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Legeza PT, Lettenberger AB, Murali B, Johnson LR, Berczeli M, Byrne MD, Britz G, O'Malley MK, Lumsden AB. Evaluation of Robotic-Assisted Carotid Artery Stenting in a Virtual Model Using Motion-Based Performance Metrics. J Endovasc Ther 2024; 31:457-465. [PMID: 36147025 DOI: 10.1177/15266028221125592] [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: 11/15/2022]
Abstract
PURPOSE Robotic-assisted carotid artery stenting (CAS) cases have been demonstrated with promising results. However, no quantitative measurements have been made to compare manual with robotic-assisted CAS. This study aims to quantify surgical performance using tool tip kinematic data and metrics of precision during CAS with manual and robotic control in an ex vivo model. MATERIALS AND METHODS Transfemoral CAS cases were performed in a high-fidelity endovascular simulator. Participants completed cases with manual and robotic techniques in 2 different carotid anatomies in random order. C-arm angulations, table position, and endovascular devices were standardized. Endovascular tool tip kinematic data were extracted. We calculated the spectral arc length (SPARC), average velocity, and idle time during navigation in the common carotid artery and lesion crossing. Procedural time, fluoroscopy time, movements of the deployed filter wire, precision of stent, and balloon positioning were recorded. Data were analyzed and compared between the 2 modalities. RESULTS Ten participants performed 40 CAS cases with a procedural success of 100% and 0% residual stenosis. The median procedural time was significantly higher during the robotic-assisted cases (seconds, median [interquartile range, IQR]: 128 [49.5] and 161.5 [62.5], p=0.02). Fluoroscopy time differed significantly between manual and robotic-assisted procedures (seconds, median [IQR]: 81.5 [32] and 98.5 [39.5], p=0.1). Movement of the deployed filter wire did not show significant difference between manual and robotic interventions (mm, median [IQR]: 13 [10.5] and 12.5 [11], p=0.5). The postdilation balloon exceeded the margin of the stent with a median of 2 [1] mm in both groups. Navigation with robotic assistance showed significantly lower SPARC values (-5.78±3.14 and -8.63±3.98, p=0.04) and higher idle time values (8.92±8.71 and 3.47±3.9, p=0.02) than those performed manually. CONCLUSIONS Robotic-assisted and manual CAS cases are comparable in the precision of stent and balloon positioning. Navigation in the carotid artery is associated with smoother motion and higher idle time values. These findings highlight the accuracy and the motion stabilizing capability of the endovascular robotic system. CLINICAL IMPACT Robotic assistance in the treatment of peripheral vascular disease is an emerging field and may be a tool for radiation protection and the geographic distribution of endovascular interventions in the future. This preclinical study compares the characteristics of manual and robotic-assisted carotid stenting (CAS). Our results highlight, that robotic-assisted CAS is associated with precise navigation and device positioning, and smoother navigation compared to manual CAS.
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Affiliation(s)
- Peter T Legeza
- Department of Cardiovascular Surgery, Houston Methodist Hospital, Houston, TX, USA
- Department of Vascular and Endovascular Surgery, Semmelweis University, Budapest, Hungary
| | - Ahalya B Lettenberger
- Department of Mechanical Engineering, Mechatronics and Haptic Interfaces Laboratory, Rice University, Houston, TX, USA
| | - Barathwaj Murali
- Department of Mechanical Engineering, Mechatronics and Haptic Interfaces Laboratory, Rice University, Houston, TX, USA
| | - Lianne R Johnson
- Department of Mechanical Engineering, Mechatronics and Haptic Interfaces Laboratory, Rice University, Houston, TX, USA
| | - Marton Berczeli
- Department of Cardiovascular Surgery, Houston Methodist Hospital, Houston, TX, USA
- Department of Vascular and Endovascular Surgery, Semmelweis University, Budapest, Hungary
| | - Michael D Byrne
- Department of Psychological Sciences, Rice University, Houston, TX, USA
| | - Gavin Britz
- Department of Neurosurgery, Houston Methodist Hospital, Houston, TX, USA
| | - Marcia K O'Malley
- Department of Mechanical Engineering, Mechatronics and Haptic Interfaces Laboratory, Rice University, Houston, TX, USA
| | - Alan B Lumsden
- Department of Cardiovascular Surgery, Houston Methodist Hospital, Houston, TX, USA
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Loufopoulos G, Manaki V, Tasoudis P, Karela NR, Sénéchaud C, Giannopoulos A, Ktenidis K, Spanos K. Trans-Carotid Artery Revascularization Versus Carotid Endarterectomy in Patients With Carotid Artery Disease: Systematic Review and Meta-analysis of 30-day Outcomes. Angiology 2024:33197241241788. [PMID: 38533833 DOI: 10.1177/00033197241241788] [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: 03/28/2024]
Abstract
This systematic review and meta-analysis compared trans-carotid artery revascularization (TCAR) as an alternative approach to carotid endarterectomy (CEA) in patients with carotid artery disease. An electronic search was conducted using PubMed, Scopus, and Cochrane databases including comparative studies with patients who underwent either TCAR or CEA. This meta-analysis is according to the recommendations of the PRISMA statement. Eight studies met our eligibility criteria, incorporating 7,606 and 7,048 patients in the TCAR and CEA groups, respectively. Thirty-day mortality (odds ratio [OR]: 0.94, 95% confidence interval [CI]: 0.56-1.56, P = .81) and stroke (OR: 0.92, 95%CI 0.70-1.22, P = .57) were similar between the two groups, with low heterogeneity. The odds of myocardial infarction (OR: 1.79, 95% CI: 1.18-2.71, P = .01) and cranial nerve injury were significantly higher in patients undergoing CEA compared with TCAR (OR: 4.11, 95% CI: 2.59-6.51, P < .001). The subgroup analysis according to symptomatic pre-intervention status revealed no statistically significant difference regarding 30-day mortality (symptomatic OR: 0.91, 95% CI: 0.40-2.07, P = .82, asymptomatic OR: 0.93, 95% CI: 0.46-1.86, P = .83) and stroke (symptomatic OR: 0.88, 95% CI:0.47-1.64, P = .68, asymptomatic OR: 0.93, 95% CI: 0.64-1.35, P = .70). TCAR offers an alternative treatment for patients with carotid artery stenosis with comparable to CEA mortality and stroke rates during a 30-day post-operative period.
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Affiliation(s)
- Georgios Loufopoulos
- Cardiothoracic and Vascular Surgery Working Group, Society of Junior Doctors, Athens, Greece
- Department of Surgery, Jura Bernois Hospital, Saint Imier, Switzerland
| | - Vasiliki Manaki
- Cardiothoracic and Vascular Surgery Working Group, Society of Junior Doctors, Athens, Greece
- Department of Vascular Surgery, AHEPA University General Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Panagiotis Tasoudis
- Cardiothoracic and Vascular Surgery Working Group, Society of Junior Doctors, Athens, Greece
- Division of Cardiothoracic Surgery, Department of Surgery, School of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Nina-Rafailia Karela
- Cardiothoracic and Vascular Surgery Working Group, Society of Junior Doctors, Athens, Greece
| | | | - Argirios Giannopoulos
- Department of Vascular Surgery, AHEPA University General Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Kiriakos Ktenidis
- Department of Vascular Surgery, AHEPA University General Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Konstantinos Spanos
- Department of Vascular Surgery, University Hospital of Larissa, Faculty of Medicine, School of Health Sciences, University of Thessaly, Larissa, Greece
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Sato D, Umekawa M, Koizumi S, Ishigami D, Kiyofuji S, Saito N. Trans-Distal Radial Artery Carotid Revascularization with Forearm Flow Reversal: An Alternative Option of CAS in the TCAR Era. World Neurosurg 2024; 183:e920-e927. [PMID: 38237802 DOI: 10.1016/j.wneu.2024.01.058] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2024] [Accepted: 01/10/2024] [Indexed: 02/10/2024]
Abstract
BACKGROUND Transcarotid artery revascularization (TCAR) has emerged as an alternative to carotid artery stenting (CAS). TCAR demonstrated its superiority by avoiding femoral artery puncture and establishing proximal protection without crossing the stenotic lesion. In the TCAR era, we focused on the possibility of a trans-distal radial approach (DRA). A balloon-guide catheter was navigated via DRA to establish proximal protection before lesion crossing. The forearm subcutaneous vein was used as the flow-reversal circuit. METHODS Six internal carotid artery stenosis patients underwent CAS using "the forearm flow reversal technique." Every procedure was performed under continuous flow reversal from the common carotid artery to the forearm cephalic vein. RESULTS Successful revascularization was achieved without ischemic or access-site complications. The distal radial artery was patent at discharge in all cases. CONCLUSIONS Trans-distal radial CAS with forearm flow reversal is a feasible and less invasive technical option.
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Affiliation(s)
- Daisuke Sato
- Department of Neurosurgery, The University of Tokyo Hospital, Tokyo, Japan
| | - Motoyuki Umekawa
- Department of Neurosurgery, The University of Tokyo Hospital, Tokyo, Japan
| | - Satoshi Koizumi
- Department of Neurosurgery, The University of Tokyo Hospital, Tokyo, Japan.
| | - Daiichiro Ishigami
- Department of Neurosurgery, The University of Tokyo Hospital, Tokyo, Japan
| | - Satoshi Kiyofuji
- Department of Neurosurgery, The University of Tokyo Hospital, Tokyo, Japan
| | - Nobuhito Saito
- Department of Neurosurgery, The University of Tokyo Hospital, Tokyo, Japan
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Wu H, Wang Z, Li M, Sun P, Wei S, Xie B, Zhang C, Zhang L, Bai H. Outcomes of transcarotid artery revascularization: A systematic review. Interv Neuroradiol 2022:15910199221123283. [PMID: 36039496 DOI: 10.1177/15910199221123283] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
BACKGROUND Ischemic stroke and disability caused by carotid artery stenosis have always been worldwide problems. At present, carotid endarterectomy (CEA) and transfemoral carotid artery stenting (TFCAS) have been commonly used to treat carotid artery stenosis. Recently, transcarotid artery revascularization (TCAR) seems to be another option. METHODS We searched PubMed and Embase to find literatures comparing TCAR with TFCAS and CEA. The primary outcomes were stroke, myocardial infarction (MI), transient ischemic attack (TIA), death, cranial nerve injure (CNI), and operative time. Secondary outcomes were stroke, death, MI in the elderly; cost; radiation; and entry site complication. RESULTS Initial search of the literature included 165 articles, of which 12 studies were chosen in the end. These studies demonstrated high technical success rate of TCAR. Patients who received TCAR had lower risks of death, stroke/death and less radiation exposure compared to TFCAS. In meta analysis, the risk of stroke was significantly lower in TCAR group than TFCAS (OR 0.63; 95%CI 0.47-0.85). And there was no significant difference in TIA and MI. TCAR was associated with shorter operative time, lower risk of CNI and less blood loss compared to CEA. In older patients, the effect of TCAR was significantly better than that of TFCAS. CONCLUSION TCAR is associated with a lower risk of perioperative stroke compared to TFCAS. TCAR is also associated with shorter operative time, lower risk of CNI and less blood loss compared to CEA. TCAR may be a promising treatment option besides TFCAS and CEA.
