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Penton A, Boland T, Weise L, Crisostomo P. Transcarotid arterial revascularization is feasible and safe with concomitant inferior vena cava occlusion. J Vasc Surg Cases Innov Tech 2024; 10:101414. [PMID: 38559375 PMCID: PMC10979231 DOI: 10.1016/j.jvscit.2023.101414] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2023] [Accepted: 12/19/2023] [Indexed: 04/04/2024] Open
Abstract
Transcarotid artery revascularization (TCAR) has risen as a promising minimally invasive intervention for high-risk patients with favorable anatomy. TCAR's noninferiority to carotid endarterectomy regarding stroke is reliant on its flow reversal technology and lack of aortic arch manipulation. We present the case of a 79-year-old man with a chronically occluded inferior vena cava who safely underwent staged bilateral TCAR for bilateral high-grade carotid artery stenosis. Although chronic inferior vena cava occlusion alters flow mechanics, we suspect that any pressure gradient facilitating retrograde flow from the carotid artery to the femoral vein provides neuroprotective benefits.
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Affiliation(s)
- Ashley Penton
- Division of Vascular Surgery and Endovascular Therapy, Department of Surgery, Loyola University Medical Center, Maywood, IL
| | - Thomas Boland
- Division of Vascular Surgery and Endovascular Therapy, Department of Surgery, Loyola University Medical Center, Maywood, IL
| | - Lorela Weise
- Division of Vascular Surgery and Endovascular Therapy, Department of Surgery, Loyola University Medical Center, Maywood, IL
| | - Paul Crisostomo
- Division of Vascular Surgery and Endovascular Therapy, Department of Surgery, Loyola University Medical Center, Maywood, IL
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2
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Pini R, Faggioli G, Paraskevas KI, Campana F, Sufali G, Rocchi C, Palermo S, Gallitto E, Gargiulo M. Carotid Artery Stenting With Double-Layer Stent: A Systematic Review and Meta-Analysis. J Endovasc Ther 2024; 31:339-349. [PMID: 36214459 PMCID: PMC11110467 DOI: 10.1177/15266028221126940] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
BACKGROUND Carotid artery stenting (CAS) in the treatment of significant stenosis is a cause of stroke due to both plaque prolapse and cerebral embolization. New types of stents with a double-layer structure have been designed to minimize plaque prolapse and embolization; these double-layer stents (DLSs) should be able to reduce the stroke risk; however, definite data on their performance are scarce in the literature. METHODS A systematic search was performed through PubMed, Scopus, and Cochrane Library, according to PRISMA guidelines; all studies on CAS with DLS (Roadsaver/Casper or CGuard) up to January 1, 2022, with a cohort of at least 20 patients were considered eligible. The present meta-analysis was approved and registered on PROSPERO register (CRD42022297512). Patients with tandem lesions or complete carotid occlusion were excluded from the study. The 30-day stroke rate after CAS was analyzed evaluating the preoperative symptomatic status and DLS occlusion. The estimated pooled rate of events was calculated by random effect model and moderators were evaluated. RESULTS A total of 14 studies were included in the meta-analysis for a total of 1955 patients. The estimated overall (95% confidence interval [CI]) stroke rate was 1.4% (0.9%-2.2%, I2 = 0%), which was not influenced by the type of DLS used: CGuard 0.8% (0.4%-1.8%, I2 = 0%) versus Roadsaver/Casper 1.5% (0.7%-3.2%, I2 = 0%), p=0.30. The 30-day estimated stroke rate was 1.5% (0.8%-2.9%, I2 = 0%) in asymptomatic and 1.9% (1.0%-3.6%, I2 = 0%) in symptomatic patients, with no influence by moderators. The 30-day DLS occlusion rate was 0.8% (0.4%-1.8%, I2 = 0%). The publication bias assessment identified asymmetry in the asymptomatic populations. CONCLUSION The overall 30-day stroke rate in CAS with DLS is low (1.4%), with similar results in symptomatic and asymptomatic patients. Acute occlusion of DLS is rare (0.8%). Further studies are necessary to reduce the publication bias for asymptomatic patients. CLINICAL IMPACT CAS with DLS is associated to a low rate of 30-day stroke in both symptomatic (1.9%) and asymptomatic (1.5%) patients. The type of DLS (CGuard or Roadsaver/Casper) did not affect the 30-day stroke rate.
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Affiliation(s)
- Rodolfo Pini
- Department of Vascular Surgery, University of Bologna and Policlinico Sant’Orsola Malpighi, Bologna, Italy
| | - Gianluca Faggioli
- Department of Vascular Surgery, University of Bologna and Policlinico Sant’Orsola Malpighi, Bologna, Italy
| | | | - Federica Campana
- Department of Vascular Surgery, University of Bologna and Policlinico Sant’Orsola Malpighi, Bologna, Italy
| | - Gemmi Sufali
- Department of Vascular Surgery, University of Bologna and Policlinico Sant’Orsola Malpighi, Bologna, Italy
| | - Cristina Rocchi
- Department of Vascular Surgery, University of Bologna and Policlinico Sant’Orsola Malpighi, Bologna, Italy
| | - Sergio Palermo
- Department of Vascular Surgery, University of Bologna and Policlinico Sant’Orsola Malpighi, Bologna, Italy
| | - Enrico Gallitto
- Department of Vascular Surgery, University of Bologna and Policlinico Sant’Orsola Malpighi, Bologna, Italy
| | - Mauro Gargiulo
- Department of Vascular Surgery, University of Bologna and Policlinico Sant’Orsola Malpighi, Bologna, Italy
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Ryu JC, Lee SH, Kwon B, Song Y, Lee DH, Kim BJ, Kang DW, Kwon SU, Kim JS, Chang JY. Distal normal vessel diameter might be associated with silent brain infarcts after stenting for symptomatic carotid stenosis. J Clin Neurosci 2024; 125:1-6. [PMID: 38728814 DOI: 10.1016/j.jocn.2024.05.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2024] [Revised: 03/28/2024] [Accepted: 05/02/2024] [Indexed: 05/12/2024]
Abstract
BACKGROUND Carotid artery stenting (CAS) has been the standard treatment for carotid stenosis because it is less invasive; however, the risk of periprocedural thromboembolism is high. We investigated the predictors for silent brain infarcts (SBIs), focusing on embolic protection in CAS. METHODS This study was single-center retrospective study, and we obtained baseline demographics and clinical, laboratory, and periprocedural variables of patients who underwent CAS. Also, methods used for embolic protection (no EPD, distal EPD, or proximal balloon guiding catheter) during CAS were obtained. Distal normal vessel diameter was defined as the diameter of cervical internal carotid artery where the artery wall becomes parallel. Diffusion-weighted imaging was performed before and after procedure to detect SBIs. The primary outcome was stented territory SBIs, and the secondary outcomes were any territories SBIs and stented territory SBIs in cases with EPD. RESULTS A total of 196 CAS procedures with mean age 69.1 ± 9.9 years were included. After CAS, stented territory SBIs occurred in 53 (27.0 %) cases and any territories SBIs in 60 (30.6 %) cases. Univariable analyses revealed that distal normal vessel diameter (odds ratio = 1.71, 95 % confidence interval = 1.20-2.43, P = 0.003) was associated with the occurrence of stented territory SBIs after CAS. After adjusting for potential variables, larger distal normal vessel diameter (1.61 [1.10-2.36], P = 0.014) increased the occurrence of SBIs after CAS. Consistent results were obtained when the outcome was any territories SBIs or stented territory SBIs in cases with EPD. CONCLUSIONS Distal normal vessel diameter was a predictor for the occurrence of SBI after CAS. The passable pore size of EPDs may vary depending on vessel diameter, and may impact the occurrence of SBIs.
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Affiliation(s)
- Jae-Chan Ryu
- Department of Neurology, Korea University Ansan Hospital, Korea University College of Medicine, Ansan, South Korea
| | - Sang-Hun Lee
- Department of Neurology, Korea University Ansan Hospital, Korea University College of Medicine, Ansan, South Korea
| | - Boseong Kwon
- Departments of Radiology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, South Korea
| | - Yunsun Song
- Departments of Radiology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, South Korea
| | - Deok Hee Lee
- Departments of Radiology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, South Korea
| | - Bum Joon Kim
- Departments of Neurology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, South Korea
| | - Dong-Wha Kang
- Departments of Neurology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, South Korea
| | - Sun U Kwon
- Departments of Neurology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, South Korea
| | - Jong S Kim
- Department of Neurology, Gangneung Asan Hospital, University of Ulsan College of Medicine, Gangneung, South Korea
| | - Jun Young Chang
- Departments of Neurology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, South Korea.
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Zohourian T, Hines G. The Evolution of Current Management for Carotid Artery Bifurcation Disease. Cardiol Rev 2024; 32:257-262. [PMID: 36729106 DOI: 10.1097/crd.0000000000000497] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
Options for treatment of symptomatic carotid bifurcation disease include carotid endarterectomy (CEA) and carotid artery stenting (CAS). While over the years CEA has established itself as the gold standard for carotid artery revascularization, results from recent trials have shown CAS to be safe and effective in selected patients. This review details the evolution of carotid artery bifurcation disease by highlighting key clinical trials.
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Affiliation(s)
- Tirajeh Zohourian
- From the Department of Surgery, New York University Langone Long Island Hospital, Mineola, NY
- Department of Surgery, New York University Long Island School of Medicine, Mineola, NY
| | - George Hines
- From the Department of Surgery, New York University Langone Long Island Hospital, Mineola, NY
- Department of Surgery, New York University Long Island School of Medicine, Mineola, NY
- New York University Langone Vascular Surgery Associates-Mineola, Mineola, NY
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Parrino CR, Grewal A, Gibbons M, Toursavadkohi SA, Rock P, Anders MG. Nasal Intubation is not Associated with "Smoother" Emergence from General Anesthesia for Carotid Endarterectomy: A Case-Cohort Study. Ann Vasc Surg 2024; 102:56-63. [PMID: 38296037 DOI: 10.1016/j.avsg.2023.10.034] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2023] [Revised: 10/22/2023] [Accepted: 10/30/2023] [Indexed: 02/23/2024]
Abstract
BACKGROUND Postoperative hematoma after carotid endarterectomy (CEA) is a devastating complication and may be more likely in patients with uncontrolled hypertension and coughing on emergence from anesthesia. We sought to determine if intubation with a nasal endotracheal tube (ETT)-instead of an oral ETT-is associated with "smoother" (i.e., less hemodynamic instability) emergence from general anesthesia for CEA. METHODS Patients receiving CEA between December 2015 and September 2021 at a single tertiary academic medical center were included. We examined the electronic anesthesia records for 323 patients who underwent CEA during the 6-year study period and recorded consecutive systolic blood pressure (SBP) values during the 10 minutes before extubation as a surrogate for "smoothness" of the emergence. RESULTS Intubation with a nasal ETT, when compared with intubation with an oral ETT, was not associated with any difference in maximum, minimum, average, median, or standard deviation of serial SBP values in the 10 minutes before extubation. The average SBP on emergence for patients with an oral ETT was 141 mm Hg and with a nasal ETT was 144 mm Hg (P = 0.562). The maximum SBP for patients with oral and nasal ETTs were 170 mm Hg and 174 mm Hg, respectively (P = 0.491). There were also no differences in the qualitative "smoothness" of emergence or in the percentage of patients who required an intravenous dose of 1 or more antihypertensive medications. The incidence of postoperative complications was similar between the 2 groups. CONCLUSIONS When SBP is used as a surrogate for smoothness of emergence from general anesthesia for CEA, intubation with a nasal ETT was not associated with better hemodynamic stability compared to intubation with an oral ETT.
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Affiliation(s)
- Christopher R Parrino
- Department of Anesthesiology, University of Maryland School of Medicine, Baltimore, MD.
| | - Ashanpreet Grewal
- Department of Anesthesiology, University of Maryland School of Medicine, Baltimore, MD
| | - Miranda Gibbons
- Department of Anesthesiology, University of Maryland School of Medicine, Baltimore, MD
| | - Shahab A Toursavadkohi
- Division of Vascular Surgery, Department of Surgery, University of Maryland School of Medicine, Baltimore, MD
| | - Peter Rock
- Department of Anesthesiology, University of Maryland School of Medicine, Baltimore, MD
| | - Megan G Anders
- Department of Anesthesiology, University of Maryland School of Medicine, Baltimore, MD
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Yei KS, Janssen C, Elsayed N, Naazie I, Sedrakyan A, Malas MB. Long-term outcomes of carotid endarterectomy vs transfemoral carotid stenting in a Medicare-matched database. J Vasc Surg 2024; 79:826-834.e3. [PMID: 37634620 DOI: 10.1016/j.jvs.2023.08.118] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2023] [Revised: 08/14/2023] [Accepted: 08/22/2023] [Indexed: 08/29/2023]
Abstract
BACKGROUND Carotid endarterectomy (CEA) is associated with lower risk of perioperative stroke compared with transfemoral carotid artery stenting (TFCAS) in the treatment of carotid artery stenosis. However, there is discrepancy in data regarding long-term outcomes. We aimed to compare long-term outcomes of CEA vs TFCAS using the Medicare-matched Vascular Quality Initiative Vascular Implant Surveillance and Interventional Outcomes Network database. METHODS We assessed patients undergoing first-time CEA or TFCAS in Vascular Quality Initiative Vascular-Vascular Implant Surveillance and Interventional Outcomes Network from January 2003 to December 2018. Patients with prior history of carotid revascularization, nontransfemoral stenting, stenting performed without distal embolic protection, multiple or nonatherosclerotic lesions, or concomitant procedures were excluded. The primary outcome of interest was all-cause mortality, any stroke, and a combined end point of death or stroke. We additionally performed propensity score matching and stratification based on symptomatic status. RESULTS A total of 80,146 carotid revascularizations were performed, of which 72,615 were CEA and 7531 were TFCAS. CEA was associated with significantly lower risk of death (57.8% vs 70.4%, adjusted hazard ratio [aHR], 0.46; 95% confidence interval [CI], 0.41-0.52; P < .001), stroke (21.3% vs 26.6%; aHR, 0.63; 95% CI, 0.57-0.69; P < .001) and combined end point of death and stroke (65.3% vs 76.5%; HR, 0.49; 95% CI, 0.44-0.55; P < .001) at 10 years. These findings were reflected in the propensity-matched cohort (combined end point: 34.6% vs 46.8%; HR, 0.53; 95% CI, 0.46-0.62) at 4 years, as well as stratified analyses of combined end point by symptomatic status (asymptomatic: 63.2% vs 74.9%; HR, 0.49; 95% CI, 0.43-0.58; P < .001; symptomatic: 69.9% vs 78.3%; HR, 0.51; 95% CI, 0.45-0.59; P < .001) at 10 years. CONCLUSIONS In this analysis of North American real-world data, CEA was associated with greater long-term survival and fewer strokes compared with TFCAS. These findings support the continued use of CEA as the first-line revascularization procedure.
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Affiliation(s)
- Kevin S Yei
- Division of Vascular and Endovascular Surgery, University of California San Diego, La Jolla, CA
| | - Claire Janssen
- Division of Vascular and Endovascular Surgery, University of California San Diego, La Jolla, CA
| | - Nadin Elsayed
- Division of Vascular and Endovascular Surgery, University of California San Diego, La Jolla, CA
| | - Isaac Naazie
- Division of Vascular and Endovascular Surgery, University of California San Diego, La Jolla, CA
| | - Art Sedrakyan
- Division of Vascular and Endovascular Surgery, Weill Cornell Medical College, New York, NY
| | - Mahmoud B Malas
- Division of Vascular and Endovascular Surgery, University of California San Diego, La Jolla, CA.
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Lun R, Zitikyte G, Yogendrakumar V, Bereznyakova O, Dewar B, Dowlatshahi D, Fahed R, Shamy M. Network meta-analysis can inform the ethical evaluation of trials that randomise away from standard of care: The case of symptomatic carotid stenosis. J Eval Clin Pract 2024; 30:376-384. [PMID: 38059277 DOI: 10.1111/jep.13951] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/10/2023] [Revised: 09/27/2023] [Accepted: 10/19/2023] [Indexed: 12/08/2023]
Abstract
OBJECTIVE Little guidance exists on the conduct of randomised clinical trials (RCT) that seek to randomise patients away from standard of care. We sought to test the technique of network meta-analysis (NMA) to ascertain best available evidence for the purposes of informing the ethical evaluation of RCTs under these circumstances. We used the example of RCTs for patients with symptomatic, moderate to severe carotid stenosis that seek to compare surgical intervention plus medical therapy (standard of care) versus medical therapy (less than standard of care). STUDY DESIGN AND SETTING Network meta-analysis of RCTs of adults with symptomatic carotid artery stenosis of 50%-99% who were treated with carotid endarterectomy (CEA), carotid artery stenting (CAS), or medical therapy (MT). The primary outcome was any stroke or death until end of follow-up, and secondary outcome was 30-day risk of ipsilateral stroke/death. RESULTS We analysed eight studies, with 7187 subjects with symptomatic moderate/severe stenosis (50%-99%). CEA was more efficacious than MT (HR = 0.82, 95% credible intervals [95% CrI] = 0.73-0.92) and CAS (HR 0.73, 95% CrI = 0.62-0.85) for the prevention of any stroke/death. At 30 days, the odds of experiencing an ipsilateral stroke/death were significantly lower in the CEA group compared to both MT (OR = 0.58, 95% CrI = 0.47-0.72) and CAS (OR = 0.68, 95% CrI = 0.55-0.83). CONCLUSION Our results support the feasibility of using NMA to assess best available evidence to inform the ethical evaluation of RCTs seeking to randomise patients away from standard of care. Our results suggest that a strong argument is required to ethically justify the conduct of RCTs that seek to randomise patients away from standard of care in the setting of symptomatic moderate to severe carotid stenosis.
