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Kuehnl A, Kallmayer M, Bohmann B, Lohe V, Moser R, Naher S, Kirchhoff F, Eckstein HH, Knappich C. Association between hospital ownership and patient selection, management, and outcomes after carotid endarterectomy or carotid artery stenting : - Secondary data analysis of the Bavarian statutory quality assurance database. BMC Surg 2024; 24:158. [PMID: 38760789 PMCID: PMC11100040 DOI: 10.1186/s12893-024-02448-6] [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: 03/10/2024] [Accepted: 05/08/2024] [Indexed: 05/19/2024] Open
Abstract
BACKGROUND This study analyses the association between hospital ownership and patient selection, treatment, and outcome of carotid endarterectomy (CEA) or carotid artery stenting (CAS). METHODS The analysis is based on the Bavarian subset of the nationwide German statutory quality assurance database. All patients receiving CEA or CAS for carotid artery stenosis between 2014 and 2018 were included. Hospitals were subdivided into four groups: university hospitals, public hospitals, hospitals owned by charitable organizations, and private hospitals. The primary outcome was any stroke or death until discharge from hospital. Research was funded by Germany's Federal Joint Committee Innovation Fund (01VSF19016 ISAR-IQ). RESULTS In total, 22,446 patients were included. The majority of patients were treated in public hospitals (62%), followed by private hospitals (17%), university hospitals (16%), and hospitals under charitable ownership (6%). Two thirds of patients were male (68%), and the median age was 72 years. CAS was most often applied in university hospitals (25%) and most rarely used in private hospitals (9%). Compared to university hospitals, patients in private hospitals were more likely asymptomatic (65% vs. 49%). In asymptomatic patients, the risk of stroke or death was 1.3% in university hospitals, 1.5% in public hospitals, 1.0% in hospitals of charitable owners, and 1.2% in private hospitals. In symptomatic patients, these figures were 3.0%, 2.5%, 3.4%, and 1.2% respectively. Univariate analysis revealed no statistically significant differences between hospital groups. In the multivariable analysis, compared to university hospitals, the odds ratio of stroke or death in asymptomatic patients treated by CEA was significantly lower in charitable hospitals (OR 0.19 [95%-CI 0.07-0.56, p = 0.002]) and private hospitals (OR 0.47 [95%-CI 0.23-0.98, p = 0.043]). In symptomatic patients (elective treatment, CEA), patients treated in private or public hospitals showed a significantly lower odds ratio compared to university hospitals (0.36 [95%-CI 0.17-0.72, p = 0.004] and 0.65 [95%-CI 0.42-1.00, p = 0.048], respectively). CONCLUSIONS Hospital ownership was related to patient selection and treatment, but not generally to outcomes. The lower risk of stroke or death in the subgroup of electively treated patients in private hospitals might be due to the right timing, the choice of treatment modality or actually to better structural and process quality.
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Affiliation(s)
- Andreas Kuehnl
- Department for Vascular and Endovascular Surgery, Klinikum rechts der Isar, Technical University of Munich, Ismaninger Str. 22, 81675, Munich, Germany.
| | - Michael Kallmayer
- Department for Vascular and Endovascular Surgery, Klinikum rechts der Isar, Technical University of Munich, Ismaninger Str. 22, 81675, Munich, Germany
| | - Bianca Bohmann
- Department for Vascular and Endovascular Surgery, Klinikum rechts der Isar, Technical University of Munich, Ismaninger Str. 22, 81675, Munich, Germany
| | - Vanessa Lohe
- Department for Vascular and Endovascular Surgery, Klinikum rechts der Isar, Technical University of Munich, Ismaninger Str. 22, 81675, Munich, Germany
| | - Rebecca Moser
- Landesarbeitsgemeinschaft zur datengestützten, einrichtungsübergreifenden Qualitätssicherung in Bayern, Munich, Germany
| | - Shamsun Naher
- Department for Vascular and Endovascular Surgery, Klinikum rechts der Isar, Technical University of Munich, Ismaninger Str. 22, 81675, Munich, Germany
| | - Felix Kirchhoff
- Department for Vascular and Endovascular Surgery, Klinikum rechts der Isar, Technical University of Munich, Ismaninger Str. 22, 81675, Munich, Germany
| | - Hans-Henning Eckstein
- Department for Vascular and Endovascular Surgery, Klinikum rechts der Isar, Technical University of Munich, Ismaninger Str. 22, 81675, Munich, Germany
| | - Christoph Knappich
- Department for Vascular and Endovascular Surgery, Klinikum rechts der Isar, Technical University of Munich, Ismaninger Str. 22, 81675, Munich, Germany
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Monaco F, Licheri M, Labanca R, Russetti F, Oriani A, Melissano G, Chiesa R, Barucco G. Association of Impedance Aggregometry-Measured Platelet Aggregation With Thromboembolic Events in Patients Who Undergo Carotid Endarterectomy: A Pilot Study. J Cardiothorac Vasc Anesth 2024; 38:771-779. [PMID: 38320918 DOI: 10.1053/j.jvca.2023.12.002] [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: 09/16/2023] [Revised: 11/29/2023] [Accepted: 12/01/2023] [Indexed: 02/08/2024]
Abstract
OBJECTIVES The aim of the current study was to assess the relationship among thrombin receptor activator peptide 6 (TRAP test), adenosine-5'-diphosphate (ADP test), arachidonic acid (ASPI test), and stroke/transient ischemic attack (TIA), using the multiple electrode aggregometry (Multiplate) in patients undergoing carotid thromboendarterectomy (CEA). DESIGN A retrospective study. SETTING Vascular surgery operating rooms of a university hospital. PARTICIPANTS One hundred thirty-one out of 474 patients undergoing CEA between November 2020 and October 2022. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS A preoperative blood sample of all enrolled patients was analyzed using the Multiplate analyzer. Receiver operating characteristics curves, were generated to test the ability of TRAP, ADP, and ASPI in discriminating perioperative thromboembolic stroke/TIA. A logistic LASSO regression model was used to identify factors independently associated with stroke/TIA. Eight patients experienced a perioperative stroke/TIA. Although all the platelet functional assays showed excellent predictive performance, an ADP value exceeding 72 U showed the highest specificity (87%) and sensitivity (68%) in discriminating patients who had a perioperative thromboembolic stroke/TIA, with a negative predictive value of 99% and a positive predictive value of 15%. After LASSO regression, an ADP >72 U and the need for a shunt during CEA were the only 2 variables independently associated with perioperative stroke/TIA. CONCLUSION Because the ADP test was independently associated with perioperative stroke/TIA, the assessment of platelet reactivity using Multiplate may offer potential utility in monitoring patients undergoing CEA.
