1
|
AbuRahma AF, Santini A, AbuRahma ZT, Lee A, Veith C, Dargy N, Cragon R, Dean S, Mattox E. Clinical outcomes of transcarotid artery revascularization vs carotid endarterectomy from a large single-center experience. J Vasc Surg 2024; 79:1402-1411.e3. [PMID: 38320692 DOI: 10.1016/j.jvs.2024.01.213] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2023] [Revised: 01/24/2024] [Accepted: 01/29/2024] [Indexed: 03/03/2024]
Abstract
BACKGROUND Transcarotid artery revascularization (TCAR) has been practiced as an alternative for both carotid endarterectomy (CEA) and transfemoral carotid artery stenting, specifically in high-risk patients. More recently, the Centers for Medicare and Medicaid Services expanded coverage for TCAR in standard surgical risk patients if done within the Society for Vascular Surgery Vascular Quality Initiative TCAR surveillance project. A few registry studies (primarily from the Society for Vascular Surgery Vascular Quality Initiative) compared the early and up to 1-year outcomes of TCAR vs CEA or transfemoral carotid artery stenting. There is no large single-center study that reported late clinical outcomes. The present study compares intermediate clinical outcomes of TCAR vs CEA. METHODS This study retrospectively analyzed collected data from TCAR surveillance project patients enrolled in our institution and compare it with CEA patients done by the same providers at the same time period. The primary outcome was combined perioperative stroke/death and late stroke/death. Secondary outcomes included combined stroke, death, and myocardial infarction, cranial nerve injury (CNI), and bleeding. Propensity matching was done to analyze outcome. Kaplan-Meier analysis was used to estimate freedom from stroke, stroke/death, and ≥50% and ≥80% restenosis. RESULTS We analyzed 646 procedures (637 patients) (404 CEA, 242 TCAR). There was no significant difference in the indications for carotid intervention. However, TCAR patients had more high-risk criteria, including hypertension, coronary artery disease, congestive heart failure, and renal failure. There was no significant differences between CEA vs TCAR in 30-day perioperative stroke (1% vs 2%), stroke/death rate (1% vs 3%; P = .0849), or major hematomas (2% vs 2%). The rate of CNI was significantly different (5% for CEA vs 1% for TCAR; P = .0138). At late follow-up (2 years), the rate of stroke was 1% vs 4% (P = .0273), stroke/death 8% vs 15% (P = .008), ≥80 % restenosis 0.5% vs 3% (P = .0139) for CEA patients vs TCAR patients, respectively. After matching 242 CEAs and 242 TCARs, the perioperative stroke rate was 1% for CEA vs 2% for TCAR (P = .5037), the stroke/death rate was 2% vs 3% (P = .2423), and the CNI rate was 3% vs 1% (P = .127). At late follow-up, rates of stroke were 1% for CEA vs 4% for TCAR (P = .0615) and stroke/death were 8% vs 15% (P = .0345). The rate of ≥80% restenosis was 0.9% for CEA vs 3% for TCAR (P = .099). The rates of freedom from stroke at 6, 12, 18, and 24 months for CEA vs TCAR were 99%, 99%, 99%, and 99% vs 97%, 95%, 93% and 93%, respectively (P = .0806); stroke/death were 94%, 90%, 87%, and 86% vs 93%, 87%, 76%, and 75%, respectively (P = .0529); and ≥80% restenosis were 100%, 99%, 98%, and 98% vs 97%, 95%, 93%, and 93%, respectively (P = .1132). CONCLUSIONS In a propensity-matched analysis, both CEA and TCAR have similar perioperative clinical outcomes. However, CEA was superior to TCAR for the rates of late stroke/death and had a somewhat lower rate of ≥80% restenosis at 2 years, but this difference was not statistically significant.
Collapse
Affiliation(s)
- Ali F AbuRahma
- Department of Surgery, Charleston Area Medical Center/West Virginia University, Charleston, WV.
| | - Adrian Santini
- Department of Surgery, Charleston Area Medical Center/West Virginia University, Charleston, WV
| | - Zachary T AbuRahma
- Department of Surgery, Charleston Area Medical Center/West Virginia University, Charleston, WV
| | - Andrew Lee
- Department of Surgery, Charleston Area Medical Center/West Virginia University, Charleston, WV
| | - Christina Veith
- Department of Surgery, Charleston Area Medical Center/West Virginia University, Charleston, WV
| | - Noah Dargy
- Department of Surgery, Charleston Area Medical Center/West Virginia University, Charleston, WV
| | - Robert Cragon
- Department of Surgery, Charleston Area Medical Center/West Virginia University, Charleston, WV
| | - Scott Dean
- CAMC Health Education and Research Institute, Charleston, WV
| | - Elaine Mattox
- CAMC Health Education and Research Institute, Charleston, WV
| |
Collapse
|
2
|
Yei KS, Goodney PP, Malas MB. Transparency in our VISION: Author commentary on our Medicare-matched study. J Vasc Surg 2024; 79:835-836. [PMID: 38519213 DOI: 10.1016/j.jvs.2023.10.047] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2023] [Accepted: 10/24/2023] [Indexed: 03/24/2024]
Affiliation(s)
- Kevin S Yei
- The University of California San Diego, La Jolla, CA
| | | | | |
Collapse
|
3
|
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] [Abstract] [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]
Abstract
OBJECTIVE On October 11, 2023, the Centers for Medicare and Medicaid Services (CMS) expanded the indications for carotid artery stenting (CAS) to include patients with ≥50% symptomatic or ≥70% asymptomatic carotid stenosis. The aim of this article was to investigate the implications of this decision. METHODS The reasons behind the increased coverage for CAS are analyzed and discussed, as well as the various Societies supporting or opposing the expansion of indications for CAS. RESULTS The benefits associated with expanding CAS indications include providing an additional therapeutic option to patients and enabling individualization of treatment according to patient-specific characteristics. The drawbacks of expanding CAS indications include a possible bias in decision-making and an increase in inappropriate CAS procedures. CONCLUSIONS The purpose of the CMS recommendation to expand indications for CAS is to improve the available therapeutic options for patients. Hopefully this decision will not be misinterpreted and will be used to improve patient options and patient outcomes.
Collapse
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
| |
Collapse
|
4
|
Hajiyev K, Henkes H, Khanafer A, Bücke P, Hennersdorf F, Bäzner H, von Gottberg P. Drug-Coated Balloons for Treatment of Internal Carotid Artery Restenosis After Stenting: A Single-Center Mid-Term Outcome Study. Cardiovasc Intervent Radiol 2024; 47:291-298. [PMID: 38326576 PMCID: PMC10920408 DOI: 10.1007/s00270-024-03663-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/29/2023] [Accepted: 01/11/2024] [Indexed: 02/09/2024]
Abstract
PURPOSE Endovascular and surgical treatments of stenosis of the extracranial internal carotid artery (ICA) are common procedures, yet both introduce a risk of restenosis due to endothelial hyperplasia. Drug-coated balloons (DCBs) are designed to decrease neointimal hyperplasia, however rarely used in the neurovascular setting. This study retrospectively analyzes mid-term results of DCB-treated in-stent restenosis (ISR) of the ICA. MATERIALS AND METHODS The medical history, comorbidities, and periprocedural data of patients receiving DCB treatment for > 50% ISR of the ICA after carotid artery stenting were analyzed. Follow-up after DCB treatment was performed with Doppler ultrasound. Suspicious cases were checked with CT- or MR-angiography and-if there was agreement between the modalities-validated with digital subtraction angiography. Potential risk factors for restenosis and differences in outcomes after PTA with three types of DCB balloons were evaluated. RESULTS DCB treatment was performed in 109 cases, 0.9% of which involved in-hospital major stroke; no minor strokes occurred. A total of 17 patients (15.6%) had recurrent ISR after DCB treatment, after a mean time of 30.2 months (7-85 months). Tobacco use was significantly associated with a higher incidence of recurrent ISR. CONCLUSION DCB angioplasty for ISR is an effective treatment that may delay and decrease restenosis. Treating comorbidities and adopting lifestyle changes may additionally help prevent ISR.
Collapse
Affiliation(s)
- Kamran Hajiyev
- Neuroradiologische Klinik, Klinikum Stuttgart, Stuttgart, Germany
| | - Hans Henkes
- Neuroradiologische Klinik, Klinikum Stuttgart, Stuttgart, Germany
- Medizinische Fakultät, Universität Duisburg-Essen, Essen, Germany
| | - Ali Khanafer
- Neuroradiologische Klinik, Klinikum Stuttgart, Stuttgart, Germany
| | - Philipp Bücke
- Universitätsklinik für Neurologie, Bern University Hospital, Inselspital, Bern, Switzerland
| | - Florian Hennersdorf
- Abteilung Diagnostische und Interventionelle Neuroradiologie, Radiologische Universitätsklinik Tübingen, Tübingen, Germany
| | - Hansjörg Bäzner
- Neurologische Klinik, Klinikum Stuttgart, Stuttgart, Germany
| | | |
Collapse
|
5
|
Hajiyev K, Cimpoca A, Ernemann U, Bäzner H, Henkes H, von Gottberg P. Long-term outcomes of carotid stenting in a single neurovascular center: up to 12-year retrospective analysis with a focus on the influence of comorbidities. Neuroradiology 2024; 66:117-127. [PMID: 38010404 DOI: 10.1007/s00234-023-03248-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2023] [Accepted: 11/12/2023] [Indexed: 11/29/2023]
Abstract
BACKGROUND The aim of this study was to evaluate long-term outcomes in patients who underwent carotid artery stenting (CAS) for symptomatic or asymptomatic high-grade stenosis. METHODS A total of 1158 patients (asymptomatic, n = 636; symptomatic, n = 522) underwent CAS at our center between 2009 and 2020. A total of 560 patients or contacts (asymptomatic, n = 316; symptomatic, n = 244) were interviewed by telephone to evaluate long-term outcomes with a mean follow-up of 5 years. Mortality from all causes, myocardial infarction, and stroke, as well as comorbidities influencing their occurrence, including overall survival and stroke-free survival, were examined. RESULTS The overall survival rate for all-cause mortality was 91.6% at 1 year, 77.1% at 5 years, and 55.7% at 10 years. A total of 39 (6.9%) patients had an ischemic stroke during long-term follow-up. The stroke-free survival rates at 1 year, 5 years, and 10 years were 97.9%, 92.7%, and 86.6%, respectively. Stroke-free survival and overall survival did not differ significantly between the symptomatic and asymptomatic groups (overall survival, p = 0.304; stroke-free survival, p = 0.336). Regular physical activity reduced the risk of stroke and death and was associated with better long-term clinical outcomes. Age at treatment and diabetes mellitus were statistically significantly associated with death during follow-up. CONCLUSION Long-term follow-up data confirmed the effectiveness and durability of CAS as a therapy option for both symptomatic and asymptomatic patients. In patient selection for CAS, special consideration should be paid to patient age, ability to engage in physical activity, and diabetes mellitus.
Collapse
Affiliation(s)
- K Hajiyev
- Neuroradiologische Klinik, Klinikum Stuttgart, Stuttgart, Germany.
| | - A Cimpoca
- Neuroradiologische Klinik, Klinikum Stuttgart, Stuttgart, Germany
| | - U Ernemann
- Diagnostische Und Interventionelle Neuroradiologie, Universitätsklinikum Tübingen, Tübingen, Germany
| | - H Bäzner
- Neurologische Klinik, Klinikum Stuttgart, Stuttgart, Germany
| | - H Henkes
- Neuroradiologische Klinik, Klinikum Stuttgart, Stuttgart, Germany
| | - P von Gottberg
- Neuroradiologische Klinik, Klinikum Stuttgart, Stuttgart, Germany
| |
Collapse
|
6
|
Gerardi D, Fioretti V, Stabile E. Editorial: Carotid artery stenting with DLS: New insights for long-term outcome. CARDIOVASCULAR REVASCULARIZATION MEDICINE 2023; 57:41-42. [PMID: 37543501 DOI: 10.1016/j.carrev.2023.07.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2023] [Accepted: 07/20/2023] [Indexed: 08/07/2023]
Affiliation(s)
- Donato Gerardi
- Division of Cardiology, Cardiovascular Department, Azienda Ospedaliera Regionale "San Carlo", Potenza, Italy; CardioPath PhD Student, Federico II University, Naples, Italy
| | - Vincenzo Fioretti
- Division of Cardiology, Cardiovascular Department, Azienda Ospedaliera Regionale "San Carlo", Potenza, Italy
| | - Eugenio Stabile
- Division of Cardiology, Cardiovascular Department, Azienda Ospedaliera Regionale "San Carlo", Potenza, Italy.
| |
Collapse
|
7
|
Mazurek A, Malinowski K, Sirignano P, Kolvenbach R, Capoccia L, DE Donato G, VAN Herzeele I, Siddiqui AH, Castrucci T, Tekieli L, Stefanini M, Wissgott C, Rosenfield K, Metzger DC, Snyder K, Karpenko A, Kuczmik W, Stabile E, Knapik M, Casana R, Pieniazek P, Podlasek A, Taurino M, Schofer J, Cremonesi A, Sievert H, Schmidt A, Grunwald IQ, Speziale F, Setacci C, Musialek P. Carotid artery revascularization using second generation stents versus surgery: a meta-analysis of clinical outcomes. THE JOURNAL OF CARDIOVASCULAR SURGERY 2023; 64:570-582. [PMID: 38385840 DOI: 10.23736/s0021-9509.24.12933-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/23/2024]
Abstract
INTRODUCTION Meta-analyses and emerging randomized data indicate that second-generation ('mesh') carotid stents (SGS) may improve outcomes versus conventional (single-layer) stents but clinically-relevant differences in individual SGS-type performance have been identified. No comparisons exist for SGS versus carotid endarterectomy (CEA). EVIDENCE ACQUISITION Thirty-day death (D), stroke (S), myocardial infarction (M), and 12-month ipsilateral stroke and restenosis in SGS studies were meta-analyzed (random effect model) against CEA outcomes. Eligible studies were identified through PubMed/EMBASE/COCHRANE. Forest plots were formed for absolute adverse evet risk in individual studies and for relative outcomes with each SGS deign versus contemporary CEA outcomes as reference. Meta-regression was performed to identify potential modifiers of treatment modality effect. EVIDENCE SYNTHESIS Data were extracted from 103,642 patients in 25 studies (14 SGS-treated, 41% symptomatic; nine randomized controlled trial (RCT)-CEA-treated, 37% symptomatic; and two Vascular Quality Initiative (VQI)-CEA-treated, 23% symptomatic). Casper/Roadsaver and CGuard significantly reduced DSM versus RCT-CEA (-2.70% and -2.95%, P<0.001 for both) and versus VQI-CEA (-1.11% and -1.36%, P<0.001 for both). Gore stent 30-day DSM was similar to RCT-CEA (P=0.581) but increased against VQI-CEA (+2.38%, P=0.033). At 12 months, Casper/Roadsaver ipsilateral stroke rate was lower than RCT-CEA (-0.75%, P=0.026) and similar to VQI-CEA (P=0.584). Restenosis with Casper/Roadsaver was +4.18% vs. RCT-CEA and +4.83% vs. VQI-CEA (P=0.005, P<0.001). CGuard 12-month ipsilateral stroke rate was similar to VQI-CEA (P=0.850) and reduced versus RCT-CEA (-0.63%, P=0.030); restenosis was reduced respectively by -0.26% and -0.63% (P=0.033, P<0.001). Twelve-month Gore stent outcomes were overall inferior to surgery. CONCLUSIONS Meta-analytic integration of available clinical data indicates: 1) reduction in stroke but increased restenosis rate with Casper/Roadsaver, and 2) reduction in both stroke and restenosis with CGuard MicroNET-covered stent against contemporary CEA outcomes at 30 days and 12 months used as a reference. This may inform clinical practice in anticipation of large-scale randomized trials powered for low clinical event rates (PROSPERO-CRD42022339789).
