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Vaddavalli VV, Shekhar S, Jiang L, Chait JD, Ramakrishna H. Transcarotid Artery Revascularization Versus Carotid Endarterectomy: Analysis of Outcomes. J Cardiothorac Vasc Anesth 2024; 38:2471-2476. [PMID: 38880675 DOI: 10.1053/j.jvca.2024.05.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/08/2024] [Accepted: 05/10/2024] [Indexed: 06/18/2024]
Affiliation(s)
| | - Shashank Shekhar
- Department of Cardiovascular Medicine, Heart and Vascular Institute, Cleveland Clinic, Cleveland, OH
| | - Lai Jiang
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, MN
| | - Jesse D Chait
- Division of Vascular and Endovascular Surgery, Mayo Clinic, Rochester, MN
| | - Harish Ramakrishna
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, MN.
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Mazzolai L, Teixido-Tura G, Lanzi S, Boc V, Bossone E, Brodmann M, Bura-Rivière A, De Backer J, Deglise S, Della Corte A, Heiss C, Kałużna-Oleksy M, Kurpas D, McEniery CM, Mirault T, Pasquet AA, Pitcher A, Schaubroeck HAI, Schlager O, Sirnes PA, Sprynger MG, Stabile E, Steinbach F, Thielmann M, van Kimmenade RRJ, Venermo M, Rodriguez-Palomares JF. 2024 ESC Guidelines for the management of peripheral arterial and aortic diseases. Eur Heart J 2024; 45:3538-3700. [PMID: 39210722 DOI: 10.1093/eurheartj/ehae179] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 09/04/2024] Open
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Hakimi A, Choi ES, Aziz F, Aziz F. Evolution of Medical and Surgical Management of Carotid Disease - From Carotid Endarterectomy to Transfemoral Carotid Stenting to TCAR. Ann Vasc Surg 2024:S0890-5096(24)00597-1. [PMID: 39332702 DOI: 10.1016/j.avsg.2024.09.042] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2024] [Revised: 09/09/2024] [Accepted: 09/17/2024] [Indexed: 09/29/2024]
Abstract
Patients with carotid stenosis can be broadly classified into two categories: symptomatic and asymptomatic. While there is little disagreement about surgical management of symptomatic carotid stenosis, the optimal management strategy for the patients with asymptomatic carotid disease has undergone significant evolution over past five decades. With increasing focus on role of plaque morphology on the etiology of symptoms, there has been an increased focus on optimizing the medical management targeted at plaque stabilization, especially for the patients with asymptomatic carotid disease, while reserving the most aggressive surgical treatment options for the patients with symptomatic carotid stenosis. This review summarizes the scientific evidence based on multiple large clinical studies showing how the modern-day management of carotid stenosis has evolved. Multiple, large randomized clinical trials have established carotid endarterectomy (CEA) as the treatment of choice for symptomatic patients with symptomatic, >50% stenosis of carotid artery or those who have asymptomatic high grade carotid stenosis. With the advancements in endovascular techniques, the technique of Trans Femoral Carotid Artery Stenting (TF-CAS) was popularized, but after multiple, large randomized controlled trials demonstrated superiority of CEA, the indications for TF-CAS as the initial operation of choice for carotid disease for all patients have been reduced. In the past five years, the introduction of the newer technique of Trans Carotid Artery Revascularization (TCAR) has shown promising results with significant reduction in the incidence of perioperative complications as compared to CEA and TF-CAS, however, there have been no randomized controlled trials comparing TCAR to either CEA or TF-CAS. Moreover, with the developments in the medical field with introduction of several new medications which have been demonstrated to successfully change the plaque morphology, there has been a renewed interest in exploring if the indications for surgical management for the asymptomatic carotid disease should be revisited.
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Affiliation(s)
- Ali Hakimi
- Division of Vascular Surgery, Heart & Vascular Institute, Penn State Milton S. Hershey Medical Center, Hershey, PA 17033
| | - Esther S Choi
- Office of Medical Education, Penn State College of Medicine, Penn State University, Hershey, PA 17033
| | - Faryal Aziz
- Division of Vascular Surgery, Heart & Vascular Institute, Penn State Milton S. Hershey Medical Center, Hershey, PA 17033
| | - Faisal Aziz
- Division of Vascular Surgery, Heart & Vascular Institute, Penn State Milton S. Hershey Medical Center, Hershey, PA 17033.
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Voeks JH, Panthofer AM, Matsumura JS, Howard VJ, Howard G, Roubin GS, Brott TG, Rosenfield K, Hanlon BM. Sex and outcomes after stenting and endarterectomy in asymptomatic severe carotid stenosis patients. J Stroke Cerebrovasc Dis 2024; 33:108004. [PMID: 39284461 DOI: 10.1016/j.jstrokecerebrovasdis.2024.108004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2024] [Revised: 09/04/2024] [Accepted: 09/06/2024] [Indexed: 09/21/2024] Open
Abstract
OBJECTIVES To determine if sex was an effect modifier in a pooled analysis of asymptomatic patients from CREST and ACT I. MATERIALS AND METHODS We analyzed data from 2544 patients aged <80 with ≥70 % asymptomatic carotid stenosis randomized to CAS or CEA (nCREST = 1091; nACT-1 = 1453). The pre-specified primary endpoint in both trials was any stroke, myocardial infarction or death during the peri-procedural period, or ipsilateral stroke within 4 years of randomization. The secondary endpoint was any stroke or death during the peri-procedural period, or ipsilateral stroke within 4 years of randomization. RESULTS There was no significant difference in the frequency of events for men or women between CAS and CEA for the primary or secondary endpoints. When assessing for an interaction of sex and risks between procedures, the treatment-by-sex interaction was not significant for either primary or secondary endpoints in the four-year period or the peri-procedural period. However, women had significantly fewer post-procedural events (ipsilateral stroke) with CAS than CEA (HR = 0.33, 95 % CI: 0.09-1.18) compared to men (HR = 2.09, 95 % CI: 0.78-5.61), p = 0.02 for interaction. CONCLUSIONS In this large, pooled analysis of asymptomatic patients comparing CAS to CEA, sex did not act as an effect modifier of treatment differences in the four-year primary stroke-MI-or-death endpoint or the secondary stroke-or-death endpoint. However, during the post-procedural period men treated with CAS were at higher risk than their female counterparts.
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Affiliation(s)
- Jenifer H Voeks
- Department of Neurology, Medical University of South Carolina, Charleston, SC, USA.
| | - Annalise M Panthofer
- Department of Surgery, University of Wisconsin School of Medicine and Public Health, Madison, WI, USA.
| | - Jon S Matsumura
- Division of Vascular Surgery, University of Colorado School of Medicine, Aurora, CO, USA.
| | - Virginia J Howard
- Department of Epidemiology, School of Public Health, University of Alabama at Birmingham, Birmingham, AL, USA.
| | - George Howard
- Department of Biostatistics, School of Public Health, University of Alabama at Birmingham, Birmingham, AL, USA.
| | - Gary S Roubin
- Chair, CREST-2 Interventional Management Committee, Jackson, WY, USA.
| | - Thomas G Brott
- Department of Neurology, Mayo Clinic, Jacksonville, FL, USA.
| | - Kenneth Rosenfield
- Division of Cardiology, Massachusetts General Hospital, Boston, MA, USA.
| | - Bret M Hanlon
- Department of Biostatistics & Medical Informatics, University of Wisconsin-Madison, Madison, WI, USA.
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Vitali F, Torrandell-Haro G, Branigan G, Arias Aristizabal J, Reiman E, Bedrick EJ, Brinton RD, Weinkauf C. Asymptomatic carotid artery stenosis is associated with increased Alzheimer's disease and non-Alzheimer's disease dementia risk. Stroke Vasc Neurol 2024:svn-2024-003164. [PMID: 39266210 DOI: 10.1136/svn-2024-003164] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2024] [Accepted: 08/23/2024] [Indexed: 09/14/2024] Open
Abstract
BACKGROUND In the absence of a cerebrovascular accident, whether asymptomatic extracranial carotid atherosclerotic disease (aECAD) affects Alzheimer's disease (AD) and non-AD dementia risk is not clear. Understanding whether aECAD is associated with an increased risk for AD is important as it is present in roughly 10% of the population over 60 and could represent a modifiable risk factor for AD and non-AD dementia. METHODS This retrospective cohort study analysed Mariner insurance claims. Enrolment criteria included patients aged 55 years or older with at least 5 years of data and no initial dementia diagnosis. Subjects with and without aECAD were evaluated for subsequent AD and non-AD dementia diagnoses. Propensity score matching was performed using confounding factors identified by logistic regression. χ2 tests and Kaplan-Meier survival curves were used to evaluate the impact of aECAD diagnosis on AD and non-AD dementia risk over time. RESULTS 767 354 patients met enrolment criteria. After propensity score matching, 62 963 subjects with aECAD and 62 963 subjects without ECAD were followed through data records. The aECAD cohort exhibited an increased relative risk of 1.22 (95% CI 1.15 to 1.29, p<0.001) for AD and 1.48 (95% CI 1.38 to 1.59, p<0.001) for non-AD dementias compared with the propensity score-matched cohort without aECAD. The increased AD risk associated with aECAD was evident in patients younger than 75 years old and was less apparent in patients over 75 years of age. CONCLUSIONS aECAD is associated with an increased risk of developing AD and non-AD dementias. These findings underscore the need for further prospective evaluation of interactions between aECAD and dementia, with potential implications for change of clinical care in both of these large patient populations.
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Affiliation(s)
- Francesca Vitali
- Neurology, The University of Arizona College of Medicine, Tucson, Arizona, USA
- Center for Innovation In Brain Science, The University of Arizona College of Medicine, Tucson, Arizona, USA
| | - Georgina Torrandell-Haro
- Center for Innovation In Brain Science, The University of Arizona College of Medicine, Tucson, Arizona, USA
| | - Gregory Branigan
- The University of Arizona College of Medicine, Tucson, Arizona, USA
| | - Juan Arias Aristizabal
- Department of Surgery, The University of Arizona College of Medicine, Tucson, Arizona, USA
| | - Eric Reiman
- Banner Alzheimer's Institute, Phoenix, Arizona, USA
| | - Edward J Bedrick
- Center for Biomedical Informatics and Biostatistics, University of Arizona Medical Center - University Campus, Tucson, Arizona, USA
| | - Roberta Diaz Brinton
- Center for Innovation In Brain Science, The University of Arizona College of Medicine, Tucson, Arizona, USA
| | - Craig Weinkauf
- Department of Surgery, The University of Arizona College of Medicine, Tucson, Arizona, USA
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Oomori D, Akamatsu Y, Uwano I, Mori F, Matsuda T, Sugimoto R, Suzuki M, Fujiwara S, Kobayashi M, Sasaki M, Yoshioka K, Yanagawa N, Ogasawara K. Diagnostic Accuracy of Preoperative Quantitative Susceptibility Mapping for Detecting Histologic Intraplaque Hemorrhage in Cervical ICA Stenosis in Patients Undergoing Carotid Endarterectomy. AJNR Am J Neuroradiol 2024:ajnr.A8356. [PMID: 38789122 DOI: 10.3174/ajnr.a8356] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2024] [Accepted: 05/21/2024] [Indexed: 05/26/2024]
Abstract
BACKGROUND AND PURPOSE Quantitative susceptibility mapping has been proposed to assess intraplaque hemorrhage (IPH) in the carotid artery. The purpose of this study was to compare the diagnostic accuracy of preoperative quantitative susceptibility mapping with that of the conventional T1-weighed 3D-FSE sequence for detecting IPH in cervical ICA stenosis in patients undergoing carotid endarterectomy by using histology as the reference standard. MATERIALS AND METHODS Carotid T1-weighted 3D-FSE and QSM images were obtained from 16 patients with cervical ICA stenosis before carotid endarterectomy. Relative signal intensity and susceptibility of the ICA were measured on 3 axial images, including the location of most severe stenosis on T1-weighted 3D-FSE and quantitative susceptibility mapping images, respectively. Three transverse sections of carotid plaques excised by carotid endarterectomy, which corresponded with images on MR imaging, were stained with H&E, antibody against glycophorin A, and Prussian blue, and the relative area of histologic IPH was calculated. RESULTS The correlation coefficient was significantly greater between susceptibility and relative area-histologic IPH (ρ = 0.691) than between relative signal intensity and relative area-histologic IPH (ρ = 0.413; P = .0259). The areas under the receiver operating characteristic curves for detecting histologic sections consisting primarily of IPH (relative area-histologic IPH > 40.7%) tended to be greater for susceptibility (0.964) than for T1WI FSE-relative signal intensity (0.811). Marginal homogeneity was observed between susceptibility and histologic sections consisting primarily of IPH (P = .0412), but not between T1-weighted FSE-relative signal intensity and histologic sections consisting primarily of IPH (P = .1824). CONCLUSIONS Pre-carotid endarterectomy quantitative susceptibility mapping detects histologic IPH in cervical ICA stenosis more accurately than preoperative T1-weighted 3D-FSE imaging.
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Affiliation(s)
- Daisuke Oomori
- From the Department of Neurosurgery (D.O., Y.A., S.F., M.K., K.O.), Iwate Medical University School of Medicine, Yahaba-cho, Japan
| | - Yosuke Akamatsu
- From the Department of Neurosurgery (D.O., Y.A., S.F., M.K., K.O.), Iwate Medical University School of Medicine, Yahaba-cho, Japan
| | - Ikuko Uwano
- Division of Ultrahigh Field MRI (I.U., F.M., T.M., M. Suzuki), Institute for Biomedical Sciences, Iwate Medical University School of Medicine, Yahaba-cho, Japan
| | - Futoshi Mori
- Division of Ultrahigh Field MRI (I.U., F.M., T.M., M. Suzuki), Institute for Biomedical Sciences, Iwate Medical University School of Medicine, Yahaba-cho, Japan
| | - Tsuyoshi Matsuda
- Division of Ultrahigh Field MRI (I.U., F.M., T.M., M. Suzuki), Institute for Biomedical Sciences, Iwate Medical University School of Medicine, Yahaba-cho, Japan
| | - Ryo Sugimoto
- Department of Molecular Diagnostic Pathology (R.S., N.Y.), Iwate Medical University School of Medicine, Yahaba-cho, Japan
| | - Michiko Suzuki
- Division of Ultrahigh Field MRI (I.U., F.M., T.M., M. Suzuki), Institute for Biomedical Sciences, Iwate Medical University School of Medicine, Yahaba-cho, Japan
| | - Shunrou Fujiwara
- From the Department of Neurosurgery (D.O., Y.A., S.F., M.K., K.O.), Iwate Medical University School of Medicine, Yahaba-cho, Japan
| | - Masakazu Kobayashi
- From the Department of Neurosurgery (D.O., Y.A., S.F., M.K., K.O.), Iwate Medical University School of Medicine, Yahaba-cho, Japan
| | - Makoto Sasaki
- Department of Radiology (M.S, K.Y), Iwate Medical University School of Medicine, Yahaba-cho, Japan
| | - Kunihiro Yoshioka
- Department of Radiology (M.S, K.Y), Iwate Medical University School of Medicine, Yahaba-cho, Japan
| | - Naoki Yanagawa
- Department of Molecular Diagnostic Pathology (R.S., N.Y.), Iwate Medical University School of Medicine, Yahaba-cho, Japan
| | - Kuniaki Ogasawara
- From the Department of Neurosurgery (D.O., Y.A., S.F., M.K., K.O.), Iwate Medical University School of Medicine, Yahaba-cho, Japan
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Li B, Eisenberg N, Beaton D, Lee DS, Al-Omran L, Wijeysundera DN, Hussain MA, Rotstein OD, de Mestral C, Mamdani M, Roche-Nagle G, Al-Omran M. Using Machine Learning to Predict Outcomes Following Transfemoral Carotid Artery Stenting. J Am Heart Assoc 2024; 13:e035425. [PMID: 39189482 DOI: 10.1161/jaha.124.035425] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/08/2024] [Accepted: 07/23/2024] [Indexed: 08/28/2024]
Abstract
BACKGROUND Transfemoral carotid artery stenting (TFCAS) carries important perioperative risks. Outcome prediction tools may help guide clinical decision-making but remain limited. We developed machine learning algorithms that predict 1-year stroke or death following TFCAS. METHODS AND RESULTS The VQI (Vascular Quality Initiative) database was used to identify patients who underwent TFCAS for carotid artery stenosis between 2005 and 2024. We identified 112 features from the index hospitalization (82 preoperative [demographic/clinical], 13 intraoperative [procedural], and 17 postoperative [in-hospital course/complications]). The primary outcome was 1-year postprocedural stroke or death. The data were divided into training (70%) and test (30%) sets. Six machine learning models were trained using preoperative features with 10-fold cross-validation. The primary model evaluation metric was area under the receiver operating characteristic curve. The algorithm with the best performance was further trained using intra- and postoperative features. Model robustness was assessed using calibration plots and Brier scores. Overall, 35 214 patients underwent TFCAS during the study period and 3257 (9.2%) developed 1-year stroke or death. The best preoperative prediction model was extreme gradient boosting, achieving an area under the receiver operating characteristic curve of 0.94 (95% CI, 0.93-0.95). In comparison, logistic regression had an AUROC of 0.65 (95% CI, 0.63-0.67). The extreme gradient boosting model maintained excellent performance at the intra- and postoperative stages, with area under the receiver operating characteristic curve values of 0.94 (95% CI, 0.93-0.95) and 0.98 (95% CI, 0.97-0.99), respectively. Calibration plots showed good agreement between predicted/observed event probabilities with Brier scores of 0.11 (preoperative), 0.11 (intraoperative), and 0.09 (postoperative). CONCLUSIONS Machine learning can accurately predict 1-year stroke or death following TFCAS, performing better than logistic regression.