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Affiliation(s)
- Ronda Lun
- School of Epidemiology and Public Health, University of Ottawa, Ottawa, Canada
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Canada
- Department of Medicine, Division of Neurology, The Ottawa Hospital, Ottawa, Canada
| | - Gabriele Zitikyte
- School of Epidemiology and Public Health, University of Ottawa, Ottawa, Canada
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Canada
| | - Vignan Yogendrakumar
- Department of Medicine, Division of Neurology, The Ottawa Hospital, Ottawa, Canada
- Department of Medicine and Neurology, The Royal Melbourne Hospital, Parkville, Australia
| | - Olena Bereznyakova
- Department of Neurosciences, Centre Hospitalier de l'Universite de Montreal, Montreal, Canada
| | - Brian Dewar
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Canada
- Department of Medicine, Division of Neurology, The Ottawa Hospital, Ottawa, Canada
| | - Dar Dowlatshahi
- School of Epidemiology and Public Health, University of Ottawa, Ottawa, Canada
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Canada
- Department of Medicine, Division of Neurology, The Ottawa Hospital, Ottawa, Canada
| | - Robert Fahed
- School of Epidemiology and Public Health, University of Ottawa, Ottawa, Canada
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Canada
- Department of Medicine, Division of Neurology, The Ottawa Hospital, Ottawa, Canada
| | - Michel Shamy
- School of Epidemiology and Public Health, University of Ottawa, Ottawa, Canada
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Canada
- Department of Medicine, Division of Neurology, The Ottawa Hospital, Ottawa, Canada
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Rodríguez I, Gramegna LL, Requena M, Rizzuti M, Elosua I, Mayol J, Olivé-Gadea M, Diana F, Rodrigo-Gisbert M, Muchada M, Rivera E, García-Tornel Á, Rizzo F, De Dios M, Rodríguez-Luna D, Piñana C, Pagola J, Hernández D, Juega J, Rodríguez N, Quintana M, Molina C, Ribo M, Tomasello A. Safety and efficacy of early carotid artery stenting in patients with symptomatic stenosis. Interv Neuroradiol 2024:15910199241239204. [PMID: 38515363 DOI: 10.1177/15910199241239204] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/23/2024] Open
Abstract
BACKGROUND Symptomatic carotid artery stenosis is a significant contributor to ischemic strokes. Carotid artery stenting (CAS) is usually indicated for secondary stroke prevention. This study evaluates the safety and efficacy of CAS performed within a short time frame from symptom onset. METHODS We conducted a single-center, retrospective study of consecutive patients who underwent CAS for symptomatic carotid stenosis within eight days of symptom onset from July 2019 to January 2022. Data on demographics, medical history, procedural details, and follow-up outcomes were analyzed. The primary outcome measure was the recurrence of the stroke within the first month post-procedure. Secondary outcomes included mortality, the rate of intra-procedural complications, and hyperperfusion syndrome. RESULTS We included 93 patients with a mean age of 71.7 ± 11.7 years. The median time from symptom onset to CAS was 96 h. The rate of stroke recurrence was 5.4% in the first month, with a significant association between the number of stents used and increased recurrence risk. Mortality within the first month was 3.2%, with an overall mortality rate of 11.8% after a median follow-up of 19 months. Intra-procedural complications were present in five (5.4%) cases and were related to the number of stents used (p = 0.002) and post-procedural angioplasty (p = 0.045). Hyperperfusion syndrome occurred in 3.2% of cases. CONCLUSION Early CAS within the high-risk window post-symptom onset is a viable secondary stroke prevention strategy in patients with symptomatic carotid artery stenosis. The procedure rate of complication is acceptable, with a low recurrence of stroke. However, further careful selection of patients for this procedural strategy is crucial to optimize outcomes.
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Affiliation(s)
- Isabel Rodríguez
- Interventional Neuroradiology Unit, Department of Neurosciences, Hospital Universitari Germans Trias i Pujol, Badalona, Spain
| | - Laura Ludovica Gramegna
- Vall d'Hebron Institut de Recerca, Vall d'Hebron Barcelona Hospital Campus, Barcelona, Spain
| | - Manuel Requena
- Vall d'Hebron Institut de Recerca, Vall d'Hebron Barcelona Hospital Campus, Barcelona, Spain
- Department of Radiology, Interventional Neuroradiology Section, Hospital Universitari Vall d'Hebron, Barcelona, Spain
- Stroke Unit, Department of Neurology, Hospital Universitari Vall d'Hebron Barcelona Spain, Barcelona, Spain
| | | | - Iker Elosua
- Stroke Unit, Department of Neurology, Hospital Universitari Vall d'Hebron Barcelona Spain, Barcelona, Spain
| | - Jordi Mayol
- Stroke Unit, Department of Neurology, Hospital Universitari Vall d'Hebron Barcelona Spain, Barcelona, Spain
| | - Marta Olivé-Gadea
- Vall d'Hebron Institut de Recerca, Vall d'Hebron Barcelona Hospital Campus, Barcelona, Spain
- Stroke Unit, Department of Neurology, Hospital Universitari Vall d'Hebron Barcelona Spain, Barcelona, Spain
| | - Francesco Diana
- Vall d'Hebron Institut de Recerca, Vall d'Hebron Barcelona Hospital Campus, Barcelona, Spain
- Department of Radiology, Interventional Neuroradiology Section, Hospital Universitari Vall d'Hebron, Barcelona, Spain
| | - Marc Rodrigo-Gisbert
- Vall d'Hebron Institut de Recerca, Vall d'Hebron Barcelona Hospital Campus, Barcelona, Spain
- Stroke Unit, Department of Neurology, Hospital Universitari Vall d'Hebron Barcelona Spain, Barcelona, Spain
| | - Marián Muchada
- Vall d'Hebron Institut de Recerca, Vall d'Hebron Barcelona Hospital Campus, Barcelona, Spain
- Stroke Unit, Department of Neurology, Hospital Universitari Vall d'Hebron Barcelona Spain, Barcelona, Spain
| | - Eila Rivera
- Vall d'Hebron Institut de Recerca, Vall d'Hebron Barcelona Hospital Campus, Barcelona, Spain
| | - Álvaro García-Tornel
- Vall d'Hebron Institut de Recerca, Vall d'Hebron Barcelona Hospital Campus, Barcelona, Spain
- Stroke Unit, Department of Neurology, Hospital Universitari Vall d'Hebron Barcelona Spain, Barcelona, Spain
| | - Federica Rizzo
- Vall d'Hebron Institut de Recerca, Vall d'Hebron Barcelona Hospital Campus, Barcelona, Spain
- Stroke Unit, Department of Neurology, Hospital Universitari Vall d'Hebron Barcelona Spain, Barcelona, Spain
| | - Marta De Dios
- Vall d'Hebron Institut de Recerca, Vall d'Hebron Barcelona Hospital Campus, Barcelona, Spain
- Department of Radiology, Interventional Neuroradiology Section, Hospital Universitari Vall d'Hebron, Barcelona, Spain
| | - David Rodríguez-Luna
- Vall d'Hebron Institut de Recerca, Vall d'Hebron Barcelona Hospital Campus, Barcelona, Spain
- Stroke Unit, Department of Neurology, Hospital Universitari Vall d'Hebron Barcelona Spain, Barcelona, Spain
| | - Carlos Piñana
- Interventional Radiology, Hospital Clínico Valencia, Barcelona, Spain
| | - Jorge Pagola
- Vall d'Hebron Institut de Recerca, Vall d'Hebron Barcelona Hospital Campus, Barcelona, Spain
- Stroke Unit, Department of Neurology, Hospital Universitari Vall d'Hebron Barcelona Spain, Barcelona, Spain
| | - David Hernández
- Vall d'Hebron Institut de Recerca, Vall d'Hebron Barcelona Hospital Campus, Barcelona, Spain
- Department of Radiology, Interventional Neuroradiology Section, Hospital Universitari Vall d'Hebron, Barcelona, Spain
| | - Jesús Juega
- Vall d'Hebron Institut de Recerca, Vall d'Hebron Barcelona Hospital Campus, Barcelona, Spain
- Stroke Unit, Department of Neurology, Hospital Universitari Vall d'Hebron Barcelona Spain, Barcelona, Spain
| | - Noelia Rodríguez
- Vall d'Hebron Institut de Recerca, Vall d'Hebron Barcelona Hospital Campus, Barcelona, Spain
- Stroke Unit, Department of Neurology, Hospital Universitari Vall d'Hebron Barcelona Spain, Barcelona, Spain
| | - Manuel Quintana
- Epilepsy Unit, Department of Neurology, Hospital Universitari Vall d'Hebron, Barcelona, Spain
| | - Carlos Molina
- Vall d'Hebron Institut de Recerca, Vall d'Hebron Barcelona Hospital Campus, Barcelona, Spain
- Stroke Unit, Department of Neurology, Hospital Universitari Vall d'Hebron Barcelona Spain, Barcelona, Spain
| | - Marc Ribo
- Vall d'Hebron Institut de Recerca, Vall d'Hebron Barcelona Hospital Campus, Barcelona, Spain
- Stroke Unit, Department of Neurology, Hospital Universitari Vall d'Hebron Barcelona Spain, Barcelona, Spain
| | - Alejandro Tomasello
- Vall d'Hebron Institut de Recerca, Vall d'Hebron Barcelona Hospital Campus, Barcelona, Spain
- Department of Radiology, Interventional Neuroradiology Section, Hospital Universitari Vall d'Hebron, Barcelona, Spain
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9
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Grüter BE, Croci D, Vakharia K, Gruber P, Taussky P. Editorial: Hybrid (combined endovascular and microsurgical) treatments for cerebrovascular diseases. Front Neurol 2024; 15:1378269. [PMID: 38533415 PMCID: PMC10964722 DOI: 10.3389/fneur.2024.1378269] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2024] [Accepted: 02/19/2024] [Indexed: 03/28/2024] Open
Affiliation(s)
- Basil E. Grüter
- Institute of Neuroradiology, Aarau Cantonal Hospital, Aarau, Switzerland
- Service de Neuroradiologie, Hôpital de la Timone, Marseille, France
| | - Davide Croci
- Department of Neurosurgery and Brain Repair, University of South Florida, Morsani College of Medicine, Tampa, FL, United States
| | - Kunal Vakharia
- Department of Neurosurgery and Brain Repair, University of South Florida, Morsani College of Medicine, Tampa, FL, United States
| | - Philipp Gruber
- Institute of Neuroradiology, Aarau Cantonal Hospital, Aarau, Switzerland
| | - Philipp Taussky
- Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, United States
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10
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Paraskevas KI, Zeebregts CJ, AbuRahma AF, Perler BA. Implications of the Centers for Medicare and Medicaid Services (CMS) decision to expand indications for carotid artery stenting. J Vasc Surg 2024:S0741-5214(24)00425-7. [PMID: 38462061 DOI: 10.1016/j.jvs.2024.03.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2024] [Revised: 02/24/2024] [Accepted: 03/03/2024] [Indexed: 03/12/2024]
Affiliation(s)
| | - Clark J Zeebregts
- Department of Surgery (Division of Vascular Surgery), University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Ali F AbuRahma
- Department of Surgery, Charleston Area Medical Center/West Virginia University, Charleston, WV
| | - Bruce A Perler
- Department of Surgery, The Johns Hopkins Hospital, Baltimore, MD
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11
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Salih M, Mallick A, Rai HH, Nwajei F, Cappuzzo JM, Snyder K, Ogilvy CS. Percutaneous transluminal angioplasty or stenting of petrous and cavernous internal carotid artery stenosis - a systematic review. J Neuroradiol 2024; 51:82-88. [PMID: 37364744 DOI: 10.1016/j.neurad.2023.06.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2022] [Revised: 06/20/2023] [Accepted: 06/23/2023] [Indexed: 06/28/2023]
Abstract
Percutaneous transluminal angioplasty (PTA) and stenting have been used for the treatment of internal carotid artery (ICA) stenosis over the past two decades. A systematic review was performed to understand the efficacy of PTA and/or stenting for petrous and cavernous ICA stenosis. In total, 151 patients (mean age 64.9) met criteria for analysis, 117 (77.5%%) were male and 34 (22.5%) were female. Of the 151 patients, 35 of them (23.2%) had PTA, and 116 (76.8%) had endovascular stenting. Twenty-two patients had periprocedural complications. There was no significant difference in the complication rates between the PTA (14.3%) and stent (14.7%) groups. Distal embolism was the most common periprocedural complication. Average clinical follow up for 146 patients was 27.3 months. Eleven patients (7.5%) out of 146 had retreatment. The treatment of petrous and cavernous ICA with PTA and stenting has relatively significant procedure related complication rates and adequate long-term patency.
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Affiliation(s)
- Mira Salih
- Neurosurgical Service, Beth Israel Deaconess Medical Center, Harvard Medical School, 110 Francis Street Boston, Boston, MA 02215, United States
| | - Akashleena Mallick
- Neurosurgical Service, Beth Israel Deaconess Medical Center, Harvard Medical School, 110 Francis Street Boston, Boston, MA 02215, United States
| | | | - Felix Nwajei
- Boston Medical Center, Boston, MA, United States
| | | | - Kenneth Snyder
- University at Buffalo Neurosurgery, Buffalo, NY, United States
| | - Christopher S Ogilvy
- Neurosurgical Service, Beth Israel Deaconess Medical Center, Harvard Medical School, 110 Francis Street Boston, Boston, MA 02215, United States.
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12
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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] [What about the content of this article? (0)] [Affiliation(s)] [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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13
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Javidan A, Benipal H, Vi L, Li A, Lee Y, Feridooni T, Alaichi J, Naji F. Assessing the robustness of positive vascular surgery randomized controlled trials using their fragility index. J Vasc Surg 2024; 79:148-158.e3. [PMID: 37315910 DOI: 10.1016/j.jvs.2023.05.051] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2021] [Revised: 05/15/2023] [Accepted: 05/17/2023] [Indexed: 06/16/2023]
Abstract
OBJECTIVE The fragility index (FI) measures the robustness of statistically significant findings in randomized controlled trials (RCTs) by quantifying the minimum number of event conversions required to reverse a dichotomous outcome's statistical significance. In vascular surgery, many clinical guidelines and critical decision-making points are informed by a handful of key RCTs, especially regarding open surgical versus endovascular treatment. The objective of this study is to evaluate the FI of RCTs with statistically significant primary outcomes that compared open vs endovascular surgery in vascular surgery. METHODS In this meta-epidemiological study and systematic review, MEDLINE, Embase, and CENTRAL were searched for RCTs comparing open versus endovascular treatments for abdominal aortic aneurysms, carotid artery stenosis, and peripheral arterial disease to December 2022. RCTs with statistically significant primary outcomes were included. Data screening and extraction were conducted in duplicate. The FI was calculated by adding an event to the group with the smaller number of events while subtracting a nonevent to the same group until Fisher's exact test produced a nonstatistically significant result. The primary outcome was the FI and proportion of outcomes where the loss to follow-up was greater than the FI. The secondary outcomes assessed the relationship of the FI to disease state, presence of commercial funding, and study design. RESULTS Overall, 5133 articles were captured in the initial search with 21 RCTs reporting 23 different primary outcomes being included in the final analysis. The median FI (first quartile, third quartile) was 3 (3, 20) with 16 outcomes (70%) reporting a loss to follow-up greater than its FI. Mann-Whitney U test revealed that commercially funded RCTs and composite outcomes had greater FIs (median, 20.0 [5.5, 24.5] vs median, 3.0 [2.0, 5.5], P = .035; median, 21 [8, 38] vs median, 3.0 [2.0, 8.5], P = .01, respectively). The FI did not vary between disease states (P = .285) or between index and follow-up trials (P = .147). There were significant correlations between the FI and P values (Pearson r = 0.90; 95% confidence interval, 0.77-0.96), and the number of events (r = 0.82; 95% confidence interval, 0.48-0.97). CONCLUSIONS A small number of event conversions (median, 3) are needed to alter the statistical significance of primary outcomes in vascular surgery RCTs evaluating open surgical and endovascular treatments. Most studies had loss to follow-up greater than its FI, which can call into question trial results, and commercially funded studies had a greater FI. The FI and these findings should be considered in future trial design in vascular surgery.