Collapse
Affiliation(s)
- Adam Mazurek
- Department of Cardiac and Vascular Diseases, Jagiellonian University Medical College, Krakow, Poland -
- St. John Paul II Hospital Stroke Thrombectomy-Capable Center, Krakow, Poland -
| | - Krzysztof Malinowski
- Department of Bioinformatics and Telemedicine, Faculty of Medicine, Jagiellonian University Medical College, Krakow, Poland
- KCRI, Krakow, Poland
| | - Pasqualino Sirignano
- Department of Vascular and Endovascular Surgery, Sant'Andrea Hospital, La Sapienza University, Rome, Italy
| | - Ralf Kolvenbach
- Department of Vascular Surgery in Sana Kliniken, Düsseldorf Gerresheim, Germany
| | - Laura Capoccia
- Department of Vascular Surgery "Paride Stefanini", Policlinico Umberto I, La Sapienza University, Rome, Italy
| | | | | | - Adnan H Siddiqui
- Department of Radiology, Jacobs School of Medicine and Biomedical Sciences, and Canon Stroke and Vascular Research Center, University at Buffalo, Buffalo, NY, USA
- Jacobs Institute, Buffalo, NY, USA
| | - Tomaso Castrucci
- Department of Vascular Surgery, Sant' Eugenio Hospital, University of Rome Tor Vergata, Rome, Italy
| | - Lukasz Tekieli
- Department of Cardiac and Vascular Diseases, Jagiellonian University Medical College, Krakow, Poland
- St. John Paul II Hospital Stroke Thrombectomy-Capable Center, Krakow, Poland
- Department of Interventional Cardiology, Jagiellonian University Medical College, Krakow, Poland
| | - Matteo Stefanini
- Department of Radiology and Interventional Radiology, Casilino Hospital, Rome, Italy
| | - Christian Wissgott
- Institut für Diagnostische und Interventionelle Radiologie/Neuroradiologie, Imland Klinik Rendsburg, Rendsburg, Germany
| | - Kenneth Rosenfield
- Section of Vascular Medicine and Intervention, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | | | - Kenneth Snyder
- Department of Neurosurgery, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, Buffalo, NY, USA
| | - Andrey Karpenko
- Center of Vascular and Hybrid Surgery, E.N. Meshalkin National Medical Research Center, Novosibirsk, Russia
| | - Waclaw Kuczmik
- Department of General, Vascular Surgery, Angiology and Phlebology, Medical University of Silesia, Katowice, Poland
| | - Eugenio Stabile
- Dipartimento Cardiovascolare, Azienda Ospedaliera Regionale "San Carlo", Potenza, Italy
| | - Magdalena Knapik
- Department of Radiology, Podhalanski Multispecialty Regional Hospital, Nowy Targ, Poland
| | - Renato Casana
- Vascular Surgery Unit, IRCCS Istituto Auxologico Italiano, Milan, Italy
| | - Piotr Pieniazek
- Department of Cardiac and Vascular Diseases, Jagiellonian University Medical College, Krakow, Poland
- Department of Interventional Cardiology, Jagiellonian University Medical College, Krakow, Poland
| | - Anna Podlasek
- Tayside Innovation MedTech Ecosystem (TIME), University of Dundee, Dundee, UK
- Precison Imaging Beacon, Radiological Sciences, University of Nottingham, Nottingham, UK
| | - Maurizio Taurino
- Department of Vascular and Endovascular Surgery, Sant'Andrea Hospital, La Sapienza University, Rome, Italy
| | - Joachim Schofer
- MVZ-Department Structural Heart Disease, Asklepios Clinic St Georg, Hamburg, Germany
| | - Alberto Cremonesi
- Department of Cardiology, Humanitas Gavazzeni, Bergamo, Italy
- Department of Biomedical Sciences, Humanitas University, Milan, Italy
| | - Horst Sievert
- Department of Cardiology and Vascular Medicine, Cardiovascular Center, Frankfurt, Germany
| | - Andrej Schmidt
- Department of Angiology, University Hospital Leipzig, Leipzig, Germany
| | - Iris Q Grunwald
- Tayside Innovation MedTech Ecosystem (TIME), University of Dundee, Dundee, UK
- Department of Radiology Ninewells Hospital, University of Dundee, Dundee, UK
| | - Francesco Speziale
- Department of Vascular Surgery "Paride Stefanini", Policlinico Umberto I, La Sapienza University, Rome, Italy
| | - Carlo Setacci
- Department of Vascular Surgery, University of Siena, Siena, Italy
| | - Piotr Musialek
- Department of Cardiac and Vascular Diseases, Jagiellonian University Medical College, Krakow, Poland
- St. John Paul II Hospital Stroke Thrombectomy-Capable Center, Krakow, Poland
| |
Collapse
|
8
|
Szkolka L, Lyko-Morawska D, Balocco S, Bedkowski L, Buczek M, Medon E, Wolkowski M, Dryjski M, Kuczmik W. Vascular surgery study of the CGuard MicroNet-covered stent in patients with indication to carotid revascularization: POLGUARD. THE JOURNAL OF CARDIOVASCULAR SURGERY 2023; 64:615-623. [PMID: 37947755 DOI: 10.23736/s0021-9509.23.12891-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/12/2023]
Abstract
BACKGROUND In a recent randomized study, MicroNet-covered stent (CGuard) significantly reduced procedural and post-procedural cerebral embolism in relation to a single-layer CREST study carotid stent, but real-life clinical practice data are limited. The aim is to prospectively assess clinical outcomes of CGuard as a routine revascularization tool for patients with indication to carotid revascularization. METHODS From April 2019 to November 2021, 204 elective patients (age 71.0±7.1years, 69.6% males, 21.7% symptomatic) were enrolled. RESULTS Mean basal peak-systolic velocity was 251.41±91.85 cm/s with angiographic diameter stenosis 89.7±8.46%. About 34.4% lesions were severely calcified, 6.8% were angulated, and 4.4% showed significant access tortuosity. Access was femoral, with 100% protection device (filter) use. Two hundred and three lesions in 203 patients were treated (1 cross-over to surgery for lack of effective access, no cross-over to other devices); in most cases (66.9%) the stent was placed directly. For pre-dilated lesions, mean balloon diameter was 3.36±0.34mm. Mean nominal stent diameter was 7.64±0.5 mm; length was 37.19±4.5 mm. All stents were post-dilated (balloon diameter 5.2±0.25 mm). Residual stenosis was <30% in all (3.77±6.91%). By discharge, there were 2 minor strokes (0.9%) and one transient ischemic attack. By 30-days, one other minor stroke occurred in relation to de-novo atrial fibrillation. With no deaths or myocardial infarctions, 30-day total death/stroke/myocardial infarction rate was 1.48%. No in-stent thrombosis or patency loss occurred by 30-days. In-stent peak-systolic velocity was 55.49±22.73 cm/s. CONCLUSIONS Thirty-day results from POLGUARD study indicate safety and a low complication rate of the MicroNet-covered carotid stent use in every-day vascular surgery practice of carotid revascularization. Long-term observation is underway.
Collapse
Affiliation(s)
- Lukasz Szkolka
- Department of Vascular Surgery, General Surgery, Angiology and Phlebology, Silesian Medical University, Katowice, Poland -
| | - Dorota Lyko-Morawska
- Department of Vascular Surgery, General Surgery, Angiology and Phlebology, Silesian Medical University, Katowice, Poland
| | - Simone Balocco
- Department of Mathematics and Computer Science, University of Barcelona, Barcelona, Spain
| | - Lukasz Bedkowski
- Department of Vascular Surgery, General Surgery, Angiology and Phlebology, Silesian Medical University, Katowice, Poland
| | - Michal Buczek
- Department of Vascular Surgery, General Surgery, Angiology and Phlebology, Silesian Medical University, Katowice, Poland
| | - Ewa Medon
- Department of Vascular Surgery, General Surgery, Angiology and Phlebology, Silesian Medical University, Katowice, Poland
| | - Maciej Wolkowski
- Department of Vascular Surgery, General Surgery, Angiology and Phlebology, Silesian Medical University, Katowice, Poland
| | - Maciej Dryjski
- Department of Surgery at the University at Buffalo, Buffalo, NY, USA
| | - Waclaw Kuczmik
- Department of Vascular Surgery, General Surgery, Angiology and Phlebology, Silesian Medical University, Katowice, Poland
| |
Collapse
|
9
|
Onishi S, Ohba S, Isobe N, Ito Y, Takano M, Maeda Y, Horie N. T1-T2 Mismatch Sign as a Predictor of Ipsilateral Ischemic Change After Carotid Artery Stenting. World Neurosurg 2023; 179:e450-e457. [PMID: 37660840 DOI: 10.1016/j.wneu.2023.08.117] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2023] [Revised: 08/26/2023] [Accepted: 08/28/2023] [Indexed: 09/05/2023]
Abstract
BACKGROUND Magnetic resonance (MR)-plaque imaging reflects the characteristics of carotid plaque. We evaluated the relationship between MR-plaque images and ischemic change after carotid artery stenting (CAS). METHODS MR-plaque images were acquired from patients with carotid artery stenosis before CAS treatment. We calculated the relative signal intensity of plaque components compared with that of the sternocleidomastoid muscle and evaluated the presence/absence of T1-T2 mismatch and match sign. We then assessed the appearance of new ischemic lesions after CAS on diffusion-weighted imaging (DWI). Factors associated with the appearance of a high-intensity lesion on DWI were retrospectively analyzed. RESULTS A total of 64 patients with carotid artery stenoses treated with CAS were included in this study. In univariate analysis, T1-T2 mismatch sign was associated with the appearance of high-intensity lesions on DWI after CAS (odds ratio [OR], 12.00; 95% confidence interval [CI], 3.593-40.072; P < 0.0001), whereas T1-T2 match sign and high intensity on T2-weighted imaging were negatively associated (OR, 0.061, 95% CI, 0.007-0.502, P = 0.009 and OR, 0.085; 95% CI, 0.022-0.334, P = 0.0004, respectively). In multivariate logistic regression analysis, T1-T2 mismatch sign was independently associated with the appearance of a high-intensity lesion on DWI after CAS (OR, 16.695; 95% CI, 1.324-210.52; P = 0.0295). CONCLUSIONS T1-T2 mismatch sign on MR-plaque imaging is significantly associated with the appearance of new ischemic lesions after CAS. T1-T2 mismatch sign may be useful in considering treatment strategies for carotid artery stenosis.
Collapse
Affiliation(s)
- Shumpei Onishi
- Department of Neurosurgery, National Hospital Organization Kure Medical Center and Chugoku Cancer Center, Hiroshima, Japan; Department of Neurosurgery, Graduate School of Biomedical and Health Sciences, Hiroshima University, Hiroshima, Japan.
| | - Shinji Ohba
- Department of Neurosurgery, National Hospital Organization Kure Medical Center and Chugoku Cancer Center, Hiroshima, Japan
| | - Naoyuki Isobe
- Department of Neurosurgery, National Hospital Organization Kure Medical Center and Chugoku Cancer Center, Hiroshima, Japan
| | - Yoko Ito
- Department of Neurosurgery, National Hospital Organization Kure Medical Center and Chugoku Cancer Center, Hiroshima, Japan
| | - Motoki Takano
- Department of Neurosurgery, National Hospital Organization Kure Medical Center and Chugoku Cancer Center, Hiroshima, Japan
| | - Yugo Maeda
- Department of Neurosurgery, National Hospital Organization Kure Medical Center and Chugoku Cancer Center, Hiroshima, Japan
| | - Nobutaka Horie
- Department of Neurosurgery, Graduate School of Biomedical and Health Sciences, Hiroshima University, Hiroshima, Japan
| |
Collapse
|
10
|
Röder F, Banning LBD, Bokkers RPH, de Vries JPPM, Schuurmann RCL, Zeebregts CJ, Pol RA. Carotid calcium burden derived from computed tomography angiography as a predictor of all-cause mortality after carotid endarterectomy. J Vasc Surg 2023; 78:995-1002. [PMID: 37257670 DOI: 10.1016/j.jvs.2023.05.036] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2023] [Revised: 05/07/2023] [Accepted: 05/21/2023] [Indexed: 06/02/2023]
Abstract
OBJECTIVE Carotid endarterectomy (CEA) aims to reduce the risk of stroke in patients with atherosclerotic carotid disease. Preoperative risk assessments that predict complications are needed to optimize the care in this patient group. The current approach, namely relying solely on symptomatology and degree of stenosis, is outdated and calls for innovation. The Agatston calcium score was applied in several vascular specialties to assess cardiovascular risk profile but has been little studied in carotid surgery. It is hypothesized that a higher calcium burden at initial presentation equates to a worse prognosis attributable to an increased cerebrovascular and cardiovascular risk profile. The aim was to investigate the association between preoperative ipsilateral calcium score and postoperative all-cause mortality in patients undergoing CEA. METHODS This single-center retrospective cohort study included 89 patients who underwent CEA at a tertiary referral center between 2010 and 2018. Preoperative calcium scores were measured on contrast-enhanced computed tomography images with patient-specific Hounsfield thresholds at the level of the carotid bifurcation. The association between these calcium scores and all-cause mortality was analyzed using multivariable adjusted Cox proportional hazard analysis. RESULTS Cox proportional hazard analysis demonstrated a significant association between preoperative ipsilateral carotid calcium score and all-cause mortality (hazard ratio, 1.10; 95% confidence interval, 1.03-1.16; P = .003). After adjusting for age, preoperative estimated glomerular filtration rate, and diabetes mellitus, a significant association remained (hazard ratio, 1.07; 95% confidence interval, 1.00-1.15; P = .05). CONCLUSIONS A higher calcium burden was predictive of worse outcome, which might be explained by an overall poorer health status. These results highlight the potential of calcium measurements in combination with other traditional risk factors, for preoperative risk assessment and thus for improved patient education and care.
Collapse
Affiliation(s)
- Franziska Röder
- Division of Vascular Surgery, Department of Surgery, University Medical Centre Groningen, University of Groningen, Groningen, The Netherlands
| | - Louise B D Banning
- Division of Vascular Surgery, Department of Surgery, University Medical Centre Groningen, University of Groningen, Groningen, The Netherlands
| | - Reinoud P H Bokkers
- Department of Radiology, University Medical Centre Groningen, University of Groningen, Groningen, The Netherlands
| | - Jean-Paul P M de Vries
- Division of Vascular Surgery, Department of Surgery, University Medical Centre Groningen, University of Groningen, Groningen, The Netherlands
| | - Richte C L Schuurmann
- Division of Vascular Surgery, Department of Surgery, University Medical Centre Groningen, University of Groningen, Groningen, The Netherlands
| | - Clark J Zeebregts
- Division of Vascular Surgery, Department of Surgery, University Medical Centre Groningen, University of Groningen, Groningen, The Netherlands
| | - Robert A Pol
- Division of Vascular Surgery, Department of Surgery, University Medical Centre Groningen, University of Groningen, Groningen, The Netherlands.
| |
Collapse
|
11
|
Zimmermann M, Larena-Avellaneda A, Rother U, Lareyre F, Søgaard M, Tulamo R, Venermo M, Behrendt CA. Editor's Choice - Long Term Outcomes After Invasive Treatment of Carotid Artery Stenosis: a Longitudinal Study of German Health Insurance Claims. Eur J Vasc Endovasc Surg 2023; 66:493-500. [PMID: 37490978 DOI: 10.1016/j.ejvs.2023.07.030] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2023] [Revised: 06/23/2023] [Accepted: 07/19/2023] [Indexed: 07/27/2023]
Abstract
OBJECTIVE There is a paucity of observational data including long term outcomes after invasive treatment for carotid artery stenosis. METHODS This retrospective study used nationwide insurance claims from the third largest provider in Germany, DAK-Gesundheit. Patients who underwent inpatient carotid endarterectomy (CEA) or carotid artery stenting (CAS) between 1 January 2008 and 31 May 2017 were included. The Elixhauser comorbidity scores from longitudinally linked hospital episodes were used. Kaplan-Meier analysis and the log rank test were used to determine long term stroke free survival. Multivariable regression models were developed to adjust for confounding. RESULTS A total of 22 637 individual patients (41.6% female, median age 72.5 years) were included, of whom 15 005 (66.3%) were asymptomatic and 17 955 (79.3%) underwent CEA. After a median of 48 months, 5 504 any stroke or death events were registered. The mortality rate varied between 0.4% (CEA for asymptomatic stenosis) and 2.1% (urgent CAS for acute stroke patients) at 30 days, and between 4.1% and 8.4% at one year, respectively. The rate for any stroke varied between 0.6% (CEA for asymptomatic stenosis) and 2.5% (CAS for symptomatic patients) at 30 days, and between 2.5% and 6.4% at one year, respectively. The combined rate for any stroke and mortality at one year was 6.3% (CEA for asymptomatic stenosis), 8.7% (CAS for asymptomatic stenosis), and 12.5% (urgent CAS for acute stroke patients). After five years, the overall stroke rate was 7.4% after CEA and 9.0% after CAS. In adjusted analyses, both older age and van Walraven comorbidity score were associated with events, while treatment of asymptomatic stenosis was associated with lower event rates. CONCLUSION The current study revealed striking differences between previous landmark trials and real world practice. It further suggested excess deaths among invasively treated asymptomatic patients.
