Last neurologic event is associated with risk of in-hospital stroke or death after carotid endarterectomy or carotid artery stenting: Secondary data analysis of the German statutory quality assurance database

CIRSE Standards of Practice on Carotid Artery Stenting

BACKGROUND

Carotid artery stenting has been used effectively to treat internal carotid artery stenosis since 1989 (Mathias et al. in World J Surg. 25(3):328-34, 2001), with refined and expanded techniques and tools presently delivering outstanding results in percutaneous endoluminal treatment of carotid artery stenosis.

PURPOSE

This CIRSE Standards of Practice document is directed at interventional radiologists and details the guidelines for carotid artery stenting, as well as the different implementation techniques. In addition to updating all previously published material on the different clinical indications, it will provide all technical details reflective of European practice for carotid artery stenting. CIRSE Standards of Practice documents do not aim to implement a standard of clinical patient care, but rather to provide a realistic strategy and best practices for the execution of this procedure.

METHODS

The writing group, which was established by the CIRSE Standards of Practice Committee, consisted of five clinicians with internationally recognised expertise in carotid artery stenting procedures. The writing group reviewed existing literature on carotid artery stenting procedures, performing a pragmatic evidence search using PubMed to select relevant publications in the English language from 2006 to 2022.

RESULTS

Carotid artery stenting has an established role in the management of internal carotid artery stenosis; this Standards of Practice document provides up-to-date recommendations for its safe performance.

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

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.

Postoperative Disability and One-Year Outcomes for Patients Suffering a Stroke after Carotid Endarterectomy

OBJECTIVES

Although post-carotid endarterectomy (CEA) strokes are rare, they can be devastating. The degree of disability that patients develop after such events and its effects on long-term outcomes are unclear. Our goal was to assess the extent of postoperative disability in patients suffering strokes after CEA and evaluate its association with long-term outcomes.

METHODS

The Vascular Quality Initiative CEA registry (2016-2020) was queried for CEAs performed for asymptomatic or symptomatic indications in patients with preoperative modified Rankin Scale (mRS) scores of 0-1. The mRS grades stroke-related disability as 0 (none), 1 (not significant), 2-3 (moderate), 4-5 (severe), and 6 (dead). Patients suffering postoperative strokes with recorded mRS scores were included. Postoperative stroke-related disability based on mRS and its association with long-term outcomes were analyzed.

RESULTS

Among 149,285 patients undergoing CEA, there were 1,178 patients without preoperative disability who had postoperative strokes and reported mRS scores. Mean age was 71 ± 9.2 years and 59.6% of patients were male. Regarding ipsilateral cortical symptoms within six months preoperatively, 83.5% of patients were asymptomatic, 7.3% had transient ischemic attacks, and 9.2% had strokes. Postoperative stroke-related disability was classified as mRS 0 (11.6%), 1 (19.5%), 2-3 (29.4%), 4-5 (31.5%), and 6 (8%). One-year survival stratified by postoperative stroke-related disability was 91.4% for mRS 0, 95.6% for mRS 1, 92.1% for mRS 2-3, and 81.5% for mRS 4-5 (P<.001). Multivariable analysis demonstrated that while severe postoperative disability was associated with increased death at one year (HR 2.97, 95% CI 1.5-5.89, P=.002), moderate postoperative disability had no such association (HR .95, 95% CI .45-2, P=.88). One-year freedom from subsequent ipsilateral neurological events or death stratified by postoperative stroke-related disability was 87.8% for mRS 0, 93.3% for mRS 1, 88.5% for mRS 2-3, and 77.9% for mRS 4-5 (P<.001). Severe postoperative disability was independently associated with increased ipsilateral neurological events or death at one year (HR 2.34, 95% CI 1.25-4.38, P=.01). However, moderate postoperative disability exhibited no such association (HR .92, 95% CI .46-1.82, P=.8).

CONCLUSIONS

The majority of patients without preoperative disability who suffered strokes after CEA developed significant disability. Severe stroke-related disability was associated with higher one-year mortality and subsequent neurological events. These data can improve informed consent for CEA and guide prognostication after postoperative strokes.

Locoregional Anaesthesia and Intra-Operative Angiography in Carotid Endarterectomy: 16 Year Results of a Consecutive Single Centre Series

OBJECTIVE

The benefit of local (LA) over general (GA) anaesthesia and the rationale of intra-operative imaging strategies during carotid endarterectomy (CEA) is debated. This study analysed the associations between patient characteristics, LA, and intra-operative imaging strategies and the in hospital stroke and death rates in elective CEA over a 16 year period.

METHODS

All consecutive patients treated by elective CEA between January 2004 and December 2019 (n = 1 872; median age 71 years, 70% male, 37% symptomatic) were included. All patients were assessed neurologically before and within 48 hours after CEA. The primary outcome event was the combined rate of any in hospital stroke or death. Secondary outcome events were the combined rates of any in hospital major stroke (modified Rankin scale [mRS] 3 - 5) or death, stroke, minor stroke (mRS 0 - 2), major stroke, and death alone. To detect changes over time, four quartiles (2004 - 2007, 2008 - 2011, 2012 - 2015, and 2016 - 2019) of this cohort were analysed. Statistical analysis comprised trend tests, and uni- and multivariable logistic regression.