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Affiliation(s)
- Arshia Javidan
- Division of Vascular Surgery, University of Toronto, Toronto, Ontario, Canada.
| | - Harsukh Benipal
- Temerty Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Lisa Vi
- Temerty Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Allen Li
- Faculty of Medicine/The Ottawa Hospital Research Institute, University of Ottawa, Ottawa, Ontario, Canada
| | - Yung Lee
- Division of General Surgery, Department of Surgery, McMaster University, Hamilton, Ontario, Canada; Harvard T.H. Chan School of Public Health, Harvard University, Boston, MA
| | - Tiam Feridooni
- Division of Vascular Surgery, University of Toronto, Toronto, Ontario, Canada
| | - Jacob Alaichi
- Division of Vascular Surgery, Department of Surgery, McMaster University, Hamilton, Ontario, Canada
| | - Faysal Naji
- Division of Vascular Surgery, Department of Surgery, McMaster University, Hamilton, Ontario, Canada
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14
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Liu L, Li Z, Zhou H, Duan W, Huo X, Xu W, Li S, Nie X, Liu H, Liu J, Sun D, Wei Y, Zhang G, Yuan W, Zheng L, Liu J, Wang D, Miao Z, Wang Y. Chinese Stroke Association guidelines for clinical management of ischaemic cerebrovascular diseases: executive summary and 2023 update. Stroke Vasc Neurol 2023; 8:e3. [PMID: 38158224 PMCID: PMC10800268 DOI: 10.1136/svn-2023-002998] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2023] [Accepted: 11/23/2023] [Indexed: 01/03/2024] Open
Abstract
BACKGROUND China is one of the countries with the highest burden of stroke. Implementing multidimensional management guidelines will help clinicians practise evidence-based care, improve patient outcomes and alleviate societal burdens. This update of the 2019 edition will provide the latest comprehensive recommendations for the diagnosis and treatment of ischaemic cerebrovascular diseases. METHODS We conducted a comprehensive search on MEDLINE (via PubMed) up to 31 August 2023. The writing team established the recommendations through multiple rounds of online and offline discussions. Each recommendation was graded using the evidence grading algorithm developed by the Chinese Stroke Association (CSA). The draft was reviewed and finalised by the CSA Stroke Guidelines Writing Committee. RESULTS This update included revisions of 15 existing recommendations and 136 new recommendations in the following areas of stroke care: emergency assessment and diagnosis of ischaemic cerebrovascular disease, acute-phase reperfusion therapy, evaluation of underlying mechanisms, antithrombotic therapy, prevention and treatment of complications, and risk factor management. CONCLUSIONS This guideline updated the recommendations for the clinical management of ischaemic cerebrovascular disease from 2019.
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Affiliation(s)
- Liping Liu
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
- China National Clinical Research Center for Neurological Diseases, Beijing, China
| | - Zixiao Li
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
- China National Clinical Research Center for Neurological Diseases, Beijing, China
- National Center for Healthcare Quality Management in Neurological Diseases, Beijing, China
- Research Unit of Artificial Intelligence in Cerebrovascular Disease, Chinese Academy of Medical Sciences, Beijing, China
- Chinese Institute for Brain Research, Beijing, China
| | - Hongyu Zhou
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
- China National Clinical Research Center for Neurological Diseases, Beijing, China
| | - Wanying Duan
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
- China National Clinical Research Center for Neurological Diseases, Beijing, China
| | - Xiaochuan Huo
- Neurological Disease Center, Cerebral Vascular Disease Department, Beijing Anzhen Hospital, Capital Medical University, Beijing, China
| | - Weihai Xu
- Department of Neurology, State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Shujuan Li
- Department of Neurology, National Clinical Research Center for Cardiovascular Diseases, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Ximing Nie
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
- China National Clinical Research Center for Neurological Diseases, Beijing, China
| | - Huihui Liu
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
- China National Clinical Research Center for Neurological Diseases, Beijing, China
- Department of Neurology and Suzhou Clinical Research Center of Neurological Disease, the Second Affiliated Hospital of Soochow University, Suzhou, China
| | - Jinjie Liu
- Department of General Medicine, Dalian Municipal Central Hospital Affiliated Dalian University of Technology, Dalian, China
| | - Dapeng Sun
- China National Clinical Research Center for Neurological Diseases, Beijing, China
- Interventional Neuroradiology, Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Yufei Wei
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
- China National Clinical Research Center for Neurological Diseases, Beijing, China
| | - Guitao Zhang
- Department of Neurology, National Clinical Research Center for Cardiovascular Diseases, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Weizhuang Yuan
- Department of Neurology, State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Lina Zheng
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
- China National Clinical Research Center for Neurological Diseases, Beijing, China
| | - Jingyi Liu
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
- China National Clinical Research Center for Neurological Diseases, Beijing, China
| | - David Wang
- Neurovascular Division, Department of Neurology, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona, USA
| | - Zhongrong Miao
- China National Clinical Research Center for Neurological Diseases, Beijing, China
- Interventional Neuroradiology, Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Yongjun Wang
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
- China National Clinical Research Center for Neurological Diseases, Beijing, China
- National Center for Healthcare Quality Management in Neurological Diseases, Beijing, China
- Advanced Innovation Center for Human Brain Protection, Capital Medical University, Beijing, China
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15
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Nakagawa I, Kotsugi M, Yokoyama S, Maeoka R, Furuta T, Tanaka H, Takeshima Y, Matsuda R, Yamada S, Nakase H. Dual-layered stents reduce cerebral embolism compared with first-generation stents during carotid stenting of high lipid core plaque lesions. J Neurointerv Surg 2023; 16:67-72. [PMID: 36944492 DOI: 10.1136/jnis-2023-020106] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2023] [Accepted: 03/13/2023] [Indexed: 03/23/2023]
Abstract
BACKGROUND Periprocedural lipid core plaque (LCP) has been detected in carotid arteries assessed by catheter-based near-infrared spectroscopy (NIRS). High LCP is associated with cerebral embolism after carotid artery stenting (CAS) using a first-generation stent. We aimed to evaluate whether dual-layered stents reduce embolic infarcts in patients with high LCP and change of lipid signal as assessed by NIRS during CAS. METHODS Participants comprised 210 consecutive patients undergoing CAS. The study was divided into two distinct periods, with first-generation closed-cell stents used in the earlier period and dual-layered stents used in the later period. NIRS was performed at baseline, after stent implantation, and after balloon post-dilatation to analyze maximal lipid core burden index at minimal luminal area (max-LCBIMLA). RESULTS The ipsilateral cerebral embolism rate was significantly lower with dual-layered stents (9%) than with first-generation stents (33%, p<0.001), particularly with highly lipidic lesions (12% vs 60%, p<0.001). On multivariate logistic regression analysis, high LCP and first-generation stent usage were factors related to ipsilateral cerebral embolism (both p<0.001; OR 8.28 (95% CI 3.49 to 19.64) and OR 8.07 (95% CI 2.33 to 27.93), respectively). Max-LCBIMLA decreased significantly after stenting in both groups (both p<0.01) and max-LCBIMLA after balloon post-dilatation was significantly lower with dual-layered stents (22.4±65.6) than with first-generation stents (124.2±208.2; p=0.006). CONCLUSIONS Dual-layered stents reduce embolic infarcts in patients with highly lipidic plaque lesions as assessed by NIRS who undergo CAS. Dual-layered stents significantly reduced NIRS-derived lipid signals after stenting.
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Affiliation(s)
- Ichiro Nakagawa
- Department of Neurosurgery, Nara Medical University, Kashihara, Japan
| | - Masashi Kotsugi
- Department of Neurosurgery, Nara Medical University, Kashihara, Japan
| | - Shohei Yokoyama
- Department of Neurosurgery, Nara Medical University, Kashihara, Japan
| | - Ryosuke Maeoka
- Department of Neurosurgery, Nara Medical University, Kashihara, Japan
| | - Takanori Furuta
- Department of Neurosurgery, Nara Medical University, Kashihara, Japan
| | - Haku Tanaka
- Department of Neurosurgery, Nara Medical University, Kashihara, Japan
| | | | - Ryosuke Matsuda
- Department of Neurosurgery, Nara Medical University, Kashihara, Japan
| | - Shuichi Yamada
- Department of Neurosurgery, Nara Medical University, Kashihara, Japan
| | - Hiroyuki Nakase
- Department of Neurosurgery, Nara Medical University, Kashihara, Japan
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16
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Lamarca MP, Flores Á, Martín A, Peinado J, Estébanez S, Arriola M, Llergo B, García E, Tique J, Torralbas F, Millán E, Rigolin M, Lobato P, Segundo JC, Morín M, Jamilena Á, Moreno R, Orgaz A. Prospective evaluation of acute cerebral injury by DW-MRI following transcarotid artery revascularization using a double-layer micromesh stent. J Cardiovasc Surg (Torino) 2023; 64:583-590. [PMID: 38078708 DOI: 10.23736/s0021-9509.23.12764-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/23/2024]
Abstract
BACKGROUND Transcervical carotid artery revascularization (TCAR) has demonstrated a low overall stroke rate in carotid artery stenting (CAS). Furthermore, the use of a double-layer micromesh stent is expected to reduce embolization and plaque prolapse. The combination of TCAR and the double layer stent may lead to improved results compared to previously reported outcomes. The objective of this study is to present the findings of a prospective study including patients treated with the Roadsaver stent and TCAR. METHODS Between January 2017 and May 2022, 85 patients were enrolled. Every patient underwent TCAR with the Roadsaver stent. As per our protocol, a neurological examination and an ultrasound were performed within 24 hours before and after the procedure, and again 30 days after. A diffusion-weighted magnetic resonance imaging (DW-MRI) was conducted 24 hours before the procedure and 48-72 hours after the procedure. The primary endpoint was the detection of new ischemic lesions on postoperative DW-MRI. The secondary endpoint was a composite of all strokes, death, and myocardial infarction within 30 days. RESULTS Sixty-four patients (75.29%) were symptomatic, out of which 25 were treated within 14 days of the onset of the symptoms. Pre and postprocedural DW-MRI were performed in 83 patients. Postprocedural lesions were found in nine patients (10.84%). There were no strokes or death within 30 days, but two patients experienced a myocardial infarction. CONCLUSIONS Our study suggests that the use of TCAR and the Roadsaver stent could be a safe alternative to carotid endarterectomy because it entails a low incidence of cerebral embolization, even in recently symptomatic and elderly patients.
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Affiliation(s)
- María P Lamarca
- Department of Vascular and Endovascular Surgery, Complejo Hospitalario de Toledo, Toledo, Spain -
| | - Ángel Flores
- Department of Vascular and Endovascular Surgery, Complejo Hospitalario de Toledo, Toledo, Spain
| | - Alberto Martín
- Department of Vascular and Endovascular Surgery, Complejo Hospitalario de Toledo, Toledo, Spain
| | - Javier Peinado
- Department of Vascular and Endovascular Surgery, Complejo Hospitalario de Toledo, Toledo, Spain
| | - Santiago Estébanez
- Department of Vascular and Endovascular Surgery, Complejo Hospitalario de Toledo, Toledo, Spain
| | - Maite Arriola
- Department of Vascular and Endovascular Surgery, Complejo Hospitalario de Toledo, Toledo, Spain
| | - Belén Llergo
- Department of Vascular and Endovascular Surgery, Complejo Hospitalario de Toledo, Toledo, Spain
| | - Enrique García
- Department of Vascular and Endovascular Surgery, Complejo Hospitalario de Toledo, Toledo, Spain
| | - Julián Tique
- Department of Vascular and Endovascular Surgery, Complejo Hospitalario de Toledo, Toledo, Spain
| | - Fredy Torralbas
- Department of Vascular and Endovascular Surgery, Complejo Hospitalario de Toledo, Toledo, Spain
| | - Elisa Millán
- Department of Vascular and Endovascular Surgery, Complejo Hospitalario de Toledo, Toledo, Spain
| | - Martina Rigolin
- Department of Vascular and Endovascular Surgery, Complejo Hospitalario de Toledo, Toledo, Spain
| | - Paula Lobato
- Stroke Section, Department of Neurology, Complejo Hospitalario de Toledo, Toledo, Spain
| | - José C Segundo
- Stroke Section, Department of Neurology, Complejo Hospitalario de Toledo, Toledo, Spain
| | - Mar Morín
- Stroke Section, Department of Neurology, Complejo Hospitalario de Toledo, Toledo, Spain
| | - Álvaro Jamilena
- Stroke Section, Department of Neurology, Complejo Hospitalario de Toledo, Toledo, Spain
| | - Raquel Moreno
- Neuroradiology Section, Department of Radiology, Complejo Hospitalario de Toledo, Toledo, Spain
| | - Antonio Orgaz
- Department of Vascular and Endovascular Surgery, Complejo Hospitalario de Toledo, Toledo, Spain
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17
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Keil F, Stahn S, Reitz SC, Lieschke F, du Mesnil de Rochemont R, Hattingen E, Berkefeld J. Elective carotid stenting fulfills quality standards defined in guidelines. ROFO-FORTSCHR RONTG 2023. [PMID: 37963550 DOI: 10.1055/a-2175-4029] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2023]
Abstract
PURPOSE According to evidence from randomized trials and current guidelines, elective carotid artery stenting (CAS) is still considered second-line therapy compared with carotid endarterectomy (CEA). However, the publication of randomized comparative trials for patients with symptomatic stenoses occurred well over 10 years ago. In view of problems regarding German quality assurance when differentiating elective from emergency interventions and low case numbers for CAS indications, it seemed reasonable to present neurologically controlled CAS results and to investigate whether elective CAS consistently fulfills the strict quality criteria and what differences exist with respect to emergency CAS interventions in acute ischemic stroke. MATERIALS AND METHODS Between 01/2012 and 07/2022, 141 elective CAS procedures were performed to treat patients with symptomatic (n = 123) and asymptomatic (n = 18) stenoses. Protection by a filter system was achieved in 134 of these elective procedures (95 %). During the same period, 158 patients underwent carotid stenting for acute stroke. Complication rates were determined using neurologically controlled data. CAS-related complications (stent thrombosis, stent-associated vascular damage, thromboembolism, and symptomatic hemorrhage) were extracted from emergency interventions, and clinical outcome (NIHSS progression) was determined during the inpatient stay. RESULTS The rate of stroke and death determined during the inpatient stay for elective symptomatic patients was 0.8 %. Early treatment within the first 7 days after the index event, age > 70 years, and operator experience were not significant risk factors for the occurrence of complications. No complications were observed after CAS of asymptomatic stenoses. The procedure-related complication rate for emergency procedures was 7.8 %, which was significantly higher than after elective CAS, as expected (p < 0.006). CONCLUSION Even with limited indications and limited case numbers, compliance with the strict quality criteria of the current S3 Guideline 2022 for elective CAS interventions is possible for both symptomatic and asymptomatic stenoses in an experienced center. Emergency CAS interventions have significantly higher complication rates under other conditions and must be considered separately with regard to quality assurance. KEY POINTS · Elective carotid stenting fulfills the strict quality criteria of the current S3 guideline 2022.. · Emergency carotid stenting has significantly higher complication rates than elective procedures.. · Elective and emergency carotid stenting cannot be meaningfully compared.. CITATION FORMAT · Keil F, Stahn S, Reitz SC et al. Elective carotid stenting fulfills quality standards defined in guidelines. Fortschr Röntgenstr 2023; DOI: 10.1055/a-2175-4029.