Collapse
Affiliation(s)
| | - Axel Larena-Avellaneda
- Department of Vascular and Endovascular Surgery, Asklepios Clinic Altona, Asklepios Medical School, Hamburg, Germany
| | - Ulrich Rother
- Department of Vascular Surgery, University Hospital Erlangen, Friedrich Alexander Universität Erlangen-Nürnberg (FAU), Erlangen, Germany
| | - Fabien Lareyre
- Department of Vascular Surgery, Hospital of Antibes-Juan-les-Pins, Antibes, Institut National de la Santé et de la Recherche Médicale (INSERM), Centre Méditerranéen de Médecine Moléculaire (C3M), Université Côte d'Azur, Nice, France
| | - Mette Søgaard
- Aalborg Thrombosis Research Unit, Department of Clinical Medicine, Faculty of Medicine, Aalborg University, Aalborg, Denmark; Department of Cardiology, Aalborg University Hospital, Aalborg, Denmark
| | - Riikka Tulamo
- Department of Vascular Surgery, Helsinki University Hospital, University of Helsinki, Helsinki, Finland
| | - Maarit Venermo
- Department of Vascular Surgery, Helsinki University Hospital, University of Helsinki, Helsinki, Finland
| | - Christian-Alexander Behrendt
- Department of Vascular and Endovascular Surgery, Asklepios Clinic Wandsbek, Asklepios Medical School, Hamburg, Germany; Brandenburg Medical School Theodor Fontane, Neuruppin, Germany.
| |
Collapse
|
12
|
Ismail A, Ravipati S, Gonzalez-Hernandez D, Mahmood H, Imran A, Munoz EJ, Naeem S, Abdin ZU, Siddiqui HF. Carotid Artery Stenosis: A Look Into the Diagnostic and Management Strategies, and Related Complications. Cureus 2023; 15:e38794. [PMID: 37303351 PMCID: PMC10250083 DOI: 10.7759/cureus.38794] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/09/2023] [Indexed: 06/13/2023] Open
Abstract
Carotid stenosis (CS) is a buildup of atherosclerotic plaque within the artery leading to a wide range of symptoms, from mild symptoms, including blurred vision and confusion, to much more life-threatening presentations, including paralysis due to stroke. The presentation is insidious, with symptoms exhibiting predominantly at severe stenosis; hence the emphasis is placed on the importance of early diagnosis, treatment, and lifestyle modifications. CS is seen undergoing almost the same pathogenesis of any atherosclerotic plaque formation, from endothelial damage of the artery lumen to the formation of a fibrous cap with a foam cell, lipid-filled core. The findings of our review article were consistent with the recent literature, depicting that comorbid hypertension, diabetes, and chronic kidney disease (CKD), and lifestyle aspects, including smoking and diet, played the most salient role in plaque development. Among several imaging modalities, duplex ultrasound (DUS) imaging is the widely preferred method in clinical practice. Carotid endarterectomy (CEA) and carotid stenting are the primarily advocated procedures for symptomatic severe stenosis, with similar long-term outcomes. Although, earlier clinical trials showed promising results in mitigating the risk of stroke among asymptomatic severe CS with surgical intervention. However, recent advancements have shifted the focus to medical management alone due to comparable results among the asymptomatic population. Both surgical and medical regimens are beneficial in treating patients, but it is still an ongoing debate as to which is predominantly superior. The currently advancing trials and research will help elucidate definitive guidelines. However, the massive impact of lifestyle modifications advocates some degree of individualized multidisciplinary management strategies.
Collapse
Affiliation(s)
- Aqsa Ismail
- Department of Medicine, United Medical and Dental College, Karachi, PAK
| | - Shivani Ravipati
- Department of Medicine, Dr. Pinnamaneni Siddhartha Institute of Medical Sciences and Research Foundation, Vijayawada, IND
| | | | - Hashim Mahmood
- Department of Medicine, University College of Medicine and Dentistry, University of Lahore, Lahore, PAK
| | - Alizay Imran
- Department of Surgery, Windsor University School of Medicine, Chicago, USA
| | - Eduardo J Munoz
- Department of General Medicine, Montemorelos University, Montemorelos, MEX
| | - Saad Naeem
- Department of Internal Medicine, Faisalabad Medical University, Faisalabad, PAK
- Department of Internal Medicine, Punjab Social Security Hospital, Faisalabad, PAK
| | - Zain U Abdin
- Department of Medicine, District Head Quarters Hospital, Faisalabad, PAK
| | - Humza F Siddiqui
- Department of Medicine, Jinnah Sindh Medical University, Karachi, PAK
| |
Collapse
|
13
|
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] [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.
Collapse
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.
| |
Collapse
|
14
|
Kazantsev AN, Korotkikh AV, Unguryan VM, Belov YV. Update in Carotid Disease. Curr Probl Cardiol 2023; 48:101676. [PMID: 36828045 DOI: 10.1016/j.cpcardiol.2023.101676] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2023] [Revised: 02/17/2023] [Accepted: 02/17/2023] [Indexed: 02/24/2023]
Abstract
This review of the literature analyzes publications over the past five years on various problems associated with carotid endarterectomy: 1. Is the eversion or classical technique of surgery with plastic repair of the reconstruction area with a patch more effective? 2. Carotid endarterectomy or carotid angioplasty with stenting is more optimal? 3. When should brain revascularization be performed after the development of ischemic stroke? 4. Should a temporary shunt be used to protect the brain during carotid endarterectomy? 5. How to prevent and treat different types of intraoperative ischemic strokes? 6. What tactics of treatment of patients with combined lesions of the carotid and coronary arteries is more effective? 7. What are the causes and methods of elimination of restenosis of the internal carotid artery known? 8. Is carotid endarterectomy safe in old age?
Collapse
Affiliation(s)
- Anton Nikolaevich Kazantsev
- Kostroma Regional Clinical Hospital named after Korolev E.I., Kostroma, Russian Federation; Kostroma oncological dispensary, Kostroma, Russian Federation.
| | - Alexander Vladimirovich Korotkikh
- Clinic of Cardiac Surgery of the Amur State Medical Academy of the Ministry of Health of Russia, Blagoveshchensk, Russian Federation
| | | | - Yuriy Vladimirovich Belov
- First Moscow State Medical University named after Sechenov, Moscow, Russian Federation; Federal State Budgetary Scientific Institution Russian Scientific Center for Surgery named after Academician B.V. Petrovsky, Moscow, Russian Federation
| |
Collapse
|
15
|
Kirchhoff F, Eckstein HH. Locoregional Anaesthesia and Intra-Operative Angiography in Carotid Endarterectomy: 16 Year Results of a Consecutive Single Centre Series. Eur J Vasc Endovasc Surg 2023; 65:223-232. [PMID: 36229016 DOI: 10.1016/j.ejvs.2022.10.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2022] [Revised: 08/11/2022] [Accepted: 10/02/2022] [Indexed: 11/30/2022]
Abstract
OBJECTIVE The benefit of local (LA) over general (GA) anaesthesia and the rationale of intra-operative imaging strategies during carotid endarterectomy (CEA) is debated. This study analysed the associations between patient characteristics, LA, and intra-operative imaging strategies and the in hospital stroke and death rates in elective CEA over a 16 year period. METHODS All consecutive patients treated by elective CEA between January 2004 and December 2019 (n = 1 872; median age 71 years, 70% male, 37% symptomatic) were included. All patients were assessed neurologically before and within 48 hours after CEA. The primary outcome event was the combined rate of any in hospital stroke or death. Secondary outcome events were the combined rates of any in hospital major stroke (modified Rankin scale [mRS] 3 - 5) or death, stroke, minor stroke (mRS 0 - 2), major stroke, and death alone. To detect changes over time, four quartiles (2004 - 2007, 2008 - 2011, 2012 - 2015, and 2016 - 2019) of this cohort were analysed. Statistical analysis comprised trend tests, and uni- and multivariable logistic regression. RESULTS Median patient age increased from 68 to 73 years (p < .001). Over time, LA (from 28% to 91%) and intra-operative imaging (angiography 2.8 - 98.1%, duplex ultrasound 0 - 78.2%) was applied more frequently. Surgical techniques did not change. The in hospital stroke or death and major stroke or death rates decreased from 3.7% to 1.5% (p = .041) and from 2.8% to 0.9% (p = .014), respectively, corresponding to a relative risk of decline of 7% and 12% annually. Multivariable analysis revealed that LA (odds ratio [OR] 0.25, 95% confidence interval [CI] 0.1 - 0.62) and intra-operative angiography (OR 0.09, 95% CI 0.10 - 0.81) were associated with lower in hospital major stroke and death rates. CONCLUSION These data demonstrate a decline in the combined rates of any in hospital major stroke or death after non-emergency CEA over time. Locoregional anaesthesia and intra-operative quality control were associated with these improvements and might be worthwhile in elective CEA.
Collapse
Affiliation(s)
- Felix Kirchhoff
- Department for Vascular and Endovascular Surgery, Klinikum rechts der Isar, Technical University of Munich, Munich, Germany
| | - Hans-Henning Eckstein
- Department for Vascular and Endovascular Surgery, Klinikum rechts der Isar, Technical University of Munich, Munich, Germany.
| |
Collapse
|
16
|
de Borst GJ. Transcarotid artery revascularization. Br J Surg 2023; 110:127-128. [PMID: 36453074 PMCID: PMC10364484 DOI: 10.1093/bjs/znac421] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2022] [Accepted: 11/04/2022] [Indexed: 12/03/2022]
Affiliation(s)
- Gert J de Borst
- Department of Vascular Surgery G04.129, University Medical Center Utrecht, Utrecht, The Netherlands
| |
Collapse
|
17
|
Pérez-Sánchez S, Barragán Prieto A, Gamero García MÁ, Moniche F, Tomasello A, Delgado-Acosta F, González A, Montaner J. Predictive Factors for Stroke and TIA Following Carotid Artery Stenting. J Endovasc Ther 2023:15266028221144586. [PMID: 36609162 DOI: 10.1177/15266028221144586] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
PURPOSE Carotid artery stenting (CAS) is an effective and minimally invasive method for the treatment of extracranial carotid artery stenosis. The aim of the present study was to explore independent risk factors to predict cerebrovascular events following CAS to identify high-risk patients and improve the safety of CAS in this population. MATERIALS AND METHODS HISPANIAS is a national prospective multicenter study that included 14 hospitals that collected data from patients who underwent CAS. We analyzed morbidity and mortality within 30 days after CAS, looking for factors that might be associated with cerebrovascular events (stroke and transient ischemic attack [TIA]). RESULTS The HISPANIAS cohort included 757 patients: 80.32% were men, the mean age was 70.73 years, and 82.96% underwent symptomatic CAS. Cerebrovascular complications occurred in 42 patients (5.6%), including TIA in 24 patients (70.8% ipsilateral; mean 2.79 days after CAS) and stroke in 18 patients (72.2% ipsilateral; mean 6.72 days after CAS). The main independent clinical predictors of stroke/TIA identified by logistic regression were female sex (odds ratio [OR] 2.29, 95% CI 1.15-4.54) and diabetes (OR 3.29, 95% CI 1.71-6.40). Survival analysis showed that diabetic women, compared with the rest of the patients, had a higher number of events concentrated mainly in the first days after the intervention (p=0.003). CONCLUSION Cerebrovascular ischemic complications after CAS continue to be a challenge for the management of these patients. Although there are other factors, female sex and the presence of diabetes are emerging as strong risk factors for the development of complications after symptomatic CAS. CLINICAL IMPACT Carotid artery stenting (CAS) is an effective and minimally invasive method for the treatment of extracranial carotid artery stenosis. Although CAS has been regarded as a reliable and safety approach, some studies reported that CAS was associated with a higher risk of procedure-related stroke. Cerebrovascular complications after CAS continue to be a main problem and a challenge for the management of these patients. Therefore, it is essential to identify the factors involved in the development of these complications. Our study shows that the combination of female sex and diabetes is associated with a clearly worse outcome, with a greater number of events concentrated mainly in the first days. This is different from other studies that have explored each factor separately. It would be interesting to perform separate interventions for this group given the increased risk of complications.
Collapse
Affiliation(s)
- Soledad Pérez-Sánchez
- Department of Neurology, Hospital Universitario Virgen Macarena, Sevilla, Spain
- Neurovascular Research Group, Biomedicine Institute of Seville, IBiS/Hospital Virgen del Rocío/CSIC/University of Seville, Seville, Spain
| | - Ana Barragán Prieto
- Department of Neurology, Hospital Universitario Virgen Macarena, Sevilla, Spain
- Neurovascular Research Laboratory, Instituto de Biomedicina de Sevilla-IBiS, Sevilla, Spain
| | - Miguel Ángel Gamero García
- Department of Neurology, Hospital Universitario Virgen Macarena, Sevilla, Spain
- Neurovascular Research Laboratory, Instituto de Biomedicina de Sevilla-IBiS, Sevilla, Spain
| | - Francisco Moniche
- Neurovascular Research Laboratory, Instituto de Biomedicina de Sevilla-IBiS, Sevilla, Spain
- Department of Neurology, Hospital Universitario Virgen del Rocío, Sevilla, Spain
| | - Alejandro Tomasello
- Interventional Neuroradiology, Department of Radiology, Hospital Vall d'Hebron, Barcelona, Spain
| | - Fernando Delgado-Acosta
- Interventional Neuroradiology, Department of Radiology, Hospital Reina Sofía, Córdoba, Spain
| | - Alejandro González
- Neurovascular Research Laboratory, Instituto de Biomedicina de Sevilla-IBiS, Sevilla, Spain
- Interventional Neuroradiology, Department of Radiology, Hospital Universitario Virgen del Rocío, Sevilla, Spain
| | - Joan Montaner
- Department of Neurology, Hospital Universitario Virgen Macarena, Sevilla, Spain
- Neurovascular Research Laboratory, Instituto de Biomedicina de Sevilla-IBiS, Sevilla, Spain
| |
Collapse
|
18
|
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] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2022] [Accepted: 04/20/2022] [Indexed: 01/17/2023]
|
19
|
Halliday A. Treatment of asymptomatic carotid artery stenosis. Lancet Neurol 2022; 21:858-859. [DOI: 10.1016/s1474-4422(22)00348-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2022] [Accepted: 08/22/2022] [Indexed: 11/16/2022]
|
20
|
Mazurek A, Malinowski K, Rosenfield K, Capoccia L, Speziale F, de Donato G, Setacci C, Wissgott C, Sirignano P, Tekieli L, Karpenko A, Kuczmik W, Stabile E, Metzger DC, Amor M, Siddiqui AH, Micari A, Pieniążek P, Cremonesi A, Schofer J, Schmidt A, Musialek P. Clinical Outcomes of Second- versus First-Generation Carotid Stents: A Systematic Review and Meta-Analysis. J Clin Med 2022; 11:jcm11164819. [PMID: 36013058 PMCID: PMC9409706 DOI: 10.3390/jcm11164819] [Citation(s) in RCA: 18] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2022] [Revised: 07/20/2022] [Accepted: 07/29/2022] [Indexed: 01/10/2023] Open
Abstract
Background: Single-cohort studies suggest that second-generation stents (SGS; “mesh stents”) may improve carotid artery stenting (CAS) outcomes by limiting peri- and postprocedural cerebral embolism. SGS differ in the stent frame construction, mesh material, and design, as well as in mesh-to-frame position (inside/outside). Objectives: To compare clinical outcomes of SGS in relation to first-generation stents (FGSs; single-layer) in CAS. Methods: We performed a systematic review and meta-analysis of clinical studies with FGSs and SGS (PRISMA methodology, 3302 records). Endpoints were 30-day death, stroke, myocardial infarction (DSM), and 12-month ipsilateral stroke (IS) and restenosis (ISR). A random-effect model was applied. Results: Data of 68,422 patients from 112 eligible studies (68.2% men, 44.9% symptomatic) were meta-analyzed. Thirty-day DSM was 1.30% vs. 4.11% (p < 0.01, data for SGS vs. FGS). Among SGS, both Casper/Roadsaver and CGuard reduced 30-day DSM (by 2.78 and 3.03 absolute percent, p = 0.02 and p < 0.001), whereas the Gore stent was neutral. SGSs significantly improved outcomes compared with closed-cell FGS (30-day stroke 0.6% vs. 2.32%, p = 0.014; DSM 1.3% vs. 3.15%, p < 0.01). At 12 months, in relation to FGS, Casper/Roadsaver reduced IS (−3.25%, p < 0.05) but increased ISR (+3.19%, p = 0.04), CGuard showed a reduction in both IS and ISR (−3.13%, −3.63%; p = 0.01, p < 0.01), whereas the Gore stent was neutral. Conclusions: Pooled SGS use was associated with improved short- and long-term clinical results of CAS. Individual SGS types, however, differed significantly in their outcomes, indicating a lack of a “mesh stent” class effect. Findings from this meta-analysis may provide clinically relevant information in anticipation of large-scale randomized trials.