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Affiliation(s)
- Fabrizio Monaco
- Department of Anesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, Milan, Italy.
| | - Margherita Licheri
- Department of Anesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Rosa Labanca
- Department of Anesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Federica Russetti
- Department of Anesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Alessandro Oriani
- Department of Anesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Germano Melissano
- Department of Vascular Surgery, IRCCS San Raffaele Scientific Institute, Milan, Italy; Vita-Salute San Raffaele University, Milan, Italy
| | - Roberto Chiesa
- Department of Vascular Surgery, IRCCS San Raffaele Scientific Institute, Milan, Italy; Vita-Salute San Raffaele University, Milan, Italy
| | - Gaia Barucco
- Department of Anesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, Milan, Italy
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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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Thilagar BP, Mueller MR, Ganesh R. Perioperative cardiac risk reduction in non cardiac surgery. Minerva Med 2023; 114:861-877. [PMID: 37140483 DOI: 10.23736/s0026-4806.23.08474-4] [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: 05/05/2023]
Abstract
For patients undergoing nonemergent noncardiac surgery, care must be taken to identify patients at increased risk of major adverse cardiovascular events, as these remain a significant source of perioperative morbidity and mortality. Identification of at-risk patients requires careful attention to risk factors including assessment of functional status, medical comorbidities, and a medication assessment. After identification, to minimize perioperative cardiac risk, care should be taken through a combination of appropriate medication management, close monitoring for cardiovascular ischemic events, and optimization of pre-existing medical conditions. There are multiple society guidelines that aim to mitigate risk of cardiovascular morbidity and mortality in patients undergoing nonemergent noncardiac surgery. However, the rapid evolution of medical literature often creates gaps between the existing evidence and best practice recommendations. In this review, we aim to reconcile the recommendations made in the guidelines from the major cardiovascular and anesthesiology societies from the USA, Canada, and Europe, and to provide updated recommendations based on new evidence.
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Affiliation(s)
- Bright P Thilagar
- Division of General Internal Medicine, Mayo Clinic, Rochester, MN, USA
| | - Michael R Mueller
- Division of General Internal Medicine, Mayo Clinic, Rochester, MN, USA
| | - Ravindra Ganesh
- Division of General Internal Medicine, Mayo Clinic, Rochester, MN, USA -
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Ismail A, Ravipati S, Gonzalez-Hernandez D, Mahmood H, Imran A, Munoz EJ, Naeem S, Abdin ZU, Siddiqui HF. Carotid Artery Stenosis: A Look Into the Diagnostic and Management Strategies, and Related Complications. Cureus 2023; 15:e38794. [PMID: 37303351 PMCID: PMC10250083 DOI: 10.7759/cureus.38794] [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] [Accepted: 05/09/2023] [Indexed: 06/13/2023] Open
Abstract
Carotid stenosis (CS) is a buildup of atherosclerotic plaque within the artery leading to a wide range of symptoms, from mild symptoms, including blurred vision and confusion, to much more life-threatening presentations, including paralysis due to stroke. The presentation is insidious, with symptoms exhibiting predominantly at severe stenosis; hence the emphasis is placed on the importance of early diagnosis, treatment, and lifestyle modifications. CS is seen undergoing almost the same pathogenesis of any atherosclerotic plaque formation, from endothelial damage of the artery lumen to the formation of a fibrous cap with a foam cell, lipid-filled core. The findings of our review article were consistent with the recent literature, depicting that comorbid hypertension, diabetes, and chronic kidney disease (CKD), and lifestyle aspects, including smoking and diet, played the most salient role in plaque development. Among several imaging modalities, duplex ultrasound (DUS) imaging is the widely preferred method in clinical practice. Carotid endarterectomy (CEA) and carotid stenting are the primarily advocated procedures for symptomatic severe stenosis, with similar long-term outcomes. Although, earlier clinical trials showed promising results in mitigating the risk of stroke among asymptomatic severe CS with surgical intervention. However, recent advancements have shifted the focus to medical management alone due to comparable results among the asymptomatic population. Both surgical and medical regimens are beneficial in treating patients, but it is still an ongoing debate as to which is predominantly superior. The currently advancing trials and research will help elucidate definitive guidelines. However, the massive impact of lifestyle modifications advocates some degree of individualized multidisciplinary management strategies.
