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Penton A, Kelly R, Le L, Blecha M. Temporal Trends and Contemporary Regional Variation in Management of Patients Undergoing Carotid Endarterectomy. Vasc Endovascular Surg 2023; 57:869-877. [PMID: 37303024 DOI: 10.1177/15385744231183750] [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] [Indexed: 06/13/2023]
Abstract
INTRODUCTION The purpose of this study is to investigate regional variation and temporal trends in seven quality metrics amongst CEA patients: discharge on antiplatelet after CEA; discharge on statin after CEA; protamine administration during CEA; patch placement at conventional CEA site; continued statin usage at the time of most recent follow-up; continued antiplatelet usage at the time of most recent follow-up; and smoking cessation at the time of long term follow up. METHODS There are 19 de-identified regions within the VQI database in the United States. Patients were placed into one of three temporal eras based on the time of their CEA: 2003-2008; 2009-2015; and 2016-2022. We first investigated temporal trends across the seven quality metrics for all regions combined on a national basis. The percentage of patients in each time era with the presence/absence of each metric was identified. Chi-squared testing was performed to confirm statistical significance of the differences across eras. Next, analysis was performed within each region and within each time metric. We separated out the 2016-2022 patients within each region to serve as the status of each metric application in the most modern era. We then compared the frequency of metric non-adherence in each region utilizing Chi-squared testing. RESULTS There was statistically significant improvement in achievement of all seven metrics between the initial 2003-2008 era and the modern 2016-2022 era. The most marked change in practice pattern was noted for lack of protamine usage at surgery (decreased from 48.7% to 25.9%), discharge home postoperatively without statin (decreased from 50.6% to 15.3%), and lack of statin usage confirmed at time of most recent long term follow up (decreased from 24% to 8.9%). Significant regional variation exists across all metrics (P < .01 for all). Lack of patch placement at the time of conventional endarterectomy ranges from 1.9% to 17.8% across regions in the modern era. Lack of protamine utilization ranges from 10.8% to 49.7%. Lack of antiplatelet and statin at the time of discharge varies from 5.5% to 8.2% and 4.8% to 14.4% respectively. Adherence to the various measures at the time of most recent follow up are more tightly aligned across regions with ranges of: 5.3% to 7.5% for lack of antiplatelet usage; 6.6% to 11.7% lack of statin utilization; and 13.3 to 15.4% for persistent smoking. CONCLUSIONS Prior studies and societal initiatives on CEA documenting the beneficial effects of patch angioplasty, protamine use at surgery, smoking cessation, antiplatelet utilization and statin compliance have positively impacted adherence to these measures over time. In the modern 2016-2022 era the widest regional variation is noted in patch placement, protamine utilization and discharge medications allowing individual geographic areas to identify areas for potential improvement via internal VQI administrative feedback.
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Affiliation(s)
- Ashley Penton
- Division of Vascular Surgery and Endovascular Therapy, Loyola University Health System, Loyola University Chicago Stritch School of Medicine, Maywood, IL, USA
| | - Robert Kelly
- Division of Vascular Surgery and Endovascular Therapy, Loyola University Health System, Loyola University Chicago Stritch School of Medicine, Maywood, IL, USA
| | - Linda Le
- Department of Cardiovascular Surgery, Methodist DeBakey Heart & Vascular Center, Houston Methodist Hospital, Houston, TX, USA
| | - Matthew Blecha
- Division of Vascular Surgery and Endovascular Therapy, Loyola University Health System, Loyola University Chicago Stritch School of Medicine, Maywood, IL, USA
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Banks CA, Pearce BJ. Interventions in Carotid Artery Surgery: An Overview of Current Management and Future Implications. Surg Clin North Am 2023; 103:645-671. [PMID: 37455030 DOI: 10.1016/j.suc.2023.05.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/18/2023]
Abstract
Atherosclerotic carotid artery disease has been well studied over the last half-century by multiple randomized controlled trials attempting to elucidate the appropriate modality of therapy for this disease process. Surgical techniques have evolved from carotid artery endarterectomy and transfemoral carotid artery stenting to the development of hybrid techniques in transcarotid artery revascularization. In this article, the authors provide a review of the available literature regarding operative and medical management of carotid artery disease.
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Affiliation(s)
- Charles Adam Banks
- Division of Vascular Surgery and Endovascular Therapy, University of Alabama at Birmingham, 1808 7th Avenue South, Boshell Diabetes Building 652, Birmingham, AL 35294, USA
| | - Benjamin J Pearce
- Division of Vascular Surgery and Endovascular Therapy, University of Alabama at Birmingham, 1808 7th Avenue South, Boshell Diabetes Building 652, Birmingham, AL 35294, USA.
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Ratner M, Garg K, Chang H, Johnson W, Sadek M, Maldonado T, Cayne N, Siracuse J, Jacobowitz G, Rockman C. Young patients undergoing carotid endarterectomy have increased rates of recurrent disease and late neurological events. J Vasc Surg 2023; 78:123-130. [PMID: 36870458 DOI: 10.1016/j.jvs.2023.02.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2022] [Revised: 02/19/2023] [Accepted: 02/21/2023] [Indexed: 03/06/2023]
Abstract
OBJECTIVES There are few data regarding outcomes of patients with premature cerebrovascular disease (age ≤55 years) who undergo carotid endarterectomy (CEA). The objective of this study was to analyze the demographics, presentation, perioperative and later outcomes of younger patients undergoing CEA. METHODS The Society for Vascular Surgery Vascular Quality Initiative was queried for CEA cases between 2012 and 2022. Patients were stratified based on age of less than 55 or age greater than 55 years. Primary end points were periprocedural stroke, death, myocardial infarction, and composite outcomes. Secondary end points included restenosis (≥80%) or occlusion, late neurological events and reintervention. RESULTS Of 120,549 patients undergoing CEA, 7009 (5.5%) were 55 years old or younger (mean age, 51.3 years). Younger patients were more likely to be African American (7.7% vs 4.5%; P < .001), female (45.2% vs 38.9%; P < .001), and active smokers (57.3% vs 24.1%; P < .001). They were less likely than older patients to have hypertension (82.5% vs 89.7%; P < .001), coronary artery disease (25.0% vs 27.3%; P < .001), and congestive heart failure (7.8% vs 11.4%; P < .001). Younger patients were significantly less likely than older patients to be on aspirin, anticoagulation, statins, or beta-blockers, but were more likely to be taking P2Y12 inhibitors (37.2 vs 33.7%; P < .001). Younger patients were more likely to present with symptomatic disease (35.1% vs 27.6%; P < .001) and were more likely to undergo nonelective CEA (19.2% vs 12.8%; P < .001). Younger and older patients had similar rates of perioperative stroke/death (2% vs 2%; P = NS) and postoperative neurological events (1.9% vs 1.8%; P = NS). However, younger patients had lower rates of overall postoperative complications compared with their older counterparts (3.7% vs 4.7%; P < .001). Of these patients, 72.6% had recorded follow-up (mean, 13 months). During follow-up, younger patients were significantly more likely than older patients to experience a late failure, defined as significant restenosis (≥80%) or complete occlusion of the operated artery (2.4% vs 1.5%; P < .001) and were more likely to experience any neurological event (3.1% vs 2.3%; P < .001). Reintervention rates did not significantly differ between the two cohorts. After controlling for covariates using a logistic regression model, age 55 years or younger was independently associated with increased odds of late restenosis or occlusion (odds ratio, 1.591; 95% confidence interval, 1.221-2.073; P < .001) as well as late neurological events (odds ratio, 1.304; 95% confidence interval, 1.079-1.576; P = .006). CONCLUSIONS Young patients undergoing CEA are more likely to be African American, female, and active smokers. They are more likely to present symptomatically and undergo nonelective CEA. Although perioperative outcomes are similar, younger patients are more likely to experience carotid occlusion or restenosis as well as subsequent neurological events, during a relatively short follow-up period. These data suggest that younger CEA patients may require more diligent follow-up, as well as a continued aggressive approach to medical management of atherosclerosis to prevent future events related to the operated artery, given the particularly aggressive nature of premature atherosclerosis.
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Affiliation(s)
- Molly Ratner
- New York University Langone Medical Center, Department of Surgery, Division of Vascular Surgery, New York, NY
| | - Karan Garg
- New York University Langone Medical Center, Department of Surgery, Division of Vascular Surgery, New York, NY
| | - Heepeel Chang
- Westchester Medical Center, Department of Surgery, Division of Vascular Surgery, Valhalla, NY
| | - William Johnson
- New York University Langone Medical Center, Department of Surgery, Division of Vascular Surgery, New York, NY
| | - Mikel Sadek
- New York University Langone Medical Center, Department of Surgery, Division of Vascular Surgery, New York, NY
| | - Thomas Maldonado
- New York University Langone Medical Center, Department of Surgery, Division of Vascular Surgery, New York, NY
| | - Neal Cayne
- New York University Langone Medical Center, Department of Surgery, Division of Vascular Surgery, New York, NY
| | - Jeffrey Siracuse
- Boston Medical Center, Department of Surgery, Division of Vascular and Endovascular Surgery, Boston, MA
| | - Glenn Jacobowitz
- New York University Langone Medical Center, Department of Surgery, Division of Vascular Surgery, New York, NY
| | - Caron Rockman
- New York University Langone Medical Center, Department of Surgery, Division of Vascular Surgery, New York, NY.
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AbuRahma Z, Williams E, Lee A, AbuRahma A, Davis-Jordan M, Veith C, Dargy N, Dean S, Davis E. Long-term durability and clinical outcome of a prospective randomized trial comparing carotid endarterectomy with ACUSEAL polytetrafluoroethylene patching versus pericardial patching. J Vasc Surg 2023; 77:1694-1699.e2. [PMID: 36958535 DOI: 10.1016/j.jvs.2023.01.189] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2022] [Revised: 01/27/2023] [Accepted: 01/27/2023] [Indexed: 03/25/2023]
Abstract
BACKGROUND Several studies have shown the superiority of carotid endarterectomy (CEA) with patch closure over primary closure. However, no definite study has shown any significant differences in clinical outcome between various types of patches. Because more vascular surgeons have used pericardial patching recently, this study will analyze the late clinical outcome (≥10 years) of our previously reported prospective randomized trial comparing CEA with ACUSEAL (polytetrafluoroethylene) vs pericardial patching. METHODS A total of 200 CEAs were randomized (1:1) to either Vascu-Guard pericardial patching or ACUSEAL patching. All patients had immediate duplex ultrasound imaging, which was repeated at 6 months and annually thereafter. Kaplan-Meier analysis was used to estimate rates of freedom from stroke, stroke-free survival, and rates of freedom from ≥50% and ≥80% restenosis. RESULTS Overall demographic and clinical characteristics were somewhat similar with a mean follow-up of 80 months (range: 0-149 months). The rates of freedom from stroke were 97, 97, 97, 96, 93 for ACUSEAL vs 99, 98, 97, 97, 92 for pericardial patching (P = .1112) at 1, 2, 3, 5, and 10 years, respectively. Similarly, the rates of freedom from stroke/death were 94, 93, 90, 76, 50 for ACUSEAL vs 99, 96, 91, 78, 47 for pericardial patching (P = .8591). The rates of freedom from ≥50% restenosis were 98, 98, 96, 89, 79 for ACUSEAL vs 87, 83, 83, 81, 71 for pericardial patching (P = .0489). The rates of freedom from ≥80% restenosis were 99, 99, 99, 96, 85 for ACUSEAL vs 96, 96, 96, 93, 93 for pericardial patching (P = .9407). The overall survival rates were 95, 94, 91, 77, 51 for ACUSEAL vs 100, 98, 93, 79, 50 for pericardial patching (P = .9123). Other patch complications (eg, rupture, aneurysmal dilation, infection, etc) were similar. CONCLUSIONS Both CEA with ACUSEAL (polytetrafluoroethylene) and pericardial patching are durable and have similar clinical outcomes at 10 years except that ACUSEAL patching has significantly better rates of freedom from ≥50% restenosis.
