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Worthmann H, Ernst J, Grosse GM. [What is confirmed in the treatment of ischemic stroke]. INNERE MEDIZIN (HEIDELBERG, GERMANY) 2023; 64:1143-1153. [PMID: 37947809 DOI: 10.1007/s00108-023-01622-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 10/20/2023] [Indexed: 11/12/2023]
Abstract
Ischemic stroke is one of the leading causes of death worldwide and the most frequent cause of permanent disability in adulthood. The acute treatment of stroke is time-critical and, according to the time is brain principle, it is important to determine as soon as possible whether recanalization treatment that can save the penumbra is possible. Intravenous thrombolysis (IVT) and, if a large vessel occlusion is identified, endovascular treatment (EVT) possibly in combination with IVT, are recommended. Further treatment in a stroke unit is another important component of acute stroke treatment. The best secondary preventive treatment must already be initiated in the acute phase. The cause of stroke guides making decisions on the ideal secondary preventive strategy. The most important etiologies of stroke are cardiac embolism, atherosclerotic macroangiopathy and cerebral microangiopathy (small vessel disease). Less frequent causes are dissections of arteries supplying the brain or vasculitis. In up to 20-30% of all cases, however, no clear etiology can be determined despite intensive investigation of the cause. This means corresponding uncertainty in the optimal secondary prevention that consists in particular of an anticoagulant medication adapted to the etiology, treatment of cardiovascular risk factors and if necessary surgical or interventional desobliterative procedures. This article describes the diagnostic procedure and the evidence-based treatment of ischemic stroke.
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Affiliation(s)
- Hans Worthmann
- Neurologische Klinik mit Klinischer Neurophysiologie, Medizinische Hochschule Hannover, Carl-Neuberg-Str. 1, 30623, Hannover, Deutschland.
| | - Johanna Ernst
- Neurologische Klinik mit Klinischer Neurophysiologie, Medizinische Hochschule Hannover, Carl-Neuberg-Str. 1, 30623, Hannover, Deutschland
| | - Gerrit M Grosse
- Neurologische Klinik mit Klinischer Neurophysiologie, Medizinische Hochschule Hannover, Carl-Neuberg-Str. 1, 30623, Hannover, Deutschland
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2
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Keil F, Stahn S, Reitz SC, Lieschke F, du Mesnil de Rochemont R, Hattingen E, Berkefeld J. Elective carotid stenting fulfills quality standards defined in guidelines. ROFO-FORTSCHR RONTG 2023. [PMID: 37963550 DOI: 10.1055/a-2175-4029] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2023]
Abstract
PURPOSE According to evidence from randomized trials and current guidelines, elective carotid artery stenting (CAS) is still considered second-line therapy compared with carotid endarterectomy (CEA). However, the publication of randomized comparative trials for patients with symptomatic stenoses occurred well over 10 years ago. In view of problems regarding German quality assurance when differentiating elective from emergency interventions and low case numbers for CAS indications, it seemed reasonable to present neurologically controlled CAS results and to investigate whether elective CAS consistently fulfills the strict quality criteria and what differences exist with respect to emergency CAS interventions in acute ischemic stroke. MATERIALS AND METHODS Between 01/2012 and 07/2022, 141 elective CAS procedures were performed to treat patients with symptomatic (n = 123) and asymptomatic (n = 18) stenoses. Protection by a filter system was achieved in 134 of these elective procedures (95 %). During the same period, 158 patients underwent carotid stenting for acute stroke. Complication rates were determined using neurologically controlled data. CAS-related complications (stent thrombosis, stent-associated vascular damage, thromboembolism, and symptomatic hemorrhage) were extracted from emergency interventions, and clinical outcome (NIHSS progression) was determined during the inpatient stay. RESULTS The rate of stroke and death determined during the inpatient stay for elective symptomatic patients was 0.8 %. Early treatment within the first 7 days after the index event, age > 70 years, and operator experience were not significant risk factors for the occurrence of complications. No complications were observed after CAS of asymptomatic stenoses. The procedure-related complication rate for emergency procedures was 7.8 %, which was significantly higher than after elective CAS, as expected (p < 0.006). CONCLUSION Even with limited indications and limited case numbers, compliance with the strict quality criteria of the current S3 Guideline 2022 for elective CAS interventions is possible for both symptomatic and asymptomatic stenoses in an experienced center. Emergency CAS interventions have significantly higher complication rates under other conditions and must be considered separately with regard to quality assurance. KEY POINTS · Elective carotid stenting fulfills the strict quality criteria of the current S3 guideline 2022.. · Emergency carotid stenting has significantly higher complication rates than elective procedures.. · Elective and emergency carotid stenting cannot be meaningfully compared.. CITATION FORMAT · Keil F, Stahn S, Reitz SC et al. Elective carotid stenting fulfills quality standards defined in guidelines. Fortschr Röntgenstr 2023; DOI: 10.1055/a-2175-4029.
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Affiliation(s)
- Fee Keil
- Neuroradiology, Hospital of the Goethe University Frankfurt Institute of Neuroradiology, Frankfurt am Main, Germany
| | - Simon Stahn
- Radiology, Hospital Nordwest Frankfurt, Germany
| | - Sarah Christina Reitz
- Neurosurgery, Hospital of the Goethe University Frankfurt Center of Neurology and Neurosurgery, Frankfurt am Main, Germany
| | - Franziska Lieschke
- Neurology, Hospital of the Goethe University Frankfurt Center of Neurology and Neurosurgery, Frankfurt am Main, Germany
| | | | - Elke Hattingen
- Neuroradiology, Hospital of the Goethe University Frankfurt Institute of Neuroradiology, Frankfurt am Main, Germany
| | - Joachim Berkefeld
- Neuroradiology, Hospital of the Goethe University Frankfurt Institute of Neuroradiology, Frankfurt am Main, Germany
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Liu KQ, Rangwala SD, Cheng J, Han JS, Ding L, Attenello FJ, Mack W. Carotid artery stenting for asymptomatic stenosis is associated with decreased 30-day readmission at very high volume centers. J Clin Neurosci 2023; 114:1-8. [PMID: 37276740 PMCID: PMC10527537 DOI: 10.1016/j.jocn.2023.05.024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2023] [Revised: 05/17/2023] [Accepted: 05/28/2023] [Indexed: 06/07/2023]
Abstract
Endovascular carotid artery stenting (CAS) is a common treatment for carotid artery stenosis and stroke prevention. Previous studies have shown that high procedural volume centers are associated with improved patient outcomes. Unplanned 30-day readmissions, which are associated with significant expenses, are increasingly used as a metric of patient outcome. Despite prior studies evaluating associations between procedural volume and multiple outcomes, the association between very high CAS volume and short-term (30-day) readmission has not yet been evaluated in a large multicenter study. The National Readmissions Database (NRD) was analyzed retrospectively from 2010 to 2015 to evaluate the association between hospital procedural volume and patient outcomes in asymptomatic and symptomatic CAS patients. Very high volume centers (VHVC) were defined as the top 10% hospitals in terms of procedural volume, performing >= 79 procedures a year. Univariate and multivariate analyses of patient and hospital characteristics evaluated associations with short-term (30-day) readmissions (SR), long-term (90-day) readmissions (LR), index mortality, discharge disposition, major complications, and neurological complications. A total of 36,128 asymptomatic patients and 8,390 symptomatic patients who underwent CAS were identified. Asymptomatic CAS patients treated at VHVCs were associated with decreased likelihood of SR (OR 0.88, 95% CI 0.80-0.95, p = 0.003) and LR (OR 0.91, 95% CI 0.85-0.99, p = 0.037) compared to asymptomatic patients at non-VHVCs. There was no significant difference in SR or LR between symptomatic CAS patients treated at a VHVC vs. non-VHVC. Our findings provide additional evidence to support the role of experience in improved CAS treatment outcomes.
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Affiliation(s)
- Kristie Q Liu
- Department of Neurological Surgery, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA.
| | - Shivani D Rangwala
- Department of Neurological Surgery, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA
| | - Justin Cheng
- Department of Neurological Surgery, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA
| | - Jane S Han
- Department of Neurological Surgery, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA
| | - Li Ding
- Department of Neurological Surgery, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA
| | - Frank J Attenello
- Department of Neurological Surgery, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA
| | - William Mack
- Department of Neurological Surgery, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA
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Cheng SF, van Velzen TJ, Gregson J, Richards T, Jäger HR, Simister R, Kooi ME, de Borst GJ, Pizzini FB, Nederkoorn PJ, Brown MM, Bonati LH. The 2nd European Carotid Surgery Trial (ECST-2): rationale and protocol for a randomised clinical trial comparing immediate revascularisation versus optimised medical therapy alone in patients with symptomatic and asymptomatic carotid stenosis at low to intermediate risk of stroke. Trials 2022; 23:606. [PMID: 35897114 PMCID: PMC9328625 DOI: 10.1186/s13063-022-06429-z] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2022] [Accepted: 05/26/2022] [Indexed: 11/24/2022] Open
Abstract
Background Carotid endarterectomy is currently recommended for patients with recently symptomatic carotid stenosis ≥50%, based on randomised trials conducted 30 years ago. Several factors such as carotid plaque ulceration, age and associated comorbidities might influence the risk-benefit ratio of carotid revascularisation. A model developed in previous trials that calculates the future risk of stroke based on these features can be used to stratify patients into low, intermediate or high risk. Since the original trials, medical treatment has improved significantly. Our hypothesis is that patients with carotid stenosis ≥50% associated with a low to intermediate risk of stroke will not benefit from additional carotid revascularisation when treated with optimised medical therapy. We also hypothesise that prediction of future risk of stroke in individual patients with carotid stenosis can be improved using the results of magnetic resonance imaging (MRI) of the carotid plaque. Methods Patients are randomised between immediate revascularisation plus OMT versus OMT alone. Suitable patients are those with asymptomatic or symptomatic carotid stenosis ≥50% with an estimated 5-year risk of stroke of <20%, as calculated using the Carotid Artery Risk score. MRI of the brain at baseline and during follow-up will be used as a blinded measure to assess the incidence of silent infarction and haemorrhage, while carotid plaque MRI at baseline will be used to investigate the hypotheses that plaque characteristics determine future stroke risk and help identify a subgroup of patients that will benefit from revascularisation. An initial analysis will be conducted after recruitment of 320 patients with baseline MRI and a minimum of 2 years of follow-up, to provide data to inform the design and sample size for a continuation or re-launch of the study. The primary outcome measure of this initial analysis is the combined 2-year rate of any clinically manifest stroke, new cerebral infarct on MRI, myocardial infarction or periprocedural death. Discussion ECST-2 will provide new data on the efficacy of modern optimal medical therapy alone versus added carotid revascularisation in patients with carotid stenosis at low to intermediate risk of future stroke selected by individualised risk assessment. We anticipate that the results of baseline brain and carotid plaque MRI will provide data to improve the prediction of the risk of stroke and the effect of treatment in patients with carotid stenosis. Trial registration ISRCTN registry ISRCTN97744893. Registered on 05 July 2012
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Affiliation(s)
- Suk Fun Cheng
- Stroke Research Centre, Department of Brain Repair and Rehabilitation, UCL Queen Square Institute of Neurology, University College London, London, UK
| | - Twan J van Velzen
- Department of Neurology, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - John Gregson
- Department of Medical Statistics, London School of Hygiene and Tropical Medicine, London, UK
| | - Toby Richards
- Faculty of Health and Medical Sciences, Surgery, University of Western Australia, Perth, Australia
| | - Hans Rolf Jäger
- Neuroradiological Academic Unit, Department of Brain Repair and Rehabilitation, UCL Queen Square Institute of Neurology, University College London, London, UK.,Lysholm Department of Neuroradiology, National Hospital for Neurology and Neurosurgery, University College London Hospitals NHS Foundation Trust, London, UK
| | - Robert Simister
- Stroke Research Centre, Department of Brain Repair and Rehabilitation, UCL Queen Square Institute of Neurology, University College London, London, UK.,Comprehensive Stroke Service, University College London Hospitals NHS Foundation Trust, London, UK
| | - M Eline Kooi
- Department of Radiology and Nuclear Medicine, CARIM School for Cardiovascular Diseases, Maastricht University, Maastricht, The Netherlands
| | - Gert J de Borst
- Department of Vascular Surgery, University Medical Center, Utrecht, The Netherlands
| | - Francesca B Pizzini
- Radiology, Department of Diagnostic and Public Health, University of Verona, Verona, Italy
| | - Paul J Nederkoorn
- Department of Neurology, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Martin M Brown
- Stroke Research Centre, Department of Brain Repair and Rehabilitation, UCL Queen Square Institute of Neurology, University College London, London, UK.
| | - Leo H Bonati
- Department of Neurology, University Hospital Basel, Basel, Switzerland.,Department of Clinical Research, University of Basel, Basel, Switzerland.,Research Department, Reha Rheinfelden, Rheinfelden, Switzerland
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Abbott AL. Extra-Cranial Carotid Artery Stenosis: An Objective Analysis of the Available Evidence. Front Neurol 2022; 13:739999. [PMID: 35800089 PMCID: PMC9253595 DOI: 10.3389/fneur.2022.739999] [Citation(s) in RCA: 15] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2021] [Accepted: 01/24/2022] [Indexed: 12/26/2022] Open
Abstract
Background and Purpose Carotid stenosis is arterial disease narrowing of the origin of the internal carotid artery (main brain artery). Knowing how to best manage this is imperative because it is common in older people and an important cause of stroke. Inappropriately high expectations have grown regarding the value of carotid artery procedures, such as surgery (endarterectomy) and stenting, for lowering the stroke risk associated with carotid stenosis. Meanwhile, the improving and predominant value of medical intervention (lifestyle coaching and medication) continues to be underappreciated. Methods and Results This article aims to be an objective presentation and discussion of the scientific literature critical for decision making when the primary goal is to optimize patient outcome. This compilation follows from many years of author scrutiny to separate fact from fiction. Common sense conclusions are drawn from factual statements backed by original citations. Detailed research methodology is given in cited papers. This article has been written in plain language given the importance of the general public understanding this topic. Issues covered include key terminology and the economic impact of carotid stenosis. There is a summary of the evidence-base regarding the efficacy and safety of procedural and medical (non-invasive) interventions for both asymptomatic and symptomatic patients. Conclusions are drawn with respect to current best management and research priorities. Several "furphies" (misconceptions) are exposed that are commonly used to make carotid stenting and endarterectomy outcomes appear similar. Ongoing randomized trials are mentioned and why they are unlikely to identify a routine practice indication for carotid artery procedures. There is a discussion of relevant worldwide guidelines regarding carotid artery procedures, including how they should be improved. There is an outline of systematic changes that are resulting in better application of the evidence-base. Conclusion The cornerstone of stroke prevention is medical intervention given it is non-invasive and protects against all arterial disease complications in all at risk. The "big" question is, does a carotid artery procedure add patient benefit in the modern era and, if so, for whom?