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Affiliation(s)
- Aqsa Ismail
- Department of Medicine, United Medical and Dental College, Karachi, PAK
| | - Shivani Ravipati
- Department of Medicine, Dr. Pinnamaneni Siddhartha Institute of Medical Sciences and Research Foundation, Vijayawada, IND
| | | | - Hashim Mahmood
- Department of Medicine, University College of Medicine and Dentistry, University of Lahore, Lahore, PAK
| | - Alizay Imran
- Department of Surgery, Windsor University School of Medicine, Chicago, USA
| | - Eduardo J Munoz
- Department of General Medicine, Montemorelos University, Montemorelos, MEX
| | - Saad Naeem
- Department of Internal Medicine, Faisalabad Medical University, Faisalabad, PAK
- Department of Internal Medicine, Punjab Social Security Hospital, Faisalabad, PAK
| | - Zain U Abdin
- Department of Medicine, District Head Quarters Hospital, Faisalabad, PAK
| | - Humza F Siddiqui
- Department of Medicine, Jinnah Sindh Medical University, Karachi, PAK
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Patel RJ, Marmor R, Dakour H, Elsayed N, Ramachandran M, Malas MB. Dual Antiplatelet Therapy Is Associated with Increased Risk of Bleeding and Decreased Risk of Stroke Following Carotid Endarterectomy. Ann Vasc Surg 2023; 88:191-198. [PMID: 35921978 PMCID: PMC10238168 DOI: 10.1016/j.avsg.2022.07.010] [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: 04/15/2022] [Revised: 06/22/2022] [Accepted: 07/07/2022] [Indexed: 11/27/2022]
Abstract
BACKGROUND Despite many patients undergoing carotid endarterectomy (CEA) being on dual antiplatelet therapy (DAPT) for cardiac or neurologic indications, the impact of such therapy on perioperative outcomes remains unclear. We aim to compare rates of postoperative bleeding, stroke and major adverse events (stroke, death or MI) among patients on Aspirin alone (ASAA) versus DAPT (Clopidogrel and Aspirin). METHODS Patients undergoing CEA for carotid artery stenosis between 2010 and 2021 in the Vascular Quality Initiative (VQI) were included. We excluded patients undergoing concomitant or re-do operations or patients with missing antiplatelet information. Propensity score matching was performed between the 2 groups ASAA and DAPT based on age, sex, race, presenting symptoms, major comorbidities [hypertension, diabetes and coronary artery disease (CAD)], degree of ipsilateral stenosis, presence of contralateral occlusion, as well as preoperative medications. Intergroup differences between the treatment groups and differences in perioperative outcomes were tested with the McNemar's test for categorical variables and paired t-test or Wilcoxon matched-pairs signed-rank test for continuous variables where appropriate. Relative risks with 95% confidence intervals were estimated as the ratio of the probability of the outcome event in the patients treated within each treatment group. RESULTS A total of 125,469 patients were included [ASAA n = 82,920 (66%) and DAPT n = 42,549 (34%)]. Patients on DAPT were more likely to be symptomatic, had higher rates of CAD, prior percutaneous coronary intervention or coronary artery bypass grafting, and higher rates of diabetes. After propensity score matching, the DAPT group had an increased rate of bleeding complications (RR: 1.6: 1.4-1.8, P < 0.001) as compared with those on ASAA despite being more likely to receive both drains and protamine. In addition, patients on DAPT had a slight decrease in the risk of in-hospital stroke as compared with patients on ASAA (RR: 0.80: 0.7-0.9, P = 0.001). CONCLUSIONS This large multi-institutional study demonstrates a modest decrease in the risk of in-hospital stroke for patients on DAPT undergoing CEA as compared with those on ASAA. This small benefit is at the expense of a significant increase in the risk of perioperative bleeding events incurred by those on DAPT at the time of CEA. This analysis suggests avoiding DAPT when possible, during CEA.
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Affiliation(s)
- Rohini J Patel
- Division of Vascular and Endovascular Surgery, University of California San Diego, San Diego, CA
| | - Rebecca Marmor
- Division of Vascular Surgery and Endovascular Therapy, The Johns Hopkins University, Baltimore, MD
| | - Hanaa Dakour
- Division of Vascular Surgery, Indiana University, Indianapolis, IN
| | - Nadin Elsayed
- Division of Vascular and Endovascular Surgery, University of California San Diego, San Diego, CA
| | - Mokhshan Ramachandran
- Division of Vascular and Endovascular Surgery, University of California San Diego, San Diego, CA
| | - Mahmoud B Malas
- Division of Vascular and Endovascular Surgery, University of California San Diego, San Diego, CA.
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Lee M, Ahmed ZV, Huang J, Brice A, Arham A, Castro-Dominguez Y, Aboian E, Nagpal S, Smolderen KG, Mena-Hurtado C. Antiplatelet regimens following carotid artery revascularization. Am Heart J 2022; 253:48-52. [PMID: 35863439 DOI: 10.1016/j.ahj.2022.07.004] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/13/2022] [Revised: 07/06/2022] [Accepted: 07/07/2022] [Indexed: 06/15/2023]
Abstract
Dual antiplatelet therapy (DAPT) is indicated following carotid artery stenting (CAS) and single antiplatelet therapy (SAPT) following carotid endarterectomy (CEA), but it remains unknown how providers adhere to these guidelines in real-world clinical practice. Using the Vascular Quality Initiative New England data, we found that of 12,257 patients, 82% patients were discharged on DAPT following CAS and 66% were discharged on SAPT following CEA. While a high percentage of patients undergoing CAS appropriately receive DAPT, the use of SAPT following CEA exists with more variability and lower adherence rates.
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Affiliation(s)
- Megan Lee
- Yale School of Medicine, Yale New Haven Health System, CT
| | - Zain V Ahmed
- Department of Cardiovascular Medicine, Yale New Haven Health System, Yale School of Medicine, New Haven, CT
| | - Jiaming Huang
- Department of Cardiovascular Medicine, Yale New Haven Health System, Yale School of Medicine, New Haven, CT
| | - Aaron Brice
- Department of Cardiovascular Medicine, Yale New Haven Health System, Yale School of Medicine, New Haven, CT
| | - Ahmad Arham
- Department of Cardiovascular Medicine, Yale New Haven Health System, Yale School of Medicine, New Haven, CT
| | - Yulanka Castro-Dominguez
- Department of Cardiovascular Medicine, Yale New Haven Health System, Yale School of Medicine, New Haven, CT
| | - Edouard Aboian
- Department of Vascular Surgery, Yale New Haven Health System, Yale School of Medicine, New Haven, CT
| | - Sameer Nagpal
- Department of Cardiovascular Medicine, Yale New Haven Health System, Yale School of Medicine, New Haven, CT
| | - Kim G Smolderen
- Department of Vascular Surgery, Yale New Haven Health System, Yale School of Medicine, New Haven, CT; Department of Psychiatry, Yale New Haven Health System, Yale School of Medicine, New Haven, CT
| | - Carlos Mena-Hurtado
- Department of Cardiovascular Medicine, Yale New Haven Health System, Yale School of Medicine, New Haven, CT.
