Stenting versus endarterectomy for treatment of carotid-artery stenosis

Inflammation and in-stent restenosis: the role of serum markers and stent characteristics in carotid artery stenting

Background

Carotid angioplasty and stenting (CAS) may currently be recommended especially in younger patients with a high-grade carotid artery stenosis. However, evidence is accumulating that in-stent restenosis (ISR) could be an important factor endangering the long-term efficacy of CAS. The aim of this study was to investigate the influence of inflammatory serum markers and procedure-related factors on ISR as diagnosed with duplex sonography.

Methods

We analyzed 210 CAS procedures in 194 patients which were done at a single university hospital between May 2003 and June 2010. Periprocedural C-reactive protein (CRP) and leukocyte count as well as stent design and geometry, and other periprocedural factors were analyzed with respect to the occurrence of an ISR as diagnosed with serial carotid duplex ultrasound investigations during clinical long-term follow-up.

Results

Over a median of 33.4 months follow-up (IQR: 14.9–53.7) of 210 procedures (mean age of 67.9±9.7 years, 71.9% male, 71.0% symptomatic) an ISR of ≥70% was detected in 5.7% after a median of 8.6 months (IQR: 3.4–17.3). After multiple regression analysis, leukocyte count after CAS-intervention (odds ratio (OR): 1.31, 95% confidence interval (CI): 1.02–1.69; p = 0.036), as well as stent length and width were associated with the development of an ISR during follow-up (OR: 1.25, 95% CI: 1.05–1.65, p = 0.022 and OR: 0.28, 95% CI: 0.09–0.84, p = 0.010).

Conclusions

The majority of ISR during long-term follow-up after CAS occur within the first year. ISR is associated with periinterventional inflammation markers and influenced by certain stent characteristics such as stent length and width. Our findings support the assumption that stent geometry leading to vessel injury as well as periprocedural inflammation during CAS plays a pivotal role in the development of carotid artery ISR.

[Difficult decisions in stroke therapy]

In numerous situations stroke physicians face a lack of evidence during their daily practice. In this report the authors address some of the difficult treatment decisions encountered in acute therapy and secondary prevention. Examples include off-label thrombolysis and prevention in high-risk situations. The available data from trials and registries are discussed, and personal views and recommendations are expressed.

Carotid artery stenting trials: conduct, results, critique, and current recommendations

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.

Cardiovascular disease in chronic kidney disease. A clinical update from Kidney Disease: Improving Global Outcomes (KDIGO)

Cardiovascular morbidity and mortality in patients with chronic kidney disease (CKD) is high, and the presence of CKD worsens outcomes of cardiovascular disease (CVD). CKD is associated with specific risk factors. Emerging evidence indicates that the pathology and manifestation of CVD differ in the presence of CKD. During a clinical update conference convened by the Kidney Disease: Improving Global Outcomes (KDIGO), an international group of experts defined the current state of knowledge and the implications for patient care in important topic areas, including coronary artery disease and myocardial infarction, congestive heart failure, cerebrovascular disease, atrial fibrillation, peripheral arterial disease, and sudden cardiac death. Although optimal strategies for prevention, diagnosis, and management of these complications likely should be modified in the presence of CKD, the evidence base for decision making is limited. Trials targeting CVD in patients with CKD have a large potential to improve outcomes.

Carotid Atherosclerotic Disease and Cognitive Function: Mechanisms Identifying New Therapeutic Targets

The treatment of carotid atherosclerotic disease lies primarily in decreasing the risk of stroke. Many investigations have suggested carotid atherosclerotic disease as being independently associated with cognitive dysfunction, also supporting the notion that in sub-clinical stages, carotid atherosclerotic disease may not be truly silent. An improvement in cognitive function following revascularization approaches may be expected from the reduced embolism and the improved hemodynamics achieved. However, there are no strong data indicating a cognitive change after carotid angioplasty and stenting or carotid endarterectomy in patients who do not experience stroke complications and there is no evidence to support the performance of prophylactic revascularization procedures with the aim of preventing a cognitive decline in otherwise asymptomatic patients. Given the burden of dementia and its tragic implications for individuals and societies, the identification and treatment of such a preventable condition as carotid atherosclerotic disease should be considered. Therefore, it would be desirable in the design of future comparative studies of treatment strategies for carotid atherosclerotic disease to consider cognitive outcome as an endpoint.

