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Metschl S, Bruder L, Paloschi V, Jakob K, Reutersberg B, Reeps C, Maegdefessel L, Gee M, Eckstein HH, Pelisek J. Changes in endocan and dermatan sulfate are associated with biomechanical properties of abdominal aortic wall during aneurysm expansion and rupture. Thromb Haemost 2022; 122:1513-1523. [PMID: 35170008 DOI: 10.1055/a-1772-0574] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
BACKGROUND AND AIMS The study aimed to assess the potential of proteoglycans (PG) and collagens as serological biomarkers in the abdominal aortic aneurysm (AAA). Furthermore, we investigated the underlying mechano-biological interactions and signaling pathways. METHODS Tissue and serum samples from patients with ruptured AAA (rAAA, n=29), elective AAA (eAAA, n=78), and healthy individuals (n=8) were evaluated by histology, immunohistochemistry and Enzyme-linked Immunosorbent Assay (ELISA), mechanical properties were assessed by tensile tests. Regulatory pathways were determined by membrane-based sandwich immunoassay. RESULTS In AAA samples, collagen type I and III (Col1, Col3), chondroitin sulfate (CS), and dermatan sulfate (DS) were significantly increased compared to controls (3.0-, 3.2-, 1.3-, and 53-fold; p<0.01). Col1 and endocan were also elevated in the serum of AAA patients (3.6- and 6.0-fold; p<0.01), while DS was significantly decreased (2.5-fold; p<0.01). Histological scoring showed increased total PGs and focal accumulation in rAAA compared to eAAA. Tissue β-stiffness was higher in rAAA compared to eAAA (2.0-fold, p=0.02). Serum Col1 correlated with maximum tensile force and failure tension (r=0.448 and 0.333; p<0.01 and =0.02), tissue endocan correlated with α-stiffness (r=0.340; p<0.01). Signaling pathways in AAA were associated with ECM synthesis and VSMC proliferation. In particular, Src family kinases, PDGF- and EGF-related proteins seem to be involved. CONCLUSIONS Our findings reveal a structural association between collagen and PGs and their response to changes in mechanical loads in AAA. Particularly Col1 and endocan reflect the mechano-biological conditions of the aortic wall also in the patient's serum and might serve for AAA risk stratification.
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Affiliation(s)
- Susanne Metschl
- Vascular and Endovascular Surgery, Technical University of Munich School of Medicine, Munchen, Germany
| | - Lukas Bruder
- Mechanics & High Performance Computing Group, Technical University of Munich, Munchen, Germany
| | - Valentina Paloschi
- Vascular and Endovascular surgery, Klinikum rechts der Isar der Technischen Universitat Munchen, Munchen, Germany
| | - Katharina Jakob
- Vascular and Endovascular Surgery, Technical University of Munich School of Medicine, Munchen, Germany
| | | | - Christian Reeps
- Visceral, Thoracic, and Vascular Surgery, Medizinische Fakultät an der TU-Dresden, Dresden, Germany
| | - Lars Maegdefessel
- Department for Vascular and Endovascular Surgery, Klinikum rechts der Isar der Technischen Universitat Munchen, Munchen, Germany
| | - Michael Gee
- Mechanics & High Performance Computing Group, Technical University of Munich, Munchen, Germany
| | - Hans-Henning Eckstein
- Vascular and Endovascular Surgery, Technical University of Munich School of Medicine, Munchen, Germany
| | - Jaroslav Pelisek
- Experimental Vascular Surgery, University of Zurich, Zurich, Switzerland
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Parker L, Reutersberg B, Syed M, Munshi B, Richards S, Sakalihasan N, Eckstein HH, Norman P, Doyle B. False Lumen Thrombosis and Pressure Predicts Outcome in Patients with Acute Type B Aortic Dissection. Eur J Vasc Endovasc Surg 2022. [DOI: 10.1016/j.ejvs.2021.12.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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53
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Paraskevas KI, Mikhailidis DP, Baradaran H, Bokkers RPH, Davies AH, Eckstein HH, Faggioli G, Fernandes E Fernandes J, Gargiulo M, Jawien A, Jezovnik MK, Kakkos SK, Knoflach M, Kooi ME, Lanza G, Liapis CD, Loftus IM, Mansilha A, Mechtouff L, Millon A, Myrcha P, Nicolaides AN, Pini R, Poredos P, Ricco JB, Rundek T, Saba L, Silvestrini M, Spinelli F, Stilo F, Sultan S, Suri JS, Svetlikov AV, Wijeratne T, Zeebregts CJ, Gloviczki P. The burden of carotid-related strokes. Ann Transl Med 2022; 10:159. [PMID: 35284552 PMCID: PMC8904971 DOI: 10.21037/atm-2021-12] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 11/23/2021] [Accepted: 12/24/2021] [Indexed: 11/06/2022]
Affiliation(s)
| | - Dimitri P. Mikhailidis
- Department of Clinical Biochemistry, Royal Free Hospital Campus, University College London Medical School, University College London (UCL), London, UK
| | - Hediyeh Baradaran
- Department of Radiology and Imaging Sciences, Neuroradiology Division, University of Utah Health, Salt Lake City, UT, USA
| | - Reinoud P. H. Bokkers
- Department of Radiology, Medical Imaging Center, University Medical Center Groningen, Groningen, The Netherlands
| | - Alun H. Davies
- Section of Vascular Surgery, Imperial College & Imperial Healthcare NHS Trust, London, UK
| | - Hans-Henning Eckstein
- Department for Vascular and Endovascular Surgery, Klinikum rechts der Isar, Technical University of Munich, Munich, Germany
| | - Gianluca Faggioli
- Vascular Surgery, Department of Experimental, Diagnostic and Specialty Medicine, University of Bologna, IRCSS Policlinico di Sant’Orsola, Bologna, Italy
| | | | - Mauro Gargiulo
- Vascular Surgery, Department of Experimental, Diagnostic and Specialty Medicine, University of Bologna, IRCSS Policlinico di Sant’Orsola, Bologna, Italy
| | - Arkadiusz Jawien
- Department for Vascular Surgery and Angiology, L. Rydygier Collegium Medicum in Bydgoszcz, Nicolaus Copernicus University in Torun, Poland
| | - Mateja K. Jezovnik
- Department of Advanced Cardiopulmonary Therapies and Transplantation, The University of Texas Health Science Centre at Houston, Houston, TX, USA
| | - Stavros K. Kakkos
- Department of Vascular Surgery, University of Patras Medical School, Patras, Greece
| | - Michael Knoflach
- Department of Neurology, Medical University of Innsbruck, Innsbruck, Austria
| | - M. Eline Kooi
- CARIM School for Cardiovascular Diseases, Maastricht University, Maastricht, The Netherlands
- Department of Radiology and Nuclear Medicine, Maastricht University Medical Center, Maastricht, The Netherlands
| | - Gaetano Lanza
- Vascular Surgery Department, IRCSS MultiMedica Hospital, Castellanza, Italy
| | | | - Ian M. Loftus
- St. George’s Vascular Institute, St. George’s University London, London, UK
| | | | | | - Antoine Millon
- Vascular Surgery Department, Hospices Civils de Lyon, Lyon, France
| | - Piotr Myrcha
- First Chair and Department of General and Vascular Surgery, Faculty of Medicine, Medical University of Warsaw, Warsaw, Poland
| | | | - Rodolfo Pini
- Vascular Surgery, Department of Experimental, Diagnostic and Specialty Medicine, University of Bologna, IRCSS Policlinico di Sant’Orsola, Bologna, Italy
| | - Pavel Poredos
- Department of Vascular Disease, University Medical Centre Ljubljana, Slovenia
| | - Jean-Baptiste Ricco
- Department of Clinical Research, University of Poitiers, CHU de Poitiers, Poitiers, France
| | - Tatjana Rundek
- Department of Neurology, Miller School of Medicine, University of Miami, Miami, FL, USA
| | - Luca Saba
- Department of Radiology, Azienda Ospedaliera Universitaria Di Cagliari, Cagliari, Italy
| | - Mauro Silvestrini
- Neurological Clinic, Department of Experimental and Clinical Medicine, Marche Polytechnic University, Ancona, Italy
| | - Francesco Spinelli
- Vascular Surgery Division, Campus Bio-Medico University of Rome, Rome, Italy
| | - Francesco Stilo
- Vascular Surgery Division, Campus Bio-Medico University of Rome, Rome, Italy
| | - Sherif Sultan
- Western Vascular Institute, Department of Vascular and Endovascular Surgery, University Hospital Galway, National University of Ireland, Galway, Ireland
| | - Jasjit S. Suri
- Stroke Diagnosis and Monitoring Division, AtheroPointTM, Roseville, USA
| | - Alexei V. Svetlikov
- Division of Vascular and Endovascular Surgery, North-Western Scientific Clinical Center of Federal Medical Biological Agency of Russia, St. Petersburgh, Russia
| | - Tissa Wijeratne
- Department of Neurology, Sunshine Hospital and Melbourne Medical School, St. Albans, Victoria, Australia
| | - Clark J. Zeebregts
- Division of Vascular Surgery, Department of Surgery, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Peter Gloviczki
- Division of Vascular and Endovascular Surgery, Mayo Clinic, Rochester, MN, USA
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Paraskevas KI, Mikhailidis DP, Baradaran H, Davies AH, Eckstein HH, Faggioli G, Fernandes JFE, Gupta A, Jezovnik MK, Kakkos SK, Katsiki N, Kooi ME, Lanza G, Liapis CD, Loftus IM, Millon A, Nicolaides AN, Poredos P, Pini R, Ricco JB, Rundek T, Saba L, Spinelli F, Stilo F, Sultan S, Zeebregts CJ, Chaturvedi S. Optimal Management of Asymptomatic Carotid Stenosis: Counterbalancing the Benefits with the Potential Risks. J Stroke 2022; 24:163-165. [PMID: 35135072 PMCID: PMC8829475 DOI: 10.5853/jos.2021.04420] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2021] [Accepted: 12/31/2021] [Indexed: 11/12/2022] Open
Affiliation(s)
- Kosmas I. Paraskevas
- Department of Vascular Surgery, Central Clinic of Athens, Athens, Greece
- Correspondence: Kosmas I. Paraskevas Department of Vascular Surgery, Central Clinic of Athens, 24, Alexander Papagou Street, N. Iraklio 14122, Athens, Greece Tel: +30-698-3133883 Fax: +30-210-3215792 E-mail:
| | - Dimitri P. Mikhailidis
- Department of Clinical Biochemistry, Royal Free Hospital Campus, University College London Medical School, University College London (UCL), London, UK
| | - Hediyeh Baradaran
- Department of Radiology, University of Utah, Salt Lake City, UT, USA
| | - Alun H. Davies
- Section of Vascular Surgery, Imperial College & Imperial Healthcare NHS Trust, London, UK
| | - Hans-Henning Eckstein
- Department of Vascular and Endovascular Surgery, University Hospital rechts der Isar, Technical University of Munich, Munich, Germany
| | - Gianluca Faggioli
- Vascular Surgery, University of Bologna “Alma Mater Studiorum”, S. Orsola-Malpighi Polyclinic, Bologna, Italy
| | | | - Ajay Gupta
- Department of Radiology, Weill Cornell Medicine, New York, NY, USA
| | - Mateja K. Jezovnik
- Department of Advanced Cardiopulmonary Therapies and Transplantation, The University of Texas Health Science Centre at Houston, Houston, TX, USA
| | - Stavros K. Kakkos
- Department of Vascular Surgery, University of Patras Medical School, Patras, Greece
| | - Niki Katsiki
- First Department of Internal Medicine, AHEPA University Hospital, Thessaloniki, Greece
| | - M. Eline Kooi
- CARIM School for Cardiovascular Diseases, Maastricht University, Maastricht, The Netherlands
- Department of Radiology and Nuclear Medicine, Maastricht University Medical Center, Maastricht, The Netherlands
| | - Gaetano Lanza
- Vascular Surgery Department, IRCSS MultiMedica Hospital, Castellanza, Italy
| | | | - Ian M. Loftus
- St. George’s Vascular Institute, St. George’s University London, London, UK
| | - Antoine Millon
- Department of Vascular and Endovascular Surgery, Louis Pradel Hospital, Hospices Civils de Lyon, Lyon, France
| | | | - Pavel Poredos
- Department of Vascular Disease, University Medical Center Ljubljana, Ljubljana, Slovenia
| | - Rodolfo Pini
- Vascular Surgery, University of Bologna “Alma Mater Studiorum”, S. Orsola-Malpighi Polyclinic, Bologna, Italy
| | - Jean-Baptiste Ricco
- Department of Clinical Research, University of Poitiers, CHU de Poitiers, Poitiers, France
| | - Tatjana Rundek
- Department of Neurology, Miller School of Medicine, University of Miami, Miami, FL, USA
| | - Luca Saba
- Department of Radiology, University Hospital Center of Cagliari, Cagliari, Italy
| | - Francesco Spinelli
- Vascular Surgery Division, Campus Bio-Medico University of Rome, Rome, Italy
| | - Francesco Stilo
- Vascular Surgery Division, Campus Bio-Medico University of Rome, Rome, Italy
| | - Sherif Sultan
- Western Vascular Institute, Department of Vascular and Endovascular Surgery, University Hospital Galway, National University of Ireland, Galway, Ireland
| | - Clark J. Zeebregts
- Division of Vascular Surgery, Department of Surgery, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Seemant Chaturvedi
- Department of Neurology & Stroke Program, University of Maryland School of Medicine, Baltimore, MD, USA
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55
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Reutersberg B, Trimarchi S, Gilon D, Kaiser C, Harris K, Shalhub S, Reece TB, Nienaber C, Ehrlich M, Isselbacher E, De Oliveira N, Montgomery D, Eagle K, Tolva V, Chen EP, Eckstein HH. Pleural effusion: a potential surrogate marker for higher-risk patients with acute type B aortic dissections. Eur J Cardiothorac Surg 2021; 61:816-825. [PMID: 34966915 DOI: 10.1093/ejcts/ezab540] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/22/2021] [Revised: 08/31/2021] [Accepted: 11/21/2021] [Indexed: 11/14/2022] Open
Abstract
OBJECTIVES Pleural effusions (PEffs) are known to occur in type B acute aortic dissection (TBAAD). We investigated the relationship between pleural effusion and the development of early or late complications following TBAAD. METHODS The incidence of PEff (defined as at least an obliteration of the costophrenic angle in a frontal projection) diagnosed on their initial chest X-ray in patients with TBAAD enrolled in the International Registry of Acute Aortic Dissection was examined. We analysed in-hospital outcomes and long-term survival separately for patients with and without PEffs (PEff+ versus PEff-, respectively). RESULTS Included were 1252 patients with TBAAD, of whom 224 (17.9%) had PEff. Compared with patients without PEff in the initial chest X-ray, these were significantly older [mean age 67 (SD: 14.7) vs 63.4 (SD: 14.2) years, P = 0.001] and more often female (42.4% vs 34.2%, P = 0.021) and had more comorbidities (known aortic aneurysm, chronic obstructive pulmonary disease, chronic renal failure, diabetes, congestive heart failure or mitral valve disease). PEff was associated with higher in-hospital mortality (16.1% vs 9.1%, P = 0.002) and increased rates of neurological complications (16.6% vs 11.1%, P = 0.029), acute renal failure (27.2% vs 19.7%, P = 0.017) and hypotension (17.4% vs 9.6%, P = 0.001). In addition, patients with PEff underwent aortic repair more frequently (44.6% vs 32.5%, P < 0.001). In the long-term patients with PEff showed lower 5-year post-discharge survival (67.6% vs 77.6%, P = 0.004). Multivariable analysis with propensity-matched data showed that PEff was not an independent risk factor for in-hospital mortality (odds ratio 1.9, 95% CI 0.8-4.4, P = 0.141). CONCLUSIONS Patients with TBAAD and evidence of PEff showed a higher in-hospital mortality, are more likely to develop additional in-hospital complications and have a decreased likelihood of survival during follow-up. However, according to propensity-matched analysis, PEff remained not as an independent predictor of worse outcome but might serve as an early surrogate marker to identify higher-risk patients.
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Affiliation(s)
- Benedikt Reutersberg
- Department for Vascular and Endovascular Surgery, Munich Aortic Center (MAC), Klinikum rechts der Isar, Technical University of Munich (TUM), Munich, Germany
| | - Santi Trimarchi
- Department of Clinical and Community Sciences-University of Milan, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Dan Gilon
- Department of Noninvasive Cardiology and Echocardiography, Heart Institute, Hadassah-Hebrew University Medical Center, Faculty of Medicine, Jerusalem, Israel
| | - Clayton Kaiser
- Department of Cardiac Surgery, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Kevin Harris
- Department of Cardiology, Minneapolis Heart Institute, Abbott, Northwestern Hospital, Minneapolis, MN, USA
| | - Sherene Shalhub
- Division of Vascular Surgery, Department of Surgery, University of Washington, Seattle, WA, USA
| | - T Brett Reece
- Division of Cardiothoracic Surgery, Department of Surgery, University of Colorado Anschutz Medical Campus, Aurora, CO, USA
| | - Christoph Nienaber
- Department of Cardiology, The Royal Brompton & Harefield NHS Trust, Cardiology and Aortic Centre, Imperial College, London, UK
| | - Marek Ehrlich
- Department of Cardiothoracic Surgery, University of Vienna, Vienna, Austria
| | - Eric Isselbacher
- Division of Cardiac Surgery, Thoracic Aortic Center, Massachusetts General Hospital, Boston, MA, USA
| | - Nilto De Oliveira
- Division of Cardiac Surgery, Department of Surgery, University of Wisconsin School of Medicine and Public Health, Madison, WI, USA
| | - Daniel Montgomery
- Department of Medicine, Frankel Cardiovascular Center, University of Michigan, Ann Arbor, MI, USA.,Department of Cardiac Surgery, Frankel Cardiovascular Center, University of Michigan, Ann Arbor, MI, USA
| | - Kim Eagle
- Department of Medicine, Frankel Cardiovascular Center, University of Michigan, Ann Arbor, MI, USA.,Department of Cardiac Surgery, Frankel Cardiovascular Center, University of Michigan, Ann Arbor, MI, USA
| | - Valerio Tolva
- Department of Vascular Surgery, Policlinico di Monza Hospital, Centro Cuore. Policlinico di Monza, Monza, Italy
| | - Edward P Chen
- Division of Cardiothoracic Surgery, Emory University, Atlanta, GA, USA
| | - Hans-Henning Eckstein
- Department for Vascular and Endovascular Surgery, Munich Aortic Center (MAC), Klinikum rechts der Isar, Technical University of Munich (TUM), Munich, Germany
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56
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Tsantilas P, Lao S, Wu Z, Eberhard A, Winski G, Vaerst M, Nanda V, Wang Y, Kojima Y, Ye J, Flores A, Jarr KU, Pelisek J, Eckstein HH, Matic L, Hedin U, Tsao PS, Paloschi V, Maegdefessel L, Leeper NJ. Chitinase 3 like 1 is a regulator of smooth muscle cell physiology and atherosclerotic lesion stability. Cardiovasc Res 2021; 117:2767-2780. [PMID: 33471078 PMCID: PMC8848327 DOI: 10.1093/cvr/cvab014] [Citation(s) in RCA: 19] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/25/2020] [Revised: 10/17/2020] [Accepted: 02/07/2021] [Indexed: 12/13/2022] Open
Abstract
AIMS Atherosclerotic cerebrovascular disease underlies the majority of ischaemic strokes and is a major cause of death and disability. While plaque burden is a predictor of adverse outcomes, plaque vulnerability is increasingly recognized as a driver of lesion rupture and risk for clinical events. Defining the molecular regulators of carotid instability could inform the development of new biomarkers and/or translational targets for at-risk individuals. METHODS AND RESULTS Using two independent human endarterectomy biobanks, we found that the understudied glycoprotein, chitinase 3 like 1 (CHI3L1), is up-regulated in patients with carotid disease compared to healthy controls. Further, CHI3L1 levels were found to stratify individuals based on symptomatology and histopathological evidence of an unstable fibrous cap. Gain- and loss-of-function studies in cultured human carotid artery smooth muscle cells (SMCs) showed that CHI3L1 prevents a number of maladaptive changes in that cell type, including phenotype switching towards a synthetic and hyperproliferative state. Using two murine models of carotid remodelling and lesion vulnerability, we found that knockdown of Chil1 resulted in larger neointimal lesions comprised by de-differentiated SMCs that failed to invest within and stabilize the fibrous cap. Exploratory mechanistic studies identified alterations in potential downstream regulatory genes, including large tumour suppressor kinase 2 (LATS2), which mediates macrophage marker and inflammatory cytokine expression on SMCs, and may explain how CHI3L1 modulates cellular plasticity. CONCLUSION CHI3L1 is up-regulated in humans with carotid artery disease and appears to be a strong mediator of plaque vulnerability. Mechanistic studies suggest this change may be a context-dependent adaptive response meant to maintain vascular SMCs in a differentiated state and to prevent rupture of the fibrous cap. Part of this effect may be mediated through downstream suppression of LATS2. Future studies should determine how these changes occur at the molecular level, and whether this gene can be targeted as a novel translational therapy for subjects at risk of stroke.
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MESH Headings
- Animals
- Carotid Arteries/enzymology
- Carotid Arteries/pathology
- Carotid Arteries/physiopathology
- Carotid Artery Diseases/enzymology
- Carotid Artery Diseases/genetics
- Carotid Artery Diseases/pathology
- Carotid Artery Diseases/physiopathology
- Cell Differentiation
- Cells, Cultured
- Chitinase-3-Like Protein 1/genetics
- Chitinase-3-Like Protein 1/metabolism
- Disease Models, Animal
- Fibrosis
- Humans
- Mice, Inbred C57BL
- Mice, Knockout, ApoE
- Muscle, Smooth, Vascular/enzymology
- Muscle, Smooth, Vascular/pathology
- Muscle, Smooth, Vascular/physiopathology
- Myocytes, Smooth Muscle/enzymology
- Myocytes, Smooth Muscle/pathology
- Neointima
- Phenotype
- Plaque, Atherosclerotic
- Rupture, Spontaneous
- Vascular Remodeling
- Mice
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Affiliation(s)
- Pavlos Tsantilas
- Department of Surgery, Division of Vascular Surgery, Stanford University School of Medicine, 300 Pasteur Drive, Alway Bldg., M121 Stanford, CA 94305, USA
- Stanford Cardiovascular Institute, Stanford University School of Medicine, 265 Campus Drive Stanford, CA 94305, USA
- Department for Vascular and Endovascular Surgery, Klinikum rechts der Isar, Technical University Munich, Ismaningerstr. 22, 81675 Munich, Germany
| | - Shen Lao
- Department for Vascular and Endovascular Surgery, Klinikum rechts der Isar, Technical University Munich, Ismaningerstr. 22, 81675 Munich, Germany
- Department of Thoracic Oncology and Surgery, China State Key Laboratory of Respiratory Disease and National Clinical Research Center for Respiratory Disease, The First Affiliated Hospital of Guangzhou Medical University, 151 Yanjiang Road, Guangzhou 510120, China
| | - Zhiyuan Wu
- Department for Vascular and Endovascular Surgery, Klinikum rechts der Isar, Technical University Munich, Ismaningerstr. 22, 81675 Munich, Germany
| | - Anne Eberhard
- Department of Surgery, Division of Vascular Surgery, Stanford University School of Medicine, 300 Pasteur Drive, Alway Bldg., M121 Stanford, CA 94305, USA
- Stanford Cardiovascular Institute, Stanford University School of Medicine, 265 Campus Drive Stanford, CA 94305, USA
| | - Greg Winski
- Department of Medicine, Karolinska Institute, Stockholm, Solnavägen 1, 171 77 Solna, Sweden
| | - Monika Vaerst
- Department of Surgery, Division of Vascular Surgery, Stanford University School of Medicine, 300 Pasteur Drive, Alway Bldg., M121 Stanford, CA 94305, USA
- Stanford Cardiovascular Institute, Stanford University School of Medicine, 265 Campus Drive Stanford, CA 94305, USA
| | - Vivek Nanda
- Department of Surgery, Division of Vascular Surgery, Stanford University School of Medicine, 300 Pasteur Drive, Alway Bldg., M121 Stanford, CA 94305, USA
- Stanford Cardiovascular Institute, Stanford University School of Medicine, 265 Campus Drive Stanford, CA 94305, USA
| | - Ying Wang
- Department of Surgery, Division of Vascular Surgery, Stanford University School of Medicine, 300 Pasteur Drive, Alway Bldg., M121 Stanford, CA 94305, USA
- Stanford Cardiovascular Institute, Stanford University School of Medicine, 265 Campus Drive Stanford, CA 94305, USA
| | - Yoko Kojima
- Department of Surgery, Division of Vascular Surgery, Stanford University School of Medicine, 300 Pasteur Drive, Alway Bldg., M121 Stanford, CA 94305, USA
- Stanford Cardiovascular Institute, Stanford University School of Medicine, 265 Campus Drive Stanford, CA 94305, USA
| | - Jianqin Ye
- Department of Surgery, Division of Vascular Surgery, Stanford University School of Medicine, 300 Pasteur Drive, Alway Bldg., M121 Stanford, CA 94305, USA
- Stanford Cardiovascular Institute, Stanford University School of Medicine, 265 Campus Drive Stanford, CA 94305, USA
| | - Alyssa Flores
- Department of Surgery, Division of Vascular Surgery, Stanford University School of Medicine, 300 Pasteur Drive, Alway Bldg., M121 Stanford, CA 94305, USA
- Stanford Cardiovascular Institute, Stanford University School of Medicine, 265 Campus Drive Stanford, CA 94305, USA
| | - Kai-Uwe Jarr
- Department of Surgery, Division of Vascular Surgery, Stanford University School of Medicine, 300 Pasteur Drive, Alway Bldg., M121 Stanford, CA 94305, USA
- Stanford Cardiovascular Institute, Stanford University School of Medicine, 265 Campus Drive Stanford, CA 94305, USA
| | - Jaroslav Pelisek
- Department for Vascular and Endovascular Surgery, Klinikum rechts der Isar, Technical University Munich, Ismaningerstr. 22, 81675 Munich, Germany
- Department for Vascular Surgery, University Hospital Zurich, Rämistrasse 100, 8091 Zurich, Switzerland
| | - Hans-Henning Eckstein
- Department for Vascular and Endovascular Surgery, Klinikum rechts der Isar, Technical University Munich, Ismaningerstr. 22, 81675 Munich, Germany
- German Center for Cardiovascular Research (DZHK), Potsdamer Str. 58, 10785 Berlin, Germany, partner site Munich Heart Alliance
| | - Ljubica Matic
- Department of Molecular Medicine and Surgery, Karolinska Institute, Stockholm, Solnavägen 1, 171 77 Solna, Sweden
| | - Ulf Hedin
- Department of Molecular Medicine and Surgery, Karolinska Institute, Stockholm, Solnavägen 1, 171 77 Solna, Sweden
| | - Philip S Tsao
- Department of Medicine, Division of Cardiovascular Medicine, Stanford University School of Medicine, 870 Quarry Road, Stanford, CA 94305, USA
- Veterans Affairs (VA) Health Care System, 3801 Miranda Ave, Palo Alto, CA 94304, USA
| | - Valentina Paloschi
- Department for Vascular and Endovascular Surgery, Klinikum rechts der Isar, Technical University Munich, Ismaningerstr. 22, 81675 Munich, Germany
- German Center for Cardiovascular Research (DZHK), Potsdamer Str. 58, 10785 Berlin, Germany, partner site Munich Heart Alliance
| | - Lars Maegdefessel
- Department for Vascular and Endovascular Surgery, Klinikum rechts der Isar, Technical University Munich, Ismaningerstr. 22, 81675 Munich, Germany
- Department of Medicine, Karolinska Institute, Stockholm, Solnavägen 1, 171 77 Solna, Sweden
- German Center for Cardiovascular Research (DZHK), Potsdamer Str. 58, 10785 Berlin, Germany, partner site Munich Heart Alliance
| | - Nicholas J Leeper
- Department of Surgery, Division of Vascular Surgery, Stanford University School of Medicine, 300 Pasteur Drive, Alway Bldg., M121 Stanford, CA 94305, USA
- Stanford Cardiovascular Institute, Stanford University School of Medicine, 265 Campus Drive Stanford, CA 94305, USA
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Paraskevas KI, Mikhailidis DP, Antignani PL, Baradaran H, Bokkers RP, Cambria RP, Dardik A, Davies AH, Eckstein HH, Faggioli G, Fernandes E Fernandes J, Fraedrich G, Geroulakos G, Gloviczki P, Golledge J, Gupta A, Jezovnik MK, Kakkos SK, Katsiki N, Knoflach M, Kooi ME, Lanza G, Liapis CD, Loftus IM, Mansilha A, Millon A, Nicolaides AN, Pini R, Poredos P, Ricco JB, Riles TS, Ringleb PA, Rundek T, Saba L, Schlachetzki F, Silvestrini M, Spinelli F, Stilo F, Sultan S, Suri JS, Zeebregts CJ, Chaturvedi S. Optimal management of asymptomatic carotid stenosis in 2021: the jury is still out. An International, multispecialty, expert review and position statement. INT ANGIOL 2021; 41:158-169. [PMID: 34913633 DOI: 10.23736/s0392-9590.21.04825-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
OBJECTIVES The recommendations of international guidelines for the management of asymptomatic carotid stenosis (ACS) often vary considerably and extend from a conservative approach with risk factor modification and best medical treatment (BMT) alone, to a more aggressive approach with a carotid intervention plus BMT. The aim of the current multispecialty position statement is to reconcile the conflicting views on the topic. MATERIALS AND METHODS A literature review was performed with a focus on data from recent studies. RESULTS Several clinical and imaging high-risk features have been identified that are associated with an increased long-term ipsilateral ischemic stroke risk in patients with ACS. Such high-risk clinical/imaging features include intraplaque hemorrhage, impaired cerebrovascular reserve, carotid plaque echolucency/ulceration/ neovascularization, a lipid-rich necrotic core, a thin or ruptured fibrous cap, silent brain infarction, a contralateral transient ischemic attack/stroke episode, male patients <75 years and microembolic signals on transcranial Doppler. There is growing evidence that 80-99% ACS indicate a higher stroke risk than 50-79% stenoses. CONCLUSIONS Although aggressive risk factor control and BMT should be implemented in all ACS patients, several high-risk features that may increase the risk of a future cerebrovascular event are now documented. Consequently, some guidelines recommend a prophylactic carotid intervention in high-risk patients to prevent future cerebrovascular events. Until the results of the much-anticipated randomized controlled trials emerge, the jury is still out regarding the optimal management of ACS patients.
