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Eller A, Wuest W, Kramer M, May M, Schmid A, Uder M, Lell MM. Carotid CTA: radiation exposure and image quality with the use of attenuation-based, automated kilovolt selection. AJNR Am J Neuroradiol 2013; 35:237-41. [PMID: 23907241 DOI: 10.3174/ajnr.a3659] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
BACKGROUND AND PURPOSE CTA is considered the imaging modality of choice in evaluating the supraaortic vessels in many institutions, but radiation exposure remains a matter of concern. The objective of the study was to evaluate a fully automated, attenuation-based kilovolt selection algorithm in carotid CTA in respect to radiation dose and image quality compared with a standard 120-kV protocol. MATERIALS AND METHODS Ninety-eight patients were included: 53 examinations (patient age, 66 ± 12 years) were performed by use of automated adaption of tube potential (80-140 kV) on the basis of the attenuation profile of the scout scan (study group), and 45 examinations (patient age, 67 ± 11 years) were performed by use of a standard 120-kV protocol (control group). CT dose index volume and dose-length product were recorded from the examination protocol. Image quality was assessed by ROI measurements and calculations of SNR and contrast-to-noise ratio. Subjective image quality was evaluated by 2 observers with the use of a 4-point scale (3, excellent; 0, not diagnostic). RESULTS Subjective image quality was rated as "excellent" or "good" in all examinations (study group, 2.8; control group, 2.8). The algorithm automatically selected 100 kV in 47% and 80 kV in 34%; 120 kV was retained in 19%. An elevation to 140 kV did not occur. Compared with the control group, overall CT dose index volume reduction was 33.7%; overall dose-length product reduction was 31.5%. In the low-kilovolt scans, image noise and mean attenuation of ROIs inside the carotid arteries were significantly higher than in 120-kV scans, resulting in a constant or increased (80-kV group) contrast-to-noise ratio. CONCLUSIONS The attenuation-based, kilovolt selection algorithm enables a dose reduction of >30% in carotid artery CTA while maintaining contrast-to-noise ratio and subjective image quality at adequate levels.
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Affiliation(s)
- A Eller
- From the Department of Radiology, University Erlangen, Erlangen, Germany
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152
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Abstract
Stroke is one of the most common causes of morbidity and mortality in hospitalized patients in the United States. A proper understanding of stroke mechanisms helps to guide specific case management. The only therapy approved by the US Food and Drug Administration for the management of acute ischemic stroke is initiation of intravenous recombinant tissue plasminogen activator within 3 hours of symptom onset. Other treatment options include intra-arterial recombinant tissue plasminogen activator, mechanical thrombectomy, clot retrieval, or a combination of these approaches. In this article, we provide an evidence-based review of the diagnostic approach for acute ischemic stroke, including recognizing common stroke mimics. We detail the initial medical management of acute stroke and the medical and surgical therapeutic interventions for patients who have sustained acute ischemic stroke.
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153
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Hosseini AA, Kandiyil N, Macsweeney STS, Altaf N, Auer DP. Carotid plaque hemorrhage on magnetic resonance imaging strongly predicts recurrent ischemia and stroke. Ann Neurol 2013; 73:774-84. [PMID: 23463579 PMCID: PMC3824333 DOI: 10.1002/ana.23876] [Citation(s) in RCA: 136] [Impact Index Per Article: 12.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2012] [Revised: 01/23/2013] [Accepted: 02/22/2013] [Indexed: 12/02/2022]
Abstract
Objective There is a recognized need to improve selection of patients with carotid artery stenosis for carotid endarterectomy (CEA). We assessed the value of magnetic resonance imaging (MRI)-defined carotid plaque hemorrhage (MRIPH) to predict recurrent ipsilateral cerebral ischemic events, and stroke in symptomatic carotid stenosis. Methods One hundred seventy-nine symptomatic patients with ≥50% stenosis were prospectively recruited, underwent carotid MRI, and were clinically followed up until CEA, death, or ischemic event. MRIPH was diagnosed if the plaque signal intensity was >150% that of the adjacent muscle. Event-free survival analysis was done using Kaplan–Meier plots and Cox regression models controlling for known vascular risk factors. We also undertook a meta-analysis of reported data on MRIPH and recurrent events. Results One hundred fourteen patients (63.7%) showed MRIPH, suffering 92% (57 of 62) of all recurrent ipsilateral events and all but 1 (25 of 26) future strokes. Patients without MRIPH had an estimated annual absolute stroke risk of only 0.6%. Cox multivariate regression analysis proved MRIPH as a strong predictor of recurrent ischemic events (hazard ratio [HR] = 12.0, 95% confidence interval [CI] = 4.8–30.1, p < 0.001) and stroke alone (HR = 35.0, 95% CI = 4.7–261.6, p = 0.001). Meta-analysis of published data confirmed this association between MRIPH and recurrent cerebral ischemic events in symptomatic carotid artery stenosis (odds ratio = 12.2, 95% CI = 5.5–27.1, p < 0.00001). Interpretation MRIPH independently and strongly predicts recurrent ipsilateral ischemic events, and stroke alone, in symptomatic ≥50% carotid artery stenosis. The very low stroke risk in patients without MRIPH puts into question current risk–benefit assessment for CEA in this subgroup. ANN NEUROL 2013;73:774–784
