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Paraskevas KI, AbuRahma AF. A comparison of the 2022 Society for Vascular Surgery and the 2023 European Society for Vascular Surgery guidelines for the management of patients with asymptomatic and symptomatic carotid stenosis. J Vasc Surg 2024; 79:1272-1275. [PMID: 38310980 DOI: 10.1016/j.jvs.2024.01.210] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2023] [Revised: 01/20/2024] [Accepted: 01/28/2024] [Indexed: 02/06/2024]
Affiliation(s)
| | - Ali F AbuRahma
- Department of Surgery, Charleston Area Medical Center/West Virginia University, Charleston, WV
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Rokosh RS, Rockman C, Garg K, Wang SK, Motaganahalli RL, Schroeder AC, Sobraske PJ, Stoner MC, Tarbunou YA, Marmor RA, Malas MB, Maldonado TS. Multi-institutional patterns of clopidogrel response among patients undergoing transcarotid artery revascularization. Vascular 2024; 32:558-564. [PMID: 36428145 DOI: 10.1177/17085381221142219] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/17/2024]
Abstract
OBJECTIVE Current guidelines recommend dual antiplatelet therapy (DAPT) in patients undergoing carotid artery stenting. The most common DAPT regimen is aspirin and clopidogrel, a P2Y12 receptor antagonist; however, the prevalence of clopidogrel resistance (CR) in patients undergoing percutaneous coronary interventions may exceed 60%. Few studies have investigated the prevalence and impact of CR in patients undergoing extracranial carotid artery stenting, particularly transcarotid artery revascularization (TCAR). METHODS Consecutive high-risk patients ≥ 18 years who underwent TCAR for high grade (≥70%) and/or symptomatic (≥50%) carotid stenosis with preoperative P2Y12 testing between August 2019 and December 2021 were identified across five institutions. Preoperative platelet reactivity was measured with the VerifyNow P2Y12 Reaction Unit (PRU) Test (Instrumentation Laboratory, Bedford, MA), with CR defined as PRU ≥ 194 and hyper-response as PRU <70. Patients without preoperative P2Y12 testing within 30 days prior to TCAR or those on a non-clopidogrel P2Y12 inhibitor preoperatively were excluded. The primary outcome of interest was prevalence of CR. Secondary outcomes of interest included the incidence of ischemic and hemorrhagic complications. RESULTS Of 92 patients identified, the majority were male (59%) and Caucasian (75%) with a mean age of 75 years (±8, range 56-92). Preoperatively, 93% of patients were on aspirin, 100% on clopidogrel, and 13% on therapeutic anticoagulation. At presentation, 36% were symptomatic. The mean preoperative P2Y12 was 156 PRU (±76, range 6-349). In total, 30 (33%) patients met criteria for CR (mean PRU 240 ± 37; range 197-349), and 15 (16%) met criteria for hyper-responder (mean PRU 38 ± 20; range 6-68). There was no significant difference by clopidogrel response phenotype in terms of sex (p = 0.246), race (p = 0.384), or symptomatic presentation (p = 0.956). Postoperatively, the cumulative incidence of stroke and MI was 2.1%, with no statistically significant difference in the incidence of in-hospital stroke (PRU 238, p = 0.489) or MI (PRU 168, p = 1) between clopidogrel phenotypes. Three (3.3%) patients, one CR (PRU 240) and two responders (PRU 119 and PRU 189), experienced postoperative access site hematomas that required no subsequent intervention. No other index hospitalization hemorrhagic complications occurred. CONCLUSIONS Using preoperative P2Y12 testing with a threshold PRU ≥ 194 to define CR, we identified a high prevalence of CR in patients undergoing TCAR similar to that in the pre-existing coronary literature. We found no significant differences in postoperative ischemic or hemorrhagic complications by clopidogrel response phenotype, although complication rates in the overall study cohort were low. CR may be a spectrum from responder to partial responder to complete non-responder, and this may account for the differences in our CR cohort compared to the ROADSTER 2 protocol deviation cohort. Further investigation is warranted to determine if a quantitative assessment of CR is sufficient to identify patients at risk of developing secondary cerebrovascular ischemic events in this patient population.
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Affiliation(s)
- Rae S Rokosh
- Division of Vascular Surgery, Department of Surgery, NYU Langone Health, New York, NY, USA
| | - Caron Rockman
- Division of Vascular Surgery, Department of Surgery, NYU Langone Health, New York, NY, USA
| | - Karan Garg
- Division of Vascular Surgery, Department of Surgery, NYU Langone Health, New York, NY, USA
| | - Shihuan Keisin Wang
- Division of Vascular Surgery, Department of Surgery, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Raghu L Motaganahalli
- Division of Vascular Surgery, Department of Surgery, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Andrew C Schroeder
- Division of Vascular Surgery, Department of Surgery, University of Rochester Medical Center, Rochester, NY, USA
| | - Peter J Sobraske
- Division of Vascular Surgery, Department of Surgery, University of Rochester Medical Center, Rochester, NY, USA
| | - Michael C Stoner
- Division of Vascular Surgery, Department of Surgery, University of Rochester Medical Center, Rochester, NY, USA
| | - Yauhen A Tarbunou
- Division of Vascular Surgery, Department of Surgery, University of Minnesota Medical Center, Minneapolis, MN, USA
| | - Rebecca A Marmor
- Division of Vascular & Endovascular Surgery, Department of Surgery, University of California San Diego, La Jolla, CA, USA
| | - Mahmoud B Malas
- Division of Vascular & Endovascular Surgery, Department of Surgery, University of California San Diego, La Jolla, CA, USA
| | - Thomas S Maldonado
- Division of Vascular Surgery, Department of Surgery, NYU Langone Health, New York, NY, USA
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Yu S, Chaney MA. Combined Coronary and Carotid Artery Disease: What to Operate on First? Or Both at the Same Time? J Cardiothorac Vasc Anesth 2024; 38:1417-1422. [PMID: 37839940 DOI: 10.1053/j.jvca.2023.09.021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/12/2023] [Accepted: 09/16/2023] [Indexed: 10/17/2023]
Affiliation(s)
- Sherman Yu
- Department of Anesthesia and Critical Care, University of Chicago, Chicago, IL
| | - Mark A Chaney
- Department of Anesthesia and Critical Care, University of Chicago, Chicago, IL.
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4
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Locham S, Balceniuk MD, Byrne M, Hoang T, Mix D, Newhall K, Doyle A, Stoner M. Use of Glycoprotein IIb-IIIa Inhibitors in Patients Undergoing Carotid Artery Stenting in the Vascular Quality Initiative. Ann Vasc Surg 2024; 103:151-158. [PMID: 37473837 DOI: 10.1016/j.avsg.2023.07.097] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2023] [Revised: 07/03/2023] [Accepted: 07/06/2023] [Indexed: 07/22/2023]
Abstract
BACKGROUND Antiplatelet therapies with thromboxane inhibitors and adenosine 5'-diphosphate antagonists have been widely used following carotid artery stenting (CAS). However, these therapies may not apply to patients who are intolerant or present acutely. Glycoprotein IIb/IIIa inhibitors (GPI) are a proposed alternative therapy in these patients; however, their use has been limited due to concerns of increased risk for intracranial bleeding. Thus, this study aims to assess the safety profile of GPI in patients undergoing CAS. METHODS All patients undergoing CAS in the Society of Vascular Surgery - Vascular Quality Initiative database from 2012 to 2021 was included and grouped into GPI versus non-GPI therapy (control). The primary outcome was in-hospital stroke or death, and secondary outcomes included in-hospital stroke/transient ischemic attack (TIA), death, myocardial infarction, and intracranial hemorrhage (ICH)/seizure. Patients were stratified by surgical approach (Transcarotid artery revascularization using flow reversal (TCAR) and transfemoral carotid artery stenting), and stepwise backward logistic regression analysis was conducted to evaluate major primary and secondary outcomes. RESULTS A total of 50,628 patients underwent carotid revascularization. Of these, 4.4% of the patients received GPI. Mean age was similar between control versus GPI (71.35(9.67) vs. 71.36(10.20) years). Compared to the control group, patients who receive GPI are less likely to be on optimal medical therapy, including aspirin (83.0% vs. 88.1%), P2Y12 inhibitor (73.0% vs. 82.7%), and statin (82.3% vs. 86.0%) (All P < 0.05). In addition, patients in the GPI group were more likely to undergo TCAR for carotid revascularization (52.2% vs. 48.4%) for emergent/urgent (29.4% vs. 16.8%) and symptomatic indications (55.5% vs. 49.7%) (All P < 0.001). After stratifying by surgical approach, if patients underwent TFCAS and received a GPI, they were at increased odds of developing stroke/death (1.77(1.25-2.51)), death (odds ratio (OR) (95% CI): 1.67(1.07-2.61)), stroke/TIA (OR (95% confidence interval (CI)): 1.65(1.09-2.51)), and ICH/seizure (OR (95% CI): 2.13(1.23-3.68)) (All P < 0.05). No difference was seen in outcomes between the 2 groups if undergoing TCAR. CONCLUSIONS Patients who receive GPI were more likely to be symptomatic at presentation and less likely to be medically optimized before their carotid revascularization. Transfemoral access in patients receiving GPI was associated with increased odds of morbidity and mortality. However, this was not observed if undergoing TCAR. TCAR can be considered for its overall favorable results in high-risk patients who are not medically optimized.
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Affiliation(s)
- Satinderjit Locham
- Division of Vascular Surgery, Department of Surgery, University of Rochester Medical Center, Rochester, NY
| | - Mark D Balceniuk
- Division of Vascular Surgery, Department of Surgery, University of Rochester Medical Center, Rochester, NY
| | - Matthew Byrne
- Division of Vascular Surgery, Department of Surgery, University of Rochester Medical Center, Rochester, NY
| | - Timothy Hoang
- Division of Vascular Surgery, Department of Surgery, University of Rochester Medical Center, Rochester, NY
| | - Doran Mix
- Division of Vascular Surgery, Department of Surgery, University of Rochester Medical Center, Rochester, NY
| | - Karina Newhall
- Division of Vascular Surgery, Department of Surgery, University of Rochester Medical Center, Rochester, NY
| | - Adam Doyle
- Division of Vascular Surgery, Department of Surgery, University of Rochester Medical Center, Rochester, NY
| | - Michael Stoner
- Division of Vascular Surgery, Department of Surgery, University of Rochester Medical Center, Rochester, NY.
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Rothenberg P, Lopez SJ, Thibault D, Pillai L, Minc SD. Predictors of Occlusion after Carotid Stenting. Ann Vasc Surg 2024; 102:172-180. [PMID: 38307227 PMCID: PMC10997468 DOI: 10.1016/j.avsg.2023.11.045] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2023] [Revised: 11/20/2023] [Accepted: 11/24/2023] [Indexed: 02/04/2024]
Abstract
BACKGROUND Carotid artery stent (CAS) occlusion is a rare complication not well studied. We used a national dataset to assess real world CAS experience to determine the rate of stent occlusion. The purpose of this study was to 1) Identify risk factors associated with CAS occlusion on long-term follow-up (LTFU) and 2) Determine the adjusted odds of death/transient ischemic attack (TIA)/stroke (cerebrovascular accident (CVA)) in patients with occlusion. METHODS The national Vascular Quality Initiative CAS dataset (2016-2021) comprised the sample. The primary endpoint was occlusion on LTFU (9-21 months postoperatively as defined by the Vascular Quality Initiative LTFU dataset) with secondary endpoint examining a composite of death/TIA/CVA. Descriptive analyses used chi-square and Wilcoxon tests for categorical and continuous variables respectively. Adjustment variables were selected a priori based on clinical expertise and univariate analyses. Multivariable logistic regression was used to model the odds of occlusion and the odds of death/TIA/CVA. Generalized estimating equations accounted for center level variation. RESULTS During the study period, 109 occlusions occurred in 12,143 cases (0.9%). On univariate analyses, symptomatic indication, prior stroke, prior neck radiation, lesion calcification (>50%), stenosis (>80%), distal embolic protection device (compared to flow reversal), balloon size, >1 stent and current smoking at time of LTFU were predictive for occlusion. Age ≥ 65, coronary artery disease (CAD), elective status, preoperative statin, preoperative and discharge P2Y12 inhibitor, use of any protection device intraoperatively and protamine were protective. On multivariable analyses, age ≥ 65, CAD, elective status and P2Y12 inhibitor on discharge were protective for occlusion, while patients with prior radiation and those taking P2Y12 inhibitor on LTFU were at increased odds. The adjusted odds of death/TIA/CVA in patients with occlusion on LTFU were 6.05; 95% confidence interval: 3.61-10.11, P < 0.0001. CONCLUSIONS This study provides an in-depth analysis of predictors for CAS occlusion on LTFU. On univariate analyses, variables related to disease severity (urgency, degree of stenosis, nature of lesion) and intraoperative details (balloon diameter, >1 stent) were predictive for occlusion. These variables were not statistically significant after risk adjustment. On multivariable analyses, prior neck radiation was strongly predictive of occlusion. Elective status, patient age ≥ 65, CAD, and P2Y12 inhibitor upon discharge (but not on LTFU) were protective for occlusion. Additionally, patients who developed occlusion had high odds for death/TIA/CVA. These findings provide important data to guide clinical decision-making for carotid disease management, particularly identifying high-risk features for CAS occlusion. Closer postoperative follow-up and aggressive risk factor modification in these patients may be merited.
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Affiliation(s)
- Paul Rothenberg
- Division of Vascular and Endovascular Surgery, Department of Cardiovascular and Thoracic Surgery, West Virginia University School of Medicine, Morgantown, WV.
| | - Santiago Joaquin Lopez
- Division of Vascular and Endovascular Surgery, Department of Cardiovascular and Thoracic Surgery, West Virginia University School of Medicine, Morgantown, WV
| | - Dylan Thibault
- Division of Vascular and Endovascular Surgery, Department of Cardiovascular and Thoracic Surgery, West Virginia University School of Medicine, Morgantown, WV
| | - Lakshmikumar Pillai
- Division of Vascular and Endovascular Surgery, Department of Cardiovascular and Thoracic Surgery, West Virginia University School of Medicine, Morgantown, WV
| | - Samantha Danielle Minc
- Division of Vascular and Endovascular Surgery, Department of Cardiovascular and Thoracic Surgery, West Virginia University School of Medicine, Morgantown, WV
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Avdic T, Eliasson B, Rawshani A, Boren J, Gerstein HC, Nordanstig J, Rihawi M, Beckman JA, McGuire DK, Omerovic E, Sattar N, Bhatt DL, Rawshani A. Non-coronary arterial outcomes in people with type 1 diabetes mellitus: a Swedish retrospective cohort study. THE LANCET REGIONAL HEALTH. EUROPE 2024; 39:100852. [PMID: 38803631 PMCID: PMC11129280 DOI: 10.1016/j.lanepe.2024.100852] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 08/04/2023] [Revised: 01/15/2024] [Accepted: 01/17/2024] [Indexed: 05/29/2024]
Abstract
Background Observational studies on long-term trends, risk factor association and importance are scarce for type 1 diabetes mellitus and peripheral arterial outcomes. We set out to investigate trends in non-coronary complications and their relationships with cardiovascular risk factors in persons with type 1 diabetes mellitus compared to matched controls. Methods 34,263 persons with type 1 diabetes mellitus from the Swedish National Diabetes Register and 164,063 matched controls were included. Incidence rates of extracranial large artery disease, aortic aneurysm, aortic dissection, lower extremity artery disease, and diabetic foot syndrome were analyzed using standardized incidence rates and Cox regression. Findings Between 2001 and 2019, type 1 diabetes mellitus incidence rates per 100,000 person-years were as follows: extracranial large artery disease 296.5-84.3, aortic aneurysm 0-9.2, aortic dissection remained at 0, lower extremity artery disease 456.6-311.1, and diabetic foot disease 814.7-77.6. Persons with type 1 diabetes mellitus with cardiometabolic risk factors at target range did not exhibit excess risk of extracranial large artery disease [HR 0.83 (95% CI, 0.20-3.36)] or lower extremity artery disease [HR 0.94 (95% CI, 0.30-2.93)], compared to controls. Persons with type 1 diabetes with all risk factors at baseline, had substantially elevated risk for diabetic foot disease [HR 29.44 (95% CI, 3.83-226.04)], compared to persons with type 1 diabetes with no risk factors. Persons with type 1 diabetes mellitus continued to display a lower risk for aortic aneurysm, even with three cardiovascular risk factors at baseline [HR 0.31 (95% CI, 0.15-0.67)]. Relative importance analyses demonstrated that education, glycated hemoglobin (HbA1c), duration of diabetes and lipids explained 54% of extracranial large artery disease, while HbA1c, smoking and systolic blood pressure explained 50% of lower extremity artery disease and HbA1c alone contributed to 41% of diabetic foot disease. Income, duration of diabetes and body mass index explained 66% of the contribution to aortic aneurysm. Interpretation Peripheral arterial complications decreased in persons with type 1 diabetes mellitus, except for aortic aneurysm which remained low. Besides glycemic control, traditional cardiovascular risk factors were associated with incident outcomes. Risk of these outcomes increased with additional risk factors present. Persons with type 1 diabetes mellitus exhibited a lower risk of aortic aneurysm compared to controls, despite presence of cardiovascular risk factors. Funding Swedish Governmental and the county support of research and education of doctors, the Swedish Heart and Lung Foundation, Sweden and Åke-Wibergs grant.
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Affiliation(s)
- Tarik Avdic
- Sahlgrenska Academy, Gothenburg, Sweden
- Department of Medicine, Sahlgrenska University Hospital Gothenburg, Sweden
- Department of Molecular and Clinical Medicine, Institute of Medicine, University of Gothenburg, Sweden
| | - Björn Eliasson
- Department of Medicine, Sahlgrenska University Hospital Gothenburg, Sweden
| | - Araz Rawshani
- Department of Molecular and Clinical Medicine, Institute of Medicine, University of Gothenburg, Sweden
- Wallenberg Laboratory for Cardiovascular and Metabolic Research, Institute of Medicine, University of Gothenburg, Sweden
| | - Jan Boren
- Department of Molecular and Clinical Medicine, Institute of Medicine, University of Gothenburg, Sweden
- Wallenberg Laboratory for Cardiovascular and Metabolic Research, Institute of Medicine, University of Gothenburg, Sweden
| | - Hertzel C Gerstein
- Population Health Research Institute, McMaster University and Hamilton Health Sciences, Hamilton, ON, Canada
| | - Joakim Nordanstig
- Department of Molecular and Clinical Medicine, Institute of Medicine, University of Gothenburg, Sweden
- Department of Vascular Surgery at the Sahlgrenska University Hospital, Gothenburg, Sweden
| | | | - Joshua A Beckman
- Division of Vascular Medicine, Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Darren K McGuire
- Division of Cardiology, Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas, TX, USA
- Parkland Health, Dallas, TX, USA
| | - Elmir Omerovic
- Department of Molecular and Clinical Medicine, Institute of Medicine, University of Gothenburg, Sweden
- Wallenberg Laboratory for Cardiovascular and Metabolic Research, Institute of Medicine, University of Gothenburg, Sweden
| | - Naveed Sattar
- Institute of Cardiovascular and Medical Sciences, British Heart Foundation Glasgow Cardiovascular Research Centre Division of Cardiology, United Kingdom
| | - Deepak L Bhatt
- Mount Sinai Fuster Heart Hospital, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Aidin Rawshani
- Department of Molecular and Clinical Medicine, Institute of Medicine, University of Gothenburg, Sweden
- Wallenberg Laboratory for Cardiovascular and Metabolic Research, Institute of Medicine, University of Gothenburg, Sweden
- The Lundberg Laboratory for Diabetes Research, Department of Molecular and Clinical Medicine, University of Gothenburg
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Lee KB, Tanenbaum MT, Wang A, Tsai S, Modrall JG, Timaran CH, Kirkwood ML, Ramanan B. Impact of head and neck radiation on long-term outcomes after carotid revascularization. J Vasc Surg 2024:S0741-5214(24)00928-5. [PMID: 38570175 DOI: 10.1016/j.jvs.2024.03.441] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2024] [Revised: 03/21/2024] [Accepted: 03/25/2024] [Indexed: 04/05/2024]
Abstract
OBJECTIVE Radiation-induced carotid artery stenosis (RICS) is a well-described phenomenon seen after head and neck cancer radiation. Previously published literature suggests that, compared with atherosclerotic disease, RICS may result in worse long-term outcomes and early restenosis. This study aims to evaluate the effect of radiation on long-term outcomes after various carotid revascularization techniques using a multi-center registry database. METHODS Patients in the Society for Vascular Surgery (SVS) Vascular Quality Initiative (VQI) registry for carotid artery intervention (carotid endarterectomy [CEA]; transfemoral carotid artery stenting [CAS]; transcarotid artery revascularization [TCAR]), who are 65 years or older were included in the study. VQI Vascular Implant Surveillance and Interventional Outcomes Network (VISION) Medicare-linked database was used to obtain long-term procedure-specific outcomes. Primary endpoints were 3-year death, stroke, and reintervention. We performed propensity matching between patients with prior radiation and those without. Kaplan-Meier analysis and a multivariate logistic regression model were used to analyze the outcome variables. RESULTS A total of 56,472 patients had undergone carotid revascularization (CEA, n = 48,307; TCAR, n = 4593; CAS, n = 3572), 1244 patients with prior radiation and 54,925 patients without prior radiation. The prior radiation group was more likely to be male (71.9% vs 60.3%; P < .01), to receive a stent (47.5% vs 13.5%; P < .01), and to be on P2Y12 inhibitor (55.2% vs 38.3%; P < .01). Propensity matching was performed on 1223 patients (CEA, n = 655; TCAR, n = 292; CAS, n = 287). There were no significant differences in 30-day outcomes for death, stroke, or major adverse cardiovascular events for all three procedures. The prior radiation group had higher rates of cranial nerve injury (3.7% vs 1.8%; P = .04) and 90-day readmission (23.5% vs 18.3%; P = .01) after CEA. For long-term outcomes, prior radiation significantly increased mortality risk for CEA and CAS (hazard ratio [HR], 1.77; 95% confidence interval [CI], 1.38-2.27 and HR, 1.56; 95% CI, 1.02-2.36, respectively). The 3-year risk of stroke for CEA in radiated patients was also significantly higher (HR, 1.47; 95% CI, 1.03-2.09) compared with non-radiated patients. Prior radiation did not significantly affect death and stroke in patients undergoing TCAR. Prior radiation also did not impact the rates of short and long-term reintervention after CEA, CAS, or TCAR. CONCLUSIONS Prior head and neck radiation significantly increases the risk for mortality and stroke for CEA and the risk for mortality after CAS. Long-term outcomes for TCAR are not significantly affected by prior radiation. TCAR may be the preferred treatment modality for patients with radiation-induced carotid stenosis.