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Affiliation(s)
| | - Dimitri P Mikhailidis
- Department of Clinical Biochemistry, Royal Free Hospital Campus, University College London Medical School, University College London (UCL), London, UK
| | | | - Hediyeh Baradaran
- Department of Radiology, University of Utah, Salt Lake City, UT, USA
| | - Reinoud P Bokkers
- Department of Radiology, Medical Imaging Center, University Medical Center Groningen, Groningen, The Netherlands
| | - Richard P Cambria
- Division of Vascular and Endovascular Surgery, St. Elizabeth's Medical Center, Brighton, MA, USA
| | - Alan Dardik
- Division of Vascular and Endovascular Surgery, Yale University School of Medicine, New Haven, CT, USA
| | - Alun H Davies
- Section of Vascular Surgery, Imperial College & Imperial Healthcare NHS Trust, London, UK
| | - Hans-Henning Eckstein
- Department for Vascular and Endovascular Surgery, Klinikum rechts der Isar, Technical University of Munich, Munich, Germany
| | - Gianluca Faggioli
- Vascular Surgery, Policlinico S. Orsola Malpighi, University of Bologna Alma Mater Studiorum, Bologna, Italy
| | | | - Gustav Fraedrich
- Department of Vascular Surgery, Medical University of Innsbruck, Innsbruck, Austria
| | - George Geroulakos
- Department of Vascular Surgery, Attikon University Hospital, National and Kapodistrian University of Athens, Athens, Greece
| | - Peter Gloviczki
- Division of Vascular and Endovascular Surgery, Mayo Clinic, Rochester, MN, USA
| | - Jonathan Golledge
- Queensland Research Centre for Peripheral Vascular Disease, James Cook University and Townsville University Hospital, Townsville, Australia
| | - Ajay Gupta
- Department of Radiology, Weill Cornell Medicine, New York, NY, USA
| | - Mateja K Jezovnik
- Department of Advanced Cardiopulmonary Therapies and Transplantation, The University of Texas Health Science Centre at Houston, Houston, Texas, USA
| | - Stavros K Kakkos
- Department of Vascular Surgery, University of Patras Medical School, Patras, Greece
| | - Niki Katsiki
- First Department of Internal Medicine, AHEPA University Hospital, Thessaloniki, Greece
| | - Michael Knoflach
- Department of Neurology, Medical University of Innsbruck, Innsbruck, Austria
| | - M Eline Kooi
- CARIM School for Cardiovascular Diseases, Maastricht University, Maastricht, The Netherlands.,Department of Radiology and Nuclear Medicine, Maastricht University Medical Center, Maastricht, The Netherlands
| | - Gaetano Lanza
- Vascular Surgery Department, IRCSS MultiMedica Hospital, Castellanza, Varese, Italy
| | | | - Ian M Loftus
- St. George's Vascular Institute, St. George's University London, London, UK
| | - Armando Mansilha
- Faculty of Medicine of the University of Porto, Porto, Portugal.,Department of Angiology and Vascular Surgery, Hospital de S. Joao, Porto, Portugal
| | - Antoine Millon
- Department of Vascular and Endovascular Surgery, Louis Pradel Hospital, Hospices Civils de Lyon, Lyon, France
| | - Andrew N Nicolaides
- Department of Surgery, University of Nicosia Medical School, Nicosia, Cyprus
| | - Rodolfo Pini
- Vascular Surgery, Policlinico S. Orsola Malpighi, University of Bologna Alma Mater Studiorum, Bologna, Italy
| | - Pavel Poredos
- Department of Vascular Disease, University Medical Centre Ljubljana, Ljubljana, Slovenia
| | - Jean-Baptiste Ricco
- Department of Clinical Research, University of Poitiers, CHU de Poitiers, Poitiers, France
| | - Thomas S Riles
- Department of Surgery, Division of Vascular Surgery, New York University Langone Medical Centre, New York, NY, USA
| | | | - Tatjana Rundek
- Department of Neurology, Miller School of Medicine, University of Miami, Miami, FL, USA
| | - Luca Saba
- Department of Radiology, Azienda Ospedaliera Universitaria di Cagliari, Cagliari, Italy
| | | | - Mauro Silvestrini
- Neurological Clinic, Department of Experimental and Clinical Medicine, Marche Polytechnic University, Ancona, Italy
| | - Francesco Spinelli
- Vascular Surgery Division, Campus Bio-Medico University of Rome, Rome, Italy
| | - Francesco Stilo
- Vascular Surgery Division, Campus Bio-Medico University of Rome, Rome, Italy
| | - Sherif Sultan
- Western Vascular Institute, Department of Vascular and Endovascular Surgery, University Hospital Galway, National University of Ireland, Galway, Ireland
| | - Jasjit S Suri
- Stroke Diagnosis and Monitoring Division, AtheroPointTM, Roseville, CA, USA
| | - Clark J Zeebregts
- Division of Vascular Surgery, Department of Surgery, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Seemant Chaturvedi
- Department of Neurology & Stroke Program, University of Maryland School of Medicine, Baltimore, MD, USA
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58
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von Rose AB, Kobus K, Bohmann B, Trenner M, Wahida A, Eckstein HH, Bassermann F, von Heckel K, Wolk S, Reeps C, Schwaiger BJ, Eilenberg WH, Neumayer C, Burghuber C, Busch A. Concomitantly discovered visceral artery aneurysms do rarely grow during cancer therapy. Clin Anat 2021; 35:296-304. [PMID: 34837270 DOI: 10.1002/ca.23813] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2021] [Revised: 11/16/2021] [Accepted: 11/21/2021] [Indexed: 01/21/2023]
Abstract
Visceral artery aneurysms (VAA) are a rare entity of arterial aneurysms with the imminent threat of rupture. The impact of cancer and chemotherapy on the growth of VAAs is unknown. A retrospective dual center cohort study of patients with concomitant VAA and different types of cancer was conducted and the impact of various chemotherapeutic agents on VAA growth was studied by sequential CT analysis. For comparison, a non-cancer all comer cohort with VAAs and no cancer was studied to compare different growth rates. The primary endpoint was aneurysm progress or regression >1.75 mm. Chi-square test, Fisher's exact test and Mann-Whitney test was used for statistical comparison. In the 17-year-period from January 2003 to March 2020, 59 patients with 30 splenic artery aneurysms, 14 celiac trunk aneurysms, 11 renal artery aneurysms and 4 other VAA and additional malignancy were identified. 20% of patients suffered from prostate cancer, the rest were heterogeneous. The most prevalent chemotherapies were alkylating agents (23%), antimetabolites (14%) and mitose inhibitors (10%). Eight patients had relevant growth of their VAA and one patient showed diameter regression (average growth rate 0.1 ± 0.5 mm/year). Twenty-nine patients with 14 splenic, 11 RAAs (seven right) and 4 celiac trunk aneurysms were available in the non-cancer comparison cohort (average growth rate 0.5 ± 0.9 mm/year, p = 0.058). However, the growth rate of patients receiving operative treatment for relevant VAA growth was significantly higher (p = 0.004). VAAs grow rarely, and rather slow. Cancer and/or chemotherapy do not significantly influence the annual growth rate. Additional control examinations seem unnecessary.
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Affiliation(s)
- Aaron Becker von Rose
- III. Medical Department for Hematology and Oncology, Klinikum rechts der Isar Technical University Munich, Munich, Germany
| | - Kathrin Kobus
- Department for Vascular and Endovascular Surgery, Klinikum rechts der Isar, Technical University Munich, Munich, Germany
| | - Bianca Bohmann
- Department for Vascular and Endovascular Surgery, Klinikum rechts der Isar, Technical University Munich, Munich, Germany
| | - Matthias Trenner
- Department for Vascular and Endovascular Surgery, Klinikum rechts der Isar, Technical University Munich, Munich, Germany
| | - Adam Wahida
- III. Medical Department for Hematology and Oncology, Klinikum rechts der Isar Technical University Munich, Munich, Germany
| | - Hans-Henning Eckstein
- Department for Vascular and Endovascular Surgery, Klinikum rechts der Isar, Technical University Munich, Munich, Germany
| | - Florian Bassermann
- III. Medical Department for Hematology and Oncology, Klinikum rechts der Isar Technical University Munich, Munich, Germany
| | | | - Steffen Wolk
- Division of Vascular and Endovascular Surgery, Department for Visceral, Thoracic and Vascular Surgery, Medical Faculty Carl Gustav Carus and University Hospital, Technische Universität Dresden, Dresden, Germany
| | - Christian Reeps
- Division of Vascular and Endovascular Surgery, Department for Visceral, Thoracic and Vascular Surgery, Medical Faculty Carl Gustav Carus and University Hospital, Technische Universität Dresden, Dresden, Germany
| | - Benedikt J Schwaiger
- Department of Radiology and Department of Neuroradiology, School of Medicine, Technical University of Munich, Munich, Germany
| | - Wolf-Hans Eilenberg
- Division of Vascular Surgery and Surgical Research Laboratories, Department of Surgery, Medical University of Vienna, General Hospital of Vienna, Vienna, Austria
| | - Christoph Neumayer
- Division of Vascular Surgery and Surgical Research Laboratories, Department of Surgery, Medical University of Vienna, General Hospital of Vienna, Vienna, Austria
| | - Christoph Burghuber
- Division of Vascular Surgery and Surgical Research Laboratories, Department of Surgery, Medical University of Vienna, General Hospital of Vienna, Vienna, Austria
| | - Albert Busch
- Department for Vascular and Endovascular Surgery, Klinikum rechts der Isar, Technical University Munich, Munich, Germany.,Division of Vascular and Endovascular Surgery, Department for Visceral, Thoracic and Vascular Surgery, Medical Faculty Carl Gustav Carus and University Hospital, Technische Universität Dresden, Dresden, Germany
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59
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Busch A, Bleichert S, Ibrahim N, Wortmann M, Eckstein HH, Brostjan C, Wagenhäuser MU, Goergen CJ, Maegdefessel L. Translating mouse models of abdominal aortic aneurysm to the translational needs of vascular surgery. JVS Vasc Sci 2021; 2:219-234. [PMID: 34778850 PMCID: PMC8577080 DOI: 10.1016/j.jvssci.2021.01.002] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2020] [Accepted: 01/04/2021] [Indexed: 01/03/2023] Open
Abstract
Introduction Abdominal aortic aneurysm (AAA) is a condition that has considerable socioeconomic impact and an eventual rupture is associated with high mortality and morbidity. Despite decades of research, surgical repair remains the treatment of choice and no medical therapy is currently available. Animal models and, in particular, murine models, of AAA are a vital tool for experimental in vivo research. However, each of the different models has individual limitations and provide only partial mimicry of human disease. This narrative review addresses the translational potential of the available mouse models, highlighting unanswered questions from a clinical perspective. It is based on a thorough presentation of the available literature and more than a decade of personal experience, with most of the available models in experimental and translational AAA research. Results From all the models published, only the four inducible models, namely the angiotensin II model (AngII), the porcine pancreatic elastase perfusion model (PPE), the external periadventitial elastase application (ePPE), and the CaCl2 model have been widely used by different independent research groups. Although the angiotensin II model provides features of dissection and aneurysm formation, the PPE model shows reliable features of human AAA, especially beyond day 7 after induction, but remains technically challenging. The translational value of ePPE as a model and the combination with β-aminopropionitrile to induce rupture and intraluminal thrombus formation is promising, but warrants further mechanistic insights. Finally, the external CaCl2 application is known to produce inflammatory vascular wall thickening. Unmet translational research questions include the origin of AAA development, monitoring aneurysm growth, gender issues, and novel surgical therapies as well as novel nonsurgical therapies. Conclusion New imaging techniques, experimental therapeutic alternatives, and endovascular treatment options provide a plethora of research topics to strengthen the individual features of currently available mouse models, creating the possibility of shedding new light on translational research questions.
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Affiliation(s)
- Albert Busch
- Department for Vascular and Endovascular Surgery, Technical University Munich, Munich, Germany.,Deutsches Zentrum für Herz-Kreislaufforschung (DZHK), Berlin, Germany
| | - Sonja Bleichert
- Division of Vascular Surgery and Surgical Research Laboratories, Department of Surgery, Medical University of Vienna, Vienna General Hospital, Vienna, Austria
| | - Nahla Ibrahim
- Division of Vascular Surgery and Surgical Research Laboratories, Department of Surgery, Medical University of Vienna, Vienna General Hospital, Vienna, Austria
| | - Markus Wortmann
- Department of Vascular and Endovascular Surgery, Universitaetsklinik Heidelberg, Heidelberg, Germany
| | - Hans-Henning Eckstein
- Department for Vascular and Endovascular Surgery, Technical University Munich, Munich, Germany
| | - Christine Brostjan
- Division of Vascular Surgery and Surgical Research Laboratories, Department of Surgery, Medical University of Vienna, Vienna General Hospital, Vienna, Austria
| | - Markus U Wagenhäuser
- Department of Vascular and Endovascular Surgery, Heinrich-Heine-University Medical Center Düsseldorf, Düsseldorf, Germany
| | - Craig J Goergen
- Weldon School of Biomedical Engineering, Purdue University, West Lafayette, Ind
| | - Lars Maegdefessel
- Department for Vascular and Endovascular Surgery, Technical University Munich, Munich, Germany.,Deutsches Zentrum für Herz-Kreislaufforschung (DZHK), Berlin, Germany
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60
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Fasolo F, Jin H, Winski G, Chernogubova E, Pauli J, Winter H, Li DY, Glukha N, Bauer S, Metschl S, Wu Z, Koschinsky ML, Reilly M, Pelisek J, Kempf W, Eckstein HH, Soehnlein O, Matic L, Hedin U, Bäcklund A, Bergmark C, Paloschi V, Maegdefessel L. Long Noncoding RNA MIAT Controls Advanced Atherosclerotic Lesion Formation and Plaque Destabilization. Circulation 2021; 144:1567-1583. [PMID: 34647815 PMCID: PMC8570347 DOI: 10.1161/circulationaha.120.052023] [Citation(s) in RCA: 55] [Impact Index Per Article: 18.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Supplemental Digital Content is available in the text. Long noncoding RNAs (lncRNAs) are important regulators of biological processes involved in vascular tissue homeostasis and disease development. The present study assessed the functional contribution of the lncRNA myocardial infarction-associated transcript (MIAT) to atherosclerosis and carotid artery disease.
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Affiliation(s)
- Francesca Fasolo
- Department for Vascular and Endovascular Surgery, Klinikum rechts der Isar, Technical University Munich, Germany (F.F., J. Pauli, H.W., N.G., S.B., S.M., Z.W., W.K., H.-H.E., V.P., L. Maegdefessel).,German Center for Cardiovascular Research (DZHK), Berlin, Germany; partner site Munich Heart Alliance (F.F., J. Pauli, H.W., F.F., N.G., S.B., S.M., Z.W., W.K., H.-H.E., V.P., L. Maegdefessel)
| | - Hong Jin
- Department of Medicine (H.J., G.W., E.C., A.B.), Karolinska Institutet, Stockholm, Sweden.,Department of Molecular Medicine and Surgery (H.J., L. Matic, U.H., C.B., L. Maegdefessel), Karolinska Institutet, Stockholm, Sweden
| | - Greg Winski
- Department of Medicine (H.J., G.W., E.C., A.B.), Karolinska Institutet, Stockholm, Sweden
| | - Ekaterina Chernogubova
- Department of Medicine (H.J., G.W., E.C., A.B.), Karolinska Institutet, Stockholm, Sweden
| | - Jessica Pauli
- Department for Vascular and Endovascular Surgery, Klinikum rechts der Isar, Technical University Munich, Germany (F.F., J. Pauli, H.W., N.G., S.B., S.M., Z.W., W.K., H.-H.E., V.P., L. Maegdefessel).,German Center for Cardiovascular Research (DZHK), Berlin, Germany; partner site Munich Heart Alliance (F.F., J. Pauli, H.W., F.F., N.G., S.B., S.M., Z.W., W.K., H.-H.E., V.P., L. Maegdefessel)
| | - Hanna Winter
- Department for Vascular and Endovascular Surgery, Klinikum rechts der Isar, Technical University Munich, Germany (F.F., J. Pauli, H.W., N.G., S.B., S.M., Z.W., W.K., H.-H.E., V.P., L. Maegdefessel).,German Center for Cardiovascular Research (DZHK), Berlin, Germany; partner site Munich Heart Alliance (F.F., J. Pauli, H.W., F.F., N.G., S.B., S.M., Z.W., W.K., H.-H.E., V.P., L. Maegdefessel)
| | - Daniel Y Li
- Department of Cardiology, Columbia University Medical Center, New York, NY (D.Y.L., M.R.)
| | - Nadiya Glukha
- Department for Vascular and Endovascular Surgery, Klinikum rechts der Isar, Technical University Munich, Germany (F.F., J. Pauli, H.W., N.G., S.B., S.M., Z.W., W.K., H.-H.E., V.P., L. Maegdefessel).,German Center for Cardiovascular Research (DZHK), Berlin, Germany; partner site Munich Heart Alliance (F.F., J. Pauli, H.W., F.F., N.G., S.B., S.M., Z.W., W.K., H.-H.E., V.P., L. Maegdefessel)
| | - Sabine Bauer
- Department for Vascular and Endovascular Surgery, Klinikum rechts der Isar, Technical University Munich, Germany (F.F., J. Pauli, H.W., N.G., S.B., S.M., Z.W., W.K., H.-H.E., V.P., L. Maegdefessel).,German Center for Cardiovascular Research (DZHK), Berlin, Germany; partner site Munich Heart Alliance (F.F., J. Pauli, H.W., F.F., N.G., S.B., S.M., Z.W., W.K., H.-H.E., V.P., L. Maegdefessel)
| | - Susanne Metschl
- Department for Vascular and Endovascular Surgery, Klinikum rechts der Isar, Technical University Munich, Germany (F.F., J. Pauli, H.W., N.G., S.B., S.M., Z.W., W.K., H.-H.E., V.P., L. Maegdefessel).,German Center for Cardiovascular Research (DZHK), Berlin, Germany; partner site Munich Heart Alliance (F.F., J. Pauli, H.W., F.F., N.G., S.B., S.M., Z.W., W.K., H.-H.E., V.P., L. Maegdefessel)
| | - Zhiyuan Wu
- Department for Vascular and Endovascular Surgery, Klinikum rechts der Isar, Technical University Munich, Germany (F.F., J. Pauli, H.W., N.G., S.B., S.M., Z.W., W.K., H.-H.E., V.P., L. Maegdefessel).,German Center for Cardiovascular Research (DZHK), Berlin, Germany; partner site Munich Heart Alliance (F.F., J. Pauli, H.W., F.F., N.G., S.B., S.M., Z.W., W.K., H.-H.E., V.P., L. Maegdefessel)
| | | | - Muredach Reilly
- Department of Cardiology, Columbia University Medical Center, New York, NY (D.Y.L., M.R.)
| | - Jaroslav Pelisek
- Department of Vascular Surgery, University Hospital Zurich, Switzerland (J. Pelisek)
| | - Wolfgang Kempf
- Department for Vascular and Endovascular Surgery, Klinikum rechts der Isar, Technical University Munich, Germany (F.F., J. Pauli, H.W., N.G., S.B., S.M., Z.W., W.K., H.-H.E., V.P., L. Maegdefessel).,German Center for Cardiovascular Research (DZHK), Berlin, Germany; partner site Munich Heart Alliance (F.F., J. Pauli, H.W., F.F., N.G., S.B., S.M., Z.W., W.K., H.-H.E., V.P., L. Maegdefessel)
| | - Hans-Henning Eckstein
- Department for Vascular and Endovascular Surgery, Klinikum rechts der Isar, Technical University Munich, Germany (F.F., J. Pauli, H.W., N.G., S.B., S.M., Z.W., W.K., H.-H.E., V.P., L. Maegdefessel).,German Center for Cardiovascular Research (DZHK), Berlin, Germany; partner site Munich Heart Alliance (F.F., J. Pauli, H.W., F.F., N.G., S.B., S.M., Z.W., W.K., H.-H.E., V.P., L. Maegdefessel)
| | - Oliver Soehnlein
- Department of Experimental Pathology, Westphalian Wilhelms University, Munster, Germany (O.S.).,Department of Physiology and Pharmacology, Karolinska Institutet, Stockholm, Sweden (O.S.).,Institute for Cardiovascular Prevention, Ludwig Maximilian University of Munich, Germany (O.S.)
| | - Ljubica Matic
- Department of Molecular Medicine and Surgery (H.J., L. Matic, U.H., C.B., L. Maegdefessel), Karolinska Institutet, Stockholm, Sweden
| | - Ulf Hedin
- Department of Molecular Medicine and Surgery (H.J., L. Matic, U.H., C.B., L. Maegdefessel), Karolinska Institutet, Stockholm, Sweden
| | - Alexandra Bäcklund
- Department of Medicine (H.J., G.W., E.C., A.B.), Karolinska Institutet, Stockholm, Sweden
| | - Claes Bergmark
- Department of Molecular Medicine and Surgery (H.J., L. Matic, U.H., C.B., L. Maegdefessel), Karolinska Institutet, Stockholm, Sweden
| | - Valentina Paloschi
- German Center for Cardiovascular Research (DZHK), Berlin, Germany; partner site Munich Heart Alliance (F.F., J. Pauli, H.W., F.F., N.G., S.B., S.M., Z.W., W.K., H.-H.E., V.P., L. Maegdefessel)
| | - Lars Maegdefessel
- Department for Vascular and Endovascular Surgery, Klinikum rechts der Isar, Technical University Munich, Germany (F.F., J. Pauli, H.W., N.G., S.B., S.M., Z.W., W.K., H.-H.E., V.P., L. Maegdefessel).,German Center for Cardiovascular Research (DZHK), Berlin, Germany; partner site Munich Heart Alliance (F.F., J. Pauli, H.W., F.F., N.G., S.B., S.M., Z.W., W.K., H.-H.E., V.P., L. Maegdefessel).,Department of Molecular Medicine and Surgery (H.J., L. Matic, U.H., C.B., L. Maegdefessel), Karolinska Institutet, Stockholm, Sweden
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61
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Parker LP, Reutersberg B, Syed MBJ, Munshi B, Richards S, Kelsey LJ, Sakalihasan N, Eckstein HH, Norman PE, Doyle BJ. Proximal False Lumen Thrombosis is Associated with Low False Lumen Pressure and Fewer Complications in Type B Aortic Dissection. J Vasc Surg 2021; 75:1181-1190.e5. [PMID: 34742883 DOI: 10.1016/j.jvs.2021.10.035] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2021] [Accepted: 10/20/2021] [Indexed: 12/28/2022]
Abstract
BACKGROUND Improved risk stratification is a key priority for type B aortic dissection (TBAD). Partial false lumen thrombus morphology is an emerging predictor of complications however, partial thrombosis is poorly defined and its evaluation in clinical studies is inconsistent. PURPOSE This work aims to characterise hemodynamic pressure in TBAD and determine how pressure relates to false lumen thrombus morphology and clinical events. METHODS Retrospective admission computed tomography angiography of 69 patients with acute TBAD was used to construct three-dimensional computational models for simulation of cyclical blood flow and calculation of pressure. Patients were categorised based on false lumen thrombus morphology: minimal; proximal; distal; or extensive thrombosis. Linear regression analysis compared the luminal pressure difference between the true and false lumen for each morphology group. The impact of morphology classification on acute complications within 14 days was studied using logistic regression adjusted for clinical parameters. A survival analysis for adverse aortic events at one-year was also performed using Cox regression. RESULTS 44 patients experienced acute complications and 45 had an adverse aortic event at one-year. Mean (±standard deviation) age was 62.6 (±12.6) years and 75.4% were male. Compared to patients with minimal thrombosis, those with proximal thrombosis had reduced false lumen pressure by 10.1mmHg (95% CI 4.3-15.9mmHg, p=.001). Individuals that did not experience an acute complication had reduced relative false lumen pressure (-6.35mmHg vs -0.62mmHg, p=.03). Proximal thrombosis was associated with fewer acute complications (OR 0.17, 95% CI 0.04-0.60 p=.01) and one-year adverse aortic events (HR 0.36, 95% CI 0.16-0.80, p=.01). CONCLUSIONS Proximal false lumen thrombosis is a marker of reduced false lumen pressure. This may explain how proximal false lumen thrombosis appears protective of acute complications (refractory hypertension or pain, aortic rupture, visceral or limb malperfusion and acute expansion) and adverse aortic events within the first year.