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Affiliation(s)
- Akram A Hosseini
- Division of Radiological and Imaging Sciences, University of Nottingham, Queen's Medical Campus, Nottingham, United Kingdom
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A hybrid framework for registration of carotid ultrasound images combining iconic and geometric features. Med Biol Eng Comput 2013; 51:1043-50. [DOI: 10.1007/s11517-013-1086-x] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2013] [Accepted: 05/14/2013] [Indexed: 11/25/2022]
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MacDonald D, Chan A, Harris A, Vertinsky T, Farman AG, Scarfe WC. Diagnosis and management of calcified carotid artery atheroma: dental perspectives. Oral Surg Oral Med Oral Pathol Oral Radiol 2013; 114:533-47. [PMID: 22986250 DOI: 10.1016/j.oooo.2012.06.020] [Citation(s) in RCA: 50] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2012] [Revised: 06/26/2012] [Accepted: 07/09/2012] [Indexed: 10/27/2022]
Abstract
The calcification of cervical carotid artery atheroma (CCAA) represents maturation of a lumenal atherosclerotic plaque that has been associated with a high risk of cerebral stroke. The demonstration of CCAA on rotational panoramic images has received increasing attention in dentistry since it was first described in 1981. The purposes of this article are to provide a background to the mechanism of arterial calcification, to review the clinical diagnostic and management algorithms for dental practitioners when CCAA are identified radiologically, and to describe and illustrate current appropriate radiographic modalities and medical management strategies used to confirm and assess stenosis associated with CCAA.
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Affiliation(s)
- David MacDonald
- Division of Oral and Maxillofacial Radiology, Faculty of Dentistry, University of British Columbia, Vancouver, British Columbia, Canada.
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157
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González A, López-Rueda A, Gutiérrez I, Moniche F, Cayuela A, Bustamante A, Mayol A, Gonzalez-Marcos JR, Gil-Peralta A. Carotid plaque characterization by virtual histology intravascular ultrasound related to the timing of carotid intervention. J Endovasc Ther 2013; 19:764-73. [PMID: 23210875 DOI: 10.1583/jevt-12-3914mr2.1] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
PURPOSE To determine the incidence of vulnerable plaques characterized by virtual histology intravascular ultrasound (VH IVUS) in patients with severe internal carotid artery (ICA) stenosis and its relationship to the timing of protected carotid artery stenting (CAS). METHODS The study included 141 patients (119 men; mean age 66.9 ± 9 years) with severe ICA stenosis undergoing CAS with cerebral protection. Patients were classified in 3 groups: 39 symptomatic early CAS (<14 days from clinical symptoms); 58 symptomatic delayed CAS (range 15-180 days), and 44 asymptomatic CAS. Culprit plaque component was evaluated by VH IVUS. A vulnerable plaque was defined by a thin-cap fibroatheroma and/or calcified thin-cap fibroatheroma. RESULTS The composite disabling stroke/mortality was 2.1%. The incidence of vulnerable plaques was significantly higher in the symptomatic early CAS group (25/39, 64.1%) than in the symptomatic delayed CAS group (26/58, 44.8%; p=0.048) or the asymptomatic CAS group (14/44, 31.8%; p=0.003). Symptomatic patients showed a significantly higher incidence of vulnerable plaques (52.6%) than asymptomatic patients (31.8%, p=0.022). There were no significant differences between the symptomatic delayed and asymptomatic groups (p=0.129). By clinical subgroup, a vulnerable plaque was observed in 29 (52.7%) of the patients with 55 transient ischemic attacks, 22 (52.4%) of the 42 minor stroke patients, and 14 (31.8%) of the 44 asymptomatic patients (p=0.152). CONCLUSION The incidence of vulnerable plaques was significantly higher in symptomatic patients, increasing as the intravascular study was performed closer to the index ischemic episode.
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Affiliation(s)
- Alejandro González
- Department of Radiology and Interventional Neuroradiology, Virgen del Rocio University Hospital, Seville, Spain.