Collapse
Affiliation(s)
- Adam Mazurek
- Department of Cardiac and Vascular Diseases, John Paul II Hospital, Jagiellonian University, 31-202 Krakow, Poland
- Correspondence: (A.M.); (P.M.)
| | - Krzysztof Malinowski
- Department of Bioinformatics and Telemedicine, Faculty of Medicine, Jagiellonian University Medical College, 31-008 Krakow, Poland
| | - Kenneth Rosenfield
- Vascular Surgery, Surgery Department, Massachusetts General Hospital, Boston, MA 02114, USA
| | - Laura Capoccia
- Vascular and Endovascular Surgery Unit, Department of Surgery, Sapienza University of Rome, 00185 Rome, Italy
| | - Francesco Speziale
- Vascular and Endovascular Surgery Unit, Department of Surgery, Sapienza University of Rome, 00185 Rome, Italy
| | | | - Carlo Setacci
- Department of Vascular Surgery, University of Siena, 53100 Siena, Italy
| | - Christian Wissgott
- Institut für Diagnostische und Interventionelle Radiologie/Neuroradiologie, Imland Klinik Rendsburg, 24768 Rendsburg, Germany
| | - Pasqualino Sirignano
- Vascular and Endovascular Surgery Unit, Department of Surgery, Sapienza University of Rome, 00185 Rome, Italy
| | - Lukasz Tekieli
- Department of Interventional Cardiology, John Paul II Hospital, Jagiellonian University, 31-202 Krakow, Poland
| | - Andrey Karpenko
- Centre of Vascular and Hybrid Surgery, E.N. Meshalkin National Medical Research Center, 630055 Novosibirsk, Russia
| | - Waclaw Kuczmik
- Department of General, Vascular Surgery, Angiology and Phlebology, Medical University of Silesia, 40-055 Katowice, Poland
| | | | | | - Max Amor
- Department of Interventional Cardiology, U.C.C.I. Polyclinique d’Essey, 54270 Nancy, France
| | - Adnan H. Siddiqui
- Department of Neurosurgery, SUNY University at Buffalo, Buffalo, NY 14203, USA
| | - Antonio Micari
- Department of Biomedical and Dental Sciences and Morphological and Functional Imaging, University of Messina, 98122 Messina, Italy
| | - Piotr Pieniążek
- Department of Cardiac and Vascular Diseases, John Paul II Hospital, Jagiellonian University, 31-202 Krakow, Poland
- Department of Interventional Cardiology, John Paul II Hospital, Jagiellonian University, 31-202 Krakow, Poland
| | - Alberto Cremonesi
- Cardiovascular Department, Humanitas Gavazzeni Hospital, 24125 Bergamo, Italy
| | - Joachim Schofer
- MVZ-Department Structural Heart Disease, Asklepios Clinic St. Georg, 20099 Hamburg, Germany
| | - Andrej Schmidt
- Department of Angiology, University Hospital Leipzig, 04103 Leipzig, Germany
| | - Piotr Musialek
- Department of Cardiac and Vascular Diseases, John Paul II Hospital, Jagiellonian University, 31-202 Krakow, Poland
- Correspondence: (A.M.); (P.M.)
| |
Collapse
|
21
|
Lanza G, Orso M, Alba G, Bevilacqua S, Capoccia L, Cappelli A, Carrafiello G, Cernetti C, Diomedi M, Dorigo W, Faggioli G, Giannace V, Giannandrea D, Giannetta M, Lanza J, Lessiani G, Marone EM, Mazzaccaro D, Migliacci R, Nano G, Pagliariccio G, Petruzzellis M, Plutino A, Pomatto S, Pulli R, Reale N, Santalucia P, Sirignano P, Ticozzelli G, Vacirca A, Visco E. Guideline on carotid surgery for stroke prevention: updates from the Italian Society of Vascular and Endovascular Surgery. A trend towards personalized medicine. THE JOURNAL OF CARDIOVASCULAR SURGERY 2022; 63:471-491. [PMID: 35848869 DOI: 10.23736/s0021-9509.22.12368-2] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/15/2023]
Abstract
BACKGROUND This guideline (GL) on carotid surgery as updating of "Stroke: Italian guidelines for Prevention and Treatment" of the ISO-SPREAD Italian Stroke Organization-Group, has recently been published in the National Guideline System and shared with the Italian Society of Vascular and Endovascular Surgery (SICVE) and other Scientific Societies and Patient's Association. METHODS GRADE-SIGN version, AGREE quality of reporting checklist. Clinical questions formulated according to the PICO model. Recommendations developed based on clinical questions by a multidisciplinary experts' panel and patients' representatives. Systematic reviews performed for each PICO question. Considered judgements filled by assessing the evidence level, direction, and strength of the recommendations. RESULTS The panel provided indications and recommendations for appropriate, comprehensive, and individualized management of patients with carotid stenosis. Diagnostic and therapeutic processes of the best medical therapy, carotid endarterectomy (CEA), carotid stenting (CAS) according to the evidences and the judged opinions were included. Symptomatic carotid stenosis in elective and emergency, asymptomatic carotid stenosis, association with ischemic heart disease, preoperative diagnostics, types of anesthesia, monitoring in case of CEA, CEA techniques, comparison between CEA and CAS, post-surgical carotid restenosis, and medical therapy are the main topics, even with analysis of uncertainty areas for risk-benefit assessments in the individual patient (personalized medicine [PM]). CONCLUSIONS This GL updates on the main recommendations for the most appropriate diagnostic and medical-surgical management of patients with atherosclerotic carotid artery stenosis to prevent ischemic stroke. This GL also provides useful elements for the application of PM in good clinical practice.
Collapse
Affiliation(s)
- Gaetano Lanza
- Department of Vascular Surgery, IRCCS MultiMedica, Castellanza Hospital, Castellanza, Varese, Italy
| | - Massimiliano Orso
- Experimental Zooprophylactic Institute of Umbria and Marche, Perugia, Italy
| | - Giuseppe Alba
- Unit of Vascular Surgery, Department of Medicine, Surgery and Neuroscience, University of Siena, Siena, Italy
| | - Sergio Bevilacqua
- Department of Cardiac Anesthesia and Resuscitation, Careggi University Hospital, Florence, Italy
| | - Laura Capoccia
- Department of Vascular and Endovascular Surgery, Umberto I Polyclinic Hospital, Sapienza University, Rome, Italy
| | - Alessandro Cappelli
- Unit of Vascular Surgery, Department of Medicine, Surgery and Neuroscience, University of Siena, Siena, Italy
| | - Giampaolo Carrafiello
- Department of Radiology, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, University of Milan, Milan, Italy
| | - Carlo Cernetti
- Department of Cardiology and Hemodynamics, San Giacomo Apostolo Hospital, Castelfranco Veneto, Treviso, Italy
- Cardiology and Hemodynamics Unit, Ca' Foncello Hospital, Treviso, Italy
| | - Marina Diomedi
- Stroke Unit, Tor Vergata Polyclinic Hospital, Tor Vergata University, Rome, Italy
| | - Walter Dorigo
- Department of Vascular Surgery, Careggi Polyclinic Hospital, University of Florence, Florence, Italy
| | - Gianluca Faggioli
- Department of Vascular Surgery, Alma Mater Studiorum University, Bologna, Italy
| | - Vanni Giannace
- Unit of Vascular Surgery, Department of Medicine, Surgery and Neuroscience, University of Siena, Siena, Italy
| | - David Giannandrea
- Department of Neurology, USL Umbria 1, Hospitals of Gubbio, Gualdo Tadino and Città di Castello, Perugia, Italy
| | - Matteo Giannetta
- Department of Vascular Surgery, IRCCS San Donato Hospitals, San Donato Polyclinic Hospital, Milan, Italy
| | - Jessica Lanza
- Department of Vascular Surgery, IRCCS San Martino Polyclinic Hospital, University of Genoa, Genoa, Italy -
| | - Gianfranco Lessiani
- Unit of Vascular Medicine and Diagnostics, Department of Internal Medicine, Villa Serena Hospital, Città Sant'Angelo, Pesaro, Italy
| | - Enrico M Marone
- Vascular Surgery, Department of Clinical-Surgical, Diagnostic and Pediatric Sciences, University of Pavia, Pavia, Italy
| | - Daniela Mazzaccaro
- Department of Vascular Surgery, IRCCS San Donato Hospitals, San Donato Polyclinic Hospital, Milan, Italy
| | - Rino Migliacci
- Department of Internal Medicine, Valdichiana S. Margherita Hospital, USL Toscana Sud-Est, Cortona, Arezzo, Italy
| | - Giovanni Nano
- Department of Vascular Surgery, IRCCS San Donato Hospitals, San Donato Polyclinic Hospital, Milan, Italy
| | - Gabriele Pagliariccio
- Department of Emergency Vascular Surgery, Ospedali Riuniti University of Ancona, Ancona, Italy
| | | | - Andrea Plutino
- Stroke Unit, Ospedali Riuniti Marche Nord, Ancona, Italy
| | - Sara Pomatto
- Department of Vascular Surgery, Sant'Orsola Malpighi Polyclinic Hospital, University of Bologna, Bologna, Italy
| | - Raffaele Pulli
- Department of Vascular Surgery, University of Bari, Bari, Italy
| | | | | | - Pasqualino Sirignano
- Department of Vascular and Endovascular Surgery, Umberto I Polyclinic Hospital, Sapienza University, Rome, Italy
| | - Giulia Ticozzelli
- First Department of Anesthesia and Resuscitation, IRCCS Policlinico San Matteo Foundation, Pavia, Italy
| | - Andrea Vacirca
- Unit of Vascular Surgery, Department of Experimental, Diagnostic and Specialty Medicine (DIMES), IRCSS Sant'Orsola Polyclinic Hospital, University of Bologna, Bologna, Italy
| | - Emanuele Visco
- Department of Cardiology and Hemodynamics, San Giacomo Apostolo Hospital, Castelfranco Veneto, Treviso, Italy
| |
Collapse
|
22
|
Andereggen L, Amin-Hanjani S, Beck J, Luedi MM, Gralla J, Schubert GA, Tortora A, Andres RH, Arnold M, Raabe A, Reinert M. Prediction of Long-Term Restenosis After Carotid Endarterectomy Using Quantitative Magnetic Resonance Angiography. Front Neurol 2022; 13:862809. [PMID: 35847222 PMCID: PMC9279565 DOI: 10.3389/fneur.2022.862809] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2022] [Accepted: 05/23/2022] [Indexed: 11/28/2022] Open
Abstract
Background To detect restenosis after carotid endarterectomy (CEA), long-term monitoring is required. However, non-selective follow-up is controversial and can be limited by costs and logistical considerations. Objective To examine the value of immediate perioperative vessel flow measurements after CEA using quantitative magnetic resonance angiography (QMRA) to detect patients at risk of long-term restenosis. Methods A prospective cohort study with long-term sonographic follow-up after CEA for symptomatic internal carotid artery stenosis (ICAs) > 50%. In all patients, vessel flow has been assessed both pre- and postoperatively using QMRA within ±3 days of surgery. Data on QMRA assessment were analyzed to identify patients at risk of restenosis for up to 10 years. Results Restenosis was recorded in 4 of 24 patients (17%) at a median follow-up of 6.8 ± 2.6 years. None of them experienced an ischemic event. Perioperative flow differences were significantly greater in patients without long-term restenosis, both for the ipsilateral ICA (p < 0.001) and MCA (p = 0.03), compared to those with restenosis (p = 0.22 and p = 0.3, respectively). The ICA mean flow ratio (p = 0.05) tended to be more effective than the MCA ratio in predicting restenosis over the long term (p = 0.35). Conclusion Our preliminary findings suggest that QMRA-based mean flow increases after CEA may be predictive of restenosis over the long term. Perioperative QMRA assessment could become an operator-independent screening tool to identify a subgroup of patients at risk for restenosis, in whom long-term monitoring is advised.
Collapse
Affiliation(s)
- Lukas Andereggen
- Department of Neurosurgery, Kantonsspital Aarau, Aarau, Switzerland
- Faculty of Medicine, University of Bern, Bern, Switzerland
- *Correspondence: Lukas Andereggen ; orcid.org/0000-0003-1764-688X
| | - Sepideh Amin-Hanjani
- Department of Neurosurgery, The University of Illinois at Chicago, Chicago, IL, United States
| | - Jürgen Beck
- Departments of Neurosurgery, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
- Department of Neurosurgery, Medical Center, University of Freiburg, Freiburg, Germany
| | - Markus M. Luedi
- Department of Anaesthesiology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Jan Gralla
- Department of Neuroradiology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | | | - Angelo Tortora
- Department of Neurosurgery, Kantonsspital Aarau, Aarau, Switzerland
| | - Robert H. Andres
- Faculty of Medicine, University of Bern, Bern, Switzerland
- Departments of Neurosurgery, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Marcel Arnold
- Department of Neurology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Andreas Raabe
- Departments of Neurosurgery, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Michael Reinert
- Faculty of Medicine, University of Bern, Bern, Switzerland
- Clinic for Neurosurgery, Hirslanden Klinik St. Anna, Lucerne, Switzerland
| |
Collapse
|
23
|
Neurologic outcomes of carotid and other emergent interventions for ischemic stroke over six years with dataset enhanced by machine learning. J Vasc Surg 2022; 76:1280-1288.e2. [PMID: 35760242 DOI: 10.1016/j.jvs.2022.06.020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2022] [Revised: 06/04/2022] [Accepted: 06/15/2022] [Indexed: 11/21/2022]
Abstract
INTRODUCTION Current mainstays of ischemic stroke treatment include the use of thrombolysis (tissue plasminogen activator, tPA), urgent carotid endarterectomy (uCEA) or carotid artery stenting (uCAS), and mechanical endovascular reperfusion/thrombectomy (MER). Scarce data describe the presenting stroke severity and neurologic outcomes for these acute ischemic stroke interventions, alone or in combination. The authors hypothesize that patients undergoing carotid interventions experience better functional neurologic outcomes than other stroke interventions. METHODS A comprehensive stroke center dataset was combined with data for stroke-related procedures, comorbidities, complications, and physician documentation collected from electronic medical record data. A total of 10,975 patient encounter records from January 1, 2015, through July 31, 2021, were retrieved. The presenting stroke severity was determined by vascular/stroke neurologists using the National Institutes of Health Stroke Scale (NIHSS). Functional neurologic outcomes were reported using the modified Rankin scale (mRS) score which quantifies the degree of neurologic disability. Because mRS values were only available for 3,627 encounters in the original dataset, the authors developed a machine learning algorithm to analyze physician documentation and assign an mRS value. Following exclusion and machine learning analysis, a total of 5,170 patient encounters were included for statistical analysis. Statistical analyses included chi-squared test, one-way ANOVA and logistic regression on 30-day complications, stroke severity, and neurologic outcomes. RESULTS Patients were divided into five cohorts: (1) uCEA or uCAS (n=189), (2) tPA alone (n=1,053), (3) MER alone (n=418), (4) tPA + MER (n=199), and (5) no intervention (n=3,311). Patients undergoing uCEA/uCAS were significantly more likely to be male, smokers, and have a history of peripheral arterial disease compared to other stroke cohorts. The length of stay was shortest for patients who only received tPA or no intervention (6 days), followed by uCEA/uCAS (7.2 days), MER (10.2 days), and tPA + MER (8.8 days) cohorts (P<.001). The 30-day mortality was highest in the MER cohort (12.2%) and lowest in the uCEA/uCAS cohort (2.6%). The uCEA/uCAS cohort compared to other cohorts had the lowest presenting stroke severity (NIHSS 4.9 vs 6.9-16), and best neurologic outcomes (mRS 1.7 vs 1.8-2.6). CONCLUSIONS Following an ischemic stroke, patients undergoing urgent carotid interventions had the lowest presenting stroke severity (NIHSS) and highest rate of independent neurologic outcomes (mRS) compared to other stroke interventions. Incoming stroke severity correlates with functional neurologic outcomes, and patients who present with an NIHSS ≤ 10 who undergo uCEA/uCAS have a high likelihood of independent neurologic functional outcome (mRS ≤2).
Collapse
|
24
|
Liu X, Zheng P, Xu X, Tu Y. Persistent Hemodynamic Depression After Carotid Artery Stenting: A Review and Update. Vasc Endovascular Surg 2022; 56:15385744221096220. [PMID: 35549604 DOI: 10.1177/15385744221096220] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
According to the American Heart Association, ischemic stroke is the second leading cause of death globally and is responsible for approximately 11% of deaths. Carotid endarterectomy (CEA) is the standard treatment for moderate or severe extracranial internal carotid artery (ICA) stenoses. With the development of materials and technology in neurointervention, the Centers for Medicare and Medicaid Services (CMS) have proposed that carotid artery stenting (CAS) can serve as an alternative treatment for CEA. As CAS is widely used worldwide, comorbidities, especially persistent hemodynamic depression (PHD) and stroke, have attracted public attention. In this review, we summarized the current advances in PHD after CAS. A better understanding of CAS-related PHD may inspire the design of potential prognostic and therapeutic tools.
