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Yu S, Chaney MA. Combined Coronary and Carotid Artery Disease: What to Operate on First? Or Both at the Same Time? J Cardiothorac Vasc Anesth 2024; 38:1417-1422. [PMID: 37839940 DOI: 10.1053/j.jvca.2023.09.021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/12/2023] [Accepted: 09/16/2023] [Indexed: 10/17/2023]
Affiliation(s)
- Sherman Yu
- Department of Anesthesia and Critical Care, University of Chicago, Chicago, IL
| | - Mark A Chaney
- Department of Anesthesia and Critical Care, University of Chicago, Chicago, IL.
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2
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Oye H, Abbas N. Transcarotid Artery Revascularization (TCAR): The Best Surgical Intervention Option in an Unusual Presentation of Carotid Dissection in a 37-Year-Old Pregnant Female. Cureus 2024; 16:e54600. [PMID: 38523914 PMCID: PMC10958752 DOI: 10.7759/cureus.54600] [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: 02/20/2024] [Indexed: 03/26/2024] Open
Abstract
Carotid artery dissection (CAD) is a condition that compromises blood flow and leads to serious complications such as a stroke or cerebrovascular accident (CVA). This case report demonstrates an unusual case of right internal carotid artery dissection, stenosis of >70%, and an intraluminal thrombus. The patient presented to the emergency department with complaints of right-sided neck pain and severe headache status-post a complicated pregnancy. A computed tomography (CT) angiogram of the right carotid was conducted and showed a right internal carotid artery dissection with 70% luminal stenosis and thrombosis. Carotid endarterectomy (CEA), transfemoral carotid angioplasty with stenting (CAS), or transcarotid artery revascularization (TCAR) were all surgical intervention options that were explored. Risks and benefits were compared between the three surgical intervention options, and transcarotid artery revascularization was deemed the best surgical option in this patient's case.
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Affiliation(s)
- Herbert Oye
- Endovascular and Vascular Surgery, Raleigh General Hospital, Beckley, USA
- Endovascular and Vascular Surgery, West Virginia Vascular Institute, Beckley, USA
| | - Nitasha Abbas
- Medicine, Lincoln Memorial University-DeBusk College of Osteopathic Medicine, Knoxville, USA
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3
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Václavík D, Pakizer D, Hrbáč T, Roubec M, Procházka V, Jonszta T, Herzig R, Školoudík D. Changes in Cognitive Functions after Carotid Endarterectomy and Carotid Stenting: A Decade-Apart Comparison. Biomedicines 2023; 12:13. [PMID: 38275374 PMCID: PMC10813376 DOI: 10.3390/biomedicines12010013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2023] [Revised: 11/28/2023] [Accepted: 12/10/2023] [Indexed: 01/27/2024] Open
Abstract
BACKGROUND This study investigates changes in cognitive function in patients with severe carotid stenosis who underwent carotid endarterectomy (CEA) and carotid stenting (CAS) over two decades. METHODS We compared cognitive function within 30 days after the procedure in 267 patients (first 100 each for CEA and CAS in two periods: 2008-2012 and 2018-2022) in a single institution. Assessments used Adenbrooke's Cognitive Examination-Revised (ACE-R), the Mini-Mental State Examination (MMSE), Speech Fluency Test (SFT), and Clock Drawing Test (CDT), conducted before and 30 ± 2 days after surgery. RESULTS Patients (mean age 67.2 years, 70%+ carotid stenosis) exhibited different cognitive changes over periods. In 2008-2012, significant declines in MMSE (CEA, p = 0.049) and CDT (CAS, p = 0.015) were observed among asymptomatic patients. On the contrary, in 2018-2022, improvements were observed in ACE-R and MMSE for symptomatic and asymptomatic patients undergoing CEA and CAS. CONCLUSION Over a decade, advances in interventional techniques and patient management have reduced risks of cognitive decline in patients with asymptomatic carotid stenosis and also have improved cognitive functions in both symptomatic and asymptomatic individuals.
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Affiliation(s)
- Daniel Václavík
- Department of Neurology, University Hospital Ostrava, 708 00 Ostrava, Czech Republic; (D.V.); (M.R.)
- Comprehensive Stroke Centre, Department of Neurology, Charles University Faculty of Medicine and University Hospital, 500 05 Hradec Králové, Czech Republic;
- Stroke Centre, Department of Neurology, Hospital Agel Ostrava Vitkovice, 703 00 Ostrava, Czech Republic
| | - David Pakizer
- Centre for Health Research, Faculty of Medicine, University of Ostrava, Syllabova 19, 703 00 Ostrava, Czech Republic;
| | - Tomáš Hrbáč
- Department of Neurosurgery, University Hospital Ostrava, 708 52 Ostrava, Czech Republic;
- Department of Neuroscience, Faculty of Medicine, University of Ostrava, 703 00 Ostrava, Czech Republic
| | - Martin Roubec
- Department of Neurology, University Hospital Ostrava, 708 00 Ostrava, Czech Republic; (D.V.); (M.R.)
- Centre for Health Research, Faculty of Medicine, University of Ostrava, Syllabova 19, 703 00 Ostrava, Czech Republic;
| | - Václav Procházka
- Department of Radiodiagnostics, University Hospital Ostrava and Faculty of Medicine, University of Ostrava, 703 00 Ostrava, Czech Republic; (V.P.); (T.J.)
| | - Tomáš Jonszta
- Department of Radiodiagnostics, University Hospital Ostrava and Faculty of Medicine, University of Ostrava, 703 00 Ostrava, Czech Republic; (V.P.); (T.J.)
| | - Roman Herzig
- Comprehensive Stroke Centre, Department of Neurology, Charles University Faculty of Medicine and University Hospital, 500 05 Hradec Králové, Czech Republic;
| | - David Školoudík
- Department of Neurology, University Hospital Ostrava, 708 00 Ostrava, Czech Republic; (D.V.); (M.R.)
- Centre for Health Research, Faculty of Medicine, University of Ostrava, Syllabova 19, 703 00 Ostrava, Czech Republic;
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4
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Gasior SA, O'Donnell JPM, Davey M, Clarke J, Jalali A, Ryan É, Aherne TM, Walsh SR. Optimal Management of Asymptomatic Carotid Artery Stenosis: A Systematic Review and Network Meta-Analysis. Eur J Vasc Endovasc Surg 2023; 65:690-699. [PMID: 36682406 DOI: 10.1016/j.ejvs.2023.01.020] [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: 05/14/2022] [Revised: 12/02/2022] [Accepted: 01/11/2023] [Indexed: 01/21/2023]
Abstract
OBJECTIVE Management of asymptomatic carotid artery stenosis (ACAS), including carotid endarterectomy (CEA), carotid artery stenting (CAS), and best medical treatment (BMT), remains inconsistent in current practice. Early studies reported a benefit of CEA vs. BMT; however, the current risk-benefit profile of invasive therapy lacks consensus. By evaluating the effects of modern BMT vs. invasive intervention on patient outcomes, this study aimed to influence the future management of ACAS. METHODS A systematic review and series of network meta-analyses were performed assessing peri-operative (within 30 days) and long term (30 days - 5 years) stroke and mortality risk between ACAS interventions. Total stroke, major, minor, ipsilateral, and contralateral stroke subtypes were assessed independently. Traditional (pre-2000) and modern (post-2000) BMT were compared to assess clinical improvements in medical therapy over the previous two decades. Risks of myocardial infarction (MI) and cranial nerve injury (CNI) were also assessed. RESULTS Seventeen reports of 14 310 patients with > 50% ACAS were included. CEA reduced the odds of a peri-operative stroke event occurring vs. CAS (odds ratio [OR] 1.6, 95% confidence interval [CI] 1.1 - 2.2 [0 - 20 fewer/1 000]). CEA and CAS reduced the long term odds of minor strokes (OR 0.35, 95% CI 0.21 - 0.59 [20 fewer/1 000]) and ipsilateral strokes (OR 0.27, 95% CI 0.19 - 0.39 [30 fewer/1 000]) vs. all BMT. CEA reduced the odds of major strokes and combined stroke and mortality vs. traditional BMT; however, no difference was found between CEA and modern BMT. CAS reduced the odds of peri-operative MI (OR 0.49, 95% CI 0. 26 - 0.91) and CNI (OR 0.07, 95% CI 0.01 - 0.42) vs. CEA. CONCLUSION Modern BMT demonstrates similar reductions in major stroke, combined stroke, and mortality to CEA. The overall risk reductions are low and data were unavailable to assess subgroups which may benefit from intervention. However, BMT carries the potential to reduce the requirement for surgical intervention in patients with ACAS.
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Affiliation(s)
- Sara A Gasior
- Department of Vascular Surgery, University Hospital Galway, Galway, Ireland.
| | - John P M O'Donnell
- Department of Vascular Surgery, University Hospital Galway, Galway, Ireland; Lambe Institute for Translational Discipline of Surgery, National University of Ireland, Galway, Ireland
| | - Matthew Davey
- Lambe Institute for Translational Discipline of Surgery, National University of Ireland, Galway, Ireland; Department of Surgery, Royal College of Surgeons in Ireland, Dublin, Ireland
| | - James Clarke
- Lambe Institute for Translational Discipline of Surgery, National University of Ireland, Galway, Ireland
| | | | - Éanna Ryan
- Lambe Institute for Translational Discipline of Surgery, National University of Ireland, Galway, Ireland
| | - Thomas M Aherne
- Department of Surgery, Royal College of Surgeons in Ireland, Dublin, Ireland
| | - Stewart R Walsh
- Department of Vascular Surgery, University Hospital Galway, Galway, Ireland; Lambe Institute for Translational Discipline of Surgery, National University of Ireland, Galway, Ireland
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Baek JH. Carotid Artery Stenting for Asymptomatic Carotid Stenosis: What We Need to Know for Treatment Decision. Neurointervention 2023; 18:9-22. [PMID: 36809873 PMCID: PMC9986346 DOI: 10.5469/neuroint.2023.00031] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2023] [Accepted: 02/05/2023] [Indexed: 02/24/2023] Open
Abstract
A clinical decision on the treatment of asymptomatic carotid stenosis is challenging, unlike symptomatic carotid stenosis. Carotid artery stenting (CAS) has been recommended as an alternative to carotid endarterectomy (CEA) based on the finding that the efficacy and safety of CAS were comparable to CEA in randomized trials. However, in some countries, CAS is often performed more frequently than CEA for asymptomatic carotid stenosis. Moreover, it has been recently reported that CAS is not superior to the best medical treatment in asymptomatic carotid stenosis. Due to these recent changes, the role of CAS in asymptomatic carotid stenosis should be revisited. When determining the treatment for asymptomatic carotid stenosis, one should consider several clinical factors including stenosis degree, patient life expectancy, stroke risk by medical treatment, availability of a vascular surgeon, high risk for CEA or CAS, and insurance coverage. This review aimed to present and pragmatically organize the information that is necessary for a clinical decision on CAS in asymptomatic carotid stenosis. In conclusion, although the traditional benefit of CAS is being revisited recently, it seems too early to conclude that CAS is no longer beneficial under intense and systemic medical treatment. Instead, a treatment strategy with CAS should evolve to select eligible or medically high-risk patients more precisely.
