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Transient flow reversal combined with sustained embolic prevention in transcervical revascularization of symptomatic and highly-emboligenic carotid stenoses for optimized endovascular lumen reconstruction and improved peri- and post-procedural outcomes. ADVANCES IN INTERVENTIONAL CARDIOLOGY 2020; 16:495-506. [PMID: 33598027 PMCID: PMC7863838 DOI: 10.5114/aic.2020.102134] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2020] [Accepted: 12/20/2020] [Indexed: 11/24/2022] Open
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Musiałek P, Roubin GS. Commentary: Double-Layer Carotid Stents: From the Clinical Need, through a Stent-in-Stent Strategy, to Effective Plaque Isolation… the Journey Toward Safe Carotid Revascularization Using the Endovascular Route. J Endovasc Ther 2019; 26:572-577. [DOI: 10.1177/1526602819861546] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Piotr Musiałek
- Jagiellonian University Department of Cardiac & Vascular Diseases, John Paul II Hospital, Krakow, Poland
| | - Gary S. Roubin
- Cardiovascular Associates of the Southeast, Birmingham, AL, USA
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Health-related quality of life in ischaemic stroke survivors after carotid endarterectomy (CEA) and carotid artery stenting (CAS): confounder-controlled analysis. ADVANCES IN INTERVENTIONAL CARDIOLOGY 2019; 15:226-233. [PMID: 31497056 PMCID: PMC6727227 DOI: 10.5114/aic.2019.84441] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2019] [Accepted: 03/29/2019] [Indexed: 11/17/2022] Open
Abstract
Introduction Atherosclerotic carotid artery stenosis (CS)-related strokes are a significant overall stroke burden contributor. Aim To evaluate the effect of surgical (carotid endarterectomy – CEA) vs. percutaneous (neuroprotected carotid artery stenting – CAS) carotid revascularization on health-related quality of life (HRQoL) in stroke survivors: analysis controlled for major HRQoL determinants beyond strokes. Material and methods Our database of 856 carotid revascularization procedures (48.7% symptomatic CS) performed over 3 years showed 42 pairs (CEA-CAS) of right hemispheric stroke patients matched for age, sex, marital and educational status, hyper-tension, heart failure and diabetes, who underwent uneventful carotid revascularization, experienced no major adverse clinical events, and completed the Short Form Outcome Study (SF-36) questionnaire within 7 days before, 14 days after, 6 months after, and 12 months after carotid revascularization. Results Baseline HRQoL was low and similar in both groups (30.8 ±4.6% vs. 29.1 ±3.9%, p = 0.68; data given for CEA vs. CAS). National Institute of Health Stroke Scale chronic severity was 5.4 ±2.8 vs. 5.9 ±3.1 (p = 0.44). Revascularization was associated with a major HRQoL improvement, that was significantly greater in CAS (60.4 ±9.2% vs. 71.5 ±6.2%, p < 0.001). At 6 months the CEA-CAS difference was narrower (70.7 ±9.7% vs. 74.6 ±5.9%, p = 0.026), becoming statistically insignificant at 12 months (72.6 ±6.7% vs. 75.1 ±5.1%, p = 0.062). The early CEA-CAS difference was driven by less bodily pain and better physical functioning/role-physical plus better role-emotional and higher general well-being scores in CAS (p < 0.05). Conclusions Carotid revascularization has a major positive impact on stroke survivor patient-reported HRQoL. The improvement is initially greater in CAS, with the remaining difference small at 12 months and statistically insignificant.
