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Squizzato F, Zivelonghi C, Menegolo M, Xodo A, Colacchio EC, De Massari C, Grego F, Piazza M, Antonello M. A systematic review and meta-analysis on the outcomes of carotid endarterectomy after intravenous thrombolysis for acute ischemic stroke. J Vasc Surg 2024:S0741-5214(24)01682-3. [PMID: 39159889 DOI: 10.1016/j.jvs.2024.08.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2024] [Revised: 07/18/2024] [Accepted: 08/03/2024] [Indexed: 08/21/2024]
Abstract
BACKGROUND Intravenous thrombolysis (IVT) is the mainstay of treatment for patients presenting with acute ischemic stroke, whereas carotid endarterectomy (CEA) is indicated in patients with symptomatic carotid stenosis. However, the impact of prior IVT on the outcomes of CEA (IVT-CEA) is not clear. The aim of this study was to determine whether IVT may create additional stroke and death risk for CEA, compared with CEA performed in the absence of a history of recent IVT, and to determine the optimal timing for CEA after IVT. METHODS We conducted a systematic review and meta-analysis of studies comparing the outcomes of IVT-CEA vs CEA, using the Medline, Embase, and Cochrane databases. RESULTS We included 11 retrospective comparative studies, in which 135,644 patients underwent CEA and 2070 underwent IVT-CEA. The pooled rate of perioperative stroke was 4.2% in the IVT-CEA group and 1.3% in the CEA group (odds ratio [OR], 0.44; 95% confidence interval [CI], 0.12-1.58; P = .21), with a high heterogenicity (I2 = 93%). The rate of stroke/death was 5.9% in patients undergoing IVT-CEA 1.9% in those receiving CEA only (OR, 0.42; 95% CI, 0.15-1.14; I2 = 92%; P = .09); after exclusion of studies including TIA as presenting symptom, stroke/death risk was 3.6% in IVT-CEA and 3.0% in CEA (OR, 1.42; 95% CI, 0.80-2.53; I2 = 50%; P = .11). The risk of stoke decreased with a delay in the performance of CEA (P = .268). Using results of the metaregression, the calculated delay of CEA that allows for a <6% risk was 4.6 days. Compared with CEA, patients undergoing IVT-CEA had a significantly higher risk of intracranial hemorrhage (2.5% vs 0.1%; OR, 0.11; 95% CI, 0.06-0.21; I2 = 28%; P < .001) and neck hematoma requiring reintervention (3.6% vs 2.3%; OR, 0.61; 95% CI, 0.43-0.85; I2 = 0%; P = .003). CONCLUSIONS In patients presenting with an acute ischemic stroke, CEA can be safely performed after a prior endovenous thrombolysis, maintaining a stroke/death risk of <6%. After IVT, CEA should be deferred for ≥5 days to minimize the risk for intracranial hemorrhage and neck bleeding.
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Affiliation(s)
| | - Cecilia Zivelonghi
- Department of Neurology and Stroke Unit, Verona University Hospital, Verona, Italy
| | - Mirko Menegolo
- Vascular and Endovascular Surgery Division, Padua University, Padua, Italy
| | - Andrea Xodo
- Vascular and Endovascular Surgery Division, "San Bortolo" Hospital, Vicenza, Italy
| | | | - Chiara De Massari
- Vascular and Endovascular Surgery Division, Padua University, Padua, Italy
| | - Franco Grego
- Vascular and Endovascular Surgery Division, Padua University, Padua, Italy
| | - Michele Piazza
- Vascular and Endovascular Surgery Division, Padua University, Padua, Italy
| | - Michele Antonello
- Vascular and Endovascular Surgery Division, Padua University, Padua, Italy
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Rodríguez I, Gramegna LL, Requena M, Rizzuti M, Elosua I, Mayol J, Olivé-Gadea M, Diana F, Rodrigo-Gisbert M, Muchada M, Rivera E, García-Tornel Á, Rizzo F, De Dios M, Rodríguez-Luna D, Piñana C, Pagola J, Hernández D, Juega J, Rodríguez N, Quintana M, Molina C, Ribo M, Tomasello A. Safety and efficacy of early carotid artery stenting in patients with symptomatic stenosis. Interv Neuroradiol 2024:15910199241239204. [PMID: 38515363 DOI: 10.1177/15910199241239204] [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: 03/23/2024] Open
Abstract
BACKGROUND Symptomatic carotid artery stenosis is a significant contributor to ischemic strokes. Carotid artery stenting (CAS) is usually indicated for secondary stroke prevention. This study evaluates the safety and efficacy of CAS performed within a short time frame from symptom onset. METHODS We conducted a single-center, retrospective study of consecutive patients who underwent CAS for symptomatic carotid stenosis within eight days of symptom onset from July 2019 to January 2022. Data on demographics, medical history, procedural details, and follow-up outcomes were analyzed. The primary outcome measure was the recurrence of the stroke within the first month post-procedure. Secondary outcomes included mortality, the rate of intra-procedural complications, and hyperperfusion syndrome. RESULTS We included 93 patients with a mean age of 71.7 ± 11.7 years. The median time from symptom onset to CAS was 96 h. The rate of stroke recurrence was 5.4% in the first month, with a significant association between the number of stents used and increased recurrence risk. Mortality within the first month was 3.2%, with an overall mortality rate of 11.8% after a median follow-up of 19 months. Intra-procedural complications were present in five (5.4%) cases and were related to the number of stents used (p = 0.002) and post-procedural angioplasty (p = 0.045). Hyperperfusion syndrome occurred in 3.2% of cases. CONCLUSION Early CAS within the high-risk window post-symptom onset is a viable secondary stroke prevention strategy in patients with symptomatic carotid artery stenosis. The procedure rate of complication is acceptable, with a low recurrence of stroke. However, further careful selection of patients for this procedural strategy is crucial to optimize outcomes.
