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Li W, Wu C, Deng R, Li L, Wu Q, Zhang L, Yan T, Chen S. Comparison of Perioperative Safety of Carotid Artery Stenting and Endarterectomy in the Treatment of Carotid Artery Stenosis: A Meta-Analysis of Randomized Controlled Trials. World Neurosurg 2024; 181:e356-e375. [PMID: 37863425 DOI: 10.1016/j.wneu.2023.10.054] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2023] [Revised: 10/09/2023] [Accepted: 10/10/2023] [Indexed: 10/22/2023]
Abstract
BACKGROUND Current management guidelines for the treatment of carotid stenosis are controversial. We performed this meta-analysis to evaluate the perioperative safety of carotid artery stenting (CAS) and endarterectomy. METHODS We systematically searched EMBASE, PubMed, Web of Science, and the Cochrane Library from inception to November 10, 2022, for randomized controlled trials that compared CAS with carotid endarterectomy (CEA) among patients with carotid stenosis. The analyzed outcomes mainly included stroke, death, myocardial infarction (MI), cranial nerve palsy, the cumulative incidence of mortality, stroke, or MI and the cumulative incidence of death or stroke in the perioperative periods. The risk ratio (RR) and 95% confidence interval (95% CI) were calculated and pooled. Subgroup analyses were based on whether patients were symptomatic or asymptomatic. We assessed the certainty of evidence using the Grading of Recommendations Assessment, Development and Evaluation framework. RESULTS Seventeen randomized controlled trials with 12,277 participants (6514 and 5763 in the CAS and CEA groups, respectively) were included. Pooled analysis demonstrated that compared with CEA, CAS was associated with decreased risks of perioperative MI (RR = 0.47, 95% CI = 0.29∼0.77) and perioperative cranial nerve palsy (RR = 0.02, 95% CI = 0.01∼0.06) but higher risks of perioperative stroke (RR = 1.48, 95% CI = 1.18∼1.87) and cumulative incidence of death or stroke (RR = 1.52, 95% CI = 1.20∼1.93). CONCLUSIONS The perioperative safety was equivalent between CAS and CEA. However, CEA may be preferred when considering both procedural safety and long-term efficacy in preventing recurrent stroke.
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Affiliation(s)
- Wenkui Li
- Department of Neurology, Chongqing University Three Gorges Hospital, Chongqing, China; School of Medicine, Chongqing University, Chongqing, China
| | - Chuyue Wu
- Department of Neurology, Chongqing University Three Gorges Hospital, Chongqing, China; School of Medicine, Chongqing University, Chongqing, China; Chongqing Municipality Clinical Research Center for Geriatric Diseases, Chongqing University Three Gorges Hospital, Chongqing, China
| | - Rong Deng
- Department of Neurology, Chongqing University Three Gorges Hospital, Chongqing, China; School of Medicine, Chongqing University, Chongqing, China
| | - Li Li
- Department of Neurology, Chongqing University Three Gorges Hospital, Chongqing, China; School of Medicine, Chongqing University, Chongqing, China
| | - Qingyuan Wu
- Department of Neurology, Chongqing University Three Gorges Hospital, Chongqing, China; School of Medicine, Chongqing University, Chongqing, China; Chongqing Municipality Clinical Research Center for Geriatric Diseases, Chongqing University Three Gorges Hospital, Chongqing, China
| | - Lina Zhang
- Department of Neurology, Chongqing University Three Gorges Hospital, Chongqing, China; School of Medicine, Chongqing University, Chongqing, China; Chongqing Municipality Clinical Research Center for Geriatric Diseases, Chongqing University Three Gorges Hospital, Chongqing, China
| | - Tao Yan
- Department of Clinical Laboratory, Tianjin Medical University General Hospital, Tianjin, China
| | - Shengli Chen
- Department of Neurology, Chongqing University Three Gorges Hospital, Chongqing, China.
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Petrovic J, Ilijevski N, Sagic D, Antonic Z, Tanaskovic S. Risk Factors for Carotid Restenosis in Patients After Eversion Endarterectomy vs Stenting: A Single-Center Experience. Angiology 2023; 74:317-324. [PMID: 35968755 DOI: 10.1177/00033197221121005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
The primary aim of the presented study is to analyze and compare the rate of carotid restenosis in patients after eversion carotid endarterectomy (eCEA), primary carotid angioplasty and stenting (CASp), and stenting for carotid artery restenosis after previous eCEA (CASr). The secondary aim is to compare clinical outcomes in patients with carotid restenosis. The total number of patients with evident carotid restenosis was 223 (24.8%). In patients with eCEA, significant carotid restenosis rate was 12.7%, in the CASp group 18.7%, and CASr 6.7%. Patients with carotid restenosis were asymptomatic in 95.1% of cases. Patients in the CASp group experienced transient ischemic attack more than patients with eCEA (P = .007), while no difference was observed regarding cerebrovascular insult (CVI). The incidence of carotid restenosis was higher in CASp patients, and increased during the follow-up. The majority of patients are asymptomatic post-procedural and the degree of carotid restenosis does not correlate with the occurrence of postoperative symptoms. High low-density lipoprotein cholesterol (LDL-C) levels, low high-density lipoprotein cholesterol (HDL-C) levels, smoking, and a history of vascular surgery correlate with higher degrees of carotid restenosis. The most important factor in the prevention of carotid restenosis is risk factor control as well as adequate pharmacological therapy.
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Affiliation(s)
- Jovan Petrovic
- Faculty of Medicine, 54801University of Belgrade, Beograd, Serbia
| | - Nenad Ilijevski
- Faculty of Medicine, 54801University of Belgrade, Beograd, Serbia.,Vascular Surgery Clinic, Dedinje Cardiovascular Institute, Belgrade, Serbia
| | - Dragan Sagic
- Faculty of Medicine, 54801University of Belgrade, Beograd, Serbia.,Clinic for Radiology, Dedinje Cardiovascular Institute, Belgrade, Serbia
| | - Zelimir Antonic
- Clinic for Radiology, Dedinje Cardiovascular Institute, Belgrade, Serbia
| | - Slobodan Tanaskovic
- Faculty of Medicine, 54801University of Belgrade, Beograd, Serbia.,Vascular Surgery Clinic, Dedinje Cardiovascular Institute, Belgrade, Serbia
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3
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Short- and Mid-Term Outcomes of Stenting in Patients with Isolated Distal Internal Carotid Artery Stenosis or Post-Surgical Restenosis. J Clin Med 2022; 11:jcm11195640. [PMID: 36233508 PMCID: PMC9571211 DOI: 10.3390/jcm11195640] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2022] [Revised: 09/20/2022] [Accepted: 09/21/2022] [Indexed: 12/24/2022] Open
Abstract
The aim was to evaluate the outcome of stenting in patients with isolated distal internal carotid artery (ICA) stenosis or post-surgical restenosis, as no data are currently available in the literature. Sixty-six patients (men, N = 53; median age: 66 [IQR, 61–73] years) with ≥50% distal ICA (re)stenosis were included in this single-center retrospective study. The narrowest part of the (re)stenosis was at least 20 mm from the bifurcation in all patients. Patients were divided into two etiological groups, atherosclerotic (AS, N = 40) and post-surgical restenotic (RES, N = 26). Postprocedural neurological events were observed in two patients (5%) in the AS group and in two patients (7.7%) in the RES group. The median follow-up time was 40 (IQR, 18–86) months. Three patients (7.5%) in the AS group had an in-stent restenosis (ISR) ≥ 50%, but none in the RES group. Three patients (7.5%) in the AS group and seven patients (26.9%) in the RES group died. None of the deaths in the RES group were directly related to stenting itself. The early neurological complication rate of stenting due to distal ICA (re)stenoses is acceptable. However, the mid-term mortality rate of stenting for distal ICA post-surgical restenoses is high, indicating the vulnerability of this subgroup.
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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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Nguyen J, Li A, Tam DY, Forbes TL. ANALYSIS OF SPIN IN VASCULAR SURGERY RANDOMIZED CONTROLLED TRIALS WITH NONSIGNIFICANT OUTCOMES. J Vasc Surg 2021; 75:1074-1080.e17. [PMID: 34923067 DOI: 10.1016/j.jvs.2021.09.051] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2021] [Accepted: 09/25/2021] [Indexed: 12/17/2022]
Abstract
OBJECTIVES Spin is the manipulation of language that distorts the interpretation of objective findings. The purpose of this study is to describe the characteristics of spin found in statistically nonsignificant randomized controlled trials (RCT) comparing carotid endarterectomy (CEA) to carotid artery stenting (CAS) for carotid stenosis (CS), and endovascular repair (EVAR) to open repair (OR) for abdominal aortic aneurysms (AAA). METHODS A search of MEDLINE, EMBASE, and the Cochrane Controlled Register of Trials was performed in June 2020 for studies published describing AAA or CS. All phase three RCTs with nonsignificant primary outcomes comparing OR to EVAR or CEA to CAS were included. Studies were appraised for the characteristics and severity of spin using a validated tool. Binary logistic regression was performed to assess the association of spin grade to (1) funding source (commercial vs non-commercial) and (2) the publishing journal's impact factor. RESULTS Thirty-one of 355 articles captured were included for analysis. Spin was identified in nine abstracts (9/18) and 13 main texts (13/18) of AAA articles and seven abstracts (7/13) and ten main texts (10/13) of CS articles. For both AAA and CS articles, spin was most commonly found in the manuscript discussion section, with the most commonly employed strategy being the interpretation of statistically nonsignificant primary results to show treatment equivalence or rule out adverse treatment effects. Increasing journal impact factor was associated with a statistically significant lower likelihood of spin in the study title or abstract conclusion (βOR = 0.96, 95% CI: 0.94 - 0.98, p < 0.01) while no significant association could be found with funding source (βOR = 1.33, 95% CI: 0.30-5.92, p = 0.71). CONCLUSIONS A large proportion of statistically nonsignificant RCTs contain interpretations that are inconsistent with their results. These findings should prompt authors and readers to appraise study findings independently and to limit the use of spin in study interpretations.
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Affiliation(s)
| | - Allen Li
- University of Ottawa, Faculty of Medicine
| | - Derrick Y Tam
- Division of Cardiac Surgery, University of Toronto; Department of Surgery, University of Toronto, Toronto, ON, Canada
| | - Thomas L Forbes
- Division of Vascular Surgery, Peter Munk Cardiac Centre, University Health Network; Department of Surgery, University of Toronto, Toronto, ON, Canada.
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Bonati LH, Kakkos S, Berkefeld J, de Borst GJ, Bulbulia R, Halliday A, van Herzeele I, Koncar I, McCabe DJ, Lal A, Ricco JB, Ringleb P, Taylor-Rowan M, Eckstein HH. European Stroke Organisation guideline on endarterectomy and stenting for carotid artery stenosis. Eur Stroke J 2021; 6:I-XLVII. [PMID: 34414302 DOI: 10.1177/23969873211012121] [Citation(s) in RCA: 114] [Impact Index Per Article: 38.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2021] [Accepted: 04/05/2021] [Indexed: 01/01/2023] Open
Abstract
Atherosclerotic stenosis of the internal carotid artery is an important cause of stroke. The aim of this guideline is to analyse the evidence pertaining to medical, surgical and endovascular treatment of patients with carotid stenosis. These guidelines were developed based on the ESO standard operating procedure and followed the Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) approach. The working group identified relevant questions, performed systematic reviews and meta-analyses of the literature, assessed the quality of the available evidence, and wrote recommendations. Based on moderate quality evidence, we recommend carotid endarterectomy (CEA) in patients with ≥60-99% asymptomatic carotid stenosis considered to be at increased risk of stroke on best medical treatment (BMT) alone. We also recommend CEA for patients with ≥70-99% symptomatic stenosis, and we suggest CEA for patients with 50-69% symptomatic stenosis. Based on high quality evidence, we recommend CEA should be performed early, ideally within two weeks of the last retinal or cerebral ischaemic event in patients with ≥50-99% symptomatic stenosis. Based on low quality evidence, carotid artery stenting (CAS) may be considered in patients < 70 years old with symptomatic ≥50-99% carotid stenosis. Several randomised trials supporting these recommendations were started decades ago, and BMT, CEA and CAS have evolved since. The results of another large trial comparing outcomes after CAS versus CEA in patients with asymptomatic stenosis are anticipated in the near future. Further trials are needed to reassess the benefits of carotid revascularisation in combination with modern BMT in subgroups of patients with carotid stenosis.
