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Zimmermann M, Larena-Avellaneda A, Rother U, Lareyre F, Søgaard M, Tulamo R, Venermo M, Behrendt CA. Editor's Choice - Long Term Outcomes After Invasive Treatment of Carotid Artery Stenosis: a Longitudinal Study of German Health Insurance Claims. Eur J Vasc Endovasc Surg 2023; 66:493-500. [PMID: 37490978 DOI: 10.1016/j.ejvs.2023.07.030] [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: 03/19/2023] [Revised: 06/23/2023] [Accepted: 07/19/2023] [Indexed: 07/27/2023]
Abstract
OBJECTIVE There is a paucity of observational data including long term outcomes after invasive treatment for carotid artery stenosis. METHODS This retrospective study used nationwide insurance claims from the third largest provider in Germany, DAK-Gesundheit. Patients who underwent inpatient carotid endarterectomy (CEA) or carotid artery stenting (CAS) between 1 January 2008 and 31 May 2017 were included. The Elixhauser comorbidity scores from longitudinally linked hospital episodes were used. Kaplan-Meier analysis and the log rank test were used to determine long term stroke free survival. Multivariable regression models were developed to adjust for confounding. RESULTS A total of 22 637 individual patients (41.6% female, median age 72.5 years) were included, of whom 15 005 (66.3%) were asymptomatic and 17 955 (79.3%) underwent CEA. After a median of 48 months, 5 504 any stroke or death events were registered. The mortality rate varied between 0.4% (CEA for asymptomatic stenosis) and 2.1% (urgent CAS for acute stroke patients) at 30 days, and between 4.1% and 8.4% at one year, respectively. The rate for any stroke varied between 0.6% (CEA for asymptomatic stenosis) and 2.5% (CAS for symptomatic patients) at 30 days, and between 2.5% and 6.4% at one year, respectively. The combined rate for any stroke and mortality at one year was 6.3% (CEA for asymptomatic stenosis), 8.7% (CAS for asymptomatic stenosis), and 12.5% (urgent CAS for acute stroke patients). After five years, the overall stroke rate was 7.4% after CEA and 9.0% after CAS. In adjusted analyses, both older age and van Walraven comorbidity score were associated with events, while treatment of asymptomatic stenosis was associated with lower event rates. CONCLUSION The current study revealed striking differences between previous landmark trials and real world practice. It further suggested excess deaths among invasively treated asymptomatic patients.
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Affiliation(s)
| | - Axel Larena-Avellaneda
- Department of Vascular and Endovascular Surgery, Asklepios Clinic Altona, Asklepios Medical School, Hamburg, Germany
| | - Ulrich Rother
- Department of Vascular Surgery, University Hospital Erlangen, Friedrich Alexander Universität Erlangen-Nürnberg (FAU), Erlangen, Germany
| | - Fabien Lareyre
- Department of Vascular Surgery, Hospital of Antibes-Juan-les-Pins, Antibes, Institut National de la Santé et de la Recherche Médicale (INSERM), Centre Méditerranéen de Médecine Moléculaire (C3M), Université Côte d'Azur, Nice, France
| | - Mette Søgaard
- Aalborg Thrombosis Research Unit, Department of Clinical Medicine, Faculty of Medicine, Aalborg University, Aalborg, Denmark; Department of Cardiology, Aalborg University Hospital, Aalborg, Denmark
| | - Riikka Tulamo
- Department of Vascular Surgery, Helsinki University Hospital, University of Helsinki, Helsinki, Finland
| | - Maarit Venermo
- Department of Vascular Surgery, Helsinki University Hospital, University of Helsinki, Helsinki, Finland
| | - Christian-Alexander Behrendt
- Department of Vascular and Endovascular Surgery, Asklepios Clinic Wandsbek, Asklepios Medical School, Hamburg, Germany; Brandenburg Medical School Theodor Fontane, Neuruppin, Germany.
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Zalaquett Z, Zgheib G, Karam L, Zaatar M, Nehme K, Tabet G. A rare association of subclavian steal syndrome with bilateral carotid artery stenosis: a case report. J Vasc Surg Cases Innov Tech 2023; 9:101243. [PMID: 37799832 PMCID: PMC10547741 DOI: 10.1016/j.jvscit.2023.101243] [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: 04/04/2023] [Accepted: 05/26/2023] [Indexed: 10/07/2023] Open
Abstract
Bilateral carotid artery stenosis in the context of subclavian steal syndrome is an extremely rare finding. We report the case of a 75-year-old woman who presented with a transient ischemic attack. Bilateral internal carotid stenosis associated with left subclavian steal syndrome was diagnosed. Left internal carotid endarterectomy was performed under locoregional anesthesia. Inflation of a blood pressure cuff reversed the neurologic symptoms that appeared after internal carotid clamping. This rarely reported case remains a challenge to diagnose and treat because of its complex mechanisms and multiple risk factors. Our case highlights the importance of the surgical strategy adopted and the need for a good initial assessment.
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Affiliation(s)
- Ziad Zalaquett
- Department of Thoracic and Cardiovascular Surgery, Hôtel-Dieu de France University Hospital, Beirut, Lebanon
| | - Ghady Zgheib
- Department of Thoracic and Cardiovascular Surgery, Hôtel-Dieu de France University Hospital, Beirut, Lebanon
| | - Lamisse Karam
- Department of Thoracic and Cardiovascular Surgery, Hôtel-Dieu de France University Hospital, Beirut, Lebanon
| | - Maya Zaatar
- Department of Radiology and Medical Imaging, Hôtel-Dieu de France University Hospital, Beirut, Lebanon
| | - Karim Nehme
- Department of Thoracic and Cardiovascular Surgery, Hôtel-Dieu de France University Hospital, Beirut, Lebanon
| | - Georges Tabet
- Department of Thoracic and Cardiovascular Surgery, Hôtel-Dieu de France University Hospital, Beirut, Lebanon
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Kremer C, Lorenzano S, Bejot Y, Lal A, Epple C, Gdovinova Z, Mono ML, Karapanayiotides T, Jovanovic D, Dawson J, Caso V. Sex differences in outcome after carotid revascularization in symptomatic and asymptomatic carotid artery stenosis. J Vasc Surg 2023; 78:817-827.e10. [PMID: 37055001 DOI: 10.1016/j.jvs.2023.03.502] [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: 11/22/2022] [Revised: 03/11/2023] [Accepted: 03/19/2023] [Indexed: 04/15/2023]
Abstract
OBJECTIVE Sex differences regarding the safety and efficacy of carotid revascularization in carotid artery stenosis have been addressed in several studies with conflicting results. Moreover, women are underrepresented in clinical trials, leading to limited conclusions regarding the safety and efficacy of acute stroke treatments. METHODS A systematic review and meta-analysis was performed by literature search including four databases from January 1985 to December 2021. Sex differences in the efficacy and safety of revascularization procedures, including carotid endarterectomy (CEA) and carotid artery stenting (CAS), for symptomatic and asymptomatic carotid artery stenoses were analyzed. RESULTS Regarding CEA in symptomatic carotid artery stenosis, the stroke risk in men (3.6%) and women (3.9%) based on 99,495 patients (30 studies) did not differ (P = .16). There was also no difference in the stroke risk by different time frames up to 10 years. Compared with men, women treated with CEA had a significantly higher stroke or death rate at 4 months (2 studies, 2565 patients; 7.2% vs 5.0%; odds ratio [OR], 1.49; 95% confidence interval [CI], 1.04-2.12; I2 = 0%; P = .03), and a significantly higher rate of restenosis (1 study, 615; 17.2% vs 6.7%; OR, 2.81; 95% CI, 1.66-4.75; P = .0001). For CAS in symptomatic artery stenosis, data showed a non-significant tendency toward higher peri-procedural stroke in women, whereas for asymptomatic carotid artery stenosis, data based on 332,344 patients showed that women (compared with men) after CEA had similar rates of stroke, stroke or death, and the composite outcome stroke/death/myocardial infarction. The rate of restenosis at 1 year was significantly higher in women compared with men (1 study, 372 patients; 10.8% vs 3.2%; OR, 3.71; 95% CI, 1.49-9.2; P = .005). Furthermore, CAS in asymptomatic patients was associated with low risk of a postprocedural stroke in both sexes, but a significantly higher risk of in-hospital myocardial infarction in women than men (8445 patients, 1.2% vs 0.6%; OR, 2.01; 95% CI, 1.23-3.28; I2 = 0%; P = .005). CONCLUSIONS A few sex-differences in short-term outcomes after carotid revascularization for symptomatic and asymptomatic carotid artery stenosis were found, although there were no significant differences in the overall stroke. This indicates a need for larger multicenter prospective studies to evaluate these sex-specific differences. More women, including those aged over 80 years, need to be enrolled in randomized controlled trials, to better understand if sex differences exist and to tailor carotid revascularization accordingly.
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Affiliation(s)
- Christine Kremer
- Neurology Department, Skåne University Hospital, Department Clinical Sciences Lund University, Malmö, Sweden.
| | - Svetlana Lorenzano
- Department of Human Neurosciences, Sapienza University of Rome, Rome, Italy
| | - Yannick Bejot
- Dijon Stroke Registry, EA7460, Pathophysiology and Epidemiology of Cerebro-Cardiovascular diseases (PEC2), University Hospital of Dijon, University of Burgundy, UBFC, Dijon, France
| | - Avtar Lal
- European Stroke Organisation (ESO), Basel, Switzerland
| | - Corina Epple
- Neurology Department, Klinikum Hanau, Hanau, Germany
| | - Zuzana Gdovinova
- Neurology Department, Faculty of Medicine P.J. Safarik University Košice, Košice, Slovakia
| | - Marie-Luise Mono
- Department of Neurology, Municipal Hospital Waid und Triemli, Zürich, Switzerland; University Hospital and University of Bern, Bern, Switzerland
| | - Theodore Karapanayiotides
- Second Department of Neurology, School of Medicine, Faculty of Health Sciences, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Dejana Jovanovic
- Department of Emergency Neurology, Neurology Clinic, Clinical Center of Serbia, Medical Faculty, University of Belgrade, Belgrade, Serbia
| | - Jesse Dawson
- Institute of Cardiovascular and Medical Sciences, College of Medical, Veterinary, and Life Sciences, University of Glasgow, Glasgow, Scotland
| | - Valeria Caso
- Stroke Unit, Santa Maria della Misericordia Hospital, University of Perugia, Perugia, Italy
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Kedev S. Carotid artery interventions - endarterectomy versus stenting. ASIAINTERVENTION 2023; 9:172-179. [PMID: 37736202 PMCID: PMC10509610 DOI: 10.4244/aij-d-23-00009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/07/2023] [Accepted: 06/02/2023] [Indexed: 09/23/2023]
Abstract
Current management of patients with carotid artery stenosis is based on well-established guidelines, including surgical procedures - carotid endarterectomy (CEA) and endovascular carotid artery stenting (CAS) - and optimal medical treatment alone. Outcomes in the postprocedural period after CAS and CEA are similar, suggesting strong clinical durability for both treatments. Recent advances, which include the emergence of novel endovascular treatment tools and techniques, combined with more recent randomised trial data shed new light on optimal patient selection and treatment in contemporary practice. Improved, modern technologies including enhanced embolic protection devices and dual-layered micromesh stents yield better outcomes and should result in further improvements in CAS. In centres of excellence, nowadays, the majority of patients with severe carotid artery stenosis can be successfully treated with either CEA or CAS.
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Affiliation(s)
- Sasko Kedev
- University Clinic of Cardiology, Faculty of Medicine, Ss. Cyril and Methodius University, Skopje, Republic of North Macedonia
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Wawak M, Tekieli Ł, Badacz R, Pieniążek P, Maciejewski D, Trystuła M, Przewłocki T, Kabłak-Ziembicka A. Clinical Characteristics and Outcomes of Aortic Arch Emergencies: Takayasu Disease, Fibromuscular Dysplasia, and Aortic Arch Pathologies: A Retrospective Study and Review of the Literature. Biomedicines 2023; 11:2207. [PMID: 37626704 PMCID: PMC10452526 DOI: 10.3390/biomedicines11082207] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2023] [Revised: 08/02/2023] [Accepted: 08/04/2023] [Indexed: 08/27/2023] Open
Abstract
Non-atherosclerotic aortic arch pathologies (NA-AAPs) and anatomical variants are characterized as rare cardiovascular diseases with a low incidence rate, below 1 case per 2000 population, but enormous heterogeneity in terms of anatomical variants, i.e., Takayasu disease (TAK) and fibromuscular dysplasia (FMD). In specific clinical scenarios, NA-AAPs constitute life-threatening disorders. METHODS In this study, 82 (1.07%) consecutive patients with NA-AAPs (including 38 TAKs, 26 FMDs, and 18 other AAPs) out of 7645 patients who underwent endovascular treatment (EVT) for the aortic arch and its side-branch diseases at a single institution between 2002 and 2022 were retrospectively reviewed. The recorded demographic, biochemical, diagnostic, operative, and postoperative factors were reviewed, and the functional outcomes were determined during follow-up. A systematic review of the literature was also performed. RESULTS The study group comprised 65 (79.3%) female and 17 (21.7%) male subjects with a mean age of 46.1 ± 14.9 years. Overall, 62 (75.6%) patients were diagnosed with either cerebral ischemia symptoms or aortic arch dissection on admission. The EVT was feasible in 59 (72%) patients, whereas 23 (28%) patients were referred for medical treatment. In EVT patients, severe periprocedural complications occurred in two (3.39%) patients, including one periprocedural death and one cerebral hyperperfusion syndrome. During a median follow-up period of 64 months, cardiovascular events occurred in 24 (29.6%) patients (5 deaths, 13 ISs, and 6 myocardial infarctions). Repeated EVT for the index lesion was performed in 21/59 (35.6%) patients, including 19/33 (57.6%) in TAK and 2/13 (15.4%) in FMD. In the AAP group, one patient required additional stent-graft implantation for progressing dissection to the iliac arteries at 12 months. A baseline white blood count (odds ratio [HR]: 1.25, 95% confidence interval [CI]: 1.11-1.39; p < 0.001) was the only independent prognostic factor for recurrent stenosis, while a baseline hemoglobin level (HR: 0.73, 95%CI: 0.59-0.89; p = 0.002) and coronary involvement (HR: 4.11, 95%CI: 1.74-9.71; p = 0.001) were independently associated with a risk of major cardiac and cerebral events according to the multivariate Cox proportional hazards regression analysis. CONCLUSIONS This study showed that AAPs should not be neglected in clinical settings, as it can be a life-threatening condition requiring a multidisciplinary approach. The knowledge of prognostic risk factors for adverse outcomes may improve surveillance in this group of patients.
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Affiliation(s)
- Magdalena Wawak
- Department of Interventional Cardiology, The John Paul II Hospital, Prądnicka 80, 31-202 Kraków, Poland
| | - Łukasz Tekieli
- Department of Interventional Cardiology, The John Paul II Hospital, Prądnicka 80, 31-202 Kraków, Poland
| | - Rafał Badacz
- Department of Interventional Cardiology, The John Paul II Hospital, Prądnicka 80, 31-202 Kraków, Poland
- Department of Interventional Cardiology, Institute of Cardiology, Jagiellonian University Medical College, św. Anny 12, 31-007 Kraków, Poland
| | - Piotr Pieniążek
- Department of Interventional Cardiology, The John Paul II Hospital, Prądnicka 80, 31-202 Kraków, Poland
- Department of Cardiac and Vascular Diseases, Institute of Cardiology, Jagiellonian University Medical College, św. Anny 12, 31-007 Kraków, Poland
| | - Damian Maciejewski
- Department of Interventional Cardiology, The John Paul II Hospital, Prądnicka 80, 31-202 Kraków, Poland
| | - Mariusz Trystuła
- Department of Vascular and Endovascular Surgery, The John Paul II Hospital, Prądnicka 80, 31-202 Kraków, Poland;
| | - Tadeusz Przewłocki
- Department of Interventional Cardiology, The John Paul II Hospital, Prądnicka 80, 31-202 Kraków, Poland
- Department of Cardiac and Vascular Diseases, Institute of Cardiology, Jagiellonian University Medical College, św. Anny 12, 31-007 Kraków, Poland
| | - Anna Kabłak-Ziembicka
- Department of Interventional Cardiology, Institute of Cardiology, Jagiellonian University Medical College, św. Anny 12, 31-007 Kraków, Poland
- Noninvasive Cardiovascular Laboratory, The John Paul II Hospital, Prądnicka 80, 31-202 Kraków, Poland
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Mohd AB, Alabdallat Y, Mohd OB, Ghannam RA, Sawaqed S, Hasan H, Ellebedy M, Turkmani K, Al-Ezzi S. Medical and Surgical Management of Symptomatic and Asymptomatic Carotid Artery Stenosis: A Comprehensive Literature Review. Cureus 2023; 15:e43263. [PMID: 37692579 PMCID: PMC10491926 DOI: 10.7759/cureus.43263] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/09/2023] [Indexed: 09/12/2023] Open
Abstract
Carotid artery stenosis is a condition where the carotid artery is blocked by fatty cholesterol deposits called plaque, increasing the risk of stroke. Elderly individuals with high cardiovascular risk are more susceptible, along with smokers, those with high cholesterol, males, and older individuals. Young females may also be affected by fibromuscular dysplasia. Carotid stenosis significantly raises stroke risk, and the severity is closely linked to stroke incidence and other cardiovascular events. Early detection and treatment are essential to prevent complications. Treatment options include medical and surgical interventions, such as carotid endarterectomy (CEA) and carotid artery stenting (CAS). The choice between surgery and medical management varies depending on patient characteristics and risk factors. This review explores carotid artery stenosis pathophysiology, risk factors, the importance of early detection and treatment, and the surgical approaches of CEA and CAS, addressing their roles and controversies. Healthcare professionals must understand these aspects to provide optimal care to patients with this condition.
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Affiliation(s)
- Ahmed B Mohd
- Faculty of Medicine, Hashemite University, Zarqa, JOR
| | | | - Omar B Mohd
- Faculty of Medicine, Hashemite University, Zarqa, JOR
| | | | - Seri Sawaqed
- Infectious Disease, Faculty of Medicine, Hashemite University, Zarqa, JOR
| | - Hanan Hasan
- Medical Laboratory, The Lab Medical Laboratories, Amman, JOR
| | | | | | - Shakir Al-Ezzi
- Internal Medicine, Hospital Corporation of America (HCA) Medical City Arlington, Dallas, USA
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Goss A, Ge C, Crawford S, Goostrey K, Buddadhumaruk P, Hough CL, Lo B, Carson S, Steingrub J, White DB, Muehlschlegel S. Prognostic Language in Critical Neurologic Illness: A Multicenter Mixed-Methods Study. Neurology 2023; 101:e558-e569. [PMID: 37290972 PMCID: PMC10401677 DOI: 10.1212/wnl.0000000000207462] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2022] [Accepted: 04/13/2023] [Indexed: 06/10/2023] Open
Abstract
BACKGROUND AND OBJECTIVES There are no evidence-based guidelines for discussing prognosis in critical neurologic illness, but in general, experts recommend that clinicians communicate prognosis using estimates, such as numerical or qualitative expressions of risk. Little is known about how real-world clinicians communicate prognosis in critical neurologic illness. Our primary objective was to characterize prognostic language clinicians used in critical neurologic illness. We additionally explored whether prognostic language differed between prognostic domains (e.g., survival, cognition). METHODS We conducted a multicenter cross-sectional mixed-methods study analyzing deidentified transcripts of audio-recorded clinician-family meetings for patients with neurologic illness requiring intensive care (e.g., intracerebral hemorrhage, traumatic brain injury, severe stroke) from 7 US centers. Two coders assigned codes for prognostic language type and domain of prognosis to each clinician prognostic statement. Prognostic language was coded as probabilistic (estimating the likelihood of an outcome occurring, e.g., "80% survival"; "She'll probably survive") or nonprobabilistic (characterizing outcomes without offering likelihood; e.g., "She may not survive"). We applied univariate and multivariate binomial logistic regression to examine independent associations between prognostic language and domain of prognosis. RESULTS We analyzed 43 clinician-family meetings for 39 patients with 78 surrogates and 27 clinicians. Clinicians made 512 statements about survival (median 0/meeting [interquartile range (IQR) 0-2]), physical function (median 2 [IQR 0-7]), cognition (median 2 [IQR 0-6]), and overall recovery (median 2 [IQR 1-4]). Most statements were nonprobabilistic (316/512 [62%]); 10 of 512 prognostic statements (2%) offered numeric estimates; and 21% (9/43) of family meetings only contained nonprobabilistic language. Compared with statements about cognition, statements about survival (odds ratio [OR] 2.50, 95% CI 1.01-6.18, p = 0.048) and physical function (OR 3.22, 95% 1.77-5.86, p < 0.001) were more frequently probabilistic. Statements about physical function were less likely to be uncertainty-based than statements about cognition (OR 0.34, 95% CI 0.17-0.66, p = 0.002). DISCUSSION Clinicians preferred not to use estimates (either numeric or qualitative) when discussing critical neurologic illness prognosis, especially when they discussed cognitive outcomes. These findings may inform interventions to improve prognostic communication in critical neurologic illness.