RESULTS

Median patient age increased from 68 to 73 years (p < .001). Over time, LA (from 28% to 91%) and intra-operative imaging (angiography 2.8 - 98.1%, duplex ultrasound 0 - 78.2%) was applied more frequently. Surgical techniques did not change. The in hospital stroke or death and major stroke or death rates decreased from 3.7% to 1.5% (p = .041) and from 2.8% to 0.9% (p = .014), respectively, corresponding to a relative risk of decline of 7% and 12% annually. Multivariable analysis revealed that LA (odds ratio [OR] 0.25, 95% confidence interval [CI] 0.1 - 0.62) and intra-operative angiography (OR 0.09, 95% CI 0.10 - 0.81) were associated with lower in hospital major stroke and death rates.

CONCLUSION

These data demonstrate a decline in the combined rates of any in hospital major stroke or death after non-emergency CEA over time. Locoregional anaesthesia and intra-operative quality control were associated with these improvements and might be worthwhile in elective CEA.

Carotid Endarterectomy is often not Possible after an Unheralded Stroke: Unheralded Stroke in Carotid Artery Stenosis

OBJECTIVES

The ongoing literature recommends carotid endarterectomy (CEA) primarily for patients with neurological symptoms, however CEA can be precluded by the onset of a severe stroke or a total carotid occlusion. The present study aims to evaluate the effect of unheralded strokes in patients with a previously asymptomatic carotid stenosis (ACS) possibly considered for CEA.

MATERIALS AND METHODS

From 2009 to 2019, patients with an unheralded stroke from an ACS were considered. By neurological examination, patients were divided in unfit-for-CEA (uCEA) - either for the severity of the stroke (according to modified Rankin-Scale - mRS) or the onset of a total carotid occlusion - and patients submitted to CEA. Predictors for uCEA and stroke severity were evaluated.

RESULTS

Over a total of 532 patients with symptomatic carotid stenosis, 277 (52%) with unheralded stroke were included in the study. One hundred and one (36%) were considered uCEA: 64(23%) due to their neurological conditions (mRS:5) and 37 (13%) because of the onset of carotid occlusion. One hundred seventy-six (64%) patients underwent CEA. The preoperative medical therapy was similar in uCEA vs CEA patients. Age≥80 years and female sex were independently associated with uCEA (OR:5.9, 95%CI:3.1-11.4, P<.01; OR:3.9, 95%CI:2.0-7.6, P<.01. respectively). Patients submitted to CEA had mRS: 0-2 in 102(37%) cases and mRS:3-4 in 74 (27%). The contralateral carotid occlusion (CCO) was independently associated with mRS:3-4 (OR:8.4, 95%CI 1.8-79, P=.01). Postoperative stroke rate after CEA was 2.9% (4/167); patients with preoperative mRS:3-4 had a higher risk for postoperative stroke compared to those with mRS:0-2 (5.9% vs. 0%. P=.02).

CONCLUSIONS

An unheralded stroke in patients with ACS leads to a severe neurological damage in more than half of cases, either precluding CEA (36%) or increasing the risk of postoperative complications (27%). Female sex, age≥80 and CCO are independent predictors of these occurrences and should be considered in ACS patients.

The effect of carotid revascularization on the ophthalmic artery flow: systematic review and meta-analysis

INTRODUCTION

High-grade internal carotid stenosis results in impaired flow dynamics in the ocular circulation that may lead to a rare clinical entity; ophthalmic ischemic syndrome (OIS). The aim of this study was to investigate hemodynamic changes in the ophthalmic circulation after carotid revascularization, assessed with duplex ultrasonography (DUS), and their potential impact on ocular function in patients suffering from OIS.

EVIDENCE ACQUISITION

A systematic review of the literature was performed according to the PRISMA guidelines. Medline, Embase and Central databases were searched.

EVIDENCE SYNTHESIS

The analysis included fourteen cohort studies (589 patients) reporting on the hemodynamic effect of carotid revascularization on the ophthalmic circulation using DUS. Eighty-five per cent of patients were treated for symptomatic carotid stenosis. The pre- and postoperative ophthalmological evaluation was recorded in four studies (227 out of 358 patients [63%] diagnosed with OIS). Reversed ophthalmic artery (OA) flow prior to carotid revascularization was present in 86 cases (24%). Following carotid revascularization, a significant increase in peak systolic velocity (PSV) (mean difference [MD] 14.712 cm/s, 95% confidence interval [CI] 10.566-18.858, P<0.001, I²=96%) and a significant anterograde restoration of flow in the OA (OR: 2.047, 95% CI: 1.72-2.42, P<0.001, Ι²=0%) were recorded. Carotid revascularization resulted in regression of ischemic symptoms in 93.1% of patients (95% CI: 56.4-99.3%), P=0.001, I²=82%).

CONCLUSIONS

Carotid revascularization may be associated with a significant flow restoration and PSV increase in the OA; as well as clinical improvement in ischemic ophthalmic symptoms in patients with OIS.