Collapse
Affiliation(s)
- Xiaowei Liu
- Department of Neurosurgery, 117852Chengdu Second People's Hospital, Chengdu, China
| | - Peilin Zheng
- The Second Clinical Medical College of Jinan University, The First Affiliated Hospital of Southern University of Science and Technology, 12387Shenzhen People's Hospital, Shenzhen, China
| | - Xuejun Xu
- Department of Neurosurgery, 117852Chengdu Second People's Hospital, Chengdu, China
| | - Yiting Tu
- Department of Neurology, 560852Shenzhen Samii International Medical Center (The Fourth People's Hospital of Shenzhen), Shenzhen, China
| |
Collapse
|
25
|
Golnari P, Nazari P, Hurley MC, Shaibani A, Ansari SA, Potts MB, Jahromi BS. Continued dominance of carotid endarterectomy over stenting in the United States: Volumes, outcomes, and complications from the National Inpatient Sample (1997-2015). World Neurosurg 2022; 163:e238-e252. [PMID: 35367640 DOI: 10.1016/j.wneu.2022.03.110] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2021] [Revised: 03/23/2022] [Accepted: 03/24/2022] [Indexed: 01/10/2023]
Abstract
BACKGROUND The introduction of carotid stenting (CAS) has led to numerous comparative trials with carotid endarterectomy (CEA). OBJECTIVE To review real-world volumes, outcomes and complications following CEA versus CAS over an extended period to identify durable changes in practice. METHODS Data were extracted from the National Inpatient Sample. Trends were assessed by annual percent change (APC) and adjusted risk ratios (aRR)s were calculated across the last 5 years of the study period. RESULTS During 1997-2015, 199,330 symptomatic and 1,995,637 asymptomatic patients underwent carotid revascularization. In symptomatic patients, CEA declined (1997-2004; APC -7.68%, p<0.001) and CAS rose (1997-2008; APC 15.48%, p<0.001) during the first decade, subsequently becoming more muted. In asymptomatic patients, CEA decreased whereas CAS initially increased (1997-2006; APC 20.27%, p<0.001) and then decreased (2007-2015; APC -4.52%, p<0.001). Routine discharge after symptomatic revascularization declined in CEA after 2003 and in CAS after 2006 (APC -1.72% and -3.11% respectively, p<0.001 for both), corresponding to increasing patient comorbidity; similar trends were seen in asymptomatic patients. Death decreased after CEA (symptomatic and asymptomatic; APC -4.85% and -3.53% respectively, p<0.001 for both) and CAS (asymptomatic only, APC -2.53%, p=0.04). CAS remained associated with higher aRR for death, venous thromboembolism and seizures in all patients, and stroke and non-routine discharge in symptomatic patients, during the last 5 years of the study period. CONCLUSIONS Mortality has improved but routine discharge has decreased following both CEA and CAS, congruent with increasing patient comorbidity. Trends in volumes, outcomes and complication rates continue to favor CEA in real-world practice.
Collapse
Affiliation(s)
- Pedram Golnari
- Departments of Radiology; Neurological Surgery, Northwestern Memorial Hospital, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Pouya Nazari
- Departments of Radiology; Neurological Surgery, Northwestern Memorial Hospital, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Michael C Hurley
- Department of Radiology, University of Chicago Medical Center, Chicago, IL, USA
| | - Ali Shaibani
- Departments of Radiology; Neurological Surgery, Northwestern Memorial Hospital, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Sameer A Ansari
- Departments of Radiology; Neurological Surgery, Northwestern Memorial Hospital, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Matthew B Potts
- Neurological Surgery, Northwestern Memorial Hospital, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Babak S Jahromi
- Neurological Surgery, Northwestern Memorial Hospital, Northwestern University Feinberg School of Medicine, Chicago, IL, USA.
| |
Collapse
|
26
|
[Important recommendations of the German-Austrian S3 guidelines on management of extracranial carotid artery stenosis]. Chirurg 2022; 93:476-484. [PMID: 35318494 DOI: 10.1007/s00104-022-01622-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/21/2022] [Indexed: 11/27/2022]
Abstract
BACKGROUND Lesions of the extracranial carotid artery are the cause of 10-15 % of all cases of cerebral ischemia. The aims of the updated S3 guidelines are evidence-based and consensus-based recommendations for action on comprehensive care of patients with extracranial carotid stenosis in Germany and Austria. METHODS A systematic literature search (1990-2019) and methodical assessment of existing guidelines and systematic reviews were carried out. Consensus answers to 37 key questions with evidence-based recommendations. RESULTS The prevalence of extracranial carotid stenosis is approximately 4% and increases after the age of 65 years. The most important examination method is duplex sonography. Randomized controlled studies (RCT) have shown that carotid endarterectomy (CEA) of an asymptomatic 60-99% carotid artery stenosis reduces the absolute risk of stroke (absolute risk reduction, ARR) within 5 years in comparison to drug treatment alone by 4.1%. Due to an improved pharmaceutical prevention of arteriosclerosis, the S3 guidelines recommend a prophylactic CEA of a 60-99% stenosis only for patients without an increased surgical risk. Additionally, one or more clinical or imaging results should be present, which indicate an increased risk of carotid-related stroke in the follow-up. For medium-grade (50-69 %) and high-grade (70-99 %) symptomatic stenoses the ARRs after 5 years are 4.6% and 15.6%, respectively. Systematic reviews of RCTs have shown that CEA is associated with a ca. 50% lower periprocedural risk of stroke compared to carotid artery stenting (CAS). There are no differences in the long-term course. The CEA is recommended for high-grade asymptomatic, medium-grade and high-grade symptomatic carotid stenosis as a standard procedure, alternatively CAS can be considered. For both procedures the periprocedural stroke rate/mortality during hospitalization should be a maximum of 2% (asymptomatic stenosis) or 4% (symptomatic stenosis). CONCLUSION Both CEA and CAS necessitate a critical evaluation of the indications and strict quality criteria. Future studies should evaluate even better selection criteria for an individual, optimal, conservative, operative or endovascular treatment.
Collapse
|
27
|
Management of atherosclerotic extracranial carotid artery stenosis. Lancet Neurol 2022; 21:273-283. [DOI: 10.1016/s1474-4422(21)00359-8] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2020] [Revised: 09/30/2021] [Accepted: 10/08/2021] [Indexed: 02/05/2023]
|
28
|
Chisci E, Lazzeri E, Masciello F, Troisi N, Turini F, Sapio PL, Tramacere L, Cincotta M, Fortini A, Baruffi C, Michelagnoli S. "Timing to carotid endarterectomy affects early and long term outcomes of symptomatic carotid stenosis.". Ann Vasc Surg 2021; 82:314-324. [PMID: 34902463 DOI: 10.1016/j.avsg.2021.10.071] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2021] [Revised: 10/26/2021] [Accepted: 10/26/2021] [Indexed: 11/18/2022]
Abstract
OBJECTIVE The aim of this study is to evaluate early and long-term outcomes according to the timing to carotid endarterectomy (CEA) of symptomatic carotid stenosis. METHODS Consecutive CEAs with selective shunting for symptomatic carotid stenosis ≥50% performed between 2009 and 2020. Patients had acute neurological impairment on presentation, defined as <5 points on the National Institutes of Health Stroke Scale(NIHSS). We grouped patients according to time between index event and CEA: the first group was operated between 0-2 days, the second group between 3 and 7 days, the third group between 8 and 14 days and the last group after 15 days. Thirty-day neurological status improvement was defined as a decrease (≥1) in the 30-day NIHSS score vs. NIHSS score immediately before surgery. RESULTS 500 CEAs were performed. The perioperative combined stroke and mortality rate was 3.6% (18/500), representing a perioperative mortality rate of .2 (n=1) and stroke rate of 3.4% (n=17). Overall freedom from stroke was 95% at 1 year, 89 % at 6 years, and 88% at 10 years. Annual stroke rate was 0.6% after the 30-day period. Thirty-day improvement in neurologic status occurred in 103 patients (20.6%), while in 380 (76%) neurologic status was unchanged, and 17 (3.4%) experienced worsening of their neurologic status. Patients treated within 7 days from the index event had significant benefit (OR=2.6) in the 30-day neurological improvement vs. those treated after 7 days from the index event. Timing to CEA <2 days increased significantly the risk of late stroke (OR=9.7). CONCLUSIONS The ideal timing for performing CEA is between 3 and 7 days from the index event if NIHSS <5 as it is associated with the best rates of improvement in neurological status and durability in the long term. Very early CEA (<48 hours) was associated with increased late stroke occurrence.
Collapse
Affiliation(s)
- Emiliano Chisci
- Department of Surgery, Vascular and Endovascular Surgery Unit "San Giovanni di Dio" Hospital, Florence, Italy.
| | - Elisa Lazzeri
- Department of Surgery, Vascular and Endovascular Surgery Unit "San Giovanni di Dio" Hospital, Florence, Italy
| | - Fabrizio Masciello
- Department of Surgery, Vascular and Endovascular Surgery Unit "San Giovanni di Dio" Hospital, Florence, Italy
| | - Nicola Troisi
- Vascular Surgery Unit, Department of Translational Research and New Technologies in Medicine and Surgery, University of Pisa, Pisa, Italy
| | - Filippo Turini
- Department of Surgery, Vascular and Endovascular Surgery Unit "San Giovanni di Dio" Hospital, Florence, Italy
| | - Patrizia Lo Sapio
- Department of Surgery, Vascular and Endovascular Surgery Unit "San Giovanni di Dio" Hospital, Florence, Italy
| | - Luciana Tramacere
- Department of Medicine, Unit of Neurology of Florence, "San Giovanni di Dio" Hospital, Florence, Italy
| | - Massimo Cincotta
- Department of Medicine, Unit of Neurology of Florence, "San Giovanni di Dio" Hospital, Florence, Italy
| | - Alberto Fortini
- Department of Medicine, Internal Medicine and Stroke Unit, "San Giovanni di Dio" Hospital, Florence, Italy
| | - Cristina Baruffi
- Department of Medicine, Internal Medicine and Stroke Unit, "San Giovanni di Dio" Hospital, Florence, Italy
| | - Stefano Michelagnoli
- Department of Surgery, Vascular and Endovascular Surgery Unit "San Giovanni di Dio" Hospital, Florence, Italy
| |
Collapse
|
29
|
Affiliation(s)
- Gert J de Borst
- Department of Vascular Surgery G04.129, University Medical Center Utrecht, the Netherlands
| |
Collapse
|
30
|
Cui CL, Dakour-Aridi H, Lu JJ, Yei KS, Schermerhorn ML, Malas MB. In-Hospital Outcomes of Urgent, Early, or Late Revascularization for Symptomatic Carotid Artery Stenosis. Stroke 2021; 53:100-107. [PMID: 34872337 DOI: 10.1161/strokeaha.120.032410] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND AND PURPOSE Advancements in carotid revascularization have produced promising outcomes in patients with symptomatic carotid artery stenosis. However, the optimal timing of revascularization procedures after symptomatic presentation remains unclear. The purpose of this study is to compare in-hospital outcomes of transcarotid artery revascularization (TCAR), transfemoral carotid stenting (TFCAS), or carotid endarterectomy (CEA) performed within different time intervals after most recent symptoms. METHODS This is a retrospective cohort study of United States patients in the vascular quality initiative. All carotid revascularizations performed for symptomatic carotid artery stenosis between September 2016 and November 2019 were included. Procedures were categorized as urgent (0-2 days after most recent symptom), early (3-14 days), or late (15-180 days). The primary outcome of interest was in-hospital stroke and death. Secondary outcomes include in-hospital stroke, death, and transient ischemic attacks. Multivariable logistic regression was used to compare outcomes. RESULTS A total of 18 643 revascularizations were included: 2006 (10.8%) urgent, 7423 (39.8%) early, and 9214 (49.42%) late. Patients with TFCAS had the highest rates of stroke/death at all timing cohorts (urgent: 4.0% CEA, 6.9% TFCAS, 6.5% TCAR, P=0.018; early: 2.5% CEA, 3.8% TFCAS, 2.9% TCAR, P=0.054; late: 1.6% CEA, 2.8% TFCAS, 2.3% TCAR, P=0.003). TFCAS also had increased odds of in-hospital stroke/death compared with CEA in all 3 groups (urgent adjusted odds ratio [aOR], 1.7 [95% CI, 1.0-2.9] P=0.03; early aOR, 1.6 [95% CI, 1.1-2.4] P=0.01; and late aOR, 1.9 [95% CI, 1.2-3.0] P=0.01). TCAR and CEA had comparable odds of in-hospital stroke/death in all 3 groups (urgent aOR, 1.9 [95% CI, 0.9-4], P=0.10), (early aOR, 1.1 [95% CI, 0.7-1.7], P=0.66), (late aOR, 1.5 [95% CI, 0.9-2.3], P=0.08). CONCLUSIONS CEA remains the safest method of revascularization within the urgent period. Among revascularization performed outside of the 48 hours, TCAR and CEA have comparable outcomes.
Collapse
Affiliation(s)
- Christina L Cui
- University of California San Diego (C.L.C., H.D.-A., K.S.Y., M.B.M.)
| | | | - Jinny J Lu
- Beth Israel Deaconess Medical Center, Boston, MA (J.J.L., M.L.S.)
| | - Kevin S Yei
- University of California San Diego (C.L.C., H.D.-A., K.S.Y., M.B.M.)
| | | | - Mahmoud B Malas
- University of California San Diego (C.L.C., H.D.-A., K.S.Y., M.B.M.)
| |
Collapse
|
31
|
Salem MM, Kvint S, Choudhri OA, Burkhardt JK. Endovascular Transcarotid Artery Revascularization Using the Walrus Balloon Guide Catheter: Preliminary Experience. World Neurosurg 2021; 156:e175-e182. [PMID: 34534717 DOI: 10.1016/j.wneu.2021.09.026] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2021] [Revised: 09/04/2021] [Accepted: 09/06/2021] [Indexed: 02/08/2023]
Abstract
BACKGROUND The Walrus Balloon Guided System Catheter is a new generation of balloon guide catheter (BGC) designed to bypass some technical limitations of conventional BGC devices. Their utility in cervical carotid disease treatment has not been reported. We report our preliminary experience in cervical carotid treatment using the Walrus BGC to perform a modified endovascular transcarotid artery revascularization technique. METHODS Patients with cervical carotid disease undergoing endovascular treatment using the Walrus BGC at our institution were identified. The pertinent baseline demographics and procedural outcomes were collected and analyzed. RESULTS Twelve patients were included (median age, 70; 58.3% females). All patients had an imaging-confirmed cervical carotid disease that indicated intervention: 6 with high-grade cervical arteriosclerotic carotid stenosis, 2 with intraluminal thrombi, 1 with traumatic carotid dissection, and 3 patients with cervical carotid tandem occlusion along with acute ischemic stroke secondary to large vessel occlusion that required mechanical thrombectomy. Carotid artery stenting was performed in all cases, except 2 of the 3 mechanical thrombectomy cases (angioplasty only). All patients had at least periprocedural follow-up of 30 days, with no stroke, myocardial infarction, or death encountered. CONCLUSIONS We describe a modified endovascular transcarotid artery revascularization technique. We used a standard femoral access to navigate the Walrus catheter in the common carotid artery, followed by balloon inflation for proximal flow arrest or flow reversal (when connected to the aspiration pump) to deploy the carotid stent across the stenosis, while avoiding distal external carotid artery balloon occlusion. Successful treatment was achieved in all cases, with no periprocedural complications encountered.
Collapse
Affiliation(s)
- Mohamed M Salem
- Department of Neurosurgery, Hospital of the University of Pennsylvania, Penn Medicine, Philadelphia, Pennsylvania, USA
| | - Svetlana Kvint
- Department of Neurosurgery, Hospital of the University of Pennsylvania, Penn Medicine, Philadelphia, Pennsylvania, USA
| | - Omar A Choudhri
- Department of Neurosurgery, Hospital of the University of Pennsylvania, Penn Medicine, Philadelphia, Pennsylvania, USA
| | - Jan-Karl Burkhardt
- Department of Neurosurgery, Hospital of the University of Pennsylvania, Penn Medicine, Philadelphia, Pennsylvania, USA.
| |
Collapse
|
32
|
Hammar K, Laska AC, Wester P, Mani K, Lundström A, Jonsson M. Low Incidence of Late Ipsilateral Ischaemic Stroke After Treatment for Symptomatic Carotid Stenosis in Sweden 2008-2017: Increased Risk in the Elderly and After Carotid Stenting. Eur J Vasc Endovasc Surg 2021; 63:24-32. [PMID: 34794877 DOI: 10.1016/j.ejvs.2021.09.019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2020] [Revised: 08/29/2021] [Accepted: 09/17/2021] [Indexed: 11/25/2022]
Abstract
OBJECTIVE Carotid stenosis is a major risk factor for stroke and surgical treatment is key in preventing recurrent ischaemic events. Previous randomised trials have demonstrated the net benefit of surgery for significant symptomatic carotid stenosis but, with present day medical treatment, there is limited evidence on the risk of late ipsilateral ischaemic stroke (IS) and its main risk factors. METHOD Ipsilateral IS after the peri-operative period (≤ 30 days) was investigated in a nationwide, registry based cohort study of patients treated for symptomatic carotid stenosis in Sweden between 2008 - 2017. The Swedish National Registry for Vascular Surgery (Swedvasc) was used to establish the cohort, and the Swedish stroke registry (Riksstroke), combined with hospital records, was used to determine outcome. Stroke of any type and all cause mortality after the peri-operative period were studied as secondary outcomes. Cox regression was used to analyse associations between clinical factors and outcomes. RESULTS In total, 7 589 patients (mean age 72 ± 8 years, 68% men) were followed for 4.2 ± 2.6 years. Ipsilateral IS occurred in 232 patients corresponding to a yearly incidence of 0.73%. Age above 80 years compared with 65 - 79 years was associated with an increased risk of ipsilateral IS (adjusted HR 1.94, 95% CI 1.43 - 2.65). Carotid artery stenting (CAS) compared with carotid endarterectomy (CEA) was also associated with increased risk (adjusted HR 3.20, 95% CI 2.03 - 5.03). Stroke of any type occurred in 7.7% of patients, and 19.6% of patients died during the follow up period. CONCLUSION The incidence of ipsilateral IS after treatment for symptomatic carotid stenosis in Sweden 2008-2017 was low, demonstrating the effectiveness and durability of surgery in a real world setting. Only age above 80 years and CAS compared with CEA were associated with increased risk of ipsilateral IS.