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Affiliation(s)
- Adeline Goss
- From the Division of Neurology (A.G.), Department of Internal Medicine, Highland Hospital, Oakland, CA; Department of Neurology (C.G., K.G.), and Tan Chingfang Graduate School of Nursing (S. Crawford), University of Massachusetts Chan Medical School, Worcester; Department of Critical Care Medicine (P.B., D.B.W.), University of Pittsburgh School of Medicine, PA; Division of Pulmonary, Allergy, and Critical Care Medicine (C.L.H.), Department of Medicine, Oregon Health & Science University, Portland; Department of Medicine (B.L.), University of California San Francisco; Division of Pulmonary and Critical Care Medicine (S. Carson), Department of Medicine, University of North Carolina Hospitals, Chapel Hill; Division of Pulmonary Medicine and Critical Care Medicine (J.S.), Department of Internal Medicine, University of Massachusetts Chan Medical School-Baystate, Springfield; and Departments of Neurology, Anesthesia/Critical Care, and Surgery (S.M.), University of Massachusetts Chan Medical School, Worcester
| | - Connie Ge
- From the Division of Neurology (A.G.), Department of Internal Medicine, Highland Hospital, Oakland, CA; Department of Neurology (C.G., K.G.), and Tan Chingfang Graduate School of Nursing (S. Crawford), University of Massachusetts Chan Medical School, Worcester; Department of Critical Care Medicine (P.B., D.B.W.), University of Pittsburgh School of Medicine, PA; Division of Pulmonary, Allergy, and Critical Care Medicine (C.L.H.), Department of Medicine, Oregon Health & Science University, Portland; Department of Medicine (B.L.), University of California San Francisco; Division of Pulmonary and Critical Care Medicine (S. Carson), Department of Medicine, University of North Carolina Hospitals, Chapel Hill; Division of Pulmonary Medicine and Critical Care Medicine (J.S.), Department of Internal Medicine, University of Massachusetts Chan Medical School-Baystate, Springfield; and Departments of Neurology, Anesthesia/Critical Care, and Surgery (S.M.), University of Massachusetts Chan Medical School, Worcester.
| | - Sybil Crawford
- From the Division of Neurology (A.G.), Department of Internal Medicine, Highland Hospital, Oakland, CA; Department of Neurology (C.G., K.G.), and Tan Chingfang Graduate School of Nursing (S. Crawford), University of Massachusetts Chan Medical School, Worcester; Department of Critical Care Medicine (P.B., D.B.W.), University of Pittsburgh School of Medicine, PA; Division of Pulmonary, Allergy, and Critical Care Medicine (C.L.H.), Department of Medicine, Oregon Health & Science University, Portland; Department of Medicine (B.L.), University of California San Francisco; Division of Pulmonary and Critical Care Medicine (S. Carson), Department of Medicine, University of North Carolina Hospitals, Chapel Hill; Division of Pulmonary Medicine and Critical Care Medicine (J.S.), Department of Internal Medicine, University of Massachusetts Chan Medical School-Baystate, Springfield; and Departments of Neurology, Anesthesia/Critical Care, and Surgery (S.M.), University of Massachusetts Chan Medical School, Worcester
| | - Kelsey Goostrey
- From the Division of Neurology (A.G.), Department of Internal Medicine, Highland Hospital, Oakland, CA; Department of Neurology (C.G., K.G.), and Tan Chingfang Graduate School of Nursing (S. Crawford), University of Massachusetts Chan Medical School, Worcester; Department of Critical Care Medicine (P.B., D.B.W.), University of Pittsburgh School of Medicine, PA; Division of Pulmonary, Allergy, and Critical Care Medicine (C.L.H.), Department of Medicine, Oregon Health & Science University, Portland; Department of Medicine (B.L.), University of California San Francisco; Division of Pulmonary and Critical Care Medicine (S. Carson), Department of Medicine, University of North Carolina Hospitals, Chapel Hill; Division of Pulmonary Medicine and Critical Care Medicine (J.S.), Department of Internal Medicine, University of Massachusetts Chan Medical School-Baystate, Springfield; and Departments of Neurology, Anesthesia/Critical Care, and Surgery (S.M.), University of Massachusetts Chan Medical School, Worcester
| | - Praewpannanrai Buddadhumaruk
- From the Division of Neurology (A.G.), Department of Internal Medicine, Highland Hospital, Oakland, CA; Department of Neurology (C.G., K.G.), and Tan Chingfang Graduate School of Nursing (S. Crawford), University of Massachusetts Chan Medical School, Worcester; Department of Critical Care Medicine (P.B., D.B.W.), University of Pittsburgh School of Medicine, PA; Division of Pulmonary, Allergy, and Critical Care Medicine (C.L.H.), Department of Medicine, Oregon Health & Science University, Portland; Department of Medicine (B.L.), University of California San Francisco; Division of Pulmonary and Critical Care Medicine (S. Carson), Department of Medicine, University of North Carolina Hospitals, Chapel Hill; Division of Pulmonary Medicine and Critical Care Medicine (J.S.), Department of Internal Medicine, University of Massachusetts Chan Medical School-Baystate, Springfield; and Departments of Neurology, Anesthesia/Critical Care, and Surgery (S.M.), University of Massachusetts Chan Medical School, Worcester
| | - Catherine L Hough
- From the Division of Neurology (A.G.), Department of Internal Medicine, Highland Hospital, Oakland, CA; Department of Neurology (C.G., K.G.), and Tan Chingfang Graduate School of Nursing (S. Crawford), University of Massachusetts Chan Medical School, Worcester; Department of Critical Care Medicine (P.B., D.B.W.), University of Pittsburgh School of Medicine, PA; Division of Pulmonary, Allergy, and Critical Care Medicine (C.L.H.), Department of Medicine, Oregon Health & Science University, Portland; Department of Medicine (B.L.), University of California San Francisco; Division of Pulmonary and Critical Care Medicine (S. Carson), Department of Medicine, University of North Carolina Hospitals, Chapel Hill; Division of Pulmonary Medicine and Critical Care Medicine (J.S.), Department of Internal Medicine, University of Massachusetts Chan Medical School-Baystate, Springfield; and Departments of Neurology, Anesthesia/Critical Care, and Surgery (S.M.), University of Massachusetts Chan Medical School, Worcester
| | - Bernard Lo
- From the Division of Neurology (A.G.), Department of Internal Medicine, Highland Hospital, Oakland, CA; Department of Neurology (C.G., K.G.), and Tan Chingfang Graduate School of Nursing (S. Crawford), University of Massachusetts Chan Medical School, Worcester; Department of Critical Care Medicine (P.B., D.B.W.), University of Pittsburgh School of Medicine, PA; Division of Pulmonary, Allergy, and Critical Care Medicine (C.L.H.), Department of Medicine, Oregon Health & Science University, Portland; Department of Medicine (B.L.), University of California San Francisco; Division of Pulmonary and Critical Care Medicine (S. Carson), Department of Medicine, University of North Carolina Hospitals, Chapel Hill; Division of Pulmonary Medicine and Critical Care Medicine (J.S.), Department of Internal Medicine, University of Massachusetts Chan Medical School-Baystate, Springfield; and Departments of Neurology, Anesthesia/Critical Care, and Surgery (S.M.), University of Massachusetts Chan Medical School, Worcester
| | - Shannon Carson
- From the Division of Neurology (A.G.), Department of Internal Medicine, Highland Hospital, Oakland, CA; Department of Neurology (C.G., K.G.), and Tan Chingfang Graduate School of Nursing (S. Crawford), University of Massachusetts Chan Medical School, Worcester; Department of Critical Care Medicine (P.B., D.B.W.), University of Pittsburgh School of Medicine, PA; Division of Pulmonary, Allergy, and Critical Care Medicine (C.L.H.), Department of Medicine, Oregon Health & Science University, Portland; Department of Medicine (B.L.), University of California San Francisco; Division of Pulmonary and Critical Care Medicine (S. Carson), Department of Medicine, University of North Carolina Hospitals, Chapel Hill; Division of Pulmonary Medicine and Critical Care Medicine (J.S.), Department of Internal Medicine, University of Massachusetts Chan Medical School-Baystate, Springfield; and Departments of Neurology, Anesthesia/Critical Care, and Surgery (S.M.), University of Massachusetts Chan Medical School, Worcester
| | - Jay Steingrub
- From the Division of Neurology (A.G.), Department of Internal Medicine, Highland Hospital, Oakland, CA; Department of Neurology (C.G., K.G.), and Tan Chingfang Graduate School of Nursing (S. Crawford), University of Massachusetts Chan Medical School, Worcester; Department of Critical Care Medicine (P.B., D.B.W.), University of Pittsburgh School of Medicine, PA; Division of Pulmonary, Allergy, and Critical Care Medicine (C.L.H.), Department of Medicine, Oregon Health & Science University, Portland; Department of Medicine (B.L.), University of California San Francisco; Division of Pulmonary and Critical Care Medicine (S. Carson), Department of Medicine, University of North Carolina Hospitals, Chapel Hill; Division of Pulmonary Medicine and Critical Care Medicine (J.S.), Department of Internal Medicine, University of Massachusetts Chan Medical School-Baystate, Springfield; and Departments of Neurology, Anesthesia/Critical Care, and Surgery (S.M.), University of Massachusetts Chan Medical School, Worcester
| | - Douglas B White
- From the Division of Neurology (A.G.), Department of Internal Medicine, Highland Hospital, Oakland, CA; Department of Neurology (C.G., K.G.), and Tan Chingfang Graduate School of Nursing (S. Crawford), University of Massachusetts Chan Medical School, Worcester; Department of Critical Care Medicine (P.B., D.B.W.), University of Pittsburgh School of Medicine, PA; Division of Pulmonary, Allergy, and Critical Care Medicine (C.L.H.), Department of Medicine, Oregon Health & Science University, Portland; Department of Medicine (B.L.), University of California San Francisco; Division of Pulmonary and Critical Care Medicine (S. Carson), Department of Medicine, University of North Carolina Hospitals, Chapel Hill; Division of Pulmonary Medicine and Critical Care Medicine (J.S.), Department of Internal Medicine, University of Massachusetts Chan Medical School-Baystate, Springfield; and Departments of Neurology, Anesthesia/Critical Care, and Surgery (S.M.), University of Massachusetts Chan Medical School, Worcester
| | - Susanne Muehlschlegel
- From the Division of Neurology (A.G.), Department of Internal Medicine, Highland Hospital, Oakland, CA; Department of Neurology (C.G., K.G.), and Tan Chingfang Graduate School of Nursing (S. Crawford), University of Massachusetts Chan Medical School, Worcester; Department of Critical Care Medicine (P.B., D.B.W.), University of Pittsburgh School of Medicine, PA; Division of Pulmonary, Allergy, and Critical Care Medicine (C.L.H.), Department of Medicine, Oregon Health & Science University, Portland; Department of Medicine (B.L.), University of California San Francisco; Division of Pulmonary and Critical Care Medicine (S. Carson), Department of Medicine, University of North Carolina Hospitals, Chapel Hill; Division of Pulmonary Medicine and Critical Care Medicine (J.S.), Department of Internal Medicine, University of Massachusetts Chan Medical School-Baystate, Springfield; and Departments of Neurology, Anesthesia/Critical Care, and Surgery (S.M.), University of Massachusetts Chan Medical School, Worcester.
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Johnston JC, Sartwelle TP. Medical Malpractice and the Neurologist: Specific Neurological Claims. Neurol Clin 2023; 41:493-512. [PMID: 37407102 DOI: 10.1016/j.ncl.2023.05.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/07/2023]
Abstract
This chapter highlights the most frequently encountered neurological malpractice claims. The format is designed to provide a rudimentary understanding of how lawsuits arise and thereby focus discussion on adapting practice patterns to improve patient care and minimize liability risk.
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Affiliation(s)
- James C Johnston
- GlobalNeurology, 17B Farnham Street, Auckland 1052, New Zealand; GlobalNeurology®, 5290 Medical Drive, San Antonio, TX 78229, USA.
| | - Thomas P Sartwelle
- Hicks Davis Wynn, PC, 3555 Timmons Lane, Suite 1000, Houston, TX 77027, USA
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Noda K, Hattori Y, Hori M, Nakaoku Y, Tanaka A, Yoshimoto T, Nishimura K, Yokota T, Harada-Shiba M, Ihara M. Amplified Risk of Intracranial Artery Stenosis/Occlusion Associated With RNF213 p.R4810K in Familial Hypercholesterolemia. JACC. ASIA 2023; 3:625-633. [PMID: 37614551 PMCID: PMC10442882 DOI: 10.1016/j.jacasi.2023.03.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/07/2022] [Revised: 02/23/2023] [Accepted: 03/18/2023] [Indexed: 08/25/2023]
Abstract
Background The RNF213 p.R4810K variant is associated with moyamoya disease in East Asian individuals and increases the risk of developing intracranial major artery stenosis/occlusion (ICASO) that affects anterior circulation. Meanwhile, 0.5% to 2.5% of asymptomatic East Asian individuals also carry this variant. As such, additional factors are likely required to develop ICASO in variant carriers. Familial hypercholesterolemia (FH) is a common genetic disorder in Japan that has a significant associated risk of developing premature coronary atherosclerosis; however, the relationship between ICASO and FH remains unknown. Objectives This study aimed to determine if FH facilitates RNF213 p.R4810K carriers to develop ICASO. Methods We enrolled patients with FH who had undergone brain magnetic resonance angiography at our hospital from May 2005 to March 2020. The RNF213 p.R4810K variant, and LDLR and PCSK9 mutations were genotyped. ICASO lesions in the brain magnetic resonance angiogram were analyzed. Results Six RNF213 p.R4810K variant carriers were identified among 167 patients with FH (LDLR, n = 104; PCSK9, n = 22). Five of the carriers (83.3%) exhibited ICASO in the anterior circulation; a significant difference in ICASO frequency was observed between the variant carriers and noncarriers (P = 0.025). The median number of stenotic or occluded arteries in the anterior circulation was also significantly larger in the variant carriers (3 vs 1, P = 0.01); however, did not differ between patients with FH with LDLR and PCSK9 mutations. Conclusions Patients with FH exhibit increased prevalence and severity of ICASO associated with RNF213 p.R4810K. Gene mutations for FH may confer an increased risk of ICASO in RNF213 p.R4810K carriers.
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Affiliation(s)
- Kotaro Noda
- Department of Neurology, National Cerebral and Cardiovascular Center, Suita, Japan
- Department of Neurology and Neurological Science, Graduate School of Medical and Dental Sciences, Tokyo Medical and Dental University, Tokyo, Japan
| | - Yorito Hattori
- Department of Neurology, National Cerebral and Cardiovascular Center, Suita, Japan
| | - Mika Hori
- Department of Endocrinology, Research Institute of Environmental Medicine, Nagoya University, Nagoya, Japan
| | - Yuriko Nakaoku
- Department of Preventive Medicine and Epidemiology, National Cerebral and Cardiovascular Center, Suita, Japan
| | - Akito Tanaka
- Department of Neurology, National Cerebral and Cardiovascular Center, Suita, Japan
| | - Takeshi Yoshimoto
- Department of Neurology, National Cerebral and Cardiovascular Center, Suita, Japan
| | - Kunihiro Nishimura
- Department of Preventive Medicine and Epidemiology, National Cerebral and Cardiovascular Center, Suita, Japan
| | - Takanori Yokota
- Department of Neurology and Neurological Science, Graduate School of Medical and Dental Sciences, Tokyo Medical and Dental University, Tokyo, Japan
| | - Mariko Harada-Shiba
- Cardiovascular Center, Osaka Medical and Pharmaceutical University, Takatsuki, Japan
| | - Masafumi Ihara
- Department of Neurology, National Cerebral and Cardiovascular Center, Suita, Japan
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Said S, Dardik A, Ochoa Chaar CI. What are the benefits and drawbacks of statins in carotid artery disease? A perspective review. Expert Rev Cardiovasc Ther 2023; 21:763-777. [PMID: 37994875 DOI: 10.1080/14779072.2023.2286011] [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: 09/15/2023] [Accepted: 11/16/2023] [Indexed: 11/24/2023]
Abstract
INTRODUCTION The prevalence of carotid artery stenosis in the general population is approximately 3%, but approximately 20% among people with acute ischemic stroke. Statins are recommended by multiple international guidelines as the drug of choice for lipid control in people with asymptomatic or symptomatic carotid artery stenosis due to their lipid-lowering and other pleiotropic effects. AREAS COVERED This review discusses the guidelines for statin usage as a cornerstone in the prevention and management of atherosclerotic carotid artery disease and the impact of statins on stroke incidence and mortality. Statin side effects, alternative therapy, and genetic polymorphisms are reviewed. EXPERT OPINION Statin therapy is associated with a decreased incidence of stroke and mortality as well as improved outcomes for patients treated with carotid revascularization. Statins are a safe and effective class of medications, but the initiation of therapy warrants close monitoring to avoid rare and potentially serious side effects. Lack of clinical efficacy or the presence of side effects suggests a need for treatment with an alternative therapy such as PCSK9 inhibitors. Understanding the interplay between the mechanisms of statins and PCSK9 inhibition therapies will allow optimal benefits while minimizing risks. Future research into genetic polymorphisms may improve patient selection for personalized therapy.
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Affiliation(s)
- Shreef Said
- Division of Vascular Surgery and Endovascular Therapy, Department of Surgery, Yale School of Medicine, New Haven, CT, USA
| | - Alan Dardik
- Division of Vascular Surgery and Endovascular Therapy, Department of Surgery, Yale School of Medicine, New Haven, CT, USA
- Department of Cellular and Molecular Physiology, Yale School of Medicine, New Haven, CT, USA
- Department of Surgery, VA Connecticut Healthcare Systems, West Haven, CT, USA
| | - Cassius Iyad Ochoa Chaar
- Division of Vascular Surgery and Endovascular Therapy, Department of Surgery, Yale School of Medicine, New Haven, CT, USA
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Delgardo M, Rabin G, Tudor T, Tang AJ, Reeves G, Connolly ES. Monitoring risk and preventing ischemic stroke in the very old. Expert Rev Neurother 2023; 23:791-801. [PMID: 37540092 DOI: 10.1080/14737175.2023.2244674] [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: 04/29/2023] [Revised: 07/28/2023] [Accepted: 08/01/2023] [Indexed: 08/05/2023]
Abstract
INTRODUCTION Stroke is a significant cause of death, and the leading cause of severe long-term disability for individuals over 80 (the very old), yet few studies of such risk factors for ischemic stroke, or the known mitigation techniques, in this population, and the evidence base regarding risk modification strategies in this susceptible population can be inconsistent and incomplete. This article examines current guidelines and evidence regarding medical management, lifestyle changes, and psychosocial interactions that can contribute to the primary and secondary prevention of ischemic stroke in the very old. AREAS COVERED The authors conducted a literature search for ischemic stroke prevention and risk assessment in the elderly via PubMed. Furthermore, they describe current strategies for monitoring risk and preventing ischemic stroke in the elderly population. EXPERT OPINION Ischemic stroke poses a significant health risk to the elderly, with prevention relying on managing modifiable risk factors such as hypertension, atrial fibrillation, diabetes, and high cholesterol, as well as promoting healthy lifestyle choices like quitting smoking, regular physical activity and a heart-healthy diet. Healthcare providers must adopt a multifaceted approach, addressing individual and population-level factors while remaining vigilant in monitoring and managing risk factors to reduce the incidence and impact of stroke in older adults.
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Affiliation(s)
- Mychael Delgardo
- Department of Neurological Surgery, Columbia University Medical Center, New York, NY, USA
| | - Grant Rabin
- Department of Neurological Surgery, Columbia University Medical Center, New York, NY, USA
| | - Thilan Tudor
- Department of Neurological Surgery, Columbia University Medical Center, New York, NY, USA
| | - Anthony J Tang
- Department of Neurological Surgery, Columbia University Medical Center, New York, NY, USA
| | - Geoffrey Reeves
- Department of Neurological Surgery, Columbia University Medical Center, New York, NY, USA
| | - E Sander Connolly
- Department of Neurological Surgery, Columbia University Medical Center, New York, NY, USA
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Dogariu OA, Dogariu I, Vasile CM, Berceanu MC, Raicea VC, Albu CV, Gheonea IA. Diagnosis and treatment of Watershed strokes: a narrative review. J Med Life 2023; 16:842-850. [PMID: 37675172 PMCID: PMC10478671 DOI: 10.25122/jml-2023-0127] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2023] [Accepted: 05/25/2023] [Indexed: 09/08/2023] Open
Abstract
Watershed strokes have been described previously as ischemic strokes located in vulnerable border zones between brain tissue supplied by the anterior, posterior, and middle cerebral arteries in the distal junction between two non-anastomotic arterial territories. Ischemic strokes in border zones are well-recognized entities and well-described in terms of imaging features, but the pathophysiological mechanism of brain injury production is not fully defined. Border zone ischemia is caused by cerebral hypoperfusion through decreased cerebral blood flow and arterial embolism in unstable atheroma plaque. It is often difficult to say which mechanisms are fully responsible for producing cerebral ischemic lesions. This review aimed to highlight the imaging aspect of watershed strokes and to correlate the clinical characteristics of this type of stroke with the diagnostic algorithm for optimal therapeutic management. Neurologists should promptly recognize this type of stroke and investigate its etiology in the shortest possible time.