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Affiliation(s)
- Isabel Rodríguez
- Interventional Neuroradiology Unit, Department of Neurosciences, Hospital Universitari Germans Trias i Pujol, Badalona, Spain
| | - Laura Ludovica Gramegna
- Vall d'Hebron Institut de Recerca, Vall d'Hebron Barcelona Hospital Campus, Barcelona, Spain
| | - Manuel Requena
- Vall d'Hebron Institut de Recerca, Vall d'Hebron Barcelona Hospital Campus, Barcelona, Spain
- Department of Radiology, Interventional Neuroradiology Section, Hospital Universitari Vall d'Hebron, Barcelona, Spain
- Stroke Unit, Department of Neurology, Hospital Universitari Vall d'Hebron Barcelona Spain, Barcelona, Spain
| | | | - Iker Elosua
- Stroke Unit, Department of Neurology, Hospital Universitari Vall d'Hebron Barcelona Spain, Barcelona, Spain
| | - Jordi Mayol
- Stroke Unit, Department of Neurology, Hospital Universitari Vall d'Hebron Barcelona Spain, Barcelona, Spain
| | - Marta Olivé-Gadea
- Vall d'Hebron Institut de Recerca, Vall d'Hebron Barcelona Hospital Campus, Barcelona, Spain
- Stroke Unit, Department of Neurology, Hospital Universitari Vall d'Hebron Barcelona Spain, Barcelona, Spain
| | - Francesco Diana
- Vall d'Hebron Institut de Recerca, Vall d'Hebron Barcelona Hospital Campus, Barcelona, Spain
- Department of Radiology, Interventional Neuroradiology Section, Hospital Universitari Vall d'Hebron, Barcelona, Spain
| | - Marc Rodrigo-Gisbert
- Vall d'Hebron Institut de Recerca, Vall d'Hebron Barcelona Hospital Campus, Barcelona, Spain
- Stroke Unit, Department of Neurology, Hospital Universitari Vall d'Hebron Barcelona Spain, Barcelona, Spain
| | - Marián Muchada
- Vall d'Hebron Institut de Recerca, Vall d'Hebron Barcelona Hospital Campus, Barcelona, Spain
- Stroke Unit, Department of Neurology, Hospital Universitari Vall d'Hebron Barcelona Spain, Barcelona, Spain
| | - Eila Rivera
- Vall d'Hebron Institut de Recerca, Vall d'Hebron Barcelona Hospital Campus, Barcelona, Spain
| | - Álvaro García-Tornel
- Vall d'Hebron Institut de Recerca, Vall d'Hebron Barcelona Hospital Campus, Barcelona, Spain
- Stroke Unit, Department of Neurology, Hospital Universitari Vall d'Hebron Barcelona Spain, Barcelona, Spain
| | - Federica Rizzo
- Vall d'Hebron Institut de Recerca, Vall d'Hebron Barcelona Hospital Campus, Barcelona, Spain
- Stroke Unit, Department of Neurology, Hospital Universitari Vall d'Hebron Barcelona Spain, Barcelona, Spain
| | - Marta De Dios
- Vall d'Hebron Institut de Recerca, Vall d'Hebron Barcelona Hospital Campus, Barcelona, Spain
- Department of Radiology, Interventional Neuroradiology Section, Hospital Universitari Vall d'Hebron, Barcelona, Spain
| | - David Rodríguez-Luna
- Vall d'Hebron Institut de Recerca, Vall d'Hebron Barcelona Hospital Campus, Barcelona, Spain
- Stroke Unit, Department of Neurology, Hospital Universitari Vall d'Hebron Barcelona Spain, Barcelona, Spain
| | - Carlos Piñana
- Interventional Radiology, Hospital Clínico Valencia, Barcelona, Spain
| | - Jorge Pagola
- Vall d'Hebron Institut de Recerca, Vall d'Hebron Barcelona Hospital Campus, Barcelona, Spain
- Stroke Unit, Department of Neurology, Hospital Universitari Vall d'Hebron Barcelona Spain, Barcelona, Spain
| | - David Hernández
- Vall d'Hebron Institut de Recerca, Vall d'Hebron Barcelona Hospital Campus, Barcelona, Spain
- Department of Radiology, Interventional Neuroradiology Section, Hospital Universitari Vall d'Hebron, Barcelona, Spain
| | - Jesús Juega
- Vall d'Hebron Institut de Recerca, Vall d'Hebron Barcelona Hospital Campus, Barcelona, Spain
- Stroke Unit, Department of Neurology, Hospital Universitari Vall d'Hebron Barcelona Spain, Barcelona, Spain
| | - Noelia Rodríguez
- Vall d'Hebron Institut de Recerca, Vall d'Hebron Barcelona Hospital Campus, Barcelona, Spain
- Stroke Unit, Department of Neurology, Hospital Universitari Vall d'Hebron Barcelona Spain, Barcelona, Spain
| | - Manuel Quintana
- Epilepsy Unit, Department of Neurology, Hospital Universitari Vall d'Hebron, Barcelona, Spain
| | - Carlos Molina
- Vall d'Hebron Institut de Recerca, Vall d'Hebron Barcelona Hospital Campus, Barcelona, Spain
- Stroke Unit, Department of Neurology, Hospital Universitari Vall d'Hebron Barcelona Spain, Barcelona, Spain
| | - Marc Ribo
- Vall d'Hebron Institut de Recerca, Vall d'Hebron Barcelona Hospital Campus, Barcelona, Spain
- Stroke Unit, Department of Neurology, Hospital Universitari Vall d'Hebron Barcelona Spain, Barcelona, Spain
| | - Alejandro Tomasello
- Vall d'Hebron Institut de Recerca, Vall d'Hebron Barcelona Hospital Campus, Barcelona, Spain
- Department of Radiology, Interventional Neuroradiology Section, Hospital Universitari Vall d'Hebron, Barcelona, Spain
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Bains N, Nunna RS, Ma X, Fakih R, Jaura A, French BR, Siddiq F, Gomez CR, Qureshi AI. Risk of new cerebral ischemic events in patients with symptomatic internal carotid artery stenosis while awaiting carotid stent placement. J Neuroimaging 2023; 33:976-982. [PMID: 37697475 DOI: 10.1111/jon.13150] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2023] [Revised: 08/08/2023] [Accepted: 08/18/2023] [Indexed: 09/13/2023] Open
Abstract
BACKGROUND AND PURPOSE Although there is an emphasis on performing carotid artery stent (CAS) placement within 2 weeks after index event of transient ischemic attack (TIA) or minor stroke in patients with significant extracranial internal carotid artery (ICA) stenosis, the risks and characteristics of recurrent cerebral ischemic event while waiting for CAS placement are not well defined. METHOD We analyzed patients admitted to our institution over a 45-month period with symptomatic extracranial ICA stenosis. We identified any new cerebral ischemic events that occurred between index cerebral or retinal ischemic event and CAS placement and categorized them as TIA and minor or major ischemic strokes. We calculated the risk of new ipsilateral cerebral ischemic events between index cerebral or retinal ischemic event and CAS placement. RESULTS The mean age of 131 patients analyzed was 67 years (range: 47-94 years; 92 were men), and 94 and 37 patients had 70%-99% and 50%-69% severity of stenosis, respectively. The mean and median time intervals between index cerebral or retinal ischemic event and CAS performance were 28 (standard deviation [SD] 30) and 7 (interquartile range 33) days, respectively. A total of 9 of 131 patients (6.9%, 95% confidence interval 2.5%-11.2%) experienced new cerebral ischemic events over 3637 patient days of observation. The risk of new ipsilateral cerebral ischemic events was 2.5 per 1000 patient days of observation. CONCLUSION We estimated the risk of new ipsilateral cerebral ischemic events in patients with ICA stenosis ≥50% in severity while waiting for CAS placement to guide appropriate timing of procedure.
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Affiliation(s)
- Navpreet Bains
- Department of Neurology, University of Missouri, Columbia, Missouri, USA
| | - Ravi S Nunna
- Division of Neurosurgery, University of Missouri, Columbia, Missouri, USA
| | - Xiaoyu Ma
- Department of Neurology, University of Missouri, Columbia, Missouri, USA
| | - Rami Fakih
- Department of Neurology, University of Missouri, Columbia, Missouri, USA
| | - Attiya Jaura
- Department of Neurology, University of Missouri, Columbia, Missouri, USA
| | - Brandi R French
- Department of Neurology, University of Missouri, Columbia, Missouri, USA
| | - Farhan Siddiq
- Division of Neurosurgery, University of Missouri, Columbia, Missouri, USA
| | - Camilo R Gomez
- Department of Neurology, University of Missouri, Columbia, Missouri, USA
| | - Adnan I Qureshi
- Department of Neurology, University of Missouri, Columbia, Missouri, USA
- Department of Neurology, Zeenat Qureshi Stroke Institute, St. Cloud, Minnesota, USA
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Abstract
Stroke is the second leading cause of death worldwide. One of the main causes of stroke is carotid artery stenosis. Stenosis with atherosclerosis in the carotid artery can cause stroke by hemodynamic ischemia or artery to artery embolism. A most common surgical intervention for carotid artery stenosis is carotid endarterectomy (CEA). Many studies on CEA have been reported and suggested medical indications. For symptomatic carotid stenosis, generally, CEA may be indicated for patients with more than 50% stenosis and is especially beneficial in men, patients aged 75 years or older, and patients who underwent surgery within 2 weeks of their last symptoms. For asymptomatic carotid stenosis, CEA may be indicated for those with more than 60% stenosis, though each guideline has different suggestions in detail. In order to evaluate the indication for CEA in each case, it is important to assess risks for CEA carefully including anatomical factors and comorbidities, and to elaborate each strategy for each operation based on preoperative imaging studies including carotid ultrasonography, magnetic resonance imaging and angiography. In surgery there are many tips on operative position, procedure, shunt usage and monitoring to perform a safe and smooth operation. Now that carotid artery stenting has been rapidly developed, better understanding for CEA is required to treat carotid artery stenosis adequately. This chapter must be a good help to understand CEA well.