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Speziale F, Capoccia L, Sirignano P, Mansour W, Pranteda C, Casana R, Setacci C, Accrocca F, Alberti D, de Donato G, Ferri M, Gaggiano A, Galzerano G, Ippoliti A, Mangialardi N, Pratesi G, Ronchey S, Ruffino M, Siani A, Spinazzola A, Sponza M. Thirty-day results from prospective multi-specialty evaluation of carotid artery stenting using the CGuard MicroNet-covered Embolic Prevention System in real-world multicentre clinical practice: the IRON-Guard study. EUROINTERVENTION 2019; 13:1714-1720. [PMID: 28485278 DOI: 10.4244/eij-d-17-00008] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
AIMS The aim of the present study was to evaluate periprocedural and 30-day outcomes in a prospective series of patients treated with the CGuard Embolic Prevention System (EPS). METHODS AND RESULTS From April 2015 to June 2016, a physician-initiated prospective multicentre study was performed in 200 consecutive patients admitted for protected carotid artery stenting (CAS) and treated using the CGuard EPS in twelve vascular centres. Outcome measures were: technical success, periprocedural (0-24 hours) and post-procedural (24 hours-30 days) major and minor strokes, death, acute myocardial infarction (AMI), transient ischaemic attack (TIA), and external carotid occlusion. In three centres, consecutive diffusion-weighted magnetic resonance cerebral imaging (DW-MRI) was performed ≤72 hours prior to and within 72 hours after the intervention. A distal embolic protection device was employed in 182 patients (91%). Technical success was 100%. No death, AMI or major stroke occurred periprocedurally. There were two TIAs and five periprocedural minor strokes (2.5%), including one thrombosis solved by surgery. In the remaining patients (199/200; 99.5%) one-month follow-up duplex ultrasound revealed optimal technical results. Post-procedural clinical follow-up was uneventful. No external carotid artery occlusion occurred. New post-procedural DW-MRI lesions were detected in 12 patients out of 61 (19.6%), including bilateral in five (8.2%) and isolated ipsilateral in six (9.8%), whereas one patient (1.6%) had contralateral only lesions. CONCLUSIONS Multicentre multi-specialty use of the CGuard EPS in routine clinical practice was associated with no major periprocedural neurologic complications and a total elimination of post-procedural neurologic complications by 30 days.
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Affiliation(s)
- Francesco Speziale
- Vascular and Endovascular Surgery Division, Department of Surgery "Paride Stefanini", Policlinico Umberto I, "Sapienza" University of Rome, Rome, Italy
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Mazurek A, Partyka L, Trystula M, Jakala J, Proniewska K, Borratynska A, Tomaszewski T, Slezak M, Malinowski KP, Drazkiewicz T, Podolec P, Rosenfiled K, Musialek P. Highly-calcific carotid lesions endovascular management in symptomatic and increased-stroke-risk asymptomatic patients using the CGuard™ dual-layer carotid stent system: Analysis from the PARADIGM study. Catheter Cardiovasc Interv 2019; 94:149-156. [PMID: 30945420 DOI: 10.1002/ccd.28219] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/29/2019] [Revised: 03/13/2019] [Accepted: 03/23/2019] [Indexed: 11/08/2022]
Abstract
OBJECTIVES To assess feasibility, safety, angiographic, and clinical outcome of highly-calcific carotid stenosis (HCCS) endovascular management using CGuard™ dual-layer carotid stents. BACKGROUND HCCS has been a challenge to carotid artery stenting (CAS) using conventional stents. CGuard combines a high-radial-force open-cell frame conformability with MicroNet sealing properties. METHODS The PARADIGM study is prospectively assessing routine CGuard use in all-comer carotid revascularization patients; the focus of the present analysis is HCCS versus non-HCCS lesions. Angiographic HCCS (core laboratory evaluation) required calcific segment length to lesion length ≥2/3, minimal calcification thickness ≥3 mm, circularity (≥3 quadrants), and calcification severity grade ≥3 (carotid calcification severity scoring system [CCSS]; G0-G4). RESULTS One hundred and one consecutive patients (51-86 years, 54.4% symptomatic; 106 lesions) received CAS (16 HCCS and 90 non-HCCS); eight others (two HCCS) were treated surgically. CCSS evaluation was reproducible, with weighted kappa (95% CI) of 0.73 (0.58-0.88) and 0.83 (0.71-0.94) for inter- and intra-observer reproducibility respectively. HCCS postdilatation pressures were higher than those in non-HCCS; 22 (20-24) versus 20 (18-24) atm, p = .028; median (Q1-Q3). Angiography-optimized HCCS-CAS was feasible and free of contrast extravasation or clinical complications. Overall residual diameter stenosis was single-digit but it was higher in HCCS; 9 (4-17) versus 3 (1-7) %, p = .002. At 30 days and 12 months HCCS in-stent velocities were normal and there were no adverse clinical events. CONCLUSION CGuard HCCS endovascular management was feasible and safe. A novel algorithm to grade carotid artery calcification severity was reproducible and applicable in clinical study setting. Larger HCCS series and longer-term follow-up are warranted.
