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Kazantsev AN, Tarasov RS, Burkov NN, Shabayev AR, Mironov AV, Lider RY, Grachev KI, Yakhnis EY, Sargsyan MT, Soldatov EO. [Predictors of long-term complications after carotid endarterectomy]. Khirurgiia (Mosk) 2019:20-25. [PMID: 31317937 DOI: 10.17116/hirurgia201906120] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
AIM To analyze the predictors of complications within 3 years after carotid endarterectomy (CEE). MATERIAL AND METHODS The study included 1035 patients after CEE for the period 2011-2016. Long-term follow-up period was 42.4±18.6 months (≈ 3.5 years). The endpoints were such unfavorable cardiovascular events as death, myocardial infarction, stroke/transient ischemic attack, redo revascularization. Statistical analysis was carried out by using of Statistica for Windows 8.0 software package (StatSoft Inc., USA). Stepwise logistic regression was applied to identify risk factors of adverse outcomes and death in long-term postoperative period. RESULTS Comprehensive analysis of numerous factors (anamnestic, instrumental-diagnostic, surgical) allowed us to identify predictors of long-term unfavorable outcomes in patients with occlusive-stenotic lesions of carotid arteries. Risk factors of long-term complications were SYNTAX score ≥33 (high risk), unstable plaque in the contralateral ICA, occlusion of contralateral ICA, LVEF <39%, ICA cross-clamping >40 min, previous CABG. CONCLUSION These data are extremely important and can be used to create prognostic models. The last ones are necessary to determine optimal treatment strategy in patients with occlusive-stenotic lesions of supra-aortic vessels.
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Affiliation(s)
- A N Kazantsev
- Research Institute for Complex Issues of Cardiovascular Diseases, Kemerovo, Russia
| | - R S Tarasov
- Research Institute for Complex Issues of Cardiovascular Diseases, Kemerovo, Russia
| | - N N Burkov
- Research Institute for Complex Issues of Cardiovascular Diseases, Kemerovo, Russia
| | - A R Shabayev
- Research Institute for Complex Issues of Cardiovascular Diseases, Kemerovo, Russia
| | - A V Mironov
- Research Institute for Complex Issues of Cardiovascular Diseases, Kemerovo, Russia
| | - R Yu Lider
- Kemerovo State Medical University of Ministry of Health of Russia, Kemerovo, Russia
| | - K I Grachev
- Kemerovo State Medical University of Ministry of Health of Russia, Kemerovo, Russia
| | - E Ya Yakhnis
- Kemerovo State Medical University of Ministry of Health of Russia, Kemerovo, Russia
| | - M T Sargsyan
- Kemerovo State Medical University of Ministry of Health of Russia, Kemerovo, Russia
| | - E O Soldatov
- Kemerovo State Medical University of Ministry of Health of Russia, Kemerovo, Russia
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Alves-Ferreira J, Rocha-Neves J, Dias-Neto M, Braga SF. Poor long-term outcomes after carotid endarterectomy: a retrospective analysis of two portuguese centers. SCAND CARDIOVASC J 2019; 53:266-273. [PMID: 31251084 DOI: 10.1080/14017431.2019.1638518] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
Objetives. Carotid endarterectomy (CEA) is an established treatment for carotid stenosis (CS). However, this procedure is not risk-free and it is insufficient to control disseminated atherosclerosis. Our aim was to determine long-term cardiovascular morbidity and mortality after CEA and identify associated risk predictors. Design. Consecutive cohorts of CEAs performed between 2010 and 2018 in two Portuguese hospitals were retrospectively analysed. The major end-points were acute myocardial infarction (AMI), stroke, all-cause death and major adverse cardiovascular events (MACE). Results. 248 patients (mean age 69 years; 79% male) were enrolled in the study. 24% had postoperative complications. At 52 months median follow-up, 9 ± 2.0% (mean ± standard error) of patients experienced an acute myocardial infarction (AMI), 12 ± 2.4% a stroke and 26 ± 3.2% a MACE. All-cause mortality rate was 21 ± 3.0%. Multivariate analysis identified coronary artery disease (CAD) as significant predictor of AMI (p < .001; Hazard Ratio (HR):9.628; 95% Confidence Interval (95%CI):2.805-33.046), whereas no statistically significant risk factor of stroke was found. Predictors of death included left sided CS (p = .042; HR:1.886; 95%CI:1.024-3.475), chronic kidney disease (CKD) (p = .007; HR:2.352; 95%CI:1.266-4.372) and anticoagulant medication (p = .015; HR:2.107; 95%CI:1.216-6.026), while statin use was significantly protective (p = .049; HR:0.482; 95%CI:0.233-0.998). Concerning MACE, male gender (p = .040; HR:1.709; 95%CI:1.025-2.849), tobacco use (p = .004; HR:2.181; 95%CI:1.277-3.726), CAD (p = .002; HR:2.235; 95%CI:1.340-3.727) and CKD (p < .001; HR:3.029; 95%CI:1.745-5.258) were risk predictors. Conclusions. Patients continue to have high rates of AMI, MACE and death after CEA. Prior CAD is a risk factor for future AMI, whereas CKD is a significant predictor of MACE and death. Aggressive best medical treatment and risk factors modification should be advised in all patients with systemic atherosclerosis.