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Affiliation(s)
- Haoliang Wu
- Department of Vascular and Endovascular Surgery, 191599First Affiliated Hospital of Zhengzhou University, Henan, China
- Key Vascular Physiology and Applied Research Laboratory of Zhengzhou City, Henan, China
| | - Zhiwei Wang
- Department of Vascular and Endovascular Surgery, 191599First Affiliated Hospital of Zhengzhou University, Henan, China
| | - Mingxing Li
- Department of Vascular and Endovascular Surgery, 191599First Affiliated Hospital of Zhengzhou University, Henan, China
| | - Peng Sun
- Department of Vascular and Endovascular Surgery, 191599First Affiliated Hospital of Zhengzhou University, Henan, China
| | - Shunbo Wei
- Department of Vascular and Endovascular Surgery, 191599First Affiliated Hospital of Zhengzhou University, Henan, China
| | - Boao Xie
- Department of Vascular and Endovascular Surgery, 191599First Affiliated Hospital of Zhengzhou University, Henan, China
| | - Cong Zhang
- Department of Vascular and Endovascular Surgery, 191599First Affiliated Hospital of Zhengzhou University, Henan, China
| | - Liwei Zhang
- Department of Vascular and Endovascular Surgery, 191599First Affiliated Hospital of Zhengzhou University, Henan, China
| | - Hualong Bai
- Department of Vascular and Endovascular Surgery, 191599First Affiliated Hospital of Zhengzhou University, Henan, China
- Key Vascular Physiology and Applied Research Laboratory of Zhengzhou City, Henan, China
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Christian ZK, Hoang AN, Dang H, Khan AB, Raper DM, Pallister ZS, Tanweer O. Use of transcarotid artery revascularization for mechanical thrombectomy and treatment of symptomatic high-grade carotid artery stenosis associated with free-floating thrombus: illustrative case. JOURNAL OF NEUROSURGERY: CASE LESSONS 2022; 3:CASE21553. [PMID: 36130533 PMCID: PMC9379636 DOI: 10.3171/case21553] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/28/2021] [Accepted: 12/09/2021] [Indexed: 11/25/2022]
Abstract
BACKGROUND Patients with symptomatic high-grade stenosis of the internal carotid artery (ICA) associated with a free-floating thrombus (FFT) present a significant clinical challenge. In general, for patients with moderate to severe symptomatic ICA stenosis, carotid revascularization is recommended within 2 weeks of symptom onset; however, some physicians suggest that revascularization should be delayed in cases with FFT because some data suggest that early surgery with carotid endarterectomy or carotid stent poses a higher risk for stroke. Likewise, delayed revascularization with anticoagulation may increase risk of recurrent stroke. Few reports on the management of FTT included the use of a transcarotid artery revascularization (TCAR) approach for carotid revascularization with mechanical aspiration thrombectomy. OBSERVATIONS This report described the use of TCAR for direct mechanical thrombectomy and carotid stent placement for a patient with 80% right ICA stenosis along with a large FFT extending into the bulb and the external carotid artery. LESSONS The TCAR approach for mechanical thrombectomy and carotid stenting is a safe alternative for early revascularization with low periprocedural stroke risks.
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Affiliation(s)
| | | | | | | | | | - Zachary S. Pallister
- Division of Vascular Surgery and Endovascular Therapy, Baylor College of Medicine, Houston, Texas; and
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Management of atherosclerotic extracranial carotid artery stenosis. Lancet Neurol 2022; 21:273-283. [DOI: 10.1016/s1474-4422(21)00359-8] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2020] [Revised: 09/30/2021] [Accepted: 10/08/2021] [Indexed: 02/05/2023]
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Balloon Dilation Strategy Does Not Affect Outcomes for Transcarotid Artery Revascularization (TCAR) in Prospective Trials. J Vasc Surg 2022; 76:202-208. [PMID: 35149162 DOI: 10.1016/j.jvs.2022.01.124] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2021] [Accepted: 01/21/2022] [Indexed: 11/21/2022]
Abstract
OBJECTIVES Strategies of balloon dilation during trans-femoral carotid artery stenting (TFCAS) include pre-stent dilation only (PRE), post-stent dilation only (POST), or both pre- and post- dilation (PRE+POST). Concerns over higher neurological risk have been raised with POST and PRE+POST during TFCAS. Whether these concerns are applicable to Transcarotid Artery Revascularization (TCAR) which utilizes proximal clamping and cerebral blood flow reversal during stent deployment and balloon angioplasty remains unknown. Our aim is to analyze outcomes of PRE, POST or PRE+POST balloon dilation strategies during TCAR. METHODS We analyzed the prospectively collected data from the ROADSTER1 (pivotal), ROADSTER2 (FDA indicated post-market), and Roadster Extended Access TCAR trials. All trial patients had high risk anatomic or clinical factors for carotid endarterectomy and were included unless they did not undergo stent deployment nor balloon dilation. For trial inclusion, asymptomatic patients had >80% carotid stenosis, and symptomatic patients had >50% stenosis. Primary outcome measures were stroke, death, and myocardial infarction (MI) at 30 days. Data were statistically analyzed with chi-square, ANOVA, and multivariable analysis as appropriate. RESULTS There were 851 patients (566 male) who underwent dilation by PRE (N=216), POST (N=249), or PRE+POST (N=386). Patients had carotid stenosis >70% (N=828, 97%), and 207 (24%) were symptomatic. Flow reversal times were longer in the PRE+POST group (PRE 10.2mins, POST 9.8mins, PRE+ POST 13.3mins, P<.001). The 30-day stroke rate for the whole cohort was 1.9%, mortality was 0.5%, and MI rate was 0.94%. Stroke rates for the PRE cohort (1.9%), POST cohort (2.0%), and PRE+POST cohort (1.8%, P=.98) were similar. Also, death rates at 30 days, and composite stroke/death/myocardial infarction rates were similar in the three cohorts. No significant differences in adverse outcomes were noted among the various dilation strategies for both symptomatic and asymptomatic patients. CONCLUSION Based on these prospective trial data, there is no difference in neurological complications due to balloon dilation strategy during TCAR. Balloon dilation technique best suited to the patient's specific lesion morphology should be utilized. Further studies are needed to evaluate the relationship of these dilation strategies to long term outcomes including stent patency, restenosis and reintervention.
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Gao J, Chen Z, Kou L, Zhang H, Yang Y. The Efficacy of Transcarotid Artery Revascularization With Flow Reversal System Compared to Carotid Endarterectomy: A Systematic Review and Meta-Analysis. Front Cardiovasc Med 2021; 8:695295. [PMID: 34869622 PMCID: PMC8640218 DOI: 10.3389/fcvm.2021.695295] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2021] [Accepted: 10/18/2021] [Indexed: 01/10/2023] Open
Abstract
Background: Carotid artery stenosis has long been a critical cause of stroke and death, and it can seriously affect the life quality. Transcarotid artery revascularization (TCAR) and carotid endarterectomy (CEA) are both feasible therapies for this disease. This systematic review and meta-analysis aim to evaluate if the efficacy of the two approaches is comparable. Methods: Clinical studies up to March 2021 were searched through PubMed, Embase, and Scopus from a computer. The screening process was designed according to the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) statement. Newcastle-Ottawa Scale (NOS) was used for methodological quality assessment of works of literature meeting the inclusion criteria, and Review Manager 5.4 was used for data synthesis. The I2 statistic was performed to measure the heterogeneity, and M-H/I-V fixed or random model was utilized depending on the I2 value. The evidence evaluation was accomplished based on grades of recommendation, assessment, development, and evaluation (GRADE) online tool. Results: A total of 14,200 subjects (six comparative studies) were finally included in this pooled study. There is no statistical discrepancy between the two treatments on reducing stroke/death/myocardial infarction (odds ratio [OR] 0.85, 95% CI 0.67–1.07), stroke (OR 1.03, 95% CI 0.77–1.37), or death (OR 1.14, 95% CI 0.67–1.94). Besides, TCAR is associated with a lower incidence of myocardial infarction (P = 0.004), cranial nerve injury (P < 0.00001), and shorter procedure time (P < 0.00001) than CEA among the overall cohort. Conclusions: TCAR is a rapidly developing treatment that reaches a comparable prognosis to CEA and significantly reduces the risk of myocardial infarction under the well-matched condition, which is a dependable choice for patients with carotid stenosis.
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Affiliation(s)
- Jianfeng Gao
- Department of Vascular, Beijing Anzhen Hospital, Capital Medical University, Beijing, China
| | - Zhong Chen
- Department of Vascular, Beijing Anzhen Hospital, Capital Medical University, Beijing, China
| | - Lei Kou
- Department of Vascular, Beijing Anzhen Hospital, Capital Medical University, Beijing, China
| | - Hanfang Zhang
- Department of Vascular, Beijing Anzhen Hospital, Capital Medical University, Beijing, China
| | - Yaoguo Yang
- Department of Vascular, Beijing Anzhen Hospital, Capital Medical University, Beijing, China
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Cui CL, Zarrintan S, Marmor RA, Nichols J, Cajas-Monson L, Malas M. Performance of Carotid Revascularization Procedures as Modified by Sex. Ann Vasc Surg 2021; 81:171-182. [PMID: 34752853 DOI: 10.1016/j.avsg.2021.08.051] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2021] [Revised: 08/27/2021] [Accepted: 08/31/2021] [Indexed: 11/25/2022]
Abstract
BACKGROUND Current recommendations on carotid revascularization postulate that women have both increased perioperative risks, such as stroke and death, as well as reduced benefit from intervention. These recommendations do not include data on transcarotid artery revascularization (TCAR). This study strives to compare safety and benefits of TCAR, TFCAS (Transfemoral Carotid Artery Stenting), and CEA (Carotid Endarterectomy) with regard to patient sex. METHODS We performed retrospective analysis of the Society for Vascular Surgery (SVS) Vascular Quality Initiative (VQI) CEA and stenting registries, as well as TCAR Surveillance Project data. We compared outcomes after TCAR, TFCAS, and CEA based on sex. The primary outcome was the rate of in-hospital stroke or death. Secondary outcomes included in-hospital stroke, death, transient ischemic attack (TIA), myocardial infarction (MI), stroke/death/MI, stroke/TIA, and recurrent ipsilateral stroke and/or death at 1-year of follow-up. RESULTS A total of 75,538 patients were included, of which 28,960 (38.3%) were female and 46,578 (61.7%) were male. TFCAS females had more than 2 times higher odds of stroke/death (OR:2.85, 95%CI: 2.21-3.67, P < 0.001) and stroke/death/MI (OR:2.23, 95%CI:1.75-2.83, P < 0.001) when compared to CEA females. Odds of TIA were also higher in both TFCAS females (OR:2.01, 95%CI:1.19-3.42, P = 0.010) and TCAR females (OR:1.91, 95%CI:1.09-3.35, P = .023) when compared to CEA females. However, only TFCAS females experienced increased odds of stroke/TIA (OR:1.96, 95%CI:1.45-2.65, P < 0.001) when compared to CEA females. TFCAS males had almost twice the odds of stroke/death (OR:1.74, 95%CI:1.39-2.16, P < 0.001) and 44% higher odds of stroke/death/MI (OR:1.44, 95%CI:1.19-1.75, P < 0.001), and more than 3-times increased odds of death (OR:3.45, 95%CI:2.53-4.71, P < 0.001) when compared to CEA males. Odds of in-hospital stroke were comparable between TFCAS and CEA after adjusting for covariates. TCAR males have half the odds of MI when compared to CEA males (OR:0.52, 95%CI:0.34-0.80, P = 0.003). At 1-year TCAR had comparable risk of stroke/death while TFCAS had increased risk of stroke/death when compared to CEA among both males and females. CONCLUSION TCAR performed similarly to CEA in both sexes regardless of symptomatic status. Stroke/death and stroke/death/MI rates were similar in symptomatic and asymptomatic males and females treated by CEA or TCAR. The 1-year outcomes of TCAR were also comparable to CEA in both sexes. It seems that TCAR may be a safe alternative to CEA particularly in women when surgical risk prohibits CEA and while TFCAS is associated with substantial adverse outcomes.