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Affiliation(s)
- Adam Mazurek
- Department of Cardiac & Vascular Diseases, John Paul II Hospital, Jagiellonian University Medical College, Krakow, Poland
| | - Lukasz Partyka
- KCRI Angiographic Core Laboratory and Data Management Division, Krakow, Poland
| | - Mariusz Trystula
- Department of Vascular Surgery, John Paul II Hospital, Krakow, Poland
| | - Jacek Jakala
- KCRI Angiographic Core Laboratory and Data Management Division, Krakow, Poland
| | - Klaudia Proniewska
- KCRI Angiographic Core Laboratory and Data Management Division, Krakow, Poland
| | - Anna Borratynska
- Neurology Inpatient and Outpatient Department, John Paul II Hospital, Krakow, Poland
| | - Tomasz Tomaszewski
- Neurology Inpatient and Outpatient Department, John Paul II Hospital, Krakow, Poland
| | - Magdalena Slezak
- Department of Vascular Surgery, John Paul II Hospital, Krakow, Poland
| | - Krzysztof P Malinowski
- Department of Vascular Surgery, John Paul II Hospital, Krakow, Poland.,Institute of Public Health, Faculty of Health Science, Jagiellonian University Medical College, Krakow, Poland
| | - Tomasz Drazkiewicz
- KCRI Angiographic Core Laboratory and Data Management Division, Krakow, Poland
| | - Piotr Podolec
- Department of Cardiac & Vascular Diseases, John Paul II Hospital, Jagiellonian University Medical College, Krakow, Poland
| | - Kenneth Rosenfiled
- Division of Cardiology, Massachusetts General Hospital, Boston, Massachusetts
| | - Piotr Musialek
- Department of Cardiac & Vascular Diseases, John Paul II Hospital, Jagiellonian University Medical College, Krakow, Poland
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Texakalidis P, Giannopoulos S, Jonnalagadda AK, Chitale RV, Jabbour P, Armstrong EJ, Schwartz GG, Kokkinidis DG. Preoperative Use of Statins in Carotid Artery Stenting: A Systematic Review and Meta-analysis. J Endovasc Ther 2018; 25:624-631. [PMID: 30101624 DOI: 10.1177/1526602818794030] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
PURPOSE To determine through meta-analysis whether administration of statins before carotid artery stenting (CAS) is associated with fewer periprocedural adverse events. METHODS All randomized and observational English-language studies of periprocedural statin administration prior to CAS that reported the outcomes of interest (stroke, transient ischemic attack, myocardial infarction, and death at 30 days) were included in a random-effects meta-analysis. The I2 statistic was used to assess heterogeneity. Meta-regression analysis was performed to determine whether an association of statin treatment with risk of outcome events was influenced by other trial-level baseline characteristics of statin-treated and untreated patients. RESULTS Eleven studies comprising 4088 patients were included. Patients who received statins prior to CAS had a significantly lower risk of stroke (OR 0.39, 95% CI 0.27 to 0.58, p<0.01; I2=0%) and death (OR 0.30, 95% CI 0.10 to 0.96, p=0.042; I2=0%). Statin use was not associated with a reduced risk of transient ischemic attack or myocardial infarction. In meta-regression analysis, other trial-level baseline characteristics had no significant influence on the association of statin treatment with death or stroke. CONCLUSION Statin therapy prior to CAS is associated with decreased risk of perioperative stroke and death without any effect on the rates of transient ischemic attack or myocardial infarction.