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Affiliation(s)
- Zachary AbuRahma
- Department of Surgery, West Virginia University, Charleston, WV.
| | | | - Andrew Lee
- Department of Surgery, West Virginia University, Charleston, WV
| | - Ali AbuRahma
- Department of Surgery, West Virginia University, Charleston, WV
| | | | - Christina Veith
- Department of Surgery, West Virginia University, Charleston, WV
| | - Noah Dargy
- Department of Surgery, West Virginia University, Charleston, WV
| | - Scott Dean
- Research Department for CAMC Hospital, CAMC Health Education and Research Institute, Charleston, WV
| | - Elaine Davis
- Research Department for CAMC Hospital, CAMC Health Education and Research Institute, Charleston, WV
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Esposito A, Menna D, Baiano A, Benedetto P, DI Leo F, Trani A, Cappiello AP. Carotid endarterectomy with saphenous vein patch angioplasty: a single-center experience. Minerva Cardiol Angiol 2023; 71:120-125. [PMID: 34472771 DOI: 10.23736/s2724-5683.21.05685-4] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
BACKGROUND When performing a conventional CEA it is recommended the use of patch angioplasty (PA), since previous meta-analyses have shown PA to be superior to primary closure (PRC) in terms of stroke and restenosis rates. Different materials patches can be employed although none of them has been proved to be superior. Although autologous veins are potentially more resistant to immediate thrombosis as well as infection, cons may be represented by patch rupture and late dilatation. Aim of this study is to evaluate immediate and long-term results of CEA with saphenous vein patch angioplasty (SVPA) in a single-center experience. METHODS A retrospective study was performed analyzing all patients undergoing CEA with SVPA at our institution from January 2012 to March 2020. CEA was performed in symptomatic patients with 50-99% carotid stenosis degree or asymptomatic patients with 70-99% stenosis degree. Exclusion criteria were critical limb ischemia, varicose disease, unavailability of saphenous veins, vein diameter <3.5 mm. All CEAs were performed under general anesthesia with routine shunting. Primary endpoints were perioperative stroke, death, carotid thrombosis and hematoma requiring surgery rates. Secondary endpoints included the rate of recurrent stenosis >70%, patch aneurysm/rupture/infection at follow-up. RESULTS Overall, 488 interventions were performed on 461 patients. Most patients were male (77.8%) with a mean age of 71.2±8.3 years. Thirty-day mortality and stroke rates were 0.4% and 1.2% respectively. Carotid thrombosis occurred in five patients (1%). Five patients (1%) developed a surgical site hematoma requiring surgical drainage. At a mean follow-up of 34.4±25.8 months 12 restenoses (2.5%) were detected. Five-year freedom from restenosis rate was 96.7%. Restenosis at follow-up was more frequent in patients who had contralateral carotid stenosis (P=0.019). Two patients (0.4%) developed carotid patch aneurysmal degeneration at a mean follow-up of 78.7 months. No infection nor patch disruption were detected. CONCLUSIONS CEA with SVPA resulted safe and effective in terms of early and late results. The perioperative complications rates we recorded were quite similar to those reported by other larger reviews and meta-analyses.
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Affiliation(s)
- Andrea Esposito
- Division of Vascular Surgery, Cardiovascular Department, San Carlo Hospital, Potenza, Italy
| | - Danilo Menna
- Division of Vascular Surgery, Cardiovascular Department, San Carlo Hospital, Potenza, Italy -
| | - Angela Baiano
- Division of Vascular Surgery, Cardiovascular Department, San Carlo Hospital, Potenza, Italy
| | - Pietro Benedetto
- Division of Vascular Surgery, Cardiovascular Department, San Carlo Hospital, Potenza, Italy
| | - Ferdinando DI Leo
- Division of Vascular Surgery, Cardiovascular Department, San Carlo Hospital, Potenza, Italy
| | - Antonio Trani
- Division of Vascular Surgery, Cardiovascular Department, San Carlo Hospital, Potenza, Italy
| | - Antonino P Cappiello
- Division of Vascular Surgery, Cardiovascular Department, San Carlo Hospital, Potenza, Italy
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Blecha M, DeJong M, Nam J, Penton A. Modifiable risk factors for occurrence of ipsilateral ischemic events after carotid endarterectomy beyond perioperative period. J Vasc Surg 2023; 77:538-547.e2. [PMID: 36181995 DOI: 10.1016/j.jvs.2022.09.021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2022] [Revised: 09/07/2022] [Accepted: 09/19/2022] [Indexed: 01/25/2023]
Abstract
OBJECTIVE The purpose of this study was to quantify the effects of several modifiable variables on the occurrence of stroke after the initial perioperative period for patients who had undergone carotid endarterectomy (CEA). METHODS The primary outcome for the present study was the development of an ischemic stroke or transient ischemic attack (TIA) in the cerebral hemisphere ipsilateral to CEA after the initial hospitalization. All CEAs in the VQI between January 2003 and May 2022 were queried. We identified 171,816 CEAs in the database. The exclusion criteria for the study were the lack of follow-up data for >30 days, concomitant coronary artery bypass surgery, concomitant proximal or distal carotid intervention at CEA, other arterial interventions at CEA, and stroke or TIA during the initial hospital admission, leaving 126,290 patients for analysis. We used the χ2 test for statistical analysis of the outcome of ipsilateral ischemic stroke or TIA after the initial CEA hospital admission to determine the relevant variables. Age was evaluated as an ordinal variable using the Student t test. Variables with P ≤ .05 on univariable analysis were included in the multivariable Cox regression time-to-event analysis for the primary outcome. Kaplan-Meier curves were constructed of the most significant variables on Cox regression as a visual aid. RESULTS The following variables achieved significance on Cox regression for an association with development of ipsilateral hemispheric ischemic events after the index CEA hospital admission: lack of patch placement at CEA site (hazard ratio [HR], 18.24; P < .0001), lack of antiplatelet therapy at long-term follow-up (LTFU; HR, 9.75; P < .0001), lack of statin therapy at LTFU (HR, 3.18; P < .001), lack of statin therapy at hospital discharge (HR, 1.25; P = .015), anticoagulation at LTFU (HR, 1.53; P < .001), development of >70% recurrent stenosis (HR, 2.15; P < .001), and shunt use at surgery (HR, 1.20; P = .007). Patients with patch placement at surgery and patients with confirmed antiplatelet therapy at LTFU had had 99.8% and 99.6% freedom from an ischemic event ipsilateral to the side of the CEA at LTFU, respectively. This finding is in contrast to the 5.7% and 4.7% positivity for ischemic events for those without patch placement at surgery and those not receiving antiplatelet therapy at LTFU, respectively (P < .0001 for both). CONCLUSIONS Performance of patch angioplasty arterial closure was remarkably protective against ipsilateral cerebral ischemic events at LTFU after CEA. Discharging and maintaining patients with antiplatelet and statin medication after CEA significantly reduces the incidence of future ipsilateral ischemic events. Thus, a significant opportunity exists for enhanced outcomes with improved implementation of these measures.
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Affiliation(s)
- Matthew Blecha
- Division of Vascular Surgery and Endovascular Therapy, Loyola University Health System, Maywood, IL.
| | - Matthew DeJong
- Department of Surgery, Loyola University Medical Center, Maywood, IL
| | - Janice Nam
- Stritch School of Medicine, Loyola University Chicago, Maywood, IL
| | - Ashley Penton
- Department of Surgery, Loyola University Medical Center, Maywood, IL
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Suroto NS, Rantam FA, Al Fauzi A, Widiyanti P, Turchan A, Pangaribuan V. Selection criteria for patch angioplasty material in carotid endarterectomy. Surg Neurol Int 2022; 13:362. [PMID: 36128094 PMCID: PMC9479565 DOI: 10.25259/sni_470_2022] [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: 05/17/2022] [Accepted: 06/30/2022] [Indexed: 11/04/2022] Open
Abstract
Background:
Carotid endarterectomy (CEA) with patch angioplasty has been favored due to its lower reoccurrence of restenosis compared to primary CEA. There are multiple types of patch angioplasty material available. However, selection of patch material is based on uncertain criteria. The aim of this study is to determine the ideal criteria for selecting the best patch material for CEA.
Methods:
We conducted a comprehensive literature search for studies that describe the ideal criteria for selecting patch material for CEA. We compiled all of the criteria mentioned into one table and selecting the criteria which were most frequently mentioned with a simple scoring system.
Results:
A total of 65 studies out of 784 studies were assessed for its full-text eligibility. Thus, we found 23 studies that were eligible for analysis. There are 22 ideal criteria that were mentioned in the analyzed studies. We grouped these criteria into physical characteristics, safety, contribution to hemodynamic, contribution in tissue healing, economic aspect, and ability to prevent postsurgical complication. We proposed 10 ideal criteria for guiding vascular surgeon in selecting the best patch angioplasty material.
Conclusion:
To this day, no material has been discovered which meets all ten criteria. This study’s proposed ideal criteria serve as the foundation for the creation of the best patch angioplasty material.
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Affiliation(s)
- Nur Setiawan Suroto
- Doctoral Program of Medical Science, Faculty of Medicine, Universitas Airlangga,
- Department of Neurosurgery, Faculty of Medicine, Universitas Airlangga, / Dr. Soetomo General Academic Hospital, Surabaya, East Java, Indonesia,
| | - Fedik Abdul Rantam
- Stem Cell Research and Development Center, Universitas Airlangga,
- Department of Microbiology, Virology and Immunology Laboratory, Faculty of Veterinary Medicine, Universitas Airlangga,
| | - Asra Al Fauzi
- Department of Neurosurgery, Faculty of Medicine, Universitas Airlangga, / Dr. Soetomo General Academic Hospital, Surabaya, East Java, Indonesia,
| | - Prihartini Widiyanti
- Biomedical Engineering Study Program, Department of Physics, Faculty of Science and Technology, Universitas Airlangga, Surabaya 60115, Indonesia
| | - Agus Turchan
- Department of Neurosurgery, Faculty of Medicine, Universitas Airlangga, / Dr. Soetomo General Academic Hospital, Surabaya, East Java, Indonesia,
| | - Vega Pangaribuan
- Department of Neurosurgery, Faculty of Medicine, Universitas Airlangga, / Dr. Soetomo General Academic Hospital, Surabaya, East Java, Indonesia,
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Andereggen L, Amin-Hanjani S, Beck J, Luedi MM, Gralla J, Schubert GA, Tortora A, Andres RH, Arnold M, Raabe A, Reinert M. Prediction of Long-Term Restenosis After Carotid Endarterectomy Using Quantitative Magnetic Resonance Angiography. Front Neurol 2022; 13:862809. [PMID: 35847222 PMCID: PMC9279565 DOI: 10.3389/fneur.2022.862809] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2022] [Accepted: 05/23/2022] [Indexed: 11/28/2022] Open
Abstract
Background To detect restenosis after carotid endarterectomy (CEA), long-term monitoring is required. However, non-selective follow-up is controversial and can be limited by costs and logistical considerations. Objective To examine the value of immediate perioperative vessel flow measurements after CEA using quantitative magnetic resonance angiography (QMRA) to detect patients at risk of long-term restenosis. Methods A prospective cohort study with long-term sonographic follow-up after CEA for symptomatic internal carotid artery stenosis (ICAs) > 50%. In all patients, vessel flow has been assessed both pre- and postoperatively using QMRA within ±3 days of surgery. Data on QMRA assessment were analyzed to identify patients at risk of restenosis for up to 10 years. Results Restenosis was recorded in 4 of 24 patients (17%) at a median follow-up of 6.8 ± 2.6 years. None of them experienced an ischemic event. Perioperative flow differences were significantly greater in patients without long-term restenosis, both for the ipsilateral ICA (p < 0.001) and MCA (p = 0.03), compared to those with restenosis (p = 0.22 and p = 0.3, respectively). The ICA mean flow ratio (p = 0.05) tended to be more effective than the MCA ratio in predicting restenosis over the long term (p = 0.35). Conclusion Our preliminary findings suggest that QMRA-based mean flow increases after CEA may be predictive of restenosis over the long term. Perioperative QMRA assessment could become an operator-independent screening tool to identify a subgroup of patients at risk for restenosis, in whom long-term monitoring is advised.