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Affiliation(s)
- K Benjamin Lee
- Division of Vascular Diseases and Surgery, Department of Surgery, The Ohio State University Wexner Medical Center, Columbus, OH
| | - Mira T Tanenbaum
- Division of Vascular and Endovascular Surgery, Department of Surgery, University of Texas Southwestern Medical Center, Dallas, TX
| | - Angela Wang
- Division of Vascular and Endovascular Surgery, Department of Surgery, University of Texas Southwestern Medical Center, Dallas, TX
| | - Shirling Tsai
- Division of Vascular and Endovascular Surgery, Department of Surgery, University of Texas Southwestern Medical Center, Dallas, TX; Division of Vascular and Endovascular Surgery, Department of Surgery, Dallas VA Medical Center, Dallas, TX
| | - J Gregory Modrall
- Division of Vascular and Endovascular Surgery, Department of Surgery, University of Texas Southwestern Medical Center, Dallas, TX; Division of Vascular and Endovascular Surgery, Department of Surgery, Dallas VA Medical Center, Dallas, TX
| | - Carlos H Timaran
- Division of Vascular and Endovascular Surgery, Department of Surgery, University of Texas Southwestern Medical Center, Dallas, TX
| | - Melissa L Kirkwood
- Division of Vascular and Endovascular Surgery, Department of Surgery, University of Texas Southwestern Medical Center, Dallas, TX
| | - Bala Ramanan
- Division of Vascular and Endovascular Surgery, Department of Surgery, University of Texas Southwestern Medical Center, Dallas, TX; Division of Vascular and Endovascular Surgery, Department of Surgery, Dallas VA Medical Center, Dallas, TX.
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8
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Paraskevas KI, Dardik A, Schermerhorn ML, Liapis CD, Mansilha A, Lal BK, Gray WA, Brown MM, Myrcha P, Lavie CJ, Zeebregts CJ, Secemsky EA, Saba L, Blecha M, Gurevich V, Silvestrini M, Blinc A, Svetlikov A, Fernandes E Fernandes J, Schneider PA, Gloviczki P, White CJ, AbuRahma AF. Why selective screening for asymptomatic carotid stenosis is currently appropriate: a special report. Expert Rev Cardiovasc Ther 2024; 22:159-165. [PMID: 38480465 DOI: 10.1080/14779072.2024.2330660] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/08/2023] [Accepted: 03/11/2024] [Indexed: 03/19/2024]
Abstract
INTRODUCTION Two of the main reasons recent guidelines do not recommend routine population-wide screening programs for asymptomatic carotid artery stenosis (AsxCS) is that screening could lead to an increase of carotid revascularization procedures and that such mass screening programs may not be cost-effective. Nevertheless, selective screening for AsxCS could have several benefits. This article presents the rationale for such a program. AREAS COVERED The benefits of selective screening for AsxCS include early recognition of AsxCS allowing timely initiation of preventive measures to reduce future myocardial infarction (MI), stroke, cardiac death and cardiovascular (CV) event rates. EXPERT OPINION Mass screening programs for AsxCS are neither clinically effective nor cost-effective. Nevertheless, targeted screening of populations at high risk for AsxCS provides an opportunity to identify these individuals earlier rather than later and to initiate a number of lifestyle measures, risk factor modifications, and intensive medical therapy in order to prevent future strokes and CV events. For patients at 'higher risk of stroke' on best medical treatment, a prophylactic carotid intervention may be considered.
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Affiliation(s)
| | - Alan Dardik
- Department of Surgery, Yale School of Medicine, New Haven, CT, USA
- Department of Surgery, VA Connecticut Healthcare System, West Haven, CT, USA
| | - Marc L Schermerhorn
- Department of Surgery, Division of Vascular and Endovascular Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
| | - Christos D Liapis
- Department of Vascular Surgery, Athens Vascular Research Center, Athens, Greece
| | - Armando Mansilha
- Faculty of Medicine of the University of Porto, Porto, Portugal
- Department of Angiology and Vascular Surgery, Hospital de S. Joao, Porto, Portugal
| | - Brajesh K Lal
- Department of Vascular Surgery, University of Maryland School of Medicine, Baltimore, USA
- Department of Vascular Surgery, Baltimore VA Medical Center, Baltimore, USA
- Department of Neurology, Mayo Clinic, Rochester, MN, USA
| | | | - Martin M Brown
- Stroke Research Centre, UCL Institute of Neurology, University College London, London, UK
| | - Piotr Myrcha
- Department of General and Vascular Surgery, Faculty of Medicine, Medical University of Warsaw, Warsaw, Poland
| | - Carl J Lavie
- John Ochsner Heart and Vascular Institute, Ochsner Clinical School, The University of Queensland School of Medicine, New Orleans, LA, USA
| | - Clark J Zeebregts
- Department of Surgery (Division of Vascular Surgery), University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Eric A Secemsky
- Smith Center for Outcomes Research, Division of Cardiology, Department of Medicine, Beth Israel Deaconess Medical Center, Boston, MA, USA
- Harvard Medical School, Boston, MA, USA
| | - Luca Saba
- Department of Radiology, Azienda Ospedaliera Universitaria Di Cagliari, Cagliari, Italy
| | - Matthew Blecha
- Division of Vascular Surgery, Stritch School of Medicine, Loyola University Chicago, Chicago, IL, USA
| | - Victor Gurevich
- Center of Atherosclerosis and Lipid Disorders, Lab of Microangiopathic Mechanisms of Atherogenesis, Saint-Petersburg State University, Mechnikov, Saint-Petersburgh, Russia
| | - Mauro Silvestrini
- Neurological Clinic, Department of Experimental and Clinical Medicine, Marche Polytechnic University, Ancona, Italy
| | - Ales Blinc
- Department of Vascular Diseases, Division of Internal Medicine, University Medical Centre Ljubljana, Ljubljana, Slovenia
- Faculty of Medicine, University of Ljubljana, Ljubljana, Slovenia
| | - Alexei Svetlikov
- Division of Vascular & Endovascular Surgery, North-Western Scientific Clinical Center of Federal Medical Biological Agency, Department of Hospital Surgery, Saint-Petersburg State University, Saint-Petersburg, Russia
| | - Jose Fernandes E Fernandes
- Cardiovascular Center (CCUL), Faculty of Medicine University of Lisbon, Lisbon, Portugal
- Department of Vascular Surgery, Hospital da Luz Torres de Lisboa, Lisbon, Portugal
| | - Peter A Schneider
- Division of Vascular and Endovascular Surgery, University of California, San Francisco, CA, USA
| | - Peter Gloviczki
- Division of Vascular and Endovascular Surgery, Mayo Clinic, Rochester, MN, USA
| | - Christopher J White
- John Ochsner Heart and Vascular Institute, Ochsner Clinical School, The University of Queensland School of Medicine, New Orleans, LA, USA
| | - Ali F AbuRahma
- Department of Surgery, Division of Vascular and Endovascular Surgery, Charleston Area Medical Center/West Virginia University Health Sciences Center, Charleston, WV, USA
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Speranza G, Harish K, Rockman C, Sadek M, Jacobowitz G, Garg K, Chang H, Teter K, Maldonado TS. Duplex ultrasound and cross-sectional imaging in carotid artery occlusion diagnosis. J Vasc Surg 2024; 79:577-583. [PMID: 37992947 DOI: 10.1016/j.jvs.2023.11.029] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2023] [Revised: 11/05/2023] [Accepted: 11/16/2023] [Indexed: 11/24/2023]
Abstract
OBJECTIVE Investigations into imaging modalities in the diagnosis of extracranial carotid artery occlusion (CAO) have raised questions about the inter-modality comparability of duplex ultrasound (DUS) and cross-sectional imaging (CSI). This study examines the relationship between DUS and CSI diagnoses of extracranial CAO. METHODS This single-institution retrospective analysis studied patients with CAO diagnosed by DUS from 2010 to 2021. Patients were identified in our office-based accredited vascular laboratory database. Imaging and clinical data was obtained via our institutional electronic medical record. Primary outcome was discrepancy between DUS and CSI modalities. Secondary outcomes included incidence of stroke and intervention subsequent to CAO diagnosis. RESULTS Of our 140-patient cohort, 95 patients (67.9%) had DUS follow-up (mean, 42.7 ± 31.3 months). At index duplex, 68.0% of individuals (n = 51) were asymptomatic. Seventy-five patients (53.6%) had CSI of the carotids after DUS CAO diagnosis; 18 (24%) underwent magnetic resonance imaging and 57 (76%) underwent computed tomography. Indications for CSI included follow-up of DUS findings of carotid stenosis/occlusion (44%), stroke/transient ischemic attack (16%), other symptoms (12%), preoperative evaluation (2.7%), unrelated pathology follow-up (9.3%), and outside institution imaging with unavailable indications (16%). When comparing patients with CSI and those without, there were no differences with regard to symptoms at diagnosis, prior neck interventions, or hypertension. There was a significant difference between cross-sectionally imaged and non-imaged patients in anti-hypertensive medications (72% vs 53.8%; P = .04). Despite initial DUS diagnoses of carotid occlusion, 10 patients (13.3%) ultimately had CSI indicating patent carotids. Four of these 10 patients had stenoses of ∼99% (with 1 string sign), four of 70% to 99%, one of 50% to 69%, and one of less than 50% on CSI. The majority of patients (70%) had CSI within 1 month of the index ultrasound. There were no significant relationships between imaging discrepancies and body mass index, heart failure, upper body edema, carotid artery calcification, and neck hardware. Eight individuals (10.7%) underwent ipsilateral revascularization; 62.5% (n = 5) were carotid endarterectomy procedures, and the remaining three procedures were a transcervical carotid revascularization, subclavian to internal carotid artery bypass, and transfemoral carotid artery stenting. Eight patients (10.7%) underwent contralateral revascularization, with the same distribution of procedures as those ipsilateral to occlusions. Two of the 10 patients with discrepancies underwent carotid endarterectomy, and one underwent carotid stenting. CONCLUSIONS In our experience, duplex diagnosis of CAO is associated with a greater than 10% discordance when compared with CSI. These patients may benefit from closer surveillance as well as confirmatory computed tomography or magnetic resonance angiography. Further work is needed to determine the optimal diagnostic modality for CAO.
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Affiliation(s)
| | - Keerthi Harish
- New York University Grossman School of Medicine, New York, NY
| | - Caron Rockman
- Division of Vascular Surgery, Department of Surgery, New York University Langone Health, New York, NY
| | - Mikel Sadek
- Division of Vascular Surgery, Department of Surgery, New York University Langone Health, New York, NY
| | - Glenn Jacobowitz
- Division of Vascular Surgery, Department of Surgery, New York University Langone Health, New York, NY
| | - Karan Garg
- Division of Vascular Surgery, Department of Surgery, New York University Langone Health, New York, NY
| | - Heepeel Chang
- Division of Vascular and Endovascular Surgery, Department of Surgery, Westchester Medical Center, New York Medical College, Valhalla, NY
| | - Katherine Teter
- Division of Vascular Surgery, Department of Surgery, New York University Langone Health, New York, NY
| | - Thomas S Maldonado
- Division of Vascular Surgery, Department of Surgery, New York University Langone Health, New York, NY.
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10
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Teh R, Raymond W, Sieunarine K. Uptake of Best Medical Therapy: Secondary Prevention of Cardiovascular Disease in Vascular Surgical Patients in Western Australia. Angiology 2024; 75:288-294. [PMID: 36927174 DOI: 10.1177/00033197231159246] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/18/2023]
Abstract
Best medical therapy (BMT) for peripheral arterial disease (PAD), carotid artery stenosis (CAS) and abdominal aortic aneurysm (AAA) involving concomitant use of antiplatelets, lipid-lowering agents, and blood pressure control, improves patient survival and prevents clinical cardiovascular disease (CVD). We performed a single-center cross-sectional study, over a 4-year period, describing BMT use in Western Australian patients with symptomatic PAD, CAS and AAA in the community. Overall, 45.3% of our cohort (n = 1689) were on appropriate BMT (CAS, 58.1%; PAD, 43.1%; AAA, 41.1%). There was highest uptake of blood pressure control at 93.0% (lipid-lowering agents, 65.3%; antithrombotics 63.5%). PAD was associated with highest uptake of blood pressure control (PAD 93.9%; CAS, 91.4%; AAA, 91.1%, P = .092) whilst CAS had highest uptake of antithrombotics (CAS 76.3%; PAD, 61.0%; AAA 60.4%, P < .001) and lipid-lowering agents (CAS 78.7%; PAD, 63.1%; AAA, 60.4%, P < .001). Our study indicates suboptimal use of BMT in patients with vascular disease in the community. The risk of CVD in CAS is likely misperceived as higher than PAD and AAA.
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Affiliation(s)
- Ryan Teh
- South Metropolitan Health Service, WA Health, Fiona Stanley Hospital, Perth, WA, Australia
| | - Warren Raymond
- Medical School, The University of Western Australia, Crawley, WA, Australia
- School of Health and Medical Sciences, Edith Cowan University, Joondalup, WA, Australia
| | - Kishore Sieunarine
- Department of Vascular Surgery, Hollywood Hospital, Perth, WA, Australia
- Medical School, Curtin University, Bentley, WA, Australia
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11
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Han T, Tang H, Lin C, Zhu J, Shen Y, Yan D, Zhao Z, Lin J, Gao B, Si Y, Wei X, Tang X, Guo D, Fu W. One month follow-up of carotid endarterectomy with in-hospital preoperative aspirin monotherapy and postoperative dual antiplatelet therapy in asymptomatic and symptomatic patients: A multi-center study. Heliyon 2024; 10:e24755. [PMID: 38322935 PMCID: PMC10844113 DOI: 10.1016/j.heliyon.2024.e24755] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2023] [Revised: 12/15/2023] [Accepted: 01/12/2024] [Indexed: 02/08/2024] Open
Abstract
Background There is currently no consensus regarding the optimal perioperative antiplatelet strategy for carotid artery surgery. This multicentre study aimed to analyse the association between preoperative aspirin monotherapy following postoperative dual antiplatelet therapy (DAPT) and the risk for stroke and death after carotid endarterectomy (CEA). Methods This cohort study included 821 patients with carotid artery stenosis who underwent CEA. Primary outcomes included any stroke or death up to the one-month postoperative follow-up. Multilevel multivariate regression analyses and descriptive statistics were performed. Results Patients were predominantly male (53 %), with a mean age of 66.2 years. The primary outcome occurred in 1.6 % of patients. Univariate and multivariate analyses revealed that patients with chronic obstructive pulmonary disease (COPD) exhibited a high risk for stroke or death (P = 0.011). The occurrence of any local complications in the neck was accompanied by an increase in diastolic blood pressure (DBP) (P = 0.007). Patients with a high systolic blood pressure (SBP) (P = 0.002) experienced a longer operative duration. The length of hospital stay was longer in the patients with COPD (P = 0.020), minor stroke (P = 0.011), and major stroke (P = 0.001). A positive linear correlation was found between SBP and operative duration in the overall population (β 0.4 [95 % confidence interval (CI) 0.1-0.7]; P = 0.002). The resultant curve for DBP and any local complications in the neck exhibited a two-stage change and one breakpoint in the entire population (k = 68 mmHg, <68; odds ratio [OR] 0.9 [95 % CI 0.7-1.1], P = 0.461; ≥68: OR 1.1 [95 % CI 1.0-1.1], P = 0.003). Conclusions Preoperative aspirin monotherapy and postoperative DAPT were safe and effective antiplatelet treatments for patients who underwent CEA.
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Affiliation(s)
- Tonglei Han
- Department of Vascular Surgery, Zhongshan Hospital, Fudan University, Shanghai, 200030, China
| | - Hanfei Tang
- Department of Vascular Surgery, Zhongshan Hospital, Fudan University, Shanghai, 200030, China
| | - Changpo Lin
- Department of Vascular Surgery, Zhongshan Hospital, Fudan University, Shanghai, 200030, China
| | - Jiaqi Zhu
- Department of Vascular Surgery, Zhongshan Hospital, Fudan University, Shanghai, 200030, China
| | - Yang Shen
- Department of Vascular Surgery, Zhongshan Hospital, Fudan University, Shanghai, 200030, China
| | - Dong Yan
- Department of Vascular Surgery, Zhongshan Hospital, Fudan University, Shanghai, 200030, China
| | - Zhiqing Zhao
- Department of Vascular Surgery, Changhai Hospital, The PLA Naval Medical University, Shanghai, 200433, China
| | - Jiang Lin
- Department of Radiology, Zhongshan Hospital, Fudan University and Shanghai Institute of Medical Imaging, Shanghai, 200030, China
| | - Bin Gao
- Department of Vascular Surgery, Zhongshan Hospital, Fudan University, Shanghai, 200030, China
| | - Yi Si
- Department of Vascular Surgery, Zhongshan Hospital, Fudan University, Shanghai, 200030, China
| | - Xiaolong Wei
- Department of Vascular Surgery, Changhai Hospital, The PLA Naval Medical University, Shanghai, 200433, China
| | - Xiao Tang
- Department of Vascular Surgery, Zhongshan Hospital, Fudan University, Shanghai, 200030, China
| | - Daqiao Guo
- Department of Vascular Surgery, Zhongshan Hospital, Fudan University, Shanghai, 200030, China
| | - Weiguo Fu
- Department of Vascular Surgery, Zhongshan Hospital, Fudan University, Shanghai, 200030, China
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12
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Nguyen T, Jokisch C, Dargan C, Janjua H, Brooks J, Moudgill N, Latz C, Shames M. The Effects of Clopidogrel Duration On Carotid Artery In-stent Restenosis. Ann Vasc Surg 2024:S0890-5096(24)00035-9. [PMID: 38350539 DOI: 10.1016/j.avsg.2023.12.064] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2023] [Revised: 12/11/2023] [Accepted: 12/11/2023] [Indexed: 02/15/2024]
Abstract
OBJECTIVE There is limited data supporting a specific duration for dual antiplatelet therapy in carotid artery stenting (CAS), and most clinical evidence is derived from studies involving coronary interventions. As a result, the appropriate duration of dual antiplatelet therapy after CAS has yet to be determined. We aimed to elucidate whether the duration of dual antiplatelet therapy played a role in the rate of carotid in-stent restenosis. METHODS A retrospective analysis of all patients who underwent CAS at our institution over a 20-year period (1996-2016) was performed (n=279). Patients who did not complete their follow-up duplex studies or were not discharged on clopidogrel were excluded from the study. Patients were separated into short-term (<6 weeks, n=159) and long-term (>6 weeks, n=112) clopidogrel users based on duration of therapy. We defined clinically significant in-stent restenosis as >50% restenosis (PSV = 224 cm/s) in symptomatic patients and >80% restenosis (PSV = 325 cm/s) in asymptomatic patients status-post prior CAS based on published velocity criteria. Rates of in-stent restenosis at 1-year, 2-year, and 5-year intervals were analyzed between the two groups using chi-squared analysis. RESULTS Demographic information was largely similar between the two groups; however, short-term clopidogrel users were more likely to have a history of atrial fibrillation (9.43% vs. 1.68%, p=0.008) and were less likely to have a history of CABG (16.35% vs. 29.41%, p=0.009), diabetes (33.34% vs. 49.58%, p=0.006) and CAD (50.31% vs. 63.03%, p=0.035). All patients were on long-term aspirin therapy. There was no significant difference between overall rates of in-stent restenosis between the short-term and long-term clopidogrel users (5.03% vs. 9.24%, p=0.168) within 5 years of the index procedure. Similar results were observed when these groups were evaluated at 1-year (5.61 % vs. 3%, p=0.321), 2-year (2.02% vs. 6.59%, p=0.072), and 5-year (2.24% vs. 3.57%, p=0.635) follow-up. CONCLUSION No statistically significant difference was observed in the rate of in-stent restenosis after CAS between short-term and long-term clopidogrel therapy. Patients in whom there is no other indication for longer duration clopidogrel therapy may be considered for shorter duration course of dual antiplatelet therapy following CAS.