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Jashari F, Ibrahimi P, Nicoll R, Bajraktari G, Wester P, Henein MY. Coronary and carotid atherosclerosis: similarities and differences. Atherosclerosis 2013; 227:193-200. [PMID: 23218802 DOI: 10.1016/j.atherosclerosis.2012.11.008] [Citation(s) in RCA: 107] [Impact Index Per Article: 9.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/28/2012] [Revised: 11/10/2012] [Accepted: 11/12/2012] [Indexed: 02/05/2023]
Abstract
Although a relationship is commonly accepted between coronary and carotid arterial disease, suggesting that atherosclerosis is a systemic condition, the extent of this association and correspondence has not been fully elucidated. This review discusses recent research in this field and highlights areas for future study. The prevalence of severe carotid stenosis increases with prevalence of coronary stenosis, with the latter being found in a significant number of stroke patients, while those with carotid stenosis may be at higher risk of myocardial infarction than stroke. There also appear to be common risk factors (age, diabetes, hypertension, smoking and dyslipidemia), although the effects in both vascular systems may not be identical. Furthermore, while the degree of stenosis in the coronary artery has little ability to predict acute coronary syndrome, which is caused by local thrombosis from a ruptured or eroded plaque, severe carotid stenosis causing hypoperfusion is highly predictive of stroke, although this effect may be time-limited. This apparent difference in event mechanism in the two arteries is interesting as is the difference in the rate of development of collaterals. Overall, the evidence shows that a clear relationship exists between disease in the coronary and carotid arteries, since conventional risk factors and the extent of stenosis and/or previous events emanating from one artery have a strong bearing on the prevalence of events in the other artery. Nevertheless, the exact correspondence between the two arteries is unclear, with sometimes contradictory study results. More research is needed to identify the full extent of risk factors for severe stenosis and cardio- or cerebral vascular events, among which, inflammatory biomarkers such as hs-CRP and prior vascular events are likely to play a key role.
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Affiliation(s)
- Fisnik Jashari
- Department of Public Health and Clinical Medicine, and Heart Centre, Umea University, SE-901 87 Umea, Sweden
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Gorgui J, Doonan RJ, Gomez YH, Kwong C, Daskalopoulou SS. Carotid endarterectomy improves peripheral but not central arterial stiffness. Eur J Vasc Endovasc Surg 2013; 45:548-53. [PMID: 23540801 DOI: 10.1016/j.ejvs.2013.02.012] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2012] [Accepted: 02/19/2013] [Indexed: 12/24/2022]
Abstract
OBJECTIVE Carotid endarterectomy (CEA) reduces the risk of cerebrovascular events due to the presence of atherosclerotic plaque in the internal carotid artery. Arterial stiffness is an indicator of cardiovascular risk and strongly associates with the development of atherosclerosis. This study aims to assess the short-term effect of CEA on arterial stiffness and haemodynamics. DESIGN Prospective observational study. METHODS Measurements of arterial stiffness and haemodynamics, including carotid-femoral pulse wave velocity (cfPWV), carotid-radial PWV (crPWV), augmentation pressure, augmentation index, subendocardial viability ratio, central pressures and pulse pressure amplification, were performed pre- and 6 weeks post-CEA on both surgical and non-surgical sides. RESULTS Fifty-nine patients completed the study (n = 46 men, age 68.9 ± 10.1 years). crPWV was decreased after CEA on the surgical (P = 0.01) and non-surgical side (P = 0.0008), AIx75 tended to decrease only on the surgical side (P = 0.06). cfPWV did not change significantly on either side. CONCLUSION We assessed, for the first time, the short-term effect of CEA on arterial stiffness and haemodynamics. CEA improved peripheral but not central arterial stiffness. This study provides evidence for significant changes in certain arterial stiffness and haemodynamic parameters. Longer-term follow-up will assess whether these changes are sustained and whether CEA is associated with further haemodynamic benefits.
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Affiliation(s)
- J Gorgui
- Department of Medicine, Faculty of Medicine, McGill University, Montreal, QC, Canada
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Kocak B, Kizilkilic O, Korkmazer B, Tureci E, Kocer N, Islak C. Carotid stenting with low-dose contrast medium for patients with moderate-to-severe chronic renal insufficiency: Keyhole carotid stenting. Eur J Radiol 2013; 82:508-11. [DOI: 10.1016/j.ejrad.2012.08.025] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2012] [Revised: 08/17/2012] [Accepted: 08/31/2012] [Indexed: 11/29/2022]
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Ritter JC, Tyrrell MR. The current management of carotid atherosclerotic disease: who, when and how? Interact Cardiovasc Thorac Surg 2013; 16:339-46. [PMID: 23197661 PMCID: PMC3568792 DOI: 10.1093/icvts/ivs453] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2012] [Revised: 08/30/2012] [Accepted: 09/07/2012] [Indexed: 11/14/2022] Open
Abstract
Ischaemic stroke represents a major health hazard in the western world, which has a severe impact on society and the health-care system. Roughly, 10% of all first ischaemic strokes can be attributed to significant atherosclerotic disease of the carotid arteries. Correct management of these lesions is essential in the prevention and treatment of carotid disease-related ischaemic events. The close relationship between diagnosis and medical and surgical management makes it necessary that all involved physicians and surgeons have profound knowledge of management strategies beyond their specific speciality. Continuous improvement in pharmacological therapy and operative techniques as well as frequently changing guidelines represent a constant challenge for the individual health-care professional. This review gives a thorough outline of the up-to-date evidence-based management of carotid artery disease and discusses its current controversies.