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Affiliation(s)
- Oana Andreea Dogariu
- University of Medicine and Pharmacy, Craiova, Romania
- Department of Neurology, Emergency County Hospital, Targu-Jiu, Romania
| | - Ioan Dogariu
- Department of Neurology, Emergency County Hospital, Targu-Jiu, Romania
| | - Corina Maria Vasile
- Department of Pediatric and Adult Congenital Cardiology, University of Bordeaux, Bordeaux, France
| | - Mihaela Corina Berceanu
- University of Medicine and Pharmacy, Craiova, Romania
- Department of Cardiology, County Hospital, Craiova, Romania
| | - Victor Cornel Raicea
- University of Medicine and Pharmacy, Craiova, Romania
- Department of Cardiology, County Hospital, Craiova, Romania
| | - Carmen Valeria Albu
- University of Medicine and Pharmacy, Craiova, Romania
- Department of Neurology, Neuropsychiatry Hospital, Craiova, Romania
| | - Ioana Andreea Gheonea
- University of Medicine and Pharmacy, Craiova, Romania
- Department of Radiology, Emergency County Hospital, Craiova, Romania
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Collette SL, Rodgers MP, van Walderveen MAA, Compagne KCJ, Nederkoorn PJ, Hofmeijer J, Martens JM, de Borst GJ, Luijckx GJR, Majoie CBLM, van der Lugt A, Bokkers RPH, Uyttenboogaart M. Management of extracranial carotid artery stenosis during endovascular treatment for acute ischaemic stroke: results from the MR CLEAN Registry. Stroke Vasc Neurol 2023; 8:229-237. [PMID: 36572506 PMCID: PMC10359798 DOI: 10.1136/svn-2022-001891] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2022] [Accepted: 11/02/2022] [Indexed: 12/27/2022] Open
Abstract
BACKGROUND The optimal management of ipsilateral extracranial internal carotid artery (ICA) stenosis during endovascular treatment (EVT) is unclear. We compared the outcomes of two different strategies: EVT with vs without carotid artery stenting (CAS). METHODS In this observational study, we included patients who had an acute ischaemic stroke undergoing EVT and a concomitant ipsilateral extracranial ICA stenosis of ≥50% or occlusion of presumed atherosclerotic origin, from the Dutch Multicenter Randomized Clinical Trial of Endovascular Treatment for Acute Ischemic Stroke in the Netherlands (MR CLEAN) Registry (2014-2017). The primary endpoint was a good functional outcome at 90 days, defined as a modified Rankin Scale score ≤2. Secondary endpoints were successful intracranial reperfusion, new clot in a different vascular territory, symptomatic intracranial haemorrhage, recurrent ischaemic stroke and any serious adverse event. RESULTS Of the 433 included patients, 169 (39%) underwent EVT with CAS. In 123/168 (73%) patients, CAS was performed before intracranial thrombectomy. In 42/224 (19%) patients who underwent EVT without CAS, a deferred carotid endarterectomy or CAS was performed. EVT with and without CAS were associated with similar proportions of good functional outcome (47% vs 42%, respectively; adjusted OR (aOR), 0.90; 95% CI, 0.50 to 1.62). There were no major differences between the groups in any of the secondary endpoints, except for the increased odds of a new clot in a different vascular territory in the EVT with CAS group (aOR, 2.96; 95% CI, 1.07 to 8.21). CONCLUSIONS Functional outcomes were comparable after EVT with and without CAS. CAS during EVT might be a feasible option to treat the extracranial ICA stenosis but randomised studies are warranted to prove non-inferiority or superiority.
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Affiliation(s)
- Sabine L Collette
- University Medical Centre Groningen, University of Groningen, Groningen, The Netherlands
| | - Michael P Rodgers
- University Medical Centre Groningen, University of Groningen, Groningen, The Netherlands
| | | | | | - Paul J Nederkoorn
- Amsterdam University Medical Centres, University of Amsterdam, Amsterdam, The Netherlands
| | | | | | - Gert J de Borst
- University Medical Centre Utrecht, University of Utrecht, Utrecht, The Netherlands
| | - Gert Jan R Luijckx
- University Medical Centre Groningen, University of Groningen, Groningen, The Netherlands
| | - Charles B L M Majoie
- Amsterdam University Medical Centres, University of Amsterdam, Amsterdam, The Netherlands
| | - Aad van der Lugt
- Erasmus MC, University Medical Centre, Rotterdam, The Netherlands
| | - Reinoud P H Bokkers
- University Medical Centre Groningen, University of Groningen, Groningen, The Netherlands
| | - Maarten Uyttenboogaart
- University Medical Centre Groningen, University of Groningen, Groningen, The Netherlands
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Hu J, Hu N, Hu T, Zhang J, Han D, Wang H. Associations between preprocedural carotid artery perivascular fat density and early in-stent restenosis after carotid artery stenting. Heliyon 2023; 9:e16220. [PMID: 37346364 PMCID: PMC10279783 DOI: 10.1016/j.heliyon.2023.e16220] [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: 02/10/2023] [Revised: 05/04/2023] [Accepted: 05/10/2023] [Indexed: 06/23/2023] Open
Abstract
Objectives This study investigated the association between perivascular fat density (PFD) via preoperative computed tomographic angiography (CTA) and early in-stent restenosis (ISR) after carotid artery stenting (CAS). Methods We retrospectively evaluated 248 consecutive patients who had undergone initial CAS and received a preoperative cervical CTA examination between January 2019 and October 2020. The patients were categorized into two according to whether they sustained ISR during the 2 years postoperative follow-up period. Correlations between PFD and ISR were assessed, and multivariate regression for evaluating predictors of ISR was conducted. Receiver operating characteristic (ROC) curves were used to determine the cutoff value for the PFD. Results A total of 181 eligible patients (mean age 61.25 ± 10.35 years, 57 male) were enrolled. The ISR group had a higher proportion of closed-cell stents (48.8% versus 27.5%; p = 0.009) and a greater degree of residual stenosis (28[20,33] % versus 20[14.75,30] %; p < 0.001) than the non-ISR group. The ISR group had a higher mean HU value of PFD than the non-ISR group on the operated side (-42.26 ± 6.81 versus -59.66 ± 10.75; p < 0.001). The degree of residual stenosis (OR 1.146, 95%CI 1.071-1.226, p < 0.001) and PFD on the operated side (OR1.353, 95%CI 1.215-1.506, p < 0.001) were significantly associated with the ISR. Conclusions The occurrence of the early ISR after CAS is associated with a higher PFD on the operated side. The results indicate that PFD is a promising marker to predict the ISR after CAS.
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Affiliation(s)
- Jun Hu
- Faculty of Integrated Traditional Chinese and Western Medicine, Hebei University of Chinese Medicine, Shijiazhuang, China
- Department of Neurosurgery, Affiliated Hospital of Chengde Medical University, Chengde, China
| | - Na Hu
- Department of Radiology, Chengde Central Hospital, Chengde, China
| | - Tiemin Hu
- Department of Neurosurgery, Affiliated Hospital of Chengde Medical University, Chengde, China
| | - Jiwei Zhang
- Department of Neurosurgery, Affiliated Hospital of Chengde Medical University, Chengde, China
| | - Dong Han
- Department of Radiology, Affiliated Hospital of Chengde Medical University, Chengde, China
| | - Hong Wang
- Faculty of Integrated Traditional Chinese and Western Medicine, Hebei University of Chinese Medicine, Shijiazhuang, China
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Ahmet Y, Murat Y. Evaluation of the association between silent ischemic lesions and stent design in carotid stenting applications. REVISTA DA ASSOCIACAO MEDICA BRASILEIRA (1992) 2023; 69:e20221437. [PMID: 37222323 DOI: 10.1590/1806-9282.20221437] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/10/2023] [Accepted: 02/23/2023] [Indexed: 05/25/2023]
Abstract
OBJECTIVE Minor ischemic events and silent ischemic lesions are more common in carotid stenting than in endarterectomy. These silent ischemic lesions are also associated with stroke risk and cognitive impairment, so it is important to understand the factors that increase the risk and develop strategies to reduce the risk. We aimed to evaluate the association between carotid stent design and silent ischemic lesion development. METHODS The files of the patients who underwent carotid stenting between January 2020 and April 2022 were scanned. Patients with diffusion MR images taken within the postoperative 24 h were included in the study, while those undergoing acute stent placement were excluded. The patients were divided into two groups: those with open-cell stents and those with closed-cell stents. RESULTS A total of 65 patients, including 39 patients undergoing open-cell stenting and 26 patients undergoing closed-cell stenting, were included in the study. There was no significant difference in demographic data and vascular risk factors between the groups. New ischemic lesions were detected in 29 (74.4%) patients in the open-cell stent group and 10 (38.4%) patients in the closed-cell stent group and were significantly higher in the open-cell group. There was no significant difference between the two groups in terms of major and minor ischemic events and stent restenosis at the 3-month follow-up. CONCLUSION The rate of new ischemic lesion development was found to be significantly higher in carotid stent procedures performed with an open-cell Protégé stent than in those performed with a closed-cell Wallstent stent.
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Affiliation(s)
- Yabalak Ahmet
- Düzce Üniversitesi, Faculty of Medicine, Department of Neurology - Düzce, Turkey
| | - Yılmaz Murat
- Bolu Abant İzzet Baysal Üniversitesi, Faculty of Medicine, Department of Neurology - Bolu, Turkey
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Desantis C, Zacà S, Wiesel P, Mastrangelo G, Pulli R, Angiletta D. Sex-Related Outcomes in Asymptomatic Patients Undergoing Carotid Artery Stenting. J Endovasc Ther 2023:15266028231172356. [PMID: 37190763 DOI: 10.1177/15266028231172356] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/17/2023]
Abstract
PURPOSE Aim of the study was to evaluate the influence of sex in asymptomatic patients undergoing carotid artery stenting (CAS). MATERIALS AND METHODS A retrospective observational study was conducted from January 2006 to December 2020. A total of 438 consecutive patients with asymptomatic carotid artery stenosis >70% underwent transfemoral CAS and were stratified in males (M) and females (F). Periprocedural 30-day outcomes were: stroke, death, and myocardial infarction (MI). Follow-up outcomes were: death and stroke rates (primary) and freedom from restenosis (FFR) and reintervention rates (secondary). Follow-up data were analyzed at 1, 5, and 10 years. Data were analyzed with χ2 test and Fisher's exact test and follow-up outcomes with Kaplan-Meier curves. The log-rank test was used to determine differences between the groups and univariate analysis to identify the association between risk factors and intraoperative details with mortality and restenosis rates. RESULTS A total of 462 procedures were performed (M: n=321, 69.4%), in which 24 CAS were bilateral (5.5%). Mean age was 71.9±7.6 years (M: 72.1±7.8; F: 71.7±7.3). Periprocedural outcomes were: stroke rate 2.2% (n=10; M: n=5, 1.6%; F: n=5, 3.5%; p=0.176), mortality rate 0.6% (M: n=3, p=0.334), and stroke/death rate 2.8% (n=13; M: n=8, 2.5%; F: n=5, 3.5%; p=0.528); no cardiac events (MI) were recorded. A not-disabling (minor) stroke was detected in 3 males (0.9%), while a disabling (major) stroke was reported in 7 patients (1.7%) of whom 5 were ischemic events (M: n=2, 0.6%; F: n=3, 2.2%) and 2 were cerebral hemorrhages (F: 1.3%, p=0.046). Mean follow-up was 73.66±40.83 months (M: 72.66; F: 76.01; p=0.246). Overall survival rate was 96.1% (95% confidence interval [CI]: 93-98), 81.8% (95% CI: 77-86), and 45.5% (95% CI: 38-53) at 1, 5, and 10 years, respectively (p=0.236). The overall stroke rate was 0.3% (freedom from stroke [FFS]: 99.7%; 95% CI: 98-100), 0.9% (FFS: 99%; 95% CI: 98-100), and 4.3% (FFS: 95.7%; 95% CI: 89-98; M: n=6; F: n=2; p=0.774). Stroke-related mortality rate was 0.7% (FFS: 99.3%; 95% CI: 97-100) and 2.9% (FFS: 97.1%; 95% CI: 91-99) at 5 and 10 years, respectively, without differences between the groups (M: n=4; F: n=2; p=0.763). Overall FFR rate was 97.4% (95% CI: 95-99), 93.4% (95% CI: 90-96), and 89.5% (95% CI: 84-93; p=0.322). Two severe symptomatic restenosis (>70%, M) required a new endovascular revascularization. CONCLUSION The sex variable does not influence outcomes of CAS in asymptomatic patients at short- and long-term follow-up, although females show a worst incidence of periprocedural major strokes. Carotid artery stenting may be safely proposed when a careful patient selection is applied. CLINICAL IMPACT The sex variable has been advocated as a considerable factor that could influence the outcomes of transfemoral carotid artery stenting (CAS). Literature data are contrasting, even if different papers mainly reported that CAS is associated to worst outcomes in female patients. Our study shows that the sex-variable does not influence outcomes of CAS in asymptomatic patients at short and long-term follow-up, although females had a worst incidence of periprocedural major strokes. CAS may be safely proposed when a careful patient selection is applied.
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Affiliation(s)
- Claudio Desantis
- Vascular and Endovascular Surgery-Department of Emergency and Organs Transplantation, "Aldo Moro" University of Bari School of Medicine, Bari, Italy
| | - Sergio Zacà
- Vascular and Endovascular Surgery-Department of Emergency and Organs Transplantation, "Aldo Moro" University of Bari School of Medicine, Bari, Italy
| | - Paola Wiesel
- Vascular and Endovascular Surgery-Department of Emergency and Organs Transplantation, "Aldo Moro" University of Bari School of Medicine, Bari, Italy
| | - Giovanni Mastrangelo
- Vascular and Endovascular Surgery-Department of Emergency and Organs Transplantation, "Aldo Moro" University of Bari School of Medicine, Bari, Italy
| | - Raffaele Pulli
- Vascular and Endovascular Surgery-Department of Emergency and Organs Transplantation, "Aldo Moro" University of Bari School of Medicine, Bari, Italy
| | - Domenico Angiletta
- Vascular and Endovascular Surgery-Department of Emergency and Organs Transplantation, "Aldo Moro" University of Bari School of Medicine, Bari, Italy
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Van der Linden LR, Neefs J, Vanassche T, Lemmens R, Verhamme P. From bad to worse: the shortage of fibrinolytics. Eur J Hosp Pharm 2023; 30:125-126. [PMID: 36822844 PMCID: PMC10176976 DOI: 10.1136/ejhpharm-2023-003719] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/25/2023] Open
Affiliation(s)
- Lorenz Roger Van der Linden
- Hospital Pharmacy Department, UZ Leuven, Leuven, Flanders, Belgium
- Department of Pharmaceutical and Pharmacological Sciences, KU Leuven, Leuven, Flanders, Belgium
| | - Jens Neefs
- Hospital Pharmacy Department, UZ Leuven, Leuven, Flanders, Belgium
| | - Thomas Vanassche
- Department of Cardiovascular Sciences, KU Leuven, Leuven, Flanders, Belgium
- Department of Cardiology, UZ Leuven, Leuven, Flanders, Belgium
| | - Robin Lemmens
- Department of Neurosciences, KU Leuven, Leuven, Flanders, Belgium
- Department of Neurology, UZ Leuven, Leuven, Flanders, Belgium
| | - Peter Verhamme
- Department of Cardiovascular Sciences, KU Leuven, Leuven, Flanders, Belgium
- Department of Cardiology, UZ Leuven, Leuven, Flanders, Belgium
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Ye Z, Zhou T, Zhang M, Zhou J, Xie F, Hill MD, Smith EE, Busse JW, Zhang Y, Liu Y, Wang X, Ma Z, An Z. Cost-effectiveness of endovascular thrombectomy with alteplase versus endovascular thrombectomy alone for acute ischemic stroke secondary to large vessel occlusion. CMAJ Open 2023; 11:E443-E450. [PMID: 37192770 DOI: 10.9778/cmajo.20220096] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 05/18/2023] Open
Abstract
BACKGROUND Recent randomized trials have suggested that endovascular thrombectomy (EVT) alone may provide similar functional outcomes as the current standard of care, EVT combined with intravenous alteplase treatment, for acute ischemic stroke secondary to large vessel occlusion. We conducted an economic evaluation of these 2 therapeutic options. METHODS We constructed a decision analytic model with a hypothetical cohort of 1000 patients to assess the cost-effectiveness of EVT with intravenous alteplase treatment versus EVT alone for acute ischemic stroke secondary to large vessel occlusion from both the societal and public health care payer perspectives. We used studies and data published in 2009-2021 for model inputs, and acquired cost data for Canada and China, representing high- and middle-income countries, respectively. We calculated incremental cost-effectiveness ratios (ICERs) using a lifetime horizon and accounted for uncertainty using 1-way and probabilistic sensitivity analyses. All costs are reported in 2021 Canadian dollars. RESULTS In Canada, the difference in quality-adjusted life-years (QALYs) gained between EVT with alteplase and EVT alone was 0.10 from both the societal and health care payer perspectives. The difference in cost was $2847 from a societal perspective and $2767 from the payer perspective. In China, the difference in QALYs gained was 0.07 from both perspectives, and the difference in cost was $1550 from the societal perspective and $1607 from the payer perspective. One-way sensitivity analyses showed that the distributions of modified Rankin Scale scores at 90 days after stroke were the most influential factor on ICERs. For Canada, compared to EVT alone, the probability that EVT with alteplase would be cost-effective at a willingness-to-pay threshold of $50 000 per QALY gained was 58.7% from a societal perspective and 58.4% from a payer perspective. The corresponding values for at a willingness-to-pay threshold of $47 185 (3 times the Chinese gross domestic product per capita in 2021) were 65.2% and 67.4%. INTERPRETATION For patients with acute ischemic stroke due to large vessel occlusion eligible for immediate treatment with both EVT alone and EVT with intravenous alteplase treatment, it is uncertain whether EVT with alteplase is cost-effective compared to EVT alone in Canada and China.