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Lettenberger AB, Murali B, Legeza P, Byrne MD, Lumsden AB, O'Malley MK. Comparing Manual and Robotic-Assisted Carotid Artery Stenting Using Motion-Based Performance Metrics. ANNUAL INTERNATIONAL CONFERENCE OF THE IEEE ENGINEERING IN MEDICINE AND BIOLOGY SOCIETY. IEEE ENGINEERING IN MEDICINE AND BIOLOGY SOCIETY. ANNUAL INTERNATIONAL CONFERENCE 2021; 2021:1388-1391. [PMID: 34891544 DOI: 10.1109/embc46164.2021.9630895] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
Carotid artery stenting (CAS) is a minimally invasive endovascular procedure used to treat carotid artery disease and is an alternative treatment option for carotid artery stenosis. Robotic assistance is becoming increasingly widespread in these procedures and can provide potential benefits over manual intervention, including decreasing peri- and post-operative risks associated with CAS. However, the benefits of robotic assistance in CAS procedures have not been quantitatively verified at the level of surgical tool motions. In this work, we compare manual and robot-assisted navigation in CAS procedures using performance metrics that reliably indicate surgical navigation proficiency. After extracting guidewire tip motion profiles from recorded procedure videos, we computed spectral arc length (SPARC), a frequency-domain metric of movement smoothness, average guidewire velocity, and amount of idle tool motion (idle time) for a set of CAS procedures performed on a commercial endovascular surgical simulator. We analyzed the metrics for two procedural steps that influence post-operative outcomes. Our results indicate that during advancement of the sheath to the distal common carotid artery, there are significant differences in SPARC (F(1, 22.3) = 6.12, p = .021) and idle time (F(1, 22.6) = 6.26, p = .02) between manual and robot-assisted navigation, as well as a general trend of lower SPARC, lower average velocity, and higher idle time values associated with robot-assisted navigation for both procedural steps. Our findings indicate that significant differences exist between manual and robot-assisted CAS procedures. These are quantitatively detectable at the granular-level of physical tool motion, improving the ability to evaluate robotic assistance as it grows in clinical use.
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Bonati LH, Kakkos S, Berkefeld J, de Borst GJ, Bulbulia R, Halliday A, van Herzeele I, Koncar I, McCabe DJ, Lal A, Ricco JB, Ringleb P, Taylor-Rowan M, Eckstein HH. European Stroke Organisation guideline on endarterectomy and stenting for carotid artery stenosis. Eur Stroke J 2021; 6:I-XLVII. [PMID: 34414302 DOI: 10.1177/23969873211012121] [Citation(s) in RCA: 114] [Impact Index Per Article: 38.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2021] [Accepted: 04/05/2021] [Indexed: 01/01/2023] Open
Abstract
Atherosclerotic stenosis of the internal carotid artery is an important cause of stroke. The aim of this guideline is to analyse the evidence pertaining to medical, surgical and endovascular treatment of patients with carotid stenosis. These guidelines were developed based on the ESO standard operating procedure and followed the Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) approach. The working group identified relevant questions, performed systematic reviews and meta-analyses of the literature, assessed the quality of the available evidence, and wrote recommendations. Based on moderate quality evidence, we recommend carotid endarterectomy (CEA) in patients with ≥60-99% asymptomatic carotid stenosis considered to be at increased risk of stroke on best medical treatment (BMT) alone. We also recommend CEA for patients with ≥70-99% symptomatic stenosis, and we suggest CEA for patients with 50-69% symptomatic stenosis. Based on high quality evidence, we recommend CEA should be performed early, ideally within two weeks of the last retinal or cerebral ischaemic event in patients with ≥50-99% symptomatic stenosis. Based on low quality evidence, carotid artery stenting (CAS) may be considered in patients < 70 years old with symptomatic ≥50-99% carotid stenosis. Several randomised trials supporting these recommendations were started decades ago, and BMT, CEA and CAS have evolved since. The results of another large trial comparing outcomes after CAS versus CEA in patients with asymptomatic stenosis are anticipated in the near future. Further trials are needed to reassess the benefits of carotid revascularisation in combination with modern BMT in subgroups of patients with carotid stenosis.
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Affiliation(s)
- Leo H Bonati
- Department of Neurology, University Hospital Basel, Basel, Switzerland; Department of Clinical Research, University of Basel, Basel, Switzerland
| | - Stavros Kakkos
- Department of Vascular Surgery, University of Patras Medical School, Patras, Greece
| | - Joachim Berkefeld
- Institute of Neuroradiology, University Hospital of Frankfurt am Main, Frankfurt, Germany
| | - Gert J de Borst
- Department of Vascular Surgery, University Medical Center Utrecht, Utrecht, the Netherlands
| | - Richard Bulbulia
- Medical Research Council Population Health Research Unit, Clinical Trial Service Unit and Epidemiological Studies Unit, Nuffield Department of Population Health, University of Oxford, Oxford, UK
| | - Alison Halliday
- Medical Research Council Population Health Research Unit, Clinical Trial Service Unit and Epidemiological Studies Unit, Nuffield Department of Population Health, University of Oxford, Oxford, UK
| | - Isabelle van Herzeele
- Department of Thoracic and Vascular Surgery, Ghent University Hospital, Ghent, Belgium
| | - Igor Koncar
- Clinic for Vascular and Endovascular Surgery, Serbian Clinical Centre, Belgrade, Serbia
| | - Dominick Jh McCabe
- Department of Neurology and Stroke Service, The Adelaide and Meath Hospital, Dublin, incorporating the National Children's Hospital - Tallaght University Hospital, Dublin, Ireland; Royal Free Campus, UCL Queen Square Institute of Neurology, London, UK; Academic Unit of Neurology, School of Medicine, Trinity College Dublin, Ireland
| | - Avtar Lal
- European Stroke Organisation, Basel, Switzerland
| | - Jean-Baptiste Ricco
- Department of Vascular Surgery and Department of Clinical Research, University of Poitiers, Poitiers, France
| | - Peter Ringleb
- Department of Neurology, University Hospital Heidelberg, Heidelberg, Germany
| | | | - Hans-Henning Eckstein
- Department for Vascular and Endovascular Surgery, University Hospital, Technical University of Munich (TUM), Munich, Germany
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Bai X, Zhang X, Yang W, Wang T, Wang Y, Feng Y, Yang K, Wang X, Ma Y, Jiao L. Safety and efficacy of transcarotid artery revascularisation versus carotid endarterectomy: protocol for a systematic review and meta-analysis study. BMJ Open 2021; 11:e043039. [PMID: 33947730 PMCID: PMC8098965 DOI: 10.1136/bmjopen-2020-043039] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/29/2022] Open
Abstract
INTRODUCTION In recent years, the transcarotid artery revascularisation (TCAR) with flow reversal technique has been developed to treat carotid artery stenosis. The superiority of TCAR over transfemoral carotid artery stenting has been demonstrated. However, the safety and efficacy of TCAR and carotid endarterectomy remain unclear. This study aims to introduce a protocol for a systematic review and meta-analysis to compare the morbidity and mortality rates between TCAR and carotid endarterectomy in the treatment of atherosclerotic carotid artery stenosis. METHODS AND ANALYSIS This protocol was drafted using the Preferred Reporting Items for Systematic Review and Meta-Analysis Protocols statement. Herein, major databases will be searched, including Medline, Web of Science, Embase and the Cochrane Library, and randomised controlled trials and high-quality observational studies will be included. We will screen all studies published from January 2000 to March 2021. Bias risk will be evaluated using the Cochrane Collaboration criteria or Methodological Index for Non-randomised Studies criteria, depending on the study type. Two reviewers will select eligible studies and extract the data independently. The primary outcome will include stroke or death during the perioperative period and follow-up. Subgroup and sensitivity analyses will be performed to explore any potential sources of heterogeneity. Specific results will be described in a narrative form when available eligible studies are insufficient for meta-analysis. Publication bias will be assessed using a funnel plot. ETHICS AND DISSEMINATION This study will summarise and analyse the existing literature; hence, ethics approval will not be required. The final results may be published at a relevant academic conference or in a journal. PROSPERO REGISTRATION NUMBER CRD42020178691.
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Affiliation(s)
- Xuesong Bai
- China International Neuroscience Institute (China-INI), Beijing, China
- Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Xiao Zhang
- China International Neuroscience Institute (China-INI), Beijing, China
- Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Wuyang Yang
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Tao Wang
- China International Neuroscience Institute (China-INI), Beijing, China
- Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Yan Wang
- China Medical University, Shenyang, Liaoning, China
| | - Yao Feng
- China International Neuroscience Institute (China-INI), Beijing, China
- Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Kun Yang
- Department of Evidence-Based Medicine, Xuanwu Hospital, Beijing, China
| | - Xue Wang
- Medical Library, Xuanwu Hospital, Beijing, China
| | - Yan Ma
- China International Neuroscience Institute (China-INI), Beijing, China
- Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Liqun Jiao
- China International Neuroscience Institute (China-INI), Beijing, China
- Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, Beijing, China
- Department of Interventional Neuroradiology, Xuanwu Hospital, Capital Medical University, Beijing, China
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Transcervical carotid artery revascularization: A systematic review and meta-analysis of outcomes. J Vasc Surg 2021; 74:657-665.e12. [PMID: 33864829 DOI: 10.1016/j.jvs.2021.03.032] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2020] [Accepted: 03/14/2021] [Indexed: 11/21/2022]
Abstract
OBJECTIVE Carotid artery stenosis is considered a determinant factor for cerebrovascular events, estimated to be the cause of 10% to 20% of all ischemic strokes. Transcervical carotid artery revascularization (TCAR) has been offered as an alternative to transfemoral carotid artery stenting and carotid endarterectomy to treat carotid artery stenosis. METHODS We performed a systematic review and meta-analysis of prospective and retrospective studies reporting the outcomes of patients who had undergone TCAR for carotid artery stenosis. The incidence of periprocedural adverse events was calculated. RESULTS A total of 45 studies with 14,588 patients met the predefined eligibility criteria and were included in the present meta-analysis. The technical success rate was 99% (95% confidence interval [CI], 98%-99%). The reasons for technical failure included an inability to cross the lesion and/or failure to deploy the stent. Access site complications occurred in 2% of all cases (95% CI, 1%-2%; 30 studies). Overall, the incidence of cranial nerve (CN) injuries was very rare, with only 33 of 8994 patients experiencing neurologic deficits attributed to CN involvement. Bleeding complications were reported by 20 studies and occurred in 2% (95% CI, 1%-3%) of all cases. The overall periprocedural all-cause mortality and stroke rate was 0.5% and 1.3%, respectively. In-stent restenosis was observed in 4 of 260 patients (1.5%; 7 studies), and early (30-day) reocclusion or acute thrombosis of the target lesion occurred in 12 of 1243 patients (∼1%; 11 studies). CONCLUSIONS The results from the present study have provided significant evidence that TCAR is a very promising and safe carotid revascularization approach with favorable technical success rates associated with low periprocedural stroke and CN injury rates.