Collapse
Affiliation(s)
- Kimberley Hammar
- Department of Clinical Sciences, Danderyd Hospital, Division of Neurology, Karolinska Institute, Stockholm, Sweden.
| | - Ann Charlotte Laska
- Department of Clinical Sciences, Danderyd Hospital, Division of Neurology, Karolinska Institute, Stockholm, Sweden
| | - Per Wester
- Department of Clinical Sciences, Danderyd Hospital, Division of Neurology, Karolinska Institute, Stockholm, Sweden; Department of Public Health and Clinical Medicine, Umeå University, Umeå, Sweden
| | - Kevin Mani
- Section of Vascular Surgery, Department of Surgical Sciences, Uppsala University, Uppsala, Sweden; Department of Surgery, University of Auckland, New Zealand
| | - Annika Lundström
- Department of Clinical Sciences, Danderyd Hospital, Division of Neurology, Karolinska Institute, Stockholm, Sweden
| | - Magnus Jonsson
- Department of Vascular Surgery, Karolinska University Hospital, Stockholm, Sweden; Department of Molecular Medicine and Surgery, Karolinska Institute, Stockholm, Sweden
| |
Collapse
|
33
|
Stabile E, Gerardi D. Carotid Artery Stenting With Dual-Layer Stent: Expanding Evidence With a Randomized Trial. JACC Cardiovasc Interv 2021; 14:2388-2390. [PMID: 34736738 DOI: 10.1016/j.jcin.2021.08.051] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/10/2021] [Accepted: 08/17/2021] [Indexed: 12/24/2022]
Affiliation(s)
- Eugenio Stabile
- Cardiovascular Department, Azienda Ospedaliera Regionale "San Carlo," Potenza, Italy.
| | - Donato Gerardi
- Division of Cardiology, Azienda Ospedaliera Regionale "San Carlo"-"San Giovanni di Dio" Hospital, Melfi, Italy
| |
Collapse
|
34
|
Karpenko A, Bugurov S, Ignatenko P, Starodubtsev V, Popova I, Malinowski K, Musialek P. Randomized Controlled Trial of Conventional Versus MicroNet-Covered Stent in Carotid Artery Revascularization. JACC Cardiovasc Interv 2021; 14:2377-2387. [PMID: 34736737 DOI: 10.1016/j.jcin.2021.08.005] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/19/2021] [Revised: 07/27/2021] [Accepted: 08/03/2021] [Indexed: 10/19/2022]
Abstract
OBJECTIVES The aim of this study was to compare procedure-related ipsilateral cerebral embolism with a conventional (Acculink, Abbott Vascular) versus a MicroNet-covered (CGuard, InspireMD) stent in carotid artery stenting (CAS). BACKGROUND The MicroNet-covered stent may reduce periprocedural cerebral embolism in CAS, but level 1 evidence is lacking. METHODS A total of 100 consecutive patients were randomized 1:1 to filter-protected CAS using the Acculink or the CGuard device. The study was powered for its primary endpoint of at least 50% reduction in ipsilateral diffusion-weighted magnetic resonance imaging lesion average volume 48 hours postprocedure (blinded external core laboratory analysis). RESULTS The baseline characteristics of the study groups were similar. Eighty-two (total volume = 18,212 mm3) diffusion-weighted magnetic resonance imaging postprocedural cerebral lesions occurred in 26 Acculink-treated patients and 45 lesions (total volume = 3,930 mm3; 78.4% reduction) in 25 CGuard-treated patients. New cerebral lesion average volume was 171 mm3 vs 73 mm3 (P = 0.017) per affected patient and 222 mm3 vs 84 mm3 (P = 0.038) per lesion (Acculink vs CGuard). In lesion-affected patients, the average sum of lesion volumes was 701 mm3 vs 157 mm3 (P = 0.007). The Acculink significantly increased the risk for multiple (≥5) cerebral lesions (relative risk: 7.8; 95% CI: 1.3-14.9; P = 0.021). At 30 days, new permanent (fluid-attenuated inversion recovery) lesion prevalence was 3:1 (P < 0.001), with total permanent lesion volume 7,474 mm3 vs 574 mm3 (92.3% reduction with the CGuard). There were 6 vs 0 new ipsilateral lesions (P = 0.030) and 2 versus 0 strokes. CONCLUSIONS The MicroNet-covered stent significantly reduced periprocedural and abolished postprocedural cerebral embolism in relation to a conventional carotid stent. This is consistent with the MicroNet-covered stent's sustained embolism prevention, translating into cerebral protection not only during but also after CAS. The present findings may influence decision making in carotid revascularization. (The SIBERIA Trial [Acculink™ Versus CGuard™]; NCT03488199).
Collapse
Affiliation(s)
- Andrey Karpenko
- Centre of Vascular and Hybrid Surgery, E.N. Meshalkin National Medical Research Center, Novosibirsk, Russia.
| | - Savr Bugurov
- Centre of Vascular and Hybrid Surgery, E.N. Meshalkin National Medical Research Center, Novosibirsk, Russia
| | - Pavel Ignatenko
- Centre of Vascular and Hybrid Surgery, E.N. Meshalkin National Medical Research Center, Novosibirsk, Russia
| | - Vladimir Starodubtsev
- Centre of Vascular and Hybrid Surgery, E.N. Meshalkin National Medical Research Center, Novosibirsk, Russia
| | - Irina Popova
- Centre of Vascular and Hybrid Surgery, E.N. Meshalkin National Medical Research Center, Novosibirsk, Russia
| | | | - Piotr Musialek
- Jagiellonian University, Department of Cardiac and Vascular Diseases, John Paul II Hospital, Krakow, Poland.
| |
Collapse
|
35
|
Matsumura JS, Hanlon BM, Rosenfield K, Voeks JH, Howard G, Roubin GS, Brott TG. Treatment of carotid stenosis in asymptomatic, non-octogenarian, standard risk patients with stenting versus endarterectomy trials. J Vasc Surg 2021; 75:1276-1283.e1. [PMID: 34695552 DOI: 10.1016/j.jvs.2021.10.020] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2021] [Accepted: 10/08/2021] [Indexed: 10/20/2022]
Abstract
OBJECTIVE Asymptomatic carotid stenosis is the most frequent indication for carotid endarterectomy (CEA) in the United States. Published trials and guidelines support CEA indications in selected patients with longer projected survival and when periprocedural complications are low. Transfemoral carotid artery stenting with embolic protection (CAS) is a newer treatment option. The objective of this study was to compare outcomes in asymptomatic, nonoctogenarian patients treated with CAS vs CEA. METHODS Patient-level data was analyzed from 2544 subjects with ≥70% asymptomatic carotid stenosis who were randomized to CAS or CEA in addition to standard medical therapy. One trial enrolled 1091 (548 CAS, 543 CEA) and another enrolled 1453 (1089 CAS, 364 CEA) asymptomatic patients less than 80 years old (upper age eligibility). Independent neurologic assessment and routine cardiac enzyme screening were performed. The prespecified, primary composite endpoint was any stroke, myocardial infarction, or death during the periprocedural period or ipsilateral stroke within 4 years after randomization. RESULTS There was no significant difference in the primary endpoint between CAS and CEA (5.3% vs 5.1%; hazard ratio, 1.02; 95% confidence interval, 0.7-1.5; P = .91). Periprocedural rates for the components are (CAS vs CEA): any stroke (2.7% vs 1.5%; P = .07), myocardial infarction (0.6% vs 1.7%; P = .01), death (0.1% vs 0.2%; P = .62), and any stroke or death (2.7% vs 1.6%; P = .07). After this period, the rates of ipsilateral stroke were similar (2.3% vs 2.2%; P = .97). CONCLUSIONS In a pooled analysis of two large randomized trials of CAS and CEA in asymptomatic, nonoctogenarian patients, CAS achieves comparable short- and long-term results to CEA.
Collapse
Affiliation(s)
- Jon S Matsumura
- Department of Surgery, University of Wisconsin School of Medicine and Public Health, Madison, Wisc.
| | - Bret M Hanlon
- Department of Surgery, University of Wisconsin School of Medicine and Public Health, Madison, Wisc
| | | | - Jenifer H Voeks
- Department of Neurology, Medical University of South Carolina, Charleston, SC
| | - George Howard
- Department of Biostatistics, University of Alabama at Birmingham, Birmingham, Ala
| | - Gary S Roubin
- Cardiovascular Associates of the Southeast, Birmingham, Ala
| | | |
Collapse
|
36
|
Salem MM, Kvint S, Baig AA, Monteiro A, Cortez GM, Kuhn AL, Goren O, Dalal S, Jankowitz BT, Choudhri O, Raper D, Tanweer O, Jabbour P, Kan P, Starke RM, Levy EI, Griessenauer CJ, Puri AS, Hanel R, Siddiqui AH, Burkhardt JK. Carotid artery revascularization using the Walrus balloon guide catheter: safety and feasibility from a US multicenter experience. J Neurointerv Surg 2021; 14:709-717. [PMID: 34686574 DOI: 10.1136/neurintsurg-2021-018126] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2021] [Accepted: 10/03/2021] [Indexed: 11/04/2022]
Abstract
INTRODUCTION The Walrus balloon guide catheter (BGC) is a new generation of BGC, designed to eliminate conventional limitations during mechanical thrombectomy. OBJECTIVE To report a multi-institutional experience using this BGC for proximal flow control (PFC) in the setting of carotid artery angioplasty/stenting (CAS) in elective (eCAS) and tandem strokes (tCAS). METHODS Prospectively maintained databases at 8 North American centers were queried to identify patients with cervical carotid disease undergoing eCAS/tCAS with a Walrus BGC. RESULTS 110 patients (median age 68, 64.6% male), 80 (72.7%) undergoing eCAS and 30 (27.3%) tCAS procedures, were included (median cervical carotid stenosis 90%; 46 (41.8%) with contralateral stenosis). Using a proximal flow-arrest technique in 95 (87.2%) and flow-reversal in 14 (12.8%) procedures, the Walrus was navigated into the common carotid artery successfully in all cases despite challenging arch anatomy (31, 28.2%), with preferred femoral access (103, 93.6%) and in monitored anesthesia care (90, 81.8%). Angioplasty and distal embolic protection devices (EPDs) were used in 91 (83.7%) and 58 (52.7%) procedures, respectively. tCAS led to a modified Thrombolysis in Cerebral Infarction 2b/3 in all cases. Periprocedural ischemic stroke (up to 30 days postoperatively) rate was 0.9% (n=1) and remote complications occurred in 2 (1.8%) cases. Last follow-up modified Rankin Scale score of 0-2 was seen in 95.3% of eCAS cohort, with no differences in complications in the eCAS subgroup between PFC only versus PFC and distal EPD (median follow-up 4.1 months). CONCLUSION Walrus BGC for proximal flow control is safe and effective during eCAS and tCAS. Procedural success was achieved in all cases, with favorable safety and functional outcomes on short-term follow-up.
Collapse
Affiliation(s)
- Mohamed M Salem
- Department of Neurosurgery, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Svetlana Kvint
- Department of Neurosurgery, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Ammad A Baig
- Department of Neurosurgery, University at Buffalo Jacobs School of Medicine and Biomedical Science, Buffalo, New York, USA.,Department of Neurosurgery, Gates Vascular Institute, Buffalo, New York, USA
| | - Andre Monteiro
- Department of Neurosurgery, University at Buffalo Jacobs School of Medicine and Biomedical Science, Buffalo, New York, USA.,Department of Neurosurgery, Gates Vascular Institute, Buffalo, New York, USA
| | - Gustavo M Cortez
- Department of Cerebrovascular and Endovascular Surgery, Baptist Neurological Institute and Lyerly Neurosurgery, Jacksonville, Florida, USA
| | - Anna L Kuhn
- Department of Radiology, University of Massachusetts Medical School, Worcester, Massachusetts, USA
| | - Oded Goren
- Department of Neurosurgery, Geisinger Medical Center, Danville, Pennsylvania, USA
| | - Shamsher Dalal
- Department of Neurosurgery, Geisinger Medical Center, Danville, Pennsylvania, USA
| | - Brian T Jankowitz
- Department of Neurosurgery, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Omar Choudhri
- Department of Neurosurgery, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Daniel Raper
- Department of Neurological Surgery, Baylor College of Medicine, Houston, Texas, USA
| | - Omar Tanweer
- Department of Neurological Surgery, Baylor College of Medicine, Houston, Texas, USA
| | - Pascal Jabbour
- Department of Neurological Surgery, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Peter Kan
- Department of Neurosurgery, The University of Texas Medical Branch at Galveston, Galveston, Texas, USA
| | - Robert M Starke
- Department of Neurosurgery and Radiology, University of Miami Miller School of Medicine, Miami, Florida, USA
| | - Elad I Levy
- Department of Neurosurgery, University at Buffalo Jacobs School of Medicine and Biomedical Science, Buffalo, New York, USA.,Department of Neurosurgery, Gates Vascular Institute, Buffalo, New York, USA
| | - Christoph J Griessenauer
- Department of Neurosurgery, Geisinger Medical Center, Danville, Pennsylvania, USA.,Department of Neurosurgery, Christian Doppler Clinic, Paracelsus Medical University, Salzburg, Austria
| | - Ajit S Puri
- Department of Radiology, University of Massachusetts Medical School, Worcester, Massachusetts, USA
| | - Ricardo Hanel
- Department of Cerebrovascular and Endovascular Surgery, Baptist Neurological Institute and Lyerly Neurosurgery, Jacksonville, Florida, USA
| | - Adnan H Siddiqui
- Department of Neurosurgery, University at Buffalo Jacobs School of Medicine and Biomedical Science, Buffalo, New York, USA.,Department of Neurosurgery, Gates Vascular Institute, Buffalo, New York, USA
| | - Jan-Karl Burkhardt
- Department of Neurosurgery, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| |
Collapse
|
37
|
Nakagawa I, Kotsugi M, Park H, Furuta T, Sato F, Myochin K, Nishimura F, Yamada S, Motoyama Y, Nakase H. Near-infrared spectroscopy carotid plaque characteristics and cerebral embolism in carotid artery stenting. EUROINTERVENTION 2021; 17:599-606. [PMID: 33283761 PMCID: PMC9725057 DOI: 10.4244/eij-d-20-01050] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
BACKGROUND Perioperative thromboembolism is the main consideration in carotid artery stenting (CAS). Precise evaluation of carotid plaque components is clinically important to reduce ischaemic complications since CAS mechanically pushes plaque outwards, which releases plaque debris into the bloodstream. AIMS This study aimed to determine whether high lipid core plaque (LCP) assessed by catheter-based near-infrared spectroscopy (NIRS) is associated with ipsilateral cerebral embolism by diffusion-weighted magnetic resonance imaging during CAS using a first-generation stent. METHODS Carotid stenosis magnetic resonance (MR) T1-weighted plaque signal intensity ratio (T1W-SIR) followed by NIRS assessment at the time of CAS (using the carotid artery Wallstent) was performed in 117 consecutive patients. RESULTS The maximum lipid core burden index (max-LCBI) at minimal luminal areas (MLA; max-LCBIMLA) and the max-LCBI for any 4 mm segment in a target lesion defined as max-LCBIarea were significantly higher for the post-procedural new ipsilateral diffusion-weighted magnetic resonance imaging (DWI)-positive than negative patients (p<0.001 for all). There was a significant linear correlation between max-LCBIarea and the number of new emboli (r=0.544, p<0.0001). We also found that the second quantile (Q2) of T1W-SIRMLA had a significantly higher max-LCBIMLA and a higher incidence of DWI positivity than Q1 and Q3 (p<0.001 for all). Furthermore, max-LCBIMLA appeared to distinguish between patients with and without postoperative new ipsilateral DWI positivity (AUC 0.91, 95% CI: 0.86-0.96; p<0.0001). CONCLUSIONS High LCP assessed by NIRS is associated with cerebral embolism by diffusion-weighted imaging in CAS using a first-generation stent.