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Affiliation(s)
- Zhikang Ye
- Department of Pharmacy (Ye, Y. Zhang, Liu, Wang, Ma, An), Beijing Chaoyang Hospital, Capital Medical University, Beijing, China; School of International Pharmaceutical Business (T. Zhou), China Pharmaceutical University, Nanjing, China; The Michael G. DeGroote National Pain Centre (Ye, Busse), McMaster University, Hamilton, Ont.; Department of Health Research Methods, Evidence, and Impact (M. Zhang, Xie, Busse), McMaster University, Hamilton, Ont.; Health Economics Research Centre (J. Zhou), Nuffield Department of Population Health, University of Oxford, Oxford, UK; Department of Clinical Neurosciences and Hotchkiss Brain Institute (Hill), Departments of Medicine, Community Health Sciences and Radiology, Cumming School of Medicine, and Department of Clinical Neurosciences and Calgary Stroke Program (Smith), University of Calgary, Calgary, Alta.; Department of Anesthesia (Busse), McMaster University; The Chronic Pain Centre of Excellence for Canadian Veterans (Busse), Hamilton, Ont
| | - Ting Zhou
- Department of Pharmacy (Ye, Y. Zhang, Liu, Wang, Ma, An), Beijing Chaoyang Hospital, Capital Medical University, Beijing, China; School of International Pharmaceutical Business (T. Zhou), China Pharmaceutical University, Nanjing, China; The Michael G. DeGroote National Pain Centre (Ye, Busse), McMaster University, Hamilton, Ont.; Department of Health Research Methods, Evidence, and Impact (M. Zhang, Xie, Busse), McMaster University, Hamilton, Ont.; Health Economics Research Centre (J. Zhou), Nuffield Department of Population Health, University of Oxford, Oxford, UK; Department of Clinical Neurosciences and Hotchkiss Brain Institute (Hill), Departments of Medicine, Community Health Sciences and Radiology, Cumming School of Medicine, and Department of Clinical Neurosciences and Calgary Stroke Program (Smith), University of Calgary, Calgary, Alta.; Department of Anesthesia (Busse), McMaster University; The Chronic Pain Centre of Excellence for Canadian Veterans (Busse), Hamilton, Ont
| | - Mengmeng Zhang
- Department of Pharmacy (Ye, Y. Zhang, Liu, Wang, Ma, An), Beijing Chaoyang Hospital, Capital Medical University, Beijing, China; School of International Pharmaceutical Business (T. Zhou), China Pharmaceutical University, Nanjing, China; The Michael G. DeGroote National Pain Centre (Ye, Busse), McMaster University, Hamilton, Ont.; Department of Health Research Methods, Evidence, and Impact (M. Zhang, Xie, Busse), McMaster University, Hamilton, Ont.; Health Economics Research Centre (J. Zhou), Nuffield Department of Population Health, University of Oxford, Oxford, UK; Department of Clinical Neurosciences and Hotchkiss Brain Institute (Hill), Departments of Medicine, Community Health Sciences and Radiology, Cumming School of Medicine, and Department of Clinical Neurosciences and Calgary Stroke Program (Smith), University of Calgary, Calgary, Alta.; Department of Anesthesia (Busse), McMaster University; The Chronic Pain Centre of Excellence for Canadian Veterans (Busse), Hamilton, Ont
| | - Junwen Zhou
- Department of Pharmacy (Ye, Y. Zhang, Liu, Wang, Ma, An), Beijing Chaoyang Hospital, Capital Medical University, Beijing, China; School of International Pharmaceutical Business (T. Zhou), China Pharmaceutical University, Nanjing, China; The Michael G. DeGroote National Pain Centre (Ye, Busse), McMaster University, Hamilton, Ont.; Department of Health Research Methods, Evidence, and Impact (M. Zhang, Xie, Busse), McMaster University, Hamilton, Ont.; Health Economics Research Centre (J. Zhou), Nuffield Department of Population Health, University of Oxford, Oxford, UK; Department of Clinical Neurosciences and Hotchkiss Brain Institute (Hill), Departments of Medicine, Community Health Sciences and Radiology, Cumming School of Medicine, and Department of Clinical Neurosciences and Calgary Stroke Program (Smith), University of Calgary, Calgary, Alta.; Department of Anesthesia (Busse), McMaster University; The Chronic Pain Centre of Excellence for Canadian Veterans (Busse), Hamilton, Ont
| | - Feng Xie
- Department of Pharmacy (Ye, Y. Zhang, Liu, Wang, Ma, An), Beijing Chaoyang Hospital, Capital Medical University, Beijing, China; School of International Pharmaceutical Business (T. Zhou), China Pharmaceutical University, Nanjing, China; The Michael G. DeGroote National Pain Centre (Ye, Busse), McMaster University, Hamilton, Ont.; Department of Health Research Methods, Evidence, and Impact (M. Zhang, Xie, Busse), McMaster University, Hamilton, Ont.; Health Economics Research Centre (J. Zhou), Nuffield Department of Population Health, University of Oxford, Oxford, UK; Department of Clinical Neurosciences and Hotchkiss Brain Institute (Hill), Departments of Medicine, Community Health Sciences and Radiology, Cumming School of Medicine, and Department of Clinical Neurosciences and Calgary Stroke Program (Smith), University of Calgary, Calgary, Alta.; Department of Anesthesia (Busse), McMaster University; The Chronic Pain Centre of Excellence for Canadian Veterans (Busse), Hamilton, Ont
| | - Michael D Hill
- Department of Pharmacy (Ye, Y. Zhang, Liu, Wang, Ma, An), Beijing Chaoyang Hospital, Capital Medical University, Beijing, China; School of International Pharmaceutical Business (T. Zhou), China Pharmaceutical University, Nanjing, China; The Michael G. DeGroote National Pain Centre (Ye, Busse), McMaster University, Hamilton, Ont.; Department of Health Research Methods, Evidence, and Impact (M. Zhang, Xie, Busse), McMaster University, Hamilton, Ont.; Health Economics Research Centre (J. Zhou), Nuffield Department of Population Health, University of Oxford, Oxford, UK; Department of Clinical Neurosciences and Hotchkiss Brain Institute (Hill), Departments of Medicine, Community Health Sciences and Radiology, Cumming School of Medicine, and Department of Clinical Neurosciences and Calgary Stroke Program (Smith), University of Calgary, Calgary, Alta.; Department of Anesthesia (Busse), McMaster University; The Chronic Pain Centre of Excellence for Canadian Veterans (Busse), Hamilton, Ont
| | - Eric E Smith
- Department of Pharmacy (Ye, Y. Zhang, Liu, Wang, Ma, An), Beijing Chaoyang Hospital, Capital Medical University, Beijing, China; School of International Pharmaceutical Business (T. Zhou), China Pharmaceutical University, Nanjing, China; The Michael G. DeGroote National Pain Centre (Ye, Busse), McMaster University, Hamilton, Ont.; Department of Health Research Methods, Evidence, and Impact (M. Zhang, Xie, Busse), McMaster University, Hamilton, Ont.; Health Economics Research Centre (J. Zhou), Nuffield Department of Population Health, University of Oxford, Oxford, UK; Department of Clinical Neurosciences and Hotchkiss Brain Institute (Hill), Departments of Medicine, Community Health Sciences and Radiology, Cumming School of Medicine, and Department of Clinical Neurosciences and Calgary Stroke Program (Smith), University of Calgary, Calgary, Alta.; Department of Anesthesia (Busse), McMaster University; The Chronic Pain Centre of Excellence for Canadian Veterans (Busse), Hamilton, Ont
| | - Jason W Busse
- Department of Pharmacy (Ye, Y. Zhang, Liu, Wang, Ma, An), Beijing Chaoyang Hospital, Capital Medical University, Beijing, China; School of International Pharmaceutical Business (T. Zhou), China Pharmaceutical University, Nanjing, China; The Michael G. DeGroote National Pain Centre (Ye, Busse), McMaster University, Hamilton, Ont.; Department of Health Research Methods, Evidence, and Impact (M. Zhang, Xie, Busse), McMaster University, Hamilton, Ont.; Health Economics Research Centre (J. Zhou), Nuffield Department of Population Health, University of Oxford, Oxford, UK; Department of Clinical Neurosciences and Hotchkiss Brain Institute (Hill), Departments of Medicine, Community Health Sciences and Radiology, Cumming School of Medicine, and Department of Clinical Neurosciences and Calgary Stroke Program (Smith), University of Calgary, Calgary, Alta.; Department of Anesthesia (Busse), McMaster University; The Chronic Pain Centre of Excellence for Canadian Veterans (Busse), Hamilton, Ont
| | - Yi Zhang
- Department of Pharmacy (Ye, Y. Zhang, Liu, Wang, Ma, An), Beijing Chaoyang Hospital, Capital Medical University, Beijing, China; School of International Pharmaceutical Business (T. Zhou), China Pharmaceutical University, Nanjing, China; The Michael G. DeGroote National Pain Centre (Ye, Busse), McMaster University, Hamilton, Ont.; Department of Health Research Methods, Evidence, and Impact (M. Zhang, Xie, Busse), McMaster University, Hamilton, Ont.; Health Economics Research Centre (J. Zhou), Nuffield Department of Population Health, University of Oxford, Oxford, UK; Department of Clinical Neurosciences and Hotchkiss Brain Institute (Hill), Departments of Medicine, Community Health Sciences and Radiology, Cumming School of Medicine, and Department of Clinical Neurosciences and Calgary Stroke Program (Smith), University of Calgary, Calgary, Alta.; Department of Anesthesia (Busse), McMaster University; The Chronic Pain Centre of Excellence for Canadian Veterans (Busse), Hamilton, Ont
| | - Ying Liu
- Department of Pharmacy (Ye, Y. Zhang, Liu, Wang, Ma, An), Beijing Chaoyang Hospital, Capital Medical University, Beijing, China; School of International Pharmaceutical Business (T. Zhou), China Pharmaceutical University, Nanjing, China; The Michael G. DeGroote National Pain Centre (Ye, Busse), McMaster University, Hamilton, Ont.; Department of Health Research Methods, Evidence, and Impact (M. Zhang, Xie, Busse), McMaster University, Hamilton, Ont.; Health Economics Research Centre (J. Zhou), Nuffield Department of Population Health, University of Oxford, Oxford, UK; Department of Clinical Neurosciences and Hotchkiss Brain Institute (Hill), Departments of Medicine, Community Health Sciences and Radiology, Cumming School of Medicine, and Department of Clinical Neurosciences and Calgary Stroke Program (Smith), University of Calgary, Calgary, Alta.; Department of Anesthesia (Busse), McMaster University; The Chronic Pain Centre of Excellence for Canadian Veterans (Busse), Hamilton, Ont
| | - Xin Wang
- Department of Pharmacy (Ye, Y. Zhang, Liu, Wang, Ma, An), Beijing Chaoyang Hospital, Capital Medical University, Beijing, China; School of International Pharmaceutical Business (T. Zhou), China Pharmaceutical University, Nanjing, China; The Michael G. DeGroote National Pain Centre (Ye, Busse), McMaster University, Hamilton, Ont.; Department of Health Research Methods, Evidence, and Impact (M. Zhang, Xie, Busse), McMaster University, Hamilton, Ont.; Health Economics Research Centre (J. Zhou), Nuffield Department of Population Health, University of Oxford, Oxford, UK; Department of Clinical Neurosciences and Hotchkiss Brain Institute (Hill), Departments of Medicine, Community Health Sciences and Radiology, Cumming School of Medicine, and Department of Clinical Neurosciences and Calgary Stroke Program (Smith), University of Calgary, Calgary, Alta.; Department of Anesthesia (Busse), McMaster University; The Chronic Pain Centre of Excellence for Canadian Veterans (Busse), Hamilton, Ont
| | - Zhuo Ma
- Department of Pharmacy (Ye, Y. Zhang, Liu, Wang, Ma, An), Beijing Chaoyang Hospital, Capital Medical University, Beijing, China; School of International Pharmaceutical Business (T. Zhou), China Pharmaceutical University, Nanjing, China; The Michael G. DeGroote National Pain Centre (Ye, Busse), McMaster University, Hamilton, Ont.; Department of Health Research Methods, Evidence, and Impact (M. Zhang, Xie, Busse), McMaster University, Hamilton, Ont.; Health Economics Research Centre (J. Zhou), Nuffield Department of Population Health, University of Oxford, Oxford, UK; Department of Clinical Neurosciences and Hotchkiss Brain Institute (Hill), Departments of Medicine, Community Health Sciences and Radiology, Cumming School of Medicine, and Department of Clinical Neurosciences and Calgary Stroke Program (Smith), University of Calgary, Calgary, Alta.; Department of Anesthesia (Busse), McMaster University; The Chronic Pain Centre of Excellence for Canadian Veterans (Busse), Hamilton, Ont
| | - Zhuoling An
- Department of Pharmacy (Ye, Y. Zhang, Liu, Wang, Ma, An), Beijing Chaoyang Hospital, Capital Medical University, Beijing, China; School of International Pharmaceutical Business (T. Zhou), China Pharmaceutical University, Nanjing, China; The Michael G. DeGroote National Pain Centre (Ye, Busse), McMaster University, Hamilton, Ont.; Department of Health Research Methods, Evidence, and Impact (M. Zhang, Xie, Busse), McMaster University, Hamilton, Ont.; Health Economics Research Centre (J. Zhou), Nuffield Department of Population Health, University of Oxford, Oxford, UK; Department of Clinical Neurosciences and Hotchkiss Brain Institute (Hill), Departments of Medicine, Community Health Sciences and Radiology, Cumming School of Medicine, and Department of Clinical Neurosciences and Calgary Stroke Program (Smith), University of Calgary, Calgary, Alta.; Department of Anesthesia (Busse), McMaster University; The Chronic Pain Centre of Excellence for Canadian Veterans (Busse), Hamilton, Ont.
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69
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Muszynski P, Richard S, Finitsis S, Humbertjean L, Audibert G, Mione G, Harsan O, Derelle AL, Liao L, Zhu F, Olivot JM, Anxionnat R, Calvet D, Gory B. Transradial access with Simmons guiding catheter for carotid artery stenting: Feasibility and procedural complications in a single-center experience. Interv Neuroradiol 2023:15910199231171845. [PMID: 37113013 DOI: 10.1177/15910199231171845] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/29/2023] Open
Abstract
BACKGROUND There is an increasing number of transradial approach (TRA) for carotid artery stenting (CAS), however, similar techniques and materials as for femoral access are used. We report the results of TRA lower profile technique for CAS using a 7 F Simmons guiding catheter, especially in terms of feasibility and procedural safety in a single center. MATERIALS AND METHODS We retrospectively analyzed 68 consecutive patients with symptomatic extracranial carotid stenoses who underwent 75 CAS between January 2018 and December 2021. The success and crossover rate, procedural time, fluoroscopy, clinical outcomes, technical considerations, and procedural complications were analyzed. RESULTS TRA CAS with Simmons guiding catheter was successful in 67/75 (89.3%) cases, with a 7 (9.3%) crossover rate. Fluoroscopy mean time was 15.8 minutes. Two forearm hematomas were described. No ischemic or surgical site complications were reported. CONCLUSIONS In our experience frontline TRA with a 7 F Simmons guiding catheter is feasible with high procedural success and a low rate of access site complications.
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Affiliation(s)
- P Muszynski
- Department of Diagnostic and Therapeutic Neuroradiology, CHRU Nancy, France
| | - S Richard
- Université de Lorraine, Nancy, France
- Department of Neurology, Stroke Unit, CHRU Nancy, France
| | - S Finitsis
- Neuroradiolology, University General Hospital of Thessaloniki AHEPA, Thessaloniki, Greece
| | - L Humbertjean
- Department of Neurology, Stroke Unit, CHRU Nancy, France
| | - G Audibert
- Department of intensive care unit, CHRU Nancy, France
| | - G Mione
- Department of Neurology, Stroke Unit, CHRU Nancy, France
| | - O Harsan
- Department of Diagnostic and Therapeutic Neuroradiology, CHRU Nancy, France
| | - A L Derelle
- Department of Diagnostic and Therapeutic Neuroradiology, CHRU Nancy, France
| | - L Liao
- Department of Diagnostic and Therapeutic Neuroradiology, CHRU Nancy, France
- Université de Lorraine, Nancy, France
| | - F Zhu
- Department of Diagnostic and Therapeutic Neuroradiology, CHRU Nancy, France
- Université de Lorraine, Nancy, France
| | - J M Olivot
- Department of Neurology, Neuroradiology, and Pathology, Hôpital Pierre-Paul Riquet, CHU Toulouse, Toulouse Neuroimaging Centre, Universite da Toulouse, France
| | - R Anxionnat
- Department of Diagnostic and Therapeutic Neuroradiology, CHRU Nancy, France
- Université de Lorraine, Nancy, France
| | - D Calvet
- Neurology and neurovascular unit, GHU Psychiatrie et Neurosciences, Hôpital Sainte-Anne, Paris, France
| | - Benjamin Gory
- Department of Diagnostic and Therapeutic Neuroradiology, CHRU Nancy, France
- Université de Lorraine, Nancy, France
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70
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Torun SG, Munoz PDM, Crielaard H, Verhagen HJM, Kremers GJ, van der Steen AFW, Akyildiz AC. Local Characterization of Collagen Architecture and Mechanical Failure Properties of Fibrous Plaque Tissue of Atherosclerotic Human Carotid Arteries. Acta Biomater 2023; 164:293-302. [PMID: 37086826 DOI: 10.1016/j.actbio.2023.04.022] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2022] [Revised: 04/05/2023] [Accepted: 04/13/2023] [Indexed: 04/24/2023]
Abstract
Atherosclerotic plaque rupture in carotid arteries is a major cause of cerebrovascular events. Plaque rupture is the mechanical failure of the heterogeneous fibrous plaque tissue. Local characterization of the tissue's failure properties and the collagen architecture are of great importance to have insights in plaque rupture for clinical event prevention. Previous studies were limited to average rupture properties and global structural characterization, and did not provide the necessary local information. In this study, we assessed the local collagen architecture and failure properties of fibrous plaque tissue, by analyzing 30 tissue strips from 18 carotid plaques. Our study framework entailed second harmonic generation imaging for local collagen orientation and dispersion, and uniaxial tensile testing and digital image correlation for local tissue mechanics. The results showed that 87% of the imaged locations had collagen orientation close to the circumferential direction (0°) of the artery, and substantial dispersion locally. All regions combined, median [Q1:Q3] of the predominant angle measurements was -2° [-16°:16°]. The stretch ratio measurements clearly demonstrated a nonuniform stretch ratio distribution in the tissue under uniaxial loading. The rupture initiation regions had significantly higher stretch ratios (1.26 [1.15-1.40]) than the tissue average stretch ratio (1.11 [1.10-1.16]). No significant difference in collagen direction and dispersion was identified between the rupture regions and the rest of the tissue. The presented study forms an initial step towards gaining better insights into the characterization of local structural and mechanical fingerprints of fibrous plaque tissue in order to aid improved assessment of plaque rupture risk. STATEMENT OF SIGNIFICANCE: Plaque rupture risk assessment, critical to prevent cardiovascular events, requires knowledge on local failure properties and structure of collagenous plaque tissue. Our current knowledge is unfortunately limited to tissue's overall ultimate failure properties with scarce information on collagen architecture. In this study, local failure properties and collagen architecture of fibrous plaque tissue were obtained. We found predominant circumferential alignment of collagen fibers with substantial local dispersion. The tissue showed nonuniform stretch distribution under uniaxial tensile loading, with high stretches at rupture spots. This study highlights the significance of local mechanical and structural assessment for better insights into plaque rupture and the potential use of local stretches as risk marker for plaque rupture for patient-specific clinical applications.
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Affiliation(s)
- Su Guvenir Torun
- Department of Biomedical Engineering, Erasmus Medical Center, Rotterdam, The Netherlands
| | - Pablo de Miguel Munoz
- Department of Biomedical Engineering, Erasmus Medical Center, Rotterdam, The Netherlands; Department of Biomechanical Engineering, Delft University of Technology, Delft, The Netherlands
| | - Hanneke Crielaard
- Department of Biomedical Engineering, Erasmus Medical Center, Rotterdam, The Netherlands
| | - Hence J M Verhagen
- Department of Vascular Surgery, Erasmus Medical Center, Rotterdam, The Netherlands
| | - Gert-Jan Kremers
- Erasmus Optical Imaging Center, Erasmus Medical Center, Rotterdam, The Netherlands
| | - Antonius F W van der Steen
- Department of Biomedical Engineering, Erasmus Medical Center, Rotterdam, The Netherlands; Department of Biomechanical Engineering, Delft University of Technology, Delft, The Netherlands
| | - Ali C Akyildiz
- Department of Biomedical Engineering, Erasmus Medical Center, Rotterdam, The Netherlands; Department of Biomechanical Engineering, Delft University of Technology, Delft, The Netherlands.
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71
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Petrovic J, Ilijevski N, Sagic D, Antonic Z, Tanaskovic S. Risk Factors for Carotid Restenosis in Patients After Eversion Endarterectomy vs Stenting: A Single-Center Experience. Angiology 2023; 74:317-324. [PMID: 35968755 DOI: 10.1177/00033197221121005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
The primary aim of the presented study is to analyze and compare the rate of carotid restenosis in patients after eversion carotid endarterectomy (eCEA), primary carotid angioplasty and stenting (CASp), and stenting for carotid artery restenosis after previous eCEA (CASr). The secondary aim is to compare clinical outcomes in patients with carotid restenosis. The total number of patients with evident carotid restenosis was 223 (24.8%). In patients with eCEA, significant carotid restenosis rate was 12.7%, in the CASp group 18.7%, and CASr 6.7%. Patients with carotid restenosis were asymptomatic in 95.1% of cases. Patients in the CASp group experienced transient ischemic attack more than patients with eCEA (P = .007), while no difference was observed regarding cerebrovascular insult (CVI). The incidence of carotid restenosis was higher in CASp patients, and increased during the follow-up. The majority of patients are asymptomatic post-procedural and the degree of carotid restenosis does not correlate with the occurrence of postoperative symptoms. High low-density lipoprotein cholesterol (LDL-C) levels, low high-density lipoprotein cholesterol (HDL-C) levels, smoking, and a history of vascular surgery correlate with higher degrees of carotid restenosis. The most important factor in the prevention of carotid restenosis is risk factor control as well as adequate pharmacological therapy.
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Affiliation(s)
- Jovan Petrovic
- Faculty of Medicine, 54801University of Belgrade, Beograd, Serbia
| | - Nenad Ilijevski
- Faculty of Medicine, 54801University of Belgrade, Beograd, Serbia.,Vascular Surgery Clinic, Dedinje Cardiovascular Institute, Belgrade, Serbia
| | - Dragan Sagic
- Faculty of Medicine, 54801University of Belgrade, Beograd, Serbia.,Clinic for Radiology, Dedinje Cardiovascular Institute, Belgrade, Serbia
| | - Zelimir Antonic
- Clinic for Radiology, Dedinje Cardiovascular Institute, Belgrade, Serbia
| | - Slobodan Tanaskovic
- Faculty of Medicine, 54801University of Belgrade, Beograd, Serbia.,Vascular Surgery Clinic, Dedinje Cardiovascular Institute, Belgrade, Serbia
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72
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Inflammation, Microcalcification, and Increased Expression of Osteopontin Are Histological Hallmarks of Plaque Vulnerability in Patients with Advanced Carotid Artery Stenosis. Biomedicines 2023; 11:biomedicines11030881. [PMID: 36979863 PMCID: PMC10045225 DOI: 10.3390/biomedicines11030881] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2023] [Revised: 03/03/2023] [Accepted: 03/07/2023] [Indexed: 03/18/2023] Open
Abstract
Background: severe carotid artery stenosis is a major cause of ischemic stroke and consequent neurological deficits. The most important steps of atherosclerotic plaque development, leading to carotid stenosis, are well-known; however, their exact timeline and intricate causal relationships need to be more characterized. Methods: in a cohort of 119 patients, who underwent carotid endarterectomy, we studied the histological correlations between arterial calcification patterns and localization, the presence of the inflammatory infiltrate and osteopontin expression, with ulceration, thrombosis, and intra-plaque hemorrhage, as direct signs of vulnerability. Results: in patients with an inflammatory infiltrate, aphasia was more prevalent, and microcalcification, superficial calcification, and high-grade osteopontin expression were characteristic. Higher osteopontin expression was also correlated with the presence of a lipid core. Inflammation and microcalcification were significantly associated with plaque ulceration in logistic regression models; furthermore, ulceration and the inflammatory infiltrate were significant determinants of atherothrombosis. Conclusion: our results bring histological evidence for the critically important role of microcalcification and inflammatory cell invasion in the formation and destabilization of advanced carotid plaques. In addition, as a calcification organizer, high-grade osteopontin expression is associated with ulceration, the presence of a large lipid core, and may also have an intrinsic role in plaque progression.
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73
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Quesado J, Dias L, Pereira-Macedo J, Duarte-Gamas L, Khairy A, Pinheiro M, Reis P, Andrade JP, Rocha-Neves J, Marreiros A. R2CHA2DS2-VA predicts the cardiovascular risk after carotid endarterectomy. Ann Vasc Surg 2023:S0890-5096(23)00116-4. [PMID: 36868457 DOI: 10.1016/j.avsg.2023.02.016] [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: 10/19/2022] [Revised: 02/06/2023] [Accepted: 02/08/2023] [Indexed: 03/05/2023]
Abstract
OBJECTIVE R2CHA2DS2-VA score has been used to predict short and long-term outcomes in many cardiovascular diseases. This study aims to validate the R2CHA2DS2-VA score as a long-term major adverse cardiovascular events (MACE) predictor after CEA. Secondary outcomes were also assessed regarding the incidence of all-cause mortality, acute myocardial infarction (AMI), major adverse limb events (MALE), and acute heart failure (AHF). METHODS From January 2012 to December 2021, patients (n= 205) from a Portuguese tertiary care and referral center that underwent CEA with regional anesthesia (RA) for carotid stenosis were selected from a previously collected prospective database, and a post-hoc analysis was performed. Demographics and comorbidities were registered. Clinical adverse events were assessed 30-days after the procedure and in the subsequent long-term surveillance period. Statistical analysis was performed by the Kaplan-Meier method and Cox proportional hazards regression. RESULTS Of the patients enrolled, 78.5% were males with a mean age of 70.44 ± 8.9 years. Higher scores of R2CHA2DS2-VA were associated with long-term MACE (adjusted Hazard Ratio (aHR) 1.390; 95% Confidence Interval (CI) 1.173-1.647) and mortality (aHR 1.295; 95% CI 1.08-1.545) CONCLUSIONS: This study demonstrated the potential of the R2CHA2DS2-VA score to predict long-term outcomes such as AMI, AHF, MACE, and all-cause mortality in a population of patients submitted to carotid endarterectomy.