Best clinical trials reported in 2010

Each year, a number of clinical trials emerge with data sufficient to change clinical practice. Determining which findings will result in practice change and which will provide only incremental benefit can be a dilemma for clinicians. The authors review selected clinical trials reported in 2010 in journals, at society meetings, and at conferences, focusing on those studies that have the potential to change clinical practice. This review offers 3 separate means of analysis: an abbreviated text summary, organized by subject area; a comprehensive table of relevant clinical trials that provides a schematic review of the hypotheses, interventions, methods, primary end points, results, and implications; and a complete bibliography for further reading as warranted. It is hoped that this compilation of relevant clinical trials and their important findings released in 2010 will be of benefit in the everyday practice of cardiovascular medicine.

What Is the Current Status of Invasive Treatment of Extracranial Carotid Artery Disease?

Year 2011 sees the publication of US guidelines that recommend expanding indications for carotid artery stenting into “average-risk” patients, whereas guidelines from Australia/New Zealand largely do not. This article reviews the status of invasive treatment of carotid disease and highlights 2 controversial issues that were not really addressed in these guidelines: (1) a lack of emphasis on the importance of intervening rapidly after transient ischemic attack/minor stroke; and (2) why continue to recommend that only “highly selected” asymptomatic patients should undergo intervention when virtually no-one pays any attention?

Outcomes After Carotid Artery Stenting and Endarterectomy in the Medicare Population

Background and Purpose—

Carotid artery stenting (CAS) is an alternative to carotid endarterectomy (CEA) for stroke prevention. The value of this therapy relative to CEA remains uncertain.

Methods—

In 10 958 Medicare patients aged 66 years or older between 2004 and 2006, we analyzed in-hospital, 1-year stroke, myocardial infarction, and death rate outcomes and the effects of potential confounding variables.

Results—

CAS patients (87% were asymptomatic) had a higher baseline risk profile, including having a higher percentage of coronary and peripheral arterial disease, heart failure, and renal failure. In-hospital stroke rate (1.9% CAS versus 1.4% CEA; P =0.14) and mortality (CAS 0.9% versus 0.6% CEA; P =0.20) were similar. By 1 year, CAS patients had similar stroke rates (5.3% CAS versus 4.1% CEA; P =0.12) but higher all-cause mortality rates (9.9% CAS versus 6.1% CEA; P <0.001). Using Cox multivariable models, there was a similar stroke risk (hazard ratio, 1.28; 95% CI, 0.90–1.79) but CAS patients had a significantly higher mortality (HR, 1.32; 95% CI, 1.02–1.71). Sensitivity analyses suggested that unmeasured confounders could be responsible for the mortality difference. In multivariable analysis, stroke risk was highest in the patients symptomatic at the time of revascularization.

Conclusions—

CAS patients had a similar stroke risk but an increased mortality rate at 1 year compared with CEA patients, possibly related to the higher baseline risk profile in the CAS patient group.

Cognitive changes after surgery vs stenting for carotid artery stenosis

OBJECTIVES

Cognitive function has not been evaluated systematically in the context of carotid endarterectomy (CEA) versus carotid artery stenting (CAS). Cognitive decline can occur from microembolization or hypoperfusion during CEA or CAS. Carotid revascularization may, however, also improve cognitive dysfunction resulting from chronic hypoperfusion. We compared cognitive outcomes in consecutive asymptomatic patients undergoing CAS or CEA.

METHODS

This is a prospective nonrandomized single-center study of patients with asymptomatic carotid stenosis ≥ 70% undergoing CAS or CEA using standard techniques. Neurologic symptoms were evaluated by history, physical examination, and the National Institutes of Health Stroke Scale. A 50-minute cognitive battery was performed 1 to 3 days before and 4 to 6 months after CEA/CAS. The tests (Trail Making Tests A/B, Processing Speed Index (PSI) of the Wechsler Adult Intelligence Scale - Third Edition (WAIS-III), Boston Naming Test, Working Memory Index (WMI) of the Wechsler Memory Scale - Third Edition (WMS-III), Controlled Oral Word Association, and Hopkins Verbal Learning Test) for six cognitive domains (motor speed/coordination and executive function, psychomotor speed, language (naming), working memory/concentration, verbal fluency, and learning/memory) were conducted by a neuropsychologist. The primary analysis of impact of treatment modality was a normalized cognitive change score.