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Affiliation(s)
- Jens C Ritter
- Department of Vascular Surgery, King's Health Partners, Kings College Hospital, London, UK.
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162
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Wagdi P. Carotid Artery Stenting 2013: Thumbs up. Cardiol Res 2013; 4:8-14. [PMID: 28348697 PMCID: PMC5358182 DOI: 10.4021/cr253w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/19/2013] [Indexed: 11/06/2022] Open
Abstract
It has been customary for interventional cardiologists involved in carotid artery stenting, to underline non-inferiority of the percutaneous technique versus surgical carotid endarterectomy. To that end, all cause morbidity and mortality figures of both methods are compared. Surgery has, in most large randomized studies, had an edge over stenting in terms of cerebrovascular adverse events. This may have partly been due to occasional indiscriminate indication for stenting in lesions and/or vessels with unfavourable characteristics (severe target vessel tortuosity and calcification, Type III aortic arch, and so on). On one hand, the author pleads for improvement of the excellent results of endarterectomy, by subjecting all patients planned for surgery to a thorough preoperative cardiological work up, including generous invasive investigation, thus reducing the incidence of perioperative myocardial infarction, heart failure and cardiac death. On the other hand, we are convinced that the results of carotid stenting should then be compared to best practice surgery. The rate of neurological adverse event rate after carotid endarterectomy at our institution lies under 0.7% at 30 days postoperatively. Specifically, the goal should be that carotid stenting underbids surgical endarterectomy, also and mainly, in terms of cerebral and cerebrovascular adverse events. Cardiac morbidity and mortality as well as laryngeal nerve palsy should no more be the main arguments for the percutaneous approach. This should easily be possible if patient selection for carotid revascularisation would be approached according to morphological criteria, in analogy with the “Syntax”-score used to optimise revascularisation strategies in coronary artery disease.
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Affiliation(s)
- Philipp Wagdi
- Interventional Cardiology, HerzZentrum Hirslanden, Witellikerstrasse 36, 8008 Zurich, Switzerland.
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163
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Cheng EM, Bravata DM, El-Saden S, Vassar SD, Ofner S, Williams LS, Keyhani S. Carotid artery stenosis: wide variability in reporting formats--a review of 127 Veterans Affairs medical centers. Radiology 2013; 266:289-94. [PMID: 23143022 PMCID: PMC3528970 DOI: 10.1148/radiol.12120453] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
PURPOSE To determine whether radiology reports describe clinically significant carotid arterial stenosis in a consistent format that is actionable by ordering clinicians. MATERIALS AND METHODS This study was HIPAA compliant. Informed consent was waived. Institutional review board approval was obtained for this retrospective chart review, which included radiology reports of carotid artery imaging for patients hospitalized with ischemic stroke at 127 Veterans Affairs medical centers in 2006-2007. "Clinically significant results" were defined as results with at least 50% stenosis or at least moderate stenosis, excluding complete occlusion. How often clinically significant results were reported as an exact percentage stenosis (such as 60%), range (such as 50%-69%), or category (such as moderate) was determined. Among results reported as a range, how often the range bracketed clinical thresholds of 50% and 70% (typically used to determine appropriateness of carotid arterial revascularization) was determined. RESULTS Among 2675 patients, there were 6618 carotid imaging results, of which 1015 (15%) were considered clinically significant. Among 695 clinically significant results at ultrasonography (US), 348 (50%) were described as a range, and another 314 (45%) were reported as an exact percentage stenosis. Among the 348 clinically significant US results reported as a range, 259 (74%) bracketed the thresholds of 50% or 70%. For magnetic resonance angiographic results, 48% (106 of 221) qualitatively described clinically significant results as a category, 38% (84 of 221) as an exact percentage stenosis, and 14% (31 of 221) as a range. CONCLUSION In this national health care system, the manner in which clinically significant carotid arterial stenosis was reported varied widely.
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Affiliation(s)
- Eric M Cheng
- Department of Neurology, VA Greater Los Angeles Healthcare System, 11301 Wilshire Blvd, ML 127, Los Angeles, CA 90073, USA.