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Affiliation(s)
- Leo H Bonati
- Department of Neurology, University Hospital Basel, Basel, Switzerland; Department of Clinical Research, University of Basel, Basel, Switzerland
| | - Stavros Kakkos
- Department of Vascular Surgery, University of Patras Medical School, Patras, Greece
| | - Joachim Berkefeld
- Institute of Neuroradiology, University Hospital of Frankfurt am Main, Frankfurt, Germany
| | - Gert J de Borst
- Department of Vascular Surgery, University Medical Center Utrecht, Utrecht, the Netherlands
| | - Richard Bulbulia
- Medical Research Council Population Health Research Unit, Clinical Trial Service Unit and Epidemiological Studies Unit, Nuffield Department of Population Health, University of Oxford, Oxford, UK
| | - Alison Halliday
- Medical Research Council Population Health Research Unit, Clinical Trial Service Unit and Epidemiological Studies Unit, Nuffield Department of Population Health, University of Oxford, Oxford, UK
| | - Isabelle van Herzeele
- Department of Thoracic and Vascular Surgery, Ghent University Hospital, Ghent, Belgium
| | - Igor Koncar
- Clinic for Vascular and Endovascular Surgery, Serbian Clinical Centre, Belgrade, Serbia
| | - Dominick Jh McCabe
- Department of Neurology and Stroke Service, The Adelaide and Meath Hospital, Dublin, incorporating the National Children's Hospital - Tallaght University Hospital, Dublin, Ireland; Royal Free Campus, UCL Queen Square Institute of Neurology, London, UK; Academic Unit of Neurology, School of Medicine, Trinity College Dublin, Ireland
| | - Avtar Lal
- European Stroke Organisation, Basel, Switzerland
| | - Jean-Baptiste Ricco
- Department of Vascular Surgery and Department of Clinical Research, University of Poitiers, Poitiers, France
| | - Peter Ringleb
- Department of Neurology, University Hospital Heidelberg, Heidelberg, Germany
| | | | - Hans-Henning Eckstein
- Department for Vascular and Endovascular Surgery, University Hospital, Technical University of Munich (TUM), Munich, Germany
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Hasan B, Farah M, Nayfeh T, Amin M, Malandris K, Abd-Rabu R, Shah S, Rajjoub R, Seisa MO, Saadi S, Hassett L, Prokop LJ, AbuRahma A, Murad MH. A Systematic Review Supporting the Society for Vascular Surgery Guidelines on the Management of Carotid Artery Disease. J Vasc Surg 2021; 75:99S-108S.e42. [PMID: 34153350 DOI: 10.1016/j.jvs.2021.06.001] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2021] [Accepted: 06/01/2021] [Indexed: 12/29/2022]
Abstract
BACKGROUND To support the development of guidelines on the management of carotid disease, a writing committee from the Society for Vascular Surgery has commissioned this systematic review. METHODS We searched multiple data bases for studies addressing 5 questions: medical management vs. carotid revascularization (CEA) in asymptomatic patients, CEA vs. CAS in symptomatic low surgical risk patients, the optimal timing of revascularization after acute stroke, screening high risk patients for carotid disease, and the optimal sequence of interventions in patients with combined coronary and carotid disease. Studies were selected and appraised by pairs of independent reviewers. Meta-analyses were performed when feasible. RESULTS Medical management compared to carotid interventions in asymptomatic patients was associated with better early outcome during the first 30 days. However, CEA was associated with significantly lower long-term rate of stroke/death at 5 years. In symptomatic low risk surgical patients, CEA was associated with lower risk of stroke, but a significant increase in MI compared to CAS during the first 30 days. When the long-term outcome of transfemoral CAS vs. CEA in symptomatic patients were examined using pre-planned pooled analysis of individual patient data from four randomized trials, the risk of death or stroke within 120 days of the index procedure was 5.5% for CEA and 8.7% for CAS, which lends support that over the long-term, CEA has superior outcome than transfemoral CAS. When managing acute stroke, the comparison of CEA during the first 48 hours to that between day 2 and day14 did not reveal a statistically significant difference on outcomes during the first 30 days. Registry data show good results with CEA performed in the first week, but not within the first 48 hours. A single risk factor, aside from PAD, was associated with low carotid screening yield. Multiple risk factors greatly increase the yield of screening. Evidence on the timing of interventions in patients with combined carotid and coronary disease was sparse and imprecise. Patients without carotid symptoms, who had the carotid intervention first, compared to a combined carotid intervention and CABG, had better outcomes. CONCLUSIONS This updated evidence summary will support the SVS clinical practice guidelines for commonly raised clinical scenarios. CEA was superior to medical therapy in long-term prevention of stroke/death over medical therapy. CEA was also superior to transfemoral CAS in minimizing long-term stroke/death for symptomatic low risk surgical patients. CEA should optimally be performed between 2-14 days from the onset of acute stroke. Having multiple risk factors increases the value of carotid screening.
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Affiliation(s)
- Bashar Hasan
- Evidence-Based Practice Research Program, Mayo Clinic, MN, USA; Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, MN, USA
| | - Magdoleen Farah
- Evidence-Based Practice Research Program, Mayo Clinic, MN, USA; Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, MN, USA
| | - Tarek Nayfeh
- Evidence-Based Practice Research Program, Mayo Clinic, MN, USA; Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, MN, USA
| | - Mustapha Amin
- Evidence-Based Practice Research Program, Mayo Clinic, MN, USA; Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, MN, USA
| | - Kostantinos Malandris
- Evidence-Based Practice Research Program, Mayo Clinic, MN, USA; Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, MN, USA
| | - Rami Abd-Rabu
- Evidence-Based Practice Research Program, Mayo Clinic, MN, USA; Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, MN, USA
| | - Sahrish Shah
- Evidence-Based Practice Research Program, Mayo Clinic, MN, USA; Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, MN, USA
| | - Rami Rajjoub
- Evidence-Based Practice Research Program, Mayo Clinic, MN, USA; Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, MN, USA
| | - Mohamed O Seisa
- Evidence-Based Practice Research Program, Mayo Clinic, MN, USA; Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, MN, USA
| | - Samer Saadi
- Evidence-Based Practice Research Program, Mayo Clinic, MN, USA; Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, MN, USA
| | | | | | - Ali AbuRahma
- Department of Surgery, West Virginia University 3110 MacCorkle Ave., SE, Charleston, WV 25304
| | - M Hassan Murad
- Evidence-Based Practice Research Program, Mayo Clinic, MN, USA; Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, MN, USA.
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Nana P, Kouvelos G, Brotis A, Spanos K, Dardiotis E, Matsagkas M, Giannoukas A. Early Outcomes of Carotid Revascularization in Retrospective Case Series. J Clin Med 2021; 10:jcm10050935. [PMID: 33804315 PMCID: PMC7957582 DOI: 10.3390/jcm10050935] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2021] [Revised: 02/06/2021] [Accepted: 02/10/2021] [Indexed: 11/28/2022] Open
Abstract
Background: Most data in carotid stenosis treatment arise from randomized control trials (RCTs) and cohort studies. The aim of this meta-analysis was to compare 30-day outcomes in real-world practice from centers providing both modalities. Methods: A data search of the English literature was conducted, using PubMed, EMBASE and CENTRAL databases, until December 2019, using the Preferred Reporting Items for Systematic Reviews and Meta-Analysis statement (PRISMA) guidelines. Only studies reporting on 30-day outcomes from centers, where both techniques were performed, were eligible for this analysis. Results: In total, 15 articles were included (16,043 patients). Of the patients, 68.1% were asymptomatic. Carotid artery stenting (CAS) did not differ from carotid endarterectomy (CEA) in terms of stroke (odds ratio (OR) 0.98; 0.77–1.25; I2 = 0%), myocardial ischemic events (OR 1.03; 0.72–1.48; I2 = 0%) and all events (OR 1.0; 0.82–1.21; I2 = 0%). Pooled stroke incidence in asymptomatic patients was 1% (95% CI: 0–2%) for CEA and 1% for CAS (95% CI: 0–2%). Pooled stroke rate in symptomatic patients was 3% (95% CI: 1–4%) for CEA and 3% (95% CI: 1–4%) for CAS. The two techniques did not differ in either outcome both in asymptomatic and symptomatic patients. Conclusion: Carotid revascularization, performed in centers providing both CAS and CEA, is safe and effective. Both techniques did not differ in terms of post-procedural neurological and cardiac events, both in asymptomatic and symptomatic patients. These findings reiterate the importance of a tailored therapeutic strategy and that “real-world” outcomes may only be valid from centers providing both treatments.
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Affiliation(s)
- Petroula Nana
- Vascular Surgery Department, Larissa University Hospital, Faculty of Medicine, School of Health Sciences, University of Thessaly, 41334 Larissa, Greece; (P.N.); (K.S.); (M.M.); (A.G.)
| | - George Kouvelos
- Vascular Surgery Department, Larissa University Hospital, Faculty of Medicine, School of Health Sciences, University of Thessaly, 41334 Larissa, Greece; (P.N.); (K.S.); (M.M.); (A.G.)
- Correspondence: ; Tel.: +30-694-558-5876
| | - Alexandros Brotis
- Department of Neurosurgery, Larissa University Hospital, Faculty of Medicine, School of Health Sciences, University of Thessaly, 38221 Volos, Greece;
| | - Konstantinos Spanos
- Vascular Surgery Department, Larissa University Hospital, Faculty of Medicine, School of Health Sciences, University of Thessaly, 41334 Larissa, Greece; (P.N.); (K.S.); (M.M.); (A.G.)
| | - Efthimios Dardiotis
- Department of Neurology, University Hospital of Larissa, School of Medicine, University of Thessaly, 38221 Volos, Greece;
| | - Miltiadis Matsagkas
- Vascular Surgery Department, Larissa University Hospital, Faculty of Medicine, School of Health Sciences, University of Thessaly, 41334 Larissa, Greece; (P.N.); (K.S.); (M.M.); (A.G.)
| | - Athanasios Giannoukas
- Vascular Surgery Department, Larissa University Hospital, Faculty of Medicine, School of Health Sciences, University of Thessaly, 41334 Larissa, Greece; (P.N.); (K.S.); (M.M.); (A.G.)
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Mendoza JFW, Latorraca CDOC, Oliveira RDÁ, Pachito DV, Martimbianco ALC, Pacheco RL, Riera R. Methodological quality and redundancy of systematic reviews that compare endarterectomy versus stenting for carotid stenosis. BMJ Evid Based Med 2021; 26:14-18. [PMID: 31266765 DOI: 10.1136/bmjebm-2018-111151] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 06/10/2019] [Indexed: 12/14/2022]
Abstract
A review of systematic reviews (SRs) and a critical appraisal study was conducted at Escola Paulista de Medicina, Universidade Federal de São Paulo (Unifesp). The objectives of this review are (1) to identify all published SRs comparing the effectiveness and safety of carotid endarterectomy (CEA) versus carotid artery stenting (CAS) for carotid artery stenosis, (2) to assess their methodological quality and (3) to compare the primary studies contained in each SR. We included 17 SRs published between 2005 and 2017. None of the SRs fulfilled all items of AMSTAR-2. The overall confidence in the results was graded as critically low for 16 SRs (94%) and low for 1 SR (6%). Five items were judged inadequate in all SRs: reference to a published protocol, explanation to the selection of study design, comprehensive search of the literature, methods for statistical combination of findings and consideration of the risk of bias on the results of meta-analysis. In total, 15 randomised clinical trials (RCTs) were included at least in one SR. The number of included RCTs in each SR was inconsistent (4 to 15) and was not related to the year of publication of the SR. Our study found redundant and low methodological quality SR comparing CAS versus CEA for carotid stenosis.