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Editor's Choice - Early and Late Outcomes after Transcarotid Revascularisation for Internal Carotid Artery Stenosis: A Systematic Review and Meta-Analysis. Eur J Vasc Endovasc Surg 2021; 61:725-738. [PMID: 33674158 DOI: 10.1016/j.ejvs.2021.01.039] [Citation(s) in RCA: 25] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2020] [Revised: 12/01/2020] [Accepted: 01/20/2021] [Indexed: 01/11/2023]
Abstract
OBJECTIVE Transcarotid/transcervical revascularisation (TCAR) is an alternative to carotid endarterectomy (CEA) and transfemoral carotid stenting (tfCAS). This review aimed to evaluate pooled data on patients undergoing TCAR. DATA SOURCES Medline, Embase, Scopus, and Cochrane Library databases were used. REVIEW METHODS This systematic review was conducted under Systematic Reviews and Meta-Analysis guidelines. Eligible studies (published online up to September 2020) reported 30 day mortality and stroke/transient ischaemic attack (TIA) rates in patients undergoing TCAR. Data were pooled in a random effects model and weight of effect for each study was also reported. Quality of studies was evaluated according to Newcastle - Ottawa scale. RESULTS Eighteen studies (three low, seven medium, and eight high quality) included 4 852 patients (4 867 TCAR procedures). The pooled 30 day mortality rate was 0.7% (n = 32) (95% confidence interval [CI] 0.5 - 1.0), 30 day stroke rate 1.4% (n = 62) (95% CI 1.0 - 1.7), and 30 day stroke/TIA rate 2.0% (n = 92) (95% CI 1.4 - 2.7). Pooled technical success was 97.6% (95% CI 95.9 - 98.8). The cranial nerve injury rate was 1.2% (95% CI 0.7 - 1.9) (n = 14; data from 10 studies) while the early myocardial infarction (MI) rate was 0.4% (95% CI 0.2 - 0.6) (n = 16; data from 17 studies). The haematoma/bleeding rate was 3.4% (95% CI 1.7 - 5.8) (n = 135; data from 10 studies), with one third of these cases needing drainage or intervention. Within a follow up of 3 - 40 months the restenosis rate was 4% (95% CI 0.1 - 13.1) (data from nine studies; n = 64/530 patients) and death/stroke rate 4.5% (95% CI 1.8 - 8.4) (data from five studies; n = 184/3 742 patients). Symptomatic patients had a higher risk of early stroke/TIA than asymptomatic patients (2.5% vs. 1.2%; odds ratio 1.99; 95% CI 1.01 - 3.92); p = .046; data from eight studies). CONCLUSION TCAR is associated with promising early and late outcomes, with symptomatic patients having a higher risk of early cerebrovascular events. More prospective comparative studies are needed in order to verify TCAR as an established alternative treatment technique.
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Cui CL, Dakour-Aridi H, Eldrup-Jorgensen J, Schermerhorn ML, Siracuse JJ, Malas MB. Effects of timing on in-hospital and one-year outcomes after transcarotid artery revascularization. J Vasc Surg 2020; 73:1649-1657.e1. [PMID: 33038481 DOI: 10.1016/j.jvs.2020.08.148] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2020] [Accepted: 08/27/2020] [Indexed: 11/28/2022]
Abstract
OBJECTIVE The current recommendations are to perform carotid endarterectomy within 2 weeks of symptoms for maximum long-term stroke prevention, although urgent carotid endarterectomy within 48 hours has been associated with increased perioperative stroke. With the development and rapid adoption of transcarotid artery revascularization (TCAR), we decided to study the effect of timing on the outcomes after TCAR. METHODS The Vascular Quality Initiative database was searched for symptomatic patients who had undergone TCAR from September 2016 to November 2019. These patients were stratified by the interval to TCAR after symptom onset: urgent, within 48 hours; early, 3 to 14 days; and late, >14 days. The primary outcome was the in-hospital rate of combined stroke and death (stroke/death), evaluated using logistic regression analysis. The secondary outcome was the 1-year rate of recurrent ipsilateral stroke and mortality, evaluated using Kaplan-Meier survival analysis. RESULTS A total of 2608 symptomatic patients who had undergone TCAR were included. The timing was urgent for 144 patients (5.52%), early for 928 patients (35.58%), and late for 1536 patients (58.90%). Patients undergoing urgent intervention had an increased risk of in-hospital stroke/death, which was driven primarily by an increased risk of stroke. No differences were seen for in-hospital death. On adjusted analysis, urgent intervention resulted in a threefold increased risk of stroke (odds ratio [OR], 2.8; 95% confidence interval [CI], 1.3-6.2; P = .01) and a threefold increased risk of stroke/death (OR, 2.9; 95% CI, 1.3-6.4; P = .01) compared with late intervention. Patients undergoing early intervention had comparable risks of stroke (OR, 1.3; 95% CI, 0.7-2.3; P = .40) and stroke/death (OR, 1.2; 95% CI, 0.7-2.1; P = .48) compared with late intervention. On subset analysis, the type of presenting symptoms was an effect modifier. Patients presenting with stroke and those presenting with transient ischemic attack or amaurosis fugax both had an increased risk of stroke/death when undergoing urgent compared with late TCAR (OR, 2.7; 95% CI, 1.1-6.6; P = .04; and OR, 4.1; 95% CI, 1.1-15.0; P = .03, respectively). However only patients presenting with transient ischemic attack or amaurosis fugax had experienced an increased risk of stroke with urgent compared with late TCAR (OR, 5.0; 95% CI, 1.4-17.5; P < .01). At 1 year of follow-up, no differences were seen in the incidence of recurrent ipsilateral stroke (urgent, 0.7%; early, 0.2%; late, 0.1%; P = .13) or postdischarge mortality (urgent, 0.7%; early, 1.6%; late, 1.8%; P = .71). CONCLUSIONS We found that TCAR had a reduced incidence of stroke when performed 48 hours after symptom onset. Urgent TCAR within 48 hours of the onset of stroke was associated with a threefold increased risk of in-hospital stroke/death, with no added benefit for ≤1 year after intervention. Further studies are needed on long-term outcomes of TCAR stratified by the timing of the procedure.
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Affiliation(s)
- Christina L Cui
- Division of Vascular and Endovascular Surgery, Department of Surgery, University of California, San Diego, La Jolla, Calif
| | - Hanaa Dakour-Aridi
- Division of Vascular and Endovascular Surgery, Department of Surgery, University of California, San Diego, La Jolla, Calif
| | - Jens Eldrup-Jorgensen
- Division of Vascular and Endovascular Therapy, Department of Surgery, Maine Medical Center, Portland, Me
| | - Marc L Schermerhorn
- Division of Vascular and Endovascular Surgery, Department of Surgery, Beth Israel Deaconess Medical Center, Boston, Mass
| | - Jeffrey J Siracuse
- Division of Vascular and Endovascular Surgery, Department of Surgery, Boston University, Boston Medical Center, Boston, Mass
| | - Mahmoud B Malas
- Division of Vascular and Endovascular Surgery, Department of Surgery, University of California, San Diego, La Jolla, Calif.
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Malas MB, Dakour-Aridi H, Kashyap VS, Eldrup-Jorgensen J, Wang GJ, Motaganahalli RL, Cronenwett JL, Schermerhorn ML. TransCarotid Revascularization with Dynamic Flow reversal versus Carotid Endarterectomy in the Vascular Quality Initiative Surveillance Project. Ann Surg 2020; 276:398-403. [DOI: 10.1097/sla.0000000000004496] [Citation(s) in RCA: 30] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Coelho A, Prassaparo T, Mansilha A, Kappelle J, Naylor R, de Borst GJ. Critical Appraisal on the Quality of Reporting on Safety and Efficacy of Transcarotid Artery Stenting With Flow Reversal. Stroke 2020; 51:2863-2871. [PMID: 32811389 DOI: 10.1161/strokeaha.120.030283] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Transcarotid revascularization is an alternative to transfemoral carotid artery stenting, designed to avoid aortic arch manipulation and concomitant periprocedural stroke. This article aims to perform a detailed analysis on the quality of the currently available evidence on safety and efficacy of transcarotid artery revascularization. Although current evidence is promising, independent randomized controlled studies comparing transcarotid artery revascularization with carotid endarterectomy in recently symptomatic patients are lacking and will be necessary to establish the true value of transcarotid artery revascularization in carotid artery revascularization.
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Affiliation(s)
- Andreia Coelho
- Department of Angiology and Vascular Surgery, Centro Hospitalar Vila Nova de Gaia/Espinho, Portugal (A.C.).,Faculdade Medicina da Universidade do Porto, Portugal (A.C., A.M.)
| | | | - Armando Mansilha
- Faculdade Medicina da Universidade do Porto, Portugal (A.C., A.M.)
| | - Jaap Kappelle
- Department of Neurology (J.K.), University Medical Center Utrecht, the Netherlands
| | - Ross Naylor
- Department of Vascular Surgery, Leicester, United Kingdom (R.N.)
| | - Gert J de Borst
- Department of Vascular Surgery (G.J.d.B.), University Medical Center Utrecht, the Netherlands
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Mareedu R, Hwang J, Vyakaranam S, Inkollu S. Use of Transcarotid Artery Revascularization to Treat Symptomatic Carotid Artery Stenosis Associated with Free-Floating Thrombus. Ann Vasc Surg 2020; 70:568.e1-568.e3. [PMID: 32800887 DOI: 10.1016/j.avsg.2020.08.010] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2020] [Revised: 05/29/2020] [Accepted: 08/04/2020] [Indexed: 11/26/2022]
Abstract
BACKGROUND Free-floating thrombus in the internal carotid artery (ICA) has traditionally been treated via an open surgical approach through a longitudinal incision and exposure similar to that for carotid endarterectomy (CEA). In this case report, we present a novel use of transcarotid artery revascularization (TCAR) for the treatment of recurrent carotid stenosis associated with free-floating ICA thrombus. CASE DESCRIPTION We describe a 67-year-old female who presented with a diagnosis of right hemispheric stroke in evolution and prior history of right CEA and a mechanical mitral valve. Imaging confirmed high-grade recurrent stenosis of the right ICA with free-floating thrombus. TCAR was utilized to repair both the recurrent stenosis and the thrombus. CONCLUSIONS Redo CEA in the face of recurrent stenosis is a challenging clinical scenario, which in this instance, was further complicated by the presence of free-floating thrombus and active anticoagulation due to a mechanical mitral valve. This case report describes the successful management of ICA thrombus and restenosis with the novel use of TCAR.
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Affiliation(s)
- Ravi Mareedu
- Department of Cardiology, Ascension All Saints, Racine, WI, USA
| | - Jason Hwang
- Department of Vascular Surgery, West Virginia University, Morgantown, WV, USA
| | - Sudhir Vyakaranam
- Nephrology Phys LLC, Mishawaka, IN/IU School of Medicine-South Bend Campus, Indiana, USA
| | - Sashi Inkollu
- Department of Vascular Surgery, Marshfield Clinic Health System, Marshfield, WI, USA.