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Affiliation(s)
- Jang-Hyun Baek
- Department of Neurology, Kangbuk Samsung Hospital, Sungkyunkwan University School of Medicine, Seoul, Korea
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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]
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Implementation of Predictive Algorithms for the Study of the Endarterectomy LOS. Bioengineering (Basel) 2022; 9:bioengineering9100546. [PMID: 36290514 PMCID: PMC9598220 DOI: 10.3390/bioengineering9100546] [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: 09/05/2022] [Revised: 10/04/2022] [Accepted: 10/07/2022] [Indexed: 11/26/2022] Open
Abstract
Background: In recent years, the length of hospital stay (LOS) following endarterectomy has decreased significantly from 4 days to 1 day. LOS is influenced by several common complications and factors that can adversely affect the patient’s health and may vary from one healthcare facility to another. The aim of this work is to develop a forecasting model of the LOS value to investigate the main factors affecting LOS in order to save healthcare cost and improve management. Methods: We used different regression and machine learning models to predict the LOS value based on the clinical and organizational data of patients undergoing endarterectomy. Data were obtained from the discharge forms of the “San Giovanni di Dio e Ruggi d’Aragona” University Hospital (Salerno, Italy). R2 goodness of fit and the results in terms of accuracy, precision, recall and F1-score were used to compare the performance of various algorithms. Results: Before implementing the models, the preliminary correlation study showed that LOS was more dependent on the type of endarterectomy performed. Among the regression algorithms, the best was the multiple linear regression model with an R2 value of 0.854, while among the classification algorithms for LOS divided into classes, the best was decision tree, with an accuracy of 80%. The best performance was obtained in the third class, which identifies patients with prolonged LOS, with a precision of 95%. Among the independent variables, the most influential on LOS was type of endarterectomy, followed by diabetes and kidney disorders. Conclusion: The resulting forecast model demonstrates its effectiveness in predicting the value of LOS that could be used to improve the endarterectomy surgery planning.
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Qaryouti D, Greene-Chandos D. Neurocritical Care Aspects of Ischemic Stroke Management. Crit Care Clin 2022; 39:55-70. [DOI: 10.1016/j.ccc.2022.07.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
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Micheel A, Konietschke F, Hinterseher I, Kapahnke S, Bürger M, Raude B, Schawe L, Omran S, Greiner A, Frese JP. Perioperative risk prediction using the POSSUM and V-POSSUM models in symptomatic carotid stenosis. VASA 2022; 51:150-157. [DOI: 10.1024/0301-1526/a000997] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
Summary: Background: This study aimed to evaluate risk factors for adverse outcomes and perioperative stroke and death in patients with symptomatic carotid stenosis undergoing open endarterectomy (CEA). The second objective was to assess the predictive value of the POSSUM and V-POSSUM models for predicting morbidity and mortality from CEA in symptomatic carotid stenosis. Patients and methods: A retrospective observational study of all patients admitted to a single center who underwent CEA for symptomatic carotid stenosis was performed. 320 patients from 1999 to 2013 were included. Postoperative complications, 30-day survival, and stroke rates were recorded. The observed outcomes were compared to the POSSUM and V-POSSUM expected mortality (observed to expected ratio (O:E)). Results: The mean age was 68.1±10.0 years. 215 patients were male (67%). Risk factors for surgical complications were: age, with a higher risk in both groups of less than 60 years and more than 75 years of age (p=0.04), a higher ASA score (p=0.04), and hyperlipidemia (p=0.017). Risk factors for the combined endpoint stroke or death were a higher ASA category (p<0.001), stroke as indication for CEA (p 0.022), and a high degree of stenosis (p=0.019). For POSSUM predicted mortality, there was a good O:E ratio in the two lowest risk groups, but a 2-fold overprediction of death or stroke in the two high-risk strata. The area under the curve (AUC) was 0.58 (95% CI: 0.43–0.73). The V-POSSUM showed a better fit in the high-risk groups, but an underprediction of mortality in the low-risk strata. Conclusions: Age and comorbid conditions are risk factors for adverse outcomes after CEA. The V-POSSUM model is better than POSSUM to predict postoperative death and stroke after CEA in patients with symptomatic carotid stenosis and a high preoperative physiological score. In patients with low physiological scores, both POSSUM and V-POSSUM show a limited predictive value.
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Affiliation(s)
- Anita Micheel
- Charité – Universitätsmedizin Berlin, Corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Department of Vascular Surgery, Berlin, Germany
- Department of Internal Medicine, Bundeswehr-Zentralkrankenhaus, Koblenz, Germany
| | - Frank Konietschke
- Charité – Universitätsmedizin Berlin, Corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Institute of Medical Biometrics and Clinical Epidemiology, Berlin, Germany
| | - Irene Hinterseher
- Charité – Universitätsmedizin Berlin, Corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Department of Vascular Surgery, Berlin, Germany
- Department of Vascular Surgery, Medizinische Hochschule Brandenburg Theodor-Fontane – Campus Neuruppin, Neuruppin, Germany
| | - Sebastian Kapahnke
- Charité – Universitätsmedizin Berlin, Corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Department of Vascular Surgery, Berlin, Germany
| | - Matthias Bürger
- Charité – Universitätsmedizin Berlin, Corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Department of Vascular Surgery, Berlin, Germany
| | - Ben Raude
- Charité – Universitätsmedizin Berlin, Corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Department of Vascular Surgery, Berlin, Germany
| | - Larissa Schawe
- Charité – Universitätsmedizin Berlin, Corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Department of Vascular Surgery, Berlin, Germany
| | - Safwan Omran
- Charité – Universitätsmedizin Berlin, Corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Department of Vascular Surgery, Berlin, Germany
| | - Andreas Greiner
- Charité – Universitätsmedizin Berlin, Corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Department of Vascular Surgery, Berlin, Germany
| | - Jan Paul Frese
- Charité – Universitätsmedizin Berlin, Corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Department of Vascular Surgery, Berlin, Germany
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Carotid and Intracranial Surgery. Perioper Med (Lond) 2022. [DOI: 10.1016/b978-0-323-56724-4.00021-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
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Paraskevas KI, Mikhailidis DP, Antignani PL, Baradaran H, Bokkers RP, Cambria RP, Dardik A, Davies AH, Eckstein HH, Faggioli G, Fernandes E Fernandes J, Fraedrich G, Geroulakos G, Gloviczki P, Golledge J, Gupta A, Jezovnik MK, Kakkos SK, Katsiki N, Knoflach M, Kooi ME, Lanza G, Liapis CD, Loftus IM, Mansilha A, Millon A, Nicolaides AN, Pini R, Poredos P, Ricco JB, Riles TS, Ringleb PA, Rundek T, Saba L, Schlachetzki F, Silvestrini M, Spinelli F, Stilo F, Sultan S, Suri JS, Zeebregts CJ, Chaturvedi S. Optimal management of asymptomatic carotid stenosis in 2021: the jury is still out. An International, multispecialty, expert review and position statement. INT ANGIOL 2021; 41:158-169. [PMID: 34913633 DOI: 10.23736/s0392-9590.21.04825-2] [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
OBJECTIVES The recommendations of international guidelines for the management of asymptomatic carotid stenosis (ACS) often vary considerably and extend from a conservative approach with risk factor modification and best medical treatment (BMT) alone, to a more aggressive approach with a carotid intervention plus BMT. The aim of the current multispecialty position statement is to reconcile the conflicting views on the topic. MATERIALS AND METHODS A literature review was performed with a focus on data from recent studies. RESULTS Several clinical and imaging high-risk features have been identified that are associated with an increased long-term ipsilateral ischemic stroke risk in patients with ACS. Such high-risk clinical/imaging features include intraplaque hemorrhage, impaired cerebrovascular reserve, carotid plaque echolucency/ulceration/ neovascularization, a lipid-rich necrotic core, a thin or ruptured fibrous cap, silent brain infarction, a contralateral transient ischemic attack/stroke episode, male patients <75 years and microembolic signals on transcranial Doppler. There is growing evidence that 80-99% ACS indicate a higher stroke risk than 50-79% stenoses. CONCLUSIONS Although aggressive risk factor control and BMT should be implemented in all ACS patients, several high-risk features that may increase the risk of a future cerebrovascular event are now documented. Consequently, some guidelines recommend a prophylactic carotid intervention in high-risk patients to prevent future cerebrovascular events. Until the results of the much-anticipated randomized controlled trials emerge, the jury is still out regarding the optimal management of ACS patients.
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Affiliation(s)
| | - Dimitri P Mikhailidis
- Department of Clinical Biochemistry, Royal Free Hospital Campus, University College London Medical School, University College London (UCL), London, UK
| | | | - Hediyeh Baradaran
- Department of Radiology, University of Utah, Salt Lake City, UT, USA
| | - Reinoud P Bokkers
- Department of Radiology, Medical Imaging Center, University Medical Center Groningen, Groningen, The Netherlands
| | - Richard P Cambria
- Division of Vascular and Endovascular Surgery, St. Elizabeth's Medical Center, Brighton, MA, USA
| | - Alan Dardik
- Division of Vascular and Endovascular Surgery, Yale University School of Medicine, New Haven, CT, USA
| | - Alun H Davies
- Section of Vascular Surgery, Imperial College & Imperial Healthcare NHS Trust, London, UK
| | - Hans-Henning Eckstein
- Department for Vascular and Endovascular Surgery, Klinikum rechts der Isar, Technical University of Munich, Munich, Germany
| | - Gianluca Faggioli
- Vascular Surgery, Policlinico S. Orsola Malpighi, University of Bologna Alma Mater Studiorum, Bologna, Italy
| | | | - Gustav Fraedrich
- Department of Vascular Surgery, Medical University of Innsbruck, Innsbruck, Austria
| | - George Geroulakos
- Department of Vascular Surgery, Attikon University Hospital, National and Kapodistrian University of Athens, Athens, Greece
| | - Peter Gloviczki
- Division of Vascular and Endovascular Surgery, Mayo Clinic, Rochester, MN, USA
| | - Jonathan Golledge
- Queensland Research Centre for Peripheral Vascular Disease, James Cook University and Townsville University Hospital, Townsville, Australia
| | - Ajay Gupta
- Department of Radiology, Weill Cornell Medicine, New York, NY, USA
| | - Mateja K Jezovnik
- Department of Advanced Cardiopulmonary Therapies and Transplantation, The University of Texas Health Science Centre at Houston, Houston, Texas, USA
| | - Stavros K Kakkos
- Department of Vascular Surgery, University of Patras Medical School, Patras, Greece
| | - Niki Katsiki
- First Department of Internal Medicine, AHEPA University Hospital, Thessaloniki, Greece
| | - Michael Knoflach
- Department of Neurology, Medical University of Innsbruck, Innsbruck, Austria
| | - M Eline Kooi
- CARIM School for Cardiovascular Diseases, Maastricht University, Maastricht, The Netherlands.,Department of Radiology and Nuclear Medicine, Maastricht University Medical Center, Maastricht, The Netherlands
| | - Gaetano Lanza
- Vascular Surgery Department, IRCSS MultiMedica Hospital, Castellanza, Varese, Italy
| | | | - Ian M Loftus
- St. George's Vascular Institute, St. George's University London, London, UK
| | - Armando Mansilha
- Faculty of Medicine of the University of Porto, Porto, Portugal.,Department of Angiology and Vascular Surgery, Hospital de S. Joao, Porto, Portugal
| | - Antoine Millon
- Department of Vascular and Endovascular Surgery, Louis Pradel Hospital, Hospices Civils de Lyon, Lyon, France
| | - Andrew N Nicolaides
- Department of Surgery, University of Nicosia Medical School, Nicosia, Cyprus
| | - Rodolfo Pini
- Vascular Surgery, Policlinico S. Orsola Malpighi, University of Bologna Alma Mater Studiorum, Bologna, Italy
| | - Pavel Poredos
- Department of Vascular Disease, University Medical Centre Ljubljana, Ljubljana, Slovenia
| | - Jean-Baptiste Ricco
- Department of Clinical Research, University of Poitiers, CHU de Poitiers, Poitiers, France
| | - Thomas S Riles
- Department of Surgery, Division of Vascular Surgery, New York University Langone Medical Centre, New York, NY, USA
| | | | - Tatjana Rundek
- Department of Neurology, Miller School of Medicine, University of Miami, Miami, FL, USA
| | - Luca Saba
- Department of Radiology, Azienda Ospedaliera Universitaria di Cagliari, Cagliari, Italy
| | | | - Mauro Silvestrini
- Neurological Clinic, Department of Experimental and Clinical Medicine, Marche Polytechnic University, Ancona, Italy
| | - Francesco Spinelli
- Vascular Surgery Division, Campus Bio-Medico University of Rome, Rome, Italy
| | - Francesco Stilo
- Vascular Surgery Division, Campus Bio-Medico University of Rome, Rome, Italy
| | - Sherif Sultan
- Western Vascular Institute, Department of Vascular and Endovascular Surgery, University Hospital Galway, National University of Ireland, Galway, Ireland
| | - Jasjit S Suri
- Stroke Diagnosis and Monitoring Division, AtheroPointTM, Roseville, CA, USA
| | - Clark J Zeebregts
- Division of Vascular Surgery, Department of Surgery, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Seemant Chaturvedi
- Department of Neurology & Stroke Program, University of Maryland School of Medicine, Baltimore, MD, USA
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CT angiographic biomarkers help identify vulnerable carotid artery plaque. J Vasc Surg 2021; 75:1311-1322.e3. [PMID: 34793923 DOI: 10.1016/j.jvs.2021.10.056] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2021] [Accepted: 10/30/2021] [Indexed: 11/23/2022]
Abstract
OBJECTIVE Current risk assessment for patients with carotid atherosclerosis relies primarily on measuring the degree of stenosis. More reliable risk-stratification could improve patient selection for targeted treatment. We developed and validated a model to predict major adverse neurological events (MANE; stroke, transient ischemic attack, and amaurosis fugax) incorporating a combination of plaque morphology, patient demographics, and patient clinical information. METHODS We enrolled 221 patients with asymptomatic carotid stenosis of any severity who had CT angiography at baseline and at least 6 months later. Images were analyzed for carotid plaque morphology (plaque geometry and tissue composition). Data were partitioned (training and validation cohorts). 190 patients had complete records and were advanced to analysis. The training cohort was used to develop the best model for predicting MANE, incorporating patient and plaque features. First, single-variable correlation and unsupervised clustering were performed. Next, several multi-variable models were implemented for the response variable of MANE. The best model was selected by optimizing area under the receiver operating characteristic curve (AUC, ROC) and Kappa. The model was validated on the sequestered data to demonstrate generalizability. RESULTS Sixty-two patients suffered a MANE on follow-up. Unsupervised clustering of patient and plaque features identified single-variable predictors of MANE. Multi-variable predictive modeling showed that a combination of plaque features at baseline (matrix, intra-plaque hemorrhage (IPH), wall thickness, plaque burden) with clinical features (age, BMI, lipid levels) best predicted MANE (AUC 0.79), while percent diameter stenosis performed worst (AUC 0.55). The strongest single variable in discriminating between patients with and without events was IPH, and the most predictive model was produced when IPH was considered together with wall remodeling. The selected model also performed well on the validation dataset (AUC of 0.64) and maintained superiority over percent diameter stenosis (AUC of 0.49). CONCLUSIONS A composite of plaque geometry, plaque tissue composition, patient demographics, and clinical information predicts MANE better than the traditionally utilized degree of stenosis alone in carotid atherosclerosis. Implementing this predictive model in the clinical setting can help identify patients at high-risk for major adverse neurological events.
