[Stenting of the extracranial internal carotid artery]

The treatment of patients with stenosis of the internal carotid artery (ICA) is based on established guidelines, which includes both surgical and endovascular treatment options; however, the most recent advances, including the emergence of new endovascular treatment methods and techniques, combined with more recent clinical results, throw a new light on the optimal selection and treatment of patients in the current practice. This article deals with the most recent advances in the field of stenting of the extracranial internal carotid artery.

Association of Centre Quality Certification with Characteristics of Patients, Management, and Outcomes Following Carotid Endarterectomy or Carotid Artery Stenting

Background: The aim of this study was to analyze the association between center quality certifications and patients' characteristics, clinical management, and outcomes after carotid revascularization. Methods: This study is a pre-planned sub-study of the ISAR-IQ project, which analyzes data from the Bavarian subset of the nationwide German statutory quality assurance carotid database. Hospitals were classified as to whether a certified vascular center (cVC) or a certified stroke unit (cSU) was present on-site or not. The primary outcome event was any stroke or death until discharge from the hospital. Results: In total, 31,793 cases were included between 2012 and 2018. The primary outcome rate in asymptomatic patients treated by CEA ranged from 0.7% to 1.5%, with the highest rate in hospitals with cVC but without cSU. The multivariable regression analysis revealed a significantly lower primary outcome rate in centers with cSU in asymptomatic patients (aOR 0.69; 95% CI 0.56-0.86; p < 0.001). In symptomatic patients needing emergency treatment, the on-site availability of a cSU was associated with a significantly lower primary outcome rate (aOR 0.56; 95% CI 0.40-0.80; p < 0.001), whereas the presence of a cVC was associated with higher risk (aOR 3.07; 95% CI 1.65-5.72). Conclusions: This study provides evidence of statistically significant better results in some sub-cohorts in certified centers. In centers with cSU, the risk of any stroke or death was significantly lower in asymptomatic patients receiving CEA or symptomatic patients treated by emergency CEA.

Carotid artery interventions - endarterectomy versus stenting

Current management of patients with carotid artery stenosis is based on well-established guidelines, including surgical procedures - carotid endarterectomy (CEA) and endovascular carotid artery stenting (CAS) - and optimal medical treatment alone. Outcomes in the postprocedural period after CAS and CEA are similar, suggesting strong clinical durability for both treatments. Recent advances, which include the emergence of novel endovascular treatment tools and techniques, combined with more recent randomised trial data shed new light on optimal patient selection and treatment in contemporary practice. Improved, modern technologies including enhanced embolic protection devices and dual-layered micromesh stents yield better outcomes and should result in further improvements in CAS. In centres of excellence, nowadays, the majority of patients with severe carotid artery stenosis can be successfully treated with either CEA or CAS.

Transcarotid Artery Revascularization Versus Carotid Endarterectomy and Transfemoral Stenting in Octogenarians

OBJECTIVE

Transfemoral carotid artery stenting (TFCAS) has higher combined stroke and death rates in elderly patients with carotid artery stenosis compared with carotid endarterectomy (CEA). However, transcarotid artery revascularization (TCAR) may have similar outcomes to CEA. This study compared outcomes after TCARs relative to those after CEAs and TFCAS, focusing on elderly patients.

METHODS

We included all patients with carotid artery stenosis, and no prior endarterectomy or stenting, who underwent either a CEA, TFCAS, or TCAR in the Vascular Quality Initiative from September 2016 (TCAR commercially available) to December 2019. We categorized patients into age decades: 60-69 years, 70-79 years, and 80-90 years. Outcomes included 30-day and one-year composite rates of stroke or death. Cox-proportional hazards models evaluated both outcomes after adjusting for patient demographics, clinical factors, symptomatology, hospital CEA volume, and clustering.

RESULTS

We identified 33,115 patients who underwent either a CEA, TFCAS, or TCAR for carotid artery stenosis (35% in their 60s, 44% in their 70s, and 21% in their 80s), where half (50%) were symptomatic. The majority of patients had CEAs (80%), followed by TFCAS (11%) and then TCARs (9.1%). The overall rate of 30-day stroke/death was 1.5% and of one-year stroke/death was 4.4%. Octogenarians had the highest 30-day and one-year stroke/death rates relative to their peers (2.3% and 6.3%, respectively). Among all patients, the adjusted hazards of TCARs relative to CEAs was similar for 30-day stroke/death (HR 1.10 [95%-CI 0.75-1.62]) and slightly higher for one-year stroke/death (HR 1.34 [1.02-1.76]). Among octogenarians, however, the adjusted hazards of TCARs relative to CEAs was similar for both 30-day stroke/death (HR 1.12 [0.59-2.13]) and one-year stroke/death (HR 1.28 [0.85-1.94]). TFCAS relative to CEAs had higher hazards of both 30-day stroke/death (HR 1.78 [1.10-2.89]) and one-year stroke/death (HR 1.85 [1.35-2.54]) in octogenarians.