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Affiliation(s)
- Takayuki Hara
- Department of Neurosurgery, Toranomon Hospital, Minato-ku, Tokyo, Japan.
| | - Yurie Rai
- Department of Neurosurgery, Toranomon Hospital, Minato-ku, Tokyo, Japan
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5
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Ostrý S, Nevšímal M, Reiser M, Voldřich R, Krtička O, Kubále J, Nevšímalová M, Fiedler J. Intraoperative neurophysiological monitoring during urgent surgical extracranial internal carotid artery recanalization. Clin Neurophysiol 2022; 138:221-230. [DOI: 10.1016/j.clinph.2022.01.135] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2021] [Revised: 12/23/2021] [Accepted: 01/18/2022] [Indexed: 12/14/2022]
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Cui CL, Dakour-Aridi H, Lu JJ, Yei KS, Schermerhorn ML, Malas MB. In-Hospital Outcomes of Urgent, Early, or Late Revascularization for Symptomatic Carotid Artery Stenosis. Stroke 2021; 53:100-107. [PMID: 34872337 DOI: 10.1161/strokeaha.120.032410] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND AND PURPOSE Advancements in carotid revascularization have produced promising outcomes in patients with symptomatic carotid artery stenosis. However, the optimal timing of revascularization procedures after symptomatic presentation remains unclear. The purpose of this study is to compare in-hospital outcomes of transcarotid artery revascularization (TCAR), transfemoral carotid stenting (TFCAS), or carotid endarterectomy (CEA) performed within different time intervals after most recent symptoms. METHODS This is a retrospective cohort study of United States patients in the vascular quality initiative. All carotid revascularizations performed for symptomatic carotid artery stenosis between September 2016 and November 2019 were included. Procedures were categorized as urgent (0-2 days after most recent symptom), early (3-14 days), or late (15-180 days). The primary outcome of interest was in-hospital stroke and death. Secondary outcomes include in-hospital stroke, death, and transient ischemic attacks. Multivariable logistic regression was used to compare outcomes. RESULTS A total of 18 643 revascularizations were included: 2006 (10.8%) urgent, 7423 (39.8%) early, and 9214 (49.42%) late. Patients with TFCAS had the highest rates of stroke/death at all timing cohorts (urgent: 4.0% CEA, 6.9% TFCAS, 6.5% TCAR, P=0.018; early: 2.5% CEA, 3.8% TFCAS, 2.9% TCAR, P=0.054; late: 1.6% CEA, 2.8% TFCAS, 2.3% TCAR, P=0.003). TFCAS also had increased odds of in-hospital stroke/death compared with CEA in all 3 groups (urgent adjusted odds ratio [aOR], 1.7 [95% CI, 1.0-2.9] P=0.03; early aOR, 1.6 [95% CI, 1.1-2.4] P=0.01; and late aOR, 1.9 [95% CI, 1.2-3.0] P=0.01). TCAR and CEA had comparable odds of in-hospital stroke/death in all 3 groups (urgent aOR, 1.9 [95% CI, 0.9-4], P=0.10), (early aOR, 1.1 [95% CI, 0.7-1.7], P=0.66), (late aOR, 1.5 [95% CI, 0.9-2.3], P=0.08). CONCLUSIONS CEA remains the safest method of revascularization within the urgent period. Among revascularization performed outside of the 48 hours, TCAR and CEA have comparable outcomes.
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Affiliation(s)
- Christina L Cui
- University of California San Diego (C.L.C., H.D.-A., K.S.Y., M.B.M.)
| | | | - Jinny J Lu
- Beth Israel Deaconess Medical Center, Boston, MA (J.J.L., M.L.S.)
| | - Kevin S Yei
- University of California San Diego (C.L.C., H.D.-A., K.S.Y., M.B.M.)
| | | | - Mahmoud B Malas
- University of California San Diego (C.L.C., H.D.-A., K.S.Y., M.B.M.)
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7
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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: 12] [Impact Index Per Article: 3.0] [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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8
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Gavrilenko AV, Kuklin AV, Khripkov AS. [Early carotid endarterectomy in patients after endured acute cerebral circulation impairment]. ANGIOLOGII︠A︡ I SOSUDISTAI︠A︡ KHIRURGII︠A︡ = ANGIOLOGY AND VASCULAR SURGERY 2019; 25:186-193. [PMID: 31150007 DOI: 10.33529/angio2019203] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
Recent years have witnessed a series of studies dedicated to assessment of optimal terms of performing carotid endarterectomy (CEA) after sustained acute cerebral circulatory impairment (ACCI). However, there is no commonly accepted opinion concerning feasibility and safety of early CEA in 'symptomatic' patients. The 2015 Guidelines of the American Heart Association suggest that surgical intervention should be performed within the shortest terms or during 2 weeks after a neurological event (class IIb, level B evidence). In the presented herein review of literature most authors demonstrated safety and efficacy of performing early CEA after endured ACCI. However, further prospective, randomized studies are needed in order to work out new standards of examination and to determine optimal surgical policy.
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Affiliation(s)
- A V Gavrilenko
- Vascular Surgery Department, Russian Research Centre of Surgery named after Academician B.V. Petrovsky, Moscow, Russia; First Moscow State Medical University named after I.M. Sechenov under the RF Ministry of Public Health, Moscow, Russia
| | - A V Kuklin
- Vascular Surgery Department, Russian Research Centre of Surgery named after Academician B.V. Petrovsky, Moscow, Russia
| | - A S Khripkov
- Regional Vascular Centre, Krasnogorsk Municipal Hospital #1, Kasnogorsk, Moscow Region, Russia
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Savardekar AR, Narayan V, Patra DP, Spetzler RF, Sun H. Timing of Carotid Endarterectomy for Symptomatic Carotid Stenosis: A Snapshot of Current Trends and Systematic Review of Literature on Changing Paradigm towards Early Surgery. Neurosurgery 2019; 85:E214-E225. [DOI: 10.1093/neuros/nyy557] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2018] [Accepted: 01/31/2019] [Indexed: 11/14/2022] Open
Abstract
Abstract
Carotid revascularization has been recommended as the maximally beneficial treatment for stroke prevention in patients with recently symptomatic carotid stenosis (SCS). The appropriate timing for performing carotid endarterectomy (CEA) within the first 14 d after the occurrence of the index event remains controversial. We aim to provide a snapshot of the pertinent current literature related to the timing of CEA for patients with SCS. A systematic review of literature was conducted to study the timing of CEA for SCS. The guidelines of the Preferred Reporting Items for Systematic Reviews and Meta-analysis (PRISMA) were followed. A total of 63 articles were identified as relevant to this topic. A summary of 15 articles favoring urgent CEA (within 48 h) for SCS within 48 h of index event and 9 articles not favoring urgent CEA is presented. A consensus is still to be achieved on the ideal timing of CEA for SCS within the 14-d window presently prescribed. The current literature suggests that patients who undergo urgent CEA (within 48 h) after nondisabling stroke as the index event have an increased periprocedural risk as compared to those who had transient ischemic attack (TIA) as the index event. Further prospective studies and clinical trials studying this question with separate groups classified as per the index event are required to shed more light on the subject. The current literature points to a changing paradigm towards early carotid surgery, specifically targeted within 48 h if the index event is TIA, and within 7 d if the index event is stroke.