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Paraskevas KI, Mikhailidis DP, Antignani PL, Baradaran H, Bokkers RPH, Cambria RP, Dardik A, Davies AH, Eckstein HH, Faggioli G, E Fernandes JF, Fraedrich G, Geroulakos G, Gloviczki P, Golledge J, Gupta A, Jezovnik MK, Kakkos SK, Katsiki N, Knoflach M, Kooi ME, Lanza G, Liapis CD, Loftus IM, Mansilha A, Millon A, Nicolaides AN, Pini R, Poredos P, Ricco JB, Riles TS, Ringleb PA, Rundek T, Saba L, Schlachetzki F, Silvestrini M, Spinelli F, Stilo F, Sultan S, Suri JS, Zeebregts CJ, Chaturvedi S. Optimal Management of Asymptomatic Carotid Stenosis in 2021: The Jury is Still Out. An International, Multispecialty, Expert Review and Position Statement. J Stroke Cerebrovasc Dis 2021; 31:106182. [PMID: 34735900 DOI: 10.1016/j.jstrokecerebrovasdis.2021.106182] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2021] [Revised: 10/14/2021] [Accepted: 10/17/2021] [Indexed: 01/19/2023] Open
Abstract
OBJECTIVES The recommendations of international guidelines for the management of asymptomatic carotid stenosis (ACS) often vary considerably and extend from a conservative approach with risk factor modification and best medical treatment (BMT) alone, to a more aggressive approach with a carotid intervention plus BMT. The aim of the current multispecialty position statement is to reconcile the conflicting views on the topic. MATERIALS AND METHODS A literature review was performed with a focus on data from recent studies. RESULTS Several clinical and imaging high-risk features have been identified that are associated with an increased long-term ipsilateral ischemic stroke risk in patients with ACS. Such high-risk clinical/imaging features include intraplaque hemorrhage, impaired cerebrovascular reserve, carotid plaque echolucency/ulceration/ neovascularization, a lipid-rich necrotic core, a thin or ruptured fibrous cap, silent brain infarction, a contralateral transient ischemic attack/stroke episode, male patients < 75 years and microembolic signals on transcranial Doppler. There is growing evidence that 80-99% ACS indicate a higher stroke risk than 50-79% stenoses. CONCLUSIONS Although aggressive risk factor control and BMT should be implemented in all ACS patients, several high-risk features that may increase the risk of a future cerebrovascular event are now documented. Consequently, some guidelines recommend a prophylactic carotid intervention in high-risk patients to prevent future cerebrovascular events. Until the results of the much-anticipated randomized controlled trials emerge, the jury is still out regarding the optimal management of ACS patients.
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Affiliation(s)
- Kosmas I Paraskevas
- Department of Vascular Surgery, Central Clinic of Athens, 24, Alexander Papagou street, N. Iraklio, Athens 14122, Greece.
| | - Dimitri P Mikhailidis
- Department of Clinical Biochemistry, Royal Free Hospital Campus, University College London Medical School, University College London (UCL), London, UK
| | | | - Hediyeh Baradaran
- Department of Radiology, University of Utah, Salt Lake City, UT, United States
| | - Reinoud P H Bokkers
- Department of Radiology, Medical Imaging Center, University Medical Center Groningen, Groningen, the Netherland
| | - Richard P Cambria
- Division of Vascular and Endovascular Surgery, St. Elizabeth's Medical Center, Brighton, MA, United States
| | - Alan Dardik
- Division of Vascular and Endovascular Surgery, Yale University School of Medicine, New Haven, CT, United States
| | - Alun H Davies
- Section of Vascular Surgery, Imperial College and Imperial Healthcare NHS Trust, London, UK
| | - Hans-Henning Eckstein
- Department for Vascular and Endovascular Surgery, Klinikum rechts der Isar, Technical University of Munich, Munich, Germany
| | - Gianluca Faggioli
- Vascular Surgery, University of Bologna "Alma Mater Studiorum", Policlinico S. Orsola Malpighi, Bologna, Italy
| | | | - Gustav Fraedrich
- Department of Vascular Surgery, Medical University of Innsbruck, Innsbruck, Austria
| | - George Geroulakos
- Department of Vascular Surgery, Attikon University Hospital, National and Kapodistrian University of Athens, Athens, Greece
| | - Peter Gloviczki
- Division of Vascular and Endovascular Surgery, Mayo Clinic, Rochester, MN, United States
| | - Jonathan Golledge
- Queensland Research Center for Peripheral Vascular Disease, James Cook University, Townsville University Hospital, Townsville, Queensland, Australia
| | - Ajay Gupta
- Department of Radiology, Weill Cornell Medicine, New York, United States
| | - Mateja K Jezovnik
- Department of Advanced Cardiopulmonary Therapies and Transplantation, The University of Texas Health Science Center, Houston, TX, United States
| | - Stavros K Kakkos
- Department of Vascular Surgery, University of Patras Medical School, Patras, Greece
| | - Niki Katsiki
- First Department of Internal Medicine, AHEPA University Hospital, Thessaloniki, Greece
| | - Michael Knoflach
- Department of Neurology, Medical University of Innsbruck, Innsbruck, Austria
| | - M Eline Kooi
- CARIM School for Cardiovascular Diseases, Maastricht University, Maastricht, the Netherland; Department of Radiology and Nuclear Medicine, Maastricht University Medical Center, Maastricht, the Netherland
| | - Gaetano Lanza
- Vascular Surgery Department, IRCSS MultiMedica Hospital, Castellanza, Italy
| | | | - Ian M Loftus
- St. George's Vascular Institute, St. George's University of London, London, UK
| | - Armando Mansilha
- Faculty of Medicine of the University of Porto, Porto, Portugal; Department of Angiology and Vascular Surgery, Hospital de S. Joao, Porto, Portugal
| | - Antoine Millon
- Department of Vascular and Endovascular Surgery, Louis Pradel Hospital, Hospices Civils de Lyon, France
| | - Andrew N Nicolaides
- Department of Surgery, University of Nicosia Medical School, Nicosia, Cyprus
| | - Rodolfo Pini
- Vascular Surgery, University of Bologna "Alma Mater Studiorum", Policlinico S. Orsola Malpighi, Bologna, Italy
| | - Pavel Poredos
- Department of Vascular Disease, University Medical Center, Ljubljana, Slovenia
| | - Jean-Baptiste Ricco
- Department of Clinical Research, University of Poitiers, CHU de Poitiers, Poitiers, France
| | - Thomas S Riles
- Department of Surgery, Division of Vascular Surgery, New York University, Langone Medical Center, New York, United States
| | | | - Tatjana Rundek
- Department of Neurology, Miller School of Medicine, University of Miami, Miami, FL, United States
| | - Luca Saba
- Department of Radiology, Azienda Ospedaliera Universitaria Di Cagliari, Cagliari, Italy
| | | | - Mauro Silvestrini
- Neurological Clinic, Department of Experimental and Clinical Medicine, Marche Polytechnic University, Ancona, Italy
| | - Francesco Spinelli
- Vascular Surgery Division, Campus Bio-Medico University of Rome, Rome, Italy
| | - Francesco Stilo
- Vascular Surgery Division, Campus Bio-Medico University of Rome, Rome, Italy
| | - Sherif Sultan
- Department of Vascular and Endovascular Surgery, Western Vascular Institute, University Hospital Galway, National University of Ireland, Galway, Ireland
| | - Jasjit S Suri
- Stroke Diagnosis and Monitoring Division, AtheroPointTM, Roseville, United States
| | - Clark J Zeebregts
- Division of Vascular Surgery, Department of Surgery, University Medical Center Groningen, University of Groningen, Groningen, the Netherland
| | - Seemant Chaturvedi
- Department of Neurology and Stroke Program, University of Maryland School of Medicine, Baltimore, MD, United States
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Kleindorfer DO, Towfighi A, Chaturvedi S, Cockroft KM, Gutierrez J, Lombardi-Hill D, Kamel H, Kernan WN, Kittner SJ, Leira EC, Lennon O, Meschia JF, Nguyen TN, Pollak PM, Santangeli P, Sharrief AZ, Smith SC, Turan TN, Williams LS. 2021 Guideline for the Prevention of Stroke in Patients With Stroke and Transient Ischemic Attack: A Guideline From the American Heart Association/American Stroke Association. Stroke 2021; 52:e364-e467. [PMID: 34024117 DOI: 10.1161/str.0000000000000375] [Citation(s) in RCA: 1004] [Impact Index Per Article: 334.7] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
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15
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Voss S, Schechtl J, Nöbauer C, Bleiziffer S, Lange R. Patient eligibility for application of a two-filter cerebral embolic protection device during transcatheter aortic valve implantation: does one size fit all? Interact Cardiovasc Thorac Surg 2020; 30:605-612. [PMID: 31904829 DOI: 10.1093/icvts/ivz306] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2019] [Revised: 11/27/2019] [Accepted: 12/02/2019] [Indexed: 11/14/2022] Open
Abstract
OBJECTIVES This study sought to determine the percentage of patients potentially eligible for implantation of the Sentinel™ Cerebral Protection System (Sentinel-CPS) during transcatheter aortic valve implantation (TAVI) and to identify the reasons for treatment exclusion. METHODS We retrospectively performed an analysis of pre-TAVI multislice computed tomography (MSCT) aortograms and data review of all patients undergoing a TAVI procedure in 2017 (n = 317). MSCT evaluation included the assessment of aortic arch anatomy and the vascular dimensions of the brachiocephalic and left common carotid artery. Data analysis focused on comorbid conditions, precluding 6-Fr sheath radial access and filter deployment due to history of previous artery interventions. RESULTS MSCT and data analysis showed Sentinel-CPS compatibility in 61.5% of patients (n = 195). Sentinel-CPS would have been contraindicated in 38.5% (n = 122) due to one or more of the following: (i) measured diameters of the filter-landing zones <9 or >15 mm in the brachiocephalic artery and <6.5 or >10 mm in the left common carotid artery (n = 116; 88 with carotid dimensions too small); (ii) significant subclavian artery stenosis (n = 4) or an aberrant subclavian artery (n = 3) precluding Sentinel-CPS implantation and (iii) clinical characteristics including hypersensitivity to nickel-titanium (n = 1), radial artery occlusion (n = 1) or previous left common carotid artery interventions (n = 5). CONCLUSIONS MSCT and clinical data supported Sentinel-CPS compatibility in 61.5% of patients. The most common reason for treatment exclusion was inappropriate diameter within the target landing zone of the left carotid artery. Future device development should address this limitation.