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Liu X, Xiong Y, Zhou Z, Niu G, Wang W, Xiao G, Lin M, Leung TW, Liu D, Liu W, Fan X, Yin Q, Zhu W, Ma M, Zhang R, Xu G. China Interventional Stroke Registry: Rationale and Study Design. Cerebrovasc Dis 2013; 35:349-54. [DOI: 10.1159/000350210] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2012] [Accepted: 02/25/2013] [Indexed: 11/19/2022] Open
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Takayama K, Taoka T, Nakagawa H, Myouchin K, Wada T, Sakamoto M, Furuichi K, Iwasaki S, Kurokawa S, Kichikawa K. Effect of cilostazol in preventing restenosis after carotid artery stenting using the carotid wallstent: a multicenter retrospective study. AJNR Am J Neuroradiol 2012; 33:2167-70. [PMID: 22595898 PMCID: PMC7965589 DOI: 10.3174/ajnr.a3127] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2012] [Accepted: 02/28/2012] [Indexed: 12/27/2022]
Abstract
BACKGROUND AND PURPOSE Restenosis after CAS is a postoperative problem, with a reported frequency of approximately 2%-8%. However differences in stent design, procedure, and the antiplatelet agent appear to affect the incidence of restenosis. We assessed the frequency of restenosis and the effect of the antiplatelet agent CLZ in preventing restenosis after CAS by the standard procedure using the CWS. MATERIALS AND METHODS Between May 2010 and October 2011, 62 lesions in 60 consecutive patients underwent CAS using the CWS at 4 medical institutions, and all patients were followed clinically and assessed by sonography, 3D-CTA, or angiography at 3 and 6 months postoperatively. Restenosis was defined as ≥50% stenosis. The incidence of restenosis and the variation in the incidence of restenosis by the difference in type of antiplatelet agent between the CLZ group (n = 30; aspirin, 100 mg, and CLZ, 200 mg) and the non-CLZ group (n = 32; aspirin, 100 mg, and clopidogrel, 75 mg [n = 29]; or ticlopidine, 100 mg [n = 2] or 200 mg [n = 1]) were retrospectively investigated. Two antiplatelet agents were given starting 1 week preoperatively until at least 3 months postoperatively. RESULTS Restenosis occurred in 5 patients (8.3%), but all were cases of asymptomatic lesions in the follow-up period. All 5 patients with restenosis were in the non-CLZ group, with no cases of restenosis in the CLZ group; the difference was significant (P = .0239). CONCLUSIONS The restenosis rate after CAS by using the CWS was 8.3%. CLZ was associated with significant inhibition of restenosis.
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Affiliation(s)
- K Takayama
- Departments of Radiology and Interventional Neuroradiology, Ishinkai Yao General Hospital, Yao, Japan.
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Toutouzas K, Sfikakis PP, Karanasos A, Aggeli C, Felekos I, Kitas G, Zampeli E, Protogerou A, Stefanadis C. Myocardial ischaemia without obstructive coronary artery disease in rheumatoid arthritis: hypothesis-generating insights from a cross-sectional study. Rheumatology (Oxford) 2012. [PMID: 23185038 DOI: 10.1093/rheumatology/kes349] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
OBJECTIVE RA is associated with increased cardiovascular events, reportedly to equal diabetes mellitus (DM). The presence of myocardial ischaemia was assessed in asymptomatic high-risk RA patients and compared with patients with DM and a healthy control group. METHODS Eighteen consecutive non-diabetic RA patients without known cardiovascular disease who developed a new carotid atheromatic plaque during the last 3 years were matched 1:1 for traditional cardiovascular risk factors with asymptomatic type 2 DM patients and 1:2 with asymptomatic non-RA, non-DM control subjects. After dobutamine stress contrast echocardiography with wall-motion and perfusion evaluation, coronary angiography was performed in those with positive stress tests. RESULTS Ischaemia by echocardiography was found in 67% of RA patients; this was significantly higher than controls (31%, P = 0.019) but comparable to those with DM (78%, P = 0.71). Angiography performed in eight consenting RA patients was normal in four, revealed non-flow-limiting coronary atheromatic lesions in two and significant lesions in two patients. RA patients with ischaemia had CRP serum levels significantly higher by six-fold compared with those with normal stress echocardiography. CONCLUSION Asymptomatic RA patients may display myocardial ischaemia at similar levels to DM patients but with low prevalence of obstructive coronary artery disease. Microvascular abnormalities associated with increased inflammatory response may account for these findings. Their exact nature and significance require further evaluation.
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Affiliation(s)
- Konstantinos Toutouzas
- 1st Department of Cardiology, Hippokration Hospital, Athens Medical School, Athens, Greece.