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Nana PN, Brotis AG, Spanos KT, Kouvelos GN, Matsagkas MI, Giannoukas AD. A systematic review and meta-analysis of carotid artery stenting using the transcervical approach. INT ANGIOL 2020; 39:372-380. [PMID: 32536113 DOI: 10.23736/s0392-9590.20.04434-x] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
Abstract
INTRODUCTION Carotid artery stenting (CAS) via a transcarotid revascularization (TCAR) approach has emerged as an alternative when carotid endarterectomy or conventional CAS is contraindicated. The present study was conducted to assess the feasibility and safety of TCAR in patients with carotid artery stenosis. EVIDENCE ACQUISITION A systematic review of the literature was performed, according to PRISMA guidelines (Preferred Reporting Items for Systematic reviews and Meta-Analyses), using PubMed, EMBASE and CENTRAL databases. The primary outcomes included technical success, perioperative neurological event, myocardial ischemic events, death and their composite. Operational duration, flow reversal time and any local procedure related complication (carotid dissection and cranial nerve injury) were also recorded. EVIDENCE SYNTHESIS Twenty-three studies were included, reporting on 3130 patients, undergoing TCAR. Thirty-five per cent of them were symptomatic. Technical success was 98% (95% CI: 0.97-0.99; P=0.11, I<sup>2</sup>=32%). Early (30-day) new neurological event rate was estimated at 2% (95% CI: 0.01-0.02; P=1.0, I<sup>2</sup>=0%, respectively) while early death rate was 1% (95% CI: 0.00-0.01; P=1.0, I<sup>2</sup>=0%). Myocardial ischemic (MI) event rate was 1% (95% CI, 0.00-0.01, P=0.97, I<sup>2</sup>=6.6%). The composite outcome of neurological event/MI/death at 30-day follow-up was 2% (95% CI: 0.01-0.02, P=0.79, I<sup>2</sup>=14%). Carotid dissection rate during the intervention was 2% (95% CI: 0.01-0.03, P=0.58, I<sup>2</sup>=2.9%) while the post-operatively detected cranial nerve injury rate was 1% (95% CI, 0.00-0.01, P=1.0, I<sup>2</sup>=0%). Regarding the technical aspects of the procedures, operational and flow reversal time were at 73.8 min and 13.7 min, respectively (95% CI: 68.2-79.3, P=0.18, I<sup>2</sup>=37.6% and 95% CI: 11.3-16.1, P=0.48, I<sup>2</sup>=0%, respectively). CONCLUSIONS TCAR is feasible with high technical success rate. The procedure presents low incidence of local complications, neurological events, myocardial complications and mortality during the early postoperative period and should be considered an acceptable alternative for patients treated for carotid artery stenosis.
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Affiliation(s)
- Petroula N Nana
- Department of Vascular Surgery, Faculty of Medicine, School of Health Sciences, University Hospital of Larissa, University of Thessaly, Larissa, Greece -
| | - Alexandros G Brotis
- Department of Neurosurgery, Faculty of Medicine, School of Health Sciences, University Hospital of Larissa, University of Thessaly, Larissa, Greece
| | - Konstantinos T Spanos
- Department of Vascular Surgery, Faculty of Medicine, School of Health Sciences, University Hospital of Larissa, University of Thessaly, Larissa, Greece
| | - George N Kouvelos
- Department of Vascular Surgery, Faculty of Medicine, School of Health Sciences, University Hospital of Larissa, University of Thessaly, Larissa, Greece
| | - Miltiadis I Matsagkas
- Department of Vascular Surgery, Faculty of Medicine, School of Health Sciences, University Hospital of Larissa, University of Thessaly, Larissa, Greece
| | - Athanasios D Giannoukas
- Department of Vascular Surgery, Faculty of Medicine, School of Health Sciences, University Hospital of Larissa, University of Thessaly, Larissa, Greece
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A Systematic Review and Meta-Analysis of Transcarotid Artery Revascularization with Dynamic Flow Reversal Versus Transfemoral Carotid Artery Stenting and Carotid Endarterectomy. Ann Vasc Surg 2020; 69:426-436. [PMID: 32505684 DOI: 10.1016/j.avsg.2020.05.070] [Citation(s) in RCA: 46] [Impact Index Per Article: 11.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2020] [Revised: 05/20/2020] [Accepted: 05/24/2020] [Indexed: 10/24/2022]
Abstract
BACKGROUND Transfemoral carotid artery stenting (TFCAS) was introduced as a less invasive option for carotid revascularization in patients at high risk for complications from carotid endarterectomy (CEA). The increased perioperative stroke and death risk of TFCAS has however prevented TFCAS from widespread acceptance as an alternative to CEA in high-risk patients. Recent research suggests that transcarotid artery revascularization (TCAR) may be associated with a low stroke and death risk and potentially meet the needs of patients at high surgical risk. We aimed to estimate the 30-day risk of stroke or death of TCAR and compare it to TFCAS and CEA. METHODS We searched PubMed, Cochrane, Embase, and Scopus for studies of patients treated with TCAR. Meta-analysis was conducted when appropriate. A logistic-normal random-effects model with logit transformation was used to estimate the pooled event rates after TCAR. Pooled Mantel-Haenszel odds ratios (ORs) of events comparing TCAR to TFCAS and CEA were calculated using a fixed-effects model. Heterogeneity among studies was quantified with the chi-squared statistic of the likelihood ratio (LR) test that compares the random-effects and fixed-effects models. RESULTS Nine nonrandomized studies evaluating 4012 patients who underwent TCAR were included. The overall 30-day risks after TCAR were stroke/death, 1.89% (95% confidence interval [CI]: 1.50, 2.37); stroke, 1.34% (95% CI: 1.02,1.75); death, 0.76% (95% CI: 0.56, 1.08); myocardial infarction (MI), 0.60% (95% CI: 0.23, 1.59); stroke/death/MI, 2.20% (95% CI: 1.31, 3.69); cranial nerve injury (CNI), 0.31% (95% CI: 0.12, 0.83). The failure rate of TCAR was 1.27% (95% CI: 0.32, 4.92). Two nonrandomized studies suggested that TCAR was associated with lower risk of stroke and death as compared with TFCAS (1.33% vs. 2.55%, OR: 0.52, 95% CI: 0.36, 0.74 and 0.76% vs. 1.46%, OR: 0.52, 95% CI: 0.32, 0.84, respectively). Four nonrandomized studies suggested that TCAR was associated with a lower risk of CNI (0.54% and 1.84%, OR: 0.52, 95% CI: 0.36, 0.74) than CEA, but no statistically significant difference in the 30-day risk of stroke, stroke/death, or stroke/death/MI. CONCLUSIONS Among patients undergoing TCAR with dynamic flow reversal for carotid stenosis the 30-day risk of stroke or death was low. The perioperative stroke/death rate of TCAR was similar to that of CEA while CNI risk was lower. Larger prospective studies are needed to account for confounding factors and provide higher certainty.
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Paraskevas KI, Antonopoulos CN, Kakisis JD, Geroulakos G. An updated systematic review and meta-analysis of results of transcervical carotid artery stenting with flow reversal. J Vasc Surg 2020; 72:1489-1498.e1. [PMID: 32422272 DOI: 10.1016/j.jvs.2020.04.501] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2019] [Accepted: 04/07/2020] [Indexed: 01/12/2023]
Abstract
OBJECTIVE Transcervical carotid artery stenting (CAS) has emerged as an alternative to transfemoral CAS. An earlier systematic review from our group (n = 12 studies; 739 transcervical CAS procedures [489/739 with flow reversal]) demonstrated that transcervical CAS is a safe procedure associated with a low incidence of stroke and complications. Since then, new studies have been published adding nearly 1600 patients to the literature. We aimed to update our early systematic review and also to perform a meta-analysis to investigate outcomes specifically after transcervical CAS with flow reversal. METHODS An electronic search of PubMed/MEDLINE, Embase, and the Cochrane databases was carried out to identify studies reporting outcomes after transcervical CAS with flow reversal. Crude event rates for outcomes of interest were estimated by simple pooling of data. A proportion meta-analysis was also performed to estimate pooled outcome rates. RESULTS A total of 18 studies (n = 2110 transcervical CAS procedures with flow reversal) were identified. A high technical success (98.25%) and a low mortality rate (0.48%) were recorded. The crude rates of major stroke, minor stroke, transient ischemic attack, and myocardial infarction (MI) were 0.71%, 0.90%, 0.57%, and 0.57%, respectively; a cranial nerve injury occurred in 0.28% of the procedures. A neck hematoma was reported in 1.04% of the procedures, and a carotid artery dissection occurred in 0.76% of the interventions; in 1.09% of the cases, conversion to carotid endarterectomy was required. After a meta-analysis was undertaken, the pooled technical success rate was 98.69% (95% confidence interval [CI], 97.19-99.70). A pooled mortality rate of 0.04% (95% CI, 0.00-0.29) was recorded. The pooled rate of any type of neurologic complications was 1.88 (95% CI, 1.24-2.61), whereas the pooled rates of major stroke, minor stroke, and transient ischemic attack were 0.12% (95% CI, 0.00-0.46), 0.15% (95% CI, 0.00-0.50), and 0.01% (95% CI, 0.00-0.22), respectively. The pooled rate of bradycardia/hypotension was 10.21% (95% CI, 3.99-18.51), whereas the pooled rate of MI was 0.08% (95% CI, 0.00-0.39). A neck hematoma after transcervical CAS was recorded in 1.51% (95% CI, 0.22-3.54) of the procedures; in 0.74% (95% CI, 0.05-1.95) of the interventions, conversion to CEA was required. Finally, a carotid artery dissection during transcervical CAS occurred in 0.47% (95% CI, 0.00-1.38) of the procedures. CONCLUSIONS This updated systematic review and meta-analysis demonstrated that transcervical CAS with flow reversal is associated with high technical success, almost zero mortality, and low rates of major stroke, minor stroke, MI, and complications.
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Affiliation(s)
- Kosmas I Paraskevas
- Department of Vascular Surgery, "Attikon" University Hospital, National and Kapodistrian University of Athens, Athens, Greece.
| | - Constantine N Antonopoulos
- Department of Vascular Surgery, "Attikon" University Hospital, National and Kapodistrian University of Athens, Athens, Greece
| | - John D Kakisis
- Department of Vascular Surgery, "Attikon" University Hospital, National and Kapodistrian University of Athens, Athens, Greece
| | - George Geroulakos
- Department of Vascular Surgery, "Attikon" University Hospital, National and Kapodistrian University of Athens, Athens, Greece
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Giannopoulos S, Armstrong EJ. WIRION™ embolic protection system for carotid artery stenting and lower extremity endovascular intervention. Future Cardiol 2020; 16:527-538. [PMID: 32253940 DOI: 10.2217/fca-2020-0023] [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: 12/24/2022] Open
Abstract
Aim: To summarize all available literature regarding the Wirion™ embolic protection system (EPS) and present examples from our center. Materials & methods: A review of literture was performed about the utilization of Wirion EPS. Results: One study was identified investigating the outcomes of Wirion during carotid artery stenting. The study demonstrated 98.3% procedural success with stroke occurring in only 2.5%. Two single arm studies were identified investigating the efficacy of the Wirion filter during lower extremity endovascular interventions. The reported device success ranged from 95.1 to 97.3%. Conclusion: While carotid artery stenting should always be performed with adjunctive EPS in order to decrease the risk of cerebrovascular accidents, the routine use of EPS in femorpopliteal interventions remains an active area of investigation.