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Affiliation(s)
- Stephanie Voss
- Department of Cardiovascular Surgery, German Heart Centre Munich, Technische Universität München, Munich, Germany.,Department of Cardiovascular Surgery, German Heart Centre Munich, Insure (Institute of Translational Cardiac Surgery), Technische Universität München, Munich, Germany
| | - Johanna Schechtl
- Department of Cardiovascular Surgery, German Heart Centre Munich, Technische Universität München, Munich, Germany.,Department of Cardiovascular Surgery, German Heart Centre Munich, Insure (Institute of Translational Cardiac Surgery), Technische Universität München, Munich, Germany
| | - Christian Nöbauer
- Department of Cardiovascular Surgery, German Heart Centre Munich, Technische Universität München, Munich, Germany.,Department of Cardiovascular Surgery, German Heart Centre Munich, Insure (Institute of Translational Cardiac Surgery), Technische Universität München, Munich, Germany
| | - Sabine Bleiziffer
- Clinic for Thoracic and Cardiovascular Surgery, Heart and Diabetes Centre North Rhine Westphalia, Bad Oeynhausen, Germany
| | - Rüdiger Lange
- Department of Cardiovascular Surgery, German Heart Centre Munich, Technische Universität München, Munich, Germany.,Department of Cardiovascular Surgery, German Heart Centre Munich, Insure (Institute of Translational Cardiac Surgery), Technische Universität München, Munich, Germany.,DZHK (German Centre for Cardiovascular Research), Partner Site Munich Heart Alliance, Munich, Germany
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16
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Cui CL, Dakour-Aridi H, Eldrup-Jorgensen J, Schermerhorn ML, Siracuse JJ, Malas MB. Effects of timing on in-hospital and one-year outcomes after transcarotid artery revascularization. J Vasc Surg 2020; 73:1649-1657.e1. [PMID: 33038481 DOI: 10.1016/j.jvs.2020.08.148] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2020] [Accepted: 08/27/2020] [Indexed: 11/28/2022]
Abstract
OBJECTIVE The current recommendations are to perform carotid endarterectomy within 2 weeks of symptoms for maximum long-term stroke prevention, although urgent carotid endarterectomy within 48 hours has been associated with increased perioperative stroke. With the development and rapid adoption of transcarotid artery revascularization (TCAR), we decided to study the effect of timing on the outcomes after TCAR. METHODS The Vascular Quality Initiative database was searched for symptomatic patients who had undergone TCAR from September 2016 to November 2019. These patients were stratified by the interval to TCAR after symptom onset: urgent, within 48 hours; early, 3 to 14 days; and late, >14 days. The primary outcome was the in-hospital rate of combined stroke and death (stroke/death), evaluated using logistic regression analysis. The secondary outcome was the 1-year rate of recurrent ipsilateral stroke and mortality, evaluated using Kaplan-Meier survival analysis. RESULTS A total of 2608 symptomatic patients who had undergone TCAR were included. The timing was urgent for 144 patients (5.52%), early for 928 patients (35.58%), and late for 1536 patients (58.90%). Patients undergoing urgent intervention had an increased risk of in-hospital stroke/death, which was driven primarily by an increased risk of stroke. No differences were seen for in-hospital death. On adjusted analysis, urgent intervention resulted in a threefold increased risk of stroke (odds ratio [OR], 2.8; 95% confidence interval [CI], 1.3-6.2; P = .01) and a threefold increased risk of stroke/death (OR, 2.9; 95% CI, 1.3-6.4; P = .01) compared with late intervention. Patients undergoing early intervention had comparable risks of stroke (OR, 1.3; 95% CI, 0.7-2.3; P = .40) and stroke/death (OR, 1.2; 95% CI, 0.7-2.1; P = .48) compared with late intervention. On subset analysis, the type of presenting symptoms was an effect modifier. Patients presenting with stroke and those presenting with transient ischemic attack or amaurosis fugax both had an increased risk of stroke/death when undergoing urgent compared with late TCAR (OR, 2.7; 95% CI, 1.1-6.6; P = .04; and OR, 4.1; 95% CI, 1.1-15.0; P = .03, respectively). However only patients presenting with transient ischemic attack or amaurosis fugax had experienced an increased risk of stroke with urgent compared with late TCAR (OR, 5.0; 95% CI, 1.4-17.5; P < .01). At 1 year of follow-up, no differences were seen in the incidence of recurrent ipsilateral stroke (urgent, 0.7%; early, 0.2%; late, 0.1%; P = .13) or postdischarge mortality (urgent, 0.7%; early, 1.6%; late, 1.8%; P = .71). CONCLUSIONS We found that TCAR had a reduced incidence of stroke when performed 48 hours after symptom onset. Urgent TCAR within 48 hours of the onset of stroke was associated with a threefold increased risk of in-hospital stroke/death, with no added benefit for ≤1 year after intervention. Further studies are needed on long-term outcomes of TCAR stratified by the timing of the procedure.
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Affiliation(s)
- Christina L Cui
- Division of Vascular and Endovascular Surgery, Department of Surgery, University of California, San Diego, La Jolla, Calif
| | - Hanaa Dakour-Aridi
- Division of Vascular and Endovascular Surgery, Department of Surgery, University of California, San Diego, La Jolla, Calif
| | - Jens Eldrup-Jorgensen
- Division of Vascular and Endovascular Therapy, Department of Surgery, Maine Medical Center, Portland, Me
| | - Marc L Schermerhorn
- Division of Vascular and Endovascular Surgery, Department of Surgery, Beth Israel Deaconess Medical Center, Boston, Mass
| | - Jeffrey J Siracuse
- Division of Vascular and Endovascular Surgery, Department of Surgery, Boston University, Boston Medical Center, Boston, Mass
| | - Mahmoud B Malas
- Division of Vascular and Endovascular Surgery, Department of Surgery, University of California, San Diego, La Jolla, Calif.
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17
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Sajja LR, Sarkar K, Mannam G, Kodali VKK, Padmanabhan C, Peter S, Mulay A, Sardar S, Beri P. One-year outcomes of off- and on-pump coronary artery bypass grafting: PROMOTE patency trial. Indian J Thorac Cardiovasc Surg 2020; 36:469-475. [PMID: 33061158 PMCID: PMC7525622 DOI: 10.1007/s12055-020-00940-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2019] [Revised: 02/10/2020] [Accepted: 02/12/2020] [Indexed: 11/30/2022] Open
Abstract
PURPOSE Earlier we reported 3-month graft patency and clinical outcomes of prospective randomized comparison of off-pump and on-pump multivessel coronary artery bypass surgery to evaluate outcomes and graft patency (PROMOTE patency) trial. We now report major adverse cardiac and cerebrovascular events (MACCE) at 1 year of patients who underwent coronary artery bypass grafting (CABG) using either off-pump technique or on-pump technique. METHODS The PROMOTE patency trial is a two-arm, prospective, randomized, multicentre trial, and enrolled 320 patients with multivessel coronary artery disease from March 2016 through March 2017 at 6 centres and were randomly assigned to undergo either off-pump CABG (OPCAB) (n = 158 patients) or on-pump CABG (n = 162 patients). The outcomes at 1 year were assessed. RESULTS One mortality (0.64%) occurred in off-pump group (at 30 days) and 4 (2.48%) in on-pump group (1 at 30 days, 2 at 3 months, and 1 at 1 year) (p = 0.37). There was no difference between off-pump and on-pump groups in the outcomes of nonfatal myocardial infarction (1 in off-pump and 2 in on-pump group, p = 1.00) and cerebrovascular accident (none in off-pump and 2 in on-pump group, p = 0.49). Repeat revascularization was done in one patient in each group (p = 1.00). CONCLUSION There was no significant difference in the incidence of MACCE between off-pump and on-pump CABG group at 1 year.