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Affiliation(s)
- João Quesado
- ICVS, Life and Health Sciences Research Institute, School of Medicine, University of Minho, Braga, Portugal
| | - Lara Dias
- Department of Angiology and Vascular Surgery, Centro Hospitalar Universitário de São João, Porto, Portugal
| | - Juliana Pereira-Macedo
- Department of surgery - Centro Hospitalar do Médio Ave; Center for Health Technology and Services Research (CINTESIS), Porto, Portugal
| | - Luís Duarte-Gamas
- Department of Angiology and Vascular Surgery, Centro Hospitalar Universitário de São João, Porto, Portugal; Department of Surgery and Physiology, Faculdade de Medicina da Universidade do Porto, Portugal
| | - Ahmed Khairy
- Faculty of Medicine-Assiut University-Assiut-Egypt
| | - Marina Pinheiro
- ICVS, Life and Health Sciences Research Institute, School of Medicine, University of Minho, Braga, Portugal; REQUIMTE, University of Porto, Porto, Portugal; Public Health Unit - ACES Cávado III , Braga, Portugal
| | - Pedro Reis
- Burn Unit-Department of Plastic Surgery, Centro Hospitalar Universitário de São João, Porto, Portugal
| | - José P Andrade
- CINTESIS@RISE, Department of Biomedicine - Unit of Anatomy, Faculty of Medicine, University of Porto, Portugal; Department of Biomedicine - Unit of Anatomy, Faculty of Medicine, University of Porto, Portugal
| | - João Rocha-Neves
- Department of Angiology and Vascular Surgery, Centro Hospitalar Universitário de São João, Porto, Portugal; Department of Surgery and Physiology, Faculdade de Medicina da Universidade do Porto, Portugal; Department of Biomedicine - Unit of Anatomy, Faculty of Medicine, University of Porto, Portugal.
| | - Ana Marreiros
- Faculdade de Medicina e Ciências Biomédicas da Universidade do Algarve, Portugal, ABC, Algarve Biomedical Center, Faro, Portugal
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74
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Goel A, Soteriou I, Normando E. Treatment of asymptomatic carotid stenosis in SPACE-2. Lancet Neurol 2023; 22:197. [PMID: 36804081 DOI: 10.1016/s1474-4422(23)00025-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2022] [Accepted: 01/19/2023] [Indexed: 02/17/2023]
Affiliation(s)
- Akshit Goel
- Imperial College School of Medicine, Imperial College London, London SW7 2BX, UK.
| | - Iris Soteriou
- Imperial College School of Medicine, Imperial College London, London SW7 2BX, UK
| | - Eduardo Normando
- Department of Surgery and Cancer, Imperial College London, London SW7 2BX, UK
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Mastrorilli D, D'Oria M, Lepidi S, Mezzetto L, Calvagna C, Taglialavoro J, Bruno S, Veraldi GF. Prediction of long-term mortality for patients with severe asymptomatic de novo carotid stenosis undergoing carotid endarterectomy (PREMY 2SE-CEA): Derivation and validation of a novel risk score. J Vasc Surg 2023; 77:804-810.e3. [PMID: 36265668 DOI: 10.1016/j.jvs.2022.10.011] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2022] [Revised: 09/29/2022] [Accepted: 10/03/2022] [Indexed: 11/06/2022]
Abstract
OBJECTIVE The aim of the present study was to develop and validate a risk prediction model for the prediction of long-term mortality for patients with severe asymptomatic de novo carotid stenosis undergoing carotid endarterectomy (PREMY2SE-CEA). METHODS Data were collected retrospectively from a dedicated database of consecutive patients who had undergone elective CEA for severe (>70% using the NASCET [North American Symptomatic Carotid Endarterectomy Trial] criteria) asymptomatic carotid stenosis at two Italian University Hospitals from 2008 through 2016. Internal validation of the score was performed after random sampling in a 3:1 fashion. The primary end point of the PREMY2SE-CEA risk score was the 5-year mortality. RESULTS Of the 1214 patients, 901 were included in the derivation cohort and 313 in the validation cohort. Using multivariable logistic regression with backward elimination, a parsimonious model was derived. A risk score incorporating eight risk factors was generated and found to be highly predictive of long-term mortality in the derivation (odds ratio [OR], 1.38; 95% confidence interval [CI], 1.28-1.41; P < .001) and validation (OR, 1.29; 95% CI, 1.21-1.37; P <.001) cohorts. The discrimination power in the receiver operating characteristic curve analysis was C = 0.775 (95% CI, 0.74-.80), and the optimism-corrected area under the curve in the bootstrapped samples was 0.761 (P < .001). A strong correlation was found between the predicted and actual mortality rates in the validation cohort (r = 0.71; P < .001). CONCLUSIONS In the present study, we have described the development, evaluation, and validation of a risk prediction model (PREMY2SE-CEA) for long-term mortality after CEA in asymptomatic patients. Physicians could use the PREMY2SE-CEA risk scoring tool to complement their estimates of life expectancy and prompt selective consideration of prophylactic CEA to improve the long-term benefits of interventions.
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Affiliation(s)
- Davide Mastrorilli
- Department of Vascular Surgery, University of Verona School of Medicine, University Hospital of Verona, Verona, Italy
| | - Mario D'Oria
- Division of Vascular and Endovascular Surgery, Cardiovascular Department, University Hospital of Trieste, Giuliano Isontina University Health Authority, Trieste, Italy.
| | - Sandro Lepidi
- Division of Vascular and Endovascular Surgery, Cardiovascular Department, University Hospital of Trieste, Giuliano Isontina University Health Authority, Trieste, Italy
| | - Luca Mezzetto
- Department of Vascular Surgery, University of Verona School of Medicine, University Hospital of Verona, Verona, Italy
| | - Cristiano Calvagna
- Division of Vascular and Endovascular Surgery, Cardiovascular Department, University Hospital of Trieste, Giuliano Isontina University Health Authority, Trieste, Italy
| | - Jacopo Taglialavoro
- Division of Vascular and Endovascular Surgery, Cardiovascular Department, University Hospital of Trieste, Giuliano Isontina University Health Authority, Trieste, Italy
| | - Salvatore Bruno
- Department of Vascular Surgery, University of Verona School of Medicine, University Hospital of Verona, Verona, Italy
| | - Gian Franco Veraldi
- Department of Vascular Surgery, University of Verona School of Medicine, University Hospital of Verona, Verona, Italy
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Baek JH. Carotid Artery Stenting for Asymptomatic Carotid Stenosis: What We Need to Know for Treatment Decision. Neurointervention 2023; 18:9-22. [PMID: 36809873 PMCID: PMC9986346 DOI: 10.5469/neuroint.2023.00031] [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: 01/22/2023] [Accepted: 02/05/2023] [Indexed: 02/24/2023] Open
Abstract
A clinical decision on the treatment of asymptomatic carotid stenosis is challenging, unlike symptomatic carotid stenosis. Carotid artery stenting (CAS) has been recommended as an alternative to carotid endarterectomy (CEA) based on the finding that the efficacy and safety of CAS were comparable to CEA in randomized trials. However, in some countries, CAS is often performed more frequently than CEA for asymptomatic carotid stenosis. Moreover, it has been recently reported that CAS is not superior to the best medical treatment in asymptomatic carotid stenosis. Due to these recent changes, the role of CAS in asymptomatic carotid stenosis should be revisited. When determining the treatment for asymptomatic carotid stenosis, one should consider several clinical factors including stenosis degree, patient life expectancy, stroke risk by medical treatment, availability of a vascular surgeon, high risk for CEA or CAS, and insurance coverage. This review aimed to present and pragmatically organize the information that is necessary for a clinical decision on CAS in asymptomatic carotid stenosis. In conclusion, although the traditional benefit of CAS is being revisited recently, it seems too early to conclude that CAS is no longer beneficial under intense and systemic medical treatment. Instead, a treatment strategy with CAS should evolve to select eligible or medically high-risk patients more precisely.
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Affiliation(s)
- Jang-Hyun Baek
- Department of Neurology, Kangbuk Samsung Hospital, Sungkyunkwan University School of Medicine, Seoul, Korea
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FEDORINA M, DAVYDKIN I, GALATI G, BIONDI-ZOCCAI G, GERMANOVA O. Carotid bifurcation stenosis: functional importance in physical exercises. ITALIAN JOURNAL OF VASCULAR AND ENDOVASCULAR SURGERY 2023. [DOI: 10.23736/s1824-4777.22.01572-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/15/2023]
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Kim MJ, Ha SK. Outcomes Following Carotid Endarterectomy and Carotid Artery Stenting in Patients with Carotid Artery Stenosis: A Retrospective Study from a Single Center in South Korea. Med Sci Monit 2023; 29:e939223. [PMID: 36788720 PMCID: PMC9940449 DOI: 10.12659/msm.939223] [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] [Indexed: 01/19/2023] Open
Abstract
BACKGROUND Previous randomized controlled trials and meta-analyses comparing carotid endarterectomy (CEA) and carotid artery stenting (CAS) included a large number of patients, but the diagnosis, treatment selection, and performance were heterogeneous. This retrospective study from a single center in South Korea aimed to evaluate outcomes following CEA and CAS in patients with carotid artery stenosis. MATERIAL AND METHODS A retrospective analysis was performed using the data of patients who underwent carotid revascularization between September 2016 and June 2021 at a single institution. The primary outcomes were stroke, myocardial infarction (MI), and death during the periprocedural period. RESULTS We enrolled a total of 61 (44 symptomatic and 17 asymptomatic) patients who underwent CEA or CAS. Among them, 36 (59%) underwent CEA and 25 (41%) underwent CAS. Statistically significant differences were found between the groups in degree of carotid stenosis (CEA: 87.0±9.1, CAS: 80.5±9.3, P=0.007). All patients with confirmed plaque ulceration before carotid revascularization underwent CEA. Two (3.3%) periprocedural strokes occurred, 1 in each group, on the ipsilateral side. There were no significant differences between CEA and CAS in the event-free survival rate for stroke during the follow-up (log-rank test=0.806). CONCLUSIONS Favorable outcomes in terms of periprocedural stroke were observed. We found no significant difference between the 2 carotid revascularization techniques in the incidence of periprocedural stroke in symptomatic and asymptomatic patients. To confirm our findings, further studies involving a larger number of patients and continuous follow-up are necessary.
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Affiliation(s)
- Myung Ji Kim
- Department of Neurosurgery, Korea University College of Medicine, Korea University Medical Center, Ansan Hospital, Ansan, Gyeonggi, South Korea
| | - Sung-Kon Ha
- Department of Neurosurgery, Korea University College of Medicine, Korea University Medical Center, Ansan Hospital, Ansan, Gyeonggi, South Korea
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79
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Electronegative LDL Is Associated with Plaque Vulnerability in Patients with Ischemic Stroke and Carotid Atherosclerosis. Antioxidants (Basel) 2023; 12:antiox12020438. [PMID: 36829998 PMCID: PMC9952764 DOI: 10.3390/antiox12020438] [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] [Received: 12/20/2022] [Revised: 02/06/2023] [Accepted: 02/08/2023] [Indexed: 02/12/2023] Open
Abstract
Owing to the high risk of recurrence, identifying indicators of carotid plaque vulnerability in atherothrombotic ischemic stroke is essential. In this study, we aimed to identify modified LDLs and antioxidant enzymes associated with plaque vulnerability in plasma from patients with a recent ischemic stroke and carotid atherosclerosis. Patients underwent an ultrasound, a CT-angiography, and an 18F-FDG PET. A blood sample was obtained from patients (n = 64, 57.8% with stenosis ≥50%) and healthy controls (n = 24). Compared to the controls, patients showed lower levels of total cholesterol, LDL cholesterol, HDL cholesterol, apolipoprotein B (apoB), apoA-I, apoA-II, and apoE, and higher levels of apoJ. Patients showed lower platelet-activating factor acetylhydrolase (PAF-AH) and paraoxonase-1 (PON-1) enzymatic activities in HDL, and higher plasma levels of oxidized LDL (oxLDL) and electronegative LDL (LDL(-)). The only difference between patients with stenosis ≥50% and <50% was the proportion of LDL(-). In a multivariable logistic regression analysis, the levels of LDL(-), but not of oxLDL, were independently associated with the degree of carotid stenosis (OR: 5.40, CI: 1.15-25.44, p < 0.033), the presence of hypoechoic plaque (OR: 7.52, CI: 1.26-44.83, p < 0.027), and of diffuse neovessels (OR: 10.77, CI: 1.21-95.93, p < 0.033), indicating that an increased proportion of LDL(-) is associated with vulnerable atherosclerotic plaque.
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Kirchhoff F, Eckstein HH. Locoregional Anaesthesia and Intra-Operative Angiography in Carotid Endarterectomy: 16 Year Results of a Consecutive Single Centre Series. Eur J Vasc Endovasc Surg 2023; 65:223-232. [PMID: 36229016 DOI: 10.1016/j.ejvs.2022.10.002] [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: 01/18/2022] [Revised: 08/11/2022] [Accepted: 10/02/2022] [Indexed: 11/30/2022]
Abstract
OBJECTIVE The benefit of local (LA) over general (GA) anaesthesia and the rationale of intra-operative imaging strategies during carotid endarterectomy (CEA) is debated. This study analysed the associations between patient characteristics, LA, and intra-operative imaging strategies and the in hospital stroke and death rates in elective CEA over a 16 year period. METHODS All consecutive patients treated by elective CEA between January 2004 and December 2019 (n = 1 872; median age 71 years, 70% male, 37% symptomatic) were included. All patients were assessed neurologically before and within 48 hours after CEA. The primary outcome event was the combined rate of any in hospital stroke or death. Secondary outcome events were the combined rates of any in hospital major stroke (modified Rankin scale [mRS] 3 - 5) or death, stroke, minor stroke (mRS 0 - 2), major stroke, and death alone. To detect changes over time, four quartiles (2004 - 2007, 2008 - 2011, 2012 - 2015, and 2016 - 2019) of this cohort were analysed. Statistical analysis comprised trend tests, and uni- and multivariable logistic regression. RESULTS Median patient age increased from 68 to 73 years (p < .001). Over time, LA (from 28% to 91%) and intra-operative imaging (angiography 2.8 - 98.1%, duplex ultrasound 0 - 78.2%) was applied more frequently. Surgical techniques did not change. The in hospital stroke or death and major stroke or death rates decreased from 3.7% to 1.5% (p = .041) and from 2.8% to 0.9% (p = .014), respectively, corresponding to a relative risk of decline of 7% and 12% annually. Multivariable analysis revealed that LA (odds ratio [OR] 0.25, 95% confidence interval [CI] 0.1 - 0.62) and intra-operative angiography (OR 0.09, 95% CI 0.10 - 0.81) were associated with lower in hospital major stroke and death rates. CONCLUSION These data demonstrate a decline in the combined rates of any in hospital major stroke or death after non-emergency CEA over time. Locoregional anaesthesia and intra-operative quality control were associated with these improvements and might be worthwhile in elective CEA.
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Affiliation(s)
- Felix Kirchhoff
- Department for Vascular and Endovascular Surgery, Klinikum rechts der Isar, Technical University of Munich, Munich, Germany
| | - Hans-Henning Eckstein
- Department for Vascular and Endovascular Surgery, Klinikum rechts der Isar, Technical University of Munich, Munich, Germany.
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Solomon Y, Marcaccio CL, Rastogi V, Lu JJ, Malas MB, Wang GJ, Schneider PA, de Borst GJ, Schermerhorn ML. In-hospital outcomes after carotid endarterectomy for stroke stratified by modified Rankin scale score and time of intervention. J Vasc Surg 2023; 77:529-537.e1. [PMID: 36395901 DOI: 10.1016/j.jvs.2022.09.018] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2022] [Revised: 09/09/2022] [Accepted: 09/19/2022] [Indexed: 11/16/2022]
Abstract
OBJECTIVE Although the benefits of carotid endarterectomy (CEA) for treating symptomatic carotid stenosis are well known, the optimal timing of intervention after acute stroke and whether the optimal timing will vary with preoperative stroke severity has remained unclear. Therefore, we assessed the effect of stroke severity and timing of the intervention on the postoperative outcomes for patients who had undergone CEA for stroke. METHODS We identified all patients in the Vascular Quality Initiative who had undergone CEA from 2012 to 2020 for prior stroke. The patients were stratified using the preoperative modified Rankin scale score (mRS score, 0-5) and time to CEA after stroke onset (≤2 days, 3-14 days, 15-90 days, 91-180 days). After univariate comparisons, the patients were stratified into the following mRS cohorts for further analysis: 0 to 1, 2, 3 to 4, and 5. The primary outcome was in-hospital stroke/death. RESULTS We identified 15,601 patients, of whom 30% had had an mRS score of 0, 34% an mRS score of 1, 17% an mRS score of 2, 11% an mRS score of 3, 8% an mRS score of 4, and 1% an mRS score of 5. Overall, 9.3% of the patients had undergone CEA within ≤2 days, 46% within 3 to 14 days, 36% in 15 to 90 days, and 8.4% within 90 to 180 days. A decreasing mRS score and an increasing time to CEA were associated with lower rates of perioperative stroke/death (Ptrend < .01). After risk adjustment, with CEA at 3 to 14 days as the comparator group, the mRS score 0 to 1 group had had a higher incidence of stroke/death after CEA within ≤2 days (3.6% vs 2.0%; odds ratio [OR], 1.8; 95% confidence interval [CI], 1.2-2.7). The mRS score 2 group had had a similar incidence of stroke/death after CEA within ≤2 days (4.4% vs 3.9%; OR, 1.2; 95% CI, 0.6-2.3) but a lower incidence after CEA at 15 to 90 days (2.1% vs 3.9%; OR 0.5; 95% CI, 0.3-0.96). The mRS score 3 to 4 group had had a higher incidence of stroke/death after CEA within ≤2 days (8.0% vs 3.8%; OR, 2.4; 95% CI, 1.5-3.9) but a similar incidence of stroke/death after CEA at 15 to 90 days (3.0% vs 3.8%; OR, 0.8; 95% CI, 0.5-1.3). For the mRS score 5 group, the stroke/death rates were ≥6.5% across all the time to CEA groups. However, the low sample size limited meaningful comparisons. CONCLUSIONS Patients with minimal disability after stroke (mRS score, 0-1) seemed to benefit from CEA within 3 to 14 days. However, those with severe disability (mRS score 5) have a very high risk from CEA at any time point given the poor outcomes. In contrast to the current guidelines, patients with mild disability (mRS score 2) could benefit from delaying CEA to 15 to 90 days, and those with moderate disability (mRS score 3-4) might benefit from CEA within 3 to 90 days given the acceptable in-hospital outcomes. These data should be considered within the context of the clinical situation in the weeks after index event to determine the net benefit of delayed CEA.
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Affiliation(s)
- Yoel Solomon
- Division of Vascular and Endovascular Surgery, Department of Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA; Department of Vascular Surgery, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Christina L Marcaccio
- Division of Vascular and Endovascular Surgery, Department of Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA
| | - Vinamr Rastogi
- Division of Vascular and Endovascular Surgery, Department of Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA
| | - Jinny J Lu
- Division of Vascular and Endovascular Surgery, Department of Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA
| | - Mahmoud B Malas
- Division of Vascular and Endovascular Surgery, Department of Surgery, University of California San Diego Health System, San Diego, CA
| | - Grace J Wang
- Division of Vascular Surgery and Endovascular Therapy, Department of Surgery, Hospital of the University of Pennsylvania, Philadelphia, PA
| | - Peter A Schneider
- Division of Vascular and Endovascular Surgery, University of California, San Francisco, San Francisco, CA
| | - Gert J de Borst
- Department of Vascular Surgery, University Medical Center Utrecht, Utrecht, The Netherlands
| | - 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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Shukurov FB, Rudenko BА, Feshchenko DA, Vasiliev DK, Taliuridze MT. Strategy for endovascular treatment of a patient with combined coronary and carotid artery atherosclerosis: a case report. КАРДИОВАСКУЛЯРНАЯ ТЕРАПИЯ И ПРОФИЛАКТИКА 2023. [DOI: 10.15829/1728-8800-2022-3442] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/21/2023] Open
Abstract
Treatment of patients with combined coronary and carotid artery atherosclerosis is a difficult task due to the increased risk of surgical intervention in this cohort of patients. Lack of timely treatment can lead to a decrease in the quality of life of patients, as well as to death. In some cases with combined coronary and carotid artery atherosclerosis, the choice of surgical intervention may depend on vascular bed involvement. In a case report, open surgery was associated with a very high risk of perioperative complications; so the only way of myocardial revascularization was minimally invasive endovascular surgery. The article presents a case of the treatment of a patient with a combined multivessel coronary and bilateral carotid artery atherosclerosis.