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Affiliation(s)
- Amey R Savardekar
- Department of Neurosurgery, Louisiana State University Health Sciences Center, Shreveport, Louisiana
| | - Vinayak Narayan
- Department of Neurosurgery, Louisiana State University Health Sciences Center, Shreveport, Louisiana
| | - Devi P Patra
- Department of Neurosurgery, Louisiana State University Health Sciences Center, Shreveport, Louisiana
| | - Robert F Spetzler
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona
| | - Hai Sun
- Department of Neurosurgery, Louisiana State University Health Sciences Center, Shreveport, Louisiana
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Rantner B, Kollerits B, Roubin GS, Ringleb PA, Jansen O, Howard G, Hendrikse J, Halliday A, Gregson J, Eckstein HH, Calvet D, Bulbulia R, Bonati LH, Becquemin JP, Algra A, Brown MM, Mas JL, Brott TG, Fraedrich G. Early Endarterectomy Carries a Lower Procedural Risk Than Early Stenting in Patients With Symptomatic Stenosis of the Internal Carotid Artery. Stroke 2017; 48:1580-1587. [DOI: 10.1161/strokeaha.116.016233] [Citation(s) in RCA: 64] [Impact Index Per Article: 9.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2016] [Revised: 03/07/2017] [Accepted: 03/13/2017] [Indexed: 01/22/2023]
Abstract
Background and Purpose—
Patients undergoing carotid endarterectomy (CEA) for symptomatic stenosis of the internal carotid artery benefit from early intervention. Heterogeneous data are available on the influence of timing of carotid artery stenting (CAS) on procedural risk.
Methods—
We investigated the association between timing of treatment (0–7 days and >7 days after the qualifying neurological event) and the 30-day risk of stroke or death after CAS or CEA in a pooled analysis of individual patient data from 4 randomized trials by the Carotid Stenosis Trialists’ Collaboration. Analyses were done per protocol. To obtain combined estimates, logistic mixed models were applied.
Results—
Among a total of 4138 patients, a minority received their allocated treatment within 7 days after symptom onset (14% CAS versus 11% CEA). Among patients treated within 1 week of symptoms, those treated by CAS had a higher risk of stroke or death compared with those treated with CEA: 8.3% versus 1.3%, risk ratio, 6.7; 95% confidence interval, 2.1 to 21.9 (adjusted for age at treatment, sex, and type of qualifying event). For interventions after 1 week, CAS was also more hazardous than CEA: 7.1% versus 3.6%, adjusted risk ratio, 2.0; 95% confidence interval, 1.5 to 2.7 (
P
value for interaction with time interval 0.06).
Conclusions—
In randomized trials comparing stenting with CEA for symptomatic carotid artery stenosis, CAS was associated with a substantially higher periprocedural risk during the first 7 days after the onset of symptoms. Early surgery is safer than stenting for preventing future stroke.
Clinical Trial Registration—
URL:
http://www.clinicaltrials.gov
. Unique identifier: NCT00190398; URL:
http://www.controlled-trials.com
. Unique identifier: ISRCTN57874028; Unique identifier: ISRCTN25337470; URL:
http://www.clinicaltrials.gov
. Unique identifier: NCT00004732.
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Affiliation(s)
- Barbara Rantner
- From the Department of Vascular Surgery (B.R., G.F.) and Division of Genetic Epidemiology, Department of Medical Genetics, Molecular and Clinical Pharmacology (B.K.), Medical University of Innsbruck, Austria; Cardiovascular Associates of the Southeast, Birmingham, AL (G.S.R.); Department of Neurology, University of Heidelberg Medical School, Germany (P.A.R.); Clinic for Radiology and Neuroradiology, UKSH Campus Kiel, Germany (O.J.); Department of Biostatistics, UAB School of Public Health,
| | - Barbara Kollerits
- From the Department of Vascular Surgery (B.R., G.F.) and Division of Genetic Epidemiology, Department of Medical Genetics, Molecular and Clinical Pharmacology (B.K.), Medical University of Innsbruck, Austria; Cardiovascular Associates of the Southeast, Birmingham, AL (G.S.R.); Department of Neurology, University of Heidelberg Medical School, Germany (P.A.R.); Clinic for Radiology and Neuroradiology, UKSH Campus Kiel, Germany (O.J.); Department of Biostatistics, UAB School of Public Health,
| | - Gary S. Roubin
- From the Department of Vascular Surgery (B.R., G.F.) and Division of Genetic Epidemiology, Department of Medical Genetics, Molecular and Clinical Pharmacology (B.K.), Medical University of Innsbruck, Austria; Cardiovascular Associates of the Southeast, Birmingham, AL (G.S.R.); Department of Neurology, University of Heidelberg Medical School, Germany (P.A.R.); Clinic for Radiology and Neuroradiology, UKSH Campus Kiel, Germany (O.J.); Department of Biostatistics, UAB School of Public Health,
| | - Peter A. Ringleb
- From the Department of Vascular Surgery (B.R., G.F.) and Division of Genetic Epidemiology, Department of Medical Genetics, Molecular and Clinical Pharmacology (B.K.), Medical University of Innsbruck, Austria; Cardiovascular Associates of the Southeast, Birmingham, AL (G.S.R.); Department of Neurology, University of Heidelberg Medical School, Germany (P.A.R.); Clinic for Radiology and Neuroradiology, UKSH Campus Kiel, Germany (O.J.); Department of Biostatistics, UAB School of Public Health,
| | - Olaf Jansen
- From the Department of Vascular Surgery (B.R., G.F.) and Division of Genetic Epidemiology, Department of Medical Genetics, Molecular and Clinical Pharmacology (B.K.), Medical University of Innsbruck, Austria; Cardiovascular Associates of the Southeast, Birmingham, AL (G.S.R.); Department of Neurology, University of Heidelberg Medical School, Germany (P.A.R.); Clinic for Radiology and Neuroradiology, UKSH Campus Kiel, Germany (O.J.); Department of Biostatistics, UAB School of Public Health,
| | - George Howard
- From the Department of Vascular Surgery (B.R., G.F.) and Division of Genetic Epidemiology, Department of Medical Genetics, Molecular and Clinical Pharmacology (B.K.), Medical University of Innsbruck, Austria; Cardiovascular Associates of the Southeast, Birmingham, AL (G.S.R.); Department of Neurology, University of Heidelberg Medical School, Germany (P.A.R.); Clinic for Radiology and Neuroradiology, UKSH Campus Kiel, Germany (O.J.); Department of Biostatistics, UAB School of Public Health,
| | - Jeroen Hendrikse
- From the Department of Vascular Surgery (B.R., G.F.) and Division of Genetic Epidemiology, Department of Medical Genetics, Molecular and Clinical Pharmacology (B.K.), Medical University of Innsbruck, Austria; Cardiovascular Associates of the Southeast, Birmingham, AL (G.S.R.); Department of Neurology, University of Heidelberg Medical School, Germany (P.A.R.); Clinic for Radiology and Neuroradiology, UKSH Campus Kiel, Germany (O.J.); Department of Biostatistics, UAB School of Public Health,
| | - Alison Halliday
- From the Department of Vascular Surgery (B.R., G.F.) and Division of Genetic Epidemiology, Department of Medical Genetics, Molecular and Clinical Pharmacology (B.K.), Medical University of Innsbruck, Austria; Cardiovascular Associates of the Southeast, Birmingham, AL (G.S.R.); Department of Neurology, University of Heidelberg Medical School, Germany (P.A.R.); Clinic for Radiology and Neuroradiology, UKSH Campus Kiel, Germany (O.J.); Department of Biostatistics, UAB School of Public Health,
| | - John Gregson
- From the Department of Vascular Surgery (B.R., G.F.) and Division of Genetic Epidemiology, Department of Medical Genetics, Molecular and Clinical Pharmacology (B.K.), Medical University of Innsbruck, Austria; Cardiovascular Associates of the Southeast, Birmingham, AL (G.S.R.); Department of Neurology, University of Heidelberg Medical School, Germany (P.A.R.); Clinic for Radiology and Neuroradiology, UKSH Campus Kiel, Germany (O.J.); Department of Biostatistics, UAB School of Public Health,