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Affiliation(s)
- Trung Nguyen
- Division of Vascular Surgery University of South Florida College of Medicine, Tampa, Florida
| | - Christine Jokisch
- Division of Vascular Surgery University of South Florida College of Medicine, Tampa, Florida
| | - Chetan Dargan
- Division of Vascular Surgery University of South Florida College of Medicine, Tampa, Florida
| | - Haroon Janjua
- Division of Vascular Surgery University of South Florida College of Medicine, Tampa, Florida
| | - James Brooks
- Division of Vascular Surgery University of South Florida College of Medicine, Tampa, Florida
| | - Neil Moudgill
- Division of Vascular Surgery University of South Florida College of Medicine, Tampa, Florida
| | - Christopher Latz
- Division of Vascular Surgery University of South Florida College of Medicine, Tampa, Florida
| | - Murray Shames
- Division of Vascular Surgery University of South Florida College of Medicine, Tampa, Florida.
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13
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Solomon Y, Conroy PD, Rastogi V, Yadavalli SD, Schneider PA, Wang GJ, Malas MB, de Borst GJ, Schermerhorn ML. Outcomes following carotid revascularization for stroke stratified by Modified Rankin Scale and time of intervention. J Vasc Surg 2024; 79:287-296.e1. [PMID: 38179993 DOI: 10.1016/j.jvs.2023.10.041] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2023] [Revised: 10/12/2023] [Accepted: 10/13/2023] [Indexed: 01/06/2024]
Abstract
OBJECTIVES The relationship between baseline Modified Rankin Scale (mRS) in patients with prior stroke and optimal timing of carotid revascularization is unclear. Therefore, we evaluated the timing of transfemoral carotid artery stenting (tfCAS), transcarotid artery revascularization (TCAR), and carotid endarterectomy (CEA) after prior stroke, stratified by preoperative mRS. METHODS We identified patients with recent stroke who underwent tfCAS, TCAR, or CEA between 2012 and 2021. Patients were stratified by preoperative mRS (0-1, 2, 3-4, or 5) and days from symptom onset to intervention (time to intervention; ≤2 days, 3-14 days, 15-90 days, and 91-180 days). First, we performed univariate analyses comparing in-hospital outcomes between separate mRS or time-to-intervention cohorts for all carotid intervention methods. Afterward, multivariable logistic regression was used to adjust for demographics and comorbidities across groups, and outcomes between the various intervention methods were compared. Primary outcome was the in-hospital stroke/death rate. RESULTS We identified 4260 patients who underwent tfCAS, 3130 patients who underwent TCAR, and 20,012 patients who underwent CEA. Patients were most likely to have minimal disability (mRS, 0-1 [61%]) and least likely to have severe disability (mRS, 5 [1.5%]). Patients most often underwent revascularization in 3 to 14 days (45%). Across all intervention methods, increasing preoperative mRS was associated with higher procedural in-hospital stroke/death (all P < .03), whereas increasing time to intervention was associated with lower stroke/death rates (all P < .01). After adjustment for demographics and comorbidities, undergoing tfCAS was associated with higher stroke/death compared with undergoing CEA (adjusted odds ratio, 1.6; 95% confidence interval, 1.3-1.9; P < .01) or undergoing TCAR (adjusted odds ratio, 1.3; 95% confidence interval, 1.0-1.8; P = .03). CONCLUSIONS In patients with preoperative stroke, optimal timing for carotid revascularization varies with stroke severity. Increasing preoperative mRS was associated with higher procedural in-hospital stroke/death rates, whereas increasing time to-intervention was associated with lower stroke/death rates. Overall, patients undergoing CEA were associated with lower in-hospital stroke/deaths. To determine benefit for delayed intervention, these results should be weighed against the risk of recurrent stroke during the interval before intervention.
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Affiliation(s)
- Yoel Solomon
- Department of Surgery, Division of Vascular and Endovascular Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA; Department of Vascular Surgery, University Medical Center, Utrecht, the Netherlands
| | - Patrick D Conroy
- Department of Surgery, Division of Vascular and Endovascular Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA
| | - Vinamr Rastogi
- Department of Surgery, Division of Vascular and Endovascular Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA
| | - Sai Divya Yadavalli
- Department of Surgery, Division of Vascular and Endovascular Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA
| | - Peter A Schneider
- Division of Vascular and Endovascular Surgery, University of California San Francisco, San Francisco, CA
| | - Grace J Wang
- Division of Vascular Surgery and Endovascular Therapy, Department of Surgery, Hospital of the University of Pennsylvania, Philadelphia, PA
| | - Mahmoud B Malas
- Division of Vascular and Endovascular Surgery, Department of Surgery, University of California San Diego Health System, San Diego, CA
| | - Gert J de Borst
- Department of Vascular Surgery, University Medical Center, Utrecht, the Netherlands
| | - Marc L Schermerhorn
- Department of Surgery, Division of Vascular and Endovascular Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA.
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Penton A, Driscoll M, Li R, DeJong M, Blecha M. Carotid Endarterectomy for Asymptomatic Stenosis Based on Duplex Ultrasound Alone Achieves Equivalent Perioperative and Long-Term Outcomes Relative to Advanced Imaging Based Endarterectomy. Ann Vasc Surg 2024; 98:44-57. [PMID: 37454891 DOI: 10.1016/j.avsg.2023.07.093] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2022] [Revised: 05/08/2023] [Accepted: 07/03/2023] [Indexed: 07/18/2023]
Abstract
BACKGROUND The purpose of this study is to compare both perioperative as well as long-term outcomes of patients undergoing carotid endarterectomy (CEA) for asymptomatic carotid bifurcation stenosis based on duplex ultrasound in isolation relative to a combination of duplex and more advanced imaging. METHODS All CEA in the VQI between January 2003 and May 2022 were queried. We identified 171,816 CEAs in the database. Exclusions were symptomatic carotid lesion (57,742), lack of imaging documentation (908), lack of advanced imaging status (1,816), simultaneous additional arterial intervention in the carotid, coronary, or peripheral arterial system (n = 4,118), and anatomic high-risk status for CEA (n = 4,071). Included patients were then placed into 1 of 2 cohorts: patients undergoing CEA based on duplex imaging alone (n = 33,437) and those undergoing CEA based on advanced imaging (CTA, MRA, or invasive angiography) with or without duplex (n = 69,715). We performed multivariable analysis for the following outcomes utilizing CEA based on duplex in isolation as 1 of the variables: perioperative neurological ischemic event utilizing binary logistic regression; combined 90-day mortality and neurological ischemic event utilizing binary logistic regression; neurological event in long-term follow-up with date of surgery serving as time zero; time dependent Cox regression analysis; mortality in long-term follow-up utilizing time-dependent Cox regression. RESULTS Carotid endarterectomy based on duplex alone and CEA based on advanced imaging had essentially equivalent rates of 90-day mortality (0.9% vs. 1.0%, P = 0.108); combined perioperative neurological event and 90-day mortality (2.0% vs. 2.2%, P = 0.042); and, return to the operating room (1.6% vs. 1.7%, P = 0.154). On multivariable analysis CEA based on advanced imaging was noted to have a slightly higher absolute rate of perioperative neurological event without achieving multivariable significance (1.3% vs. 1.2%, adjusted odds ratio 1.11 (0.98-1.25), P = 0.092. CEA based on advanced imaging had a higher rate of neurological event after index hospital admission relative to duplex in isolation (hazard ratio (HR) 1.44 (1.31-1.60), P < 0.001). However, the absolute percentage difference was just 0.5% (1.6% vs. 2.1%). CEA based on duplex alone was associated with a slightly increased risk of mortality in LTFU (HR 1.16 (1.11-1.21), P < 0.001). At 5 years the absolute risk of mortality was less than 1% different between the cohorts. CONCLUSIONS Performing CEA for asymptomatic bifurcation stenosis based on duplex ultrasound alone is a safe practice which achieves clinically equivalent perioperative and long-term freedom from cerebral ischemia and mortality relative to CEA based on advanced imaging. This has potential implications for health care cost saving as well as avoidance of radiation and iodinated contrast.
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Affiliation(s)
- Ashley Penton
- Loyola University Medical Center Department of Sugery, Maywood, IL
| | - Matthew Driscoll
- Loyola University Chicago Stritch School of Medicine, Maywood, IL
| | - Ruojia Li
- Division of Vascular Surgery and Endovascular Therapy, Maywood, IL
| | - Matthew DeJong
- Loyola University Medical Center Department of Sugery, Maywood, IL
| | - Matthew Blecha
- Division of Vascular Surgery and Endovascular Therapy, Maywood, IL.
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Singh J, Kuhn AL, Massari F, Elnazeir M, Kutcher R, Puri AS. Intravascular lithotripsy for severely calcified carotid artery stenosis - A new frontier in carotid artery stenting? Interv Neuroradiol 2023; 29:768-772. [PMID: 35505603 PMCID: PMC10680962 DOI: 10.1177/15910199221097887] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2022] [Accepted: 04/11/2022] [Indexed: 11/17/2022] Open
Abstract
Carotid stenosis due to severely calcified plaque can pose a significant therapeutic challenge. Extremely calcified scars/stenosis plaques can be challenging from an endovascular treatment perspective as severely calcified lesions are prone to technical failure, stent re-coil and restenosis. Intravascular lithotripsy, approved for treatment of severely calcified coronary lesions, can be used for breaking up the calcium build up in the intimal and medial layers of the vessel wall prior to stenting. This was designated as a breakthrough device innovation by the Food and Drug Administration. This new technique addresses the challenge of the disease without compromising patient safety during the procedure. We here report procedural set-up, execution and early patient follow up from our first use of this emerging technology in a neurointerventional practice setting.
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Affiliation(s)
- Jasmeet Singh
- Division of Neurointerventional Radiology, Department of Radiology, University of Massachusetts Medical Center, Worcester, MA, USA
| | - Anna Luisa Kuhn
- Division of Neurointerventional Radiology, Department of Radiology, University of Massachusetts Medical Center, Worcester, MA, USA
| | - Francesco Massari
- Division of Neurointerventional Radiology, Department of Radiology, University of Massachusetts Medical Center, Worcester, MA, USA
| | - Marwa Elnazeir
- Division of Neurointerventional Radiology, Department of Radiology, University of Massachusetts Medical Center, Worcester, MA, USA
| | - Roberto Kutcher
- Division of Neurointerventional Radiology, Department of Radiology, University of Massachusetts Medical Center, Worcester, MA, USA
| | - Ajit S. Puri
- Division of Neurointerventional Radiology, Department of Radiology, University of Massachusetts Medical Center, Worcester, MA, USA
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Pakizer D, Vybíralová A, Jonszta T, Roubec M, Král M, Chovanec V, Herzig R, Heryán T, Školoudík D. Peak systolic velocity ratio for evaluation of internal carotid artery stenosis correlated with plaque morphology: substudy results of the ANTIQUE study. Front Neurol 2023; 14:1206483. [PMID: 38020621 PMCID: PMC10657818 DOI: 10.3389/fneur.2023.1206483] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2023] [Accepted: 10/23/2023] [Indexed: 12/01/2023] Open
Abstract
Background Accurate assessment of carotid stenosis severity is important for proper patient management. The present study aimed to compare the evaluation of carotid stenosis severity using four duplex sonography (DUS) measurements, including peak systolic velocity (PSV), PSV ratio in stenosis and distal to stenosis (PSVICA/ICA ratio), end-diastolic velocity (EDV), and B-mode, with computed tomography angiography (CTA), and to evaluate the impact of plaque morphology on correlation between DUS and CTA. Methods Consecutive patients with carotid stenosis of ≥40% examined using DUS and CTA were included. Plaque morphology was also determined using magnetic resonance imaging. Spearman's correlation and Kendall's rank correlation were used to evaluate the results. Results A total of 143 cases of internal carotid artery stenosis of ≥40% based on DUS were analyzed. The PSVICA/ICA ratio showed the highest correlation [Spearman's correlation r = 0.576) with CTA, followed by PSV (r = 0.526), B-mode measurement (r = 0.482), and EDV (r = 0.441; p < 0.001 in all cases]. The worst correlation was found for PSV when the plaque was calcified (r = 0.238), whereas EDV showed a higher correlation (r = 0.523). Correlations of B-mode measurement were superior for plaques with smooth surface (r = 0.677), while the PSVICA/ICA ratio showed the highest correlation in stenoses with irregular (r = 0.373) or ulcerated (r = 0.382) surfaces, as well as lipid (r = 0.406), fibrous (r = 0.461), and mixed (r = 0.403; p < 0.01 in all cases) plaques. Nevertheless, differences between the mentioned correlations were not statistically significant (p > 0.05 in all cases). Conclusion PSV, PSVICA/ICA ratio, EDV, and B-mode measurements showed comparable correlations with CTA in evaluation of carotid artery stenosis based on their correlation with CTA results. Heavy calcifications and plaque surface irregularity or ulceration negatively influenced the measurement accuracy.
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Affiliation(s)
- David Pakizer
- Faculty of Medicine, University of Ostrava, Ostrava, Czechia
| | - Anna Vybíralová
- Faculty of Medicine, University of Ostrava, Ostrava, Czechia
- Faculty of Health Sciences, Palacký University Olomouc, Olomouc, Czechia
| | - Tomáš Jonszta
- Department of Radiology, University Hospital Ostrava, Ostrava, Czechia
| | - Martin Roubec
- Faculty of Medicine, University of Ostrava, Ostrava, Czechia
- Department of Neurology, Clinic of Neurology, University Hospital Ostrava, Ostrava, Czechia
| | - Michal Král
- Department of Neurology, University Hospital Olomouc, Olomouc, Czechia
| | - Vendelín Chovanec
- Department of Radiology, University Hospital Hradec Kralove, Hradec Králové, Czechia
| | - Roman Herzig
- Department of Neurology, University Hospital Hradec Kralove, Hradec Kralove, Czechia
- Department of Neurology, Faculty of Medicine in Hradec Králové, Charles University, Prague, Czechia
| | - Tomáš Heryán
- Department of Finance and Accounting, Silesian University in Opava, Opava, Czechia
| | - David Školoudík
- Faculty of Medicine, University of Ostrava, Ostrava, Czechia
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17
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Chang RW, Pimentel N, Tucker LY, Rothenberg KA, Avins AL, Flint AC, Faruqi RM, Nguyen-Huynh MN, Neugebauer R. A comparative effectiveness study of carotid intervention for long-term stroke prevention in patients with severe asymptomatic stenosis from a large integrated health system. J Vasc Surg 2023; 78:1239-1247.e4. [PMID: 37406943 PMCID: PMC11020993 DOI: 10.1016/j.jvs.2023.06.024] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2023] [Revised: 06/23/2023] [Accepted: 06/26/2023] [Indexed: 07/07/2023]
Abstract
OBJECTIVE The results of current prospective trials comparing the effectiveness of carotid endarterectomy (CEA) vs standard medical therapy for long-term stroke prevention in patients with asymptomatic carotid stenosis (ACS) will not be available for several years. In this study, we compared the observed effectiveness of CEA and standard medical therapy vs standard medical therapy alone to prevent ipsilateral stroke in a contemporary cohort of patients with ACS. METHODS This cohort study was conducted in a large integrated health system in adult subjects with 70% to 99% ACS (no neurologic symptom within 6 months) with no prior ipsilateral carotid artery intervention. Causal inference methods were used to emulate a conceptual randomized trial using data from January 1, 2008, through December 31, 2017, for comparing the event-free survival over 96 months between two treatment strategies: (1) CEA within 12 months from cohort entry vs (2) no CEA (standard medical therapy alone). To account for both baseline and time-dependent confounding, inverse probability weighting estimation was used to derive adjusted hazard ratios, and cumulative risk differences were assessed based on two logistic marginal structural models for counterfactual hazards. Propensity scores were data-adaptively estimated using super learning. The primary outcome was ipsilateral anterior ischemic stroke. RESULTS The cohort included 3824 eligible patients with ACS (mean age: 73.7 years, 57.9% male, 12.3% active smokers), of whom 1467 underwent CEA in the first year, whereas 2297 never underwent CEA. The median follow-up was 68 months. A total of 1760 participants (46%) died, 445 (12%) were lost to follow-up, and 158 (4%) experienced ipsilateral stroke. The cumulative risk differences for each year of follow-up showed a protective effect of CEA starting in year 2 (risk difference = 1.1%, 95% confidence interval: 0.5%-1.6%) and persisting to year 8 (2.6%, 95% confidence interval: 0.3%-4.8%) compared with patients not receiving CEA. CONCLUSIONS In this contemporary cohort study of patients with ACS using rigorous analytic methodology, CEA appears to have a small but statistically significant effect on stroke prevention out to 8 years. Further study is needed to appropriately select the subset of patients most likely to benefit from intervention.
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Affiliation(s)
- Robert W Chang
- Department of Vascular Surgery, the Permanente Medical Group, South San Francisco, CA; Division of Research, Kaiser Permanente Northern California, Oakland, CA.
| | - Noel Pimentel
- Division of Research, Kaiser Permanente Northern California, Oakland, CA
| | - Lue-Yen Tucker
- Division of Research, Kaiser Permanente Northern California, Oakland, CA
| | - Kara A Rothenberg
- Department of Surgery, University of California San Francisco-East Bay, Oakland, CA
| | - Andrew L Avins
- Division of Research, Kaiser Permanente Northern California, Oakland, CA; Departments of Medicine and Epidemiology & Biostatistics, University of California San Francisco, San Francisco, CA
| | - Alexander C Flint
- Department of Neurology, The Permanente Medical Group, Redwood City, CA
| | - Rishad M Faruqi
- Department of Vascular Surgery, The Permanente Medical Group, Santa Clara, CA
| | - Mai N Nguyen-Huynh
- Division of Research, Kaiser Permanente Northern California, Oakland, CA; Department of Neurology, The Permanente Medical Group, Walnut Creek, CA
| | - Romain Neugebauer
- Division of Research, Kaiser Permanente Northern California, Oakland, CA; Department of Health System Science, Kaiser Permanente Bernard J. Tyson School of Medicine, Pasadena, CA
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18
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Sanjuan-Sanjuan A, Ogledzki MJ, Haouilou JC, Ramirez CA. Neck dissection for head and neck malignancies with concurrent carotid endarterectomy. Int J Oral Maxillofac Surg 2023; 52:1120-1126. [PMID: 37062645 DOI: 10.1016/j.ijom.2023.03.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2022] [Revised: 03/03/2023] [Accepted: 03/21/2023] [Indexed: 04/18/2023]
Abstract
Head and neck malignancies share similar risk factors as carotid artery stenosis and these can often present together. Patients who require external beam radiotherapy are at a higher risk of developing significant worsening stenosis. The workup of the oncologic patient often includes computed tomography, which can reveal underlying carotid artery stenosis, offering an opportunity to address both conditions in one operation and prevent the need for a complicated carotid endarterectomy (CEA) in irradiated and previously operated tissue. It was postulated that these two operations can be combined safely. The surgical protocol, surgical technique, and outcomes of a case series of four patients with head and neck cancer who underwent neck dissection and CEA for carotid artery stenosis during the same operation is presented. CEA was performed safely, simultaneously with neck dissection. CEA did not affect the surgical outcomes or postoperative course of the patients, and no minor or major complications were observed related to this procedure. Carotid endarterectomy performed by a vascular surgeon can be safely combined with oncologic neck dissection in the same procedure to avoid future complications in head and neck cancer patients.
