101
|
Schwarzmaier-D'Assie A, Nyolczas N, Hemetsberger R, Strehblow C, Matiasek J, Farhan S, Petrasi Z, Huber K, Wojta J, Glogar D, Plass C, Gyöngyösi M, Karnik R. Comparison of short- and long-term results of drug-eluting vs. bare metal stenting in the porcine internal carotid artery. J Endovasc Ther 2011; 18:547-58. [PMID: 21861747 DOI: 10.1583/10-3347.1] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/17/2022]
Abstract
PURPOSE To evaluate the development of neointimal hyperplasia after implantation of drug-eluting stents (paclitaxel) compared to bare metal stents in porcine internal carotid arteries (ICAs). METHODS While drug-eluting stents have effectively reduced neointimal proliferation in porcine external carotid arteries, the porcine internal carotid artery (ICA) is more sensitive to shear stress and altered flow conditions. Thus, a study was conducted to evaluate bare vs. drug-eluting stents in porcine ICAs. Under general anesthesia, 18 domestic pigs were implanted with paclitaxel-eluting (n = 18) and bare (n = 18) stents in the left and right ICAs, respectively. After 1 and 3 months, control carotid angiography was performed, followed by histopathological and histomorphometric analyses of the stented ICA. RESULTS Histopathological results (fibrin deposition, necrosis, inflammation) were similar in the groups at 1 and 3 months. Moreover, the injury score and rate of endothelialization did not differ between the groups. Histomorphometric analysis after 1 month revealed significantly (p<0.05) less neointimal hyperplasia after implantation of paclitaxel-eluting stents. The antiproliferative effect of paclitaxel-eluting stents were maintained during the 3-month follow-up: the neointimal area was 0.7 ± 0.5 vs. 1.2 ± 0.6 mm(2) (p<0.01), the area stenosis was 23.5% ± 13.9% vs. 37.8% ± 14.4% (p<0.01), the maximal neointimal thickness was 0.2 ± 0.1 vs. 0.2 ± 0.9 mm (p<0.05) in paclitaxel-eluting vs. bare stents, respectively. Implantation of paclitaxel-eluting and bare stents did not lead to edge restenosis or vessel remodeling in porcine ICAs at 1 or 3 months. CONCLUSION Compared to bare metal stents, drug-eluting stents implanted in the porcine ICA produced significantly less neointimal hyperplasia.
Collapse
|
102
|
Jiang L, Ling F, Wang B, Miao Z. Insight into the periprocedural embolic events of internal carotid artery angioplasty. A report of four cases and literature review. Interv Neuroradiol 2011; 17:452-8. [PMID: 22192549 DOI: 10.1177/159101991101700409] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2011] [Accepted: 10/16/2011] [Indexed: 11/17/2022] Open
Abstract
Thromboembolism is a major risk of carotid angioplasty and stenting (CAS). Although the incidence of distal embolism has been documented by MRI and TCD studies, the mechanisms and management of this complication are rarely reported. Here we describe four patients with periprocedural embolic events to demonstrate the mechanisms of thromboembolism in CAS. Different remedies were applied to these patients according to the underlying mechanisms of thromboembolism and good clinical outcomes were achieved.
Collapse
Affiliation(s)
- L Jiang
- Department of Neurosurgery, Xuanwu hospital, Capital Medical University, Beijing, China
| | | | | | | |
Collapse
|
103
|
Gray WA. Carotid artery stenting before cardiac surgery a promising path down a muddy road? JACC Cardiovasc Interv 2011; 4:1197-9. [PMID: 22115659 DOI: 10.1016/j.jcin.2011.09.009] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/21/2011] [Accepted: 09/23/2011] [Indexed: 11/29/2022]
|
104
|
White CJ, Avula SB, Mintz RT, Iskander A, Chervu A, Feldman RL, Schermerhorn ML, Woo HH, Hopkins LN. Carotid artery revascularization with distal protection in high-surgical-risk patients in routine clinical practice: rationale and design of the CABANA safety surveillance program. Catheter Cardiovasc Interv 2011; 79:167-73. [PMID: 21805584 DOI: 10.1002/ccd.23257] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/04/2011] [Accepted: 05/12/2011] [Indexed: 11/10/2022]
Abstract
BACKGROUND Continuous improvement in carotid artery stenting (CAS) outcomes, especially for periprocedural death and stroke in high-surgical-risk patients, have been seen in recent randomized trials of CAS versus carotid endarterectomy and CAS registries. However, these studies use stringent inclusion/exclusion criteria for patient, institution, and physician selection. The Carotid Stenting Boston Scientific Surveillance Program (CABANA) study was initiated to evaluate periprocedural outcomes with modern versions of the Carotid Wallstent and FilterWire EZ System for operators with a wide range of clinical specialties, CAS experience and training levels, in patients with a broad range of high-surgical-risk conditions and lesion types. METHODS This prospective, single-arm study enrolled 1,097 subjects with 1,098 carotid artery lesions at 99 study centers. Investigators were grouped into one of three tiers according to whether they had a high, medium, or low level of previous CAS experience and were also categorized by their CAS-credential-based training requirements for the CABANA study. Follow-up at 30 days includes clinical evaluation and independent neurological and NIH stroke scale assessments. The primary endpoint rate of 30-day composite stroke, death, and MI, as well as the rates of these individual events, will be evaluated across the overall study, by physician experience tier, and by physician training tier. DISCUSSION The evaluation of periprocedural CAS safety in a real-world environment with modern devices in high-surgical-risk patients treated by physicians with a broad range of training and experience will better inform treatment decisions in the future.
Collapse
Affiliation(s)
- Christopher J White
- Department of Cardiovascular Diseases and Director, John Ochsner Heart and Vascular Institute, Ochsner Clinic Foundation, New Orleans, Louisiana 70121, USA.
| | | | | | | | | | | | | | | | | |
Collapse
|
105
|
Celis R, Chaer RA. Carotid angioplasty and stenting: evolution and current status. Hosp Pract (1995) 2011; 39:62-70. [PMID: 21881393 DOI: 10.3810/hp.2011.08.581] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
The management of carotid stenosis is in evolution. Carotid endarterectomy has been the gold standard for the treatment of carotid stenosis for many years. However, recently, carotid angioplasty and stenting has emerged as a feasible and relatively safe management alternative. The appropriate clinical setting for its preferential use over carotid endarterectomy continues to be the subject of ongoing clinical trials. In this article, we review the evolution of carotid angioplasty and stenting, the evidence behind the current indications, and limitations of this procedure, as well as provide an overview of preprocedural evaluations and periprocedural management.
Collapse
Affiliation(s)
- Rolando Celis
- University of Pittsburgh Medical Center, Division of Vascular Surgery, Pittsburgh, PA, USA
| | | |
Collapse
|
106
|
Ricotta JJ, Aburahma A, Ascher E, Eskandari M, Faries P, Lal BK. Updated Society for Vascular Surgery guidelines for management of extracranial carotid disease. J Vasc Surg 2011; 54:e1-31. [PMID: 21889701 DOI: 10.1016/j.jvs.2011.07.031] [Citation(s) in RCA: 439] [Impact Index Per Article: 33.8] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2011] [Revised: 06/21/2011] [Accepted: 07/12/2011] [Indexed: 11/30/2022]
Affiliation(s)
- John J Ricotta
- Washington Hospital Center, Georgetown University School of Medicine, Washington, DC 20010, USA.
| | | | | | | | | | | |
Collapse
|
107
|
Siewiorek GM, Krafty RT, Wholey MH, Finol EA. The association of clinical variables and filter design with carotid artery stenting thirty-day outcome. Eur J Vasc Endovasc Surg 2011; 42:282-91. [PMID: 21530332 PMCID: PMC3157584 DOI: 10.1016/j.ejvs.2011.04.006] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2010] [Accepted: 04/02/2011] [Indexed: 10/18/2022]
Abstract
OBJECTIVE Patient and device selection are important for the success of carotid artery stenting (CAS). We hypothesize that distal protection filter (DPF) design characteristics that minimize blood flow resistance and maximize capture efficiency are associated with the absence of transient ischemic attack (TIA), stroke and neurologic-related death after 30 days. METHODS Records from 208 patients were reviewed retrospectively. Filter design characteristics were quantified previously in our laboratory. The association between risk factors and design characteristics with 30-day outcome was quantified using univariate analysis. RESULTS The 30-day all-cause stroke and death rate was 8.7% (asymptomatic: 7.7%, symptomatic: 10.6%). Five DPFs were used in the study: Accunet (41.3%), Angioguard (33.2%), FilterWire (24%), Emboshield (1%), and Spider (.5%). Diabetes (P = .04) and prior carotid endarterectomy (CEA, P = .03) were associated with adverse outcome. Prior stroke (P = .01) and prior CEA (P = .04) were significant for peri-procedural stroke. Design characteristics such as capture efficiency were associated with favorable outcomes. CONCLUSIONS Patients with prior CEA or stroke are more likely to have unfavorable CAS outcomes after 30 days. Filters with high capture efficiency may yield the best clinical results. Analysis of the effect of design characteristics on CAS outcome should aid the design of future devices.