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Affiliation(s)
- Ben Li
- Department of Surgery University of Toronto Ontario Canada
- Division of Vascular Surgery St. Michael's Hospital, Unity Health Toronto Toronto Ontario Canada
- Institute of Medical Science, University of Toronto Ontario Canada
- Temerty Centre for Artificial Intelligence Research and Education in Medicine (T-CAIREM) University of Toronto Ontario Canada
| | - Naomi Eisenberg
- Division of Vascular Surgery, Peter Munk Cardiac Centre University Health Network Toronto Ontario Canada
| | - Derek Beaton
- Data Science & Advanced Analytics, Unity Health Toronto University of Toronto Ontario Canada
| | - Douglas S Lee
- Division of Cardiology, Peter Munk Cardiac Centre University Health Network Toronto Ontario Canada
- Institute of Health Policy, Management and Evaluation, University of Toronto Ontario Canada
- ICES, University of Toronto Ontario Canada
| | - Leen Al-Omran
- School of Medicine Alfaisal University Riyadh Saudi Arabia
| | - Duminda N Wijeysundera
- Institute of Health Policy, Management and Evaluation, University of Toronto Ontario Canada
- ICES, University of Toronto Ontario Canada
- Department of Anesthesia St. Michael's Hospital, Unity Health Toronto Toronto Ontario Canada
- Li Ka Shing Knowledge Institute, St. Michael's Hospital, Unity Health Toronto Toronto Ontario Canada
| | - Mohamad A Hussain
- Division of Vascular and Endovascular Surgery and the Center for Surgery and Public Health Brigham and Women's Hospital, Harvard Medical School Boston MA USA
| | - Ori D Rotstein
- Department of Surgery University of Toronto Ontario Canada
- Institute of Medical Science, University of Toronto Ontario Canada
- Li Ka Shing Knowledge Institute, St. Michael's Hospital, Unity Health Toronto Toronto Ontario Canada
- Division of General Surgery St. Michael's Hospital, Unity Health Toronto Toronto Ontario Canada
| | - Charles de Mestral
- Department of Surgery University of Toronto Ontario Canada
- Division of Vascular Surgery St. Michael's Hospital, Unity Health Toronto Toronto Ontario Canada
- Institute of Health Policy, Management and Evaluation, University of Toronto Ontario Canada
- ICES, University of Toronto Ontario Canada
- Li Ka Shing Knowledge Institute, St. Michael's Hospital, Unity Health Toronto Toronto Ontario Canada
| | - Muhammad Mamdani
- Institute of Medical Science, University of Toronto Ontario Canada
- Temerty Centre for Artificial Intelligence Research and Education in Medicine (T-CAIREM) University of Toronto Ontario Canada
- Data Science & Advanced Analytics, Unity Health Toronto University of Toronto Ontario Canada
- Institute of Health Policy, Management and Evaluation, University of Toronto Ontario Canada
- ICES, University of Toronto Ontario Canada
- Li Ka Shing Knowledge Institute, St. Michael's Hospital, Unity Health Toronto Toronto Ontario Canada
- Leslie Dan Faculty of Pharmacy University of Toronto Ontario Canada
| | - Graham Roche-Nagle
- Department of Surgery University of Toronto Ontario Canada
- Division of Vascular Surgery, Peter Munk Cardiac Centre University Health Network Toronto Ontario Canada
- Division of Vascular and Interventional Radiology University Health Network Toronto Ontario Canada
| | - Mohammed Al-Omran
- Department of Surgery University of Toronto Ontario Canada
- Division of Vascular Surgery St. Michael's Hospital, Unity Health Toronto Toronto Ontario Canada
- Institute of Medical Science, University of Toronto Ontario Canada
- Temerty Centre for Artificial Intelligence Research and Education in Medicine (T-CAIREM) University of Toronto Ontario Canada
- Li Ka Shing Knowledge Institute, St. Michael's Hospital, Unity Health Toronto Toronto Ontario Canada
- Department of Surgery King Faisal Specialist Hospital and Research Center Riyadh Saudi Arabia
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Im SH, Moon BH, Han YM, Cho BR, Park SK. Comparative Analysis of Balloon Angioplasty Alone versus Carotid Artery Stenting for Severe Extracranial Carotid Artery Stenosis: A 4-Year Retrospective Study. World Neurosurg 2024; 189:e1013-e1021. [PMID: 39004183 DOI: 10.1016/j.wneu.2024.07.066] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2024] [Revised: 07/07/2024] [Accepted: 07/08/2024] [Indexed: 07/16/2024]
Abstract
BACKGROUND This retrospective study aimed to compare the efficacy of balloon angioplasty alone (BAA) with carotid artery stenting (CAS) for severe extracranial carotid artery stenosis. The primary outcomes assessed were restenosis requiring retreatment and symptomatic stroke occurrence within a 4-year follow-up period. METHODS A total of 77 patients with 89 carotid artery stenoses undergoing endovascular carotid revascularization between January 2015 and December 2019 were included. Neuroradiologic evaluations, including computed tomography angiography or magnetic resonance angiography, were performed at defined intervals. Statistical analyses were conducted to compare patient characteristics, angiographic outcomes, and clinical outcomes between the BAA and CAS groups. RESULTS The study demonstrated successful outcomes in both groups with low adverse event rates. The overall restenosis rate was 40.2%, but severe restenosis requiring retreatment occurred in only 10 cases (7 in BAA, and 3 in CAS). No significant difference was found in retreatment rates between the 2 groups (P = 0.53). Stroke occurrence within the 4-year follow-up period was observed in 3 patients, with no statistically significant difference between BAA and CAS groups. CONCLUSIONS This study provides valuable insights into the comparative effectiveness of BAA and CAS for severe extracranial carotid artery stenosis. Despite slightly shorter intervals to restenosis in the BAA group, there was no significant difference in retreatment or stroke occurrence rates between the 2 procedures. BAA offers advantages in terms of retreatment options.
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Affiliation(s)
- Sang Hyuk Im
- Department of Neurosurgery, Eunpyeong St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| | - Byung Hoo Moon
- Department of Neurosurgery, Incheon Sarang Hospital, Incheon, Republic of Korea
| | - Young-Min Han
- Department of Neurosurgery, Naeun Hospital, Incheon, Republic of Korea
| | - Byung-Rae Cho
- Department of Neurosurgery, Incheon St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| | - Sang Kyu Park
- Department of Neurosurgery, Gangnam Severance Hospital, College of Medicine, Yonsei University Seoul, Seoul, Republic of Korea.
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Ishii D, Hara T, Kuwabara M, Kondo H, Kume S, Horie N. Outcome of CAS under flow reversal and analysis for the intraprocedural flow of internal carotid artery. Clin Neurol Neurosurg 2024; 244:108443. [PMID: 38991391 DOI: 10.1016/j.clineuro.2024.108443] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2024] [Revised: 05/31/2024] [Accepted: 07/07/2024] [Indexed: 07/13/2024]
Abstract
OBJECTIVE Carotid artery stenting (CAS) under flow reversal with dual protection using a proximal balloon and distal filter has been an established procedure for internal carotid artery (ICA) stenosis. This study investigates the effect of external carotid artery (ECA) occlusion on outcomes of CAS and ICA flow under flow reversal. METHODS We reviewed 231 cases of CAS under flow reversal with ECA occlusion and 32 without. In the last 14 of 32 cases, the flow in the ICA under flow reversal was analyzed by ultrasound. The collateral index, which was defined as the total value of the maximum diameters of the ipsilateral anterior cerebral artery at the A1 segment and the anterior communicating artery, as well as those of the ipsilateral posterior cerebral artery at the P1 segment and the ipsilateral posterior communicating artery, and the maximum diameter of the ipsilateral ECA were correlated with the flow direction in the ICA. RESULTS There was no significant difference in the outcome of CAS between the groups with or without ECA occlusion. Among the 14 cases without ECA occlusion, antegrade flow in the ICA was observed in 6 cases (42.9 %). The group with the antegrade flow in the ICA exhibited a significantly lower collateral index (5.08±0.33 vs 6.71±0.28, p=0.01) and a significantly larger ECA diameter (4.66±0.51 mm vs 3.21±1.24 mm, p=0.01) than the group with the stagnant or retrograde flow in the ICA. CONCLUSIONS The outcomes of CAS under flow reversal were acceptable even without ECA occlusion. The ECA occlusion may not be necessary for CAS under dual protection; however, distal filter protection should be used even under flow reversal.
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Affiliation(s)
- Daizo Ishii
- Department of Neurosurgery, Graduate School of Biomedical and Health Sciences, Hiroshima University, Hiroshima, Japan.
| | - Takeshi Hara
- Department of Neurosurgery, Graduate School of Biomedical and Health Sciences, Hiroshima University, Hiroshima, Japan
| | - Masashi Kuwabara
- Department of Neurosurgery, Graduate School of Biomedical and Health Sciences, Hiroshima University, Hiroshima, Japan
| | - Hiroshi Kondo
- Department of Neurosurgery, Graduate School of Biomedical and Health Sciences, Hiroshima University, Hiroshima, Japan
| | - Shinji Kume
- Department of Clinical Laboratory, Hiroshima University Hospital, Hiroshima, Japan
| | - Nobutaka Horie
- Department of Neurosurgery, Graduate School of Biomedical and Health Sciences, Hiroshima University, Hiroshima, Japan
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Chamseddine H, Chahrour M, Aboul Hosn M, Kabbani L. In Patients with Heart Failure Undergoing Carotid Endarterectomy, Locoregional Anesthesia is Not Associated with Decreased Mortality, Stroke, or Myocardial Infarction Compared to General Anesthesia. Ann Vasc Surg 2024; 106:189-195. [PMID: 38821474 DOI: 10.1016/j.avsg.2024.03.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2024] [Revised: 03/05/2024] [Accepted: 03/09/2024] [Indexed: 06/02/2024]
Abstract
BACKGROUND While existing literature reports no benefit of locoregional anesthesia (LRA) over general anesthesia (GA) in patients undergoing carotid endarterectomy (CEA), the effect of LRA on patients with congestive heart failure (CHF) has not been explored. This study aims to assess whether the choice of anesthesia plays a role in influencing outcomes within this population. METHODS Using the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) files between 2005 and 2022 and the procedural targeted ACS-NSQIP database for CEA between 2011-2022, all patients receiving CEA were identified, and the subset of patients with CHF was included. Patient characteristics and 30-day outcomes were compared using χ2 or Fischer's exact test as appropriate for categorical variables and the independent t-test or Mann-Whitney U test as appropriate for continuous variables. Mortality, stroke, myocardial infarction (MI), and major adverse cardiac events (MACE) were compared between patients receiving GA and LRA using univariate analysis. RESULTS A total of 3,040 patients (2,733 undergoing GA, 307 undergoing LRA) with a diagnosis of CHF undergoing CEA were identified. No difference in mortality (GA 3.1% vs. LRA 4.6%, P = 0.162), MI (GA 3.0% vs. LRA 2.3%, P = 0.478), stroke (2.4% vs. 2.6%, P = 0.805) or MACE (GA 7.4% vs. LRA 8.1%, P = 0.654) was observed. LRA patients had a significantly lower hospital stay compared to GA patients (1 day [interquartile range (IQR) 1-3] vs. 2 days [IQR 1-4], P < 0.001). Shunt was more commonly used in patients receiving GA (32.9% vs. 12.5%, P < 0.001) compared to LRA. CONCLUSIONS While utilizing LRA compared to GA during CEA in patients with CHF is associated with a shorter hospital stay and less intraoperative shunting, the choice of anesthesia did not impact the outcomes of mortality, MI or stroke. Further research is needed to determine the effect of LRA on the outcomes of CEA among patients with different stages of heart failure.
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Affiliation(s)
- Hassan Chamseddine
- Division of Vascular Surgery, Department of Surgery, Henry Ford Hospital, Detroit, MI.
| | - Mohamad Chahrour
- Division of Vascular Surgery, Department of Surgery, University of Iowa Hospital and Clinics, Iowa City, IA
| | - Maen Aboul Hosn
- Division of Vascular Surgery, Department of Surgery, University of Iowa Hospital and Clinics, Iowa City, IA
| | - Loay Kabbani
- Division of Vascular Surgery, Department of Surgery, Henry Ford Hospital, Detroit, MI.
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11
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Desikan SK, Brahmbhatt B, Patel J, Kankaria AA, Anagnostakos J, Dux M, Beach K, Gray VL, McDonald T, Crone C, Sikdar S, Sorkin JD, Lal BK. Cognitive impairment in asymptomatic carotid artery stenosis is associated with abnormal segments in the Circle of Willis. J Vasc Surg 2024; 80:746-755.e2. [PMID: 38710420 PMCID: PMC11343677 DOI: 10.1016/j.jvs.2024.04.059] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2024] [Revised: 04/11/2024] [Accepted: 04/24/2024] [Indexed: 05/08/2024]
Abstract
OBJECTIVE Our group has previously demonstrated that patients with asymptomatic carotid artery stenosis (ACAS) demonstrate cognitive impairment. One proposed mechanism for cognitive impairment in patients with ACAS is cerebral hypoperfusion due to flow-restriction. We tested whether the combination of a high-grade carotid stenosis and inadequate cross-collateralization in the Circle of Willis (CoW) resulted in worsened cognitive impairment. METHODS Twenty-four patients with high-grade (≥70% diameter-reducing) ACAS underwent carotid duplex ultrasound, cognitive assessment, and 3D time-of-flight magnetic resonance angiography. The cognitive battery consisted of nine neuropsychological tests assessing four cognitive domains: learning and recall, attention and working memory, motor and processing speed, and executive function. Raw cognitive scores were converted into standardized T-scores. A structured interpretation of the magnetic resonance angiography images was performed with each segment of the CoW categorized as being either normal or abnormal. Abnormal segments of the CoW were defined as segments characterized as narrowed or occluded due to congenital aplasia or hypoplasia, or acquired atherosclerotic stenosis or occlusion. Linear regression was used to estimate the association between the number of abnormal segments in the CoW, and individual cognitive domain scores. Significance was set to P < .05. RESULTS The mean age of the patients was 66.1 ± 9.6 years, and 79.2% (n = 19) were male. A significant negative association was found between the number of abnormal segments in the CoW and cognitive scores in the learning and recall (β = -6.5; P = .01), and attention and working memory (β = -7.0; P = .02) domains. There was a trend suggesting a negative association in the motor and processing speed (β = -2.4; P = .35) and executive function (β = -4.5; P = .06) domains that did not reach significance. CONCLUSIONS In patients with high-grade ACAS, the concomitant presence of increasing occlusive disease in the CoW correlates with worse cognitive function. This association was significant in the learning and recall and attention and working memory domains. Although motor and processing speed and executive function also declined numerically with increasing abnormal segments in the CoW, the relationship was not significant. Since flow restriction at a carotid stenosis compounded by inadequate collateral compensation across a diseased CoW worsens cerebral perfusion, our findings support the hypothesis that cerebral hypoperfusion underlies the observed cognitive impairment in patients with ACAS.
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Affiliation(s)
- Sarasijhaa K Desikan
- Division of Vascular Surgery, University of Maryland School of Medicine, Baltimore, MD; Vascular Service, Veterans Affairs Medical Center, Baltimore, MD.
| | - Binal Brahmbhatt
- Department of Bioengineering, George Mason University, Fairfax, VA
| | - Jigar Patel
- Radiology Service, Veterans Affairs Medical Center, Baltimore, MD
| | - Aman A Kankaria
- Division of Vascular Surgery, University of Maryland School of Medicine, Baltimore, MD; Vascular Service, Veterans Affairs Medical Center, Baltimore, MD
| | - John Anagnostakos
- Division of Vascular Surgery, University of Maryland School of Medicine, Baltimore, MD; Vascular Service, Veterans Affairs Medical Center, Baltimore, MD
| | - Moira Dux
- Neuropsychology Section, Veterans Affairs Medical Center, Baltimore, MD
| | - Kirk Beach
- D. Eugene Strandness Vascular Laboratory, Department of Surgery, University of Washington, Seattle, WA
| | - Vicki L Gray
- Department of Physical Therapy and Rehabilitation Science, University of Maryland, Baltimore, MD
| | - Tara McDonald
- Division of Vascular Surgery, University of Maryland School of Medicine, Baltimore, MD; Vascular Service, Veterans Affairs Medical Center, Baltimore, MD
| | - Caroline Crone
- Division of Vascular Surgery, University of Maryland School of Medicine, Baltimore, MD; Vascular Service, Veterans Affairs Medical Center, Baltimore, MD
| | | | - John D Sorkin
- Baltimore VA Geriatric Research, Education, and Clinical Center, Baltimore, MD; Department of Medicine, Division of Gerontology and Palliative Care, University of Maryland School of Medicine, Baltimore, MD
| | - Brajesh K Lal
- Division of Vascular Surgery, University of Maryland School of Medicine, Baltimore, MD; Vascular Service, Veterans Affairs Medical Center, Baltimore, MD.
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12
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Abdelkarim A, Hamouda M, Malas MB. What Is the Best Technique for Treating Carotid Disease? Adv Surg 2024; 58:161-189. [PMID: 39089775 DOI: 10.1016/j.yasu.2024.04.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/04/2024]
Abstract
This is a comprehensive review of carotid artery revascularization techniques: Carotid Endarterectomy (CEA), Transfemoral Carotid Artery Stenting (TFCAS), and Transcarotid Artery Revascularization (TCAR). CEA is the gold standard and is particularly effective in elderly and high-risk patients. TFCAS, introduced as a less invasive alternative, poses increased periprocedural stroke risks. TCAR, which combines minimally invasive benefits with CEA's neuroprotection principles, emerges as a safer option for high-risk patients, showing comparable results to CEA and better outcomes than TFCAS. The decision-making process for carotid revascularization is complex and influenced by the patient's medical comorbidities and anatomic factors.
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Affiliation(s)
- Ahmed Abdelkarim
- Department of Surgery, Division of Vascular and Endovascular Surgery, UC San Diego, San Diego, CA, USA; Center for Learning and Excellence in Vascular & Endovascular Research (CLEVER), UC San Diego, San Diego, CA, USA; Altman Center for Clinical and Translational Research, 9452 Medical Center Drive - LL2W 502A, La Jolla, CA 92037, USA
| | - Mohammed Hamouda
- Department of Surgery, Division of Vascular and Endovascular Surgery, UC San Diego, San Diego, CA, USA; Center for Learning and Excellence in Vascular & Endovascular Research (CLEVER), UC San Diego, San Diego, CA, USA; Altman Center for Clinical and Translational Research, 9452 Medical Center Drive - LL2W 502A, La Jolla, CA 92037, USA
| | - Mahmoud B Malas
- Department of Surgery, Division of Vascular and Endovascular Surgery, UC San Diego, San Diego, CA, USA; Center for Learning and Excellence in Vascular & Endovascular Research (CLEVER), UC San Diego, San Diego, CA, USA; Altman Center for Clinical and Translational Research, 9452 Medical Center Drive - LL2W 502A, La Jolla, CA 92037, USA.
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13
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Long B, Marcolini E, Gottlieb M. Emergency medicine updates: Transient ischemic attack. Am J Emerg Med 2024; 83:82-90. [PMID: 38986211 DOI: 10.1016/j.ajem.2024.06.023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2024] [Revised: 06/07/2024] [Accepted: 06/12/2024] [Indexed: 07/12/2024] Open
Abstract
INTRODUCTION Transient ischemic attack (TIA) is a condition commonly evaluated for in the emergency department (ED). Therefore, it is important for emergency clinicians to be aware of the current evidence regarding the diagnosis and management of this disease. OBJECTIVE This paper evaluates key evidence-based updates concerning TIA for the emergency clinician. DISCUSSION TIA is a harbinger of ischemic stroke and can result from a variety of pathologic causes. While prior definitions incorporated symptoms resolving within 24 h, modern definitions recommend a tissue-based definition utilizing advanced imaging to evaluate for neurologic injury and the etiology. In the ED, emergent evaluation includes assessing for current signs and symptoms of neurologic dysfunction, appropriate imaging to investigate for minor stroke or stroke risk, and arranging appropriate disposition and follow up to mitigate risk of subsequent ischemic stroke. Imaging should include evaluation of great vessels and intracranial arteries, as well as advanced cerebral imaging to evaluate for minor or subclinical stroke. Non-contrast computed tomography (CT) has limited utility for this situation; it can rule out hemorrhage or a large mass causing symptoms but should not be relied on for any definitive diagnosis. Noninvasive imaging of the cervical vessels can also be used (CT angiography or Doppler ultrasound). Treatment includes antithrombotic medications if there are no contraindications. Dual antiplatelet therapy may reduce the risk of recurrent ischemic events in higher risk patients, while anticoagulation is recommended in patients with a cardioembolic source. A variety of scoring systems or tools are available that seek to predict stroke risk after a TIA. The Canadian TIA risk score appears to have the best diagnostic accuracy. However, these scores should not be used in isolation. Disposition may include admission, management in an ED-based observation unit with rapid diagnostic protocol, or expedited follow-up in a specialty clinic. CONCLUSIONS An understanding of literature updates concerning TIA can improve the ED care of patients with TIA.