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Affiliation(s)
- Juan Fulgencio Welko Mendoza
- Discipline of Evidence-Based Medicine, Universidade Federal de São Paulo (Unifesp), São Paulo, São Paulo, Brazil
| | | | - Ricardo de Ávila Oliveira
- Discipline of Evidence-Based Medicine, Universidade Federal de São Paulo (Unifesp), São Paulo, São Paulo, Brazil
- Department of Surgery, Universidade Federal de Uberlândia, Uberlândia, Minas Gerais, Brazil
| | - Daniela Vianna Pachito
- Center of Health Technology Assessment, Hospital Sírio-Libanês, São Paulo, São Paulo, Brazil
| | - Ana Luiza Cabrera Martimbianco
- Postgraduate of Health and Environment, Universidade Metropolitana de Santos, Santos, São Paulo, Brazil
- Medical Research Center, Centro Universitário São Camilo, São Paulo, São Paulo, Brazil
| | - Rafael Leite Pacheco
- Discipline of Evidence-Based Medicine, Universidade Federal de São Paulo (Unifesp), São Paulo, São Paulo, Brazil
- Medical Research Center, Centro Universitário São Camilo, São Paulo, São Paulo, Brazil
| | - Rachel Riera
- Discipline of Evidence-Based Medicine, Universidade Federal de São Paulo (Unifesp), São Paulo, São Paulo, Brazil
- Center of Health Technology Assessment, Hospital Sírio-Libanês, São Paulo, São Paulo, Brazil
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Müller MD, Lyrer PA, Brown MM, Bonati LH. Carotid Artery Stenting Versus Endarterectomy for Treatment of Carotid Artery Stenosis. Stroke 2020; 52:e3-e5. [PMID: 33370200 DOI: 10.1161/strokeaha.120.030521] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Mandy D Müller
- Department of Neurology and Stroke Center, University Hospital Basel, University of Basel, Switzerland (M.D.M., P.A.L., L.H.B.).,Department of Neurosurgery, Inselspital, Bern University Hospital and University of Bern, Switzerland (M.D.M.)
| | - Philippe A Lyrer
- Department of Neurology and Stroke Center, University Hospital Basel, University of Basel, Switzerland (M.D.M., P.A.L., L.H.B.)
| | - Martin M Brown
- Stroke Research Centre, Department of Brain Repair and Rehabilitation, UCL Institute of Neurology, University College London, United Kingdom (M.M.B., L.H.B.)
| | - Leo H Bonati
- Department of Neurology and Stroke Center, University Hospital Basel, University of Basel, Switzerland (M.D.M., P.A.L., L.H.B.).,Stroke Research Centre, Department of Brain Repair and Rehabilitation, UCL Institute of Neurology, University College London, United Kingdom (M.M.B., L.H.B.)
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11
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Stilo F, Montelione N, Calandrelli R, Distefano M, Spinelli F, Di Lazzaro V, Pilato F. The management of carotid restenosis: a comprehensive review. ANNALS OF TRANSLATIONAL MEDICINE 2020; 8:1272. [PMID: 33178804 PMCID: PMC7607074 DOI: 10.21037/atm-20-963] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Carotid artery stenosis (CS) is a major medical problem affecting approximately 10% of the general population 80 years or older and causes stroke in approximately 10% of all ischemic events. In patients with symptomatic, moderate-to-severe CS, carotid endarterectomy (CEA) and carotid angioplasty and stenting (CAS), has been used to lower the risk of stroke. In primary CS, CEA was found to be superior to best medical therapy (BMT) according to 3 large randomized controlled trials (RCT). Following CEA and CAS, restenosis remains an unsolved problem involving a large number of patients as the current treatment recommendations are not as clear as those for primary stenosis. Several studies have evaluated the risk of restenosis, reporting an incidence ranging from 5% to 22% after CEA and an in-stent restenosis (ISR) rate ranging from 2.7% to 33%. Treatment and optimal management of this disease process, however, is a matter of ongoing debate, and, given the dearth of level 1evidence for the management of these conditions, the relevant guidelines lack clarity. Moreover, the incidence rates of stroke and complications in patients with carotid stenosis are derived from studies that did not use contemporary techniques and materials. Rapidly changing guidelines, updated techniques, and materials, and modern medical treatments make actual incidence rates barely comparable to previous ones. For these reasons, RCTs are critical for determining whether these patients should be treated with more aggressive treatments additional to BMT and identifying those patients indicated for surgical or endovascular treatments. This review summarizes the current evidence and controversies concerning the risks, causes, current treatment options, and prognoses in patients with restenosis after CEA or CAS.
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Affiliation(s)
- Francesco Stilo
- Vascular Surgery Division, Campus Bio-Medico University of Rome, Rome, Italy
| | - Nunzio Montelione
- Vascular Surgery Division, Campus Bio-Medico University of Rome, Rome, Italy
| | - Rosalinda Calandrelli
- Fondazione Policlinico Universitario A. Gemelli - IRCCS, Roma, UOC Radiologia e Neuroradiologia, Dipartimento di Diagnostica per Immagini, Radioterapia Oncologica ed Ematologia, Rome, Italy
| | - Marisa Distefano
- UOC Neurologia e UTN, Ospedale Belcolle, Strada Sammartinese 01100 Viterbo, Viterbo, Italy
| | - Francesco Spinelli
- Vascular Surgery Division, Campus Bio-Medico University of Rome, Rome, Italy
| | - Vincenzo Di Lazzaro
- Neurology, Neurophysiology, and Neurobiology Unit, Department of Medicine, Campus Bio-Medico University of Rome, Rome, Italy
| | - Fabio Pilato
- Fondazione Policlinico Universitario A. Gemelli - IRCCS, Roma, UOC Neurologia, Dipartimento di Scienze Dell'invecchiamento, Neurologiche, Ortopediche e della Testa-collo, Roma, Italy
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12
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Müller MD, Lyrer P, Brown MM, Bonati LH. Carotid artery stenting versus endarterectomy for treatment of carotid artery stenosis. Cochrane Database Syst Rev 2020; 2:CD000515. [PMID: 32096559 PMCID: PMC7041119 DOI: 10.1002/14651858.cd000515.pub5] [Citation(s) in RCA: 29] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
BACKGROUND Carotid artery stenting is an alternative to carotid endarterectomy for the treatment of atherosclerotic carotid artery stenosis. This review updates a previous version first published in 1997 and subsequently updated in 2004, 2007, and 2012. OBJECTIVES To assess the benefits and risks of stenting compared with endarterectomy in people with symptomatic or asymptomatic carotid stenosis. SEARCH METHODS We searched the Cochrane Stroke Group Trials Register (last searched August 2018) and the following databases: CENTRAL, MEDLINE, Embase, and Science Citation Index to August 2018. We also searched ongoing trials registers (August 2018) and reference lists, and contacted researchers in the field. SELECTION CRITERIA Randomised controlled trials (RCTs) comparing stenting with endarterectomy for symptomatic or asymptomatic atherosclerotic carotid stenosis. In addition, we included RCTs comparing carotid artery stenting with medical therapy alone. DATA COLLECTION AND ANALYSIS One review author selected trials for inclusion, assessed trial quality and risk of bias, and extracted data. A second review author independently validated trial selection and a third review author independently validated data extraction. We calculated treatment effects as odds ratios (OR) and 95% confidence intervals (CI), with endarterectomy as the reference group. We quantified heterogeneity using the I² statistic and used GRADE to assess the overall certainty of evidence. MAIN RESULTS We included 22 trials involving 9753 participants. In participants with symptomatic carotid stenosis, compared with endarterectomy stenting was associated with a higher risk of periprocedural death or stroke (the primary safety outcome; OR 1.70, 95% CI 1.31 to 2.19; P < 0.0001, I² = 5%; 10 trials, 5396 participants; high-certainty evidence); and periprocedural death, stroke, or myocardial infarction (OR 1.43, 95% CI 1.14 to 1.80; P = 0.002, I² = 0%; 6 trials, 4861 participants; high-certainty evidence). The OR for the primary safety outcome was 1.11 (95% CI 0.74 to 1.64) in participants under 70 years old and 2.23 (95% CI 1.61 to 3.08) in participants 70 years old or more (interaction P = 0.007). There was a non-significant increase in periprocedural death or major or disabling stroke with stenting (OR 1.36, 95% CI 0.97 to 1.91; P = 0.08, I² = 0%; 7 trials, 4983 participants; high-certainty evidence). Compared with endarterectomy, stenting was associated with lower risks of myocardial infarction (OR 0.47, 95% CI 0.24 to 0.94; P = 0.03, I² = 0%), cranial nerve palsy (OR 0.09, 95% CI 0.06 to 0.16; P < 0.00001, I² = 0%), and access site haematoma (OR 0.32, 95% CI 0.15 to 0.68; P = 0.003, I² = 27%). The combination of periprocedural death or stroke or ipsilateral stroke during follow-up (the primary combined safety and efficacy outcome) favoured endarterectomy (OR 1.51, 95% CI 1.24 to 1.85; P < 0.0001, I² = 0%; 8 trials, 5080 participants; high-certainty evidence). The rate of ipsilateral stroke after the periprocedural period did not differ between treatments (OR 1.05, 95% CI 0.75 to 1.47; P = 0.77, I² = 0%). In participants with asymptomatic carotid stenosis, there was a non-significant increase in periprocedural death or stroke with stenting compared with endarterectomy (OR 1.72, 95% CI 1.00 to 2.97; P = 0.05, I² = 0%; 7 trials, 3378 participants; moderate-certainty evidence). The risk of periprocedural death or stroke or ipsilateral stroke during follow-up did not differ significantly between treatments (OR 1.27, 95% CI 0.87 to 1.84; P = 0.22, I² = 0%; 6 trials, 3315 participants; moderate-certainty evidence). Moderate or higher carotid artery restenosis (50% or greater) or occlusion during follow-up was more common after stenting (OR 2.00, 95% CI 1.12 to 3.60; P = 0.02, I² = 44%), but the difference in risk of severe restenosis was not significant (70% or greater; OR 1.26, 95% CI 0.79 to 2.00; P = 0.33, I² = 58%; low-certainty evidence). AUTHORS' CONCLUSIONS Stenting for symptomatic carotid stenosis is associated with a higher risk of periprocedural stroke or death than endarterectomy. This extra risk is mostly attributed to an increase in minor, non-disabling strokes occurring in people older than 70 years. Beyond the periprocedural period, carotid stenting is as effective in preventing recurrent stroke as endarterectomy. However, combining procedural safety and long-term efficacy in preventing recurrent stroke still favours endarterectomy. In people with asymptomatic carotid stenosis, there may be a small increase in the risk of periprocedural stroke or death with stenting compared with endarterectomy. However, CIs of treatment effects were wide and further data from randomised trials in people with asymptomatic stenosis are needed.