Collapse
Affiliation(s)
- Gail M. Siewiorek
- Biomedical Engineering Department Carnegie Mellon University 1210 Hamburg Hall 5000 Forbes Avenue Pittsburgh, PA 15213 USA
| | - Robert T. Krafty
- Department of Statistics University of Pittsburgh 2702 Cathedral of Learning Pittsburgh, PA 15260 USA
| | - Mark H. Wholey
- University of Pittsburgh Medical Center – Shadyside 5230 Centre Avenue, Suite 603 Pittsburgh, PA 15232 USA
| | - Ender A. Finol
- Biomedical Engineering Department Carnegie Mellon University 1210 Hamburg Hall 5000 Forbes Avenue Pittsburgh, PA 15213 USA
- Institute for Complex Engineered Systems and Department of Mechanical Engineering 1205 Hamburg Hall 5000 Forbes Avenue Carnegie Mellon University Pittsburgh, PA 15213 USA
| |
Collapse
|
108
|
Abstract
Embolic protection devices were initially developed for use in the treatment of saphenous vein aortocoronary bypass graft stenosis as well as in carotid artery stenting because of the significant risk of atheroembolism and their use is well accepted. The use of these devices for lower-extremity arterial interventions is becoming well accepted because of the significant consequences of embolization in patients with limited circulatory runoff. This is especially true in the use of mechanical atherectomy devices for femoropopliteal arterial lesions.
Collapse
Affiliation(s)
- Michael Wholey
- Department of Radiology, University of Texas Health Science Center at San Antonio, San Antonio, TX 78229, USA.
| |
Collapse
|
109
|
Brott TG, Halperin JL, Abbara S, Bacharach JM, Barr JD, Bush RL, Cates CU, Creager MA, Fowler SB, Friday G, Hertzberg VS, McIff EB, Moore WS, Panagos PD, Riles TS, Rosenwasser RH, Taylor AJ. 2011 ASA/ACCF/AHA/AANN/AANS/ACR/ASNR/CNS/SAIP/SCAI/SIR/SNIS/SVM/SVS Guideline on the Management of Patients With Extracranial Carotid and Vertebral Artery Disease: Executive Summary. Stroke 2011; 42:e420-63. [DOI: 10.1161/str.0b013e3182112d08] [Citation(s) in RCA: 94] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/20/2023]
Affiliation(s)
| | - Thomas G. Brott
- ASA Representative. ACCF/AHA Representative and ACCF/AHA Task Force on Performance Measures Liaison. SCCT Representative. SVM Representative. ACR, ASNR, and SNIS Representative. SCAI Representative. ACCF/AHA Task Force on Practice Guidelines Liaison. AANN Representative. AAN Representative. SIR Representative. ACEP Representative. SVS Representative. AANS and CNS Representative. SAIP Representative. Former Task Force member during this writing effort
| | - Jonathan L. Halperin
- ASA Representative. ACCF/AHA Representative and ACCF/AHA Task Force on Performance Measures Liaison. SCCT Representative. SVM Representative. ACR, ASNR, and SNIS Representative. SCAI Representative. ACCF/AHA Task Force on Practice Guidelines Liaison. AANN Representative. AAN Representative. SIR Representative. ACEP Representative. SVS Representative. AANS and CNS Representative. SAIP Representative. Former Task Force member during this writing effort
| | - Suhny Abbara
- ASA Representative. ACCF/AHA Representative and ACCF/AHA Task Force on Performance Measures Liaison. SCCT Representative. SVM Representative. ACR, ASNR, and SNIS Representative. SCAI Representative. ACCF/AHA Task Force on Practice Guidelines Liaison. AANN Representative. AAN Representative. SIR Representative. ACEP Representative. SVS Representative. AANS and CNS Representative. SAIP Representative. Former Task Force member during this writing effort
| | - J. Michael Bacharach
- ASA Representative. ACCF/AHA Representative and ACCF/AHA Task Force on Performance Measures Liaison. SCCT Representative. SVM Representative. ACR, ASNR, and SNIS Representative. SCAI Representative. ACCF/AHA Task Force on Practice Guidelines Liaison. AANN Representative. AAN Representative. SIR Representative. ACEP Representative. SVS Representative. AANS and CNS Representative. SAIP Representative. Former Task Force member during this writing effort
| | - John D. Barr
- ASA Representative. ACCF/AHA Representative and ACCF/AHA Task Force on Performance Measures Liaison. SCCT Representative. SVM Representative. ACR, ASNR, and SNIS Representative. SCAI Representative. ACCF/AHA Task Force on Practice Guidelines Liaison. AANN Representative. AAN Representative. SIR Representative. ACEP Representative. SVS Representative. AANS and CNS Representative. SAIP Representative. Former Task Force member during this writing effort
| | | | - Christopher U. Cates
- ASA Representative. ACCF/AHA Representative and ACCF/AHA Task Force on Performance Measures Liaison. SCCT Representative. SVM Representative. ACR, ASNR, and SNIS Representative. SCAI Representative. ACCF/AHA Task Force on Practice Guidelines Liaison. AANN Representative. AAN Representative. SIR Representative. ACEP Representative. SVS Representative. AANS and CNS Representative. SAIP Representative. Former Task Force member during this writing effort
| | - Mark A. Creager
- ASA Representative. ACCF/AHA Representative and ACCF/AHA Task Force on Performance Measures Liaison. SCCT Representative. SVM Representative. ACR, ASNR, and SNIS Representative. SCAI Representative. ACCF/AHA Task Force on Practice Guidelines Liaison. AANN Representative. AAN Representative. SIR Representative. ACEP Representative. SVS Representative. AANS and CNS Representative. SAIP Representative. Former Task Force member during this writing effort
| | - Susan B. Fowler
- ASA Representative. ACCF/AHA Representative and ACCF/AHA Task Force on Performance Measures Liaison. SCCT Representative. SVM Representative. ACR, ASNR, and SNIS Representative. SCAI Representative. ACCF/AHA Task Force on Practice Guidelines Liaison. AANN Representative. AAN Representative. SIR Representative. ACEP Representative. SVS Representative. AANS and CNS Representative. SAIP Representative. Former Task Force member during this writing effort
| | - Gary Friday
- ASA Representative. ACCF/AHA Representative and ACCF/AHA Task Force on Performance Measures Liaison. SCCT Representative. SVM Representative. ACR, ASNR, and SNIS Representative. SCAI Representative. ACCF/AHA Task Force on Practice Guidelines Liaison. AANN Representative. AAN Representative. SIR Representative. ACEP Representative. SVS Representative. AANS and CNS Representative. SAIP Representative. Former Task Force member during this writing effort
| | | | - E. Bruce McIff
- ASA Representative. ACCF/AHA Representative and ACCF/AHA Task Force on Performance Measures Liaison. SCCT Representative. SVM Representative. ACR, ASNR, and SNIS Representative. SCAI Representative. ACCF/AHA Task Force on Practice Guidelines Liaison. AANN Representative. AAN Representative. SIR Representative. ACEP Representative. SVS Representative. AANS and CNS Representative. SAIP Representative. Former Task Force member during this writing effort
| | | | - Peter D. Panagos
- ASA Representative. ACCF/AHA Representative and ACCF/AHA Task Force on Performance Measures Liaison. SCCT Representative. SVM Representative. ACR, ASNR, and SNIS Representative. SCAI Representative. ACCF/AHA Task Force on Practice Guidelines Liaison. AANN Representative. AAN Representative. SIR Representative. ACEP Representative. SVS Representative. AANS and CNS Representative. SAIP Representative. Former Task Force member during this writing effort
| | - Thomas S. Riles
- ASA Representative. ACCF/AHA Representative and ACCF/AHA Task Force on Performance Measures Liaison. SCCT Representative. SVM Representative. ACR, ASNR, and SNIS Representative. SCAI Representative. ACCF/AHA Task Force on Practice Guidelines Liaison. AANN Representative. AAN Representative. SIR Representative. ACEP Representative. SVS Representative. AANS and CNS Representative. SAIP Representative. Former Task Force member during this writing effort
| | - Robert H. Rosenwasser
- ASA Representative. ACCF/AHA Representative and ACCF/AHA Task Force on Performance Measures Liaison. SCCT Representative. SVM Representative. ACR, ASNR, and SNIS Representative. SCAI Representative. ACCF/AHA Task Force on Practice Guidelines Liaison. AANN Representative. AAN Representative. SIR Representative. ACEP Representative. SVS Representative. AANS and CNS Representative. SAIP Representative. Former Task Force member during this writing effort
| | - Allen J. Taylor
- ASA Representative. ACCF/AHA Representative and ACCF/AHA Task Force on Performance Measures Liaison. SCCT Representative. SVM Representative. ACR, ASNR, and SNIS Representative. SCAI Representative. ACCF/AHA Task Force on Practice Guidelines Liaison. AANN Representative. AAN Representative. SIR Representative. ACEP Representative. SVS Representative. AANS and CNS Representative. SAIP Representative. Former Task Force member during this writing effort
| |
Collapse
|
110
|