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Donners SJA, Mekke JM, van Hattum ES, Toorop RJ, de Borst GJ. Editor's Choice - Risk of Bleeding Complications With Different Peri-Operative Antithrombotic Regimens During Carotid Endarterectomy: a National Registry Analysis. Eur J Vasc Endovasc Surg 2022; 64:444-451. [PMID: 36031046 DOI: 10.1016/j.ejvs.2022.08.020] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2022] [Revised: 08/09/2022] [Accepted: 08/12/2022] [Indexed: 01/12/2023]
Abstract
OBJECTIVE Antithrombotic therapy is one of the cornerstones of the prevention of (recurrent) ocular or cerebral ischaemic events in patients with carotid artery stenosis. Randomised controlled trials on antithrombotic therapy for patients with minor ischaemic stroke and transient ischaemic attack (TIA) have recommended dual antiplatelet therapy (DAPT) in the three weeks following the index event. However, these trials excluded patients undergoing carotid revascularisation. To date, the optimal antithrombotic therapy during the peri-operative period of carotid endarterectomy (CEA) remains unclear. METHODS Symptomatic and asymptomatic patients with carotid artery stenosis undergoing primary CEA from the Dutch Audit for Carotid Interventions registry between June 2013 and December 2020 were eligible for inclusion. The primary outcome was defined as post-operative cervical bleeding needing re-intervention or intracranial haemorrhage during the first 30 days following CEA. The secondary outcomes were ischaemic stroke or TIA or all cause mortality during the first 30 days following CEA. Descriptive statistics and multiple logistic regressions analyses were applied, with acetylsalicylic acid (ASA) as the reference value. RESULTS A total of 12 317 patients were included. In the peri-operative phase, 31.0% of patients were treated with ASA, 32.4% with clopidogrel, 11.1% with ASA plus clopidogrel, 10.4% with ASA plus dipyridamole, 10.3% with vitamin K antagonist, and 4.8% with direct acting oral anticoagulants therapy. After multiple logistic regression analysis, no association was seen with the primary outcome in ASA plus clopidogrel (odds ratio [OR] 0.81; confidence interval [CI] 0.58 - 1.13; p = .23), and ASA plus dipyridamole (OR 0.69; CI 0.47 - 1.00; p = .059). Both the DAPT therapies were not associated with the secondary outcome. CONCLUSION The effectiveness and safety of DAPT did not differ from single antiplatelet therapy (SAPT) in patients undergoing CEA and further evaluation is needed in prospective studies. Considering additional data from the literature and guideline recommendations, DAPT should be started immediately after stroke until 30 days after CEA followed by SAPT, due to a possible reduction in the risk of recurrence.
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Affiliation(s)
- Simone J A Donners
- Department of Vascular Surgery, Division of Surgical Specialties, University Medical Centre Utrecht, Utrecht University, Utrecht, the Netherlands
| | - Joost M Mekke
- Department of Vascular Surgery, Division of Surgical Specialties, University Medical Centre Utrecht, Utrecht University, Utrecht, the Netherlands
| | - Eline S van Hattum
- Department of Vascular Surgery, Division of Surgical Specialties, University Medical Centre Utrecht, Utrecht University, Utrecht, the Netherlands
| | - Raechel J Toorop
- Department of Vascular Surgery, Division of Surgical Specialties, University Medical Centre Utrecht, Utrecht University, Utrecht, the Netherlands
| | - Gert J de Borst
- Department of Vascular Surgery, Division of Surgical Specialties, University Medical Centre Utrecht, Utrecht University, Utrecht, the Netherlands.
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- Department of Vascular Surgery, Division of Surgical Specialties, University Medical Centre Utrecht, Utrecht University, Utrecht, the Netherlands
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Cruz Silva J, Constâncio V, Lima P, Anacleto G, Fonseca M. Effect of Chronic Antiplatelet and Anticoagulant Medication in Neck Haematoma and Perioperative Outomes After Carotid Endarterectomy. Ann Vasc Surg 2022; 88:199-209. [PMID: 36116744 DOI: 10.1016/j.avsg.2022.08.018] [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: 06/08/2022] [Revised: 08/01/2022] [Accepted: 08/04/2022] [Indexed: 11/18/2022]
Abstract
OBJECTIVES A retrospective analysis of neck haematoma, stroke and mortality after symptomatic and asymptomatic carotid endarterectomy (CEA) was conducted, in order to determine the most appropriate perioperative medication for these patients. Thirty-day outcomes of moderate and severe neck bleeding were also investigated. METHODS Patients undergoing CEA in a Vascular Surgery department were analysed (2015-2019). Pre-procedure antithrombotic medication (from the 5-days prior to surgery) was identified. End point predictors were identified by univariate and multivariable analyses and adjusted for confounders. RESULTS A total of 304 CEA were included. Almost half of the included patients (49.67%) were under low-dose aspirin, 17.55% other single antiplatelet agent, 12.59% dual antiplatelet therapy, 8.61% anticoagulation and 10.92% no antithrombotic therapy. There was 8.22% rate of important haematoma, including 4.93% severe (requiring surgical exploration) hematomas and a 30-day all-stroke incidence of 2.94% in symptomatic and 1.79% asymptomatic patients (p=.51). When compared to aspirin, severe haematoma was more prevalent with single clopidogrel or triflusal (RR 4.25, p=.11), dual antiplatelet group (RR 11.84, p=.002) and anticoagulation (RR 8.604, p=.02). Dual antiaggregation and anticoagulation did not confer post-operative stroke protection compared to single aspirin in either symptomatic or asymptomatic patients. Non-significant higher intra-hospital mortality was noted in no medication, dual antiplatelet and anticoagulation groups in contrast to aspirin. Severe neck bleeding was associated with increased congestive heart failure (9.26-fold, p=.03) and longer hospital stay (11.20±24.69 days versus 3.18±4.79 with no bleeding, p<.001), with a tendency for higher hospital readmission at 30-days (4.66-fold, p=.13). Mortality and stroke rates were similar. CONCLUSIONS Double antiaggregation and anticoagulation did not confer better perioperative outcomes after elective CEA in our study. These regimens were associated with increased risk of neck haematoma, especially severe bleeding, with similar rates of neurologic events in both symptomatic and asymptomatic patients and no mortality benefit. Monotherapy with aspirin appears to be the safest perioperative antithrombotic regimen for elective CEA.