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Affiliation(s)
- Fee Keil
- Neuroradiology, Hospital of the Goethe University Frankfurt Institute of Neuroradiology, Frankfurt am Main, Germany
| | - Simon Stahn
- Radiology, Hospital Nordwest Frankfurt, Germany
| | - Sarah Christina Reitz
- Neurosurgery, Hospital of the Goethe University Frankfurt Center of Neurology and Neurosurgery, Frankfurt am Main, Germany
| | - Franziska Lieschke
- Neurology, Hospital of the Goethe University Frankfurt Center of Neurology and Neurosurgery, Frankfurt am Main, Germany
| | | | - Elke Hattingen
- Neuroradiology, Hospital of the Goethe University Frankfurt Institute of Neuroradiology, Frankfurt am Main, Germany
| | - Joachim Berkefeld
- Neuroradiology, Hospital of the Goethe University Frankfurt Institute of Neuroradiology, Frankfurt am Main, Germany
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18
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Hsu AC, Williams B, Ding L, Weaver FA, Han SM, Magee GA. Risk Factors for Cerebral Hyperperfusion Syndrome following Carotid Revascularization. Ann Vasc Surg 2023; 97:89-96. [PMID: 37356658 DOI: 10.1016/j.avsg.2023.06.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2023] [Revised: 05/31/2023] [Accepted: 06/04/2023] [Indexed: 06/27/2023]
Abstract
BACKGROUND Cerebral hyperperfusion syndrome (CHS) is a rare but known complication of carotid revascularization that can result in severe postoperative disability and death. CHS is a well-described sequela of carotid endarterectomy (CEA) and, more recently, of transfemoral carotid artery stenting (TFCAS), but its incidence after transcarotid artery revascularization (TCAR) has not been delineated. The aims of this study were to determine the impact of procedure type (CEA versus TCAR versus TFCAS) on the development of CHS as well as to identify perioperative risk factors associated with CHS. METHODS The Society for Vascular Surgery Vascular Quality Initiative was queried for patients aged ≥18 years who underwent CEA, TCAR, or TFCAS from 2015-2021. Emergent procedures were excluded. The primary outcome was postoperative development of CHS, defined as the presence of postoperative seizures, intracerebral hemorrhage due to hyperperfusion, or both. Bivariate and multivariable logistic regression analyses were performed to identify factors associated with CHS. RESULTS 156,003 procedures were included (72.7% CEA, 12.4% TCAR, and 14.9% TFCAS). The incidence of CHS after CEA, TCAR, and TFCAS were 0.15%, 0.18%, and 0.53%, respectively. There was no significant difference in risk of CHS after TFCAS compared to CEA (odds ratio [OR]: 1.21; 95% confidence interval [CI] 0.76-1.92; P = 0.416), nor was there a difference between TCAR and CEA (OR: 0.91; 95% CI 0.57-1.45; P = 0.691). Perioperative risk factors associated with an increased risk of CHS included previous history of transient ischemic attack or stroke (OR: 2.50; 95% CI 1.69-3.68; P < 0.0001), necessity for urgent intervention within 48 hr (OR: 2.03; 95% CI 1.43-2.89; P < 0.0001), treatment of a total occlusion (OR: 3.80; 95% CI 1.16-12.47; P = 0.028), and need for postoperative intravenous blood pressure medication (OR: 5.45; 95% CI 3.97-7.48; P < 0.0001). Age, preoperative hypertension, degree of ipsilateral stenosis less than or equal to 99%, and history of prior carotid procedures were not statistically associated with an increased risk of CHS. Discharging patients on an angiotensin-converting enzyme inhibitor or angiotensin II receptor blocker was associated with a decreased risk of developing CHS (OR: 0.47; 95% CI 0.34-0.65; P < 0.0001). CONCLUSIONS Compared with CEA, TCAR and TFCAS were not statistically associated with an increased risk of postoperative CHS. Patients with a previous history of transient ischemic attack or stroke, who require urgent intervention or postoperative intravenous blood pressure medication, or who are treated for a total occlusion are at a higher risk of developing CHS. Using an angiotensin-converting enzyme inhibitor/angiotensin II receptor blocker on discharge appears to be protective against CHS and should be considered for the highest risk patients.
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Affiliation(s)
- Ashley C Hsu
- Division of Vascular Surgery and Endovascular Therapy, Keck Medicine of USC, Los Angeles, CA
| | - Brian Williams
- Department of Surgery, University of Southern California, Los Angeles, CA
| | - Li Ding
- Department of Population and Public Health Sciences, University of Southern California, Los Angeles, CA
| | - Fred A Weaver
- Division of Vascular Surgery and Endovascular Therapy, Keck Medicine of USC, Los Angeles, CA
| | - Sukgu M Han
- Division of Vascular Surgery and Endovascular Therapy, Keck Medicine of USC, Los Angeles, CA
| | - Gregory A Magee
- Division of Vascular Surgery and Endovascular Therapy, Keck Medicine of USC, Los Angeles, CA.
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19
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Nana P, Spanos K, Kouvelos G, Georgakopoulou VE, Lempesis IG, Trakas N, Sklapani P, Paterakis K, Fotakopoulos G, Brotis AG. Carotid artery stenting and endarterectomy surgery techniques: A 30‑year time‑lapse. Med Int (Lond) 2023; 3:61. [PMID: 38204583 PMCID: PMC10777268 DOI: 10.3892/mi.2023.121] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 08/22/2023] [Accepted: 10/30/2023] [Indexed: 01/12/2024]
Abstract
Carotid endarterectomy or carotid artery stenting (CAS), are the most important axes in carotid artery interventional management. A bibliometric analysis permits an easier access to the current literature trends and information to design future studies. The aim of the present study was to identify the knowledge routes on CAS and examine the research front on the topic. The search was interpreted in Scopus, from 1994 to 2023, and included only original articles and reviews. The BibTex format was used to download all citation and bibliographic data. The present analysis was conducted in two parts, a descriptive one and a network extraction process. Between 1994 and 2023, 34,503 references and 7,758 authors were recorded. The annual growth rate was 21.64%. The CAVATAS trial was the most cited article. As regards word trends, since 2017, trans-carotid stenting, risk factors and plaque characteristics are highlighted. CAS remains an area of high interest with a publication growth rate of >20% per year. As numerous questions remain to be answered, the need to determine the role of CAS may drive further research.
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Affiliation(s)
- Petroula Nana
- Department of Vascular Surgery, Larissa University Hospital, Faculty of Medicine, School of Health Sciences, University of Thessaly, 41221 Larissa, Greece
| | - Konstantinos Spanos
- Department of Vascular Surgery, Larissa University Hospital, Faculty of Medicine, School of Health Sciences, University of Thessaly, 41221 Larissa, Greece
| | - George Kouvelos
- Department of Vascular Surgery, Larissa University Hospital, Faculty of Medicine, School of Health Sciences, University of Thessaly, 41221 Larissa, Greece
| | | | - Ioannis G. Lempesis
- Department of Pathophysiology, National and Kapodistrian University of Athens, 11527 Athens, Greece
| | - Nikolaos Trakas
- Department of Biochemistry, Sismanogleio Hospital, 15126 Athens, Greece
| | - Pagona Sklapani
- Department of Biochemistry, Sismanogleio Hospital, 15126 Athens, Greece
| | - Konstantinos Paterakis
- Department of Neurosurgery, General University Hospital of Larissa, 41221 Larissa, Greece
| | - George Fotakopoulos
- Department of Neurosurgery, General University Hospital of Larissa, 41221 Larissa, Greece
| | - Alexandros G. Brotis
- Department of Neurosurgery, General University Hospital of Larissa, 41221 Larissa, Greece
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20
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Ito Y, Ishikawa E, Sato M, Marushima A, Hayakawa M, Maruo K, Takigawa T, Kato N, Tsuruta W, Uemura K, Matsumaru Y. Comparison of the Clinical Outcome of Carotid Artery Stenting Between Institutions With a Treatment Strategy Based on Risk Factors and Those With First-Line Treatment. J Endovasc Ther 2023; 30:746-755. [PMID: 35678727 DOI: 10.1177/15266028221102654] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
PURPOSE Carotid endarterectomy (CEA) and carotid artery stenting (CAS) are recommended based on certain risk factors. The volume of an institution's treatment experience may be associated with good clinical outcomes. There is a dilemma between the treatment strategy based on risk factors and the experience volume. Therefore, we investigated the clinical outcomes of CAS performed at institutions that selected the treatment strategy based on risk factors and those that performed CAS at the first-line treatment. MATERIALS AND METHODS Patients who underwent CAS at 5 institutions were included in this retrospective case-control study. We defined CEA/CAS institutions as those that selected the treatment option based on risk factors, and CAS-first institutions as those that performed CAS as the first-line treatment. We investigated cases of ischemic stroke, hemorrhagic stroke, myocardial infarction, and deaths within 30 days of the intervention between the CEA/CAS- and CAS-first institution groups. One-to-one propensity score matching was performed to compare rates of ischemic and hemorrhagic strokes within 30 days of the intervention. RESULTS A total of 239 and 302 patients underwent CAS at the CEA/CAS institutions and CAS-first institutions, respectively; ischemic stroke occurred in 12 (5.0%) and 7 patients (2.3%), respectively (p=0.09). No differences in major ischemic strokes (0.8% vs 1.3%; p=0.59), hemorrhagic strokes (0.4% vs 0.3%; p=0.87), or deaths (0.0% vs 0.7%; p=0.21) were observed. Myocardial infarction did not occur in either group. Propensity score analysis showed that ischemic stroke (odds ratio: 1.845, 95% confidence interval: 0.601-5.668, p=0.28) and hemorrhagic stroke (odds ratio: 1.000, 95% confidence interval: 0.0061-16.418, p=1.00) were not significantly associated with either institution group. CONCLUSIONS The CAS-specific treatment strategies for CAS can achieve the same level of outcomes as the treatment strategy based on risk factors. The CAS performed based on risk factors in CEA/CAS institutions and the treatment of more than 30 patients/year/institution in CAS-first institutions were associated with good clinical outcomes.
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Affiliation(s)
- Yoshiro Ito
- Department of Neurosurgery, Faculty of Medicine, University of Tsukuba, Tsukuba, Japan
| | - Eiichi Ishikawa
- Department of Neurosurgery, Faculty of Medicine, University of Tsukuba, Tsukuba, Japan
| | - Masayuki Sato
- Department of Neurosurgery, Faculty of Medicine, University of Tsukuba, Tsukuba, Japan
| | - Aiki Marushima
- Department of Neurosurgery, Faculty of Medicine, University of Tsukuba, Tsukuba, Japan
| | - Mikito Hayakawa
- Division of Stroke Prevention and Treatment, Faculty of Medicine, University of Tsukuba, Tsukuba, Japan
| | - Kazushi Maruo
- Department of Biostatistics, Faculty of Medicine, University of Tsukuba, Tsukuba, Japan
| | - Tomoji Takigawa
- Department of Neurosurgery, Saitama Medical Center, Dokkyo Medical University, Koshigaya, Japan
| | - Noriyuki Kato
- Department of Neurosurgery, Mito Medical Center, Mito, Japan
| | - Wataro Tsuruta
- Department of Endovascular Neurosurgery, Toranomon Hospital, Tokyo, Japan
| | - Kazuya Uemura
- Department of Neurosurgery, Tsukuba Medical Center Hospital, Tsukuba, Japan
| | - Yuji Matsumaru
- Department of Neurosurgery, Faculty of Medicine, University of Tsukuba, Tsukuba, Japan
- Division of Stroke Prevention and Treatment, Faculty of Medicine, University of Tsukuba, Tsukuba, Japan
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21
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Kremer C, Lorenzano S, Bejot Y, Lal A, Epple C, Gdovinova Z, Mono ML, Karapanayiotides T, Jovanovic D, Dawson J, Caso V. Sex differences in outcome after carotid revascularization in symptomatic and asymptomatic carotid artery stenosis. J Vasc Surg 2023; 78:817-827.e10. [PMID: 37055001 DOI: 10.1016/j.jvs.2023.03.502] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2022] [Revised: 03/11/2023] [Accepted: 03/19/2023] [Indexed: 04/15/2023]
Abstract
OBJECTIVE Sex differences regarding the safety and efficacy of carotid revascularization in carotid artery stenosis have been addressed in several studies with conflicting results. Moreover, women are underrepresented in clinical trials, leading to limited conclusions regarding the safety and efficacy of acute stroke treatments. METHODS A systematic review and meta-analysis was performed by literature search including four databases from January 1985 to December 2021. Sex differences in the efficacy and safety of revascularization procedures, including carotid endarterectomy (CEA) and carotid artery stenting (CAS), for symptomatic and asymptomatic carotid artery stenoses were analyzed. RESULTS Regarding CEA in symptomatic carotid artery stenosis, the stroke risk in men (3.6%) and women (3.9%) based on 99,495 patients (30 studies) did not differ (P = .16). There was also no difference in the stroke risk by different time frames up to 10 years. Compared with men, women treated with CEA had a significantly higher stroke or death rate at 4 months (2 studies, 2565 patients; 7.2% vs 5.0%; odds ratio [OR], 1.49; 95% confidence interval [CI], 1.04-2.12; I2 = 0%; P = .03), and a significantly higher rate of restenosis (1 study, 615; 17.2% vs 6.7%; OR, 2.81; 95% CI, 1.66-4.75; P = .0001). For CAS in symptomatic artery stenosis, data showed a non-significant tendency toward higher peri-procedural stroke in women, whereas for asymptomatic carotid artery stenosis, data based on 332,344 patients showed that women (compared with men) after CEA had similar rates of stroke, stroke or death, and the composite outcome stroke/death/myocardial infarction. The rate of restenosis at 1 year was significantly higher in women compared with men (1 study, 372 patients; 10.8% vs 3.2%; OR, 3.71; 95% CI, 1.49-9.2; P = .005). Furthermore, CAS in asymptomatic patients was associated with low risk of a postprocedural stroke in both sexes, but a significantly higher risk of in-hospital myocardial infarction in women than men (8445 patients, 1.2% vs 0.6%; OR, 2.01; 95% CI, 1.23-3.28; I2 = 0%; P = .005). CONCLUSIONS A few sex-differences in short-term outcomes after carotid revascularization for symptomatic and asymptomatic carotid artery stenosis were found, although there were no significant differences in the overall stroke. This indicates a need for larger multicenter prospective studies to evaluate these sex-specific differences. More women, including those aged over 80 years, need to be enrolled in randomized controlled trials, to better understand if sex differences exist and to tailor carotid revascularization accordingly.
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Affiliation(s)
- Christine Kremer
- Neurology Department, Skåne University Hospital, Department Clinical Sciences Lund University, Malmö, Sweden.
| | - Svetlana Lorenzano
- Department of Human Neurosciences, Sapienza University of Rome, Rome, Italy
| | - Yannick Bejot
- Dijon Stroke Registry, EA7460, Pathophysiology and Epidemiology of Cerebro-Cardiovascular diseases (PEC2), University Hospital of Dijon, University of Burgundy, UBFC, Dijon, France
| | - Avtar Lal
- European Stroke Organisation (ESO), Basel, Switzerland
| | - Corina Epple
- Neurology Department, Klinikum Hanau, Hanau, Germany
| | - Zuzana Gdovinova
- Neurology Department, Faculty of Medicine P.J. Safarik University Košice, Košice, Slovakia
| | - Marie-Luise Mono
- Department of Neurology, Municipal Hospital Waid und Triemli, Zürich, Switzerland; University Hospital and University of Bern, Bern, Switzerland
| | - Theodore Karapanayiotides
- Second Department of Neurology, School of Medicine, Faculty of Health Sciences, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Dejana Jovanovic
- Department of Emergency Neurology, Neurology Clinic, Clinical Center of Serbia, Medical Faculty, University of Belgrade, Belgrade, Serbia
| | - Jesse Dawson
- Institute of Cardiovascular and Medical Sciences, College of Medical, Veterinary, and Life Sciences, University of Glasgow, Glasgow, Scotland
| | - Valeria Caso
- Stroke Unit, Santa Maria della Misericordia Hospital, University of Perugia, Perugia, Italy
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22
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Columbo JA, Stone DH, Martinez-Camblor P, Goodney PP, O’Malley AJ. Adoption and Diffusion of Transcarotid Artery Revascularization in Contemporary Practice. Circ Cardiovasc Interv 2023; 16:e012805. [PMID: 37725675 PMCID: PMC10516509 DOI: 10.1161/circinterventions.122.012805] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/02/2023] [Accepted: 07/14/2023] [Indexed: 09/21/2023]
Abstract
BACKGROUND In 2015, the FDA approved transcarotid artery revascularization (TCAR) as an alternative to carotid endarterectomy (CEA) and transfemoral carotid artery stenting (TF-CAS) for high-risk patients with carotid stenosis. This was granted in the absence of level 1 evidence to support TCAR. We aimed to document trends in TCAR utilization, its diffusion over time, and the clinical phenotypes of patients undergoing TCAR, CEA, and TF-CAS. METHODS We used the Vascular Quality Initiative to study patients who underwent TCAR. We calculated the number of TCARs performed and the percent of TCAR utilization versus CEA/TF-CAS. Using data from before TCAR was widespread, we calculated propensity scores for patients to receive CEA. We applied this model to patients undergoing carotid revascularization from 2016 to 2022 and grouped patients by the procedure they ultimately underwent, examining overlap in score distribution to measure patient similarity. We measured the trend of in-hospital stroke/death after TCAR. RESULTS We studied 31 447 patients who underwent TCAR from January 1, 2016 to March 31, 2022. The number of centers performing TCAR increased from 29 to 606. In 2021, TCAR represented 22.5% of carotid revascularizations at centers offering all 3 procedures. The percentage of patients that underwent TCAR who met approved high-risk criteria decreased from 88.5% to 80.9% (P<0.001). Those with a prior ipsilateral carotid procedure decreased from 20.6% in 2016 to 12.0% in 2021 (P<0.001). Patients undergoing TCAR after stroke increased from 19.7% to 30.7% (P<0.001). Propensity-score overlap was 55.4% for TCAR/CEA, and 58.6% for TCAR/TF-CAS, demonstrating that TCAR patients have a clinical phenotype mixed between those who undergo CEA and TF-CAS. The average in-hospital stroke/death risk after TCAR was 2.3% in 2016 and 1.7% in 2022 (P trend: 0.954). CONCLUSIONS TCAR now represents nearly 1-in-4 procedures at centers offering it. TCAR was increasingly performed among standard-risk patients and as a first-line procedural option after stroke. The absence of level 1 evidence underscores the importance of high-quality registry-based analyses to document TCAR's real-world outcomes and durability.