Brott TG, Halperin JL, Abbara S, Bacharach JM, Barr JD, Bush RL, Cates CU, Creager MA, Fowler SB, Friday G, Hertzberg VS, McIff EB, Moore WS, Panagos PD, Riles TS, Rosenwasser RH, Taylor AJ. 2011 ASA/ACCF/AHA/AANN/AANS/ACR/ASNR/CNS/SAIP/SCAI/SIR/SNIS/SVM/SVS Guideline on the Management of Patients With Extracranial Carotid and Vertebral Artery Disease: Executive Summary. Circulation 2011; 124:489-532. [DOI: 10.1161/cir.0b013e31820d8d78] [Citation(s) in RCA: 406] [Impact Index Per Article: 31.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Thomas G. Brott
- ASA Representative. ACCF/AHA Representative and ACCF/AHA Task Force on Performance Measures Liaison. SCCT Representative. SVM Representative. ACR, ASNR, and SNIS Representative. SCAI Representative. ACCF/AHA Task Force on Practice Guidelines Liaison. AANN Representative. AAN Representative. SIR Representative. ACEP Representative. SVS Representative. AANS and CNS Representative. SAIP Representative. Former Task Force member during this writing effort
| | - Jonathan L. Halperin
- ASA Representative. ACCF/AHA Representative and ACCF/AHA Task Force on Performance Measures Liaison. SCCT Representative. SVM Representative. ACR, ASNR, and SNIS Representative. SCAI Representative. ACCF/AHA Task Force on Practice Guidelines Liaison. AANN Representative. AAN Representative. SIR Representative. ACEP Representative. SVS Representative. AANS and CNS Representative. SAIP Representative. Former Task Force member during this writing effort
| | - Suhny Abbara
- ASA Representative. ACCF/AHA Representative and ACCF/AHA Task Force on Performance Measures Liaison. SCCT Representative. SVM Representative. ACR, ASNR, and SNIS Representative. SCAI Representative. ACCF/AHA Task Force on Practice Guidelines Liaison. AANN Representative. AAN Representative. SIR Representative. ACEP Representative. SVS Representative. AANS and CNS Representative. SAIP Representative. Former Task Force member during this writing effort
| | - J. Michael Bacharach
- ASA Representative. ACCF/AHA Representative and ACCF/AHA Task Force on Performance Measures Liaison. SCCT Representative. SVM Representative. ACR, ASNR, and SNIS Representative. SCAI Representative. ACCF/AHA Task Force on Practice Guidelines Liaison. AANN Representative. AAN Representative. SIR Representative. ACEP Representative. SVS Representative. AANS and CNS Representative. SAIP Representative. Former Task Force member during this writing effort
| | - John D. Barr
- ASA Representative. ACCF/AHA Representative and ACCF/AHA Task Force on Performance Measures Liaison. SCCT Representative. SVM Representative. ACR, ASNR, and SNIS Representative. SCAI Representative. ACCF/AHA Task Force on Practice Guidelines Liaison. AANN Representative. AAN Representative. SIR Representative. ACEP Representative. SVS Representative. AANS and CNS Representative. SAIP Representative. Former Task Force member during this writing effort
| | | | - Christopher U. Cates
- ASA Representative. ACCF/AHA Representative and ACCF/AHA Task Force on Performance Measures Liaison. SCCT Representative. SVM Representative. ACR, ASNR, and SNIS Representative. SCAI Representative. ACCF/AHA Task Force on Practice Guidelines Liaison. AANN Representative. AAN Representative. SIR Representative. ACEP Representative. SVS Representative. AANS and CNS Representative. SAIP Representative. Former Task Force member during this writing effort
| | - Mark A. Creager
- ASA Representative. ACCF/AHA Representative and ACCF/AHA Task Force on Performance Measures Liaison. SCCT Representative. SVM Representative. ACR, ASNR, and SNIS Representative. SCAI Representative. ACCF/AHA Task Force on Practice Guidelines Liaison. AANN Representative. AAN Representative. SIR Representative. ACEP Representative. SVS Representative. AANS and CNS Representative. SAIP Representative. Former Task Force member during this writing effort
| | - Susan B. Fowler
- ASA Representative. ACCF/AHA Representative and ACCF/AHA Task Force on Performance Measures Liaison. SCCT Representative. SVM Representative. ACR, ASNR, and SNIS Representative. SCAI Representative. ACCF/AHA Task Force on Practice Guidelines Liaison. AANN Representative. AAN Representative. SIR Representative. ACEP Representative. SVS Representative. AANS and CNS Representative. SAIP Representative. Former Task Force member during this writing effort
| | - Gary Friday
- ASA Representative. ACCF/AHA Representative and ACCF/AHA Task Force on Performance Measures Liaison. SCCT Representative. SVM Representative. ACR, ASNR, and SNIS Representative. SCAI Representative. ACCF/AHA Task Force on Practice Guidelines Liaison. AANN Representative. AAN Representative. SIR Representative. ACEP Representative. SVS Representative. AANS and CNS Representative. SAIP Representative. Former Task Force member during this writing effort
| | | | - E. Bruce McIff
- ASA Representative. ACCF/AHA Representative and ACCF/AHA Task Force on Performance Measures Liaison. SCCT Representative. SVM Representative. ACR, ASNR, and SNIS Representative. SCAI Representative. ACCF/AHA Task Force on Practice Guidelines Liaison. AANN Representative. AAN Representative. SIR Representative. ACEP Representative. SVS Representative. AANS and CNS Representative. SAIP Representative. Former Task Force member during this writing effort
| | | | - Peter D. Panagos
- ASA Representative. ACCF/AHA Representative and ACCF/AHA Task Force on Performance Measures Liaison. SCCT Representative. SVM Representative. ACR, ASNR, and SNIS Representative. SCAI Representative. ACCF/AHA Task Force on Practice Guidelines Liaison. AANN Representative. AAN Representative. SIR Representative. ACEP Representative. SVS Representative. AANS and CNS Representative. SAIP Representative. Former Task Force member during this writing effort
| | - Thomas S. Riles
- ASA Representative. ACCF/AHA Representative and ACCF/AHA Task Force on Performance Measures Liaison. SCCT Representative. SVM Representative. ACR, ASNR, and SNIS Representative. SCAI Representative. ACCF/AHA Task Force on Practice Guidelines Liaison. AANN Representative. AAN Representative. SIR Representative. ACEP Representative. SVS Representative. AANS and CNS Representative. SAIP Representative. Former Task Force member during this writing effort
| | - Robert H. Rosenwasser
- ASA Representative. ACCF/AHA Representative and ACCF/AHA Task Force on Performance Measures Liaison. SCCT Representative. SVM Representative. ACR, ASNR, and SNIS Representative. SCAI Representative. ACCF/AHA Task Force on Practice Guidelines Liaison. AANN Representative. AAN Representative. SIR Representative. ACEP Representative. SVS Representative. AANS and CNS Representative. SAIP Representative. Former Task Force member during this writing effort
| | - Allen J. Taylor
- ASA Representative. ACCF/AHA Representative and ACCF/AHA Task Force on Performance Measures Liaison. SCCT Representative. SVM Representative. ACR, ASNR, and SNIS Representative. SCAI Representative. ACCF/AHA Task Force on Practice Guidelines Liaison. AANN Representative. AAN Representative. SIR Representative. ACEP Representative. SVS Representative. AANS and CNS Representative. SAIP Representative. Former Task Force member during this writing effort
| |
Collapse
|
111
|
Macdonald S. Carotid artery stenting trials: conduct, results, critique, and current recommendations. Cardiovasc Intervent Radiol 2011; 35:15-29. [PMID: 21789697 DOI: 10.1007/s00270-011-0223-x] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/09/2011] [Accepted: 06/22/2011] [Indexed: 10/18/2022]
Abstract
The carotid stenting trialists have demonstrated persistence and determination in comparing an evolving technique, carotid artery stenting (CAS), against a mature and exacting standard for carotid revascularisation, carotid endarterectomy (CEA). This review focuses on their endeavours. A total of 12 1-on-1 randomised trials comparing CAS and CEA have been reported; 6 of these can be considered major, and 5 of these reflect (in part) current CAS standards of practice and form the basis of this review. At least 18 meta-analyses seeking to compare CAS and CEA exist. These are limited by the quality and heterogeneity of the data informing them (e.g., five trials were stopped prematurely such that they collectively failed to reach recruitment target by >4000 patients). The Carotid Stenting Trialists' Collaboration Publication represents a prespecified meta-analysis of European trials that were sufficiently similar to allow valid conclusions to be drawn; these trials and conclusions will be explored. When the rate of myocardial infarction (MI) is rigorously assessed, CAS and CEA are equivalent for the composite end point of stroke/death and MI, with more minor strokes for CAS and more MIs for CEA. These outcomes have a discrepant impact on quality of life and subsequent mortality. The all-stroke death outcomes for patients <70 years old are equivalent, with more minor strokes occurring in the elderly during CAS than CEA. There are significantly more severe haematomas and cranial nerve injuries after CEA. The influence of experience on outcome cannot be underestimated.