| | - Hans-Henning Eckstein
- From the Department of Vascular Surgery (B.R., G.F.) and Division of Genetic Epidemiology, Department of Medical Genetics, Molecular and Clinical Pharmacology (B.K.), Medical University of Innsbruck, Austria; Cardiovascular Associates of the Southeast, Birmingham, AL (G.S.R.); Department of Neurology, University of Heidelberg Medical School, Germany (P.A.R.); Clinic for Radiology and Neuroradiology, UKSH Campus Kiel, Germany (O.J.); Department of Biostatistics, UAB School of Public Health,
| | - David Calvet
- From the Department of Vascular Surgery (B.R., G.F.) and Division of Genetic Epidemiology, Department of Medical Genetics, Molecular and Clinical Pharmacology (B.K.), Medical University of Innsbruck, Austria; Cardiovascular Associates of the Southeast, Birmingham, AL (G.S.R.); Department of Neurology, University of Heidelberg Medical School, Germany (P.A.R.); Clinic for Radiology and Neuroradiology, UKSH Campus Kiel, Germany (O.J.); Department of Biostatistics, UAB School of Public Health,
| | - Richard Bulbulia
- From the Department of Vascular Surgery (B.R., G.F.) and Division of Genetic Epidemiology, Department of Medical Genetics, Molecular and Clinical Pharmacology (B.K.), Medical University of Innsbruck, Austria; Cardiovascular Associates of the Southeast, Birmingham, AL (G.S.R.); Department of Neurology, University of Heidelberg Medical School, Germany (P.A.R.); Clinic for Radiology and Neuroradiology, UKSH Campus Kiel, Germany (O.J.); Department of Biostatistics, UAB School of Public Health,
| | - Leo H. Bonati
- From the Department of Vascular Surgery (B.R., G.F.) and Division of Genetic Epidemiology, Department of Medical Genetics, Molecular and Clinical Pharmacology (B.K.), Medical University of Innsbruck, Austria; Cardiovascular Associates of the Southeast, Birmingham, AL (G.S.R.); Department of Neurology, University of Heidelberg Medical School, Germany (P.A.R.); Clinic for Radiology and Neuroradiology, UKSH Campus Kiel, Germany (O.J.); Department of Biostatistics, UAB School of Public Health,
| | - Jean-Pierre Becquemin
- From the Department of Vascular Surgery (B.R., G.F.) and Division of Genetic Epidemiology, Department of Medical Genetics, Molecular and Clinical Pharmacology (B.K.), Medical University of Innsbruck, Austria; Cardiovascular Associates of the Southeast, Birmingham, AL (G.S.R.); Department of Neurology, University of Heidelberg Medical School, Germany (P.A.R.); Clinic for Radiology and Neuroradiology, UKSH Campus Kiel, Germany (O.J.); Department of Biostatistics, UAB School of Public Health,
| | - Ale Algra
- From the Department of Vascular Surgery (B.R., G.F.) and Division of Genetic Epidemiology, Department of Medical Genetics, Molecular and Clinical Pharmacology (B.K.), Medical University of Innsbruck, Austria; Cardiovascular Associates of the Southeast, Birmingham, AL (G.S.R.); Department of Neurology, University of Heidelberg Medical School, Germany (P.A.R.); Clinic for Radiology and Neuroradiology, UKSH Campus Kiel, Germany (O.J.); Department of Biostatistics, UAB School of Public Health,
| | - Martin M. Brown
- From the Department of Vascular Surgery (B.R., G.F.) and Division of Genetic Epidemiology, Department of Medical Genetics, Molecular and Clinical Pharmacology (B.K.), Medical University of Innsbruck, Austria; Cardiovascular Associates of the Southeast, Birmingham, AL (G.S.R.); Department of Neurology, University of Heidelberg Medical School, Germany (P.A.R.); Clinic for Radiology and Neuroradiology, UKSH Campus Kiel, Germany (O.J.); Department of Biostatistics, UAB School of Public Health,
| | - Jean-Louis Mas
- From the Department of Vascular Surgery (B.R., G.F.) and Division of Genetic Epidemiology, Department of Medical Genetics, Molecular and Clinical Pharmacology (B.K.), Medical University of Innsbruck, Austria; Cardiovascular Associates of the Southeast, Birmingham, AL (G.S.R.); Department of Neurology, University of Heidelberg Medical School, Germany (P.A.R.); Clinic for Radiology and Neuroradiology, UKSH Campus Kiel, Germany (O.J.); Department of Biostatistics, UAB School of Public Health,
| | - Thomas G. Brott
- From the Department of Vascular Surgery (B.R., G.F.) and Division of Genetic Epidemiology, Department of Medical Genetics, Molecular and Clinical Pharmacology (B.K.), Medical University of Innsbruck, Austria; Cardiovascular Associates of the Southeast, Birmingham, AL (G.S.R.); Department of Neurology, University of Heidelberg Medical School, Germany (P.A.R.); Clinic for Radiology and Neuroradiology, UKSH Campus Kiel, Germany (O.J.); Department of Biostatistics, UAB School of Public Health,
| | - Gustav Fraedrich
- From the Department of Vascular Surgery (B.R., G.F.) and Division of Genetic Epidemiology, Department of Medical Genetics, Molecular and Clinical Pharmacology (B.K.), Medical University of Innsbruck, Austria; Cardiovascular Associates of the Southeast, Birmingham, AL (G.S.R.); Department of Neurology, University of Heidelberg Medical School, Germany (P.A.R.); Clinic for Radiology and Neuroradiology, UKSH Campus Kiel, Germany (O.J.); Department of Biostatistics, UAB School of Public Health,
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11
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Yang NR, Jeon P, Kim B, Kim KH, Jo KI. Usefulness of Early Stenting for Symptomatic Extracranial Carotid Stenosis. World Neurosurg 2016; 96:334-339. [PMID: 27641265 DOI: 10.1016/j.wneu.2016.09.027] [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] [Received: 02/11/2016] [Revised: 09/06/2016] [Accepted: 09/06/2016] [Indexed: 11/28/2022]
Abstract
BACKGROUND While carotid angioplasty and stenting (CAS) have become an established procedure, outcomes of early CAS for symptomatic extracranial carotid stenosis (SECS) remain poorly understood. The present study aimed at determining the effectiveness of early CAS in SECS. METHODS Herein, 224 SECS patients underwent elective CAS between January 2008 and June 2015. The study population was stratified based on the time from symptom onset to the procedure (early CAS group: within 14 days; delayed CAS group: later than 14 days). Subgroup analysis (chi-square test, Mantel-Haenszel chi-square test, and analysis of covariance) evaluated the demographics, incidence of periprocedural thromboembolic complications, cerebral hyperperfusion syndrome (CHS), intracranial bleeding, and treatment outcomes on the modified Rankin Scale (mRS). RESULTS Symptomatic thromboembolic complications and CHS were noted in 2.68% and 0.89% of patients, respectively. The initial National Institutes of Health Stroke Scale (NIHSS) score was significantly higher in patients who underwent early CAS than in those who underwent delayed CAS (2.50 ± 3.97 vs. 0.97 ± 2.08, P = 0.001). After adjusting for age, duration of preprocedural dual antiplatelet therapy, initial NIHSS score, and preprocedural NIHSS score, the groups did not differ significantly regarding the incidence of symptomatic thromboembolic complications (P = 0.195), incidence of CHS (P = 0.950), incidence of intracranial bleeding (P = 0.970), 30-day mRS score (P = 0.124), and mRS score at final follow-up (P = 0.132). CONCLUSIONS For SECS patients who cannot undergo early carotid endarterectomy, early CAS is effective and safe if selectively indicated considering disease severity. Early and delayed CAS provide comparable mRS scores, incidence of symptomatic thromboembolic complications, CHS, and intracranial bleeding.