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Affiliation(s)
- Louis P Parker
- Vascular Engineering Laboratory, Harry Perkins Institute of Medical Research, QEII Medical Centre, Nedlands and the UWA Centre for Medical Research, The University of Western Australia, Perth, Australia; School of Engineering, The University of Western Australia, Perth, Australia
| | - Benedikt Reutersberg
- Department for Vascular and Endovascular Surgery and Munich Aortic Center, Klinikum rechts der Isar, Technical University of Munich, Munich, Germany; Department for Vascular Surgery, University Hospital of Zurich, Switzerland
| | - Maaz B J Syed
- Centre for Cardiovascular Science, Queens Medical Research Institute, University of Edinburgh, UK
| | - Bijit Munshi
- Vascular Engineering Laboratory, Harry Perkins Institute of Medical Research, QEII Medical Centre, Nedlands and the UWA Centre for Medical Research, The University of Western Australia, Perth, Australia; Medical School, The University of Western Australia, Australia
| | - Samantha Richards
- Vascular Engineering Laboratory, Harry Perkins Institute of Medical Research, QEII Medical Centre, Nedlands and the UWA Centre for Medical Research, The University of Western Australia, Perth, Australia; School of Engineering, The University of Western Australia, Perth, Australia
| | - Lachlan J Kelsey
- Vascular Engineering Laboratory, Harry Perkins Institute of Medical Research, QEII Medical Centre, Nedlands and the UWA Centre for Medical Research, The University of Western Australia, Perth, Australia; School of Engineering, The University of Western Australia, Perth, Australia
| | - Natzi Sakalihasan
- Cardiovascular and Thoracic Surgery Department, Centre Hospitalier Universitaire de Liège, Belgium
| | - Hans-Henning Eckstein
- Department for Vascular and Endovascular Surgery and Munich Aortic Center, Klinikum rechts der Isar, Technical University of Munich, Munich, Germany
| | - Paul E Norman
- Vascular Engineering Laboratory, Harry Perkins Institute of Medical Research, QEII Medical Centre, Nedlands and the UWA Centre for Medical Research, The University of Western Australia, Perth, Australia; Medical School, The University of Western Australia, Australia
| | - Barry J Doyle
- Vascular Engineering Laboratory, Harry Perkins Institute of Medical Research, QEII Medical Centre, Nedlands and the UWA Centre for Medical Research, The University of Western Australia, Perth, Australia; School of Engineering, The University of Western Australia, Perth, Australia; Centre for Cardiovascular Science, Queens Medical Research Institute, University of Edinburgh, UK; Cardiovascular and Thoracic Surgery Department, Centre Hospitalier Universitaire de Liège, Belgium.
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Nana P, Dakis K, Brodis A, Spanos K, Kouvelos G, Eckstein HH, Giannoukas A. A systematic review and meta-analysis on early mortality after abdominal aortic aneurysm repair in females in urgent and elective setting. J Vasc Surg 2021; 75:1082-1088.e6. [PMID: 34740807 DOI: 10.1016/j.jvs.2021.10.040] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2021] [Accepted: 10/24/2021] [Indexed: 12/19/2022]
Abstract
OBJECTIVE Females represent a group of patients with higher mortality after abdominal aortic aneurysm (AAA), endovascular (EVAR) or open (OSR), repair. This systematic review aimed to evaluate the 30-day mortality after AAA repair in females, comparing both EVAR and OSR, in elective and urgent settings. METHODS The protocol of the review was registered to the PROSPERO (CRD42021242686). A search of the English literature was conducted, using PubMed, EMBASE and CENTRAL databases, from inception to March 5, 2021, using the Systematic Reviews and Meta-Analysis guidelines (PRISMA). Only studies reporting on 30-day mortality of AAA repair, in urgent and elective setting, comparing EVAR and OSR, in female population were eligible. Patients were stratified according to the need for elective or urgent repair. Symptomatic and ruptured cases were included into the urgent group. Individual studies were assessed for risk of bias using the ROBINS-I tool. The GRADE approach was used to evaluate the quality of evidence. The primary outcome was 30-day mortality after AAA repair in the female population, comparing EVAR and OSR. The outcomes were summarized as odds ratio along with their 95% confidence intervals (CI), through a paired meta-analysis. RESULTS Eight studies reported data on 30-day mortality following AAA repair. A total of 56,982 females (22,995 EVAR vs. 33,987 OSR) were included. A significantly reduced total 30-day mortality rate was recorded among females that underwent EVAR compared to OSR (OR, 0.25; 95% CI, 0.23-0.27; P<.001, Ι2=86%). Also a reduced 30-day mortality was found in females that underwent elective EVAR compared to OSR (OR, 0.37; 95% CI, 0.33-0.41; P< .001, Ι2=48%). Despite that OSR was more frequently offered in the urgent setting (OR, 0.21; 95% CI, 0.19-0.23; P< .001, Ι2=84%), EVAR was associated with a reduced 30-day mortality (OR, 0.48; 95% CI, 0.40-0.57; P<.001, Ι2=0%). CONCLUSIONS In females, EVAR is associated with lower 30-day mortality in both elective and urgent AAA repair, although it appears as less likely to be offered in the setting of urgent AAA repair.
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Affiliation(s)
- Petroula Nana
- Vascular Surgery Department, Larissa University Hospital, Faculty of Medicine, School of Health Sciences, University of Thessaly, Larissa, Greece.
| | - Konstantinos Dakis
- Vascular Surgery Department, Larissa University Hospital, Faculty of Medicine, School of Health Sciences, University of Thessaly, Larissa, Greece
| | - Alexandros Brodis
- Department of Neurosurgery, Larissa University Hospital, Faculty of Medicine, School of Health Sciences, University of Thessaly, Larissa, Greece
| | - Konstantinos Spanos
- Vascular Surgery Department, Larissa University Hospital, Faculty of Medicine, School of Health Sciences, University of Thessaly, Larissa, Greece
| | - George Kouvelos
- Vascular Surgery Department, Larissa University Hospital, Faculty of Medicine, School of Health Sciences, University of Thessaly, Larissa, Greece
| | - Hans-Henning Eckstein
- Department for Vascular and Endovascular Surgery, Technical University of Munich TUM, Germany
| | - Athanasios Giannoukas
- Vascular Surgery Department, Larissa University Hospital, Faculty of Medicine, School of Health Sciences, University of Thessaly, Larissa, Greece
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Paraskevas KI, Mikhailidis DP, Antignani PL, Baradaran H, Bokkers RPH, Cambria RP, Dardik A, Davies AH, Eckstein HH, Faggioli G, E Fernandes JF, Fraedrich G, Geroulakos G, Gloviczki P, Golledge J, Gupta A, Jezovnik MK, Kakkos SK, Katsiki N, Knoflach M, Kooi ME, Lanza G, Liapis CD, Loftus IM, Mansilha A, Millon A, Nicolaides AN, Pini R, Poredos P, Ricco JB, Riles TS, Ringleb PA, Rundek T, Saba L, Schlachetzki F, Silvestrini M, Spinelli F, Stilo F, Sultan S, Suri JS, Zeebregts CJ, Chaturvedi S. Optimal Management of Asymptomatic Carotid Stenosis in 2021: The Jury is Still Out. An International, Multispecialty, Expert Review and Position Statement. J Stroke Cerebrovasc Dis 2021; 31:106182. [PMID: 34735900 DOI: 10.1016/j.jstrokecerebrovasdis.2021.106182] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2021] [Revised: 10/14/2021] [Accepted: 10/17/2021] [Indexed: 01/19/2023] Open
Abstract
OBJECTIVES The recommendations of international guidelines for the management of asymptomatic carotid stenosis (ACS) often vary considerably and extend from a conservative approach with risk factor modification and best medical treatment (BMT) alone, to a more aggressive approach with a carotid intervention plus BMT. The aim of the current multispecialty position statement is to reconcile the conflicting views on the topic. MATERIALS AND METHODS A literature review was performed with a focus on data from recent studies. RESULTS Several clinical and imaging high-risk features have been identified that are associated with an increased long-term ipsilateral ischemic stroke risk in patients with ACS. Such high-risk clinical/imaging features include intraplaque hemorrhage, impaired cerebrovascular reserve, carotid plaque echolucency/ulceration/ neovascularization, a lipid-rich necrotic core, a thin or ruptured fibrous cap, silent brain infarction, a contralateral transient ischemic attack/stroke episode, male patients < 75 years and microembolic signals on transcranial Doppler. There is growing evidence that 80-99% ACS indicate a higher stroke risk than 50-79% stenoses. CONCLUSIONS Although aggressive risk factor control and BMT should be implemented in all ACS patients, several high-risk features that may increase the risk of a future cerebrovascular event are now documented. Consequently, some guidelines recommend a prophylactic carotid intervention in high-risk patients to prevent future cerebrovascular events. Until the results of the much-anticipated randomized controlled trials emerge, the jury is still out regarding the optimal management of ACS patients.
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Affiliation(s)
- Kosmas I Paraskevas
- Department of Vascular Surgery, Central Clinic of Athens, 24, Alexander Papagou street, N. Iraklio, Athens 14122, Greece.
| | - Dimitri P Mikhailidis
- Department of Clinical Biochemistry, Royal Free Hospital Campus, University College London Medical School, University College London (UCL), London, UK
| | | | - Hediyeh Baradaran
- Department of Radiology, University of Utah, Salt Lake City, UT, United States
| | - Reinoud P H Bokkers
- Department of Radiology, Medical Imaging Center, University Medical Center Groningen, Groningen, the Netherland
| | - Richard P Cambria
- Division of Vascular and Endovascular Surgery, St. Elizabeth's Medical Center, Brighton, MA, United States
| | - Alan Dardik
- Division of Vascular and Endovascular Surgery, Yale University School of Medicine, New Haven, CT, United States
| | - Alun H Davies
- Section of Vascular Surgery, Imperial College and Imperial Healthcare NHS Trust, London, UK
| | - Hans-Henning Eckstein
- Department for Vascular and Endovascular Surgery, Klinikum rechts der Isar, Technical University of Munich, Munich, Germany
| | - Gianluca Faggioli
- Vascular Surgery, University of Bologna "Alma Mater Studiorum", Policlinico S. Orsola Malpighi, Bologna, Italy
| | | | - Gustav Fraedrich
- Department of Vascular Surgery, Medical University of Innsbruck, Innsbruck, Austria
| | - George Geroulakos
- Department of Vascular Surgery, Attikon University Hospital, National and Kapodistrian University of Athens, Athens, Greece
| | - Peter Gloviczki
- Division of Vascular and Endovascular Surgery, Mayo Clinic, Rochester, MN, United States
| | - Jonathan Golledge
- Queensland Research Center for Peripheral Vascular Disease, James Cook University, Townsville University Hospital, Townsville, Queensland, Australia
| | - Ajay Gupta
- Department of Radiology, Weill Cornell Medicine, New York, United States
| | - Mateja K Jezovnik
- Department of Advanced Cardiopulmonary Therapies and Transplantation, The University of Texas Health Science Center, Houston, TX, United States
| | - Stavros K Kakkos
- Department of Vascular Surgery, University of Patras Medical School, Patras, Greece
| | - Niki Katsiki
- First Department of Internal Medicine, AHEPA University Hospital, Thessaloniki, Greece
| | - Michael Knoflach
- Department of Neurology, Medical University of Innsbruck, Innsbruck, Austria
| | - M Eline Kooi
- CARIM School for Cardiovascular Diseases, Maastricht University, Maastricht, the Netherland; Department of Radiology and Nuclear Medicine, Maastricht University Medical Center, Maastricht, the Netherland
| | - Gaetano Lanza
- Vascular Surgery Department, IRCSS MultiMedica Hospital, Castellanza, Italy
| | | | - Ian M Loftus
- St. George's Vascular Institute, St. George's University of London, London, UK
| | - Armando Mansilha
- Faculty of Medicine of the University of Porto, Porto, Portugal; Department of Angiology and Vascular Surgery, Hospital de S. Joao, Porto, Portugal
| | - Antoine Millon
- Department of Vascular and Endovascular Surgery, Louis Pradel Hospital, Hospices Civils de Lyon, France
| | - Andrew N Nicolaides
- Department of Surgery, University of Nicosia Medical School, Nicosia, Cyprus
| | - Rodolfo Pini
- Vascular Surgery, University of Bologna "Alma Mater Studiorum", Policlinico S. Orsola Malpighi, Bologna, Italy
| | - Pavel Poredos
- Department of Vascular Disease, University Medical Center, Ljubljana, Slovenia
| | - Jean-Baptiste Ricco
- Department of Clinical Research, University of Poitiers, CHU de Poitiers, Poitiers, France
| | - Thomas S Riles
- Department of Surgery, Division of Vascular Surgery, New York University, Langone Medical Center, New York, United States
| | | | - Tatjana Rundek
- Department of Neurology, Miller School of Medicine, University of Miami, Miami, FL, United States
| | - Luca Saba
- Department of Radiology, Azienda Ospedaliera Universitaria Di Cagliari, Cagliari, Italy
| | | | - Mauro Silvestrini
- Neurological Clinic, Department of Experimental and Clinical Medicine, Marche Polytechnic University, Ancona, Italy
| | - Francesco Spinelli
- Vascular Surgery Division, Campus Bio-Medico University of Rome, Rome, Italy
| | - Francesco Stilo
- Vascular Surgery Division, Campus Bio-Medico University of Rome, Rome, Italy
| | - Sherif Sultan
- Department of Vascular and Endovascular Surgery, Western Vascular Institute, University Hospital Galway, National University of Ireland, Galway, Ireland
| | - Jasjit S Suri
- Stroke Diagnosis and Monitoring Division, AtheroPointTM, Roseville, United States
| | - Clark J Zeebregts
- Division of Vascular Surgery, Department of Surgery, University Medical Center Groningen, University of Groningen, Groningen, the Netherland
| | - Seemant Chaturvedi
- Department of Neurology and Stroke Program, University of Maryland School of Medicine, Baltimore, MD, United States
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Reiff T, Eckstein HH, Mansmann U, Jansen O, Fraedrich G, Mudra H, Hacke W, Ringleb PA. Successful implementation of best medical treatment for patients with asymptomatic carotid artery stenosis within a randomized controlled trial (SPACE-2). Neurol Res Pract 2021; 3:62. [PMID: 34666833 PMCID: PMC8524978 DOI: 10.1186/s42466-021-00153-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2021] [Accepted: 08/24/2021] [Indexed: 11/11/2022] Open
Abstract
Background Asymptomatic carotid artery stenosis (ACS) can be treated with carotid endarterectomy (CEA), carotid artery stenting (CAS), or best medical treatment (BMT) only. For all treatment options, optimization of vascular risk factors such as arterial hypertension, hyperlipidemia, smoking, obesity, and insufficient physical activity is essential. Data on adherence to BMT and lifestyle modification in patients with ACS are sparse. The subject of this investigation is the implementation and quality of risk factor adjustment in the context of a randomized controlled trial. Methods A total of 513 patients in the prematurely terminated, randomized, controlled, multicenter SPACE-2 trial (ISRCTN 78592017) were analyzed within one year after randomization into 3 groups (CEA, CAS, and BMT only) for implementation of prespecified BMT recommendations and lifestyle modifications. Measurement time points were the screening visit and visits after one month (D30), 6 months (M6), and one year (A1). Differences between groups and follow-up visits (FUVs) relative to the screening visit were investigated. Findings For all FUVs, a significant increase in statin medication (91% at A1; p < 0.0001) was demonstrated to be associated with a significant decrease (p < 0.01) in cholesterol levels (median 167 mg/dl at A1) and LDL cholesterol levels (median 93 mg/dl at A1). The lowest cholesterol levels were achieved by patients in the BMT group. Seventy-eight percent of all patients reached predefined target cholesterol levels (< 200 mg/dl), with significantly better rates in the BMT group (p = 0.036 at D30). Furthermore, a significant decrease in arterial blood pressure at all FUVs (p < 0.05) was associated with a significant increase in antihypertensive medication (96% at A1, p < 0.0001). However, only 28% of patients achieved the predefined treatment goal of a systolic blood pressure of ≤ 130 mmHg. Forty-two of a total of 100 smokers at the screening visit quit smoking within one year, resulting in a significant increase in nonsmokers at all FUVs (p < 0.0001). Recommended HbA1c levels (< 7%) were achieved in 82% without significant changes after one year. Only 7% of obese (BMI > 25) patients achieved sufficient weight reduction after one year without significant changes at all FUVs (median BMI 27 at A1; p = 0.1201). The BMT group showed significantly (p = 0.024) higher rates of adequate physical activity than the intervention groups. Furthermore, after one year, the BMT group showed a comparatively significantly better implementation of risk factor modification (77%; p = 0.027) according to the treating physician. Interpretation SPACE-2 demonstrated sustained improvement in the noninterventional management of vascular risk factors in patients treated in a clinical trial by general practitioners, internists and neurologists. The best implemented treatment targets were a reduction in cholesterol and HbA1c levels. In this context, a significant increase in statin use was demonstrated. Blood pressure control missed its target but was significantly reduced by intensification of antihypertensive medication. Patients on BMT only had better adjusted lipid parameters and were more physically active. However, all groups failed to achieve sufficient weight reduction. Due to insufficient patient recruitment, the results must be interpreted cautiously. Trial registration: ISRCTN Registry, ISRCTN78592017, Registered 16 June 2007, https://www.isrctn.com/search?q=78592017. Supplementary Information The online version contains supplementary material available at 10.1186/s42466-021-00153-w.
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Affiliation(s)
- Tilman Reiff
- Department of Neurology, University Hospital of Heidelberg, Im Neuenheimer Feld 400, 69120, Heidelberg, Germany.
| | - Hans-Henning Eckstein
- Department for Vascular and Endovascular Surgery, Klinikum Rechts Der Isar, Technical University of Munich, Munich, Germany
| | - Ulrich Mansmann
- Institute of Medical Informatics, Biometry and Epidemiology, Ludwig-Maximilians-Universität München, Munich, Germany
| | - Olav Jansen
- Department of Radiology and Neuroradiology, UKSH Campus Kiel, Kiel, Germany
| | - Gustav Fraedrich
- Department of Vascular Surgery, University Hospital of Innsbruck, Innsbruck, Austria
| | - Harald Mudra
- Department of Cardiology, Klinikum Neuperlach, München KlinikMunich, Germany
| | - Werner Hacke
- Department of Neurology, University Hospital of Heidelberg, Im Neuenheimer Feld 400, 69120, Heidelberg, Germany
| | - Peter Arthur Ringleb
- Department of Neurology, University Hospital of Heidelberg, Im Neuenheimer Feld 400, 69120, Heidelberg, Germany
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So KL, Kashyap VS, Schneider PA, Rathore R, Pham T, Motaganahalli RL, Massop DW, Foteh MI, Eckstein HH, Jim J. Outcomes in 1-year Cohort After Transcarotid Artery Revascularization in the ROADSTER2 Trial. J Vasc Surg 2021. [DOI: 10.1016/j.jvs.2021.07.161] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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Karlas A, Kallmayer M, Bariotakis M, Fasoula NA, Liapis E, Hyafil F, Pelisek J, Wildgruber M, Eckstein HH, Ntziachristos V. Multispectral optoacoustic tomography of lipid and hemoglobin contrast in human carotid atherosclerosis. Photoacoustics 2021; 23:100283. [PMID: 34381689 PMCID: PMC8340302 DOI: 10.1016/j.pacs.2021.100283] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/24/2020] [Revised: 07/07/2021] [Accepted: 07/08/2021] [Indexed: 05/09/2023]
Abstract
Several imaging techniques aim at identifying features of carotid plaque instability but come with limitations, such as the use of contrast agents, long examination times and poor portability. Multispectral optoacoustic tomography (MSOT) employs light and sound to resolve lipid and hemoglobin content, both features associated with plaque instability, in a label-free, fast and highly portable way. Herein, 5 patients with carotid atherosclerosis, 5 healthy volunteers and 2 excised plaques, were scanned with handheld MSOT. Spectral unmixing allowed visualization of lipid and hemoglobin content within three ROIs: whole arterial cross-section, plaque and arterial lumen. Calculation of the fat-blood-ratio (FBR) value within the ROIs enabled the differentiation between patients and healthy volunteers (P = 0.001) and between plaque and lumen in patients (P = 0.04). Our results introduce MSOT as a tool for molecular imaging of human carotid atherosclerosis and open new possibilities for research and clinical assessment of carotid plaques.
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Affiliation(s)
- Angelos Karlas
- Chair of Biological Imaging, Central Institute for Translational Cancer Research (TranslaTUM), Technical University of Munich, Munich, Germany
- Helmholtz Zentrum München, Institute of Biological and Medical Imaging, Neuherberg, Germany
- Clinic for Vascular and Endovascular Surgery, Technical University of Munich, Klinikum rechts der Isar, Munich, Germany
- DZHK (German Centre for Cardiovascular Research), Partner Site Munich Heart Alliance, Munich, Germany
| | - Michael Kallmayer
- Clinic for Vascular and Endovascular Surgery, Technical University of Munich, Klinikum rechts der Isar, Munich, Germany
| | - Michael Bariotakis
- Chair of Biological Imaging, Central Institute for Translational Cancer Research (TranslaTUM), Technical University of Munich, Munich, Germany
- Helmholtz Zentrum München, Institute of Biological and Medical Imaging, Neuherberg, Germany
| | - Nikolina-Alexia Fasoula
- Chair of Biological Imaging, Central Institute for Translational Cancer Research (TranslaTUM), Technical University of Munich, Munich, Germany
- Helmholtz Zentrum München, Institute of Biological and Medical Imaging, Neuherberg, Germany
| | - Evangelos Liapis
- Chair of Biological Imaging, Central Institute for Translational Cancer Research (TranslaTUM), Technical University of Munich, Munich, Germany
- Helmholtz Zentrum München, Institute of Biological and Medical Imaging, Neuherberg, Germany
| | - Fabien Hyafil
- INSERM U1148, Laboratory for Vascular Translational Science (LVTS), DHU FIRE, University de Paris, Paris, France
- Department of Nuclear Medicine, Bichat University Hospital, Assistance-Publique-Hôpitaux de Paris, Paris, France
| | - Jaroslav Pelisek
- Clinic for Vascular and Endovascular Surgery, Technical University of Munich, Klinikum rechts der Isar, Munich, Germany
- Department of Vascular Surgery, University Hospital Zurich, Zurich, Switzerland
| | - Moritz Wildgruber
- Department of Radiology, University Hospital, LMU Munich, Munich, Germany
| | - Hans-Henning Eckstein
- Clinic for Vascular and Endovascular Surgery, Technical University of Munich, Klinikum rechts der Isar, Munich, Germany
- DZHK (German Centre for Cardiovascular Research), Partner Site Munich Heart Alliance, Munich, Germany
| | - Vasilis Ntziachristos
- Chair of Biological Imaging, Central Institute for Translational Cancer Research (TranslaTUM), Technical University of Munich, Munich, Germany
- Helmholtz Zentrum München, Institute of Biological and Medical Imaging, Neuherberg, Germany
- DZHK (German Centre for Cardiovascular Research), Partner Site Munich Heart Alliance, Munich, Germany
- Corresponding author at: Chair of Biological Imaging, Central Institute for Translational Cancer Research (TranslaTUM), Technical University of Munich, Munich, Germany.