Collapse
Affiliation(s)
- Sumaira Macdonald
- Interventional Radiology, Freeman Hospital, Newcastle-Upon-Tyne NE7 7DN, UK.
| |
Collapse
|
112
|
Abstract
Carotid stenting has become an accepted alternative in patients with carotid stenosis. The purpose of this article is to review the relevant trials, describe the different devices available for stenting, the devices for cerebral protection, as well as describe techniques and tricks for successful carotid artery stenting. Understanding how to appropriately preoperatively evaluate patients and intra- and postoperative procedures, carotid artery stenting can be a safe procedure.
Collapse
Affiliation(s)
- Rahul S Patel
- Division of Vascular and Interventional Radiology, University of Maryland Medical Center, Baltimore, Maryland
| | | |
Collapse
|
113
|
Abstract
Embolic protection devices were initially developed for the treatment of saphenous vein aorto-coronary bypass graft stenosis due to the significant risk of atheroembolism, and their use is well accepted. The use of these devices for carotid arterial interventions is also well accepted due to the significant consequences of embolization in the cerebral circulation. The use of these devices is extending to other vascular beds to include the renal arteries and lower extremities. We review the basic principles of these devices and their uses in various vascular beds based on our own experience as well as that in the literature.
Collapse
Affiliation(s)
- Martin G Radvany
- Department of Radiology, Brooke Army Medical Center, Fort Sam Houston, Texas
| | | |
Collapse
|
114
|
Jin SC, Kwon OK, Oh CW, Jung C, Han MG, Bae HJ, Lee SH, Jung YS, Han MH, Kang HS. A technical strategy for carotid artery stenting: suboptimal prestent balloon angioplasty without poststenting balloon dilatation. Neurosurgery 2011; 67:1438-42; discussion 1442-3. [PMID: 20871446 DOI: 10.1227/neu.0b013e3181f07c97] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Traditional carotid artery stenting (CAS) consists of predilatation, optional deployment of embolic protection devices, stenting, and poststent angioplasty. Each step carries a risk of thromboembolism. OBJECTIVE To design a new and simplified procedural protocol, suboptimal balloon angioplasty without routine poststenting balloon dilatation, and to describe the efficacy this protocol in terms of procedural risks and angiographic and clinical outcomes. METHODS Over a period of 6 years, 161 carotid artery stenoses in 156 consecutive patients were treated by CAS with embolic protection devices. Among them, 110 lesions in 107 patients (68.3%) were treated by our simplified method (symptomatic, > 50% stenosis; asymptomatic, > 70% stenosis). Overall, 98 lesions (88.3%) had severe stenosis (> 70%). RESULTS The mean stenosis was reduced from 77% to 10% after CAS. A persistent neurological deficit developed in 2 patients from thromboembolism. Hemodynamic insufficiency developed in 14 lesions during CAS (12.7%). The ipsilateral stroke and mortality rate was 4.5% within 1 month after CAS (asymptomatic, 3.6%; symptomatic, 4.8%). Over a mean of 19 months of follow-up, additive angioplasty was performed in 2 patients as a result of progressive restenosis (≥ 50%). A comparison of the balloon sizes of the prestent angioplasty for group 1 (balloon, ≤ 4 mm) and group 2 (balloon, ≥ 5 mm) showed no difference in restenosis between the groups at 15 months of follow-up after CAS. CONCLUSION Our CAS technique with suboptimal prestenting angioplasty without routine use of poststenting dilatation is safe, simple, and efficient with acceptable risks.
Collapse
Affiliation(s)
- Sung-Chul Jin
- Department of Neurosurgery, Seoul National University, Bundang Hospital, Seongnam, South Korea
| | | | | | | | | | | | | | | | | | | |
Collapse
|
115
|
Mahoney EM, Greenberg D, Lavelle TA, Natarajan A, Berezin R, Ishak KJ, Caro JJ, Yadav JS, Gray WA, Wholey MH, Cohen DJ. Costs and cost-effectiveness of carotid stenting versus endarterectomy for patients at increased surgical risk: results from the SAPPHIRE trial. Catheter Cardiovasc Interv 2011; 77:463-72. [PMID: 21351220 DOI: 10.1002/ccd.22869] [Citation(s) in RCA: 33] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
Abstract
OBJECTIVES To evaluate the cost-effectiveness of carotid stenting vs. carotid endarterectomy using data from the SAPPHIRE trial. BACKGROUND Carotid stenting with embolic protection has been introduced as an alternative to carotid endarterectomy for prevention of cerebrovascular and cardiovascular events among patients at increased surgical risk. METHODS Between August 2000 and July 2002, 310 patients with an accepted indication for carotid endarterectomy but at high risk of complications were randomized to and subsequently underwent either carotid stenting (n = 159) or endarterectomy (n = 151). Clinical outcomes, resource use, costs, and quality of life were assessed prospectively for all patients over a 1-year period. Life expectancy, quality-adjusted life expectancy, and health care costs beyond the follow-up period were estimated for patients alive at 1 year, based on observed clinical events during the first year of follow-up. RESULTS Although initial procedural costs were significantly higher for stenting than for endarterectomy (mean difference: $4,081/patient; 95% CI, $3,849-$4,355), mean post-procedure length of stay was shorter for stenting (1.9 vs. 2.9 days; P < 0.001) with significant associated cost offsets. As a result, initial hospital costs were just $559/patient higher with stenting (95% CI, $3,470 less to $2,289 more). Neither follow-up costs after discharge nor total 1-year costs differed significantly. The incremental cost-effectiveness ratio for stenting compared with endarterectomy was $6,555 per quality-adjusted life year (QALY) gained, with over 98 percent of bootstrap estimates < $50,000/QALY gained. CONCLUSIONS Although carotid stenting with embolic protection is more costly than carotid endarterectomy, by commonly accepted standards, stenting is an economically attractive alternative to endarterectomy for patients at high surgical risk.