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Affiliation(s)
- Brit Long
- SAUSHEC, Emergency Medicine, Brooke Army Medical Center, Fort Sam Houston, TX, USA.
| | - Evie Marcolini
- Department of Emergency Medicine, Dartmouth Hitchcock Medical Center, Lebanon, NH, USA
| | - Michael Gottlieb
- Department of Emergency Medicine, Rush University Medical Center, Chicago, IL, USA
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14
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Patel PD, Khanna O, Lan M, Baldassari M, Momin A, Mouchtouris N, Tjoumakaris S, Gooch MR, Rosenwasser RH, Farrell C, Jabbour P. The effect of institutional case volume on post-operative outcomes after endarterectomy and stenting for symptomatic carotid stenosis. J Stroke Cerebrovasc Dis 2024; 33:107828. [PMID: 38908611 DOI: 10.1016/j.jstrokecerebrovasdis.2024.107828] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2023] [Revised: 05/23/2024] [Accepted: 06/18/2024] [Indexed: 06/24/2024] Open
Abstract
OBJECTIVE To investigate the effects of yearly institutional case volume for carotid endarterectomy (CEA) and stenting (CAS) among symptomatic carotid stenosis patients on the rates of postoperative stroke and inpatient mortality. MATERIALS AND METHODS Patients with prior stroke ("symptomatic") undergoing CEA or CAS during an inpatient stay were identified from the National Inpatient Sample for years 2012-2015. The primary variable was volume of CEA or CAS performed annually by each institution. The primary outcome was a composite variable for in-hospital death or postoperative stroke. RESULTS A total of 5,628 patients with symptomatic carotid stenosis underwent CEA, while 245 underwent CAS. In the symptomatic CEA population, 519 (9.2 %) patients experienced postoperative stroke or mortality, and were more likely to be treated at centers with a lower yearly institutional volume (median 10 [IQR 5-15] versus 10 [7-20] cases, p < 0.001). In the symptomatic CAS population, 32 (13.1 %) patients experienced stroke or mortality, and these patients were also more likely to undergo treatment at hospitals with a lower yearly institutional volume (median 5 [IQR 5-7] versus 5 [5-10] cases, p = 0.044). Thresholds for yearly institutional volume found differences in adverse outcome between 0-9, 10-29, and ≥30 cases/year (11.7 % vs 8.4 % vs 6.0 %, p < 0.001) for CEA, and differences in postoperative stroke between 0-9 and ≥10 cases/year for CAS (11.0 % vs 1.4 %, p = 0.028). CONCLUSIONS Hospitals performing higher volumes of CEA or CAS have fewer postoperative strokes. The threshold reported herein is ≥30 CEA procedures or ≥10 CAS procedures annually for appreciably improved outcomes.
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Affiliation(s)
- Pious D Patel
- Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA.
| | - Omaditya Khanna
- Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA
| | - Matthews Lan
- Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA
| | - Michael Baldassari
- Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA
| | - Arbaz Momin
- Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA
| | - Nikolaos Mouchtouris
- Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA
| | - Stavropoula Tjoumakaris
- Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA
| | - M Reid Gooch
- Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA
| | - Robert H Rosenwasser
- Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA
| | - Christopher Farrell
- Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA
| | - Pascal Jabbour
- Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA
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15
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Paraskevas KI, Zeebregts CJ, AbuRahma AF, Perler BA. Implications of the Centers for Medicare and Medicaid Services decision to expand indications for carotid artery stenting. J Vasc Surg 2024; 80:599-603. [PMID: 38462061 DOI: 10.1016/j.jvs.2024.03.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2024] [Revised: 02/24/2024] [Accepted: 03/03/2024] [Indexed: 03/12/2024]
Abstract
OBJECTIVE On October 11, 2023, the Centers for Medicare and Medicaid Services (CMS) expanded the indications for carotid artery stenting (CAS) to include patients with ≥50% symptomatic or ≥70% asymptomatic carotid stenosis. The aim of this article was to investigate the implications of this decision. METHODS The reasons behind the increased coverage for CAS are analyzed and discussed, as well as the various Societies supporting or opposing the expansion of indications for CAS. RESULTS The benefits associated with expanding CAS indications include providing an additional therapeutic option to patients and enabling individualization of treatment according to patient-specific characteristics. The drawbacks of expanding CAS indications include a possible bias in decision-making and an increase in inappropriate CAS procedures. CONCLUSIONS The purpose of the CMS recommendation to expand indications for CAS is to improve the available therapeutic options for patients. Hopefully this decision will not be misinterpreted and will be used to improve patient options and patient outcomes.
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Affiliation(s)
| | - Clark J Zeebregts
- Department of Surgery (Division of Vascular Surgery), University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Ali F AbuRahma
- Department of Surgery, Charleston Area Medical Center/West Virginia University, Charleston, WV
| | - Bruce A Perler
- Department of Surgery, The Johns Hopkins Hospital, Baltimore, MD
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16
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Fries F. [Stent angioplasty for internal carotid artery stenosis]. RADIOLOGIE (HEIDELBERG, GERMANY) 2024; 64:694-698. [PMID: 38700713 DOI: 10.1007/s00117-024-01306-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 04/17/2024] [Indexed: 08/28/2024]
Abstract
BACKGROUND Stent angioplasty of carotid stenosis has become established as a safe and efficient treatment method alongside carotid endarterectomy due to developments in stent design and refinement of interventional techniques. Today, the protocol for stent angioplasty is largely standardized. OBJECTIVE The aim of this article is to provide sound insight into the development and current practice of stent angioplasty. Particular attention is paid to technical implementation and periprocedural management.
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Affiliation(s)
- Frederik Fries
- Klinik für Diagnostische und Interventionelle Neuroradiologie, Universitätsklinikum des Saarlandes, Kirrberger Straße, 66421, Homburg/Saar, Deutschland.
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17
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DiLosa K, Schonefeld S, El-Khoury R, Eichler C, DiBartolomeo A, Magee GA, Yi J, Simioni A, Gable D, Barghout R, Ayad M, Mouawad NJ, Maximus S, Baril D, Aranson N, Azizzadeh A, Humphries M. Multi-center experience with intravascular lithotripsy for treatment of severe calcification during transcarotid artery revascularization for high-risk patients. J Vasc Surg 2024; 80:757-763. [PMID: 38777157 DOI: 10.1016/j.jvs.2024.04.049] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2024] [Revised: 03/31/2024] [Accepted: 04/04/2024] [Indexed: 05/25/2024]
Abstract
OBJECTIVE Transcarotid artery revascularization (TCAR) offers a safe alternative to carotid endarterectomy (CEA), but severe calcification is currently considered a contraindication in carotid artery stenting. This study aims to describe the safety and effectiveness of TCAR with intravascular lithotripsy (IVL) in patients with traditionally prohibitive calcific disease. METHODS All consecutive patients who underwent TCAR+IVL from 2018-2022 at nine institutions were identified. IVL was combined with pre-dilatation angioplasty to treat calcified vessels before stent deployment. The primary outcome was a new ipsilateral stroke within 30 days. Secondary outcomes included any new ipsilateral neurologic event (stroke/transient ischemic attack [TIA]) at 30 days, technical success, and <30% residual stenosis. RESULTS Fifty-eight patients (62% male; mean age, 78 ± 6.6 years) underwent TCAR+IVL, with 22 (38%) for symptomatic disease. Fifty-seven patients (98%) met high-risk anatomical or physiologic criteria for CEA. Forty-seven patients had severely calcific lesions. Fourteen patients (30%) had isolated eccentric plaque, 20 patients (43%) had isolated circumferential plaque, and 13 (27%) had eccentric and circumferential calcification. Mean procedure and flow reversal times were 87 ± 27 minutes and 25 ± 14 minutes. The median number of lithotripsy pulses per case was 90 (range, 30-330), and mean contrast usage was 29 mL. No patients had electroencephalogram changes or new deficits observed intraoperatively. Technical success was achieved in 100% of cases, with 98% having <30% residual stenosis on completion angiography. One patient had an in-hospital post-procedural stroke (1.72%). Four patients total had any new ipsilateral neurologic event (stroke/TIA) within 30 days for an overall rate of 6.8%. One TIA and one stroke occurred during the index hospitalization, and two TIAs occurred after discharge. Preoperative mean stenosis in patients with any postoperative neurologic event was 93% (vs 86% in non-stroke/TIA patients; P = .32), and chronic renal insufficiency was higher in patients who had a new neurologic event (75% vs 17%; P = .005). No differences were observed in calcium, procedural, or patient characteristics between the two groups. The mean follow-up was 132 days (range, 19-520 days). Three stents developed recurrent stenosis (5%) on follow-up duplex; the remainder were patent without issue. There were no reported interventions for recurrent stenosis during the study period. CONCLUSIONS IVL sufficiently remodels calcified carotid arteries to facilitate TCAR effectively in patients with traditionally prohibitive calcific disease. One patient (1.7%) suffered a stroke within 30 days, although four patients (6.8%) sustained any new neurological event (stroke/TIA). These results raise concerns about the risks of TCAR+IVL and whether it is an appropriate strategy for patients who could potentially undergo CEA.
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Affiliation(s)
- Kathryn DiLosa
- University of California, Davis Medical Center, Sacramento, CA.
| | | | - Rym El-Khoury
- University of California, San Francisco Medical Center, San Francisco, CA
| | - Charles Eichler
- University of California, San Francisco Medical Center, San Francisco, CA
| | | | - Gregory A Magee
- Keck School of Medicine of University of Southern California, Los Angeles, CA
| | - Jeniann Yi
- University of Colorado Anschutz School of Medicine, Aurora, CO
| | - Andrea Simioni
- University of Colorado Anschutz School of Medicine, Aurora, CO
| | - Dennis Gable
- Baylor Scott and White Heart Hospital Plano, Plano, TX
| | | | | | | | - Steven Maximus
- University of California, Davis Medical Center, Sacramento, CA
| | | | | | | | - Misty Humphries
- University of California, Davis Medical Center, Sacramento, CA
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18
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Farah M, Moghaddam M, Zarrintan S, Willie-Permor D, Schermerhorn M, Malas M. The effect of controlled vs uncontrolled hypertension on outcomes of carotid revascularization procedures. J Vasc Surg 2024; 80:765-773. [PMID: 38763456 DOI: 10.1016/j.jvs.2024.05.021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2024] [Revised: 05/08/2024] [Accepted: 05/10/2024] [Indexed: 05/21/2024]
Abstract
BACKGROUND Hypertension (HTN) has been implicated as a strong predictive factor for poorer outcomes in patients undergoing various vascular procedures. However, limited research is available that examines the effect of uncontrolled HTN (uHTN) on outcomes after carotid revascularization. We aimed to determine which carotid revascularization procedure yields the best outcome in this patient population. METHODS We studied patients undergoing carotid endarterectomy (CEA), transfemoral carotid artery stenting (TFCAS), or transcarotid artery revascularization (TCAR) from April 2020 to June 2022 using data from the Vascular Quality Initiative. Patients were stratified into two groups: those with cHTN and those with uHTN. Patients with cHTN were those with HTN treated with medication and a blood pressure of <130/80 mm Hg. Patients with uHTN had a blood pressure of ≥130/80 mm Hg. Our primary outcomes were in-hospital stroke, death, myocardial infarction (MI), and 30-day mortality. Our secondary outcomes were postoperative hypotension or HTN, reperfusion syndrome, prolonged length of stay (LOS) (>1 day), stroke/death, and stroke/death/MI. We used logistic regression models for the multivariate analysis. RESULTS A total of 34,653 CEA (uHTN, 11,347 [32.7%]), 8199 TFCAS (uHTN, 2307 [28.1%]), and 17,309 TCAR (uHTN, 4990 [28.8%]) patients were included in this study. There was no significant difference in age between patients with cHTN and patients with uHTN for each carotid revascularization procedure. However, compared with patients with cHTN, patients with uHTN had significantly more comorbidities. uHTN was associated with an increased risk of combined in-hospital stroke/death/MI after CEA (adjusted odds ratio [aOR], 1.56; 95% confidence interval [CI], 1.30-1.87; P < .001), TFCAS (aOR, 1.59; 95% CI, 1.21-2.08; P < .001), and TCAR (aOR, 1.39; 95% CI, 1.12-1.73; P = .003) compared with cHTN. Additionally, uHTN was associated with a prolonged LOS after all carotid revascularization methods. For the subanalysis of patients with uHTN, TFCAS was associated with an increased risk of stroke (aOR, 1.82; 95% CI, 1.39-2.37; P < .001), in-hospital death (aOR, 3.73; 95% CI, 2.25-6.19; P < .001), reperfusion syndrome (aOR, 6.24; 95% CI, 3.57-10.93; P < .001), and extended LOS (aOR, 1.87; 95% CI, 1.51-2.32; P < .001) compared with CEA. There was no statistically significant difference between the outcomes of TCAR compared with CEA. CONCLUSIONS The results from this study show that patients with uHTN are at a higher risk of stroke and death postoperatively compared with patients with cHTN, highlighting the importance of treating HTN before undergoing elective carotid revascularization. Additionally, in patients with uHTN, TFCAS yields the worst outcomes, whereas CEA and TCAR proved to be safer interventions. Patients with uTHN with symptomatic carotid disease treated with CEA or TCAR have better outcomes compared with those treated with TFCAS.
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Affiliation(s)
- Marc Farah
- Georgetown University School of Medicine, Washington, DC
| | - Marjan Moghaddam
- Center for Learning and Excellence in Vascular and Endovascular Surgery (CLEVER), Department of Surgery, Division of Vascular and Endovascular Surgery, University of California San Diego Health System, San Diego, MA
| | - Sina Zarrintan
- Center for Learning and Excellence in Vascular and Endovascular Surgery (CLEVER), Department of Surgery, Division of Vascular and Endovascular Surgery, University of California San Diego Health System, San Diego, MA
| | - Daniel Willie-Permor
- Center for Learning and Excellence in Vascular and Endovascular Surgery (CLEVER), Department of Surgery, Division of Vascular and Endovascular Surgery, University of California San Diego Health System, San Diego, MA
| | - Marc Schermerhorn
- Department of Surgery, Division of Vascular and Endovascular Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, CA
| | - Mahmoud Malas
- Center for Learning and Excellence in Vascular and Endovascular Surgery (CLEVER), Department of Surgery, Division of Vascular and Endovascular Surgery, University of California San Diego Health System, San Diego, MA.
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19
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Keles A, Uyaniker ZA, Aagaard-Kienitz B, Baskaya MK. Emergency Carotid Thrombo-Endarterectomy after Failed Endovascular Recanalization for Acute Complete Carotid Occlusion: A Case Report. Brain Sci 2024; 14:882. [PMID: 39335378 DOI: 10.3390/brainsci14090882] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2024] [Revised: 08/21/2024] [Accepted: 08/26/2024] [Indexed: 09/30/2024] Open
Abstract
Rapid identification of the type and origin of a stroke is crucial for prompt and appropriate treatment, which can significantly influences patient outcomes. We report a multidisciplinary management case involving a 76-year-old man who presented with left-sided weakness and mild dysarthria. Imaging revealed a completely occluded right internal carotid artery. Despite multiple endovascular recanalization attempts, adequate flow could not be achieved, leading to the decision to perform an open thrombo-endarterectomy. The patient underwent carotid endarterectomy with microsurgical techniques under general anesthesia. The atheroma plaque and central thrombus were removed, which reestablished flow. Continuous intraoperative neuromonitoring was utilized to ensure patient safety. The patient woke up without new deficits and was discharged for rehabilitation. Follow-up imaging confirmed arterial patency, and the patient eventually made an excellent recovery, including being independent over one and a half years. Emergent recanalization with carotid endarterectomy following a failed endovascular recanalization is both safe and feasible, emphasizing the need for collaboration between different treatment providers to ensure optimal patient outcomes. Our report highlights the importance of a multidisciplinary approach and the advantages of a hybrid operating room in the treatment of acute complete carotid artery occlusion.
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Affiliation(s)
- Abdullah Keles
- Department of Neurological Surgery, School of Medicine and Public Health, University of Wisconsin-Madison, Madison, WI 53792, USA
| | - Zeynep Arzum Uyaniker
- Department of Neurological Surgery, School of Medicine and Public Health, University of Wisconsin-Madison, Madison, WI 53792, USA
| | - Beverly Aagaard-Kienitz
- Department of Neurological Surgery, School of Medicine and Public Health, University of Wisconsin-Madison, Madison, WI 53792, USA
| | - Mustafa K Baskaya
- Department of Neurological Surgery, School of Medicine and Public Health, University of Wisconsin-Madison, Madison, WI 53792, USA
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20
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Lal BK, Mayorga-Carlin M, Sahoo S, Cambria R, Raffetto JD, Gasper W, Ju M, Macdonald S, Sorkin JD. Impact of the type of anesthesia on adverse events during transcarotid artery revascularization. J Vasc Surg 2024:S0741-5214(24)01662-8. [PMID: 39179003 DOI: 10.1016/j.jvs.2024.07.091] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2024] [Revised: 07/22/2024] [Accepted: 07/23/2024] [Indexed: 08/26/2024]
Abstract
OBJECTIVE The use of local or regional anesthesia (LRA) is encouraged during transcarotid artery revascularization (TCAR) because the procedure is performed through a small incision. LRA permits neurologic evaluation during the procedure and may reduce periprocedural cardiac morbidity compared with general anesthesia (GA). There is limited and conflicting information regarding the preferred anesthesia to use during TCAR. We compared periprocedural clinical and technical complications, and intraprocedural performance metrics of TCAR performed under GA vs LRA. METHODS Patient, lesion, physician, and procedural information was collected in a worldwide quality assurance program of consecutive TCAR procedures. A composite clinical adverse event rate (death, stroke, transient ischemic attack, myocardial infarction) and a composite technical adverse event rate (aborted procedure, conversion to carotid endarterectomy, bleeding, dissection, cranial-nerve injury, device failure) in the periprocedural period were computed. Four intraprocedural performance measures (flow-reversal time, fluoroscopy time, contrast volume, and skin-to-skin time) were recorded. Deidentified data were analyzed independently at the Center for Vascular Research, University of Maryland. Poisson regressions were used to assess the impact of anesthesia type on adverse event rates. Linear regressions were used to compare performance measures. RESULTS A total of 27,043 TCARs were performed by 1456 physicians between 2012 and 2021. A majority of patients (83%) received GA, and this proportion increased over time (R2 = 0.74; P < .0001). Some physicians (33.4%) used LRA in some of their procedures; only 2.7% used LRA in all of their procedures. Clinical risk factors were more common in the LRA group (P < .0001) and anatomic risk factors in the GA group (P < .0001); these differences were adjusted for in subsequent analyses. LRA was more likely to be used by vascular surgeons and by physicians with higher prior transfemoral carotid stenting experience (P < .0001). When comparing GA vs LRA, clinical adverse events (1.49%; 95% confidence interval [CI], 1.3-1.8 vs 1.55%; 95% CI, 1.2-2.0; P = .78), technical adverse events (5.6%; 95% CI, 5.2-6.2 vs 5.3%; 95% CI, 4.5-6.3; P = .47), and intraprocedural performance measures did not differ by type of anesthesia. CONCLUSIONS Almost two-thirds of physicians performed TCAR exclusively under GA, and the overall proportion of procedures performed under GA increased over time. A larger fraction of patients with severe medical risk factors received LRA vs GA, whereas a larger fraction of patients with anatomic risk-factors received GA. Periprocedural clinical and technical adverse events did not differ by type of anesthesia. Intraprocedural performance metrics that drive procedural cost were similar between groups; potential differences in procedural cost driven by anesthetic choice require further study.