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Affiliation(s)
- A Sanjuan-Sanjuan
- Oral and Maxillofacial Surgery Department, Ascension-St. John Hospital, Detroit, Michigan, USA
| | - M J Ogledzki
- Oral and Maxillofacial Surgery Department, Ascension-St. John Hospital, Detroit, Michigan, USA
| | - J C Haouilou
- Vascular Surgery, Department of Surgery, Ascension-St. John Hospital, Detroit, Michigan, USA
| | - C A Ramirez
- Oral and Maxillofacial Surgery Department, Ascension-St. John Hospital, Detroit, Michigan, USA.
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19
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Dossabhoy SS, Sorondo SM, Fisher AT, Ho VT, Stern JR, Lee JT. Association of Baseline Chronic Kidney Disease Stage With Short- and Long-Term Outcomes After Fenestrated Endovascular Aneurysm Repair. Ann Vasc Surg 2023; 97:163-173. [PMID: 37586562 PMCID: PMC10956480 DOI: 10.1016/j.avsg.2023.07.102] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2023] [Revised: 07/19/2023] [Accepted: 07/31/2023] [Indexed: 08/18/2023]
Abstract
BACKGROUND Fenestrated endovascular aneurysm repair (FEVAR) is a well-established treatment approach for juxtarenal and short-neck infrarenal aortic aneurysms. Recommendations and clinical outcomes are lacking for offering FEVAR in patients with chronic kidney disease (CKD). We aimed to compare short- and long-term outcomes for patients with none-to-mild versus moderate-to-severe CKD undergoing FEVAR. METHODS We retrospectively reviewed consecutive patients undergoing standard FEVAR with Cook devices at a single institution. The cohort was stratified by preoperative CKD stage none-to-mild or moderate-to-severe (CKD 1-2 and CKD 3-5, respectively). The primary outcome was postoperative acute kidney injury (AKI). Secondary outcomes included 30-day perioperative complications, 1- and 5-year rates of overall survival, dialysis, renal target artery patency, endoleak, and reintervention assessed by the Kaplan-Meier method. Aneurysm sac regression, number of surveillance computed tomography (CT) scans, and CKD stage progression were assessed at latest follow-up. Multivariate Cox proportional hazards modeling was used to evaluate the association of CKD stage 3 and stage 4-5 with all-cause mortality, controlling for differences in baseline characteristics. RESULTS From 2012- to 2022, 184 patients (of which 82% were male) underwent FEVAR with the Cook ZFEN device (mean follow-up 34.3 months). Group CKD 3-5 comprised 77 patients (42%), was older (75.2 vs. 73.0 years, P = 0.04), had increased preoperative creatinine (1.6 vs. 0.9 mg/dL, P < 0.01), and demonstrated increased renal artery ostial calcification (37.7% vs. 21.5%, P = 0.02) compared with Group CKD 1-2. Perioperatively, CKD 3-5 sustained higher estimated blood loss (342 vs. 228 ml, P = 0.01), longer operative times (186 vs. 162 min, P = 0.04), and longer length of stay (3 vs. 2 days, P < 0.01). Kaplan-Meier 1- and 5-year survival estimates were lower for CKD 3-5 (82.3% vs. 95.1%, P < 0.01 and 55.4% vs. 70.8%, P = 0.02). Fewer CKD 3-5 patients remained free from chronic dialysis at 1 year (94.4% vs. 100%, P = 0.015) and 5 years (84.7% vs. 100%, P < 0.01). There were no significant differences in postoperative AKI rate (CKD 1-2 6.5% vs. CKD 3-5 14.3%, P = 0.13), long-term renal artery patency, reinterventions, type I or III endoleak, mean sac regression, or total follow-up CT scans between groups. CKD stage progression occurred in 47 patients (31%) at latest follow-up but did not differ between stratified groups (P = 0.17). On multivariable modeling, age (hazard ratio 1.05, 95% confidence interval 1.01-1.09, P = 0.02) and CKD stage 4-5 (hazard ratio 6.39, 95% confidence interval 2.26-18.05, P < 0.01) were independently associated with mortality. CONCLUSIONS Preoperative CKD status did not negatively impact the durability or technical success related to aneurysm outcomes after FEVAR. Worsening CKD stage was associated with lower 1- and 5-year overall survival and freedom from dialysis after FEVAR with no statistically significant differences in 30-day or long-term technical aneurysm outcomes.
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Affiliation(s)
- Shernaz S Dossabhoy
- Division of Vascular and Endovascular Surgery, Department of Surgery, Stanford University School of Medicine, Stanford, CA
| | - Sabina M Sorondo
- Division of Vascular and Endovascular Surgery, Department of Surgery, Stanford University School of Medicine, Stanford, CA
| | - Andrea T Fisher
- Division of Vascular and Endovascular Surgery, Department of Surgery, Stanford University School of Medicine, Stanford, CA
| | - Vy T Ho
- Division of Vascular and Endovascular Surgery, Department of Surgery, Stanford University School of Medicine, Stanford, CA
| | - Jordan R Stern
- Division of Vascular and Endovascular Surgery, Department of Surgery, Stanford University School of Medicine, Stanford, CA
| | - Jason T Lee
- Division of Vascular and Endovascular Surgery, Department of Surgery, Stanford University School of Medicine, Stanford, CA.
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20
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Li B, Verma R, Beaton D, Tamim H, Hussain MA, Hoballah JJ, Lee DS, Wijeysundera DN, de Mestral C, Mamdani M, Al‐Omran M. Predicting Major Adverse Cardiovascular Events Following Carotid Endarterectomy Using Machine Learning. J Am Heart Assoc 2023; 12:e030508. [PMID: 37804197 PMCID: PMC10757546 DOI: 10.1161/jaha.123.030508] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/05/2023] [Accepted: 08/28/2023] [Indexed: 10/09/2023]
Abstract
Background Carotid endarterectomy (CEA) is a major vascular operation for stroke prevention that carries significant perioperative risks; however, outcome prediction tools remain limited. The authors developed machine learning algorithms to predict outcomes following CEA. Methods and Results The National Surgical Quality Improvement Program targeted vascular database was used to identify patients who underwent CEA between 2011 and 2021. Input features included 36 preoperative demographic/clinical variables. The primary outcome was 30-day major adverse cardiovascular events (composite of stroke, myocardial infarction, or death). The data were split into training (70%) and test (30%) sets. Using 10-fold cross-validation, 6 machine learning models were trained using preoperative features. The primary metric for evaluating model performance was area under the receiver operating characteristic curve. Model robustness was evaluated with calibration plot and Brier score. Overall, 38 853 patients underwent CEA during the study period. Thirty-day major adverse cardiovascular events occurred in 1683 (4.3%) patients. The best performing prediction model was XGBoost, achieving an area under the receiver operating characteristic curve of 0.91 (95% CI, 0.90-0.92). In comparison, logistic regression had an area under the receiver operating characteristic curve of 0.62 (95% CI, 0.60-0.64), and existing tools in the literature demonstrate area under the receiver operating characteristic curve values ranging from 0.58 to 0.74. The calibration plot showed good agreement between predicted and observed event probabilities with a Brier score of 0.02. The strongest predictive feature in our algorithm was carotid symptom status. Conclusions The machine learning models accurately predicted 30-day outcomes following CEA using preoperative data and performed better than existing tools. They have potential for important utility in guiding risk-mitigation strategies to improve outcomes for patients being considered for CEA.
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Affiliation(s)
- Ben Li
- Department of SurgeryUniversity of TorontoCanada
- Division of Vascular Surgery, St. Michael’s Hospital, Unity Health TorontoUniversity of TorontoCanada
- Institute of Medical ScienceUniversity of TorontoCanada
- Temerty Centre for Artificial Intelligence Research and Education in Medicine (T‐CAIREM)University of TorontoCanada
| | - Raj Verma
- School of Medicine, Royal College of Surgeons in IrelandUniversity of Medicine and Health SciencesDublinIreland
| | - Derek Beaton
- Data Science & Advanced Analytics, Unity Health TorontoUniversity of TorontoCanada
| | - Hani Tamim
- Faculty of Medicine, Clinical Research InstituteAmerican University of Beirut Medical CenterBeirutLebanon
- College of MedicineAlfaisal UniversityRiyadhKingdom of Saudi Arabia
| | - Mohamad A. Hussain
- Division of Vascular and Endovascular Surgery and the Center for Surgery and Public Health, Brigham and Women’s HospitalHarvard Medical SchoolBostonMAUSA
| | - Jamal J. Hoballah
- Division of Vascular and Endovascular Surgery, Department of SurgeryAmerican University of Beirut Medical CenterBeirutLebanon
| | - Douglas S. Lee
- Division of Cardiology, Peter Munk Cardiac CentreUniversity Health NetworkTorontoCanada
- Institute of Health Policy, Management and EvaluationUniversity of TorontoCanada
- ICESUniversity of TorontoCanada
| | - Duminda N. Wijeysundera
- Institute of Health Policy, Management and EvaluationUniversity of TorontoCanada
- ICESUniversity of TorontoCanada
- Department of AnesthesiaSt. Michael’s Hospital, Unity Health TorontoTorontoCanada
- Li Ka Shing Knowledge InstituteSt. Michael’s Hospital, Unity Health TorontoTorontoCanada
| | - Charles de Mestral
- Department of SurgeryUniversity of TorontoCanada
- Division of Vascular Surgery, St. Michael’s Hospital, Unity Health TorontoUniversity of TorontoCanada
- Institute of Health Policy, Management and EvaluationUniversity of TorontoCanada
- ICESUniversity of TorontoCanada
- Li Ka Shing Knowledge InstituteSt. Michael’s Hospital, Unity Health TorontoTorontoCanada
| | - Muhammad Mamdani
- Institute of Medical ScienceUniversity of TorontoCanada
- Temerty Centre for Artificial Intelligence Research and Education in Medicine (T‐CAIREM)University of TorontoCanada
- Data Science & Advanced Analytics, Unity Health TorontoUniversity of TorontoCanada
- Institute of Health Policy, Management and EvaluationUniversity of TorontoCanada
- ICESUniversity of TorontoCanada
- Li Ka Shing Knowledge InstituteSt. Michael’s Hospital, Unity Health TorontoTorontoCanada
- Leslie Dan Faculty of PharmacyUniversity of TorontoCanada
| | - Mohammed Al‐Omran
- Department of SurgeryUniversity of TorontoCanada
- Division of Vascular Surgery, St. Michael’s Hospital, Unity Health TorontoUniversity of TorontoCanada
- Institute of Medical ScienceUniversity of TorontoCanada
- Temerty Centre for Artificial Intelligence Research and Education in Medicine (T‐CAIREM)University of TorontoCanada
- College of MedicineAlfaisal UniversityRiyadhKingdom of Saudi Arabia
- Li Ka Shing Knowledge InstituteSt. Michael’s Hospital, Unity Health TorontoTorontoCanada
- Department of SurgeryKing Faisal Specialist Hospital and Research CenterRiyadhKingdom of Saudi Arabia
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21
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Zarrintan S, Elsayed N, Patel RJ, Clary B, Goodney PP, Malas MB. Propensity-Score Matched Analysis of Three Years Survival of Trans Carotid Artery Revascularization Versus Carotid Endarterectomy in the Vascular Quality Initiative Medicare-Linked Database. Ann Surg 2023; 278:559-567. [PMID: 37436847 DOI: 10.1097/sla.0000000000006009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/14/2023]
Abstract
OBJECTIVE Carotid endarterectomy (CEA) remains the gold standard procedure for carotid revascularization. Transfemoral carotid artery stenting (TFCAS) was introduced as a minimally invasive alternative procedure in patients who are at high risk for surgery. However, TFCAS was associated with an increased risk of stroke and death compared to CEA. BACKGROUND Transcarotid artery revascularization (TCAR) has outperformed TFCAS in several prior studies and has shown similar perioperative and 1-year outcomes compared with CEA. We aimed to compare the 1-year and 3-year outcomes of TCAR versus CEA in the Vascular Quality Initiative (VQI)-Medicare-Linked [Vascular Implant Surveillance and Interventional Outcomes Network (VISION)] database. METHODS The VISION database was queried for all patients undergoing CEA and TCAR between September 2016 to December 2019. The primary outcome was 1-year and 3-year survival. One-to-one propensity-score matching (PSM) without replacement was used to produce 2 well-matched cohorts. Kaplan-Meier estimates, and Cox regression was used for analyses. Exploratory analyses compared stroke rates using claims-based algorithms for comparison. RESULTS A total of 43,714 patients underwent CEA and 8089 patients underwent TCAR during the study period. Patients in the TCAR cohort were older and were more likely to have severe comorbidities. PSM produced two well-matched cohorts of 7351 pairs of TCAR and CEA. In the matched cohorts, there were no differences in 1-year death [hazard ratio (HR)=1.13; 95% CI, 0.99-1.30; P =0.065]. At 3-years, TCAR was associated with slight increased risk of death (HR=1.16; 95% CI, 1.04-1.30; P =0.008). When stratifying by initial symptomatic presentation, the increased 3-year death associated with TCAR persisted only in symptomatic patients (HR=1.33; 95% CI, 1.08-1.63; P =0.008). Exploratory analyses of postoperative stroke rates using administrative sources suggested that validated measures of claims-based stroke ascertainment are necessary. CONCLUSIONS In this large multi-institutional PSM analysis with robust Medicare-linked follow-up for survival analysis, the rate of death at 1 year was similar in TCAR and CEA regardless of symptomatic status. The slight increase in the risk of 3-year death in symptomatic patients undergoing TCAR is likely confounded by more severe comorbidities despite matching. A randomized controlled trial comparing TCAR to CEA is necessary to further determine the role of TCAR in standard-risk patients requiring carotid revascularization.
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Affiliation(s)
- Sina Zarrintan
- Department of Surgery, UC San Diego, San Diego, CA
- Center for Learning and Excellence in Vascular and Endovascular Research (CLEVER), UC San Diego, San Diego, CA
| | - Nadin Elsayed
- Department of Surgery, UC San Diego, San Diego, CA
- Center for Learning and Excellence in Vascular and Endovascular Research (CLEVER), UC San Diego, San Diego, CA
| | - Rohini J Patel
- Department of Surgery, UC San Diego, San Diego, CA
- Center for Learning and Excellence in Vascular and Endovascular Research (CLEVER), UC San Diego, San Diego, CA
| | - Bryan Clary
- Department of Surgery, UC San Diego, San Diego, CA
| | - Philip P Goodney
- Dartmouth Institute for Health Policy and Clinical Practice, Geisel School of Medicine at Dartmouth, Lebanon, NH
- Section of Vascular Surgery, Department of Surgery, Dartmouth-Hitchcock Medical Center, Lebanon, NH
| | - Mahmoud B Malas
- Department of Surgery, UC San Diego, San Diego, CA
- Center for Learning and Excellence in Vascular and Endovascular Research (CLEVER), UC San Diego, San Diego, CA
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22
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Li B, Beaton D, Eisenberg N, Lee DS, Wijeysundera DN, Lindsay TF, de Mestral C, Mamdani M, Roche-Nagle G, Al-Omran M. Using machine learning to predict outcomes following carotid endarterectomy. J Vasc Surg 2023; 78:973-987.e6. [PMID: 37211142 DOI: 10.1016/j.jvs.2023.05.024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2023] [Revised: 05/08/2023] [Accepted: 05/13/2023] [Indexed: 05/23/2023]
Abstract
OBJECTIVE Prediction of outcomes following carotid endarterectomy (CEA) remains challenging, with a lack of standardized tools to guide perioperative management. We used machine learning (ML) to develop automated algorithms that predict outcomes following CEA. METHODS The Vascular Quality Initiative (VQI) database was used to identify patients who underwent CEA between 2003 and 2022. We identified 71 potential predictor variables (features) from the index hospitalization (43 preoperative [demographic/clinical], 21 intraoperative [procedural], and 7 postoperative [in-hospital complications]). The primary outcome was stroke or death at 1 year following CEA. Our data were split into training (70%) and test (30%) sets. Using 10-fold cross-validation, we trained six ML models using preoperative features (Extreme Gradient Boosting [XGBoost], random forest, Naïve Bayes classifier, support vector machine, artificial neural network, and logistic regression). The primary model evaluation metric was area under the receiver operating characteristic curve (AUROC). After selecting the best performing algorithm, additional models were built using intra- and postoperative data. Model robustness was evaluated using calibration plots and Brier scores. Performance was assessed on subgroups based on age, sex, race, ethnicity, insurance status, symptom status, and urgency of surgery. RESULTS Overall, 166,369 patients underwent CEA during the study period. In total, 7749 patients (4.7%) had the primary outcome of stroke or death at 1 year. Patients with an outcome were older with more comorbidities, had poorer functional status, and demonstrated higher risk anatomic features. They were also more likely to undergo intraoperative surgical re-exploration and have in-hospital complications. Our best performing prediction model at the preoperative stage was XGBoost, achieving an AUROC of 0.90 (95% confidence interval [CI], 0.89-0.91). In comparison, logistic regression had an AUROC of 0.65 (95% CI, 0.63-0.67), and existing tools in the literature demonstrate AUROCs ranging from 0.58 to 0.74. Our XGBoost models maintained excellent performance at the intra- and postoperative stages, with AUROCs of 0.90 (95% CI, 0.89-0.91) and 0.94 (95% CI, 0.93-0.95), respectively. Calibration plots showed good agreement between predicted and observed event probabilities with Brier scores of 0.15 (preoperative), 0.14 (intraoperative), and 0.11 (postoperative). Of the top 10 predictors, eight were preoperative features, including comorbidities, functional status, and previous procedures. Model performance remained robust on all subgroup analyses. CONCLUSIONS We developed ML models that accurately predict outcomes following CEA. Our algorithms perform better than logistic regression and existing tools, and therefore, have potential for important utility in guiding perioperative risk mitigation strategies to prevent adverse outcomes.