Collapse
Affiliation(s)
- Elizabeth M Mahoney
- Cardiovascular Research Center, Saint Luke's Mid America Heart and Vascular Institute, Kansas City, Missouri, USA
| | | | | | | | | | | | | | | | | | | | | |
Collapse
|
116
|
Timaran CH, McKinsey JF, Schneider PA, Littooy F. Reporting standards for carotid interventions from the Society for Vascular Surgery. J Vasc Surg 2011; 53:1679-95. [DOI: 10.1016/j.jvs.2010.11.122] [Citation(s) in RCA: 55] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2010] [Revised: 11/24/2010] [Accepted: 11/28/2010] [Indexed: 10/18/2022]
|
117
|
|
118
|
Bliagos D, Gray WA. Past, present and future of carotid artery stenting: a critical review of randomized studies and registries. Interv Cardiol 2011. [DOI: 10.2217/ica.11.35] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
|
119
|
|
120
|
GRIBAR JOHNJ, JIDDOU MONICA, CHOKSI NISHIT, ABBAS AMRE, BOWERS TERRY, KAZMIERCZAK CHRIS, TIMMS CHRIS, SAFIAN ROBERTD. Carotid Stenting in High-Risk Patients: Early and Late Outcomes. J Interv Cardiol 2011; 24:247-53. [DOI: 10.1111/j.1540-8183.2011.00635.x] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
|
121
|
Brott TG, Halperin JL, Abbara S, Bacharach JM, Barr JD, Bush RL, Cates CU, Creager MA, Fowler SB, Friday G, Hertzberg VS, McIff EB, Moore WS, Panagos PD, Riles TS, Rosenwasser RH, Taylor AJ. 2011 ASA/ACCF/AHA/AANN/AANS/ACR/ASNR/CNS/SAIP/ SCAI/SIR/SNIS/SVM/SVS Guideline on the Management of Patients With Extracranial Carotid and Vertebral Artery Disease: Executive Summary. Vasc Med 2011; 16:35-77. [DOI: 10.1177/1358863x11399328] [Citation(s) in RCA: 68] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
|
122
|
Shrikhande GV, McKinsey JF. Choosing the Appropriate Intervention for Symptomatic and Asymptomatic Carotid Disease in the Era of Multiple Therapies: Integration of Risk Profile and Technical Data. Semin Vasc Surg 2011; 24:53-9. [DOI: 10.1053/j.semvascsurg.2011.03.006] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
|
123
|
Gray WA. Role of Carotid Stenting in Management of Carotid Bifurcation Disease: Was the Revolution Overstated? Semin Vasc Surg 2011; 24:21-3. [DOI: 10.1053/j.semvascsurg.2011.03.004] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
|
124
|
Clevert DA, Sommer WH, Zengel P, Helck A, Reiser M. Imaging of carotid arterial diseases with contrast-enhanced ultrasound (CEUS). Eur J Radiol 2011; 80:68-76. [PMID: 21354734 DOI: 10.1016/j.ejrad.2010.12.103] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2010] [Accepted: 12/29/2010] [Indexed: 10/18/2022]
Abstract
Carotid duplex ultrasound is the standard of care for the initial diagnosis of carotid artery bifurcation diseases. But in difficult examinations, carotid abnormalities are commonly encountered and may represent a diagnostic challenge in patients with clinical symptoms as well as in the follow up after carotid endarterectomy or carotid artery stenting. Contrast enhanced ultrasound (CEUS) with low mechanical index (low MI) is a promising new method in the diagnosis and follow up of pathological carotid diseases. Unlike most contrast agents used for magnetic resonance imaging or computed tomography, the microbubbles used in CEUS with SonoVue(®) remain within the vascular space and hence can be used to study vascular disease. In addition to improving current carotid structural scans, CEUS has potential to improve or add extra information on carotid arterial diseases. This review describes the current carotid duplex ultrasound examination and compares the pathological findings with CEUS.
Collapse
Affiliation(s)
- D A Clevert
- Department of Radiology, Klinikum Grosshadern, University of Munich, Munich 81377, Germany.
| | | | | | | | | |
Collapse
|
125
|
Baldi S, Zander T, Rabellino M, González G, Maynar M. Carotid artery stenting without angioplasty and cerebral protection: a single-center experience with up to 7 years' follow-up. AJNR Am J Neuroradiol 2011; 32:759-63. [PMID: 21349967 DOI: 10.3174/ajnr.a2375] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
BACKGROUND AND PURPOSE The use of cerebral protection during CAS in the treatment of carotid artery disease is matter of controversy. The purpose of this study was to evaluate the outcome of CASWBAP in a large cohort of patients, with ≤7 years' follow-up. MATERIALS AND METHODS Two hundred thirty-six patients with 255 symptomatic carotid stenoses and/or with high-risk-morphology plaques of >50% and asymptomatic plaques of >70% were prospectively identified. Patients underwent neurologic and carotid US examination before the procedure and during follow-up at 1, 3, 6, and 12 months and annually thereafter. Plain films of the neck were obtained immediately after the procedure and then at 1 and 3 months. RESULTS Technical success was achieved in 253/255 (99%) patients. Primary stent placement was successful in 248/253 (98%) patients. Neurologic periprocedural complications within 30 days included 1 (0.4%) nondisabling stroke, 1 (0.4%) disabling stroke, 11 (4.3%) TIAs, and 1 (0.4%) death. The mean duration of follow-up was 23 ± 1.4 months (range, 3-84 months). During the follow-up period, there were 9 additional deaths (7 unrelated to the carotid disease and 2 stroke-related) and 2 strokes (in other vascular territories). The degree of stenosis decreased from a mean of 82% before the procedure to a mean of 30% immediately after. During follow-up, 38 (14.8%) angioplasties were performed due to restenosis in 19 (7.4%) patients, lack of stent expansion in 14 (5.4%), or both in 5 (1.9%). CONCLUSIONS CASWBAP is effective and safe with a low incidence of periprocedural complications, providing satisfactory long-term clinical results.
Collapse
Affiliation(s)
- S Baldi
- Department of Endovascular Therapy, Hospiten Rambla Hospital, Santa Cruz de Tenerife, Spain.
| | | | | | | | | |
Collapse
|
126
|
Slovut DP. Carotid artery stenting. Ann Vasc Surg 2011; 25:287-93. [PMID: 21315237 DOI: 10.1016/j.avsg.2010.12.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2010] [Accepted: 12/17/2010] [Indexed: 11/17/2022]
Affiliation(s)
- David Paul Slovut
- Department of Vascular Medicine, Heart Hospital of South Dakota, Sioux Falls, SD, USA.
| |
Collapse
|
127
|
Margey R, Drachman DE. Carotid artery disease and stenting: insights from recent clinical trials. CURRENT TREATMENT OPTIONS IN CARDIOVASCULAR MEDICINE 2011; 13:129-45. [PMID: 21318556 DOI: 10.1007/s11936-011-0116-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Abstract
OPINION STATEMENT Cerebrovascular disease remains a leading cause of morbidity, mortality, and health care expenditure in the United States. Approximately 80% of strokes are ischemic in origin, with 20% to 25% due to atherosclerotic disease of the carotid artery. It is well established that untreated, symptomatic carotid stenosis confers a 25% risk of stroke within 2 years, and that asymptomatic carotid stenosis > 60% is associated with an 11% stroke risk at 5 years. Over the past six decades, surgical revascularization with carotid endarterectomy, when performed by experienced surgeons, has been demonstrated to be effective in reducing stroke risk in patients with severe stenosis. During the same time, medical therapy has improved considerably, and endovascular therapy with carotid angioplasty and stenting has emerged as an important alternative strategy that may play a significant role in reducing the risk of stroke in patients with carotid disease. In this review, we examine the current evidence regarding optimal medical therapy, endarterectomy, and stenting for the management of patients with carotid stenosis. Armed with these data, we may tailor our approach to optimize care based on patient- and lesion-specific considerations.