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Affiliation(s)
- F. B. Shukurov
- National Medical Research Center for Therapy and Preventive Medicine
| | - B. А. Rudenko
- National Medical Research Center for Therapy and Preventive Medicine
| | - D. A. Feshchenko
- National Medical Research Center for Therapy and Preventive Medicine
| | - D. K. Vasiliev
- National Medical Research Center for Therapy and Preventive Medicine
| | - M. T. Taliuridze
- National Medical Research Center for Therapy and Preventive Medicine
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Pérez-Sánchez S, Barragán Prieto A, Gamero García MÁ, Moniche F, Tomasello A, Delgado-Acosta F, González A, Montaner J. Predictive Factors for Stroke and TIA Following Carotid Artery Stenting. J Endovasc Ther 2023:15266028221144586. [PMID: 36609162 DOI: 10.1177/15266028221144586] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
PURPOSE Carotid artery stenting (CAS) is an effective and minimally invasive method for the treatment of extracranial carotid artery stenosis. The aim of the present study was to explore independent risk factors to predict cerebrovascular events following CAS to identify high-risk patients and improve the safety of CAS in this population. MATERIALS AND METHODS HISPANIAS is a national prospective multicenter study that included 14 hospitals that collected data from patients who underwent CAS. We analyzed morbidity and mortality within 30 days after CAS, looking for factors that might be associated with cerebrovascular events (stroke and transient ischemic attack [TIA]). RESULTS The HISPANIAS cohort included 757 patients: 80.32% were men, the mean age was 70.73 years, and 82.96% underwent symptomatic CAS. Cerebrovascular complications occurred in 42 patients (5.6%), including TIA in 24 patients (70.8% ipsilateral; mean 2.79 days after CAS) and stroke in 18 patients (72.2% ipsilateral; mean 6.72 days after CAS). The main independent clinical predictors of stroke/TIA identified by logistic regression were female sex (odds ratio [OR] 2.29, 95% CI 1.15-4.54) and diabetes (OR 3.29, 95% CI 1.71-6.40). Survival analysis showed that diabetic women, compared with the rest of the patients, had a higher number of events concentrated mainly in the first days after the intervention (p=0.003). CONCLUSION Cerebrovascular ischemic complications after CAS continue to be a challenge for the management of these patients. Although there are other factors, female sex and the presence of diabetes are emerging as strong risk factors for the development of complications after symptomatic CAS. CLINICAL IMPACT Carotid artery stenting (CAS) is an effective and minimally invasive method for the treatment of extracranial carotid artery stenosis. Although CAS has been regarded as a reliable and safety approach, some studies reported that CAS was associated with a higher risk of procedure-related stroke. Cerebrovascular complications after CAS continue to be a main problem and a challenge for the management of these patients. Therefore, it is essential to identify the factors involved in the development of these complications. Our study shows that the combination of female sex and diabetes is associated with a clearly worse outcome, with a greater number of events concentrated mainly in the first days. This is different from other studies that have explored each factor separately. It would be interesting to perform separate interventions for this group given the increased risk of complications.
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Affiliation(s)
- Soledad Pérez-Sánchez
- Department of Neurology, Hospital Universitario Virgen Macarena, Sevilla, Spain
- Neurovascular Research Group, Biomedicine Institute of Seville, IBiS/Hospital Virgen del Rocío/CSIC/University of Seville, Seville, Spain
| | - Ana Barragán Prieto
- Department of Neurology, Hospital Universitario Virgen Macarena, Sevilla, Spain
- Neurovascular Research Laboratory, Instituto de Biomedicina de Sevilla-IBiS, Sevilla, Spain
| | - Miguel Ángel Gamero García
- Department of Neurology, Hospital Universitario Virgen Macarena, Sevilla, Spain
- Neurovascular Research Laboratory, Instituto de Biomedicina de Sevilla-IBiS, Sevilla, Spain
| | - Francisco Moniche
- Neurovascular Research Laboratory, Instituto de Biomedicina de Sevilla-IBiS, Sevilla, Spain
- Department of Neurology, Hospital Universitario Virgen del Rocío, Sevilla, Spain
| | - Alejandro Tomasello
- Interventional Neuroradiology, Department of Radiology, Hospital Vall d'Hebron, Barcelona, Spain
| | - Fernando Delgado-Acosta
- Interventional Neuroradiology, Department of Radiology, Hospital Reina Sofía, Córdoba, Spain
| | - Alejandro González
- Neurovascular Research Laboratory, Instituto de Biomedicina de Sevilla-IBiS, Sevilla, Spain
- Interventional Neuroradiology, Department of Radiology, Hospital Universitario Virgen del Rocío, Sevilla, Spain
| | - Joan Montaner
- Department of Neurology, Hospital Universitario Virgen Macarena, Sevilla, Spain
- Neurovascular Research Laboratory, Instituto de Biomedicina de Sevilla-IBiS, Sevilla, Spain
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84
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Naylor R, Rantner B, Ancetti S, de Borst GJ, De Carlo M, Halliday A, Kakkos SK, Markus HS, McCabe DJH, Sillesen H, van den Berg JC, Vega de Ceniga M, Venermo MA, Vermassen FEG, Esvs Guidelines Committee, Antoniou GA, Bastos Goncalves F, Bjorck M, Chakfe N, Coscas R, Dias NV, Dick F, Hinchliffe RJ, Kolh P, Koncar IB, Lindholt JS, Mees BME, Resch TA, Trimarchi S, Tulamo R, Twine CP, Wanhainen A, Document Reviewers, Bellmunt-Montoya S, Bulbulia R, Darling RC, Eckstein HH, Giannoukas A, Koelemay MJW, Lindström D, Schermerhorn M, Stone DH. Editor's Choice - European Society for Vascular Surgery (ESVS) 2023 Clinical Practice Guidelines on the Management of Atherosclerotic Carotid and Vertebral Artery Disease. Eur J Vasc Endovasc Surg 2023; 65:7-111. [PMID: 35598721 DOI: 10.1016/j.ejvs.2022.04.011] [Citation(s) in RCA: 184] [Impact Index Per Article: 184.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2022] [Accepted: 04/20/2022] [Indexed: 01/17/2023]
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85
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Marnat G, Holay Q, Darcourt J, Desilles JP, Obadia M, Viguier A, Caroff J, Denier C, Papillon L, Barreau X, Cognard C, Berge J, Bourgeois-Beauvais Q, Landais A, Boulanger M, Macian F, Guillon B, Pico F, Lamy M, Robinet-Borgomano E, Richard S, Gory B, Sibon I, Gaillard N, Chausson N, Olindo S. Dual-layer carotid stenting for symptomatic carotid web: Results from the Caroweb study. J Neuroradiol 2022; 50:444-448. [PMID: 36563743 DOI: 10.1016/j.neurad.2022.12.005] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2022] [Revised: 12/16/2022] [Accepted: 12/16/2022] [Indexed: 12/24/2022]
Abstract
BACKGROUND & PURPOSE Carotid Web (CaW) is a growingly recognized cause of ischemic stroke, associated with a high recurrence risk. Several therapeutic strategies have been proposed as a tertiary prevention including carotid stenting, endarterectomy and antithrombotic medications. Among these, carotid stenting with dual-layer stent may be promising to adequately cover the focal arterial dysplasia. Our aim was to investigate the safety and efficacy of the Casper stent in the treatment of symptomatic CaW. METHODS We conducted a retrospective analysis of consecutive patients presenting with a symptomatic CaW and included in the ongoing prospective observational multicenter CAROWEB registry. The study period was January 2015 to December 2021. Inclusion criteria were CaW treated with dual-layer Casper stent. Patients treated with other types of carotid stent, endarterectomy or antithrombotic medication were excluded. Clinical and radiological initial data and outcomes were recorded. RESULTS twenty-seven patients (with 28 caw) were included. median age was 52 (iqr: 46-68). median delay between index cerebrovascular event and cervical stenting was 9 days (IQR: 6-101). In all cases, the cervical carotid stenting was successfully performed. No major perioperative complication was recorded. No recurrent stroke or transient ischemic attack was observed during a median follow-up time of 272 days (IQR: 114-635). Long-term imaging follow-up was available in 25/28 (89.3%) stented CaW with a median imaging follow-up of 183 days (IQR: 107-676; range: 90-1542). No in-stent occlusion or stenosis was detected. CONCLUSION In this study, carotid stenting with dual-layer Casper stent in the treatment of symptomatic CaW was effective regarding stroke recurrence prevention and safe, without procedural nor delayed detected adverse event. However, the optimal therapeutic approach of symptomatic CaW still needs to be explored through randomized trials.
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Affiliation(s)
- Gaultier Marnat
- Department of Interventional and Diagnostic Neuroradiology, Bordeaux University Hospital, Bordeaux, France
| | - Quentin Holay
- Department of Interventional Neuroradiology, Rothschild foundation hospital, Paris, France
| | - Jean Darcourt
- Department of Interventional and Diagnostic Neuroradiology, Toulouse University Hospital, Toulouse, France
| | - Jean-Philippe Desilles
- Department of Interventional Neuroradiology, Rothschild foundation hospital, Paris, France
| | - Michael Obadia
- Department of Neurology, Rothschild foundation hospital Paris, France
| | - Alain Viguier
- Department of Neurology, Toulouse University Hospital, Toulouse, France
| | - Jildaz Caroff
- Department of Interventional Neuroradiology, CHU Bicêtre APHP, Kremlin Bicêtre, France
| | - Christian Denier
- Department of Neurology, CHU Kremlin Bicêtre, Kremlin Bicêtre, France
| | - Lisa Papillon
- Department of Neurology, Stroke Unit, Bordeaux University Hospital, Bordeaux, France
| | - Xavier Barreau
- Department of Interventional and Diagnostic Neuroradiology, Bordeaux University Hospital, Bordeaux, France
| | - Christophe Cognard
- Department of Interventional and Diagnostic Neuroradiology, Toulouse University Hospital, Toulouse, France
| | - Jerome Berge
- Department of Interventional and Diagnostic Neuroradiology, Bordeaux University Hospital, Bordeaux, France
| | | | - Anne Landais
- Department of Neurology, Point à Pitre Hospital, Pointe à Pitre, France
| | - Marion Boulanger
- Department of Neurology, Caen University Hospital, Caen, University Caen Normandy, France
| | - Francisco Macian
- Department of Neurology, Limoges University Hospital, Limoges, France
| | - Benoit Guillon
- Department of Neurology, Nantes University Hospital, Nantes, France
| | - Fernando Pico
- Department of Neurology, Versailles Hospital, Le Chesnay, France
| | - Mathias Lamy
- Department of Neurology, Poitiers University Hospital, Poitiers, France
| | | | - Sébastien Richard
- Neurology Department, Nancy University Hospital, Nancy, France - INSERM U1116, Nancy, France
| | - Benjamin Gory
- France Department of Interventional and Diagnostic Neuroradiology, Nancy University Hospital, Nancy, France
| | - Igor Sibon
- Department of Neurology, Martinique University Hospital, Fort-de-France, France
| | - Nicolas Gaillard
- Department of Neurology, Montpellier University Hospital, Montpellier, France
| | - Nicolas Chausson
- Department of Neurology, Sud Francilien Hospital, Corbeil-Essonnes, France
| | - Stephane Olindo
- Department of Neurology, Martinique University Hospital, Fort-de-France, France
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Pineau S, Fajardo A, Saqib NU, Tanaka A, Motaganahalli RL, Keyhani A, Keyhani K, Wang KS. Transcarotid Revascularization Timing and Early Postoperative Outcomes in Symptomatic Patients. Vasc Endovascular Surg 2022; 57:344-349. [PMID: 36533891 DOI: 10.1177/15385744221146678] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
Objective Carotid endarterectomy (CEA) performed several days after onset of symptoms has been shown to be optimal in preventing procedure-related stroke. Transcarotid artery revascularization (TCAR) is an alternative hybrid procedure to treat high-risk for CEA patients. In this investigation, our aim is to determine the effect of timing of TCAR in symptomatic patients. Methods Procedures were captured prospectively at 2 independent health systems from 2016-2022 within a carotid intervention database. A retrospective analysis of this database was performed to generate cohorts by time to revascularization from onset of symptoms, with the short-interval revascularization (SIR) group defined as having a time to revascularization between 2-5 days; and long-interval revascularization (LIR) group having a time to revascularization of 6-180 days. Univariate analysis was performed comparing the cohorts at an α of .05. Results During the study period, 875 TCARs were captured, including 321 procedures performed in symptomatic patients. Of these, 84 had revascularization performed within 6 days after onset of symptoms (SIR) while 237 additional cases were completed 6 or more days after onset of symptoms (LIR). Baseline comorbidities were grossly similar between cohorts. Intraoperatively, SIR patients were less likely to develop bradycardia (4.8% vs 22.2%, P = .01) and experienced a shorter operative time (58 minutes vs 65 minutes, P = .02). Estimated blood loss, flow reversal time, radiation exposure, fluoroscopic time and contrast volume were identical between the groups. Length of stay in SIR patients was longer (1, IQR [1-3] vs 1, IQR [1-2] days, P < .01). Additionally, SIR patients seemed to trend toward a higher rate of reinterventions (3.6% vs .4%, P = .06). The incidence of ipsilateral or contralateral stroke, cranial nerve palsy, myocardial infarction, hematoma, stent thrombosis and death were statistically identical between the 2 groups. Conclusion Like the previous results established for CEA, symptomatic patients undergoing TCAR demonstrate similar outcomes if the procedure is performed 48 hours after the neurologic event.
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Affiliation(s)
- Sylvestre Pineau
- Division of Vascular Surgery, Department of Cardiothoracic and Vascular Surgery, McGovern Medical School at The University of Texas Health Science Center at Houston (UTHealth), Houston, TX, USA
| | - Andres Fajardo
- Division of Vascular Surgery, Department of Surgery, Indiana University School of Medicine, Indianapolis, IN, USA
| | | | - Akiko Tanaka
- Division of Vascular Surgery, Department of Cardiothoracic and Vascular Surgery, McGovern Medical School at The University of Texas Health Science Center at Houston (UTHealth), Houston, TX, USA
| | - Raghu L. Motaganahalli
- Division of Vascular Surgery, Department of Surgery, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Arash Keyhani
- Division of Vascular Surgery, Department of Cardiothoracic and Vascular Surgery, McGovern Medical School at The University of Texas Health Science Center at Houston (UTHealth), Houston, TX, USA
| | - Kourosh Keyhani
- Division of Vascular Surgery, Department of Cardiothoracic and Vascular Surgery, McGovern Medical School at The University of Texas Health Science Center at Houston (UTHealth), Houston, TX, USA
| | - Keisin S. Wang
- Division of Vascular Surgery, Department of Cardiothoracic and Vascular Surgery, McGovern Medical School at The University of Texas Health Science Center at Houston (UTHealth), Houston, TX, USA
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microRNAs Associated with Carotid Plaque Development and Vulnerability: The Clinician's Perspective. Int J Mol Sci 2022; 23:ijms232415645. [PMID: 36555285 PMCID: PMC9779323 DOI: 10.3390/ijms232415645] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2022] [Accepted: 12/07/2022] [Indexed: 12/14/2022] Open
Abstract
Ischemic stroke (IS) related to atherosclerosis of large arteries is one of the leading causes of mortality and disability in developed countries. Atherosclerotic internal carotid artery stenosis (ICAS) contributes to 20% of all cerebral ischemia cases. Nowadays, atherosclerosis prevention and treatment measures aim at controlling the atherosclerosis risk factors, or at the interventional (surgical or endovascular) management of mature occlusive lesions. There is a definite lack of the established circulating biomarkers which, once modulated, could prevent development of atherosclerosis, and consequently prevent the carotid-artery-related IS. Recent studies emphasize that microRNA (miRNA) are the emerging particles that could potentially play a pivotal role in this approach. There are some research studies on the association between the expression of small non-coding microRNAs with a carotid plaque development and vulnerability. However, the data remain inconsistent. In addition, all major studies on carotid atherosclerotic plaque were conducted on cell culture or animal models; very few were conducted on humans, whereas the accumulating evidence demonstrates that it cannot be automatically extrapolated to processes in humans. Therefore, this paper aims to review the current knowledge on how miRNA participate in the process of carotid plaque formation and rupture, as well as stroke occurrence. We discuss potential target miRNA that could be used as a prognostic or therapeutic tool.
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88
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Hu X, Hu Y, Sun X, Li Y, Zhu Y. Effect of aspirin in patients with established asymptomatic carotid atherosclerosis: A systematic review and meta-analysis. Front Pharmacol 2022; 13:1041400. [PMID: 36569309 PMCID: PMC9768439 DOI: 10.3389/fphar.2022.1041400] [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] [Received: 09/10/2022] [Accepted: 11/24/2022] [Indexed: 12/12/2022] Open
Abstract
Background: Aspirin is widely used as an antiplatelet agent for secondary prevention in patients with atherosclerotic cardiovascular disease. However, it remains unclear whether aspirin can prevent the progression of carotid atherosclerosis or reduce vascular events and all-cause death. Methods: We performed a meta-analysis of the effect of aspirin in asymptomatic carotid atherosclerotic patients. Electronic databases including Pubmed, EMBase, ISI Web, Medline, Cochrane, and clinicaltrial.gov were searched for relevant randomized controlled trials. A total of five studies (841 individuals, 2,145 person-years) were included in this study. Two reviewers independently performed the study assessment and data extraction. Forest plots were used to assess the efficacy of aspirin. Egger's test was used to evaluate publication bias. Results: Aspirin did not alleviate the progression of carotid intima-media thickness (cIMT) compared with control patients (WMD: -0.05 mm, 95% confidence interval 95%CI: -0.12, 0.03). In subset analysis, aspirin was only associated with regression of cIMT when compared with the empty/placebo group (WMD: -0.10 mm, 95%CI: -0.18, -0.02). In type 2 diabetes mellitus, there were no statistical significance between groups (WMD: 0.10 mm, 95%CI: -0.31, 0.50). For the main vascular events and all-cause death, there were no differences between the aspirin group (RR: 0.73, 95%CI: 0.41, 1.31) and the control group (RR: 0.88, 95%CI: 0.41, 1.90). For outcome events, similar results were observed when patients were classified by different cIMT value (p > 0.05). The risk of gastrointestinal bleeding was similar between participants receiving and not receiving aspirin therapy (RR: 1.04, 95%CI: 0.07, 16.46). Conclusion: In patients with asymptomatic carotid atherosclerosis, low-dose aspirin may slightly alleviate the progression of cIMT, but does not reduce vascular events and all-cause death. Systematic Review Registration: https://www.crd.york.ac.uk/PROSPERO/, identifier PROSPERO.
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Affiliation(s)
- Xianjin Hu
- Department of Cardiology, West China Hospital, Sichuan University, Chengdu, China
| | - Yao Hu
- Department of Traditional Chinese Medicine, Xiang He Community Healthcare Center, Chengdu, Sichuan, China
| | - Xiankun Sun
- Department of Nephrology, West China Hospital, Sichuan University, Chengdu, China
| | - Ying Li
- Department of Cardiology, West China Fourth Hospital, Sichuan University, Chengdu, China
| | - Ye Zhu
- Department of Cardiology, West China Hospital, Sichuan University, Chengdu, China,*Correspondence: Ye Zhu,
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Dzierwa K, Knapik M, Tekieli Ł, Mazurek A, Urbańczyk-Zawadzka M, Klecha A, Kowalczyk T, Koźmik T, Wiewiórka Ł, Banyś P, Węglarz E, Stefaniak J, Nizankowski RT, Grunwald IQ, Musiałek P. Clinical Outcomes of Extracranial Carotid Artery-Related Stroke Eligible for Mechanical Reperfusion on Top of Per-Guidelines Thrombolytic Therapy: Analysis from a 6-Month Consecutive Patient Sample in 2 Centers. Med Sci Monit 2022; 28:e938549. [PMID: 36451526 PMCID: PMC9724447 DOI: 10.12659/msm.938549] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2022] [Accepted: 10/24/2022] [Indexed: 06/20/2024] Open
Abstract
BACKGROUND Systemic intravenous thrombolysis and mechanical thrombectomy (MT) are guideline-recommended reperfusion therapies in large-vessel-occlusion ischemic stroke. However, for acute ischemic stroke of extracranial carotid artery origin (AIS-CA) there have been no specific trials, resulting in a data gap. MATERIAL AND METHODS We evaluated referral/treatment pathways, serial imaging, and neurologic 90-day outcomes in consecutive patients, presenting in a real-life series in 2 stroke centers over a period of 6 months, with AIS-CA eligible for emergency mechanical reperfusion (EMR) on top of thrombolysis as per guideline criteria. RESULTS Of 30 EMR-eligible patients (33.3% in-window for thrombolysis and thrombolysed, 73.3% male, age 39-87 years, median Alberta Stroke Program Early Computed Tomography Score (ASPECTS) 10, pre-stroke mRS 0-1 in all, tandem lesions 26.7%), 20 (66.7%) were EMR-referred (60% - endovascular, 6.7% - surgery referrals). Only 40% received EMR, nearly exclusively in stroke centers with carotid artery stenting (CAS) expertise (100% eligible patient acceptance rate, 100% treatment delivery involving CAS±MT with culprit lesion sequestration using micronet-covered stents). The emergency surgery rate was 0%. Baseline clinical and imaging characteristics did not differ between EMR-treated and EMR-untreated patients. Ninety-day neurologic status was profoundly better in EMR-treated patients: mRS 0-2 (91.7% vs 0%; P<0.001); mRS 3-5 (8.3% vs 88.9%; P<0.001), mRS 6 (0% vs 11.1%; P<0.001). CONCLUSIONS In a real-life AIS-CA setting, the referral rate of EMR-eligible patients for EMR was low, and the treatment rate was even lower. AIS-CA revascularization was delivered predominantly in stroke thrombectomy-capable cardioangiology centers, resulting in overwhelmingly superior patient outcome. Large vessel occlusion stroke referral and management pathways should involve centers with proximal-protected CAS expertise. AIS-CA, irrespective of any thrombolysis administration, is a hyperacute cerebral emergency and EMR-eligible patients should be immediately referred for mechanical reperfusion.