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Affiliation(s)
- Ben Li
- Department of Surgery, University of Toronto, Toronto, ON, Canada; Division of Vascular Surgery, St. Michael's Hospital, Unity Health Toronto, Toronto, ON, Canada; Institute of Medical Science, University of Toronto, Toronto, ON, Canada; Temerty Centre for Artificial Intelligence Research and Education in Medicine (T-CAIREM), University of Toronto, Toronto, ON, Canada
| | - Derek Beaton
- Data Science and Advanced Analytics Department, Unity Health Toronto, University of Toronto, Toronto, ON, Canada
| | - Naomi Eisenberg
- Division of Vascular Surgery, Peter Munk Cardiac Centre, University Health Network, Toronto, ON, Canada
| | - Douglas S Lee
- Division of Cardiology, Peter Munk Cardiac Centre, University Health Network, Toronto, ON, Canada; Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, ON, Canada; ICES, University of Toronto, Toronto, ON, Canada
| | - Duminda N Wijeysundera
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, ON, Canada; ICES, University of Toronto, Toronto, ON, Canada; Department of Anesthesia, St Michael's Hospital, Unity Health Toronto, Toronto, ON, Canada; Li Ka Shing Knowledge Institute, St. Michael's Hospital, Unity Health Toronto, Toronto, ON, Canada
| | - Thomas F Lindsay
- Department of Surgery, University of Toronto, Toronto, ON, Canada; Institute of Medical Science, University of Toronto, Toronto, ON, Canada; Division of Vascular Surgery, Peter Munk Cardiac Centre, University Health Network, Toronto, ON, Canada
| | - Charles de Mestral
- Department of Surgery, University of Toronto, Toronto, ON, Canada; Division of Vascular Surgery, St. Michael's Hospital, Unity Health Toronto, Toronto, ON, Canada; Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, ON, Canada; ICES, University of Toronto, Toronto, ON, Canada; Li Ka Shing Knowledge Institute, St. Michael's Hospital, Unity Health Toronto, Toronto, ON, Canada
| | - Muhammad Mamdani
- Institute of Medical Science, University of Toronto, Toronto, ON, Canada; Temerty Centre for Artificial Intelligence Research and Education in Medicine (T-CAIREM), University of Toronto, Toronto, ON, Canada; Data Science and Advanced Analytics Department, Unity Health Toronto, University of Toronto, Toronto, ON, Canada; Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, ON, Canada; ICES, University of Toronto, Toronto, ON, Canada; Li Ka Shing Knowledge Institute, St. Michael's Hospital, Unity Health Toronto, Toronto, ON, Canada; Leslie Dan Faculty of Pharmacy, University of Toronto, Toronto, ON, Canada
| | - Graham Roche-Nagle
- Department of Surgery, University of Toronto, Toronto, ON, Canada; Division of Vascular Surgery, Peter Munk Cardiac Centre, University Health Network, Toronto, ON, Canada
| | - Mohammed Al-Omran
- Department of Surgery, University of Toronto, Toronto, ON, Canada; Division of Vascular Surgery, St. Michael's Hospital, Unity Health Toronto, Toronto, ON, Canada; Institute of Medical Science, University of Toronto, Toronto, ON, Canada; Temerty Centre for Artificial Intelligence Research and Education in Medicine (T-CAIREM), University of Toronto, Toronto, ON, Canada; Li Ka Shing Knowledge Institute, St. Michael's Hospital, Unity Health Toronto, Toronto, ON, Canada; Department of Surgery, King Faisal Specialist Hospital and Research Center, Riyadh, Kingdom of Saudi Arabia.
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23
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Zarrintan S, Malas MB. What Is the Role of Transcarotid Artery Revascularization? Adv Surg 2023; 57:115-140. [PMID: 37536848 DOI: 10.1016/j.yasu.2023.04.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/05/2023]
Abstract
Carotid endarterectomy (CEA) is the gold-standard method of carotid revascularization in symptomatic patients with ≥50% and in asymptomatic patients with ≥70% stenosis. Transfemoral carotid artery stenting (TFCAS) has been associated with higher perioperative stroke rates compared to CEA in several studies. On the other hand, transcarotid artery revascularization (TCAR) has outperformed TFCAS in patients who are considered high risk for surgery. There is increasing data that supports TCAR as a safe and efficient technique with outcomes similar to those of CEA, but additional level-one studies are necessary to evaluate the long-term outcomes of TCAR in high- and standard-risk patients.
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Affiliation(s)
- Sina Zarrintan
- Department of Surgery, Division of Vascular and Endovascular Surgery, UC San Diego, San Diego, CA, USA; Center for Learning and Excellence in Vascular & Endovascular Research (CLEVER), UC San Diego, San Diego, CA, USA; Altman Center for Clinical and Translational Research, 9452 Medical Center Drive - LL2W 502A, La Jolla, CA 92037, USA
| | - Mahmoud B Malas
- Department of Surgery, Division of Vascular and Endovascular Surgery, UC San Diego, San Diego, CA, USA; Center for Learning and Excellence in Vascular & Endovascular Research (CLEVER), UC San Diego, San Diego, CA, USA; Altman Center for Clinical and Translational Research, 9452 Medical Center Drive - LL2W 502A, La Jolla, CA 92037, USA.
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24
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Clezar CN, Flumignan CD, Cassola N, Nakano LC, Trevisani VF, Flumignan RL. Pharmacological interventions for asymptomatic carotid stenosis. Cochrane Database Syst Rev 2023; 8:CD013573. [PMID: 37565307 PMCID: PMC10401652 DOI: 10.1002/14651858.cd013573.pub2] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 08/12/2023]
Abstract
BACKGROUND Carotid artery stenosis is narrowing of the carotid arteries. Asymptomatic carotid stenosis is when this narrowing occurs in people without a history or symptoms of this disease. It is caused by atherosclerosis; that is, the build-up of fats, cholesterol, and other substances in and on the artery walls. Atherosclerosis is more likely to occur in people with several risk factors, such as diabetes, hypertension, hyperlipidaemia, and smoking. As this damage can develop without symptoms, the first symptom can be a fatal or disabling stroke, known as ischaemic stroke. Carotid stenosis leading to ischaemic stroke is most common in men older than 70 years. Ischaemic stroke is a worldwide public health problem. OBJECTIVES To assess the effects of pharmacological interventions for the treatment of asymptomatic carotid stenosis in preventing neurological impairment, ipsilateral major or disabling stroke, death, major bleeding, and other outcomes. SEARCH METHODS We searched the Cochrane Stroke Group trials register, CENTRAL, MEDLINE, Embase, two other databases, and three trials registers from their inception to 9 August 2022. We also checked the reference lists of any relevant systematic reviews identified and contacted specialists in the field for additional references to trials. SELECTION CRITERIA We included all randomised controlled trials (RCTs), irrespective of publication status and language, comparing a pharmacological intervention to placebo, no treatment, or another pharmacological intervention for asymptomatic carotid stenosis. DATA COLLECTION AND ANALYSIS We used standard Cochrane methodological procedures. Two review authors independently extracted the data and assessed the risk of bias of the trials. A third author resolved disagreements when necessary. We assessed the evidence certainty for key outcomes using GRADE. MAIN RESULTS We included 34 RCTs with 11,571 participants. Data for meta-analysis were available from only 22 studies with 6887 participants. The mean follow-up period was 2.5 years. None of the 34 included studies assessed neurological impairment and quality of life. Antiplatelet agent (acetylsalicylic acid) versus placebo Acetylsalicylic acid (1 study, 372 participants) may result in little to no difference in ipsilateral major or disabling stroke (risk ratio (RR) 1.08, 95% confidence interval (CI) 0.47 to 2.47), stroke-related mortality (RR 1.40, 95% CI 0.54 to 3.59), progression of carotid stenosis (RR 1.16, 95% CI 0.79 to 1.71), and adverse events (RR 0.81, 95% CI 0.41 to 1.59), compared to placebo (all low-certainty evidence). The effect of acetylsalicylic acid on major bleeding is very uncertain (RR 0.98, 95% CI 0.06 to 15.53; very low-certainty evidence). The study did not measure neurological impairment or quality of life. Antihypertensive agents (metoprolol and chlorthalidone) versus placebo The antihypertensive agent, metoprolol, may result in no difference in ipsilateral major or disabling stroke (RR 0.14, 95% CI 0.02 to1.16; 1 study, 793 participants) and stroke-related mortality (RR 0.57, 95% CI 0.17 to 1.94; 1 study, 793 participants) compared to placebo (both low-certainty evidence). However, chlorthalidone may slow the progression of carotid stenosis (RR 0.45, 95% CI 0.23 to 0.91; 1 study, 129 participants; low-certainty evidence) compared to placebo. Neither study measured neurological impairment, major bleeding, adverse events, or quality of life. Anticoagulant agent (warfarin) versus placebo The evidence is very uncertain about the effects of warfarin (1 study, 919 participants) on major bleeding (RR 1.19, 95% CI 0.97 to 1.46; very low-certainty evidence), but it may reduce adverse events (RR 0.89, 95% CI 0.81 to 0.99; low-certainty evidence) compared to placebo. The study did not measure neurological impairment, ipsilateral major or disabling stroke, stroke-related mortality, progression of carotid stenosis, or quality of life. Lipid-lowering agents (atorvastatin, fluvastatin, lovastatin, pravastatin, probucol, and rosuvastatin) versus placebo or no treatment Lipid-lowering agents may result in little to no difference in ipsilateral major or disabling stroke (atorvastatin, lovastatin, pravastatin, and rosuvastatin; RR 0.36, 95% CI 0.09 to 1.53; 5 studies, 2235 participants) stroke-related mortality (lovastatin and pravastatin; RR 0.25, 95% CI 0.03 to 2.29; 2 studies, 1366 participants), and adverse events (fluvastatin, lovastatin, pravastatin, probucol, and rosuvastatin; RR 0.76, 95% CI 0.53 to1.10; 7 studies, 3726 participants) compared to placebo or no treatment (all low-certainty evidence). The studies did not measure neurological impairment, major bleeding, progression of carotid stenosis, or quality of life. AUTHORS' CONCLUSIONS Although there is no high-certainty evidence to support pharmacological intervention, this does not mean that pharmacological treatments are ineffective in preventing ischaemic cerebral events, morbidity, and mortality. High-quality RCTs are needed to better inform the best medical treatment that may reduce the burden of carotid stenosis. In the interim, clinicians will have to use other sources of information.
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Affiliation(s)
- Caroline Nb Clezar
- Department of Surgery, Division of Vascular and Endovascular Surgery, Universidade Federal de São Paulo, São Paulo, Brazil
| | - Carolina Dq Flumignan
- Department of Surgery, Division of Vascular and Endovascular Surgery, Universidade Federal de São Paulo, São Paulo, Brazil
| | - Nicolle Cassola
- Department of Surgery, Division of Vascular and Endovascular Surgery, Universidade Federal de São Paulo, São Paulo, Brazil
| | - Luis Cu Nakano
- Department of Surgery, Division of Vascular and Endovascular Surgery, Universidade Federal de São Paulo, São Paulo, Brazil
| | - Virginia Fm Trevisani
- Medicina de Urgência and Rheumatology, Escola Paulista de Medicina, Universidade Federal de São Paulo and Universidade de Santo Amaro, São Paulo, Brazil
| | - Ronald Lg Flumignan
- Department of Surgery, Division of Vascular and Endovascular Surgery, Universidade Federal de São Paulo, São Paulo, Brazil
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Steiger K, Fuentes A, Erben Y. Medical Management of Cardiovascular Disease. Surg Clin North Am 2023; 103:565-575. [PMID: 37455025 DOI: 10.1016/j.suc.2023.04.019] [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: 07/18/2023]
Abstract
We offer an overview of lipid lowering, antiplatelet, antihypertensive, and glucose-lowering therapies for vascular surgeons and their respective medical teams. Further reviews should offer additional guidance on smoking cessation, exercise therapy, and nutritional optimization.
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Affiliation(s)
- Kyle Steiger
- Department of Internal Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Ana Fuentes
- Division of Vascular and Endovascular Surgery, Mayo Clinic, Jacksonville, FL, USA
| | - Young Erben
- Division of Vascular and Endovascular Surgery, Mayo Clinic, Jacksonville, FL, USA.
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Li R, Zheng J, Zayed MA, Saffitz JE, Woodard PK, Jha AK. Carotid atherosclerotic plaque segmentation in multi-weighted MRI using a two-stage neural network: advantages of training with high-resolution imaging and histology. Front Cardiovasc Med 2023; 10:1127653. [PMID: 37293278 PMCID: PMC10244753 DOI: 10.3389/fcvm.2023.1127653] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2022] [Accepted: 04/27/2023] [Indexed: 06/10/2023] Open
Abstract
Introduction A reliable and automated method to segment and classify carotid artery atherosclerotic plaque components is needed to efficiently analyze multi-weighted magnetic resonance (MR) images to allow their integration into patient risk assessment for ischemic stroke. Certain plaque components such as lipid-rich necrotic core (LRNC) with hemorrhage suggest a greater likelihood of plaque rupture and stroke event. Assessment for presence and extent of LRNC could assist in directing treatment with impact upon patient outcomes. Methods To address the need to accurately determine the presence and extent of plaque components on carotid plaque MRI, we proposed a two-staged deep-learning-based approach that consists of a convolutional neural network (CNN), followed by a Bayesian neural network (BNN). The rationale for the two-stage network approach is to account for the class imbalance of vessel wall and background by providing an attention mask to the BNN. A unique feature of the network training was to use ground truth defined by both high-resolution ex vivo MRI data and histopathology. More specifically, standard resolution 1.5 T in vivo MR image sets with corresponding high resolution 3.0 T ex vivo MR image sets and histopathology image sets were used to define ground-truth segmentations. Of these, data from 7 patients was used for training and from the remaining two was used for testing the proposed method. Next, to evaluate the generalizability of the method, we tested the method with an additional standard resolution 3.0 T in vivo data set of 23 patients obtained from a different scanner. Results Our results show that the proposed method yielded accurate segmentation of carotid atherosclerotic plaque and outperforms not only manual segmentation by trained readers, who did not have access to the ex vivo or histopathology data, but also three state-of-the-art deep-learning-based segmentation methods. Further, the proposed approach outperformed a strategy where the ground truth was generated without access to the high resolution ex vivo MRI and histopathology. The accurate performance of this method was also observed in the additional 23-patient dataset from a different scanner. Conclusion In conclusion, the proposed method provides a mechanism to perform accurate segmentation of the carotid atherosclerotic plaque in multi-weighted MRI. Further, our study shows the advantages of using high-resolution imaging and histology to define ground truth for training deep-learning-based segmentation methods.
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Affiliation(s)
- Ran Li
- Mallinckrodt Institute of Radiology, Washington University in St. Louis, St. Louis, MO, United States
- Department of Biomedical Engineering, Washington University in St. Louis, St. Louis, MO, United States
| | - Jie Zheng
- Mallinckrodt Institute of Radiology, Washington University in St. Louis, St. Louis, MO, United States
- Department of Biomedical Engineering, Washington University in St. Louis, St. Louis, MO, United States
| | - Mohamed A. Zayed
- Department of Surgery, Washington University School of Medicine in St. Louis, St. Louis, MO, United States
| | - Jeffrey E. Saffitz
- Department of Pathology, Beth Israel Deaconess Medical Center, Boston, MA, United States
| | - Pamela K. Woodard
- Mallinckrodt Institute of Radiology, Washington University in St. Louis, St. Louis, MO, United States
- Department of Biomedical Engineering, Washington University in St. Louis, St. Louis, MO, United States
| | - Abhinav K. Jha
- Mallinckrodt Institute of Radiology, Washington University in St. Louis, St. Louis, MO, United States
- Department of Biomedical Engineering, Washington University in St. Louis, St. Louis, MO, United States
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Desantis C, Zacà S, Wiesel P, Mastrangelo G, Pulli R, Angiletta D. Sex-Related Outcomes in Asymptomatic Patients Undergoing Carotid Artery Stenting. J Endovasc Ther 2023:15266028231172356. [PMID: 37190763 DOI: 10.1177/15266028231172356] [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: 05/17/2023]
Abstract
PURPOSE Aim of the study was to evaluate the influence of sex in asymptomatic patients undergoing carotid artery stenting (CAS). MATERIALS AND METHODS A retrospective observational study was conducted from January 2006 to December 2020. A total of 438 consecutive patients with asymptomatic carotid artery stenosis >70% underwent transfemoral CAS and were stratified in males (M) and females (F). Periprocedural 30-day outcomes were: stroke, death, and myocardial infarction (MI). Follow-up outcomes were: death and stroke rates (primary) and freedom from restenosis (FFR) and reintervention rates (secondary). Follow-up data were analyzed at 1, 5, and 10 years. Data were analyzed with χ2 test and Fisher's exact test and follow-up outcomes with Kaplan-Meier curves. The log-rank test was used to determine differences between the groups and univariate analysis to identify the association between risk factors and intraoperative details with mortality and restenosis rates. RESULTS A total of 462 procedures were performed (M: n=321, 69.4%), in which 24 CAS were bilateral (5.5%). Mean age was 71.9±7.6 years (M: 72.1±7.8; F: 71.7±7.3). Periprocedural outcomes were: stroke rate 2.2% (n=10; M: n=5, 1.6%; F: n=5, 3.5%; p=0.176), mortality rate 0.6% (M: n=3, p=0.334), and stroke/death rate 2.8% (n=13; M: n=8, 2.5%; F: n=5, 3.5%; p=0.528); no cardiac events (MI) were recorded. A not-disabling (minor) stroke was detected in 3 males (0.9%), while a disabling (major) stroke was reported in 7 patients (1.7%) of whom 5 were ischemic events (M: n=2, 0.6%; F: n=3, 2.2%) and 2 were cerebral hemorrhages (F: 1.3%, p=0.046). Mean follow-up was 73.66±40.83 months (M: 72.66; F: 76.01; p=0.246). Overall survival rate was 96.1% (95% confidence interval [CI]: 93-98), 81.8% (95% CI: 77-86), and 45.5% (95% CI: 38-53) at 1, 5, and 10 years, respectively (p=0.236). The overall stroke rate was 0.3% (freedom from stroke [FFS]: 99.7%; 95% CI: 98-100), 0.9% (FFS: 99%; 95% CI: 98-100), and 4.3% (FFS: 95.7%; 95% CI: 89-98; M: n=6; F: n=2; p=0.774). Stroke-related mortality rate was 0.7% (FFS: 99.3%; 95% CI: 97-100) and 2.9% (FFS: 97.1%; 95% CI: 91-99) at 5 and 10 years, respectively, without differences between the groups (M: n=4; F: n=2; p=0.763). Overall FFR rate was 97.4% (95% CI: 95-99), 93.4% (95% CI: 90-96), and 89.5% (95% CI: 84-93; p=0.322). Two severe symptomatic restenosis (>70%, M) required a new endovascular revascularization. CONCLUSION The sex variable does not influence outcomes of CAS in asymptomatic patients at short- and long-term follow-up, although females show a worst incidence of periprocedural major strokes. Carotid artery stenting may be safely proposed when a careful patient selection is applied. CLINICAL IMPACT The sex variable has been advocated as a considerable factor that could influence the outcomes of transfemoral carotid artery stenting (CAS). Literature data are contrasting, even if different papers mainly reported that CAS is associated to worst outcomes in female patients. Our study shows that the sex-variable does not influence outcomes of CAS in asymptomatic patients at short and long-term follow-up, although females had a worst incidence of periprocedural major strokes. CAS may be safely proposed when a careful patient selection is applied.
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Affiliation(s)
- Claudio Desantis
- Vascular and Endovascular Surgery-Department of Emergency and Organs Transplantation, "Aldo Moro" University of Bari School of Medicine, Bari, Italy
| | - Sergio Zacà
- Vascular and Endovascular Surgery-Department of Emergency and Organs Transplantation, "Aldo Moro" University of Bari School of Medicine, Bari, Italy
| | - Paola Wiesel
- Vascular and Endovascular Surgery-Department of Emergency and Organs Transplantation, "Aldo Moro" University of Bari School of Medicine, Bari, Italy
| | - Giovanni Mastrangelo
- Vascular and Endovascular Surgery-Department of Emergency and Organs Transplantation, "Aldo Moro" University of Bari School of Medicine, Bari, Italy
| | - Raffaele Pulli
- Vascular and Endovascular Surgery-Department of Emergency and Organs Transplantation, "Aldo Moro" University of Bari School of Medicine, Bari, Italy
| | - Domenico Angiletta
- Vascular and Endovascular Surgery-Department of Emergency and Organs Transplantation, "Aldo Moro" University of Bari School of Medicine, Bari, Italy
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Nardi V, Benson JC, Saba L, Bois MC, Meyer FB, Lanzino G, Lerman LO, Lerman A. Patients with Carotid Intraplaque Hemorrhage Have Higher Incidence of Cerebral Microbleeds. Curr Probl Cardiol 2023:101779. [PMID: 37172877 DOI: 10.1016/j.cpcardiol.2023.101779] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2023] [Accepted: 05/07/2023] [Indexed: 05/15/2023]
Abstract
AIMS Carotid intraplaque hemorrhage (IPH) is considered a marker of plaque vulnerability. Cerebral microbleeds (CMBs) are recognized on magnetic resonance imaging (MRI) in patients with cerebrovascular disease. Any connection between carotid IPH and CMBs remains scantly investigated. This study aimed to determine whether the histologic evidence of carotid IPH is related to CMBs. METHODS We retrospectively enrolled 101 consecutive patients undergoing carotid endarterectomy with symptomatic (ischemic stroke, TIA, and amaurosis fugax) or asymptomatic ipsilateral carotid artery disease. The presence and the extent (%) of IPH were identified on carotid plaques stained with Movat Pentachrome. CMBs were localized on T2*-weighted gradient-recalled echo or susceptibility-weighted imaging sequence on brain MRI before surgery. The degree of carotid stenosis was measured by neck CTA. RESULTS IPH was identified in 57 (56.4%) patients, and CMBs were found in 24 (23.7%) patients. CMBs were more commonly observed in patients with carotid IPH compared to those without [19 (33.3%) vs 5 (11.4%); p=0.010]. The carotid IPH extent was significantly higher in patients with CMBs than in those without [9.0 % (2.8-27.1%) vs 0.9% (0.0-13.9%); p=0.004] and was associated with the number of CMBs (p=0.004). Logistic regression analysis demonstrated an independent association between carotid IPH extent and the presence of CMBs [OR 1.051 (95% CI 1.012-1.090); p=0.009]. Additionally, patients with CMBs had a lower degree of ipsilateral carotid stenosis compared to those without [40% (35-65%) vs 70% (50-80%); p=0.049]. CONCLUSIONS CMBs may be potential markers of the ongoing process of carotid IPH, especially in those with nonobstructive plaques.