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Knappich C, Lang T, Tsantilas P, Schmid S, Kallmayer M, Haller B, Eckstein HH. Intraoperative completion studies in carotid endarterectomy: systematic review and meta-analysis of techniques and outcomes. Ann Transl Med 2021; 9:1201. [PMID: 34430642 PMCID: PMC8350645 DOI: 10.21037/atm-20-2931] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/28/2020] [Accepted: 10/16/2020] [Indexed: 11/18/2022]
Abstract
Background Declining perioperative stroke and death rates over the past 3 decades have been paralleled by an increasing use of intraoperative completion studies (ICS) following carotid endarterectomy (CEA). Techniques applied include angiography, intraoperative duplex ultrasound (IDUS), flowmetry, and angioscopy. This systematic review and meta-analysis is aiming on providing an overview of techniques and corresponding outcomes. Methods A PubMed based systematic literature review comprising the years 1980 through 2020 was performed using predefined keywords to identify articles on different ICS techniques. Pooled analyses and meta-analyses estimating risk ratios (RR) and 95% confidence intervals (CI) were performed to compare outcomes of different ICS modes to nonapplication of any ICS. I2 values were assessed to quantify study heterogeneities. Results Identification of 34 studies including patients undergoing CEA with angiography (n=53,218), IDUS (n=20,030), flowmetry (n=16,812), and angioscopy (n=2,291). Corresponding rates of perioperative stroke were 1.5%, 1.8%, 3.6%, and 1.5%, perioperative stroke or death occurred in 1.7%, 1.9%, 2.2%, and 2.0%. Intraoperative surgical revision rates were 6.2%, 5.9%, and 7.9% after CEA with angiography, IDUS, and angioscopy, respectively. Compared to nonapplication of any ICS, the pooled analysis revealed angiography to be significantly associated with lower rates of stroke (RR 0.47; 95% CI, 0.36–0.62; P<0.0001) and stroke or death (RR 0.76; 95% CI, 0.70–0.83; P<0.0001). IDUS was significantly associated with lower rates of stroke (RR 0.56; 95% CI, 0.43–0.73; P<0.0001) and stroke or death (RR 0.83; 95% CI, 0.74–0.93; P=0.0018), whereas angioscopy showed a significant association with a lower stroke rate (RR 0.48; 95% CI, 0.033–0.68; P=0.0001), but no effect on the combined stroke or death rate. Angioscopy was associated with a higher intraoperative revision rate compared to angiography (RR 1.29; 95% CI, 1.07–1.54; P=0.006). The meta-analyses confirmed lower perioperative stroke or death rates for angiography (RR 0.83; 95% CI, 0.76–0.91) and IDUS (RR 0.86; 95% CI, 0.76–0.98) compared to non-application of any ICS, whereas flowmetry showed no significant association. Conclusions This study represents the first systematic literature review and meta-analysis on usage of ICSs in CEA. Data strongly indicate a significant beneficial effect of angiography, IDUS, and angioscopy on perioperative CEA outcomes. Any carotid surgeon should consider implementation of ICSs in his routine armamentarium.
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Affiliation(s)
- Christoph Knappich
- Department for Vascular and Endovascular Surgery, Klinikum rechts der Isar, Technical University of Munich, Munich, Germany
| | - Thomas Lang
- Department for Vascular and Endovascular Surgery, Klinikum rechts der Isar, Technical University of Munich, Munich, Germany
| | - Pavlos Tsantilas
- Department for Vascular and Endovascular Surgery, Klinikum rechts der Isar, Technical University of Munich, Munich, Germany
| | - Sofie Schmid
- Department for Vascular and Endovascular Surgery, Klinikum rechts der Isar, Technical University of Munich, Munich, Germany
| | - Michael Kallmayer
- Department for Vascular and Endovascular Surgery, Klinikum rechts der Isar, Technical University of Munich, Munich, Germany
| | - Bernhard Haller
- Institute of Medical Informatics, Statistics and Epidemiology, Klinikum rechts der Isar, Technical University of Munich, Munich, Germany
| | - Hans-Henning Eckstein
- Department for Vascular and Endovascular Surgery, Klinikum rechts der Isar, Technical University of Munich, Munich, Germany
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Bonati LH, Kakkos S, Berkefeld J, de Borst GJ, Bulbulia R, Halliday A, van Herzeele I, Koncar I, McCabe DJ, Lal A, Ricco JB, Ringleb P, Taylor-Rowan M, Eckstein HH. European Stroke Organisation guideline on endarterectomy and stenting for carotid artery stenosis. Eur Stroke J 2021; 6:I. [PMID: 34414303 DOI: 10.1177/23969873211026990] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2021] [Accepted: 04/05/2021] [Indexed: 11/16/2022] Open
Abstract
Atherosclerotic stenosis of the internal carotid artery is an important cause of stroke. The aim of this guideline is to analyse the evidence pertaining to medical, surgical and endovascular treatment of patients with carotid stenosis. These guidelines were developed based on the ESO standard operating procedure and followed the Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) approach. The working group identified relevant questions, performed systematic reviews and meta-analyses of the literature, assessed the quality of the available evidence, and wrote recommendations. Based on moderate quality evidence, we recommend carotid endarterectomy (CEA) in patients with ≥60-99% asymptomatic carotid stenosis considered to be at increased risk of stroke on best medical treatment (BMT) alone. We also recommend CEA for patients with ≥70-99% symptomatic stenosis, and we suggest CEA for patients with 50-69% symptomatic stenosis. Based on high quality evidence, we recommend CEA should be performed early, ideally within two weeks of the last retinal or cerebral ischaemic event in patients with ≥50-99% symptomatic stenosis. Based on low quality evidence, carotid artery stenting (CAS) may be considered in patients < 70 years old with symptomatic ≥50-99% carotid stenosis. Several randomised trials supporting these recommendations were started decades ago, and BMT, CEA and CAS have evolved since. The results of another large trial comparing outcomes after CAS versus CEA in patients with asymptomatic stenosis are anticipated in the near future. Further trials are needed to reassess the benefits of carotid revascularisation in combination with modern BMT in subgroups of patients with carotid stenosis.
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Affiliation(s)
- Leo H Bonati
- Department of Neurology, University Hospital Basel, Basel, Switzerland; Department of Clinical Research, University of Basel, Basel, Switzerland
| | - Stavros Kakkos
- Department of Vascular Surgery, University of Patras Medical School, Patras, Greece
| | - Joachim Berkefeld
- Institute of Neuroradiology, University Hospital of Frankfurt am Main, Frankfurt, Germany
| | - Gert J de Borst
- Department of Vascular Surgery, University Medical Center Utrecht, Utrecht, the Netherlands
| | - Richard Bulbulia
- Medical Research Council Population Health Research Unit, Clinical Trial Service Unit and Epidemiological Studies Unit, Nuffield Department of Population Health, University of Oxford, Oxford, UK
| | - Alison Halliday
- Medical Research Council Population Health Research Unit, Clinical Trial Service Unit and Epidemiological Studies Unit, Nuffield Department of Population Health, University of Oxford, Oxford, UK
| | - Isabelle van Herzeele
- Department of Thoracic and Vascular Surgery, Ghent University Hospital, Ghent, Belgium
| | - Igor Koncar
- Clinic for Vascular and Endovascular Surgery, Serbian Clinical Centre, Belgrade, Serbia
| | - Dominick Jh McCabe
- Department of Neurology and Stroke Service, The Adelaide and Meath Hospital, Dublin, incorporating the National Children's Hospital - Tallaght University Hospital, Dublin, Ireland; Royal Free Campus, UCL Queen Square Institute of Neurology, London, UK; Academic Unit of Neurology, School of Medicine, Trinity College Dublin, Ireland
| | - Avtar Lal
- European Stroke Organisation, Basel, Switzerland
| | - Jean-Baptiste Ricco
- Department of Vascular Surgery and Department of Clinical Research, University of Poitiers, Poitiers, France
| | - Peter Ringleb
- Department of Neurology, University Hospital Heidelberg, Heidelberg, Germany
| | | | - Hans-Henning Eckstein
- Department for Vascular and Endovascular Surgery, University Hospital, Technical University of Munich (TUM), Munich, Germany
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Bonati LH, Kakkos S, Berkefeld J, de Borst GJ, Bulbulia R, Halliday A, van Herzeele I, Koncar I, McCabe DJ, Lal A, Ricco JB, Ringleb P, Taylor-Rowan M, Eckstein HH. European Stroke Organisation guideline on endarterectomy and stenting for carotid artery stenosis. Eur Stroke J 2021; 6:I-XLVII. [PMID: 34414302 DOI: 10.1177/23969873211012121] [Citation(s) in RCA: 113] [Impact Index Per Article: 37.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2021] [Accepted: 04/05/2021] [Indexed: 01/01/2023] Open
Abstract
Atherosclerotic stenosis of the internal carotid artery is an important cause of stroke. The aim of this guideline is to analyse the evidence pertaining to medical, surgical and endovascular treatment of patients with carotid stenosis. These guidelines were developed based on the ESO standard operating procedure and followed the Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) approach. The working group identified relevant questions, performed systematic reviews and meta-analyses of the literature, assessed the quality of the available evidence, and wrote recommendations. Based on moderate quality evidence, we recommend carotid endarterectomy (CEA) in patients with ≥60-99% asymptomatic carotid stenosis considered to be at increased risk of stroke on best medical treatment (BMT) alone. We also recommend CEA for patients with ≥70-99% symptomatic stenosis, and we suggest CEA for patients with 50-69% symptomatic stenosis. Based on high quality evidence, we recommend CEA should be performed early, ideally within two weeks of the last retinal or cerebral ischaemic event in patients with ≥50-99% symptomatic stenosis. Based on low quality evidence, carotid artery stenting (CAS) may be considered in patients < 70 years old with symptomatic ≥50-99% carotid stenosis. Several randomised trials supporting these recommendations were started decades ago, and BMT, CEA and CAS have evolved since. The results of another large trial comparing outcomes after CAS versus CEA in patients with asymptomatic stenosis are anticipated in the near future. Further trials are needed to reassess the benefits of carotid revascularisation in combination with modern BMT in subgroups of patients with carotid stenosis.
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Affiliation(s)
- Leo H Bonati
- Department of Neurology, University Hospital Basel, Basel, Switzerland; Department of Clinical Research, University of Basel, Basel, Switzerland
| | - Stavros Kakkos
- Department of Vascular Surgery, University of Patras Medical School, Patras, Greece
| | - Joachim Berkefeld
- Institute of Neuroradiology, University Hospital of Frankfurt am Main, Frankfurt, Germany
| | - Gert J de Borst
- Department of Vascular Surgery, University Medical Center Utrecht, Utrecht, the Netherlands
| | - Richard Bulbulia
- Medical Research Council Population Health Research Unit, Clinical Trial Service Unit and Epidemiological Studies Unit, Nuffield Department of Population Health, University of Oxford, Oxford, UK
| | - Alison Halliday
- Medical Research Council Population Health Research Unit, Clinical Trial Service Unit and Epidemiological Studies Unit, Nuffield Department of Population Health, University of Oxford, Oxford, UK
| | - Isabelle van Herzeele
- Department of Thoracic and Vascular Surgery, Ghent University Hospital, Ghent, Belgium
| | - Igor Koncar
- Clinic for Vascular and Endovascular Surgery, Serbian Clinical Centre, Belgrade, Serbia
| | - Dominick Jh McCabe
- Department of Neurology and Stroke Service, The Adelaide and Meath Hospital, Dublin, incorporating the National Children's Hospital - Tallaght University Hospital, Dublin, Ireland; Royal Free Campus, UCL Queen Square Institute of Neurology, London, UK; Academic Unit of Neurology, School of Medicine, Trinity College Dublin, Ireland
| | - Avtar Lal
- European Stroke Organisation, Basel, Switzerland
| | - Jean-Baptiste Ricco
- Department of Vascular Surgery and Department of Clinical Research, University of Poitiers, Poitiers, France
| | - Peter Ringleb
- Department of Neurology, University Hospital Heidelberg, Heidelberg, Germany
| | | | - Hans-Henning Eckstein
- Department for Vascular and Endovascular Surgery, University Hospital, Technical University of Munich (TUM), Munich, Germany
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70
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Busch A, Pauli J, Winski G, Bleichert S, Chernogubova E, Metschl S, Winter H, Trenner M, Wiegering A, Otto C, Fischer J, Reiser J, Werner J, Roy J, Brostjan C, Knappich C, Eckstein HH, Paloschi V, Maegdefessel L. Lenvatinib halts aortic aneurysm growth by restoring smooth muscle cell contractility. JCI Insight 2021; 6:e140364. [PMID: 34185710 PMCID: PMC8410098 DOI: 10.1172/jci.insight.140364] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2020] [Accepted: 06/24/2021] [Indexed: 11/17/2022] Open
Abstract
Abdominal aortic aneurysm (AAA) is a disease with high morbidity and mortality, especially when ruptured. The rationale of this study was to evaluate the repurposing of lenvatinib, a multi–tyrosine kinase inhibitor, in limiting experimental AAA growth targeting vascular smooth muscle cells (VSMCs) and angiogenesis. We applied systemic and local lenvatinib treatment to elastase-induced murine aortic aneurysms, and RNA profiling identified myosin heavy chain 11 (Myh11) as the most deregulated transcript. Daily oral treatment substantially reduced aneurysm formation in 2 independent mouse models. In addition, a large animal aneurysm model in hypercholesterolemic low-density lipoprotein receptor–knockout (LDLR–/–) Yucatan minipigs was applied to endovascularly deliver lenvatinib via drug-eluting balloons (DEBs). Here, a single local endovascular delivery blocked AAA progression successfully compared with a DEB-delivered control treatment. Reduced VSMC proliferation and a restored contractile phenotype were observed in animal tissues (murine and porcine), as well as AAA patient-derived cells. Apart from increasing MYH11 levels, lenvatinib reduced downstream ERK signaling. Hence, lenvatinib is a promising therapy to limit aortic aneurysm expansion upon local endovascular delivery. The tyrosine kinase inhibitor was able to positively affect pathways of key relevance to human AAA disease, even in a potentially new local delivery using DEBs.
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Affiliation(s)
- Albert Busch
- Department for Vascular and Endovascular Surgery, Klinikum rechts der Isar, Technical University of Munich, Munich, Germany.,German Center for Cardiovascular Research (DZHK), Berlin, Germany.,Division of Vascular and Endovascular Surgery, Department of Visceral, Thoracic and Vascular Surgery, Medical Faculty, Carl Gustav Carus and University Hospital Carl Gustav Carus Dresden, Technische Universität Dresden, Dresden, Germany
| | - Jessica Pauli
- Department for Vascular and Endovascular Surgery, Klinikum rechts der Isar, Technical University of Munich, Munich, Germany.,German Center for Cardiovascular Research (DZHK), Berlin, Germany
| | - Greg Winski
- Molecular Vascular Medicine Unit, Department of Medicine, Karolinska Institutet, Stockholm, Sweden
| | - Sonja Bleichert
- Division of Vascular Surgery, Department of General Surgery, Medical University of Vienna, Vienna General Hospital, Vienna, Austria
| | - Ekaterina Chernogubova
- Molecular Vascular Medicine Unit, Department of Medicine, Karolinska Institutet, Stockholm, Sweden
| | - Susanne Metschl
- Department for Vascular and Endovascular Surgery, Klinikum rechts der Isar, Technical University of Munich, Munich, Germany.,German Center for Cardiovascular Research (DZHK), Berlin, Germany
| | - Hanna Winter
- Department for Vascular and Endovascular Surgery, Klinikum rechts der Isar, Technical University of Munich, Munich, Germany.,German Center for Cardiovascular Research (DZHK), Berlin, Germany
| | - Matthias Trenner
- Department for Vascular and Endovascular Surgery, Klinikum rechts der Isar, Technical University of Munich, Munich, Germany
| | - Armin Wiegering
- Department of General, Visceral, Transplantation, Vascular & Pediatric Surgery (Department of Surgery I), University Hospital Würzburg, Würzburg, Germany
| | - Christoph Otto
- Department of General, Visceral, Transplantation, Vascular & Pediatric Surgery (Department of Surgery I), University Hospital Würzburg, Würzburg, Germany
| | - Johannes Fischer
- Centre of Preclinical Research, Klinikum rechts der Isar, Technical University of Munich, Munich, Germany
| | - Judith Reiser
- Centre of Preclinical Research, Klinikum rechts der Isar, Technical University of Munich, Munich, Germany
| | - Julia Werner
- Centre of Preclinical Research, Klinikum rechts der Isar, Technical University of Munich, Munich, Germany
| | - Joy Roy
- Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden
| | - Christine Brostjan
- Division of Vascular Surgery, Department of General Surgery, Medical University of Vienna, Vienna General Hospital, Vienna, Austria
| | - Christoph Knappich
- Department for Vascular and Endovascular Surgery, Klinikum rechts der Isar, Technical University of Munich, Munich, Germany
| | - Hans-Henning Eckstein
- Department for Vascular and Endovascular Surgery, Klinikum rechts der Isar, Technical University of Munich, Munich, Germany
| | - Valentina Paloschi
- Department for Vascular and Endovascular Surgery, Klinikum rechts der Isar, Technical University of Munich, Munich, Germany.,German Center for Cardiovascular Research (DZHK), Berlin, Germany
| | - Lars Maegdefessel
- Department for Vascular and Endovascular Surgery, Klinikum rechts der Isar, Technical University of Munich, Munich, Germany.,German Center for Cardiovascular Research (DZHK), Berlin, Germany.,Molecular Vascular Medicine Unit, Department of Medicine, Karolinska Institutet, Stockholm, Sweden
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71
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Paraskevas KI, Mikhailidis DP, Baradaran H, Davies AH, Eckstein HH, Faggioli G, Fernandes E Fernandes J, Gupta A, Jezovnik MK, Kakkos SK, Katsiki N, Kooi ME, Lanza G, Liapis CD, Loftus IM, Millon A, Nicolaides AN, Poredos P, Pini R, Ricco JB, Rundek T, Saba L, Spinelli F, Stilo F, Sultan S, Zeebregts CJ, Chaturvedi S. Management of patients with asymptomatic carotid stenosis may need to be individualized: a multidisciplinary call for action. Republication of J Stroke 2021;23:202-212. INT ANGIOL 2021; 40:487-496. [PMID: 34313413 DOI: 10.23736/s0392-9590.21.04751-9] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
The optimal management of patients with asymptomatic carotid stenosis (ACS) is the subject of extensive debate. According to the 2017 European Society for Vascular Surgery guidelines, carotid endarterectomy should (Class IIa; Level of Evidence: B) or carotid artery stenting may be considered (Class IIb; Level of Evidence: B) in the presence of one or more clinical/imaging characteristics that may be associated with an increased risk of late ipsilateral stroke (e.g. silent embolic infarcts on brain computed tomography/magnetic resonance imaging, progression in the severity of ACS, a history of contralateral transient ischemic attack/stroke, microemboli detection on transcranial Doppler, etc.), provided documented perioperative stroke/death rates are <3% and the patient's life expectancy is >5 years. Besides these clinical/imaging characteristics, there are additional individual, ethnic/racial or social factors that should probably be evaluated in the decision process regarding the optimal management of these patients, such as individual patient needs/patient choice, patient compliance with best medical treatment, patient sex, culture, race/ethnicity, age and comorbidities, as well as improvements in imaging/operative techniques/outcomes. The present multispecialty position paper will present the rationale why the management of patients with ACS may need to be individualized.
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Affiliation(s)
| | - Dimitri P Mikhailidis
- Department of Clinical Biochemistry, Royal Free Hospital Campus, University College London Medical School, University College London (UCL), London, UK
| | - Hediyeh Baradaran
- Department of Radiology, University of Utah, Salt Lake City, UT, USA
| | - Alun H Davies
- Section of Vascular Surgery, Imperial College & Imperial Healthcare NHS Trust, London, UK
| | - Hans-Henning Eckstein
- Department of Vascular and Endovascular Surgery, Klinikum rechts der Isar, Technical University of Munich, Munich, Germany
| | - Gianluca Faggioli
- Vascular Surgery, University of Bologna Alma Mater Studiorum, Policlinico S. Orsola Malpighi, Bologna, Italy
| | | | - Ajay Gupta
- Department of Radiology, Weill Cornell Medicine, New York, NY, USA
| | - Mateja K Jezovnik
- Department of Advanced Cardiopulmonary Therapies and Transplantation, The University of Texas Health Science Centre at Houston, Houston, TX, USA
| | - Stavros K Kakkos
- Department of Vascular Surgery, University of Patras Medical School, Patras, Greece
| | - Niki Katsiki
- First Department of Internal Medicine, AHEPA University Hospital, Thessaloniki, Greece
| | - M Eline Kooi
- CARIM School for Cardiovascular Diseases, Maastricht University, Maastricht, The Netherlands.,Department of Radiology and Nuclear Medicine, Maastricht University Medical Center, Maastricht, The Netherlands
| | - Gaetano Lanza
- Vascular Surgery Department, IRCSS MultiMedica Hospital, Castellanza, Varese, Italy
| | | | - Ian M Loftus
- St. George's Vascular Institute, St. George's University London, London, UK
| | - Antoine Millon
- Department of Vascular and Endovascular Surgery, Louis Pradel Hospital, Hospices Civils de Lyon, Lyon, France
| | - Andrew N Nicolaides
- Department of Surgery, University of Nicosia Medical School, Nicosia, Cyprus
| | - Pavel Poredos
- Department of Vascular Disease, University Medical Centre Ljubljana, Ljubljana, Slovenia
| | - Rodolfo Pini
- Vascular Surgery, University of Bologna Alma Mater Studiorum, Policlinico S. Orsola Malpighi, Bologna, Italy
| | - Jean-Baptiste Ricco
- Department of Clinical Research, University of Poitiers, CHU de Poitiers, Poitiers, France
| | - Tatjana Rundek
- Department of Neurology, Miller School of Medicine, University of Miami, Miami, FL, USA
| | - Luca Saba
- Department of Radiology, Azienda Ospedaliera Universitaria di Cagliari, Cagliari, Italy
| | - Francesco Spinelli
- Vascular Surgery Division, Campus Bio-Medico University of Rome, Rome, Italy
| | - Francesco Stilo
- Vascular Surgery Division, Campus Bio-Medico University of Rome, Rome, Italy
| | - Sherif Sultan
- Western Vascular Institute, Department of Vascular and Endovascular Surgery, University Hospital Galway, National University of Ireland, Galway, Ireland
| | - Clark J Zeebregts
- Division of Vascular Surgery, Department of Surgery, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Seemant Chaturvedi
- Department of Neurology & Stroke Program, University of Maryland School of Medicine, Baltimore, MD, USA
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72
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Reiff T, Eckstein HH, Mansmann U, Jansen O, Fraedrich G, Mudra H, Böckler D, Böhm M, Brückmann H, Debus ES, Fiehler J, Mathias K, Ringelstein EB, Schmidli J, Stingele R, Zahn R, Zeller T, Niesen WD, Barlinn K, Binder A, Glahn J, Ringleb PA. Contralateral Stenosis and Echolucent Plaque Morphology are Associated with Elevated Stroke Risk in Patients Treated with Asymptomatic Carotid Artery Stenosis within a Controlled Clinical Trial (SPACE-2). J Stroke Cerebrovasc Dis 2021; 30:105940. [PMID: 34311420 DOI: 10.1016/j.jstrokecerebrovasdis.2021.105940] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2021] [Revised: 05/30/2021] [Accepted: 06/01/2021] [Indexed: 10/20/2022] Open
Abstract
BACKGROUND Asymptomatic carotid artery stenosis (ACS) has a low risk of stroke. To achieve an advantage over noninterventional best medical treatment (BMT), carotid endarterectomy (CEA) or carotid artery stenting (CAS) must be performed with the lowest possible risk of stroke. Therefore, an analysis of risk-elevating factors is essential. Grade of ipsilateral and contralateral stenosis as well as plaque morphology are known risk factors in ACS. METHODS The randomized, controlled, multicenter SPACE-2 trial had to be stopped prematurely after recruiting 513 patients. 203 patients were randomized to CEA, 197 to CAS, and 113 to BMT. Within one year, risk factors such as grade of stenosis and plaque morphology were analyzed. RESULTS Grade of contralateral stenosis (GCS) was higher in patients with any stroke (50%ECST vs. 20%ECST; p=0.012). Echolucent plaque morphology was associated with any stroke on the day of intervention (OR 5.23; p=0.041). In the periprocedural period, any stroke was correlated with GCS in the CEA group (70%ECST vs. 20%ECST; p=0.026) and with echolucent plaque morphology in the CAS group (6% vs. 1%; p=0.048). In multivariate analysis, occlusion of the contralateral carotid artery (CCO) was associated with risk of any stroke (OR 7.00; p=0.006), without heterogeneity between CEA and CAS. CONCLUSION In patients with asymptomatic carotid artery stenosis, GCS, CCO, as well as echolucent plaque morphology were associated with a higher risk of cerebrovascular events. The risk of stroke in the periprocedural period was increased by GCS in CEA and by echolucent plaque in CAS. Due to small sample size, results must be interpreted carefully.