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Affiliation(s)
- Karolina Dzierwa
- Cardiovascular Imaging Laboratory, John Paul II Hospital, Cracow, Poland
- Thrombectomy-Capable Stroke Centre, John Paul II Hospital, Cracow, Poland
| | - Magdalena Knapik
- Thrombectomy-Capable Stroke Centre, John Paul II Hospital, Cracow, Poland
- Jagiellonian University Department of Cardiac and Vascular Diseases, John Paul II Hospital, Cracow, Poland
- Department of Radiology, Podhalanski Multispecialty Regional Hospital, Nowy Targ, Poland
| | - Łukasz Tekieli
- Thrombectomy-Capable Stroke Centre, John Paul II Hospital, Cracow, Poland
- Jagiellonian University Department of Cardiac and Vascular Diseases, John Paul II Hospital, Cracow, Poland
- Jagiellonian University Department of of Interventional Cardiology, John Paul II Hospital, Cracow, Poland
| | - Adam Mazurek
- Thrombectomy-Capable Stroke Centre, John Paul II Hospital, Cracow, Poland
- Jagiellonian University Department of Cardiac and Vascular Diseases, John Paul II Hospital, Cracow, Poland
| | - Małgorzata Urbańczyk-Zawadzka
- Thrombectomy-Capable Stroke Centre, John Paul II Hospital, Cracow, Poland
- Department of of Radiology, John Paul II Hospital, Cracow, Poland
| | - Artur Klecha
- Department of of Cardiology, Podhalanski Multispecialty Regional Hospital, Nowy Targ, Poland
| | - Tomasz Kowalczyk
- Department of of Cardiology, Podhalanski Multispecialty Regional Hospital, Nowy Targ, Poland
| | - Teresa Koźmik
- Department of of Cardiology, Podhalanski Multispecialty Regional Hospital, Nowy Targ, Poland
| | - Łukasz Wiewiórka
- Thrombectomy-Capable Stroke Centre, John Paul II Hospital, Cracow, Poland
- Jagiellonian University Department of of Interventional Cardiology, John Paul II Hospital, Cracow, Poland
- Department of of Radiology, John Paul II Hospital, Cracow, Poland
- Department of of Cardiology, Podhalanski Multispecialty Regional Hospital, Nowy Targ, Poland
| | - Paweł Banyś
- Department of of Radiology, John Paul II Hospital, Cracow, Poland
| | - Ewa Węglarz
- Thrombectomy-Capable Stroke Centre, John Paul II Hospital, Cracow, Poland
- Jagiellonian University Department of of Interventional Cardiology, John Paul II Hospital, Cracow, Poland
| | - Justyna Stefaniak
- Department of of Bioinformatics and Telemedicine, Jagiellonian University Medical College, Cracow, Poland
| | - Rafał T. Nizankowski
- Accreditation Council, National Centre for Healthcare Quality Assessment, Cracow, Poland
| | - Iris Q. Grunwald
- University of Dundee Chair of Neuroradiology and Department of Radiology, Ninewells Hospital, Dundee, Scotland, United Kingdom
- Division of Imaging Science and Technology, School of Medicine, University of Dundee, Dundee, Scotland, United Kingdom
| | - Piotr Musiałek
- Thrombectomy-Capable Stroke Centre, John Paul II Hospital, Cracow, Poland
- Jagiellonian University Department of Cardiac and Vascular Diseases, John Paul II Hospital, Cracow, Poland
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Solomon Y, Rastogi V, Marcaccio CL, Patel PB, Wang GJ, Malas MB, Motaganahalli RL, Nolan BW, Verhagen HJM, de Borst GJ, Schermerhorn ML. Outcomes after transcarotid artery revascularization stratified by preprocedural symptom status. J Vasc Surg 2022; 76:1307-1315.e1. [PMID: 35798281 PMCID: PMC9613587 DOI: 10.1016/j.jvs.2022.05.024] [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: 02/18/2022] [Revised: 04/14/2022] [Accepted: 05/09/2022] [Indexed: 10/31/2022]
Abstract
OBJECTIVE Previous studies on carotid endarterectomy and transfemoral carotid artery stenting demonstrated that perioperative outcomes differed according to preoperative neurologic injury severity, but this has not been assessed in transcarotid artery revascularization (TCAR). In this study, we examined contemporary perioperative outcomes in patients who underwent TCAR stratified by specific preprocedural symptom status. METHODS Patients who underwent TCAR between 2016 and 2021 in the Vascular Quality Initiative were included. We stratified patients into the following groups based on preprocedural symptoms: asymptomatic, recent (symptoms occurring <180 days before TCAR) ocular transient ischemic attack (TIA), recent hemispheric TIA, recent stroke, or formerly symptomatic (symptoms occurring >180 days before TCAR). First, we used trend tests to assess outcomes in asymptomatic patients versus those with an increasing severity of recent neurologic injury (recent ocular TIA vs recent hemispheric TIA vs recent stroke). Then, we compared outcomes between asymptomatic and formerly symptomatic patients. Our primary outcome was in-hospital stroke/death rates. Multivariable logistic regression was used to adjust for demographics and comorbidities across groups. RESULTS We identified 18,477 patients undergoing TCAR, of whom 62.0% were asymptomatic, 3.2% had a recent ocular TIA, 7.6a % had recent hemispheric TIA, 18.0% had a recent stroke, and 9.2% were formerly symptomatic. In patients with recent symptoms, we observed higher rates of stroke/death with increasing neurologic injury severity: asymptomatic 1.1% versus recent ocular TIA 0.8% versus recent hemispheric TIA 2.1% versus recent stroke 3.1% (Ptrend < .01). In formerly symptomatic patients, the rate of stroke/death was higher compared with asymptomatic patients, but this difference was not statistically significant (1.7% vs 1.1%; P = .06). After risk adjustment, compared with asymptomatic patients, there was a higher odds of stroke/death in patients with a recent stroke (odds ratio [OR], 2.8; 95% confidence interval [CI], 2.1-3.7; P < .01), a recent hemispheric TIA (OR, 2.0; 95% CI, 1.3-3.0; P < .01), and former symptoms (OR, 1.6; 95% CI, 1.1-2.5; P = .02), but there was no difference in stroke/death rates in patients with a recent ocular TIA (OR, 0.9; 95% CI, 0.4-2.2; P = .78). CONCLUSIONS After TCAR, compared with asymptomatic status, a recent stroke and a recent hemispheric TIA were associated with higher stroke/death rates, whereas a recent ocular TIA was associated with similar stroke/death rates. In addition, a formerly symptomatic status was associated with higher stroke/death rates compared with an asymptomatic status. Overall, our findings suggest that classifying patients undergoing TCAR as symptomatic versus asymptomatic may be an oversimplification and that patients' specific preoperative neurologic symptoms should instead be used in risk assessment and outcome reporting for TCAR.
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Affiliation(s)
- Yoel Solomon
- Department of Surgery, Division of Vascular and Endovascular Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA; Department of Vascular Surgery, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Vinamr Rastogi
- Department of Surgery, Division of Vascular and Endovascular Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA; Department of Vascular Surgery, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Christina L Marcaccio
- Department of Surgery, Division of Vascular and Endovascular Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA
| | - Priya B Patel
- Department of Surgery, Division of Vascular and Endovascular Surgery, 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
| | - Mahmoud B Malas
- Division of Vascular and Endovascular Surgery, Department of Surgery, University of California San Diego Health System, San Diego, CA
| | - Raghu L Motaganahalli
- Division of Vascular Surgery, Department of Surgery, Indiana University School of Medicine, Indianapolis, IN
| | - Brian W Nolan
- Division of Vascular and Endovascular Therapy, Department of Surgery, Maine Medical Center, Portland, ME
| | - Hence J M Verhagen
- Department of Vascular Surgery, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Gert J de Borst
- Department of Vascular Surgery, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Marc L Schermerhorn
- Department of Surgery, Division of Vascular and Endovascular Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA.
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Lo WC, Chang CM, Cheng PC, Wen MH, Wang CT, Cheng PW, Liao LJ. The Applications and Potential Developments of Ultrasound in Oral Cancer Management. Technol Cancer Res Treat 2022; 21:15330338221133216. [PMID: 36254559 PMCID: PMC9580086 DOI: 10.1177/15330338221133216] [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] [Indexed: 11/23/2022] Open
Abstract
Oral cancer is endemic and causes a great burden in Southern Asia. It is preferably treated by surgery with/without adjuvant radiotherapy (RT) or chemoradiation therapy, depending on the stage of the disease. Close or positive resection margin and cervical lymph node (LN) metastasis are important prognostic factors that have been presented to be related to undesirable locoregional recurrence and poor survival. Ultrasound (US) is a simple, noninvasive, time-saving, and inexpensive diagnostic modality. It can depict soft tissues very clearly without the risk of radiation exposure. Additionally, it is real-time and continuous image is demonstrated during the exam. Furthermore, the clinician can perform US-guided fine needle aspiration (FNA) or core needle biopsy (CNB) at the same time. US with/without US-guided FNA/CNB is reported to be of value in determining tumor thickness (TT), depth of invasion (DOI), and cervical LN metastasis, and in aiding the staging of oral cancer. DOI has a relevant prognostic value as reported in the eighth edition of the American Joint Committee on Cancer staging of oral cancer. In the present review, we describe the clinical applications of US in oral cancer management in different phases and potential applications in the future. In the pretreatment and surgical phase, US can be used to evaluate TT/DOI and surgical margins of oral cancer in vivo and ex vivo. The prediction of a malignant cervical LN (nodal metastasis) by the US-based prediction model can guide the necessity of FNA/CNB and elective neck dissection in clinical early-stage oral cancer. In the posttreatment surveillance phase, US with/without US-guided FNA or CNB is helpful in the detection of nodal persistence or LN recurrence, and can assess the possibility and extent of carotid artery stenosis after irradiation therapy. Both US elastography and US swallowing assessment are potentially helpful to the management of oral cancer.
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Affiliation(s)
- Wu-Chia Lo
- Department of Otolaryngology Head and Neck Surgery, Far Eastern Memorial Hospital, Taipei,Graduate Institute of Medicine, Yuan Ze University, Taoyuan,Head and Neck Cancer Surveillance and Research Study Group, Far Eastern Memorial Hospital, New Taipei City
| | - Chih-Ming Chang
- Department of Otolaryngology Head and Neck Surgery, Far Eastern Memorial Hospital, Taipei,Department of Biomedical Engineering, National Yang-Ming University, Taipei
| | - Ping-Chia Cheng
- Department of Otolaryngology Head and Neck Surgery, Far Eastern Memorial Hospital, Taipei,Head and Neck Cancer Surveillance and Research Study Group, Far Eastern Memorial Hospital, New Taipei City,Department of Biomedical Engineering, National Yang-Ming University, Taipei,Department of Communication Engineering, Asia Eastern University of Science and Technology, New Taipei City
| | - Ming-Hsun Wen
- Department of Otolaryngology Head and Neck Surgery, Far Eastern Memorial Hospital, Taipei
| | - Chi-Te Wang
- Department of Otolaryngology Head and Neck Surgery, Far Eastern Memorial Hospital, Taipei,Department of Electrical Engineering, Yuan Ze University, Taoyuan
| | - Po-Wen Cheng
- Department of Otolaryngology Head and Neck Surgery, Far Eastern Memorial Hospital, Taipei
| | - Li-Jen Liao
- Department of Otolaryngology Head and Neck Surgery, Far Eastern Memorial Hospital, Taipei,Head and Neck Cancer Surveillance and Research Study Group, Far Eastern Memorial Hospital, New Taipei City,Department of Electrical Engineering, Yuan Ze University, Taoyuan,Li-Jen Liao, MD, PhD, Department of Otolaryngology, Far Eastern Memorial Hospital, 21, Section 2, Nan-Ya South Road, Banqiao, New Taipei 22061.
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Reiff T, Eckstein HH, Mansmann U, Jansen O, Fraedrich G, Mudra H, Böckler D, Böhm M, Debus ES, Fiehler J, Mathias K, Ringelstein EB, Schmidli J, Stingele R, Zahn R, Zeller T, Niesen WD, Barlinn K, Binder A, Glahn J, Hacke W, Ringleb PA, Macharzina RR, Lechner G, Menz C, Schonhardt S, Weinbeck M, Greb O, Otto D, Winker T, Berger H, Poppert H, Kühnl A, Pütz V, Haase K, Bodechtel U, Weiss N, Bergert H, Meyne J, Groß J, Kruse M, Gerdes B, Reinbold WD, Wuttig H, Maier-Hasselmann A, Segerer M, Fuchs HH, Gass S, Groden C, Niedergethmann M, Griebe M, Rosenkranz M, Beck J, Thomalla G, Zeumer HH, Jauß M, Kneist W, Kneist M, Staudacher T, Bernhard A, Jost P, Prey N, Knippschild J, Kastrup O, Köhrmann M, Frank B, Bongers V, Hoffmann J, Kniemeyer HW, Knauth M, Wasser K, Stojanovic T, Emmert H, Tacke J, Schwalbe B, Nam EM, van Lengerich U, Lowens S, Gröschel K, Uphaus T, Gröschel S, Boor S, Dorweiler B, Schmid E, Henkes H, Hupp T, Singer O, Hamann G, Wagner-Heck M, Kerth-Krick S, Kilic M, Huppert P, Niederkorn K, Fruhwirth J, Klein G, Pulkowski U, Jöster K, Wacks JH, Kloppmann E, Vatankhah B, Hopf-Jensen S, Stolze H, Müller-Hülsbeck S, Walluscheck KP, Schmitt HM, Grüger A, Seemann J, Tilahun B, Dichgans M, Wollenweber FA, Dörr A, Zollver A, Gäbel G, Hedtmann G, Kollmar R, Claus D, Petermann C, Kirsch S, Bosnjak B, Heiß J, Mühling H, Wunderlich S, Sabisch PN, Gahn G, Storck M, Arnold S, Fischer U, Gralla J, von Mering M, Dißmann R, Kirsch D, Schmidauer C, Waldenberger P, Furtner M, Kazarians H, Breuer P, Arning C, Rieper J, Schmidt G, Arnold M, Schroth G, Weise J, Zanow J, Mayer T, Töpper R, Gross-Fengels W, Daum H, Dittrich R, Ritter M, Kasprzak B, Torsello G, Pohlmann C, Brüning R, Breuer P, Crispin A, Hofmann M, Müller T, Blessing E, Möhlenbruch M, Ludwig I, Amiri H. Carotid endarterectomy or stenting or best medical treatment alone for moderate-to-severe asymptomatic carotid artery stenosis: 5-year results of a multicentre, randomised controlled trial. Lancet Neurol 2022; 21:877-888. [PMID: 36115360 DOI: 10.1016/s1474-4422(22)00290-3] [Citation(s) in RCA: 31] [Impact Index Per Article: 15.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2022] [Revised: 06/28/2022] [Accepted: 06/30/2022] [Indexed: 10/14/2022]
Abstract
BACKGROUND The optimal treatment for patients with asymptomatic carotid artery stenosis is under debate. Since best medical treatment (BMT) has improved over time, the benefit of carotid endarterectomy (CEA) or carotid artery stenting (CAS) is unclear. Randomised data comparing the effect of CEA and CAS versus BMT alone are absent. We aimed to directly compare CEA plus BMT with CAS plus BMT and both with BMT only. METHODS SPACE-2 was a multicentre, randomised, controlled trial at 36 study centres in Austria, Germany, and Switzerland. We enrolled participants aged 50-85 years with asymptomatic carotid artery stenosis at the distal common carotid artery or the extracranial internal carotid artery of at least 70%, according to European Carotid Surgery Trial criteria. Initially designed as a three-arm trial including one group for BMT alone (with a randomised allocation ratio of 2·9:2·9:1), the SPACE-2 study design was amended (due to slow recruitment) to become two substudies with two arms each comparing CEA plus BMT with BMT alone (SPACE-2a) and CAS plus BMT with BMT alone (SPACE-2b); in each case in a 1:1 randomisation. Participants and clinicians were not masked to allocation. The primary efficacy endpoint was the cumulative incidence of any stroke or death from any cause within 30 days or any ipsilateral ischaemic stroke within 5 years. The primary safety endpoint was any stroke or death from any cause within 30 days after CEA or CAS. The primary analysis was by intention-to treat, which included all randomly assigned patients in SPACE-2, SPACE-2a, and SPACE-2b, analysed using meta-analysis of individual patient data. We did two-step hierarchical testing to first show superiority of CEA and CAS to BMT alone then to assess non-inferiority of CAS to CEA. Originally, we planned to recruit 3640 patients; however, the study had to be stopped prematurely due to insufficient recruitment. This report presents the primary analysis at 5-year follow-up. This trial is registered with ISRCTN, number ISRCTN78592017. FINDINGS 513 patients across SPACE-2, SPACE-2a, and SPACE-2b were recruited and surveyed between July 9, 2009, and Dec 12, 2019, of whom 203 (40%) were allocated to CEA plus BMT, 197 (38%) to CAS plus BMT, and 113 (22%) to BMT alone. Median follow-up was 59·9 months (IQR 46·6-60·0). The cumulative incidence of any stroke or death from any cause within 30 days or any ipsilateral ischaemic stroke within 5 years (primary efficacy endpoint) was 2·5% (95% CI 1·0-5·8) with CEA plus BMT, 4·4% (2·2-8·6) with CAS plus BMT, and 3·1% (1·0-9·4) with BMT alone. Cox proportional-hazard testing showed no difference in risk for the primary efficacy endpoint for CEA plus BMT versus BMT alone (hazard ratio [HR] 0·93, 95% CI 0·22-3·91; p=0·93) or for CAS plus BMT versus BMT alone (1·55, 0·41-5·85; p=0·52). Superiority of CEA or CAS to BMT was not shown, therefore non-inferiority testing was not done. In both the CEA group and the CAS group, five strokes and no deaths occurred in the 30-day period after the procedure. During the 5-year follow-up period, three ipsilateral strokes occurred in both the CAS plus BMT and BMT alone group, with none in the CEA plus BMT group. INTERPRETATION CEA plus BMT or CAS plus BMT were not found to be superior to BMT alone regarding risk of any stroke or death within 30 days or ipsilateral stroke during the 5-year observation period. Because of the small sample size, results should be interpreted with caution. FUNDING German Federal Ministry of Education and Research (BMBF) and German Research Foundation (DFG).
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Affiliation(s)
- Tilman Reiff
- Department of Neurology, University Hospital of Heidelberg, Heidelberg, Germany.
| | - Hans-Henning Eckstein
- Department for Vascular and Endovascular Surgery, Klinikum rechts der Isar, Technical University of Munich, Munich, Germany
| | - Ulrich Mansmann
- Institute of Medical Informatics, Biometry and Epidemiology, Ludwig-Maximilians-Universität München, Munich, Germany
| | - Olav Jansen
- Department of Radiology and Neuroradiology, UKSH Campus Kiel, Kiel, Germany
| | - Gustav Fraedrich
- Department of Vascular Surgery, University Hospital of Innsbruck, Innsbruck, Austria
| | - Harald Mudra
- Department of Cardiology, München Klinik, Klinikum Neuperlach, Munich, Germany
| | - Dittmar Böckler
- Department of Vascular and Endovascular Surgery, University Hospital of Heidelberg, Heidelberg, Germany
| | - Michael Böhm
- Department of Internal Medicine, University Hospital of Homburg/Saar, Homburg, Germany
| | - E Sebastian Debus
- Department of Vascular Surgery, University Hospital of Hamburg, Hamburg, Germany
| | - Jens Fiehler
- Department of Neuroradiology, University Hospital of Hamburg, Hamburg, Germany
| | - Klaus Mathias
- Department of Radiology, Klinikum Dortmund, Dortmund, Germany
| | | | - Jürg Schmidli
- Department of Vascular Surgery, University Hospital of Bern, Bern, Switzerland
| | - Robert Stingele
- Department of Neurology, DRK-Kliniken Berlin, Berlin, Germany
| | - Ralf Zahn
- Department of Internal Medicine, Klinikum Ludwigshafen, Ludwigshafen, Germany
| | - Thomas Zeller
- Department of Angiology, University Heart-Center Freiburg-Bad Krozingen, Bad Krozingen, Germany
| | - Wolf-Dirk Niesen
- Department of Neurology, University Hospital Freiburg, Freiburg, Germany
| | - Kristian Barlinn
- Department of Neurology, University Hospital of Dresden, Dresden, Germany
| | - Andreas Binder
- Department of Neurology, UKSH Campus Kiel, Kiel, Germany
| | - Jörg Glahn
- Department of Neurology, Johannes Wesling Klinikum, Minden, Germany
| | - Werner Hacke
- Department of Neurology, University Hospital of Heidelberg, Heidelberg, Germany
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Shaffi M, Saad N, Arnold J, Parker G, Nguyen D, Eftekhar B. An Ocular Chameleon. Neurohospitalist 2022; 12:672-675. [PMID: 36147764 PMCID: PMC9485686 DOI: 10.1177/19418744221111251] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/16/2023] Open
Abstract
Patients presenting with transient visual loss is common in emergency departments. Neurologists, ophthalmologists and emergency care physicians may be called upon to evaluate such patients. Monocular visual loss should be differentiated from the binocular involvement as the oetologies, investigations and management of such patients differ considerably. We report a case of monocular visual loss that involved predominantly one eye but affected the other side independently, albeit less frequently. A meticulous history, thorough general, neurological and ophthalmological examinations are necessary in such patients to identify the cause and to treat appropriately. Ocular ischemic syndrome (OIS) is due to chronic hypoperfusion of the structures supplied by ophthalmic artery leading to monocular visual loss. Stenosis of the ipsilateral internal carotid artery from a variety of causes is the main underlying mechanism. The first case of OIS was reported by Hedges in 1963 and the term was coined later by Barry and Magargal. Ocular ischemic syndrome is an important differential diagnosis to consider especially in older people and those with vascular risk factors. An overview of important differential diagnosis, clinical features and treatment of OIC are discussed in this article. A multidisciplinary team is optimal for the management of ocular ischemic syndrome.