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Affiliation(s)
- Mandy D Müller
- University Hospital BaselDepartment of Neurology and Stroke CenterPetersgraben 4BaselSwitzerland4031
| | - Philippe Lyrer
- University Hospital BaselDepartment of Neurology and Stroke CenterPetersgraben 4BaselSwitzerland4031
| | - Martin M Brown
- UCL Institute of NeurologyDepartment of Brain Repair & RehabilitationBox 6, The National HospitalQueen SquareLondonUKWC1N 3BG
| | - Leo H Bonati
- University Hospital BaselDepartment of Neurology and Stroke CenterPetersgraben 4BaselSwitzerland4031
- UCL Institute of NeurologyDepartment of Brain Repair & RehabilitationBox 6, The National HospitalQueen SquareLondonUKWC1N 3BG
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Batchelder AJ, Saratzis A, Ross Naylor A. Editor's Choice - Overview of Primary and Secondary Analyses From 20 Randomised Controlled Trials Comparing Carotid Artery Stenting With Carotid Endarterectomy. Eur J Vasc Endovasc Surg 2019; 58:479-493. [PMID: 31492510 DOI: 10.1016/j.ejvs.2019.06.003] [Citation(s) in RCA: 46] [Impact Index Per Article: 9.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2018] [Revised: 05/30/2019] [Accepted: 06/05/2019] [Indexed: 12/19/2022]
Abstract
OBJECTIVES The aim of this review was to carry out primary and secondary analyses of 20 randomised controlled trials (RCTs) comparing carotid endarterectomy (CEA) with carotid artery stenting (CAS). METHODS A systematic review and meta-analysis of data from 20 RCTs (126 publications) was carried out. RESULTS Compared with CEA, the 30 day death/stroke rate was significantly higher after CAS in seven RCTs involving 3467 asymptomatic patients (odds ratio [OR] 1.64, 95% confidence interval [CI] 1.02-2.64) and in 10 RCTs involving 5797 symptomatic patients (OR 1.71, 95% CI 1.38-2.11). Excluding procedural risks, late ipsilateral stroke was about 4% at 9 years for both CEA and CAS, i.e., CAS was durable. Reducing procedural death/stroke after CAS may be achieved through better case selection, e.g., performing CEA in (i) symptomatic patients aged > 70 years; (ii) interventions within 14 days of symptom onset; and (iii) situations where stroke risk after CAS is predicted to be higher (segmental/remote plaques, plaque length > 13 mm, heavy burden of white matter lesions [WMLs], where two or more stents might be needed). New WMLs were significantly more common after CAS (52% vs. 17%) and were associated with higher rates of late stroke/transient ischaemic attack (23% vs. 9%), but there was no evidence that new WMLs predisposed towards late cognitive impairment. Restenoses were more common after CAS (10%) but did not increase late ipsilateral stroke. Restenoses (70%-99%) after CEA were associated with a small but significant increase in late ipsilateral stroke (OR 3.87, 95% CI 1.96-7.67; p < .001). CONCLUSIONS CAS confers higher rates of 30 day death/stroke than CEA. After 30 days, ipsilateral stroke is virtually identical for CEA and CAS. Key issues to be resolved include the following: (i) Will newer stent technologies and improved cerebral protection allow CAS to be performed < 14 days after symptom onset with risks similar to CEA? (ii) What is the optimal volume of CAS procedures to maintain competency? (iii) How to deliver better risk factor control and best medical treatment? (iv) Is there a role for CEA/CAS in preventing/reversing cognitive impairment?
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Affiliation(s)
| | | | - A Ross Naylor
- The Leicester Vascular Institute, Glenfield Hospital, Leicester, UK.
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Meershoek AJA, de Borst GJ. Timing of carotid intervention. Br J Surg 2019; 105:1231-1233. [PMID: 30133763 PMCID: PMC6099369 DOI: 10.1002/bjs.10950] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2018] [Accepted: 06/19/2018] [Indexed: 11/11/2022]
Abstract
Flimsy evidence
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Affiliation(s)
- A J A Meershoek
- Department of Vascular Surgery, University Medical Centre Utrecht, Room G04.129, PO Box 85500, 3508, GA, Utrecht, The Netherlands
| | - G J de Borst
- Department of Vascular Surgery, University Medical Centre Utrecht, Room G04.129, PO Box 85500, 3508, GA, Utrecht, The Netherlands
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15
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Systematic and Comprehensive Comparison of Incidence of Restenosis Between Carotid Endarterectomy and Carotid Artery Stenting in Patients with Atherosclerotic Carotid Stenosis. World Neurosurg 2019; 125:74-86. [PMID: 30710719 DOI: 10.1016/j.wneu.2019.01.118] [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: 11/28/2018] [Revised: 01/20/2019] [Accepted: 01/21/2019] [Indexed: 11/22/2022]
Abstract
OBJECTIVE The purpose of the present study was to conduct a meta-analysis to systematically compare the incidence rates of in-stent restenosis after carotid artery stenting (CAS) and restenosis after carotid endarterectomy (CEA) for patients with atherosclerotic carotid stenosis. METHODS We retrieved potential academic reports comparing restenosis between CEA and CAS from the MEDLINE, PubMed, and EMBASE databases and the Cochrane Library from the date of the first CEA (January 1951) to July 20, 2018. The references of the identified studies were carefully reviewed to ensure that all available reports were included in the present study. RESULTS Our meta-analysis included 27 studies (15 randomized controlled trials, 12 nonrandomized controlled trials) and 20,479 participants with atherosclerotic carotid stenosis. A statistically significant difference was found in the cumulative incidence of restenosis >70% between CEA and CAS (risk difference, -0.033, 95% confidence interval [CI] -0.054 to -0.013; P = 0.002). For the restenosis >70% outcomes, although CEA was relevant with a lower rate of restenosis than CAS within 6 months (odds ratio [OR], 0.495; 95% CI, 0.285-0.861; P = 0.013) and 1 year (OR, 0.626; 95% CI, 0.483-0.811; P < 0.001), no statistically significant differences were found at 1.5 years (P = 0.210), 2 years (P = 0.123), 4 years (P = 0.124), 5 years (P = 0.327), or 10 years (P = 0.839). For the restenosis >50% outcomes, a significant difference was found in the rate of restenosis between the CEA and CAS groups within 1 year (OR, 0.317; 95% CI, 0.228-0.441; P < 0.001) but not at 1.5 years (P = 0.301), 2 years (P = 0.686), or 5 years (P = 0.920). No nominally significant effects were demonstrated with respect to the cumulative incidence of occlusion (P = 0.195) or the cumulative incidence of restenosis for symptomatic patients (P = 0.170) between CEA and CAS. CONCLUSIONS Although CAS was preferred over CEA, regardless of restenosis >50% or >70% after revascularization within 1 year, no significant difference was observed with extension of the follow-up period to >1 year. CAS was not associated with a greater cumulative incidence of occlusion or the cumulative incidence of restenosis for symptomatic patients.
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16
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Lee HJ, Chang FC, Luo CB, Guo WY. Influence of stenting with open-cell stents vs close-cell stents on the outcomes of patients with bilateral carotid stenosis. J Chin Med Assoc 2019; 82:66-71. [PMID: 30839407 DOI: 10.1097/jcma.0000000000000006] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
BACKGROUND Carotid artery stenting (CAS) is an effective way to prevent stroke in patients with severe carotid stenosis. However, several studies comparing the outcomes of stenting with open-cell stents (OCS) vs closed-cell stents (CCS) have yielded inconclusive results. This study aimed to compare the outcomes of CAS with OCS vs CCS in the same patients. METHODS From year 2000 to 2016, we included 52 patients with severe bilateral carotid stenosis who underwent OCS deployment in one artery and CCS deployment in the contralateral artery. Stents were selected according to arterial anatomy and lesion morphology, and the peri-procedural and long-term outcomes of treatment with OCS vs CCS, were compared in terms of rates of ischemic spot development on early post-procedural diffusion-weighted imaging (ISDWI), in-stent restenosis (ISR), and recurrent stroke. RESULTS After stenting with OCS vs CCS, the number (rate) of arteries with no lesion, < 5 lesions, and ≥ 5 lesions on DWI was 9 (32%) vs 8 (27%), 8 (29%) vs 17 (57%), and 11 (39%) vs 5 (17%) (p = .10); number (rate) of arteries with 0%, < 50%, and >50% ISR was 34 (65%) vs 34 (65%), 9 (17%) vs 11 (21%), and 9 (17%) vs 7 (13%) (p = .71); number (rate) of recurrent strokes after CAS was 2 (4%) vs 0 (0%). CONCLUSION The rates of peri-procedural cerebral ischemic insult, long-term stent patency, and stroke recurrence indicate that no one carotid stent cell design is superior to the other. We suggest both OCS and CCS are reasonable options for the treatment of severe carotid stenosis.
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Affiliation(s)
- Han-Jui Lee
- Department of Radiology, Taipei Veterans General Hospital, Taipei, Taiwan, ROC
- School of Medicine, National Yang-Ming University, Taipei, Taiwan, ROC
| | - Feng-Chi Chang
- Department of Radiology, Taipei Veterans General Hospital, Taipei, Taiwan, ROC
- School of Medicine, National Yang-Ming University, Taipei, Taiwan, ROC
| | - Chao-Bao Luo
- Department of Radiology, Taipei Veterans General Hospital, Taipei, Taiwan, ROC
- School of Medicine, National Yang-Ming University, Taipei, Taiwan, ROC
| | - Wan-Yuo Guo
- Department of Radiology, Taipei Veterans General Hospital, Taipei, Taiwan, ROC
- School of Medicine, National Yang-Ming University, Taipei, Taiwan, ROC
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Salem MM, Alturki AY, Fusco MR, Thomas AJ, Carter BS, Chen CC, Kasper EM. Carotid artery stenting vs. carotid endarterectomy in the management of carotid artery stenosis: Lessons learned from randomized controlled trials. Surg Neurol Int 2018; 9:85. [PMID: 29740506 PMCID: PMC5926211 DOI: 10.4103/sni.sni_400_17] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2017] [Accepted: 02/28/2018] [Indexed: 12/02/2022] Open
Abstract
Background: Carotid artery stenosis, both symptomatic and asymptomatic, has been well studied with several multicenter randomized trials. The superiority of carotid endarterectomy (CEA) to medical therapy alone in both symptomatic and asymptomatic carotid artery stenosis has been well established in previous trials in the 1990s. The consequent era of endovascular carotid artery stenting (CAS) has offered another option for treating carotid artery stenosis. A series of randomized trials have now been conducted to compare CEA and CAS in the treatment of carotid artery disease. The large number of similar trials has created some confusion due to inconsistent results. Here, the authors review the trials that compare CEA and CAS in the management of carotid artery stenosis. Methods: The PubMed database was searched systematically for randomized controlled trials published in English that compared CEA and CAS. Only human studies on adult patients were assessed. The references of identified articles were reviewed for additional manuscripts to be included if inclusion criteria were met. The following terms were used during search: carotid stenosis, endarterectomy, stenting. Retrospective or single-center studies were excluded from the review. Results: Thirteen reports of seven large-scale prospective multicenter studies, comparing both interventions for symptomatic or asymptomatic extracranial carotid artery stenosis, were identified. Conclusions: While the superiority of intervention to medical management for symptomatic patients has been well established in the literatures, careful selection of asymptomatic patients for intervention should be undertaken and only be pursued after institution of appropriate medical therapy until further reports on trials comparing medical therapy to intervention in this patient group are available.
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Affiliation(s)
- Mohamed M Salem
- Division of Neurosurgery, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, Massachusetts, USA
| | - Abdulrahman Y Alturki
- Division of Neurosurgery, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, Massachusetts, USA.,Department of Neurosurgery, National Neuroscience Institute, Riyadh, Saudi Arabia
| | - Matthew R Fusco
- Department of Neurosurgery, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Ajith J Thomas
- Division of Neurosurgery, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, Massachusetts, USA
| | - Bob S Carter
- Department of Neurosurgery, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Clark C Chen
- Department of Neurosurgery, University of Minnesota, Minneapolis, Minnesota, USA
| | - Ekkehard M Kasper
- Division of Neurosurgery, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, Massachusetts, USA
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Naylor AR. Endarterectomy versus stenting for stroke prevention. Stroke Vasc Neurol 2018; 3:101-106. [PMID: 30022797 PMCID: PMC6047339 DOI: 10.1136/svn-2018-000146] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2018] [Accepted: 02/04/2018] [Indexed: 11/23/2022] Open
Abstract
The European Society for Vascular Surgery (ESVS) has recently prepared updated guidelines for the management of patients with symptomatic and asymptomatic atherosclerotic carotid artery disease, with specific reference to the roles of best medical therapy, carotid endarterectomy (CEA) and carotid artery stenting (CAS). In symptomatic patients, there is a drive towards performing carotid interventions as soon as possible after onset of symptoms. This is because it is now recognised that the highest risk period for recurrent stroke is the first 7–14 days after onset of symptoms. The guidelines advise that there is a role for both CEA and CAS, but the levels of evidence are slightly lower for CAS than for CEA. This is because 30-day risks of death/stroke in the randomised controlled trials (RCTs) were significantly higher than after CEA (especially in the first 7–14 days after onset of symptoms) and there are concerns that the results obtained in the RCTs may not be generalisable into routine clinical practice. In asymptomatic patients, the 2018 ESVS guidelines were the first to recommend that CEA/CAS should be targeted into a smaller cohort of patients who may be ‘higher risk for stroke’ on medical therapy. As with symptomatic patients, the ESVS guidelines advise that there is a potential role for both CEA and CAS, but the levels of evidence are again slightly lower for CAS than for CEA. This is because 30-day risks of death/stroke in the two largest RCTs, which used credentialed (experienced CAS practitioners), were only just within the accepted 3% risk threshold and there remain concerns that the results obtained in RCTs may not be generalisable into routine clinical practice.
