany
| | - J Fiehler
- Department of Neuroradiology,
University Hospital of Hamburg, Hamburg, Germany
| | - W Lang
- Department of Vascular Surgery,
University Hospital Erlangen, Erlangen, Germany
| | - K Mathias
- Department of Radiology, Klinikum
Dortmund, Dortmund, Germany
| | - EB Ringelstein
- Department of Neurology,
University Hospital of Münster, Münster, Germany
| | - J Schmidli
- Department of Vascular Surgery,
University Hospital of Bern, Bern, Switzerland
| | - R Stingele
- Department of Neurology,
University of Kiel, Kiel, Germany
| | - R Zahn
- Department of Internal Medicine,
Klinikum Ludwigshafen, Ludwigshafen, Germany
| | - T Zeller
- Department of Angiology,
University Hospital Freiburg, Bad Krozingen, Germany
| | - A Hetzel
- Department of Neurology,
University Hospital Freiburg, Freiburg, Germany
| | - U Bodechtel
- Department of Neurology,
University Hospital of Dresden, Dresden, Germany
| | - A Binder
- Department of Neurology, UKSH
Campus Kiel, Kiel, Germany
| | - J Glahn
- Department of Neurology, Johannes
Wesling Klinikum, Minden, Germany
| | - W Hacke
- Department of Neurology, University
Hospital of Heidelberg, Heidelberg, Germany
| | - PA Ringleb
- Department of Neurology, University
Hospital of Heidelberg, Heidelberg, Germany
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Behrendt CA, Sigvant B, Szeberin Z, Beiles B, Eldrup N, Thomson IA, Venermo M, Altreuther M, Menyhei G, Nordanstig J, Clarke M, Rieß HC, Björck M, Debus ES. International Variations in Amputation Practice: A VASCUNET Report. Eur J Vasc Endovasc Surg 2018; 56:391-399. [DOI: 10.1016/j.ejvs.2018.04.017] [Citation(s) in RCA: 76] [Impact Index Per Article: 12.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2017] [Accepted: 04/26/2018] [Indexed: 11/25/2022]
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The Vascunet Report on Amputations: Does it Contribute? Eur J Vasc Endovasc Surg 2018; 56:400. [DOI: 10.1016/j.ejvs.2018.05.016] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2018] [Accepted: 05/16/2018] [Indexed: 11/23/2022]
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Treatment of aortic aneurysms registered in Swedvasc: Development reflected in a national vascular registry with an almost 100% coverage. GEFASSCHIRURGIE 2018; 23:340-345. [PMID: 30237668 PMCID: PMC6133088 DOI: 10.1007/s00772-018-0414-8] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
Swedvasc is a registry for vascular surgical procedures, both open and endovascular. It was started in 1987 and since 1994 the whole population of Sweden is covered, at present around 10 million inhabitants. In a recent external validation, it was found to be highly accurate with abdominal aortic aneurysm surgery correctly reported in >96%. In this paper various factors explaining the almost 100% coverage are discussed, one important being that the registry has been developed and maintained within the profession of vascular surgery and not dictated by authorities. Another factor of importance is the possibility to use data in various research projects and so far 15 PhD theses have used Swedvasc data. To exemplify the practical use of the registry, the treatment of abdominal aortic aneurysms is scrutinized and among the various complications abdominal compartment syndrome is analyzed. Several significant temporal changes have been observed over the almost 25 years of Swedvasc: increasing use of endovascular surgery, treatment of aneurysms detected by screening , decreasing treatment for rupture, improved outcome, increasing treatment of older patients and patients with comorbid conditions. In conclusion, a high quality national vascular registry can be valid with high compliance and can be used to study population-based development of treatment and outcome. It can also be used to perform international comparisons with other registries, thereby getting an indication of the quality of care.
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Coscas R. Good Things Come to Those Who Wait: Toward a Common Dataset for Peripheral Vascular Registries. Eur J Vasc Endovasc Surg 2018; 56:238. [PMID: 29885844 DOI: 10.1016/j.ejvs.2018.05.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2018] [Accepted: 05/10/2018] [Indexed: 11/25/2022]
Affiliation(s)
- Raphaël Coscas
- Department of Vascular Surgery, Ambroise Paré University Hospital, AP-HP, Boulogne-Billancourt, France; UMR 1018, Inserm-Paris11 - CESP, Versailles Saint-Quentin-en-Yvelines University, Paris-Saclay University, Paul Brousse Hospital, Villejuif, France.
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Jones DW, Brott TG, Schermerhorn ML. Trials and Frontiers in Carotid Endarterectomy and Stenting. Stroke 2018; 49:1776-1783. [PMID: 29866753 DOI: 10.1161/strokeaha.117.019496] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2017] [Revised: 04/19/2018] [Accepted: 04/30/2018] [Indexed: 11/16/2022]
Affiliation(s)
- Douglas W Jones
- From the Division of Vascular and Endovascular Surgery, Boston Medical Center, Boston University School of Medicine, MA (D.W.J.)
| | - Thomas G Brott
- Department of Neurology, Mayo Clinic, Jacksonville, FL (T.G.B.)
| | - Marc L Schermerhorn
- Division of Vascular and Endovascular Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA (M.L.S.).