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Affiliation(s)
- Stefanos Giannopoulos
- Division of Cardiology, Rocky Mountain Regional VA Medical Center, University of Colorado, Denver, CO 80045, USA
| | - Ehrin J Armstrong
- Division of Cardiology, Rocky Mountain Regional VA Medical Center, University of Colorado, Denver, CO 80045, USA
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Luk Y, Chan YC, Cheng SW. Transcarotid Artery Revascularization as a New Modality of Treatment for Carotid Stenosis. Ann Vasc Surg 2020; 64:397-404. [DOI: 10.1016/j.avsg.2019.11.001] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2019] [Revised: 10/22/2019] [Accepted: 11/01/2019] [Indexed: 10/25/2022]
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Carotid Artery Stenting in Asymptomatic Carotid Artery Stenosis: JACC Review Topic of the Week. J Am Coll Cardiol 2020; 75:648-656. [PMID: 32057380 DOI: 10.1016/j.jacc.2019.11.054] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/08/2019] [Accepted: 11/19/2019] [Indexed: 01/22/2023]
Abstract
The advance of therapies to reduce the stroke impact of asymptomatic carotid artery stenosis has proved difficult over the last decade. Disagreement concerning the underlying randomized control trials has limited entry into the care arena of endovascular therapies. Recently, advances in percutaneous therapies for carotid artery disease have been reported and provide a substantial database supporting the further incorporation of endovascular-based therapies in patients who need revascularization and meet selection criteria. With a second randomized control trial now published, it is time for a re-evaluation of endovascular therapy as a component of carotid artery care. This review describes the advances in the field in the last 5 years, clarifying the current position of these therapies in the care of the patient with asymptomatic carotid artery disease.
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Kolvenbach RR. Current role of transcervical carotid artery stenting with flow reversal. ITALIAN JOURNAL OF VASCULAR AND ENDOVASCULAR SURGERY 2019. [DOI: 10.23736/s1824-4777.19.01423-2] [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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Sabat J, Bock D, Hsu CH, Tan TW, Weinkauf C, Trouard T, Perez-Carrillo GG, Zhou W. Risk factors associated with microembolization after carotid intervention. J Vasc Surg 2019; 71:1572-1578. [PMID: 31493967 DOI: 10.1016/j.jvs.2019.06.202] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2019] [Accepted: 06/30/2019] [Indexed: 11/19/2022]
Abstract
BACKGROUND Microembolization after carotid artery stenting (CAS) and carotid endarterectomy (CEA) has been documented and may confer risk for neurocognitive impairment. Patients undergoing stenting are known to be at higher risk for microembolization. In this prospective cohort study, we compare the microembolization rates for patients undergoing CAS and CEA and perioperative characteristics that may be associated with microembolization. METHODS Patients undergoing CAS and CEA were prospectively recruited under local institutional review board approval from an academic medical center. All patients also received 3T brain magnetic resonance imaging with a diffusion-weighted imaging sequence preoperatively and within 24 hours postoperatively to identify procedure-related new embolic lesions. Preoperative, postoperative, procedural factors, and plaque characteristics were collected. Factors were tested for statistical significance with logistic regression. RESULTS A total of 202 patients were enrolled in the study. There were 107 patients who underwent CAS and 95 underwent CEA. Patients undergoing CAS were more likely to have microemboli than patients undergoing CEA (78% vs 27%; P < .0001). For patients undergoing CAS, patency of the external carotid artery (odds ratio [OR], 11.4; 95% confidence interval [CI], 1.11-117.6; P = .04), lesion calcification (OR, 5.68; 95% CI, 1.12-28.79; P = .04), and lesion length (OR, 0.29; 95% CI, 0.08-1.01; P = .05) were all found to be independent risk factors for perioperative embolization. These factors did not confer increased risk to patients undergoing CEA. CONCLUSIONS Patients undergoing CAS are at higher risk for perioperative embolization. The risk for perioperative embolization is related to the length of the lesion and calcification. Identifying the preoperative risk factors may help to guide patient selection and, thereby, reduce embolization-related neurocognitive impairment.
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Affiliation(s)
- Joseph Sabat
- Division of Vascular Surgery, University of Arizona College of Medicine, Tucson, Ariz
| | - Diane Bock
- Division of Vascular Surgery, University of Arizona College of Medicine, Tucson, Ariz
| | - Chiu-Hsieh Hsu
- Division of Epidemiology and Biostatistics, University of Arizona College of Medicine, Tucson, Ariz
| | - Tze-Woei Tan
- Division of Vascular Surgery, University of Arizona College of Medicine, Tucson, Ariz
| | - Craig Weinkauf
- Division of Vascular Surgery, University of Arizona College of Medicine, Tucson, Ariz
| | | | | | - Wei Zhou
- Division of Vascular Surgery, University of Arizona College of Medicine, Tucson, Ariz.
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Müller MD, von Felten S, Algra A, Becquemin JP, Bulbulia R, Calvet D, Eckstein HH, Fraedrich G, Halliday A, Hendrikse J, Howard G, Gregson J, Jansen O, Brown MM, Mas JL, Brott TG, Ringleb PA, Bonati LH. Secular Trends in Procedural Stroke or Death Risks of Stenting Versus Endarterectomy for Symptomatic Carotid Stenosis. Circ Cardiovasc Interv 2019; 12:e007870. [PMID: 31378071 DOI: 10.1161/circinterventions.119.007870] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Over the past decades, stroke risk associated with carotid disease has decreased, reflecting improvements in medical therapy and a more rigorous control of vascular risk factors. It is less clear whether the procedural risk of carotid revascularization has declined over time. METHODS We analyzed temporal changes in procedural risks among 4597 patients with symptomatic carotid stenosis treated with carotid artery stenting (n=2326) or carotid endarterectomy (n=2271) in 4 randomized trials between 2000 and 2008, using generalized linear mixed-effects models with a random intercept for each source trial. Models were additionally adjusted for age and other baseline characteristics predicting treatment risk. The primary outcome event was any procedural stroke or death, occurring during or within 30 days after revascularization. RESULTS The procedural stroke or death risk decreased significantly over time in all patients (unadjusted odds ratio per year, 0.91; 95% CI, 0.85-0.97; P=0.006). This effect was driven by a decrease in the carotid endarterectomy group (unadjusted odds ratio per year, 0.82; 95% CI, 0.73-0.92; P=0.003), whereas no significant decrease was found after carotid artery stenting (unadjusted odds ratio, 0.96; 95% CI, 0.88-1.04; P=0.33). Carotid endarterectomy patients had a lower procedural stroke or death risk compared with carotid artery stenting patients, and the difference significantly increased over time (interaction P=0.031). After adjustment for baseline characteristics, the results remained essentially the same. CONCLUSIONS The risk of stroke or death associated with carotid endarterectomy for symptomatic carotid stenosis decreased over an 8-year period, independent of clinical predictors of procedural risk. No corresponding reduction in procedural risk was seen in patients treated with stenting. CLINICAL TRIAL REGISTRATION URL: https://www.clinicaltrials.gov; http://www.isrctn.com. Unique identifier: NCT00190398 (EVA-3S), NCT00004732 (CREST), ISRCTN57874028 (SPACE), and ISRCTN25337470 (ICSS).
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Affiliation(s)
- Mandy D Müller
- Department of Neurology and Stroke Center (M.D.M. and L.H.B.), University Hospital Basel, University of Basel, Switzerland
| | - Stefanie von Felten
- Department of Clinical Research, Clinical Trial Unit (S.v.F.), University Hospital Basel, University of Basel, Switzerland
| | - Ale Algra
- Department of Neurology and Neurosurgery, Brain Center Rudolf Magnus and Julius Center for Health Sciences and Primary Care (A.A.), University Medical Center Utrecht, Utrecht University, the Netherlands
| | - Jean-Pierre Becquemin
- Vascular Institute Paris East, Hôpital privé Paul D'Egine, Ramsay Group, Champigny sur Marne, France (J.-P.B.)
| | - Richard Bulbulia
- Clinical Trial Service Unit and Epidemiological Studies Unit (R.B.), Nuffield Department of Population Health, University of Oxford, United Kingdom
- Medical Research Council Population Health Research Unit (R.B.), Nuffield Department of Population Health, University of Oxford, United Kingdom
| | - David Calvet
- Department of Neurology, Hôpital Sainte-Anne, Université Paris-Descartes, DHU Neurovasc Sorbonne Paris Cité, INSERM U894, France (D.C., J.-L.M.)
| | - Hans-Henning Eckstein
- Department of Vascular and Endovascular Surgery, Klinikum rechts der Isar, Technical University of Munich, Germany (H.-H.E.)
| | - Gustav Fraedrich
- Department of Vascular Surgery, Medical University of Innsbruck, Austria (G.F.)
| | - Alison Halliday
- Nuffield Department of Surgical Sciences, John Radcliffe Hospital, Oxford, United Kingdom (A.H.)
| | - Jeroen Hendrikse
- Department of Radiology (J.H.), University Medical Center Utrecht, Utrecht University, the Netherlands
| | - George Howard
- Department of Biostatistics, UAB School of Public Health, Birmingham, AL (G.H.)
| | - John Gregson
- Department of Medical Statistics, London School of Hygiene and Tropical Medicine, United Kingdom (J.G.)
| | - Olav Jansen
- Clinic for Radiology and Neuroradiology, Universitätsklinikum Schleswig-Holstein Campus Kiel, Germany (O.J.)
| | - Martin M Brown
- Department of Brain Repair and Rehabilitation, Stroke Research Centre, UCL Queen Square Institute of Neurology, University College London, United Kingdom (M.M.B., L.H.B.)
| | - Jean-Louis Mas
- Department of Neurology, Hôpital Sainte-Anne, Université Paris-Descartes, DHU Neurovasc Sorbonne Paris Cité, INSERM U894, France (D.C., J.-L.M.)
| | - Thomas G Brott
- Department of Neurology, Mayo Clinic, Jacksonville, FL (T.G.B.)
| | - Peter A Ringleb
- Department of Neurology, University of Heidelberg Medical School, Germany (P.A.R.)
| | - Leo H Bonati
- Department of Neurology and Stroke Center (M.D.M. and L.H.B.), University Hospital Basel, University of Basel, Switzerland
- Department of Brain Repair and Rehabilitation, Stroke Research Centre, UCL Queen Square Institute of Neurology, University College London, United Kingdom (M.M.B., L.H.B.)