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Affiliation(s)
- Anne L. Abbott
- Department of Neuroscience, Central Clinical School, Monash University, Melbourne, VIC, Australia
- Neurology Private Practice, Knox Private Hospital, Wantirna, VIC, Australia
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Current Status and Outlook of Temporary Implants (Magnesium/Zinc) in Cardiovascular Applications. METALS 2022. [DOI: 10.3390/met12060999] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Medical application materials must meet multiple requirements, and the designed material must mimic the structure, shape. and support the formation of the replacing tissue. Magnesium (Mg) and Zinc alloys (Zn), as a “smart” biodegradable material and as “the green engineering material in the 21st century”, have become an outstanding implant material due to their natural degradability, smart biocompatibility, and desirable mechanical properties. Magnesium and Zinc are recognized as the next generation of cardiovascular stents and bioresorbable scaffolds. At the same time, improving the properties and corrosion resistance of these alloys is an urgent challenge. particularly to promote the application of magnesium alloys. A relatively fast deterioration rate of magnesium-based materials generally results in premature mechanical integrity compromise and local hydrogen build-up, resulting in restricted applicability. This review article aims to give a comprehensive comparison between Zn-based alloys and Mg-based alloys, focusing primarily on degradation and biocompatibility for cardiovascular applications. The recent clinical trials using these biodegradable metals have also been addressed.
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Nguyen DT, Vokó B, Nyárádi BB, Munkácsi T, Bérczi Á, Vokó Z, Dósa E. Restenosis rates in patients with ipsilateral carotid endarterectomy and contralateral carotid artery stenting. PLoS One 2022; 17:e0262735. [PMID: 35148323 PMCID: PMC8836368 DOI: 10.1371/journal.pone.0262735] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2021] [Accepted: 01/04/2022] [Indexed: 11/28/2022] Open
Abstract
Purpose We aimed to evaluate the long-term outcome of carotid endarterectomy (CEA) and carotid artery stenting (CAS) in patients who underwent both procedures on different sides. Methods In this single-center retrospective study (2001–2019), 117 patients (men, N = 78; median age at CEA, 64.4 [interquartile range {IQR}, 57.8–72.2] years; median age at CAS, 68.8 [IQR, 61.0–76.0] years) with ≥50% internal carotid artery stenosis who had CEA on one side and CAS on the other side were included. The risk of restenosis was estimated by treatment adjusted for patient and lesion characteristics. Results Neurological symptoms were significantly more common (41.9% vs 16.2%, P<0.001) and patients had a significantly shorter mean duration of smoking (30.2 [standard deviation {SD}, 22.2] years vs 31.8 [SD, 23.4] years, P<0.001), hypertension (10.1 [SD, 9.8] years vs 13.4 [SD, 9.1] years, P<0.001), hyperlipidemia (3.6 [SD, 6.6] years vs 5.0 [SD, 7.3] years, P = 0.001), and diabetes mellitus (3.9 [SD, 6.9] years vs 5.7 [SD, 8.9] years, P<0.001) before CEA compared to those before CAS. While the prevalence of heavily calcified stenoses on the operated side (25.6% vs 6.8%, P<0.001), the incidence of predominantly echogenic/echogenic plaques (53.0% vs 70.1%, P = 0.011) and suprabulbar lesions (1.7% vs 22.2%, P<0.001) on the stented side was significantly higher. Restenosis rates were 10.4% at 1 year, 22.3% at 5 years, and 33.7% at the end of the follow-up (at 11 years) for CEA, while these were 11.4%, 14.7%, and 17.2%, respectively, for CAS. Cox regression analysis revealed a significantly higher risk of restenosis (hazard ratio [HR], 1.80; 95% confidence interval [CI], 1.05–3.10; P = 0.030) for CEA compared to that for CAS. After adjusting for relevant confounding factors (smoking, hypertension, diabetes mellitus, calcification severity, plaque echogenicity, and lesion location), the estimate effect size materially did not change, although it did not remain statistically significant (HR, 1.85; 95% CI, 0.95–3.60; P = 0.070). Conclusion Intra-patient comparison of CEA and CAS in terms of restenosis tilts the balance toward CAS.
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Affiliation(s)
- Dat Tin Nguyen
- Heart and Vascular Center, Semmelweis University, Budapest, Hungary
- Hungarian Vascular Radiology Research Group, Budapest, Hungary
| | - Boldizsár Vokó
- Heart and Vascular Center, Semmelweis University, Budapest, Hungary
| | | | - Tamás Munkácsi
- Heart and Vascular Center, Semmelweis University, Budapest, Hungary
| | - Ákos Bérczi
- Heart and Vascular Center, Semmelweis University, Budapest, Hungary
- Hungarian Vascular Radiology Research Group, Budapest, Hungary
| | - Zoltán Vokó
- Center for Health Technology Assessment, Semmelweis University, Budapest, Hungary
| | - Edit Dósa
- Heart and Vascular Center, Semmelweis University, Budapest, Hungary
- Hungarian Vascular Radiology Research Group, Budapest, Hungary
- * E-mail:
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Abstract
Stroke is the fifth leading cause of death in the United States and is a leading cause of disability. Extracranial internal carotid artery stenosis is a major cause of ischemic stroke, as it is estimated to cause 8% to 15% of ischemic strokes. It is critical to improve our strategies for stroke prevention and treatment in order to reduce the burden of this disease. Herein, we review approaches for the diagnosis and risk stratification of carotid artery disease as well as interventional strategies for the prevention and treatment of strokes caused by carotid artery disease.
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Affiliation(s)
- Anna K Krawisz
- Richard A. and Susan F. Smith Center for Outcomes Research in Cardiology, Division of Cardiology, Department of Medicine, Beth Israel Deaconess Medical Center, 375 Longwood Avenue, 4th Floor, Boston, MA 02215, USA; Harvard Medical School, Boston, MA, USA; Division of Cardiology, Department of Medicine, Beth Israel Deaconess Medical Center, 185 Pilgrim Road, Palmer Building, 4th Floor, Boston, MA 02215, USA
| | - Brett J Carroll
- Harvard Medical School, Boston, MA, USA; Division of Cardiology, Department of Medicine, Beth Israel Deaconess Medical Center, 185 Pilgrim Road, Palmer Building, 4th Floor, Boston, MA 02215, USA
| | - Eric A Secemsky
- Richard A. and Susan F. Smith Center for Outcomes Research in Cardiology, Division of Cardiology, Department of Medicine, Beth Israel Deaconess Medical Center, 375 Longwood Avenue, 4th Floor, Boston, MA 02215, USA; Harvard Medical School, Boston, MA, USA; Division of Cardiology, Department of Medicine, Beth Israel Deaconess Medical Center, 185 Pilgrim Road, Palmer Building, 4th Floor, Boston, MA 02215, USA.
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Optimal Management of Carotid Artery Restenosis. CURRENT SURGERY REPORTS 2021. [DOI: 10.1007/s40137-021-00303-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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10
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Fan W, Li B, Qu X, Jiang B, Rong J, Liu Y. Recanalization of symptomatic chronic internal carotid artery occlusions by hybrid treatment. Clin Neurol Neurosurg 2021; 207:106752. [PMID: 34144464 DOI: 10.1016/j.clineuro.2021.106752] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2020] [Revised: 05/11/2021] [Accepted: 05/22/2021] [Indexed: 11/26/2022]
Abstract
OBJECTIVE To evaluate the efficacy and safety of hybrid revascularization by carotid endarterectomy and endovascular intervention in the treatment of chronic internal carotid artery occlusion (ICAO). METHODS We performed a retrospective analysis of patients who received hybrid treatment for symptomatic chronic ICAO between December 2016 and December 2018. Fifty-six patients with long-segment ICAO were enrolled and divided into the short duration (1-3 months) and long ICAO duration (>3 months) groups, and their clinical and angiographic data were analyzed. RESULTS The mean duration was 106.8 ± 36.1 days from the date of ICAO diagnosis to revascularization. Totally, 10 patients (17.8%, n = 56) in the short duration group while no patients in the long duration group failed recanalization (n = 7). Perioperative complications included intraoperative thromboembolism in 1 (1.8%) patient and subarachnoid hemorrhage in 2 (3.6%) patients. Early phase postoperative hypertension was noted in 11 (19.6%) patients and cervical hemorrhage in 1 (1.8%) patient. No severe neurological deficits occurred. Overall, the 6-month modified Rankin score, Mini-mental State Examination (MMSE) and Montreal Cognitive Assessment (MoCA) scores in patients with successful recanalization significantly improved versus the baseline (P < 0.05). After successful recanalization, the long duration group demonstrated more stents for revascularization compared with the short duration group (P < 0.05). Five (10.8%) patients had recurrent transient ischemic attack, and 1 (2.2%) patient developed stroke in the successful revascularization group during 6 months of follow-up. ICA restenosis occurred in 5 (8.9%) patients and re-occlusion was noted in 1 (1.8%) patient. CONCLUSIONS Hybrid operation may be feasible and effective for patients with symptomatic chronic complete ICAO according to our limited data. The original occlusion site from the carotid bifurcation and the duration of ICAO should be considered as independent indicators for successful recanalization as well as perioperative outcomes.
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Affiliation(s)
- Weijian Fan
- Department of Vascular Surgery, Suzhou TCM Hospital Affiliated to Nanjing University of Chinese Medicine, Suzhou 215003, PR China; Department of Vascular Surgery, Shanghai Pudong Hospital, Fudan University Pudong Medical Center, Shanghai 201399, PR China.
| | - Bo Li
- Department of Interventional Radiology, The First Affiliated Hospital of Soochow University, Suzhou, Jiangsu Province 215000, PR China; Medical College of Soochow University, Suzhou 215000, PR China.
| | - Xiaofeng Qu
- Department of Interventional Radiology, The First Affiliated Hospital of Soochow University, Suzhou, Jiangsu Province 215000, PR China; Department of Neurology, Yancheng City No.1 People's Hospital, Yancheng, Jiangsu Province 224000, PR China.
| | - Bingxin Jiang
- Department of Interventional Radiology, The First Affiliated Hospital of Soochow University, Suzhou, Jiangsu Province 215000, PR China.
| | - Jianjie Rong
- Department of Vascular Surgery, Suzhou TCM Hospital Affiliated to Nanjing University of Chinese Medicine, Suzhou 215003, PR China.
| | - Yizhi Liu
- Department of Interventional Radiology, The First Affiliated Hospital of Soochow University, Suzhou, Jiangsu Province 215000, PR China.
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de Mik SML, Stubenrouch FE, Balm R, Ubbink DT. Development of three different decision support tools to support shared decision-making in vascular surgery. PATIENT EDUCATION AND COUNSELING 2021; 104:282-289. [PMID: 33277102 DOI: 10.1016/j.pec.2020.11.036] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/20/2019] [Revised: 11/25/2020] [Accepted: 11/26/2020] [Indexed: 06/12/2023]
Abstract
BACKGROUND Shared decision-making (SDM) is known to improve quality of care. Particularly in vascular surgery treatment options are often preference-sensitive. Unfortunately, vascular surgeons infrequently apply SDM. Decision support tools (DSTs) have been shown to be helpful in SDM. OBJECTIVE This article describes the development process of three different DSTs to help vascular surgeons and patients apply SDM. PATIENT INVOLVEMENT Patients' information needs were obtained via focus group meetings. Fifty-two patients and eighteen vascular surgeons not involved in the development process evaluated the comprehensibility and usability of the DST-prototypes. METHODS A multidisciplinary steering group commissioned the development of the three DSTs according to international standards. RESULTS Digital decision aids and paper-based consultation cards and decision cards were developed for patients with an abdominal aortic aneurysm, carotid artery disease, intermittent claudication or varicose veins. Patients preferred the use of the decision aids followed by consultation cards, whereas vascular surgeons preferred to use decision cards followed by decision aids. DISCUSSION Decision aids, consultation cards and decision cards for four vascular diseases are now available to all vascular surgeons and patients in the Netherlands. The DSTs were well received by both surgeons and patients. English versions are also available.
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Affiliation(s)
- Sylvana M L de Mik
- Amsterdam University Medical Centers, Department of Surgery, location Academic Medical Center, Amsterdam Cardiovascular Sciences, University of Amsterdam, Amsterdam, the Netherlands
| | - Fabienne E Stubenrouch
- Amsterdam University Medical Centers, Department of Surgery, location Academic Medical Center, Amsterdam Cardiovascular Sciences, University of Amsterdam, Amsterdam, the Netherlands
| | - Ron Balm
- Amsterdam University Medical Centers, Department of Surgery, location Academic Medical Center, Amsterdam Cardiovascular Sciences, University of Amsterdam, Amsterdam, the Netherlands
| | - Dirk T Ubbink
- Amsterdam University Medical Centers, Department of Surgery, location Academic Medical Center, Amsterdam Cardiovascular Sciences, University of Amsterdam, Amsterdam, the Netherlands.
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Hoving AM, Voorneveld J, Mikhal J, Bosch JG, Groot Jebbink E, Slump CH. In vitro performance of echoPIV for assessment of laminar flow profiles in a carotid artery stent. J Med Imaging (Bellingham) 2021; 8:017001. [PMID: 33457445 PMCID: PMC7804295 DOI: 10.1117/1.jmi.8.1.017001] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2020] [Accepted: 12/22/2020] [Indexed: 11/14/2022] Open
Abstract
Purpose: Detailed blood flow studies may contribute to improvements in carotid artery stenting. High-frame-rate contrast-enhanced ultrasound followed by particle image velocimetry (PIV), also called echoPIV, is a technique to study blood flow patterns in detail. The performance of echoPIV in presence of a stent has not yet been studied extensively. We compared the performance of echoPIV in stented and nonstented regions in an in vitro flow setup. Approach: A carotid artery stent was deployed in a vessel-mimicking phantom. High-frame-rate contrast-enhanced ultrasound images were acquired with various settings. Signal intensities of the contrast agent, velocity values, and flow profiles were calculated. Results: The results showed decreased signal intensities and correlation coefficients inside the stent, however, PIV analysis in the stent still resulted in plausible flow vectors. Conclusions: Velocity values and laminar flow profiles can be measured in vitro in stented arteries using echoPIV.