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Affiliation(s)
- Joana Cruz Silva
- Angiology and Vascular Surgery Department, Centro Hospitalar e Universitário de Coimbra, Coimbra, Portugal.
| | - Vânia Constâncio
- Angiology and Vascular Surgery Department, Centro Hospitalar e Universitário de Coimbra, Coimbra, Portugal
| | - Pedro Lima
- Angiology and Vascular Surgery Department, Centro Hospitalar e Universitário de Coimbra, Coimbra, Portugal
| | - Gabriel Anacleto
- Angiology and Vascular Surgery Department, Centro Hospitalar e Universitário de Coimbra, Coimbra, Portugal
| | - Manuel Fonseca
- Angiology and Vascular Surgery Department, Centro Hospitalar e Universitário de Coimbra, Coimbra, Portugal
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10
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Krishnan K, Law ZK, Minhas JS, Bath PM, Robinson TG, Sprigg N, Mavilakandy A, England TJ, Eveson D, Mistri A, Dawson J, Appleton JP. Antiplatelet treatment for acute secondary prevention of non-cardioembolic minor stroke / transient ischaemic attack: an update for the acute physician. Clin Med (Lond) 2022; 22:449-454. [PMID: 38589066 PMCID: PMC9595021 DOI: 10.7861/clinmed.2021-0597] [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: 12/15/2022]
Abstract
Acute stroke is the leading cause of disability in the UK and a leading cause of mortality worldwide. The majority of patients with ischaemic stroke present with minor deficits or transient ischaemic attack (TIA), and are often first seen by patient-facing clinicians. Urgent evaluation and treatment are important as many patients are at high risk of major vascular events and death within hours to days after the index event. This narrative review summarises the evidence on four antiplatelet treatments for non-cardioembolic stroke prevention: aspirin, clopidogrel, dipyridamole and ticagrelor. Each of these drugs has a unique mechanism and has been tested as a single agent or in combination. Aspirin, when given early is beneficial and short-term treatment with aspirin and clopidogrel has been shown to be more effective in high-risk TIA / minor stroke. This review concludes by highlighting gaps in evidence, including scope for future trials that could potentially change clinical practice.
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Affiliation(s)
| | - Zhe Kang Law
- National University of Malaysia, Kuala Lumpur, Malaysia
| | - Jatinder S Minhas
- University of Leicester, Leicester, UK and Leicester Royal Infirmary, Leicester, UK
| | | | - Thompson G Robinson
- University of Leicester, Leicester, UK and Leicester Royal Infirmary, Leicester, UK
| | | | | | - Timothy J England
- Queen's Medical Centre, Nottingham, UK and Royal Derby Hospital, Derby, UK
| | | | | | - Jesse Dawson
- University of Glasgow College of Medical, Veterinary and Life Sciences, Glasgow, UK and Queen Elizabeth University Hospital, Glasgow, UK
| | - Jason P Appleton
- Queen Elizabeth Hospital, Birmingham, UK and University of Birmingham College of Dental and Medical Sciences, Birmingham, UK
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11
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Ku JC, Taslimi S, Zuccato J, Pasarikovski CR, Nasr N, Chechik O, Chisci E, Bissacco D, Larrue V, Rabinovich Y, Michelagnoli S, Settembrini PG, Priola SM, Cusimano MD, Yang VXD, Macdonald RL. Peri-Operative Outcomes of Carotid Endarterectomy are Not Improved on Dual Antiplatelet Therapy vs. Aspirin Monotherapy: A Systematic Review and Meta-Analysis. Eur J Vasc Endovasc Surg 2022; 63:546-555. [PMID: 35241374 DOI: 10.1016/j.ejvs.2021.12.037] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2021] [Revised: 12/01/2021] [Accepted: 12/28/2021] [Indexed: 12/27/2022]
Abstract
OBJECTIVE A systematic review and meta-analysis of the peri-operative outcomes of carotid endarterectomy (CEA) on dual antiplatelet therapy (DAPT) vs. aspirin monotherapy was carried out, to determine optimal peri-operative management with these antiplatelet agents. DATA SOURCES The Web of Science, Pubmed, and Embase databases were searched from inception to July 2021. The corresponding authors of excluded articles were contacted to obtain additional data for possible inclusion. REVIEW METHODS The main outcomes included ischaemic complications (stroke, transient ischaemic attack [TIA], and transcranial Doppler [TCD] measured micro-emboli), haemorrhagic complications (haemorrhagic stroke, neck haematoma, and re-operation for bleeding), and composite outcomes. Pooled estimates using odds ratios (ORs) were combined using a random or fixed effects model based on the results of the chi square test and calculation of I2. RESULTS In total, 47 411 patients were included in 11 studies, with 14 345 (30.2%) receiving DAPT and 33 066 (69.7%) receiving aspirin only. There was no significant difference in the rates of peri-operative stroke (OR 0.87, 95% confidence interval [CI] 0.72 - 1.05) and TIA (OR 0.78, 95% CI 0.52 - 1.17) despite a significant reduction in TCD measured micro-emboli (OR 0.19, 95% CI 0.10 - 0.35) in the DAPT compared with the aspirin monotherapy group. Subgroup analysis did not reveal any significant difference in ischaemic stroke risk between patients with asymptomatic and symptomatic carotid artery stenosis. DAPT was associated with an increased risk of neck haematoma (OR 2.79, 95% CI 1.87 - 4.18) and re-operation for bleeding (OR 1.98, 95% CI 1.77 - 2.23) vs. aspirin. Haemorrhagic stroke was an under reported outcome in the literature. CONCLUSION This meta-analysis found that CEA while on DAPT increased the risk of haemorrhagic complications, with similar rates of ischaemic complications, vs. aspirin monotherapy. This suggests that the risks of performing CEA on DAPT outweigh the benefits, even in patients with symptomatic carotid stenosis. The overall quality of studies was low, and improved reporting of CEA outcomes in the literature is necessary.