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Affiliation(s)
- A Ross Naylor
- The Leicester Vascular Institute, Glenfield Hospital, Leicester, UK
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Demirel S, Böckler D, Storck M. Comparison of long-term results of carotid endarterectomy for asymptomatic carotid artery stenosis. GEFASSCHIRURGIE 2018; 23:1-7. [PMID: 29950789 PMCID: PMC5997101 DOI: 10.1007/s00772-018-0355-2] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
This article summarizes the current study situation on treatment of asymptomatic carotid artery stenosis and discusses the evidence situation in the literature. The 10-year results of the ACST study have shown that in comparison to conservative treatment, carotid endarterectomy (CEA) has retained a positive long-term effect on the reduction of all forms of stroke. All multicenter randomized controlled trials comparing CEA with carotid artery stenting (CAS) and, in particular the SAPHIRE and CAVATAS studies, have in common that despite a basic evidence level of Ib, the case numbers of asymptomatic patients are too small for a conclusive therapy recommendation. In the overall assessment of the CREST study the resulting difference in the questionable endpoint of “perioperative myocardial infarction” in favor of the CAS methods, could not be confirmed for exclusively asymptomatic patients. In the long-term course of the CREST study, both methods were classified as equivalent, even when the 4‑year results of periprocedural and postprocedural stroke rates in the separate assessment of the asymptomatic study participants clearly favored the CEA. The results of the ACST-1 study showed an equivalent effect of both treatment methods with respect to all investigated endpoints; however, the unequal sizes of the groups in addition to the statistically insufficient case numbers put a question mark on the validity of the study results. The results of the ASCT-2 and CREST-2 studies are to be awaited, which also investigate the significance of “CEA versus CAS” (ASCT-2) and “CEA/CAS + best medical treatment (BMT) versus BMT alone” in only asymptomatic stenoses. The current S3 guidelines allow operative therapy to be considered in patients with a 60–99% asymptomatic carotid artery stenosis, because the risk of stroke is statistically significantly reduced.
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Affiliation(s)
- S Demirel
- 1Department of Vascular and Endovascular Surgery, Department of Surgery, University Hospital Heidelberg, Im Neuenheimer Feld 110, 69120 Heidelberg, Germany
| | - D Böckler
- 1Department of Vascular and Endovascular Surgery, Department of Surgery, University Hospital Heidelberg, Im Neuenheimer Feld 110, 69120 Heidelberg, Germany
| | - M Storck
- Department of Vascular and Chest Surgery, Municipal Hospital Karlsruhe, Karlsruhe, Germany
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Naylor AR, Ricco JB, de Borst GJ, Debus S, de Haro J, Halliday A, Hamilton G, Kakisis J, Kakkos S, Lepidi S, Markus HS, McCabe DJ, Roy J, Sillesen H, van den Berg JC, Vermassen F, Kolh P, Chakfe N, Hinchliffe RJ, Koncar I, Lindholt JS, Vega de Ceniga M, Verzini F, Archie J, Bellmunt S, Chaudhuri A, Koelemay M, Lindahl AK, Padberg F, Venermo M. Editor's Choice - Management of Atherosclerotic Carotid and Vertebral Artery Disease: 2017 Clinical Practice Guidelines of the European Society for Vascular Surgery (ESVS). Eur J Vasc Endovasc Surg 2018; 55:3-81. [PMID: 28851594 DOI: 10.1016/j.ejvs.2017.06.021] [Citation(s) in RCA: 789] [Impact Index Per Article: 131.5] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
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Abstract
Carotid artery stenting (CAS) has been recommended as an alternative treatment to carotid endarterectomy for patients with significant carotid stenosis. Only a few studies have analyzed clinical/anatomical and technical variables that affect perioperative outcomes of CAS. Following a comprehensive Medline search, it was reported that clinical factors, including age of >80 years, chronic renal failure, diabetes mellitus, symptomatic indications, and procedures performed within 2 weeks of transient ischemic attack symptoms, are associated with high perioperative stroke and death rates. They also highlighted that angiographic variables, e.g., ulcerated and calcified plaques, left carotid intervention, >90% stenosis, >10-mm target lesion length, ostial involvement, type III aortic arch, and >60°-angulated internal carotid and common carotid arteries, are predictors of increased stroke rates. Technical factors associated with increased perioperative risk of stroke include percutaneous transluminal angioplasty (PTA) without embolic protection devices, PTA before stent placement, and the use of multiple stents. This review describes the most widely quoted data in defining various predictors of perioperative stroke and death after CAS. (This is a review article based on the invited lecture of the 45th Annual Meeting of Japanese Society for Vascular Surgery.)
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Affiliation(s)
- Ali F AbuRahma
- Department of Surgery, West Virginia University, Charleston, West Virginia, USA
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22
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Li Y, Yang JJ, Zhu SH, Xu B, Wang L. Long-term efficacy and safety of carotid artery stenting versus endarterectomy: A meta-analysis of randomized controlled trials. PLoS One 2017; 12:e0180804. [PMID: 28708869 PMCID: PMC5510818 DOI: 10.1371/journal.pone.0180804] [Citation(s) in RCA: 30] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2016] [Accepted: 06/21/2017] [Indexed: 12/04/2022] Open
Abstract
Background Many recent trials have investigated the long-term efficacy and safety of endarterectomy versus stenting in treating patients with carotid artery stenosis. We aimed to determine the long-term comparative efficacy and safety of both procedures by pooling this evidence in a meta-analysis. Methods We searched PubMed, EMBASE, and the Cochrane Central Register of Controlled Trials for studies published until May 6, 2016. Randomized controlled trials, which reported outcomes of interest with a median follow-up of at least 4-year, were included. Results Eight trials involving 7005 patients and 41824 patient-years of follow-up were included. In terms of the periprocedural outcomes, stenting was associated with a lower risk of myocardial infarction (OR: 0.51; 95% CI: 0.33 to 0.80; P = 0.003) but a higher risk of death or stroke (the composite endpoint, OR: 1.76; 95% CI: 1.38 to 2.25; P < 0.0001), a result that was primarily driven by minor stroke (OR: 2.19; 95% CI: 1.59 to 3.01; P < 0.0001), less so by periprocedural death (OR: 1.68; 95% CI: 0.82 to 3.44; P = 0.16) and major stroke (OR: 1.41; 95% CI: 0.95 to 2.09; P = 0.09). In terms of the long-term outcomes, stenting was associated with a higher risk of stroke (OR 1.45; 95% CI: 1.22 to 1.73; P < 0.0001) and the composite outcome of death or stroke (OR 1.25; 95% CI: 1.05 to 1.48; P = 0.01). No difference was found in long-term all-cause mortality between stenting and endarterectomy (OR: 1.09; 95% CI: 0.95 to 1.26; P = 0.21) and restenosis (OR: 1.48 (95% CI: 0.93 to 2.35; P = 0.10). No evidence of significant heterogeneity was found in any of the analyses. Conclusions Carotid endarterectomy was found to be superior to stenting for short- and long-term outcomes, although endarterectomy was associated with a higher risk of periprocedural myocardial infarction. Carotid endarterectomy should be offered as the first choice for carotid stenosis at present, however, more evidence is needed because rapid progress in concurrent devices and medical treatments is being made.
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Affiliation(s)
- Yang Li
- Department of Cardiology, Affiliated Drum Tower Hospital, Nanjing University School of Medicine, Nanjing China
| | - Jing-Jing Yang
- Department of Traditional Chinese Medicine, Nanjing Drum Tower Hospital, Clinical College of Traditional Chinese and Western Medicine, Nanjing University of Chinese Medicine, Nanjng, China
| | - Su-Hui Zhu
- Department of Cardiology, Affiliated Drum Tower Hospital, Nanjing University School of Medicine, Nanjing China
| | - Biao Xu
- Department of Cardiology, Affiliated Drum Tower Hospital, Nanjing University School of Medicine, Nanjing China
- * E-mail: (LW); (BX)
| | - Lian Wang
- Department of Cardiology, Affiliated Drum Tower Hospital, Nanjing University School of Medicine, Nanjing China
- * E-mail: (LW); (BX)
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Restenosis after Carotid Interventions and Its Relationship with Recurrent Ipsilateral Stroke: A Systematic Review and Meta-analysis. Eur J Vasc Endovasc Surg 2017; 53:766-775. [DOI: 10.1016/j.ejvs.2017.02.016] [Citation(s) in RCA: 61] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2016] [Accepted: 02/13/2017] [Indexed: 11/18/2022]
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Baron EL, Fremed DI, Tadros RO, Villablanca PA, Evans AS, Weiner MM, Yang EH, Augoustides JT, Mookadam F, Ramakrishna H. Surgical Versus Percutaneous Therapy of Carotid Artery Disease: An Evidence-Based Outcomes Analysis. J Cardiothorac Vasc Anesth 2017; 31:755-767. [DOI: 10.1053/j.jvca.2016.07.023] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/13/2016] [Indexed: 11/11/2022]
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Demirel S, Böckler D, Storck M. Langzeitergebnisse der Karotisendarteriektomie im Methodenvergleich bei asymptomatischer Karotisstenose. GEFÄSSCHIRURGIE 2017. [DOI: 10.1007/s00772-016-0238-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
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Diao Z, Jia G, Wu W, Wang C. Carotid endarterectomy versus carotid angioplasty for stroke prevention: a systematic review and meta-analysis. J Cardiothorac Surg 2016; 11:142. [PMID: 27608767 PMCID: PMC5017049 DOI: 10.1186/s13019-016-0532-x] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2016] [Accepted: 08/23/2016] [Indexed: 11/15/2022] Open
Abstract
BACKGROUND This meta-analysis aimed to evaluate the efficacy of carotid endarterectomy (CE) compared with carotid angioplasty (CA) in preventing stroke. Whether the use of CE is more efficient in preventing stroke than CA is a matter of debate. METHODS Data were gathered from randomized controlled trials to evaluate the effect of CE compared with CA on the risk of stroke. Electronic searches in PubMed, Embase, and the Cochrane Library were performed to identify studies till November 2014. Only randomized controlled trials performed on patients who received either CE or CA for stroke prevention were included. RESULTS Nine relevant trials (n = 7163) that met the inclusion criteria were identified. In a pooled analysis, CE resulted in 35 % reduction in relative risk (RR) for short-term stroke [RR, 0.65; 95 % confidence interval (CI): 0.47-0.89; P = 0.007)] and 22 % reduction in RR for long-term stroke (RR, 0.78; 95 % CI: 0.66-0.93; P = 0.006) relative to CA. However, CE also increased the risk of 30-day myocardial infarction by 114 % compared with CA (RR, 2.14; 95 % CI: 1.30-3.53; P = 0.003). Sensitivity analyses suggested that CE might influence the risk of 30-day major vascular events and 1-year major vascular events compared with CA. CONCLUSIONS CE could reduce the risk of stroke (whether short term or long term), but resulted in a relative increase in the risk of myocardial infarction. This study might guide appropriate judgments about treatment approach. It also provided evidence to justify general guidelines for patients with carotid artery stenosis.