Collapse
Affiliation(s)
- Ronan Margey
- Cardiology Division, Section of Vascular Medicine, Massachusetts General Hospital and Harvard Medical School, Gray-Bigelow 800, 55 Fruit Street, Boston, MA, 02114, USA
| | | |
Collapse
|
128
|
Brott TG, Halperin JL, Abbara S, Bacharach JM, Barr JD, Bush RL, Cates CU, Creager MA, Fowler SB, Friday G, Hertzberg VS, McIff EB, Moore WS, Panagos PD, Riles TS, Rosenwasser RH, Taylor AJ, Jacobs AK, Smith SC, Anderson JL, Adams CD, Albert N, Buller CE, Creager MA, Ettinger SM, Guyton RA, Halperin JL, Hochman JS, Hunt SA, Krumholz HM, Kushner FG, Lytle BW, Nishimura RA, Ohman EM, Page RL, Riegel B, Stevenson WG, Tarkington LG, Yancy CW. 2011 ASA/ACCF/AHA/AANN/AANS/ACR/ASNR/CNS/SAIP/SCAI/SIR/SNIS/SVM/SVS Guideline on the Management of Patients With Extracranial Carotid and Vertebral Artery Disease: Executive summary. Catheter Cardiovasc Interv 2011; 81:E76-123. [DOI: 10.1002/ccd.22983] [Citation(s) in RCA: 164] [Impact Index Per Article: 12.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
|
129
|
2011 ASA/ACCF/AHA/AANN/AANS/ACR/ASNR/CNS/SAIP/SCAI/SIR/SNIS/SVM/SVS Guideline on the Management of Patients With Extracranial Carotid and Vertebral Artery Disease: Executive Summary. J Am Coll Cardiol 2011; 57:1002-44. [DOI: 10.1016/j.jacc.2010.11.005] [Citation(s) in RCA: 262] [Impact Index Per Article: 20.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
|
130
|
Groeneveld PW, Epstein AJ, Yang F, Yang L, Polsky D. Medicare's policy on carotid stents limited use to hospitals meeting quality guidelines yet did not hurt disadvantaged. Health Aff (Millwood) 2011; 30:312-21. [PMID: 21289353 PMCID: PMC3164858 DOI: 10.1377/hlthaff.2010.0320] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Medicare began covering the use of carotid stents to treat arterial blockages in 2005 under an innovative policy requiring hospitals to meet quality-of-care benchmarks before seeking reimbursement. By restricting carotid stent provision to a smaller subset of US hospitals than those typically adopting new cardiovascular technologies, this policy could have disproportionately reduced the availability of this technology for minority, low-income, and rural patients. Such patients are often served by hospitals less able than others to meet increasingly stringent quality requirements. However, our analysis of hospitals that provided stents during 2005-07 demonstrated that although 21-38 percent fewer hospitals offered stents than offered other types of interventional cardiovascular procedures, such as heart bypass grafts, stents were no less available in localities with substantial poor, black, or rural populations than they were in other areas. Our study provides important evidence that the carotid stent coverage policy met its goal of limiting the adoption of the technology by hospitals that weren't well prepared to provide it-while still maintaining equitable availability of the technology. Therefore, it may be a useful model for future Medicare coverage decisions.
Collapse
|
131
|
Eslami MH, McPhee JT, Simons JP, Schanzer A, Messina LM. National trends in utilization and postprocedure outcomes for carotid artery revascularization 2005 to 2007. J Vasc Surg 2011; 53:307-15. [DOI: 10.1016/j.jvs.2010.08.080] [Citation(s) in RCA: 70] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2010] [Revised: 08/26/2010] [Accepted: 08/26/2010] [Indexed: 10/18/2022]
|
132
|
Brott TG, Halperin JL, Abbara S, Bacharach JM, Barr JD, Bush RL, Cates CU, Creager MA, Fowler SB, Friday G, Hertzberg VS, McIff EB, Moore WS, Panagos PD, Riles TS, Rosenwasser RH, Taylor AJ. 2011 ASA/ACCF/AHA/AANN/AANS/ACR/ASNR/CNS/SAIP/SCAI/SIR/SNIS/SVM/SVS Guideline on the Management of Patients With Extracranial Carotid and Vertebral Artery Disease. J Am Coll Cardiol 2011; 57:e16-94. [PMID: 21288679 DOI: 10.1016/j.jacc.2010.11.006] [Citation(s) in RCA: 194] [Impact Index Per Article: 14.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
|
133
|
Brott TG, Halperin JL, Abbara S, Bacharach JM, Barr JD, Bush RL, Cates CU, Creager MA, Fowler SB, Friday G, Hertzberg VS, McIff EB, Moore WS, Panagos PD, Riles TS, Rosenwasser RH, Taylor AJ. 2011 ASA/ACCF/AHA/AANN/AANS/ACR/ASNR/CNS/SAIP/SCAI/SIR/SNIS/SVM/SVS guideline on the management of patients with extracranial carotid and vertebral artery disease. Stroke 2011; 42:e464-540. [PMID: 21282493 DOI: 10.1161/str.0b013e3182112cc2] [Citation(s) in RCA: 96] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
|
134
|
Brott TG, Halperin JL, Abbara S, Bacharach JM, Barr JD, Bush RL, Cates CU, Creager MA, Fowler SB, Friday G, Hertzberg VS, McIff EB, Moore WS, Panagos PD, Riles TS, Rosenwasser RH, Taylor AJ. 2011 ASA/ACCF/AHA/AANN/AANS/ACR/ASNR/CNS/SAIP/SCAI/SIR/SNIS/SVM/SVS guideline on the management of patients with extracranial carotid and vertebral artery disease. A report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines, and the American Stroke Association, American Association of Neuroscience Nurses, American Association of Neurological Surgeons, American College of Radiology, American Society of Neuroradiology, Congress of Neurological Surgeons, Society of Atherosclerosis Imaging and Prevention, Society for Cardiovascular Angiography and Interventions, Society of Interventional Radiology, Society of NeuroInterventional Surgery, Society for Vascular Medicine, and Society for Vascular Surgery. Circulation 2011; 124:e54-130. [PMID: 21282504 DOI: 10.1161/cir.0b013e31820d8c98] [Citation(s) in RCA: 59] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
|
135
|
Young KC, Holloway RG, Burgin WS, Benesch CG. A cost-effectiveness analysis of carotid artery stenting compared with endarterectomy. J Stroke Cerebrovasc Dis 2011; 19:404-9. [PMID: 20816349 DOI: 10.1016/j.jstrokecerebrovasdis.2009.08.003] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2009] [Accepted: 08/11/2009] [Indexed: 10/19/2022] Open
Abstract
Endarterectomy and angioplasty with stenting have emerged as 2 alternative treatments for carotid artery stenosis. This study's objective was to determine the cost-effectiveness of carotid artery stenting (CAS) compared with carotid endarterectomy (CEA) in symptomatic subjects who are suitable for either intervention. A Markov analysis of these 2 revascularization procedures was conducted using direct Medicare costs (2007 US$) and characteristics of a symptomatic 70-year-old cohort over a lifetime. In the base case analysis, CAS produced 8.97 quality-adjusted life-years, compared with 9.64 quality-adjusted life-years for CEA. The incremental cost of stenting was $17,700, and thus CAS was dominated by CEA. Sensitivity analyses show that the long-term probabilities of major stroke or mortality influenced the results. In the base case analysis, CEA for patients with symptomatic stenosis has a greater benefit than CAS, with lower direct costs. With 59% probability, CEA will be the optimal intervention when all of the model assumptions are varied simultaneously.
Collapse
Affiliation(s)
- Kate C Young
- Department of Surgery, University of Rochester Medical Center, Rochester, New York, USA.
| | | | | | | |
Collapse
|
136
|
Rizwan Khalid M, Khalid F, Farooqui FA, Dragoi D, Niazi K. Can experienced physicians with high peripheral interventional volume but low carotid artery stenting (CAS) volume achieve low complication rates during CAS? EUROINTERVENTION 2011; 6:744-7. [DOI: 10.4244/eijv6i6a126] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
|
137
|
Predictors of Neurological Events Associated With Carotid Artery Stenting in High-Surgical-Risk Patients. Circ Cardiovasc Interv 2010; 3:577-84. [DOI: 10.1161/circinterventions.110.950097] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background—
Comorbid and anatomic characteristics that portend higher procedural risk are well defined for carotid endarterectomy but less so for carotid artery stenting.
Methods and Results—
We pooled carotid stent data from 4 Cordis-sponsored trials (n=2104) with similar patient cohorts and end point determination to identify predictors of neurological death or stroke within 30 days of the procedure. Median age was 74 years (24% >80 years), 36% were women, and 24.2% were symptomatic in the previous 6 months. There were 88 (4.2%) neurological deaths or strokes at 30 days. Among symptomatic patients, the risk of adverse neurological outcome declined with increasing time between the incident neurological event and carotid stent procedure. In a logistic regression model that included preprocedural and procedural variables, significant multivariable predictors of 30-day neurological death or stroke were older age (continuous), black race, angiographically visible thrombus in symptomatic patients, procedural use of glycoprotein IIb/IIIa inhibitors, procedural transient ischemic attack, final residual stenosis >30%, and periprocedural use of protamine or vasopressors.
Conclusions—
In this pooled analysis, a number of preprocedural and procedural factors predicted higher risk of stroke and neurological death within 30 days of a carotid stent procedure. Identification of such predictors may help to guide patient selection and further refine procedural technique.