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Behrendt CA, Bertges D, Eldrup N, Beck AW, Mani K, Venermo M, Szeberin Z, Menyhei G, Thomson I, Heller G, Wigger P, Danielsson G, Galzerano G, Lopez C, Altreuther M, Sigvant B, Rieß HC, Sedrakyan A, Beiles B, Björck M, Boyle JR, Debus ES, Cronenwett J. International Consortium of Vascular Registries Consensus Recommendations for Peripheral Revascularisation Registry Data Collection. Eur J Vasc Endovasc Surg 2018; 56:217-237. [PMID: 29776646 DOI: 10.1016/j.ejvs.2018.04.006] [Citation(s) in RCA: 51] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2018] [Accepted: 04/09/2018] [Indexed: 01/28/2023]
Abstract
OBJECTIVE/BACKGROUND To achieve consensus on the minimum core data set for evaluation of peripheral arterial revascularisation outcomes and enable collaboration among international registries. METHODS A modified Delphi approach was used to achieve consensus among international vascular surgeons and registry members of the International Consortium of Vascular Registries (ICVR). Variables, including definitions, from registries covering open and endovascular surgery, representing 14 countries in ICVR, were collected and analysed to define a minimum core data set and to develop an optimum data set for registries. Up to three different levels of variable specification were suggested to allow inclusion of registries with simpler versus more complex data capture, while still allowing for data aggregation based on harmonised core definitions. RESULTS Among 31 invited experts, 25 completed five Delphi rounds via internet exchange and face to face discussions. In total, 187 different items from the various registry data forms were identified for potential inclusion in the recommended data set. Ultimately, 79 items were recommended for inclusion in minimum core data sets, including 65 items in the level 1 data set, and an additional 14 items in the more specific level 2 and 3 recommended data sets. Data elements were broadly divided into (i) patient characteristics; (ii) comorbidities; (iii) current medications; (iv) lesion treated; (v) procedure; (vi) bypass; (vii) endarterectomy (viii) catheter based intervention; (ix) complications; and (x) follow up. CONCLUSION A modified Delphi study allowed 25 international vascular registry experts to achieve a consensus recommendation for a minimum core data set and an optimum data set for peripheral arterial revascularisation registries. Continued global harmonisation of registry infrastructure and definition of items will overcome limitations related to single country investigations and enhance the development of real world evidence.
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Affiliation(s)
- Christian-Alexander Behrendt
- Department of Vascular Medicine, University Heart Centre Hamburg, University Medical Centre Hamburg-Eppendorf, Hamburg, Germany.
| | - Daniel Bertges
- Division of Vascular Surgery, University of Vermont Medical Center, Burlington, VT, USA
| | - Nikolaj Eldrup
- Department of Cardio-Thoracic and Vascular Surgery, Aarhus University Hospital, Aarhus, Denmark
| | - Adam W Beck
- Division of Vascular Surgery and Endovascular Therapy, University of Alabama at Birmingham, AL, USA
| | - Kevin Mani
- Department of Surgical Sciences, Uppsala University, Uppsala, Sweden
| | - Maarit Venermo
- Department of Vascular Surgery, Helsinki University Hospital and University of Helsinki, Helsinki, Finland
| | - Zoltán Szeberin
- Department of Vascular Surgery, Semmelweis University, Budapest, Hungary
| | - Gabor Menyhei
- Department of Vascular Surgery, Pecs University Medical Centre, Pecs, Hungary
| | - Ian Thomson
- Department of Vascular Surgery, Dunedin School of Medicine, Dunedin Hospital, Dunedin, New Zealand
| | - Georg Heller
- Department of Vascular Surgery, Kantonsspital St. Gallen, Switzerland
| | - Pius Wigger
- Department of Surgery, Kantonspital, Winterthur, Switzerland
| | | | - Giuseppe Galzerano
- Vascular Surgery, Misericordia Hospital of Grosseto, Usl Toscana Sud-Est, Grosseto, Italy
| | - Cristina Lopez
- Department of Vascular Surgery, University Hospital of Granada, Spain
| | - Martin Altreuther
- Department of Vascular Surgery, St. Olavs Hospital, Trondheim, Norway
| | - Birgitta Sigvant
- Department of Surgical Sciences, Uppsala University, Uppsala, Sweden
| | - Henrik C Rieß
- Department of Vascular Medicine, University Heart Centre Hamburg, University Medical Centre Hamburg-Eppendorf, Hamburg, Germany
| | - Art Sedrakyan
- Healthcare Policy and Research, Weill Cornell Medical College, New York, NY, USA
| | - Barry Beiles
- Australian and New Zealand Society for Vascular Surgery, Melbourne, Australia
| | - Martin Björck
- Department of Surgical Sciences, Uppsala University, Uppsala, Sweden
| | - Jonathan R Boyle
- Department of Vascular Surgery, Cambridge University Hospitals NHS Trust, Cambridge, UK
| | - E Sebastian Debus
- Department of Vascular Medicine, University Heart Centre Hamburg, University Medical Centre Hamburg-Eppendorf, Hamburg, Germany
| | - Jack Cronenwett
- Department of Surgery Dartmouth-Hitchcock Medical Centre, Lebanon, NH, USA
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Behrendt CA, Joassart Ir A, Debus ES, Kolh P. The Challenge of Data Privacy Compliant Registry Based Research. Eur J Vasc Endovasc Surg 2018; 55:601-602. [DOI: 10.1016/j.ejvs.2018.02.018] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2018] [Accepted: 02/11/2018] [Indexed: 11/26/2022]
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Publication of Vascular Surgical Registry Data: Strengths and Limitations. Eur J Vasc Endovasc Surg 2017; 54:788. [DOI: 10.1016/j.ejvs.2017.09.013] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2017] [Accepted: 09/19/2017] [Indexed: 11/17/2022]
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