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167
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Gupta A, Verma HK, Gupta S. Technology and research developments in carotid image registration. Biomed Signal Process Control 2012. [DOI: 10.1016/j.bspc.2012.05.003] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
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Kakisis J, Avgerinos E, Antonopoulos C, Giannakopoulos T, Moulakakis K, Liapis C. The European Society for Vascular Surgery Guidelines for Carotid Intervention: An Updated Independent Assessment and Literature Review. Eur J Vasc Endovasc Surg 2012; 44:238-43. [DOI: 10.1016/j.ejvs.2012.04.015] [Citation(s) in RCA: 56] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2011] [Accepted: 04/19/2012] [Indexed: 11/16/2022]
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169
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ACCF/ACR/AIUM/ASE/ASN/ICAVL/SCAI/SCCT/SIR/SVM/SVS 2012 Appropriate Use Criteria for Peripheral Vascular Ultrasound and Physiological Testing Part I: Arterial Ultrasound and Physiological Testing. Vasc Med 2012. [DOI: 10.1177/1358863x12452197] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
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170
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Cheng EM, Keyhani S, Ofner S, Williams LS, Hebert PL, Ordin DL, Bravata DM. Lower use of carotid artery imaging at minority-serving hospitals. Neurology 2012; 79:138-44. [PMID: 22700815 PMCID: PMC3390541 DOI: 10.1212/wnl.0b013e31825f04c5] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2011] [Accepted: 11/17/2011] [Indexed: 12/13/2022] Open
Abstract
OBJECTIVE We determined whether site of care explains a previously identified racial disparity in carotid artery imaging. METHODS In this retrospective cohort study, data were obtained from a chart review of veterans hospitalized with ischemic stroke at 127 Veterans Administration hospitals in 2007. Extensive exclusion criteria were applied to obtain a sample who should have received carotid artery imaging. Minority-serving hospitals were defined as the top 10% of hospitals ranked by the proportion of stroke patients who were black. Population level multivariate logistic regression models with adjustment for correlation of patients in hospitals were used to calculate predictive probabilities of carotid artery imaging by race and minority-service hospital status. Bootstrapping was used to obtain 95% confidence intervals (CIs). RESULTS The sample consisted of 1,534 white patients and 628 black patients. Nearly 40% of all black patients were admitted to 1 of 13 minority-serving hospitals. No racial disparity in receipt of carotid artery imaging was detected within nonminority serving hospitals. However, the predicted probability of receiving carotid artery imaging for white patients at nonminority-serving hospitals (89.7%, 95% CI [87.3%, 92.1%]) was significantly higher than both white patients (78.0% [68.3%, 87.8%] and black patients (70.5% [59.3%, 81.6%]) at minority-serving hospitals. CONCLUSIONS Underuse of carotid artery imaging occurred most often among patients hospitalized at minority-serving hospitals. Further work is required to explore why site of care is a mechanism for racial disparities in this clinically important diagnostic test.
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Affiliation(s)
- Eric M Cheng
- Department of Neurology, VA Greater Los Angeles Healthcare System, Los Angeles, USA.
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ACCF/ACR/AIUM/ASE/ASN/ICAVL/SCAI/SCCT/SIR/SVM/SVS 2012 appropriate use criteria for peripheral vascular ultrasound and physiological testing part I: arterial ultrasound and physiological testing: a report of the American College of Cardiology Foundation Appropriate Use Criteria Task Force, American College of Radiology, American Institute of Ultrasound in Medicine, American Society of Echocardiography, American Society of Nephrology, Intersocietal Commission for the Accreditation of Vascular Laboratories, Society for Cardiovascular Angiography and Interventions, Society of Cardiovascular Computed Tomography, Society for Interventional Radiology, Society for Vascular Medicine, and Society for Vascular Surgery. J Vasc Surg 2012; 56:e17-51. [PMID: 22694919 DOI: 10.1016/j.jvs.2012.05.054] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
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ACCF/ACR/AIUM/ASE/ASN/ICAVL/SCAI/SCCT/SIR/SVM/SVS/SVU [corrected] 2012 appropriate use criteria for peripheral vascular ultrasound and physiological testing part I: arterial ultrasound and physiological testing: a report of the American College of Cardiology Foundation appropriate use criteria task force, American College of Radiology, American Institute of Ultrasound in Medicine, American Society of Echocardiography, American Society of Nephrology, Intersocietal Commission for the Accreditation of Vascular Laboratories, Society for Cardiovascular Angiography and Interventions, Society of Cardiovascular Computed Tomography, Society for Interventional Radiology, Society for Vascular Medicine, Society for Vascular Surgery, [corrected] and Society for Vascular Ultrasound. [corrected]. J Am Coll Cardiol 2012; 60:242-76. [PMID: 22694840 DOI: 10.1016/j.jacc.2012.02.009] [Citation(s) in RCA: 52] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
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Holmes DR, Tomaselli GF, Bradfield L. ACCF and AHA Presidents' Letter on MEDCAC. J Am Coll Cardiol 2012; 59:1199. [PMID: 22440223 DOI: 10.1016/j.jacc.2012.02.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/08/2012] [Accepted: 02/09/2012] [Indexed: 11/28/2022]
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174
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Comentario Bibliográfico. ANGIOLOGIA 2012. [DOI: 10.1016/j.angio.2012.01.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