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Affiliation(s)
- Mohamed Shaffi
- Department of Medicine, University of Notre Dame, Sydney, NSW, Australia
| | - Nick Saad
- Department of Ophthalmology, Marsden Eye Specialists, Parramatta, NSW, Australia
| | - Jennifer Arnold
- Department of Ophthalmology, Marsden Eye Specialists, Parramatta, NSW, Australia
| | - Geoffrey Parker
- Department of Radiology, Macquarie University Hospital, North Ryde, NSW, Australia
| | - Daniel Nguyen
- Department of Surgery, Macquarie University Hospital, North Ryde, NSW, Australia
| | - Behzad Eftekhar
- Department of Neurosurgery, The University of Sydney, Sydney, NSW, Australia
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94
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Wang J, Bai X, Wang T, Dmytriw AA, Patel AB, Jiao L. Carotid Stenting Versus Endarterectomy for Asymptomatic Carotid Artery Stenosis: A Systematic Review and Meta-Analysis. Stroke 2022; 53:3047-3054. [PMID: 35730457 DOI: 10.1161/strokeaha.122.038994] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND To compare safety and efficacy between carotid artery stenting (CAS) and carotid endarterectomy (CEA) in treating asymptomatic carotid artery stenosis based on results from randomized controlled trials. METHODS Randomized controlled trials comparing CAS and CEA in treating asymptomatic carotid artery stenosis were searched from databases of the EMBASE, PubMed, MEDLINE, and Cochrane libraries. Two independent reviewers identified eligible studies, extracted relevant data, and used the Cochrane risk of bias tool to assess quality. Mantel-Haenszel method random-effects models were used to estimate odds ratio (OR) regarding perioperative risks between CAS and CEA. Kaplan-Meier curve data were extracted and analyzed through Exp[(O-E)/Var] fixed-effect models to calculate the Peto odds ratio (OR) regarding long-term outcomes. RESULTS Sixteen articles from 7 randomized controlled trials were included, reporting relevant outcomes for 7230 asymptomatic carotid artery stenosis patients (CAS: n=3920; CEA: n=3198). Compared with the CEA group, CAS group had no difference in perioperative composite end point events including stroke, death, and myocardial infarction (MI; OR, 1.13 [95% CI, 0.87-1.47]; P=0.37, I2=0%). Compared with CEA, CAS had a higher risk of any stroke during the perioperative period (OR, 1.62 [95% CI, 1.16-2.24]; P=0.004, I2=0%) and an increased risk of nondisabling stroke (OR, 1.81 [95% CI, 1.23-2.65]; P=0.003, I2=0%), but there was no significant difference in disabling stroke and death between groups (OR, 0.91 [95% CI, 0.50-1.65]; P=0.76, I2=0%). For long-term outcomes, no difference regarding the composite outcome of any stroke, death, and myocardial infarction existed between CEA and CAS (Peto OR, 1.18 [95% CI, 0.94-1.48]; P=0.14, I2=0%). Individual-level patient data would be important to verify the long-term outcome results. CONCLUSIONS When treating asymptomatic carotid artery stenosis, CAS has comparable perioperative and long-term composite outcomes compared with CEA. However, CAS may have a higher risk of any stroke and nondisabling stroke in the perioperative period.
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Affiliation(s)
- Jie Wang
- China International Neuroscience Institute (China-INI), Peoples Republic of China (J.W., X.B., T.W., L.J.).,Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, Beijing, Peoples Republic of China (J.W., X.B., T.W., L.J.)
| | - Xuesong Bai
- China International Neuroscience Institute (China-INI), Peoples Republic of China (J.W., X.B., T.W., L.J.).,Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, Beijing, Peoples Republic of China (J.W., X.B., T.W., L.J.)
| | - Tao Wang
- China International Neuroscience Institute (China-INI), Peoples Republic of China (J.W., X.B., T.W., L.J.).,Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, Beijing, Peoples Republic of China (J.W., X.B., T.W., L.J.)
| | - Adam A Dmytriw
- Neuroendovascular Program, Massachusetts General Hospital, Harvard Medical School, Boston (A.A.D.)
| | | | - Liqun Jiao
- China International Neuroscience Institute (China-INI), Peoples Republic of China (J.W., X.B., T.W., L.J.).,Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, Beijing, Peoples Republic of China (J.W., X.B., T.W., L.J.).,Department of Interventional Neuroradiology, Xuanwu Hospital, Capital Medical University, Peoples Republic of China (L.J.)
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95
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Columbo JA, Martinez-Camblor P, Stone DH, Goodney PP, O'Malley AJ. Procedural Safety Comparison Between Transcarotid Artery Revascularization, Carotid Endarterectomy, and Carotid Stenting: Perioperative and 1-Year Rates of Stroke or Death. J Am Heart Assoc 2022; 11:e024964. [PMID: 36172943 DOI: 10.1161/jaha.121.024964] [Citation(s) in RCA: 20] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background Transcarotid artery revascularization (TCAR) was approved by the Food and Drug Administration in 2015 for patients with carotid artery stenosis. However, no randomized trial to evaluate TCAR has been performed to date, and previous reports have important limitations. Accordingly, we measured stroke or death after TCAR compared with carotid endarterectomy (CEA) and transfemoral carotid artery stenting (TF-CAS). Methods and Results We used the Vascular Quality Initiative registry to study patients who underwent TCAR, CEA, or TF-CAS from September 2016 to June 2021. Our primary outcomes were perioperative and 1-year stroke or death. We used logistic regression for risk adjustment for perioperative outcomes and Cox regression for risk adjustment for 1-year outcomes. We used a 2-stage residual inclusion instrumental variable (IV) method to adjust for selection bias and other unmeasured confounding. Our instrument was a center's preference to perform TCAR versus CEA or TF-CAS. We performed a subgroup analysis stratified by presenting neurologic symptoms. We studied 21 234 patients who underwent TCAR, 82 737 who underwent CEA, and 14 595 who underwent TF-CAS across 662 centers. The perioperative rate of stroke or death was 2.0% for TCAR, 1.7% for CEA, and 3.7% for TF-CAS (P<0.001). Compared with TCAR, the IV-adjusted odds ratio of perioperative stroke or death for CEA was 0.74 (95% CI, 0.55-0.99) and for TF-CAS was 1.66 (95% CI, 0.99-2.79). Results were similar among both symptomatic and asymptomatic patients. The 1-year rate of stroke or death was 6.4% for TCAR, 5.2% for CEA, and 9.7% for TF-CAS (P<0.001). Compared with TCAR, the IV-adjusted hazard ratio of 1 year stroke or death for CEA was 0.97 (95% CI, 0.80-1.17), and for TF-CAS was 1.45 (95% CI, 1.04-2.02). IV analysis further demonstrated that symptomatic patients with carotid stenosis had the lowest 1-year likelihood of stroke or death with TCAR (compared with TCAR, symptomatic IV-adjusted hazard ratio for CEA: 1.30 [95% CI, 1.04-1.64], and TF-CAS: 1.86 [95% CI, 1.27-2.71]). Conclusions Perioperative stroke or death was greater following TCAR when compared with CEA. However, at 1 year there was no statistically significant difference in stroke or death between the 2 procedures. TCAR performed favorably compared with TF-CAS at both time points. Although CEA remains the gold standard procedure for patients with carotid stenosis, TCAR appears to be a safe alternative to CEA and TF-CAS when used selectively and may be useful when treating symptomatic patients.
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Affiliation(s)
- Jesse A Columbo
- Section of Vascular Surgery, Heart and Vascular Center Dartmouth-Hitchcock Medical Center Lebanon NH.,Geisel School of Medicine at Dartmouth College Hanover NH
| | - Pablo Martinez-Camblor
- Department of Anesthesia Dartmouth-Hitchcock Medical Center Lebanon NH.,Department of Biomedical Data Science Dartmouth College Hanover NH
| | - David H Stone
- Section of Vascular Surgery, Heart and Vascular Center Dartmouth-Hitchcock Medical Center Lebanon NH.,Geisel School of Medicine at Dartmouth College Hanover NH
| | - Philip P Goodney
- Section of Vascular Surgery, Heart and Vascular Center Dartmouth-Hitchcock Medical Center Lebanon NH.,Geisel School of Medicine at Dartmouth College Hanover NH
| | - A James O'Malley
- Geisel School of Medicine at Dartmouth College Hanover NH.,Department of Biomedical Data Science Dartmouth College Hanover NH
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96
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Takekawa H, Tsukui D, Kobayasi S, Suzuki K, Hamaguchi H. Ultrasound diagnosis of carotid artery stenosis and occlusion. J Med Ultrason (2001) 2022; 49:675-687. [PMID: 36175716 DOI: 10.1007/s10396-022-01259-7] [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: 05/01/2022] [Accepted: 08/14/2022] [Indexed: 11/25/2022]
Abstract
Carotid artery ultrasonography is capable of diagnosing or inferring the presence or absence of stenosis or occlusion of the internal carotid artery (ICA) and vertebral artery (VA), as well as the not directly observable distal ICA, middle cerebral artery (MCA), and basilar artery (BA). Stenosis at the origin of the ICA is mainly evaluated using the parameter peak systolic velocity (PSV), with values of ≥ 200-230 cm/s indicating severe stenosis. Recently, the acceleration time ratio has been reported for diagnosis of ICA origin stenosis. An indicator called the end-diastolic (ED) ratio can be used for diagnosing occlusion of the distal ICA or the M1 segment of the MCA. The PSV of stenosis can be used to diagnose stenosis at the beginning of the VA or V1, and mean flow velocity, mean ratio, and diameter ratio can be used to diagnose distal VA occlusion. Furthermore, the usefulness of the VA pulsatility index and resistance index has been suggested for diagnosing stenosis or occlusion of the BA. This review outlines diagnostic sonography criteria for stenosis and occlusion of extracranial and intracranial arteries.
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Affiliation(s)
- Hidehiro Takekawa
- Stroke Center, Dokkyo Medical University, 880 Kitakobayashi, Shimotsuga, Mibu, Tochigi, 321-0293, Japan.
- Department of Neurology, Dokkyo Medical University, Mibu, Tochigi, Japan.
- Center of Medical Ultrasonics, Dokkyo Medical University, Mibu, Tochigi, Japan.
| | - Daisuke Tsukui
- Stroke Center, Dokkyo Medical University, 880 Kitakobayashi, Shimotsuga, Mibu, Tochigi, 321-0293, Japan
- Department of Neurology, Dokkyo Medical University, Mibu, Tochigi, Japan
| | - Saro Kobayasi
- Stroke Center, Dokkyo Medical University, 880 Kitakobayashi, Shimotsuga, Mibu, Tochigi, 321-0293, Japan
- Department of Neurology, Dokkyo Medical University, Mibu, Tochigi, Japan
| | - Keisuke Suzuki
- Department of Neurology, Dokkyo Medical University, Mibu, Tochigi, Japan
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97
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Štěchovský C, Hulíková Tesárková K, Hájek P, Horváth M, Hansvenclová E, Veselka J. Comparison of 30-Day Outcomes after Carotid Artery Stenting in Patients with Near-Occlusion and Severe Stenosis: A Propensity Score Matching Analysis. AJNR Am J Neuroradiol 2022; 43:1311-1317. [PMID: 35981760 PMCID: PMC9451624 DOI: 10.3174/ajnr.a7598] [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: 03/02/2022] [Accepted: 06/17/2022] [Indexed: 01/26/2023]
Abstract
BACKGROUND AND PURPOSE Carotid artery near-occlusion is a type of severe stenosis with complete or partial distal luminal collapse and intracranial collaterals. This study aimed to compare 30-day outcomes and 10-year survival in patients undergoing carotid artery stenting for near-occlusion with a control group of patients with severe stenosis. MATERIALS AND METHODS We used data from a registry of 639 patients who underwent 789 carotid artery stenting procedures between 2005 and 2021. The primary end point was any stroke or death within 30 days after carotid artery stenting. Patients were matched using propensity scores based on 6 variables. RESULTS Propensity score matching yielded 84 subjects in the near-occlusion group matched with 168 subjects in the control group. In the matched cohort, the primary end point occurred in 7 (8.3%) and 11 (6.6%) patients in the near-occlusion and control groups, respectively (P = .611). In the unmatched cohort, the primary end point occurred in 7 (8.3%) and 19 (4.1%) patients (P = .101). Survival in the near-occlusion group versus the control group in the matched cohort at 5 and 10 years was 69.8% (95% CI, 58.0%-78.8%) versus 77.3% (95% CI, 70.0%-83.1%) and 53.3% (95% CI, 39.9%-65.0%) versus 53.3% (95% CI, 44.5%-61.4%) (log-rank, P = .798). CONCLUSIONS Carotid stent placement in patients with ICA near-occlusion was not associated with an increased 30-day risk of stroke or death compared with severe stenosis. Survival up to 10 years after carotid artery stenting was similar in both groups.
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Affiliation(s)
- C Štěchovský
- From the Department of Cardiology (C.Š., P,H., M.H., E.H., J.V.), Second Faculty of Medicine, Charles University, Motol University Hospital, Prague, Czech Republic
| | - K Hulíková Tesárková
- Department of Demography and Geodemography (K.H.T.), Faculty of Science, Charles University, Prague, Czech Republic
| | - P Hájek
- From the Department of Cardiology (C.Š., P,H., M.H., E.H., J.V.), Second Faculty of Medicine, Charles University, Motol University Hospital, Prague, Czech Republic
| | - M Horváth
- From the Department of Cardiology (C.Š., P,H., M.H., E.H., J.V.), Second Faculty of Medicine, Charles University, Motol University Hospital, Prague, Czech Republic
| | - E Hansvenclová
- From the Department of Cardiology (C.Š., P,H., M.H., E.H., J.V.), Second Faculty of Medicine, Charles University, Motol University Hospital, Prague, Czech Republic
| | - J Veselka
- From the Department of Cardiology (C.Š., P,H., M.H., E.H., J.V.), Second Faculty of Medicine, Charles University, Motol University Hospital, Prague, Czech Republic
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98
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Abbott AL, Brunser A, Uyagu OD, Budincevic H, Spanos K, Veith FJ. Regarding Comparison of Recent Practice Guidelines for the Management of Patients with Asymptomatic Carotid Stenosis. Angiology 2022; 74:496-497. [PMID: 35750480 DOI: 10.1177/00033197221110962] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Affiliation(s)
- Anne L Abbott
- Department of Neuroscience, Central Clinical School, Monash University, Melbourne, VIC, Australia
| | - Alejandro Brunser
- Neurology Service, Department of Medicine, Clínica Alemana de Santiago, Facultad de Medicina Clínica Alemana, 28071Universidad del Desarrollo, Santiago, Chile
| | | | - Hrvoje Budincevic
- Department of Neurology, Sveti Duh University Hospital, Zagreb, Croatia.,Department of Neurology and Neurosurgery, Faculty of Medicine, J.J. Strossmayer University of Osijek, Osijek, Croatia
| | - Konstantinos Spanos
- Vascular Surgery Department, Faculty of Medicine, University of Thessaly, University Hospital of Larissa, Larissa, Greece
| | - Frank J Veith
- NYU Langone Medical Center and Cleveland Clinic, New York, NY, USA
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99
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Manrique-Zegarra M, García-Pastor A, Castro-Reyes E, Guzmán-De-Villoria JA, Herrera Herrera I, Garrido Morro I, Del Valle Diéguez M, Fortea Gil F, González Cantero J, Saura Lorente J. CT angiography for diagnosis of carotid near-occlusion: a digital subtraction angiography validation study. Neuroradiology 2022; 64:1729-1735. [PMID: 35729332 DOI: 10.1007/s00234-022-02995-w] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2022] [Accepted: 06/07/2022] [Indexed: 11/28/2022]
Abstract
INTRODUCTION Carotid near-occlusion (CNO) is a variant of severe stenosis where there is a distal luminal collapse of the internal carotid artery (ICA) beyond a tight stenosis. This study aimed to validate new visual extracranial diagnostic CT angiography (CTA) criteria, for the diagnosis of CNO. The new criteria include distal ICA diameter smaller than contralateral ICA and distal ICA diameter less than or equal to the ipsilateral external carotid artery (ECA). We also assessed the previously described CTA criteria: stenosis ≤ 1.3 mm, ipsilateral distal ICA ≤ 3.5 mm, ipsilateral distal ICA/contralateral distal ICA ratio ≤ 0.87, ipsilateral distal ICA/ipsilateral ECA ≤ 1.27. METHODS Fifty-eight patients with ICA stenosis (including the near-occlusion variant) or occlusion on digital subtraction angiography (DSA) were included. These patients had DSA and CTA studies completed within 30 days of each other. DSA was considered the reference test. Two neuroradiologists blinded to the DSA results assessed the CTA images and evaluated the new and previously published CNO diagnostic criteria. RESULTS Twenty-eight CNO were identified with DSA. The "distal ICA diameter less than or equal to the ipsilateral ECA" criterion had 79% sensitivity and 83% specificity with excellent interobserver agreement (kappa = 0.80), while three or more of the previously published criteria reached 82% sensitivity and 90% specificity, with a good interobserver agreement (kappa = 0.64). CONCLUSIONS CT angiography may be useful for CNO diagnosis. The new visual diagnostic criteria provide acceptable results of sensitivity and specificity with an excellent interobserver agreement. However, false-negative and positive results persist.
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Affiliation(s)
| | | | - Enrique Castro-Reyes
- Interventional Neuroradiology, Hospital General Universitario Gregorio Marañón, Madrid, Spain
| | | | | | - Irene Garrido Morro
- Neuroradiology, Hospital General Universitario Gregorio Marañón, Madrid, Spain
| | | | - Fernando Fortea Gil
- Interventional Neuroradiology, Hospital General Universitario Gregorio Marañón, Madrid, Spain
| | - Jorge González Cantero
- Interventional Neuroradiology, Hospital General Universitario Gregorio Marañón, Madrid, Spain
| | - Javier Saura Lorente
- Interventional Neuroradiology, Hospital General Universitario Gregorio Marañón, Madrid, Spain
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Porcu M, Cocco L, Cau R, Suri JS, Wintermark M, Puig J, Qi Y, Lanzino G, Caulo M, Saba L. The restoring of interhemispheric brain connectivity following carotid endarterectomy: an exploratory observational study. Brain Imaging Behav 2022; 16:2037-2048. [PMID: 35622267 DOI: 10.1007/s11682-022-00674-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/03/2022] [Indexed: 12/24/2022]
Abstract
This study aimed to evaluate the differences of brain connectivity between healthy subjects (HS) and patients with extracranial internal carotid artery (eICA) stenosis before and after carotid endarterectomy (CEA). An exploratory prospective study was designed. The study population consisted of a patient group (PG) of 20 patients with eICA stenosis eligible for CEA, and a control group (CG) of 20 HS, matched for age and sex. The subjects of the PG group underwent Magnetic Resonance Imaging (MRI) for resting-state functional connectivity MRI (rs-fc MRI) analysis within one week from the CEA (pre-CEA) and 12 months following CEA (post-CEA). The CG underwent a single MRI with the same protocol utilized for the PG. Three region-of-interest to region-of-interest (ROI-to-ROI) rs-fc MRI analyses were conducted: analysis 1 to compare pre-CEA PG and CG; analysis 2 to compare pre-CEA PG and post-CEA PG; analysis 3 to compare post-CEA PG and CG. The Functional Network Connectivity multivariate parametric technique was used for statistical analysis, adopting a p-uncorrected (p-unc) < 0.05 as connection threshold, and a cluster level False Discovery Rate corrected p (p-FDR) < 0.05 as cluster threshold. The clusters were defined by using a data-driven hierarchical clustering procedure. Analysis 1 revealed two clusters of reduced interhemispheric connectivity of pre-CEA PG when compared to CG. Analysis 2 and 3 showed no statistically significant differences. Our exploratory analysis suggests that patients with eICA stenosis have reduced interhemispheric connectivity when compared to a matched control group, and this difference was not evident anymore following endarterectomy.
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Affiliation(s)
- Michele Porcu
- Department of Radiology, AOU Cagliari, University of Cagliari, Cagliari, Italy. .,Department of Medical Imaging, Azienda Ospedaliera Universitaria Di Cagliari, S.S: 554, km 4,500, Monserrato, CAP: 09042, Cagliari, Italy.
| | - Luigi Cocco
- Department of Radiology, AOU Cagliari, University of Cagliari, Cagliari, Italy
| | - Riccardo Cau
- Department of Radiology, AOU Cagliari, University of Cagliari, Cagliari, Italy
| | - Jasjit S Suri
- Stroke Monitoring and Diagnostic Division, AtheroPoint™, Roseville, CA, USA
| | - Max Wintermark
- Department of Neuroradiology, Stanford University, Stanford, CA, USA
| | - Josep Puig
- Department of Radiology (IDI) and Girona Biomedical Research Institute (IDIBGI), Hospital Universitari de Girona Dr Josep Trueta, Girona, Spain
| | - Yang Qi
- Xuanwu Hospital, Capital Medical University, No.45 Changchun Street, Xicheng District, Beijing, China
| | | | - Massimo Caulo
- Department of Neuroscience, Imaging and Clinical Sciences, University "G. d'Annunzio", Chieti, Italy
| | - Luca Saba
- Department of Radiology, AOU Cagliari, University of Cagliari, Cagliari, Italy
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