Collapse
|
138
|
Giles KA, Hamdan AD, Pomposelli FB, Wyers MC, Schermerhorn ML. Stroke and death after carotid endarterectomy and carotid artery stenting with and without high risk criteria. J Vasc Surg 2010; 52:1497-504. [PMID: 20864299 PMCID: PMC3005797 DOI: 10.1016/j.jvs.2010.06.174] [Citation(s) in RCA: 65] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2010] [Revised: 06/24/2010] [Accepted: 06/28/2010] [Indexed: 11/29/2022]
Abstract
OBJECTIVE Centers for Medicare and Medicaid Services (CMS) reimbursement criteria for carotid artery stenting (CAS) require that patients be high surgical risk or enrolled in a clinical trial. This may bias comparisons of CAS and carotid endarterectomy (CEA). We evaluate mortality and stroke following CAS and CEA stratified by medical high risk criteria. METHODS The Nationwide Inpatient Sample (2004-2007) was queried by ICD-9 code for CAS and CEA with diagnosis of carotid artery stenosis. Medical high risk criteria were identified for each patient including patients undergoing a coronary artery bypass and/or valve repair (CABG/V) during the same admission. Symptom status was defined by history of stroke, transient ischemic attack (TIA), and/or amarosis fugax. The primary outcome was postoperative death, stroke (complication code 997.02), and combined stroke or death, stratified by high risk vs non-high risk status and symptom status. RESULTS Patient totals of 56,564 (10.5%) CAS and 482,394 (89.5%) CEA were identified. Half of the patients in each group were high risk. CABG/V was performed less commonly with CAS than CEA (2.8% vs 4.0%, P < .001). Patients undergoing CAS were more likely symptomatic than those undergoing CEA (13.1% vs 9.4%, P < .001). Mortality was higher after CAS than CEA for both high risk and non-high risk patients. Stroke was also higher after CAS for both high risk and non-high risk patients. Combined stroke or death was higher after CAS again for both high risk (asymptomatic 1.5% vs 1.2%, P < .05, symptomatic 14.4% vs 6.9%, P < .001) and non-high risk (asymptomatic 1.8% vs 0.6%, P < .001, symptomatic 11.8% vs 4.9%, P < .001). Combined stroke or death for patients undergoing CABG/V during the same admission was similar for CAS and CEA (4.8% vs 3.2%, P = .19). Multivariate predictors of combined stroke or death adjusted for age and gender included CAS vs CEA (odds ratio [OR] 2.4, P < .001), symptom status (OR 6.8, P < .001), high risk (OR 1.6, P < .001), and earlier year of procedure (OR 1.1, P < .01). CONCLUSIONS In the United States from 2004 to 2007, CAS has a higher risk of stroke and death than CEA after adjustment for medical high risk criteria. Further analysis with prospective assessment of risk factors is needed to guide appropriate patient selection for CEA and CAS in the general population.
Collapse
Affiliation(s)
- Kristina A Giles
- Beth Israel Deaconess Medical Center, Division of Vascular and Endovascular Surgery, 110 Francis Street, Boston, MA 02115, USA
| | | | | | | | | |
Collapse
|
139
|
Binning MJ, Khalessi AA, Hopkins LN. Carotid Revascularization Endarterectomy Versus Stenting Trial (CREST): current and future implications for carotid artery stenting. Interv Cardiol 2010. [DOI: 10.2217/ica.10.85] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
|
140
|
Clair DG, Hopkins LN, Mehta M, Kasirajan K, Schermerhorn M, Schönholz C, Kwolek CJ, Eskandari MK, Powell RJ, Ansel GM. Neuroprotection during carotid artery stenting using the GORE flow reversal system: 30-day outcomes in the EMPiRE Clinical Study. Catheter Cardiovasc Interv 2010; 77:420-9. [DOI: 10.1002/ccd.22789] [Citation(s) in RCA: 97] [Impact Index Per Article: 6.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/16/2010] [Accepted: 08/20/2010] [Indexed: 11/11/2022]
|
141
|
AbuRahma AF, Abu-Halimah S, Hass SM, Nanjundappa A, Stone PA, Mousa A, Lough E, Dean L. Carotid artery stenting outcomes are equivalent to carotid endarterectomy outcomes for patients with post-carotid endarterectomy stenosis. J Vasc Surg 2010; 52:1180-7. [DOI: 10.1016/j.jvs.2010.06.074] [Citation(s) in RCA: 39] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2010] [Revised: 06/01/2010] [Accepted: 06/05/2010] [Indexed: 10/19/2022]
|
142
|
Carotid artery stenting with distal filter protection: single-center experience in high-surgical-risk patients. Heart Vessels 2010; 26:125-30. [DOI: 10.1007/s00380-010-0002-7] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/09/2009] [Accepted: 11/26/2009] [Indexed: 10/18/2022]
|
143
|
Ansel GM, Hopkins LN, Jaff MR, Rubino P, Bacharach JM, Scheinert D, Myla S, Das T, Cremonesi A. Safety and effectiveness of the INVATEC MO.MA proximal cerebral protection device during carotid artery stenting: results from the ARMOUR pivotal trial. Catheter Cardiovasc Interv 2010; 76:1-8. [PMID: 20222019 DOI: 10.1002/ccd.22439] [Citation(s) in RCA: 135] [Impact Index Per Article: 9.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
OBJECTIVE The multicenter ARMOUR (ProximAl PRotection with the MO.MA Device DUring CaRotid Stenting) trial evaluated the 30-day safety and effectiveness of the MO.MA Proximal Cerebral Protection Device (Invatec, Roncadelle, Italy) utilized to treat high surgical risk patients undergoing carotid artery stenting (CAS). BACKGROUND Distal embolic protection devices (EPD) have been traditionally utilized during CAS. The MO.MA device acts as a balloon occlusion "endovascular clamping" system to achieve cerebral protection prior to crossing the carotid stenosis. METHODS This prospective registry enrolled 262 subjects, 37 roll-in and 225 pivotal subjects evaluated with intention to treat (ITT) from September 2007 to February 2009. Subjects underwent CAS using the MO.MA device. The primary endpoint, myocardial infarction, stroke, or death through 30 days (30-day major adverse cardiac and cerebrovascular events [MACCE]) was compared to a performance goal of 13% derived from trials utilizing distal EPD. RESULTS For the ITT population, the mean age was 74.7 years with 66.7% of the cohort being male. Symptomatic patients comprised 15.1% and 28.9% were octogenarians. Device success was 98.2% and procedural success was 93.2%. The 30-day MACCE rate was 2.7% [95% CI (1.0-5.8%)] with a 30-day major stroke rate of 0.9%. No symptomatic patient suffered a stroke during this trial. CONCLUSIONS The ARMOUR trial demonstrated that the MO.MA(R) Proximal Cerebral Protection Device is safe and effective for high surgical risk patients undergoing CAS. The absence of stroke in symptomatic patients is the lowest rate reported in any independently adjudicated prospective multicenter registry trial to date.
Collapse
Affiliation(s)
- Gary M Ansel
- Department of Cardiology, Riverside Methodist Hospital, 3705 Olentangy River Road, Columbus, OH 43214, USA.