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Affiliation(s)
| | - João Rocha-Neves
- Department of Biomedicine - Unit of Anatomy, Faculty of Medicine, University of Porto , Porto , Portugal.,Department of Physiology and Surgery - Cardiovascular Research Unit, Faculty of Medicine, University of Porto , Porto , Portugal.,Department of Angiology and Vascular Surgery, São João Hospital Center , Porto , Portugal
| | - Marina Dias-Neto
- Department of Physiology and Surgery - Cardiovascular Research Unit, Faculty of Medicine, University of Porto , Porto , Portugal.,Department of Angiology and Vascular Surgery, São João Hospital Center , Porto , Portugal
| | - Sandrina F Braga
- Department of Angiology and Vascular Surgery, Senhora de Oliveira Hospital Center , Guimarães , Portugal
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Thomas MA, Pearce WH, Rodriguez HE, Helenowski IB, Eskandari MK. Durability of Stroke Prevention with Carotid Endarterectomy and Carotid Stenting. Surgery 2018; 164:1271-1278. [DOI: 10.1016/j.surg.2018.06.041] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2018] [Revised: 06/11/2018] [Accepted: 06/28/2018] [Indexed: 11/17/2022]
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Hoshino M, Kawai H, Sarai M, Sadato A, Hayakawa M, Motoyama S, Nagahara Y, Miyajima K, Takahashi H, Ishii J, Nakahara I, Hirose Y, Ozaki Y. Noninvasive Assessment of Stenotic Severity and Plaque Characteristics by Coronary CT Angiography in Patients Scheduled for Carotid Artery Revascularization. J Atheroscler Thromb 2018; 25:1022-1031. [PMID: 29459518 PMCID: PMC6193191 DOI: 10.5551/jat.42176] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
Aims: Coronary artery atherosclerosis in patients needing carotid revascularization has not been fully clarified. The aim of this study was to evaluate the stenotic severity and plaque characteristics of coronary arteries by coronary computed tomography angiography (CTA) in patients scheduled for carotid-artery stenting (CAS) or carotid endarterectomy (CEA). Methods: We performed coronary CTA after carotid ultrasound (US) in 164 patients (81.7% male, aged 68.1 ± 12.2 years) from 2014 to 2016. Of all, 70 were scheduled for CAS or CEA (CAS/CEA group) and 94 were not (non-CAS/CEA group). Carotid US and coronary CTA were compared for the evaluation of stenotic severity and plaque characteristics of each vessel between CAS/CEA and non-CAS/CEA groups. Results: Between the two groups, there were significant differences in the presence of significant stenosis (SS: ≥ 70% stenosis of coronary artery) (55.7% vs. 39.4%, P = 0.038), triple-vessel disease (TVD)/left main trunk (LMT) (SS in each of three epicardial vessels and/or LMT) (24.3% vs. 7.5%, P = 0.0025), and high-risk plaque (HRP: positive remodeling and/or low attenuation) (55.7% vs. 24.5%, P < 0.0001). CAS/CEA was independently associated with TVD/LMT (OR = 2.30, 95%CI: 1.14–8.59, P = 0.026) and HRP (OR = 3.17, 95%CI: 1.57–6.54, P = 0.0012) in multivariable logistic regression analysis. Similarly, vulnerable plaque (78.6% vs. 2.1%, P < 0.0001) as well as severe stenosis of carotid artery (98.6% vs. 0%, P < 0.0001) was seen more often in CAS/CEA than in non-CAS/CEA group. Conclusions: The prevalence of TVD/LMT and HRP determined by coronary CTA is higher in patients needing CAS/CEA than in those without. Management of systemic atherosclerosis is required in the perioperative period of CAS/CEA.