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175
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Akar Bayram N, Bozkurt E, Ayhan H, Gürkaş E, Orhan G, Ak F, Bilen E, Sari C, Akçay M, Durmaz T, Keles T. Early outcomes of carotid artery stenting. Perfusion 2012; 27:146-9. [PMID: 22249963 DOI: 10.1177/0267659111431759] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
BACKGROUND AND AIM Ischemic cerebrovascular events are the most common reason for patients to be bedridden and the third most common reason for death. Many studies in recent years have demonstrated that carotid artery stenting (CAS) may be an alternative to carotid endarterectomy (CEA). In this study, we aimed to report early outcomes of patients who were treated with CAS in our clinic and discuss practicability, advantages and safety of CAS. METHODS AND FINDINGS Eighty patients who underwent CAS between December 2009 and May 2011 were eligible. The mean age was 65 years (range, 49 - 89 years). Of the study group, 73.75% were males and 26.25% were female. The percentage of asymptomatic patients was 11.7%, and the remaining patients were symptomatic. A distal embolic protection device (Angioguard®) was used in 22% of the patients whereas, in the other patients (78%), a proximal blockage system (Mo.MA®) was used. Self-expandable hybrid stents were implanted in all patients and post-dilatation was performed after implantation. None of the patients suffered from stroke, myocardial infarction or death due to CAS during their hospital stay. The mean follow-up period was 10 months (range 2 - 18 months) after discharge. None of the patients had died or had a stroke, a transient ischemic attack (TIA), or a myocardial infarction during the follow-up period. Re-stenosis was not observed in the follow-up carotid Doppler ultrasonography; flow rates were within normal limits. CONCLUSION No major complication was observed during the early follow-up period in patients who underwent CAS in our clinic. Only 2 (2.5%) patients showed transient numbness and weakness and these did not lead to morbidity. In the management guide of extracranial carotid and vertebral artery diseases, CAS, in the light of recent studies, is recommended as an alternative to CEA in recommendations for revascularization. One of the important issues emphasized in this guide is the experience of centers. Very low complication rates after CAS suggested that, with suitable patient selection and an experienced team, similar results may be obtained.
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Affiliation(s)
- N Akar Bayram
- Cardiology Clinics, Ankara Atatürk Education and Research Hospital, Ankara, Turkey.
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Abstract
Since the landmark NASCET and ECST trials demonstrated the superiority of carotid endarterectomy over medical therapy in the prevention of stroke for patients with symptomatic carotid artery stenosis, surgical intervention as a part of secondary prevention of stroke has become widespread. However, the newer technology of carotid artery angioplasty and stenting challenges this mode of intervention, promising the benefits of a procedure under local anesthesia and potentially avoiding the surgical complications of cranial nerve palsy and hematoma. Pooled evidence from randomized controlled trials of endarterectomy versus stenting shows a higher rate of stroke or death in the stenting groups-but this finding is mitigated to an extent by the lower incidence of myocardial infarction and cranial nerve palsy in patients undergoing stenting. At present, carotid endarterectomy combined with optimal drug therapy remains the standard of care for symptomatic 70%-99% stenosis of the internal carotid artery, but stenting might be an option in younger patients and in those not suitable for endarterectomy.
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Affiliation(s)
- David Doig
- Institute of Neurology, University College London, London WC1N 3BG, United Kingdom.
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177
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Pecoraro F, Dinoto E, Mirabella D, Corte G, Bracale UM, Bajardi G. Basal Cerebral Computed Tomography as Diagnostic Tool to Improve Patient Selection in Asymptomatic Carotid Artery Stenosis. Angiology 2011; 63:504-8. [DOI: 10.1177/0003319711431448] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
One-hundred patients were included to evaluate the role of cerebral computed tomography (CT) to improve patient selection in asymptomatic internal carotid stenosis. Symptomatic patients were assigned to group A, asymptomatic patients to group B. A cerebral CT pattern A was observed in groups A and B in 60% and 20%, respectively ( P < .0001). Between A and B groups, type 6 plaques were found, respectively, in 26.7% and 7.5% of patients ( P = .01); a type 5 in 51.7% and 45% ( P = .32) of patients; and a type 4 in 21.7% and 47.5% of patients, respectively ( P = .006). Within B group, the association of CT pattern A and histological plaque level 4, 5, and 6 was, respectively, 25% ( P = .15), 50% ( P = .53), and 25% ( P = .16). In group B, a 7-fold risk increase in CT pattern A was found in patients with level 6 plaque. In asymptomatic patients with high-risk plaque, a basal cerebral CT scan can be used as diagnostic tool to improve patient selection for intervention.
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Affiliation(s)
- Felice Pecoraro
- Vascular Surgery Unit, University of Palermo, AOUP “P. Giaccone”, Italy
| | - Ettore Dinoto
- Vascular Surgery Unit, University of Palermo, AOUP “P. Giaccone”, Italy
| | | | - Giuseppe Corte
- Vascular Surgery Unit, University of Palermo, AOUP “P. Giaccone”, Italy
| | | | - Guido Bajardi
- Vascular Surgery Unit, University of Palermo, AOUP “P. Giaccone”, Italy
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178
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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.