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Affiliation(s)
- Lokeswara Rao Sajja
- Division of Cardiothoracic Surgery, Star Hospitals, Road no. 10, Banjara Hills, Hyderabad, AP 500 034 India
- Division of Cardiothoracic Surgery, Sajja Heart Foundation, Srinagar Colony, Hyderabad, 500 073 India
| | - Kunal Sarkar
- Division of Cardiothoracic Surgery, Medica Superspeciality Hospital, 127-Mukundapur, EM Bypass, Kolkata, 700025 India
| | - Gopichand Mannam
- Division of Cardiothoracic Surgery, Star Hospitals, Road no. 10, Banjara Hills, Hyderabad, AP 500 034 India
| | - Venkata Krishna Kumar Kodali
- Division of Cardiothoracic Surgery, Krishna Institute of Medical Sciences, 1-8-31/1, Minister Road, Secunderabad, Telangana 500003 India
| | - Chandrasekar Padmanabhan
- Division of Cardiothoracic Surgery, G Kuppuswamy Naidu Memorial Hospital, Pappanaickenpalayam, Coimbatore, 641 037 India
| | - Sanjeeth Peter
- Division of Cardiothoracic Surgery, DDMM Heart Institute, Mission Road, Nadiad, Gujarat 387 002 India
| | - Anvay Mulay
- Division of Cardiothoracic Surgery, Fortis Hospital, Multi-Specialty Hospital Mulund West, Mumbai, 400 078 India
| | - Sandip Sardar
- Division of Cardiothoracic Surgery, Medica Superspeciality Hospital, 127-Mukundapur, EM Bypass, Kolkata, 700025 India
| | - Prashanthi Beri
- Division of Clinical Research, Sajja Heart Foundation, Srinagar Colony, Hyderabad, 500 073 India
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Lin SL, Yeh JL, Tsai PC, Chang TH, Huang WC, Lee ST, Wassler M, Geng YJ, Sulistyowati E. Inhibition of Neointima Hyperplasia, Inflammation, and Reactive Oxygen Species in Balloon-Injured Arteries by HVJ Envelope Vector-Mediated Delivery of Superoxide Dismutase Gene. Transl Stroke Res 2019; 10:413-427. [PMID: 30191468 PMCID: PMC6647364 DOI: 10.1007/s12975-018-0660-9] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2017] [Revised: 08/18/2018] [Accepted: 08/22/2018] [Indexed: 11/19/2022]
Abstract
Extracellular superoxide dismutase (EC-SOD) has been implicated in regulation of vascular function but its underlying molecular mechanism is largely unknown. These two-step experiments investigate whether hemagglutinating virus of Japan envelope (HVJ-E) vector-mediated EC-SOD gene delivery might protect against neointima formation, vascular inflammation, and reactive oxygen species (ROS) generation, and also explore cell growth signaling pathways. The first in-vitro experiment was performed to assess the transfection efficacy and safety of HVJ-E compared to lipofectamine®. Results revealed that HVJ-E has higher transfection efficiency and lower cytotoxicity than those of lipofectamine®. Another in-vivo study initially used balloon denudation to rat carotid artery, then delivered EC-SOD cDNA through the vector of HVJ-E. Arterial section with H&E staining from the animals 14 days after balloon injury showed a significant reduction of intima-to-media area ratio in EC-SOD transfected arteries when compared with control (empty vector-transfected arteries) (p < 0.05). Arterial tissue with EC-SOD gene delivery also exhibited lower levels of ROS, as assessed by fluorescent microphotography with dihydroethidium staining. Quantitative RT-PCR revealed that EC-SOD gene delivery significantly diminished mRNA expression of tumor necrosis factor (TNF)-α and interleukin (IL)-1β (p < 0.05 in all comparisons). An immunoblotting assay from vascular smooth muscle cell (VSMC) cultures showed that the EC-SOD transfected group attenuated the activation of MEK1/2, ERK1/2, and Akt signaling significantly. In conclusion, EC-SOD overexpression by HVJ-E vector inhibits neointima hyperplasia, inflammation, and ROS level triggered by balloon injury. The modulation of cell growth-signaling pathways by EC-SOD in VSMCs might play an important role in these inhibitory effects.
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Affiliation(s)
- Shoa-Lin Lin
- Intensive Care Unit, Yuan's General Hospital, 162, Cheng-Kung First Road, Lingya District, Kaohsiung, 80249, Taiwan.
- School of Medicine, National Yang-Ming University, Taipei, Taiwan.
| | - Jwu-Lai Yeh
- Department of Pharmacology and Graduate Institute of Medicine, College of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan
- Department of Medical Research, Kaohsiung Medical University Hospital, Kaohsiung, Taiwan
- Department of Marine Biotechnology and Resources, National Sun Yat-sen University, Kaohsiung, Taiwan
| | - Pei-Chia Tsai
- Intensive Care Unit, Kaohsiung Veterans General Hospital, Kaohsiung, Taiwan
| | - Tsung-Hsien Chang
- Department of Medical Education and Research, Kaohsiung Veterans General Hospital, Kaohsiung, Taiwan
- Department of Medical Laboratory Science and Biotechnology, Chung Hwa University of Medical Technology, Tainan, Taiwan
| | - Wei-Chun Huang
- School of Medicine, National Yang-Ming University, Taipei, Taiwan
- Intensive Care Unit, Kaohsiung Veterans General Hospital, Kaohsiung, Taiwan
| | - Song-Tay Lee
- Department of Biotechnology, Southern Taiwan University of Science and Technology, Tainan, Taiwan
| | - Michael Wassler
- Department of Cardiovascular Biology and Atherosclerosis, University of Texas at Houston, Houston, TX, USA
| | - Yong-Jian Geng
- Department of Cardiovascular Biology and Atherosclerosis, University of Texas at Houston, Houston, TX, USA
| | - Erna Sulistyowati
- Department of Pharmacology and Graduate Institute of Medicine, College of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan
- Faculty of Medicine, Islamic University of Malang, Malang, East Java, Indonesia
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Vinogradov RA, Pykhteev VS, Martirosova KI, Lashevich KA. [Perioperative complications prognosis in carotid endarterectomy]. Khirurgiia (Mosk) 2018:82-85. [PMID: 29376964 DOI: 10.17116/hirurgia2018182-85] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/07/2023]
Affiliation(s)
- R A Vinogradov
- Research Institute - Ochapovsky Regional Clinical Hospital # 1, Krasnodar, Russia; Kuban State Medical University of Healthcare Ministry of the Russian Federation, Krasnodar, Russia
| | - V S Pykhteev
- Kuban State Medical University of Healthcare Ministry of the Russian Federation, Krasnodar, Russia
| | - K I Martirosova
- Pirogov Russian National Research Medical University of Healthcare Ministry of the Russian Federation, Moscow, Russia
| | - K A Lashevich
- Kuban State Medical University of Healthcare Ministry of the Russian Federation, Krasnodar, Russia
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20
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Koizumi S, Yamaoka Y, Matsuo T, Kimura T, Inoue T. Changes in Blood Flow Velocity of the Middle Cerebral Artery After Carotid Endarterectomy: Daily Assessment with Transcranial Color-Coded Sonography. World Neurosurg 2017; 110:e710-e714. [PMID: 29180087 DOI: 10.1016/j.wneu.2017.11.090] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2017] [Revised: 11/15/2017] [Accepted: 11/17/2017] [Indexed: 11/26/2022]
Abstract
BACKGROUND Hyperperfusion syndrome (HPS) is a well-known complication of carotid endarterectomy (CEA) warranting repeatable inexpensive monitoring. Transcranial color-coded sonography (TCCS) may provide a potential modality for such monitoring, but little is known about TCCS trends after CEA. METHODS Between January 2016 and February 2017, we prospectively included patients with CEA at our institute in this study. TCCS was performed preoperatively and repeated daily from the operation day until postoperative day (POD) 7. Daily trends in mean flow velocity (MFV) at the M1 portion of the middle cerebral artery were compared between patients with and without HPS. RESULTS Among 35 patients with CEA, daily TCCS monitoring was performed in 18 patients (mean age ± SD, 72 ± 7 years; male/female, 17:1). Among these 18 patients, 3 had probable HPS. On POD 0, MFV of the 18 patients showed a 32% increase from the initial preoperative value (from 52.5 to 69.4 cm/s, P = 0.0013). This increased MFV lasted for several days and recovered gradually by POD 7. Patients with probable HPS demonstrated a trend to higher MFV than those without; however, the difference was below the significance level. CONCLUSIONS We used daily TCCS after CEA to depict cerebral blood flow changes after CEA in our cohort. This technique may be useful both for the detection and prevention of HPS.
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Affiliation(s)
- Satoshi Koizumi
- Department of Neurosurgery, NTT Medical Center Tokyo, Tokyo, Japan.
| | | | - Takeshi Matsuo
- Department of Neurosurgery, NTT Medical Center Tokyo, Tokyo, Japan
| | - Toshikazu Kimura
- Department of Neurosurgery, NTT Medical Center Tokyo, Tokyo, Japan
| | - Tomohiro Inoue
- Department of Neurosurgery, NTT Medical Center Tokyo, Tokyo, Japan
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Uncommon Etiology for Seizure: Cerebral Hyperperfusion Syndrome. Case Rep Neurol Med 2017; 2017:7965758. [PMID: 28573058 PMCID: PMC5442331 DOI: 10.1155/2017/7965758] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/01/2017] [Revised: 03/23/2017] [Accepted: 04/19/2017] [Indexed: 11/25/2022] Open
Abstract
Cerebral hyperperfusion syndrome (CHS) is a rare life-threatening complication of carotid endarterectomy (CEA) and carotid artery stenting (CAS) for carotid artery stenosis. The incidence varies between 0 and 3%, depending on the severity of the stenosis, perioperative hypertension, and contralateral carotid stenosis. This case report reports a 53-year-old female patient presenting with decreased alertness and multiple tonic-clonic seizures, in the background of bilateral CEA. She was found to have bilateral carotid stenosis. Her left CEA was performed three months prior and right CEA was four days prior to her current presentation with seizures. After bilateral CEA, the imaging showed extensive pathologic process involving primarily the subcortical white matter and overlying cortex, more on the right cerebral hemisphere. On follow-up six weeks later, she reported no recurrent seizures and imaging showed decrease in abnormal signal intensity of the grey and white matter. This was indicative of near complete resolution of hyperperfusion damage. CHS is a rare complication due to the loss of autoregulation of the cerebrovascular system and increased blood flow status after bilateral CEA. This case is reported because of a rare and unique presentation of seizures in the background of bilateral CEA.
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Finn C, Giambrone AE, Gialdini G, Delgado D, Baradaran H, Kamel H, Gupta A. The Association between Carotid Artery Atherosclerosis and Silent Brain Infarction: A Systematic Review and Meta-analysis. J Stroke Cerebrovasc Dis 2017; 26:1594-1601. [PMID: 28318958 DOI: 10.1016/j.jstrokecerebrovasdis.2017.02.028] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2016] [Revised: 02/03/2017] [Accepted: 02/20/2017] [Indexed: 10/19/2022] Open
Abstract
BACKGROUND Carotid atherosclerosis is responsible for ~20% of ischemic strokes, but it is unclear whether carotid disease is associated with the presence of downstream silent brain infarction (SBI). We performed a systematic review and meta-analysis to study the relationship between SBI and 2 separate manifestations of carotid atherosclerosis, carotid intima-media thickening (IMT) and luminal stenosis. METHODS Ovid MEDLINE, Ovid Embase, and the Cochrane Library Database were searched with an additional search of references and citing articles of target studies. Articles were included if they reported an association between carotid IMT or stenosis and magnetic resonance imaging-defined SBI, excluding SBIs found after carotid intervention. RESULTS We pooled 7 studies of carotid IMT reporting on 1469 subjects with SBI and 5102 subjects without SBI. Subjects with SBI had a larger mean IMT than subjects without SBI (pooled standardized mean difference, .37; 95% confidence interval [CI], .23-.51; P < .0001). We pooled 11 studies of carotid stenosis reporting on 12,347 subjects (2110 subjects with carotid stenosis and 10,237 subjects without carotid stenosis). We found a higher prevalence of SBI among subjects with carotid stenosis (30.4% versus 17.4%). Our pooled random-effects analysis showed a significant positive relationship between carotid stenosis and SBI (odds ratio, 2.78; 95% CI, 2.19-3.52; P < .0001). CONCLUSIONS Two forms of atherosclerotic disease, carotid IMT and stenosis, are both significantly associated with SBI. This review highlights a lack of consistent definitions for carotid disease measures and little evidence evaluating SBI prevalence downstream from carotid stenosis.
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Affiliation(s)
- Caitlin Finn
- Department of Radiology, Weill Cornell Medical College (WCMC), New York, New York
| | | | - Gino Gialdini
- Feil Family Brain and Mind Research Institute, WCMC, New York, New York
| | - Diana Delgado
- Samuel J. Wood Library and C.V. Starr Biomedical Information Center, WCMC, New York, New York
| | - Hediyeh Baradaran
- Department of Radiology, Weill Cornell Medical College (WCMC), New York, New York
| | - Hooman Kamel
- Feil Family Brain and Mind Research Institute, WCMC, New York, New York; Department of Neurology, WCMC, New York, New York
| | - Ajay Gupta
- Department of Radiology, Weill Cornell Medical College (WCMC), New York, New York; Feil Family Brain and Mind Research Institute, WCMC, New York, New York.