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Affiliation(s)
- Jesse A. Columbo
- Section of Vascular Surgery, Heart and Vascular Center, Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire
- Geisel School of Medicine at Dartmouth College, Hanover, New Hampshire
| | - David H. Stone
- Section of Vascular Surgery, Heart and Vascular Center, Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire
- Geisel School of Medicine at Dartmouth College, Hanover, New Hampshire
| | - Pablo Martinez-Camblor
- Department of Anesthesia, Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire
- Department of Biomedical Data Science, Dartmouth College, Hanover, New Hampshire
| | - Philip P. Goodney
- Section of Vascular Surgery, Heart and Vascular Center, Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire
- Geisel School of Medicine at Dartmouth College, Hanover, New Hampshire
| | - A. James O’Malley
- Geisel School of Medicine at Dartmouth College, Hanover, New Hampshire
- Department of Biomedical Data Science, Dartmouth College, Hanover, New Hampshire
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23
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Mohd AB, Alabdallat Y, Mohd OB, Ghannam RA, Sawaqed S, Hasan H, Ellebedy M, Turkmani K, Al-Ezzi S. Medical and Surgical Management of Symptomatic and Asymptomatic Carotid Artery Stenosis: A Comprehensive Literature Review. Cureus 2023; 15:e43263. [PMID: 37692579 PMCID: PMC10491926 DOI: 10.7759/cureus.43263] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/09/2023] [Indexed: 09/12/2023] Open
Abstract
Carotid artery stenosis is a condition where the carotid artery is blocked by fatty cholesterol deposits called plaque, increasing the risk of stroke. Elderly individuals with high cardiovascular risk are more susceptible, along with smokers, those with high cholesterol, males, and older individuals. Young females may also be affected by fibromuscular dysplasia. Carotid stenosis significantly raises stroke risk, and the severity is closely linked to stroke incidence and other cardiovascular events. Early detection and treatment are essential to prevent complications. Treatment options include medical and surgical interventions, such as carotid endarterectomy (CEA) and carotid artery stenting (CAS). The choice between surgery and medical management varies depending on patient characteristics and risk factors. This review explores carotid artery stenosis pathophysiology, risk factors, the importance of early detection and treatment, and the surgical approaches of CEA and CAS, addressing their roles and controversies. Healthcare professionals must understand these aspects to provide optimal care to patients with this condition.
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Affiliation(s)
- Ahmed B Mohd
- Faculty of Medicine, Hashemite University, Zarqa, JOR
| | | | - Omar B Mohd
- Faculty of Medicine, Hashemite University, Zarqa, JOR
| | | | - Seri Sawaqed
- Infectious Disease, Faculty of Medicine, Hashemite University, Zarqa, JOR
| | - Hanan Hasan
- Medical Laboratory, The Lab Medical Laboratories, Amman, JOR
| | | | | | - Shakir Al-Ezzi
- Internal Medicine, Hospital Corporation of America (HCA) Medical City Arlington, Dallas, USA
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24
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Banks CA, Pearce BJ. Interventions in Carotid Artery Surgery: An Overview of Current Management and Future Implications. Surg Clin North Am 2023; 103:645-671. [PMID: 37455030 DOI: 10.1016/j.suc.2023.05.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/18/2023]
Abstract
Atherosclerotic carotid artery disease has been well studied over the last half-century by multiple randomized controlled trials attempting to elucidate the appropriate modality of therapy for this disease process. Surgical techniques have evolved from carotid artery endarterectomy and transfemoral carotid artery stenting to the development of hybrid techniques in transcarotid artery revascularization. In this article, the authors provide a review of the available literature regarding operative and medical management of carotid artery disease.
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Affiliation(s)
- Charles Adam Banks
- Division of Vascular Surgery and Endovascular Therapy, University of Alabama at Birmingham, 1808 7th Avenue South, Boshell Diabetes Building 652, Birmingham, AL 35294, USA
| | - Benjamin J Pearce
- Division of Vascular Surgery and Endovascular Therapy, University of Alabama at Birmingham, 1808 7th Avenue South, Boshell Diabetes Building 652, Birmingham, AL 35294, USA.
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25
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Uno M. History of Carotid Artery Reconstruction around the World and in Japan. Neurol Med Chir (Tokyo) 2023; 63:283-294. [PMID: 37081650 PMCID: PMC10406461 DOI: 10.2176/jns-nmc.2022-0362] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2022] [Accepted: 02/15/2023] [Indexed: 04/22/2023] Open
Abstract
Since ancient times, physicians have been aware of correlations between the carotid artery and consciousness; however, carotid stenosis was only recently identified as the cause of atherothrombotic ischemic stroke. In 1658, Wepfer described the first suggestion of a link between symptoms of cerebral arterial insufficiency and carotid pathology. In 1951, Fisher reported details of the symptoms and pathological findings and emphasized that cervical atheromatous lesions induced cerebral infarction with various symptoms. The beginning of carotid artery surgery was ligation of the carotid artery for neck or head injury, but surgeons were aware that this operation induced cerebral symptoms due to lack of blood supply. Carotid endarterectomy (CEA) was first reported by Eastcott et al. in 1954, and in Japan, Kimoto performed a successful CEA in 1962. In 1979, percutaneous transluminal angioplasty (PTA) was performed for patients with fibromuscular dysplasia, and then, carotid artery stenting (CAS) was first performed in 1989 by Mathias. In Japan, Kuwana et al. were the first to perform carotid PTA, in 1981, whereas Yamashita et al. performed the first CAS in 1997. Yoshimura et al. proposed staged carotid stenting to prevent hyperperfusion syndrome. Some issues in carotid reconstruction are still debated today, which include conventional (standard) CEA versus the eversion technique, CEA versus CAS versus medical therapy, and medical economic problems. In the future, we must continue to develop more effective, safer, and less expensive therapeutic methods to prevent carotid stroke, carrying on the efforts of the ancient peoples who pioneered this research.
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Affiliation(s)
- Masaaki Uno
- Department of Neurosurgery, Kawasaki Medical School
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26
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Calo P, Oberhuber A, Görtz H. Patient Selection Criteria and Procedural Standardization for Carotid Artery Stenting-A Single Center Experience. J Clin Med 2023; 12:jcm12103534. [PMID: 37240640 DOI: 10.3390/jcm12103534] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2023] [Revised: 04/26/2023] [Accepted: 05/16/2023] [Indexed: 05/28/2023] Open
Abstract
The gold standard for the treatment of carotid artery stenosis is the carotid endarterectomy (CEA). According to current guidelines, carotid artery stenting (CAS) is an alternative. Randomized control trials (RCTs) show significantly higher rates of peri-interventional strokes after CAS compared to CEA. However, these trials were usually characterized by a great heterogeneity in the CAS procedure. In this retrospective analysis from 2012 to 2020, 202 symptomatic and asymptomatic patients were treated with CAS. Patients were carefully pre-selected according to anatomical and clinical criteria. In all cases, the same steps and material were used. All interventions were performed by five experienced vascular surgeons. Primary endpoints of this study were perioperative death and stroke. Asymptomatic carotid stenosis was present in 77% of the patients and symptomatic in 23%. The mean age was 66 years. The average degree of stenosis was 81%. The CAS technical success rate was 100%. Periprocedural complications occurred in 1.5% of cases, including one major stroke (0.5%) and two minor strokes (1%). The results of this study indicate that through a strict patient selection based on anatomical and clinical criteria, CAS can be performed with very low complication rates. Furthermore, standardization of the materials and the procedure itself is crucial.
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Affiliation(s)
- Paolo Calo
- Department of Vascular Surgery, Bonifatius Hospital Lingen, 49808 Lingen, Germany
| | - Alexander Oberhuber
- Department of Vascular and Endovascular Surgery, University Hospital Muenster, 48149 Muenster, Germany
| | - Hartmut Görtz
- Department of Vascular Surgery, Bonifatius Hospital Lingen, 49808 Lingen, Germany
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27
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Liang P, Cronenwett JL, Secemsky EA, Eldrup-Jorgensen J, Malas MB, Wang GJ, Nolan BW, Kashyap VS, Motaganahalli RL, Schermerhorn ML. Risk of Stroke, Death, and Myocardial Infarction Following Transcarotid Artery Revascularization vs Carotid Endarterectomy in Patients With Standard Surgical Risk. JAMA Neurol 2023; 80:437-444. [PMID: 36939697 PMCID: PMC10028539 DOI: 10.1001/jamaneurol.2023.0285] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2022] [Accepted: 01/13/2023] [Indexed: 03/21/2023]
Abstract
Importance Carotid artery stenting has been limited to use in patients with high surgical risk; outcomes in patients with standard surgical risk are not well known. Objective To compare stroke, death, and myocardial infarction outcomes following transcarotid artery revascularization vs carotid endarterectomy in patients with standard surgical risk. Design, Setting, and Participants This retrospective propensity-matched cohort study was conducted from August 2016 to August 2019 with follow-up until August 31, 2020, using data from the multicenter Vascular Quality Initiative Carotid Artery Stent and Carotid Endarterectomy registries. Patients with standard surgical risk, defined as those lacking Medicare-defined high medical or surgical risk characteristics and undergoing transcarotid artery revascularization (n = 2962) or carotid endarterectomy (n = 35 063) for atherosclerotic carotid disease. In total, 760 patients were excluded for treatment of multiple lesions or in conjunction with other procedures. Exposures Transcarotid artery revascularization vs carotid endarterectomy. Main Outcomes and Measures The primary outcome was a composite end point of 30-day stroke, death, or myocardial infarction or 1-year ipsilateral stroke. Results After 1:3 matching, 2962 patients undergoing transcarotid artery revascularization (mean [SD] age, 70.4 [6.9] years; 1910 [64.5%] male) and 8886 undergoing endarterectomy (mean [SD] age, 70.0 [6.5] years; 5777 [65.0%] male) were identified. There was no statistically significant difference in the risk of the primary composite end point between the 2 cohorts (transcarotid 3.0% vs endarterectomy 2.6%; absolute difference, 0.40% [95% CI, -0.43% to 1.24%]; relative risk [RR], 1.14 [95% CI, 0.87 to 1.50]; P = .34). Transcarotid artery revascularization was associated with a higher risk of 1-year ipsilateral stroke (1.6% vs 1.1%; absolute difference, 0.52% [95% CI, 0.03 to 1.08]; RR, 1.49 [95% CI, 1.05 to 2.11%]; P = .02) but no difference in 1-year all-cause mortality (2.6% vs 2.5%; absolute difference, -0.13% [95% CI, -0.18% to 0.33%]; RR, 1.04 [95% CI, 0.78 to 1.39]; P = .67). Conclusions and Relevance In this study, the risk of 30-day stroke, death, or myocardial infarction or 1-year ipsilateral stroke was similar in patients undergoing transcarotid artery revascularization compared with those undergoing endarterectomy for carotid stenosis.
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Affiliation(s)
- Patric Liang
- Division of Vascular and Endovascular Surgery, Department of Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
| | - Jack L. Cronenwett
- Section of Vascular Surgery, Dartmouth Institute, Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire
| | - Eric A. Secemsky
- Smith Center for Outcomes Research in Cardiology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
| | - Jens Eldrup-Jorgensen
- Division of Vascular and Endovascular Therapy, Department of Surgery, Maine Medical Center, Portland
| | - Mahmoud B. Malas
- Division of Vascular and Endovascular Surgery, Department of Surgery, University of California, San Diego Health System, San Diego
| | - Grace J. Wang
- Division of Vascular Surgery and Endovascular Therapy, Department of Surgery, Hospital of the University of Pennsylvania, Philadelphia
| | - Brian W. Nolan
- Division of Vascular and Endovascular Therapy, Department of Surgery, Maine Medical Center, Portland
| | - Vikram S. Kashyap
- Frederik Meijer Heart and Vascular Institute, Corewell Health, Grand Rapids, Michigan
| | - Raghu L. Motaganahalli
- Division of Vascular Surgery, Department of Surgery, Indiana University School of Medicine, Indianapolis
| | - Marc L. Schermerhorn
- Division of Vascular and Endovascular Surgery, Department of Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
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Omi T, Hayakawa M, Adachi K, Ohba S, Sadato A, Hasebe A, Ishihara T, Nakahara I, Hirose Y. Carotid Plaque Diagnosis With 3-Dimensional Computed Tomography Angiography: A Comparison With Magnetic Resonance Imaging-Based Plaque Diagnosis. J Comput Assist Tomogr 2023; 47:00004728-990000000-00163. [PMID: 36944131 DOI: 10.1097/rct.0000000000001416] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/23/2023]
Abstract
OBJECTIVE Although a qualitative diagnosis of plaque causing carotid stenosis has been attempted with carotid computed tomography angiography (CaCTA), no clear findings have been reported. We examined the correlation between the plaque CT values and plaque images obtained by magnetic resonance imaging to derive a qualitative diagnosis of the plaque using CaCTA. METHODS Preoperative CaCTA images acquired from patients stented for carotid stenosis were retrospectively analyzed with respect to magnetization-prepared rapid acquisition with gradient echo and time-of-flight magnetic resonance angiography data. Carotid plaques in the stenosed region were quantified in terms of CT density and the plaque/muscle ratio (magnetization-prepared rapid acquisition with gradient echo), and correlations between these 2 features were determined. Plaques were classified as stable or unstable based on the plaque/muscle ratio, with the smallest plaque/muscle ratio observed among plaques positive for intraplaque hemorrhage set as the cutoff value (1.76). RESULTS A total of 165 patients (179 plaques) were included. Perioperative complications included minor stroke (n = 3), major stroke (n = 1, fatal), and hyperperfusion (n = 2). The correlation between CT density and the plaque/muscle ratio was nonlinear (P = 0.0139) and negative (P < 0.0001). The cutoff point (1.76) corresponded to a CT density of 83 HU, supporting this value as a standard reference for plaque stability. CONCLUSIONS Computed tomography density exhibits a nonlinear (P = 0.0139) and highly negative correlation (P < 0.0001) with the plaque/muscle ratio. Our results demonstrate that plaque characteristics can be meaningfully diagnosed based on CaCTA image data.
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Affiliation(s)
| | | | | | | | | | - Akiko Hasebe
- Comprehensive Strokology, Fujita Health University, Toyoake
| | - Takuma Ishihara
- Innovative and Clinical Research Promotion Center, Gifu University Hospital I, Gifu, Japan
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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] [What about the content of this article? (0)] [Affiliation(s)] [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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Klail T, Kurmann C, Kaesmacher J, Mujanovic A, Piechowiak EI, Dobrocky T, Pilgram-Pastor S, Scutelnic A, Heldner MR, Gralla J, Mordasini P. Safety and Efficacy of Carotid Artery Stenting with the CGuard Double-layer Stent in Acute Ischemic Stroke. Clin Neuroradiol 2023; 33:237-44. [PMID: 36070140 DOI: 10.1007/s00062-022-01209-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2022] [Accepted: 07/30/2022] [Indexed: 11/03/2022]
Abstract
BACKGROUND Double-layer stents show promising results in preventing periinterventional and postinterventional embolic events in elective settings of carotid artery stenting (CAS). We report a single-center experience with the CGuard stent in the treatment of acute ischemic stroke (AIS) due to symptomatic internal carotid artery (ICA) stenosis or occlusion with or without intracranial occlusion. METHODS We retrospectively analyzed all patients who received a CGuard stent in the setting of AIS at our institution. Neuroimaging and clinical data were analyzed with the following primary endpoints: technical feasibility, acute and delayed stent occlusion or thrombosis, distal embolism, symptomatic intracranial hemorrhage (sICH) and functional outcome at 3 months. RESULTS In 33 patients, stenting with the CGuard was performed. Stent deployment was successful in all patients (28 with tandem occlusions, 5 with isolated ICA occlusion). Transient acute in-stent thrombus formation occurred in three patients (9%) without early stent occlusion. Delayed, asymptomatic stent occlusion was seen in 1 patient (3%) after 49 days. Asymptomatic periinterventional distal emboli occurred in 2 patients (6%), 1 patient experienced a transient ischemic attack 79 days after the procedure and 1 patient (3%) developed sICH. Favorable clinical outcome (mRS 0-2) at 3 months was achieved in 12 patients (36%) and the mortality rate was 24%. CONCLUSION The CGuard use in emergencies was technically feasible, the safety has to be confirmed by further multicentric studies.