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Affiliation(s)
| | - Hideki Kawai
- Department of Cardiology, Fujita Health University
| | | | - Akiyo Sadato
- Department of Neurosurgery, Fujita Health University
| | | | | | | | | | | | | | - Ichiro Nakahara
- Department of Comprehensive Strokology, Fujita Health University
| | - Yuichi Hirose
- Department of Neurosurgery, Fujita Health University
| | - Yukio Ozaki
- Department of Cardiology, Fujita Health University
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Long-Term Outcome After Carotid Endarterectomy in Patients with Ischemic Heart Disease. World Neurosurg 2017; 110:e806-e814. [PMID: 29180080 DOI: 10.1016/j.wneu.2017.11.092] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2017] [Revised: 11/16/2017] [Accepted: 11/18/2017] [Indexed: 12/17/2022]
Abstract
BACKGROUND The long-term outcome after carotid endarterectomy (CEA) is determined by many confounding factors. Ischemic heart disease (IHD) is linked to atherosclerotic stroke, and it is an important cause of death during the perioperative and follow-up periods after CEA. We aimed to investigate mortality and long-term major adverse cardiovascular events (MACEs) in patients with IHD compared with patients who do not have IHD. METHODS We consecutively enrolled 229 patients who underwent CEA procedures from 2000 to 2011. Of these patients, 45 had known or probable IHD defined by history or medical record of myocardial infarction, stable/unstable angina, previous coronary revascularization such as percutaneous coronary intervention or coronary artery bypass graft, or positive stress test. Long-term outcome was identified by using death certificates from the Korean National Statistical Office and telephone interviews by June 2013. We investigated predictors of early (≤30 days) and long-term mortality and MACEs (stroke, myocardial infarction, and death). RESULTS Mean follow-up period was 49 months. Cox proportional analysis adjusted for potent predictors revealed symptomatic stenosis (hazard ratio, 1.72; 95% confidence interval, 1.02-2.88; P = 0.042) and presence of IHD (hazard ratio, 1.93; 95% confidence interval, 1.09-3.42; P = 0.025) as significant predictors of long-term MACEs. Kaplan-Meier analysis showed a significantly lower rate of survival (P = 0.030) and MACE-free survival (P = 0.003) in the IHD group. CONCLUSIONS In this study, a poor long-term outcome was observed in patients with IHD and symptomatic stenosis but not in patients with conventional high-risk factors for surgery. Therefore, appropriate evaluation and treatment of IHD before and after CEA might be helpful for better outcome.
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Kim JW, Do Y. Hemodynamic Depression of Early Carotid Revascularization on Ischemic Stroke Patients with Symptomatic Carotid Stenosis. JOURNAL OF NEUROCRITICAL CARE 2017. [DOI: 10.18700/jnc.170012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022] Open
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Heo SH, Bushnell CD. Factors Influencing Decision Making for Carotid Endarterectomy versus Stenting in the Very Elderly. Front Neurol 2017; 8:220. [PMID: 28603515 PMCID: PMC5445117 DOI: 10.3389/fneur.2017.00220] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2017] [Accepted: 05/08/2017] [Indexed: 12/29/2022] Open
Abstract
As the population ages worldwide, the number of elderly patients with carotid stenosis is also increasing. There have been many large clinical trials comparing carotid endarterectomy (CAE) versus stenting, but the inclusion criteria (i.e., symptomatic or asymptomatic), stenting methods (i.e., protection device), and primary end point (i.e., the definition of myocardial infarction and follow-up period) were different between trials. Therefore, the interpretation of those results is difficult and requires attention. When it comes to age, the patients older than 80 years were excluded or stratified to a high risk group in previous landmark trials. However, a recent guideline recommended that endarterectomy may be associated with lower stroke risk compared with carotid artery stenting in patients older than 70 years with symptomatic carotid disease. The annual risk of stroke in individuals with asymptomatic carotid stenosis is about 1-3% but the risk is about 4-12% with symptomatic stenosis without carotid intervention. Although the outcome of CAE is better than that of carotid stenting in patients older than 70 years, the perioperative risk is higher in older patients. Therefore, it is important to classify high risk patients and consider underlying disability and life expectancy of very elderly patients before deciding whether to undergo a carotid intervention. In addition, we should also consider that the stroke rate with intensive medical treatment is unknown and is currently being investigated in randomized controlled trials. Intensive medical treatment includes high intensity statins, diabetes and blood pressure control, and aggressive antiplatelet treatment. The aim of this review is to report the factors that may be responsible for the variability in the treatment of carotid stenosis, particularly in the elderly population. This will allow the readers to integrate the current available evidence to individualize the treatment of carotid stenosis in this challenging population.