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Affiliation(s)
- Brajesh K Lal
- Department of Vascular Surgery, University of Maryland School of Medicine, Vascular Service, Baltimore VA Medical Center, Baltimore, MD; Department of Vascular Surgery, University of Maryland School of Medicine, Baltimore, MD.
| | - Minerva Mayorga-Carlin
- Department of Vascular Surgery, University of Maryland School of Medicine, Baltimore, MD
| | - Shalini Sahoo
- Department of Vascular Surgery, University of Maryland School of Medicine, Vascular Service, Baltimore VA Medical Center, Baltimore, MD
| | - Richard Cambria
- Department of Vascular Surgery, University of Maryland School of Medicine, Baltimore, MD
| | - Joseph D Raffetto
- Division of Vascular and Endovascular Surgery, St Elizabeth's Medical Center, Boston, MA; Department of Surgery, Harvard Medical School, Vascular Service, VA Boston Healthcare System, Boston, MA
| | - Warren Gasper
- Division of Vascular and Endovascular Surgery, Department of Surgery, University of California San Francisco, Vascular Service, San Francisco VA Medical Center, San Francisco, CA, USA; Department of Vascular and Endovascular Surgery, Lehigh Valley Health Network, Allentown, PA, USA
| | - Mila Ju
- Silk Road Medical, Sunnyvale, CA
| | - Sumaira Macdonald
- Department of Medicine, University of Maryland School of M, Baltimore VA Medical Center, Baltimore, MD, USA
| | - John D Sorkin
- Department of Medicine, University of Maryland School of Medicine, Geriatric Research, Education, and Clinical Center, Baltimore VA Medical Center, Baltimore, MD, USA
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21
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Abdelkarim A, Straus SL, Moghaddam M, Nakhaei P, Clary B, Malas MB. Postoperative outcomes in patients with anemia undergoing carotid revascularization. J Vasc Surg 2024:S0741-5214(24)01777-4. [PMID: 39179005 DOI: 10.1016/j.jvs.2024.08.027] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2024] [Revised: 08/08/2024] [Accepted: 08/11/2024] [Indexed: 08/26/2024]
Abstract
BACKGROUND Preoperative anemia is associated with worse postoperative morbidity and mortality after major vascular procedures. Limited research has examined the optimal method of carotid revascularization in patients with anemia. Therefore, we aim to compare the postoperative outcomes after carotid endarterectomy (CEA), transfemoral carotid artery stenting (TFCAS), and transcarotid artery revascularization (TCAR) among patients with anemia. STUDY DESIGN This is a retrospective review of patients with anemia undergoing CEA, TFCAS, and TCAR in the Vascular Quality Initiative database between 2016 and 2023. We defined anemia as a preoperative hemoglobin level of <13 g/dL in men and <12 g/dL in women. The primary outcomes were 30-day mortality and in-hospital major adverse cardiac events (MACEs). Logistic regression models were used for multivariate analyses. RESULTS Our study included 40,383 CEA (59.3%), 9159 TFCAS (13.5%), and 18,555 TCAR (27.3%) cases in patients with anemia. TCAR patients were older and had more medical comorbidities than CEA and TFCAS patients. TCAR was associated with decreased 30-day mortality (adjusted odds ratio [aOR], 0.45; 95% confidence interval [CI], 0.37-0.59; P < .001), in-hospital MACE (aOR, 0.58; 95% CI, 0.46-0.75; P < .001) compared with TFCAS. Additionally, TCAR was associated with a 20% decrease in the risk of 30-day mortality (aOR, 0.80; 95% CI, 0.65-0.98; P = .03) and a similar risk of in-hospital MACE (aOR, 0.86; 95% CI, 0.77-1.01; P = .07) compared with CEA. Furthermore, TFCAS was associated with an increased risk of 30-day mortality (aOR, 2; 95% CI, 1.5-2.68; P < .001) and in-hospital MACE (aOR, 1.7; 95% CI, 1.4-2; P < .001) compared with CEA. CONCLUSIONS In this multi-institutional national retrospective analysis of a prospectively collected database, TFCAS is associated with a high risk of 30-day mortality and in-hospital MACE compared with CEA and TCAR in patients with anemia. TCAR was associated with a lower risk of 30-day mortality compared with CEA. These findings suggest TCAR as the optimal minimally invasive procedure for carotid revascularization in patients with anemia.
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Affiliation(s)
- Ahmed Abdelkarim
- Division of Vascular & Endovascular Surgery, Department of Surgery, Center for Learning and Excellence in Vascular and Endovascular Surgery, UC San Diego, San Diego, CA
| | - Sabrina L Straus
- Division of Vascular & Endovascular Surgery, Department of Surgery, Center for Learning and Excellence in Vascular and Endovascular Surgery, UC San Diego, San Diego, CA
| | - Marjan Moghaddam
- Division of Vascular & Endovascular Surgery, Department of Surgery, Center for Learning and Excellence in Vascular and Endovascular Surgery, UC San Diego, San Diego, CA
| | - Pooria Nakhaei
- Division of Vascular & Endovascular Surgery, Department of Surgery, Center for Learning and Excellence in Vascular and Endovascular Surgery, UC San Diego, San Diego, CA
| | - Bryan Clary
- Division of Vascular & Endovascular Surgery, Department of Surgery, Center for Learning and Excellence in Vascular and Endovascular Surgery, UC San Diego, San Diego, CA
| | - Mahmoud B Malas
- Division of Vascular & Endovascular Surgery, Department of Surgery, Center for Learning and Excellence in Vascular and Endovascular Surgery, UC San Diego, San Diego, CA.
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22
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Hamouda M, Alqrain S, Zarrintan S, Yei K, Barleben A, Malas MB. Transcarotid artery revascularization outperforms transfemoral carotid artery stenting regardless of aortic arch type or degree of atherosclerosis. J Vasc Surg 2024:S0741-5214(24)01680-X. [PMID: 39134214 DOI: 10.1016/j.jvs.2024.07.101] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2024] [Revised: 07/31/2024] [Accepted: 07/31/2024] [Indexed: 09/09/2024]
Abstract
OBJECTIVE The Centers for Medicare and Medicaid Services now approve reimbursement for transfemoral carotid artery stenting (TFCAS) in the treatment of standard-risk patients with carotid artery occlusive disease. TFCAS in patients with complex aortic arch anatomy is known to be challenging with worse outcomes. Transcarotid artery revascularization (TCAR) could be a preferable alternative in these patients owing to avoiding the aortic arch and using flow reversal during stent deployment. We aim to compare the outcomes of TCAR vs TFCAS across all aortic arch types and degrees of arch atherosclerosis. METHODS All patients undergoing carotid artery stenting between September 2016 and October 2023 were identified in the Vascular Quality Initiative database. Patients were stratified into four groups: Group A (mild atherosclerosis and type I/II arch), Group B (mild atherosclerosis and type III arch), Group C (moderate/severe atherosclerosis and type I/II arch), and Group D (moderate/severe atherosclerosis and type III arch). The primary outcome was in-hospital composite stroke or death. Analysis of variance and χ2 tests analyzed differences for baseline characteristics. Logistic regression models were adjusted for potential confounders, and backward stepwise selection was implemented to identify significant variables for inclusion in the final models. Kaplan-Meier survival estimates, log rank test, and multivariable Cox regression models analyzed hazard ratios for 1-year mortality. RESULTS A total of 20,114 patients were included (Group A: 12,980 [64.53%]; Group B: 1175 [5.84%]; Group C: 5124 [25.47%]; and Group D: 835 [4.15%]). TCAR was more commonly performed across the four groups (72.21%, 67.06%, 74.94%, and 69.22%; P < .001). Compared with patients with mild arch atherosclerosis, patients with advanced arch atherosclerosis in Group C and Group D were more likely to be female, hypertensive, smokers, and have chronic kidney disease. Patients with type III arch in Group B and Group D were more likely to present with stroke preoperatively. On multivariable analysis, TCAR had less than one-half the risk of stroke/death and 1-year mortality compared with TFCAS in the patients with the mildest atherosclerosis and simple arch anatomy (Group A) (odds ratio [OR], 0.43; 95% confidence interval [CI], 0.31-0.61; P < .001; hazard ratio, 0.42; 95% CI, 0.32-0.57; P < .001). Group B patients with similar atherosclerosis but more complex arch anatomy had 70% lower odds of stroke/death with TCAR compared with TFCAS (OR, 0.30; 95% CI, 0.12-0.75; P = .01). Similar findings were also evident in patients with more severe atherosclerosis and simple arch anatomy (OR, 0.66; 95% CI, 0.44-0.97; P = .037). There was no significant difference in odds of stroke/death in patients with advanced arch atherosclerosis and complex arch (Group D) (OR, 0.91; 95% CI, 0.39-2.16; P = .834). CONCLUSIONS TCAR is safer than TFCAS in patients with simple and advanced arch anatomy. This could be related to the efficiency of flow reversal vs distal embolic protection. The current Centers for Medicare and Medicaid Services decision will likely increase stroke and death outcomes of carotid stenting nationally if multidisciplinary approach and appropriate patient selection are not implemented.
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Affiliation(s)
- Mohammed Hamouda
- Division of Vascular & Endovascular Surgery, Department of Surgery, Center for Learning and Excellence in Vascular and Endovascular Surgery (CLEVER), UC San Diego (UCSD), San Diego, CA
| | - Shaima Alqrain
- Division of Vascular & Endovascular Surgery, Department of Surgery, Center for Learning and Excellence in Vascular and Endovascular Surgery (CLEVER), UC San Diego (UCSD), San Diego, CA
| | - Sina Zarrintan
- Division of Vascular & Endovascular Surgery, Department of Surgery, Center for Learning and Excellence in Vascular and Endovascular Surgery (CLEVER), UC San Diego (UCSD), San Diego, CA
| | - Kevin Yei
- Division of Vascular & Endovascular Surgery, Department of Surgery, Center for Learning and Excellence in Vascular and Endovascular Surgery (CLEVER), UC San Diego (UCSD), San Diego, CA
| | - Andrew Barleben
- Division of Vascular & Endovascular Surgery, Department of Surgery, Center for Learning and Excellence in Vascular and Endovascular Surgery (CLEVER), UC San Diego (UCSD), San Diego, CA
| | - Mahmoud B Malas
- Division of Vascular & Endovascular Surgery, Department of Surgery, Center for Learning and Excellence in Vascular and Endovascular Surgery (CLEVER), UC San Diego (UCSD), San Diego, CA.
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Qing L, Wu W. The mechanism of geniposide in patients with COVID-19 and atherosclerosis: A pharmacological and bioinformatics analysis. Medicine (Baltimore) 2024; 103:e39065. [PMID: 39093733 PMCID: PMC11296471 DOI: 10.1097/md.0000000000039065] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/01/2024] [Accepted: 07/03/2024] [Indexed: 08/04/2024] Open
Abstract
In patients with severe acute respiratory syndrome coronavirus 2 (which causes coronavirus disease 2019 [COVID-19]), oxidative stress (OS) is associated with disease severity and death. OS is also involved in the pathogenesis of atherosclerosis (AS). Previous studies have shown that geniposide has anti-inflammatory and anti-viral properties, and can protect cells against OS. However, the potential target(s) of geniposide in patients with COVID-19 and AS, as well as the mechanism it uses, are unclear. We combined pharmacology and bioinformatics analysis to obtain geniposide against COVID-19/AS targets, and build protein-protein interaction network to filter hub genes. The hub genes were performed an enrichment analysis by ClueGO, including Gene Ontology and KEGG. The Enrichr database and the target microRNAs (miRNAs) of hub genes were predicted through the MiRTarBase via Enrichr. The common miRNAs were used to construct the miRNAs-mRNAs regulated network, and the miRNAs' function was evaluated by mirPath v3.0 software. Two hundred forty-seven targets of geniposide were identified in patients with COVID-19/AS comorbidity by observing the overlap between the genes modulated by geniposide, COVID-19, and AS. A protein-protein interaction network of geniposide in patients with COVID-19/AS was constructed, and 27 hub genes were identified. The results of enrichment analysis suggested that geniposide may be involved in regulating the OS via the FoxO signaling pathway. MiRNA-mRNA network revealed that hsa-miR-34a-5p may play an important role in the therapeutic mechanism of geniposide in COVID-19/AS patients. Our study found that geniposide represents a promising therapy for patients with COVID-19 and AS comorbidity. Furthermore, the target genes and miRNAs that we identified may aid the development of new treatment strategies against COVID-19/AS.
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Affiliation(s)
- Lijin Qing
- First Affiliated Hospital of Guangzhou University of Chinese Medicine, Guangzhou, Guangdong 510405, China
| | - Wei Wu
- First Affiliated Hospital of Guangzhou University of Chinese Medicine, Guangzhou, Guangdong 510405, China
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24
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Patel RJ, Dodo-Williams TS, Sendek G, Elsayed N, Malas MB. Non-White Patients Have a Higher Risk of Stroke Following Transcarotid Artery Revascularization. J Surg Res 2024; 300:71-78. [PMID: 38796903 DOI: 10.1016/j.jss.2024.04.062] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2023] [Revised: 01/28/2024] [Accepted: 04/14/2024] [Indexed: 05/29/2024]
Abstract
INTRODUCTION Carotid artery revascularization has traditionally been performed by either a carotid endarterectomy or carotid artery stent. Large data analysis has suggested there are differences in perioperative outcomes with regards to race, with non-White patients (NWP) having worse outcomes of stroke, restenosis and return to the operating room (RTOR). The introduction of transcarotid artery revascularization (TCAR) has started to shift the paradigm of carotid disease treatment. However, to date, there have been no studies assessing the difference in postoperative outcomes after TCAR between racial groups. METHODS All patients from 2016 to 2021 in the Vascular Quality Initiative who underwent TCAR were included in our analysis. Patients were split into two groups based on race: individuals who identified as White and a second group that comprised all other races. Demographic and clinical variables were compared using Student's t-Test and chi-square test of independence. Logistic regression analysis was performed to determine the impact of race on perioperative outcomes of stroke, myocardial infarction (MI), death, restenosis, RTOR, and transient ischemic attack (TIA). RESULTS The cohort consisted of 22,609 patients: 20,424 (90.3%) White patients and 2185 (9.7%) NWP. After adjusting for sex, diabetes, hypertension, coronary artery disease, history of prior stroke or TIA, symptomatic status, and high-risk criteria at time of TCAR, there was a significant difference in postoperative stroke, with 63% increased risk in NWP (odds ratio = 1.63, 95% confidence interval: 1.11-2.40, P = 0.014). However, we found no significant difference in the odds of MI, death, postoperative TIA, restenosis, or RTOR when comparing NWP to White patients. CONCLUSIONS This study demonstrates that NWP have increased risk of stroke but similar outcomes of death, MI, RTOR and restenosis following TCAR. Future studies are needed to elucidate and address the underlying causes of racial disparity in carotid revascularization.
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Affiliation(s)
- Rohini J Patel
- Center for Learning and Excellence in Vascular & Endovascular Research (CLEVER), Division of Vascular and Endovascular Surgery, Department of Surgery, University of California San Diego, San Diego, California
| | - Taiwo S Dodo-Williams
- Center for Learning and Excellence in Vascular & Endovascular Research (CLEVER), Division of Vascular and Endovascular Surgery, Department of Surgery, University of California San Diego, San Diego, California
| | - Gabriela Sendek
- Center for Learning and Excellence in Vascular & Endovascular Research (CLEVER), Division of Vascular and Endovascular Surgery, Department of Surgery, University of California San Diego, San Diego, California
| | - Nadin Elsayed
- Center for Learning and Excellence in Vascular & Endovascular Research (CLEVER), Division of Vascular and Endovascular Surgery, Department of Surgery, University of California San Diego, San Diego, California
| | - Mahmoud B Malas
- Center for Learning and Excellence in Vascular & Endovascular Research (CLEVER), Division of Vascular and Endovascular Surgery, Department of Surgery, University of California San Diego, San Diego, California.
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25
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Shahat M, Cieri E, Rocha-Neves J, Sa K. Carotid stenting: Does stent design matter? Vascular 2024; 32:774-783. [PMID: 36867405 DOI: 10.1177/17085381231160957] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/04/2023]
Abstract
BACKGROUND Carotid artery stenting (CAS) is considered an important tool in carotid revascularization. Carotid artery stenting is usually performed by using self-expandable stent with different designs. The stent design influences many physical characteristics. Also, it may affect the complication rate with special relevance to perioperative stroke, hemodynamic instability, and late restenosis. METHODS This study comprised all consecutive patients who underwent carotid artery stenting for atherosclerotic carotid stenosis from March 2014 to May 2021. Both symptomatic patient and asymptomatic patients were included. Patients with a symptomatic carotid stenosis of ≥50% or asymptomatic carotid stenosis of ≥60% were selected for carotid artery stenting . Patients with fibromuscular dysplasia and acute or unstable plaque were not included. Variables of clinical relevance were tested in multivariable analysis using binary logistic regression model. RESULTS A total of 728 patients were enrolled. The majority of this cohort was asymptomatic (578/728, 79.4%), while 150/728 (20.6%) were symptomatic. The mean degree of carotid stenosis was 77.82 ± 4.73%, with a mean plaque length of 1.76 ± 0.55 cm. A total of 277 (38%) patients were treated with Xact® Carotid Stent System. Successful carotid artery stenting was achieved in 698 (96%) of patients. Of these patients, stroke rate in symptomatic patients was nine (5.8%), while in asymptomatic patients was 20 (3.4%). In a multivariable analysis, the open-cell carotid stent was not associated with a differential risk for combined acute and sub-acute neurologic complications as compared with closed-cell stents. Patients treated with open cell stents had a significantly lower rate of procedural hypotension (P 0.0188) at bivariate analysis. CONCLUSION Carotid artery stenting is considered a safe alternative to CEA that can be used in selected average surgical risk patient. Different stent designs can affect the rate of major adverse events in carotid artery stenting patients, but further studies are necessary with avoiding different bias to study the effect of different stent designs.