| | | | | | | | | | | | | | | | | | | |
Collapse
|
144
|
Giacovelli JK, Egorova N, Dayal R, Gelijns A, McKinsey J, Kent KC. Outcomes of carotid stenting compared with endarterectomy are equivalent in asymptomatic patients and inferior in symptomatic patients. J Vasc Surg 2010; 52:906-13, 913.e1-4. [DOI: 10.1016/j.jvs.2010.05.010] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2010] [Revised: 05/04/2010] [Accepted: 05/04/2010] [Indexed: 10/19/2022]
|
145
|
|
146
|
Schreiber TL, Strickman N, Davis T, Kumar V, Mishkel G, Foster M, Donohoe D, Britto S, Ansel G. Carotid artery stenting with emboli protection surveillance study: outcomes at 1 year. J Am Coll Cardiol 2010; 56:49-57. [PMID: 20620717 DOI: 10.1016/j.jacc.2010.02.045] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/03/2009] [Revised: 02/17/2010] [Accepted: 02/25/2010] [Indexed: 10/19/2022]
Abstract
OBJECTIVES The CASES-PMS (Carotid Artery Stenting With Emboli Protection Surveillance-Post-Marketing Study) multicenter, prospective, single-arm, surveillance study was designed to assess the safety and efficacy of carotid artery stenting (CAS) when performed by physicians with varied experience in CAS utilizing a formal training program. Whether the excellent results achieved at 30 days would be sustained to 1 year was the subject of the current investigation. BACKGROUND Previously, the pivotal SAPPHIRE (Stenting and Angioplasty with Protection of Patients with High Risk for Endarterectomy) trial demonstrated that CAS was not inferior to carotid endarterectomy (CEA) when performed by physicians experienced in carotid stenting. METHODS High surgical-risk patients with de novo atherosclerotic or post-endarterectomy restenotic lesions in native carotid arteries were enrolled at participating centers. Inclusion and exclusion criteria matched those of the SAPPHIRE trial. The primary end point was a composite of 30-day major adverse events (MAE) including death, any stroke, or myocardial infarction. RESULTS A total of 1,492 patients were enrolled at 73 sites. The primary end point of 30-day MAE was 5.0%, meeting criteria for noninferiority to the prespecified objective performance criteria (OPC) established by the SAPPHIRE trial. The 1-year cumulative percentage of MAE was 12.5% by Kaplan-Meier analysis. All strokes to 30 days plus ipsilateral stroke between 31 and 360 days with CASES-PMS (5.4%) was similar to the rate seen with the SAPPHIRE trial stent cohort (4.9%). There were no significant differences in outcomes at 1 year by symptom status and high-risk status. CONCLUSIONS With the formalized training program utilized in this study, physicians with varied experience in carotid stenting can achieve similar short- and longer-term results to the highly experienced SAPPHIRE Investigators. (Carotid Artery Stenting With Emboli Protection Surveillance-Post-Marketing Study [CASES-PMS]; NCT00231231).
Collapse
|
147
|
Myla S, Bacharach JM, Ansel GM, Dippel EJ, McCormick DJ, Popma JJ. Carotid artery stenting in high surgical risk patients using the FiberNet embolic protection system: the EPIC trial results. Catheter Cardiovasc Interv 2010; 75:817-22. [PMID: 20201102 DOI: 10.1002/ccd.22386] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
OBJECTIVE The multicenter EPIC (FiberNet Embolic Protection System in Carotid Artery Stenting Trial) single-arm trial evaluated the 30-day outcomes of a new design concept for embolic protection during carotid artery stenting (CAS). BACKGROUND Embolic protection filters available for use during CAS include fixed and over-the-wire systems that rely on embolic material capture within a "basket" structure. The FiberNet Embolic Protection System (EPS), which features a very low crossing profile, consists of a three-dimensional fiber-based filter distally mounted on a 0.014 inch guidewire with integrated aspiration during filter retrieval. METHODS The trial enrolled 237 patients from 26 centers. Demographics, clinical and lesion characteristics, as well as adverse events through a 30-day follow-up were recorded. The mean age of the patients was 74 years, 64% were male and 20% had symptomatic carotid artery disease. RESULTS The combined major adverse event (MAE) rate at 30 days for all death, stroke, and myocardial infarction was 3.0%. There were three major strokes (two ischemic and one hemorrhagic) and two minor strokes (both ischemic) for a 2.1% 30-day stroke rate. The procedural technical success rate was 97.5% and macroscopic evidence of debris was reported in 90.9% of the procedures. CONCLUSIONS The FiberNet EPS, used with commercially available stents, produced low stroke rates following CAS in high surgical risk patients presenting with carotid artery disease. The unique filter design including aspiration during retrieval may have contributed to the low 30-day stroke rate reported during CAS in patients considered at high risk for complications following carotid endarterectomy (CEA).
Collapse
Affiliation(s)
- Subbarao Myla
- Hoag Memorial Hospital, Newport Beach, California 92663, USA.
| | | | | | | | | | | |
Collapse
|
148
|
Young KC, Jahromi BS, Singh MJ, Illig KA, Benesch CG. Hospital resource use following carotid endarterectomy in 2006: analysis of the nationwide inpatient sample. J Stroke Cerebrovasc Dis 2010; 19:458-64. [PMID: 20538482 DOI: 10.1016/j.jstrokecerebrovasdis.2009.10.004] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2009] [Accepted: 10/27/2009] [Indexed: 11/19/2022] Open
Abstract
To explore the relationships among patient age and length of stay (LOS), hospital costs, and discharge disposition following carotid endarterectomy (CEA), we identified discharge records from the 2006 Nationwide Inpatient Sample (NIS). The primary outcome was LOS from the surgical procedure to discharge. We examined LOS from procedure to discharge because the time from procedure to discharge may better reflect hospital stay due to the procedure itself for subjects with symptomatic carotid artery disease compared with the inclusion of days hospitalized for stroke recovery. Secondary endpoints included total LOS, discharge disposition, and cost of hospitalization. More than 90% of the 118,218 discharge records for CEA examined were for patients with asymptomatic carotid disease. The LOS from procedure to discharge and total LOS increased per decade, starting at age 70-79 years. Age per decade increased the likelihood of needed an LOS from procedure to discharge of >1 day. The same trend was seen for the likelihood of needing a >2-day postoperative stay; patients age ≥80 years required the longest postoperative LOS (odds ratio [OR]=1.45 for >1 day and 1.45 for >2 days; both P<.001). Total hospital costs averaged $10,965 for all discharges. For age dichotomized at 80 years, the average cost increased by $845. Age≥80 years also was independently associated with discharge to a skilled nursing facility (SNF) (OR=2.4; 95% confidence interval=2.09-2.76). Hospital LOS and costs following CEA increased with increasing patient age. Morbidity after CEA should be discussed with patients in whom revascularization for asymptomatic disease is being considered.
Collapse
Affiliation(s)
- Kate C Young
- Department of Neurology, University of Rochester School of Medicine and Dentistry, Rochester, New York 14642, USA.
| | | | | | | | | |
Collapse
|
149
|
Hopkins LN, Roubin GS, Chakhtoura EY, Gray WA, Ferguson RD, Katzen BT, Rosenfield K, Goldstein J, Cutlip DE, Morrish W, Lal BK, Sheffet AJ, Tom M, Hughes S, Voeks J, Kathir K, Meschia JF, Hobson RW, Brott TG. The Carotid Revascularization Endarterectomy versus Stenting Trial: credentialing of interventionalists and final results of lead-in phase. J Stroke Cerebrovasc Dis 2010; 19:153-62. [PMID: 20189092 DOI: 10.1016/j.jstrokecerebrovasdis.2010.01.001] [Citation(s) in RCA: 146] [Impact Index Per Article: 10.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2010] [Accepted: 01/06/2010] [Indexed: 11/27/2022] Open
Abstract
The success of carotid artery stenting in preventing stroke requires a low risk of periprocedural stroke and death. A comprehensive training and credentialing process was prerequisite to the randomized Carotid Revascularization Endarterectomy versus Stenting Trial (CREST) to assemble a competent team of interventionalists with low periprocedural event rates. Interventionalists submitted cases to a multidisciplinary Interventional Management Committee. This committee evaluated 427 applicants. Of these, 238 (56%) were selected to participate in the training program and the lead-in phase, 73 (17%) who had clinical registry experience and satisfactory results with the devices used in CREST were exempt from training and were approved for the randomized phase, and 116 (27%) did not qualify for training. At 30 days in the lead-in study, stroke, myocardial infarction, or death occurred in 6.1% of symptomatic subjects and 4.8% of asymptomatic subjects. Stroke or death occurred in 5.8% of symptomatic subjects and 3.8% of asymptomatic subjects. Outcomes were better for younger subjects and varied by operator training. Based on experience, training, and lead-in results, the Interventional Management Committee selected 224 interventionalists to participate in the randomized phase of CREST. We believe that the credentialing and training of interventionalists participating in CREST have been the most rigorous reported to date for any randomized trial evaluating endovascular treatments. The study identified competent operators, which ensured that the randomized trial results fairly contrasted outcomes between endarterectomy and stenting.
Collapse
Affiliation(s)
- L Nelson Hopkins
- Department of Neurosurgery, Millard Fillmore Hospital, University at Buffalo, State University of New York, Buffalo, New York, USA
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|
150
|
Ielasi A, Latib A, Godino C, Sharp ASP, Al Lamee R, Montorfano M, Airoldi F, Carlino M, Chieffo A, Sangiorgi GM, Colombo A. Clinical Outcomes Following Protected Carotid Artery Stenting in Symptomatic and Asymptomatic Patients. J Endovasc Ther 2010; 17:298-307. [DOI: 10.1583/09-2997.1] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
|