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Affiliation(s)
| | | | - Anil K Jonnalagadda
- 3 Division of Cardiology, Medstar Washington Hospital Center, Washington, DC, USA
| | - Rohan V Chitale
- 4 Department of Neurosurgery, Vanderbilt University Hospital, Nashville, TN, USA
| | - Pascal Jabbour
- 5 Department of Neurosurgery, Thomas Jefferson University, Philadelphia, PA, USA
| | - Ehrin J Armstrong
- 6 Division of Cardiology, Denver VA Medical Center, University of Colorado, Denver, CO, USA
| | - Gregory G Schwartz
- 6 Division of Cardiology, Denver VA Medical Center, University of Colorado, Denver, CO, USA
| | - Damianos G Kokkinidis
- 7 Department of Medicine, Jacobi Medical Center, Albert Einstein College of Medicine, Bronx, NY, USA
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Carotid Artery Endarterectomy versus Carotid Artery Stenting for Restenosis After Carotid Artery Endarterectomy: A Systematic Review and Meta-Analysis. World Neurosurg 2018; 115:421-429.e1. [DOI: 10.1016/j.wneu.2018.02.196] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2017] [Revised: 02/25/2018] [Accepted: 02/28/2018] [Indexed: 11/24/2022]
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Wang C, Redgrave J, Shafizadeh M, Majid A, Kilner K, Ali AN. Aerobic exercise interventions reduce blood pressure in patients after stroke or transient ischaemic attack: a systematic review and meta-analysis. Br J Sports Med 2018; 53:1515-1525. [PMID: 29743171 DOI: 10.1136/bjsports-2017-098903] [Citation(s) in RCA: 38] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/10/2018] [Indexed: 12/30/2022]
Abstract
OBJECTIVE Secondary vascular risk reduction is critical to preventing recurrent stroke. We aimed to evaluate the effect of exercise interventions on vascular risk factors and recurrent ischaemic events after stroke or transient ischaemic attack (TIA). DESIGN Intervention systematic review and meta-analysis. DATA SOURCES OVID MEDLINE, PubMed, The Cochrane Library, Web of Science, The National Institute for Health and Care Excellence, TRIP Database, CINAHL, PsycINFO, SCOPUS, UK Clinical Trials Gateway and the China National Knowledge Infrastructure were searched from 1966 to October 2017. ELIGIBILITY CRITERIA Randomised controlled trials evaluating aerobic or resistance exercise interventions on vascular risk factors and recurrent ischaemic events among patients with stroke or TIA, compared with control. RESULTS Twenty studies (n=1031) were included. Exercise interventions resulted in significant reductions in systolic blood pressure (SBP) -4.30 mm Hg (95% CI -6.77 to -1.83) and diastolic blood pressure -2.58 mm Hg (95% CI -4.7 to -0.46) compared with control. Reduction in SBP was most pronounced among studies initiating exercise within 6 months of stroke or TIA (-8.46 mm Hg, 95% CI -12.18 to -4.75 vs -2.33 mm Hg, 95% CI -3.94 to -0.72), and in those incorporating an educational component (-7.81 mm Hg, 95% CI -14.34 to -1.28 vs -2.78 mm Hg, 95% CI -4.33 to -1.23). Exercise was also associated with reductions in total cholesterol (-0.27 mmol/L, 95% CI -0.54 to 0.00), but not fasting glucose or body mass index. One trial reported reductions in secondary vascular events with exercise, but was insufficiently powered. SUMMARY Exercise interventions can result in clinically meaningful blood pressure reductions, particularly if initiated early and alongside education.
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Affiliation(s)
- Cheng Wang
- Faculty of Medicine Dentistry and Health, University of Sheffield, Sheffield, UK
| | - Jessica Redgrave
- Department of Neurosciences, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
| | - Mohsen Shafizadeh
- Sheffield Hallam University, Academy of Sport and Physical Activity, Sheffield, UK
| | - Arshad Majid
- Faculty of Medicine Dentistry and Health, University of Sheffield, Sheffield, UK.,Sheffield NIHR Biomedical Research Centre, Sheffield, UK
| | - Karen Kilner
- Sheffield Hallam University, Centre for Health and Social Care Research, Sheffield, UK
| | - Ali N Ali
- Faculty of Medicine Dentistry and Health, University of Sheffield, Sheffield, UK.,Sheffield Teaching Hospitals NHS Foundation Trust, Geriatrics and Stroke Medicine, Sheffield, UK
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Umemoto T, de Donato G, Pacchioni A, Reimers B, Ferrante G, Isobe M, Setacci C. Optical coherence tomography assessment of newgeneration mesh-covered stents after carotid stenting. EUROINTERVENTION 2017; 13:1347-1354. [DOI: 10.4244/eij-d-16-00866] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
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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. Will Carotid Artery Stenting Become a Safer Procedure Than Carotid Endarterectomy? J Endovasc Ther 2017; 24:297-298. [PMID: 28335708 DOI: 10.1177/1526602817691753] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
| | - Frank J Veith
- 2 Division of Vascular Surgery, New York University Langone Medical Center, New York, NY, USA.,3 The Cleveland Clinic, Cleveland, OH, USA
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