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Affiliation(s)
- Zengyan Diao
- Department of Neurology, Qilu Hospital of Shandong University, Jinan, 250012 Shandong Province China
| | - Guoyong Jia
- Department of Neurology, Qilu Hospital of Shandong University, Jinan, 250012 Shandong Province China
| | - Wei Wu
- Department of Neurology, Qilu Hospital of Shandong University, Jinan, 250012 Shandong Province China
| | - Cuilan Wang
- Department of Neurology, Qilu Hospital of Shandong University, Jinan, 250012 Shandong Province China
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Vincent S, Eberg M, Eisenberg MJ, Filion KB. Meta-Analysis of Randomized Controlled Trials Comparing the Long-Term Outcomes of Carotid Artery Stenting Versus Endarterectomy. Circ Cardiovasc Qual Outcomes 2015; 8:S99-108. [DOI: 10.1161/circoutcomes.115.001933] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
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Ouyang YA, Jiang Y, Yu M, Zhang Y, Huang H. Efficacy and safety of stenting for elderly patients with severe and symptomatic carotid artery stenosis: a critical meta-analysis of randomized controlled trials. Clin Interv Aging 2015; 10:1733-42. [PMID: 26604720 PMCID: PMC4631412 DOI: 10.2147/cia.s91721] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/05/2022] Open
Abstract
OBJECTIVE To investigate both short-term and long-term therapeutic efficacy and safety of carotid artery stenting (CAS) and carotid artery endarterectomy (CEA) for elderly patients with severe and symptomatic carotid artery stenosis. METHODS PubMed, EMBASE, Cochrane Library, Clinical Trials Register Centers, and Google Scholar were comprehensively searched. After identifying relevant randomized controlled trials, methodological quality was assessed by using Cochrane tools of bias assessment. Meta-analysis was performed by RevMan software, and subgroup analyses according to different follow-up periods were also conducted. RESULTS Sixteen articles of nine randomized controlled trials containing 6,984 patients were included. Compared with CEA, CAS was associated with high risks of stroke during periprocedural 30 days (risk ratio [RR]=1.47, 95% confidence interval [CI]: 1.15-1.88), 48 months (RR=1.37, 95% CI: 1.11-1.70), and >48 months (RR=1.76, 95% CI: 1.34-2.31). There was no significant difference in the aspects of death, disabling stroke, or death at any time between the groups. For other periprocedural complications, CAS decreased the risk of myocardial infarction (RR=0.44, 95% CI: 0.26-0.75), cranial nerve palsy (RR=0.09, 95% CI: 0.04-0.22) and hematoma (RR=0.31, 95% CI: 0.14-0.68) compared with CEA, while it increased the risk of bradycardia or hypotension (RR=8.45, 95% CI 2.91-24.58). CONCLUSION Compared with CEA, CAS reduced hematoma, periprocedural myocardial infarction, and cranial nerve palsy, while it was associated with higher risks of both short-term and long-term nondisabling stroke. And they seemed to be equivalent in other outcome measures. As regards to its minimal invasion, it should be applied only in specific patients.
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Affiliation(s)
- Yi-An Ouyang
- Department of Neurosurgery, Second Xiang-Ya Hospital of Central South University, Changsha, People’s Republic of China
| | - Yugang Jiang
- Department of Neurosurgery, Second Xiang-Ya Hospital of Central South University, Changsha, People’s Republic of China
| | - Mengqiang Yu
- Department of Neurosurgery, Second Xiang-Ya Hospital of Central South University, Changsha, People’s Republic of China
| | - Yunze Zhang
- Department of Neurosurgery, Second Xiang-Ya Hospital of Central South University, Changsha, People’s Republic of China
| | - Hao Huang
- Department of Neurosurgery, Second Xiang-Ya Hospital of Central South University, Changsha, People’s Republic of China
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Zhang L, Zhao Z, Ouyang Y, Bao J, Lu Q, Feng R, Zhou J, Jing Z. Systematic Review and Meta-Analysis of Carotid Artery Stenting Versus Endarterectomy for Carotid Stenosis: A Chronological and Worldwide Study. Medicine (Baltimore) 2015; 94:e1060. [PMID: 26131824 PMCID: PMC4504641 DOI: 10.1097/md.0000000000001060] [Citation(s) in RCA: 38] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/30/2015] [Revised: 05/30/2015] [Accepted: 06/02/2015] [Indexed: 11/26/2022] Open
Abstract
There are disparities among the results of meta-analyses under different circumstances of carotid artery stenting (CAS) versus endarterectomy (CEA) for carotid stenosis. This study aimed to assess the efficacies of CAS and CEA for carotid stenosis at 5-year intervals and worldwide.Comparative studies simultaneously reporting CAS and CEA for carotid stenosis with at least 10 patients in each group were identified by searching PubMed and Embase in accordance with preferred reporting items for systematic reviews and meta-analyses guidelines, and by reviewing the reference lists of retrieved articles.The studies were stratified into different subgroups according to the publication year, location in which the study was mainly performed, and randomized and nonrandomized study designs.Thirty-five comparative studies encompassing 27,525 patients were identified. The risk ratios (RRs) of stroke/death when CAS was compared with CEA within 30 d of treatment were 1.51 (95% CI 1.32-1.74, P < 0.001) for overall, 1.50 (95% CI 1.14-1.98, P = 0.004) from 2011 to 2015, 1.61 (95% CI 1.35-1.91, P < 0.001) from 2006 to 2010, 1.59 (95% CI 1.27-1.99, P < 0.001) in North America, 1.50 (95% CI 1.24-1.81, P < 0.001) in Europe, 1.63 (95% CI 1.31-2.02, P < 0.001) for randomized, and 1.44 (95% CI 1.20-1.73, P < 0.001) for nonrandomized comparative studies. CEA decreased the risks of transient ischemic attack at 30 d (RR: 2.07, 95% CI 1.50-2.85, P < 0.001) and restenosis at 1-year (RR: 1.97, 95% CI 1.28-3.05, P = 0.002). Data from follow-up showed that the RRs of stroke/death were 0.74 (95% CI 0.55-0.99, P = 0.04) at 1 year, 1.24 (95% CI 1.04-1.46, P = 0.01) at 4 year, and 2.27 (95% CI 1.39-3.71, P = 0.001) at 10 year. This systematic review, compared with those of other meta-analyses, included all available comparative studies and analyzed them at 5-year intervals, in different continents, and under different study designs. Current evidence suggests that the efficacy of CEA is superior to CAS for freedom from stroke/death within 30 d, especially from 2006 to 2015, in North America and Europe. Meanwhile, the superiority was also observed for restenosis at 1-year, transient ischemic attack within 30 d, and stroke/death at 4- and 10-year follow-ups.
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Affiliation(s)
- Lei Zhang
- From the Department of Vascular Surgery, Changhai Hospital, Second Military Medical University, Shanghai, China (LZ, ZZ, YO, JB, QL, RF, ZJ); and Department of Surgery, Changhai Hospital, Second Military Medical University, Shanghai, China (JZ)
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Abstract
Carotid artery stenting is a less invasive alternative to endarterectomy to treat symptomatic carotid stenosis. Clinical trials showed a higher periprocedural risk of nondisabling stroke with stenting, and a higher periprocedural risk of myocardial infarction, cranial nerve palsy, and access site hematoma with endarterectomy. The excess in procedure-related strokes with stenting is mainly seen in patients aged 70 and over. After the procedural period, stenting and endarterectomy are equally effective in preventing stroke and recurrent carotid stenosis in the medium to long term. The choice of stenting versus endarterectomy should take into account risks of both procedures in individual patients.
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Affiliation(s)
- Leo Bonati
- Department of Neurology, Stroke Center, University Hospital Basel, Petersgraben 4, Basel CH-4031, Switzerland.
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Abstract
Background:A meta-analysis of randomized controlled trials (RCTs) was conducted to update the available evidence on the safety and efficacy of carotid endarterectomy (CEA) versus carotid artery stenting (CAS) in the treatment of carotid artery stenosis.Methods:A comprehensive search was performed of MEDLINE, EMBASE, CENTRAL, bibliographies of included articles and past systematic reviews, and abstract lists of recent scientific conferences. For each reported outcome, a Mantel-Haenszel random-effects model was used to calculate odds ratios (ORs) and 95% confidence intervals (CI). The I2 statistic was used as a measure of heterogeneity.Results:Twelve RCTs enrolling 6,973 patients were included in the meta-analysis. Carotid artery stenting was associated with a significantly greater odds of periprocedural stroke (OR 1.72, 95% CI 1.20 to 2.47) and a significantly lower odds of periprocedural myocardial infarction (OR 0.47, 95% CI 0.29 to 0.78) and cranial neuropathy (OR 0.08, 95% CI, 0.04 to 0.16). The odds of periprocedural death (OR 1.11, 95% CI 0.56 to 2.18), target vessel restenosis (OR 1.95, 95% CI 0.63 to 6.06), and access-related hematoma were similar following either intervention (OR 0.60, 95% CI 0.30 to 1.21).Conclusions:In comparison with CEA, CAS is associated with a greater odds of stroke and a lower odds of myocardial infarction. While the results our meta-analysis support the continued use of CEA as the standard of care in the treatment of carotid artery stenosis, CAS is a viable alternative in patients at elevated risk of cardiac complications.
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Cardiac damage after carotid intervention: a meta-analysis after a decade of randomized trials. J Anesth 2014; 28:866-72. [DOI: 10.1007/s00540-014-1843-5] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2014] [Accepted: 04/28/2014] [Indexed: 10/25/2022]
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Affiliation(s)
- Thomas Korff
- From the Division of Cardiovascular Physiology, Institute of Physiology and Pathophysiology, University of Heidelberg, Heidelberg, Germany
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Cervical Carotid Disease: Carotid Endarterectomy and Stenting. World Neurosurg 2014; 81:257-60. [DOI: 10.1016/j.wneu.2013.01.085] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2012] [Accepted: 01/19/2013] [Indexed: 11/18/2022]
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Almekhlafi MA, Hill MD, Wiebe S, Goyal M, Yavin D, Wong JH, Clement FM. When is carotid angioplasty and stenting the cost-effective alternative for revascularization of symptomatic carotid stenosis? A Canadian health system perspective. AJNR Am J Neuroradiol 2013; 35:327-32. [PMID: 23928136 DOI: 10.3174/ajnr.a3682] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
BACKGROUND AND PURPOSE Carotid revascularization procedures can be complicated by stroke. Additional disability adds to the already high costs of the procedure. To weigh the cost and benefit, we estimated the cost-utility of carotid angioplasty and stenting compared with carotid endarterectomy among patients with symptomatic carotid stenosis, with special emphasis on scenario analyses that would yield carotid angioplasty and stenting as the cost-effective alternative relative to carotid endarterectomy. MATERIALS AND METHODS A cost-utility analysis from the perspective of the health system payer was performed by using a Markov analytic model. Clinical estimates were based on a meta-analysis. The procedural costs were derived from a microcosting data base. The costs for hospitalization and rehabilitation of patients with stroke were based on a Canadian multicenter study. Utilities were based on a randomized controlled trial. RESULTS In the base case analysis, carotid angioplasty and stenting were more expensive (incremental cost of $6107) and had a lower utility (-0.12 quality-adjusted life years) than carotid endarterectomy. The results are sensitive to changes in the risk of clinical events and the relative risk of death and stroke. Carotid angioplasty and stenting were more economically attractive among high-risk surgical patients. For carotid angioplasty and stenting to become the preferred option, their costs would need to fall from more than $7300 to $4350 or less and the risks of the periprocedural and annual minor strokes would have to be equivalent to that of carotid endarterectomy. CONCLUSIONS In the base case analysis, carotid angioplasty and stenting were associated with higher costs and lower utility compared with carotid endarterectomy for patients with symptomatic carotid stenosis. Carotid angioplasty and stenting were cost-effective for patients with high surgical risk.