Collapse
Affiliation(s)
- Ichiro Nakagawa
- Department of Neurosurgery, Nara Medical University, 840 Shijo-cho, Kashihara, Nara, 634-8522, Japan
| | - Masashi Kotsugi
- Department of Neurosurgery, Nara Medical University, Nara, Japan
| | - Hun Park
- Department of Neurosurgery, Nara Medical University, Nara, Japan
| | - Takanori Furuta
- Department of Neurosurgery, Nara Medical University, Nara, Japan
| | - Fumiya Sato
- Department of Neurosurgery, Nara Medical University, Nara, Japan
| | - Kaoru Myochin
- Department of Radiology, Nara Medical University, Nara, Japan
| | | | - Syuichi Yamada
- Department of Neurosurgery, Nara Medical University, Nara, Japan
| | - Yasushi Motoyama
- Department of Neurosurgery, Nara Medical University, Nara, Japan
| | - Hiroyuki Nakase
- Department of Neurosurgery, Nara Medical University, Nara, Japan
| |
Collapse
|
38
|
Halliday A, Bulbulia R, Bonati LH, Chester J, Cradduck-Bamford A, Peto R, Pan H. Second asymptomatic carotid surgery trial (ACST-2): a randomised comparison of carotid artery stenting versus carotid endarterectomy. Lancet 2021; 398:1065-1073. [PMID: 34469763 PMCID: PMC8473558 DOI: 10.1016/s0140-6736(21)01910-3] [Citation(s) in RCA: 106] [Impact Index Per Article: 35.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/22/2021] [Revised: 08/09/2021] [Accepted: 08/11/2021] [Indexed: 01/16/2023]
Abstract
BACKGROUND Among asymptomatic patients with severe carotid artery stenosis but no recent stroke or transient cerebral ischaemia, either carotid artery stenting (CAS) or carotid endarterectomy (CEA) can restore patency and reduce long-term stroke risks. However, from recent national registry data, each option causes about 1% procedural risk of disabling stroke or death. Comparison of their long-term protective effects requires large-scale randomised evidence. METHODS ACST-2 is an international multicentre randomised trial of CAS versus CEA among asymptomatic patients with severe stenosis thought to require intervention, interpreted with all other relevant trials. Patients were eligible if they had severe unilateral or bilateral carotid artery stenosis and both doctor and patient agreed that a carotid procedure should be undertaken, but they were substantially uncertain which one to choose. Patients were randomly allocated to CAS or CEA and followed up at 1 month and then annually, for a mean 5 years. Procedural events were those within 30 days of the intervention. Intention-to-treat analyses are provided. Analyses including procedural hazards use tabular methods. Analyses and meta-analyses of non-procedural strokes use Kaplan-Meier and log-rank methods. The trial is registered with the ISRCTN registry, ISRCTN21144362. FINDINGS Between Jan 15, 2008, and Dec 31, 2020, 3625 patients in 130 centres were randomly allocated, 1811 to CAS and 1814 to CEA, with good compliance, good medical therapy and a mean 5 years of follow-up. Overall, 1% had disabling stroke or death procedurally (15 allocated to CAS and 18 to CEA) and 2% had non-disabling procedural stroke (48 allocated to CAS and 29 to CEA). Kaplan-Meier estimates of 5-year non-procedural stroke were 2·5% in each group for fatal or disabling stroke, and 5·3% with CAS versus 4·5% with CEA for any stroke (rate ratio [RR] 1·16, 95% CI 0·86-1·57; p=0·33). Combining RRs for any non-procedural stroke in all CAS versus CEA trials, the RR was similar in symptomatic and asymptomatic patients (overall RR 1·11, 95% CI 0·91-1·32; p=0·21). INTERPRETATION Serious complications are similarly uncommon after competent CAS and CEA, and the long-term effects of these two carotid artery procedures on fatal or disabling stroke are comparable. FUNDING UK Medical Research Council and Health Technology Assessment Programme.
Collapse
Affiliation(s)
- Alison Halliday
- Nuffield Department of Population Health, University of Oxford, Oxford, UK; Nuffield Department of Surgery, University of Oxford, Oxford, UK.
| | - Richard Bulbulia
- Nuffield Department of Population Health, University of Oxford, Oxford, UK; Medical Research Council Population Health Research Unit, Nuffield Department of Population Health, University of Oxford, Oxford, UK
| | - Leo H Bonati
- Department of Neurology, University Hospital, Basel, Switzerland
| | - Johanna Chester
- Nuffield Department of Population Health, University of Oxford, Oxford, UK
| | | | - Richard Peto
- Nuffield Department of Population Health, University of Oxford, Oxford, UK
| | - Hongchao Pan
- Nuffield Department of Population Health, University of Oxford, Oxford, UK; Medical Research Council Population Health Research Unit, Nuffield Department of Population Health, University of Oxford, Oxford, UK
| |
Collapse
|
39
|
Bonati LH, Kakkos S, Berkefeld J, de Borst GJ, Bulbulia R, Halliday A, van Herzeele I, Koncar I, McCabe DJ, Lal A, Ricco JB, Ringleb P, Taylor-Rowan M, Eckstein HH. European Stroke Organisation guideline on endarterectomy and stenting for carotid artery stenosis. Eur Stroke J 2021; 6:I-XLVII. [PMID: 34414302 DOI: 10.1177/23969873211012121] [Citation(s) in RCA: 114] [Impact Index Per Article: 38.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2021] [Accepted: 04/05/2021] [Indexed: 01/01/2023] Open
Abstract
Atherosclerotic stenosis of the internal carotid artery is an important cause of stroke. The aim of this guideline is to analyse the evidence pertaining to medical, surgical and endovascular treatment of patients with carotid stenosis. These guidelines were developed based on the ESO standard operating procedure and followed the Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) approach. The working group identified relevant questions, performed systematic reviews and meta-analyses of the literature, assessed the quality of the available evidence, and wrote recommendations. Based on moderate quality evidence, we recommend carotid endarterectomy (CEA) in patients with ≥60-99% asymptomatic carotid stenosis considered to be at increased risk of stroke on best medical treatment (BMT) alone. We also recommend CEA for patients with ≥70-99% symptomatic stenosis, and we suggest CEA for patients with 50-69% symptomatic stenosis. Based on high quality evidence, we recommend CEA should be performed early, ideally within two weeks of the last retinal or cerebral ischaemic event in patients with ≥50-99% symptomatic stenosis. Based on low quality evidence, carotid artery stenting (CAS) may be considered in patients < 70 years old with symptomatic ≥50-99% carotid stenosis. Several randomised trials supporting these recommendations were started decades ago, and BMT, CEA and CAS have evolved since. The results of another large trial comparing outcomes after CAS versus CEA in patients with asymptomatic stenosis are anticipated in the near future. Further trials are needed to reassess the benefits of carotid revascularisation in combination with modern BMT in subgroups of patients with carotid stenosis.
Collapse
Affiliation(s)
- Leo H Bonati
- Department of Neurology, University Hospital Basel, Basel, Switzerland; Department of Clinical Research, University of Basel, Basel, Switzerland
| | - Stavros Kakkos
- Department of Vascular Surgery, University of Patras Medical School, Patras, Greece
| | - Joachim Berkefeld
- Institute of Neuroradiology, University Hospital of Frankfurt am Main, Frankfurt, Germany
| | - Gert J de Borst
- Department of Vascular Surgery, University Medical Center Utrecht, Utrecht, the Netherlands
| | - Richard Bulbulia
- Medical Research Council Population Health Research Unit, Clinical Trial Service Unit and Epidemiological Studies Unit, Nuffield Department of Population Health, University of Oxford, Oxford, UK
| | - Alison Halliday
- Medical Research Council Population Health Research Unit, Clinical Trial Service Unit and Epidemiological Studies Unit, Nuffield Department of Population Health, University of Oxford, Oxford, UK
| | - Isabelle van Herzeele
- Department of Thoracic and Vascular Surgery, Ghent University Hospital, Ghent, Belgium
| | - Igor Koncar
- Clinic for Vascular and Endovascular Surgery, Serbian Clinical Centre, Belgrade, Serbia
| | - Dominick Jh McCabe
- Department of Neurology and Stroke Service, The Adelaide and Meath Hospital, Dublin, incorporating the National Children's Hospital - Tallaght University Hospital, Dublin, Ireland; Royal Free Campus, UCL Queen Square Institute of Neurology, London, UK; Academic Unit of Neurology, School of Medicine, Trinity College Dublin, Ireland
| | - Avtar Lal
- European Stroke Organisation, Basel, Switzerland
| | - Jean-Baptiste Ricco
- Department of Vascular Surgery and Department of Clinical Research, University of Poitiers, Poitiers, France
| | - Peter Ringleb
- Department of Neurology, University Hospital Heidelberg, Heidelberg, Germany
| | | | - Hans-Henning Eckstein
- Department for Vascular and Endovascular Surgery, University Hospital, Technical University of Munich (TUM), Munich, Germany
| |
Collapse
|
40
|
Assessing the Suitability of the Carotid Bifurcation for Stenting: Anatomic and Morphologic Considerations. J Vasc Surg 2021; 74:2087-2095. [PMID: 34175382 DOI: 10.1016/j.jvs.2021.05.048] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2020] [Accepted: 05/04/2021] [Indexed: 11/21/2022]
Abstract
OBJECTIVE Over the years where stents have been used to treat carotid lesions, a great deal has been learned about which anatomical characteristics lead to adverse outcomes. This review summarizes the anatomic and morphologic characteristics of the carotid vasculature that can help guide patient selection and clinical decision-making. METHODS Each of the carotid artery anatomy and lesion characteristics that are relevant to carotid stenting are described in detail. These are accompanied with evidence-based outcomes and results. RESULTS Data on the prevalence of carotid artery lesions that are unsuitable for stenting are summarized and the implications of these data for practice are discussed, especially as they pertain to transcarotid artery revascularization. CONCLUSIONS CAS can be viable option for carotid revascularization, but the lesion must be acceptable and safe for stent placement. There should be thorough assessment to rule out the presence of severe tortuosity, long-segment disease, severe calcification (circumferential or exophytic), mobile-plaque, swollen ICA sign, and carotid diameters outside the acceptable range. In carefully chosen lesions with the absence of the unfavorable characteristics described-TCAR may offer improved periprocedural success, and CAS may attain better long-term durability.
Collapse
|
41
|
AbuRahma AF, Avgerinos ED, Chang RW, Darling RC, Duncan AA, Forbes TL, Malas MB, Perler BA, Powell RJ, Rockman CB, Zhou W. The Society for Vascular Surgery implementation document for management of extracranial cerebrovascular disease. J Vasc Surg 2021; 75:26S-98S. [PMID: 34153349 DOI: 10.1016/j.jvs.2021.04.074] [Citation(s) in RCA: 58] [Impact Index Per Article: 19.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2021] [Accepted: 04/28/2021] [Indexed: 12/24/2022]
Affiliation(s)
- Ali F AbuRahma
- Department of Surgery, West Virginia University-Charleston Division, Charleston, WV.
| | - Efthymios D Avgerinos
- Division of Vascular Surgery, University of Pittsburgh School of Medicine, UPMC Hearrt & Vascular Institute, Pittsburgh, Pa
| | - Robert W Chang
- Vascular Surgery, Permanente Medical Group, San Francisco, Calif
| | | | - Audra A Duncan
- Division of Vascular & Endovascular Surgery, University of Western Ontario, London, Ontario, Canada
| | - Thomas L Forbes
- Division of Vascular & Endovascular Surgery, University of Western Ontario, London, Ontario, Canada
| | - Mahmoud B Malas
- Vascular & Endovascular Surgery, University of California San Diego, La Jolla, Calif
| | - Bruce Alan Perler
- Division of Vascular Surgery & Endovascular Therapy, Johns Hopkins, Baltimore, Md
| | | | - Caron B Rockman
- Division of Vascular Surgery, New York University Langone, New York, NY
| | - Wei Zhou
- Division of Vascular Surgery, University of Arizona, Tucson, Ariz
| |
Collapse
|
42
|
Hasan B, Farah M, Nayfeh T, Amin M, Malandris K, Abd-Rabu R, Shah S, Rajjoub R, Seisa MO, Saadi S, Hassett L, Prokop LJ, AbuRahma A, Murad MH. A Systematic Review Supporting the Society for Vascular Surgery Guidelines on the Management of Carotid Artery Disease. J Vasc Surg 2021; 75:99S-108S.e42. [PMID: 34153350 DOI: 10.1016/j.jvs.2021.06.001] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2021] [Accepted: 06/01/2021] [Indexed: 12/29/2022]
Abstract
BACKGROUND To support the development of guidelines on the management of carotid disease, a writing committee from the Society for Vascular Surgery has commissioned this systematic review. METHODS We searched multiple data bases for studies addressing 5 questions: medical management vs. carotid revascularization (CEA) in asymptomatic patients, CEA vs. CAS in symptomatic low surgical risk patients, the optimal timing of revascularization after acute stroke, screening high risk patients for carotid disease, and the optimal sequence of interventions in patients with combined coronary and carotid disease. Studies were selected and appraised by pairs of independent reviewers. Meta-analyses were performed when feasible. RESULTS Medical management compared to carotid interventions in asymptomatic patients was associated with better early outcome during the first 30 days. However, CEA was associated with significantly lower long-term rate of stroke/death at 5 years. In symptomatic low risk surgical patients, CEA was associated with lower risk of stroke, but a significant increase in MI compared to CAS during the first 30 days. When the long-term outcome of transfemoral CAS vs. CEA in symptomatic patients were examined using pre-planned pooled analysis of individual patient data from four randomized trials, the risk of death or stroke within 120 days of the index procedure was 5.5% for CEA and 8.7% for CAS, which lends support that over the long-term, CEA has superior outcome than transfemoral CAS. When managing acute stroke, the comparison of CEA during the first 48 hours to that between day 2 and day14 did not reveal a statistically significant difference on outcomes during the first 30 days. Registry data show good results with CEA performed in the first week, but not within the first 48 hours. A single risk factor, aside from PAD, was associated with low carotid screening yield. Multiple risk factors greatly increase the yield of screening. Evidence on the timing of interventions in patients with combined carotid and coronary disease was sparse and imprecise. Patients without carotid symptoms, who had the carotid intervention first, compared to a combined carotid intervention and CABG, had better outcomes. CONCLUSIONS This updated evidence summary will support the SVS clinical practice guidelines for commonly raised clinical scenarios. CEA was superior to medical therapy in long-term prevention of stroke/death over medical therapy. CEA was also superior to transfemoral CAS in minimizing long-term stroke/death for symptomatic low risk surgical patients. CEA should optimally be performed between 2-14 days from the onset of acute stroke. Having multiple risk factors increases the value of carotid screening.
Collapse
Affiliation(s)
- Bashar Hasan
- Evidence-Based Practice Research Program, Mayo Clinic, MN, USA; Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, MN, USA
| | - Magdoleen Farah
- Evidence-Based Practice Research Program, Mayo Clinic, MN, USA; Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, MN, USA
| | - Tarek Nayfeh
- Evidence-Based Practice Research Program, Mayo Clinic, MN, USA; Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, MN, USA
| | - Mustapha Amin
- Evidence-Based Practice Research Program, Mayo Clinic, MN, USA; Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, MN, USA
| | - Kostantinos Malandris
- Evidence-Based Practice Research Program, Mayo Clinic, MN, USA; Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, MN, USA
| | - Rami Abd-Rabu
- Evidence-Based Practice Research Program, Mayo Clinic, MN, USA; Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, MN, USA
| | - Sahrish Shah
- Evidence-Based Practice Research Program, Mayo Clinic, MN, USA; Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, MN, USA
| | - Rami Rajjoub
- Evidence-Based Practice Research Program, Mayo Clinic, MN, USA; Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, MN, USA
| | - Mohamed O Seisa
- Evidence-Based Practice Research Program, Mayo Clinic, MN, USA; Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, MN, USA
| | - Samer Saadi
- Evidence-Based Practice Research Program, Mayo Clinic, MN, USA; Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, MN, USA
| | | | | | - Ali AbuRahma
- Department of Surgery, West Virginia University 3110 MacCorkle Ave., SE, Charleston, WV 25304
| | - M Hassan Murad
- Evidence-Based Practice Research Program, Mayo Clinic, MN, USA; Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, MN, USA.
| |
Collapse
|
43
|
SOCIETY FOR VASCULAR SURGERY CLINICAL PRACTICE GUIDELINES FOR MANAGEMENT OF EXTRACRANIAL CEREBROVASCULAR DISEASE. J Vasc Surg 2021; 75:4S-22S. [PMID: 34153348 DOI: 10.1016/j.jvs.2021.04.073] [Citation(s) in RCA: 175] [Impact Index Per Article: 58.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2021] [Accepted: 04/20/2021] [Indexed: 11/22/2022]
Abstract
Management of carotid bifurcation stenosis in stroke prevention has been the subject of extensive investigations, including multiple randomized controlled trials. The proper treatment of patients with carotid bifurcation disease is of major interest to vascular surgeons and other vascular specialists. In 2011, the Society for Vascular Surgery published guidelines for treatment of carotid artery disease. At the time, several randomized trials, comparing carotid endarterectomy (CEA) and carotid artery stenting (CAS), were published. Since that publication, several studies and a few systematic reviews comparing CEA and CAS have been published, and the role of medical management has been re-emphasized. The current publication updates and expands the 2011 guidelines with specific emphasis on five areas: is carotid endarterectomy recommended over maximal medical therapy in low risk patients; is carotid endarterectomy recommended over trans-femoral carotid artery stenting in low surgical risk patients with symptomatic carotid artery stenosis of >50%; timing of carotid Intervention in patients presenting with acute stroke; screening for carotid artery stenosis in asymptomatic patients; and optimal sequence for intervention in patients with combined carotid and coronary artery disease. A separate implementation document will address other important clinical issues in extracranial cerebrovascular disease. Recommendations are made using the GRADE (Grades of Recommendation Assessment, Development and Evaluation) approach, as has been done with other Society for Vascular Surgery guidelines. The committee recommends CEA as the first-line treatment for symptomatic low risk surgical patients with stenosis of 50% to 99% and asymptomatic patients with stenosis of 70% to 99%. The perioperative risk of stroke and death in asymptomatic patients must be <3% to ensure benefit for the patient. In patients with recent stable stroke (modified Rankin 0-2), carotid revascularization is considered appropriate in symptomatic patients with greater than 50% stenosis and is recommended and performed as soon as the patient is neurologically stable after 48 hours but definitely before 14 days of onset of symptoms. In the general population, screening for clinically asymptomatic carotid artery stenosis in patients without cerebrovascular symptoms or significant risk factors for carotid artery disease is not recommended. In selected asymptomatic patients who are at increased risk for carotid stenosis, we suggest screening for clinically asymptomatic carotid artery stenosis as long as the patients would potentially be fit for and willing to consider carotid intervention if significant stenosis is discovered. In patients with symptomatic carotid stenosis 50-99%, who require both CEA and CABG, we suggest CEA before or concomitant with CABG to potentially reduce the risk of stroke and stroke/death. The sequencing of the intervention depends on clinical presentation and institutional experience.