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179
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Paraskevas KI, Mikhailidis DP, Veith FJ. Carotid artery stenting may be contraindicated in female patients with symptomatic carotid artery stenosis. J Vasc Surg 2011; 54:1870-1; author reply 1871. [PMID: 22137312 DOI: 10.1016/j.jvs.2011.06.119] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2011] [Revised: 06/06/2011] [Accepted: 06/06/2011] [Indexed: 11/28/2022]
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180
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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.
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Paraskevas KI, Veith FJ, Riles TS, Moore WS. Is carotid artery stenting a fair alternative to carotid endarterectomy for symptomatic carotid artery stenosis? A commentary on the AHA/ASA guidelines. J Vasc Surg 2011; 54:541-3; discussion 543. [DOI: 10.1016/j.jvs.2011.05.052] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/17/2022]
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183
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Johansson EP, Ahlqvist J, Garoff M, Karp K, Jäghagen EL, Wester P. Ultrasound screening for asymptomatic carotid stenosis in subjects with calcifications in the area of the carotid arteries on panoramic radiographs: a cross-sectional study. BMC Cardiovasc Disord 2011; 11:44. [PMID: 21752238 PMCID: PMC3161947 DOI: 10.1186/1471-2261-11-44] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2011] [Accepted: 07/13/2011] [Indexed: 11/28/2022] Open
Abstract
BACKGROUND Directed ultrasonic screening for carotid stenosis is cost-effective in populations with > 5% prevalence of the diagnosis. Occasionally, calcifications in the area of the carotid arteries are incidentally detected on odontological panoramic radiographs. We aimed to determine if directed screening for carotid stenosis with ultrasound is indicated in individuals with such calcifications. METHODS This was a cross-sectional study. Carotid ultrasound examinations were performed on consecutive persons, with findings of calcifications in the area of the carotid arteries on panoramic radiography that were otherwise eligible for asymptomatic carotid endarterectomy. RESULTS Calcification in the area of the carotid arteries was seen in 176 of 1182 persons undergoing panoramic radiography. Of these, 117 fulfilled the inclusion criterion and were examined with carotid ultrasound. Eight persons (6.8%; 95% CI 2.2-11.5%) had a carotid stenosis--not significant over the 5% pre-specified threshold (p = 0.232, Binomial test). However, there was a significant sex difference (p = 0.008), as all stenoses were found in men. Among men, 12.5% (95%CI 4.2-20.8%) had carotid stenosis--significantly over the 5% pre-specified threshold (p = 0.014, Binomial test). CONCLUSIONS The incidental finding of calcification in the area of the carotid arteries on panoramic radiographs should be followed up with carotid screening in men that are otherwise eligible for asymptomatic carotid endarterectomy. TRIAL REGISTRATION The study was registered at http://www.clinicaltrials.gov; NCT00514644.
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Affiliation(s)
- Elias P Johansson
- Department of Public Health and Clinical Medicine, Umeå University, Umeå, Sweden
| | - Jan Ahlqvist
- Department of Odontology, Umeå University, Umeå, Sweden
| | - Maria Garoff
- Department of Odontology, Umeå University, Umeå, Sweden
| | - Kjell Karp
- Clinical physiology, Department of Surgical and Perioperative Sciences, Umeå University, Umeå, Sweden
| | | | - Per Wester
- Department of Public Health and Clinical Medicine, Umeå University, Umeå, Sweden
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Shulga O, Bornstein N. Antiplatelets in secondary stroke prevention. Front Neurol 2011; 2:36. [PMID: 21772826 PMCID: PMC3131527 DOI: 10.3389/fneur.2011.00036] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2011] [Accepted: 05/17/2011] [Indexed: 11/20/2022] Open
Abstract
The aim of this review is to provide evidence-based recommendations on the secondary prevention of atherothrombotic ischemic stroke. Antiplatelets are the major therapy for the secondary stroke prevention. The most commonly used antiplatelets agents are aspirin, clopidogrel, and extended-release dipyridamole. A lot of progress had been made in last years regarding aspirin resistance and genotyping of clopidogrel metabolism. According to the results of the accomplished studies it is difficult to broadly recommend one antithrombotic agent in favor of the other. Instead, a review of the currently published data suggests the importance of focusing on the individualizing approach in antiplatelet therapy.
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Affiliation(s)
- Olga Shulga
- Department of Neurology, Volyn Regional Clinical HospitalLutsk, Ukraine
| | - Natan Bornstein
- Stroke Unit, Department of Neurology, Tel-Aviv Sourasky Medical CenterTel-Aviv, Israel
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185
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Paraskevas K, Veith F, Riles T, Moore W. Is Carotid Artery Stenting a Fair Alternative to Carotid Endarterectomy for Symptomatic Carotid Artery Stenosis? Eur J Vasc Endovasc Surg 2011; 41:717-9. [DOI: 10.1016/j.ejvs.2011.03.018] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2011] [Accepted: 03/21/2011] [Indexed: 10/18/2022]
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