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Affiliation(s)
- Sung Hyuk Heo
- Department of Neurology, School of Medicine, Kyung Hee University, Seoul, South Korea
| | - Cheryl D. Bushnell
- Department of Neurology, Wake Forest School of Medicine, Winston-Salem, NC, United States
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Liu X, Zhang H, Ren L, Xiong H, Gao Z, Xu P, Huang W, Wu W. Functional assessment of the stenotic carotid artery by CFD-based pressure gradient evaluation. Am J Physiol Heart Circ Physiol 2016; 311:H645-53. [PMID: 27371686 DOI: 10.1152/ajpheart.00888.2015] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/16/2015] [Accepted: 06/24/2016] [Indexed: 11/22/2022]
Abstract
The functional assessment of a hemodynamic significant stenosis base on blood pressure variation has been applied for evaluation of the myocardial ischemic event. This functional assessment shows great potential for improving the accuracy of the classification of the severity of carotid stenosis. To explore the value of grading the stenosis using a pressure gradient (PG)-we had reconstructed patient-specific carotid geometries based on MRI images-computational fluid dynamics were performed to analyze the PG in their stenotic arteries. Doppler ultrasound image data and the corresponding MRI image data of 19 patients with carotid stenosis were collected. Based on these, 31 stenotic carotid arterial geometries were reconstructed. A combinatorial boundary condition method was implemented for steady-state computer fluid dynamics simulations. Anatomic parameters, including tortuosity (T), the angle of bifurcation, and the cross-sectional area of the remaining lumen, were collected to investigate the effect on the pressure distribution. The PG is highly correlated with the severe stenosis (r = 0.902), whereas generally, the T and the angle of the bifurcation negatively correlate to the pressure drop of the internal carotid artery stenosis. The calculation required <10 min/case, which made it prepared for the fast diagnosis of the severe stenosis. According to the results, we had proposed a potential threshold value for distinguishing severe stenosis from mild-moderate stenosis (PG = 0.88). In conclusion, the PG could serve as the additional factor for improving the accuracy of grading the severity of the stenosis.
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Affiliation(s)
- Xin Liu
- Institute of Clinical Anatomy, Southern Medical University, Guangzhou, China
| | - Heye Zhang
- Institute of Biomedical and Health Engineering, Shenzhen Institutes of Advanced Technology, Chinese Academy of Sciences, Shenzhen, China
| | - Lijie Ren
- Neurology Department, Shenzhen Second People's Hospital, Shenzhen, Guangdon, China
| | - Huahua Xiong
- Department of Ultrasound, Shenzhen Second People's Hospital, Shenzhen, Guangdon, China; and
| | - Zhifan Gao
- Institute of Biomedical and Health Engineering, Shenzhen Institutes of Advanced Technology, Chinese Academy of Sciences, Shenzhen, China
| | - Pengcheng Xu
- Institute of Clinical Anatomy, Southern Medical University, Guangzhou, China
| | - Wenhua Huang
- Institute of Clinical Anatomy, Southern Medical University, Guangzhou, China
| | - Wanqing Wu
- Institute of Biomedical and Health Engineering, Shenzhen Institutes of Advanced Technology, Chinese Academy of Sciences, Shenzhen, China
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