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Age but not sex is associated with higher risk of in-hospital stroke or death after carotid artery stenting in symptomatic and asymptomatic carotid stenosis. J Vasc Surg 2019; 69:1090-1101.e3. [DOI: 10.1016/j.jvs.2018.03.439] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2017] [Accepted: 03/30/2018] [Indexed: 11/20/2022]
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Texakalidis P, Giannopoulos S, Kokkinidis DG, Charisis N, Kakkar A, Jabbour P, Rangel-Castilla L, Armstrong EJ, Reavey-Cantwell J. Direct Transcervical Access vs the Transfemoral Approach for Carotid Artery Stenting: A Systematic Review and Meta-Analysis. J Endovasc Ther 2019; 26:219-227. [PMID: 30821193 DOI: 10.1177/1526602819833370] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/19/2023]
Abstract
PURPOSE To examine the safety profile of transcervical access (TCA) in comparison with the transfemoral approach (TFA) in carotid artery stenting. MATERIALS AND METHODS A systematic review and meta-analysis was performed according to current guidelines. Eleven eligible studies including 11,592 patients (10,736 in the TFA group and 856 in the TCA group) were identified through a search of the PubMed, Scopus, and Cochrane databases up to October 2018. A random effects model meta-analysis was conducted, and the I2 statistic was used to assess heterogeneity. Publication bias was assessed using funnel plots and quantified using the Egger method. RESULTS The TFA group had a statistically significantly higher risk of periprocedural (30-day) stroke compared with the TCA group (OR 1.98, 95% CI 1.08 to 3.63, p=0.027; I2=0%). Also, patients in the TFA group had a significantly higher risk of developing new ischemic lesions (OR 2.97, 95% CI 1.48 to 5.96, p=0.002; I2=0%) on diffusion-weighted magnetic resonance imaging (DW-MRI). No differences in terms of transient ischemic attack (OR 1.50, 95% CI 0.73 to 3.10, p=0.268; I2=5.9%), myocardial infarction (OR 0.64, 95% CI 0.30 to 1.35; p=0.242; I2=0%), local hematoma (OR 0.53, 95% CI 0.12 to 2.25, p=0.389; I2=0%), or mortality (OR 1.35, 95% CI 0.62 to 2.92, p=0.449; I2=0%) were identified between the groups. CONCLUSION TCA is associated with a significantly lower risk for periprocedural stroke and DW-MRI ischemic lesions compared with TFA. Other periprocedural outcomes were similar between the groups.
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Affiliation(s)
- Pavlos Texakalidis
- 1 Department of Neurosurgery, School of Medicine, Emory University, Atlanta, GA, USA
| | | | - Damianos G Kokkinidis
- 3 Department of Medicine, Jacobi Medical Center, Albert Einstein College of Medicine, Bronx, NY, USA
| | | | - Amit Kakkar
- 5 Department of Cardiology, Jacobi Medical Center, Albert Einstein College of Medicine, Bronx, NY, USA
| | - Pascal Jabbour
- 6 Department of Neurosurgery, Thomas Jefferson University, Philadelphia, PA, USA
| | | | - Ehrin J Armstrong
- 8 Division of Cardiology, Denver VA Medical Center, University of Colorado, Denver, CO, USA
| | - John Reavey-Cantwell
- 9 Department of Neurosurgery, Virginia Commonwealth University, Richmond, VA, USA
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Paraskevas KI, de Borst GJ, Eckstein HH, Schermerhorn ML. Transfemoral vs Transcervical Carotid Artery Stenting. J Endovasc Ther 2019; 26:228-230. [DOI: 10.1177/1526602819833496] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/30/2023]
Affiliation(s)
| | - Gert J. de Borst
- Department of Vascular Surgery, University Medical Center, Utrecht, the Netherlands
| | - Hans-Henning Eckstein
- Department of Vascular and Endovascular Surgery, Klinikum rechts der Isar, Technical University of Munich, Germany
| | - Marc L. Schermerhorn
- Division of Vascular and Endovascular Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
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Liang P, Wu WW, Schermerhorn ML. Recent advances in the treatment of carotid artery disease. THE JOURNAL OF CARDIOVASCULAR SURGERY 2019; 60:345-353. [PMID: 30845790 DOI: 10.23736/s0021-9509.19.10922-6] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
Abstract
Transfemoral carotid stenting has struggled to become a suitable alternative to carotid endarterectomy for the treatment of carotid disease because of higher perioperative stroke risks, even with use of embolic protection devices. To reduce the perioperative stroke rates associated with carotid stenting, several advancements in stent design, embolic protection systems, and technical approaches have been developed. Transcarotid artery revascularization (TCAR) was also recently introduced as a novel carotid artery stenting option which circumvents several of the high embolic-risk maneuvers found in transfemoral carotid stenting and employs a flow reversal system that provides continuous embolic protection throughout the procedure. Early results from this technique have shown low stroke/death rates comparable to carotid endarterectomy while maintaining the minimally invasive benefits of carotid stenting. TCAR has a strong potential to become the preferred method of carotid stenting in the near future and may challenge carotid endarterectomy as the preferred carotid artery revascularization method.
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Affiliation(s)
- Patric Liang
- Division of Vascular and Endovascular Surgery, Department of Surgery, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, MA, USA
| | - Winona W Wu
- Division of Vascular and Endovascular Surgery, Department of Surgery, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, MA, USA
| | - Marc L Schermerhorn
- Division of Vascular and Endovascular Surgery, Department of Surgery, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, MA, USA -
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Garriboli L, Pruner G, Miccoli T, Recchia A, Tamellini P, Jannello AM. Carotid Artery Stenting Without Embolic Protection Device: A Single-Center Experience. J Endovasc Ther 2018; 26:121-127. [PMID: 30514133 DOI: 10.1177/1526602818816656] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
PURPOSE To evaluate the safety and efficacy of carotid artery stenting (CAS) performed without an embolic protection device (EPD) in a selected group of asymptomatic patients with primary internal carotid artery (ICA) stenosis or restenosis after carotid endarterectomy (CEA). MATERIALS AND METHODS Between May 2015 and May 2018, 77 patients (mean age 77 years; 60 men) underwent CAS without any embolic protection device. Forty-seven (61%) patients had primary ICA stenosis and were excluded from CEA because of high surgical risk; the other 30 (39%) patients had post-CEA restenosis (n=26) or a distal ICA flap after eversion CEA (n=4). The mean ICA stenosis was 82%. All procedures were performed from a femoral artery access. Pre- and/or postdilation were used in 64 patients. The primary outcome was the incidence of major complications (death, stroke, or myocardial infarction) during the procedure and within 30 days; the secondary outcome was the incidence of restenosis in follow-up. RESULTS No relevant bradycardia was encountered during CAS. The combined rate of stroke, death, or myocardial infarction at 30 days was 1.3%. The single stroke patient recovered fully after 2 months. Over a follow-up that ranged to 3 years (mean 24±18 months), no further neurological events were recorded. One (1.3%) patient had a >70% restenosis after 6 months; the lesion was dilated, successfully restoring the lumen contour. CONCLUSION In our series, endovascular treatment of carotid stenosis without the use of protection devices in patients with primary stenosis or postsurgical restenosis can achieve satisfactory safety and efficacy outcomes. The choice of performing CAS without using EPDs should follow a tailored approach based on the appropriate patient anatomy and specific clinical parameters to minimize neurological complications.
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Affiliation(s)
- Luca Garriboli
- 1 Department of Vascular and Endovascular Surgery, IRCCS Sacro Cuore Don Calabria, Negrar, Italy
| | - Gianguido Pruner
- 1 Department of Vascular and Endovascular Surgery, IRCCS Sacro Cuore Don Calabria, Negrar, Italy
| | - Tommaso Miccoli
- 1 Department of Vascular and Endovascular Surgery, IRCCS Sacro Cuore Don Calabria, Negrar, Italy
| | - Andrea Recchia
- 1 Department of Vascular and Endovascular Surgery, IRCCS Sacro Cuore Don Calabria, Negrar, Italy
| | - Paolo Tamellini
- 1 Department of Vascular and Endovascular Surgery, IRCCS Sacro Cuore Don Calabria, Negrar, Italy
| | - Antonio Maria Jannello
- 1 Department of Vascular and Endovascular Surgery, IRCCS Sacro Cuore Don Calabria, Negrar, Italy
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Texakalidis P, Letsos A, Kokkinidis DG, Schizas D, Karaolanis G, Giannopoulos S, Giannopoulos S, Economopoulos KP, Bakoyannis C. Proximal embolic protection versus distal filter protection versus combined protection in carotid artery stenting: A systematic review and meta-analysis. CARDIOVASCULAR REVASCULARIZATION MEDICINE 2017; 19:545-552. [PMID: 29502959 DOI: 10.1016/j.carrev.2017.12.010] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2017] [Accepted: 12/22/2017] [Indexed: 11/25/2022]
Abstract
OBJECTIVE Proximal embolic protection devices (P-EPD) and distal filters (DF) are used to prevent distal cerebral embolizations during carotid artery stenting (CAS). We compared their comparative effectiveness in regards to prevention of intraprocedural and periprocedural adverse events, including ischemic lesions (ipsilateral and contralateral), stroke, transient ischemic attacks (TIA) and death. We also compared the combination of the two neuroprotection strategies vs. a single strategy in regards to ischemic lesions and stroke. MATERIALS & METHODS This study was performed according to the PRISMA and MOOSE guidelines and eligible studies were identified through search of PubMed, Scopus and Cochrane Central. A meta-analysis was conducted with the use of a random effects model. The I-square statistic was used to assess for heterogeneity. RESULTS Twenty-nine studies involving 16,307 patients were included. There was a significant reduction in ischemic lesions with the use of P-EPD among observational studies (RR: 0.66 [0.45-0.97]). There were no statistically significant differences for the other outcomes between the two treatment groups. CONCLUSIONS There is a number of studies reporting outcomes on the comparison between P-EPD and DF for CAS. P-EDP can reduce distal embolization phenomena resulting into ischemic lesions when compared to DF based on the results from real-world studies. P-EPD was not superior however, in regards to periprocedural stroke, TIA and death. Further studies are anticipated to provide a clear answer to this debate.
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Affiliation(s)
- Pavlos Texakalidis
- Aristotle University of Thessaloniki, Thessaloniki, Greece; Society of Junior Doctors, Menalou 5 Street, 15123 Athens, Greece.
| | - Alexandros Letsos
- University of Crete, Heraklion, Greece; Society of Junior Doctors, Menalou 5 Street, 15123 Athens, Greece
| | - Damianos G Kokkinidis
- Department of Medicine, Jacobi Medical Center, Albert Einstein College of Medicine, Bronx, NY, United States; Society of Junior Doctors, Menalou 5 Street, 15123 Athens, Greece
| | - Dimitrios Schizas
- 1st Department of Surgery, National and Kapodistrian University of Athens, Laikon Hospital, 11527 Athens, Greece; Society of Junior Doctors, Menalou 5 Street, 15123 Athens, Greece
| | - Georgios Karaolanis
- 1st Department of Surgery, National and Kapodistrian University of Athens, Laikon Hospital, 11527 Athens, Greece; Society of Junior Doctors, Menalou 5 Street, 15123 Athens, Greece
| | - Stefanos Giannopoulos
- 1st Department of Surgery, National and Kapodistrian University of Athens, Laikon Hospital, 11527 Athens, Greece; Society of Junior Doctors, Menalou 5 Street, 15123 Athens, Greece
| | - Spyridon Giannopoulos
- 1st Department of Surgery, National and Kapodistrian University of Athens, Laikon Hospital, 11527 Athens, Greece; Society of Junior Doctors, Menalou 5 Street, 15123 Athens, Greece
| | - Konstantinos P Economopoulos
- Division of Surgery, Duke University School of Medicine; Society of Junior Doctors, Menalou 5 Street, 15123 Athens, Greece
| | - Christos Bakoyannis
- 1st Department of Surgery, National and Kapodistrian University of Athens, Laikon Hospital, 11527 Athens, Greece
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Paraskevas KI, Naylor AR. External Validation of Randomized Trial Outcomes Following Carotid Interventions in the Modern Era. Angiology 2017; 68:669-674. [DOI: 10.1177/0003319716664267] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/30/2023]
Abstract
An essential prerequisite of randomized controlled trials (RCTs) is “external validation,” that is, results obtained in the “real world” closely replicate those from RCTs. In this respect, contemporary administrative data set registries reporting outcomes after carotid endarterectomy and carotid artery stenting (CAS) have recently reported death/stroke rates that exceed the accepted risk thresholds for intervening. The current article evaluates this controversy and offers reasons why this might continue to happen, namely: (1) difference in interventionists’ competence/experience, (2) patient selection, and (3) advances in CAS technology/technique. As CAS is a continuously evolving technique, the results obtained from patients recruited into the landmark RCTs (as early as the late 1990s) do not reflect contemporary practice. Although RCTs are not always the perfect solution, the process of randomization ensures minimization of selection bias. A possible way forward may be the introduction of prospective, randomized, controlled clinical registries.