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Heib A, Chang H, Rockman C, Patel V, Jacobowitz G, Barfield M, Siracuse JJ, Faries P, Lamparello PJ, Cayne N, Maldonado T, Garg K. Periprocedural P2Y 12 inhibitors improve perioperative outcomes after carotid stenting by primarily decreasing strokes. J Vasc Surg 2023; 77:795-803. [PMID: 36328140 DOI: 10.1016/j.jvs.2022.10.038] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2022] [Revised: 09/25/2022] [Accepted: 10/03/2022] [Indexed: 11/05/2022]
Abstract
OBJECTIVE The continuation of antiplatelet agents in the periprocedural period around carotid stenting (CAS) procedures is felt to be mandatory to minimize the risk of periprocedural stroke. However, the optimal antiplatelet regimen is unclear, with some advocating dual antiplatelet therapy, and others supporting the use of P2Y12 inhibitors alone. The objective of this study was to evaluate the periprocedural effect of P2Y12 inhibitors for CAS. METHODS The Vascular Quality Initiative was used from years 2007 to 2020. All transcarotid artery revascularization (TCAR) and transfemoral carotid artery stenting (TF-CAS) procedures were included. Patients were stratified based on perioperative use of P2Y12 inhibitors as well as symptomatic status. Primary end points were perioperative neurological events (strokes and transient ischemic attacks). Secondary end points were mortality and myocardial infarction. RESULTS A total of 31,036 CAS procedures were included for analysis, with 49.8% TCAR and 50.2% TF-CAS cases; 63.8% of patients were male and 82.3% of patients were on a P2Y12 inhibitor. P2Y12 inhibitor use was more common in males, asymptomatic patients, those older than 70 years, and concurrent statin use. P2Y12 inhibitors were more likely to be used in TCAR cases than in TF-CAS cases (87.3% vs 76.8%; P < .001). The rate of periprocedural neurological events in the whole cohort was 2.6%. Patients on P2Y12 inhibitors were significantly less likely to experience a periprocedural neurological event (2.3% vs 3.9%; P < .001) and mortality (0.6% vs 2.1%; P < .001) than those who were not on a P2Y12 inhibitor. There was no effect on the rates of myocardial infarction. On multivariate analysis, both symptomatic and asymptomatic patients on P2Y12 inhibitors were significantly less likely to develop perioperative neurological events. Additionally, the use of P2Y12 inhibitors demonstrated an independent significant effect in reducing of the rate of perioperative stroke (odds ratio, 0.29; 95% confidence interval, 0.25-0.33). Finally, additional analysis of the types of P2Y12 inhibitors used revealed that all seemed to be equally effective in decreasing the periprocedural neurological event rate. CONCLUSIONS The use of perioperative P2Y12 inhibitors seems to markedly decrease the perioperative neurological event rate with TCAR and TF-CAS in both symptomatic and asymptomatic patients and should be strongly considered. Patients with contraindications to P2Y12 inhibitors may not be appropriate candidates for any CAS procedure. Additionally, alternative types of P2Y12 inhibitors seem to be equally effective as clopidogrel. Finally, an analysis of the Vascular Quality Initiative demonstrates that, even for TCAR cases, only 87.3% of patients seem to be on P2Y12 inhibitors in the periprocedural period, leaving room for significant improvement.
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Affiliation(s)
- Adele Heib
- Albert Einstein College of Medicine/Montefiore Medical Center, Bronx, NY
| | - Heepeel Chang
- Division of Vascular and Endovascular Surgery, Westchester Medical Center/New York Medical College, Valhalla, NY
| | - Caron Rockman
- Division of Vascular and Endovascular Surgery, Department of Surgery, NYU Langone Medical Center, New York, NY
| | - Virendra Patel
- Division of Cardiac, Thoracic, and Vascular Surgery, New York Presbyterian/Columbia University Irving Medical Center/Columbia University College of Physicians and Surgeons, New York, NY
| | - Glenn Jacobowitz
- Division of Vascular and Endovascular Surgery, Department of Surgery, NYU Langone Medical Center, New York, NY
| | - Michael Barfield
- Division of Vascular and Endovascular Surgery, Department of Surgery, NYU Langone Medical Center, New York, NY
| | - Jeffrey J Siracuse
- Division of Vascular and Endovascular Surgery, Department of Surgery, Boston Medical Center, Boston, MA
| | - Peter Faries
- Division of Vascular and Endovascular Surgery, Department of Surgery, The Mount Sinai Hospital, New York, NY
| | - Patrick J Lamparello
- Division of Vascular and Endovascular Surgery, Department of Surgery, NYU Langone Medical Center, New York, NY
| | - Neal Cayne
- Division of Vascular and Endovascular Surgery, Department of Surgery, NYU Langone Medical Center, New York, NY
| | - Thomas Maldonado
- Division of Vascular and Endovascular Surgery, Department of Surgery, NYU Langone Medical Center, New York, NY
| | - Karan Garg
- Division of Vascular and Endovascular Surgery, Department of Surgery, NYU Langone Medical Center, New York, NY.
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Kim MJ, Ha SK. Outcomes Following Carotid Endarterectomy and Carotid Artery Stenting in Patients with Carotid Artery Stenosis: A Retrospective Study from a Single Center in South Korea. Med Sci Monit 2023; 29:e939223. [PMID: 36788720 PMCID: PMC9940449 DOI: 10.12659/msm.939223] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023] Open
Abstract
BACKGROUND Previous randomized controlled trials and meta-analyses comparing carotid endarterectomy (CEA) and carotid artery stenting (CAS) included a large number of patients, but the diagnosis, treatment selection, and performance were heterogeneous. This retrospective study from a single center in South Korea aimed to evaluate outcomes following CEA and CAS in patients with carotid artery stenosis. MATERIAL AND METHODS A retrospective analysis was performed using the data of patients who underwent carotid revascularization between September 2016 and June 2021 at a single institution. The primary outcomes were stroke, myocardial infarction (MI), and death during the periprocedural period. RESULTS We enrolled a total of 61 (44 symptomatic and 17 asymptomatic) patients who underwent CEA or CAS. Among them, 36 (59%) underwent CEA and 25 (41%) underwent CAS. Statistically significant differences were found between the groups in degree of carotid stenosis (CEA: 87.0±9.1, CAS: 80.5±9.3, P=0.007). All patients with confirmed plaque ulceration before carotid revascularization underwent CEA. Two (3.3%) periprocedural strokes occurred, 1 in each group, on the ipsilateral side. There were no significant differences between CEA and CAS in the event-free survival rate for stroke during the follow-up (log-rank test=0.806). CONCLUSIONS Favorable outcomes in terms of periprocedural stroke were observed. We found no significant difference between the 2 carotid revascularization techniques in the incidence of periprocedural stroke in symptomatic and asymptomatic patients. To confirm our findings, further studies involving a larger number of patients and continuous follow-up are necessary.
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Affiliation(s)
- Myung Ji Kim
- Department of Neurosurgery, Korea University College of Medicine, Korea University Medical Center, Ansan Hospital, Ansan, Gyeonggi, South Korea
| | - Sung-Kon Ha
- Department of Neurosurgery, Korea University College of Medicine, Korea University Medical Center, Ansan Hospital, Ansan, Gyeonggi, South Korea
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Leung YYR, Bera K, Urriza Rodriguez D, Dardik A, Mas JL, Simonte G, Rerkasem K, Howard DP. Safety of Carotid Endarterectomy for Symptomatic Stenosis by Age: Meta-Analysis With Individual Patient Data. Stroke 2023; 54:457-467. [PMID: 36647921 PMCID: PMC9855737 DOI: 10.1161/strokeaha.122.040819] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2022] [Accepted: 12/06/2022] [Indexed: 01/18/2023]
Abstract
BACKGROUND There is uncertainty whether elderly patients with symptomatic carotid stenosis have higher rates of adverse events following carotid endarterectomy. In trials, recurrent stroke risk on medical therapy alone increased with age, whereas operative stroke risk was not related. Few octogenarians were included in trials and there has been no systematic analysis of all study types. We aimed to evaluate the safety of carotid endarterectomy in symptomatic elderly patients, particularly in octogenarians. METHODS We did a systematic review and meta-analysis of studies (from January 1, 1980 through March 1, 2022) reporting post carotid endarterectomy risk of stroke, myocardial infarction, and death in patients with symptomatic carotid stenosis. We included observational studies and interventional arms of randomized trials if the outcome rates (or the raw data to calculate these) were provided. Individual patient data from 4 prospective cohorts enabled multivariate analysis. RESULTS Of 47 studies (107 587 patients), risk of perioperative stroke was 2.04% (1.94-2.14) in octogenarians (390 strokes/19 101 patients) and 1.85% (1.75-1.95) in nonoctogenarians (1395/75 537); P=0.046. Perioperative death was 1.09% (0.94-1.25) in octogenarians (203/18 702) and 0.53% (0.48-0.59) in nonoctogenarians (392/73 327); P<0.001. Per 5-year age increment, a linear increase in perioperative stroke, myocardial infarction, and death were observed; P=0.04 to 0.002. However, during the last 3 decades, perioperative stroke±death has declined significantly in octogenarians (7.78% [5.58-10.55] before year 2000 to 2.80% [2.56-3.04] after 2010); P<0.001. In Individual patient data multivariate-analysis (5111 patients), age ≥85 years was independently associated with perioperative stroke (P<0.001) and death (P=0.005). Yet, survival was similar for octogenarians versus nonoctogenarians at 1-year (95.0% [93.2-96.5] versus 97.5% [96.4-98.6]; P=0.08), as was 5-year stroke risk (11.93% [9.98-14.16]) versus 12.78% [11.65-13.61]; P=0.24). CONCLUSIONS We found a modest increase in perioperative risk with age in symptomatic patients undergoing carotid endarterectomy. As stroke risk increases with age when on medical therapy alone, our findings support selective urgent intervention in symptomatic elderly patients.
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Affiliation(s)
- Ya Yuan Rachel Leung
- Wolfson Centre for Prevention of Stroke and Dementia, Nuffield Department of Clinical Neurosciences, University of Oxford, UK (Y.Y.R.L., D.P.J.H.)
| | - Kasia Bera
- Department of Vascular Surgery, Oxford University Hospitals NHS Trust, UK (K.B., D.U.R., D.P.J.H.)
| | - Daniel Urriza Rodriguez
- Department of Vascular Surgery, Oxford University Hospitals NHS Trust, UK (K.B., D.U.R., D.P.J.H.)
| | - Alan Dardik
- Yale Department of Surgery, Departments of Surgery and Cellular and Molecular Physiology, Yale School of Medicine, New Haven, CT (A.D.)
- Department of Surgery, VA Connecticut Healthcare System, West Haven (A.D.)
| | - Jean-Louis Mas
- Department of Neurology, GHU Paris, Hôpital Sainte-Anne, Université Paris-Cité, Inserm, France (J.-L.M.)
| | - Gioele Simonte
- Vascular and Endovascular Surgery Unit, Santa Maria della Misericordia, University of Perugia, Italy (G.S.)
| | - Kittipan Rerkasem
- Environmental - Occupational Health Sciences and Non-Communicable Diseases Research Group, Research Institute for Health Sciences, Chiang Mai University, Thailand (K.R.)
- Clinical Surgical Research Center, Department of Surgery, Faculty of Medicine, Chiang Mai University, Thailand (K.R.)
| | - Dominic P.J. Howard
- Wolfson Centre for Prevention of Stroke and Dementia, Nuffield Department of Clinical Neurosciences, University of Oxford, UK (Y.Y.R.L., D.P.J.H.)
- Department of Vascular Surgery, Oxford University Hospitals NHS Trust, UK (K.B., D.U.R., D.P.J.H.)
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Perez-Troncoso D, Epstein D, Davies AH, Thapar A. Cost-effectiveness of carotid endarterectomy in symptomatic patients. Br J Surg 2023; 110:193-199. [PMID: 36422995 DOI: 10.1093/bjs/znac386] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2022] [Revised: 10/05/2022] [Accepted: 10/22/2022] [Indexed: 11/27/2022]
Abstract
BACKGROUND Medical therapy for stroke prevention has improved significantly over the past 30 years. Recent analyses of medically treated cohorts have suggested that early rates of stroke may have reduced, and reports of the safety of carotid surgery have also shown improvements. Since the effectiveness of carotid surgery versus medical therapy was established in the 1990s, there is an urgent need to evaluate whether surgery remains cost-effective in the UK. METHODS A decision model was developed to estimate the lifetime costs and utilities of modern medical therapy with and without carotid endarterectomy in patients with symptomatic stenosis from the perspective of the UK National Health Service. The base-case population consisted of adults aged 70 years with 70-99 per cent stenosis. Model data were obtained from clinical studies and wider literature. Univariate and probabilistic sensitivity analyses were carried out. RESULTS In the base-case scenario, the 5-year absolute risk reduction with carotid endarterectomy was 5 per cent, and the incremental cost-effectiveness ratio was €12 021 (exchange rate £1 GBP = €1.1125 (Tuesday 1 January 2019)) per quality-adjusted life-year. Surgery was more cost-effective if performed rapidly after presentation. In patients with 50-69 per cent carotid stenosis, surgery appeared less clinically effective. However, there was considerable uncertainty. CONCLUSION Surgery may not now be clinically effective and cost-effective in those with moderate carotid stenosis. However, these results are uncertain because of the limited data on modern medical therapy and an RCT may be justified.
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Affiliation(s)
- Daniel Perez-Troncoso
- Health Technology Assessment and Quality of Care Area, Agency for Health Quality and Assessment of Catalonia, Barcelona, Spain
| | - David Epstein
- Department Applied Economics, University of Granada, Granada, Spain
| | - Alun Huw Davies
- Department of Surgery and Cancer, Imperial College London, London, UK
| | - Ankur Thapar
- Mid and South Essex Vascular Unit, Mid and South Essex Hospitals NHS Foundation Trust, Essex, England.,Centre for Circulatory Health, Anglia Ruskin University, Cambridge, England
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Naylor R, Rantner B, Ancetti S, de Borst GJ, De Carlo M, Halliday A, Kakkos SK, Markus HS, McCabe DJH, Sillesen H, van den Berg JC, Vega de Ceniga M, Venermo MA, Vermassen FEG, Esvs Guidelines Committee, Antoniou GA, Bastos Goncalves F, Bjorck M, Chakfe N, Coscas R, Dias NV, Dick F, Hinchliffe RJ, Kolh P, Koncar IB, Lindholt JS, Mees BME, Resch TA, Trimarchi S, Tulamo R, Twine CP, Wanhainen A, Document Reviewers, Bellmunt-Montoya S, Bulbulia R, Darling RC, Eckstein HH, Giannoukas A, Koelemay MJW, Lindström D, Schermerhorn M, Stone DH. Editor's Choice - European Society for Vascular Surgery (ESVS) 2023 Clinical Practice Guidelines on the Management of Atherosclerotic Carotid and Vertebral Artery Disease. Eur J Vasc Endovasc Surg 2023; 65:7-111. [PMID: 35598721 DOI: 10.1016/j.ejvs.2022.04.011] [Citation(s) in RCA: 166] [Impact Index Per Article: 166.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2022] [Accepted: 04/20/2022] [Indexed: 01/17/2023]
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Yei KS, Cui CL, Ramachandran M, Malas MB, Al-Nouri O. Effect of Postoperative Stroke Timing on Perioperative Mortality After Carotid Revascularization. Ann Vasc Surg 2022; 92:124-130. [PMID: 36584965 DOI: 10.1016/j.avsg.2022.12.080] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2022] [Accepted: 12/16/2022] [Indexed: 12/28/2022]
Abstract
BACKGROUND In-hospital stroke (IHS) has been associated with worse outcomes than out-of-hospital stroke (OHS) due to delays in diagnosis and treatment. A paucity of studies exists comparing the timing of postoperative stroke after carotid revascularization. We aimed to study the effect of IHS versus OHS on postoperative mortality in carotid revascularization patients in a large-scale national database. METHODS This is a retrospective cohort study of patients who underwent carotid artery stenting (CAS) and carotid endarterectomy (CEA) between 2011 and 2018 in the American College of Surgeons (ACS) National Surgical Quality Improvement Program (NSQIP) database. Statistical analysis included chi-squared test and multivariable logistic regression. Patients were divided based on postoperative stroke timing (no stroke, IHS, or OHS) as well as procedure type (CEA or CAS). RESULTS A total of 31,304 carotid revascularizations were performed with 420 (1.3%) IHSs and 207 (0.7%) OHSs. On adjusted analysis, there was significantly higher perioperative mortality with both IHS [odds ratio (OR): 19.75, 95% confidence interval (CI): 13.61-28.18, P < 0.001] and OHS [OR: 29.73, 95% CI: 18.76-45.82, P < 0.001]. There was no difference in mortality after OHS versus IHS [OR: 1.51, 95% CI: 0.89-2.55, P = 0.161]. CONCLUSIONS Any postoperative stroke after carotid revascularization significantly increased the odds of 30-day mortality. In contrast to previous studies demonstrating worse outcomes after IHS than OHS, we observed similar 30-day mortality between the 2 stroke categories. Improved follow-up and early recognition with rescue within carotid revascularization patients compared to the general population could potentially contribute to these results. However, overall mortality remains high for any postoperative stroke following carotid revascularization, emphasizing the importance of vigilant in-hospital monitoring and follow-up even after discharging the patient.