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Loftus IM, Paraskevas KI, Naylor AR. Urgent Carotid Endarterectomy Does Not Increase Risk and Will Prevent More Strokes. Angiology 2016; 68:469-471. [PMID: 27535948 DOI: 10.1177/0003319716664286] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Ian M Loftus
- 1 St George's Vascular Institute, St George's Healthcare NHS Trust, London, United Kingdom
| | - Kosmas I Paraskevas
- 2 Northern Vascular Centre, Freeman Hospital, Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle-upon-Tyne, United Kingdom
| | - A Ross Naylor
- 3 Division of Cardiovascular Sciences, Department of Vascular Surgery, Vascular Research Group, Leicester Royal Infirmary, Leicester, United Kingdom
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Attitudes of Canadian and U.S. Neurologists Regarding Carotid Endarterectomy for Asymptomatic Stenosis. Can J Neurol Sci 2016. [DOI: 10.1017/s0317167100052203] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
ABSTRACT:Background:The American Heart Association carotid endarterectomy (CE) guidelines endorse CE for asymptomatic carotid stenosis if the procedure can be performed with low morbidity. However, the Canadian Stroke Consortium has published a consensus against CE for asymptomatic stenosis. The views of practicing neurologists in the two countries on this subject are unclear.Methods:A survey was undertaken of 270 neurologists from either Florida or Indiana and 180 neurologists from either Ontario or Quebec.Results:The survey was returned by 36% of neurologists. Both Florida (65%) and Indiana neurologists (35%) were significantly more likely than Canadian neurologists (11%) to sometimes/often refer patients for surgery(p<0.001). Neurologists from Florida relied more on noninvasive methods of carotid stenosis assessment (36%) than Canadian neurologists (12%, p=0.003), who preferred angiography. Neurologists from Florida more often cited medicolegal concerns as a reason for referring patients for surgery (27%), compared to Canadian neurologists (3%, p=0.0001).Conclusions:Practices pertaining to carotid stenosis evaluation and management differ both regionally and by country. Canadian neurologists refer fewer asymptomatic patients for CE and rely more on angiography as a preoperative diagnostic tool. The potential of medicolegal liability is a greater force in clinical decision-making for certain U.S. neurologists, compared to their Canadian counterparts. These differences may partly explain the variations in CE utilization in the two countries.
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Abbott AL, Bladin CF, Levi CR, Chambers BR. What Should We Do with Asymptomatic Carotid Stenosis? Int J Stroke 2016; 2:27-39. [DOI: 10.1111/j.1747-4949.2007.00096.x] [Citation(s) in RCA: 77] [Impact Index Per Article: 9.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
The benefit of prophylactic carotid endarterectomy (CEA) for patients with asymptomatic severe carotid stenosis in the major randomised surgical studies was small, expensive and may now be absorbed by improvements in best practice medical intervention. Strategies to identify patients with high stroke risk are needed. If surgical intervention is to be considered the complication rates of individual surgeons should be available. Clinicians will differ in their interpretation of the same published data. Maintaining professional relationships with clinicians from different disciplines often involves compromise. As such, the management of a patient will, in part, depend on what kind of specialist the patient is referred to. The clinician's discussion with patients about this complex issue must be flexible to accommodate differing patient expectations. Ideally, patients prepared to undergo surgical procedures should be monitored in a trial setting or as part of an audited review process to increase our understanding of current practice outcomes.
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Affiliation(s)
- Anne L. Abbott
- National Stroke Research Institute, Austin Health, Melbourne, Vic. 3081, Australia
- The University of Melbourne, Melbourne, Vic., Australia
- Department of Neuroscience, Box Hill Hospital, Nelson Road, Box Hill, Melbourne Vic., 3128, Australia
- Neurology Department, Austin Health, Melbourne, Vic., Australia
| | - Christopher F. Bladin
- Department of Neuroscience, Box Hill Hospital, Nelson Road, Box Hill, Melbourne Vic., 3128, Australia
| | - Christopher R. Levi
- Department of Neuroscience, John Hunter Hospital, Lookout Road, Lambton Heights, Newcastle, NSW, 2035, Australia
| | - Brian R. Chambers
- National Stroke Research Institute, Austin Health, Melbourne, Vic. 3081, Australia
- The University of Melbourne, Melbourne, Vic., Australia
- Neurology Department, Austin Health, Melbourne, Vic., Australia
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27
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Paraskevas KI, Mikhailidis DP, Veith FJ. Critical Issues and Controversies in Carotid Artery Stenosis: False Knowledge Is More Dangerous Than Ignorance. Angiology 2016; 67:789-90. [PMID: 27245836 DOI: 10.1177/0003319716652533] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Kosmas I Paraskevas
- Northern Vascular Centre, Freeman Hospital, Newcastle-upon-Tyne, United Kingdom
| | - Dimitri P Mikhailidis
- Department of Clinical Biochemistry (Vascular Disease Prevention Clinics), Royal Free Hospital Campus, University College London Medical School, University College London (UCL), London, United Kingdom
| | - Frank J Veith
- Division of Vascular Surgery, New York University Langone Medical Center, Bronx, NY, USA The Cleveland Clinic, Cleveland, OH, USA
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Wayangankar S, Kapadia S, Bajzer C. Carotid Artery Stenting: 2016 and Beyond. CARDIOVASCULAR INNOVATIONS AND APPLICATIONS 2016. [DOI: 10.15212/cvia.2016.0015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
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Brenner T, Schmitt FC, Demirel S, Salgado E, Celi de la Torre JA, Göring M, Bruckner T, Böckler D, Weigand MA, Hofer S, Attigah N. The role of unfractionated heparin for the antiaggregatory effect of aspirin in patients undergoing carotid endarterectomy: Results of an observational clinical study. Vascular 2016; 25:19-27. [PMID: 26993144 DOI: 10.1177/1708538116638961] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
The aims of the present study were to examine the influence of a low-dose unfractionated heparin regime on platelet aggregation and to additionally assess the prevalence of primary aspirin resistance in patients undergoing carotid endarterectomy. Therefore, 50 patients undergoing carotid endarterectomy were enrolled. A bolus of 3000 IU unfractionated heparin was administered 2 min before carotid cross-clamping additionally to standard antiaggregatory therapy. Haemostaseological point of care testing was performed twice, prior to surgery and 10 min after unfractionated heparin administration by the use of aggregometric and viscoelastic point of care testing. Following unfractionated heparin administration, the activated partial thromboplastin time increased significantly and clotting time in viscoelastic INTEM test was shown to be significantly prolonged. In contrast, the antiaggregatory effect of aspirin was not diminished in aggregometric ASPI test. A low-dose unfractionated heparin regime during carotid endarterectomy was therefore considered to be safe, without diminishing the antiplatelet effect of aspirin. Moreover, aggregometric point of care testing was identified to be a suitable tool for the identification of patients with primary aspirin resistance ( n = 3).
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Affiliation(s)
- Thorsten Brenner
- 1 Department of Anesthesiology, Heidelberg University Hospital, Heidelberg, Germany
| | - Felix Cf Schmitt
- 1 Department of Anesthesiology, Heidelberg University Hospital, Heidelberg, Germany
| | - Serdar Demirel
- 2 Department of Vascular and Endovascular Surgery, Heidelberg University Hospital, Heidelberg, Germany
| | - Eduardo Salgado
- 1 Department of Anesthesiology, Heidelberg University Hospital, Heidelberg, Germany
| | | | - Martin Göring
- 1 Department of Anesthesiology, Heidelberg University Hospital, Heidelberg, Germany
| | - Thomas Bruckner
- 3 Institute of Medical Biometry and Informatics, University of Heidelberg, Heidelberg, Germany
| | - Dittmar Böckler
- 2 Department of Vascular and Endovascular Surgery, Heidelberg University Hospital, Heidelberg, Germany
| | - Markus A Weigand
- 1 Department of Anesthesiology, Heidelberg University Hospital, Heidelberg, Germany
| | - Stefan Hofer
- 1 Department of Anesthesiology, Heidelberg University Hospital, Heidelberg, Germany
| | - Nicolas Attigah
- 2 Department of Vascular and Endovascular Surgery, Heidelberg University Hospital, Heidelberg, Germany
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Davidovic L, Koncar I, Dragas M, Markovic M, Ilic N, Mutavdzic P, Banzic I, Ristanovic N. Female and Obese Patients Might Have Higher Risk from Surgical Repair of Asymptomatic Carotid Artery Stenosis. Ann Vasc Surg 2015; 29:1286-92. [DOI: 10.1016/j.avsg.2015.03.032] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2014] [Revised: 02/18/2015] [Accepted: 03/04/2015] [Indexed: 10/23/2022]
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Gefäßerkrankungen und -komplikationen im Rahmen von Herzoperationen. ZEITSCHRIFT FUR HERZ THORAX UND GEFASSCHIRURGIE 2015. [DOI: 10.1007/s00398-015-0006-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Jia H, Phipps M, Bravata D, Castro J, Li X, Ordin D, Myers J, Vogel WB, Williams L, Chumbler N. Inpatient Stroke Care Quality for Veterans: Are There Differences between Veterans Affairs Medical Centers in the Stroke Belt and other Areas? Int J Stroke 2015; 10:67-72. [DOI: 10.1111/j.1747-4949.2012.00861.x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2011] [Accepted: 02/09/2012] [Indexed: 11/30/2022]
Abstract
Background Stroke mortality has been found to be much higher among residents in the stroke belt region than in the rest of United States, but it is not known whether differences exist in the quality of stroke care provided in Department of Veterans Affairs medical centers in states inside and outside this region. Objective We compared mortality and inpatient stroke care quality between Veterans Affairs medical centers inside and outside the stroke belt region. Methods Study patients were veterans hospitalized for ischemic stroke at 129 Veterans Affairs medical centers. Inpatient stroke care quality was assessed by 14 quality indicators. Multivariable logistic regression models were fit to examine differences in quality between facilities inside and outside the stroke belt, adjusting for patient characteristics and Veterans Affairs medical centers clustering effect. Results Among the 3909 patients, 28·1% received inpatient ischemic stroke care in 28 stroke belt Veterans Affairs medical centers, and 71·9% obtained care in 101 non-stroke belt Veterans Affairs medical centers. Patients cared for in stroke belt Veterans Affairs medical centers were more likely to be younger, Black, married, have a higher stroke severity, and less likely to be ambulatory pre-stroke. We found no statistically significant differences in short- and long-term post-admission mortality and inpatient care quality indicators between the patients cared for in stroke belt and non-stroke belt Veterans Affairs medical centers after risk adjustment. Conclusions These data suggest that a stroke belt does not exist within the Veterans Affairs health care system in terms of either post-admission mortality or inpatient care quality.