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Affiliation(s)
- Mohamed Shahat
- Department of Vascular and Endovascular Surgery, Assiut University Hospital, Assiut University, Assiut, Egypt
| | - Enrico Cieri
- Vascular and endovascular surgery unit university of Perugia, ospedale S.Maria della Misericordia, Perugia, Italy
| | - Joao Rocha-Neves
- Department of Biomedicine - Unit of Anatomy, Faculdade de Medicina da Universidade do Porto, Portugal
| | - Khairy Sa
- Department of Vascular and Endovascular Surgery, Assiut University Hospital, Assiut University, Assiut, Egypt
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26
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El-Hajj VG, Ghaith AK, Gharios M, El Naamani K, Atallah E, Glener S, Habashy KJ, Hoang H, Sizdahkhani S, Mouchtouris N, Kaul A, Elmi-Terander A, Tjoumakaris S, Gooch MR, Rosenwasser RH, Jabbour P. General Versus Nongeneral Anesthesia for Carotid Endarterectomy: A Prospective Multicenter Registry-Based Study on 25 000 Patients. Neurosurgery 2024; 95:365-371. [PMID: 38391204 DOI: 10.1227/neu.0000000000002887] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2023] [Accepted: 01/05/2024] [Indexed: 02/24/2024] Open
Abstract
BACKGROUND AND OBJECTIVES Carotid endarterectomy (CEA) is a well-established treatment option for carotid stenosis. The choice between general anesthesia (GA) and nongeneral anesthesia (non-GA) during CEA remains a subject of debate, with concerns regarding perioperative complications, particularly myocardial infarctions. This study aimed to evaluate the outcomes associated with GA vs non-GA CEA using a large, nationwide database. METHODS The National Surgical Quality Improvement Project database was queried for patients undergoing CEA between 2013 and 2020. Primary outcome measures including surgical outcomes and 30-day postoperative complications were compared between the 2 anesthesia methods, after 2:1 propensity score matching. RESULTS After propensity score matching, a total of 25 356 patients (16 904 in the GA and 8452 in the non-GA group) were included. Non-GA compared with GA CEA was associated with significantly shorter operative times (101.9, 95% CI: 100.5-103.3 vs 115.8 95% CI: 114.4-117.2 minutes, P < .001), reduced length of hospital stays (2.3, 95% CI: 2.15-2.4 vs 2.5, 95% CI: 2.4-2.6 days, P < .001), and lower rates of 30-day postoperative complications, including myocardial infarctions (0.8% vs 1.2%, P = .003), unplanned intubations (0.8% vs 1.1%, P = .016), pneumonia (0.5% vs 1%, P < .001), and urinary tract infections (0.4% vs 0.7%, P = .003). These outcomes were notably more pronounced in the younger (≤70 years) and high morbidity (American Society of Anesthesiologists 3-5) cohorts. CONCLUSION In this nationwide registry-based study, non-GA CEA was associated with better short-term outcomes in terms of perioperative complications, compared with GA CEA. The findings suggest that non-GA CEA may be a safer alternative, especially in younger patients and those with more comorbidities.
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Affiliation(s)
| | - Abdul Karim Ghaith
- Department of Neurological Surgery, Mayo Clinic, Rochester , Minnesota , USA
| | - Maria Gharios
- Department of Clinical Neuroscience, Karolinska Institutet, Stockholm , Sweden
| | - Kareem El Naamani
- Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia , Pennsylvania , USA
| | - Elias Atallah
- Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia , Pennsylvania , USA
| | - Steven Glener
- Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia , Pennsylvania , USA
| | - Karl John Habashy
- Feinberg School of Medicine, Northwestern University, Chicago , Illinois , USA
| | - Harry Hoang
- Department of Neurological Surgery, Mayo Clinic, Rochester , Minnesota , USA
| | - Saman Sizdahkhani
- Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia , Pennsylvania , USA
| | - Nikolaos Mouchtouris
- Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia , Pennsylvania , USA
| | - Anand Kaul
- Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia , Pennsylvania , USA
| | | | - Stavropoula Tjoumakaris
- Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia , Pennsylvania , USA
| | - M Reid Gooch
- Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia , Pennsylvania , USA
| | - Robert H Rosenwasser
- Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia , Pennsylvania , USA
| | - Pascal Jabbour
- Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia , Pennsylvania , USA
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27
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Ciaramella MA, Liang P, Hamdan AD, Wyers MC, Schermerhorn ML, Stangenberg L. Bailout Distal Internal Carotid Artery Stenting after Carotid Endarterectomy: Indications, Technique, and Outcomes. Ann Vasc Surg 2024; 105:218-226. [PMID: 38599489 DOI: 10.1016/j.avsg.2024.02.025] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2023] [Revised: 02/11/2024] [Accepted: 02/20/2024] [Indexed: 04/12/2024]
Abstract
BACKGROUND Distal internal carotid artery (ICA) stenting may be employed as a bailout maneuver when an inadequate end point or clamp injury is encountered at the time of carotid endarterectomy (CEA) in a surgically inaccessible region of the distal ICA. We sought to characterize the indications, technique, and outcomes for this infrequently encountered clinical scenario. METHODS We performed a retrospective review of all patients who underwent distal ICA stenting at the time of CEA at our institution between September 2008 and July 2022. Procedural details and postoperative follow-up were reviewed for each patient. RESULTS Six patients were identified during the study period. All were male with an age range of 63 to 82 years. Five underwent carotid revascularization for asymptomatic carotid artery stenosis, and one patient was treated for amaurosis fugax. Three patients were on dual antiplatelet therapy preoperatively, whereas 2 were on aspirin monotherapy, and one was on aspirin and low-dose rivaroxaban. Five patients underwent CEA with patch angioplasty, and one underwent eversion CEA. The indication for stenting was distal ICA dissection due to clamp or shunt injury in 2 patients and an inadequate distal ICA end point in 4 patients. In all cases, access for stenting was obtained under direct visualization within the common carotid artery, and a standard carotid stent was deployed with its proximal aspect landing within the endarterectomized site. Embolic protection was typically achieved via proximal common carotid artery and external carotid artery clamping for flow arrest with aspiration of debris before restoration of antegrade flow. There was 100% technical success. Postoperatively, 2 patients were found to have a cranial nerve injury, likely occurring due to the need for high ICA exposure. Median length of stay was 2 days (range 1-7 days) with no instances of perioperative stroke or myocardial infarction. All patients were discharged on dual antiplatelet therapy with no further occurrence of stroke, carotid restenosis, or reintervention through a median follow-up of 17 months. CONCLUSIONS Distal ICA stenting is a useful adjunct in the setting of CEA complicated by inadequate end point or vessel dissection in a surgically inaccessible region of the ICA and can minimize the need for high-risk extensive distal dissection of the ICA in this situation.
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Affiliation(s)
- Michael A Ciaramella
- Department of Surgery, Division of Vascular and Endovascular Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA
| | - Patric Liang
- Department of Surgery, Division of Vascular and Endovascular Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA
| | - Allen D Hamdan
- Department of Surgery, Division of Vascular and Endovascular Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA
| | - Mark C Wyers
- Department of Surgery, Division of Vascular and Endovascular Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA
| | - Marc L Schermerhorn
- Department of Surgery, Division of Vascular and Endovascular Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA
| | - Lars Stangenberg
- Department of Surgery, Division of Vascular and Endovascular Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA.
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Saicic S, Knappich C, Kallmayer M, Kirchhoff F, Bohmann B, Lohe V, Naher S, Böhm J, Lückerath S, Eckstein HH, Kuehnl A. Association of Centre Quality Certification with Characteristics of Patients, Management, and Outcomes Following Carotid Endarterectomy or Carotid Artery Stenting. J Clin Med 2024; 13:4407. [PMID: 39124674 PMCID: PMC11313300 DOI: 10.3390/jcm13154407] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2024] [Revised: 07/11/2024] [Accepted: 07/23/2024] [Indexed: 08/12/2024] Open
Abstract
Background: The aim of this study was to analyze the association between center quality certifications and patients' characteristics, clinical management, and outcomes after carotid revascularization. Methods: This study is a pre-planned sub-study of the ISAR-IQ project, which analyzes data from the Bavarian subset of the nationwide German statutory quality assurance carotid database. Hospitals were classified as to whether a certified vascular center (cVC) or a certified stroke unit (cSU) was present on-site or not. The primary outcome event was any stroke or death until discharge from the hospital. Results: In total, 31,793 cases were included between 2012 and 2018. The primary outcome rate in asymptomatic patients treated by CEA ranged from 0.7% to 1.5%, with the highest rate in hospitals with cVC but without cSU. The multivariable regression analysis revealed a significantly lower primary outcome rate in centers with cSU in asymptomatic patients (aOR 0.69; 95% CI 0.56-0.86; p < 0.001). In symptomatic patients needing emergency treatment, the on-site availability of a cSU was associated with a significantly lower primary outcome rate (aOR 0.56; 95% CI 0.40-0.80; p < 0.001), whereas the presence of a cVC was associated with higher risk (aOR 3.07; 95% CI 1.65-5.72). Conclusions: This study provides evidence of statistically significant better results in some sub-cohorts in certified centers. In centers with cSU, the risk of any stroke or death was significantly lower in asymptomatic patients receiving CEA or symptomatic patients treated by emergency CEA.
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Affiliation(s)
- Stefan Saicic
- Department for Vascular and Endovascular Surgery, University Hospital rechts der Isar, Technical University of Munich, 81675 Munich, Germany; (S.S.)
| | - Christoph Knappich
- Department for Vascular and Endovascular Surgery, University Hospital rechts der Isar, Technical University of Munich, 81675 Munich, Germany; (S.S.)
| | - Michael Kallmayer
- Department for Vascular and Endovascular Surgery, University Hospital rechts der Isar, Technical University of Munich, 81675 Munich, Germany; (S.S.)
| | - Felix Kirchhoff
- Department for Vascular and Endovascular Surgery, University Hospital rechts der Isar, Technical University of Munich, 81675 Munich, Germany; (S.S.)
| | - Bianca Bohmann
- Department for Vascular and Endovascular Surgery, University Hospital rechts der Isar, Technical University of Munich, 81675 Munich, Germany; (S.S.)
| | - Vanessa Lohe
- Department for Vascular and Endovascular Surgery, University Hospital rechts der Isar, Technical University of Munich, 81675 Munich, Germany; (S.S.)
| | - Shamsun Naher
- Department for Vascular and Endovascular Surgery, University Hospital rechts der Isar, Technical University of Munich, 81675 Munich, Germany; (S.S.)
| | - Julian Böhm
- Landesarbeitsgemeinschaft zur Datengestützten, Einrichtungsübergreifenden Qualitätssicherung in Bayern (LAG Bayern), 80331 Munich, Germany
| | - Sofie Lückerath
- Department for Vascular and Endovascular Surgery, University Hospital rechts der Isar, Technical University of Munich, 81675 Munich, Germany; (S.S.)
| | - Hans-Henning Eckstein
- Department for Vascular and Endovascular Surgery, University Hospital rechts der Isar, Technical University of Munich, 81675 Munich, Germany; (S.S.)
| | - Andreas Kuehnl
- Department for Vascular and Endovascular Surgery, University Hospital rechts der Isar, Technical University of Munich, 81675 Munich, Germany; (S.S.)
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Raju S, Turner ME, Cao C, Abdul-Samad M, Punwasi N, Blaser MC, Cahalane RM, Botts SR, Prajapati K, Patel S, Wu R, Gustafson D, Galant NJ, Fiddes L, Chemaly M, Hedin U, Matic L, Seidman M, Subasri V, Singh SA, Aikawa E, Fish JE, Howe KL. Multiomics unveils extracellular vesicle-driven mechanisms of endothelial communication in human carotid atherosclerosis. BIORXIV : THE PREPRINT SERVER FOR BIOLOGY 2024:2024.06.21.599781. [PMID: 38979218 PMCID: PMC11230219 DOI: 10.1101/2024.06.21.599781] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 07/10/2024]
Abstract
Background: Carotid atherosclerosis is orchestrated by cell-cell communication that drives progression along a clinical continuum (asymptomatic to symptomatic). Extracellular vesicles (EVs) are cell-derived nanoparticles representing a new paradigm in cellular communication. Little is known about their biological cargo, cellular origin/destination, and functional roles in human atherosclerotic plaque. Methods: EVs were enriched via size exclusion chromatography from human carotid endarterectomy samples dissected into paired plaque and marginal zones (symptomatic n=16, asymptomatic n=13). EV cargos were assessed via whole transcriptome miRNA sequencing and mass spectrometry-based proteomics. EV multi-omics were integrated with bulk and single cell RNA-sequencing (scRNA-seq) datasets to predict EV cellular origin and ligand-receptor interactions, and multi-modal biological network integration of EV-cargo was completed. EV functional impact was assessed with endothelial angiogenesis assays. Results: Carotid plaques contained more EVs than adjacent marginal zones, with differential enrichment for EV-miRNAs and EV-proteins in key atherogenic pathways. EV cellular origin analysis suggested that tissue EV signatures originated from endothelial cells (EC), smooth muscle cells (SMC), and immune cells. Integrated tissue vesiculomics and scRNA-seq indicated complex EV-vascular cell communication that changed with disease progression and plaque vulnerability (i.e., symptomatic disease). Plaques from symptomatic patients, but not asymptomatic patients, were characterized by increased involvement of endothelial pathways and more complex ligand-receptor interactions, relative to their marginal zones. Plaque-EVs were predicted to mediate communication with ECs. Pathway enrichment analysis delineated an endothelial signature with roles in angiogenesis and neovascularization - well-known indices of plaque instability. This was validated functionally, wherein human carotid symptomatic plaque EVs induced sprouting angiogenesis in comparison to their matched marginal zones. Conclusion: Our findings indicate that EVs may drive dynamic changes in plaques through EV- vascular cell communication and effector functions that typify vulnerability to rupture, precipitating symptomatic disease. The discovery of endothelial-directed angiogenic processes mediated by EVs creates new therapeutic avenues for atherosclerosis.
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Kallmayer M, Knappich C, Kirchhoff F, Bohmann B, Lohe V, Naher S, Eckstein HH, Kuehnl A. Determinants of Pre- and Post-Procedural Neurological Assessment, and Outcome of Carotid Endarterectomy or Stenting. J Clin Med 2024; 13:4177. [PMID: 39064217 PMCID: PMC11278376 DOI: 10.3390/jcm13144177] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2024] [Revised: 07/09/2024] [Accepted: 07/11/2024] [Indexed: 07/28/2024] Open
Abstract
Background: The German-Austrian guideline on the treatment of carotid stenosis recommends specialist neurological assessment (NA) before and after carotid endarterectomy (CEA) or carotid artery stenting (CAS). This study analyzes the determinants of NA and the association of NA with the perioperative rate of stroke or death. Materials and Methods: This study is a pre-planned sub-study of the ISAR-IQ project, which analyzes data from the nationwide German statutory quality assurance carotid database. Patients were classified as asymptomatic (group A), elective symptomatic (group B), and others (group C: emergency (C1), simultaneous operation (C2), and other indications (C3)). The primary outcome event (POE) of this study was any in-hospital stroke or death. Adjusted odds ratios for pre- and post-NA and the POE were calculated using multivariable regression analyses. Results: We analyzed 228,133 patients (54% asymptomatic, 68% male, mean age 72 years) undergoing CEA or CAS between 2012 and 2018. Age and sex were not associated with the likelihood of pre-NA or post-NA. The multivariable regression analysis showed an inverse association between pre-NA and POE (adjusted odds ratio (aOR) 0.47; 95% CI 0.44-0.51, p < 0.001), and a direct association of post-NA and POE (aOR 4.39; 95% CI 4.04-4.78, p < 0.001). Conclusions: Pre- and postinterventional specialist NA is strongly associated with the risk of any in-hospital stroke or death after CEA or CAS in Germany. A relevant confounding by indication or reversed causation cannot be ruled out. Nevertheless, to improve the quality assurance of treatment, the NA recommended in the guideline should be carried out consistently.
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Affiliation(s)
| | | | | | | | | | | | | | - Andreas Kuehnl
- Department for Vascular and Endovascular Surgery, Klinikum rechts der Isar, Technical University of Munich, 81675 Munich, Germany; (M.K.)
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31
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Clemente Gouveia de Gramilho GM, Pereira-Macedo J, Dias LRP, Dias Ferreira AR, Myrcha P, Alves Vieira Andrade JP, Rocha-Neves JMPD. Brain natriuretic peptide is a long-term cardiovascular predictor in carotid endarterectomy. Acta Chir Belg 2024:1-7. [PMID: 38975870 DOI: 10.1080/00015458.2024.2377889] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2024] [Accepted: 07/04/2024] [Indexed: 07/09/2024]
Abstract
BACKGROUND In noncardiac surgery, several biomarkers are known to play a role in predicting long-term complications, such as major adverse cardiovascular events (MACE), myocardial infarction, or death. Carotid endarterectomy (CEA) is considered a low to medium-risk surgery for carotid stenosis aimed at preventing stroke events. Brain natriuretic peptide (BNP) is a biomarker with potential prognostic value regarding MACE. Since its role in patients undergoing CEA is unknown, this study aims to assess the potential role of BNP as a short and long-term predictor of all-cause mortality and MACE in patients undergoing CEA. METHODS From a prospective database, patients who underwent CEA under regional anesthesia (RA) at a tertiary hospital center were enrolled, and a post hoc analysis was conducted. Patients on which BNP levels were measured up to fifteen days before surgery, and two groups based on the BNP threshold (200 pg/mL) were defined and compared. Kaplan Meier survival curves and adjusted hazard ratios (aHR) were assessed by multivariable Cox regression. The primary outcome was the incidence of long-term MACE and all-cause mortality. Secondary outcomes included the incidence of AMI and AHF. RESULTS A total of 89 patients were evaluated. The mean age of the cohort was 71.2 ± 8.7 years, with 71 (79.8%) males, and presented a median follow-up of 30 [13.5-46.4] months. BNP > 200 pg/mL has demonstrated positive predictive value for MACE (aHR: 5.569, confidence interval (CI): 2.441-12.7, p < 0.001) and all-cause mortality (aHR: 3.469, CI: 1.315-9.150, p = 0.018). CONCLUSION BNP has been demonstrated to independently predict long-term all-cause mortality, MACE and AMI following CEA. It serves as a low-cost, ready-to-use biomarker, although further studies are necessary.
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Affiliation(s)
| | - Juliana Pereira-Macedo
- Faculdade de Medicina da Universidade do Porto, Porto, Portugal
- Department of Surgery, Unidade Local de Saúde do Médio Ave, Vila Nova de Famalicão, Portugal
- RISE@Heath, Porto, Portugal
| | - Lara Romana Pereira Dias
- Department of Angiology and Vascular Surgery, Unidade Local de Saúde de São João, Porto, Portugal
| | - Ana Rita Dias Ferreira
- Intensive Care Medicine Department, Centro Hospitalar Universitário de São João, Porto, Portugal
| | - Piotr Myrcha
- Department of General and Vascular Surgery, Faculty of Medicine, Medical University of Warsaw, Warsaw, Poland
- Department of General, Vascular and Oncological Surgery, Brodnowski Hospital, Warsaw, Poland
| | - José Paulo Alves Vieira Andrade
- RISE@Heath, Porto, Portugal
- Unit of Anatomy, Department of Biomedicine, Faculty of Medicine, University of Porto, Porto, Portugal
| | - João Manuel Palmeira da Rocha-Neves
- RISE@Heath, Porto, Portugal
- Department of Angiology and Vascular Surgery, Unidade Local de Saúde de São João, Porto, Portugal
- Unit of Anatomy, Department of Biomedicine, Faculty of Medicine, University of Porto, Porto, Portugal
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Wang T, Sun X, Wang X, Feng Y, Yang K, Wang J, Xu R, Gong H, Luo J, Dmytriw AA, Jiao L, Ma Y. Carotid revascularisation versus medical treatment for asymptomatic carotid artery stenosis. Cochrane Database Syst Rev 2024; 7:CD015499. [PMID: 38967132 PMCID: PMC11225108 DOI: 10.1002/14651858.cd015499] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 07/06/2024]
Abstract
OBJECTIVES This is a protocol for a Cochrane Review (intervention). The objectives are as follows: To compare the safety and efficacy of carotid revascularisation plus best medical treatment with best medical treatment alone in people with asymptomatic carotid artery stenosis.