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Affiliation(s)
- Astrid M Hoving
- University of Twente, TechMed Centre, Robotics and Mechatronics Group, Enschede, The Netherlands
| | - Jason Voorneveld
- Erasmus MC, Thorax Center, Department of Biomedical Engineering, Rotterdam, The Netherlands
| | - Julia Mikhal
- University of Twente, TechMed Centre, BIOS Lab-on-a-Chip Group, Enschede, The Netherlands
| | - Johan G Bosch
- Erasmus MC, Thorax Center, Department of Biomedical Engineering, Rotterdam, The Netherlands
| | - Erik Groot Jebbink
- University of Twente, TechMed Centre, Multi-Modality Medical Imaging Group, Enschede, The Netherlands
| | - Cornelis H Slump
- University of Twente, TechMed Centre, Robotics and Mechatronics Group, Enschede, The Netherlands
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13
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Oushy SH, Essibayi MA, Savastano LE, Lanzino G. Carotid artery revascularization: endarterectomy versus endovascular therapy. J Neurosurg Sci 2020; 65:322-326. [PMID: 33297612 DOI: 10.23736/s0390-5616.20.05207-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Carotid endarterectomy is considered the gold standard for primary and secondary stroke prevention in patients with asymptomatic and symptomatic carotid artery stenosis. The role of CEA has been defined by multiple randomized multicenter trials and CEA is the most studied surgical procedure. In recent years, with advances in endovascular techniques, carotid angioplasty, and stenting (CAS) has been proposed as an alternative to CEA especially in high-risk patients. In this article, we review some of the most important trials on the invasive treatment of carotid artery stenosis and summarized the most recent treatment recommendations based on current evidence. The data overwhelmingly supports revascularization of patients with symptomatic stenosis between 70-90%, with a clear preference for CEA over CAS to be done within 14 days of symptom onset is possible. However, CAS is an acceptable alternative to CEA in certain symptomatic patients such as those with severe medical comorbidities, high riding plaques, contralateral occlusion, restenosis after prior CEA, and radiation-induced stenosis. Treatment of asymptomatic patients remains controversial because of advanced of modern medical therapy and large trials are underway to define the role of invasive revascularization in these patients.
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Affiliation(s)
| | | | | | - Giuseppe Lanzino
- Department of Neurosurgery, Mayo Clinic, Rochester, MN, USA - .,Department of Radiology, Mayo Clinic, Rochester, MN, USA
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14
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Machin M, Salim S, Onida S, Davies AH. The less invasive paradox, why carotid artery stenting is not suitable for the high-risk patient. ANNALS OF TRANSLATIONAL MEDICINE 2020; 8:1269. [PMID: 33178801 PMCID: PMC7607106 DOI: 10.21037/atm-19-4085] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Carotid artery stenosis causes significant morbidity and mortality accounting for approximately 8% of all ischaemic strokes. Carotid artery stenting (CAS) offers an endovascular alternative to carotid endarterectomy (CEA), suggested as a viable option in those deemed high-risk for open CEA due to comorbidities or operative technical considerations. A number of large randomised-controlled trials (RCTs) and meta-analysis comparing CAS vs. CEA in unselected patient populations support the conclusion that CAS is associated with a higher risk of stroke and CEA is associated with a higher risk of myocardial infraction. Initial promise for CAS in high-risk patients was demonstrated by The Stenting and Angioplasty with Protection in Patients at High Risk for Endarterectomy (SAPPHIRE) trial that reported CAS was non-inferior to CEA. However, there is evidence to suggest age-related adverse outcome in patients undergoing CAS. There is limited evidence to suggest that CEA could be suitable even in patients deemed high-risk for medical or technical reasons. Further contemporary research on the use of CAS and CEA in high-risk patients is required to re-evaluate current guidelines and high-risk criterion. It is common for a composite outcome of death, ipsilateral stroke and MI which should be questioned as subsequent quality of life is likely to differ after suffering a stroke in comparison to MI. This literature review will discuss the current evidence for CAS and CEA interventions in unselected populations and high-risk patients with carotid disease requiring intervention.
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Affiliation(s)
- Matthew Machin
- Academic Department of Vascular Surgery, Department of Surgery and Cancer, Imperial College London, London, UK.,Imperial Vascular Unit, Imperial Healthcare NHS Trust, London, UK
| | - Safa Salim
- Academic Department of Vascular Surgery, Department of Surgery and Cancer, Imperial College London, London, UK.,Imperial Vascular Unit, Imperial Healthcare NHS Trust, London, UK
| | - Sarah Onida
- Academic Department of Vascular Surgery, Department of Surgery and Cancer, Imperial College London, London, UK.,Imperial Vascular Unit, Imperial Healthcare NHS Trust, London, UK
| | - Alun Huw Davies
- Academic Department of Vascular Surgery, Department of Surgery and Cancer, Imperial College London, London, UK.,Imperial Vascular Unit, Imperial Healthcare NHS Trust, London, UK
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15
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Markus HS, Larsson SC, Dennis J, Kuker W, Schulz UG, Ford I, Clifton A, Rothwell PM. Vertebral artery stenting to prevent recurrent stroke in symptomatic vertebral artery stenosis: the VIST RCT. Health Technol Assess 2020; 23:1-30. [PMID: 31422789 DOI: 10.3310/hta23410] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND Symptomatic vertebral artery (VA) stenosis has been associated with a markedly increased early risk of recurrent stroke. VA stenosis can be treated with stenting; however, there are few data from randomised controlled trials evaluating the efficacy of this treatment, and recent studies in intracranial stenosis have suggested that stenting may be associated with increased risk. OBJECTIVE The Vertebral artery Ischaemia Stenting Trial (VIST) was established to compare the risks and benefits of vertebral angioplasty and stenting with best medical treatment (BMT) alone for recently symptomatic VA stenosis. DESIGN VIST was a prospective, randomised, open, parallel, blinded end-point clinical trial. SETTING The trial was performed in 14 hospitals in the UK. PARTICIPANTS Recruitment began on 23 October 2008 and follow-up ended on 1 March 2016, by which time every patient had been followed up for at least 1 year. Participants had to have symptomatic vertebral stenosis of at least 50% resulting from presumed atheromatous disease. Both patients and clinicians were aware of treatment allocation; however, an independent adjudication committee, masked to treatment allocation, assessed all primary and secondary end points. INTERVENTIONS Participants were randomly assigned (1 : 1) to either vertebral angioplasty/stenting plus BMT (n = 91) or BMT alone (n = 88). A total of 182 patients were initially enrolled; however, three patients (two who withdrew after randomisation and one who did not attend after the initial randomisation visit) did not contribute any follow-up data and were excluded. None of these three patients had outcome events. MAIN OUTCOMES AND MEASURES The primary end point was the occurrence of fatal or non-fatal stroke in any arterial territory during follow-up. RESULTS The median follow-up was 3.5 (interquartile range 2.1-4.7) years. Of the 61 patients who were stented, 48 (78.7%) had extracranial stenosis and 13 (21.3%) had intracranial stenosis. No perioperative complications occurred with extracranial stenting; two strokes occurred during intracranial stenting. The primary end point occurred in five patients (including one fatal stroke) in the stent group and in 12 patients (including two fatal strokes) in the medical group (giving a hazard ratio of 0.40, 95% confidence interval 0.14 to 1.13; p = 0.08), with an absolute risk reduction of 25 strokes per 1000 person-years. LIMITATIONS The study was underpowered because it failed to reach target recruitment. The high rate of non-confirmation of stenosis in the stented group of the trial was a second limitation. CONCLUSIONS The trial found no difference in risk of the primary end point between the two groups. FUTURE Post hoc analysis suggested that stenting could be associated with a reduced recurrent stroke risk in symptomatic VA and further studies are now required to confirm these findings, particularly in extracranial VA stenosis where complication rates with stenting were confirmed to be very low. TRIAL REGISTRATION Current Controlled Trials ISRCTN95212240. FUNDING This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 23, No. 41. See the NIHR Journals Library website for further project information. In addition, funding for the pilot phase was provided by the Stroke Association.
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Affiliation(s)
- Hugh S Markus
- Stroke Research Group, Department of Clinical Neurosciences, University of Cambridge, Cambridge, UK
| | - Susanna C Larsson
- Stroke Research Group, Department of Clinical Neurosciences, University of Cambridge, Cambridge, UK
| | | | - Wilhelm Kuker
- Nuffield Department of Clinical Neurosciences, John Radcliffe Hospital, University of Oxford, Oxford, UK
| | - Ursula G Schulz
- Nuffield Department of Clinical Neurosciences, John Radcliffe Hospital, University of Oxford, Oxford, UK
| | - Ian Ford
- Robertson Centre for Biostatistics, University of Glasgow, Glasgow, UK
| | - Andrew Clifton
- Department of Neuroradiology, St George's Hospital, London, UK
| | - Peter M Rothwell
- Nuffield Department of Clinical Neurosciences, John Radcliffe Hospital, University of Oxford, Oxford, UK
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Lanza G, Giannandrea D, Lanza J, Ricci S, Gensini GF. Personalized-medicine on carotid endarterectomy and stenting. ANNALS OF TRANSLATIONAL MEDICINE 2020; 8:1274. [PMID: 33178806 PMCID: PMC7607117 DOI: 10.21037/atm-20-1126] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
Evidence based medicine (EBM) is the core of current clinical guidelines and is considered as the gold standard of clinical practice. Despite this, a number of limitations and criticisms are moved to EBM. The major one is that this method privileges randomized controlled trials (RCTs), in which the selection of patients is often based on rigid inclusion criteria. The lack of “pragmatism” of some RCTs sometimes makes it difficult to apply guidelines that derive from them to patients observed in clinical practice, who are often affected by comorbidities and disabilities. The new paradigm to overcome this limitation is personalized medicine (PM), which aims to take into account the particular characteristics displayed by the individual. In order to tailor the best treatment for the patient, PM uses EBM but emphasizes the person's specific information from the assessment of the clinic, lifestyle and risk/benefit scores. This narrative review tries to find the best evidence by analysing subgroups and risk scores of patients from meta-analysis and RCTs in order to try to apply PM and to provide good practice points (GPP) on grey aspects and open questions not fully covered by current guidelines on carotid endarterectomy (CEA) and stenting for stroke prevention.
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Affiliation(s)
- Gaetano Lanza
- Vascular Surgery Department, IRCCS MultiMedica Hospital, Castellanza, Italy
| | - David Giannandrea
- Neurology Department-Stroke Unit, Gubbio/Gualdo Tadino and Città di Castello Hospitals, USL Umbria 1, Perugia, Italy.,Association "Naso Sano", Umbria Regional Registry of No-Profit Organization, Corciano, Italy
| | - Jessica Lanza
- ASST Fatebenefratelli Sacco, Angioma Center, Vittore Buzzi Hospital, Milan, Italy
| | - Stefano Ricci
- Neurology Department-Stroke Unit, Gubbio/Gualdo Tadino and Città di Castello Hospitals, USL Umbria 1, Perugia, Italy
| | - Gian Franco Gensini
- Permanent Technical Committee for Guidelines, Tuscany Regional Health Service, Florence, Italy
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17
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Preventing stroke in symptomatic carotid artery disease during the COVID-19 pandemic. J Vasc Surg 2020; 72:755-756. [PMID: 32448560 PMCID: PMC7241312 DOI: 10.1016/j.jvs.2020.04.476] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2020] [Accepted: 04/18/2020] [Indexed: 11/22/2022]
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18
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Bagley JH, Priest R. Carotid Revascularization: Current Practice and Future Directions. Semin Intervent Radiol 2020; 37:132-139. [PMID: 32419725 DOI: 10.1055/s-0040-1709154] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
Carotid stenosis is responsible for approximately 15% of ischemic strokes. Carotid revascularization significantly decreases patients' stroke risk. Carotid endarterectomy has first-line therapy for moderate-to-severe carotid stenosis after a series of pivotal randomized controlled trials were published almost 30 years ago. Revascularization with carotid stenting has become a popular and effective alternative in a select subpopulation of patients. We review the current state of the literature regarding revascularization indications, patient selection, advantages of each revascularization approach, timing of intervention, and emerging interventional techniques, such as transcarotid artery revascularization.
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Affiliation(s)
- Jacob H Bagley
- Department of Neurological Surgery, Oregon Health and Science University, Portland, Oregon
| | - Ryan Priest
- Dotter Department of Interventional Radiology, Oregon Health and Science University, Portland, Oregon
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19
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Williams Z, Olivere LA, Gilmore B, Weissler H, Cox MW, Long C, Shortell CK, Schroder J, Southerland KW. Safety and Feasibility of Simultaneous Transcarotid Revascularization With Flow Reversal and Coronary Artery Bypass Grafting for Concomitant Carotid Artery Stenosis and Coronary Artery Disease. Vasc Endovascular Surg 2020; 54:395-399. [PMID: 32319354 DOI: 10.1177/1538574420918971] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
OBJECTIVE The management of patients with combined severe carotid artery and coronary artery disease (CAD) is controversial. Transcarotid stenting with flow reversal (TCAR) is a novel hybrid technique for carotid revascularization. We sought to investigate the safety and feasibility of simultaneous TCAR and coronary artery bypass grafting (CABG) for concomitant carotid and CAD. METHODS A single-institution, retrospective study of patients with critical carotid artery stenosis and symptomatic CAD who underwent simultaneous TCAR-CABG was completed. The primary outcomes were technical success, perioperative stroke, death, and hemorrhage. RESULTS Four patients underwent TCAR-CABG. All patients were male with a mean age of 64. Technical success was achieved in all cases. There were no perioperative strokes or deaths. There were no reexplorations for hemorrhage. CONCLUSIONS Transcarotid stenting with flow reversal-CABG is a technically feasible hybrid approach for simultaneous carotid and coronary revascularization. It should be part of the vascular surgeon's armamentarium for coexisting carotid and coronary disease. Further research focused on patient selection and perioperative antiplatelet management is warranted prior to the widespread adoption of this technique.