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Affiliation(s)
- Na-Rae Yang
- Department of Neurosurgery, Ewha Womans University School of Medicine, Mokdong Hospital, Seoul, Korea
| | - Pyoung Jeon
- Department of Radiology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea.
| | - Byungjun Kim
- Department of Radiology, Korea University Anam Hospital, Korea University College of Medicine, Seoul, Korea
| | - Keon Ha Kim
- Department of Radiology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Kyung-Il Jo
- Department of Neurosurgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea; Department of Neurosurgery, Hana General Hospital, Cheongju, Korea
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12
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Abstract
The '6-month' threshold for treating symptomatic patients is obsolete. There is compelling evidence that the highest-risk period for stroke (after suffering a transient ischemic attack) is the first 2 weeks, especially the first few days, and that carotid endarterectomy (CEA) confers maximal benefit when performed early. Despite well-documented anxieties, there is increasing evidence that CEA can be performed safely within the first 7 days after onset of symptoms, although risks may be higher when performed within 48 h. The role for carotid artery stenting in the hyperacute period remains uncertain. Centers performing carotid artery stenting within 14 days of symptom onset with risks equivalent to CEA should be encouraged to continue and help others to achieve similar outcomes. For the majority, however, CEA will probably remain the safer option. 'Best medical therapy' and risk factor modification should be started as soon as a transient ischemic attack is suspected, while the early introduction of dual antiplatelet therapy may reduce recurrent events prior to CEA, without increasing perioperative bleeding complications.
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Affiliation(s)
- A Ross Naylor
- a The Department of Vascular Surgery at Leicester Royal Infirmary, Leicester, UK
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13
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Johansson E, Cuadrado-Godia E, Hayden D, Bjellerup J, Ois A, Roquer J, Wester P, Kelly PJ. Recurrent stroke in symptomatic carotid stenosis awaiting revascularization: A pooled analysis. Neurology 2016; 86:498-504. [PMID: 26747885 DOI: 10.1212/wnl.0000000000002354] [Citation(s) in RCA: 57] [Impact Index Per Article: 7.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2015] [Accepted: 09/03/2015] [Indexed: 11/15/2022] Open
Abstract
OBJECTIVE We aimed to quantify the risk and predictors of ipsilateral ischemic stroke in patients with symptomatic carotid stenosis awaiting revascularization (carotid endarterectomy [CEA] or carotid artery stenting) by pooling individual patient data from recent prospective studies with high rates of treatment with modern stroke prevention medications. METHODS Data were included from 2 prospective hospital-based registries (Umeå, Barcelona) and one prospective population-based study (Dublin). Patients with symptomatic 50%-99% carotid stenosis eligible for carotid revascularization were included and followed for early recurrent ipsilateral stroke or retinal artery occlusion (RAO). RESULTS Of 607 patients with symptomatic 50%-99% carotid stenosis, 377 met prespecified inclusion criteria. Ipsilateral recurrent ischemic stroke/RAO risk pre-revascularization was 2.7% (1 day), 5.3% (3 days), 11.5% (14 days), and 18.8% (90 days). On bivariate analysis, presentation with a cerebral vs ocular event was associated with higher recurrent stroke risk (log-rank p = 0.04). On multivariable Cox regression, recurrence was associated with older age (adjusted hazard ratio [HR] per 10-year increase 1.5, p = 0.02) with a strong trend for association with cerebral (stroke/TIA) vs ocular symptoms (adjusted HR 2.7, p = 0.06), but not degree of stenosis, smoking, vascular risk factors, or medications. CONCLUSIONS We found high risk of recurrent ipsilateral ischemic events within the 14-day time period currently recommended for CEA. Randomized trials are needed to determine the benefits and safety of urgent vs subacute carotid revascularization within 14 days after symptom onset.
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Affiliation(s)
- Elias Johansson
- From the Department of Public Health and Clinical Medicine, Umeå Stroke Centre (E.J., J.B., P.W.), and Department of Pharmacology and Clinical Neuroscience (E.J.), Umeå University, Sweden; Department of Neurology (E.C.-G., A.O., J.R.), Neurovascular Research Group, IMIM-Hospital del Mar (Institut Hospital del Mar d'Investigacions Mèdiques), Universitat Autònoma de Barcelona/DCEXS-Universitat Pompeu Fabra, Spain; and Neurovascular Unit for Translational and Therapeutics Research (D.H., P.J.K.), Mater University Hospital/Dublin Academic Medical Centre, Dublin, Ireland
| | - Elisa Cuadrado-Godia
- From the Department of Public Health and Clinical Medicine, Umeå Stroke Centre (E.J., J.B., P.W.), and Department of Pharmacology and Clinical Neuroscience (E.J.), Umeå University, Sweden; Department of Neurology (E.C.-G., A.O., J.R.), Neurovascular Research Group, IMIM-Hospital del Mar (Institut Hospital del Mar d'Investigacions Mèdiques), Universitat Autònoma de Barcelona/DCEXS-Universitat Pompeu Fabra, Spain; and Neurovascular Unit for Translational and Therapeutics Research (D.H., P.J.K.), Mater University Hospital/Dublin Academic Medical Centre, Dublin, Ireland.