RESULTS

Forty-six patients underwent prepost testing (CEA = 25, CAS = 21). Women comprised 36% of the cohort, mean preprocedural stenosis was 84%, and 54% were right-sided lesions. All patients were successfully revascularized without periprocedural complications. The scores for each test improved after CEA except WMI, which decreased in 20 of 25 patients. Improvement occurred in all tests after CAS except PSI, which decreased in 18 of 21 patients. In addition to comparing the changes in individual test scores, overall cognitive change was measured by calculating the change in composite cognitive score (CCS) postprocedure versus baseline. To compute the CCS, the raw scores from each test were transformed into z scores and then averaged to calculate each patient's composite score. The composite score at baseline was then compared with that from the postprocedure testing. The CCS improved after both CEA and CAS, and the changes were not significantly different between the groups (.51 vs .47; P = NS).

CONCLUSIONS

Carotid revascularization results in an overall improvement in cognitive function. There are no differences in the composite scores of five major cognitive domains between CEA and CAS. When individual tests are compared, CEA results in a reduction in memory, while CAS patients show reduced psychomotor speed. Larger studies will help confirm these findings.

Safety and feasibility of a novel transcervical access neuroprotection system for carotid artery stenting in the PROOF Study

BACKGROUND

Randomized controlled trials have shown that periprocedural rates of stroke and death are higher with carotid artery stenting (CAS) than with carotid endarterectomy (CEA) in the treatment of carotid artery stenosis. Diffusion-weighted magnetic resonance imaging (DW-MRI) has shown higher rates of clinically silent new ischemic brain lesions when CAS is performed as compared with CEA. The Silk Road Medical Embolic PROtectiOn System: First-In-Man (PROOF) Study is a single-arm first-in-man study using the MICHI Neuroprotection System (Silk Road Medical Inc, Sunnyvale, Calif), a novel transcervical access and cerebral embolic protection system. This system enables stent implantation under controlled blood flow reversal of the carotid artery, also known as Flow Altered Short Transcervical Carotid Artery Stenting (FAST-CAS).

METHODS

Between March 2009 and February 2010, a total of 44 subjects were enrolled into the study. The primary composite endpoint was major stroke, myocardial infarction, or death within 30 days. Forty-three patients (97.7%) completed the study through the 30-day endpoint. One patient was lost to follow-up. In a subgroup of consecutive subjects, DW-MRI examinations were performed preprocedure and within 24 to 48 hours after the stent implantation. Blinded independent neuroradiologists reviewed all DW-MRI studies and confirmed the absence or presence of new ischemic brain lesions.

RESULTS

All enrolled patients were successfully treated, and no major adverse events were seen through the follow-up period. Thirty-one subjects had DW-MRI examinations. Of these, five patients (16%) had evidence of new ischemic brain lesions but no clinical sequelae. Transient intolerance to reverse flow was reported in 9% of cases, but in all cases, a stent was successfully placed, and the intolerance was managed by minimizing the duration of reverse flow during the procedure.

CONCLUSION

In this first-in-man experience, FAST-CAS using the MICHI Neuroprotection System was shown to be a safe and feasible method for carotid revascularization. DW-MRI findings suggest controlled reverse flow provides cerebral embolic protection similar to that seen with CEA.

[Neuroradiologic diagnostic and interventional procedures for diseases of the skull base]

Besides image-guided biopsy techniques, the emphasis in the interdisciplinary cooperation between head and neck surgery and neuroradiology is on vessel-occluding and preserving measures. Knowledge of dangerous anastomoses between extracranial and intracranial vessels is crucial. The principles of vessel-occluding procedures including materials are presented and illustrated with case examples. Embolization of glomus tumors or epistaxis and preoperative permanent vessel occlusion techniques are demonstrated as well as vessel-preserving therapies, such as placement of covered stents for improving tumor resectability or after iatrogenic laceration of the internal carotid artery.

Carotid endarterectomy is superior to carotid angioplasty and stenting for perioperative and long-term results

OBJECTIVE

Carotid angioplasty and stenting (CAS) has challenged carotid endarterectomy (CEA) as the therapy of choice for carotid disease. This meta-analysis aims at summarizing the most current body of evidence.

METHODS

All prospective, controlled clinical trials comparing CEA versus CAS were included. The outcome measures of interest were relative risk (RR) of 30-day stroke, 30-day stroke/death, long-term risk of stroke, and risk of restenosis.