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Affiliation(s)
- Zachary Williams
- Department of Surgery, Duke University Medical Center, Durham, NC, USA
| | | | - Brian Gilmore
- Department of Surgery, Duke University Medical Center, Durham, NC, USA
| | - Hope Weissler
- Department of Surgery, Duke University Medical Center, Durham, NC, USA
| | - Mitchell W Cox
- Department of Surgery, Duke University Medical Center, Durham, NC, USA
| | - Chandler Long
- Department of Surgery, Duke University Medical Center, Durham, NC, USA
| | | | - Jacob Schroder
- Department of Surgery, Duke University Medical Center, Durham, NC, USA
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20
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Squizzato F, Antonello M, Taglialavoro J, Prosdocimi L, Grego F, Lupia M, Piazza M. Clinical Impact of Routine Cardiology Consultation Prior to Elective Carotid Endarterectomy in Neurologically Asymptomatic Patients. Eur J Vasc Endovasc Surg 2020; 59:536-544. [DOI: 10.1016/j.ejvs.2019.11.007] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2018] [Revised: 09/13/2019] [Accepted: 11/06/2019] [Indexed: 01/29/2023]
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21
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Müller MD, Lyrer P, Brown MM, Bonati LH. Carotid artery stenting versus endarterectomy for treatment of carotid artery stenosis. Cochrane Database Syst Rev 2020; 2:CD000515. [PMID: 32096559 PMCID: PMC7041119 DOI: 10.1002/14651858.cd000515.pub5] [Citation(s) in RCA: 35] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
BACKGROUND Carotid artery stenting is an alternative to carotid endarterectomy for the treatment of atherosclerotic carotid artery stenosis. This review updates a previous version first published in 1997 and subsequently updated in 2004, 2007, and 2012. OBJECTIVES To assess the benefits and risks of stenting compared with endarterectomy in people with symptomatic or asymptomatic carotid stenosis. SEARCH METHODS We searched the Cochrane Stroke Group Trials Register (last searched August 2018) and the following databases: CENTRAL, MEDLINE, Embase, and Science Citation Index to August 2018. We also searched ongoing trials registers (August 2018) and reference lists, and contacted researchers in the field. SELECTION CRITERIA Randomised controlled trials (RCTs) comparing stenting with endarterectomy for symptomatic or asymptomatic atherosclerotic carotid stenosis. In addition, we included RCTs comparing carotid artery stenting with medical therapy alone. DATA COLLECTION AND ANALYSIS One review author selected trials for inclusion, assessed trial quality and risk of bias, and extracted data. A second review author independently validated trial selection and a third review author independently validated data extraction. We calculated treatment effects as odds ratios (OR) and 95% confidence intervals (CI), with endarterectomy as the reference group. We quantified heterogeneity using the I² statistic and used GRADE to assess the overall certainty of evidence. MAIN RESULTS We included 22 trials involving 9753 participants. In participants with symptomatic carotid stenosis, compared with endarterectomy stenting was associated with a higher risk of periprocedural death or stroke (the primary safety outcome; OR 1.70, 95% CI 1.31 to 2.19; P < 0.0001, I² = 5%; 10 trials, 5396 participants; high-certainty evidence); and periprocedural death, stroke, or myocardial infarction (OR 1.43, 95% CI 1.14 to 1.80; P = 0.002, I² = 0%; 6 trials, 4861 participants; high-certainty evidence). The OR for the primary safety outcome was 1.11 (95% CI 0.74 to 1.64) in participants under 70 years old and 2.23 (95% CI 1.61 to 3.08) in participants 70 years old or more (interaction P = 0.007). There was a non-significant increase in periprocedural death or major or disabling stroke with stenting (OR 1.36, 95% CI 0.97 to 1.91; P = 0.08, I² = 0%; 7 trials, 4983 participants; high-certainty evidence). Compared with endarterectomy, stenting was associated with lower risks of myocardial infarction (OR 0.47, 95% CI 0.24 to 0.94; P = 0.03, I² = 0%), cranial nerve palsy (OR 0.09, 95% CI 0.06 to 0.16; P < 0.00001, I² = 0%), and access site haematoma (OR 0.32, 95% CI 0.15 to 0.68; P = 0.003, I² = 27%). The combination of periprocedural death or stroke or ipsilateral stroke during follow-up (the primary combined safety and efficacy outcome) favoured endarterectomy (OR 1.51, 95% CI 1.24 to 1.85; P < 0.0001, I² = 0%; 8 trials, 5080 participants; high-certainty evidence). The rate of ipsilateral stroke after the periprocedural period did not differ between treatments (OR 1.05, 95% CI 0.75 to 1.47; P = 0.77, I² = 0%). In participants with asymptomatic carotid stenosis, there was a non-significant increase in periprocedural death or stroke with stenting compared with endarterectomy (OR 1.72, 95% CI 1.00 to 2.97; P = 0.05, I² = 0%; 7 trials, 3378 participants; moderate-certainty evidence). The risk of periprocedural death or stroke or ipsilateral stroke during follow-up did not differ significantly between treatments (OR 1.27, 95% CI 0.87 to 1.84; P = 0.22, I² = 0%; 6 trials, 3315 participants; moderate-certainty evidence). Moderate or higher carotid artery restenosis (50% or greater) or occlusion during follow-up was more common after stenting (OR 2.00, 95% CI 1.12 to 3.60; P = 0.02, I² = 44%), but the difference in risk of severe restenosis was not significant (70% or greater; OR 1.26, 95% CI 0.79 to 2.00; P = 0.33, I² = 58%; low-certainty evidence). AUTHORS' CONCLUSIONS Stenting for symptomatic carotid stenosis is associated with a higher risk of periprocedural stroke or death than endarterectomy. This extra risk is mostly attributed to an increase in minor, non-disabling strokes occurring in people older than 70 years. Beyond the periprocedural period, carotid stenting is as effective in preventing recurrent stroke as endarterectomy. However, combining procedural safety and long-term efficacy in preventing recurrent stroke still favours endarterectomy. In people with asymptomatic carotid stenosis, there may be a small increase in the risk of periprocedural stroke or death with stenting compared with endarterectomy. However, CIs of treatment effects were wide and further data from randomised trials in people with asymptomatic stenosis are needed.
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Affiliation(s)
- Mandy D Müller
- University Hospital BaselDepartment of Neurology and Stroke CenterPetersgraben 4BaselSwitzerland4031
| | - Philippe Lyrer
- University Hospital BaselDepartment of Neurology and Stroke CenterPetersgraben 4BaselSwitzerland4031
| | - Martin M Brown
- UCL Institute of NeurologyDepartment of Brain Repair & RehabilitationBox 6, The National HospitalQueen SquareLondonUKWC1N 3BG
| | - Leo H Bonati
- University Hospital BaselDepartment of Neurology and Stroke CenterPetersgraben 4BaselSwitzerland4031
- UCL Institute of NeurologyDepartment of Brain Repair & RehabilitationBox 6, The National HospitalQueen SquareLondonUKWC1N 3BG
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22
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Djurdjevic T, Cunha A, Schulz U, Briley D, Rothwell P, Küker W. Endovascular treatment of patients with high-risk symptomatic intracranial vertebrobasilar stenoses: long - term outcomes. Stroke Vasc Neurol 2020; 4:182-188. [PMID: 32030201 PMCID: PMC6979875 DOI: 10.1136/svn-2019-000230] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2019] [Revised: 03/23/2019] [Accepted: 04/30/2019] [Indexed: 12/02/2022] Open
Abstract
Background and purpose We present the long-term outcome after endovascular treatment of symptomatic intracranial posterior circulation stenoses. Methods 30 patients with symptomatic intracranial posterior circulation stenoses exceeding 70% underwent endovascular treatment between 2006 and 2012. Data regarding presentation, follow-up, procedure details, complications and imaging follow-up were reviewed. All surviving patients underwent a phone interview to establish their current Modified Ranking Scales (MRS). Results Stenoses of the intracranial vertebral artery (24 patients) and basilar artery (6 patients) were treated with stents (10 patients), angioplasty alone (13 patients) or both (5 patients). Two procedures failed. One patient (3.3%) died after the procedure, two had stroke (6.6%) and one a subarachnoid haemorrhage without ensuing deficit. Two patients (6.7%) had asymptomatic complications (dissection and pseudoaneurysm). The median clinical follow-up time was 7 years. Of the 29 patients who survived the procedure, 6 died due to unrelated causes. Three patients (10%) had recurrent strokes and two (6.7%) a transient ischaemic attack in the posterior circulation. Two patients had subsequent middle cerebral artery strokes. Five (16.7%) patients had recurrent stenoses and three (10%) occlusions of the treated artery. Retreatment was performed in six patients, three (10%) with PTA and three (10%) with stenting. Current MRS scores were as follows: nine MRS 0, eight MRS 1, four MRS 2 and one MRS 4. Conclusions Long-term follow-up after endovascular treatment of high-risk symptomatic intracranial posterior circulation stenoses shows few stroke recurrences. Treatment of intracranial vertebral artery stenosis may be beneficial in appropriately selected patients.
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Affiliation(s)
- Tanja Djurdjevic
- Neuroradiology, Medical University of Innsbruck, Innsbruck, Austria.,Department of Neuroradiology, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - André Cunha
- Department of Neuroradiology, Centro Hospitalar Gaia/Espinho, Vila Nova de Gaia, Portugal.,Department of Clinical Neurosciences, University of Oxford, Oxford, UK
| | - Ursula Schulz
- Department of Clinical Neurosciences, University of Oxford, Oxford, UK
| | - Dennis Briley
- Department of Clinical Neurosciences, University of Oxford, Oxford, UK.,Neurology, Stoke Mandeville Hospital, Aylesbury, Buckinghamshire, UK
| | - Peter Rothwell
- Department of Clinical Neurosciences, University of Oxford, Oxford, UK
| | - Wilhelm Küker
- Department of Neuroradiology, Oxford University Hospitals NHS Foundation Trust, Oxford, UK.,Department of Clinical Neurosciences, University of Oxford, Oxford, UK
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23
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High Operator and Hospital Volume Are Associated With a Decreased Risk of Death and Stroke After Carotid Revascularization: A Systematic Review and Meta-analysis. Ann Surg 2020; 269:631-641. [PMID: 30102632 DOI: 10.1097/sla.0000000000002880] [Citation(s) in RCA: 26] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
OBJECTIVE To examine the association between operator or hospital volume and procedural outcomes of carotid revascularization. BACKGROUND Operator and hospital volume have been proposed as determinants of outcome after carotid endarterectomy (CEA) or carotid artery stenting (CAS). The magnitude and clinical relevance of this relationship are debated. METHODS We systematically searched PubMed and EMBASE until August 21, 2017. The primary outcome was procedural (30 days, in-hospital, or perioperative) death or stroke. Obtained or estimated risk estimates were pooled with a generic inverse variance random-effects model. RESULTS We included 87 studies. A decreased risk of death or stroke following CEA was found for high compared to low operator volume with a pooled adjusted odds ratio (OR) of 0.50 (95% confidence interval [CI] 0.28-0.87; 3 cohorts), and a pooled unadjusted relative risk (RR) of 0.59 (95% CI 0.42-0.83; 9 cohorts); for high compared to low hospital volume with a pooled adjusted OR of 0.62 (95% CI 0.42-0.90; 5 cohorts), and a pooled unadjusted RR of 0.68 (95% CI 0.51-0.92; 9 cohorts). A decreased risk of death or stroke after CAS was found for high compared to low operator volume with an adjusted OR of 0.43 (95% CI 0.20-0.95; 1 cohort), and an unadjusted RR of 0.50 (95% CI 0.32-0.79; 1 cohort); for high compared to low hospital volume with an adjusted OR of 0.46 (95% CI 0.26-0.80; 1 cohort), and no significant decreased risk in a pooled unadjusted RR of 0.72 (95% CI 0.49-1.06; 2 cohorts). CONCLUSIONS We found a decreased risk of procedural death and stroke after CEA and CAS for high operator and high hospital volume, indicating that aiming for a high volume may help to reduce procedural complications. REGISTRATION This systematic review has been registered in the international prospective registry of systematic reviews (PROSPERO): CRD42017051491.
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24
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Bereznyakova O, Dewar B, Dowlatshahi D, Howard V, Hamel C, Gocan S, Fedyk M, Shamy M. Benefit of carotid revascularisation for women with symptomatic carotid stenosis: protocol for a systematic review. BMJ Open 2019; 9:e032140. [PMID: 31719088 PMCID: PMC6858193 DOI: 10.1136/bmjopen-2019-032140] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/07/2019] [Revised: 08/29/2019] [Accepted: 10/11/2019] [Indexed: 02/06/2023] Open
Abstract
INTRODUCTION Carotid intervention in the form of endarterectomy or stenting is the current standard of care for the majority of patients with symptomatic high-grade carotid stenosis. However, some randomised controlled trials (RCT) have demonstrated that women benefited significantly less from intervention than men. It is unclear if this is a true phenomenon or a study sampling artefact, as women were severely under-represented in all RCTs of carotid revascularisation. A systematic review is needed to summarise the existing data and to answer the question of whether a women-only trial for symptomatic patients with ipsilateral carotid stenosis is scientifically necessary and ethically permissible. METHODS AND ANALYSIS We will systematically search Medline, Embase, PubMed and the Cochrane libraries for all studies with data from RCTs that included women and compared either endarterectomy with stenting or revascularisation (by means of endarterectomy or stenting) with medical therapy in patients with symptomatic carotid stenosis. Search dates will be restricted to 1991-2018. Two reviewers will conduct screening search results, study selection, data extraction and quality assessment. We will include all studies reporting outcomes of interest. Planned subgroup analysis based on revascularisation technique, degree of stenosis and timing of intervention from the index event will be conducted with enough data. ETHICS AND DISSEMINATION This research is exempt of ethics approval as no primary data will be collected. The results will be published in peer-reviewed journals and disseminated through national and international-level conferences and scientific meetings. The result of this comprehensive review will provide useful information on whether further RCTs are required to study a women-only population with symptomatic carotid disease. PROSPERO REGISTRATION NUMBER CRD42019134967.