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Affiliation(s)
- Huanguang Jia
- US Department of Veterans Affairs, North Florida/South Georgia Veterans Health System, Rehabilitation Outcomes Research Center, Gainesville, FL, USA
| | - Michael Phipps
- Yale University School of Medicine, Robert Wood Johnson Foundation Clinical Scholars Program and the Department of Neurology, New Haven, CT, USA
- VA Connecticut Healthcare System, West Haven, CT, USA
| | - Dawn Bravata
- Veterans Affairs (VA) Health Services Research and Development (HSR&D) Center of Excellence on Implementing Evidence-Based Practice (CIEBP), Indianapolis, IN, USA
- VA HSR&D Stroke Quality Enhancement Research Initiative (Stroke QUERI), Indianapolis, IN, USA
- Regenstrief Institute, Indianapolis, IN, USA
| | - Jaime Castro
- US Department of Veterans Affairs, North Florida/South Georgia Veterans Health System, Rehabilitation Outcomes Research Center, Gainesville, FL, USA
| | - Xinli Li
- VA National Surgery Office, Denver, CO, USA
| | - Diana Ordin
- Department of Veterans Affairs, Veterans Health Administration, Office of Analytics and Business Intelligence, Washington, DC, USA
| | - Jennifer Myers
- Veterans Affairs (VA) Health Services Research and Development (HSR&D) Center of Excellence on Implementing Evidence-Based Practice (CIEBP), Indianapolis, IN, USA
- VA HSR&D Stroke Quality Enhancement Research Initiative (Stroke QUERI), Indianapolis, IN, USA
| | - W. Bruce Vogel
- US Department of Veterans Affairs, North Florida/South Georgia Veterans Health System, Rehabilitation Outcomes Research Center, Gainesville, FL, USA
| | - Linda Williams
- Veterans Affairs (VA) Health Services Research and Development (HSR&D) Center of Excellence on Implementing Evidence-Based Practice (CIEBP), Indianapolis, IN, USA
- VA HSR&D Stroke Quality Enhancement Research Initiative (Stroke QUERI), Indianapolis, IN, USA
- Regenstrief Institute, Indianapolis, IN, USA
- Department of Neurology, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Neale Chumbler
- Veterans Affairs (VA) Health Services Research and Development (HSR&D) Center of Excellence on Implementing Evidence-Based Practice (CIEBP), Indianapolis, IN, USA
- VA HSR&D Stroke Quality Enhancement Research Initiative (Stroke QUERI), Indianapolis, IN, USA
- Regenstrief Institute, Indianapolis, IN, USA
- Department of Sociology, Indiana University School of Liberal Arts, Indiana University Purdue University Indianapolis, Indianapolis, IN, USA
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Yamada K, Kawasaki M, Yoshimura S, Sasaki Y, Nakahara S, Sato Y. Asymptomatic moderate carotid artery stenosis with intraplaque hemorrhage: onset of new ischemic stroke. J Neurointerv Surg 2014; 8:130-4. [DOI: 10.1136/neurintsurg-2014-011317] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2014] [Accepted: 11/24/2014] [Indexed: 01/16/2023]
Abstract
BackgroundThe degree of stenosis of carotid arteries is recognized as an important risk factor for ischemic stroke. However, high-grade stenosis does not always cause cerebrovascular events, whereas low- to moderate-grade stenosis may often cause strokes. It has been reported that there is an association between carotid intraplaque hemorrhage (IPH) and new brain ischemic events.Case presentationWe present three patients with asymptomatic moderate carotid artery stenosis and carotid IPH who underwent both neurological and MRI at baseline and after at least 1 year's follow-up. These patients were admitted to our hospital (after 15–35 months of follow-up) because of neurological deficits. Diffusion-weighted MRI of the brain showed ipsilateral new ischemic lesions due to carotid artery plaques. The patients were treated with carotid artery stenting and discharged uneventfully.ConclusionsWhether plaques with severe stenosis already had severe stenosis at the onset of events or plaques with moderate stenosis progressed owing to an acute change, such as growth of an IPH, remains unclear, because no carotid imaging was carried out just before the events. This is the first case report which presents neurological symptoms and MRI at both baseline and follow-up in patients with asymptomatic moderate carotid artery stenosis and carotid IPH.
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Abstract
Background:Since the validation of carotid endarterectomy (CEA) as an effective means of stroke prevention, there has been renewed interest in its best indications and methods, as well as in how it compares to carotid angioplasty and stenting (CAS). This review examines these topics, as well as the investigation of carotid stenosis and the role of auditing and reporting CEAresults.Investigation:Brain imaging with CTor MRI should be obtained in patients considered for CEA, in order to document infarction and rule out mass lesions. Carotid investigation begins with ultrasound and, if results agree with subsequent, good-quality MRAor CTangiography, treatment can be planned and catheter angiography avoided. An equally acceptable approach is to proceed directly from ultrasound to catheter angiography, which is still the gold-standard in carotid artery assessment.Indications:Appropriate patients for CEA are those symptomatic with transient ischemic attacks or nondisabling stroke due to 70-99% carotid stenosis; the maximum allowable stroke and death rate being 6%. Uncertain candidates for CEA are those with 50 - 69% symptomatic stenosis, and those with asymptomatic stenosis ≥ 60% but, if selected carefully on the basis of additional risk factors (related to both the carotid plaque and certain patient characteristics), some will benefit from surgery. Asymptomatic patients will only benefit if surgery can be provided with exceptionally low major complication rates (3% or less). Inappropriate patients are those with less than 50% symptomatic or 60% asymptomatic stenosis, and those with unstable medical or neurological conditions.Techniques:Carotid endarterectomy can be performed with either regional or general anaesthesia and, for the latter, there are a number of monitoring techniques available to assess cerebral perfusion during carotid cross-clamping. While monitoring cannot be considered mandatory and no single monitoring technique has emerged as being clearly superior, EEG is most commonly used. “Eversion” endarterectomy is a variation in surgical technique, and there is some evidence that more widely practiced patch closure may reduce the acute risk of operative stroke and the longer-term risk of recurrent stenosis.Carotid angioplasty and stenting:Experience with this endovascular and less invasive procedure grows, and its technology continues to evolve. Some experienced therapists have reported excellent results in case series and a number of randomized trials are now underway comparing CAS to CEA. However, at this time it is premature to incorporate CAS into routine practice replacing CEA.Auditing:It has been shown that auditing of CEA indications and results with regular feed-back to the operating surgeons can significantly improve the performance of this operation. Carotid endarterectomy auditing is recommended on both local and regional levels.
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Affiliation(s)
- J Max Findlay
- Division of Neurosurgery, Department of Surgery, University of Alberta, Edmonton, Alberta, Canada
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Tsivgoulis G, Krogias C, Georgiadis GS, Mikulik R, Safouris A, Meves SH, Voumvourakis K, Haršány M, Staffa R, Papageorgiou SG, Katsanos AH, Lazaris A, Mumme A, Lazarides M, Vasdekis SN. Safety of early endarterectomy in patients with symptomatic carotid artery stenosis: an international multicenter study. Eur J Neurol 2014; 21:1251-7, e75-6. [DOI: 10.1111/ene.12461] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2014] [Accepted: 04/07/2014] [Indexed: 10/25/2022]
Affiliation(s)
- G. Tsivgoulis
- Second Department of Neurology; ‘Attikon’ Hospital; University of Athens; School of Medicine; Athens Greece
- Department of Neurology; Democritus University of Thrace; School of Medicine; Alexandroupolis Greece
- International Clinical Research Center; St Anne's University Hospital in Brno; Brno Czech Republic
| | - C. Krogias
- Department of Neurology; St Josef Hospital; Ruhr University; Bochum Germany
| | - G. S. Georgiadis
- Department of Vascular Surgery; Democritus University of Thrace; School of Medicine; Alexandroupolis Greece
| | - R. Mikulik
- International Clinical Research Center; St Anne's University Hospital in Brno; Brno Czech Republic
- Department of Neurology; St Anne's University Hospital and Medical Faculty of Masaryk University; Brno Czech Republic
| | - A. Safouris
- Stroke Unit; Department of Neurology; Brugmann University Hospital; Brussels Belgium
| | - S. H. Meves
- Department of Neurology; St Josef Hospital; Ruhr University; Bochum Germany
| | - K. Voumvourakis
- Second Department of Neurology; ‘Attikon’ Hospital; University of Athens; School of Medicine; Athens Greece
| | - M. Haršány
- International Clinical Research Center; St Anne's University Hospital in Brno; Brno Czech Republic
- Department of Neurology; St Anne's University Hospital and Medical Faculty of Masaryk University; Brno Czech Republic
| | - R. Staffa
- 2nd Department of Surgery; St Anne's University Hospital, and Faculty of Medicine; Masaryk University; Brno Czech Republic
| | - S. G. Papageorgiou
- Second Department of Neurology; ‘Attikon’ Hospital; University of Athens; School of Medicine; Athens Greece
| | - A. H. Katsanos
- Department of Neurology; University of Ioannina; School of Medicine; Ioannina Greece
| | - A. Lazaris
- Vascular Unit; 3rd Surgical Department; ‘Attikon’ Hospital; University of Athens; School of Medicine; Athens Greece
| | - A. Mumme
- Department of Vascular Surgery; St Josef Hospital; Ruhr University; Bochum Germany
| | - M. Lazarides
- Department of Vascular Surgery; Democritus University of Thrace; School of Medicine; Alexandroupolis Greece
| | - S. N. Vasdekis
- Vascular Unit; 3rd Surgical Department; ‘Attikon’ Hospital; University of Athens; School of Medicine; Athens Greece
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Mendes GAC, Zabramski JM, Elhadi AM, Kalani MYS, Preul MC, Nakaji P, Spetzler RF. Carotid Endarterectomy. Neurosurgery 2014; 75:110-6; discussion 116. [DOI: 10.1227/neu.0000000000000356] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
Abstract
BACKGROUND:
Cranial nerve injury (CNI) is the most common neurological complication associated with carotid endarterectomy (CEA). Some authors postulate that the transverse skin incision leads to increased risk of CNI.
OBJECTIVE:
We compared the incidence of CNI associated with the transverse and longitudinal skin incisions in a high-volume cerebrovascular center.
METHODS:
We reviewed the charts of 226 consecutive patients who underwent CEAs between January 2007 and August 2009. Pre- and postoperative standardized neurological evaluations were performed by faculty neurologists and neurosurgeons.
RESULTS:
One hundred sixty nine of 226 (75%) CEAs were performed with the use of a transverse incision. The longitudinal incision was generally reserved for patients with a high-riding carotid bifurcation. Mean patient age was 69 years (range, 45–91 years); 62% were men; 59% of patients were symptomatic and had high-grade stenosis (70%-99%). CNI occurred in 8 cases (3.5%): 5 (3%) in transverse and 3 (5.3%) with longitudinal incisions (P = .42). There were 2 marginal mandibular nerve injuries, 1 (0.6%) transverse and 1 longitudinal; 5 recurrent laryngeal nerve injuries, 4 transverse and 1 longitudinal; and 1 case of hypoglossal nerve injury associated with longitudinal incision. One hematoma was associated with CNI. All injuries were transient. Fourteen wound hematomas required surgical evacuation.
CONCLUSION:
The transverse skin incision for CEAs is not associated with an increased risk of CNI (P =.42). In this study, the incidence of CNI associated with the transverse incision was 3% (n = 5) vs 5% (n = 3) for longitudinal incisions. All CNIs were temporary.
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Affiliation(s)
- George A. C. Mendes
- Division of Neurological Surgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona
| | - Joseph M. Zabramski
- Division of Neurological Surgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona
| | - Ali M. Elhadi
- Division of Neurological Surgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona
| | - M. Yashar S. Kalani
- Division of Neurological Surgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona
| | - Mark C. Preul
- Division of Neurological Surgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona
| | - Peter Nakaji
- Division of Neurological Surgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona
| | - Robert F. Spetzler
- Division of Neurological Surgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona
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Naylor AR. Interventions for carotid artery disease: time to confront some ‘inconvenient truths’. Expert Rev Cardiovasc Ther 2014; 5:1053-63. [DOI: 10.1586/14779072.5.6.1053] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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Lee JH, Suh BY. Risk factor analysis of new brain lesions associated with carotid endarterectmy. Ann Surg Treat Res 2014; 86:39-44. [PMID: 24761406 PMCID: PMC3994605 DOI: 10.4174/astr.2014.86.1.39] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2013] [Revised: 09/03/2013] [Accepted: 09/24/2013] [Indexed: 11/30/2022] Open
Abstract
PURPOSE Carotid endarterectomy (CEA) is the standard treatment for carotid artery stenosis. New brain ischemia is a major concern associated with CEA and diffusion weighted imaging (DWI) is a good imaging modality for detecting early ischemic brain lesions. We aimed to investigate the surgical complications and identify the potential risk factors for the incidence of new brain lesions (NBL) on DWI after CEA. METHODS From January 2006 to November 2011, 94 patients who had been studied by magnetic resonance imaging including DWI within 1 week after CEA were included in this study. Data were retrospectively investigated by review of vascular registry protocol. Seven clinical variables and three procedural variables were analyzed as risk factors for NBL after CEA. RESULTS The incidence of periprocedural NBL on DWI was 27.7%. There were no fatal complications, such as ipsilateral disabling stroke, myocardial infarction or mortality. A significantly higher incidence of NBL was found in ulcer positive patients as opposed to ulcer negative patients (P = 0.029). The incidence of NBL after operation was significantly higher in patients treated with conventional technique than with eversion technique (P = 0.042). CONCLUSION Our data shows CEA has acceptable periprocedural complication rates and the existence of ulcerative plaque and conventional technique of endarterectomy are high risk factors for NBL development after CEA.