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Affiliation(s)
- Tao Wang
- Department of Neurosurgery, Xuanwu Hospital, China International Neuroscience Institute, Capital Medical University, National Center for Neurological Disorders, Beijing, China
| | - Xinyi Sun
- Department of Neurosurgery, Xuanwu Hospital, China International Neuroscience Institute, Capital Medical University, National Center for Neurological Disorders, Beijing, China
| | - Xue Wang
- Medical Library, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Yiding Feng
- Department of Neurosurgery, Xuanwu Hospital, China International Neuroscience Institute, Capital Medical University, National Center for Neurological Disorders, Beijing, China
| | - Kun Yang
- Department of Evidence-based Medicine, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Jie Wang
- Department of Neurosurgery, Xuanwu Hospital, China International Neuroscience Institute, Capital Medical University, National Center for Neurological Disorders, Beijing, China
| | - Ran Xu
- Department of Neurosurgery, Xuanwu Hospital, China International Neuroscience Institute, Capital Medical University, National Center for Neurological Disorders, Beijing, China
| | - Haozhi Gong
- Department of Neurosurgery, Xuanwu Hospital, China International Neuroscience Institute, Capital Medical University, National Center for Neurological Disorders, Beijing, China
| | - Jichang Luo
- Department of Neurosurgery, Xuanwu Hospital, China International Neuroscience Institute, Capital Medical University, National Center for Neurological Disorders, Beijing, China
| | - Adam A Dmytriw
- Neuroendovascular Program, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Liqun Jiao
- Department of Neurosurgery, Xuanwu Hospital, China International Neuroscience Institute, Capital Medical University, National Center for Neurological Disorders, Beijing, China
- Department of Interventional Neuroradiology, Xuanwu Hospital, China International Neuroscience Institute, Capital Medical University, National Center for Neurological Disorders, Beijing, China
| | - Yan Ma
- Department of Neurosurgery, Xuanwu Hospital, China International Neuroscience Institute, Capital Medical University, National Center for Neurological Disorders, Beijing, China
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Gao X, Guo J, Pan D, Gu Y. Treatment Strategies for Asymptomatic Carotid Stenosis: A Systematic Review and Bayesian Network Meta-Analysis. Oper Neurosurg (Hagerstown) 2024:01787389-990000000-01241. [PMID: 38967441 DOI: 10.1227/ons.0000000000001251] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2024] [Accepted: 04/23/2024] [Indexed: 07/06/2024] Open
Abstract
BACKGROUND AND OBJECTIVES To compare the safety and efficacy of carotid endarterectomy (CEA), carotid stenting (CAS), and optimal medical therapy (OMT) in patients with asymptomatic carotid stenosis. METHODS Relevant randomized controlled trials were researched with PubMed, Web of Science, and the Cochrane Library databases. Fixed-effects model and random-effects model were used to estimate the relative risks and the hazard ratios (HRs). The results of the probabilistic analysis were reported as surfaces under the cumulative ranking curve. RESULTS Eight randomized controlled trials were included. Data from 10 348 patients (CEA: n = 4758; CAS: n = 3919; OMT: n = 1673) were evaluated. Compared with the previous OMT, CEA, CAS, and the current OMT (c-OMT) were all effective in reducing the risk of stroke (CEA: HR, 0.52; CI, 0.40-0.66; CAS: HR, 0.58; CI, 0.42-0.81; c-OMT: HR, 0.40; CI, 0.15-0.94); CEA and CAS reduced the risk of ipsilateral stroke (CEA: HR, 0.41; CI, 0.28-0.59; CAS: HR, 0.51; CI, 0.31-0.84), and the risk of fatal or disabling stroke (CEA: HR, 0.59; CI, 0.43-0.81; CAS: HR, 0.57; CI, 0.34-0.95). Regarding reducing the risk of stroke, only CEA was statistically significant in patients with any degree of stenosis compared with the previous medical treatment (<80%: HR, 0.48; CI, 0.33%-0.70%; 80%-99%: HR, 0.53; CI, 0.38-0.73). CONCLUSION In the treatment of asymptomatic carotid stenosis, the perioperative outcomes of CAS were similar to that of CEA; CEA, CAS, and c-OMT shared similar long-term outcomes; and CEA and CAS may be more effective in patients with high levels of asymptomatic stenosis.
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Affiliation(s)
- Xinyi Gao
- Department of Vascular Surgery, Xuanwu Hospital, Capital Medical University, Beijing, China
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34
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Omura Y, Imamura H, Tani S, Adachi H, Sakaguchi M, Todo K, Yamagami H, Goto M, Ohara N, Fukumitsu R, Sunohara T, Matsumoto S, Fukui N, Fukuda T, Akiyama T, Ohta T, Sakai C, Sakai N. Treatment Results of Carotid Artery Stenting with an Open-Cell Stent: Analysis of 734 Consecutive Cases at a Single Center. World Neurosurg 2024; 187:e453-e459. [PMID: 38663734 DOI: 10.1016/j.wneu.2024.04.108] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2024] [Revised: 04/16/2024] [Accepted: 04/17/2024] [Indexed: 05/27/2024]
Abstract
OBJECTIVE In carotid artery stenting (CAS) for internal carotid artery stenosis, the stent is often selected according to the plaque properties and arterial tortuosity. In our institute, an open-cell stent is used as the first-line stent regardless of the characteristics of the lesion. This study was performed to examine the outcome of CAS with an open-cell stent as the real-world results. METHODS In total, 811 CAS procedures using open-cell stents were performed for internal carotid artery stenosis from April 2002 to December 2019. Of these patients, we excluded those with hyperacute conditions for which CAS was performed within 3 days of onset, those in whom acute mechanical thrombectomy was performed simultaneously with CAS, and those with stenosis due to arterial dissection. Thus, 734 patients were retrospectively analyzed. Perioperative and long-term outcomes and risk factors for perioperative infarction were investigated. RESULTS The periprocedural stroke rate and mortality rate were 3.7% (27/734) and 0.4% (3/734), respectively. Low-echoic plaque was a significant risk factor for periprocedural stroke in both univariate (P < 0.03) and multivariate (odds ratio, 2.69; 95% confidence interval, 1.14-6.66; P = 0.02) analyses. Cerebral infarction and high grade restenosis were observed in 15 (2.0%) and 17 (2.3%) patients during a median 50-month follow-up. CONCLUSIONS CAS with open-cell stents showed good results in terms of both the postoperative stroke incidence and long-term severe restenosis rate. However, low-echoic plaque was a risk factor for perioperative stroke incidence, which should be considered when deciding on the indication for CAS with an open-cell stent.
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Affiliation(s)
- Yoshihiro Omura
- Department of Neurosurgery, Kobe City Medical Center General Hospital, Kobe, Hyogo, Japan; Department of Neurosurgery, Tokyo Women's Medical University Hospital, Shinjuku, Tokyo, Japan.
| | - Hirotoshi Imamura
- Department of Neurosurgery, Kobe City Medical Center General Hospital, Kobe, Hyogo, Japan
| | - Shoichi Tani
- Department of Neurosurgery, Kobe City Medical Center General Hospital, Kobe, Hyogo, Japan
| | - Hidemitsu Adachi
- Department of Neurosurgery, Kobe City Medical Center General Hospital, Kobe, Hyogo, Japan
| | - Manabu Sakaguchi
- Department of Neurology, Kobe City Medical Center General Hospital, Kobe, Hyogo, Japan
| | - Kenichi Todo
- Department of Neurology, Kobe City Medical Center General Hospital, Kobe, Hyogo, Japan
| | - Hiroshi Yamagami
- Department of Neurology, Kobe City Medical Center General Hospital, Kobe, Hyogo, Japan
| | - Masanori Goto
- Department of Neurosurgery, Kobe City Medical Center General Hospital, Kobe, Hyogo, Japan
| | - Nobuyuki Ohara
- Department of Neurology, Kobe City Medical Center General Hospital, Kobe, Hyogo, Japan
| | - Ryu Fukumitsu
- Department of Neurosurgery, Kobe City Medical Center General Hospital, Kobe, Hyogo, Japan
| | - Tadashi Sunohara
- Department of Neurosurgery, Kobe City Medical Center General Hospital, Kobe, Hyogo, Japan
| | - Shirabe Matsumoto
- Department of Neurosurgery, Kobe City Medical Center General Hospital, Kobe, Hyogo, Japan
| | - Nobuyuki Fukui
- Department of Neurosurgery, Kobe City Medical Center General Hospital, Kobe, Hyogo, Japan
| | - Tatsumaru Fukuda
- Department of Neurosurgery, Kobe City Medical Center General Hospital, Kobe, Hyogo, Japan
| | - Tomoaki Akiyama
- Department of Neurosurgery, Kobe City Medical Center General Hospital, Kobe, Hyogo, Japan
| | - Tsuyoshi Ohta
- Department of Neurosurgery, Kobe City Medical Center General Hospital, Kobe, Hyogo, Japan
| | - Chiaki Sakai
- Department of Neurosurgery, Kobe City Medical Center General Hospital, Kobe, Hyogo, Japan
| | - Nobuyuki Sakai
- Department of Neurosurgery, Kobe City Medical Center General Hospital, Kobe, Hyogo, Japan
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35
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Dawson DL. Carotid artery stenting: Knowledge and wisdom. J Vasc Surg 2024; 80:151-152. [PMID: 38906659 DOI: 10.1016/j.jvs.2024.02.027] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2024] [Accepted: 02/22/2024] [Indexed: 06/23/2024]
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Jabbour G, Yadavalli SD, Straus S, Sanders AP, Rastogi V, Eldrup-Jorgensen J, Powell RJ, Davis RB, Schermerhorn ML. Learning curve of transfemoral carotid artery stenting in the Vascular Quality Initiative registry. J Vasc Surg 2024; 80:138-150.e8. [PMID: 38428653 DOI: 10.1016/j.jvs.2024.02.026] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2023] [Revised: 02/05/2024] [Accepted: 02/07/2024] [Indexed: 03/03/2024]
Abstract
OBJECTIVE With the recent expansion of the Centers for Medicare and Medicaid Services coverage, transfemoral carotid artery stenting (tfCAS) is expected to play a larger role in the management of carotid disease. Existing research on the tfCAS learning curve, primarily conducted over a decade ago, may not adequately describe the current effect of physician experience on outcomes. Because approximately 30% of perioperative strokes/deaths post-CAS occur after discharge, appropriate thresholds for in-hospital event rates have been suggested to be <4% for symptomatic and <2% for asymptomatic patients. This study evaluates the tfCAS learning curve using Vascular Quality Initiative (VQI) data. METHODS We identified VQI patients who underwent tfCAS between 2005 and 2023. Each physician's procedures were chronologically grouped into 12 categories, from procedure counts 1-25 to 351+. The primary outcome was in-hospital stroke/death rate; secondary outcomes were in-hospital stroke/death/myocardial infarction (MI), 30-day mortality, in-hospital stroke/transient ischemic attack (stroke/TIA), and access site complications. The relationship between outcomes and procedure counts was analyzed using the Cochran-Armitage test and a generalized linear model with restricted cubic splines. Our results were then validated using a generalized estimating equations model to account for the variability between physicians. RESULTS We analyzed 43,147 procedures by 2476 physicians. In symptomatic patients, there was a decrease in rates of in-hospital stroke/death (procedure counts 1-25 to 351+: 5.2%-1.7%), in-hospital stroke/death/MI (5.8%-1.7%), 30-day mortality (4.6%-2.8%), in-hospital stroke/TIA (5.0%-1.1%), and access site complications (4.1%-1.1%) as physician experience increased (all P values < .05). The in-hospital stroke/death rate remained above 4% until 235 procedures. Similarly, in asymptomatic patients, there was a decrease in rates of in-hospital stroke/death (2.1%-1.6%), in-hospital stroke/death/MI (2.6%-1.6%), 30-day mortality (1.7%-0.4%), and in-hospital stroke/TIA (2.8%-1.6%) with increasing physician experience (all P values <.05). The in-hospital stroke/death rate remained above 2% until 13 procedures. CONCLUSIONS In-hospital stroke/death and 30-day mortality rates after tfCAS decreased with increasing physician experience, showing a lengthy learning curve consistent with previous reports. Given that physicians' early cases may not be included in the VQI, the learning curve was likely underestimated. Nevertheless, a substantially high rate of in-hospital stroke/death was found in physicians' first 25 procedures. With the recent Centers for Medicare and Medicaid Services coverage expansion for tfCAS, a significant number of physicians would enter the early stage of the learning curve, potentially leading to increased postoperative complications.
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Affiliation(s)
- Gabriel Jabbour
- Division of Vascular and Endovascular Surgery, Department of Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA
| | - Sai Divya Yadavalli
- Division of Vascular and Endovascular Surgery, Department of Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA
| | - Sabrina Straus
- Division of Vascular and Endovascular Surgery, Department of Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA
| | - Andrew P Sanders
- Division of Vascular and Endovascular Surgery, Department of Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA
| | - Vinamr Rastogi
- Department of Vascular Surgery, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Jens Eldrup-Jorgensen
- Division of Vascular Surgery, Maine Medical Center, Tufts University School of Medicine, Portland, ME
| | - Richard J Powell
- Department of Vascular Surgery, Dartmouth-Hitchcock Medical Center, Lebanon, NH
| | - Roger B Davis
- Division of General Medicine, Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA
| | - Marc L Schermerhorn
- Division of Vascular and Endovascular Surgery, Department of Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA.
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Krafcik BM, Stone DH, Scali ST, Cai M, Jarmel IA, Hicks CW, Goodney PP, Columbo JA. Patient decision-making in the era of transcarotid artery revascularization. J Vasc Surg 2024; 80:125-135.e7. [PMID: 38447624 PMCID: PMC11193606 DOI: 10.1016/j.jvs.2024.02.035] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2023] [Revised: 02/21/2024] [Accepted: 02/26/2024] [Indexed: 03/08/2024]
Abstract
OBJECTIVE The National Coverage Determination on carotid stenting by Medicare in October 2023 stipulates that patients participate in a shared decision-making (SDM) conversation with their proceduralist before an intervention. However, to date, there is no validated SDM tool that incorporates transcarotid artery revascularization (TCAR) into its decision platform. Our objective was to elicit patient and surgeon experiences and preferences through a qualitative approach to better inform the SDM process surrounding carotid revascularization. METHODS We performed longitudinal perioperative semistructured interviews of 20 participants using purposive maximum variation sampling, a qualitative technique designed for identification and selection of information-rich cases, to define domains important to participants undergoing carotid endarterectomy or TCAR and impressions of SDM. We also performed interviews with nine vascular surgeons to elicit their input on the SDM process surrounding carotid revascularization. Interview data were coded and analyzed using inductive content analysis coding. RESULTS We identified three important domains that contribute to the participants' ultimate decision on which procedure to choose: their individual values, their understanding of the disease and each procedure, and how they prefer to make medical decisions. Participant values included themes such as success rates, "wanting to feel better," and the proceduralist's experience. Participants varied in their desired degree of understanding of carotid disease, but all individuals wished to discuss each option with their proceduralist. Participants' desired medical decision-making style varied on a spectrum from complete autonomy to wanting the proceduralist to make the decision for them. Participants who preferred carotid endarterectomy felt outcomes were superior to TCAR and often expressed a desire to eliminate the carotid plaque. Those selecting TCAR felt it was a newer, less invasive option with the shortest procedural and recovery times. Surgeons frequently noted patient factors such as age and anatomy, as well as the availability of long-term data, as reasons to preferentially select one procedure. For most participants, their surgeon was viewed as the most important source of information surrounding their disease and procedure. CONCLUSIONS SDM surrounding carotid revascularization is nuanced and marked by variation in patient preferences surrounding autonomy when choosing treatment. Given the mandate by Medicare to participate in a SDM interaction before carotid stenting, this analysis offers critical insights that can help to guide an efficient and effective dialog between patients and providers to arrive at a shared decision surrounding therapeutic intervention for patients with carotid disease.
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Affiliation(s)
- Brianna M Krafcik
- Department of Vascular Surgery, Dartmouth-Hitchcock Medical Center, Lebanon, NH.
| | - David H Stone
- Department of Vascular Surgery, Dartmouth-Hitchcock Medical Center, Lebanon, NH; Department of Vascular Surgery, White River Junction VA Hospital, White River Junction, VT
| | - Salvatore T Scali
- Division of Vascular Surgery and Endovascular Therapy, University of Florida College of Medicine, Gainesville, FL
| | - Ming Cai
- Department of General Surgery, Dartmouth-Hitchcock Medical Center, Lebanon, NH
| | | | - Caitlin W Hicks
- Division of Vascular Surgery and Endovascular Therapy, Department of Surgery, The Johns Hopkins Hospital, Baltimore, MD
| | - Philip P Goodney
- Department of Vascular Surgery, Dartmouth-Hitchcock Medical Center, Lebanon, NH; Department of Vascular Surgery, White River Junction VA Hospital, White River Junction, VT
| | - Jesse A Columbo
- Department of Vascular Surgery, Dartmouth-Hitchcock Medical Center, Lebanon, NH; Department of Vascular Surgery, White River Junction VA Hospital, White River Junction, VT
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Caron E, Yadavalli SD, Manchella M, Jabbour G, Mandigers TJ, Gomez-Mayorga JL, Bloch RA, Davis RB, Wang GJ, Nolan BA, Schermerhorn ML. Outcomes of carotid revascularization stratified by procedure in patients with an estimated glomerular filtration rate of <30 and dialysis patients. J Vasc Surg 2024:S0741-5214(24)01252-7. [PMID: 38906431 DOI: 10.1016/j.jvs.2024.06.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2024] [Revised: 06/04/2024] [Accepted: 06/07/2024] [Indexed: 06/23/2024]
Abstract
OBJECTIVE Renal failure is a predictor of adverse outcomes in carotid revascularization. There has been debate regarding the benefit of revascularization in patients with severe chronic kidney disease or on dialysis. METHODS Patients in the Vascular Quality Initiative undergoing transcarotid artery revascularization (TCAR), transfemoral carotid artery stenting (tfCAS), or CEA between 2016 and 2023 with an estimated glomerular filtration rate (eGFR) of <30 mL/min/1.73 m2 or on dialysis were included. Patients were divided into cohorts based on procedure. Additional analyses were performed for patients on dialysis only and by symptomatology. Primary outcomes were perioperative stroke/death/myocardial infarction (MI) (SDM). Secondary outcomes included perioperative death, stroke, MI, cranial nerve injury, and stroke/death. Inverse probability of treatment weighting was performed based on treatment assignment to TCAR, tfCAS, and CEA patients and adjusted for demographics, comorbidities, and preoperative symptoms. The χ2 test and multivariable logistic regression analysis were used to evaluate the association of procedure with perioperative outcomes in the weighted cohort. Five-year survival was evaluated using Kaplan-Meier and weighted Cox regression. RESULTS In the weighted cohort, 13,851 patients with an eGFR of <30 (2506 on dialysis) underwent TCAR (3639; 704 on dialysis), tfCAS (1975; 393 on dialysis), or CEA (8237; 1409 on dialysis) during the study period. Compared with TCAR, CEA had higher odds of SDM (2.8% vs 3.6%; adjusted odds ratio [aOR], 1.27; 95% confidence interval [CI], 1.00-1.61; P = .049), and MI (0.7% vs 1.5%; aOR, 2.00; 95% CI, 1.31-3.05; P = .001). Compared with TCAR, rates of SDM (2.8% vs 5.8%), stroke (1.2% vs 2.6%), and death (0.9% vs 2.4%) were all higher for tfCAS. In asymptomatic patients CEA patients had higher odds of MI (0.7% vs 1.3%; aOR, 1.85; 95% CI, 1.15-2.97; P = .011) and cranial nerve injury (0.3% vs 1.9%; aOR, 7.23; 95% CI, 3.28-15.9; P < .001). Like in the primary analysis, asymptomatic tfCAS patients demonstrated higher odds of death and stroke/death. Symptomatic CEA patients demonstrated no difference in stroke, death, or stroke/death. Although tfCAS patients demonstrated higher odds of death, stroke, MI, stroke/death, and SDM. In both groups, the 5-year survival was similar for TCAR and CEA (eGFR <30, 75.1% vs 74.2%; aHR, 1.06; P = .3) and lower for tfCAS (eGFR <30, 75.1% vs 70.4%; aHR, 1.44; P < .001). CONCLUSIONS CEA and TCAR had similar odds of stroke and death and are both a reasonable choice in this population; however, TCAR may be better in patients with an increased risk of MI. Additionally, tfCAS patients were more likely to have worse outcomes after weighting for symptom status. Finally, although patients with a reduced eGFR have worse outcomes than their healthy peers, this analysis shows that the majority of patients survive long enough to benefit from the potential stroke risk reduction provided by all revascularization procedures.