RESULTS

The RR of 30-day stroke for CAS was 1.6 times that of CEA (RR 1.6; 95%CI 1.2-2.0, P = .001). The 30-day RR of stroke/death was 1.5 times higher for CAS (RR 1.5; 95%CI 1.1-2.1, P = .008). There was a higher risk of long-term stroke (RR 1.2; 95%CI 1.0-1.5, P = .043). The risk of restenosis was twice for CAS (RR 1.8; 95%CI 1.1-3.1, P = .04).

CONCLUSION

The 30-day RR of stroke, stroke/death, long-term risk of stroke, and risk of restenosis are consistently higher for carotid artery stenting (CAS).

Ultrasonographic character of carotid plaque and postprocedural brain embolisms in carotid artery stenting and carotid endarterectomy

OBJECTIVE

To investigate ultrasonographic character of carotid plaques, and incidences of brain embolism in carotid angioplasty and stenting (CAS) and carotid endarterectomy (CEA).

MATERIALS AND METHODS

CEA (22/25 symptomatic lesions) and CAS (17/20 symptomatic lesions) between 2007 and 2010. Embolic protection devices (15 occlusion and 5 filtering devices) were used during CAS. Carotid plaques were classified into three categories (I: calcificated, II: intermediately echogenic, III: echolucent). Magnetic resonance imaging (MRI) was used to investigate brain emboli.

RESULTS

Ultrasonographic character of the plaques in CEA cases (I: 4%, II: 88%, III: 8%) was different from the one in CAS cases (I: 10%, II: 90%, III: 0%). The incidence of brain embolism in the CAS cases was 52.6% while 0% in the CEA cases (p = 0.00037). CAS had high incidences of brain embolism in any plaques (I: 100%, II: 43.8%). In the most recent 9 procedures of CAS using occlusion devices, averaged number of embolic lesion was 1.0 (0 post operative day; 0 POD). The number increased as 1.4 (1 POD) and 2.0 (7 POD).

CONCLUSION

CEA should be currently the first choice for most patients with a high-grade and symptomatic carotid artery stenosis.

Evidence-based review of primary and secondary ischemic stroke prevention in adults: a neurosurgical perspective

In this paper, the authors' aim is to provide an evidence-based review of primary and secondary ischemic stroke prevention guidelines covering most of the common risk factors and stroke etiologies for the practicing neurosurgeon. The key to stroke prevention is in the identification and treatment of the major risk factors for stroke. These include hypertension, heart disease, diabetes mellitus, dyslipidemia, and tobacco smoking. An updated approach to secondary prevention of stroke in the setting of intracranial and extracranial large vessel atherosclerosis and cardioembolism is provided along with a brief overview of pertinent clinical trials. Novel pharmacological options for prevention of cardioembolic strokes, such as new alternatives to warfarin, are addressed with recommendations for interruption of therapy for elective surgical procedures. In addition, the authors have reviewed the anticoagulation guidelines and the risk of thromboembolic complications of such therapies in the perioperative period, which is an invaluable piece of information for neurosurgeons. Less common etiologies such as arterial dissections and patent foramen ovale are also briefly discussed. Finally, the authors have outlined the quality measures in the Medicare Physician Quality Reporting System and essential guidelines for Primary Stroke Center certification, which have implications for day-to-day neurosurgical practice.

Influence of sex on outcomes of stenting versus endarterectomy: a subgroup analysis of the Carotid Revascularization Endarterectomy versus Stenting Trial (CREST)

BACKGROUND

In the randomised Carotid Revascularization Endarterectomy versus Stenting Trial (CREST), the primary endpoint did not differ between carotid artery stenting and carotid endarterectomy in patients with symptomatic and asymptomatic stenosis. A prespecified secondary aim was to examine differences by sex.

METHODS

Patients who were asymptomatic or had had a stroke or transient ischaemic attack within 180 days before random allocation were enrolled in CREST at 117 clinical centres in the USA and Canada. The primary outcome was the composite of stroke, myocardial infarction, or death during the periprocedural period or ipsilateral stroke within 4 years. We used standard survival methods including Kaplan-Meier survival curves and sex-by-treatment interaction term to assess the relation between patient factors and risk of reaching the primary outcome. Analyses were by intention to treat. CREST is registered with ClinicalTrials.gov, NCT00004732.