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Affiliation(s)
- Lukas Andereggen
- Department of Neurosurgery, Kantonsspital Aarau, Aarau, Switzerland
- Faculty of Medicine, University of Bern, Bern, Switzerland
- *Correspondence: Lukas Andereggen ; orcid.org/0000-0003-1764-688X
| | - Sepideh Amin-Hanjani
- Department of Neurosurgery, The University of Illinois at Chicago, Chicago, IL, United States
| | - Jürgen Beck
- Departments of Neurosurgery, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
- Department of Neurosurgery, Medical Center, University of Freiburg, Freiburg, Germany
| | - Markus M. Luedi
- Department of Anaesthesiology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Jan Gralla
- Department of Neuroradiology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | | | - Angelo Tortora
- Department of Neurosurgery, Kantonsspital Aarau, Aarau, Switzerland
| | - Robert H. Andres
- Faculty of Medicine, University of Bern, Bern, Switzerland
- Departments of Neurosurgery, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Marcel Arnold
- Department of Neurology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Andreas Raabe
- Departments of Neurosurgery, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Michael Reinert
- Faculty of Medicine, University of Bern, Bern, Switzerland
- Clinic for Neurosurgery, Hirslanden Klinik St. Anna, Lucerne, Switzerland
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Moacdieh MP, Khan MA, Layman P, Elsayed N, Malas MB. Innovation in the open and endovascular treatment of carotid artery stenosis. Semin Vasc Surg 2021; 34:163-171. [PMID: 34911622 DOI: 10.1053/j.semvascsurg.2021.10.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2021] [Revised: 10/17/2021] [Accepted: 10/18/2021] [Indexed: 11/11/2022]
Affiliation(s)
- Munir P Moacdieh
- Division of Vascular and Endovascular Surgery, University of California San Diego, La Jolla, CA 92093
| | - Maryam A Khan
- Division of Vascular and Endovascular Surgery, University of California San Diego, La Jolla, CA 92093
| | - Peter Layman
- Division of Vascular and Endovascular Surgery, University of California San Diego, La Jolla, CA 92093
| | - Nadin Elsayed
- Division of Vascular and Endovascular Surgery, University of California San Diego, La Jolla, CA 92093
| | - Mahmoud B Malas
- Division of Vascular and Endovascular Surgery, University of California San Diego, La Jolla, CA 92093.
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Cheng SF, Richards T, Gregson J, Brown MM, de Borst GJ, Bonati LH. Long Term Restenosis Rate After Carotid Endarterectomy: Comparison of Three Surgical Techniques and Intra-Operative Shunt Use. Eur J Vasc Endovasc Surg 2021; 62:513-521. [PMID: 34452836 DOI: 10.1016/j.ejvs.2021.06.028] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2020] [Revised: 06/07/2021] [Accepted: 06/20/2021] [Indexed: 11/20/2022]
Abstract
OBJECTIVE Closure of the artery during carotid endarterectomy (CEA) can be done with or without a patch, or performed with the eversion technique, while the use of intra-operative shunts is optional. The influence of these techniques on subsequent restenosis is uncertain. Long term carotid restenosis rates and risk of future ipsilateral stroke with these techniques were compared. METHODS Patients who underwent CEA in the International Carotid Stenting Study were divided into patch angioplasty, primary closure, or eversion endarterectomy. Intra-operative shunt use was reported. Carotid duplex ultrasound was performed at each follow up. Primary outcomes were restenosis of ≥ 50% and ≥ 70%, and ipsilateral stroke after the procedure to the end of follow up. RESULTS In total, 790 CEA patients had restenosis data at one and five years. Altogether, 511 (64.7%) had patch angioplasty, 232 (29.4%) primary closure, and 47 (5.9%) eversion endarterectomy. The cumulative incidence of ≥ 50% restenosis at one year was 18.9%, 26.1%, and 17.7%, respectively, and at five years it was 25.9%, 37.2%, and 30.0%, respectively. There was no difference in risk between the eversion and patch angioplasty group (hazard ratio [HR] 0.90, 95% confidence interval [CI] 0.45 - 1.81; p = .77). Primary closure had a higher risk of restenosis than patch angioplasty (HR 1.45, 95% CI 1.06 - 1.98; p = .019). The cumulative incidence of ≥ 70% restenosis did not differ between primary closure and patch angioplasty (12.1% vs. 7.1%, HR 1.59, 95% CI 0.88 - 2.89; p = .12) or between patch angioplasty and eversion endarterectomy (4.7%, HR 0.45, 95% CI 0.06 - 3.35; p = .44). There was no effect of shunt use on the cumulative incidence of restenosis. Post-procedural ipsilateral stroke was not more common in either of the surgical techniques or shunt use. CONCLUSION Restenosis was more common after primary closure than conventionally with a patch closure. Shunt use had no effect on restenosis. Patch closure is the treatment of choice to avoid restenosis.
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Affiliation(s)
- Suk F Cheng
- Division of Surgery and Interventional Science, University College London, London, UK
| | - Toby Richards
- Faculty of Health and Medical Sciences, Surgery, University of Western Australia, Perth, Australia
| | - John Gregson
- Department of Medical Statistics, London School of Hygiene and Tropical Medicine, London, UK
| | - Martin M Brown
- Stroke Research Centre, Department of Brain Repair and Rehabilitation, UCL Queen Square Institute of Neurology, University College London, UK.
| | - Gert J de Borst
- Department of Vascular Surgery, University Medical Centre Utrecht, Utrecht, The Netherlands
| | - Leo H Bonati
- Department of Neurology and Stroke Centre, University Hospital Basel, University of Basel, Basel, Switzerland
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11
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Valle CED, Miyamotto M, Timi JRR. Experimental comparative assay of tensile resistance of greater saphenous vein from ankle and groin. J Vasc Bras 2021; 20:e20190117. [PMID: 34249114 PMCID: PMC8244984 DOI: 10.1590/1677-5449.190117] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2019] [Accepted: 10/31/2019] [Indexed: 11/26/2022] Open
Abstract
Background The great saphenous vein is used as patch material in several types of arterial reconstruction, including trauma and carotid and femoral endarterectomy. There have been reports of saphenous patch blowout, particularly of patches constructed with veins harvested from the ankle. There is a need for objective measurement of the resistance of saphenous vein tissues. Objectives To measure the tensile strength of the great saphenous vein harvested at the ankle and groin and analyze the correlation between diameter and tissue strength. Methods Venous samples were harvested during elective saphenous stripping in patients with symptomatic varicose veins. Only segments without reflux were included. Ten limbs from eight patients were studied, providing 20 samples in total. Venous segments were opened along their longitudinal axis and fitted to electronic traction assay equipment to obtain values for material maximum tension in kilograms-force per square centimeter (kgf/cm2; the maximum force resisted by the segment, divided by its cross-sectional area). Results The average maximum tension in the ankle saphenous vein group ranged from 74.02 to 190.10 kgf/cm2 and from 13.53 to 69.45 kgf/cm2 in the groin saphenous vein group (p < 0.0001). The Pearson coefficient for the correlation between vein diameter and maximum tension was -0.852 (moderate to strong inverse correlation). Conclusions Ankle saphenous vein tissue from female patients operated for varicose veins has significantly higher resistance than saphenous vein tissue from the groin and there is an inverse relation between vein diameter and resistance of tissue from the same population.
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Affiliation(s)
- Carlos Eduardo Del Valle
- Universidade Federal do Paraná - UFPR, Hospital de Clínicas, Unidade de Cardiologia e Pneumologia, Curitiba, PR, Brasil
| | - Marcio Miyamotto
- Pontifícia Universidade Católica do Paraná - PUC-PR, Curitiba, PR, Brasil.,Hospital Universitário Cajuru - HUC, Serviço de Cirurgia Vascular e Endovascular, Curitiba, PR, Brasil.,Instituto VESSEL de Aperfeiçoamento Endovascular, Curitiba, PR, Brasil.,Hospital Nossa Senhora das Graças - HNSG, Serviço de Cirurgia Vascular e Endovascular Elias Abrão, Curitiba, PR, Brasil
| | - Jorge Rufino Ribas Timi
- Universidade Federal do Paraná - UFPR, Hospital de Clínicas, Unidade de Cardiologia e Pneumologia, Curitiba, PR, Brasil.,Núcleo Integrado de Cirurgia Endovascular do Paraná - NICEP, Curitiba, PR, Brasil
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12
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AbuRahma AF, Avgerinos ED, Chang RW, Darling RC, Duncan AA, Forbes TL, Malas MB, Perler BA, Powell RJ, Rockman CB, Zhou W. The Society for Vascular Surgery implementation document for management of extracranial cerebrovascular disease. J Vasc Surg 2021; 75:26S-98S. [PMID: 34153349 DOI: 10.1016/j.jvs.2021.04.074] [Citation(s) in RCA: 58] [Impact Index Per Article: 19.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2021] [Accepted: 04/28/2021] [Indexed: 12/24/2022]
Affiliation(s)
- Ali F AbuRahma
- Department of Surgery, West Virginia University-Charleston Division, Charleston, WV.
| | - Efthymios D Avgerinos
- Division of Vascular Surgery, University of Pittsburgh School of Medicine, UPMC Hearrt & Vascular Institute, Pittsburgh, Pa
| | - Robert W Chang
- Vascular Surgery, Permanente Medical Group, San Francisco, Calif
| | | | - Audra A Duncan
- Division of Vascular & Endovascular Surgery, University of Western Ontario, London, Ontario, Canada
| | - Thomas L Forbes
- Division of Vascular & Endovascular Surgery, University of Western Ontario, London, Ontario, Canada
| | - Mahmoud B Malas
- Vascular & Endovascular Surgery, University of California San Diego, La Jolla, Calif
| | - Bruce Alan Perler
- Division of Vascular Surgery & Endovascular Therapy, Johns Hopkins, Baltimore, Md
| | | | - Caron B Rockman
- Division of Vascular Surgery, New York University Langone, New York, NY
| | - Wei Zhou
- Division of Vascular Surgery, University of Arizona, Tucson, Ariz
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13
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AbuRahma AF, Darling RC. Literature review of primary versus patching versus eversion as carotid endarterectomy closure. J Vasc Surg 2021; 74:666-675. [PMID: 33862187 DOI: 10.1016/j.jvs.2021.02.051] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2020] [Accepted: 02/19/2021] [Indexed: 11/25/2022]
Abstract
BACKGROUND Which type of closure after carotid endarterectomy (CEA), whether primary, patching, or eversion, will provide the optimal results has remained controversial. In the present study, we compared the results of randomized controlled trials (RCTs) and systematic meta-analyses of the various types of closure. METHODS We conducted a PubMed literature review search to find studies that had compared CEA with primary closure, CEA with patching, and/or eversion CEA (ECEA) during the previous three decades with an emphasis on RCTs, previously reported systematic meta-analyses, large multicenter observational studies (Vascular Quality Initiative data), and recent single-center large studies. RESULTS The results from RCTs comparing primary patching vs primary closure were as follows. Most of the randomized trials showed CEA with patching was superior to CEA with primary closure in lowering the perioperative stroke rates, stroke and death rates, carotid thrombosis rates, and late restenosis rates. These studies also showed no significant differences between the preferential use of several patch materials, including synthetic patches (polyethylene terephthalate [Dacron; DuPont, Wilmington, Del], Acuseal [Gore Medical, Flagstaff, Ariz], polytetrafluoroethylene, or pericardial patches) and vein patches (saphenous or jugular). The results from observational studies comparing patching vs primary closure were as follows. The Vascular Study Group of New England data showed that the use of patching increased from 71% to 91% (P < .001). Also, the 1-year restenosis and occlusion (P < .01) and 1-year stroke and transient ischemic attack (P < .03) rates were significantly lower statistically with patch closure. The results from the RCTs comparing ECEA vs conventional CEA (CCEA) were as follows. Several RCTs that had compared ECEA with CCEA showed equivalency of CCEA vs ECEA (level 1 evidence) with patching in the perioperative carotid thrombosis and stroke rates. At 4 years after treatment, the incidence of carotid stenosis was lower for ECEA than for primary closure (3.6% vs 9.2%; P = .01) but was comparable between patching and eversion (1.5% for patching vs 2.8% for eversion). CONCLUSIONS Routine carotid patching or ECEA was superior to primary closure (level 1 evidence). We found no significant differences between the preferential use of several patch materials. The rates of significant post-CEA stenosis for CEA with patching was similar to that with ECEA, and both were superior to primary closure.
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Affiliation(s)
- Ali F AbuRahma
- Department of Surgery, West Virginia University-Charleston Division, Charleston, WV.