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Affiliation(s)
- M A Almekhlafi
- From the Departments of Clinical Neurosciences (M.A.A., M.D.H., S.W., M.G., D.Y., J.H.W.)
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Auricchio F, Conti M, Ferrara A, Morganti S, Reali A. Patient-specific finite element analysis of carotid artery stenting: a focus on vessel modeling. INTERNATIONAL JOURNAL FOR NUMERICAL METHODS IN BIOMEDICAL ENGINEERING 2013; 29:645-664. [PMID: 23729192 DOI: 10.1002/cnm.2511] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/08/2011] [Revised: 07/25/2012] [Accepted: 08/13/2012] [Indexed: 06/02/2023]
Abstract
Finite element analysis is nowadays a well-assessed technique to investigate the impact of stenting on vessel wall and, given the rapid progression of both medical imaging techniques and computational methods, the challenge of using the simulation of carotid artery stenting as procedure planning tool to support the clinical practice can be approached. Within this context, the present study investigates the impact of carotid stent apposition on carotid artery anatomy by means of patient-specific finite element analysis. In particular, we focus on the influence of the vessel constitutive model on the prediction of carotid artery wall tensional state of lumen gain and of vessel straightening. For this purpose, we consider, for a given stent design and CA anatomy, two constitutive models for the CA wall, that is, a hyperelastic isotropic versus a fiber-reinforced hyperelastic anisotropic model. Despite both models producing similar patterns with respect to stress distribution, the anisotropic model predicts a higher vessel straightening and a more evident discontinuity of the lumen area near the stent ends as observed in the clinical practice. Although still affected by several simplifications, the present study can be considered as further step toward a realistic simulation of carotid artery stenting.
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Affiliation(s)
- F Auricchio
- Department of Civil Engineering and Architecture, Structural Mechanics Division, University of Pavia, Via Ferrata 1, 27100 Pavia, Italy
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Di Legge S, Koch G, Diomedi M, Stanzione P, Sallustio F. Stroke prevention: managing modifiable risk factors. Stroke Res Treat 2012; 2012:391538. [PMID: 23213626 PMCID: PMC3504482 DOI: 10.1155/2012/391538] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2012] [Accepted: 10/08/2012] [Indexed: 12/12/2022] Open
Abstract
Prevention plays a crucial role in counteracting morbidity and mortality related to ischemic stroke. It has been estimated that 50% of stroke are preventable through control of modifiable risk factors and lifestyle changes. Antihypertensive treatment is recommended for both prevention of recurrent stroke and other vascular events. The use of antiplatelets and statins has been shown to reduce the risk of recurrent stroke and other vascular events. Angiotensin-converting enzyme inhibitors (ACEIs) and angiotensin II receptor blockers (ARBs) are indicated in stroke prevention because they also promote vascular health. Effective secondary-prevention strategies for selected patients include carotid revascularization for high-grade carotid stenosis and vitamin K antagonist treatment for atrial fibrillation. The results of recent clinical trials investigating new anticoagulants (factor Xa inhibitors and direct thrombin inhibitors) clearly indicate alternative strategies in stroke prevention for patients with atrial fibrillation. This paper describes the current landscape and developments in stroke prevention with special reference to medical treatment in secondary prevention of ischemic stroke.
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Affiliation(s)
- Silvia Di Legge
- Stroke Unit, Department of Neuroscience, University of Tor Vergata, Viale Oxford 81, 00133 Rome, Italy
| | - Giacomo Koch
- Stroke Unit, Department of Neuroscience, University of Tor Vergata, Viale Oxford 81, 00133 Rome, Italy
- Santa Lucia Foundation, IRCCS, Viale Ardeatina 306, 00134 Rome, Italy
| | - Marina Diomedi
- Stroke Unit, Department of Neuroscience, University of Tor Vergata, Viale Oxford 81, 00133 Rome, Italy
| | - Paolo Stanzione
- Stroke Unit, Department of Neuroscience, University of Tor Vergata, Viale Oxford 81, 00133 Rome, Italy
- Santa Lucia Foundation, IRCCS, Viale Ardeatina 306, 00134 Rome, Italy
| | - Fabrizio Sallustio
- Stroke Unit, Department of Neuroscience, University of Tor Vergata, Viale Oxford 81, 00133 Rome, Italy
- Santa Lucia Foundation, IRCCS, Viale Ardeatina 306, 00134 Rome, Italy
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Bonati LH, Lyrer P, Ederle J, Featherstone R, Brown MM. Percutaneous transluminal balloon angioplasty and stenting for carotid artery stenosis. Cochrane Database Syst Rev 2012:CD000515. [PMID: 22972047 DOI: 10.1002/14651858.cd000515.pub4] [Citation(s) in RCA: 92] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
BACKGROUND Endovascular treatment by transluminal balloon angioplasty or stent insertion may be a useful alternative to carotid endarterectomy for the treatment of atherosclerotic carotid artery stenosis. This review updates a previous version first published in 1997 and subsequently updated in 2004 and 2007. OBJECTIVES To assess the benefits and risks of endovascular treatment compared with carotid endarterectomy or medical therapy in patients with symptomatic or asymptomatic carotid stenosis. SEARCH METHODS We searched the Cochrane Stroke Group Trials Register (last searched January 2012) and the following databases: the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library 2010, Issue 4), MEDLINE (1950 to January 2011), EMBASE (1980 to January 2011) and Science Citation Index (1945 to January 2011). We also searched ongoing trials registers (January 2011) and reference lists and contacted researchers in the field. SELECTION CRITERIA Randomised trials comparing endovascular treatment (including balloon angioplasty or stenting) with endarterectomy or medical therapy for symptomatic or asymptomatic atherosclerotic carotid stenosis. DATA COLLECTION AND ANALYSIS One review author selected trials for inclusion, assessed trial quality and extracted data. A second review author independently validated trial selection and a third review author independently validated data extraction. We calculated treatment effects as odds ratios (OR) and 95% confidence intervals (CI), with endovascular treatment as the reference group. We quantified heterogeneity using the I(2) statistic. MAIN RESULTS We included 16 trials involving 7572 patients. In patients with symptomatic carotid stenosis at standard surgical risk, endovascular treatment was associated with a higher risk of the following outcome measures occurring between randomisation and 30 days after treatment than endarterectomy: death or any stroke (the primary safety outcome) (OR 1.72, 95% CI 1.29 to 2.31, P = 0.0003; I(2) = 27%), death or any stroke or myocardial infarction (OR 1.44, 95% CI 1.15 to 1.80, P = 0.002; I(2) = 7%), and any stroke (OR 1.81, 95% CI 1.40 to 2.34, P < 0.00001;I(2) = 12%). The OR for the primary safety outcome was 1.16 (95% CI 0.80 to 1.67) in patients < 70 years old and 2.20 (95% CI 1.47 to 3.29) in patients ≥ 70 years old (interaction P = 0.02).The rate of death or major or disabling stroke did not differ significantly between treatments (OR 1.28, 95% CI 0.93 to 1.77, P = 0.13; I(2) = 0%). Endovascular treatment was associated with lower risks of myocardial infarction (OR 0.44, 95% CI 0.23 to 0.87, P = 0.02; I(2) = 0%), cranial nerve palsy (OR 0.08, 95% CI 0.05 to 0.14, P < 0.00001; I(2) = 0%) and access site haematomas (OR 0.37, 95% CI 0.18 to 0.77, P = 0.008; I(2) = 27%).The combination of death or any stroke up to 30 days after treatment or ipsilateral stroke during follow-up (the primary combined safety and efficacy outcome) favoured endarterectomy (OR 1.39, 95% CI 1.10 to 1.75, P = 0.005; I(2) = 0%), but the rate of ipsilateral stroke after the peri-procedural period did not differ between treatments (OR 0.93, 95% CI 0.60 to 1.45, P = 0.76; I(2) = 0%).Restenosis during follow-up was more common in patients receiving endovascular treatment than in patients assigned surgery (OR 2.41, 95% CI 1.28 to 4.53, P = 0.007; I(2) = 55%). In patients with asymptomatic carotid stenosis, treatment effects on the primary safety (OR 1.71, 95% CI 0.78 to 3.76, P = 0.18; I(2) = 0%) and combined safety and efficacy outcomes (OR 1.75, 95% CI 0.92 to 3.33, P = 0.09; I(2) = 0%) were similar to symptomatic patients, but differences between treatments were not statistically significant. Among patients not suitable for surgery, the rate of death or any stroke between randomisation and end of follow-up did not differ significantly between endovascular treatment and medical care (OR 0.22, 95% CI 0.01 to 7.92, P = 0.41; I(2)= 79%). AUTHORS' CONCLUSIONS Endovascular treatment is associated with an increased risk of peri-procedural stroke or death compared with endarterectomy. However, this excess risk appears to be limited to older patients. The longer term efficacy of endovascular treatment and the risk of restenosis are unclear and require further follow-up of existing trials. Further trials are needed to determine the optimal treatment for asymptomatic carotid stenosis.
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Affiliation(s)
- Leo H Bonati
- Department ofNeurology,UniversityHospital Basel, Basel, Switzerland.
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Van der Heyden J, Wolters FJ, Garin N, Blant SA, Inglin M, Bal ET, Suttorp JM. The role of embolic protection devices during carotid stenting prior to cardiac surgery in asymptomatic patients: empty filters? Catheter Cardiovasc Interv 2012; 80:112-9. [PMID: 21953787 DOI: 10.1002/ccd.23383] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/16/2011] [Revised: 08/03/2011] [Accepted: 09/09/2011] [Indexed: 11/11/2022]
Abstract
OBJECTIVES The purpose of this study was to analyze the debris captured in the distal protection filters used during carotid artery stenting (CAS). BACKGROUND CAS is an option available to high-risk patients requiring revascularization. Filters are suggested for optimal stroke prevention during CAS. METHODS From May 2005 to June 2007, filters from 59 asymptomatic patients who underwent CAS were collected and sent to a specialized laboratory for light-microscope and histological analysis. Peri- and postprocedural outcomes were assessed during 1-year follow-up. RESULTS On the basis of biomedical imaging of the filter debris, the captured material could not be identified as embolized particles from the carotid plaque. On histological analysis the debris consisted mainly of red blood cell aggregates and/ or platelets, occasionally accompanied by granulocytes. We found no consistent histological evidence of embolized particles originating from atherosclerotic plaques. Post-procedure, three neurological events were reported: two (3.4%) transient ischemic attacks (TIA) and one (1.7%) ipsilateral minor stroke. CONCLUSION The filters used during CAS in asymptomatic patients planned for cardiac surgery often remained empty. These findings may be explained by assuming that asymptomatic patients feature a different atherosclerotic plaque composition or stabilization through antiplatelet medication. Larger, randomized trials are clearly warranted, especially in the asymptomatic population.
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Affiliation(s)
- Jan Van der Heyden
- Department of Interventional Cardiology, St-Antonius Hospital, Nieuwegein, The Netherlands.
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Liu ZJ, Fu WG, Guo ZY, Shen LG, Shi ZY, Li JH. Updated Systematic Review and Meta-Analysis of Randomized Clinical Trials Comparing Carotid Artery Stenting and Carotid Endarterectomy in the Treatment of Carotid Stenosis. Ann Vasc Surg 2012; 26:576-90. [DOI: 10.1016/j.avsg.2011.09.009] [Citation(s) in RCA: 45] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2011] [Revised: 08/29/2011] [Accepted: 09/06/2011] [Indexed: 10/28/2022]
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Zhou Y, Yang QW, Xiong HY. Angioplasty with stenting for intracranial atherosclerosis: a systematic review. J Int Med Res 2012; 40:18-27. [PMID: 22429342 DOI: 10.1177/147323001204000103] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
OBJECTIVE Intracranial artery stenosis can be fatal, requiring fast, safe and effective intervention. The introduction of the Wingspan™ stent system with Gateway™ percutaneous transluminal angioplasty balloon catheter has made intracranial intervention possible in a clinical trial setting. This systematic review planned to identify and review all randomized controlled trials comparing angioplasty and stenting of intracranial arteries with standard medical care. METHODS Electronic databases and relevant records were examined for possible trials using predefined inclusion and exclusion criteria. RESULTS A total of 3661 records were identified by searching several English language databases and other sources including Chinese academic journals. The recently discontinued Stenting and Aggressive Medical Management for Preventing Recurrent stroke in Intracranial Stenosis (SAMMPRIS) trial was the single qualifying study and showed clear advantage of medical management over percutaneous transluminal angioplasty and stenting (PTAS). CONCLUSIONS The SAMPRASS trial indicated that PTAS is associated with high complication and morbidity rates. Definitive recommendations cannot be made until convincing results from additional robustly designed randomized trials become available.