FINDINGS

Between Dec 21, 2000, and July 18, 2008, 2502 patients were randomly assigned to carotid endarterectomy (n=1240) or carotid artery stenting (n=1262), 872 (34.9%) of whom were women. Rates of the primary endpoint for carotid artery stenting compared with carotid endarterectomy were 6.2% versus 6.8% in men (hazard ratio [HR] 0.99, 95% CI 0.66-1.46) and 8.9% versus 6.7% in women (1.35, 0.82-2.23). There was no significant interaction in the primary endpoint between sexes (interaction p=0.34). Periprocedural events occurred in 35 (4.3%) of 807 men assigned to carotid artery stenting compared with 40 (4.9%) of 823 assigned to carotid endarterectomy (HR 0.90, 95% CI 0.57-1.41) and 31 (6.8%) of 455 women assigned to carotid artery stenting compared with 16 (3.8%) of 417 assigned to carotid endarterectomy (1.84, 1.01-3.37; interaction p=0.064).

INTERPRETATION

Periprocedural risk of events seems to be higher in women who have carotid artery stenting than those who have carotid endarterectomy whereas there is little difference in men. Additional data are needed to confirm whether this differential risk should be taken into account in decisions for treatment of carotid disease in women.

FUNDING

National Institute of Neurological Disorders and Stroke and Abbott Vascular Solutions (formerly Guidant).

Protected carotid artery stenting in patients at high risk for carotid endarterectomy

OBJECTIVES

To compare the 30-day, six-month, and one-year outcomes of carotid artery stenting (CAS) and carotid endarterectomy (CEA) in male veterans, and to identify any predictors of adverse outcomes. CAS has been shown to be non-inferior to CEA in patients at high-risk for CEA. The outcome of CAS compared to low-risk CEA is less clear.

METHODS

Retrospective analysis of 96 consecutive patients who underwent CAS (N = 31) or CEA (N = 65). The cumulative 30-day, six-month, and one-year incidence of ipsilateral transient ischemic attack (TIA) or stroke, restenosis or reocclusion, need for target vessel revascularization, non-fatal myocardial infarction (MI), and death were compared.

RESULTS

All patients in the CAS group were at high risk for CEA. Among the CEA group, 50 (76.9%) were at high risk and the remaining 15 (23.1%) were considered to be at low risk. The cumulative incidence of adverse outcomes with CAS and CEA, respectively, at 30 days (3.2% vs 9.2%, P = ns), six months (3.2 vs 18.5%, P = 0.047), and one year (9.7% vs 18.5%, P = ns) favored CAS. This difference was primarily due to adverse events in the high-risk CEA patients. There was no significant difference in outcome between the CAS and low-risk CEA groups. The independent significant predictors for adverse outcomes within six months were the group (P = 0.047) and number of risk factors (P = 0.01). Interestingly, the use of angiotensin-converting enzyme inhibitors (ACE-I) predicted adverse outcomes within one year (P = 0.01).

CONCLUSION

CAS may be superior to high-risk CEA with better six-month outcomes. The outcomes with CAS were not significantly different compared to low-risk CEA, suggesting that CAS may be non-inferior to low-risk CEA.

Myocardial infarction after carotid stenting and endarterectomy: results from the carotid revascularization endarterectomy versus stenting trial

BACKGROUND

The Carotid Revascularization Endarterectomy Versus Stenting Trial (CREST) found a higher risk of stroke after carotid artery stenting and a higher risk of myocardial infarction (MI) after carotid endarterectomy.

METHODS AND RESULTS

Cardiac biomarkers and ECGs were performed before and 6 to 8 hours after either procedure and if there was clinical evidence of ischemia. In CREST, MI was defined as biomarker elevation plus either chest pain or ECG evidence of ischemia. An additional category of biomarker elevation with neither chest pain nor ECG abnormality was prespecified (biomarker+ only). Crude mortality and risk-adjusted mortality for MI and biomarker+ only were assessed during follow-up. Among 2502 patients, 14 MIs occurred in carotid artery stenting and 28 MIs in carotid endarterectomy (hazard ratio, 0.50; 95% confidence interval, 0.26 to 0.94; P=0.032) with a median biomarker ratio of 40 times the upper limit of normal. An additional 8 carotid artery stenting and 12 carotid endarterectomy patients had biomarker+ only (hazard ratio, 0.66; 95% confidence interval, 0.27 to 1.61; P=0.36), and their median biomarker ratio was 14 times the upper limit of normal. Compared with patients without biomarker elevation, mortality was higher over 4 years for those with MI (hazard ratio, 3.40; 95% confidence interval, 1.67 to 6.92) or biomarker+ only (hazard ratio, 3.57; 95% confidence interval, 1.46 to 8.68). After adjustment for baseline risk factors, both MI and biomarker+ only remained independently associated with increased mortality.