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14
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Chen Y, Feng Y, Wang T, Zhang X, Zhang M, Bai X, Li L, Yang K, Ma Y, Zhang Z, Jiao L. In vivo endothelialization and neointimal hyperplasia assessment after rabbit carotid endarterectomy with bovine pericardium. ANNALS OF TRANSLATIONAL MEDICINE 2021; 9:471. [PMID: 33850868 PMCID: PMC8039648 DOI: 10.21037/atm-20-8103] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/05/2022]
Abstract
Background Previous studies have reported that the use of a patch in carotid endarterectomy (CEA) surgery can reduce the rate of restenosis and perioperative complications. The goal of this study was to compare the short- and medium-term outcomes of endothelialization and neointimal hyperplasia of patch closure (PC) angioplasty in CEA with direct closure (DC) in a rabbit model. A bovine pericardial patch (BPP) was used in the PC procedures. Methods Two carotid arteries were dried by air flow to simulate endarterectomy and selected for PC and DC in each rabbit. Different animals were sacrificed at 1, 2, 3, 4, and 8 weeks after the procedure. The endarterectomized segments were extracted and examined microscopically with histopathological and immunohistochemical analysis, and electron-microscopy measurements. Results In all, 19 rabbits were included in this study; 3 rabbits were placed in a 2-week postoperative group and 4 rabbits were placed in the 1-, 3-, 4-, and 8-week postoperative group respectively. Hematoxylin-eosin (HE) staining showed neointima on the PC side at an early stage (1-week postoperatively), and intimal hyperplasia could be seen on both sides. Immunohistochemical analysis showed that Ki-67 was higher on the PC side than on the DC side at an early stage (1,661.5±1,122.9 cells/mm2, P=0.060). In the 2-week postoperative group, von Willebrand factor (vWF) was higher on the DC side (−377.0±155.6 cells/mm2, P=0.052). Alpha-smooth muscle actin (α-SMA) values were comparable on both sides (P>0.05). Electron microscopy measurements showed that functional endothelial cells exhibited a cobblestone-like morphology and were nicely elongated in the direction of blood flow. Conclusions The use of BPP in PC angioplasty during CEA can maintain stability and also provide rapid endothelialization. PC with BPP has comparable ability of efficient endothelialization with DC, but is more likely to have early endothelialization.
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Affiliation(s)
- Yanfei Chen
- Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, Beijing, China.,China International Neuroscience Institute (China-INI), Beijing, China
| | - Yao Feng
- Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, Beijing, China.,China International Neuroscience Institute (China-INI), Beijing, China
| | - Tao Wang
- Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, Beijing, China.,China International Neuroscience Institute (China-INI), Beijing, China
| | - Xiao Zhang
- Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, Beijing, China.,China International Neuroscience Institute (China-INI), Beijing, China
| | - Meng Zhang
- Department of Pathology, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Xuesong Bai
- Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, Beijing, China.,China International Neuroscience Institute (China-INI), Beijing, China
| | - Long Li
- Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, Beijing, China.,China International Neuroscience Institute (China-INI), Beijing, China
| | - Kun Yang
- Department of Evidence-Based Medicine, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Yan Ma
- Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, Beijing, China.,China International Neuroscience Institute (China-INI), Beijing, China
| | - Zhiping Zhang
- Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, Beijing, China.,China International Neuroscience Institute (China-INI), Beijing, China
| | - Liqun Jiao
- Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, Beijing, China.,China International Neuroscience Institute (China-INI), Beijing, China.,Department of Interventional Neuroradiology, Xuanwu Hospital, Capital Medical University, Beijing, China
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15
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Liu D, Li ZL, Wang M, Wu RD, Wang JS, Wang SM, Yao C, Chang GQ. Comparative Analysis of Patch Angioplasty Versus Selective Primary Closure during Carotid Endarterectomy Performed at a Single Vascular Center in China. Ann Vasc Surg 2020; 73:344-350. [PMID: 33383139 DOI: 10.1016/j.avsg.2020.11.036] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2019] [Revised: 10/30/2019] [Accepted: 11/14/2020] [Indexed: 12/31/2022]
Abstract
BACKGROUND One of the ongoing debates about carotid endarterectomy (CEA) is the closure technique of arterial wall in the operation. Current guidelines recommend routine patch closure (PAC); this recommendation is based on the evidence reported 10-20 years ago. Therefore, the exact role of PAC and primary closure (PRC) remains uncertain. The objectives of this study were to compare the perioperative and long-term outcomes of patients who underwent CEA with different closure techniques. METHODS From January 2013 and December 2018, one senior vascular surgeon performed CEA for 126 patients in the First Affiliated Hospital, Sun Yat-sen University. The closure technique (PAC or PRC) was determined on the characteristics (diameter and level) of carotid arteries. Patient demographics and clinical data were retrospectively collected by two research fellows by reviewing the hospital medical records and relevant radiologic studies, as were carotid duplex reports, indications, intraoperative data, closure technique, and perioperative complications. Data of long-term outcomes were gathered by reviewing outpatient clinic visits and associated supplementary examinations. RESULTS PRC was performed in 78 operations (61.9%), and PAC was performed in 48 operations (38.1%). There were no statistical differences in demographic and clinical data between the two groups. Carotid clamp time (P < 0.001) and operating time (P < 0.001) were significantly longer when performing PAC (P < 0.001), and intraoperative blood loss was significantly more when performing PAC than that of PRC (P < 0.001). The postoperative outcome and the follow-up results showed that there was no significant difference in the short-term and middle-term overall survival rate and restenosis-free survival rate between the two groups. CONCLUSIONS There are no differences in postoperative and middle-term outcomes between PAC and selective PRC, whereas PRC technique can save operation time and shorten the intraoperative carotid clamp time. PRC can be safely applied in patients with a greater than 5 mm internal carotid artery (ICA).
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Affiliation(s)
- Duan Liu
- Division of Vascular Surgery, The First Affiliated Hospital of Sun Yat-sen University, Guangzhou, Guangdong, China
| | - Zi-Lun Li
- Division of Vascular Surgery, The First Affiliated Hospital of Sun Yat-sen University, Guangzhou, Guangdong, China
| | - Mian Wang
- Division of Vascular Surgery, The First Affiliated Hospital of Sun Yat-sen University, Guangzhou, Guangdong, China
| | - Ri-Dong Wu
- Division of Vascular Surgery, The First Affiliated Hospital of Sun Yat-sen University, Guangzhou, Guangdong, China
| | - Jin-Song Wang
- Division of Vascular Surgery, The First Affiliated Hospital of Sun Yat-sen University, Guangzhou, Guangdong, China
| | - Shen-Ming Wang
- Division of Vascular Surgery, The First Affiliated Hospital of Sun Yat-sen University, Guangzhou, Guangdong, China
| | - Chen Yao
- Division of Vascular Surgery, The First Affiliated Hospital of Sun Yat-sen University, Guangzhou, Guangdong, China
| | - Guang-Qi Chang
- Division of Vascular Surgery, The First Affiliated Hospital of Sun Yat-sen University, Guangzhou, Guangdong, China.
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16
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Zhou F, Hua Y, Ji X, Jia L. A systemic review into carotid plaque features as predictors of restenosis after carotid endarterectomy. J Vasc Surg 2020; 73:2179-2188.e4. [PMID: 33253876 DOI: 10.1016/j.jvs.2020.10.084] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2020] [Accepted: 10/29/2020] [Indexed: 10/22/2022]
Abstract
OBJECTIVE Restenosis after carotid endarterectomy (CEA) limits its long-term efficacy for stroke prevention. Thus, it is of utmost importance to identify the factors that predispose a patient to restenosis after CEA. This systemic review aims to survey the current literature regarding restenosis after CEA and discuss the predictive value of carotid plaque features. METHODS A systemic review of studies on the predictive value of carotid plaque features for restenosis after CEA was conducted according to the PRISMA guidelines. PubMed/MEDLINE and Embase databases were searched up to March 20, 2020. Two authors independently extracted the data and assessed the risk of bias with the Quality in Prognosis Studies tool. Given the heterogeneity in the measurement of prognostic factors, types of CEA, and clinical outcomes, a qualitative synthesis was performed. RESULTS Twenty-one articles with a sample size that ranged from 11 to 1203 were included in this systematic review. Based on the presence of calcification in original carotid plaques, two progression patterns of restenosis were hypothesized: patients with calcified plaques may experience a temporary increase in the intima-media thickness (IMT) followed by a decrease in IMT after CEA, whereas patients with noncalcified plaques may experience a gradual increase in IMT after CEA. Accordingly, patients with a high calcium score may have a high restenosis rate within 6 months after CEA and a low restenosis rate thereafter. Thus, the late restenosis rate in patients with uniformly echogenic plaques was lower than that in patients with uniformly echolucent plaques. Pathologically, a lipid-rich, inflammatory carotid plaque is associated with a decreased risk of restenosis within 1 year after CEA, mainly owing to the relatively mild reactive intimal hyperplasia at the surgical site and active inflammation in the remaining media and adventitia. Molecular predictors for restenosis included a Mannose-binding lectin 2 genotype, preoperative C-reactive protein, serum homocysteine, apolipoprotein J, vitamin C, and telomere length of carotid plaques. CONCLUSIONS This review demonstrated that carotid plaque features, including imaging features, cellular composition, and molecular features, are correlated with the risk of restenosis after CEA. A comprehensive evaluation of plaque characteristics may help to stratify the risk of restenosis after CEA.
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Affiliation(s)
- Fubo Zhou
- Department of Vascular Ultrasonography, Xuanwu Hospital, Capital Medical University, Beijing, China; Center of Vascular Ultrasonography, Beijing Institute of Brain Disorders, Beijing, China
| | - Yang Hua
- Department of Vascular Ultrasonography, Xuanwu Hospital, Capital Medical University, Beijing, China; Center of Vascular Ultrasonography, Beijing Institute of Brain Disorders, Beijing, China
| | - Xunming Ji
- Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, Beijing, China.
| | - Lingyun Jia
- Department of Vascular Ultrasonography, Xuanwu Hospital, Capital Medical University, Beijing, China; Center of Vascular Ultrasonography, Beijing Institute of Brain Disorders, Beijing, China
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17
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Kordzadeh A, Abbassi OA, Prionidis I, Shawish E. The Role of Carotid Stump Pressure in Carotid Endarterectomy: A Systematic Review and Meta-Analysis. Ann Vasc Dis 2020; 13:28-37. [PMID: 32273919 PMCID: PMC7140166 DOI: 10.3400/avd.ra.19-00100] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
This review evaluates the carotid stump pressure (CSP)’s role as a single parameter at any given pressure as an indicator for selective shunting, or vice versa, in carotid endarterectomy (CEA). A systematic review of literature in MEDLINE and the Cochrane Library from 1969 to 2019 was conducted. The primary end point was set at 0 to 30-day mortality, ischemic stroke (IS), transient ischemic attack (TIA), and a secondary point at recognition of an optimal CSP pressure. The data was subjected to meta-analytics. The odds ratio (OR) was reported at 95% confidence interval (CI). This study has been registered with PROSPERO: CRD42019119851. The pooled analysis on the primary endpoint of IS demonstrated higher incidence of stroke in shunted CEAs solely based on CSP measurement alone (OR, 0.14, 95%CI: 0.08–0.24, I2=48%, p<0.001). Sub group analysis demonstrated similar patterns at 25 mmHg (OR, 0.06, 95%CI: 0.01–0.5, p<0.01), 30 mmHg (OR, 0.07, 95%CI: 0.01–0.63, p=0.02) and 40 mmHg (OR, 0.23, 95%CI: 0.09–0.57, p<0.01). This effect on end points of mortality and TIA demonstrated no benefit in either direction. CSP, as a single criterion, is not a reliable parameter in reduction of TIA, mortality, and IS at any given pressure range.