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Affiliation(s)
- Tilman Reiff
- Department of Neurology, University Hospital of Heidelberg, Heidelberg, Germany.
| | - Hans-Henning Eckstein
- Department for Vascular and Endovascular Surgery, Klinikum rechts der Isar, Technical University of Munich, Munich, Germany.
| | - Ulrich Mansmann
- Institute of Medical Informatics, Biometry and Epidemiology, Ludwig-Maximilians-Universität München, Munich, Germany.
| | - Olav Jansen
- Department of Radiology and Neuroradiology, UKSH Campus Kiel, Kiel, Germany.
| | - Gustav Fraedrich
- Department of Vascular Surgery, University Hospital of Innsbruck, Innsbruck, Austria.
| | - Harald Mudra
- Department of Cardiology, München Klinik, Klinikum Neuperlach, Munich, Germany.
| | - Dittmar Böckler
- Department of Vascular and Endovascular Surgery, University Hospital of Heidelberg, Heidelberg, Germany.
| | - Michael Böhm
- Department of Internal Medicine, University Hospital of Homburg/Saar, Homburg, Germany.
| | - Hartmut Brückmann
- Department of Neuroradiology, Ludwig-Maximilians-Universität München, Munich, Germany.
| | - E Sebastian Debus
- Department of Vascular Surgery, University Hospital of Hamburg, Hamburg, Germany.
| | - Jens Fiehler
- Department of Neuroradiology, University Hospital of Hamburg, Hamburg, Germany.
| | - Klaus Mathias
- Department of Radiology, Klinikum Dortmund, Germany.
| | | | - Jürg Schmidli
- Department of Vascular Surgery, University Hospital of Bern, Bern, Switzerland.
| | - Robert Stingele
- Department of Neurology, DRK-Kliniken Berlin, Berlin, Germany.
| | - Ralf Zahn
- Department of Internal Medicine, Klinikum Ludwigshafen, Ludwigshafen, Germany.
| | - Thomas Zeller
- Department of Angiology, University Heart-Center Freiburg-Bad Krozingen, Bad Krozingen, Germany.
| | - Wolf-Dirk Niesen
- Department of Neurology, University Hospital Freiburg, Freiburg, Germany.
| | - Kristian Barlinn
- Department of Neurology, University Hospital of Dresden, Dresden, Germany.
| | - Andreas Binder
- Department of Neurology, UKSH Campus Kiel, Kiel, Germany.
| | - Jörg Glahn
- Department of Neurology, Johannes Wesling Klinikum, Minden, Germany.
| | - Peter Arthur Ringleb
- Department of Neurology, University Hospital of Heidelberg, Heidelberg, Germany.
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73
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Sieber S, Stoklasa K, Reutersberg B, Stadlbauer T, Salvermoser M, Lang T, Busch A, Eckstein HH. Acute abdominal aortic occlusion-a 16-year single-center experience. J Vasc Surg 2021; 74:1894-1903.e3. [PMID: 34182035 DOI: 10.1016/j.jvs.2021.06.021] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2020] [Accepted: 06/13/2021] [Indexed: 11/26/2022]
Abstract
BACKGROUND Acute abdominal aortic occlusion (AAO) is a rare vascular emergency associated with high morbidity and mortality. In the present study, we analyzed the clinical management and outcomes for a consecutive patient series during a 16-year period. METHODS We included all patients with an acute AAO and bilateral acute limb ischemia who had been treated between 2004 and 2019. Patients with dissection, aneurysm rupture, or chronic occlusive disease were excluded. The patient characteristics, surgical procedures, and outcomes were extracted retrospectively from a prospective aortic database, electronic patient files, and outpatient examination records. The extent of ischemia was classified according to the TASC II (Inter-Society Consensus for the Management of Peripheral Arterial Disease) section on acute limb ischemia. The primary endpoints were 30-day mortality (safety endpoint) and the combined 6-month amputation and/or death rate (efficacy endpoint). The follow-up outcomes, amputation rates, and 30-day complications were evaluated as secondary endpoints. The patient cohort was divided into four 4-year groups (2004-2007, 2008-2011, 2012-2015, 2016-2019) to assess the outcome changes over time. Statistical analysis included χ2 tests and univariate and linear regression analyses. RESULTS A total of 74 patients (57% male; median age, 64.5 years) with an acute AAO were identified. Arterial thrombosis was the most common etiology (66%). The extent of ischemia was TASC I, IIa, IIb, and III in 7%, 39%, 40%, and 14%, respectively. The patient numbers had increased significantly over time (P = .016). Of the patients, 42% had undergone open transfemoral recanalization (including hybrid procedures), 35% open aortic surgery, 15% extra-anatomic bypass surgery, and 5% (four patients) endovascular therapy alone. The overall 30-day mortality rate was 23%, and the 6-month amputation and/or death rate was 43%. The 30-day mortality rate had declined significantly from 54% for 2004 to 2007 to 10% for 2011 to 2015 (odds ratio [OR], 0.10; 95% confidence interval [CI], 0.001-0.52) and 20% for 2016 to 2019 (OR, 0.21; 95% CI, 0.05-0.90), a statistically nonsignificant trend showing that the relative decline in the use of open aortic procedures was associated with decreased 30-day mortality (P = .06). Univariate analysis indicated that elevated serum lactate on admission (OR, 3.33; 95% CI, 1.06-10.48) and an advanced stage of limb ischemia (OR, 4.33), were strongly associated with an increased 30-day mortality rate. The incidence of severe postoperative systemic complications also indicated a greater incidence of both primary endpoints. The 6-month amputation and/or mortality rates were also affected by the presence of atrial fibrillation (OR, 3.63; 95% CI, 1.34-9.79) and increased patient age (OR, 3.96; 95% CI, 1.49-10.53). CONCLUSIONS Acute AAO remains a life-threatening emergency. Immediate transfemoral open or endovascular techniques should be preferred, if technically possible and proper intraoperative imaging is available.
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Affiliation(s)
- Sabine Sieber
- Department of Vascular and Endovascular Surgery and Munich Aortic Center, University Hospital rechts der Isar, Technical University Munich, Munich, Germany
| | - Kerstin Stoklasa
- Department of Vascular and Endovascular Surgery and Munich Aortic Center, University Hospital rechts der Isar, Technical University Munich, Munich, Germany; Department of Vascular Surgery, University Hospital Zürich, Zürich, Switzerland
| | | | - Thomas Stadlbauer
- Department of Vascular Surgery, University Hospital Zürich, Zürich, Switzerland
| | - Michael Salvermoser
- Department of Vascular and Endovascular Surgery and Munich Aortic Center, University Hospital rechts der Isar, Technical University Munich, Munich, Germany
| | - Thomas Lang
- Department of Vascular and Endovascular Surgery and Munich Aortic Center, University Hospital rechts der Isar, Technical University Munich, Munich, Germany
| | - Albert Busch
- Department of Vascular and Endovascular Surgery and Munich Aortic Center, University Hospital rechts der Isar, Technical University Munich, Munich, Germany; Division of Vascular and Endovascular Surgery, Department of Visceral, Thoracic, and Vascular Surgery, Medical Faculty Carl Gustav Carus and University Hospital, Technical University Dresden, Dresden, Germany
| | - Hans-Henning Eckstein
- Department of Vascular and Endovascular Surgery and Munich Aortic Center, University Hospital rechts der Isar, Technical University Munich, Munich, Germany.
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74
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Schmitzer L, Sollmann N, Kufer J, Kallmayer M, Eckstein HH, Zimmer C, Preibisch C, Kaczmarz S, Göttler J. Decreasing Spatial Variability of Individual Watershed Areas by Revascularization Therapy in Patients With High-Grade Carotid Artery Stenosis. J Magn Reson Imaging 2021; 54:1878-1889. [PMID: 34145686 DOI: 10.1002/jmri.27788] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2021] [Revised: 06/03/2021] [Accepted: 06/04/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Carotid artery stenosis can impair cerebral hemodynamics especially within watershed areas (WSAs) between vascular territories. WSAs can shift because of collateral flow, which may be an indicator for increased hemodynamic implications and hence higher risk for ischemic stroke. However, whether revascularization treatment can reverse the spatial displacement of individual WSAs (iWSAs) and impaired hemodynamics remains unknown. HYPOTHESIS That iWSAs spatially normalize because of hemodynamic improvement resulting from revascularization treatment. STUDY TYPE Prospective. POPULATION Sixteen patients with unilateral, high-grade carotid artery stenosis confirmed by duplex ultrasonography and 17 healthy controls. FIELD STRENGTH/SEQUENCES A 3 T-magnetization-prepared rapid acquisition gradient echo (MPRAGE), gradient-echo echo planar dynamic susceptibility contrast (DSC), and fluid-attenuated inversion recovery (FLAIR) sequences. Additionally, contrast-enhanced 3D gradient echo magnetic resonance angiography (MRA) and diffusion-tensor imaging (DTI) spin-echo echo planar imaging were performed. ASSESSMENT iWSAs were delineated by a recently proposed procedure based on time-to-peak maps from DSC perfusion MRI, which were also used to evaluate perfusion delay. We spatially compared iWSAs and perfusion delay before and after treatment (endarterectomy or stenting). Additionally, the Circle of Willis collateralization status was evaluated, and basic cognitive testing was conducted. STATISTICAL TESTS Statistical tests included two-sample t-tests and Chi-squared tests. A P value < 0.05 was considered to be statistically significant. RESULTS After revascularization, patients showed a significant spatial shift of iWSAs and significantly reduced perfusion delay ipsilateral to the stenosis. Spatial shift of iWSA (P = 0.007) and cognitive improvement (P = 0.013) were more pronounced in patients with poor pre-existing collateralization. Controls demonstrated stable spatial extent of iWSAs (P = 0.437) and symmetric perfusion delays between hemispheres over time (P = 0.773). DATA CONCLUSION These results demonstrate the normalization of iWSA and impaired hemodynamics after revascularization in patients with high-grade carotid artery stenosis. LEVEL OF EVIDENCE 2 TECHNICAL EFFICACY: Stage 2.
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Affiliation(s)
- Lena Schmitzer
- Department of Diagnostic and Interventional Neuroradiology, School of Medicine, Technical University of Munich (TUM), Germany.,TUM-Neuroimaging Center, School of Medicine, Technical University of Munich (TUM), Germany
| | - Nico Sollmann
- Department of Diagnostic and Interventional Neuroradiology, School of Medicine, Technical University of Munich (TUM), Germany.,TUM-Neuroimaging Center, School of Medicine, Technical University of Munich (TUM), Germany.,Department of Diagnostic and Interventional Radiology, University Hospital Ulm, Ulm, Germany
| | - Jan Kufer
- Department of Diagnostic and Interventional Neuroradiology, School of Medicine, Technical University of Munich (TUM), Germany.,TUM-Neuroimaging Center, School of Medicine, Technical University of Munich (TUM), Germany
| | - Michael Kallmayer
- Department for Vascular and Endovascular Surgery, School of Medicine, Technical University of Munich (TUM), Germany
| | - Hans-Henning Eckstein
- Department for Vascular and Endovascular Surgery, School of Medicine, Technical University of Munich (TUM), Germany
| | - Claus Zimmer
- Department of Diagnostic and Interventional Neuroradiology, School of Medicine, Technical University of Munich (TUM), Germany.,TUM-Neuroimaging Center, School of Medicine, Technical University of Munich (TUM), Germany
| | - Christine Preibisch
- Department of Diagnostic and Interventional Neuroradiology, School of Medicine, Technical University of Munich (TUM), Germany.,TUM-Neuroimaging Center, School of Medicine, Technical University of Munich (TUM), Germany.,Department of Neurology, School of Medicine, Technical University of Munich (TUM), Germany
| | - Stephan Kaczmarz
- Department of Diagnostic and Interventional Neuroradiology, School of Medicine, Technical University of Munich (TUM), Germany.,TUM-Neuroimaging Center, School of Medicine, Technical University of Munich (TUM), Germany
| | - Jens Göttler
- Department of Diagnostic and Interventional Neuroradiology, School of Medicine, Technical University of Munich (TUM), Germany.,TUM-Neuroimaging Center, School of Medicine, Technical University of Munich (TUM), Germany
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Paraskevas KI, Mikhailidis DP, Baradaran H, Davies AH, Eckstein HH, Faggioli G, Fernandes JFE, Gupta A, Jezovnik MK, Kakkos SK, Katsiki N, Kooi ME, Lanza G, Liapis CD, Loftus IM, Millon A, Nicolaides AN, Poredos P, Pini R, Ricco JB, Rundek T, Saba L, Spinelli F, Stilo F, Sultan S, Zeebregts CJ, Chaturvedi S. Management of Patients with Asymptomatic Carotid Stenosis May Need to Be Individualized: A Multidisciplinary Call for Action. J Stroke 2021; 23:202-212. [PMID: 34102755 PMCID: PMC8189852 DOI: 10.5853/jos.2020.04273] [Citation(s) in RCA: 20] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2020] [Accepted: 04/12/2021] [Indexed: 12/15/2022] Open
Abstract
The optimal management of patients with asymptomatic carotid stenosis (ACS) is the subject of extensive debate. According to the 2017 European Society for Vascular Surgery guidelines, carotid endarterectomy should (Class IIa; Level of Evidence: B) or carotid artery stenting may be considered (Class IIb; Level of Evidence: B) in the presence of one or more clinical/imaging characteristics that may be associated with an increased risk of late ipsilateral stroke (e.g., silent embolic infarcts on brain computed tomography/magnetic resonance imaging, progression in the severity of ACS, a history of contralateral transient ischemic attack/stroke, microemboli detection on transcranial Doppler, etc.), provided documented perioperative stroke/death rates are <3% and the patient’s life expectancy is >5 years. Besides these clinical/imaging characteristics, there are additional individual, ethnic/racial or social factors that should probably be evaluated in the decision process regarding the optimal management of these patients, such as individual patient needs/patient choice, patient compliance with best medical treatment, patient sex, culture, race/ethnicity, age and comorbidities, as well as improvements in imaging/operative techniques/outcomes. The present multispecialty position paper will present the rationale why the management of patients with ACS may need to be individualized.
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Affiliation(s)
| | - Dimitri P Mikhailidis
- Department of Clinical Biochemistry, Royal Free Hospital Campus, University College London Medical School, University College London (UCL), London, UK
| | - Hediyeh Baradaran
- Department of Radiology, University of Utah, Salt Lake City, UT, USA
| | - Alun H Davies
- Section of Vascular Surgery, Imperial College & Imperial Healthcare NHS Trust, London, UK
| | - Hans-Henning Eckstein
- Department of Vascular and Endovascular Surgery, Klinikum rechts der Isar, Technical University of Munich, Munich, Germany
| | - Gianluca Faggioli
- Vascular Surgery, University of Bologna "Alma Mater Studiorum", Policlinico S. Orsola Malpighi, Bologna, Italy
| | | | - Ajay Gupta
- Department of Radiology, Weill Cornell Medicine, New York, NY, USA
| | - Mateja K Jezovnik
- Department of Advanced Cardiopulmonary Therapies and Transplantation, The University of Texas Health Science Centre at Houston, Houston, TX, USA
| | - Stavros K Kakkos
- Department of Vascular Surgery, University of Patras Medical School, Patras, Greece
| | - Niki Katsiki
- First Department of Internal Medicine, AHEPA University Hospital, Thessaloniki, Greece
| | - M Eline Kooi
- CARIM School for Cardiovascular Diseases, Maastricht University, Maastricht, The Netherlands.,Department of Radiology and Nuclear Medicine, Maastricht University Medical Center, Maastricht, The Netherlands
| | - Gaetano Lanza
- Vascular Surgery Department, IRCSS MultiMedica Hospital, Castellanza, Italy
| | | | - Ian M Loftus
- St. George's Vascular Institute, St. George's University London, London, UK
| | - Antoine Millon
- Department of Vascular and Endovascular Surgery, Louis Pradel Hospital, Hospices Civils de Lyon, France
| | - Andrew N Nicolaides
- Department of Surgery, University of Nicosia Medical School, Nicosia, Cyprus
| | - Pavel Poredos
- Department of Vascular Disease, University Medical Centre Ljubljana, Slovenia
| | - Rodolfo Pini
- Vascular Surgery, University of Bologna "Alma Mater Studiorum", Policlinico S. Orsola Malpighi, Bologna, Italy
| | - Jean-Baptiste Ricco
- Department of Clinical Research, University of Poitiers, CHU de Poitiers, Poitiers, France
| | - Tatjana Rundek
- Department of Neurology, Miller School of Medicine, University of Miami, Miami, FL, USA
| | - Luca Saba
- Department of Radiology, Azienda Ospedaliera Universitaria Di Cagliari, Cagliari, Italy
| | - Francesco Spinelli
- Vascular Surgery Division, Campus Bio-Medico University of Rome, Rome, Italy
| | - Francesco Stilo
- Vascular Surgery Division, Campus Bio-Medico University of Rome, Rome, Italy
| | - Sherif Sultan
- Western Vascular Institute, Department of Vascular and Endovascular Surgery, University Hospital Galway, National University of Ireland, Galway, Ireland
| | - Clark J Zeebregts
- Division of Vascular Surgery, Department of Surgery, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Seemant Chaturvedi
- Department of Neurology & Stroke Program, University of Maryland School of Medicine, Baltimore, MD, USA
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76
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Huckaby LV, Sultan I, Trimarchi S, Leshnower B, Chen EP, Brinster DR, Myrmel T, Estrera AL, Montgomery DG, Korach A, Eckstein HH, Coselli JS, Ota T, Kaiser CA, Eagle KA, Patel HJ, Gleason TG. Sex-Based Aortic Dissection Outcomes From the International Registry of Acute Aortic Dissection. Ann Thorac Surg 2021; 113:498-505. [PMID: 34090668 DOI: 10.1016/j.athoracsur.2021.03.100] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/31/2020] [Revised: 02/26/2021] [Accepted: 03/22/2021] [Indexed: 11/01/2022]
Abstract
BACKGROUND Worse outcomes have been reported for women with type A acute aortic dissection (TAAD). We sought to determine sex-specific operative approaches and outcomes for TAAD in the current era. METHODS The Interventional Cohort (IVC) of the International Registry of Acute Aortic Dissection (IRAD) database was queried to explore sex differences in presentation, operative approach, and outcomes. Multivariable logistic regression was performed to identify adjusted outcomes in relation to sex. RESULTS Women constituted approximately one-third (34.3%) of the 2823 patients and were significantly older than men (65.4 vs 58.6 years, P < .001). Women were more likely to present with intramural hematoma, periaortic hematoma, or complete or partial false lumen thrombosis (all P < .05) and more commonly had hypotension or coma (P = .001). Men underwent a greater proportion of Bentall, complete arch, and elephant trunk procedures (all P < .01). In-hospital mortality during the study period was higher in women (16.7% vs 13.8%, P = .039). After adjustment, female sex trended towards higher in-hospital mortality overall (odds ratio, 1.40; P = .053) but not in the last decade of enrollment (odds ratio, 0.93; P = .807). Five-year mortality and reintervention rates were not significantly different between the sexes. CONCLUSIONS In-hospital mortality remains higher among women with TAAD but demonstrates improvement in the last decade. Significant differences in presentation were noted in women, including older age, distinct imaging findings, and greater evidence of malperfusion. Although no distinctions in 5-year mortality or reintervention were observed, a tailored surgical approach should be considered to reduce sex disparities in early mortality rates for TAAD.
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Affiliation(s)
- Lauren V Huckaby
- University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Ibrahim Sultan
- University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Santi Trimarchi
- Fondazione IRCCS, Cà Granda Ospedale Maggiore Policlinico Milan, University of Milan, Milan, Italy
| | | | - Edward P Chen
- Emory University School of Medicine, Atlanta, Georgia
| | | | - Truls Myrmel
- The Arctic University of Norway, Breivika, Norwa
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77
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Erk A, Trenner M, Salvermoser M, Reutersberg B, Schmid V, Eckstein HH, Kuehnl A. [Relationship between regional settlement structure and hospital incidence, type of therapy and mortality of non-ruptured abdominal aortic aneurysms]. Z Evid Fortbild Qual Gesundhwes 2021; 163:38-46. [PMID: 34023245 DOI: 10.1016/j.zefq.2021.02.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/08/2020] [Revised: 02/11/2021] [Accepted: 02/25/2021] [Indexed: 10/21/2022]
Abstract
INTRODUCTION In Germany, the regional settlement structure is heterogenous, ranging from densely populated cities with a tight network of vascular health care to large regions in which access to health care is limited in terms of space and time. Therefore, the aim of this secondary data analysis was to investigate the association between the settlement structure of the patient's home district (KT), and the hospital incidence, type of therapy, and mortality of non-ruptured abdominal aortic aneurysms (nrAAA). METHODS The microdata of the DRG statistics of the Federal Statistical Office for the years 2005-2014 were evaluated. All patients with nrAAA (ICD-10 Code I71.4) who were admitted to a German hospital and treated by open surgery and endovascular repair were included. Classification of treatment was based on the German Operation and Procedure Code. Patients were grouped according to the settlement structure of their home district defined by the Federal Institute for Research on Building, Urban Affairs and Spatial Development (KT1 independent city, KT2 urban district, KT3 rural district, KT4 sparsely populated region). The age-, sex- and risk-adjusted association between the type of settlement structure and in-hospital mortality was analysed using a multivariable multi-level regression model. The Elixhauser co-morbidity score validated for administrative data was used for risk adjustment. RESULTS Of 95,452 cases included, 88 % were men. Mean age was 72 years. There were 28,970 (30 %) patients in KT1, 37,759 (40 %) in KT2, 14,442 (15 %) in KT3 and 14,281 (15 %) in KT4. The hospital incidence was 12.4 per 100,000 inhabitants in KT1, 11.8 in KT2, 10.8 in KT3 and 11.2 in KT4 (p <0.001, falling trend). The proportion of EVAR treatment was 56 % in KT1, 54 % in KT2, 57 % KT3, and 59 % in KT4 (p <0.001, increasing trend). The raw hospital mortality of patients from KT1 to KT4 was 3.4 %, 3.4 %, 3.2 % and 3.6 %, respectively (p=0.553 for trend). The multivariable regression analysis revealed no statistically significant association between the KT and hospital mortality (KT1=reference, RR KT2=0.97 [95% CI 0.79-1.15], RR KT3=0.98 [0.81-1.14], RR KT4=0.98 [0.86-1.11]). CONCLUSIONS The study shows that both the hospital incidence and the type of therapy (endovascular vs. open) differed between the settlement structural district types, but there is no urban-rural gap regarding in-hospital mortality of treated nrAAA.
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Affiliation(s)
- Alexander Erk
- Klinik und Poliklinik für Vaskuläre und Endovaskuläre Chirurgie, Klinikum rechts der Isar, Technische Universität München, München, Deutschland
| | - Matthias Trenner
- Klinik und Poliklinik für Vaskuläre und Endovaskuläre Chirurgie, Klinikum rechts der Isar, Technische Universität München, München, Deutschland
| | - Michael Salvermoser
- Klinik und Poliklinik für Vaskuläre und Endovaskuläre Chirurgie, Klinikum rechts der Isar, Technische Universität München, München, Deutschland
| | - Benedikt Reutersberg
- Klinik und Poliklinik für Vaskuläre und Endovaskuläre Chirurgie, Klinikum rechts der Isar, Technische Universität München, München, Deutschland
| | - Volker Schmid
- Institut für Statistik, Ludwig-Maximilians-Universität München, München, Deutschland
| | - Hans-Henning Eckstein
- Klinik und Poliklinik für Vaskuläre und Endovaskuläre Chirurgie, Klinikum rechts der Isar, Technische Universität München, München, Deutschland
| | - Andreas Kuehnl
- Klinik und Poliklinik für Vaskuläre und Endovaskuläre Chirurgie, Klinikum rechts der Isar, Technische Universität München, München, Deutschland.
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78
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Knappich C, Tsantilas P, Salvermoser M, Schmid S, Kallmayer M, Trenner M, Eckstein HH, Kuehnl A. Editor's Choice - Distribution of Care and Hospital Incidence of Carotid Endarterectomy and Carotid Artery Stenting: A Secondary Analysis of German Hospital Episode Data. Eur J Vasc Endovasc Surg 2021; 62:167-176. [PMID: 33966984 DOI: 10.1016/j.ejvs.2021.03.021] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2020] [Revised: 03/10/2021] [Accepted: 03/21/2021] [Indexed: 10/21/2022]
Abstract
OBJECTIVE This is a description of the German healthcare landscape regarding carotid artery disease, assessment of hospital incidence time courses for carotid endarterectomy (CEA) and carotid artery stenting (CAS), and simulation of potential effects of minimum hospital caseload requirements for CEA and CAS. METHODS The study is a secondary data analysis of diagnosis related group statistics data (2005-2016), provided by the German Federal Statistical Office. Cases encoded by German operation procedure codes for CEA or CAS and by International Classification of Diseases (ICD-10) codes for carotid artery disease were included. Hospitals were categorised into quartiles according to annual caseloads. Linear distances to the closest hospital fulfilling hypothetical caseload requirements were calculated. RESULTS A total of 132 411 and 33 709 patients treated with CEA and CAS from 2012 to 2016 were included. CEA patients had lower rates of myocardial infarction (1.4% vs. 1.8%) and death (1.2% vs. 4.0%), and CAS patients were more often treated after emergency admission (38.1% vs. 27.1%). Age standardised annual hospital incidences were 67.2 per 100 000 inhabitants for CEA and 16.3 per 100 000 inhabitants for CAS. The incidence for CEA declined from 2005 to 2016, with CAS rising again until 2016 after having declined from 2010 to 2013. Regarding distance from home to hospital, centres offering CEA are distributed more homogeneously across Germany, compared with those performing CAS. Hypothetical introduction of minimum annual caseloads (> 20 for CEA; > 10 for CAS) imply that 75% of the population would reach their hospital after travelling 45 km for CEA and 70 km for CAS. CONCLUSION Differences in spatial distribution mean that statutory minimum annual caseloads would have a greater impact on CAS accessibility than CEA in Germany. Presumably because of a decline in carotid artery disease and a transition towards individualised therapy for asymptomatic patients, hospital incidence for CEA has been declining.
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Affiliation(s)
- Christoph Knappich
- Department for Vascular and Endovascular Surgery, Klinikum rechts der Isar, Technical University of Munich, Munich, Germany
| | - Pavlos Tsantilas
- Department for Vascular and Endovascular Surgery, Klinikum rechts der Isar, Technical University of Munich, Munich, Germany
| | - Michael Salvermoser
- Department for Vascular and Endovascular Surgery, Klinikum rechts der Isar, Technical University of Munich, Munich, Germany
| | - Sofie Schmid
- Department for Vascular and Endovascular Surgery, Klinikum rechts der Isar, Technical University of Munich, Munich, Germany
| | - Michael Kallmayer
- Department for Vascular and Endovascular Surgery, Klinikum rechts der Isar, Technical University of Munich, Munich, Germany
| | - Matthias Trenner
- Department for Vascular and Endovascular Surgery, Klinikum rechts der Isar, Technical University of Munich, Munich, Germany
| | - Hans-Henning Eckstein
- Department for Vascular and Endovascular Surgery, Klinikum rechts der Isar, Technical University of Munich, Munich, Germany
| | - Andreas Kuehnl
- Department for Vascular and Endovascular Surgery, Klinikum rechts der Isar, Technical University of Munich, Munich, Germany.