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Affiliation(s)
| | - Brian Dewar
- Neurology, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
| | | | - Virginia Howard
- University of Alabama at Birmingham School of Public Health, Birmingham, Alabama, USA
| | - Candyce Hamel
- Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
| | - Sophia Gocan
- Neurology, Ottawa Hospital, Ottawa, Ontario, Canada
| | - Mark Fedyk
- Mount Allison University, Sackville, New Brunswick, Canada
| | - Michel Shamy
- Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
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Zhu Z, Yu W. Update in the treatment of extracranial atherosclerotic disease for stroke prevention. Stroke Vasc Neurol 2019; 5:65-70. [PMID: 32411410 PMCID: PMC7213501 DOI: 10.1136/svn-2019-000261] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2019] [Revised: 10/10/2019] [Accepted: 10/28/2019] [Indexed: 01/03/2023] Open
Abstract
Stroke is a leading cause of adult mortality and disability worldwide. Extracranial atherosclerotic disease (ECAD), primarily, carotid artery stenosis, accounts for approximately 18%–25% of ischaemic stroke. Recent advances in neuroimaging, medical therapy and interventional management have led to A significant reduction of stroke from carotid artery stenosis. The current treatment of ECAD includes optimal medical therapy, carotid endarterectomy (CEA) and carotid artery stenting (CAS). The selection of treatments depends on symptomatic status, severity of stenosis, individual factors, efficacy and risk of complications. The aim of this paper is to review current evidence and guidelines on the management of carotid artery stenosis, including the comparison of medical and interventional therapy (CAS and CEA), as well as future directions.
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Affiliation(s)
- Zhu Zhu
- Department of Neurology, University of California Irvine, Irvine, California, USA.,Department of Neurology, Huashan Hospital Fudan University, Shanghai, China
| | - Wengui Yu
- Department of Neurology, University of California Irvine, Irvine, California, USA
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26
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Volkers EJ, Algra A, Kappelle LJ, Becquemin JP, de Borst GJ, Brown MM, Bulbulia R, Calvet D, Eckstein HH, Fraedrich G, Gregson J, Halliday A, Hendrikse J, Howard G, Jansen O, Roubin GS, Bonati LH, Brott TG, Mas JL, Ringleb PA, Greving JP. Safety of Carotid Revascularization in Patients With a History of Coronary Heart Disease. Stroke 2019; 50:413-418. [PMID: 30621529 PMCID: PMC6358179 DOI: 10.1161/strokeaha.118.023085] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/02/2022]
Abstract
Supplemental Digital Content is available in the text. Background and Purpose— We investigated whether procedural stroke or death risk of carotid artery stenting (CAS) compared with carotid endarterectomy (CEA) is different in patients with and without history of coronary heart disease (CHD) and whether the treatment-specific impact of age differs. Methods— We combined individual patient data of 4754 patients with symptomatic carotid stenosis from 4 randomized trials (EVA-3S [Endarterectomy Versus Angioplasty in Patients With Symptomatic Severe Carotid Stenosis], SPACE [Stent-Protected Angioplasty Versus Carotid Endarterectomy], ICSS [International Carotid Stenting Study], and CREST [Carotid Revascularization Endarterectomy Versus Stenting Trial]). Procedural risk was defined as any stroke or death ≤30 days after treatment. We compared procedural risk between both treatments with Cox regression analysis, stratified by history of CHD and age (<70, 70–74, ≥75 years). History of CHD included myocardial infarction, angina, or coronary revascularization. Results— One thousand two hundred ninety-three (28%) patients had history of CHD. Procedural stroke or death risk was higher in patients with history of CHD. Procedural risk in patients treated with CAS compared with CEA was consistent in patients with history of CHD (8.3% versus 4.6%; hazard ratio [HR], 1.96; 95% CI, 0.67–5.73) and in those without (6.9% versus 3.6%; HR, 1.93; 95% CI, 1.40–2.65; Pinteraction=0.89). In patients with history of CHD, procedural risk was significantly higher after CAS compared with CEA in patients aged ≥75 (CAS-to-CEA HR, 2.78; 95% CI, 1.32–5.85), but not in patients aged <70 (HR, 1.71; 95% CI, 0.79–3.71) and 70 to 74 years (HR, 1.09; 95% CI, 0.45–2.65). In contrast, in patients without history of CHD, procedural risk after CAS was higher in patients aged 70 to 74 (HR, 3.62; 95% CI, 1.80–7.29) and ≥75 years (HR, 2.64; 95% CI, 1.52–4.59), but equal in patients aged <70 years (HR, 1.05; 95% CI, 0.63–1.73; 3-way Pinteraction=0.09). Conclusions— History of CHD does not modify procedural stroke or death risk of CAS compared with CEA. CAS might be as safe as CEA in patients with history of CHD aged <75 years, whereas for patients without history of CHD, risk after CAS compared with CEA was only equal in those aged <70 years.
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Affiliation(s)
- Eline J Volkers
- From the Department of Neurology and Neurosurgery, Brain Center Rudolf Magnus (E.J.V., A.A., L.J.K.), University Medical Center Utrecht, Utrecht University, Utrecht, the Netherlands.,Julius Center for Health Sciences and Primary Care (E.J.V., A.A., J.P.G.), University Medical Center Utrecht, Utrecht University, Utrecht, the Netherlands
| | - Ale Algra
- From the Department of Neurology and Neurosurgery, Brain Center Rudolf Magnus (E.J.V., A.A., L.J.K.), University Medical Center Utrecht, Utrecht University, Utrecht, the Netherlands.,Julius Center for Health Sciences and Primary Care (E.J.V., A.A., J.P.G.), University Medical Center Utrecht, Utrecht University, Utrecht, the Netherlands
| | - L Jaap Kappelle
- From the Department of Neurology and Neurosurgery, Brain Center Rudolf Magnus (E.J.V., A.A., L.J.K.), University Medical Center Utrecht, Utrecht University, Utrecht, the Netherlands
| | | | - Gert J de Borst
- Department of Vascular Surgery (G.J.d.B.), University Medical Center Utrecht, Utrecht University, Utrecht, the Netherlands
| | - Martin M Brown
- Department of Brain Repair and Rehabilitation, UCL Institute of Neurology, University College London, United Kingdom (M.M.B., L.H.B.)
| | - Richard Bulbulia
- MRC Population Health Research Unit, Clinical Trial Service Unit and Epidemiological Studies Unit, Nuffield Department of Population Health, University of Oxford, United Kingdom (R.B.)
| | - David Calvet
- Department of Neurology, Hôpital Sainte-Anne, Université Paris-Descartes, DHU Neurovasc Sorbonne Paris Cité, INSERM U894, Paris, France (D.C., J.-L.M.)
| | - Hans-Henning Eckstein
- Department of Vascular and Endovascular Surgery/Vascular Center, Klinikum rechts der Isar, Technical University Munich, Germany (H.-H.E.)
| | - Gustav Fraedrich
- Department of Vascular Surgery, Medical University of Innsbruck, Austria (G.F.)
| | - John Gregson
- Department of Medical Statistics, London School for Hygiene and Tropical Medicine, United Kingdom (J.G.)
| | - Alison Halliday
- Nuffield Department of Surgical Sciences, John Radcliffe Hospital, Oxford, United Kingdom (A.H.)
| | - Jeroen Hendrikse
- Department of Radiology (J.H.), University Medical Center Utrecht, Utrecht University, Utrecht, the Netherlands
| | - George Howard
- Department of Biostatistics, UAB School of Public Health, Birmingham, AL (G.H.)
| | - Olav Jansen
- Clinic for Radiology and Neuroradiology, UKSH Campus Kiel, Germany (O.J.)
| | - Gary S Roubin
- Cardiovascular Associates of the Southeast, Birmingham, AL (G.S.R.)
| | - Leo H Bonati
- Department of Brain Repair and Rehabilitation, UCL Institute of Neurology, University College London, United Kingdom (M.M.B., L.H.B.).,Department of Neurology and Stroke Center, Department of Clinical Research, University Hospital Basel, University of Basel, Switzerland (L.H.B.)
| | - Thomas G Brott
- Department of Neurology, Mayo Clinic, Jacksonville, FL (T.G.B.)
| | - Jean-Louis Mas
- Department of Neurology, Hôpital Sainte-Anne, Université Paris-Descartes, DHU Neurovasc Sorbonne Paris Cité, INSERM U894, Paris, France (D.C., J.-L.M.)
| | - Peter A Ringleb
- Department of Neurology, University of Heidelberg Medical School, Germany (P.A.R.)
| | - Jacoba P Greving
- Julius Center for Health Sciences and Primary Care (E.J.V., A.A., J.P.G.), University Medical Center Utrecht, Utrecht University, Utrecht, the Netherlands
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Caliste X, Laser A, Darling RC. CEA vs. stent in patients with acute strokes: are they equally effective? THE JOURNAL OF CARDIOVASCULAR SURGERY 2019; 61:133-142. [PMID: 31603298 DOI: 10.23736/s0021-9509.19.11137-8] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
INTRODUCTION Stroke is the 3rd leading cause of death worldwide with 15 million strokes annually. Extracranial carotid stenosis contributes to major stroke morbidity and mortality as a significant etiology of ischemic strokes. For acute stroke, in addition to optimal medical management, patients may be candidates for carotid endarterectomy and/or carotid stenting for secondary stroke reduction. This paper set out to review the data currently available regarding equivalency of the two intervention options. EVIDENCE ACQUISITION A comprehensive literature review was performed through PubMed and other sources using the key words carotid endarterectomy, carotid artery stent, acute stroke, symptomatic carotid stenosis, flow reversal, TCAR. Studies which solely evaluated patients with asymptomatic disease were ineligible for the study. EVIDENCE SYNTHESIS Review of landmark trials such as NASCET and CREST in addition to more recent studies demonstrates the effectiveness of surgical management with carotid endarterectomy of acute stroke. Carotid stenting has also been shown to have acceptable outcomes in certain patient populations. CONCLUSIONS Carotid endarterectomy continues to demonstrate effectiveness and safety for management of acute stroke, while carotid stenting has limitations. Carotid artery stenting has been shown to be non-inferior in some patient populations, but more recent and future technologic developments may expand the potential acceptable patient selection criteria.
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Affiliation(s)
- Xzabia Caliste
- Division of Vascular Surgery, Albany Medical Center Hospital, Albany Medical College, Albany, NY, USA
| | - Adriana Laser
- Division of Vascular Surgery, Albany Medical Center Hospital, Albany Medical College, Albany, NY, USA -
| | - R Clement Darling
- Division of Vascular Surgery, Albany Medical Center Hospital, Albany Medical College, Albany, NY, USA
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Lanza G, Lanza J, Ricci S, Pini R, Faggioli G, Gensini GF. Personalized medicine: new enhancement to guidelines on carotid endarterectomy and stenting. ITALIAN JOURNAL OF VASCULAR AND ENDOVASCULAR SURGERY 2019. [DOI: 10.23736/s1824-4777.19.01422-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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29
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Volkers EJ, Algra A, Kappelle LJ, Jansen O, Howard G, Hendrikse J, Halliday A, Gregson J, Fraedrich G, Eckstein HH, Calvet D, Bulbulia R, Brown MM, Becquemin JP, Ringleb PA, Mas JL, Bonati LH, Brott TG, Greving JP. Prediction Models for Clinical Outcome After a Carotid Revascularization Procedure. Stroke 2019; 49:1880-1885. [PMID: 30012816 PMCID: PMC6092096 DOI: 10.1161/strokeaha.117.020486] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Supplemental Digital Content is available in the text. Background and Purpose— Prediction models may help physicians to stratify patients with high and low risk for periprocedural complications or long-term stroke risk after carotid artery stenting or carotid endarterectomy. We aimed to evaluate external performance of previously published prediction models for short- and long-term outcome after carotid revascularization in patients with symptomatic carotid artery stenosis. Methods— From a literature review, we selected all prediction models that used only readily available patient characteristics known before procedure initiation. Follow-up data from 2184 carotid artery stenting and 2261 carotid endarterectomy patients from 4 randomized trials (EVA-3S [Endarterectomy Versus Angioplasty in Patients With Symptomatic Severe Carotid Stenosis], SPACE [Stent-Protected Angioplasty Versus Carotid Endarterectomy], ICSS [International Carotid Stenting Study], and CREST [Carotid Revascularization Endarterectomy Versus Stenting Trial]) were used to validate 23 short-term outcome models to estimate stroke or death risk ≤30 days after the procedure and the original outcome measure for which the model was developed. Additionally, we validated 7 long-term outcome models for the original outcome measure. Predictive performance of the models was assessed with C statistics and calibration plots. Results— Stroke or death ≤30 days after the procedure occurred in 158 (7.2%) patients after carotid artery stenting and in 84 (3.7%) patients after carotid endarterectomy. Most models for short-term outcome after carotid artery stenting (n=4) or carotid endarterectomy (n=19) had poor discriminative performance (C statistics ranging from 0.49–0.64) and poor calibration with small absolute risk differences between the lowest and highest risk groups and overestimation of risk in the highest risk groups. Long-term outcome models (n=7) had a slightly better performance with C statistics ranging from 0.59 to 0.67 and reasonable calibration. Conclusions— Current models did not reliably predict outcome after carotid revascularization in a trial population of patients with symptomatic carotid stenosis. In particular, prediction of short-term outcome seemed to be difficult. Further external validation of existing prediction models or development of new prediction models is needed before such models can be used to support treatment decisions in individual patients.