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Affiliation(s)
- Ali Kordzadeh
- Mid Essex Hospitals Services NHS Trust, Department of Vascular, Endovascular and Renal Access Surgery, Broomfield Hospital
| | - Omar Ahmed Abbassi
- Mid Essex Hospitals Services NHS Trust, Department of Vascular, Endovascular and Renal Access Surgery, Broomfield Hospital
| | - Ioannis Prionidis
- Mid Essex Hospitals Services NHS Trust, Department of Vascular, Endovascular and Renal Access Surgery, Broomfield Hospital
| | - Emad Shawish
- Department of Vascular Surgery, Royal Shrewsbury and Telford Hospitals NHS Trust
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18
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Predictors of midterm high-grade restenosis after carotid revascularization in a multicenter national database. J Vasc Surg 2020; 71:1972-1981. [PMID: 32085958 DOI: 10.1016/j.jvs.2019.07.100] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2019] [Accepted: 07/25/2019] [Indexed: 11/20/2022]
Abstract
BACKGROUND Restenosis after carotid revascularization is clinically challenging. Several studies have looked into the management of recurrent restenosis; however, studies looking into factors associated with restenosis are limited. This study evaluated the predictors of restenosis after carotid artery stenting (CAS) and carotid endarterectomy (CEA) using a large national database. METHODS Patients undergoing CEA or CAS in the Vascular Quality Initiative data set (2003-2016) were analyzed. Patients with no follow-up (33%) and those who had prior ipsilateral CEA or CAS were excluded. Significant restenosis was defined as ≥70% diameter-reducing stenosis, target artery occlusion or peak systolic velocity ≥300 cm/s, or repeated revascularization. Kaplan-Meier survival analysis and bootstrapped Cox regression models with stepwise forward and backward selection were used. RESULTS A total of 35,720 procedures were included (CEA, 31,329; CAS, 4391). No significant difference in restenosis rates was seen between CEA and CAS at 2 years (7.7% vs 9.4% [P = .09]; hazard ratio [HR], 0.99; 95% confidence interval [CI], 0.79-1.25; P = .97). However, after adjustment for age, sex, and symptomatic status at the time of the index operation, CAS patients who had postoperative restenosis were more likely to have a symptomatic presentation (odds ratio, 2.2; 95% CI, 1.2-4.0; P = .01) and to undergo repeated revascularization at 2 years (HR, 1.75; 95% CI, 1.3-2.4; P < .001) compared with patients who had restenosis after CEA. Predictors of restenosis after CAS included a common carotid artery lesion (HR, 1.65; 95% CI,1.06-2.57; P = .03), whereas age (HR, 0.91; 95% CI, 0.84-0.99; P = .03) and dilation after stent placement (HR, 0.53; 95% CI, 0.39-0.72; P < .001) were associated with decreased restenosis at 2 years. Predictors of restenosis after CEA included female sex (HR, 1.55; 95% CI, 1.38-1.74; P < .001), prior neck irradiation (HR, 2.35; 95% CI, 1.66-3.30; P < .001), and prior bypass surgery (HR, 1.29; 95% CI, 1.01-1.65; P = .04). On the other hand, factors associated with decreased restenosis after CEA included age (HR, 0.95; 95% CI, 0.92-0.98; P < .001), black race (HR, 0.57; 95% CI, 0.37-0.89; P = .01), patching (HR, 0.61; 95% CI, 0.47-0.79; P < .001), and completion imaging (HR, 0.70; 95% CI, 0.52-0.95; P = .02). CONCLUSIONS Our results show no significant difference in restenosis rates at 2 years between CEA and CAS. Restenosis after CAS is more likely to be manifested with symptoms and to undergo repeated revascularization compared with that after CEA. Poststent ballooning after CAS and completion imaging and patching after CEA are associated with decreased hazard of restenosis; however, further research is needed to assess longer term outcomes and to balance the risks vs benefits of certain practices, such as poststent ballooning.
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19
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Dakour-Aridi H, Ou M, Locham S, AbuRahma A, Schneider JR, Malas M. Outcomes following Eversion versus Conventional Endarterectomy in the Vascular Quality Initiative Database. Ann Vasc Surg 2019; 65:1-9. [PMID: 31626932 DOI: 10.1016/j.avsg.2019.07.021] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2019] [Revised: 07/04/2019] [Accepted: 07/14/2019] [Indexed: 11/28/2022]
Abstract
BACKGROUND Although the majority of vascular surgeons perform conventional carotid endarterectomy (c-CEA), others prefer eversion CEA (e-CEA). Despite several randomized controlled trials and single center studies, the advantage of one technique over the other is still not clearly defined. The purpose of this study is to compare the postoperative outcomes and durability of c-CEA versus e-CEA in a nationally representative cohort. METHODS We performed a retrospective review of the Vascular Quality Initiative database between 2003 and 2018. Patients with prior ipsilateral carotid intervention (CEA and carotid artery stenting) and those undergoing concomitant procedures were excluded. Multivariable logistic and Cox-regression analyses were used to compare risk-adjusted perioperative and 1-year outcomes (stroke, death, and high-grade restenosis [>70%]) between c-CEA (using direct closure or patch angioplasty) and e-CEA. RESULTS A total of 95,726 CEA cases were included, of which 12,050 (12.6%) were e-CEA and the remaining (87.4%) were c-CEA. Patch angioplasty was used in 94.9% of c-CEA compared with 49.7% of e-CEA (P < 0.001). On univariable analysis, no difference in perioperative outcomes was noted between the 2 approaches except for higher rates of in-hospital dysrhythmia (1.5% vs. 1.3%) and postprocedural hemodynamic instability (27.3% vs. 24.3%) after c-CEA compared with e-CEA (all P < 0.05). On the other hand, e-CEA patients were more likely to return to the operating room for bleeding (1.3% vs. c-CEA: 0.9%, P < 0.001). The outcomes of e-CEA did not differ if the common carotid artery was closed primarily or with a patch. After adjusting for potential confounders and stratifying with respect to patch use, there was no significant difference in outcomes between e-CEA and c-CEA when a patch is used in both procedures. However, when no patching was performed, e-CEA was associated with lower stroke/death at 30 days (odds ratio 0.72, 95% confidence interval [CI] 0.54-0.95, P = 0.02) and at 1 year (hazard ratio 0.75, 95% CI 0.58-0.97, P = 0.03). CONCLUSIONS Both e-CEA and c-CEA are safe and durable techniques with similar stroke/death and restenosis rates up to 1-year of follow up, as long as c-CEA is performed with patch angioplasty. However, e-CEA is superior to c-CEA without patch angioplasty and is associated with 28% and 25% reduction in 30-day and 1-year stroke/death, respectively.
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Affiliation(s)
| | - Michael Ou
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD
| | | | - Ali AbuRahma
- Department of Surgery, West Virginia University, Charleston, WV
| | - Joseph R Schneider
- Department of Surgery, Northwestern University Feinberg School of Medicine, Chicago, IL
| | - Mahmoud Malas
- Department of Surgery, University of California San Diego, La Jolla, CA.
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Batchelder AJ, Saratzis A, Ross Naylor A. Editor's Choice - Overview of Primary and Secondary Analyses From 20 Randomised Controlled Trials Comparing Carotid Artery Stenting With Carotid Endarterectomy. Eur J Vasc Endovasc Surg 2019; 58:479-493. [PMID: 31492510 DOI: 10.1016/j.ejvs.2019.06.003] [Citation(s) in RCA: 46] [Impact Index Per Article: 9.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2018] [Revised: 05/30/2019] [Accepted: 06/05/2019] [Indexed: 12/19/2022]
Abstract
OBJECTIVES The aim of this review was to carry out primary and secondary analyses of 20 randomised controlled trials (RCTs) comparing carotid endarterectomy (CEA) with carotid artery stenting (CAS). METHODS A systematic review and meta-analysis of data from 20 RCTs (126 publications) was carried out. RESULTS Compared with CEA, the 30 day death/stroke rate was significantly higher after CAS in seven RCTs involving 3467 asymptomatic patients (odds ratio [OR] 1.64, 95% confidence interval [CI] 1.02-2.64) and in 10 RCTs involving 5797 symptomatic patients (OR 1.71, 95% CI 1.38-2.11). Excluding procedural risks, late ipsilateral stroke was about 4% at 9 years for both CEA and CAS, i.e., CAS was durable. Reducing procedural death/stroke after CAS may be achieved through better case selection, e.g., performing CEA in (i) symptomatic patients aged > 70 years; (ii) interventions within 14 days of symptom onset; and (iii) situations where stroke risk after CAS is predicted to be higher (segmental/remote plaques, plaque length > 13 mm, heavy burden of white matter lesions [WMLs], where two or more stents might be needed). New WMLs were significantly more common after CAS (52% vs. 17%) and were associated with higher rates of late stroke/transient ischaemic attack (23% vs. 9%), but there was no evidence that new WMLs predisposed towards late cognitive impairment. Restenoses were more common after CAS (10%) but did not increase late ipsilateral stroke. Restenoses (70%-99%) after CEA were associated with a small but significant increase in late ipsilateral stroke (OR 3.87, 95% CI 1.96-7.67; p < .001). CONCLUSIONS CAS confers higher rates of 30 day death/stroke than CEA. After 30 days, ipsilateral stroke is virtually identical for CEA and CAS. Key issues to be resolved include the following: (i) Will newer stent technologies and improved cerebral protection allow CAS to be performed < 14 days after symptom onset with risks similar to CEA? (ii) What is the optimal volume of CAS procedures to maintain competency? (iii) How to deliver better risk factor control and best medical treatment? (iv) Is there a role for CEA/CAS in preventing/reversing cognitive impairment?
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Affiliation(s)
| | | | - A Ross Naylor
- The Leicester Vascular Institute, Glenfield Hospital, Leicester, UK.
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21
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Okazaki T, Kanematsu Y, Shimada K, Korai M, Satomi J, Uno M, Nagahiro S, Takagi Y. A Single-center Retrospective Study with 5- and 10-year Follow-up of Carotid Endarterectomy with Patch Graft. Neurol Med Chir (Tokyo) 2019; 59:231-237. [PMID: 31061257 PMCID: PMC6580045 DOI: 10.2176/nmc.oa.2018-0309] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Abstract
Carotid endarterectomy (CEA) is widely used for cervical artery stenosis. In Japan, primary closure after endarterectomy has been a standard technique. Recently, the patch closure has been shown to be superior to the primary suture for the prevention of restenosis and ipsilateral stroke. This study evaluated the 5- and 10-year outcomes following CEA with patch graft closure in our institution. Between January 2000 and March 2013, 134 patients, who underwent CEA with patch graft closure were investigated in the current retrospective study. Among these patients, 102 CEAs in 97 patients were followed up for 5 years and 66 CEAs in 61 patients were for 10 years after the procedure. Restenosis was defined as >50% recurrent luminal narrowing at the endarterectomy site. In 5 years, symptomatic restenosis exhibited minor stroke in one patient at 58 months after CEA (restenosis rate 1.0%). The ipsilateral minor stroke occurred in three patients including the above case (2.9%). In 10 years, asymptomatic restenosis occurred in three patients in addition to the above symptomatic case (restenosis rate 6.1%), and the ipsilateral minor stroke occurred in four patients (6.1%). Carotid endarterectomy with patch graft exerted a high protective effect from restenosis up to 5 and 10 years in our institution. The number of carotid artery stenting is increasing all over the world but we speculated that the established surgical procedure of patched CEA prevented restenosis and ipsilateral stroke.
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Affiliation(s)
| | | | | | | | | | - Masaaki Uno
- Department of Neurosurgery, Kawasaki medical school
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22
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Elmallah AS, McGreal GT. Outcome of conventional and modified eversion carotid endarterectomy techniques in symptomatic and asymptomatic patients with significant carotid artery stenosis. Chirurgia (Bucur) 2019. [DOI: 10.23736/s0394-9508.18.04775-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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23
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Texakalidis P, Tzoumas A, Giannopoulos S, Jonnalagadda AK, Jabbour P, Rangel-Castilla L, Machinis T, Rivet DJ, Reavey-Cantwell J. Risk Factors for Restenosis After Carotid Revascularization: A Meta-Analysis of Hazard Ratios. World Neurosurg 2019; 125:414-424. [PMID: 30822589 DOI: 10.1016/j.wneu.2019.02.065] [Citation(s) in RCA: 33] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/26/2018] [Revised: 02/04/2019] [Accepted: 02/06/2019] [Indexed: 11/15/2022]
Abstract
BACKGROUND Carotid artery restenosis after carotid endarterectomy (CEA) or carotid artery stenting (CAS) will occur in 3%-30% of cases. Restenosis can lead to more frequent clinical and imaging monitoring and the potential for reoperation. We sought to define the demographic, clinical, and radiographic characteristics that influence the restenosis risk after carotid revascularization. METHODS The present study was performed in accordance with the PRISMA (preferred reporting items for systematic reviews and meta-analyses) guidelines. A random effects model meta-analysis of hazard ratios (HRs) was conducted. RESULTS Eighteen studies with 17,106 patients were included. Diabetes (HR, 1.68; 95% confidence interval [CI], 1.00-2.83; I2, 76.7%), dyslipidemia (HR, 1.77; 95% CI, 1.08-2.91; I2, 22.5%), female gender (HR, 1.50; 95% CI, 1.14-1.98, I2, 0%), chronic kidney disease (HR, 4.15; 95% CI, 1.69-10.19; I2, 44.5%), hypertension (HR, 1.99; 95% CI, 1.07-3.72; I2, 68%), smoking (HR, 1.65; 95% CI, 1.15-2.37; I2, 54.3%), and pretreatment stenosis >70% (HR, 1.04; 95% CI, 1.0-1.08; I2, 0%) showed a statistically significant increase in restenosis risk after carotid revascularization. Subgroup analyses of CEA and CAS showed that female gender and smoking status were significantly associated with recurrent stenosis after CEA but not after CAS. In contrast, hypertension was associated with restenosis after CAS but not after CEA. Patch endarterectomy (HR, 0.33; 95% CI, 0.22-0.50; I2, 0%) and symptomatic status at presentation in the CAS group (HR, 0.61; 95% CI, 0.41-0.90; I2, 0%) were associated with a decreased risk of restenosis. Antiplatelet use and coronary artery disease were not associated with restenosis risk. CONCLUSIONS Diabetes, dyslipidemia, female gender, renal failure, hypertension, and smoking were associated with an increased risk of restenosis, and patch endarterectomy and symptomatic status at presentation were associated with a decreased risk of carotid restenosis. Both female gender and current smoking status were only associated with recurrent stenosis after CEA, and hypertension was only associated with restenosis after CAS.