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Fasoula NA, Karlas A, Kallmayer M, Milik AB, Pelisek J, Eckstein HH, Klingenspor M, Ntziachristos V. Multicompartmental non-invasive sensing of postprandial lipemia in humans with multispectral optoacoustic tomography. Mol Metab 2021; 47:101184. [PMID: 33549846 PMCID: PMC7918675 DOI: 10.1016/j.molmet.2021.101184] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/07/2020] [Revised: 02/01/2021] [Accepted: 02/01/2021] [Indexed: 12/26/2022] Open
Abstract
OBJECTIVE Postprandial lipid profiling (PLP), a risk indicator of cardiometabolic disease, is based on frequent blood sampling over several hours after a meal, an approach that is invasive and inconvenient. Non-invasive PLP may offer an alternative for disseminated human monitoring. Herein, we investigate the use of clinical multispectral optoacoustic tomography (MSOT) for non-invasive, label-free PLP via direct lipid-sensing in human vasculature and soft tissues. METHODS Four (n = 4) subjects (3 females and 1 male, age: 28 ± 7 years) were enrolled in the current pilot study. We longitudinally measured the lipid signals in arteries, veins, skeletal muscles, and adipose tissues of all participants at 30-min intervals for 6 h after the oral consumption of a high-fat meal. RESULTS Optoacoustic lipid-signal analysis showed on average a 63.4% intra-arterial increase at ~ 4 h postprandially, an 83.9% intra-venous increase at ~ 3 h, a 120.8% intra-muscular increase at ~ 3 h, and a 32.8% subcutaneous fat increase at ~ 4 h. CONCLUSION MSOT provides the potential to study lipid metabolism that could lead to novel diagnostics and prevention strategies by label-free, non-invasive detection of tissue biomarkers implicated in cardiometabolic diseases.
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Affiliation(s)
- Nikolina-Alexia Fasoula
- Technical University of Munich, School of Medicine, Chair of Biological Imaging, Germany; Helmholtz Zentrum München, Neuherberg, Institute of Biological and Medical Imaging, Germany
| | - Angelos Karlas
- Technical University of Munich, School of Medicine, Chair of Biological Imaging, Germany; Helmholtz Zentrum München, Neuherberg, Institute of Biological and Medical Imaging, Germany; Clinic of Vascular and Endovascular Surgery, Klinikum rechts der Isar, Munich, Germany
| | - Michael Kallmayer
- Clinic of Vascular and Endovascular Surgery, Klinikum rechts der Isar, Munich, Germany
| | - Anamaria Beatrice Milik
- Technical University of Munich, School of Medicine, Chair of Biological Imaging, Germany; Helmholtz Zentrum München, Neuherberg, Institute of Biological and Medical Imaging, Germany
| | - Jaroslav Pelisek
- Clinic of Vascular and Endovascular Surgery, Klinikum rechts der Isar, Munich, Germany; Department of Vascular Surgery, University Hospital Zurich, Zurich, Switzerland
| | - Hans-Henning Eckstein
- Clinic of Vascular and Endovascular Surgery, Klinikum rechts der Isar, Munich, Germany
| | - Martin Klingenspor
- Chair of Molecular Nutritional Medicine, TUM School of Life Sciences Weihenstephan, Technical University of Munich, Freising, Germany; EKFZ-Else Kröner-Fresenius Zentrum for Nutritional Medicine, Technical University of Munich, Freising, Germany; ZIEL-Institute for Food &Health, Technical University of Munich, Freising, Germany
| | - Vasilis Ntziachristos
- Technical University of Munich, School of Medicine, Chair of Biological Imaging, Germany; Helmholtz Zentrum München, Neuherberg, Institute of Biological and Medical Imaging, Germany.
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Eckstein HH, Kühnl A, Berkefeld J, Lawall H, Storck M, Sander D. [Webinar for S3 guideline "diagnosis, treatment, and aftercare of extracranial carotid stenosis"]. Chirurg 2021; 92:383-384. [PMID: 33792754 DOI: 10.1007/s00104-021-01393-x] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Affiliation(s)
- Hans-Henning Eckstein
- Klinikum rechts der Isar der Technischen Universität München (TUM), Ismaningerstraße 22, 81675, München, Deutschland.
| | - Andreas Kühnl
- Klinikum rechts der Isar der Technischen Universität München (TUM), Ismaningerstraße 22, 81675, München, Deutschland
| | | | | | | | - Dirk Sander
- Benedictus Krankenhaus Tutzing, Tutzing, Deutschland
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81
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Fisch U, von Felten S, Wiencierz A, Jansen O, Howard G, Hendrikse J, Halliday A, Fraedrich G, Eckstein HH, Calvet D, Bulbulia R, Becquemin JP, Algra A, Rothwell P, Ringleb P, Mas JL, Brown MM, Brott TG, Bonati LH. Editor's Choice - Risk of Stroke before Revascularisation in Patients with Symptomatic Carotid Stenosis: A Pooled Analysis of Randomised Controlled Trials. Eur J Vasc Endovasc Surg 2021; 61:881-887. [PMID: 33827781 DOI: 10.1016/j.ejvs.2021.02.024] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2020] [Revised: 01/17/2021] [Accepted: 02/18/2021] [Indexed: 11/25/2022]
Abstract
OBJECTIVE Current guidelines recommending rapid revascularisation of symptomatic carotid stenosis are largely based on data from clinical trials performed at a time when best medical therapy was potentially less effective than today. The risk of stroke and its predictors among patients with symptomatic carotid stenosis awaiting revascularisation in recent randomised controlled trials (RCTs) and in medical arms of earlier RCTs was assessed. METHODS The pooled data of individual patients with symptomatic carotid stenosis randomised to stenting (CAS) or endarterectomy (CEA) in four recent RCTs, and of patients randomised to medical therapy in three earlier RCTs comparing CEA vs. medical therapy, were compared. The primary outcome event was any stroke occurring between randomisation and treatment by CAS or CEA, or within 120 days after randomisation. RESULTS A total of 4 754 patients from recent trials and 1 227 from earlier trials were included. In recent trials, patients were randomised a median of 18 (IQR 7, 50) days after the qualifying event (QE). Twenty-three suffered a stroke while waiting for revascularisation (cumulative 120 day risk 1.97%, 95% confidence interval [CI] 0.75 - 3.17). Shorter time from QE until randomisation increased stroke risk after randomisation (χ2 = 6.58, p = .011). Sixty-one patients had a stroke within 120 days of randomisation in the medical arms of earlier trials (cumulative risk 5%, 95% CI 3.8 - 6.2). Stroke risk was lower in recent than earlier trials when adjusted for time between QE and randomisation, age, severity of QE, and degree of carotid stenosis (HR 0.47, 95% CI 0.25 - 0.88, p = .019). CONCLUSION Patients with symptomatic carotid stenosis enrolled in recent large RCTs had a lower risk of stroke after randomisation than historical controls. The added benefit of carotid revascularisation to modern medical care needs to be revisited in future studies. Until then, adhering to current recommendations for early revascularisation of patients with symptomatic carotid stenosis considered to require invasive treatment is advisable.
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Affiliation(s)
- Urs Fisch
- Department of Neurology and Stroke Centre, Department of Clinical Research, University Hospital, University of Basel, Basel, Switzerland
| | - Stefanie von Felten
- Clinical Trial Unit, Department of Clinical Research, University of Basel, Basel, Switzerland; Department of Biostatistics, Epidemiology, Biostatistics and Prevention Institute, University of Zurich, Zurich, Switzerland
| | - Andrea Wiencierz
- Clinical Trial Unit, Department of Clinical Research, University of Basel, Basel, Switzerland
| | - Olav Jansen
- Clinic for Radiology and Neuroradiology, University Hospital Schleswig-Holstein, Campus Kiel, Kiel, Germany
| | - George Howard
- Department of Biostatistics, UAB School of Public Health, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Jeroen Hendrikse
- Department of Radiology, University Medical Centre Utrecht, Utrecht University, Utrecht, the Netherlands
| | - Alison Halliday
- Nuffield Department of Surgery University of Oxford, Oxford, UK
| | - Gustav Fraedrich
- Department of Vascular Surgery, Medical University of Innsbruck, Innsbruck, Austria
| | - Hans-Henning Eckstein
- Department for Vascular and Endovascular Surgery-Vascular Centre, Klinikum rechts der Isar, Technical University Munich, Munich, Germany
| | - David Calvet
- Department of Neurology, Hôpital Sainte-Anne, Université Paris-Descartes, DHU Neurovasc Sorbonne Paris Cité, INSERM U894, Paris, France
| | - Richard Bulbulia
- Population Health Research Unit, Clinical Trial Service Unit and Epidemiological Studies Unit, Nuffield Department of Population Health, University of Oxford, UK
| | - Jean-Pierre Becquemin
- Vascular Institute of Paris East, Hôspital Paul D Egine, Champigny-sur-Marne, France
| | - Ale Algra
- Department of Neurology and Neurosurgery, UMC Utrecht Brain Centre, University Medical Centre Utrecht, Utrecht University, Utrecht, the Netherlands; Julius Centre for Health Sciences and Primary Care, University Medical Centre Utrecht, Utrecht University, Utrecht, the Netherlands
| | - Peter Rothwell
- Centre for Prevention of Stroke and Dementia, Nuffield Department of Clinical Neurosciences, John Radcliffe Hospital and University of Oxford, Oxford, UK
| | - Peter Ringleb
- Department of Neurology, University of Heidelberg Medical School, Heidelberg, Germany
| | - Jean-Louis Mas
- Department of Neurology, Hôpital Sainte-Anne, Université Paris-Descartes, DHU Neurovasc Sorbonne Paris Cité, INSERM U894, Paris, France
| | - Martin M Brown
- Stroke Research Centre, Department of Brain Repair and Rehabilitation, UCL Queen Square Institute of Neurology, University College London, London, UK
| | - Thomas G Brott
- Department of Neurology, Mayo Clinic, Jacksonville, FL, USA
| | - Leo H Bonati
- Department of Neurology and Stroke Centre, Department of Clinical Research, University Hospital, University of Basel, Basel, Switzerland; Stroke Research Centre, Department of Brain Repair and Rehabilitation, UCL Queen Square Institute of Neurology, University College London, London, UK.
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Affiliation(s)
- Hans-Henning Eckstein
- Department for Vascular and Endovascular Surgery, Klinikum rechts der Isar, Technical University Munich, Germany.,German Center for Cardiovascular Research (DZHK), partner site Munich, Germany
| | - Lars Maegdefessel
- Department for Vascular and Endovascular Surgery, Klinikum rechts der Isar, Technical University Munich, Germany.,German Center for Cardiovascular Research (DZHK), partner site Munich, Germany.,Karolinska Institutet and University Hospital, Department of Medicine, Stockholm, Sweden
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83
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Eckstein HH, Kühnl A, Berkefeld J, Lawall H, Storck M, Sander D. Diagnosis, Treatment and Follow-up in Extracranial Carotid Stenosis. Dtsch Arztebl Int 2021; 117:801-807. [PMID: 33549156 DOI: 10.3238/arztebl.2020.0801] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/05/2020] [Revised: 05/05/2020] [Accepted: 06/22/2020] [Indexed: 12/31/2022]
Abstract
BACKGROUND Around 15% of cerebral ischemias are caused by lesions of the extracranial carotid artery. The goal of this guideline is to provide evidence- and consensus-based recommendations for the management of patients with extracranial carotid stenoses throughout Germany and Austria. METHODS A systematic literature search (1990-2019) and methodical assessment of existing guidelines and systematic reviews; consensus-based answers to 37 key questions with evidence-based recommendations. RESULTS The prevalence of extracranial carotid artery stenoses is around 4% overall, higher from the age of 65 years. The most important examination modality is duplex sonography. Randomized trials have shown that carotid endarterectomy (CEA) significantly reduces the 5-year risk of stroke in patients with 60-99 % asymptomatic stenoses (absolute risk reduction [ARR] 4.1% over 5 years, number needed to treat [NNT] 24) or 50-99% symptomatic stenoses (50-69%: ARR 4.6 % over 5 years, NNT 22; 70-99%: 15.9 % over 5 years, NNT 6). With the aid of intensive conservative treatment, the carotid artery-associated risk of stroke can be reduced to as little as 1% per year. Critical determination of indications and strict quality criteria are therefore necessary for CEA and carotid artery stenting (CAS). Systematic reviews of controlled trials comparing CEA and CAS show that the procedural risk of stroke is higher for CAS (asymptomatic: 2.6% versus 1.3%; symptomatic: 6.2% versus 3.8%). There are no differences in the long term. CEA is recommended as standard procedure for high-grade asymptomatic and moderate to high-grade symptomatic carotid artery stenoses; CAS may be considered as an alternative. For both procedures, the periprocedural combined rate of stroke or death should not exceed 2% for asymptomatic stenoses or 4% for symptomatic stenoses. CONCLUSION Future studies should evaluate even better selection criteria for optimal individualized treatment, whether conservative, surgical, or endovascular.
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Affiliation(s)
- Hans-Henning Eckstein
- Spokesman (HHE) and Secretary (AK) of the Steering Group, Department forf Vascular and Endovascular Surgery, University Hospital "rechts der Isar", Technical University of Munich; Member of the Steering Group, Institute for Neuroradiology, University Hospital Frankfurt; Member of the Steering Group, Ettlingen; Member of the Steering Group, Department of Vascular and Thoracic Surgery, Karlsruhe Municipal Hospital Member of the Steering Group, Department of Neurology and Stroke Unit, Benedictus Hospital Tutzing; German Vascular Society (DGG); German Society of Neuroradiology (DGNR); German Society for Angiology/Vascular Medicine (DGA); German Society of Surgery (DGCH); German Society of Neurology (DGN)
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84
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Menges AL, Reutersberg B, Busch A, Salvermoser M, Feith M, Trenner M, Kallmayer M, Zimmermann A, Eckstein HH. Early and Midterm Outcomes of Open and Endovascular Revascularization of Chronic Mesenteric Ischemia. World J Surg 2021; 44:2804-2812. [PMID: 32328781 PMCID: PMC7326829 DOI: 10.1007/s00268-020-05513-2] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
Background Revascularization strategies for chronic mesenteric ischemia (CMI) include open (OR) and endovascular (ER) modalities. The primary objective of this study was to analyze the safety and effectiveness of OR and ER and the impact of clinical and morphological variables on early and midterm outcomes in a consecutive series of CMI patients in a tertiary referral center. Patients and methods From 2004 to 2017, all CMI patients treated with OR and ER were retrospectively identified. Patient records, preoperative imaging, as well as peri- and postoperative outcomes were analyzed. Univariable and multivariable analysis was performed to identify clinical or morphological variables affecting reintervention rates within 2 years. Results In total, 63 patients (33% male; mean age 71, range 60–76 years) were treated by ER (41 patients) or OR (22 patients) for CMI. Mean follow-up was 26 (10–71) months. 30-day mortality was 0.0% after ER and 4.5% after OR (p = 0.069); 30-day morbidity was 9.8% vs. 31.8%, respectively (p = 0.030). Length of stay was significantly longer after OR (14 vs. 4 days; p < 0.001). Freedom from reintervention rate after 2 years was 82% after OR and 73% after ER (p = 0.14). Overall survival did not differ after 2 years (OR 85% vs. ER 86%; p = 0.35). Multivariable analysis revealed that smoking was associated with higher risk of reintervention (hazard ratio, HR: 4.14; 95% confidence interval, CI 1.11–15.53; p = 0.03). Additionally, a nonsignificant trend of lower reintervention rates after OR was detected (HR 0.23 95% CI 0.05–1.08; p = 0.06). Conclusion Due to a lower invasiveness, despite the higher reintervention rate, an “endovascular first” strategy is justified and recommended.
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Affiliation(s)
- Anna-Leonie Menges
- Department for Vascular and Endovascular Surgery and Munich Aortic Center (MAC), University Hospital Rechts der Isar, Technical University of Munich, Munich, Germany
| | | | - Albert Busch
- Department for Vascular and Endovascular Surgery and Munich Aortic Center (MAC), University Hospital Rechts der Isar, Technical University of Munich, Munich, Germany
| | - Michael Salvermoser
- Department for Vascular and Endovascular Surgery and Munich Aortic Center (MAC), University Hospital Rechts der Isar, Technical University of Munich, Munich, Germany
| | - Marcus Feith
- Department of Surgery, University Hospital Rechts der Isar, Technical University of Munich, Munich, Germany
| | - Matthias Trenner
- Department for Vascular and Endovascular Surgery and Munich Aortic Center (MAC), University Hospital Rechts der Isar, Technical University of Munich, Munich, Germany
| | - Michael Kallmayer
- Department for Vascular and Endovascular Surgery and Munich Aortic Center (MAC), University Hospital Rechts der Isar, Technical University of Munich, Munich, Germany
| | | | - Hans-Henning Eckstein
- Department for Vascular and Endovascular Surgery and Munich Aortic Center (MAC), University Hospital Rechts der Isar, Technical University of Munich, Munich, Germany.
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85
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Karlas A, Masthoff M, Kallmayer M, Helfen A, Bariotakis M, Fasoula NA, Schäfers M, Seidensticker M, Eckstein HH, Ntziachristos V, Wildgruber M. Multispectral optoacoustic tomography of peripheral arterial disease based on muscle hemoglobin gradients-a pilot clinical study. Ann Transl Med 2021; 9:36. [PMID: 33553329 PMCID: PMC7859778 DOI: 10.21037/atm-20-3321] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
Background Current imaging assessment of peripheral artery disease (PAD) relies on anatomical cross-sectional visualizations of the affected arteries. Multispectral optoacoustic tomography (MSOT) is a novel molecular imaging technique that provides direct and label-free visualizations of soft tissue perfusion and oxygenation. Methods MSOT was prospectively assessed in a pilot trial in healthy volunteers (group n1=4, mean age 31, 50% male and group n3=4, mean age 37.3, 75% male) and patients with intermittent claudication (group n2=4, mean age 72, 75% male, PAD stage IIb). We conducted cuff-induced ischemia (group n1) and resting state measurements (groups n2 and n3) over the calf region. Spatially resolved mapping of oxygenated (HbO2), deoxygenated (Hb) and total (THb) hemoglobin, as well as oxygen saturation (SO2), were measured via hand-held hybrid MSOT-Ultrasound based purely on hemoglobin contrast. Results Calf measurements in healthy volunteers revealed distinct dynamics for HbO2, Hb, THb and SO2 under cuff-induced ischemia. HbO2, THb and SO2 levels were significantly impaired in PAD patients compared to healthy volunteers (P<0.05 for all parameters). Revascularization led to significant improvements in HbO2 of the affected limb. Conclusions Clinical MSOT allows for non-invasive, label-free and real-time imaging of muscle oxygenation in health and disease with implications for diagnostics and therapy assessment in PAD.
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Affiliation(s)
- Angelos Karlas
- Chair of Biological Imaging, School of Medicine, Technical University of Munich, Munich, Germany.,Institute of Biological and Medical Imaging, Helmholtz Zentrum München (GmbH), Neuherberg, Germany.,Clinic of Vascular and Endovascular Surgery, Technical University of Munich, Klinikum rechts der Isar, Munich, Germany.,DZHK (German Centre for Cardiovascular Research), partner site Munich Heart Alliance, Munich, Germany
| | - Max Masthoff
- Department for Clinical Radiology, University Hospital Münster, Münster, Germany
| | - Michael Kallmayer
- Clinic of Vascular and Endovascular Surgery, Technical University of Munich, Klinikum rechts der Isar, Munich, Germany
| | - Anne Helfen
- Department for Clinical Radiology, University Hospital Münster, Münster, Germany
| | - Michail Bariotakis
- Chair of Biological Imaging, School of Medicine, Technical University of Munich, Munich, Germany.,Institute of Biological and Medical Imaging, Helmholtz Zentrum München (GmbH), Neuherberg, Germany
| | - Nikolina Alexia Fasoula
- Chair of Biological Imaging, School of Medicine, Technical University of Munich, Munich, Germany.,Institute of Biological and Medical Imaging, Helmholtz Zentrum München (GmbH), Neuherberg, Germany
| | - Michael Schäfers
- Department for Nuclear Medicine and European Institute for Molecular Imaging, University Hospital Münster, Münster, Germany
| | - Max Seidensticker
- Department for Radiology, University Hospital, LMU Munich, München, Germany
| | - Hans-Henning Eckstein
- Clinic of Vascular and Endovascular Surgery, Technical University of Munich, Klinikum rechts der Isar, Munich, Germany.,DZHK (German Centre for Cardiovascular Research), partner site Munich Heart Alliance, Munich, Germany
| | - Vasilis Ntziachristos
- Chair of Biological Imaging, School of Medicine, Technical University of Munich, Munich, Germany.,Institute of Biological and Medical Imaging, Helmholtz Zentrum München (GmbH), Neuherberg, Germany.,DZHK (German Centre for Cardiovascular Research), partner site Munich Heart Alliance, Munich, Germany
| | - Moritz Wildgruber
- Department for Clinical Radiology, University Hospital Münster, Münster, Germany.,Department for Radiology, University Hospital, LMU Munich, München, Germany
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86
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Howard VJ, Algra A, Howard G, Bonati LH, de Borst GJ, Bulbulia R, Calvet D, Eckstein HH, Fraedrich G, Greving JP, Halliday A, Hendrikse J, Jansen O, Brown MM, Mas JL, Ringleb PA, Brott TG. Absence of Consistent Sex Differences in Outcomes From Symptomatic Carotid Endarterectomy and Stenting Randomized Trials. Stroke 2021; 52:416-423. [PMID: 33493046 PMCID: PMC9136999 DOI: 10.1161/strokeaha.120.030184] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND AND PURPOSE CREST (Carotid Revascularization Endarterectomy Versus Stenting Trial) reported a higher periprocedural risk for any stroke, death, or myocardial infarction for women randomized to carotid artery stenting (CAS) compared with women randomized to carotid endarterectomy (CEA). No difference in risk by treatment was detected for women relative to men in the 4-year primary outcome. We aimed to conduct a pooled analysis among symptomatic patients in large randomized trials to provide more precise estimates of sex differences in the CAS-to-CEA risk for any stroke or death during the 120-day periprocedural period and ipsilateral stroke thereafter. METHODS Data from the Carotid Stenosis Trialists' Collaboration included outcomes from symptomatic patients in EVA-3S (Endarterectomy Versus Angioplasty in Patients With Symptomatic Severe Carotid Stenosis), SPACE (Stent-Protected Angioplasty Versus Carotid Endarterectomy in Symptomatic Patients), ICSS (International Carotid Stenting Study), and CREST. The primary outcome was any stroke or death within 120 days after randomization and ipsilateral stroke thereafter. Event rates and relative risks were estimated using Poisson regression; effect modification by sex was assessed with a sex-by-treatment-by-trial interaction term, with significant interaction defined a priori as P≤0.10. RESULTS Over a median 2.7 years of follow-up, 433 outcomes occurred in 3317 men and 1437 women. The CAS-to-CEA relative risk of the primary outcome was significantly lower for women compared with men in 1 trial, nominally lower in another, and nominally higher in the other two. The sex-by-treatment-by-trial interaction term was significant (P=0.065), indicating heterogeneity among trials. Contributors to this heterogeneity are primarily differences in periprocedural period. When the trials are nevertheless pooled, there were no significant sex differences in risk in any follow-up period. CONCLUSIONS There were significant differences between trials in the magnitude of sex differences in treatment effect (CAS-to-CEA relative risk), indicating pooling data from these trials to estimate sex differences might not be valid. Whether sex is acting as an effect modifier of the CAS-to-CEA treatment effect in symptomatic patients remains uncertain. Registration: URL: https://www.clinicaltrials.gov; Unique identifier: NCT00190398 (EVA-3S) and NCT00004732 (CREST). URL: https://www.isrctn.com; Unique identifier: ISRCTN57874028 (SPACE) and ISRCTN25337470 (ICSS).
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Affiliation(s)
- Virginia J Howard
- Department of Epidemiology (V.J.H.), School of Public Health, University of Alabama at Birmingham
| | - Ale Algra
- Department of Neurology and Neurosurgery, Brain Center Rudolf Magnus and Julius Center for Health Sciences and Primary Care (A.A.), and Julius Centre for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht University, the Netherlands
| | - George Howard
- Department of Biostatistics (G.H.), School of Public Health, University of Alabama at Birmingham
| | - Leo H Bonati
- Department of Brain Repair and Rehabilitation, Stroke Research Centre, University College of London Queen Square Institute of Neurology, University College London, United Kingdom (L.H.B., M.M.B.)
- Department of Neurology, Stroke Center (L.H.B.), University Hospital Basel, University of Basel, Switzerland
- Department of Clinical Research (L.H.B.), University Hospital Basel, University of Basel, Switzerland
| | - Gert J de Borst
- Department of Vascular Surgery (G.J.d.B.), and Julius Centre for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht University, the Netherlands
| | - Richard Bulbulia
- Clinical Trial Service Unit and Epidemiological Studies Unit (R.B.), Nuffield Department of Population Health, University of Oxford, United Kingdom
- Medical Research Council Population Health Research Unit (R.B.), Nuffield Department of Population Health, University of Oxford, United Kingdom
| | - David Calvet
- Department of Neurology, Hopital Sainte-Anne, Universite Paris-Descartes, DHU Neurovasc Sorbonne Paris Cite, INSERM U894, France (D.C., J.-L.M.)
| | - Hans-Henning Eckstein
- Department of Vascular and Endovascular Surgery/Vascular Center, Klinikum rechts der Isar der Technischen Universitat Munchen, Munich, Germany (H.-H.E.)
| | - Gustav Fraedrich
- Department of Vascular Surgery, Medical University of Innsbruck, Austria (G.F.)
| | - Jacoba P Greving
- Department of Epidemiology (J.P.G.), and Julius Centre for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht University, the Netherlands
| | - Alison Halliday
- Nuffield Department of Surgical Sciences, John Radcliffe Hospital, Oxford, United Kingdom (A.H.)
| | - Jeroen Hendrikse
- Department of Radiology, University Medical Center Utrecht, the Netherlands (J.H.)
| | - Olav Jansen
- Department of Radiology and Neuroradiology, UKSH Campus Kiel, Germany (O.J.)
| | - Martin M Brown
- Department of Brain Repair and Rehabilitation, Stroke Research Centre, University College of London Queen Square Institute of Neurology, University College London, United Kingdom (L.H.B., M.M.B.)
| | - Jean-Louis Mas
- Department of Neurology, Hopital Sainte-Anne, Universite Paris-Descartes, DHU Neurovasc Sorbonne Paris Cite, INSERM U894, France (D.C., J.-L.M.)
| | - Peter A Ringleb
- Department of Neurology, University of Heidelberg Medical School, Germany (P.A.R.)
| | - Thomas G Brott
- Department of Neurology, Mayo Clinic, Jacksonville, FL (T.G.B.)