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Affiliation(s)
- Jerry C Ku
- Division of Neurosurgery, University of Toronto, Toronto, ON, Canada
| | - Shervin Taslimi
- Division of Neurosurgery, Department of Surgery, Kingston General Hospital, Toronto, ON, Canada.
| | - Jeffrey Zuccato
- Division of Neurosurgery, University of Toronto, Toronto, ON, Canada
| | | | | | - Ofir Chechik
- Sackler Faculty of Medicine, Tel-Aviv Medical Centre, Tel Aviv University, Israel
| | - Emiliano Chisci
- Department of Surgery, Vascular and Endovascular Surgery Unit, "San Giovanni di Dio" Hospital, Florence, Italy
| | - Daniele Bissacco
- School of Vascular Surgery, Università degli Studi di Milano, Milan, Italy
| | | | - Yefim Rabinovich
- Sackler Faculty of Medicine, Tel-Aviv Medical Centre, Tel Aviv University, Israel
| | - Stefano Michelagnoli
- Department of Surgery, Vascular and Endovascular Surgery Unit, "San Giovanni di Dio" Hospital, Florence, Italy
| | | | - Stefano M Priola
- Division of Neurosurgery, Health Sciences North, Sudbury, ON, Canada
| | - Michael D Cusimano
- Division of Neurosurgery, University of Toronto, Toronto, ON, Canada; Division of Neurosurgery, St. Michael's Hospital, Toronto, ON, Canada
| | - Victor X D Yang
- Division of Neurosurgery, University of Toronto, Toronto, ON, Canada; Division of Neurosurgery, Sunnybrook Hospital, Toronto, ON, Canada
| | - R Loch Macdonald
- Department of Neurological Surgery, University of California San Francisco, Fresno Campus, Fresno, CA, USA
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12
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Ganesh R, Kebede E, Mueller M, Gilman E, Mauck KF. Perioperative Cardiac Risk Reduction in Noncardiac Surgery. Mayo Clin Proc 2021; 96:2260-2276. [PMID: 34226028 DOI: 10.1016/j.mayocp.2021.03.014] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/30/2020] [Revised: 02/20/2021] [Accepted: 03/04/2021] [Indexed: 11/21/2022]
Abstract
Major adverse cardiovascular events are a significant source of morbidity and mortality in the perioperative setting, estimated to occur in approximately 5% of patients undergoing nonemergent noncardiac surgery. To minimize the incidence and impact of these events, careful attention must be paid to preoperative cardiovascular assessment to identify patients at high risk of cardiovascular complications. Once identified, cardiovascular risk reduction is achieved through optimization of medical conditions, appropriate management of medication, and careful monitoring to allow for early identification of-and intervention for-any new conditions that would increase the risk of adverse cardiovascular outcomes. The major cardiovascular and anesthesiology societies in the United States, Europe, and Canada have published guidelines for perioperative management of patients undergoing noncardiac surgery. However, since publication of these guidelines, there has been a practice-changing evolution in the medical literature. In this review, we attempt to reconcile the recommendations made in these 3 comprehensive guidelines, while updating recommendations, based on new evidence, when available.
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Affiliation(s)
- Ravindra Ganesh
- Division of General Internal Medicine, Mayo Clinic, Rochester, MN.
| | - Esayas Kebede
- Division of General Internal Medicine, Mayo Clinic, Rochester, MN
| | - Michael Mueller
- Division of General Internal Medicine, Mayo Clinic, Rochester, MN
| | - Elizabeth Gilman
- Division of General Internal Medicine, Mayo Clinic, Rochester, MN
| | - Karen F Mauck
- Division of General Internal Medicine, Mayo Clinic, Rochester, MN
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13
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Aboyans V, Bauersachs R, Mazzolai L, Brodmann M, Palomares JFR, Debus S, Collet JP, Drexel H, Espinola-Klein C, Lewis BS, Roffi M, Sibbing D, Sillesen H, Stabile E, Schlager O, De Carlo M. Antithrombotic therapies in aortic and peripheral arterial diseases in 2021: a consensus document from the ESC working group on aorta and peripheral vascular diseases, the ESC working group on thrombosis, and the ESC working group on cardiovascular pharmacotherapy. Eur Heart J 2021; 42:4013-4024. [PMID: 34279602 DOI: 10.1093/eurheartj/ehab390] [Citation(s) in RCA: 55] [Impact Index Per Article: 18.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/27/2021] [Revised: 04/27/2021] [Accepted: 06/03/2021] [Indexed: 12/24/2022] Open
Abstract
The aim of this collaborative document is to provide an update for clinicians on best antithrombotic strategies in patients with aortic and/or peripheral arterial diseases. Antithrombotic therapy is a pillar of optimal medical treatment for these patients at very high cardiovascular risk. While the number of trials on antithrombotic therapies in patients with aortic or peripheral arterial diseases is substantially smaller than for those with coronary artery disease, recent evidence deserves to be incorporated into clinical practice. In the absence of specific indications for chronic oral anticoagulation due to concomitant cardiovascular disease, a single antiplatelet agent is the basis for long-term antithrombotic treatment in patients with aortic or peripheral arterial diseases. Its association with another antiplatelet agent or low-dose anticoagulants will be discussed, based on patient's ischaemic and bleeding risk as well therapeutic paths (e.g. endovascular therapy). This consensus document aims to provide a guidance for antithrombotic therapy according to arterial disease localizations and clinical presentation. However, it cannot substitute multidisciplinary team discussions, which are particularly important in patients with uncertain ischaemic/bleeding balance. Importantly, since this balance evolves over time in an individual patient, a regular reassessment of the antithrombotic therapy is of paramount importance.