| | - Derek Hayden
- From the Department of Public Health and Clinical Medicine, Umeå Stroke Centre (E.J., J.B., P.W.), and Department of Pharmacology and Clinical Neuroscience (E.J.), Umeå University, Sweden; Department of Neurology (E.C.-G., A.O., J.R.), Neurovascular Research Group, IMIM-Hospital del Mar (Institut Hospital del Mar d'Investigacions Mèdiques), Universitat Autònoma de Barcelona/DCEXS-Universitat Pompeu Fabra, Spain; and Neurovascular Unit for Translational and Therapeutics Research (D.H., P.J.K.), Mater University Hospital/Dublin Academic Medical Centre, Dublin, Ireland
| | - Jakob Bjellerup
- From the Department of Public Health and Clinical Medicine, Umeå Stroke Centre (E.J., J.B., P.W.), and Department of Pharmacology and Clinical Neuroscience (E.J.), Umeå University, Sweden; Department of Neurology (E.C.-G., A.O., J.R.), Neurovascular Research Group, IMIM-Hospital del Mar (Institut Hospital del Mar d'Investigacions Mèdiques), Universitat Autònoma de Barcelona/DCEXS-Universitat Pompeu Fabra, Spain; and Neurovascular Unit for Translational and Therapeutics Research (D.H., P.J.K.), Mater University Hospital/Dublin Academic Medical Centre, Dublin, Ireland
| | - Angel Ois
- From the Department of Public Health and Clinical Medicine, Umeå Stroke Centre (E.J., J.B., P.W.), and Department of Pharmacology and Clinical Neuroscience (E.J.), Umeå University, Sweden; Department of Neurology (E.C.-G., A.O., J.R.), Neurovascular Research Group, IMIM-Hospital del Mar (Institut Hospital del Mar d'Investigacions Mèdiques), Universitat Autònoma de Barcelona/DCEXS-Universitat Pompeu Fabra, Spain; and Neurovascular Unit for Translational and Therapeutics Research (D.H., P.J.K.), Mater University Hospital/Dublin Academic Medical Centre, Dublin, Ireland
| | - Jaume Roquer
- From the Department of Public Health and Clinical Medicine, Umeå Stroke Centre (E.J., J.B., P.W.), and Department of Pharmacology and Clinical Neuroscience (E.J.), Umeå University, Sweden; Department of Neurology (E.C.-G., A.O., J.R.), Neurovascular Research Group, IMIM-Hospital del Mar (Institut Hospital del Mar d'Investigacions Mèdiques), Universitat Autònoma de Barcelona/DCEXS-Universitat Pompeu Fabra, Spain; and Neurovascular Unit for Translational and Therapeutics Research (D.H., P.J.K.), Mater University Hospital/Dublin Academic Medical Centre, Dublin, Ireland
| | - Per Wester
- From the Department of Public Health and Clinical Medicine, Umeå Stroke Centre (E.J., J.B., P.W.), and Department of Pharmacology and Clinical Neuroscience (E.J.), Umeå University, Sweden; Department of Neurology (E.C.-G., A.O., J.R.), Neurovascular Research Group, IMIM-Hospital del Mar (Institut Hospital del Mar d'Investigacions Mèdiques), Universitat Autònoma de Barcelona/DCEXS-Universitat Pompeu Fabra, Spain; and Neurovascular Unit for Translational and Therapeutics Research (D.H., P.J.K.), Mater University Hospital/Dublin Academic Medical Centre, Dublin, Ireland
| | - Peter J Kelly
- From the Department of Public Health and Clinical Medicine, Umeå Stroke Centre (E.J., J.B., P.W.), and Department of Pharmacology and Clinical Neuroscience (E.J.), Umeå University, Sweden; Department of Neurology (E.C.-G., A.O., J.R.), Neurovascular Research Group, IMIM-Hospital del Mar (Institut Hospital del Mar d'Investigacions Mèdiques), Universitat Autònoma de Barcelona/DCEXS-Universitat Pompeu Fabra, Spain; and Neurovascular Unit for Translational and Therapeutics Research (D.H., P.J.K.), Mater University Hospital/Dublin Academic Medical Centre, Dublin, Ireland
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14
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De Rango P, Brown MM, Chaturvedi S, Howard VJ, Jovin T, Mazya MV, Paciaroni M, Manzone A, Farchioni L, Caso V. Summary of Evidence on Early Carotid Intervention for Recently Symptomatic Stenosis Based on Meta-Analysis of Current Risks. Stroke 2015; 46:3423-36. [DOI: 10.1161/strokeaha.115.010764] [Citation(s) in RCA: 55] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2015] [Accepted: 09/14/2015] [Indexed: 12/16/2022]
Abstract
Background and Purpose—
This study aimed to assess the evidence on the periprocedural (<30 days) risks of carotid intervention in relation to timing of procedure in patients with recently symptomatic carotid stenosis.
Methods—
A systematic literature review of studies published in the past 8 years reporting periprocedural stroke/death after carotid endarterectomy (CEA) and carotid stenting (CAS) related to the time between qualifying neurological symptoms and intervention was performed. Pooled estimates of periprocedural risk for patients treated within 0 to 48 hours, 0 to 7 days, and 0 to 15 days were derived with proportional meta-analyses and reported separately for patients with stroke and transient ischemic attack as index events.
Results—
Of 47 studies included, 35 were on CEA, 7 on CAS, and 5 included both procedures. The pooled risk of periprocedural stroke was 3.4% (95% confidence interval [CI], 2.6–4.3) after CEA and 4.8% (95% CI, 2.5–7.8) after CAS performed <15 days; stroke/death rates were 3.8% and 6.9% after CEA and CAS, respectively. Pooled periprocedural stroke risk was 3.3% (95% CI, 2.1–4.6) after CEA and 4.8% (95% CI, 2.5–7.8) after CAS when performed within 0 to 7 days. In hyperacute surgery (<48 hours), periprocedural stroke risk after CEA was 5.3% (95% CI, 2.8–8.4) but with relevant risk differences among patients treated after transient ischemic attack (2.7%; 95% CI, 0.5–6.9) or stroke (8.0%; 95% CI, 4.6–12.2) as index.
Conclusions—
CEA within 15 days from stroke/transient ischemic attack can be performed with periprocedural stroke risk <3.5%. CAS within the same period may carry a stroke risk of 4.8%. Similar periprocedural risks occur after CEA and CAS performed earlier, within 0 to 7 days. Carotid revascularization can be safely performed within the first week (0–7 days) after symptom onset.
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Affiliation(s)
- Paola De Rango
- From the Unit of Vascular and Endovascular Surgery, Department of Surgical and Biomedical Sciences (P.D.R., A.M., L.F.) and Stroke Unit, Division of Cardiovascular Medicine (M.P., V.C.), Hospital S.M. Misericordia, Perugia, Italy; Department of Brain Repair and Rehabilitation, UCL Institute of Neurology, University College London, London, United Kingdom (M.M.B.); Department of Neurology and Stroke Program, University of Miami Miller School of Medicine, FL (S.C.); Department of Epidemiology, School
| | - Martin M. Brown
- From the Unit of Vascular and Endovascular Surgery, Department of Surgical and Biomedical Sciences (P.D.R., A.M., L.F.) and Stroke Unit, Division of Cardiovascular Medicine (M.P., V.C.), Hospital S.M. Misericordia, Perugia, Italy; Department of Brain Repair and Rehabilitation, UCL Institute of Neurology, University College London, London, United Kingdom (M.M.B.); Department of Neurology and Stroke Program, University of Miami Miller School of Medicine, FL (S.C.); Department of Epidemiology, School
| | - Seemant Chaturvedi
- From the Unit of Vascular and Endovascular Surgery, Department of Surgical and Biomedical Sciences (P.D.R., A.M., L.F.) and Stroke Unit, Division of Cardiovascular Medicine (M.P., V.C.), Hospital S.M. Misericordia, Perugia, Italy; Department of Brain Repair and Rehabilitation, UCL Institute of Neurology, University College London, London, United Kingdom (M.M.B.); Department of Neurology and Stroke Program, University of Miami Miller School of Medicine, FL (S.C.); Department of Epidemiology, School
| | - Virginia J. Howard
- From the Unit of Vascular and Endovascular Surgery, Department of Surgical and Biomedical Sciences (P.D.R., A.M., L.F.) and Stroke Unit, Division of Cardiovascular Medicine (M.P., V.C.), Hospital S.M. Misericordia, Perugia, Italy; Department of Brain Repair and Rehabilitation, UCL Institute of Neurology, University College London, London, United Kingdom (M.M.B.); Department of Neurology and Stroke Program, University of Miami Miller School of Medicine, FL (S.C.); Department of Epidemiology, School