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87
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Timmerman N, Galyfos G, Sigala F, Thanopoulou K, de Borst GJ, Davidovic L, Eckstein HH, Filipovic N, Grugni R, Kallmayer M, de Kleijn DPV, Koncar I, Mantzaris MD, Marchal E, Matsagkas M, Mutavdzic P, Palombo D, Pasterkamp G, Potsika VT, Andreakos E, Fotiadis DI. The TAXINOMISIS Project: A multidisciplinary approach for the development of a new risk stratification model for patients with asymptomatic carotid artery stenosis. Eur J Clin Invest 2020; 50:e13411. [PMID: 32954520 PMCID: PMC7757200 DOI: 10.1111/eci.13411] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/05/2020] [Revised: 08/21/2020] [Accepted: 08/23/2020] [Indexed: 12/13/2022]
Abstract
INTRODUCTION Asymptomatic carotid artery stenosis (ACAS) may cause future stroke and therefore patients with ACAS require best medical treatment. Patients at high risk for stroke may opt for additional revascularization (either surgery or stenting) but the future stroke risk should outweigh the risk for peri/post-operative stroke/death. Current risk stratification for patients with ACAS is largely based on outdated randomized-controlled trials that lack the integration of improved medical therapies and risk factor control. Furthermore, recent circulating and imaging biomarkers for stroke have never been included in a risk stratification model. The TAXINOMISIS Project aims to develop a new risk stratification model for cerebrovascular complications in patients with ACAS and this will be tested through a prospective observational multicentre clinical trial performed in six major European vascular surgery centres. METHODS AND ANALYSIS The risk stratification model will compromise clinical, circulating, plaque and imaging biomarkers. The prospective multicentre observational study will include 300 patients with 50%-99% ACAS. The primary endpoint is the three-year incidence of cerebrovascular complications. Biomarkers will be retrieved from plasma samples, brain MRI, carotid MRA and duplex ultrasound. The TAXINOMISIS Project will serve as a platform for the development of new computer tools that assess plaque progression based on radiology images and a lab-on-chip with genetic variants that could predict medication response in individual patients. CONCLUSION Results from the TAXINOMISIS study could potentially improve future risk stratification in patients with ACAS to assist personalized evidence-based treatment decision-making.
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Affiliation(s)
- Nathalie Timmerman
- Department of Vascular Surgery, Division of Surgical Specialties, University Medical Centre Utrecht, Utrecht University, Utrecht, the Netherlands
| | - George Galyfos
- First Propedeutic Department of Surgery, National and Kapodistrian University of Athens, Athens, Greece
| | - Fragiska Sigala
- First Propedeutic Department of Surgery, National and Kapodistrian University of Athens, Athens, Greece
| | - Kalliopi Thanopoulou
- Laboratory of Immunobiology, Center for Clinical, Experimental Surgery and Translational Research, Biomedical Research Foundation of the Academy of Athens, Athens, Greece
| | - Gert J de Borst
- Department of Vascular Surgery, Division of Surgical Specialties, University Medical Centre Utrecht, Utrecht University, Utrecht, the Netherlands
| | - Lazar Davidovic
- Clinic for Vascular and Endovascular Surgery, Serbian Clinical Center, Belgrade, Serbia.,School of Medicine, University of Belgrade, Belgrade, Serbia
| | - Hans-Henning Eckstein
- Clinic and Policlinik for vascular and endovascular Surgery, Klinikum rechts der Isar, Technical University Munich, Munich, Germany
| | - Nenad Filipovic
- BioIRC, Research and Development Center for Bioengieering, Kragujevac, Serbia.,Faculty of Engineering, University of Kragujevac, Kragujevac, Serbia
| | | | - Michael Kallmayer
- Clinic and Policlinik for vascular and endovascular Surgery, Klinikum rechts der Isar, Technical University Munich, Munich, Germany
| | - Dominique P V de Kleijn
- Department of Vascular Surgery, Division of Surgical Specialties, University Medical Centre Utrecht, Utrecht University, Utrecht, the Netherlands
| | - Igor Koncar
- Clinic for Vascular and Endovascular Surgery, Serbian Clinical Center, Belgrade, Serbia.,School of Medicine, University of Belgrade, Belgrade, Serbia
| | - Michalis D Mantzaris
- Department of Materials Science and Engineering, Unit of Medical Technology and Intelligent Information Systems, University of Ioannina, Ioannina, Greece
| | | | - Miltiadis Matsagkas
- Department of Vascular Surgery, Faculty of Medicine, University of Thessaly, Thessaly, Greece
| | - Perica Mutavdzic
- Clinic for Vascular and Endovascular Surgery, Serbian Clinical Center, Belgrade, Serbia
| | - Domenico Palombo
- Division of Vascular and Endovascular Surgery, IRCCS Ospedale Policlinico San Martino Genoa - Italian Cardiovascular Network, Genoa, Italy
| | - Gerard Pasterkamp
- Division Laboratories and Pharmacy, Laboratory of Clinical Chemistry and Hematology, University Medical Centre Utrecht, Utrecht University, Utrecht, the Netherlands
| | - Vassiliki T Potsika
- Department of Materials Science and Engineering, Unit of Medical Technology and Intelligent Information Systems, University of Ioannina, Ioannina, Greece
| | - Evangelos Andreakos
- Laboratory of Immunobiology, Center for Clinical, Experimental Surgery and Translational Research, Biomedical Research Foundation of the Academy of Athens, Athens, Greece
| | - Dimitrios I Fotiadis
- Department of Materials Science and Engineering, Unit of Medical Technology and Intelligent Information Systems, University of Ioannina, Ioannina, Greece.,Institute of Molecular Biology and Biotechnology, Foundation for Research and Technology-Hellas (FORTH), Ioannina, Greece
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88
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Chlis NK, Karlas A, Fasoula NA, Kallmayer M, Eckstein HH, Theis FJ, Ntziachristos V, Marr C. A sparse deep learning approach for automatic segmentation of human vasculature in multispectral optoacoustic tomography. Photoacoustics 2020; 20:100203. [PMID: 33194545 PMCID: PMC7644749 DOI: 10.1016/j.pacs.2020.100203] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/14/2020] [Revised: 07/20/2020] [Accepted: 07/26/2020] [Indexed: 05/02/2023]
Abstract
Multispectral Optoacoustic Tomography (MSOT) resolves oxy- (HbO2) and deoxy-hemoglobin (Hb) to perform vascular imaging. MSOT suffers from gradual signal attenuation with depth due to light-tissue interactions: an effect that hinders the precise manual segmentation of vessels. Furthermore, vascular assessment requires functional tests, which last several minutes and result in recording thousands of images. Here, we introduce a deep learning approach with a sparse-UNET (S-UNET) for automatic vascular segmentation in MSOT images to avoid the rigorous and time-consuming manual segmentation. We evaluated the S-UNET on a test-set of 33 images, achieving a median DICE score of 0.88. Apart from high segmentation performance, our method based its decision on two wavelengths with physical meaning for the task-at-hand: 850 nm (peak absorption of oxy-hemoglobin) and 810 nm (isosbestic point of oxy-and deoxy-hemoglobin). Thus, our approach achieves precise data-driven vascular segmentation for automated vascular assessment and may boost MSOT further towards its clinical translation.
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Affiliation(s)
- Nikolaos-Kosmas Chlis
- Institute of Computational Biology, Helmholtz Center Munich, Neuherberg, Germany
- Institute of Biological and Medical Imaging, Helmholtz Center Munich, Neuherberg, Germany
- Roche Pharma Research and Early Development, Large Molecule Research, Roche Innovation Center Munich, Penzberg 82377, Germany
| | - Angelos Karlas
- Institute of Biological and Medical Imaging, Helmholtz Center Munich, Neuherberg, Germany
- Chair of Biological Imaging and Center for Translational Cancer Research (TranslaTUM), Munich, Germany
- DZHK (German Centre for Cardiovascular Research), Partner Site Munich Heart Alliance, Munich, Germany
- Clinic for Vascular and Endovascular Surgery, Rechts Der Isar Hospital, Munich, Germany
| | - Nikolina-Alexia Fasoula
- Institute of Biological and Medical Imaging, Helmholtz Center Munich, Neuherberg, Germany
- Chair of Biological Imaging and Center for Translational Cancer Research (TranslaTUM), Munich, Germany
| | - Michael Kallmayer
- Clinic for Vascular and Endovascular Surgery, Rechts Der Isar Hospital, Munich, Germany
| | - Hans-Henning Eckstein
- Clinic for Vascular and Endovascular Surgery, Rechts Der Isar Hospital, Munich, Germany
| | - Fabian J. Theis
- Institute of Computational Biology, Helmholtz Center Munich, Neuherberg, Germany
- Department of Mathematics, Technical University of Munich, Munich, Germany
| | - Vasilis Ntziachristos
- Institute of Biological and Medical Imaging, Helmholtz Center Munich, Neuherberg, Germany
- Chair of Biological Imaging and Center for Translational Cancer Research (TranslaTUM), Munich, Germany
- DZHK (German Centre for Cardiovascular Research), Partner Site Munich Heart Alliance, Munich, Germany
| | - Carsten Marr
- Institute of Computational Biology, Helmholtz Center Munich, Neuherberg, Germany
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89
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Kontos C, El Bounkari O, Krammer C, Sinitski D, Hille K, Zan C, Yan G, Wang S, Gao Y, Brandhofer M, Megens RTA, Hoffmann A, Pauli J, Asare Y, Gerra S, Bourilhon P, Leng L, Eckstein HH, Kempf WE, Pelisek J, Gokce O, Maegdefessel L, Bucala R, Dichgans M, Weber C, Kapurniotu A, Bernhagen J. Designed CXCR4 mimic acts as a soluble chemokine receptor that blocks atherogenic inflammation by agonist-specific targeting. Nat Commun 2020; 11:5981. [PMID: 33239628 PMCID: PMC7689490 DOI: 10.1038/s41467-020-19764-z] [Citation(s) in RCA: 25] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2019] [Accepted: 10/28/2020] [Indexed: 11/22/2022] Open
Abstract
Targeting a specific chemokine/receptor axis in atherosclerosis remains challenging. Soluble receptor-based strategies are not established for chemokine receptors due to their discontinuous architecture. Macrophage migration-inhibitory factor (MIF) is an atypical chemokine that promotes atherosclerosis through CXC-motif chemokine receptor-4 (CXCR4). However, CXCR4/CXCL12 interactions also mediate atheroprotection. Here, we show that constrained 31-residue-peptides ('msR4Ms') designed to mimic the CXCR4-binding site to MIF, selectively bind MIF with nanomolar affinity and block MIF/CXCR4 without affecting CXCL12/CXCR4. We identify msR4M-L1, which blocks MIF- but not CXCL12-elicited CXCR4 vascular cell activities. Its potency compares well with established MIF inhibitors, whereas msR4M-L1 does not interfere with cardioprotective MIF/CD74 signaling. In vivo-administered msR4M-L1 enriches in atherosclerotic plaques, blocks arterial leukocyte adhesion, and inhibits atherosclerosis and inflammation in hyperlipidemic Apoe-/- mice in vivo. Finally, msR4M-L1 binds to MIF in plaques from human carotid-endarterectomy specimens. Together, we establish an engineered GPCR-ectodomain-based mimicry principle that differentiates between disease-exacerbating and -protective pathways and chemokine-selectively interferes with atherosclerosis.
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MESH Headings
- Aged
- Animals
- Antigens, CD/metabolism
- Atherosclerosis/drug therapy
- Atherosclerosis/genetics
- Atherosclerosis/pathology
- Atherosclerosis/surgery
- Binding Sites
- Carotid Artery, Common/pathology
- Carotid Artery, Common/surgery
- Chemokine CXCL12/metabolism
- Crystallography, X-Ray
- Disease Models, Animal
- Drug Design
- Drug Evaluation, Preclinical
- Endarterectomy, Carotid
- Female
- Humans
- Intramolecular Oxidoreductases/antagonists & inhibitors
- Intramolecular Oxidoreductases/metabolism
- Macrophage Migration-Inhibitory Factors/antagonists & inhibitors
- Macrophage Migration-Inhibitory Factors/metabolism
- Male
- Mice
- Mice, Knockout, ApoE
- Middle Aged
- Peptide Fragments/pharmacology
- Peptide Fragments/therapeutic use
- Receptors, CXCR4/chemistry
- Receptors, CXCR4/metabolism
- Receptors, CXCR4/ultrastructure
- Sialyltransferases/metabolism
- Signal Transduction/drug effects
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Affiliation(s)
- Christos Kontos
- Division of Peptide Biochemistry, TUM School of Life Sciences, Technische Universität München (TUM), 85354, Freising, Germany
| | - Omar El Bounkari
- Institute for Stroke and Dementia Research (ISD), Klinikum der Universität München, Ludwig-Maximilians-Universität (LMU) München, 81377, Munich, Germany
| | - Christine Krammer
- Institute for Stroke and Dementia Research (ISD), Klinikum der Universität München, Ludwig-Maximilians-Universität (LMU) München, 81377, Munich, Germany
| | - Dzmitry Sinitski
- Institute for Stroke and Dementia Research (ISD), Klinikum der Universität München, Ludwig-Maximilians-Universität (LMU) München, 81377, Munich, Germany
| | - Kathleen Hille
- Division of Peptide Biochemistry, TUM School of Life Sciences, Technische Universität München (TUM), 85354, Freising, Germany
| | - Chunfang Zan
- Institute for Stroke and Dementia Research (ISD), Klinikum der Universität München, Ludwig-Maximilians-Universität (LMU) München, 81377, Munich, Germany
| | - Guangyao Yan
- Institute for Stroke and Dementia Research (ISD), Klinikum der Universität München, Ludwig-Maximilians-Universität (LMU) München, 81377, Munich, Germany
| | - Sijia Wang
- Institute for Stroke and Dementia Research (ISD), Klinikum der Universität München, Ludwig-Maximilians-Universität (LMU) München, 81377, Munich, Germany
| | - Ying Gao
- Institute for Stroke and Dementia Research (ISD), Klinikum der Universität München, Ludwig-Maximilians-Universität (LMU) München, 81377, Munich, Germany
| | - Markus Brandhofer
- Institute for Stroke and Dementia Research (ISD), Klinikum der Universität München, Ludwig-Maximilians-Universität (LMU) München, 81377, Munich, Germany
| | - Remco T A Megens
- Institute for Cardiovascular Prevention, Klinikum der Universität München, Ludwig-Maximilians-Universität (LMU) München, 80336, Munich, Germany
| | - Adrian Hoffmann
- Institute for Stroke and Dementia Research (ISD), Klinikum der Universität München, Ludwig-Maximilians-Universität (LMU) München, 81377, Munich, Germany
- Department of Anaesthesiology, Klinikum der Universität München, Ludwig-Maximilians-Universität (LMU) München, 81377, Munich, Germany
| | - Jessica Pauli
- Department for Vascular and Endovascular Surgery, Klinikum rechts der Isar, Technische Universität München (TUM), 81675, Munich, Germany
| | - Yaw Asare
- Institute for Stroke and Dementia Research (ISD), Klinikum der Universität München, Ludwig-Maximilians-Universität (LMU) München, 81377, Munich, Germany
| | - Simona Gerra
- Institute for Stroke and Dementia Research (ISD), Klinikum der Universität München, Ludwig-Maximilians-Universität (LMU) München, 81377, Munich, Germany
| | - Priscila Bourilhon
- Institute for Stroke and Dementia Research (ISD), Klinikum der Universität München, Ludwig-Maximilians-Universität (LMU) München, 81377, Munich, Germany
| | - Lin Leng
- Yale University School of Medicine, New Haven, CT, 06510, USA
| | - Hans-Henning Eckstein
- Department for Vascular and Endovascular Surgery, Klinikum rechts der Isar, Technische Universität München (TUM), 81675, Munich, Germany
| | - Wolfgang E Kempf
- Department for Vascular and Endovascular Surgery, Klinikum rechts der Isar, Technische Universität München (TUM), 81675, Munich, Germany
| | - Jaroslav Pelisek
- Department for Vascular and Endovascular Surgery, Klinikum rechts der Isar, Technische Universität München (TUM), 81675, Munich, Germany
- Department of Vascular Surgery, University Hospital Zurich, 8091, Zurich, Switzerland
| | - Ozgun Gokce
- Institute for Stroke and Dementia Research (ISD), Klinikum der Universität München, Ludwig-Maximilians-Universität (LMU) München, 81377, Munich, Germany
- Munich Cluster for Systems Neurology (SyNergy), 81377, Munich, Germany
| | - Lars Maegdefessel
- Department for Vascular and Endovascular Surgery, Klinikum rechts der Isar, Technische Universität München (TUM), 81675, Munich, Germany
| | - Richard Bucala
- Yale University School of Medicine, New Haven, CT, 06510, USA
| | - Martin Dichgans
- Institute for Stroke and Dementia Research (ISD), Klinikum der Universität München, Ludwig-Maximilians-Universität (LMU) München, 81377, Munich, Germany
- Munich Cluster for Systems Neurology (SyNergy), 81377, Munich, Germany
| | - Christian Weber
- Institute for Cardiovascular Prevention, Klinikum der Universität München, Ludwig-Maximilians-Universität (LMU) München, 80336, Munich, Germany
- Munich Cluster for Systems Neurology (SyNergy), 81377, Munich, Germany
- Munich Heart Alliance, 80802, Munich, Germany
- Cardiovascular Research Institute Maastricht (CARIM), Maastricht University, 6229, Maastricht, The Netherlands
| | - Aphrodite Kapurniotu
- Division of Peptide Biochemistry, TUM School of Life Sciences, Technische Universität München (TUM), 85354, Freising, Germany.
| | - Jürgen Bernhagen
- Institute for Stroke and Dementia Research (ISD), Klinikum der Universität München, Ludwig-Maximilians-Universität (LMU) München, 81377, Munich, Germany.
- Munich Cluster for Systems Neurology (SyNergy), 81377, Munich, Germany.
- Munich Heart Alliance, 80802, Munich, Germany.
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90
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Bruder L, Pelisek J, Eckstein HH, Gee MW. Biomechanical rupture risk assessment of abdominal aortic aneurysms using clinical data: A patient-specific, probabilistic framework and comparative case-control study. PLoS One 2020; 15:e0242097. [PMID: 33211767 PMCID: PMC7676745 DOI: 10.1371/journal.pone.0242097] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2020] [Accepted: 10/26/2020] [Indexed: 11/18/2022] Open
Abstract
We present a data-informed, highly personalized, probabilistic approach for the quantification of abdominal aortic aneurysm (AAA) rupture risk. Our novel framework builds upon a comprehensive database of tensile test results that were carried out on 305 AAA tissue samples from 139 patients, as well as corresponding non-invasively and clinically accessible patient-specific data. Based on this, a multivariate regression model is created to obtain a probabilistic description of personalized vessel wall properties associated with a prospective AAA patient. We formulate a probabilistic rupture risk index that consistently incorporates the available statistical information and generalizes existing approaches. For the efficient evaluation of this index, a flexible Kriging-based surrogate model with an active training process is proposed. In a case-control study, the methodology is applied on a total of 36 retrospective, diameter matched asymptomatic (group 1, n = 18) and known symptomatic/ruptured (group 2, n = 18) cohort of AAA patients. Finally, we show its efficacy to discriminate between the two groups and demonstrate competitive performance in comparison to existing deterministic and probabilistic biomechanical indices.
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Affiliation(s)
- Lukas Bruder
- Mechanics & High Performance Computing Group, Technical University of Munich, Garching, Germany
| | - Jaroslav Pelisek
- Department of Vascular Surgery, University Hospital Zurich, Zurich, Switzerland
- Clinic for Vascular and Endovascular Surgery, Technical University of Munich, Munich, Germany
| | - Hans-Henning Eckstein
- Clinic for Vascular and Endovascular Surgery, Technical University of Munich, Munich, Germany
| | - Michael W. Gee
- Mechanics & High Performance Computing Group, Technical University of Munich, Garching, Germany
- * E-mail:
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91
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Paraskevas KI, Veith FJ, Eckstein HH, Ricco JB, Mikhailidis DP. Cholesterol, carotid artery disease and stroke: what the vascular specialist needs to know. Ann Transl Med 2020; 8:1265. [PMID: 33178797 PMCID: PMC7607102 DOI: 10.21037/atm.2020.02.176] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
Hypercholesterolemia is a risk factor for carotid artery stenosis and stroke. Statins are the main drugs for the management of hypercholesterolemia and they are strongly recommended by international guidelines for the management of vascular patients. The present review will focus on the associations between cholesterol, carotid artery stenosis and stroke and will cover several topics, including the conservative and perioperative/periprocedural management of carotid patients, the effect of statins on contrast-induced nephropathy developing after endovascular carotid interventions, the role of statin loading prior to endovascular procedures, as well as the indirect beneficial effects of statin treatment on renal function. It will also discuss the topics of statin intolerance and alternative cholesterol-lowering options for statin-intolerant vascular patients. Cholesterol levels play a prognostic role in carotid patients with regards to both short- and long-term stroke and mortality rates. Physicians should keep in mind the pivotal role of cholesterol levels in determining cardiovascular outcomes and the pleiotropic beneficial effects associated with statin use and should not miss the opportunity for cardiovascular risk reduction with aggressive statin treatment.
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Affiliation(s)
- Kosmas I Paraskevas
- Department of General and Vascular Surgery, Central Clinic of Athens, Athens, Greece
| | - Frank J Veith
- Division of Vascular Surgery, New York University Langone Medical Center, NY, USA.,Division of Vascular Surgery, The Cleveland Clinic, Cleveland, OH, USA
| | - Hans-Henning Eckstein
- Department of Vascular and Endovascular Surgery, Klinikum rechts der Isar, Technical University of Munich, Munich, Germany
| | - Jean-Baptiste Ricco
- Department of Clinical Research, University of Poitiers, CHU de Poitiers, Poitiers, France
| | - Dimitri P Mikhailidis
- Department of Clinical Biochemistry, Royal Free Hospital Campus, University College London Medical School, University College London (UCL), London, UK
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92
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Menges AL, Trenner M, Radu O, Beddoe D, Kallmayer M, Zimmermann A, Eckstein HH. Lack of durability after transarterial ethylene-vinyl alcohol copolymer-embolization of type II endoleak following endovascular abdominal aortic aneurysm repair. VASA 2020; 49:483-491. [PMID: 33103625 DOI: 10.1024/0301-1526/a000905] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
Background: Type II endoleak (T2EL) after endovascular aortic repair is associated with AAA sac enlargements in up to 25%, reduction of attachment zones and rarely with aortic rupture. Indications for therapy and efficacy of interventions of T2EL are not clearly established. Transarterial embolization with application of ethylene-vinyl alcohol copolymer has been described with varying outcomes. Aim of this study is to evaluate durability of OnyxTM embolization (OE) in T2EL in a consecutive series at a single tertiary vascular center. Patients and methods: Demographic data, technical success, pre- and postoperative aneurysm growth, morbidity, mortality and reintervention rates during hospital stay as well as in follow up were recorded in patients treated with OE for T2EL between 01/2015 and 12/2017. The primary endpoint was defined as persistence or reoccurrence of T2EL (durability of OE). Results: In total 15 patients (78 ± 6 years, 13 men) were treated with OE because of sac enlargement (average growth of 12 ± 8%, n = 12), persistent bleeding after AAA rupture (n = 2) or persistent T2EL with stable but large aneurysm diameter (n = 1). Mean length of stay was 8 ± 11 days. Technical success was 93.3% (n = 14). Inhospital-morbidity was 26.7%, in-hospital- and 1-year-mortality rate were 6.6% (n = 1) and 20.0% (n = 3). T2EL persisted in 20.0% (n = 3) despite of OE. Re-EL-II occurred after 40 (30-114) days in 33.3% (n = 5). Reintervention rate was 13.3% (n = 2, at day 48 and 319). Altogether clinical success with stable aneurysm diameter was achieved in 80.0% (n = 12), but durable elimination of EL was only achieved in 46.7% of patients (n = 7). Conclusions: OE is technically possible in more than 90% of patients but might be associated with severe complications. Durability of this treatment is low, since T2EL persist or reoccur in more than 50% of all patients. OE of T2EL should be reserved for few selected cases.