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Affiliation(s)
- Eline J Volkers
- From the Department of Neurology and Neurosurgery, Brain Center Rudolf Magnus (E.J.V., A.A., L.J.K.).,Julius Center for Health Sciences and Primary Care (E.J.V., A.A., J.P.G.)
| | - Ale Algra
- From the Department of Neurology and Neurosurgery, Brain Center Rudolf Magnus (E.J.V., A.A., L.J.K.).,Julius Center for Health Sciences and Primary Care (E.J.V., A.A., J.P.G.)
| | - L Jaap Kappelle
- From the Department of Neurology and Neurosurgery, Brain Center Rudolf Magnus (E.J.V., A.A., L.J.K.)
| | - Olav Jansen
- Clinic for Radiology and Neuroradiology, UKSH Campus Kiel, Germany (O.J.)
| | - George Howard
- Department of Biostatistics, UAB School of Public Health, Birmingham, AL (G.H.)
| | - Jeroen Hendrikse
- Department of Radiology (J.H.), University Medical Center Utrecht, Utrecht University, The Netherlands
| | - Alison Halliday
- Nuffield Department of Surgical Sciences, John Radcliffe Hospital, Oxford, United Kingdom (A.H.)
| | - John Gregson
- London School for Hygiene and Tropical Medicine, United Kingdom (J.G.)
| | - Gustav Fraedrich
- Department of Vascular Surgery, Medical University of Innsbruck, Austria (G.F.)
| | - Hans-Henning Eckstein
- Department of Vascular and Endovascular Surgery/Vascular Center, Klinikum rechts der Isar, Technical University Munich, Germany (H.-H.E.)
| | - David Calvet
- Department of Neurology, Hôpital Sainte-Anne, Université Paris-Descartes, DHU Neurovasc Sorbonne Paris Cité, INSERM U894, France (D.C., J.-L.M.)
| | - Richard Bulbulia
- MRC Population Health Research Unit, Clinical Trial Service Unit and Epidemiological Studies Unit, Nuffield Department of Population Health, University of Oxford, United Kingdom (R.B.)
| | - Martin M Brown
- Department of Brain Repair and Rehabilitation, UCL Institute of Neurology, University College London, United Kingdom (M.M.B., L.H.B.)
| | | | - Peter A Ringleb
- Department of Neurology, University of Heidelberg Medical School, Germany (P.A.R.)
| | - Jean-Louis Mas
- Department of Neurology, Hôpital Sainte-Anne, Université Paris-Descartes, DHU Neurovasc Sorbonne Paris Cité, INSERM U894, France (D.C., J.-L.M.)
| | - Leo H Bonati
- Department of Brain Repair and Rehabilitation, UCL Institute of Neurology, University College London, United Kingdom (M.M.B., L.H.B.).,Department of Neurology and Stroke Center, Department of Clinical Research, University Hospital Basel, Switzerland (L.H.B.)
| | - Thomas G Brott
- Department of Neurology, Mayo Clinic, Jacksonville, FL (T.G.B.)
| | - Jacoba P Greving
- Julius Center for Health Sciences and Primary Care (E.J.V., A.A., J.P.G.)
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de Mik SML, Stubenrouch FE, Legemate DA, Balm R, Ubbink DT. Delphi Study to Reach International Consensus Among Vascular Surgeons on Major Arterial Vascular Surgical Complications. World J Surg 2019; 43:2328-2336. [PMID: 31183537 DOI: 10.1007/s00268-019-05038-3] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
BACKGROUND The complications discussed with patients by surgeons prior to surgery vary, because no consensus on major complications exists. Such consensus may improve informed consent and shared decision-making. This study aimed to achieve consensus among vascular surgeons on which complications are considered 'major' and which 'minor,' following surgery for abdominal aortic aneurysm (AAA), carotid artery disease (CAD) and peripheral artery disease (PAD). METHODS Complications following vascular surgery were extracted from Cochrane reviews, national guidelines, and reporting standards. Vascular surgeons from Europe and North America rated complications as major or minor on five-point Likert scales via an electronic Delphi method. Consensus was reached if ≥ 80% of participants scored 1 or 2 (minor) or 4 or 5 (major). RESULTS Participants reached consensus on 9-12 major and 6-10 minor complications per disease. Myocardial infarction, stroke, renal failure and allergic reactions were considered to be major complications of all three diseases. All other major complications were treatment specific or dependent on disease severity, e.g., spinal cord ischemia, rupture following AAA repair, stroke for CAD or deep wound infection for PAD. CONCLUSION Vascular surgeons reached international consensus on major and minor complications following AAA, CAD and PAD treatment. This consensus may be helpful in harmonizing the information patients receive and improving standardization of the informed consent procedure. Since major complications differed between diseases, consensus on disease-specific complications to be discussed with patients is necessary.
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Affiliation(s)
- S M L de Mik
- Department of Surgery, Amsterdam University Medical Centers, University of Amsterdam, Amsterdam Cardiovascular Sciences, Meibergdreef 9, 1105 AZ, Amsterdam, The Netherlands
| | - F E Stubenrouch
- Department of Surgery, Amsterdam University Medical Centers, University of Amsterdam, Amsterdam Cardiovascular Sciences, Meibergdreef 9, 1105 AZ, Amsterdam, The Netherlands
| | - D A Legemate
- Department of Surgery, Amsterdam University Medical Centers, University of Amsterdam, Amsterdam Cardiovascular Sciences, Meibergdreef 9, 1105 AZ, Amsterdam, The Netherlands
| | - R Balm
- Department of Surgery, Amsterdam University Medical Centers, University of Amsterdam, Amsterdam Cardiovascular Sciences, Meibergdreef 9, 1105 AZ, Amsterdam, The Netherlands
| | - D T Ubbink
- Department of Surgery, Amsterdam University Medical Centers, University of Amsterdam, Amsterdam Cardiovascular Sciences, Meibergdreef 9, 1105 AZ, Amsterdam, The Netherlands.
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Wu WW, Liang P, O'Donnell TFX, Swerdlow NJ, Li C, Wyers MC, Schermerhorn ML. Anatomic eligibility for transcarotid artery revascularization and transfemoral carotid artery stenting. J Vasc Surg 2019; 69:1452-1460. [PMID: 30853384 PMCID: PMC6478535 DOI: 10.1016/j.jvs.2018.11.051] [Citation(s) in RCA: 54] [Impact Index Per Article: 10.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2018] [Accepted: 11/13/2018] [Indexed: 02/04/2023]
Abstract
OBJECTIVE Transcarotid artery revascularization (TCAR) has emerged as an alternative to transfemoral carotid artery stenting (tfCAS). We investigated the proportion of carotid arteries undergoing revascularization procedures that would be eligible for TCAR based on anatomic criteria and how many arteries at high anatomic risk for tfCAS would be amenable to TCAR. METHODS We performed a retrospective review of consecutive patients who underwent carotid endarterectomy or carotid stenting between 2012 and 2015. Patients were excluded if computed tomography angiography of the neck was not performed within 6 months of the procedure. We assessed TCAR eligibility on the basis of the instructions for use of the ENROUTE Transcarotid Neuroprotection System (Silk Road Medical, Sunnyvale, Calif) and high anatomic risk for tfCAS on the basis of anatomic factors known to make carotid cannulation more difficult or hazardous. RESULTS Of the 118 patients and 236 carotid arteries identified, 12 carotid arteries were excluded for presence of an occluded internal carotid artery (ICA). Of the remaining 224 carotid arteries, 72% were eligible for TCAR on the basis of the instructions for use criteria; 100% had 4- to 9-mm ICA diameters, 100% had ≥6-mm common carotid artery (CCA) diameter, 75% had ≥5-cm clavicle to carotid bifurcation distance, and 96% lacked significant CCA puncture site plaque. In addition, 7% of carotid arteries had bifurcation anatomy unfavorable for stenting; thus, of the entire cohort of arteries examined, 68% were eligible for TCAR. Hyperlipidemia (odds ratio [OR], 6.7; 95% confidence interval [CI], 1.7-26; P < .01), chronic obstructive pulmonary disease (OR, 3.5; 95% CI, 1.5-8.3; P < .01), and older age (OR, 1.1; 95% CI, 1.0-1.1; P < .01) were independently associated with TCAR ineligibility, whereas white race (OR, 0.2; 95% CI, 0.0-1.0; P = .048) and beta-blocker use (OR, 0.3; 95% CI, 0.1-0.7; P < .01) were independently associated with TCAR eligibility. In addition, 24% of carotid arteries were considered to be at high risk for tfCAS for the presence of a type III aortic arch (7.6%), severe aortic calcification (3.3%), tandem CCA lesions (7.1%), moderate to severe stenosis at the carotid ostium (8.9%), and tortuous distal ICA precluding embolic filter placement (4.5%). Active smoking (OR, 4.4; 95% CI, 1.9-10; P < .01), hyperlipidemia (OR, 4.0; 95% CI, 1.2-14; P = .03), and older age (OR, 1.1; 95% CI, 1.0-1.1; P = .02) were independently associated with tfCAS ineligibility, whereas preoperative aspirin (OR, 0.1; 95% CI, 0.0-0.4; P < .001) or clopidogrel (OR, 0.3; 95% CI, 0.1-0.8; P = .01) use was associated with tfCAS eligibility. Of the arteries that were considered to be at high risk for tfCAS, 69% were eligible for TCAR. CONCLUSIONS The majority of carotid arteries in individuals selected for revascularization meet TCAR eligibility, making TCAR a viable treatment option for many patients.
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Affiliation(s)
- Winona W Wu
- Division of Vascular and Endovascular Surgery, Beth Israel Deaconess Medical Center, Boston, Mass
| | - Patric Liang
- Division of Vascular and Endovascular Surgery, Beth Israel Deaconess Medical Center, Boston, Mass
| | - Thomas F X O'Donnell
- Division of Vascular and Endovascular Surgery, Beth Israel Deaconess Medical Center, Boston, Mass; Department of Surgery, Massachusetts General Hospital, Boston, Mass
| | - Nicholas J Swerdlow
- Division of Vascular and Endovascular Surgery, Beth Israel Deaconess Medical Center, Boston, Mass
| | - Chun Li
- Division of Vascular and Endovascular Surgery, Beth Israel Deaconess Medical Center, Boston, Mass
| | - Mark C Wyers
- Division of Vascular and Endovascular Surgery, Beth Israel Deaconess Medical Center, Boston, Mass
| | - Marc L Schermerhorn
- Division of Vascular and Endovascular Surgery, Beth Israel Deaconess Medical Center, Boston, Mass.
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In-stent restenosis associated with dual-layer Roadsaver carotid artery stent: a retrospective single-center study. LA RADIOLOGIA MEDICA 2019; 124:704-709. [DOI: 10.1007/s11547-019-01019-7] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/16/2018] [Accepted: 02/25/2019] [Indexed: 11/26/2022]
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Traenka C, Engelter ST, Brown MM, Dobson J, Frost C, Bonati LH. Silent brain infarcts on diffusion-weighted imaging after carotid revascularisation: A surrogate outcome measure for procedural stroke? A systematic review and meta-analysis. Eur Stroke J 2019; 4:127-143. [PMID: 31259261 DOI: 10.1177/2396987318824491] [Citation(s) in RCA: 32] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2018] [Accepted: 12/20/2018] [Indexed: 12/13/2022] Open
Abstract
Aim To investigate whether lesions on diffusion-weighted imaging (DWI+) after carotid artery stenting (CAS) or endarterectomy (CEA) might provide a surrogate outcome measure for procedural stroke. Materials and Methods Systematic MedLine® database search with selection of all studies published up to the end of 2016 in which DWI scans were obtained before and within seven days after CAS or CEA. The correlation between the underlying log odds of stroke and of DWI+ across all treatment groups (i.e. CAS or CEA groups) from included studies was estimated using a bivariate random effects logistic regression model. Relative risks of DWI+ and stroke in studies comparing CAS vs. CEA were estimated using fixed-effect Mantel-Haenszel models. Results We included data of 4871 CAS and 2099 CEA procedures (85 studies). Across all treatment groups (CAS and CEA), the log odds for DWI+ was significantly associated with the log odds for clinically manifest stroke (correlation coefficient 0.61 (95% CI 0.27 to 0.87), p = 0.0012). Across all carotid artery stenting groups, the correlation coefficient was 0.19 (p = 0.074). There were too few CEA groups to reliably estimate a correlation coefficient in this subset alone. In 19 studies comparing CAS vs. CEA, the relative risks (95% confidence intervals) of DWI+ and stroke were 3.83 (3.17-4.63, p < 0.00001) and 2.38 (1.44-3.94, p = 0.0007), respectively. Discussion This systematic meta-analysis demonstrates a correlation between the occurrence of silent brain infarcts on diffusion-weighted imaging and the risk of clinically manifest stroke in carotid revascularisation procedures. Conclusion Our findings strengthen the evidence base for the use of DWI as a surrogate outcome measure for procedural stroke in carotid revascularisation procedures. Further randomised studies comparing treatment effects on DWI lesions and clinical stroke are needed to fully establish surrogacy.