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Affiliation(s)
- Victor Aboyans
- Department of Cardiology, Dupuytren University Hospital, and INSERM 1094 & IRD, University of Limoges, 2, Martin Luther King ave, 87042, Limoges, France
| | - Rupert Bauersachs
- Department of Vascular Medicine, Klinikum Darmstadt GmbH, Darmstadt Germany, and Center for Thrombosis and Hemostasis, University of Mainz, Mainz, Germany
| | - Lucia Mazzolai
- Division of Angiology, Heart and Vessel Department, Lausanne University Hospital (CHUV), Lausanne, Switzerland
| | | | - José F Rodriguez Palomares
- Department of Cardiology, Vall d'Hebron Institut de Recerca (VHIR), Hospital Universitari Vall d'Hebron, Universitat Autònoma de Barcelona, Centro de Investigación Biomédica en RedCV, CIBER CV, Barcelona, Spain
| | - Sebastian Debus
- Department of Vascular Medicine, University Heart Centre Hamburg, University Medical Centre HamburgEppendorf, Hamburg, Germany
| | - Jean-Philippe Collet
- Sorbonne Université, ACTION Study Group (www.actioncoeur.org), INSERM UMRS 1166, Institut de Cardiologie, Hôpital PitiéSalpêtrière (APHP), Paris, France
| | - Heinz Drexel
- Vorarlberg Institute for Vascular Investigation and Treatment (VIVIT), Landeskrankenhaus Feldkirch, Austria
| | - Christine Espinola-Klein
- Section Angiology, Department of Cardiology, Cardiology I, University Medical Center Mainz, Mainz, Germany
| | - Basil S Lewis
- Lady Davis Carmel Medical Center and the Ruth and Bruce Rappaport School of Medicine, TechnionIsrael Institute of Technology, Haifa, Israel
| | - Marco Roffi
- Division of Cardiology, University Hospitals, Geneva, Switzerland
| | - Dirk Sibbing
- Ludwig Maximilians Universität München and Privatklinik Lauterbacher Mühle am Ostersee, Munich, Germany
| | - Henrik Sillesen
- Department of Vascular Surgery, Rigshospitalet, University of Copenhagen, Denmark.,Department of Clinical Medicine, University of Copenhagen, Denmark
| | - Eugenio Stabile
- Division of Cardiology, Department of Advanced Biomedical Sciences, University of Naples 'Federico II', Naples, Italy
| | - Oliver Schlager
- Division of Angiology, 2nd Department of Medicine, Medical University of Vienna, Austria
| | - Marco De Carlo
- Cardiothoracic and Vascular Department, Azienda OspedalieroUniversitaria Pisana, Pisa, Italy
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14
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Kargiotis O, Tsivgoulis G. The 2020 breakthroughs in early secondary prevention: dual antiplatelet therapy versus single antiplatelet therapy. Curr Opin Neurol 2021; 34:45-54. [PMID: 33196579 DOI: 10.1097/wco.0000000000000878] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
PURPOSE OF REVIEW Single antiplatelet therapy represents an established treatment in secondary prevention of ischemic strokes and transient ischemic attacks (TIAs). In contrast with coronary artery disease, the use of dual antiplatelet therapy (DAPT) for secondary prevention in patients with acute cerebral ischemia (ACI) remains under debate. In this narrative review, we present and analyse the most recent findings concerning the potential efficacy and safety of DAPT therapy after ischemic strokes or TIA. RECENT FINDINGS Following the publication of the three (CHANCE, POINT and THALES) large, randomized-controlled, clinical trials (RCTs) that showed efficacy of early DAPT for the secondary prevention after minor AIS or TIA, short-term DAPT use is becoming the most prevalent choice of treatment. Notably, DAPT is even more popular after AIS attributed to large artery atherosclerosis given randomized data from small RCTs supporting the use of DAPT in patients with extracranial or intracranial atherosclerosis and microembolization detected by transcranial Doppler. Recent subanalysis of data from the randomized trials aim to identify specific patient subgroups, which are determined by genetic, imaging or clinical characteristics, and for whom DAPT appears to be more beneficial. The potential role of different antiplatelet agents (aspirin, clopidogrel, ticagrelor) is also discussed. SUMMARY DAPT has recently proven its efficacy for the early secondary prevention of AIS patients with minor stroke severity and high-risk TIA patients. However, the length of DAPT is still controversial, as well as the individualized selection of AIS or TIA patients with the lower risk of bleeding and with the greater benefit in prevention of ischemic cerebrovascular and cardiovascular events.
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Affiliation(s)
| | - Georgios Tsivgoulis
- Second Department of Neurology, National & Kapodistrian University of Athens, School of Medicine, 'Attikon' University Hospital, Athens, Greece
- Department of Neurology, The University of Tennessee Health Science Center, Memphis, Tennessee, USA
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15
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Igarashi S, Ando T, Takahashi T, Yoshida J, Kobayashi M, Yoshida K, Terasaki K, Fujiwara S, Kubo Y, Ogasawara K. Development of cerebral microbleeds in patients with cerebral hyperperfusion following carotid endarterectomy and its relation to postoperative cognitive decline. J Neurosurg 2021; 135:1122-1128. [PMID: 33386017 DOI: 10.3171/2020.7.jns202353] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2020] [Accepted: 07/27/2020] [Indexed: 11/06/2022]
Abstract
OBJECTIVE A primary cause of cognitive decline after carotid endarterectomy (CEA) is cerebral injury due to cerebral hyperperfusion. However, the mechanisms of how cerebral hyperperfusion induces cerebral cortex and white matter injury are not known. The presence of cerebral microbleeds (CMBs) on susceptibility-weighted imaging (SWI) is independently associated with a decline in global cognitive function. The purpose of this prospective observational study was to determine whether cerebral hyperperfusion following CEA leads to the development of CMBs and if postoperative cognitive decline is related to these developed CMBs. METHODS During the 27-month study period, patients who underwent CEA for ipsilateral internal carotid artery stenosis (≥ 70%) also underwent SWI and neuropsychological testing before and 2 months after surgery, as well as quantitative brain perfusion SPECT prior to and immediately after surgery. RESULTS According to quantitative brain perfusion SPECT and SWI before and after surgery, 12 (16%) and 7 (9%) of 75 patients exhibited postoperative cerebral hyperperfusion and increased CMBs in the cerebral hemisphere ipsilateral to surgery, respectively. Cerebral hyperperfusion was associated with an increase in CMBs after surgery (logistic regression analysis, 95% CI 5.08-31.25, p < 0.0001). According to neuropsychological assessments before and after surgery, 10 patients (13%) showed postoperative cognitive decline. Increased CMBs were associated with cognitive decline after surgery (logistic regression analysis, 95% CI 6.80-66.67, p < 0.0001). Among the patients with cerebral hyperperfusion after surgery, the incidence of postoperative cognitive decline was higher in those with increased CMBs (100%) than in those without (20%; p = 0.0101). CONCLUSIONS Cerebral hyperperfusion following CEA leads to the development of CMBs, and postoperative cognitive decline is related to these developed CMBs.