Collapse
|
44
|
Reiff T, Ringleb PA. [Asymptomatic carotid artery stenosis - treatment recommendations]. Dtsch Med Wochenschr 2021; 146:793-800. [PMID: 34130321 DOI: 10.1055/a-1221-7065] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
For the asymptomatic carotid stenosis, defined as an atherosclerotic carotid stenosis without neurological symptoms for more than 6 months, there are in contrast to a symptomatic carotid stenosis still no reliable treatment recommendations. Possible therapy recommendations based on current data are presented below.
Collapse
|
45
|
Sander D. [Asymptomatic carotid stenosis: What is new?]. Dtsch Med Wochenschr 2021; 146:432-436. [PMID: 33780986 DOI: 10.1055/a-1198-3548] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
In industrialized countries, stroke is still the most common disease that leads to permanent disability. Of the 250 000 strokes that occur annually in Germany, in about 80 % are cerebral ischemia. Approximately 15 % of these ischemias are caused by lesions of the extracranial internal carotid artery, so optimal treatment of extracranial carotid stenosis is essential 1. This continues to be the subject of a controversial debate, as optimized drug therapy has led to a significant reduction in risk.In 2020, the multidisciplinary S3 guideline for the management of extracranial carotid stenoses was updated. In the following, current aspects and new recommendations for asymptomatic carotid stenosis are presented and important innovations of the guideline are explained.
Collapse
Affiliation(s)
- Dirk Sander
- Abteilung für Neurologie sowie Neurologische Früh- und weiterführende Rehabilitation, Benedictus-Krankenhaus Tutzing & Feldafing
| |
Collapse
|
46
|
Yogendrakumar V, Shamy M, Dewar B, Fergusson DA, Dowlatshahi D, Hamel C, Gocan S, Fedyk M, Mas JL, Rothwell P, Howard V, Bereznyakova O. Identifying sex-specific differences in the carotid revascularisation literature: findings from a scoping review. Stroke Vasc Neurol 2021; 6:496-499. [PMID: 33782196 PMCID: PMC8485244 DOI: 10.1136/svn-2020-000744] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2020] [Revised: 12/09/2020] [Accepted: 01/02/2021] [Indexed: 11/18/2022] Open
Abstract
Objective No systematic review of the literature has dedicated itself to looking at the management of symptomatic carotid stenosis in female patients. In this scoping review, we aimed to identify all randomised controlled trials (RCTs) that reported sex-specific outcomes for patients who underwent carotid revascularisation, and determine whether sufficient information is reported within these studies to assess short-term and long-term outcomes in female patients. Design, setting and participants We systematically searched Medline, Embase, Pubmed and Cochrane libraries for RCTs published between 1991 and 2020 that included female patients and compared either endarterectomy with stenting, or any revascularisation (endarterectomy or stenting) with medical therapy in patients with symptomatic high-grade (>50%) carotid stenosis. Results From 1537 references examined, 27 eligible studies were identified. Sex-specific outcomes were reported in 13 studies. Baseline patient characteristics of enrolled female patients were reported in 2 of those 13 studies. Common outcomes reported included stroke and death, however, there was significant heterogeneity in the reporting of both periprocedural and long-term outcomes. Sex-specific differences relating to the degree of stenosis and time from index event to treatment are largely limited to studies comparing endarterectomy to medical therapy. Adverse events were not reported by sex. Conclusions Only half of the previously published RCTs and systematic reviews report sex-specific outcomes. Detailed analyses on the results of carotid artery intervention for female patients with symptomatic stenosis are limited.
Collapse
Affiliation(s)
- Vignan Yogendrakumar
- Department of Medicine, Division of Neurology and Ottawa Hospital Research Institute, University of Ottawa, Ottawa, Ontario, Canada
| | - Michel Shamy
- Department of Medicine, Division of Neurology and Ottawa Hospital Research Institute, University of Ottawa, Ottawa, Ontario, Canada
| | - Brian Dewar
- Department of Medicine, Division of Neurology and Ottawa Hospital Research Institute, University of Ottawa, Ottawa, Ontario, Canada
| | - Dean A Fergusson
- Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
| | - Dar Dowlatshahi
- Department of Medicine, Division of Neurology and Ottawa Hospital Research Institute, University of Ottawa, Ottawa, Ontario, Canada
| | - Candyce Hamel
- Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
| | - Sophia Gocan
- Stroke Prevention Clinic, Ottawa Hospital, Ottawa, Ontario, Canada
| | - Mark Fedyk
- Bioethics Program, UC Davis Department of Medicine, Sacramento, California, USA
| | - Jean-Louis Mas
- Universite Paris Descartes Faculte de Medecine Site Cochin, Paris, Île-de-France, France
| | - Peter Rothwell
- Service de Neurologie, Hôpital Sainte-Anne, Paris, France
| | - Virginia Howard
- The University of Alabama at Birmingham School of Medicine, Birmingham, Alabama, USA
| | - Olena Bereznyakova
- School of Public Health, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | | |
Collapse
|
47
|
Eckstein HH, Kühnl A, Berkefeld J, Lawall H, Storck M, Sander D. Diagnosis, Treatment and Follow-up in Extracranial Carotid Stenosis. DEUTSCHES ARZTEBLATT INTERNATIONAL 2021; 117:801-807. [PMID: 33549156 DOI: 10.3238/arztebl.2020.0801] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/05/2020] [Revised: 05/05/2020] [Accepted: 06/22/2020] [Indexed: 12/31/2022]
Abstract
BACKGROUND Around 15% of cerebral ischemias are caused by lesions of the extracranial carotid artery. The goal of this guideline is to provide evidence- and consensus-based recommendations for the management of patients with extracranial carotid stenoses throughout Germany and Austria. METHODS A systematic literature search (1990-2019) and methodical assessment of existing guidelines and systematic reviews; consensus-based answers to 37 key questions with evidence-based recommendations. RESULTS The prevalence of extracranial carotid artery stenoses is around 4% overall, higher from the age of 65 years. The most important examination modality is duplex sonography. Randomized trials have shown that carotid endarterectomy (CEA) significantly reduces the 5-year risk of stroke in patients with 60-99 % asymptomatic stenoses (absolute risk reduction [ARR] 4.1% over 5 years, number needed to treat [NNT] 24) or 50-99% symptomatic stenoses (50-69%: ARR 4.6 % over 5 years, NNT 22; 70-99%: 15.9 % over 5 years, NNT 6). With the aid of intensive conservative treatment, the carotid artery-associated risk of stroke can be reduced to as little as 1% per year. Critical determination of indications and strict quality criteria are therefore necessary for CEA and carotid artery stenting (CAS). Systematic reviews of controlled trials comparing CEA and CAS show that the procedural risk of stroke is higher for CAS (asymptomatic: 2.6% versus 1.3%; symptomatic: 6.2% versus 3.8%). There are no differences in the long term. CEA is recommended as standard procedure for high-grade asymptomatic and moderate to high-grade symptomatic carotid artery stenoses; CAS may be considered as an alternative. For both procedures, the periprocedural combined rate of stroke or death should not exceed 2% for asymptomatic stenoses or 4% for symptomatic stenoses. CONCLUSION Future studies should evaluate even better selection criteria for optimal individualized treatment, whether conservative, surgical, or endovascular.
Collapse
Affiliation(s)
- Hans-Henning Eckstein
- Spokesman (HHE) and Secretary (AK) of the Steering Group, Department forf Vascular and Endovascular Surgery, University Hospital "rechts der Isar", Technical University of Munich; Member of the Steering Group, Institute for Neuroradiology, University Hospital Frankfurt; Member of the Steering Group, Ettlingen; Member of the Steering Group, Department of Vascular and Thoracic Surgery, Karlsruhe Municipal Hospital Member of the Steering Group, Department of Neurology and Stroke Unit, Benedictus Hospital Tutzing; German Vascular Society (DGG); German Society of Neuroradiology (DGNR); German Society for Angiology/Vascular Medicine (DGA); German Society of Surgery (DGCH); German Society of Neurology (DGN)
| | | | | | | | | | | |
Collapse
|
48
|
Tao Y, Hua Y, Jia L, Jiao L, Liu B. Risk Factors for Residual Stenosis After Carotid Artery Stenting. Front Neurol 2021; 11:606924. [PMID: 33584505 PMCID: PMC7876267 DOI: 10.3389/fneur.2020.606924] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2020] [Accepted: 12/21/2020] [Indexed: 11/13/2022] Open
Abstract
Background and purpose: Stent residual stenosis is an independent risk factor for restenosis after stenting. This study aimed to analyze the factors influencing residual stenosis after carotid artery stenting (CAS). Methods: A total of 570 patients who underwent CAS with 159 closed-loop stents (CLS) and 411 open-loop stents (OLS) from January 2013 to January 2016 were retrospectively enrolled in this study. Carotid stenosis location in the common carotid artery or in internal carotid artery, plaque size, and features (regular or irregular morphology; with or without calcification), degree of carotid artery stenosis, and stent expansion rate were detected by carotid duplex ultrasonography. Residual stenosis was defined as a stenosis rate ≥30% after CAS, as detected by digital subtraction angiography. A logistic regression analysis was used to analyze residual stenosis risk factors. Results: The overall incidence of residual stenosis was 22.8% (130/570 stents). The incidence of residual stenosis in the CLS group was higher than that in the OLS group (29.5 vs. 20.2%, χ2 = 5.71, P = 0.017). The logistic regression analysis showed that CLS [odds ratio (OR), 1.933; 95% confidence interval (CI), 1.009-3.702], irregular plaques (OR, 4.237; 95% CI, 2.391-7.742), and plaques with calcification (OR, 2.370; 95% CI, 1.337-4.199) were independent risk factors for residual stenosis after CAS. In addition, a high radial expansion rate of stent was a protective factor for residual stenosis (OR, 0.171; 95% CI, 0.123-0.238). The stenosis location and stent length did not impact the occurrence of residual stenosis. After 1-year follow-up, the incidence of restenosis in the residual stenosis group was higher than that in the group without residual stenosis (13.1 vs. 2.0%, χ2 = 28.05, P < 0.001). Conclusions: The findings of this study suggest that plaque morphology, echo characteristics (with calcification), and stents type influence residual stenosis.
Collapse
Affiliation(s)
- Yunlu Tao
- Department of Vascular Ultrasonography, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Yang Hua
- Department of Vascular Ultrasonography, Xuanwu Hospital, Capital Medical University, Beijing, China.,Center of Vascular Ultrasonography, Beijing Institute of Brain Disorders, Beijing, China
| | - Lingyun Jia
- Department of Vascular Ultrasonography, Xuanwu Hospital, Capital Medical University, Beijing, China.,Center of Vascular Ultrasonography, Beijing Institute of Brain Disorders, Beijing, China
| | - Liqun Jiao
- Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Beibei Liu
- Department of Vascular Ultrasonography, Xuanwu Hospital, Capital Medical University, Beijing, China
| |
Collapse
|
49
|
Carvalho P, Coelho A, Mansilha A. Effectiveness and safety of dual-layer stents in carotid artery disease: a systematic review. INT ANGIOL 2020; 40:97-104. [PMID: 33337115 DOI: 10.23736/s0392-9590.20.04553-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
INTRODUCTION Carotid artery stenting (CAS) has emerged as a minimally invasive alternative to carotid endarterectomy (CEA) in atherosclerotic carotid artery disease, even though the risk for procedural stroke after CAS remains significantly higher. Recently, in order to reduce embolic cerebral events after CAS, a new generation of dual-layer stents (DLS) has been developed. This review aimed to perform a detailed analysis of the available evidence on safety and efficacy of DLS in both symptomatic and asymptomatic atherosclerotic carotid artery stenosis. EVIDENCE ACQUISITION A systematic review was conducted according to the recommendations of the Preferred Reporting Items for Systematic Reviews and Meta-Analyses statement. The primary endpoint was the 30-day rate of myocardial infarction (MI), stroke and death. Secondary outcomes included rate and timing of stent occlusion/restenosis. EVIDENCE SYNTHESIS A total of 20 articles with 1193 patients were included. Thirty-day MI ranged from 0-5%, 30-day stroke ranged from 0-10.5% and 30-day mortality ranged from 0-10%. Stent occlusion rate ranged from 0-52.4%, the majority of which occurred intraprocedurally (N.=50; 61.7%), in emergency treated patients. The incidence of new ipsilateral cerebral ischemic lesions after CAS with DLS was reported in five studies, ranging from 5.5-37%. CONCLUSIONS Despite the theoretic advantage of reducing the risk for procedural embolic events when compared to conventional stents, high quality evidence is scarce. Also, safety issues regarding DLS in the emergency setting have been raised, particularly for thrombotic complications. Additional data from well-designed Randomized Controlled Trials are needed to assert the true value of DLS.
Collapse
Affiliation(s)
| | - Andreia Coelho
- Faculty of Medicine, University of Porto, Porto, Portugal.,Department of Angiology and Vascular Surgery, Hospital Center of Vila Nova de Gaia/Espinho, Vila Nova de Gaia, Portugal
| | - Armando Mansilha
- Faculty of Medicine, University of Porto, Porto, Portugal.,Department of Angiology and Vascular Surgery, University Hospital Center of São João, Porto, Portugal
| |
Collapse
|
50
|
Diaz-Quijano FA. Estimating and testing an index of bias attributable to composite outcomes in comparative studies. J Clin Epidemiol 2020; 132:1-9. [PMID: 33309888 DOI: 10.1016/j.jclinepi.2020.12.003] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2020] [Revised: 09/28/2020] [Accepted: 12/01/2020] [Indexed: 01/07/2023]
Abstract
OBJECTIVES This study aimed to develop an index to evaluate the bias attributable to composite outcomes (BACOs) in comparative clinical studies. STUDY DESIGN AND SETTING The author defined the BACO index as the ratio of the logarithm of the association measure (e.g., relative risk) of the composite outcome to that of its most relevant component endpoint (e.g., mortality). Methods to calculate the confidence intervals and test the null hypotheses (BACO index = 1) were described and applied in systematically selected clinical trials. Two other preselected trials were included as "positive controls" for being examples of primary composite outcomes disregarded because of inconsistency with the treatment effect on mortality. RESULTS The BACO index values different from 1 were classified according to whether the use of composite outcomes overestimated (BACO index >1), underestimated (BACO index between 0 and <1), or inverted (BACO index <0) the association between exposure and prognosis. In 3 of 23 systematically selected trials and the two positive controls, the BACO indices were significantly lower than 1 (P < 0.005). CONCLUSION BACO index can warn that the composite outcome association is stronger, weaker, or even opposite than that of its most critical component.
Collapse
Affiliation(s)
- Fredi Alexander Diaz-Quijano
- Department of Epidemiology, Laboratório de Inferência Causal em Epidemiologia (LINCE-USP), School of Public Health, University of São Paulo, São Paulo, São Paulo, Brazil.
| |
Collapse
|