CONCLUSIONS

In patients randomized to carotid endarterectomy versus carotid artery stenting, both MI and biomarker+ only were more common with carotid endarterectomy. Although the levels of biomarker elevation were modest, both events were independently associated with increased future mortality and remain an important consideration in choosing the mode of carotid revascularization or medical therapy.

CLINICAL TRIAL REGISTRATION

URL: http://www.ClinicalTrials.gov. Unique identifier: NCT00004732.

Effect of Carotid Artery Stenting on the Release of S-100B and Neurone-Specific Enolase

Serum levels of S-100B and neurone-specific enolase (NSE) reflect cerebral injury in a variety of neurological conditions such as stroke, traumatic brain injury, and cardiac arrest. There are limited data on the release of S-100B and NSE following carotid artery stenting (CAS). In 22 patients undergoing CAS, serial blood samples for S-100B and NSE were collected before and 2, 4, and 6 to 8 hours after the procedure. A group of 20 patients with significant CAS undergoing purely diagnostic angiography served as controls. A significant increase in S-100B levels was observed 2 hours after the procedure in patients with CAS (P = .001) with a gradual decline over the next hours. In contrast, patients who underwent purely diagnostic angiography did not show significant changes in S-100B levels up to 8 hours after the procedure. Neither patients with CAS nor those undergoing diagnostic angiography displayed any significant changes in serial NSE levels.

Are distal protection devices 'protective' during carotid angioplasty and stenting?

BACKGROUND AND PURPOSE

To evaluate the periprocedural outcome after carotid artery stenting with embolic brain protection (EBP+) versus without embolic brain protection (EBP-).

METHODS

We retrospectively reviewed data from a prospective nonrandomized database of 357 patients who underwent carotid artery stenting in the neuroradiology division of our institution from 1999 to 2009. One hundred five patients underwent angioplasty and stenting without distal protection, whereas 252 were treated with distal protection. Patients were analyzed according to their EBP status (+ or -) for the primary end points of perioperative stroke, death, or myocardial infarction.

RESULTS

Unprotected stenting was mostly performed in the early years of this study and this is reflected in significant baseline differences between the two groups. In our earlier experience, carotid artery stenting was used in patients with more significant comorbidities. Diabetes mellitus (P=0.04), previous coronary artery disease (P=0.02) and myocardial infarction (P=0.04), and symptomatic lesion (P=0.01) were significantly more common in the EBP- cohort. Despite these baseline differences, there were no significant differences in the primary end points (2% in the EBP+ group and 4.8% in the EBP-, P=0.15). The incidence of ipsilateral stroke in the EBP- and in the EBP+ group was 3.8% versus 0.8%, respectively (P=0.6). There were 2 perioperative deaths (1 in each group) and 4 myocardial infarctions (3 in the EBP+ arm and 1 in the EBP- arm, all non-Q infarcts; P=nonsignificant).

CONCLUSIONS

In accordance with recent literature, this series cast doubts as to the real effectiveness of distal embolic protection devices in reducing periprocedural complications.

Secondary prevention of stroke in the elderly: a review of the evidence

BACKGROUND

Stroke is a major health problem with significant impact on the affected individuals and the whole community. In light of stroke being the leading cause of disability, the ageing of the population and the high incidence of stroke among the elderly, highlight the importance of primary and secondary prevention interventions among this group. The elderly generally have been underrepresented in clinical trials, creating many uncertainties and less optimal medical care for this group of patients.

OBJECTIVE

This review aims to make evidence-based management recommendations for secondary stroke prevention in the elderly.

METHODS

Secondary prevention-related primary literature was identified using MEDLINE and PubMed (1982 to present) with combinations of the following search terms being employed: antiplatelets, aspirin, atrial fibrillation, elderly, geriatrics, hypertension, lipids, secondary prevention, statins, stroke, and warfarin. In addition, the references of these articles were also reviewed.