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Affiliation(s)
- Elisa Caron
- Divisions of Vascular and Endovascular Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA
| | - Sai Divya Yadavalli
- Divisions of Vascular and Endovascular Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA
| | - Mohit Manchella
- Divisions of Vascular and Endovascular Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA
| | - Gabriel Jabbour
- Divisions of Vascular and Endovascular Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA
| | - Tim J Mandigers
- Divisions of Vascular and Endovascular Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA
| | - Jorge L Gomez-Mayorga
- Divisions of Vascular and Endovascular Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA
| | - Randall A Bloch
- Division of General Surgery, St Elizabeth's Medical Center, Boston University, Boston, MA
| | - Roger B Davis
- Division of General Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA
| | - Grace J Wang
- Division of Vascular Surgery and Endovascular Therapy, Department of Surgery, Hospital of the University of Pennsylvania, Philadelphia, PA
| | - Brian A Nolan
- Division of Vascular and Endovascular Therapy, Department of Surgery, Maine Medical Center, Portland, ME
| | - Marc L Schermerhorn
- Divisions of Vascular and Endovascular Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA.
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Matsumoto H, Izawa D, Nishiyama H, Nakayama Y, Maeshima K. Clinical results of 30 consecutive patients of carotid artery stenosis treated with CASPER stent placement: 1-year follow-up and in-stent findings on intravascular ultrasound examination immediately and 6 months after treatment. J Neurointerv Surg 2024; 16:715-720. [PMID: 37399338 PMCID: PMC11228187 DOI: 10.1136/jnis-2023-020186] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2023] [Accepted: 06/14/2023] [Indexed: 07/05/2023]
Abstract
BACKGROUND The CASPER stent is expected to reduce periprocedural ischemic complications, but there is concern about restenosis in the early period. One-year follow-up results of CASPER stenting and findings on intravascular ultrasound (IVUS) immediately and 6 months after treatment are evaluated. METHODS Thirty consecutive patients were treated with CASPER stents for carotid artery stenosis. IVUS was performed immediately after stenting, and MRI and carotid ultrasonography were performed the next day, at 1 week, at 2 weeks, and then every 3 months. One-year follow-up results were evaluated. Twenty-five patients underwent follow-up angiography and IVUS after 6 months and their findings were investigated. RESULTS All patients were treated without complications during the intraoperative and periprocedural periods. After 6 months, all 25 patients with follow-up angiography and IVUS showed various degrees of intimal formation on IVUS and 8 of them had ≥50% stenosis on angiography. Three of the 30 patients required retreatment within 6 months because of severe restenosis. In these patients, the inner layer of the stent was deformed toward the inside due to intimal hyperplasia on follow-up IVUS, and there was dissociation between the inner and outer layers. All but the 3 of 30 patients with 1-year follow-up did not lead to symptomatic cerebrovascular events or retreatment. CONCLUSIONS The CASPER stent appears to be effective for preventing periprocedural ischemic complications. IVUS showed various degrees of intimal formation within 6 months after treatment, and it is possible that the CASPER stent is structurally prone to intimal formation or hyperplasia.
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Affiliation(s)
- Hiroyuki Matsumoto
- Neurological Surgery, Kishiwada Tokushukai Hospital, Kishiwada, Osaka, Japan
| | - Daisuke Izawa
- Neurological Surgery, Kishiwada Tokushukai Hospital, Kishiwada, Osaka, Japan
| | - Hirokazu Nishiyama
- Neurological Surgery, Kishiwada Tokushukai Hospital, Kishiwada, Osaka, Japan
| | - Yukie Nakayama
- Neurological Surgery, Kishiwada Tokushukai Hospital, Kishiwada, Osaka, Japan
| | - Kazuhide Maeshima
- Neurological Surgery, Kishiwada Tokushukai Hospital, Kishiwada, Osaka, Japan
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Uchida K, Shirakawa M, Sakakibara F, Sakai N, Iihara K, Imamura H, Ishii A, Matsumaru Y, Sakai C, Satow T, Yoshimura S. Sex differences in outcomes of carotid artery stenting. J Neurol Sci 2024; 461:123062. [PMID: 38797138 DOI: 10.1016/j.jns.2024.123062] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2024] [Revised: 05/15/2024] [Accepted: 05/21/2024] [Indexed: 05/29/2024]
Abstract
OBJECTIVE Existing evidence is inconclusive on whether women after carotid artery stenting (CAS) experience worse outcomes than men. METHODS The outcomes of women and men were compared using the data from nationwide retrospective registry between 2015 and 2019. The primary outcome was the incidence of ischemic stroke and all-cause death. Secondary outcomes included the incidence of ischemic stroke, all-cause death, acute occlusion, and acute myocardial infarction. Functional outcomes were the achieving an mRS score of 0-1 and 0-2. Outcomes were assessed at 30 days after CAS. RESULTS In total, 9792 patients (1330 women, 8862 men; mean age, 73.8 vs 73.5 years, p = 0.17) were analyzed. Symptomatic stenosis was common in men (52.0% vs. 55.1%; p = 0.03), while ≥50% stenosis after CAS was common in women (3.2% vs. 2.0%; p = 0.005). The primary outcome was no significantly difference in women and men (2.0% vs. 1.9%; adjusted odds ratio [aOR], 1.19; 95% confidence interval [95%CI], 0.75-1.88).The incidence of all-cause death was higher in women (0.9% vs. 0.5%; aOR, 2.45; 95%CI, 1.11-5.39). Functional outcomes were significantly less common in women than in men (mRS0-1, 72.6% vs. 74.8%; aOR, 0.77; 95%CI, 0.63-0.95; mRS0-2, 82.1% vs. 85.6%; aOR, 0.76; 95%CI, 0.60-0.95). CONCLUSIONS This study suggests that there was no significant sex differences in the incidence of ischemic stroke and all-cause death at 30 days. However, women have higher rate of all-cause death and poorer functional outcomes at 30 days than men.
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Affiliation(s)
- Kazutaka Uchida
- Department of Neurosurgery, Hyogo Medical University, Nishinomiya, Japan.
| | - Manabu Shirakawa
- Department of Neurosurgery, Hyogo Medical University, Nishinomiya, Japan
| | | | - Nobuyuki Sakai
- Department of Neurosurgery, Seijinkai Shimizu Hospital, Kyoto, Japan
| | - Koji Iihara
- Department of Neurosurgery, National Cerebral and Cardiovascular Center, Suita, Japan
| | - Hirotoshi Imamura
- Department of Neurosurgery, National Cerebral and Cardiovascular Center, Suita, Japan
| | - Akira Ishii
- Department of Neurosurgery, Juntendo University, Tokyo, Japan
| | - Yuji Matsumaru
- Department of Neurosurgery, Faculty of Medicine, University of Tsukuba, Ibaraki, Japan
| | - Chiaki Sakai
- Department of Neurosurgery, Kyoto University, Kyoto, Japan
| | - Tetsu Satow
- Department of Neurosurgery, Kindai University, Osaka-Sayama, Japan
| | - Shinichi Yoshimura
- Department of Neurosurgery, Hyogo Medical University, Nishinomiya, Japan
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Chamseddine H, Chahrour M, Shepard A, Nypaver T, Weaver M, Kavousi Y, Onofrey K, Aboul Hosn M, Kabbani L. Locoregional anesthesia is associated with decreased cardiac complications in symptomatic heart failure patients undergoing carotid endarterectomy. J Vasc Surg 2024:S0741-5214(24)01246-1. [PMID: 38851468 DOI: 10.1016/j.jvs.2024.06.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2024] [Revised: 05/25/2024] [Accepted: 06/02/2024] [Indexed: 06/10/2024]
Abstract
OBJECTIVE Although the current literature reports no advantage for locoregional anesthesia (LRA) over general anesthesia (GA) in patients undergoing carotid endarterectomy (CEA), there remains a gap in understanding the impact of LRA on individuals with congestive heart failure (CHF). This study aims to assess whether the choice of anesthesia influences the rates of perioperative complications within this patient population. METHODS Using the Vascular Quality Initiative CEA module, all patients undergoing CEA between 2013 and 2023 were identified. The subset of patients with CHF was included, and patients were divided based on the type of anesthesia received. Patient characteristics and outcomes were compared using the χ2 or Fischer's exact test as appropriate for categorical variables and the independent t test or Mann-Whitney U test as appropriate for continuous variables. A sensitivity analysis was performed based on the symptomatic status of CHF, and the association between anesthesia modality and postoperative outcomes was studied using multivariable logistic regression analysis. The primary outcomes of this study included perioperative stroke, myocardial infarction (MI), acute HF, and the combination of MI and acute HF defined as major cardiac complications. RESULTS A total of 21,292 patients (19,730 receiving GA, 1562 receiving LRA) with a diagnosis of CHF undergoing CEA were identified. On multivariable logistic regression analysis, LRA was independently associated with lower MI (odds ratio [OR]; 0.35; 95% confidence interval [CI], 0.13-0.96), acute HF (OR, 0.27; 95% CI, 0.09-0.87), major cardiac complications (OR, 0.30; 95% CI, 0.13-0.67), hemodynamic instability (OR, 0.64; 95% CI, 0.53-0.78), cranial nerve injury (OR, 0.40; 95% CI, 0.19-0.81), shunt use (OR, 0.25; 95% CI, 0.20-0.31), and neuromonitoring device use (OR, 0.20; 95% CI, 0.17-0.24) compared with GA in patients with symptomatic CHF. No difference in MI, acute HF, and major cardiac complications was seen in patients with asymptomatic CHF. CONCLUSIONS CEA can be performed safely in patients with CHF. Using LRA is associated with a decreased incidence of perioperative cardiac complications in patients with symptomatic HF undergoing CEA.
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Affiliation(s)
- Hassan Chamseddine
- Division of Vascular Surgery, Department of Surgery, Henry Ford Hospital, Detroit, MI
| | - Mohamad Chahrour
- Division of Vascular Surgery, Department of Surgery, University of Iowa Hospital and Clinics, Iowa City, IA
| | - Alexander Shepard
- Division of Vascular Surgery, Department of Surgery, Henry Ford Hospital, Detroit, MI
| | - Timothy Nypaver
- Division of Vascular Surgery, Department of Surgery, Henry Ford Hospital, Detroit, MI
| | - Mitchell Weaver
- Division of Vascular Surgery, Department of Surgery, Henry Ford Hospital, Detroit, MI
| | - Yasaman Kavousi
- Division of Vascular Surgery, Department of Surgery, Henry Ford Hospital, Detroit, MI
| | - Kevin Onofrey
- Division of Vascular Surgery, Department of Surgery, Henry Ford Hospital, Detroit, MI
| | - Maen Aboul Hosn
- Division of Vascular Surgery, Department of Surgery, University of Iowa Hospital and Clinics, Iowa City, IA
| | - Loay Kabbani
- Division of Vascular Surgery, Department of Surgery, Henry Ford Hospital, Detroit, MI.
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Park JK, Woo SY, Park YJ, Kim DI, Kim GM, Seo WK, Jung JW, Jeon P, Kim KH, Kim YW, Yang SS. The Impact of age and outcomes of high-risk patients on carotid revascularization. Vascular 2024; 32:596-602. [PMID: 36794829 DOI: 10.1177/17085381231155035] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/17/2023]
Abstract
OBJECTIVES To validate the accuracy of high-risk criteria for carotid endarterectomy (CEA) and analyze the correlation between age and outcome of CEA and carotid artery stenting (CAS) in risk groups. METHODS We reviewed a prospectively managed vascular surgery database in a single tertiary referral center, and 2482 internal carotid arteries (ICAs) had undergone carotid revascularization from November 1994 to December 2021. To validate high-risk criteria for CEA, patients were classified as high risk (Hr) and normal risk (Nr). Subgroup analysis was performed with patients older or younger than 75 years to investigate the relationship between age and outcome in each group. Primary endpoints were 30-day outcomes including stroke, death, stroke/death, myocardial infraction (MI), and major adverse cardiovascular events (MACEs). RESULTS A total of 2345 ICAs in 2256 patients were enrolled. The number of patients in the Hr group was 543 (24%) and the number in the Nr group was 1713 (76%). CEA and CAS were performed on 1384 (61%) and 872 (39%) patients, respectively. The 30-day stroke/death rate was higher with CAS than CEA in both the Hr (1.1% vs. 3.9%, p = 0.032) and Nr (1.2% vs. 6.9%, p < 0.001) groups. In unmatched logistic regression analysis of the Nr group (n = 1778), the rate of 30-day stroke/death (OR, 5.575; 95% CI, 2.922-10.636; p < 0.001) was higher for CAS than CEA. In propensity score matching of the Nr group, the rate of 30-day stroke/death (OR, 5.165; 95% CI, 2.391-11.155; p < 0.001) was also higher for CAS than CEA. In the age <75 subgroup of the Hr group (n = 428), CAS was associated with higher 30-day stroke/death (OR, 14.089; 95% CI, 1.314-151.036; p = 0.029). In the age ≥75 subgroup of the Hr (n = 139), there was no difference in 30-day stroke/death between CEA and CAS. In the age <75 subgroup of the Nr group (n = 1318), 30-day stroke/death (OR, 6.300; 95% CI, 2.797-14.193; p < 0.001) was higher in CAS. In the age ≥75 subgroup of the Nr group (n = 460), 30-day stroke/death (OR, 6.468; 95% CI, 1.862-22.471; p = 0.003) was higher in CAS. CONCLUSIONS In patients older than 75 years in the Hr group, there were relatively poor 30-day treatment outcomes in both CEA and CAS. Alternative treatment is needed that can expect better outcomes in older high-risk patients. In the Nr group, CEA has a significant benefit compared with CAS, and CEA should be recommended more to these patients.
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Affiliation(s)
- Joon-Kee Park
- Division of Vascular Surgery, Department of Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Shin-Young Woo
- Division of Vascular Surgery, Department of Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Yang-Jin Park
- Division of Vascular Surgery, Department of Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Dong-Ik Kim
- Division of Vascular Surgery, Department of Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Gyeong-Moon Kim
- Department of Neurology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Woo-Keun Seo
- Department of Neurology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Jong-Won Jung
- Department of Neurology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Pyoung Jeon
- Department of Radiology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Keon-Ha Kim
- Department of Radiology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Young-Wook Kim
- Division of Vascular Surgery, Department of Surgery, Kangbuk Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Shin-Seok Yang
- Division of Vascular Surgery, Department of Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
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Penton A, Boland T, Weise L, Crisostomo P. Transcarotid arterial revascularization is feasible and safe with concomitant inferior vena cava occlusion. J Vasc Surg Cases Innov Tech 2024; 10:101414. [PMID: 38559375 PMCID: PMC10979231 DOI: 10.1016/j.jvscit.2023.101414] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2023] [Accepted: 12/19/2023] [Indexed: 04/04/2024] Open
Abstract
Transcarotid artery revascularization (TCAR) has risen as a promising minimally invasive intervention for high-risk patients with favorable anatomy. TCAR's noninferiority to carotid endarterectomy regarding stroke is reliant on its flow reversal technology and lack of aortic arch manipulation. We present the case of a 79-year-old man with a chronically occluded inferior vena cava who safely underwent staged bilateral TCAR for bilateral high-grade carotid artery stenosis. Although chronic inferior vena cava occlusion alters flow mechanics, we suspect that any pressure gradient facilitating retrograde flow from the carotid artery to the femoral vein provides neuroprotective benefits.
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Affiliation(s)
- Ashley Penton
- Division of Vascular Surgery and Endovascular Therapy, Department of Surgery, Loyola University Medical Center, Maywood, IL
| | - Thomas Boland
- Division of Vascular Surgery and Endovascular Therapy, Department of Surgery, Loyola University Medical Center, Maywood, IL
| | - Lorela Weise
- Division of Vascular Surgery and Endovascular Therapy, Department of Surgery, Loyola University Medical Center, Maywood, IL
| | - Paul Crisostomo
- Division of Vascular Surgery and Endovascular Therapy, Department of Surgery, Loyola University Medical Center, Maywood, IL
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Pini R, Faggioli G, Paraskevas KI, Campana F, Sufali G, Rocchi C, Palermo S, Gallitto E, Gargiulo M. Carotid Artery Stenting With Double-Layer Stent: A Systematic Review and Meta-Analysis. J Endovasc Ther 2024; 31:339-349. [PMID: 36214459 PMCID: PMC11110467 DOI: 10.1177/15266028221126940] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
BACKGROUND Carotid artery stenting (CAS) in the treatment of significant stenosis is a cause of stroke due to both plaque prolapse and cerebral embolization. New types of stents with a double-layer structure have been designed to minimize plaque prolapse and embolization; these double-layer stents (DLSs) should be able to reduce the stroke risk; however, definite data on their performance are scarce in the literature. METHODS A systematic search was performed through PubMed, Scopus, and Cochrane Library, according to PRISMA guidelines; all studies on CAS with DLS (Roadsaver/Casper or CGuard) up to January 1, 2022, with a cohort of at least 20 patients were considered eligible. The present meta-analysis was approved and registered on PROSPERO register (CRD42022297512). Patients with tandem lesions or complete carotid occlusion were excluded from the study. The 30-day stroke rate after CAS was analyzed evaluating the preoperative symptomatic status and DLS occlusion. The estimated pooled rate of events was calculated by random effect model and moderators were evaluated. RESULTS A total of 14 studies were included in the meta-analysis for a total of 1955 patients. The estimated overall (95% confidence interval [CI]) stroke rate was 1.4% (0.9%-2.2%, I2 = 0%), which was not influenced by the type of DLS used: CGuard 0.8% (0.4%-1.8%, I2 = 0%) versus Roadsaver/Casper 1.5% (0.7%-3.2%, I2 = 0%), p=0.30. The 30-day estimated stroke rate was 1.5% (0.8%-2.9%, I2 = 0%) in asymptomatic and 1.9% (1.0%-3.6%, I2 = 0%) in symptomatic patients, with no influence by moderators. The 30-day DLS occlusion rate was 0.8% (0.4%-1.8%, I2 = 0%). The publication bias assessment identified asymmetry in the asymptomatic populations. CONCLUSION The overall 30-day stroke rate in CAS with DLS is low (1.4%), with similar results in symptomatic and asymptomatic patients. Acute occlusion of DLS is rare (0.8%). Further studies are necessary to reduce the publication bias for asymptomatic patients. CLINICAL IMPACT CAS with DLS is associated to a low rate of 30-day stroke in both symptomatic (1.9%) and asymptomatic (1.5%) patients. The type of DLS (CGuard or Roadsaver/Casper) did not affect the 30-day stroke rate.