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Affiliation(s)
- Valentina Nardi
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - John C Benson
- Department of Radiology, Mayo Clinic, Rochester, Minnesota, USA
| | - Luca Saba
- Department of Radiology, Mayo Clinic, Rochester, Minnesota, USA; Department of Radiology, University of Cagliari, Italy
| | - Melanie C Bois
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, Minnesota, USA
| | - Fredric B Meyer
- Department of Neurologic Surgery, Mayo Clinic, Rochester, Minnesota, USA
| | - Giuseppe Lanzino
- Department of Neurologic Surgery, Mayo Clinic, Rochester, Minnesota, USA
| | - Lilach O Lerman
- Department of Nephrology and Hypertension, Mayo Clinic, Rochester, Minnesota, USA
| | - Amir Lerman
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota, USA.
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Haywood NS, Ratcliffe SJ, Zheng X, Mao J, Farivar BS, Tracci MC, Malas MB, Goodney PP, Clouse WD. Operative and long-term outcomes of combined and staged carotid endarterectomy and coronary bypass. J Vasc Surg 2023; 77:1424-1433.e1. [PMID: 36681256 PMCID: PMC10353412 DOI: 10.1016/j.jvs.2023.01.015] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2022] [Revised: 12/31/2022] [Accepted: 01/10/2023] [Indexed: 01/19/2023]
Abstract
OBJECTIVE Optimal temporal surgical management of significant carotid stenosis and coronary artery disease remains unknown. Carotid endarterectomy (CEA) and coronary artery bypass (CABG) are performed concurrently (CCAB) or in a staged (CEA-CABG or CABG-CEA) approach. Using the Vascular Quality Initiative-Vascular Implant Surveillance and Interventional Outcomes Coordinated Registry Network-Medicare-linked dataset, this study compared operative and long-term outcomes after CCAB and staged approaches. METHODS The Vascular Quality Initiative-Vascular Implant Surveillance and Interventional Outcomes Coordinated Registry Network dataset was used to identify CEAs from 2011 to 2018 with combined CABG or CABG within 45 days preceding or after CEA. Patients were stratified based on concurrent or staged approach. Primary outcomes were stroke, myocardial infarction (MI), all-cause mortality, stroke and death as composite (SD) and all as composite within 30 days from the last procedure as well as in the long term. Univariate analysis and risk-adjusted analysis using inverse propensity weighting were performed. Kaplan-Meier curves of stroke, MI, and death were created and compared. RESULTS There were 1058 patients included: 643 CCAB and 415 staged (309 CEA-CABG and 106 CABG-CEA). Compared with staged patients, those undergoing CCAB had a higher preoperative rate of congestive heart failure (24.8% vs 18.4%; P = .01) and decreased renal function (14.9% vs 8.5%; P < .01), as well as fewer prior neurological events (23.5% vs 31.4%; P < .01). Patients undergoing CCAB had similar weighted rate of 30-day stroke (4.6% vs 4.1%; P = .72), death (7.0% vs 5.0%; P = .32), and composite outcomes (stroke and death, 9.8% vs 8.5%; P = .56; stroke, death, and MI, 14.7% vs 17.4%; P = .31), but a lower weighted rate of MI (5.5% vs 11.5%; P < .01) vs the staged cohort. Long-term adjusted risks of stroke (hazard ratio [HR], 0.85; 95% confidence interval [CI], 0.54-1.36; P = .51) and mortality (HR, 1.02; 95% CI, 0.76-1.36; P=.91) were similar between groups, but higher risk of MI long-term was seen in those staged (HR, 1.49; 95% CI, 1.07-2.08; P = .02). CONCLUSIONS In patients undergoing CCAB or staged open revascularization for carotid stenosis and coronary artery disease, the staged approach had an increased risk of postoperative cardiac event, but the short- and long-term rates of stroke and mortality seem to be comparable. Adverse cardiovascular event risk is high between operations when staged and should be a consideration when selecting an approach. Although factors leading to staged sequencing performance need further clarity, CCAB seems to be safe and should be considered an equally reasonable option.
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Affiliation(s)
- Nathan S Haywood
- Department of Vascular and Endovascular Surgery, University of Virginia, Charlottesville, VA
| | - Sarah J Ratcliffe
- Department of Biostatistics, University of Virginia, Charlottesville, VA
| | - Xinyan Zheng
- Population Health Sciences, Weill Cornell Medicine, New York, NY
| | - Jialin Mao
- Population Health Sciences, Weill Cornell Medicine, New York, NY
| | - Behzad S Farivar
- Department of Vascular and Endovascular Surgery, University of Virginia, Charlottesville, VA
| | - Margaret C Tracci
- Department of Vascular and Endovascular Surgery, University of Virginia, Charlottesville, VA
| | - Mahmoud B Malas
- Department of Vascular and Endovascular Surgery, University of California San Diego, San Diego, CA
| | - Philip P Goodney
- Department of Vascular and Endovascular Surgery, Dartmouth-Hitchcock Medical Center, Lebanon, NH
| | - W Darrin Clouse
- Department of Vascular and Endovascular Surgery, University of Virginia, Charlottesville, VA.
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van Uden RCAE, Bakker MA, Joosten SGL, Meijer K, van den Bemt PMLA, Becker ML, Vervloet M. Implementation of a Patient Questionnaire in Community Pharmacies to Improve Care for Patients Using Combined Antithrombotic Therapy: A Qualitative Study. PHARMACY 2023; 11:80. [PMID: 37218962 PMCID: PMC10204406 DOI: 10.3390/pharmacy11030080] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2023] [Revised: 04/12/2023] [Accepted: 04/24/2023] [Indexed: 05/24/2023] Open
Abstract
For several indications or combinations of indications the use of more than one antithrombotic agent is required. The duration of combined antithrombotic therapy depends on indication and patient characteristics. This study investigated the use of an antithrombotic questionnaire tool that had been developed for pharmacists to detect patients with possible incorrect combined antithrombotic therapy. The objective of this study was to identify potential barriers and facilitators that could influence the implementation of the developed antithrombotic questionnaire tool in daily community pharmacy practice. A qualitative study was conducted at 10 Dutch community pharmacies in which the antithrombotic questionnaire tool had been used with 82 patients. Semi-structured interviews were conducted with pharmacy staff who used the antithrombotic questionnaire tool. The interview questions to identify barriers and facilitators were based on the Consolidated Framework for Implementation Research. The interview data were analysed using a deductive thematic analysis. Ten staff members from nine different pharmacies were interviewed. Facilitators for implementation were that the questionnaire was easily adaptable and easy to use, as well as the relative short duration to administer the questionnaire. A possible barrier for using the questionnaire was a lower priority for using the questionnaire at moments when the workload was high. The pharmacists estimated that the questionnaire could be used for 70-80% of the patient population and they thought that it was a useful addition to regular medication surveillance. The antithrombotic questionnaire tool can be easily implemented in pharmacy practice. To implement the tool, the focus should be on integrating its use into daily activities. Pharmacists can use this tool in addition to regular medication surveillance to improve medication safety in patients who use combined antithrombotic therapy.
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Affiliation(s)
- Renate C. A. E. van Uden
- Pharmacy Foundation of Haarlem Hospitals, Boerhaavelaan 24, 2035 RC Haarlem, The Netherlands
- Department of Clinical Pharmacy, Spaarne Gasthuis Hospital, Boerhaavelaan 22, 2035 RC Haarlem, The Netherlands
- Department of Clinical Pharmacy and Pharmacology, University Medical Center Groningen, University of Groningen, P.O. Box 30.001, 9700 RB Groningen, The Netherlands
| | - Marit A. Bakker
- Pharmacy Foundation of Haarlem Hospitals, Boerhaavelaan 24, 2035 RC Haarlem, The Netherlands
| | - Stephan G. L. Joosten
- Community Pharmacy BENU Pharmacy Nieuwpoort, Jan van der Heydenweg 352, 3401 RJ IJsselstein, The Netherlands
| | - Karina Meijer
- Department of Haematology, University Medical Center Groningen, University of Groningen, P.O. Box 30.001, 9700 RB Groningen, The Netherlands
| | - Patricia M. L. A. van den Bemt
- Department of Clinical Pharmacy and Pharmacology, University Medical Center Groningen, University of Groningen, P.O. Box 30.001, 9700 RB Groningen, The Netherlands
| | - Matthijs L. Becker
- Pharmacy Foundation of Haarlem Hospitals, Boerhaavelaan 24, 2035 RC Haarlem, The Netherlands
- Department of Clinical Pharmacy, Spaarne Gasthuis Hospital, Boerhaavelaan 22, 2035 RC Haarlem, The Netherlands
| | - Marcia Vervloet
- Nivel, Netherlands Institute for Health Services Research, P.O. Box 1568, 3500 BN Utrecht, The Netherlands
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Squizzato F, Spertino A, Lupia M, Grego F, Gerosa G, Tarantini G, Piazza M, Antonello M. Prevalence, risk factors, and clinical effect of coronary artery disease in patients with asymptomatic bilateral carotid stenosis. J Vasc Surg 2023; 77:1182-1191.e1. [PMID: 36464015 DOI: 10.1016/j.jvs.2022.11.063] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2022] [Revised: 11/22/2022] [Accepted: 11/23/2022] [Indexed: 12/03/2022]
Abstract
OBJECTIVE In the present report, we have described the prevalence, risk factors, and clinical effects of coronary artery disease (CAD) for patients with asymptomatic bilateral carotid stenosis. METHODS We conducted a single-center, retrospective cohort study of consecutive patients referred for bilateral carotid stenosis >70% (2014-2021). All the patients had undergone systematic coronary angiography. Depending on the anatomic and clinical characteristics, the patients had undergone combined carotid endarterectomy (CEA) plus coronary artery bypass grafting, coronary percutaneous intervention followed by CEA or carotid artery stenting (CAS), or staged bilateral CEA with cardiac best medical therapy. The cumulative 30-day stroke/myocardial infarction (MI) rate after cardiac and bilateral carotid interventions and long-term survival and freedom from cardiovascular mortality were assessed. RESULTS A total of 167 patients with bilateral carotid stenosis >70% had undergone preoperative coronary angiography, identifying severe CAD in 108 patients (65.1%). Echocardiographic abnormalities (odds ratio [OR], 2.07; 95% confidence interval [CI], 1.03-5.78; P = .04) and prior coronary intervention (OR, 11.94; 95% CI, 2.99-63.81; P = .001) were significantly associated with severe CAD. CAD was treatable in 91 patients (84%) and untreatable in 17 (16%). The cumulative MI rate was 4.8%; 5.6% for the patients with severe CAD and 1.7% for those without severe CAD (P = .262). The cumulative stroke rate was 1.8%; 1.8% for those with severe CAD and 1.7% for those without severe CAD (P = 1.00). The overall stroke/MI rate was 6.6%; 8.3% for those with severe CAD and 3.3% for patients without severe CAD (P = .33). Patients with severe CAD deemed untreatable for coronary bypass or percutaneous intervention had a higher risk of perioperative stroke/MI (OR, 1.24; 95% CI, 1.00-2.83; P = .04). At 10 years, overall survival was 67.1% (95% CI, 57%-79%), and freedom from cardiovascular mortality was 78.5% (95% CI, 69%-89%). Patients with untreatable CAD maintained a higher risk of 10-year mortality (hazard ratio, 5.5; 95% CI, 1.6-19.9; P < .01). CONCLUSIONS In the present study, the prevalence of CAD in patients with bilateral carotid stenosis was high, especially for those with abnormal echocardiographic findings. CAD was potentially treatable in 80% of patients, and staged or simultaneous CAD treatment was performed with an acceptable stroke/MI complication rate for these patients. The presence of untreatable CAD was associated with worsened early and long-term outcomes, questioning the benefit of carotid interventions for this subset of patients.
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Affiliation(s)
- Francesco Squizzato
- Division of Vascular and Endovascular Surgery, Department of Cardiac, Thoracic, Vascular Sciences and Public Health, University of Padua, Padua, Italy.
| | - Andrea Spertino
- Division of Vascular and Endovascular Surgery, Department of Cardiac, Thoracic, Vascular Sciences and Public Health, University of Padua, Padua, Italy
| | - Mario Lupia
- Division of Vascular and Endovascular Surgery, Department of Cardiac, Thoracic, Vascular Sciences and Public Health, University of Padua, Padua, Italy
| | - Franco Grego
- Division of Vascular and Endovascular Surgery, Department of Cardiac, Thoracic, Vascular Sciences and Public Health, University of Padua, Padua, Italy
| | - Gino Gerosa
- Division of Cardiac Surgery, Department of Cardiac, Thoracic, Vascular Sciences and Public Health, University of Padua, Padua, Italy
| | - Giuseppe Tarantini
- Interventional Cardiology Unit, Division of Cardiology, Department of Cardiac, Thoracic, Vascular Sciences and Public Health, University of Padua, Padua, Italy
| | - Michele Piazza
- Division of Vascular and Endovascular Surgery, Department of Cardiac, Thoracic, Vascular Sciences and Public Health, University of Padua, Padua, Italy
| | - Michele Antonello
- Division of Vascular and Endovascular Surgery, Department of Cardiac, Thoracic, Vascular Sciences and Public Health, University of Padua, Padua, Italy
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Speranza G, Harish K, Rockman C, Gordon R, Sadek M, Jacobowitz G, Chang H, Garg K, Maldonado TS. The Natural History of Carotid Artery Occlusions Diagnosed on Duplex Ultrasound. Ann Vasc Surg 2023; 91:1-9. [PMID: 36574830 DOI: 10.1016/j.avsg.2022.11.030] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2022] [Revised: 11/07/2022] [Accepted: 11/28/2022] [Indexed: 12/26/2022]
Abstract
BACKGROUND There is a paucity of literature on the natural history of extracranial carotid artery occlusion (CAO). This study reviews the natural history of this patient cohort. METHODS This single-institution retrospective analysis studied patients with CAO diagnosed by duplex ultrasound between 2010 and 2021. Patients were identified by searching our office-based Intersocietal Accreditation Commission accredited vascular laboratory database. Imaging and clinical data were obtained via our institutional electronic medical record. Outcomes of interest included ipsilateral stroke, attributable neurologic symptoms, and ipsilateral intervention after diagnosis. RESULTS The full duplex database consisted of 5,523 patients who underwent carotid artery duplex examination during the study period. The CAO cohort consisted of 139 patients; incidence of CAO was 2.5%. Mean age at diagnosis was 69.7 years; 31.4% were female. Hypertension (72.7%), hyperlipidemia (64.7%), and prior smoking (43.9%) were the most common comorbid conditions. Of the CAO cohort, 61.3% (n = 85) of patients were asymptomatic at diagnosis; 38.8% (n = 54) were diagnosed after a stroke or transient ischemic attack occurring within 6 months prior to diagnosis, with 21.6% occurring ipsilateral to the CAO and 10.1% occurring contralateral to the CAO. 7.2% (n = 10) had unclear symptoms or laterality at presentation. Of the CAO cohort, 95 patients (68.3%) had duplex imaging follow-up (mean 42.7 ± 31.3 months). Of those with follow-up studies, 7 patients (5.0%) developed subsequent stroke ipsilateral to the CAO with mean occurrence 27.8 ± 39.0 months postdiagnosis. In addition, 5 patients (3.6%) developed other related symptoms, including global hypoperfusion (2.4%) and transient ischemic attack (1.2%). Of those, 95 patients with follow-up duplex ultrasound imaging, 6 (4.3%) underwent eventual ipsilateral intervention, including carotid endarterectomy (n = 4), transfemoral carotid artery stent (n = 1), and carotid bypass (n = 1), with mean occurrence 17.7 ± 23.7 months postdiagnosis. The aggregate rate of ipsilateral cerebrovascular accident, attributable neurologic symptoms, or ipsilateral intervention was 11.5%. Of 95 patients with follow-up duplex ultrasound imaging, 5 underwent subsequent duplex studies demonstrating ipsilateral patency, resulting in a 5.3% discrepancy rate between sequential duplex studies. All 6 patients undergoing intervention received periprocedural cross-sectional imaging (magnetic resonance angiography or computed tomography angiography). In 5 of these 6 patients, cross-sectional demonstrated severe stenosis rather than CAO, disputing prior duplex ultrasound findings. CONCLUSIONS In this large, institutional cohort of patients with a CAO diagnosis on duplex ultrasound, a clinically meaningful subset of patients experienced cerebrovascular accident, related symptoms, or intervention. We also found a notable rate of temporal duplex discrepancies among patients with CAO diagnoses and discrepancies between CAO diagnosis per duplex ultrasound and findings on cross-sectional imaging for those patients who underwent intervention. These results suggest that use of a single duplex ultrasound as a sole diagnostic tool in CAO may not be sufficient and that physicians should consider close duplex ultrasound surveillance of these patients, potentially in conjunction with additional confirmatory imaging modalities. Further investigation into optimal workup and surveillance protocols for CAO is needed.
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Affiliation(s)
| | - Keerthi Harish
- New York University Grossman School of Medicine, New York, NY
| | - Caron Rockman
- New York University Grossman School of Medicine, New York, NY
| | - Ryan Gordon
- Department of General Surgery, ChristianaCare, Wilmington, DE
| | - Mikel Sadek
- New York University Grossman School of Medicine, New York, NY
| | | | - Heepeel Chang
- Division of Vascular and Endovascular Surgery, Department of Surgery, Westchester Medical Center, New York Medical College, Valhalla, NY
| | - Karan Garg
- Division of Vascular Surgery, Department of Surgery, New York University Langone Health, New York, NY
| | - Thomas S Maldonado
- Division of Vascular Surgery, Department of Surgery, New York University Langone Health, New York, NY.
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Shahat M, Cieri E, Rocha-Neves J, Sa K. Carotid stenting: Does stent design matter? Vascular 2023:17085381231160957. [PMID: 36867405 DOI: 10.1177/17085381231160957] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/04/2023]
Abstract
BACKGROUND Carotid artery stenting (CAS) is considered an important tool in carotid revascularization. Carotid artery stenting is usually performed by using self-expandable stent with different designs. The stent design influences many physical characteristics. Also, it may affect the complication rate with special relevance to perioperative stroke, hemodynamic instability, and late restenosis. METHODS This study comprised all consecutive patients who underwent carotid artery stenting for atherosclerotic carotid stenosis from March 2014 to May 2021. Both symptomatic patient and asymptomatic patients were included. Patients with a symptomatic carotid stenosis of ≥50% or asymptomatic carotid stenosis of ≥60% were selected for carotid artery stenting . Patients with fibromuscular dysplasia and acute or unstable plaque were not included. Variables of clinical relevance were tested in multivariable analysis using binary logistic regression model. RESULTS A total of 728 patients were enrolled. The majority of this cohort was asymptomatic (578/728, 79.4%), while 150/728 (20.6%) were symptomatic. The mean degree of carotid stenosis was 77.82 ± 4.73%, with a mean plaque length of 1.76 ± 0.55 cm. A total of 277 (38%) patients were treated with Xact® Carotid Stent System. Successful carotid artery stenting was achieved in 698 (96%) of patients. Of these patients, stroke rate in symptomatic patients was nine (5.8%), while in asymptomatic patients was 20 (3.4%). In a multivariable analysis, the open-cell carotid stent was not associated with a differential risk for combined acute and sub-acute neurologic complications as compared with closed-cell stents. Patients treated with open cell stents had a significantly lower rate of procedural hypotension (P 0.0188) at bivariate analysis. CONCLUSION Carotid artery stenting is considered a safe alternative to CEA that can be used in selected average surgical risk patient. Different stent designs can affect the rate of major adverse events in carotid artery stenting patients, but further studies are necessary with avoiding different bias to study the effect of different stent designs.