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Affiliation(s)
- Pavlos Texakalidis
- Department of Neurosurgery, Emory University School of Medicine, Atlanta, Georgia, USA.
| | - Andreas Tzoumas
- Medical School, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | | | - Anil K Jonnalagadda
- Department of Cardiology, Medstar Washington Hospital Center, Washington District of Columbia, USA
| | - Pascal Jabbour
- Department of Neurosurgery, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | | | - Theofilos Machinis
- Department of Neurosurgery, Virginia Commonwealth University, Richmond, Virginia, USA
| | - Dennis J Rivet
- Department of Neurosurgery, Virginia Commonwealth University, Richmond, Virginia, USA
| | - John Reavey-Cantwell
- Department of Neurosurgery, Virginia Commonwealth University, Richmond, Virginia, USA
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24
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Huizing E, Vos CG, van den Akker PJ, Schreve MA, de Borst GJ, Ünlü Ç. A systematic review of patch angioplasty versus primary closure for carotid endarterectomy. J Vasc Surg 2019; 69:1962-1974.e4. [PMID: 30792057 DOI: 10.1016/j.jvs.2018.10.096] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2018] [Accepted: 10/09/2018] [Indexed: 01/24/2023]
Abstract
BACKGROUND Guidelines recommend routine patching after carotid endarterectomy (CEA) on the basis of a lower restenosis rate and presumed lower procedural stroke rate than with primary repair. Underlying evidence is based on studies performed decades ago with perioperative care that significantly differed from current standards. Recent studies raise doubt about routine patching and have suggested that a more selective approach to patch closure (PAC) might be noninferior for procedural safety and long-term stroke prevention. The objective was to review the literature on the procedural safety and perioperative stroke prevention of PAC compared with primary closure (PRC) after CEA. METHODS MEDLINE, Embase, and Cochrane Central Register of Controlled Trials databases were searched from January 1966 to September 2017. Two authors independently performed the search, study selection, assessment of methodologic quality, and data extraction. Articles were eligible if they compared PAC and PRC after CEA, were published in English, included human studies, and had a full text available. Methodologic quality for nonrandomized studies was assessed using the Methodological Index for Non-Randomized Studies score; randomized controlled trials were assessed using Grading of Recommendations Assessment, Development, and Evaluation. Nonrandomized studies with a score ≤15 were excluded. The primary outcome measure was 30-day stroke risk. Secondary outcome measures were long-term restenosis (>50%) and postoperative bleeding. RESULTS Twenty-nine articles met the inclusion criteria, 9 randomized studies and 20 nonrandomized studies, for a total of 12,696 patients and 13,219 CEAs. Overall 30-day stroke risk was higher in the PRC group (odds ratio [OR], 1.9; 95% confidence interval [CI], 1.2-2.9). After exclusion of nonrandomized studies, this difference was not statistically significant anymore (OR, 1.8; 95% CI, 0.8-3.9). The restenosis rate was higher after PRC (OR, 2.2; 95% CI, 1.4-3.4). There were no differences in bleeding complications. Methodologic quality of the nonrandomized studies was moderate, and seven were excluded. Quality of the evidence according to Grading of Recommendations Assessment, Development, and Evaluation was moderate for restenosis, 30-day stroke, and bleeding. CONCLUSIONS In this systematic review, on the basis of moderate-quality evidence, perioperative stroke rate was lower after PAC compared with PRC. The rate of restenosis was higher after PRC, although the clinical significance of this finding in terms of long-term stroke prevention remained unclear.
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Affiliation(s)
- Eline Huizing
- Department of Surgery, Northwest Clinics, Alkmaar, The Netherlands.
| | - Cornelis G Vos
- Department of Surgery, Onze Lieve Vrouwe Gasthuis, Amsterdam, The Netherlands
| | | | | | - Gert J de Borst
- Department of Vascular Surgery, UMCU, Utrecht, The Netherlands
| | - Çağdaş Ünlü
- Department of Surgery, Northwest Clinics, Alkmaar, The Netherlands
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25
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Chung BH, Heo SH, Park YJ, Kim YW, Woo SY, Kim DI. Comparative Analysis Using Propensity Score Matching Analysis: Primary Closure versus Patch Angioplasty During Carotid Endarterectomy. Ann Vasc Surg 2019; 62:166-172. [PMID: 30763710 DOI: 10.1016/j.avsg.2018.11.011] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2018] [Revised: 10/29/2018] [Accepted: 11/05/2018] [Indexed: 10/27/2022]
Abstract
BACKGROUND Primary closure (PC) and patch angioplasty (PA) during carotid endarterectomy (CEA) have been disputed in many studies. Some studies announced that PC is associated with a higher restenosis rate. The aim of this study was to evaluate the outcomes of PC and PA using propensity score matching (PSM). METHODS Between November 1994 and October 2016, 1,044 patients underwent primary CEA procedures at our institution and were retrospectively analyzed. The study endpoints included rates of ipsilateral stroke, any clinical stroke, cranial nerve palsy, hematoma, bleeding warranting repeat surgery within 30 postoperative days. We also investigated the restenosis rates, overall survival, stenosis-free survival, and stroke-free survival during follow-up (median follow-up 37.1 months). RESULTS This study includes 435 cases of PC and 476 cases of PA. After PSM analysis, baseline characteristics (age, gender, hypertension, diabetes, dyslipidemia, smoking, atrial fibrillation, previous percutaneous coronary intervention or coronary artery bypass grafting, contralateral carotid occlusion, degree of carotid stenosis, and symptomatic status within 6 months) were balanced. Finally, 377 pairs of matched cases were analyzed. Statistical analysis showed no significant differences between the 2 groups in ipsilateral stroke (P = 0.45), clinical stroke (P = 0.75), cranial nerve palsy (P = 1), hematoma (P = 0.18), bleeding which required reoperation (P = 0.12) within 30 postoperative days, and restenosis rates during follow-up (P = 0.16). In addition, there were no differences between the 2 groups during follow-up in overall, stroke-free, and restenosis-free survival with P values of 0.136, 0.07, and 0.06, respectively. CONCLUSIONS According to the analysis using PSM, there were no significant differences between PC and PA closure during CEA in perioperative and long-term outcomes.
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Affiliation(s)
- Byeoung-Hoon Chung
- Division of Vascular Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea
| | - Seon-Hee Heo
- Division of Vascular Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea
| | - Yang-Jin Park
- Division of Vascular Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea
| | - Young-Wook Kim
- Division of Vascular Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea
| | - Shin-Young Woo
- Division of Vascular Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea
| | - Dong-Ik Kim
- Division of Vascular Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea.
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26
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Prediction of Long Term Restenosis Risk After Surgery in the Carotid Bifurcation by Hemodynamic and Geometric Analysis. Ann Biomed Eng 2019; 47:1129-1140. [DOI: 10.1007/s10439-019-02201-8] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2018] [Accepted: 01/05/2019] [Indexed: 11/25/2022]
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27
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Rizwan M, Aridi HD, Dang T, Alshwaily W, Nejim B, Malas MB. Long-Term Outcomes of Carotid Endarterectomy and Carotid Artery Stenting When Performed by a Single Vascular Surgeon. Vasc Endovascular Surg 2019; 53:216-223. [PMID: 30614413 DOI: 10.1177/1538574418823379] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
OBJECTIVES: Carotid artery endarterectomy (CEA) and carotid artery stenting (CAS) are 2 effective treatment options for carotid revascularization and stroke prevention. The long-term outcomes of Carotid Revascularization Endarterectomy versus Stenting Trial (CREST) reported similar stroke and death rate between the 2 procedures. This study presents the short- and long-term outcomes of CEA and CAS of all risk patients performed by a single vascular surgeon in a real-world setting. METHODS: We retrospectively reviewed all patients who underwent CEA and CAS from September 2005 to June 2017 at our institute. Student t test, χ2, and Fisher exact tests were used to compare patient's characteristics. Multivariate logistic, cox regression models and survival analysis were used to compare postoperative and long-term outcomes between the 2 groups. RESULTS: Over 2000 patients were evaluated for carotid artery stenosis during the study period, and 313 revascularization procedures were performed (CEA: 47%, CAS: 53%). Patients' age (Mean [95% confidence interval, CI] 68.8 [67.2-70.4] vs 69.7 [68.2-71.3], P = .40) was similar between CEA and CAS. Patients who underwent CAS had significantly higher comorbidities (chronic obstructive pulmonary disease [COPD], chronic heart failure [CHF], hyperlipidemia, and prior ipsilateral intervention, all P < .05). No difference was found in 30-day complications after CEA versus CAS including stroke (2.0% vs 1.2%), myocardial infarction (MI; 0.7% vs 1.2%), death (0% vs 1.2%) as well as combined major adverse events (stroke/death/MI; 2.7% vs 3.0%; all P > .05). Overall 7-year survival, stroke-free survival and restenosis-free survival were similar between the 2 groups ( P > .5). Significant predictors of mortality were diabetes (hazard ratio, HR [95% CI]: 2.41 [1.15-5.08]), chronic kidney disease (HR [95% CI]: 4.89 [1.97-12.13]), and COPD (HR [95% CI]: 3.31 [1.43-7.71]; all P values <.05). Statin use was protective with 71% reduction in risk of mortality (HR [95% CI]: 0.29 [0.12-0.67], P = .004). CONCLUSION: Our experience showed comparable short- and long-term outcomes of CAS and CEA performed for carotid artery stenosis by vascular surgeon. There was no difference between single institutional long-term outcomes and CREST outcomes following CEA and CAS.
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Affiliation(s)
- Muhammad Rizwan
- 1 The Johns Hopkins Bayview Vascular and Endovascular Research Center, Baltimore, MD, USA
| | - Hanaa Dakour Aridi
- 1 The Johns Hopkins Bayview Vascular and Endovascular Research Center, Baltimore, MD, USA
| | - Tru Dang
- 1 The Johns Hopkins Bayview Vascular and Endovascular Research Center, Baltimore, MD, USA
| | - Widian Alshwaily
- 1 The Johns Hopkins Bayview Vascular and Endovascular Research Center, Baltimore, MD, USA
| | - Besma Nejim
- 1 The Johns Hopkins Bayview Vascular and Endovascular Research Center, Baltimore, MD, USA
| | - Mahmoud B Malas
- 1 The Johns Hopkins Bayview Vascular and Endovascular Research Center, Baltimore, MD, USA.,2 Health System, University of California San Diego, San Diego, CA, USA.,3 Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
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28
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Texakalidis P, Giannopoulos S, Charisis N, Giannopoulos S, Karasavvidis T, Koullias G, Jabbour P. A meta-analysis of randomized trials comparing bovine pericardium and other patch materials for carotid endarterectomy. J Vasc Surg 2018; 68:1241-1256.e1. [PMID: 30244928 DOI: 10.1016/j.jvs.2018.07.023] [Citation(s) in RCA: 32] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2018] [Accepted: 07/14/2018] [Indexed: 01/18/2023]
Abstract
OBJECTIVE Patch angioplasty during carotid endarterectomy is commonly used to treat symptomatic and asymptomatic carotid artery stenosis. The objective of the present study was to compare the different patch materials that are currently available (synthetic vs venous vs bovine pericardium) in terms of short- and long-term outcomes. METHODS This study was performed according to the Preferred Reporting Items for Systematic reviews and Meta-Analyses (PRISMA) guidelines and eligible randomized control trials were identified through a comprehensive search of PubMed, Scopus, and Cochrane Central published until September 2017. A meta-analysis was conducted with the use of a random effects model. The I2 statistic was used to assess for heterogeneity. The primary study end point was the incidence of long-term restenosis. Secondary study end points were 30-day stroke, transient ischemic attack (TIA), myocardial infarction, neck wound infection, local hematoma, carotid artery thrombosis, cranial nerve injury, long-term stroke incidence, and death. RESULTS Eighteen studies and 3234 patients were included. The risk of 30-day stroke (relative risk [RR], 1.00; 95% confidence interval [CI], 0.45-2.19; I2 = 0%), TIA (RR, 1.14; 95% CI, 0.41-3.19; I2 = 0%), myocardial infarction (odds ratio, 0.75; 95% CI, 0.14-3.97; I2 = 0%), death (RR, 0.53; 95% CI, 0.21-1.34; I2 = 0%), wound infection (RR, 1.84; 95% CI, 0.43-7.81; I2 = 0%), carotid artery thrombosis (RR, 1.47; 95% CI, 0.44-4.97; I2 = 0%), cranial nerve palsy (RR, 1.21; 95% CI, 0.53-2.77; I2 = 0%), and long-term stroke (RR, 2.33; 95% CI, 0.76-7.10; I2 = 0%), death (RR, 1.09; 95% CI, 0.65-1.83; I2 = 0%) and restenosis of greater than 50% (RR, 0.48; 95% CI, 0.19-1.20; I2 = 0%) were similar between the synthetic vs venous patch groups. Also, no differences in terms of 30-day stroke (RR, 0.31; 95% CI, 0.02-5.16; I2 = 63.1%), TIA (RR, 0.49; 95% CI, 0.14-1.76; I2 = 0%), death (RR, 0.74; 95% CI, 0.05-10.51; I2 = 31.7%), carotid artery thrombosis (RR, 0.13; 95% CI, 0.02-1.07; I2 = 0%), and long-term restenosis of greater than 70% (RR, 0.15; 95% CI, 0.01-2.29; I2 = 70.9%) were detected between the synthetic polytetrafluoroethylene and Dacron patch groups. The comparison between the bovine pericardium vs synthetic patch did not yield any statistically significant results in terms of 30-day stroke (RR, 1.44; 95% CI, 0.19-10.79; I2 = 12.7%), TIA (RR, 1.05; 95% CI, 0.11-10.27; I2 = 0%), local neck hematoma (RR, 4.01; 95% CI, 0.46-34.85; I2 = 0%), and death (RR, 4.01; 95% CI, 0.46-34.85; I2 = 0%). CONCLUSIONS Closure of the carotid arteriotomy with any of the studied patch materials seems to be similar in terms of short- and long-term end points. However, additional randomized trials with adequate follow-up periods are needed to compare bovine pericardium patches with other patch materials.