RESULTS

Twenty-three clinical trials were included in this review, covering different aspects of secondary stroke prevention. Many of these trials were not specifically limited to the elderly, but conclusions related to their care can be derived from them. Although the American Heart Association/American Stroke Association guidelines suggest an equal benefit of aspirin, aspirin/dipyridamole, and clopidogrel in secondary prevention, the use of aspirin in the elderly may be preferred for reasons related to compliance and experience. Warfarin was largely avoided in the management of elderly stroke patients in the past, although available evidence demonstrates its efficacy and safety as a first choice for elderly patients with atrial fibrillation and presumed cardiac source of emboli. Lowering blood pressure among the elderly is an important aspect of secondary stroke prevention and can be achieved with the same agents used among younger age groups with a preference for a thiazide diuretic/angiotensin-converting enzyme inhibitor combination that has proven efficacy among elderly patients. Available evidence supports the use of statins among elderly patients with history of stroke or transient ischemic attack (TIA), and the derived benefit of treatment does not differ significantly from that in the younger age group. Elderly patients with 50% to 99% carotid artery stenosis and history of stroke or TIA should be considered for early carotid endarterectomy to reduce recurrent stroke.

CONCLUSION

Age should not be considered a barrier for the provision of optimal secondary prevention interventions. The available evidence supports similar and sometimes superior derived benefit from secondary preventive stroke measures in the elderly compared with that seen in younger patients.

Comparison of carotid artery stenting in patients with single versus bilateral carotid artery disease and factors affecting midterm outcome

BACKGROUND

Carotid artery stenting (CAS) is the method of choice for carotid artery revascularization of patients at high risk for carotid endarterectomy. In this study, we compared the midterm results of CAS in patients with unilateral versus bilateral carotid artery disease.

METHODS AND RESULTS

This is a retrospective analysis of 1-year outcome of 273 consecutive patients in whom 342 CAS procedures were performed. The incidence of periprocedural transient ischemic attacks (TIAs) differed significantly (8% vs. 1%; p = 0.01) among patients with and without bilateral internal carotid disease, and a tendency to a lower occurrence of early adverse events (death, stroke, periprocedural TIA, periprocedural myocardial infarction) was subsequently shown (11% vs. 5%; p = 0.12). At 1-year follow-up, there was a high incidence of adverse events (death, stroke, periprocedural TIA, periprocedural myocardial infarction, restenosis) in patients with bilateral carotid artery disease (40% vs. 14%; p < 0.01), which was mainly driven by a higher incidence of death, periprocedural TIA, and restenosis (p ≤ 0.02 for all). According to multivariate analysis, the independent predictors of midterm adverse events were left ventricular dysfunction, male gender, bilateral carotid artery disease, renal insufficiency, cerebral symptoms within the last 6 months before the intervention, and low-density lipoprotein cholesterol level.

CONCLUSIONS

At midterm follow-up, patients with bilateral carotid artery disease treated by CAS have significantly more adverse events than those with unilateral disease.

Regulatory T cells vary over bleeding segments in asthmatic and non-asthmatic women

Sex hormones may play an important role in observed gender differences in asthma incidence and severity. Regulatory T cells (Treg cells) are presumed to be involved in asthma and may vary with hormone levels. To investigate the effects of sex hormones on levels of Treg cells (percentage of CD4+CD25+Foxp3+ lymphocytes that are CD127-), a cohort of 13 women (6 with and 7 without an asthma diagnosis) had blood drawn multiple times over the course of a bleeding segment (bleeding interval plus the following bleeding-free interval) and collected urine samples daily for measurement of estrogen (estrone E1C) and progesterone (pregnanediol-glucuronide PDG) metabolites. The samples from non-asthmatic women indicated no association between bleeding segment day and Treg cells. Asthmatic women showed a 3% increase in Treg cell percentage with each successive day over the bleeding segment. Among non-asthmatic women, Treg cell percentages were not associated with PDG levels on the same day, or 1, 2 or 3 days before Treg cell measurement. E1C was positively correlated with the Treg cell percentage measured only on the same day - a 5% increase in E1C was associated with a 1.4% increase in Treg cell percentage. Among asthmatic women, only E1C was associated with Treg cell percentages after adjusting for PDG on the same day and 1 and 2 days before Treg cell measurement. A 5% increase in E1C was associated with a 2.3% increase in Treg cell percentage. A larger study of contiguous cycles to better determine within-woman cyclicity of the observed patterns is needed.