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Affiliation(s)
- Rodolfo Pini
- Department of Vascular Surgery, University of Bologna and Policlinico Sant’Orsola Malpighi, Bologna, Italy
| | - Gianluca Faggioli
- Department of Vascular Surgery, University of Bologna and Policlinico Sant’Orsola Malpighi, Bologna, Italy
| | | | - Federica Campana
- Department of Vascular Surgery, University of Bologna and Policlinico Sant’Orsola Malpighi, Bologna, Italy
| | - Gemmi Sufali
- Department of Vascular Surgery, University of Bologna and Policlinico Sant’Orsola Malpighi, Bologna, Italy
| | - Cristina Rocchi
- Department of Vascular Surgery, University of Bologna and Policlinico Sant’Orsola Malpighi, Bologna, Italy
| | - Sergio Palermo
- Department of Vascular Surgery, University of Bologna and Policlinico Sant’Orsola Malpighi, Bologna, Italy
| | - Enrico Gallitto
- Department of Vascular Surgery, University of Bologna and Policlinico Sant’Orsola Malpighi, Bologna, Italy
| | - Mauro Gargiulo
- Department of Vascular Surgery, University of Bologna and Policlinico Sant’Orsola Malpighi, Bologna, Italy
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Columbo JA, Stone DH. Appropriateness of care: Asymptomatic carotid stenosis including transcarotid artery revascularization. Semin Vasc Surg 2024; 37:179-187. [PMID: 39151997 PMCID: PMC11330557 DOI: 10.1053/j.semvascsurg.2024.03.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2024] [Revised: 03/14/2024] [Accepted: 03/27/2024] [Indexed: 08/19/2024]
Abstract
Carotid artery stenosis is one of the most common diagnoses treated by vascular specialists in the United States. The optimal management of carotid stenosis remains controversial, however, with notable variation surrounding diagnostic imaging modalities, longitudinal surveillance, medical therapies, and procedural interventions. Data from high-quality randomized controlled trials and observational studies form the foundation for current management paradigms and societal guidelines that inform clinical practice. Presently, a diagnosis of carotid disease is most often established with duplex ultrasound and supplemental cross-sectional imaging using computed tomography or magnetic resonance angiography as needed to provide additional anatomic information. All patients with documented occlusive disease should receive goal-directed medical therapy with antiplatelet agents and a lipid-reduction strategy, most commonly with a statin. Those with severe carotid stenosis and an acceptable life expectancy may be considered for carotid artery revascularization. The proceduralist should optimally consider a shared decision-making approach in which the tradeoffs of revascularization can be carefully considered with the patient to optimize informed therapeutic decision making. In current practice, three distinct procedure options exist to treat carotid artery stenosis, including carotid endarterectomy, transfemoral carotid artery stenting, and transcarotid artery revascularization. It should be noted that each procedure, although often used interchangeably in most clinical settings, carry technical nuances and outcome disparities. In this review, each of these topics are explored and various approaches are outlined surrounding the appropriate use of treatments for patients with asymptomatic carotid artery stenosis.
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Affiliation(s)
- Jesse A Columbo
- Geisel School of Medicine at Dartmouth, Hanover, NH; Section of Vascular Surgery, 3V, Dartmouth-Hitchcock Medical Center, 1 Medical Center Drive, Lebanon, NH 03766; Veterans Affairs Medical Center, White River Junction, VT.
| | - David H Stone
- Geisel School of Medicine at Dartmouth, Hanover, NH; Section of Vascular Surgery, 3V, Dartmouth-Hitchcock Medical Center, 1 Medical Center Drive, Lebanon, NH 03766; Veterans Affairs Medical Center, White River Junction, VT
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Yu S, Chaney MA. Combined Coronary and Carotid Artery Disease: What to Operate on First? Or Both at the Same Time? J Cardiothorac Vasc Anesth 2024; 38:1417-1422. [PMID: 37839940 DOI: 10.1053/j.jvca.2023.09.021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/12/2023] [Accepted: 09/16/2023] [Indexed: 10/17/2023]
Affiliation(s)
- Sherman Yu
- Department of Anesthesia and Critical Care, University of Chicago, Chicago, IL
| | - Mark A Chaney
- Department of Anesthesia and Critical Care, University of Chicago, Chicago, IL.
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Trystula M, VAN Herzeele I, Kolvenbach R, Tekieli L, Fonteyne C, Mazurek A, Dzierwa K, Chmiel J, Lindsay J, Kwiatkowski T, Hydzik A, Oplawski M, Bederski K, Musialek P. Next-generation transcarotid artery revascularization: TransCarotid flOw Reversal Cerebral Protection And CGUARD MicroNET-Covered Embolic Prevention Stent System To Reduce Strokes - TOPGUARD Study. THE JOURNAL OF CARDIOVASCULAR SURGERY 2024; 65:181-194. [PMID: 39007552 DOI: 10.23736/s0021-9509.24.13121-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 07/16/2024]
Abstract
BACKGROUND Stent-assisted carotid artery revascularization employing surgical cutdown for transcervical access and dynamic flow reversal (TCAR) is gaining popularity. TCAR, despite maximized intra-procedural cerebral protection, shows a marked excess of 30-day neurologic complications in symptomatic vs. asymptomatic stenoses. The TCAR conventional single-layer stent (free-cell area 5.89mm2) inability to seal embologenic lesions may be particularly relevant after the flow reversal neuroprotection is terminated. METHODS We evaluated peri-procedural and 30-day major adverse cerebral and cardiac events (MACCE) of TCAR (ENROUTE, SilkRoad Medical) paired with MicroNET-covered neuroprotective stent (CGuard, InspireMD) in consecutive patients at elevated risk of complications with transfemoral/transradial filter-protected stenting (increased lesion-related and/or access-related risk). CGuard (MicroNET free cell area ≈0.02-0.03 mm2) has level-1 evidence for reducing intra- and abolishing post-procedural lesion-related cerebral embolism. RESULTS One hundred and six increased-risk patients (age 72 [61-76] years, median [Q1-Q3]; 60.4% symptomatic, 49.1% diabetic, 36.8% women, 61.3% left-sided index lesion) were enrolled in three vascular surgery centers. Angiographic stenosis severity was 81 (75-91)%, lesion length 21 (15-26)mm, increased-risk lesional characteristics 87.7%. Study stent use was 100% (no other stent types). 74.5% lesions were predilated; post-dilatation rate was 90.6%. Flow reversal duration was 8 (5-11)min. One stroke (0.9%) occurred in an asymptomatic patient prior to establishing neuroprotection (index lesion disruption with the sheath insertion wire); there were no other peri-procedural MACCE. No further adverse events occurred by 30-days. 30-day stent patency was 100% with normal velocities and absence of any in-stent material by Duplex Doppler. CONCLUSIONS Despite a high proportion of increased-risk lesions and clinically symptomatic patients in this study, TCAR employing the MicroNET-covered anti-embolic stent showed 30-day MACCE rate <1%. This suggests a clinical role for combining maximized intra-procedural prevention of cerebral embolism by dynamic flow reversal with anti-embolic stent prevention of peri- and post-procedural cerebral embolism (TOPGUARD NCT04547387).
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Affiliation(s)
- Mariusz Trystula
- Department of Vascular Surgery, St. John Paul II Hospital, Krakow, Poland
| | - Isabelle VAN Herzeele
- Department of Thoracic and Vascular Surgery, Ghent University Hospital, Ghent, Belgium
| | - Ralf Kolvenbach
- Department of Vascular Surgery, Sana Kliniken, Düsseldorf, Germany
| | - Lukasz Tekieli
- Department of Cardiac and Vascular Diseases, Jagiellonian University Medical College, Krakow, Poland
- Stroke Thrombectomy-Capable Center, St. John Paul II Hospital, Krakow, Poland
| | - Charlotte Fonteyne
- Department of Thoracic and Vascular Surgery, University of Ghent, Ghent, Belgium
| | - Adam Mazurek
- Department of Cardiac and Vascular Diseases, Jagiellonian University Medical College, Krakow, Poland
- Stroke Thrombectomy-Capable Center, St. John Paul II Hospital, Krakow, Poland
| | - Karolina Dzierwa
- Cardiovascular Imaging Laboratory, St. John Paul II Hospital, Krakow, Poland
| | - Jakub Chmiel
- Department of Cardiac and Vascular Diseases, Jagiellonian University Medical College, Krakow, Poland
- Stroke Thrombectomy-Capable Center, St. John Paul II Hospital, Krakow, Poland
| | | | - Tomasz Kwiatkowski
- Department of Vascular Surgery, St. John Paul II Hospital, Krakow, Poland
| | - Adam Hydzik
- Department of Vascular Surgery, St. John Paul II Hospital, Krakow, Poland
| | | | - Krzysztof Bederski
- Department of Thoracic Surgery, St. John Paul II Hospital, Krakow, Poland
| | - Piotr Musialek
- Department of Cardiac and Vascular Diseases, Jagiellonian University Medical College, Krakow, Poland -
- Stroke Thrombectomy-Capable Center, St. John Paul II Hospital, Krakow, Poland
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Legeza PT, Lettenberger AB, Murali B, Johnson LR, Berczeli M, Byrne MD, Britz G, O'Malley MK, Lumsden AB. Evaluation of Robotic-Assisted Carotid Artery Stenting in a Virtual Model Using Motion-Based Performance Metrics. J Endovasc Ther 2024; 31:457-465. [PMID: 36147025 DOI: 10.1177/15266028221125592] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
PURPOSE Robotic-assisted carotid artery stenting (CAS) cases have been demonstrated with promising results. However, no quantitative measurements have been made to compare manual with robotic-assisted CAS. This study aims to quantify surgical performance using tool tip kinematic data and metrics of precision during CAS with manual and robotic control in an ex vivo model. MATERIALS AND METHODS Transfemoral CAS cases were performed in a high-fidelity endovascular simulator. Participants completed cases with manual and robotic techniques in 2 different carotid anatomies in random order. C-arm angulations, table position, and endovascular devices were standardized. Endovascular tool tip kinematic data were extracted. We calculated the spectral arc length (SPARC), average velocity, and idle time during navigation in the common carotid artery and lesion crossing. Procedural time, fluoroscopy time, movements of the deployed filter wire, precision of stent, and balloon positioning were recorded. Data were analyzed and compared between the 2 modalities. RESULTS Ten participants performed 40 CAS cases with a procedural success of 100% and 0% residual stenosis. The median procedural time was significantly higher during the robotic-assisted cases (seconds, median [interquartile range, IQR]: 128 [49.5] and 161.5 [62.5], p=0.02). Fluoroscopy time differed significantly between manual and robotic-assisted procedures (seconds, median [IQR]: 81.5 [32] and 98.5 [39.5], p=0.1). Movement of the deployed filter wire did not show significant difference between manual and robotic interventions (mm, median [IQR]: 13 [10.5] and 12.5 [11], p=0.5). The postdilation balloon exceeded the margin of the stent with a median of 2 [1] mm in both groups. Navigation with robotic assistance showed significantly lower SPARC values (-5.78±3.14 and -8.63±3.98, p=0.04) and higher idle time values (8.92±8.71 and 3.47±3.9, p=0.02) than those performed manually. CONCLUSIONS Robotic-assisted and manual CAS cases are comparable in the precision of stent and balloon positioning. Navigation in the carotid artery is associated with smoother motion and higher idle time values. These findings highlight the accuracy and the motion stabilizing capability of the endovascular robotic system. CLINICAL IMPACT Robotic assistance in the treatment of peripheral vascular disease is an emerging field and may be a tool for radiation protection and the geographic distribution of endovascular interventions in the future. This preclinical study compares the characteristics of manual and robotic-assisted carotid stenting (CAS). Our results highlight, that robotic-assisted CAS is associated with precise navigation and device positioning, and smoother navigation compared to manual CAS.
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Affiliation(s)
- Peter T Legeza
- Department of Cardiovascular Surgery, Houston Methodist Hospital, Houston, TX, USA
- Department of Vascular and Endovascular Surgery, Semmelweis University, Budapest, Hungary
| | - Ahalya B Lettenberger
- Department of Mechanical Engineering, Mechatronics and Haptic Interfaces Laboratory, Rice University, Houston, TX, USA
| | - Barathwaj Murali
- Department of Mechanical Engineering, Mechatronics and Haptic Interfaces Laboratory, Rice University, Houston, TX, USA
| | - Lianne R Johnson
- Department of Mechanical Engineering, Mechatronics and Haptic Interfaces Laboratory, Rice University, Houston, TX, USA
| | - Marton Berczeli
- Department of Cardiovascular Surgery, Houston Methodist Hospital, Houston, TX, USA
- Department of Vascular and Endovascular Surgery, Semmelweis University, Budapest, Hungary
| | - Michael D Byrne
- Department of Psychological Sciences, Rice University, Houston, TX, USA
| | - Gavin Britz
- Department of Neurosurgery, Houston Methodist Hospital, Houston, TX, USA
| | - Marcia K O'Malley
- Department of Mechanical Engineering, Mechatronics and Haptic Interfaces Laboratory, Rice University, Houston, TX, USA
| | - Alan B Lumsden
- Department of Cardiovascular Surgery, Houston Methodist Hospital, Houston, TX, USA
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Ozbek IC, Durmaz A, Ozen Y, Demir S, Celik D, Yalcinkaya E, Cunurlu M, Ugur M. Effectiveness of carotid council in the treatment of carotid artery disease: Early-term outcomes of the multidisciplinary approach. Vascular 2024; 32:573-578. [PMID: 36655573 DOI: 10.1177/17085381231153222] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/20/2023]
Abstract
OBJECTIVES Carotid arterial stenosis could be treated by surgical or percutaneous stenting. In this study, we aimed to investigate the effectiveness of the carotid council on the outcomes of patients with carotid artery disease. METHODS In this retrospective study, we analyzed the patients who had undergone carotid arterial revascularization from April 2014 to July 2022 in our hospital. All patients were evaluated in carotid council, which is constituted by neurologist, cardiologist and cardiovascular surgeon. Patient-specific treatment procedure was decided in the council. Demographics and early-term follow-up results of the patients were evaluated. RESULTS Totally 95 procedures in 85 patients were analyzed during the study period. 27.4 % of the patients had significant contralateral carotid arterial stenosis. In 88 (92.6%) procedures, patients were treated by carotid endarterectomy, and 5 procedures were performed under regional anesthesia. Shunt usage was 6.0% during the surgery, and arteriotomy was repaired with primary sutures in 87.3%. Stent implantation was performed in 7 patients. There were 5 neurological adverse events after the carotid endarterectomy and 2 neurological events were after carotid arterial stenting. In each treatment group, one patient died after the procedure. In the follow-up period, restenosis was observed just in a patient who was treated with carotid endarterectomy and primary repair. CONCLUSION Although carotid artery disease could be treated in accordance with the guidelines, treatment procedures should be patient-specific. Carotid councils might be helpful in giving patient-specific decisions, thereby providing the patient-based treatment procedure and improving the outcomes of the patients with carotid artery disease.
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Affiliation(s)
- Ismail C Ozbek
- Department of Cardiovascular Surgery, Sancaktepe Sehit Professor Doctor Ilhan Varank Education and Research Hospital, University of Health Sciences, Istanbul, Turkey
| | - Aysegul Durmaz
- Department of Cardiovascular Surgery, Sancaktepe Sehit Professor Doctor Ilhan Varank Education and Research Hospital, University of Health Sciences, Istanbul, Turkey
| | - Yucel Ozen
- Department of Cardiovascular Surgery, Sancaktepe Sehit Professor Doctor Ilhan Varank Education and Research Hospital, University of Health Sciences, Istanbul, Turkey
| | - Serkan Demir
- Department of Neurology, Sancaktepe Sehit Professor Doctor Ilhan Varank Education and Research Hospital, University of Health Sciences, Istanbul, Turkey
| | - Didem Celik
- Department of Neurology, Sancaktepe Sehit Professor Doctor Ilhan Varank Education and Research Hospital, University of Health Sciences, Istanbul, Turkey
| | - Emre Yalcinkaya
- Department of Cardiology, Sancaktepe Sehit Professor Doctor Ilhan Varank Education and Research Hospital, University of Health Sciences, Istanbul, Turkey
| | - Merve Cunurlu
- Department of Cardiovascular Surgery, Sancaktepe Sehit Professor Doctor Ilhan Varank Education and Research Hospital, University of Health Sciences, Istanbul, Turkey
| | - Murat Ugur
- Department of Cardiovascular Surgery, Sancaktepe Sehit Professor Doctor Ilhan Varank Education and Research Hospital, University of Health Sciences, Istanbul, Turkey
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Balakrishnan P, Anderson J, Arcand CM, Krantz M, Kitchen JC. Subclavian-Carotid Bypass as a Solution to Recurrent Carotid Artery Stenosis Post Endarterectomy and Transfemoral Stenting. Cureus 2024; 16:e63087. [PMID: 39055438 PMCID: PMC11270155 DOI: 10.7759/cureus.63087] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/25/2024] [Indexed: 07/27/2024] Open
Abstract
We present the case of an 80-year-old man who underwent a subclavian-to-distal internal carotid artery bypass with a reversed saphenous vein due to symptomatic in-stent restenosis, following a carotid endarterectomy 20 years ago and carotid artery stenting 10 years ago. The patient presented with right-sided hemiparesis and dysarthria. Imaging suggested in-stent restenosis of the internal carotid artery stent. He was also found to have stenosis of the common carotid artery origin stent. An initial transfemoral attempt by interventional radiology was unsuccessful. Due to the stenosed common carotid artery origin stent, a common carotid-to-internal carotid artery bypass was not feasible. Therefore, a subclavian-distal carotid artery bypass with a reversed saphenous vein was performed. He did well in the postoperative period and has been seen in the clinic since. Surveillance ultrasound demonstrated a patent graft with non-stenotic proximal and distal anastomoses. We include an in-depth review of the management of recurrent carotid artery stenosis as well.
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Affiliation(s)
- Pranav Balakrishnan
- General Surgery, Marshall University Joan C. Edwards School of Medicine, Huntington, USA
| | - Jamie Anderson
- General Surgery, Marshall University Joan C. Edwards School of Medicine, Huntington, USA
| | - Christina M Arcand
- General Surgery, Marshall University Joan C. Edwards School of Medicine, Huntington, USA
| | - Matthew Krantz
- Vascular Surgery, Marshall University Joan C. Edwards School of Medicine, Huntington, USA
| | - James C Kitchen
- Vascular Surgery, Marshall University Joan C. Edwards School of Medicine, Huntington, USA
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