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Affiliation(s)
- Pavlos Texakalidis
- Medical School, Aristotle University of Thessaloniki, Thessaloniki, Greece.
| | | | | | | | | | - George Koullias
- Division of Vascular and Endovascular Surgery, Stony Brook University Hospital, Stony Brook, NY
| | - Pascal Jabbour
- Department of Neurosurgery, Thomas Jefferson University, Philadelphia, Pa
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29
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Pothof AB, Soden PA, Deery SE, O'Donnell TFX, Wang GJ, Hughes K, de Borst GJ, Schermerhorn ML. The impact of race on outcomes after carotid endarterectomy in the United States. J Vasc Surg 2018; 68:426-435. [PMID: 29482877 PMCID: PMC6057797 DOI: 10.1016/j.jvs.2017.11.087] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2017] [Accepted: 11/10/2017] [Indexed: 11/26/2022]
Abstract
OBJECTIVE Black patients undergoing carotid endarterectomy (CEA) in the United States are more often symptomatic at presentation and have more comorbidities compared with white patients. However, the impact of race on outcomes after CEA is largely unknown. METHODS We identified CEA patients in the Vascular Quality Initiative registry (2012-2017) and compared them by race (black vs white). All other nonwhite races (891 [1.4%]) and Hispanics (2222 [3.4%]) were excluded. We used multilevel logistic regression to account for differences in demographics and comorbidities. We assessed long-term survival using multivariable Cox regression. The primary outcome was perioperative stroke/death, with long-term survival as a secondary outcome. RESULTS We included 57,622 CEA patients; 2909 (5.0%) were black, of whom 983 (34%) were symptomatic. Of the 54,713 white patients, 16,132 (30%) were symptomatic. Black patients, compared with white patients, had a higher vascular disease burden and were less likely to be operated on in a high-volume hospital or by a high-volume surgeon. In addition, black symptomatic patients, compared with white symptomatic patients, were more often operated on <2 weeks after the index neurologic symptom (47% vs 40%; P < .001). Perioperative stroke/death was comparable between black and white patients (symptomatic, 2.8% vs 2.2% [P = .2]; asymptomatic, 1.6% vs 1.3% [P = .2]), as was unadjusted survival at 3 years (93% vs 93%; P = .7). However, after adjustment, black patients did experience better long-term survival compared with white patients (hazard ratio, 0.8; 95% confidence interval, 0.7-0.9; P = .01). On multilevel logistic regression, race was not associated with perioperative stroke/death (odds ratio, 1.0; 95% confidence interval, 0.8-1.3; P = .98). CONCLUSIONS Despite the greater prevalence of vascular risk factors in black patients and racial inequalities in surgical treatment, rates of perioperative stroke/death and unadjusted survival were similar between white and black patients. Moreover, black patients experienced better adjusted long-term survival after CEA.
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Affiliation(s)
- Alexander B Pothof
- Division of Vascular and Endovascular Surgery, Department of Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Mass; Department of Vascular Surgery, University Medical Center, Utrecht, The Netherlands
| | - Peter A Soden
- Division of Vascular and Endovascular Surgery, Department of Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Mass
| | - Sarah E Deery
- Division of Vascular and Endovascular Surgery, Department of Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Mass; Department of Surgery, Massachusetts General Hospital, Boston, Mass
| | - Thomas F X O'Donnell
- Division of Vascular and Endovascular Surgery, Department of Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Mass; Department of Surgery, Massachusetts General Hospital, Boston, Mass
| | - Grace J Wang
- Department of Surgery, Hospital of the University of Pennsylvania, Philadelphia, Pa
| | - Kakra Hughes
- Department of Surgery, Howard University and Hospital, Washington, D.C
| | - Gert J de Borst
- Department of Vascular Surgery, University Medical Center, Utrecht, The Netherlands
| | - Marc L Schermerhorn
- Division of Vascular and Endovascular Surgery, Department of Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Mass.
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Huizing E, Vos CG, Hulsebos RG, van den Akker PJ, Borst GJD, Ünlü Ç. Patch Angioplasty or Primary Closure Following Carotid Endarterectomy for Symptomatic Carotid Artery Stenosis. Surg J (N Y) 2018; 4:e96-e101. [PMID: 29915809 PMCID: PMC6003887 DOI: 10.1055/s-0038-1655757] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2018] [Accepted: 04/17/2018] [Indexed: 10/28/2022] Open
Abstract
Objectives Guidelines recommend routine patching to prevent restenosis following carotid endarterectomy, mainly based on studies performed many years ago with different perioperative care and medical treatment compared with current standards. Aim of the present study was to compare primary closure (PRC) versus patch closure (PAC) in a contemporary cohort of patients. Methods Consecutive patients treated by carotid endarterectomy for symptomatic stenosis between January 2006 and April 2016 were retrospectively analyzed. Primary outcome was restenosis at 6 weeks and 1 year and occurrence of ipsilateral stroke. Secondary outcomes were mortality, complications, and reintervention rates. Results Five hundred carotid artery endarterectomies were performed. Fifty-nine patients were excluded because eversion endarterectomy was performed or because they were asymptomatic. PRC was performed in 349 and PAC in 92 patients. Restenosis at 6 weeks was 6.0% in the PAC group versus 3.0% in the PRC group ( p = 0.200). Restenosis at 1 year was 31.6 versus 14.1%, respectively ( p = 0.104). No difference was found for stroke (3.4 vs 1.1%, p = 0.319), death (1.1 vs 0.0%, p = 0.584), or other complications (1.1 vs 0.0%, p = 0.584), respectively. Conclusions It remains unclear whether routine patching should be recommended for all patients. A strategy of selective patching compared with routine patching, based on internal carotid artery diameter and other patient characteristics, deserves further investigation.
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Affiliation(s)
- Eline Huizing
- Department of Surgery, Northwest Clinics Alkmaar, Alkmaar, The Netherlands
| | - Cornelis G Vos
- Department of Surgery, Northwest Clinics Alkmaar, Alkmaar, The Netherlands.,Department of Surgery, Onze Lieve Vrouwe Gasthuis, Amsterdam, The Netherlands
| | - Robin G Hulsebos
- Department of Surgery, Northwest Clinics Alkmaar, Alkmaar, The Netherlands
| | | | - Gert Jan de Borst
- Department of Surgery, Utrecht University Medical Center, Utrecht, The Netherlands
| | - Çağdaş Ünlü
- Department of Surgery, Northwest Clinics Alkmaar, Alkmaar, The Netherlands
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Commentary on "An Updated Systematic Review and Meta-analysis of Outcomes Following Eversion vs. Conventional Carotid Endarterectomy in Randomised Controlled Trials and Observational Studies". Eur J Vasc Endovasc Surg 2018; 55:474. [PMID: 29409700 DOI: 10.1016/j.ejvs.2018.01.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2018] [Accepted: 01/15/2018] [Indexed: 11/20/2022]
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Domanin M, Buora A, Scardulla F, Guerciotti B, Forzenigo L, Biondetti P, Vergara C. Computational Fluid-Dynamic Analysis after Carotid Endarterectomy: Patch Graft versus Direct Suture Closure. Ann Vasc Surg 2017; 44:325-335. [DOI: 10.1016/j.avsg.2017.04.016] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2016] [Revised: 02/17/2017] [Accepted: 04/24/2017] [Indexed: 02/03/2023]
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Hertzer NR. The Current Status of Carotid Endarterectomy Part II: Randomized Trials versus Angioplasty and Stenting. Ann Vasc Surg 2017; 43:24-40. [DOI: 10.1016/j.avsg.2017.04.005] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2017] [Accepted: 04/10/2017] [Indexed: 10/19/2022]
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Kakkos SK, Kakisis I, Tsolakis IA, Geroulakos G. Endarterectomy achieves lower stroke and death rates compared with stenting in patients with asymptomatic carotid stenosis. J Vasc Surg 2017; 66:607-617. [PMID: 28735954 DOI: 10.1016/j.jvs.2017.04.053] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2016] [Accepted: 04/10/2017] [Indexed: 11/28/2022]
Abstract
BACKGROUND It is currently unclear if carotid artery stenting (CAS) is as safe as carotid endarterectomy (CEA) for patients with significant asymptomatic stenosis. The aim of our study was to perform a systematic review and meta-analysis of trials comparing CAS with CEA. METHODS On March 17, 2017, a search for randomized controlled trials was performed in MEDLINE and Scopus databases with no time limits. We performed meta-analyses with Peto odds ratios (ORs) and 95% confidence intervals (CIs). Quality of evidence was assessed with the Grading of Recommendations Assessment, Development, and Evaluation method. The primary safety and efficacy outcome measures were stroke or death rate at 30 days and ipsilateral stroke at 1 year (including ipsilateral stroke and death rate at 30 days), respectively. Perioperative stroke, ipsilateral stroke, myocardial infarction (MI), and cranial nerve injury (CNI) were all secondary outcome measures. RESULTS The systematic review of the literature identified nine randomized controlled trials reporting on 3709 patients allocated into CEA (n = 1479) or CAS (n = 2230). Stroke or death rate at 30 days was significantly higher for CAS (64/2176 [2.94%]) compared with CEA (27/1431 [1.89%]; OR, 1.57; 95% CI, 1.01-2.44; P = .044), with low level of heterogeneity beyond chance (I2 = 0%). Also, stroke rate at 30 days was significantly higher for CAS (63/2176 [2.90%]) than for CEA (26/1431 [1.82%]; OR, 1.63; 95% CI, 1.04-2.54; P = .032; I2 = 0%). MI at 30 days was nonsignificantly lower for CAS (12/1815 [0.66%]) compared with CEA (16/1070 [1.50%]; OR, 0.53; 95% CI, 0.24-1.14; P = .105; I2 = 0%); however, CNI at 30 days was significantly lower for CAS (2/1794 [0.11%]) than for CEA (33/1061 [3.21%]; OR, 0.13; 95% CI, 0.07-0.26; P < .00001; I2 = 0%). Regarding the long-term outcome of stroke or death rate at 30 days plus ipsilateral stroke during follow-up, this was significantly higher for CAS (79/2173 [3.64%]) than for CEA (35/1430 [2.45%]; OR, 1.51; 95% CI, 1.02-2.24; P = .04; I2 = 0%). Quality of evidence for all stroke outcomes was graded moderate. CONCLUSIONS Among patients with asymptomatic stenosis undergoing carotid intervention, there is moderate-quality evidence to suggest that CEA had significantly lower 30-day stroke and also stroke or death rates compared with CAS at the cost of higher CNI and nonsignificantly higher MI rates. The long-term efficacy of CEA in ipsilateral stroke prevention, taking into account perioperative stroke and death, was preserved during follow-up. There is an urgent need for high-quality research before a firm recommendation is made that CAS is inferior or not to CEA.