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Affiliation(s)
| | | | | | | | - Masakazu Kobayashi
- 1Department of Neurosurgery and.,2Cyclotron Research Center, Iwate Medical University School of Medicine, Morioka, Japan
| | | | - Kazunori Terasaki
- 2Cyclotron Research Center, Iwate Medical University School of Medicine, Morioka, Japan
| | | | | | - Kuniaki Ogasawara
- 1Department of Neurosurgery and.,2Cyclotron Research Center, Iwate Medical University School of Medicine, Morioka, Japan
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16
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Jiang QL, Wang PJ, Liu HX, Huang LL, Kang XK. Dual versus Single Antiplatelet Therapy in Carotid Artery Endarterectomy: Direct Comparison of Complications Related to Antiplatelet Therapy. World Neurosurg 2020; 135:e598-e609. [PMID: 31870823 DOI: 10.1016/j.wneu.2019.12.070] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2019] [Revised: 12/11/2019] [Accepted: 12/12/2019] [Indexed: 10/25/2022]
Abstract
BACKGROUND Dual and single antiplatelet therapies are routinely used in carotid artery endarterectomy (CEA). However, the efficacy and safety of these therapies are controversial. The present study aimed to comprehensively compare the clinical outcomes between dual and single antiplatelet therapies in CEA. METHODS This study retrieved available academic studies evaluating the complications related to antiplatelet therapy between dual and single antiplatelet therapies in CEA from the databases of ScienceDirect, the Cochrane Library, EMBASE, and PubMed. References to previous reviews and related clinical trials were manually checked to retrieve potential literature that was not included in our electronic search results. RESULTS A total of 10 articles (1 randomized controlled trial, 9 non-randomized controlled trials) were included in the study. The overall number of patients in the dual antiplatelet group was 14,280, and the number of patients in the single antiplatelet group was 125,850. The results revealed that the single antiplatelet group had a lower incidence of 30-day death (rate difference [RD] 0.002; 95% confidence interval [CI] 0.000-0.003; P = 0.014), neck hematoma (odds ratio [OR] 2.120; 95% CI 1.431-3.142; P < 0.001), myocardial infarction (RD 0.004; 95% CI 0.001-0.007; P = 0.003), and major bleeding (RD 0.005; 95% CI 0.002-0.008; P < 0.001). Meanwhile, the single antiplatelet group was associated with a shorter operation time (weighted mean difference 4.000; 95% CI= 2.564-5.436; P < 0.001). However, there was no significant difference in the rate of postoperative transient ischemic attack (P = 0.215), stroke (P = 0.130), or length of stay (P = 0.563). CONCLUSIONS Based on current evidence, using single antiplatelet therapy in CEA may reduce operation time and the incidences of 30-day death, neck hematoma, major bleeding, and myocardial infarction without increasing the risks of transient ischemic attack, stroke, or a longer operation time.
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Affiliation(s)
- Qun-Long Jiang
- Department of Neurosurgery, Liaocheng People's Hospital, Liaocheng, Shandong, R.P. China
| | - Pei-Jian Wang
- Department of Neurosurgery, Liaocheng People's Hospital, Liaocheng, Shandong, R.P. China
| | - Hui-Xin Liu
- Department of Medical Examination, Liaocheng People's Hospital, Liaocheng, Shandong, R.P. China
| | - Li-Li Huang
- Department of Endocrinology, Liaocheng People's Hospital, Liaocheng, Shandong, R.P. China
| | - Xiao-Kui Kang
- Department of Neurosurgery, Liaocheng People's Hospital, Liaocheng, Shandong, R.P. China.
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Shah VS, Kreatsoulas D, Dornbos D, Cua S, Powers CJ. The impact of pre-operative symptoms on carotid endarterectomy Outcomes: Analysis of the ACS-NSQIP carotid endarterectomy database. J Clin Neurosci 2020; 73:51-56. [PMID: 32019726 DOI: 10.1016/j.jocn.2020.01.077] [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: 06/20/2019] [Revised: 12/01/2019] [Accepted: 01/26/2020] [Indexed: 10/25/2022]
Abstract
Carotid artery stenosis accounts for up to 20% of ischemic strokes. Since the 1950 s, one of the primary surgical treatment for this condition is carotid endarterectomy (CEA). Because of improvement of medical therapy for carotid artery atherosclerosis and the increased use of carotid artery stents, CEA is indicated if the risk of stroke and death are low. The goal of this study is to characterize the impact of pre-operative stroke and stroke risk factors on post-operative CEA patient outcomes, using the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) Targeted Vascular Module on CEA. Using the Targeted Vascular Module of the ACS-NSQIP, 22,116 patients who underwent CEA were identified from 2011 to 2016. Univariate analysis and multivariable logistic regression analyses were conducted to identify significant risk factors that predispose patients to stroke. Patients with pre-operative stroke comprise 42.1% of the group, with post-operative stroke being the second most common complication (2.1%). Pre-operative stroke patients were also at a higher risk for transient ischemic attacks, post-operative restenosis, post-operative distal embolization, and other complications. Patients with pre-operative risk factors, including stroke or stroke-like symptoms, high risk physiologic factors, high risk anatomic factors, and contralateral internal carotid artery stenosis were at a higher risk of developing post-operative stroke and other complications. Patients with these pre-operative risk factors should be closely monitored for post-operative complications in an effort to improve patient outcomes.
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Affiliation(s)
- Varun S Shah
- The Ohio State University College of Medicine, Columbus, OH USA
| | - Daniel Kreatsoulas
- The Ohio State University Wexner Medical Center, Department of Neurological Surgery, Columbus, OH USA
| | - David Dornbos
- The Ohio State University Wexner Medical Center, Department of Neurological Surgery, Columbus, OH USA
| | - Santino Cua
- The Ohio State University College of Medicine, Columbus, OH USA
| | - Ciarán J Powers
- The Ohio State University Wexner Medical Center, Department of Neurological Surgery, Columbus, OH USA.
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Trenner M, Eckstein HH, Kallmayer MA, Reutersberg B, Kühnl A. Secondary analysis of statutorily collected routine data. GEFASSCHIRURGIE 2019. [DOI: 10.1007/s00772-019-0524-y] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
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19
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Journal of Vascular Surgery – December 2018 Audiovisual Summary. J Vasc Surg 2018. [DOI: 10.1016/j.jvs.2018.10.044] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
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