Secondary Stroke Prevention in Women

In a meta-analysis of results from 21 randomized trials comparing antiplatelet therapy with placebo in 18,270 patients with prior stroke or transient ischemic attack, antiplatelet therapy was associated with a 28% relative odds reduction in nonfatal strokes and a 16% reduction in fatal strokes, while another trial for secondary prevention with atorvastastin 80 mg showed a 16% risk reduction in time to first occurrence of stroke (adjusted hazard ratio: 0·84, 95% CI: 0·71–0·99). However, few studies have examined the sex differences regarding the efficacy of these treatments. Specifically, recent studies have reported higher rates of perioperative complications during endarterectomy in women. Nonetheless, to date, the data on the effects of carotid artery stenting in women, coming from diverse studies and meta-analyses, have been limited owing to the small number of female patients examined. Owing to this, the evidence of the benefit for women is unclear. Peculiar pathophysiological aspects of stroke, the higher stroke risk in some specific periods in life (e.g., pregnancy, puerperium and older age) and worse documented stroke outcome in women suggest that sex does matter in stroke management. Thus, future randomized controlled trials need to be sex-balanced, in order to better understand the efficacy of appropriate secondary stroke prevention therapy in women.

Longer time interval between carotid cross-clamping and shunting is associated with increased 30-day stroke and death rate

BACKGROUND

The benefit of carotid endarterectomy (CEA) in patients with a significant (>70%) (a)symptomatic stenosis has been proven thoroughly in major trials. It is unknown whether, after cross-clamping the carotid artery, the time interval between determination that a shunt is needed and the actual functioning of the shunt, defined as the need for shunt-to-shunt time (NST), influences 30-day morbidity and mortality rate after CEA.

METHODS

Experienced vascular surgeons performed 851 CEAs with a selective shunting protocol based on perioperative transcranial Doppler measurement and electroencephalographic findings, and data were analyzed retrospectively. The study included 156 shunted patients.

RESULTS

Longer NST was associated with an increase in the 30-day stroke/death rate. A binary logistic regression model was used to determine a 2-tailed P value of .004 and an odds ratio of 1.5/min increase of the NST. There was no influence on stroke-death rate of gender, age, symptomatic or asymptomatic stenosis, the use of a patch or not, or the number of periprocedural microembolic signals.

CONCLUSION

If CEA is performed with a selective shunting protocol, a longer NST increases the 30-day stroke/death rate. These results support a strong recommendation that shunt placement should be as quick as possible.

Weighting components of composite end points in clinical trials: an approach using disability-adjusted life-years

BACKGROUND AND PURPOSE

Conventional analysis of vascular prevention trials assigns equal weight to disparate vascular events in a composite end point at variance with the public's perception of their differential impact on health outcome. This study sought to apply the disability-adjusted life-year (DALY) metric to differential weighting individual vascular end points in trial analyses.

METHODS

DALY values for the most common major end points in vascular prevention trials (nonfatal myocardial infarction, nonfatal stroke, and vascular death), were derived by using World Health Organization Global Burden of Disease Project methodology. The standardized DALYs for each event were applied to recent major primary and secondary vascular prevention trials and to hypothetical model trials.

RESULTS

Standardized DALYs lost were 7.63 for nonfatal stroke, 5.14 for nonfatal myocardial infarction, and 11.59 for vascular death. In the published trials analyses, the direction of treatment effects was consistent between DALY and standard event analysis, but the rank order of treatment effect changed for 10 of 18 trials. The DALY analysis also permitted derivation of number-needed-to-treat values to gain 1 DALY: 2.1 for anticoagulation in atrial fibrillation, 2.7 for carotid endarterectomy in symptomatic stenosis, and 4.7 for clopidogrel added to aspirin in acute coronary syndrome. Hypothetical trial analyses demonstrated that the DALY metric more finely discriminates treatment effects.

CONCLUSIONS

Compared with a nonfatal myocardial infarction, a nonfatal stroke causes a 1.48-fold greater loss and vascular death a 2.25-fold greater loss of DALY. DALY analysis integrates these valuations in a summary metric reflecting the net impact of therapy on patient and societal health, complementing conventional end point analyses.