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Affiliation(s)
- Christopher Traenka
- Stroke Center and Department of Neurology, University Hospital Basel and University of Basel, Basel, Switzerland.,Neurorehabilitation Unit, University of Basel and University Center for Medicine of Aging and Rehabilitation, Felix Platter Hospital, Basel, Switzerland
| | - Stefan T Engelter
- Stroke Center and Department of Neurology, University Hospital Basel and University of Basel, Basel, Switzerland.,Neurorehabilitation Unit, University of Basel and University Center for Medicine of Aging and Rehabilitation, Felix Platter Hospital, Basel, Switzerland
| | - Martin M Brown
- Stroke Research Group, Department of Brain Repair & Rehabilitation, UCL Institute of Neurology, London, UK
| | - Joanna Dobson
- Department of Medical Statistics, Faculty of Epidemiology and Population Health, London School of Hygiene and Tropical Medicine, London, UK
| | - Chris Frost
- Department of Medical Statistics, Faculty of Epidemiology and Population Health, London School of Hygiene and Tropical Medicine, London, UK
| | - Leo H Bonati
- Stroke Center and Department of Neurology, University Hospital Basel and University of Basel, Basel, Switzerland.,Stroke Research Group, Department of Brain Repair & Rehabilitation, UCL Institute of Neurology, London, UK
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Assaad M, Berry A, Zughaib M. Transcervical Carotid Artery Stenting Without Flow Reversal: A Report of Two Cases. AMERICAN JOURNAL OF CASE REPORTS 2019; 20:15-20. [PMID: 30606999 PMCID: PMC6330995 DOI: 10.12659/ajcr.912769] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
Case series Patients: Male, 78 • Male, 69 Final Diagnosis: Severe carotid artery stenosis Symptoms: Asymptomatic Medication: — Clinical Procedure: Carotid artery stenting Specialty: Cardiology
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Affiliation(s)
- Mahmoud Assaad
- Department of Cardiology, Providence and Providence Park Hospitals, Southfield, MI, USA
| | - Abeer Berry
- Department of Cardiology, Providence and Providence Park Hospitals, Southfield, MI, USA
| | - Marcel Zughaib
- Department of Cardiology, Providence and Providence Park Hospitals, Southfield, MI, USA
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AbuRahma AF, AbuRahma ZT, Scott G, Adams E, Mata A, Beasley M, Dean LS, Davis E. The incidence of carotid in-stent stenosis is underestimated ≥50% or ≥80% and its clinical implications. J Vasc Surg 2018; 69:1807-1814. [PMID: 30552039 DOI: 10.1016/j.jvs.2018.08.185] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2018] [Accepted: 08/08/2018] [Indexed: 01/22/2023]
Abstract
BACKGROUND The incidence of carotid in-stent stenosis has been reported to vary between 1% and 30%. Most published studies have short follow-up, which may lead to underestimation of the incidence of in-stent stenosis. This study analyzed the incidence of ≥50% and ≥80% in-stent stenosis using validated duplex ultrasound criteria and its clinical implications. METHODS This is a retrospective analysis of prospectively collected data of 450 carotid artery stenting (CAS) procedures (February 6, 2001-December 19, 2016). All patients had postoperative carotid duplex ultrasound examination, which was repeated at 1 month, 6 months, and every 6 to 12 months thereafter. A Kaplan-Meier analysis was used to estimate rates of freedom from ≥50% in-stent stenosis (internal carotid artery peak systolic velocity of ≥224 cm/s) and ≥80% in-stent stenosis (internal carotid artery peak systolic velocity of ≥325 cm/s), freedom from reintervention, and survival. RESULTS The mean age was 68.3 years, with a mean follow-up of 40.3 months. A total of 201 patients (45% [201/450]) had CAS for symptomatic disease. Primary CAS was done in 291 patients (65%); in the remaining 35%, CAS was done for postcarotid endarterectomy (CEA) stenosis. A total of 101 patients (23%) had ≥50% late carotid in-stent stenosis, and of these, 33 (7.4%) had ≥80% in-stent stenosis. Nineteen patients (4.3%) developed late transient ischemic attack and three (0.7%) late stroke. Twenty-three (5.2%) patients had late reintervention. Rates of freedom from ≥50% in-stent stenosis in the whole series were 85%, 79%, 75%, 72%, and 70% at 1 year, 2 years, 3 years, 4 years, and 5 years, respectively. The rates of freedom from ≥50% in-stent stenosis for primary CAS and CAS for post-CEA stenosis were not statistically significant (P = .540). The rates of freedom from ≥80% in-stent stenosis for the whole series were 96%, 95%, 93%, 90%, and 89% at 1 year, 2 years, 3 years, 4 years, and 5 years, respectively. The rates of freedom from ≥80% in-stent stenosis for primary CAS and CAS for post-CEA stenosis were also not statistically significant (P = .516). Rates of freedom from reintervention were 98%, 96%, 93%, 93%, and 91% at 1 year, 2 years, 3 years, 4 years, and 5 years, respectively, and there were no significant differences between primary CAS and CAS for post-CEA stenosis (P = .939). The overall late survival rates were 99%, 97%, 96%, 94%, and 91% at 1 year, 2 years, 3 years, 4 years, and 5 years. CONCLUSIONS The incidence of ≥50% in-stent stenosis is relatively high; however, the rates of ≥80% stenosis and late neurologic events are low. Longer follow-up of patients with ≥50% carotid in-stent stenosis may yield higher incidence of ≥80% stenosis.
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Affiliation(s)
- Ali F AbuRahma
- Department of Surgery, West Virginia University, Charleston, WVa.
| | | | - Grant Scott
- Department of Surgery, West Virginia University, Charleston, WVa
| | - Elliot Adams
- Department of Surgery, West Virginia University, Charleston, WVa
| | - Abe Mata
- Department of Surgery, West Virginia University, Charleston, WVa
| | - Matthew Beasley
- Department of Surgery, West Virginia University, Charleston, WVa
| | - L Scott Dean
- CAMC Health Education and Research Institute, Charleston, WVa
| | - Elaine Davis
- CAMC Health Education and Research Institute, Charleston, WVa
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Cassola N, Baptista-Silva JCC, Flumignan CDQ, Sesso R, Vasconcelos V, Flumignan RLG. Duplex ultrasound for diagnosing symptomatic carotid stenosis in the extracranial segments. Hippokratia 2018. [DOI: 10.1002/14651858.cd013172] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Affiliation(s)
- Nicolle Cassola
- Universidade Federal de São Paulo; Department of Surgery, Division of Vascular and Endovascular Surgery; Rua Borges Lagoa, 754 São Paulo Brazil 04038-001
| | - Jose CC Baptista-Silva
- Universidade Federal de São Paulo; Evidence Based Medicine, Cochrane Brazil; Rua Borges Lagoa, 564, cj 124 São Paulo São Paulo Brazil 04038-000
| | - Carolina DQ Flumignan
- Universidade Federal de São Paulo; Department of Surgery, Division of Vascular and Endovascular Surgery; Rua Borges Lagoa, 754 São Paulo Brazil 04038-001
| | - Ricardo Sesso
- Escola Paulista de Medicina, Universidade Federal de São Paulo; Disciplina de Nefrologia; Rua Botucato 740 São Paulo São Paulo Brazil 04023-900
| | - Vladimir Vasconcelos
- Universidade Federal de São Paulo; Department of Surgery, Division of Vascular and Endovascular Surgery; Rua Borges Lagoa, 754 São Paulo Brazil 04038-001
| | - Ronald LG Flumignan
- Universidade Federal de São Paulo; Department of Surgery, Division of Vascular and Endovascular Surgery; Rua Borges Lagoa, 754 São Paulo Brazil 04038-001
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Ren C, Li N, Li S, Han R, Huang Q, Hu J, Jin K, Ji X. Limb Ischemic Conditioning Improved Cognitive Deficits via eNOS-Dependent Augmentation of Angiogenesis after Chronic Cerebral Hypoperfusion in Rats. Aging Dis 2018; 9:869-879. [PMID: 30271664 PMCID: PMC6147592 DOI: 10.14336/ad.2017.1106] [Citation(s) in RCA: 41] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2017] [Accepted: 11/06/2017] [Indexed: 12/27/2022] Open
Abstract
Intracranial and extracranial arterial stenosis, the primary cause of chronic cerebral hypoperfusion (CCH), is a critical reason for the pathogenesis of vascular dementia and Alzheimer’s disease characterized by cognitive impairments. Our previous study demonstrated that limb remote ischemic conditioning (LRIC) improved cerebral perfusion in intracranial arterial stenosis patients. The current study aimed to test whether LRIC promotes angiogenesis and increases phosphorylated endothelial nitric oxide synthase (p-eNOS) activity in CCH rat model. Adult male Sprague-Dawley rats were randomly assigned to three different groups: sham group, bilateral carotid artery occlusion (2VO) group and 2VO+LRIC group. Cerebral Blood Flow (CBF) was measured with laser speckle contrast imager at 4 weeks. Cognitive testing was performed at four and six weeks after 2VO surgery. We demonstrated that LRIC treatment increased cerebral perfusion and improved the CCH induced spatial learning and memory impairment. Immunohistochemistry confirmed that LRIC prevented cell death in the CA1 region, and increased the number of vessels and angiogenesis in the hippocampus after 2VO. Western blot analysis shows that LRIC therapy significantly increased p-eNOS expression in the hippocampus when compared with 2VO rats. Moreover, eNOS inhibitor reduced the effect of LRIC on angiogenesis in the hippocampus and spatial learning and memory function. Our data suggested that LRIC promoted angiogenesis, which is mediated, in part, by eNOS/NO.
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Affiliation(s)
- Changhong Ren
- 1Institute of Hypoxia Medicine, Xuanwu Hospital, Capital Medical University, Beijing 100053, China.,2Department of Pharmacology and Neuroscience, University of North Texas Health Science Center, TX Texas 76107, USA.,3Center of Stroke, Beijing Institute for Brain Disorder, Beijing 100069, China.,4Beijing Key Laboratory of Hypoxia Translational Medicine, Beijing 100053, China
| | - Ning Li
- 1Institute of Hypoxia Medicine, Xuanwu Hospital, Capital Medical University, Beijing 100053, China.,5Department of Neurobiology, Capital Medical University, Beijing 10069, China
| | - Sijie Li
- 1Institute of Hypoxia Medicine, Xuanwu Hospital, Capital Medical University, Beijing 100053, China.,4Beijing Key Laboratory of Hypoxia Translational Medicine, Beijing 100053, China
| | - Rongrong Han
- 1Institute of Hypoxia Medicine, Xuanwu Hospital, Capital Medical University, Beijing 100053, China.,4Beijing Key Laboratory of Hypoxia Translational Medicine, Beijing 100053, China
| | - Qingjian Huang
- 1Institute of Hypoxia Medicine, Xuanwu Hospital, Capital Medical University, Beijing 100053, China.,2Department of Pharmacology and Neuroscience, University of North Texas Health Science Center, TX Texas 76107, USA.,4Beijing Key Laboratory of Hypoxia Translational Medicine, Beijing 100053, China
| | - Jiangnan Hu
- 2Department of Pharmacology and Neuroscience, University of North Texas Health Science Center, TX Texas 76107, USA
| | - Kunlin Jin
- 2Department of Pharmacology and Neuroscience, University of North Texas Health Science Center, TX Texas 76107, USA
| | - Xunming Ji
- 1Institute of Hypoxia Medicine, Xuanwu Hospital, Capital Medical University, Beijing 100053, China.,3Center of Stroke, Beijing Institute for Brain Disorder, Beijing 100069, China.,4Beijing Key Laboratory of Hypoxia Translational Medicine, Beijing 100053, China
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de Oliveira PP, Vieira JLDC, Guimarães RB, Almeida ED, Savaris SL, Portal VL. Risk-Benefit Assessment of Carotid Revascularization. Arq Bras Cardiol 2018; 111:618-625. [PMID: 30365684 PMCID: PMC6199518 DOI: 10.5935/abc.20180208] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2018] [Revised: 06/21/2018] [Accepted: 07/02/2018] [Indexed: 12/24/2022] Open
Abstract
Severe carotid atherosclerotic disease is responsible for 14% of all strokes, which result in a high rate of morbidity and mortality. In recent years, advances in clinical treatment of cardiovascular diseases have resulted in a significant decrease in mortality due to these causes. To review the main studies on carotid revascularization, evaluating the relationship between risks and benefits of this procedure. The data reviewed show that, for a net benefit, carotid intervention should only be performed in cases of a periprocedural risk of less than 6% in symptomatic patients. The medical therapy significantly reduced the revascularization net benefit ratio for stroke prevention in asymptomatic patients. Real life registries indicate that carotid stenting is associated with a greater periprocedural risk. The operator annual procedure volume and patient age has an important influence in the rate of stroke and death after carotid stenting. Symptomatic patients have a higher incidence of death and stroke after the procedure. Revascularization has the greatest benefit in the first weeks of the event. There is a discrepancy in the scientific literature about carotid revascularization and/or clinical treatment, both in primary and secondary prevention of patients with carotid artery injury. The identification of patients who will really benefit is a dynamic process subject to constant review.
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Affiliation(s)
- Pedro Piccaro de Oliveira
- Instituto de Cardiologia - Fundação
Universitária de Cardiologia (IC/FUC), Porto Alegre, RS - Brazil
| | - José Luiz da Costa Vieira
- Instituto de Cardiologia - Fundação
Universitária de Cardiologia (IC/FUC), Porto Alegre, RS - Brazil
| | - Raphael Boesche Guimarães
- Instituto de Cardiologia - Fundação
Universitária de Cardiologia (IC/FUC), Porto Alegre, RS - Brazil
| | - Eduardo Dytz Almeida
- Instituto de Cardiologia - Fundação
Universitária de Cardiologia (IC/FUC), Porto Alegre, RS - Brazil
| | - Simone Louise Savaris
- Instituto de Cardiologia - Fundação
Universitária de Cardiologia (IC/FUC), Porto Alegre, RS - Brazil
| | - Vera Lucia Portal
- Instituto de Cardiologia - Fundação
Universitária de Cardiologia (IC/FUC), Porto Alegre, RS - Brazil
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Volkers EJ, Algra A, Kappelle LJ, Greving JP. Prediction models for clinical outcome after a carotid revascularisation procedure: A systematic review. Eur Stroke J 2018; 3:57-65. [PMID: 29900410 PMCID: PMC5992733 DOI: 10.1177/2396987317739122] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2017] [Accepted: 09/29/2017] [Indexed: 12/23/2022] Open
Abstract
Introduction Prediction models for clinical outcome after carotid artery stenting or carotid endarterectomy could aid physicians in estimating peri- and postprocedural risks in individual patients. We aimed to identify existing prediction models for short- and long-term outcome after carotid artery stenting or carotid endarterectomy in patients with symptomatic or asymptomatic carotid stenosis, and to summarise their most important predictors and predictive performance. Patients and methods We performed a systematic literature search for studies that developed a prediction model or risk score published until 22 December 2016. Eligible prediction models had to predict the risk of vascular events with at least one patient characteristic. Results We identified 37 studies that developed 46 prediction models. Thirty-four (74%) models were developed in carotid endarterectomy patients; 27 of these (59%) predicted short-term (in-hospital or within 30 days) risk. Most commonly predicted outcome was stroke or death (n = 12; 26%). Age (n = 31; 67%), diabetes mellitus (n = 21; 46%), heart failure (n = 16; 35%), and contralateral carotid stenosis ≥50% or occlusion (n = 16; 35%) were most commonly used as predictors. For 25 models (54%), it was unclear how missing data were handled; a complete case analysis was performed in 15 (33%) of the remaining 21 models. Twenty-eight (61%) models reported the full regression formula or risk score with risk classification. Twenty-one (46%) models were validated internally and 12 (26%) externally. Discriminative performance (c-statistic) ranged from 0.66 to 0.94 for models after carotid artery stenting and from 0.58 to 0.74 for models after carotid endarterectomy. The c-statistic ranged from 0.55 to 0.72 for the external validations. Discussion Age, diabetes mellitus, heart failure, and contralateral carotid stenosis ≥50% or occlusion were most often used as predictors in all models. Discriminative performance (c-statistic) was higher for prediction models after carotid artery stenting than after carotid endarterectomy. Conclusion The clinical usefulness of most prediction models for short- or long-term outcome after carotid artery stenting or carotid endarterectomy remains unclear because of incomplete reporting, methodological limitations, and lack of external validation.