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Affiliation(s)
- Stavros K Kakkos
- Department of Vascular Surgery, University of Patras Medical School, Patras, Greece; Department of Surgery and Cancer, Imperial College London, London, United Kingdom.
| | - Ioannis Kakisis
- National and Kapodistrian University of Athens, Athens, Greece
| | - Ioannis A Tsolakis
- Department of Vascular Surgery, University of Patras Medical School, Patras, Greece
| | - George Geroulakos
- Department of Surgery and Cancer, Imperial College London, London, United Kingdom; National and Kapodistrian University of Athens, Athens, Greece
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Cheng I, Vyas KS, Velaga S, Davenport DL, Saha SP. Outcomes of Carotid Endarterectomy with Primary Closure. Int J Angiol 2017; 26:83-88. [PMID: 28566933 DOI: 10.1055/s-0037-1601053] [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] [Indexed: 10/20/2022] Open
Abstract
Carotid endarterectomy (CEA) reduces the risk of stroke in patients with internal carotid artery stenosis, although the optimal surgical technique is debated. The literature suggests that patch angioplasty reduces complication risk, although primary closure shortens cross-clamp time and eliminates complications associated with grafts. The objective of this study was to assess the complication rate after CEA with primary closure. Retrospective review of 240 consecutive patients between 2002 and 2010. Of these patients, 70% returned for follow-up visits for at least 2 or more years. Primary closure was used in all patients. The average cross-clamp time was 18 minutes. Complications in the immediate postoperative period within 30 days were as follows: stroke (n = 3; 1.1%), transient ischemic attack (TIA; n = 4; 1.5%), myocardial infarction (MI; n = 3; 1.1%), and death (n = 1; 0.4%). Short-term follow-up revealed eight patients who were found to have significant restenosis (>80%) by carotid duplex imaging. Two to ten year postoperative complication rates were as follows: stroke (n = 7; 4.2%), TIA (n = 7; 4.2%), amaurosis fugax (n = 1; 0.6%), MI (n = 8; 4.8%), and death (n = 28; 17%). Mortality was due to stroke or heart attack (n = 2; 1.2%), cancer (n = 7; 4.2%), and unknown causes (n = 19; 11%). This study presents our experience with complications after primary closure after CEA. In our experience, CEA is a safe and effective surgical means of preventing stroke in the short term. Well-designed prospective studies are needed to confirm specific patient characteristics in which primary closure and patch angioplasty are indicated.
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Affiliation(s)
- Ivy Cheng
- Department of Surgery, University of Miami Miller School of Medicine, Miami, Florida
| | | | - Santhosh Velaga
- Department of Surgery, Division of Cardiothoracic Surgery, University of Kentucky College of Medicine, Lexington, Kentucky
| | - Daniel L Davenport
- Department of Surgery, Division of Cardiothoracic Surgery, University of Kentucky College of Medicine, Lexington, Kentucky
| | - Sibu P Saha
- Department of Surgery, Division of Cardiothoracic Surgery, University of Kentucky College of Medicine, Lexington, Kentucky
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Chou D, Tulloch A, Cossman DV, Cohen JL, Rao R, Barmparas G, Mirocha J, Wagner W. The Influence of Collagen Impregnation of a Knitted Dacron Patch Used in Carotid Endarterectomy. Ann Vasc Surg 2016; 39:209-215. [PMID: 27666808 DOI: 10.1016/j.avsg.2016.08.011] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2016] [Revised: 08/02/2016] [Accepted: 08/04/2016] [Indexed: 10/21/2022]
Abstract
BACKGROUND In selected populations, carotid endarterectomy (CEA) reduces long-term stroke risk. Studies have shown increased risk of restenosis with use of a collagen-impregnated Dacron patch compared to a polytetrafluorethylene patch. There is concern that collagen impregnation may initiate thrombosis or promote restenosis due to platelet activation. We performed a retrospective analysis of our CEA experience with routine patching using knitted Dacron patches with (Hemashield) and without (Sauvage) collagen impregnation. METHODS Our database was queried for all CEAs between January 2006 and December 2010. Seven surgeons performed 655 CEAs. Patients were excluded if no patch was used (n = 1), a primary CEA was performed before study period or by other surgeons (n = 11), or the patch type was indeterminable (n = 38). Demographics, clinical data, and outcomes were compared between the collagen-impregnated (C, Hemashield) group and non-collagen-impregnated (NC, Sauvage) group. RESULTS A total of 605 CEAs were analyzed (395 C and 210 NC). Demographics were similar except for coronary artery disease (C 54.3% vs. NC 41.6%, P = 0.003). There was no statistically significant difference in 30-day (C 99.7% vs. NC 99.5%, P > 0.99) or 5-year survival (C 80.0% vs. NC 83.7%, P = 0.26) or 30-day stroke rate (C 0.3% vs. NC 1.0%, P = 0.28). No late ipsilateral strokes occurred during 5-year follow-up. The 5-year freedom from restenosis >30% (C 85.3% vs. NC 86.4%, P = 0.33), restenosis >50% (C 94.5% vs. NC 95.5%, P = 0.44), and restenosis >70% (C 98.6% vs. NC 98.9%, P = 0.73) were similar. Two patients underwent carotid stenting for restenosis >70%. Two patients (both in the C group) developed occlusion of the carotid artery. CONCLUSIONS The thrombosis and restenosis rates in the 2 groups were similar. This suggests that collagen-impregnated patches do not initiate thrombosis or increase restenosis rates after CEA.
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Affiliation(s)
- Daisy Chou
- Division of Vascular Surgery, Cedars-Sinai Medical Center, Los Angeles, CA
| | - Allan Tulloch
- Division of Vascular Surgery, Cedars-Sinai Medical Center, Los Angeles, CA
| | - David V Cossman
- Division of Vascular Surgery, Cedars-Sinai Medical Center, Los Angeles, CA
| | - J Louis Cohen
- Division of Vascular Surgery, Cedars-Sinai Medical Center, Los Angeles, CA
| | - Rajeev Rao
- Division of Vascular Surgery, Cedars-Sinai Medical Center, Los Angeles, CA
| | - Galinos Barmparas
- Division of Vascular Surgery, Cedars-Sinai Medical Center, Los Angeles, CA
| | - James Mirocha
- Biostatistics Core, Research Institute and Clinical and Translational Science Institute (CTSI), Cedars-Sinai Medical Center, Los Angeles, CA
| | - Willis Wagner
- Division of Vascular Surgery, Cedars-Sinai Medical Center, Los Angeles, CA.
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Chaturvedi S, Chimowitz M, Brown RD, Lal BK, Meschia JF. The urgent need for contemporary clinical trials in patients with asymptomatic carotid stenosis. Neurology 2016; 87:2271-2278. [PMID: 27683853 DOI: 10.1212/wnl.0000000000003267] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2016] [Accepted: 08/10/2016] [Indexed: 11/15/2022] Open
Abstract
Asymptomatic extracranial internal carotid artery atherosclerotic stenosis increases with age and is more common in men. Studies performed more than 2 decades ago showed that carotid endarterectomy reduced the rate of stroke in carefully selected patients with asymptomatic carotid stenosis compared with medical therapy in the long term. Those trials were completed more than 20 years ago and with advances in the treatment of atherosclerotic disease, the question has been raised to as to whether endarterectomy is still of value for patients with asymptomatic narrowing. Perioperative risk of carotid revascularization procedures has also declined. Due to improvements in both medical and surgical treatments for carotid artery stenosis, it is timely to reevaluate the efficacy of carotid intervention relative to medical treatment for patients with asymptomatic stenosis.
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Affiliation(s)
- Seemant Chaturvedi
- From the University of Miami Miller School of Medicine (S.C.), FL; Medical University of South Carolina (M.C.), Charleston; Mayo Clinic (R.D.B.), Rochester, MN; University of Maryland School of Medicine (B.K.L.), Baltimore; and Mayo Clinic (J.F.M.), Jacksonville, FL.
| | - Marc Chimowitz
- From the University of Miami Miller School of Medicine (S.C.), FL; Medical University of South Carolina (M.C.), Charleston; Mayo Clinic (R.D.B.), Rochester, MN; University of Maryland School of Medicine (B.K.L.), Baltimore; and Mayo Clinic (J.F.M.), Jacksonville, FL
| | - Robert D Brown
- From the University of Miami Miller School of Medicine (S.C.), FL; Medical University of South Carolina (M.C.), Charleston; Mayo Clinic (R.D.B.), Rochester, MN; University of Maryland School of Medicine (B.K.L.), Baltimore; and Mayo Clinic (J.F.M.), Jacksonville, FL
| | - Brajesh K Lal
- From the University of Miami Miller School of Medicine (S.C.), FL; Medical University of South Carolina (M.C.), Charleston; Mayo Clinic (R.D.B.), Rochester, MN; University of Maryland School of Medicine (B.K.L.), Baltimore; and Mayo Clinic (J.F.M.), Jacksonville, FL
| | - James F Meschia
- From the University of Miami Miller School of Medicine (S.C.), FL; Medical University of South Carolina (M.C.), Charleston; Mayo Clinic (R.D.B.), Rochester, MN; University of Maryland School of Medicine (B.K.L.), Baltimore; and Mayo Clinic (J.F.M.), Jacksonville, FL
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Avgerinos ED, Chaer RA, Naddaf A, El-Shazly OM, Marone L, Makaroun MS. Primary closure after carotid endarterectomy is not inferior to other closure techniques. J Vasc Surg 2016; 64:678-683.e1. [DOI: 10.1016/j.jvs.2016.03.415] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2015] [Accepted: 03/07/2016] [Indexed: 10/21/2022]
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39
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Avgerinos ED, Go C, Ling J, Naddaf A, Steinmetz A, Abou Ali AN, Makaroun MS, Chaer RA. Carotid artery disease progression and related neurologic events after carotid endarterectomy. J Vasc Surg 2016; 64:354-360. [DOI: 10.1016/j.jvs.2016.02.026] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2015] [Accepted: 02/03/2016] [Indexed: 10/22/2022]
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Maertens V, Maertens H, Kint M, Coucke C, Blomme Y. Complication Rate after Carotid Endarterectomy Comparing Patch Angioplasty and Primary Closure. Ann Vasc Surg 2016; 30:248-52. [DOI: 10.1016/j.avsg.2015.07.045] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2015] [Revised: 07/18/2015] [Accepted: 07/26/2015] [Indexed: 10/22/2022]
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Saha SP, Saha S, Vyas KS. Carotid Endarterectomy: Current Concepts and Practice Patterns. Int J Angiol 2015; 24:223-35. [PMID: 26417192 PMCID: PMC4572020 DOI: 10.1055/s-0035-1558645] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022] Open
Abstract
Background Stroke is the number one cause of disability and third leading cause of death among adults in the United States. A major cause of stroke is carotid artery stenosis (CAS) caused by atherosclerotic plaques. Randomized trials have varying results regarding the equivalence and perioperative complication rates of stents versus carotid endarterectomy (CEA) in the management of CAS. Objectives We review the evidence for the current management of CAS and describe the current concepts and practice patterns of CEA. Methods A literature search was conducted using PubMed to identify relevant studies regarding CEA and stenting for the management of CAS. Results The introduction of CAS has led to a decrease in the percentage of CEA and an increase in the number of CAS procedures performed in the context of all revascularization procedures. However, the efficacy of stents in patients with symptomatic CAS remains unclear because of varying results among randomized trials, but the perioperative complication rates exceed those found after CEA. Conclusions Vascular surgeons are uniquely positioned to treat carotid artery disease through medical therapy, CEA, and stenting. Although data from randomized trials differ, it is important for surgeons to make clinical decisions based on the patient. We believe that CAS can be adopted with low complication rate in a selected subgroup of patients, but CEA should remain the standard of care. This current evidence should be incorporated into practice of the modern vascular surgeon.
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Affiliation(s)
- Sibu P. Saha
- Division of Cardiothoracic Surgery, Department of Surgery, University of Kentucky College of Medicine, Lexington, Kentucky
| | - Subhajit Saha
- MediCiti Institute of Medical Science, Hyderabad, India
| | - Krishna S. Vyas
- Division of Cardiothoracic Surgery, Department of Surgery, University of Kentucky College of Medicine, Lexington, Kentucky
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