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Affiliation(s)
| | - A. Ross Naylor
- Vascular Research Group, Division of Cardiovascular Sciences, Department of Vascular Surgery, Leicester Royal Infirmary, Leicester, UK
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Musiałek P, Hopkins LN, Siddiqui AH. One swallow does not a summer make but many swallows do: accumulating clinical evidence for nearly-eliminated peri-procedural and 30-day complications with mesh-covered stents transforms the carotid revascularisation field. ADVANCES IN INTERVENTIONAL CARDIOLOGY 2017; 13:95-106. [PMID: 28798779 PMCID: PMC5545669 DOI: 10.5114/pwki.2017.69012] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2017] [Accepted: 07/10/2017] [Indexed: 02/07/2023] Open
Abstract
Atherosclerotic carotid artery stenosis (CS) continues to be a common cause of acute ischaemic stroke. Optimised medical therapy (OMT), the first-line treatment modality in CS, may reduce or delay - but it does not abolish - CS-related strokes. As per current AHA/ASA and ESC/ESVS/ESO guidelines, carotid artery stenting (CAS) is a less-invasive alternative to carotid endarterectomy (CEA) for CS revascularisation in primary and secondary stroke prevention. Ten-year follow-up from the CREST trial in patients with symptomatic and asymptomatic CS confirmed equipoise of CAS and CEA in the primary endpoint. Nevertheless CAS - using a widely open-cell, first-generation stent and first-generation (distal/filter) neuroprotection - has been criticised for its relative excess of (mostly minor) strokes by 30 days, a significant proportion of which were post-procedural. Atherosclerotic plaque protrusion through conventional carotid stent struts, confirmed on intravascular imaging, has been implicated as a leading mechanism of the relative excess of strokes with CAS vs. CEA, including delayed strokes with CAS. Different designs of mesh-covered carotid stents have been developed to prevent plaque prolapse. Several multi-centre/multi-specialty clinical studies with CGurad MicroNet-Covered Embolic Prevention Stent System (EPS) and RoadSaver/Casper were recently published and included routine DW-MRI cerebral imaging peri-procedurally and at 30 days (CGuard EPS). Data from more than 550 patients in mesh-covered carotid stent clinical studies to-date show an overall 30-day complication rate of ~1% with near-elimination of post-procedural events. While more (and long-term) evidence is still anticipated, these results - taken together with optimised intra-procedural neuroprotection in CAS (increased use of proximal systems including trans-carotid dynamic flow reversal) and the positive 12-month mesh-covered stent data reports in 2017 - are transforming the carotid revascularisation field today. Establishing effective algorithms to identify the asymptomatic subjects at stroke risk despite OMT, and large-scale studies with mesh-covered stents including long-term clinical and duplex ultrasound outcomes, are the next major goals.
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Affiliation(s)
- Piotr Musiałek
- Department of Cardiac and Vascular Diseases, Jagiellonian University, School of Medicine, John Paul II Hospital, Krakow, Poland
| | - L. Nelson Hopkins
- Departments of Neurosurgery and Radiology, School of Medicine and Biomedical Sciences, University at Buffalo, State University of New York, Jacobs Institute, Gates Vascular Institute Kaleida Health, Buffalo, New York, USA
| | - Adnan H. Siddiqui
- Departments of Neurosurgery and Radiology, School of Medicine and Biomedical Sciences, University at Buffalo, State University of New York, Jacobs Institute, Gates Vascular Institute Kaleida Health, Buffalo, New York, USA
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Paraskevas KI, Veith FJ. Transcervical access, reversal of flow and mesh-covered stents: New options in the armamentarium of carotid artery stenting. World J Cardiol 2017; 9:416-421. [PMID: 28603588 PMCID: PMC5442409 DOI: 10.4330/wjc.v9.i5.416] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/14/2016] [Revised: 01/22/2017] [Accepted: 03/22/2017] [Indexed: 02/06/2023] Open
Abstract
In the last 25 years, the very existence of carotid artery stenting (CAS) has been threatened on a number of occasions. The initial disappointing results that even lead to the discontinuation of an early randomized controlled trial have improved considerably with time. Novel devices, advanced stent and equipment technology, alternative types of access and several types of filters/emboli protecting devices have been reported to reduce stroke/death rates during/after CAS and improve CAS outcomes. The present review will provide a description of the various technology advances in the field that aim to reduce stroke and death rates associated with CAS. Transcervical access, reversal of flow and mesh-covered stents are currently the most promising tools in the armamentarium of CAS.
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Huntress LA, Nassiri N, Shafritz R, Rahimi SA. Transcervical Carotid Stent Placement in the Setting of a Hostile Neck and a Type III Aortic Arch. Vasc Endovascular Surg 2017; 51:346-349. [DOI: 10.1177/1538574417710601] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Previous radical neck dissection and neck irradiation pose considerable operative risks in patients requiring carotid endarterectomy for symptomatic carotid disease. Carotid stenting is an acceptable alternative for these patients but carries a higher risk of cerebrovascular accidents especially in patients with type III aortic arch anatomy. Herein, we present a technically challenging case of a patient with an irradiated neck and a history of radical neck dissection who presented with a symptomatic high-grade left internal carotid artery stenosis in the setting of a type III aortic arch. He was treated via a hybrid approach for carotid artery stenting.
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Affiliation(s)
| | - Naiem Nassiri
- Division of Vascular Surgery, Department of Surgery, Rutgers-Robert Wood Johnson Medical School, New Brunswick, NJ, USA
| | - Randy Shafritz
- Division of Vascular Surgery, Department of Surgery, Rutgers-Robert Wood Johnson Medical School, New Brunswick, NJ, USA
| | - Saum A. Rahimi
- Division of Vascular Surgery, Department of Surgery, Rutgers-Robert Wood Johnson Medical School, New Brunswick, NJ, USA
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Preoperative cervical carotid artery contrast-enhanced ultrasound findings are associated with development of microembolic signals on transcranial Doppler during carotid exposure in endarterectomy. Atherosclerosis 2017; 260:87-93. [DOI: 10.1016/j.atherosclerosis.2017.03.026] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/21/2017] [Revised: 02/27/2017] [Accepted: 03/17/2017] [Indexed: 11/20/2022]
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Parodi J, Bates MC, Ohki T, Schönholz C. History of Proximal Carotid Protection and Flow Reversal. J Endovasc Ther 2017; 24:271-274. [PMID: 28335707 DOI: 10.1177/1526602817693601] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Juan Parodi
- 1 Department of Surgery, University of Buenos Aires, Argentina.,2 University of Michigan, Ann Arbor, MI, USA
| | - Mark C Bates
- 3 CAMC Health Education and Research Institute and Vascular Center of Excellence, Charleston, WV, USA
| | - Takao Ohki
- 4 Department of Surgery, Jikei University School of Medicine, Tokyo, Japan
| | - Claudio Schönholz
- 5 Department of Interventional Radiology, Medical University of South Carolina, Charleston, SC, USA
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40
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Alpaslan A, Wintermark M, Pintér L, Macdonald S, Ruedy R, Kolvenbach R. Transcarotid Artery Revascularization With Flow Reversal. J Endovasc Ther 2017; 24:265-270. [DOI: 10.1177/1526602817693607] [Citation(s) in RCA: 56] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Purpose: To report a study evaluating the safety and efficacy of stenting via direct carotid access with flow reversal using the ENROUTE Transcarotid Neuroprotection System. Methods: Between March 2009 and June 2012, 75 patients (mean age 72.6 years; 45 men) underwent carotid artery stenting with the ENROUTE System; the majority of patients (63, 84%) were asymptomatic. The primary safety endpoint was the composite of major stroke, myocardial infarction, or death at 30 days. Efficacy outcomes included acute device success, procedure success, and tolerance to flow reversal. Fifty-six (74.7%) patients underwent diffusion-weighted magnetic resonance imaging (DW-MRI) before and after the procedure to assess the development of new ischemic brain lesions. Results: Acute device and procedure success were achieved in 68 (90.6%) patients. The reverse flow circuit was established in 71 (94.6%) patients; only 5 patients demonstrated transient intolerance to flow reversal that did not interfere with completion of the procedure. The mean time on flow reversal was 19.1 minutes. In the DW-MRI substudy, 10 (17.9%) of 56 patients had ipsilateral new white lesions with a mean volume of 0.17 mL. At 30 days, no major stroke, myocardial infarction, or death occurred; 1 patient had experienced a minor stroke that was adjudicated as not related to either the device or procedure. Conclusion: Results of the PROOF study demonstrate the safety and efficacy of transcarotid revascularization with the ENROUTE Transcarotid Neuroprotection System.
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Affiliation(s)
- Alper Alpaslan
- Department of Vascular Surgery and Endovascular Therapy, Augusta Hospital and Catholic Hospital Group, Düsseldorf, Germany
| | - Max Wintermark
- Department of Neuroradiology, Stanford University, Stanford, CA, USA
| | - László Pintér
- Department of Surgery, Lukas Hospital, Neuss, Germany
| | | | | | - Ralf Kolvenbach
- Department of Vascular Surgery and Endovascular Therapy, Augusta Hospital and Catholic Hospital Group, Düsseldorf, Germany
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Musialek P, Hopf-Jensen S. Commentary: Carotid Artery Revascularization for Stroke Prevention: A New Era. J Endovasc Ther 2016; 24:138-148. [PMID: 27733691 DOI: 10.1177/1526602816671263] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Affiliation(s)
- Piotr Musialek
- 1 Jagiellonian University Department of Cardiac & Vascular Diseases, John Paul II Hospital, Krakow, Poland
| | - Silke Hopf-Jensen
- 2 Department of Diagnostic and Interventional Radiology and Neuroradiology, Diakonissenhospital Flensburg, Germany
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Paraskevas KI, Veith FJ, Parodi JC. Commentary: Transcervical Carotid Artery Stenting (CAS) With Flow Reversal: A Promising Technique for the Reduction of Strokes Associated With CAS. J Endovasc Ther 2016; 23:255-7. [PMID: 26984815 DOI: 10.1177/1526602816633830] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Affiliation(s)
- Kosmas I Paraskevas
- Department of Vascular Surgery, Southampton University Hospital, Southampton, UK
| | - Frank J Veith
- Divisions of Vascular Surgery, New York University Langone Medical Center, New York, NY, USA The Cleveland Clinic, Cleveland, OH, USA
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Paraskevas KI, Veith FJ. Techniques and innovations to improve carotid artery stenting outcomes. Int J Cardiol 2016; 222:986-987. [PMID: 27526376 DOI: 10.1016/j.ijcard.2016.08.148] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/13/2016] [Accepted: 08/07/2016] [Indexed: 12/17/2022]
Affiliation(s)
| | - Frank J Veith
- Division of Vascular Surgery, New York University Langone Medical Center, New York, USA; Division of Vascular Surgery, The Cleveland Clinic, Cleveland, USA
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