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Affiliation(s)
- Kevin S Yei
- Department of Surgery, Division of Vascular Surgery, UC San Diego, San Diego, CA
| | - Christina L Cui
- Department of Surgery, Division of Vascular Surgery, UC San Diego, San Diego, CA
| | | | - Mahmoud B Malas
- Department of Surgery, Division of Vascular Surgery, UC San Diego, San Diego, CA
| | - Omar Al-Nouri
- Department of Surgery, Division of Vascular Surgery, UC San Diego, San Diego, CA.
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Li A, Javidan AP, Liu E, Ahmadvand A, Tam DY, Naji F, Forbes TL. Assessing the robustness of negative vascular surgery randomized controlled trials using their reverse fragility index. J Vasc Surg 2022:S0741-5214(22)02650-7. [PMID: 36572321 DOI: 10.1016/j.jvs.2022.12.029] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2022] [Revised: 12/15/2022] [Accepted: 12/17/2022] [Indexed: 12/25/2022]
Abstract
OBJECTIVE The reverse fragility index (RFI) describes the number of event conversions needed to convert a statistically nonsignificant dichotomous outcome to a significant one. The objective of the present study was to assess the RFI of vascular surgery randomized controlled trials (RCTs) comparing endovascular vs open surgery for the treatment of abdominal aortic aneurysms (AAAs), carotid artery stenosis (CAS), and peripheral artery disease (PAD). METHODS MEDLINE and Embase were searched for RCTs that had investigated AAAs, CAS, or PAD with statistically nonsignificant binary primary outcomes. The primary outcome for the present study was the median RFI. Calculation of the RFI was performed by creating two-by-two contingency tables and subtracting events from the group with fewer events and adding nonevents to the same group until a two-tailed Fisher exact test had produced a statistically significant result (P ≤ .05). RESULTS Of 4187 reports, 49 studies reporting 103 different primary end points were included. The overall median RFI was 7 (interquartile range [IQR], 5-13). The specific RFIs for AAA, CAS, and PAD were 10 (IQR, 6-15.5), 6 (IQR, 5-9.5), and 7 (IQR, 5.5-10), respectively. Of the 103 end points, 42 (47%) had had a loss to follow-up greater than the RFI, of which 10 were AAA trials (24%), 23 were CAS trials (55%), and 9 were PAD trials (21%). The Pearson correlation demonstrated a significant positive relationship between a study's RFI and the impact factor of its publishing journal (r = 0.38; 95% confidence interval [CI], 0.20-0.54; P < .01), length of follow-up (r = 0.43; 95% CI, 0.26-0.58; P < .01), and sample size (r = 0.28; 95% CI, 0.09-0.45; P < .01). CONCLUSIONS A small number of events (median, 7) was required to change the outcome of negative RCTs from statistically nonsignificant to significant, with 47% of the studies having missing data that could have reversed the finding of its primary outcome. Reporting of the RFI relative to the loss to follow-up could be of benefit in future trials and provide confidence regarding the robustness of the P value.
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Liu YE, Zhu X, Ma Y, Tang H, Jin M. Age and Five-Year Outcomes After Carotid Artery Stenting in Symptomatic Carotid Stenosis: A Retrospective Cohort Study. Vasc Endovascular Surg 2022; 57:317-323. [PMID: 36476091 DOI: 10.1177/15385744221145147] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Background Several clinical trials have reported that periprocedural risk of carotid artery stenting (CAS) increase with age. China is experiencing one of the most rapid transitions to an aging society, while the clinical outcomes of CAS in real-world China are still limited. The study aimed to compare the periprocedural and an extending 5-year event rates between younger and older patients treated by CAS to testify the safety of CAS in older patients in China. Methods This is a single center, retrospective cohort study. Symptomatic patients who underwent CAS from Nov 2011 to June 2014 were retrospectively included in this study, The population was divided into two age groups: <70 and ≥70. The main primary endpoint was stroke, myocardial infarction or death occurring at 30 days, or ipsilateral stroke over 5-year after stenting. Results A total of 103 symptomatic patients (<70: 68%; ≥70: 32%) with CAS included in the study. During the 30-day period, the rate of primary outcome was 1.0% with only one stroke in patients younger than 70 years old ( P = 1.000). After five years, the rate of primary outcome was low (10.9%, 10/92) despite some of the patients had major stroke or underwent bilateral C1 stenting. There was no significant difference in the 5-year rates of the primary outcome between the young and old groups (12.3% vs 7.4%, P = .718). Kaplan-Meier estimates of the proportion of study participants with a primary endpoint showed that there was no significant age-dependent difference of the stroke and death outcome in symptomatic patients. Conclusions Age (<70 vs ≥ 70) had no influence on the risk of stroke or death in symptomatic patients either in the short or long term. CAS is an optimal treatment for older patients with cervical carotid artery stenosis, and CAS was safe for those with major stroke or bilateral C1 stenting.
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Affiliation(s)
- Yun-e Liu
- New Era Stroke Care and Research Institute, The PLA Rocket Force Characteristic Medical Center, Beijing, China
| | - Xianjin Zhu
- Department of Neurology, Beijing Friendship Hospital, Capital Medical University, Beijing, China
| | - Yinghao Ma
- The PLA Rocket Force Characteristic Medical Center, Beijing, China
| | - Haiyan Tang
- The PLA Rocket Force Characteristic Medical Center, Beijing, China
| | - Min Jin
- New Era Stroke Care and Research Institute, The PLA Rocket Force Characteristic Medical Center, Beijing, China
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Abstract
Patients that require major vascular surgery suffer from widespread atherosclerosis and have multiple comorbidities that place them at increased risk for postoperative complications and require admission to the intensive care unit (ICU). Postoperative critical care of these patients is focused on hemodynamic optimization, and early identification and management of complications to improve outcomes.
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Affiliation(s)
- Milad Sharifpour
- Department of Anesthesiology, Cedars Sinai Medical Center, 8700 Beverly Boulevard #8211, Los Angeles, CA 90048, USA.
| | - Edward A Bittner
- Critical Care-Anesthesiology Fellowship, Department of Anesthesia, Critical Care and Pain Medicine, Harvard Medical School, Massachusetts General Hospital, Boston MA 02114, USA
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Marcaccio CL, Anjorin A, Patel PB, Rastogi V, Jones DW, Lo RC, Wyers MC, Schermerhorn ML. In-hospital outcomes after upper extremity versus transfemoral and transcarotid access for carotid stenting in the Vascular Quality Initiative. J Vasc Surg 2022; 76:1603-1614.e7. [PMID: 35840075 PMCID: PMC9691591 DOI: 10.1016/j.jvs.2022.05.030] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2022] [Revised: 05/13/2022] [Accepted: 05/23/2022] [Indexed: 10/17/2022]
Abstract
OBJECTIVE Carotid artery stenting (CAS) is frequently used for patients at high risk for carotid endarterectomy. However, there are limited data comparing transradial or transbrachial (tr/tbCAS) access with more established CAS approaches. Therefore, we examined the effect of a tr/tbCAS approach versus a transfemoral (tfCAS) or transcarotid (TCAR) approach on outcomes after CAS. METHODS We identified all patients undergoing CAS in the Vascular Quality Initiative registry from January 2016 to December 2021. We compared outcomes across 1:3 propensity score-matched cohorts of patients who underwent tr/tbCAS versus tfCAS or tr/tbCAS versus TCAR. As a secondary analysis, we assessed outcomes stratified by carotid symptom status. Our primary outcome was a composite end point of in-hospital stroke/death. RESULTS Among 40,835 CAS patients, 962 (2.4%) underwent tr/tbCAS, 18,840 (46%) underwent tfCAS, and 21,033 (52%) underwent TCAR. Among matched patients who underwent tr/tbCAS versus tfCAS, there was no significant difference in the risk of stroke/death (4.1% vs 2.9%; relative risk [RR] 1.4; 95% confidence interval [CI], 0.95-2.1), but tr/tbCAS was associated with a higher risk of death (2.4% vs 1.3%; RR, 1.8; 95% CI, 1.1-3.1). In the symptomatic subgroup, tr/tbCAS was associated with a higher risk of stroke/death (6.1% vs 3.9%; RR, 1.6; 95% CI, 1.0-2.4) and death (3.6% vs 1.7%; RR, 2.1; 95% CI, 1.2-3.7), but there were no differences in asymptomatic patients. After adjustment for mRS in patients with preoperative stroke, there were no significant differences in stroke/death (RR, 1.1; 95% CI, 0.66-1.9) or death (RR, 1.6; 95% CI, 0.81-3.3) between groups. In matched patients who underwent tr/tbCAS versus TCAR, tr/tbCAS was associated with a higher risk of stroke/death (4.2% vs 2.3%; RR, 1.8; 95% CI, 1.2-2.7) and death (2.4% vs 0.5%; RR, 4.8; 95% CI, 2.4-9.5). In the symptomatic subgroup, tr/tbCAS remained associated with a higher risk of stroke/death (6.2% vs 2.4%; RR, 2.6; 95% CI, 1.6-4.2) and death (3.7% vs 0.7%; RR, 5.6; 95% CI, 2.6-12), but there were no differences in asymptomatic patients. After adjustment for Modified Rankin Scale in patients with preoperative stroke, there were no significant differences in stroke/death (RR, 1.4; 95% CI, 0.79-2.6) or death (RR, 2.3; 95% CI, 0.95-5.7) between groups. CONCLUSIONS Compared with tfCAS or TCAR, tr/tbCAS was associated with a higher risk of in-hospital stroke/death in symptomatic patients, which was driven primarily by a higher risk of death. These inferior outcomes were partly attributable to more severe preoperative neurologic disability in tr/tbCAS patients. In contrast, there were no differences in outcomes in asymptomatic patients. Overall, our findings highlight the importance of guideline-directed patient selection in tr/tbCAS.
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Affiliation(s)
- Christina L Marcaccio
- Department of Surgery, Division of Vascular and Endovascular Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA
| | - Aderike Anjorin
- 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
| | - 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 Centre, Rotterdam, the Netherlands
| | - Douglas W Jones
- Division of Vascular and Endovascular Surgery, UMass Memorial Medical Center, University of Massachusetts Medical School Worcester, Worcester, MA
| | - Ruby C Lo
- Department of Surgery, Division of Vascular Surgery, Rhode Island Hospital, Alpert Medical School of Brown University, Providence, RI
| | - Mark C Wyers
- Department of Surgery, Division of Vascular and Endovascular Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA
| | - 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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Abstract
The early randomized trial experience (CAVATAS, SPACE, EVA-3S, ICSS) comparing carotid artery stenting (CAS) and carotid endarterectomy (CEA) has been burdened by the limited experience of the interventionalists performing CAS. The periprocedural stroke excess with CAS observed in those trials has ever since affected carotid revascularization, especially in symptomatic carotid disease. Accordingly, no trial dedicated to this patient population has followed. In asymptomatic carotid disease, CREST, ACT-1 and ACST-2 have shown an equivalence in terms of combined periprocedural events as well as long-term protection from ipsilateral stroke or repeat revascularization between the two techniques. The management of patients with carotid stenosis should be multidisciplinary and decision to pursue medical management or proceed to revascularization in an individual patient should be based on his estimated stroke risk on medical management and his suitability for CEA and CAS. Since the majority of patients with carotid stenosis may qualify for both techniques, patient's perspective should be central in decision making.
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Affiliation(s)
- Marco Roffi
- Division of Cardiology, University Hospitals, Geneva, Switzerland -
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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] [What about the content of this article? (0)] [Affiliation(s)] [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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Muacevic A, Adler JR, Chaddha A, Chauhan R, Singh N, Kamal P, Mishra A, Kaur N. The Safety and Long-Term Efficacy of Carotid Artery Stenting: An All-Comers Registry. Cureus 2022; 14:e32060. [PMID: 36600837 PMCID: PMC9800945 DOI: 10.7759/cureus.32060] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/30/2022] [Indexed: 12/02/2022] Open
Abstract
Background Carotid artery stenting (CAS) has emerged as a less invasive alternative to carotid endarterectomy (CEA) for the prevention of future cerebrovascular events in patients with carotid artery stenosis. Despite multiple randomized controlled trials (RCTs) comparing CAS and CEA for carotid disease, real-world data outside the rigorous environment of trials is scarce. Methods The present study is a prospective observational study conducted at a tertiary care center, wherein all patients who underwent CAS between January 2007 and December 2019 were included. All patients were followed up for one year of the last enrolled patient at an interval of one, six, and 12 months and then yearly thereafter. The primary composite outcome was defined as a combination of periprocedural (until 30 days of procedure) major adverse cardiac and cerebrovascular events (MACCEs) and the long-term incidence of ipsilateral stroke. The secondary outcome included the rate of restenosis. Results A total of 115 patients (86 males and 29 females) (147 lesions) who underwent CAS between 2007 and 2019 were followed up for a median of 80.5 months. Seventy-seven (67.27%) patients were symptomatic, and 38/115 (33%) were asymptomatic. Periprocedural MACCEs were noted in six patients, and four patients had ipsilateral stroke on long-term follow-up; hence, the primary composite outcome was observed in 10 (8.7%) patients. Higher age was found to be significantly associated with the primary composite outcome (p-value = 0.005). Five (4.34%) patients were lost to follow-up, while four (3.48%) patients developed restenosis. Conclusion CAS is a safe and less invasive intervention in patients with significant carotid artery stenosis and is equally effective in preventing future strokes. The incidence of primary outcome rises with an increase in age.
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Takasaki M, Miyake R, Kamei M, Sakai R. Safety of Carotid Artery Stenting in Elderly Patients by Treatment Selection Based on Plaque Characteristics. Indian J Surg 2022. [DOI: 10.1007/s12262-022-03585-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
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Columbo JA, Martinez-Camblor P, Stone DH, Goodney PP, O'Malley AJ. Procedural Safety Comparison Between Transcarotid Artery Revascularization, Carotid Endarterectomy, and Carotid Stenting: Perioperative and 1-Year Rates of Stroke or Death. J Am Heart Assoc 2022; 11:e024964. [PMID: 36172943 DOI: 10.1161/jaha.121.024964] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background Transcarotid artery revascularization (TCAR) was approved by the Food and Drug Administration in 2015 for patients with carotid artery stenosis. However, no randomized trial to evaluate TCAR has been performed to date, and previous reports have important limitations. Accordingly, we measured stroke or death after TCAR compared with carotid endarterectomy (CEA) and transfemoral carotid artery stenting (TF-CAS). Methods and Results We used the Vascular Quality Initiative registry to study patients who underwent TCAR, CEA, or TF-CAS from September 2016 to June 2021. Our primary outcomes were perioperative and 1-year stroke or death. We used logistic regression for risk adjustment for perioperative outcomes and Cox regression for risk adjustment for 1-year outcomes. We used a 2-stage residual inclusion instrumental variable (IV) method to adjust for selection bias and other unmeasured confounding. Our instrument was a center's preference to perform TCAR versus CEA or TF-CAS. We performed a subgroup analysis stratified by presenting neurologic symptoms. We studied 21 234 patients who underwent TCAR, 82 737 who underwent CEA, and 14 595 who underwent TF-CAS across 662 centers. The perioperative rate of stroke or death was 2.0% for TCAR, 1.7% for CEA, and 3.7% for TF-CAS (P<0.001). Compared with TCAR, the IV-adjusted odds ratio of perioperative stroke or death for CEA was 0.74 (95% CI, 0.55-0.99) and for TF-CAS was 1.66 (95% CI, 0.99-2.79). Results were similar among both symptomatic and asymptomatic patients. The 1-year rate of stroke or death was 6.4% for TCAR, 5.2% for CEA, and 9.7% for TF-CAS (P<0.001). Compared with TCAR, the IV-adjusted hazard ratio of 1 year stroke or death for CEA was 0.97 (95% CI, 0.80-1.17), and for TF-CAS was 1.45 (95% CI, 1.04-2.02). IV analysis further demonstrated that symptomatic patients with carotid stenosis had the lowest 1-year likelihood of stroke or death with TCAR (compared with TCAR, symptomatic IV-adjusted hazard ratio for CEA: 1.30 [95% CI, 1.04-1.64], and TF-CAS: 1.86 [95% CI, 1.27-2.71]). Conclusions Perioperative stroke or death was greater following TCAR when compared with CEA. However, at 1 year there was no statistically significant difference in stroke or death between the 2 procedures. TCAR performed favorably compared with TF-CAS at both time points. Although CEA remains the gold standard procedure for patients with carotid stenosis, TCAR appears to be a safe alternative to CEA and TF-CAS when used selectively and may be useful when treating symptomatic patients.