CONCLUSIONS

TCARs had similar outcomes relative to CEAs among octogenarians with respect to 30-day and one-year rates of stroke/death. TCAR may serve as a promising less-invasive treatment for carotid disease in older patients who are deemed high anatomic, surgical, or clinical risk for CEAs.

Associations between gastro-oesophageal reflux disease and a range of diseases: an umbrella review of systematic reviews and meta-analyses

OBJECTIVE

Numerous meta-analyses have revealed the association between gastro-oesophageal reflux disease (GORD) and a range of diseases; however, the certainty of the evidence remains unclear. This study aimed to summarise and assess the certainty of evidence derived from meta-analyses.

METHODS

Embase, PubMed, Web of Science, Cochrane Databases of Systematic Reviews, CNKI and Wangfang databases from their inception to 22 February 2020 were queried for systematic reviews and meta-analyses on the association between GORD and various diseases. The methodological quality of the included studies was assessed using A Measurement Tool to Assess Systematic Reviews 2 (AMSTAR 2), and evidence certainty was evaluated using the Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) system. Statistical analysis was conducted using Stata V.15.

RESULTS

Ten publications with associations between GORD and different types of diseases were included. There was high heterogeneity (I2 >75%) among seven independent meta-analyses. Evidence for publication bias in two independent meta-analyses was also observed. According to the AMSTAR 2 approach, the methodological quality was high for 20% of meta-analyses, moderate for 10%, low for 40% and critically low for 30%. Based on GRADE approach, the certainty of evidence was high for the association between GORD and higher risk of chronic obstructive pulmonary disease (COPD) exacerbation (OR 5.37; 95% CI 2.71 to 10.64) and higher prevalence of oesophageal adenocarcinoma (OR 4.57; 95% CI 3.89 to 5.36), and it was moderate for the association between GORD and higher chronic rhinosinusitis prevalence (OR 2.16; 95% CI 1.37 to 3.48).

CONCLUSION

The association between GORD and a range of diseases was extensively studied, and our findings revealed a high certainty of evidence of the association between GORD and an increased risk of COPD exacerbation as well as increased prevalence of oesophageal adenocarcinoma. Further investigations using systematic reviews and meta-analyses of high methodological quality that include prospective large cohort studies and adjusted confounders are warranted.

PROSPERO REGISTRATION NUMBER

CRD42019122264.

Association between H. pylori infection and health Outcomes: an umbrella review of systematic reviews and meta-analyses

OBJECTIVE

Systematic reviews and meta-analyses have revealed the associations between H. pylori infection and various health outcomes. We aimed to evaluate the strength and breadth of evidence on the associations.

DESIGN

Umbrella review of systematic reviews and meta-analyses.

SETTING

No settings.

PARTICIPANTS

No patients involved.

DATA SOURCES

Embase, PubMed, Web of Science, Cochrane Library Databases, CNKI, VIP database and Wangfang database from inception to February 1, 2019.

OUTCOMES MEASURES

Diverse diseases (such as cancer and ischaemic heart disease).

RESULTS

Sixty articles reporting 88 unique outcomes met the eligible criteria. 74 unique outcomes had nominal significance (p<0.05). Of the outcomes with significance, 61 had harmful associations and 13 had beneficial associations. Furthermore, 73% (64) of the outcomes exhibited significant heterogeneity . Of the these meta-analyses, 32 had moderate to high heterogeneity (I²=50%-75%) and 24 had high heterogeneity (I²>75%). Moreover, 20% exhibited publication bias (p<0.1). In addition, 97% of the methodological qualities were rated 'critically low'. 36% of the evidence qualities of outcomes were rated 'low', 56% of the evidence qualities were rated 'very low' and 8% of the evidence qualities were rated 'moderate'. H. pylori infection may be associated with an increased risk of five diseases and a decreased risk of irritable bowel syndrome.

CONCLUSION

Although 60 meta-analyses explored 88 unique outcomes, moderate quality evidence only existed for six outcomes with statistical significance. H. pylori infection may be associated with a decreased risk of irritable bowel syndrome and an increased risk of hypertriglyceridemia, chronic cholecystitis and cholelithiasis, gestational diabetes mellitus, gastric cancer and systemic sclerosis.

TRIAL REGISTRATION

CRD42019124680.