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Affiliation(s)
- Jae Hoon Lee
- Division of Vascular Surgery, Department of Surgery, Yeungnam University College of Medicine, Daegu, Korea
| | - Bo Yang Suh
- Division of Vascular Surgery, Department of Surgery, Yeungnam University College of Medicine, Daegu, Korea
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Kim KH, Lee CH, Son YJ, Yang HJ, Chung YS, Lee SH. Post-carotid endarterectomy cerebral hyperperfusion syndrome : is it preventable by strict blood pressure control? J Korean Neurosurg Soc 2013; 54:159-63. [PMID: 24278642 PMCID: PMC3836920 DOI: 10.3340/jkns.2013.54.3.159] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2013] [Revised: 06/11/2013] [Accepted: 09/08/2013] [Indexed: 11/27/2022] Open
Abstract
Objective Cerebral hyperperfusion syndrome (CHS) is a serious complication after carotid endarterectomy (CEA). However, the prevalence of CHS has decreased as techniques have improved. This study evaluates the role of strict blood pressure (BP) control for the prevention of CHS. Methods All 18 patients who received CEA from February 2009 through November 2012 were retrospectively reviewed. All patients were routinely managed in an intensive care unit by a same protocol. The cerebral perfusion state was evaluated on the basis of the regional cerebral blood flow (rCBF) study by perfusion computed tomography (pCT) and mean velocity by transcranial doppler (TCD). BP was strictly controlled (<140/90 mm Hg) for 7 days. When either post-CEA hyperperfusion (>100% increase in the rCBF by pCT or in the mean velocity by TCD compared with preoperative values) or CHS was detected, BP was maintained below 120/80 mm Hg. Results TCD and pCT data on the patients were analyzed. Ipsilateral rCBF was significantly increased after CEA in the pCT (p=0.049). Post-CEA hyperperfusion was observed in 3 patients (18.7%) in the pCT and 2 patients (12.5%) in the TCD study. No patients developed clinical CHS for one month after CEA. Furthermore, no patients developed additional neurological deficits related to postoperative cerebrovascular complications. Conclusion Intensive care with strict BP control (<140/90 mm Hg) achieved a low prevalence of post-CEA hyperperfusion and prevented CHS. This study suggests that intensive care with strict BP control can prevent the prevalence of post-CEA CHS.
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Affiliation(s)
- Kyung Hyun Kim
- Department of Neurosurgery, Seoul National University Hospital, Seoul, Korea
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White CJ, Ramee SR, Collins TJ, Jenkins JS, Reilly JP, Patel RAG. Carotid artery stenting: patient, lesion, and procedural characteristics that increase procedural complications. Catheter Cardiovasc Interv 2013; 82:715-26. [PMID: 23630062 DOI: 10.1002/ccd.24984] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/25/2013] [Revised: 04/12/2013] [Accepted: 04/21/2013] [Indexed: 11/05/2022]
Abstract
From the earliest experiences with carotid artery stenting (CAS) presumptive high risk features have included thrombus-containing lesions, heavily calcified lesions, very tortuous vessels, and near occlusions. In addition patients have been routinely excluded from CAS trials if they have contra-indications to dual antiplatelet therapy (aspirin and thienopyridines), a history of bleeding complications and severe peripheral arterial disease (PAD) making femoral artery vascular access difficult. Variables that increase the risk of CAS complications can be attributed to patient characteristics, anatomic or lesion features, and procedural factors. Clinical features such as older age (≥80 years), decreased cerebral reserve (dementia, multiple prior strokes, or intracranial microangiopathy) and angiographic characteristics such as excessive tortuosity (more than two 90° bends within 5 cm of the target lesion) and heavy calcification (concentric calcification ≥ 3 mm in width) have been associated with increased CAS complications. Other high risk CAS features include those that prolong catheter or guide wire manipulation in the aortic arch, make crossing a carotid stenosis more difficult, decrease the likelihood of successful deployment or retrieval of an embolic protection device (EPD), or make stent delivery or placement more difficult. Procedure volume for the operator and the catheterization laboratory team are critical elements in reducing the risk of the procedure. In this article, we help CAS operators better understand procedure risk to allow more intelligent case selection, further improving the outcomes of this emerging procedure.
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Affiliation(s)
- Christopher J White
- Department of Cardiovascular Diseases, Ochsner Clinical School of the University of Queensland, John Ochsner Heart and Vascular Institute, Ochsner Clinic Foundation, New Orleans, Louisiana, 70121
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Tips, tricks, subtleties, and superiority of carotid artery surgery. World Neurosurg 2013; 83:758-61. [PMID: 23920286 DOI: 10.1016/j.wneu.2013.07.091] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2013] [Accepted: 07/27/2013] [Indexed: 11/21/2022]
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Radak D, Davidovic L, Tanaskovic S, Koncar I, Babic S, Kostic D, Ilijevski N. Surgical Treatment of Carotid Restenosis After Eversion Endarterectomy—Serbian Bicentric Prospective Study. Ann Vasc Surg 2012; 26:783-9. [DOI: 10.1016/j.avsg.2012.01.021] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2011] [Revised: 12/25/2011] [Accepted: 01/31/2012] [Indexed: 10/28/2022]
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Shankar JJS, Zhang J, dos Santos M, Lesiuk H, Mohan R, Lum C. Factors affecting long-term restenosis after carotid stenting for carotid atherosclerotic disease. Neuroradiology 2012; 54:1347-53. [DOI: 10.1007/s00234-012-1031-y] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2012] [Accepted: 03/14/2012] [Indexed: 10/28/2022]
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Abstract
Silent brain infarctions are frequently found by modern cerebral imaging. Up to 30% of persons without a clinical history of stroke were found to have silent brain infarction in epidemiological studies. "Silent" refers to ischemic brain lesions for which no matching clinical syndrome can be found based on history or clinical investigation. Age, education, and ethnic background have a strong impact on noticing and reporting stroke symptoms. The current clinical definition of stroke is insensitive for cognitive deficits which can also be caused by brain infarctions. The majority of silent brain infarctions are localized in the subcortical white matter of the brain; however, about 10% of silent brain infarctions are cortical. Silent brain infarctions are strongly associated with stroke risk factors and comorbidities that are known to cause clinically overt stroke. Silent brain infarctions are 5 to 10 times more frequent than clinically overt strokes. Silent brain infarctions as defined by DWI lesions on MRI imaging are a frequent finding during operative or interventional procedures and their monitoring may help improve the respective techniques in order to decrease the risk of periprocedural stroke.
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Van der Heyden J, Van Neerven D, Sonker U, Bal ET, Kelder JC, Plokker HW, Suttorp MJ. Carotid Artery Stenting and Cardiac Surgery in Symptomatic Patients. JACC Cardiovasc Interv 2011; 4:1190-6. [DOI: 10.1016/j.jcin.2011.07.012] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/13/2011] [Revised: 06/29/2011] [Accepted: 07/07/2011] [Indexed: 11/27/2022]
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Bijuklic K, Tübler T, Wandler A, Goossens H, Schofer J. Carotid artery stenting, what can be learned after more than 1,000 patients: a single centre single operator experience. EUROINTERVENTION 2011; 7:820-7. [DOI: 10.4244/eijv7i7a129] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
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Reprinted Article “Carotid Artery Disease and Stroke During Coronary Artery Bypass: A Critical Review of the Literature”. Eur J Vasc Endovasc Surg 2011; 42 Suppl 1:S73-83. [DOI: 10.1016/j.ejvs.2011.06.020] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/16/2002] [Indexed: 11/24/2022]
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Veselka J, Zimolová P, Špaček M, Hájek P, Malý M, Tomašov P, Martinkovičová L, Zemánek D. Comparison of carotid artery stenting in patients with single versus bilateral carotid artery disease and factors affecting midterm outcome. Ann Vasc Surg 2011; 25:796-804. [PMID: 21530157 DOI: 10.1016/j.avsg.2011.02.011] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2010] [Revised: 12/29/2010] [Accepted: 02/08/2011] [Indexed: 12/22/2022]
Abstract
BACKGROUND Carotid artery stenting (CAS) is the method of choice for carotid artery revascularization of patients at high risk for carotid endarterectomy. In this study, we compared the midterm results of CAS in patients with unilateral versus bilateral carotid artery disease. METHODS AND RESULTS This is a retrospective analysis of 1-year outcome of 273 consecutive patients in whom 342 CAS procedures were performed. The incidence of periprocedural transient ischemic attacks (TIAs) differed significantly (8% vs. 1%; p = 0.01) among patients with and without bilateral internal carotid disease, and a tendency to a lower occurrence of early adverse events (death, stroke, periprocedural TIA, periprocedural myocardial infarction) was subsequently shown (11% vs. 5%; p = 0.12). At 1-year follow-up, there was a high incidence of adverse events (death, stroke, periprocedural TIA, periprocedural myocardial infarction, restenosis) in patients with bilateral carotid artery disease (40% vs. 14%; p < 0.01), which was mainly driven by a higher incidence of death, periprocedural TIA, and restenosis (p ≤ 0.02 for all). According to multivariate analysis, the independent predictors of midterm adverse events were left ventricular dysfunction, male gender, bilateral carotid artery disease, renal insufficiency, cerebral symptoms within the last 6 months before the intervention, and low-density lipoprotein cholesterol level. CONCLUSIONS At midterm follow-up, patients with bilateral carotid artery disease treated by CAS have significantly more adverse events than those with unilateral disease.
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Affiliation(s)
- Josef Veselka
- Department of Cardiology, Cardiovascular Center, University Hospital Motol, 2nd Medical School, Charles University, Prague, Czech Republic.
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Naylor AR, Bown MJ. Stroke after Cardiac Surgery and its Association with Asymptomatic Carotid Disease: An Updated Systematic Review and Meta-analysis. Eur J Vasc Endovasc Surg 2011; 41:607-24. [PMID: 21396854 DOI: 10.1016/j.ejvs.2011.02.016] [Citation(s) in RCA: 96] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2011] [Accepted: 02/13/2011] [Indexed: 11/19/2022]
Affiliation(s)
- A R Naylor
- The Department of Vascular Surgery at Leicester Royal Infirmary, Leicester LE2 7LX, UK.
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Dorigo W, Pulli R, Nesi M, Alessi Innocenti A, Pratesi G, Inzitari D, Pratesi C. Urgent Carotid Endarterectomy in Patients with Recent/Crescendo Transient Ischaemic Attacks or Acute Stroke. Eur J Vasc Endovasc Surg 2011; 41:351-7. [PMID: 21196126 DOI: 10.1016/j.ejvs.2010.11.026] [Citation(s) in RCA: 33] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2010] [Accepted: 11/25/2010] [Indexed: 11/18/2022]
Affiliation(s)
- W Dorigo
- Department of Vascular Surgery, University of Florence, Florence, Italy.
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