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Affiliation(s)
- Jesse A Columbo
- Section of Vascular Surgery, Heart and Vascular Center Dartmouth-Hitchcock Medical Center Lebanon NH.,Geisel School of Medicine at Dartmouth College Hanover NH
| | - Pablo Martinez-Camblor
- Department of Anesthesia Dartmouth-Hitchcock Medical Center Lebanon NH.,Department of Biomedical Data Science Dartmouth College Hanover NH
| | - David H Stone
- Section of Vascular Surgery, Heart and Vascular Center Dartmouth-Hitchcock Medical Center Lebanon NH.,Geisel School of Medicine at Dartmouth College Hanover NH
| | - Philip P Goodney
- Section of Vascular Surgery, Heart and Vascular Center Dartmouth-Hitchcock Medical Center Lebanon NH.,Geisel School of Medicine at Dartmouth College Hanover NH
| | - A James O'Malley
- Geisel School of Medicine at Dartmouth College Hanover NH.,Department of Biomedical Data Science Dartmouth College Hanover NH
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Hak J, Arquizan C, Cagnazzo F, Mahmoudi M, Collemiche F, Gascou G, Lefevre P, Derraz I, Labreuche J, Mourand I, Gaillard N, Corti L, Charif M, Costalat V, Dargazanli C. MRI Outcomes Achieved by Simple Flow Blockage Technique in Symptomatic Carotid Artery Stenosis Stenting. J Pers Med 2022; 12:1564. [PMID: 36294703 PMCID: PMC9604835 DOI: 10.3390/jpm12101564] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2022] [Revised: 09/14/2022] [Accepted: 09/16/2022] [Indexed: 11/30/2022] Open
Abstract
In this study, we aimed to determine the frequency and clinical impact of new ischemic lesions detected with diffusion-weighted-imaging-MRI (DWI-MRI) as well as the clinical outcomes after carotid artery stenting (CAS) using the simple flow blockage technique (SFB). This is a retrospective study with data extraction from a monocentric prospective clinical registry (from 2017 to 2019) of consecutive patients admitted for symptomatic cervical ICA stenosis or web. Herein, patients benefited from DWI-MRI before and within 48 h of CAS for symptomatic ICA stenosis or web. The primary endpoint was the frequency of new DWI-MRI ischemic lesions and the secondary (composite) endpoint was the rate of mortality, symptomatic stroke or acute coronary syndrome within 30 days of the procedure. All of the 82 CAS procedures were successfully performed. Among the 33 patients (40.2%) with new DWI-MRI ischemic lesions, 30 patients were asymptomatic (90.9%). Irregular carotid plaque surface with (n = 13, 44.8%) or without ulceration (n = 12, 60.0%) was associated with higher rates of new DWI-MRI lesions by comparison to patients with a regular plaque (n = 7, 25%) (p = 0.048) using the univariate analysis. Less than half of this CAS cohort using the SFB technique had new ischemic lesions detected with DWI-MRI. Among these patients, more than 90% were asymptomatic. Irregularity of the plaque seems to increase the risk of peri-procedural DWI-MRI lesions.
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Abstract
Transcarotid artery revascularization (TCAR) is a novel carotid stenting method that avoids the manipulation of the aortic arch and uses a flow-reversal neuroprotection system that effectively reduces the risk of embolic events during carotid intervention. Studies have shown a lower risk of stroke or death compared with the transfemoral carotid stenting approach, and an equivalent risk of stroke or death compared with traditional carotid endarterectomy. TCAR has added benefits of lower risk of myocardial infarction, cranial nerve injuries, and shorter operative times compared with endarterectomy. TCAR has become widely adopted by vascular surgeons in the United States for the treatment of patients with high-risk medical comorbidities and those with challenging surgical anatomy.
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Affiliation(s)
- Patric Liang
- Beth Israel Deaconess Medical Center, Division of Vascular and Endovascular Surgery, Harvard Medical School, 110 Francis Street, Suite 5B, Boston, MA 02215, USA
| | - Marc L Schermerhorn
- Beth Israel Deaconess Medical Center, Division of Vascular and Endovascular Surgery, Harvard Medical School, 110 Francis Street, Suite 5B, Boston, MA 02215, USA.
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Wu H, Wang Z, Li M, Sun P, Wei S, Xie B, Zhang C, Zhang L, Bai H. Outcomes of transcarotid artery revascularization: A systematic review. Interv Neuroradiol 2022:15910199221123283. [PMID: 36039496 DOI: 10.1177/15910199221123283] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
BACKGROUND Ischemic stroke and disability caused by carotid artery stenosis have always been worldwide problems. At present, carotid endarterectomy (CEA) and transfemoral carotid artery stenting (TFCAS) have been commonly used to treat carotid artery stenosis. Recently, transcarotid artery revascularization (TCAR) seems to be another option. METHODS We searched PubMed and Embase to find literatures comparing TCAR with TFCAS and CEA. The primary outcomes were stroke, myocardial infarction (MI), transient ischemic attack (TIA), death, cranial nerve injure (CNI), and operative time. Secondary outcomes were stroke, death, MI in the elderly; cost; radiation; and entry site complication. RESULTS Initial search of the literature included 165 articles, of which 12 studies were chosen in the end. These studies demonstrated high technical success rate of TCAR. Patients who received TCAR had lower risks of death, stroke/death and less radiation exposure compared to TFCAS. In meta analysis, the risk of stroke was significantly lower in TCAR group than TFCAS (OR 0.63; 95%CI 0.47-0.85). And there was no significant difference in TIA and MI. TCAR was associated with shorter operative time, lower risk of CNI and less blood loss compared to CEA. In older patients, the effect of TCAR was significantly better than that of TFCAS. CONCLUSION TCAR is associated with a lower risk of perioperative stroke compared to TFCAS. TCAR is also associated with shorter operative time, lower risk of CNI and less blood loss compared to CEA. TCAR may be a promising treatment option besides TFCAS and CEA.
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Affiliation(s)
- Haoliang Wu
- Department of Vascular and Endovascular Surgery, 191599First Affiliated Hospital of Zhengzhou University, Henan, China
- Key Vascular Physiology and Applied Research Laboratory of Zhengzhou City, Henan, China
| | - Zhiwei Wang
- Department of Vascular and Endovascular Surgery, 191599First Affiliated Hospital of Zhengzhou University, Henan, China
| | - Mingxing Li
- Department of Vascular and Endovascular Surgery, 191599First Affiliated Hospital of Zhengzhou University, Henan, China
| | - Peng Sun
- Department of Vascular and Endovascular Surgery, 191599First Affiliated Hospital of Zhengzhou University, Henan, China
| | - Shunbo Wei
- Department of Vascular and Endovascular Surgery, 191599First Affiliated Hospital of Zhengzhou University, Henan, China
| | - Boao Xie
- Department of Vascular and Endovascular Surgery, 191599First Affiliated Hospital of Zhengzhou University, Henan, China
| | - Cong Zhang
- Department of Vascular and Endovascular Surgery, 191599First Affiliated Hospital of Zhengzhou University, Henan, China
| | - Liwei Zhang
- Department of Vascular and Endovascular Surgery, 191599First Affiliated Hospital of Zhengzhou University, Henan, China
| | - Hualong Bai
- Department of Vascular and Endovascular Surgery, 191599First Affiliated Hospital of Zhengzhou University, Henan, China
- Key Vascular Physiology and Applied Research Laboratory of Zhengzhou City, Henan, China
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49
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Tsai CH, Huang CC, Hsiao HM, Hung MY, Su GJ, Lin LH, Chen YH, Lin MS, Yeh CF, Hung CS, Kao HL. Detection of Carotid Artery Stenosis Based on Video Motion Analysis for Fast Screening. J Am Heart Assoc 2022; 11:e025702. [PMID: 35975739 PMCID: PMC9496434 DOI: 10.1161/jaha.122.025702] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
Background Carotid artery stenosis (CAS) is a common cause of ischemic stroke, and the early detection of CAS may improve patient outcomes. Carotid Doppler ultrasound is commonly used to diagnose CAS. However, it is costly and may not be practical for regular screening practice. This article presents a novel noninvasive and noncontact detection technique using video‐based motion analysis (VMA) to extract useful information from subtle pulses on the skin surface to screen for CAS. Methods and Results We prospectively enrolled 202 patients with prior carotid Doppler ultrasound data. A short 30‐second video clip of the neck was taken using a commercial mobile device and analyzed by VMA with mathematical quantification of the amplitude of skin motion changes in a blinded manner. The first 40 subjects were used to set up the VMA protocol and define cutoff values, and the following 162 subjects were used for validation. Overall, 54% of the 202 subjects had ultrasound‐confirmed CAS. Using receiver operating characteristic curve analysis, the area under the curve of VMA‐derived discrepancy values to differentiate patients with and without CAS was excellent (area under the curve, 0.914 [95% CI, 0.874–0.954]; P<0.01). The best cutoff value of VMA‐derived discrepancy values to screen for CAS was 5.1, with a sensitivity of 87% and a specificity of 87%. The diagnostic accuracy was consistently high in different subject subgroups. Conclusions A simple and accurate screening technique to quickly screen for CAS using a VMA system is feasible, with acceptable sensitivity and specificity.
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Affiliation(s)
- Cheng-Hsuan Tsai
- Graduate Institute of Clinical Medicine National Taiwan University College of Medicine Taipei Taiwan.,Division of Cardiology, Department of Internal Medicine and Cardiovascular Center National Taiwan University Hospital Taipei Taiwan
| | - Ching-Chang Huang
- Division of Cardiology, Department of Internal Medicine and Cardiovascular Center National Taiwan University Hospital Taipei Taiwan
| | - Hao-Ming Hsiao
- Department of Mechanical Engineering National Taiwan University Taipei Taiwan
| | - Ming-Ya Hung
- Department of Mechanical Engineering National Taiwan University Taipei Taiwan
| | - Guan-Jie Su
- Department of Mechanical Engineering National Taiwan University Taipei Taiwan
| | - Li-Han Lin
- Department of Mechanical Engineering National Taiwan University Taipei Taiwan
| | - Ying-Hsien Chen
- Division of Cardiology, Department of Internal Medicine and Cardiovascular Center National Taiwan University Hospital Taipei Taiwan
| | - Mao-Shin Lin
- Division of Cardiology, Department of Internal Medicine and Cardiovascular Center National Taiwan University Hospital Taipei Taiwan
| | - Chih-Fan Yeh
- Division of Cardiology, Department of Internal Medicine and Cardiovascular Center National Taiwan University Hospital Taipei Taiwan
| | - Chi-Sheng Hung
- Division of Cardiology, Department of Internal Medicine and Cardiovascular Center National Taiwan University Hospital Taipei Taiwan
| | - Hsien-Li Kao
- Division of Cardiology, Department of Internal Medicine and Cardiovascular Center National Taiwan University Hospital Taipei Taiwan
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50
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Borhani-Haghighi A, Hooshmandi E, Zahediasl F, Molavi Vardanjani H, Rezaei M, Rahimi-Jaberi A, Ashjazadeh N, Petramfar P, Ostovan VR, Fadakar N, Poursadeghfard M, Izadi S, Nazeri M, Zafarmand SS, Bayat M, Salehi MS, Owjfard M, Sedighi B, Iranmanesh F, Shafiei K, Vakilian A, Moghadam Ahmadi A, Nemati R, Rezaeian Jahromi F, Jalalijahromi M, Kashani K, Razmeh S, Bahrehbar M, Basir M, Qureshi AI. Early and mid-term outcomes of carotid angioplasty and stent placement in 579 patients. J Neuroimaging 2022; 32:1161-1169. [PMID: 35969379 DOI: 10.1111/jon.13036] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2022] [Revised: 07/11/2022] [Accepted: 07/28/2022] [Indexed: 11/30/2022] Open
Abstract
BACKGROUND AND PURPOSE Carotid angioplasty and stenting (CAS) could be considered for preventing stroke in patients with carotid artery stenosis. This study aimed to determine the incidence and the risk factors of the early and mid-term complications associated with CAS. METHODS This is a retrospective cohort study conducted at Shiraz University of Medical Sciences from March 2011 to March 2019. Patients at high risk and standard risk for carotid endarterectomy were included. The primary composite outcome was defined as stroke, myocardial infarction (MI), and death in the first 30 days after CAS. All-cause mortality, vascular mortality, and stroke were investigated during mid-term follow-up. RESULTS A total of 579 patients (618 CAS) were recruited (mean age: 71.52 years). Overall, 394 (68.40%), 211 (36.63%), 179 (31.07%), and 96 (16.72%) patients had hypertension, dyslipidemia, diabetes mellitus, or were cigarette smokers, respectively. Primary composite outcomes were observed in 2.59% of patients (1.55% stroke, 0.69% MI, and 1.72% death). Atrial fibrillation was a predictor of primary composite outcome in multivariate logistic regression (p = .048). The presence of total occlusion in the contralateral carotid artery was significantly associated with the risk of stroke in univariate logistic regression (p = .041). The patients were followed for a period ranging from 1 to 83 months. The overall survival rate for all-cause mortality was 93.48% at 1 year, 77.24% at 5 years, and 52.92% at 8 years. All-cause mortality was significantly higher among patients with symptomatic carotid stenosis (p = .014). CONCLUSION CAS provides acceptable short-term and mid-term outcomes in a unique population of high- and standard-surgical-risk, symptomatic and asymptomatic, octogenarian, and nonoctogenarian patients.
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Affiliation(s)
| | - Etrat Hooshmandi
- Clinical Neurology Research Center, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Farzaneh Zahediasl
- Clinical Neurology Research Center, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Hossein Molavi Vardanjani
- Research Center for Traditional Medicine and History of Medicine, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Mahdiyeh Rezaei
- Clinical Neurology Research Center, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Abbas Rahimi-Jaberi
- Clinical Neurology Research Center, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Nahid Ashjazadeh
- Clinical Neurology Research Center, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Peyman Petramfar
- Clinical Neurology Research Center, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Vahid Reza Ostovan
- Clinical Neurology Research Center, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Nima Fadakar
- Clinical Neurology Research Center, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Maryam Poursadeghfard
- Clinical Neurology Research Center, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Sadegh Izadi
- Clinical Neurology Research Center, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Masoumeh Nazeri
- Clinical Neurology Research Center, Shiraz University of Medical Sciences, Shiraz, Iran
| | | | - Mahnaz Bayat
- Clinical Neurology Research Center, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Mohammad Saied Salehi
- Clinical Neurology Research Center, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Maryam Owjfard
- Clinical Neurology Research Center, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Behnaz Sedighi
- Neurology Research Center, Kerman University of Medical Science, Kerman, Iran
| | - Farhad Iranmanesh
- Neurology Research Center, Kerman University of Medical Science, Kerman, Iran
| | - Kaveh Shafiei
- Neurology Research Center, Kerman University of Medical Science, Kerman, Iran
| | - Alireza Vakilian
- Non-Communicable Diseases Research Center, Rafsanjan University of Medical Sciences, Rafsanjan, Iran
| | - Amir Moghadam Ahmadi
- Neuro-immunology Research Scholar, Thomas Jefferson University, Philadelphia, PA, USA
| | - Reza Nemati
- Department of Neurology, Bushehr Medical University Hospital, School of Medicine, Bushehr University of Medical Sciences, Bushehr, Iran
| | | | | | - Kaveh Kashani
- Department of Neurology, Fasa University of Medical Sciences, Fasa, Iran
| | - Saeed Razmeh
- Department of Neurology, Yasuj University of Medical Sciences, Yasuj, Iran
| | - Mansour Bahrehbar
- Department of Neurology, Yasuj University of Medical Sciences, Yasuj, Iran
| | - Marzieh Basir
- Clinical Neurology Research Center, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Adnan I Qureshi
- Zeenat Qureshi Stroke Institute and University of Missouri, Columbia, Missouri, USA
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