| | - Tudor Jovin
- From the Unit of Vascular and Endovascular Surgery, Department of Surgical and Biomedical Sciences (P.D.R., A.M., L.F.) and Stroke Unit, Division of Cardiovascular Medicine (M.P., V.C.), Hospital S.M. Misericordia, Perugia, Italy; Department of Brain Repair and Rehabilitation, UCL Institute of Neurology, University College London, London, United Kingdom (M.M.B.); Department of Neurology and Stroke Program, University of Miami Miller School of Medicine, FL (S.C.); Department of Epidemiology, School
| | - Michael V. Mazya
- From the Unit of Vascular and Endovascular Surgery, Department of Surgical and Biomedical Sciences (P.D.R., A.M., L.F.) and Stroke Unit, Division of Cardiovascular Medicine (M.P., V.C.), Hospital S.M. Misericordia, Perugia, Italy; Department of Brain Repair and Rehabilitation, UCL Institute of Neurology, University College London, London, United Kingdom (M.M.B.); Department of Neurology and Stroke Program, University of Miami Miller School of Medicine, FL (S.C.); Department of Epidemiology, School
| | - Maurizio Paciaroni
- From the Unit of Vascular and Endovascular Surgery, Department of Surgical and Biomedical Sciences (P.D.R., A.M., L.F.) and Stroke Unit, Division of Cardiovascular Medicine (M.P., V.C.), Hospital S.M. Misericordia, Perugia, Italy; Department of Brain Repair and Rehabilitation, UCL Institute of Neurology, University College London, London, United Kingdom (M.M.B.); Department of Neurology and Stroke Program, University of Miami Miller School of Medicine, FL (S.C.); Department of Epidemiology, School
| | - Alessandra Manzone
- From the Unit of Vascular and Endovascular Surgery, Department of Surgical and Biomedical Sciences (P.D.R., A.M., L.F.) and Stroke Unit, Division of Cardiovascular Medicine (M.P., V.C.), Hospital S.M. Misericordia, Perugia, Italy; Department of Brain Repair and Rehabilitation, UCL Institute of Neurology, University College London, London, United Kingdom (M.M.B.); Department of Neurology and Stroke Program, University of Miami Miller School of Medicine, FL (S.C.); Department of Epidemiology, School
| | - Luca Farchioni
- From the Unit of Vascular and Endovascular Surgery, Department of Surgical and Biomedical Sciences (P.D.R., A.M., L.F.) and Stroke Unit, Division of Cardiovascular Medicine (M.P., V.C.), Hospital S.M. Misericordia, Perugia, Italy; Department of Brain Repair and Rehabilitation, UCL Institute of Neurology, University College London, London, United Kingdom (M.M.B.); Department of Neurology and Stroke Program, University of Miami Miller School of Medicine, FL (S.C.); Department of Epidemiology, School
| | - Valeria Caso
- From the Unit of Vascular and Endovascular Surgery, Department of Surgical and Biomedical Sciences (P.D.R., A.M., L.F.) and Stroke Unit, Division of Cardiovascular Medicine (M.P., V.C.), Hospital S.M. Misericordia, Perugia, Italy; Department of Brain Repair and Rehabilitation, UCL Institute of Neurology, University College London, London, United Kingdom (M.M.B.); Department of Neurology and Stroke Program, University of Miami Miller School of Medicine, FL (S.C.); Department of Epidemiology, School
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15
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AbuRahma A. Part Two: Against the Motion. Carotid Endarterectomy is not Safer than Stenting in the Hyperacute Period After Onset of Symptoms. Eur J Vasc Endovasc Surg 2015; 49:627-633. [DOI: 10.1016/j.ejvs.2015.03.035] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
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16
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Naylor AR, AbuRahma AF. Debate: Whether carotid endarterectomy is safer than stenting in the hyperacute period after onset of symptoms. J Vasc Surg 2015; 61:1642-51. [PMID: 26004334 DOI: 10.1016/j.jvs.2015.02.046] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
The carotid artery has been a regular battleground for debates regarding many issues, including appropriate management of symptomatic and asymptomatic lesions, the conduct, timing, and safety of such interventions, and now, whether endarterectomy or stenting is safer in the hyperacute period. Our discussants agree that, as a prophylactic procedure, a carotid intervention should occur early after index symptoms to prevent as many strokes as possible. However, which intervention is best?
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Affiliation(s)
- A Ross Naylor
- Vascular Research Group, Division of Cardiovascular Sciences, Leicester Royal Infirmary, Leicester, United Kingdom.
| | - Ali F AbuRahma
- Division of Vascular Surgery & Endovascular Surgery, West Virginia University, Charleston, WVa.
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Charmoille E, Brizzi V, Lepidi S, Sassoust G, Roullet S, Ducasse E, Midy D, Bérard X. Thirty-day outcome of delayed versus early management of symptomatic carotid stenosis. Ann Vasc Surg 2015; 29:977-84. [PMID: 25765637 DOI: 10.1016/j.avsg.2015.01.013] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2014] [Revised: 01/09/2015] [Accepted: 01/10/2015] [Indexed: 10/23/2022]
Abstract
BACKGROUND The aim of this study was to compare outcomes of early (<15 days) versus delayed carotid endarterectomy (CEA) in symptomatic patients. METHODS All CEA procedures performed for symptomatic carotid stenosis between January 2006 and May 2010 were retrospectively reviewed. Postoperative mortality (within 30 days), stroke, and myocardial infarction (MI) rates were analyzed in the early and delayed CEA groups. RESULTS During the study period, 149 patients were included. Carotid revascularization was performed within 15 days after symptom onset in 62 (41.6%) patients and longer than 15 days after symptom onset in 87 (58.4%) patients. The mean time lapse between onset of neurological symptoms and surgery was 9.3 days (range 1-15) in the early surgery group and 47.9 days (range 16-157) in the delayed surgery group. Thirty-day combined stroke and death rates were, respectively, 1.7% and 3.5% in the early and the delayed surgery groups. Thirty-day combined stroke, death, and MI rates were, respectively, 1.7% and 5.9% in the early and the delayed surgery groups. CONCLUSION During the study period, the reduction of the symptom-to-knife time in application to the carotid revascularization guidelines did not impact our outcomes suggesting that early CEA achieves 30-day mortality and morbidity rates at least equivalent to those of delayed CEA.
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Affiliation(s)
- Emilie Charmoille
- Vascular Surgery Department, Bordeaux University Hospital, Bordeaux, France; Bordeaux University, Bordeaux, France
| | - Vincenzo Brizzi
- Vascular Surgery Department, Bordeaux University Hospital, Bordeaux, France.
| | - Sandro Lepidi
- Vascular Surgery Department, Padova University Hospital, Padova, Italy
| | - Gérard Sassoust
- Vascular Surgery Department, Bordeaux University Hospital, Bordeaux, France
| | - Stéphanie Roullet
- Vascular Surgery Department, Bordeaux University Hospital, Bordeaux, France
| | - Eric Ducasse
- Vascular Surgery Department, Bordeaux University Hospital, Bordeaux, France; Bordeaux University, Bordeaux, France
| | - Dominique Midy
- Vascular Surgery Department, Bordeaux University Hospital, Bordeaux, France; Bordeaux University, Bordeaux, France
| | - Xavier Bérard
- Vascular Surgery Department, Bordeaux University Hospital, Bordeaux, France; Bordeaux University, Bordeaux, France
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Strömberg S, Nordanstig A, Bentzel T, Österberg K, Bergström G. Risk of Early Recurrent Stroke in Symptomatic Carotid Stenosis. Eur J Vasc Endovasc Surg 2015; 49:137-44. [DOI: 10.1016/j.ejvs.2014.11.004] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2014] [Accepted: 11/10/2014] [Indexed: 11/29/2022]
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