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Affiliation(s)
- Anna-Leonie Menges
- Department for Vascular and Endovascular Surgery and Munich Aortic Center (MAC), University Hospital rechts der Isar, Technical University of Munich, Munich, Germany.,Department of Vascular Surgery, University Hospital Zurich, Zurich, Switzerland
| | - Matthias Trenner
- Department for Vascular and Endovascular Surgery and Munich Aortic Center (MAC), University Hospital rechts der Isar, Technical University of Munich, Munich, Germany
| | - Oksana Radu
- Department for Vascular and Endovascular Surgery and Munich Aortic Center (MAC), University Hospital rechts der Isar, Technical University of Munich, Munich, Germany
| | - Daisy Beddoe
- Department of Vascular Surgery, University Hospital Zurich, Zurich, Switzerland
| | - Michael Kallmayer
- Department for Vascular and Endovascular Surgery and Munich Aortic Center (MAC), University Hospital rechts der Isar, Technical University of Munich, Munich, Germany
| | - Alexander Zimmermann
- Department for Vascular and Endovascular Surgery and Munich Aortic Center (MAC), University Hospital rechts der Isar, Technical University of Munich, Munich, Germany.,Department of Vascular Surgery, University Hospital Zurich, Zurich, Switzerland
| | - Hans-Henning Eckstein
- Department for Vascular and Endovascular Surgery and Munich Aortic Center (MAC), University Hospital rechts der Isar, Technical University of Munich, Munich, Germany
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93
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Trenner M, Salvermoser M, Busch A, Schmid V, Eckstein HH, Kühnl A. The Effects of Minimum Caseload Requirements on Management and Outcome in Abdominal Aortic Aneurysm Repair. Dtsch Arztebl Int 2020; 117:820-827. [PMID: 33568259 PMCID: PMC8005841 DOI: 10.3238/arztebl.2020.0820] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/04/2020] [Revised: 04/03/2020] [Accepted: 09/03/2020] [Indexed: 01/16/2023]
Abstract
BACKGROUND The German quality assurance guideline on abdominal aortic aneurysm (AAA) was implemented by the Joint Federal Committee (Gemeinsamer Bundesausschuss, G-BA) in 2008. The aims of this study were to verify the association between hospital case volume and outcome and to assess the hypothetical effect of minimum caseload requirements. METHODS The German diagnosis-related groups statistics for the years 2012 to 2016 were scrutinized for AAA (ICD-10 GM I71.3/4) with procedure codes for endo - vascular or open surgical treatment. The primary endpoint was in-hospital mortality. Logistic regression models were used for risk adjustment, and odds ratios (OR) were calculated as a function of the annual hospital-level case volume of AAA. In a hypo - thetical approach, the linear distances for various minimum caseloads (MC) were evaluated to assess accessibility. RESULTS The mortality of intact AAA (iAAA) was 2.7% (men [M] 2.4%, women [W] 4.2%); ruptured AAA (rAAA), 36.9% (M 36.9%, F 37.5%). An inverse relationship between annual hospital case volume of AAA and mortality was confirmed (iAAA/rAAA: from 3.9%/51% [<10 cases/year] through 3.3%/37% [30-39 cases/year] to 1.9%/28% [≥ 75 cases/year]). For a reference category of 30 AAA procedures/year, the following significant OR were found: 10 AAA cases/year, OR 1.21 (95% confidence interval [1.20; 1.21]); 20 cases, OR 1.09 [1.09; 1.09]; 50 cases, OR 0.89 [0.89; 0.89]; 75 cases, OR 0.82 [0.82; 0.82]. In a hypothetical centralization scenario with assumed MC of 30/year, 86% of the population would have to travel less than 100 km to the nearest hospital; with an MC of 40, this would apply to only 50% (without redistribution effects). CONCLUSION In the observed period, a significant correlation was confirmed between high annual case volume and low in-hospital mortality. A minimum caseload requirement of 30 AAA operations/year seems reasonable in view of the accessibility of hospitals. Cite this.
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Affiliation(s)
- Matthias Trenner
- Department for Vascular and Endovascular Surgery, University Hospital rechts der Isar, Technical University of Munich
| | - Michael Salvermoser
- Department for Vascular and Endovascular Surgery, University Hospital rechts der Isar, Technical University of Munich
| | - Albert Busch
- Department for Vascular and Endovascular Surgery, University Hospital rechts der Isar, Technical University of Munich
| | - Volker Schmid
- Department of Statistics, Ludwig Maximilians University Munich
| | - Hans-Henning Eckstein
- Department for Vascular and Endovascular Surgery, University Hospital rechts der Isar, Technical University of Munich
| | - Andreas Kühnl
- Department for Vascular and Endovascular Surgery, University Hospital rechts der Isar, Technical University of Munich
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94
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Abstract
Significance: Abdominal aortic aneurysm (AAA) is a potentially fatal condition, featuring the possibility of high-mortality rupture. To date, prophylactic surgery by means of open surgical repair or endovascular aortic repair at specific thresholds is considered standard therapy. Both surgical options hold different risk profiles of short- and long-term morbidity and mortality. Targeting early stages of AAA development to decelerate disease progression is desirable. Recent Advances: Understanding the pathomechanisms that initiate formation, maintain growth, and promote rupture of AAA is crucial to developing new medical therapeutic options. Inflammatory cells, in particular macrophages, have been investigated for their contribution to AAA disease for decades, whereas evidence on lymphocytes, mast cells, and neutrophils is sparse. Recently, there has been increasing interest in noncoding RNAs (ncRNAs) and their involvement in disease development, including AAA. Critical Issues: The current evidence on myeloid cells and ncRNAs in AAA largely originates from small animal models, making clinical extrapolation difficult. Although it is feasible to collect surgical human AAA samples, these tissues reflect end-stage disease, preventing examination of critical mechanisms behind early AAA formation. Future Directions: Gaining more insight into how myeloid cells and ncRNAs contribute to AAA disease, particularly in early stages, might suggest nonsurgical AAA treatment options. The utilization of large animal models might be helpful in this context to help bridge translational results to humans.
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Affiliation(s)
- Christoph Knappich
- Department for Vascular and Endovascular Surgery, Klinikum rechts der Isar, Technical University of Munich, Munich, Germany
| | - Joshua M Spin
- Division of Cardiovascular Medicine, Stanford University School of Medicine, Stanford, California, USA
| | - Hans-Henning Eckstein
- Department for Vascular and Endovascular Surgery, Klinikum rechts der Isar, Technical University of Munich, Munich, Germany
| | - Philip S Tsao
- Division of Cardiovascular Medicine, Stanford University School of Medicine, Stanford, California, USA
| | - Lars Maegdefessel
- Department for Vascular and Endovascular Surgery, Klinikum rechts der Isar, Technical University of Munich, Munich, Germany.,Department of Medicine, Karolinska Institute, Stockholm, Sweden
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95
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Arnaoutakis G, Bianco V, Estrera AL, Brinster DR, Ehrlich MP, Peterson MD, Bossone E, Myrmel T, Pacini D, Montgomery DG, Eagle KA, Bekeredijan R, Shalhub S, De Vincentiis C, Chad Hughes G, Chen EP, Eckstein HH, Nienaber CA, Sultan I. Time of day does not influence outcomes in acute type A aortic dissection: Results from the IRAD. J Card Surg 2020; 35:3467-3473. [PMID: 32939836 DOI: 10.1111/jocs.15017] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2020] [Revised: 07/15/2020] [Accepted: 08/05/2020] [Indexed: 12/25/2022]
Abstract
BACKGROUND Type A acute aortic dissection (TAAAD) represents a surgical emergency requiring intervention regardless of time of day. Whether such a "evening effect" exists regarding outcomes for TAAAD has not been previously studied using a large registry data. METHODS Patients with TAAAD were identified from the International Registry of Acute Aortic Dissections (1996-2019). Outcomes were compared between patients undergoing operative repair during the daytime (D), defined as 8 am-5 pm, versus the evening (N), defined as 5 pm-8 am. RESULTS Four thousand one-hundrd and ninety-seven surgically treated patients with TAAAD were identified, with 1824 patients undergoing daytime surgery (43.5%) and 2373 patients undergoing evening surgery (56.5%). Daytime patients were more likely to have undergone prior cardiac surgery (13.2% vs. 9.5%; p < .001) and have had a prior aortic dissection (4.8% vs. 3.4%; p = .04). Evening patients were more likely to have been transferred from a referring hospital (70.8% vs. 75.0%; p = .003). Daytime patients were more likely to undergo aortic valve sparing root procedures (23.3% vs. 19.2%; p = .035); however, total arch replacement was performed with equal frequency (19.4% vs. 18.8%; p = .751). In-hospital mortality (D: 17.3% vs. N. 16.2%; p = .325) was similar between both groups. Subgroup analysis examining the effect of weekend presentation revealed no significant mortality difference. CONCLUSIONS A majority of TAAAD patients underwent surgical repair at night. There were higher rates of postoperative tamponade in evening patients; however, mortality was similar. The expertise of cardiac-dedicated operative and critical care teams regardless of time of day as well as training paradigms may explain similar mortality outcomes in this high risk population.
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Affiliation(s)
| | - Valentino Bianco
- Division of Cardiac Surgery, Department of Cardiothoracic Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Anthony L Estrera
- International Registry of Acute Aortic Dissections (IRAD), Ann Arbor, Michigan, USA
| | - Derek R Brinster
- International Registry of Acute Aortic Dissections (IRAD), Ann Arbor, Michigan, USA
| | - Marek P Ehrlich
- International Registry of Acute Aortic Dissections (IRAD), Ann Arbor, Michigan, USA
| | - Mark D Peterson
- International Registry of Acute Aortic Dissections (IRAD), Ann Arbor, Michigan, USA
| | - Eduardo Bossone
- International Registry of Acute Aortic Dissections (IRAD), Ann Arbor, Michigan, USA
| | - Truls Myrmel
- International Registry of Acute Aortic Dissections (IRAD), Ann Arbor, Michigan, USA
| | - Davide Pacini
- International Registry of Acute Aortic Dissections (IRAD), Ann Arbor, Michigan, USA
| | - Daniel G Montgomery
- International Registry of Acute Aortic Dissections (IRAD), Ann Arbor, Michigan, USA
| | - Kim A Eagle
- International Registry of Acute Aortic Dissections (IRAD), Ann Arbor, Michigan, USA
| | - Raffi Bekeredijan
- International Registry of Acute Aortic Dissections (IRAD), Ann Arbor, Michigan, USA
| | - Sherene Shalhub
- International Registry of Acute Aortic Dissections (IRAD), Ann Arbor, Michigan, USA
| | - Carlo De Vincentiis
- International Registry of Acute Aortic Dissections (IRAD), Ann Arbor, Michigan, USA
| | - G Chad Hughes
- International Registry of Acute Aortic Dissections (IRAD), Ann Arbor, Michigan, USA
| | - Edward P Chen
- International Registry of Acute Aortic Dissections (IRAD), Ann Arbor, Michigan, USA
| | | | - Christoph A Nienaber
- International Registry of Acute Aortic Dissections (IRAD), Ann Arbor, Michigan, USA
| | - Ibrahim Sultan
- Division of Cardiac Surgery, Department of Cardiothoracic Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania, USA.,Heart and Vascular Institute, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
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96
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Kashyap VS, Schneider PA, Foteh M, Motaganahalli R, Shah R, Eckstein HH, Henao S, LaMuraglia G, Stoner MC, Melton J, Massop D, Hanover T, Titus J, Moore WS, Rodríguez-Carvajal R, Malas MB, Arko FR, Pierce D, Anain P, Oskin T. Early Outcomes in the ROADSTER 2 Study of Transcarotid Artery Revascularization in Patients With Significant Carotid Artery Disease. Stroke 2020; 51:2620-2629. [DOI: 10.1161/strokeaha.120.030550] [Citation(s) in RCA: 63] [Impact Index Per Article: 15.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
Background and Purpose:
Transcarotid artery revascularization (TCAR) is comprised of carotid artery stent placement with cerebral protection via proximal carotid artery clamping and reversal of cerebral arterial flow. The aim of the present study was to evaluate the safety and efficacy of TCAR performed by a broad group of physicians with variable TCAR experience.
Methods:
The ROADSTER 2 study is a prospective, open label, single arm, multicenter, postapproval registry for patients undergoing TCAR. Patients considered at high risk for complications from carotid endarterectomy with symptomatic stenosis ≥50% or asymptomatic stenosis ≥80% were included. The primary end point was procedural success, which encompassed technical success plus the absence of stroke, myocardial infarction, or death within the 30-day postoperative period. Secondary end points included technical success and individual/composite rates of stroke, death, and myocardial infarction (MI). All patients underwent independent neurological assessments before the procedure, within 24 hours, and at 30 days after TCAR. An independent clinical events committee adjudicated all major adverse events.
Results:
Between 2015 and 2019, 692 patients (Intent to Treat Population) were enrolled at 43 sites. Sixty cases had major protocol violations, leaving 632 patients adhering to the Food and Drug Administration-approved protocol (per-protocol population). The majority (81.2%) of operators were TCAR naïve before study initiation. Patients underwent TCAR for neurological symptoms in 26% of cases, and all patients had high-risk factors for carotid endarterectomy (anatomic-related 44%; physiological 32%; both 24%). Technical success occurred in 99.7% of all cases. The primary end point of procedural success rate in the Intent to Treat population was 96.5% (per-protocol 97.9%). The early postoperative outcomes in the Intent to Treat population included stroke in 13 patients (1.9%), death in 3 patients (0.4%), and MI in 6 patients (0.9%). The composite 30-day stroke/death rate was 2.3%, and stroke/death/MI rate was 3.2%. In the per-protocol population, there were strokes in 4 patients (0.6%), death in one patient (0.2%), and MI in 6 patients (0.9%) leading to a composite 30-day stroke/death rate of 0.8% and stroke/death/MI rate of 1.7%.
Conclusions:
TCAR results in excellent early outcomes with high technical success combined with low rates of postprocedure stroke and death. These results were achieved by a majority of operators new to this technology at the start of the trial. Adherence to the study protocol and peri-procedural antiplatelet therapy optimizes outcomes. Longer-term follow-up data are needed to confirm these early outcomes.
Registration:
URL:
https://www.clinicaltrials.gov
. Unique identifier: NCT02536378.
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Affiliation(s)
- Vikram S. Kashyap
- Division of Vascular and Endovascular Surgery, University Hospitals/Case Western Reserve University, Cleveland, OH (V.S.K.)
| | | | - Mazin Foteh
- Cardiothoracic and Vascular surgeons P.A., Austin, TX (M.F.)
| | | | - Rasesh Shah
- Sentara Vascular Specialists, Chesapeake, VA (R.S.)
| | - Hans-Henning Eckstein
- Department for Vascular and Endovascular Surgery, Klinikum rechts der Isar, Technical University of Munich, Germany (H.H.E.)
| | - Steve Henao
- New Mexico Heart Institute, Albuquerque (S.H.)
| | | | | | - Jim Melton
- Advanced Surgical and Research Solutions, Oklahoma City, OK (J.M.)
| | | | | | - Jessica Titus
- Abbott Northwestern Hospital, Minneapolis, MN (J.T.)
| | - Wesley S. Moore
- Division of Vascular Surgery, UCLA Medical Center, Los Angeles, CA (W.S.M.)
| | | | | | | | - Damon Pierce
- Virginia Mason Medical Center, Seattle, WA (D.P.)
| | - Paul Anain
- Sisters of Charity Hospital, Buffalo, NY (P.A.)
| | - Timothy Oskin
- St. Luke’s University Hospital, Bethlehem, PA (T.O.)
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97
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Reutersberg B, Salvermoser M, Trenner M, Geisbüsch S, Zimmermann A, Eckstein HH, Kuehnl A. Hospital Incidence and In-Hospital Mortality of Surgically and Interventionally Treated Aortic Dissections: Secondary Data Analysis of the Nationwide German Diagnosis-Related Group Statistics From 2006 to 2014. J Am Heart Assoc 2020; 8:e011402. [PMID: 30975011 PMCID: PMC6507201 DOI: 10.1161/jaha.118.011402] [Citation(s) in RCA: 46] [Impact Index Per Article: 11.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
Background Population‐based data about the incidence and mortality of patients with aortic dissections (ADs) are sparse. Therefore, the hospital incidence and in‐hospital mortality of patients undergoing open or endovascular surgery for type A ADs (TAADs) and type B ADs (TBADs) in Germany were analyzed on a nationwide basis between 2006 and 2014. Methods and Results A secondary data analysis of the nationwide diagnosis‐related group statistics, compiled by the German Federal Statistical Office, was performed for patients who were surgically/interventionally treated for AD (International Classification of Diseases, Tenth Revision, German Modification [ICD‐10‐GM] codes I71.00‐I71.07; n=20 533). By using specific procedure codes, a distinction between TAAD (n=14 911/72.6%) and TBAD (n=5622/27.4%) could be made. The standardized hospital incidence of surgically/interventionally treated AD was 2.7/100 000 per year, comprising 2.0/100 000 per year for TAAD and 0.7/100 000 per year for TBAD. The in‐hospital mortality of TAAD was 19.5%; and of TBAD, 9.3%. Both the incidence and in‐hospital mortality increased over the 9‐year period. The share of endovascularly treated TBAD increased steadily during the same time interval. A multilevel multivariable analysis revealed that, for TAAD, age and comorbidity were significantly associated with a higher mortality risk. The latter was also true for TBAD. Sex was not significantly associated with mortality. A significant association between higher annual center volume and mortality was found for TAAD, but not for TBAD. Conclusions This is the first report on hospital incidence and mortality for surgically/interventionally treated AD on a nationwide basis. Overall, in Germany, hospital incidence and mortality of TAAD and TBAD increased over time. In addition, TAAD is performed more safely in high‐volume centers. See Editorial Svensson
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Affiliation(s)
- Benedikt Reutersberg
- 1 Department of Vascular and Endovascular Surgery Munich Aortic Centre Klinikum rechts der Isar Technical University of Munich Munich Germany
| | - Michael Salvermoser
- 1 Department of Vascular and Endovascular Surgery Munich Aortic Centre Klinikum rechts der Isar Technical University of Munich Munich Germany
| | - Matthias Trenner
- 1 Department of Vascular and Endovascular Surgery Munich Aortic Centre Klinikum rechts der Isar Technical University of Munich Munich Germany
| | - Sarah Geisbüsch
- 1 Department of Vascular and Endovascular Surgery Munich Aortic Centre Klinikum rechts der Isar Technical University of Munich Munich Germany
| | - Alexander Zimmermann
- 1 Department of Vascular and Endovascular Surgery Munich Aortic Centre Klinikum rechts der Isar Technical University of Munich Munich Germany
| | - Hans-Henning Eckstein
- 1 Department of Vascular and Endovascular Surgery Munich Aortic Centre Klinikum rechts der Isar Technical University of Munich Munich Germany
| | - Andreas Kuehnl
- 1 Department of Vascular and Endovascular Surgery Munich Aortic Centre Klinikum rechts der Isar Technical University of Munich Munich Germany
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Reutersberg B, Salvermoser M, Haller B, Schäffer C, Knipfer E, Laugwitz KL, Eckstein HH. Screening cardiovascular patients for aortic aneurysms (SCAN) - high prevalence of abdominal aortic aneurysms in coronary heart disease patients requiring intervention. VASA 2020; 49:375-381. [PMID: 32631140 DOI: 10.1024/0301-1526/a000881] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
Background: Since the prevalence of abdominal aortic aneurysms (AAA) in Europe has declined to about 2.5%, general screening programs of elderly men are being called into question. On the other hand, other vascular diseases (e.g. coronary heart disease, CHD) are associated with a higher prevalence of AAA. This might have an impact on future targeted AAA screening programs. This study aimed to reevaluate the current prevalence of AAA in male patients with CHD, in order to assess whether CHD patients should be offered a targeted AAA ultrasound screening program. Patients and methods: The SCAN (Screening Cardiovascular Patients for Aortic Aneurysms) study prospectively evaluated the AAA prevalence in 1000 consecutive male CHD patients (70.1 ± 11.2 years) requiring any coronary intervention at an university hospital. All patients received transverse and longitudinal ultrasound scans of the abdominal aorta. Aortic diameter was assessed using the outer-to-outer measurement-technique. Primary endpoint was the prevalence of AAA. Secondary outcomes included stratification in 1-, 2-, or 3-vessel CHD. Results: AAA was detected in 85 patients (median diameter 38 mm, range 30-80 mm), corresponding to an overall prevalence of 8.5%. AAA prevalence was significantly associated with CHD severity: 5.6% in 1-vessel, 7.1% in 2-vessel, and 10.8% in 3-vessel CHD (P = 0.037). The multivariable analysis showed, that age per 10 years increase (OR 1.5, 95% CI 1.2-1.9, P = 0.001) and hyperlipidemia (OR 2.2, 95% CI 1.3-3.8, P = 0.003) were significantly associated with an AAA. The likelihood to be diagnosed with an AAA was significantly lower in non-smokers (OR 0.24, 95% CI, P < 0.001). Conclusions: This study confirms that CHD requiring any type of coronary intervention is strongly associated with AAA in male patients. AAA prevalence increases with CHD severity. Since the AAA prevalence is still significantly higher than in the general population, targeted ultrasound screening should be considered for all CHD patients.
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Affiliation(s)
- Benedikt Reutersberg
- Munich Aortic Center (MAC), Department for Vascular and Endovascular Surgery, Klinikum rechts der Isar, Technical University of Munich, School of Medicine, Munich, Germany
| | - Michael Salvermoser
- Munich Aortic Center (MAC), Department for Vascular and Endovascular Surgery, Klinikum rechts der Isar, Technical University of Munich, School of Medicine, Munich, Germany
| | - Bernhard Haller
- Institute of Medical Informatics, Statistics and Epidemiology, Technical University of Munich, Munich, Germany
| | - Christoph Schäffer
- Munich Aortic Center (MAC), Department for Vascular and Endovascular Surgery, Klinikum rechts der Isar, Technical University of Munich, School of Medicine, Munich, Germany
| | - Eva Knipfer
- Munich Aortic Center (MAC), Department for Vascular and Endovascular Surgery, Klinikum rechts der Isar, Technical University of Munich, School of Medicine, Munich, Germany
| | - Karl-Ludwig Laugwitz
- Department of Cardiology, Klinikum rechts der Isar, Technical University of Munich, School of Medicine, Munich, Germany
| | - Hans-Henning Eckstein
- Munich Aortic Center (MAC), Department for Vascular and Endovascular Surgery, Klinikum rechts der Isar, Technical University of Munich, School of Medicine, Munich, Germany
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Karlas A, Kallmayer M, Fasoula NA, Liapis E, Bariotakis M, Krönke M, Anastasopoulou M, Reber J, Eckstein HH, Ntziachristos V. Multispectral optoacoustic tomography of muscle perfusion and oxygenation under arterial and venous occlusion: A human pilot study. J Biophotonics 2020; 13:e201960169. [PMID: 32134550 DOI: 10.1002/jbio.201960169] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/28/2019] [Revised: 01/26/2020] [Accepted: 02/11/2020] [Indexed: 05/21/2023]
Abstract
Perfusion and oxygenation are critical parameters of muscle metabolism in health and disease. They have been both the target of many studies, in particular using near-infrared spectroscopy (NIRS). However, difficulties with quantifying NIRS signals have limited a wide dissemination of the method to the clinics. Our aim was to investigate whether clinical multispectral optoacoustic tomography (MSOT) could enable the label-free imaging of muscle perfusion and oxygenation under clinically relevant challenges: the arterial and venous occlusion. We employed a hybrid clinical MSOT/ultrasound system equipped with a hand-held scanning probe to visualize hemodynamic and oxygenation changes in skeletal muscle under arterial and venous occlusions. Four (N = 4) healthy volunteers were scanned over the forearm for both 3-minute occlusion challenges. MSOT-recorded pathophysiologically expected results during tests of disturbed blood flow with high resolution and without the need for contrast agents. During arterial occlusion, MSOT-extracted Hb-values showed an increase, while HbO2 - and total blood volume (TBV)-values remained roughly steady, followed by a discrete increase during the hyperemic period after cuff deflation. During venous occlusion, results showed a clear increase in intramuscular HbO2 , Hb and TBV within the segmented muscle area. MSOT was found to be capable of label-free non-invasive imaging of muscle hemodynamics and oxygenation under arterial and venous occlusion. We introduce herein MSOT as a novel modality for the assessment of vascular disorders characterized by disturbed blood flow, such as acute limb ischemia and venous thrombosis.
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Affiliation(s)
- Angelos Karlas
- Chair for Biological Imaging, Center for Translational Cancer Research (TranslaTUM), Technical University of Munich, Munich, Germany
- Helmholtz Zentrum München, Institute of Biological and Medical Imaging, Neuherberg, Germany
- Clinic of Vascular and Endovascular Surgery, Technical University of Munich, Munich, Germany
- DZHK (German Centre for Cardiovascular Research), Partner Site Munich Heart Alliance, Munich, Germany
| | - Michael Kallmayer
- Clinic of Vascular and Endovascular Surgery, Technical University of Munich, Munich, Germany
| | - Nikolina-Alexia Fasoula
- Chair for Biological Imaging, Center for Translational Cancer Research (TranslaTUM), Technical University of Munich, Munich, Germany
- Helmholtz Zentrum München, Institute of Biological and Medical Imaging, Neuherberg, Germany
| | - Evangelos Liapis
- Chair for Biological Imaging, Center for Translational Cancer Research (TranslaTUM), Technical University of Munich, Munich, Germany
- Helmholtz Zentrum München, Institute of Biological and Medical Imaging, Neuherberg, Germany
| | - Michail Bariotakis
- Chair for Biological Imaging, Center for Translational Cancer Research (TranslaTUM), Technical University of Munich, Munich, Germany
- Helmholtz Zentrum München, Institute of Biological and Medical Imaging, Neuherberg, Germany
| | - Markus Krönke
- Clinic of Nuclear Medicine, Technical University of Munich, Klinikum Rechts der Isar, Germany
| | - Maria Anastasopoulou
- Chair for Biological Imaging, Center for Translational Cancer Research (TranslaTUM), Technical University of Munich, Munich, Germany
- Helmholtz Zentrum München, Institute of Biological and Medical Imaging, Neuherberg, Germany
| | - Josefine Reber
- Chair for Biological Imaging, Center for Translational Cancer Research (TranslaTUM), Technical University of Munich, Munich, Germany
- Helmholtz Zentrum München, Institute of Biological and Medical Imaging, Neuherberg, Germany
| | - Hans-Henning Eckstein
- Clinic of Vascular and Endovascular Surgery, Technical University of Munich, Munich, Germany
- DZHK (German Centre for Cardiovascular Research), Partner Site Munich Heart Alliance, Munich, Germany
| | - Vasilis Ntziachristos
- Chair for Biological Imaging, Center for Translational Cancer Research (TranslaTUM), Technical University of Munich, Munich, Germany
- Helmholtz Zentrum München, Institute of Biological and Medical Imaging, Neuherberg, Germany
- DZHK (German Centre for Cardiovascular Research), Partner Site Munich Heart Alliance, Munich, Germany
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Affiliation(s)
- Kosmas I. Paraskevas
- Department of General and Vascular Surgery, Central Clinic of Athens, Athens, Greece
| | - Hans-Henning Eckstein
- Department for Vascular and Endovascular Surgery, Klinikum rechts der Isar, Technical University of Munich, Munich, Germany
| | - Frank J. Veith
- Divisions of Vascular Surgery, New York University Langone Medical Center, New York, NY, USA
- The Cleveland Clinic, Cleveland, OH, USA
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