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Affiliation(s)
- Mohamed Shahat
- Department of Vascular and Endovascular Surgery, 68866Assiut University Hospital, Assiut University, Assiut, Egypt
| | - Enrico Cieri
- 9309Vascular and endovascular surgery unit university of Perugia, ospedale S.Maria della Misericordia, Perugia, Italy
| | - Joao Rocha-Neves
- Department of Biomedicine - Unit of Anatomy, 68797Faculdade de Medicina da Universidade do Porto, Portugal
| | - Khairy Sa
- Department of Vascular and Endovascular Surgery, 68866Assiut University Hospital, Assiut University, Assiut, Egypt
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Arrese I, Cepeda S, García-García S, Sarabia R. Posterior cervical triangle approach for carotid endarterectomy: Technical note and results. NEUROCIRUGIA (ENGLISH EDITION) 2023; 34:75-79. [PMID: 36754755 DOI: 10.1016/j.neucie.2022.11.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/04/2021] [Accepted: 01/25/2022] [Indexed: 06/18/2023]
Abstract
INTRODUCTION Carotid endarterectomy (CEA) is usually performed using the anterior cervical triangle as a surgical corridor but, when needed, the retromandibular space makes dissection of higher structures difficult in some cases. The posterior cervical triangle (PCT) can be useful in these demanding cases. METHODS We retrospectively reviewed cases from July 2013 to November 2019 in which PCT was used as an approach for CEA. The surgical technique used was explained, and the complications and evolution of the patients were analysed. RESULTS We found 7 CEAs performed through this approach, of which 2 presented transient trapezius paresis. There were no cases of severe complications in this series. CONCLUSION The PCT approach for performing CEA represents a useful and easy technique that avoids the need for mandibular mobilisation or osteotomies for lesions located in anatomically high carotid bifurcations.
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Affiliation(s)
- Ignacio Arrese
- Unit of Vascular Neurosurgery, Hospital Universitario Río Hortega, Valladolid, Spain.
| | - Santiago Cepeda
- Unit of Vascular Neurosurgery, Hospital Universitario Río Hortega, Valladolid, Spain
| | - Sergio García-García
- Unit of Vascular Neurosurgery, Hospital Universitario Río Hortega, Valladolid, Spain
| | - Rosario Sarabia
- Unit of Vascular Neurosurgery, Hospital Universitario Río Hortega, Valladolid, Spain
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Bose S, Stonko DP, Pappas GM, Drudi LM, Stoner MC, Hicks CW. Females are less likely to receive best medical therapy for stroke prevention before and after carotid revascularization than males. J Vasc Surg 2023; 77:786-794.e2. [PMID: 36241125 PMCID: PMC9974567 DOI: 10.1016/j.jvs.2022.09.028] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2022] [Revised: 09/21/2022] [Accepted: 09/30/2022] [Indexed: 11/06/2022]
Abstract
BACKGROUND Current professional guidelines recommend best medical therapy (BMT) with statin agents and antiplatelet therapy for primary and secondary stroke prevention in patients with carotid artery stenosis. We aimed to assess the association of patient sex with preoperative BMT in patients undergoing carotid revascularization. METHODS We performed a retrospective review of Vascular Quality Initiative patients who underwent carotid endarterectomy or carotid artery stenting between January 2003 and February 2022. Multivariable logistic regression models were used to assess the association of patient sex with preoperative BMT after adjusting for sociodemographic, comorbidity, and disease severity characteristics. In-hospital outcomes were assessed by sex and preoperative BMT status. RESULTS Of 214,008 patients who underwent carotid revascularization, 38.7% (n = 82,855) were female and 61.3% (n = 131,153) were male. Overall, 77.2% (n = 63,922) of females were on preoperative BMT, compared with 80.4% (n = 105,375) of males (P < .001). After adjusting for baseline differences, females had 11% lower odds of being on BMT compared with males (adjusted odds ratio, 0.89; 95% confidence interval, 0.86-0.91). Postoperatively, females had 18% lower odds of being prescribed BMT than males (adjusted odds ratio, 0.82; 95% confidence interval, 0.79-0.84). In-hospital stroke (1.20% vs 1.51%), death (0.37% vs 0.66%), and stroke/death (1.46% vs 1.98%) were all significantly lower for patients on BMT (all P < .001). CONCLUSIONS There is a significant discrepancy in the proportion of females versus males receiving preoperative BMT for stroke prevention before carotid artery revascularization. In-hospital outcomes are worse in patients without BMT, highlighting the importance of raising awareness and implementing targeted interventions to improve preoperative adherence to stroke prevention guidelines.
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Affiliation(s)
- Sanuja Bose
- Division of Vascular Surgery and Endovascular Therapy, Department of Surgery, The Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - David P. Stonko
- Department of Surgery, The Johns Hopkins Hospital, Baltimore, MD, USA
| | - Georgina M. Pappas
- Division of Vascular Surgery, Department of Surgery, University of Rochester Medical Center, Rochester, NY, USA
| | - Laura M. Drudi
- Division of Vascular Surgery, Department of Surgery, Centre Hospitalier de l’Université de Montréal, Montreal, Québec, Canada
| | - Michael C. Stoner
- Division of Vascular Surgery, Department of Surgery, University of Rochester Medical Center, Rochester, NY, USA
| | - Caitlin W. Hicks
- Division of Vascular Surgery and Endovascular Therapy, Department of Surgery, The Johns Hopkins University School of Medicine, Baltimore, MD, USA
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Baek JH. Carotid Artery Stenting for Asymptomatic Carotid Stenosis: What We Need to Know for Treatment Decision. Neurointervention 2023; 18:9-22. [PMID: 36809873 PMCID: PMC9986346 DOI: 10.5469/neuroint.2023.00031] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2023] [Accepted: 02/05/2023] [Indexed: 02/24/2023] Open
Abstract
A clinical decision on the treatment of asymptomatic carotid stenosis is challenging, unlike symptomatic carotid stenosis. Carotid artery stenting (CAS) has been recommended as an alternative to carotid endarterectomy (CEA) based on the finding that the efficacy and safety of CAS were comparable to CEA in randomized trials. However, in some countries, CAS is often performed more frequently than CEA for asymptomatic carotid stenosis. Moreover, it has been recently reported that CAS is not superior to the best medical treatment in asymptomatic carotid stenosis. Due to these recent changes, the role of CAS in asymptomatic carotid stenosis should be revisited. When determining the treatment for asymptomatic carotid stenosis, one should consider several clinical factors including stenosis degree, patient life expectancy, stroke risk by medical treatment, availability of a vascular surgeon, high risk for CEA or CAS, and insurance coverage. This review aimed to present and pragmatically organize the information that is necessary for a clinical decision on CAS in asymptomatic carotid stenosis. In conclusion, although the traditional benefit of CAS is being revisited recently, it seems too early to conclude that CAS is no longer beneficial under intense and systemic medical treatment. Instead, a treatment strategy with CAS should evolve to select eligible or medically high-risk patients more precisely.
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Affiliation(s)
- Jang-Hyun Baek
- Department of Neurology, Kangbuk Samsung Hospital, Sungkyunkwan University School of Medicine, Seoul, Korea
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Wang SX, Marcaccio CL, Patel PB, Giles KA, Soden PA, Schermerhorn ML, Liang P. Distal embolic protection use during transfemoral carotid artery stenting is associated with improved in-hospital outcomes. J Vasc Surg 2023; 77:1710-1719.e6. [PMID: 36796592 DOI: 10.1016/j.jvs.2023.01.210] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2022] [Revised: 01/29/2023] [Accepted: 01/30/2023] [Indexed: 02/16/2023]
Abstract
OBJECTIVE Despite current guidelines recommending the use of distal embolic protection during transfemoral carotid artery stenting (tfCAS) to prevent periprocedural stroke, there remains significant variation in the routine use of distal filters. We sought to assess in-hospital outcomes in patients undergoing tfCAS with and without embolic protection using a distal filter. METHODS We identified all patients undergoing tfCAS in the Vascular Quality Initiative from March 2005 to December 2021 and excluded those who received proximal embolic balloon protection. We created propensity score-matched cohorts of patients who underwent tfCAS with and without attempted placement of a distal filter. Subgroup analyses of patients with failed vs successful filter placement and failed vs no attempt at filter placement were performed. In-hospital outcomes were assessed using log binomial regression, adjusted for protamine use. Outcomes of interest were composite stroke/death, stroke, death, myocardial infarction (MI), transient ischemic attack (TIA), and hyperperfusion syndrome. RESULTS Among 29,853 patients who underwent tfCAS, 28,213 (95%) had a filter attempted for distal embolic protection and 1640 (5%) did not. After matching, 6859 patients were identified. No attempted filter was associated with significantly higher risk of in-hospital stroke/death (6.4% vs 3.8%; adjusted relative risk [aRR], 1.72; 95% confidence interval [CI], 1.32-2.23; P < .001), stroke (3.7% vs 2.5%; aRR, 1.49; 95% CI, 1.06-2.08; P = .022), and mortality (3.5% vs 1.7%; aRR, 2.07; 95% CI, 1.42-3.020; P < .001). In a secondary analysis of patients who had failed attempt at filter placement vs successful filter placement, failed filter placement was associated with worse outcomes (stroke/death: 5.8% vs 2.7%; aRR, 2.10; 95% CI, 1.38-3.21; P = .001 and stroke: 5.3% vs 1.8%; aRR, 2.87; 95% CI, 1.78-4.61; P < .001). However, there were no differences in outcomes in patients with failed vs no attempted filter placement (stroke/death: 5.4% vs 6.2%; aRR, 0.99; 95% CI, 0.61-1.63; P = .99; stroke: 4.7% vs 3.7%; aRR, 1.40; 95% CI, 0.79-2.48; P = .20; death: 0.9% vs 3.4%; aRR, 0.35; 95% CI, 0.12-1.01; P = .052). CONCLUSIONS tfCAS performed without attempted distal embolic protection was associated with a significantly higher risk of in-hospital stroke and death. Patients undergoing tfCAS after failed attempt at filter placement have equivalent stroke/death to patients in whom no filter was attempted, but more than a two-fold higher risk of stroke/death compared with those with successfully placed filters. These findings support current Society for Vascular Surgery guidelines recommending routine use of distal embolic protection during tfCAS. If a filter cannot be placed safely, an alternative approach to carotid revascularization should be considered.
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Affiliation(s)
- Sophie X Wang
- Department of Surgery, Division of Vascular and Endovascular Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA
| | - Christina L Marcaccio
- Department of Surgery, Division of Vascular and Endovascular Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA
| | - Priya B Patel
- Department of Surgery, Division of Vascular and Endovascular Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA
| | - Kristina A Giles
- Department of Surgery, Division of Vascular Surgery, Maine Medical Center, Portland, ME
| | - Peter A Soden
- Department of Surgery, Division of Vascular Surgery, Brown University, Providence, RI
| | - Marc L Schermerhorn
- Department of Surgery, Division of Vascular and Endovascular Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA
| | - Patric Liang
- Department of Surgery, Division of Vascular and Endovascular Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA.
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Ucci A, de Troia A, D'Ospina RM, Pedrazzi G, Nabulsi B, Azzarone M, Perini P, Massoni CB, Rossi G, Freyrie A. Carotid endarterectomy in asymptomatic octogenarians: Outcomes at 30 days and 5 years. Vascular 2023; 31:98-106. [PMID: 34923864 DOI: 10.1177/17085381211056434] [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: 11/15/2022]
Abstract
BACKGROUND The following study investigated the 30-day and 5-year relative survival rate and freedom from neurological events in asymptomatic carotid stenosis (ACS) octogenarians who had undergone elective carotid endarterectomy (CEA). METHODS Between January 2008 and June 2014, a retrospective review was conducted on ACS patients who had undergone elective CEA. The patients' sample was divided into two groups: Group A (GA) included octogenarians and Group B (GB) included younger patients. The GA patients were subjected to a risk-scoring system and follow-up. The two groups were compared analysing the following primary endpoints: 30-day mortality, stroke, stroke/death and acute myocardial infarction (AMI); GA patients' survival rate and freedom from neurological events at 5 years. The 30-day secondary endpoints included carotid shunting, redo surgical, need for general anaesthesia with preserved consciousness (GAPC) conversion and length of hospital stay. RESULTS We identified 620 patients with ACS, of them 144 (23.2%) belonged to the GA and 476 (76.8%) belonged to the GB. No statistical difference between the two groups was found regarding the primary and secondary endpoints. One hundred nineteen of 144 GA patients (82.6%) underwent the follow-up; the median follow-up was 78.3 months. The GA patients' 5-year survival rate was 62%, while freedom from cerebral events was 94.9%. Analysis regarding GA patients' 5-year survival rate revealed a significantly lower percentage among the patients with a severe risk score compared with those with a moderate risk score (respectively, 29.5% vs 67.7%; p = .005). The multivariate analysis showed that chronic obstructive pulmonary disease (COPD) and chronic kidney disease (CKD) were independently associated with lower survival. CONCLUSIONS The 30-day outcomes of CEA in octogenarians are comparable to those in younger patients. Comprehensive life expectancy and preoperative score, rather than age alone, should be taken into account before performing CEA on octogenarian patients, considering the short- and long-term efficacy in stroke prevention.
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Affiliation(s)
- Alessandro Ucci
- Department of Medicine and Surgery, 9370University of Parma, Parma, Italy
| | - Alessandro de Troia
- Department of Medicine and Surgery, 9370University of Parma, Parma, Italy.,Department Cardio Thoracic and Vascular Surgery, Unit of Vascular Surgery, 18630University Hospital of Parma
| | | | - Giuseppe Pedrazzi
- Department of Medicine and Surgery, 9370University of Parma, Parma, Italy
| | - Bilal Nabulsi
- Department Cardio Thoracic and Vascular Surgery, Unit of Vascular Surgery, 18630University Hospital of Parma
| | - Matteo Azzarone
- Department of Medicine and Surgery, 9370University of Parma, Parma, Italy.,Department Cardio Thoracic and Vascular Surgery, Unit of Vascular Surgery, 18630University Hospital of Parma
| | - Paolo Perini
- Department Cardio Thoracic and Vascular Surgery, Unit of Vascular Surgery, 18630University Hospital of Parma
| | - Claudio Bianchini Massoni
- Department Cardio Thoracic and Vascular Surgery, Unit of Vascular Surgery, 18630University Hospital of Parma
| | - Giulia Rossi
- Department Cardio Thoracic and Vascular Surgery, Unit of Vascular Surgery, 18630University Hospital of Parma
| | - Antonio Freyrie
- Department of Medicine and Surgery, 9370University of Parma, Parma, Italy.,Department Cardio Thoracic and Vascular Surgery, Unit of Vascular Surgery, 18630University Hospital of Parma
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Riese N, Smart Y, Bailey M. Asymptomatic retinal emboli and current practice guidelines: a review. Clin Exp Optom 2023; 106:4-9. [PMID: 35109784 DOI: 10.1080/08164622.2022.2033600] [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: 01/13/2023] Open
Abstract
Asymptomatic retinal emboli are found in 1-3% of patients on routine fundus examination. As the use of teleretinal imaging for diabetic patients and ocular photography continues to increase, the number of asymptomatic retinal emboli found will also increase. This article will discuss the different aetiologies of retinal emboli and will present an overview of the recommended referrals for further systemic testing and treatment. It is important to communicate well with the primary care physician when asymptomatic retinal emboli are detected to ensure the appropriate investigations are undertaken.
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Affiliation(s)
- Nicole Riese
- Department of Optometry, VA New Jersey Healthcare System, Brick, NJ, USA
| | - Yelena Smart
- Department of Optometry, VA New Jersey Healthcare System, Brick, NJ, USA
| | - Melissa Bailey
- Department of Neurology, University of Miami, Miami, FL, USA
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Siddiqui NA, Pirzada A, Badini S, Shaikh FA. Role of Simulated Training for Carotid Endarterectomy: A Systematic Review. Ann Vasc Dis 2022; 15:253-259. [PMID: 36644270 PMCID: PMC9816038 DOI: 10.3400/avd.ra.22-00021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2022] [Accepted: 08/22/2022] [Indexed: 11/05/2022] Open
Abstract
Vascular surgery trainees often do not get to perform carotid endarterectomy (CEA) directly on the patients as it requires meticulous surgical technique and has a high risk of procedure-related complications. Hence, the role of simulation in training future vascular surgeons becomes essential. This review aims to assess the types and utility of simulators available for CEA. In this systematic review, all the studies performed on CEA simulation were included. The purpose of this review was to assess different types of simulators and their usefulness for CEA. We identified 122 articles, of which 10 were eligible for review. A variety of simulators, ranging from animal models, virtual reality simulators and commercially designed models with high fidelity options were used. Technical competence was the major domain assessed in the majority of the studies (n=8), whereas four studies evaluated anatomical and procedural knowledge. Blinding was done in five studies for assessment purposes. The majority of studies (n=9) found the simulation to be an effective tool for achieving technical competence. This review shows the potential usefulness of simulation in acquiring technical skills and procedural acumen for CEA. The available literature is unfortunately too diverse to have a common recommendation.
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Affiliation(s)
- Nadeem A. Siddiqui
- Section of Vascular Surgery, Department of Surgery, Aga Khan University Hospital, Karachi, Pakistan
| | - Ammar Pirzada
- Section of Vascular Surgery, Department of Surgery, Aga Khan University Hospital, Karachi, Pakistan
| | - Shoaib Badini
- Section of Vascular Surgery, Department of Surgery, Aga Khan University Hospital, Karachi, Pakistan
| | - Fareed A. Shaikh
- Section of Vascular Surgery, Department of Surgery, Aga Khan University Hospital, Karachi, Pakistan,Corresponding author: Fareed A. Shaikh, MBBS, MRCSEd, FCPS-GS, FCPS-Vascular Surgery. Cardiothoracic and Vascular offices, Link Building, Section of Vascular Surgery, Department of Surgery, Aga Khan University Hospital, 74800, Stadium road, Karachi, Pakistan Tel: +92-3218110155, Fax: +92-21-34934294, E-mail:
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Qumsiyeh Y, O'Banion LA, Dirks R, Ali A, Daneshvar M, Siada S. Primary arterial closure after carotid endarterectomy is a safe and expeditious technique in appropriately selected patients. Am J Surg 2022; 224:1438-1441. [PMID: 36241481 DOI: 10.1016/j.amjsurg.2022.10.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2022] [Revised: 09/17/2022] [Accepted: 10/05/2022] [Indexed: 12/14/2022]
Abstract
BACKGROUND Carotid endarterectomy (CEA) remains a safe and durable operation for both symptomatic and asymptomatic carotid stenosis, however conflicting evidence exists on the benefit of patch angioplasty and its effects on post-operative outcomes. METHODS A retrospective review of all patients undergoing CEA from 2011 to 2018 was performed. RESULTS Of 851 patients, primary closure was performed in 277 (33%). Patients with primary closure were older (74 vs 72, p = 0.001), symptomatic (39% vs 34%, p = 0.024), and male (69% vs 31% p < 0.001), with a higher incidence of diabetes mellitus (47% vs 39%, p = 0.046) and ESRD (4% vs 2%, p = 0.015). Restenosis rates were similar (7% vs 8%, p = 0.67). Operative time was shorter for primary closure (87 ± 28 vs 102 ± 26 min, p < 0.001). There were no differences in 30-day ipsilateral stroke rates (1% vs 1%, p = 0.51) or stroke-free survival. CONCLUSIONS Primary arterial closure is safe and expeditious in appropriately selected high-risk patients.