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Affiliation(s)
- Y Zhou
- Department of Military Epidemiology, The Third Military Medical University, and Department of Neurology, Daping Hospital, Chongqing, China
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Guay J. Endovascular Stenting or Carotid Endarterectomy for Treatment of Carotid Stenosis: A Meta-analysis. J Cardiothorac Vasc Anesth 2011; 25:1024-9. [DOI: 10.1053/j.jvca.2011.01.009] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/07/2010] [Indexed: 11/11/2022]
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Abstract
The role of carotid artery stenting (CAS) as an alternative to carotid endarterectomy for the treatment of extracranial carotid occlusive disease for stroke prevention continues to evolve. Although technical and device refinements aimed at making CAS safer continue to this day, safety as measured by 30-day and 1-year outcomes has been the primary recipient of regulatory and practice attention. Relatively less emphasis has been placed on the incidence of recurrent stenosis after CAS and the efficacy of CAS in late stroke prevention. Data on late outcomes of CAS, including factors of potential influence, have been emerging and are addressed in this review.
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Paraskevas KI, Veith FJ, Riles TS, Moore WS. Is carotid artery stenting a fair alternative to carotid endarterectomy for symptomatic carotid artery stenosis? A commentary on the AHA/ASA guidelines. J Vasc Surg 2011; 54:541-3; discussion 543. [DOI: 10.1016/j.jvs.2011.05.052] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/17/2022]
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Wasser K, Schnaudigel S, Wohlfahrt J, Psychogios MN, Knauth M, Gröschel K. Inflammation and in-stent restenosis: the role of serum markers and stent characteristics in carotid artery stenting. PLoS One 2011; 6:e22683. [PMID: 21829478 PMCID: PMC3145657 DOI: 10.1371/journal.pone.0022683] [Citation(s) in RCA: 37] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2011] [Accepted: 06/28/2011] [Indexed: 11/18/2022] Open
Abstract
Background Carotid angioplasty and stenting (CAS) may currently be recommended especially in younger patients with a high-grade carotid artery stenosis. However, evidence is accumulating that in-stent restenosis (ISR) could be an important factor endangering the long-term efficacy of CAS. The aim of this study was to investigate the influence of inflammatory serum markers and procedure-related factors on ISR as diagnosed with duplex sonography. Methods We analyzed 210 CAS procedures in 194 patients which were done at a single university hospital between May 2003 and June 2010. Periprocedural C-reactive protein (CRP) and leukocyte count as well as stent design and geometry, and other periprocedural factors were analyzed with respect to the occurrence of an ISR as diagnosed with serial carotid duplex ultrasound investigations during clinical long-term follow-up. Results Over a median of 33.4 months follow-up (IQR: 14.9–53.7) of 210 procedures (mean age of 67.9±9.7 years, 71.9% male, 71.0% symptomatic) an ISR of ≥70% was detected in 5.7% after a median of 8.6 months (IQR: 3.4–17.3). After multiple regression analysis, leukocyte count after CAS-intervention (odds ratio (OR): 1.31, 95% confidence interval (CI): 1.02–1.69; p = 0.036), as well as stent length and width were associated with the development of an ISR during follow-up (OR: 1.25, 95% CI: 1.05–1.65, p = 0.022 and OR: 0.28, 95% CI: 0.09–0.84, p = 0.010). Conclusions The majority of ISR during long-term follow-up after CAS occur within the first year. ISR is associated with periinterventional inflammation markers and influenced by certain stent characteristics such as stent length and width. Our findings support the assumption that stent geometry leading to vessel injury as well as periprocedural inflammation during CAS plays a pivotal role in the development of carotid artery ISR.
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Affiliation(s)
- Katrin Wasser
- Department of Neurology, University of Göttingen, Göttingen, Germany
| | - Sonja Schnaudigel
- Department of Neurology, University of Göttingen, Göttingen, Germany
| | - Janin Wohlfahrt
- Department of Neurology, University of Göttingen, Göttingen, Germany
| | - Marios-Nikos Psychogios
- Department of Neuroradiology, University of Göttingen, Göttingen, Germany
- Department of Diagnostic Radiology, University of Göttingen, Göttingen, Germany
| | - Michael Knauth
- Department of Neuroradiology, University of Göttingen, Göttingen, Germany
| | - Klaus Gröschel
- Department of Neurology, University of Göttingen, Göttingen, Germany
- * E-mail:
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Macdonald S. Carotid artery stenting trials: conduct, results, critique, and current recommendations. Cardiovasc Intervent Radiol 2011; 35:15-29. [PMID: 21789697 DOI: 10.1007/s00270-011-0223-x] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/09/2011] [Accepted: 06/22/2011] [Indexed: 10/18/2022]
Abstract
The carotid stenting trialists have demonstrated persistence and determination in comparing an evolving technique, carotid artery stenting (CAS), against a mature and exacting standard for carotid revascularisation, carotid endarterectomy (CEA). This review focuses on their endeavours. A total of 12 1-on-1 randomised trials comparing CAS and CEA have been reported; 6 of these can be considered major, and 5 of these reflect (in part) current CAS standards of practice and form the basis of this review. At least 18 meta-analyses seeking to compare CAS and CEA exist. These are limited by the quality and heterogeneity of the data informing them (e.g., five trials were stopped prematurely such that they collectively failed to reach recruitment target by >4000 patients). The Carotid Stenting Trialists' Collaboration Publication represents a prespecified meta-analysis of European trials that were sufficiently similar to allow valid conclusions to be drawn; these trials and conclusions will be explored. When the rate of myocardial infarction (MI) is rigorously assessed, CAS and CEA are equivalent for the composite end point of stroke/death and MI, with more minor strokes for CAS and more MIs for CEA. These outcomes have a discrepant impact on quality of life and subsequent mortality. The all-stroke death outcomes for patients <70 years old are equivalent, with more minor strokes occurring in the elderly during CAS than CEA. There are significantly more severe haematomas and cranial nerve injuries after CEA. The influence of experience on outcome cannot be underestimated.
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Affiliation(s)
- Sumaira Macdonald
- Interventional Radiology, Freeman Hospital, Newcastle-Upon-Tyne NE7 7DN, UK.
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Paraskevas K, Veith F, Riles T, Moore W. Is Carotid Artery Stenting a Fair Alternative to Carotid Endarterectomy for Symptomatic Carotid Artery Stenosis? Eur J Vasc Endovasc Surg 2011; 41:717-9. [DOI: 10.1016/j.ejvs.2011.03.018] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2011] [Accepted: 03/21/2011] [Indexed: 10/18/2022]
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Economopoulos KP, Sergentanis TN, Tsivgoulis G, Mariolis AD, Stefanadis C. Carotid Artery Stenting Versus Carotid Endarterectomy. Stroke 2011; 42:687-92. [PMID: 21233476 DOI: 10.1161/strokeaha.110.606079] [Citation(s) in RCA: 98] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background and Purpose—
The comparison between carotid endarterectomy and carotid artery stenting (CAS) remains a debated field, especially in the context of long-term outcomes.
Methods—
Concerning the short-term (30-day) analysis, the numbers of outcomes per arm were abstracted, whereas outcomes per arm and hazard ratios were abstracted for long-term (≥1-year) results.
Results—
Thirteen randomized trials (3723 carotid endarterectomy and 3754 CAS patients) were eligible. Regarding short-term outcomes, CAS was associated with elevated risk for stroke and “death or stroke.” CAS also exhibited a marginal trend toward higher death and “death or disabling stroke” rates. Carotid endarterectomy presented with higher rates of myocardial infarction and cranial nerve injury. Concerning long-term outcomes, CAS was associated with higher rates of stroke (pooled OR, 1.37; 95% CI, 1.13 to 1.65) and “death or stroke” (pooled OR, 1.25; 95% CI, 1.06 to 1.48). These findings were replicated at the level of pooled hazard ratios and marginally regarding secondary preventive efficacy. The difference in long-term stroke rates was particularly sizeable in patients >68 years, but little difference in rates was observed in those <68 years. No statistically significant heterogeneity became evident. Metaregression did not reveal any significant modifying effect mediated by symptomatic/asymptomatic status, distal protection, early termination of trials, area of study origin, or CAS learning curve.
Conclusions—
This meta-analysis points to the significantly less frequent stroke events after carotid endarterectomy at the long-term context. The outcomes of carotid endarterectomy seem superior to CAS, but there may be subgroups, particularly younger patients, in whom the results seem equivalent.
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Affiliation(s)
- Konstantinos P. Economopoulos
- From the School of Medicine (K.P.E., T.N.S.), University of Athens, Athens, Greece; the Department of Neurology (G.T.), Democritus University of Thrace, School of Medicine, Alexandroupolis, Greece; the Comprehensive Stroke Center (G.T.), Department of Neurology, University of Alabama at Birmingham Hospital, Birmingham, AL; and the First Department of Cardiology (A.D.M., C.S.), School of Medicine, University of Athens, Hippokration Hospital, Athens, Greece
| | - Theodoros N. Sergentanis
- From the School of Medicine (K.P.E., T.N.S.), University of Athens, Athens, Greece; the Department of Neurology (G.T.), Democritus University of Thrace, School of Medicine, Alexandroupolis, Greece; the Comprehensive Stroke Center (G.T.), Department of Neurology, University of Alabama at Birmingham Hospital, Birmingham, AL; and the First Department of Cardiology (A.D.M., C.S.), School of Medicine, University of Athens, Hippokration Hospital, Athens, Greece
| | - Georgios Tsivgoulis
- From the School of Medicine (K.P.E., T.N.S.), University of Athens, Athens, Greece; the Department of Neurology (G.T.), Democritus University of Thrace, School of Medicine, Alexandroupolis, Greece; the Comprehensive Stroke Center (G.T.), Department of Neurology, University of Alabama at Birmingham Hospital, Birmingham, AL; and the First Department of Cardiology (A.D.M., C.S.), School of Medicine, University of Athens, Hippokration Hospital, Athens, Greece
| | - Anargiros D. Mariolis
- From the School of Medicine (K.P.E., T.N.S.), University of Athens, Athens, Greece; the Department of Neurology (G.T.), Democritus University of Thrace, School of Medicine, Alexandroupolis, Greece; the Comprehensive Stroke Center (G.T.), Department of Neurology, University of Alabama at Birmingham Hospital, Birmingham, AL; and the First Department of Cardiology (A.D.M., C.S.), School of Medicine, University of Athens, Hippokration Hospital, Athens, Greece
| | - Christodoulos Stefanadis
- From the School of Medicine (K.P.E., T.N.S.), University of Athens, Athens, Greece; the Department of Neurology (G.T.), Democritus University of Thrace, School of Medicine, Alexandroupolis, Greece; the Comprehensive Stroke Center (G.T.), Department of Neurology, University of Alabama at Birmingham Hospital, Birmingham, AL; and the First Department of Cardiology (A.D.M., C.S.), School of Medicine, University of Athens, Hippokration Hospital, Athens, Greece
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50
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A systematic review and meta-analysis of randomized trials of carotid endarterectomy vs stenting. J Vasc Surg 2011; 53:792-7. [DOI: 10.1016/j.jvs.2010.10.101] [Citation(s) in RCA: 124] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2010] [Revised: 10/28/2010] [Accepted: 10/28/2010] [Indexed: 11/23/2022]
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