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Affiliation(s)
- Yazen Qumsiyeh
- Department of Surgery, University of California San Francisco, Fresno, CA, USA.
| | - Leigh Ann O'Banion
- Department of Surgery, University of California San Francisco, Fresno, CA, USA
| | - Rachel Dirks
- Department of Surgery, University of California San Francisco, Fresno, CA, USA
| | - Amna Ali
- Department of Surgery, University of California San Francisco, Fresno, CA, USA
| | - Meelod Daneshvar
- Department of Surgery, University of California San Francisco, Fresno, CA, USA
| | - Sammy Siada
- Department of Surgery, University of California San Francisco, Fresno, CA, USA
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Keegan A, Hicks CW. Surgical Decision-Making and Outcomes in Open Versus Endovascular Repair for Various Vascular Diseases. Anesthesiol Clin 2022; 40:627-644. [PMID: 36328619 PMCID: PMC9833286 DOI: 10.1016/j.anclin.2022.08.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Today's vascular surgeon must navigate their practice through a field of ever-advancing technology while maintaining knowledge of open techniques that remain equally important in the care of their patients. In this article, the authors provide insight into the perioperative decision-making that goes into choosing a surgical plan for each patient based on their disease process, anatomy, nonmodifiable risk factors, and other comorbidities.
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Affiliation(s)
- Alana Keegan
- General Surgery, Sinai Hospital of Baltimore, 2435 West Belvedere Avenue, Suite 42, Baltimore, MD 21215, USA
| | - Caitlin W Hicks
- Division of Vascular Surgery and Endovascular Therapy, Johns Hopkins School of Medicine, 600 North Wolfe Street, Halsted 668, Baltimore, MD 21287, USA.
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Franchin M, Dorigo W, Benussi S, Speziali S, Pulli R, Bonardelli S, Bashir M, Piffaretti G. Predicting early mortality following single-stage coronary artery or valve surgery and carotid endarterectomy. J Card Surg 2022; 37:4692-4697. [PMID: 36349716 DOI: 10.1111/jocs.17138] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2022] [Accepted: 10/10/2022] [Indexed: 11/11/2022]
Abstract
BACKGROUND Surgical management of coexisting cardiac disease and extra-cranial carotid artery disease is a controversial area of debate. Thus, in this challenging scenario, risk stratification may play a key role in surgical decision making. AIM To report the results of single-stage coronary/valve surgery (CVS) and carotid endarterectomy (CEA), and to identify predictive factors associated with 30-day mortality. METHODS This was a multicenter, retrospective study of prospectively maintained data from three academic tertiary referral hospitals. For this study, only patients treated with single-stage CVS, meaning coronary artery bypass surgery or valve surgery, and CEA between March 1, 2000 and March 30, 2020, were included. Primary outcome measure of interest was 30-day mortality. Secondary outcomes were neurologic events rate, and a composite endpoint of postoperative stroke/death rate. RESULTS During the study period, there were 386 patients who underwent the following procedures: CEA with isolated coronary artery bypass graft in 243 (63%) cases, with isolated valve surgery in 40 (10.4%), and combination of coronary artery bypass grafting and valve surgery in 103 (26.7%). Postoperative neurologic event rate was 2.6% (n = 10) which includes 5 (1.3%) transient ischemic attacks and 5 (1.3%) strokes (major n = 3, minor n = 2). The 30-day mortality rate was 3.9% (n = 15). Predictors of 30-day mortality included preoperative left heart insufficiency (odds ratio [OR]: 5.44, 95% confidence interval [CI]: 1.63-18.17, p = .006), and postoperative stroke (OR: 197.11, 95% CI: 18.28-2124.93, p < .001). No predictor for postoperative stroke and for composite endpoint was identified. CONCLUSIONS Considering that postoperative stroke rate and mortality was acceptably low, single-stage approach is an effective option in such selected high-risk patients.
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Affiliation(s)
- Marco Franchin
- Department of CardioThoracic and Vascular Surgery, ASST Settelaghi Universitary Teaching Hospital, Varese, Italy
| | - Walter Dorigo
- CardioThoracic and Vascular Surgery, Vascular Surgery, Careggi University Teaching Hospital, University of Florence School of Medicine, Florence, Italy
| | - Stefano Benussi
- Vascular Surgery, Department of Sperimental and Clinical Sciences, University of Brescia School of Medicine, Spedali Civili Hospital, Varese, Italy.,Cardiac Surgery, Department of Sperimental and Clinical Sciences, University of Brescia School of Medicine, Spedali Civili Hospital, Varese, Italy
| | - Sara Speziali
- CardioThoracic and Vascular Surgery, Vascular Surgery, Careggi University Teaching Hospital, University of Florence School of Medicine, Florence, Italy
| | - Raffaele Pulli
- CardioThoracic and Vascular Surgery, Vascular Surgery, Careggi University Teaching Hospital, University of Florence School of Medicine, Florence, Italy
| | - Stefano Bonardelli
- Vascular Surgery, Department of Sperimental and Clinical Sciences, University of Brescia School of Medicine, Spedali Civili Hospital, Varese, Italy
| | - Mohamad Bashir
- Vascular & Endovascular Surgery-Health Education & Improvement Wales, Velindre University NHS Trust, Wales, UK
| | - Gabriele Piffaretti
- Vascular Surgery, Department of Medicine and Surgery, University of Insubria School of Medicine, Varese, Italy
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Ristow AVON, Santos M, Vescovi A, Massière B, Demier B, Sartori P, Niemeyer Filho P. Determinants of success in treating acute ischemic cerebral and ocular ischemia through carotid revascularization. An observational study of a case series. Rev Col Bras Cir 2022; 49:e20223400. [PMID: 36449945 PMCID: PMC10578794 DOI: 10.1590/0100-6991e-20223400-en] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2022] [Accepted: 07/15/2022] [Indexed: 11/29/2022] Open
Abstract
OBJECTIVE stroke etiology is ischemia in 85%, and in circa 25% of these, the source is the extracranial carotid. Recurrence is frequent and usually more severe. Carotid revascularization prevents new ischemic strokes. The sooner the treatment is undertaken, complete recovery chances are greater with less recurrences. But, historically, intervention in the acute setting was catastrophic. Objective: Identify determinants of success when carotid revascularization after a recent cerebral ischemic event is performed. MATERIALS AND METHODS A cohort of 50 subjects underwent carotid revascularization after ischemic symptoms, within a period of 71 months. The currently diagnostic tools were used, and the symptoms stratified by the Rankin scale. The extension of the cerebral lesion and the source location the source of the event was analyzed. RESULTS indications were based on the Rankin Scale (R0: 35.4%; R1: 45.8%; R2:18.8% and R3: zero), on the location of the source and the absence of ischemic areas greater than 15mm. An early surgical approach was adopted in all patients. Extreme care was applied to control arterial pressure. At discharge, no additional deficits were observed. CONCLUSIONS carotid revascularization after ischemic events can be achieved without additional morbidity and no recurrences, using the most appropriate therapy in the shortest time, in patients with Rankin Scale up to 2, absence of intracranial hemorrhage and single or multiple ischemic intracerebral areas, with 15mm or less in their greater dimension.
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Affiliation(s)
- Arno VON Ristow
- - Pontifícia Universidade Católica do Rio de Janeiro, Pós-graduação de cirurgia vascular e endovascular - Rio de Janeiro - RJ - Brasil
| | - Marcos Santos
- - Universidade Federal do Rio de Janeiro, Instituto de Ciências Biomédicas, Laboratório de Morfogênese Celular - Rio de Janeiro - RJ - Brasil
| | - Alberto Vescovi
- - Instituto Estadual do Cérebro Paulo Niemeyer - Rio de Janeiro - RJ - Brasil
| | - Bernardo Massière
- - Pontifícia Universidade Católica do Rio de Janeiro, Pós-graduação de cirurgia vascular e endovascular - Rio de Janeiro - RJ - Brasil
| | - Bruno Demier
- - Pontifícia Universidade Católica do Rio de Janeiro, Pós-graduação de cirurgia vascular e endovascular - Rio de Janeiro - RJ - Brasil
| | - Pedro Sartori
- - Pontifícia Universidade Católica do Rio de Janeiro, Pós-graduação de cirurgia vascular e endovascular - Rio de Janeiro - RJ - Brasil
| | - Paulo Niemeyer Filho
- - Universidade Federal do Rio de Janeiro, Instituto de Ciências Biomédicas, Laboratório de Morfogênese Celular - Rio de Janeiro - RJ - Brasil
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45
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Coutinho SGB, Ricardo JC, Coutinho AIM, Cavalcante LP. The quality of guidelines for treatment of carotid artery disease: a critical appraisal using the AGREE II instrument. J Vasc Bras 2022; 21:e20220032. [PMID: 36505346 PMCID: PMC9716357 DOI: 10.1590/1677-5449.202200321] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2022] [Accepted: 07/12/2022] [Indexed: 11/27/2022] Open
Abstract
Clinical Practice Guidelines (CPG) are structured recommendations based on systematic reviews of the available evidence and are useful tools to support clinical decision-making. However, studies have raised concerns about the methodological and scientific quality of several CPG, which can affect their application in clinical practice. The objective of this study was to perform a systematic appraisal of the methodological quality of carotid atherosclerotic disease clinical guidelines, published from 2000 to 2019, using the AGREE II instrument (Appraisal of Guidelines for Research and Evaluation Instrument II). The appraisers independently assessed the quality of the CPG included in the study for each of the 6 domains of the AGREE II tool. The CPG were rated as high, moderate, or low quality using a points scale. A total of 9 CPGs were selected for appraisal. Except for domain 2 (kappa=0.715), excellent agreement was observed between the appraisers (kappa>0.75). Five of the CPGs were rated as high overall methodological quality rating, 5 were rated as moderate overall methodological quality, and 2 were rated low overall methodological quality. The authors conclude that: (1) appraisal of carotid atherosclerotic disease clinical guidelines using the AGREE II instrument is feasible, with a high degree of agreement among appraisers; and (2) that most CPGs on the management of atherosclerotic carotid disease have high methodological quality.
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Affiliation(s)
| | - Joelma Cavalcante Ricardo
- Universidade Federal do Amazonas - UFAM, Manaus, AM, Brasil.,Fundação Centro de Controle de Oncologia do Estado do Amazonas, Manaus, AM, Brasil.
| | - Alexandre Inacio Moreira Coutinho
- Marinha do Brasil, Policlínica Naval de Manaus, Manaus, AM, Brasil.,Sociedade Brasileira de Angiologia e Cirurgia Vascular, Regional Amazonas, Manaus, AM, Brasil.
| | - Leonardo Pessoa Cavalcante
- Universidade Federal do Amazonas - UFAM, Manaus, AM, Brasil.,Universidade Federal do Amazonas - UFAM, Hospital Universitário Getúlio Vargas, Manaus, AM, Brasil.
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46
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Solomon Y, Rastogi V, Marcaccio CL, Patel PB, Wang GJ, Malas MB, Motaganahalli RL, Nolan BW, Verhagen HJM, de Borst GJ, Schermerhorn ML. Outcomes after transcarotid artery revascularization stratified by preprocedural symptom status. J Vasc Surg 2022; 76:1307-1315.e1. [PMID: 35798281 PMCID: PMC9613587 DOI: 10.1016/j.jvs.2022.05.024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2022] [Revised: 04/14/2022] [Accepted: 05/09/2022] [Indexed: 10/31/2022]
Abstract
OBJECTIVE Previous studies on carotid endarterectomy and transfemoral carotid artery stenting demonstrated that perioperative outcomes differed according to preoperative neurologic injury severity, but this has not been assessed in transcarotid artery revascularization (TCAR). In this study, we examined contemporary perioperative outcomes in patients who underwent TCAR stratified by specific preprocedural symptom status. METHODS Patients who underwent TCAR between 2016 and 2021 in the Vascular Quality Initiative were included. We stratified patients into the following groups based on preprocedural symptoms: asymptomatic, recent (symptoms occurring <180 days before TCAR) ocular transient ischemic attack (TIA), recent hemispheric TIA, recent stroke, or formerly symptomatic (symptoms occurring >180 days before TCAR). First, we used trend tests to assess outcomes in asymptomatic patients versus those with an increasing severity of recent neurologic injury (recent ocular TIA vs recent hemispheric TIA vs recent stroke). Then, we compared outcomes between asymptomatic and formerly symptomatic patients. Our primary outcome was in-hospital stroke/death rates. Multivariable logistic regression was used to adjust for demographics and comorbidities across groups. RESULTS We identified 18,477 patients undergoing TCAR, of whom 62.0% were asymptomatic, 3.2% had a recent ocular TIA, 7.6a % had recent hemispheric TIA, 18.0% had a recent stroke, and 9.2% were formerly symptomatic. In patients with recent symptoms, we observed higher rates of stroke/death with increasing neurologic injury severity: asymptomatic 1.1% versus recent ocular TIA 0.8% versus recent hemispheric TIA 2.1% versus recent stroke 3.1% (Ptrend < .01). In formerly symptomatic patients, the rate of stroke/death was higher compared with asymptomatic patients, but this difference was not statistically significant (1.7% vs 1.1%; P = .06). After risk adjustment, compared with asymptomatic patients, there was a higher odds of stroke/death in patients with a recent stroke (odds ratio [OR], 2.8; 95% confidence interval [CI], 2.1-3.7; P < .01), a recent hemispheric TIA (OR, 2.0; 95% CI, 1.3-3.0; P < .01), and former symptoms (OR, 1.6; 95% CI, 1.1-2.5; P = .02), but there was no difference in stroke/death rates in patients with a recent ocular TIA (OR, 0.9; 95% CI, 0.4-2.2; P = .78). CONCLUSIONS After TCAR, compared with asymptomatic status, a recent stroke and a recent hemispheric TIA were associated with higher stroke/death rates, whereas a recent ocular TIA was associated with similar stroke/death rates. In addition, a formerly symptomatic status was associated with higher stroke/death rates compared with an asymptomatic status. Overall, our findings suggest that classifying patients undergoing TCAR as symptomatic versus asymptomatic may be an oversimplification and that patients' specific preoperative neurologic symptoms should instead be used in risk assessment and outcome reporting for TCAR.
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Affiliation(s)
- Yoel Solomon
- Department of Surgery, Division of Vascular and Endovascular Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA; Department of Vascular Surgery, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Vinamr Rastogi
- Department of Surgery, Division of Vascular and Endovascular Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA; Department of Vascular Surgery, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Christina L Marcaccio
- Department of Surgery, Division of Vascular and Endovascular Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA
| | - Priya B Patel
- Department of Surgery, Division of Vascular and Endovascular Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA
| | - Grace J Wang
- Division of Vascular Surgery and Endovascular Therapy, Department of Surgery, Hospital of the University of Pennsylvania, Philadelphia, PA
| | - Mahmoud B Malas
- Division of Vascular and Endovascular Surgery, Department of Surgery, University of California San Diego Health System, San Diego, CA
| | - Raghu L Motaganahalli
- Division of Vascular Surgery, Department of Surgery, Indiana University School of Medicine, Indianapolis, IN
| | - Brian W Nolan
- Division of Vascular and Endovascular Therapy, Department of Surgery, Maine Medical Center, Portland, ME
| | - Hence J M Verhagen
- Department of Vascular Surgery, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Gert J de Borst
- Department of Vascular Surgery, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Marc L Schermerhorn
- Department of Surgery, Division of Vascular and Endovascular Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA.
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Pierro A, Modugno P, Iezzi R, Cilla S. Challenges and Pitfalls in CT-Angiography Evaluation of Carotid Bulb Stenosis: Is It Time for a Reappraisal? LIFE (BASEL, SWITZERLAND) 2022; 12:life12111678. [PMID: 36362834 PMCID: PMC9697210 DOI: 10.3390/life12111678] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/21/2022] [Revised: 10/13/2022] [Accepted: 10/20/2022] [Indexed: 01/25/2023]
Abstract
We aimed to perform an anatomical evaluation of the carotid bulb using CT-angiography, implement a new reliable index for carotid stenosis quantification and to assess the accuracy of relationship between NASCET and ECST methods in a large adult population. The cross-sectional areas of the healthy carotid at five levels were measured by two experienced radiologists. A regression analysis was performed in order to quantify the relationship between the areas of the carotid bulb at different carotid bulbar level. A new index (Regression indeX, RegX) for carotid stenosis quantification was proposed. Five different stenoses with different grade in three bulbar locations were simulated for all patients for a total of 1365 stenoses and were used for a direct comparison of the RegX, NASCET, and ECST methods. The results of this study demonstrated that the RegX index provided a consistent and accurate measure of carotid stenosis through the application of the ECST method, avoiding the limitations of NASCET method. Furthermore, our results strongly depart from the consolidated relationships between NASCET and ECST values used in clinical practice and reported in extensive medical literature. In particular, we highlighted that a major misdiagnosis in patient selection for CEA could be introduced because of the large underestimation of real stenosis degree provided by the NASCET method. A reappraisal of carotid stenosis patients' work-up is evoked by the effectiveness of state-of-the-art noninvasive contemporary carotid imaging.
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Affiliation(s)
- Antonio Pierro
- Radiology Department, Cardarelli Regional Hospital, 86100 Campobasso, Italy
| | - Pietro Modugno
- Vascular Surgery Unit, Gemelli Molise Hospital, 86100 Campobasso, Italy
| | - Roberto Iezzi
- Radiology Department, Fondazione Policlinico Universitario A. Gemelli-IRCCS, 00168 Rome, Italy
| | - Savino Cilla
- Medical Physics Unit, Gemelli Molise Hospital, 86100 Campobasso, Italy
- Correspondence:
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48
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Perioperative Medical Management for Symptomatic Carotid Artery Interventions. CURRENT TREATMENT OPTIONS IN CARDIOVASCULAR MEDICINE 2022. [DOI: 10.1007/s11936-022-00966-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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49
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Resection of an internal carotid artery aneurysm with extreme cranial exposure maneuvers. J Vasc Surg 2022; 76:845-846. [PMID: 35995487 DOI: 10.1016/j.jvs.2021.10.037] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2021] [Accepted: 10/24/2021] [Indexed: 11/22/2022]
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50
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De Paulis S, Arlotta G, Calabrese M, Corsi F, Taccheri T, Antoniucci ME, Martinelli L, Bevilacqua F, Tinelli G, Cavaliere F. Postoperative Intensive Care Management of Aortic Repair. J Pers Med 2022; 12:jpm12081351. [PMID: 36013300 PMCID: PMC9410221 DOI: 10.3390/jpm12081351] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2022] [Revised: 08/12/2022] [Accepted: 08/19/2022] [Indexed: 11/16/2022] Open
Abstract
Vascular surgery patients have multiple comorbidities and are at high risk for perioperative complications. Aortic repair surgery has greatly evolved in recent years, with an increasing predominance of endovascular techniques (EVAR). The incidence of cardiac complications is significantly reduced with endovascular repair, but high-risk patients require postoperative ST-segment monitoring. Open aortic repair may portend a prohibitive risk of respiratory complications that could be a contraindication for surgery. This risk is greatly reduced in the case of an endovascular approach, and general anesthesia should be avoided whenever possible in the case of endovascular repair. Preoperative renal function and postoperative kidney injury are powerful determinants of short- and long-term outcome, so that preoperative risk stratification and secondary prevention are critical tasks. Intraoperative renal protection with selective renal and distal aortic perfusion is essential during open repair. EVAR has lower rates of postoperative renal failure compared to open repair, with approximately half the risk for acute kidney injury (AKI) and one-third of the risk of hemodialysis requirement. Spinal cord ischemia used to be the most distinctive and feared complication of aortic repair. The risk has significantly decreased since the beginning of aortic surgery, with advances in surgical technique and spinal protection protocols, and is lower with endovascular repair. Endovascular repair avoids extensive aortic dissection and aortic cross-clamping and is generally associated with reduced blood loss and less coagulopathy. The intensive care physician must be aware that aortic repair surgery has an impact on every organ system, and the importance of early recognition of organ failure cannot be overemphasized.
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Affiliation(s)
- Stefano De Paulis
- Fondazione Policlinico Gemelli IRCCS, 00168 Rome, Italy
- Correspondence:
| | | | | | - Filippo Corsi
- Fondazione Policlinico Gemelli IRCCS, 00168 Rome, Italy
| | | | | | - Lorenzo Martinelli
- Fondazione Policlinico Gemelli IRCCS, 00168 Rome, Italy
- Department of Cardiovascular Sciences, Università Cattolica del Sacro Cuore, 00168 Rome, Italy
| | | | - Giovanni Tinelli
- Fondazione Policlinico Gemelli IRCCS, 00168 Rome, Italy
- Department of Cardiovascular Sciences, Università Cattolica del Sacro Cuore, 00168 Rome, Italy
| | - Franco Cavaliere
- Fondazione Policlinico Gemelli IRCCS, 00168 Rome, Italy
- Department of Cardiovascular Sciences, Università Cattolica del Sacro Cuore, 00168 Rome, Italy
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