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Affiliation(s)
- Eline J Volkers
- 1Department of Neurology and Neurosurgery, Brain Centre Rudolf Magnus, University Medical Centre Utrecht, Utrecht, the Netherlands.,2Julius Centre for Health Sciences and Primary Care, University Medical Centre Utrecht, Utrecht, the Netherlands
| | - Ale Algra
- 1Department of Neurology and Neurosurgery, Brain Centre Rudolf Magnus, University Medical Centre Utrecht, Utrecht, the Netherlands.,2Julius Centre for Health Sciences and Primary Care, University Medical Centre Utrecht, Utrecht, the Netherlands
| | - L Jaap Kappelle
- 1Department of Neurology and Neurosurgery, Brain Centre Rudolf Magnus, University Medical Centre Utrecht, Utrecht, the Netherlands
| | - Jacoba P Greving
- 2Julius Centre for Health Sciences and Primary Care, University Medical Centre Utrecht, Utrecht, the Netherlands
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Gavrilenko AV, Skrylev SI, Kravchenko AA, Novikov AV. [Carotid endarterectomy and stenting in patients with internal carotid artery stenosis and contralateral occlusion]. Khirurgiia (Mosk) 2018:52-56. [PMID: 29697684 DOI: 10.17116/hirurgia2018452-56] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
AIM To determine surgical risk factors and to compare early outcomes after carotid endarterectomy and carotid stenting in patients with internal carotid artery stenosis and contralateral occlusion. MATERIAL AND METHODS 132 patients were enrolled. 62 and 70 patients underwent carotid endarterectomy and carotid stenting respectively. Early postoperative results were compared depending on type of surgical intervention and presence of risk factors. RESULTS Significant difference between groups was only found for incidence of neuropathy of the cranial nerves. It was established that cardiac comorbidities are risk factors for adverse events after carotid endarterectomy. Stable (homogeneous) atherosclerotic plaque with clear contour and no ulceration is optimal for carotid stenting.
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Affiliation(s)
- A V Gavrilenko
- Petrovsky Russian Research Center for Surgery, Vascular Surgery Department
| | - S I Skrylev
- Neurology Research Center, Department of Vascular and Endovascular Surgery, Moscow, Russia
| | - A A Kravchenko
- Petrovsky Russian Research Center for Surgery, Vascular Surgery Department
| | - A V Novikov
- Petrovsky Russian Research Center for Surgery, Vascular Surgery Department
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Cho YD, Kim SE, Lim JW, Choi HJ, Cho YJ, Jeon JP. Protected versus Unprotected Carotid Artery Stenting : Meta-Analysis of the Current Literature. J Korean Neurosurg Soc 2018; 61:458-466. [PMID: 29631386 PMCID: PMC6046577 DOI: 10.3340/jkns.2017.0202.001] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2017] [Accepted: 09/08/2017] [Indexed: 11/27/2022] Open
Abstract
Objective To compare peri-operative any symptomatic stroke after carotid angioplasty and stenting (CAS), based on the application or absence of a cerebral protection device. Methods A systematic literature review using PubMed, Embase, and the Cochrane Central was done across an online data base from January 1995 to October 2016. Procedures which were performed due to carotid dissection or aneurysm, procedures using covered stents or conducted in an emergency, were excluded. The primary endpoint was perioperative any symptomatic stroke within 30 days after the procedure. A fixed effect model was used in cases of heterogeneity less than 50%. Results In the 25 articles included in this study, the number of stroke events was 326 (2.0%) in protected CAS and 142 (3.4%) in unprotected CAS. The use of cerebral protection device significantly decreased stroke after CAS (odds ratio [OR] 0.633, 95% confidence interval [CI] 0.479–0.837, p=0.001). In the publication bias analysis, Egger’s regression test disclosed that the intercept was -0.317 (95% CI -1.015–0.382, p=0.358). Regarding symptomatic patients (four studies, 539 CAS procedures), the number of stroke was six (1.7%) in protected CAS and 11 (5.7%) in unprotected CAS. The protective effect against stroke events by cerebral protection device did not have a statistical significance (OR 0.455, 95% CI 0.151–1.366, p=0.160). Conclusion The use of protection device significantly decreased stroke after CAS. However, its efficacy was not demonstrated in symptomatic patients. Routine use of protection device during CAS should be critically assessed before mandatory use.
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Affiliation(s)
- Young Dae Cho
- Department of Radiology, Seoul National University College of Medicine, Seoul, Korea
| | - Sung-Eun Kim
- Department of Emergency Medicine, Seoul Emergency Operations Center, Seoul, Korea
| | - Jeong Wook Lim
- Department of Neurosurgery, Chungnam National University College of Medicine, Daejeon, Korea
| | - Hyuk Jai Choi
- Department of Neurosurgery, Hallym University College of Medicine, Chuncheon, Korea
| | - Yong Jun Cho
- Department of Neurosurgery, Hallym University College of Medicine, Chuncheon, Korea
| | - Jin Pyeong Jeon
- Department of Neurosurgery, Hallym University College of Medicine, Chuncheon, Korea.,Institute of New Frontier Research, Hallym University College of Medicine, Chuncheon, Korea
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Shean KE, O'Donnell TFX, Deery SE, Pothof AB, Schneider JR, Rockman CB, Nolan BW, Schermerhorn ML. Regional variation in patient outcomes in carotid artery disease treatment in the Vascular Quality Initiative. J Vasc Surg 2018; 68:749-759. [PMID: 29571620 DOI: 10.1016/j.jvs.2017.11.080] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2017] [Accepted: 11/20/2017] [Indexed: 10/17/2022]
Abstract
OBJECTIVE Quality metrics were developed to improve outcomes after carotid artery revascularization; however, few studies have evaluated regional differences in perioperative outcomes. This study aimed to evaluate regional variation in mortality and perioperative outcomes after carotid endarterectomy (CEA) and carotid artery stenting (CAS). METHODS We identified all patients who underwent CEA or CAS from 2009 to 2016 in the Vascular Quality Initiative. Patients were analyzed on the basis of their symptom status. We assessed variation in perioperative outcomes using χ2 analysis, Fisher exact test, and t-test, where appropriate. RESULTS A total of 78,467 carotid interventions were identified; 85% were CEAs, with 69% of those asymptomatic. Within CAS, 39% were asymptomatic. Perioperative stroke/death varied across regions within both CAS groups (asymptomatic, 0%-5.8% [P = .03]; symptomatic, 2.4%-8.1% [P = .1]), and several regions did not meet the American Heart Association (AHA) guidelines of 3% for asymptomatic patients and 6% for symptomatic patients, which persisted after risk adjustment. For CEA, the stroke/death rates fell within the standards set by the AHA guidelines in all regions for both the unadjusted and risk-adjusted models; however, there was significant regional variation in the cohorts (asymptomatic, 0.9%-3.1% [P < .01]; symptomatic, 1.3%-4.9% [P < .01]). Variation in 30-day mortality was significant in symptomatic patients (asymptomatic: CEA, 0%-1.3% [P = .2], CAS, 0%-2.4% [P = .2]; symptomatic: CEA, 0%-1.8% [P < .01], CAS, 0%-4.6% [P = .01]). Rates of in-hospital stroke, postoperative myocardial infarction, prolonged length of stay (>2 days), and use of intravenous blood pressure medications all varied significantly across the regions. After CEA, there was significant variation in the rates of cranial nerve injuries (asymptomatic, 0.9%-4.9% [P < .01]; symptomatic, 1.5%-7.7% [P < .01]), return to the operating room (asymptomatic, 0.9%-3.4% [P < .01]; symptomatic, 0.6%-3.4% [P = .02]), and discharge on antiplatelet and statin (asymptomatic, 75%-87% [P < .01]; symptomatic, 78%-91% [P < .01]). After CAS, significant variation was found in the rates of access site complications (asymptomatic, 2.3%-18.2% [P < .01]; symptomatic, 1.4%-16.9% [P < .01]) and discharge on dual antiplatelet therapy (asymptomatic, 79%-94% [P < .01]; symptomatic, 83%-93% [P < .01]). CONCLUSIONS Unwarranted regional variation exists in outcomes after carotid artery revascularization across the regions of the VQI. Significant variation was seen in a number of outcomes for which quality metrics currently exist, such as length of stay and discharge medications. In addition, after CAS, several regions failed to meet the AHA guidelines for stroke and death. Given these results, quality improvement projects should be targeted to improve adherence to current guidelines to promote best practices.
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Affiliation(s)
- Katie E Shean
- Division of Vascular and Endovascular Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Mass; Department of Surgery, St. Elizabeth's Medical Center, Boston, Mass
| | - Thomas F X O'Donnell
- Division of Vascular and Endovascular Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Mass; Department of Surgery, Massachusetts General Hospital, Boston, Mass
| | - Sarah E Deery
- Division of Vascular and Endovascular Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Mass; Department of Surgery, Massachusetts General Hospital, Boston, Mass
| | - Alexander B Pothof
- Division of Vascular and Endovascular Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Mass; Department of Vascular Surgery, University Medical Center, Utrecht, The Netherlands
| | - Joseph R Schneider
- Division of Vascular Surgery, Northwestern University Feinberg School of Medicine, Chicago, Ill
| | - Caron B Rockman
- Division of Vascular and Endovascular Surgery, NYU Langone Medical Center, New York, NY
| | - Brian W Nolan
- Division of Vascular and Endovascular Surgery, Maine Medical Center, Portland, Me
| | - Marc L Schermerhorn
- Division of Vascular and Endovascular Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Mass.
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Lokuge K, de Waard DD, Halliday A, Gray A, Bulbulia R, Mihaylova B. Meta-analysis of the procedural risks of carotid endarterectomy and carotid artery stenting over time. Br J Surg 2017; 105:26-36. [PMID: 29205297 PMCID: PMC5767749 DOI: 10.1002/bjs.10717] [Citation(s) in RCA: 51] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2017] [Revised: 07/27/2017] [Accepted: 09/02/2017] [Indexed: 11/18/2022]
Abstract
Background Stroke/death rates within 30 days of carotid endarterectomy (CEA) and carotid artery stenting (CAS) in RCTs inform current clinical guidelines. However, the risks may have changed in recent years with wider use of effective stroke prevention therapies, especially statins, improved patient selection and growing operator expertise. The aim of this study was to investigate whether the procedural stroke/death risks from CEA and CAS have changed over time. Methods MEDLINE and Embase were searched systematically from inception to May 2016 for observational cohort studies of CEA and CAS. Studies included reported on more than 1000 patients, with 30‐day outcomes after the procedure according to patients' symptom status (recent stroke or transient ischaemic attack). Restricted maximum likelihood random‐effects and meta‐regressions methods were used to synthesize procedural stroke/death rates of CEA and CAS according to year of study recruitment completion. Results Fifty‐one studies, including 223 313 patients undergoing CEA and 72 961 undergoing CAS, were reviewed. Procedural stroke/death risks of CEA decreased over time in symptomatic and asymptomatic patients. Risks were substantially lower in studies completing recruitment in 2005 or later, both in symptomatic (5·11 per cent before 2005 versus 2·68 per cent from 2005 onwards; P = 0·002) and asymptomatic (3·17 versus 1·50 per cent; P < 0·001) patients. Procedural stroke/death rates of CAS did not change significantly over time (4·77 per cent among symptomatic and 2·59 per cent among asymptomatic patients). There was substantial heterogeneity in event rates and recruitment periods were long. Conclusions Risks of procedural stroke/death following CEA appear to have decreased substantially. There was no evidence of a change in stroke/death rates following CAS. Endarterectomy outcomes improving
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Affiliation(s)
- K Lokuge
- Health Economics Research Centre, University of Oxford, Oxford, UK
| | - D D de Waard
- Nuffield Department of Surgical Sciences, University of Oxford, Oxford, UK.,Department of Vascular Surgery, University Medical Centre Utrecht, Utrecht, The Netherlands
| | - A Halliday
- Nuffield Department of Surgical Sciences, University of Oxford, Oxford, UK
| | - A Gray
- Health Economics Research Centre, University of Oxford, Oxford, UK
| | - R Bulbulia
- Medical Research Council Population Health Research Unit, Clinical Trial Service Unit and Epidemiological Studies Unit, Nuffield Department of Population Health, University of Oxford, Oxford, UK
| | - B Mihaylova
- Health Economics Research Centre, University of Oxford, Oxford, UK
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Cho SM, Deshpande A, Pasupuleti V, Hernandez AV, Uchino K. Radiographic and symptomatic brain ischemia in CEA and CAS: A systematic review and meta-analysis. Neurology 2017; 89:1977-1984. [PMID: 29021357 DOI: 10.1212/wnl.0000000000004626] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2017] [Accepted: 08/21/2017] [Indexed: 01/17/2023] Open
Abstract
OBJECTIVE In a systematic review, we compared ratio of new periprocedural radiographic brain ischemia (RBI) to the number of strokes and TIAs among patients undergoing carotid endarterectomy (CEA) and carotid artery stenting (CAS). METHODS We searched 5 databases for entries related to brain ischemia in CEA or CAS from inception through September 2015. We included articles with CEA or CAS and systematic performance of preprocedural and postprocedural brain MRI and reporting of RBI and stroke incidence. We calculated a symptomatic risk ratio of number of strokes and TIAs to RBI. Random effects models were used. RESULTS Fifty-nine studies (5,431 participants) met the inclusion criteria. There were 22 cohorts in CEA, 34 in CAS with distal protection, 8 in CAS with proximal protection, 9 in CAS without protection, and 9 in CAS with unspecified devices. Overall, 30.7% (95% confidence interval [CI] 26.6%-34.7%) had RBI, while 3.2% (95% CI 2.6%-3.8%) had clinical strokes or TIAs, with a stroke and TIA to RBI weighted ratio of 0.18 (95% CI 0.15-0.22). CEA had lower incidence of RBI compared to CAS (13.0% vs 37.4%) and also lower number of strokes and TIAs (1.8% vs 4.1%). The stroke and TIA to RBI ratio did not differ across 5 different types of carotid interventions (p = 0.58). CONCLUSIONS One in 5 persons with periprocedural radiographic brain ischemia during CEA and CAS had strokes and TIAs. The stable ratio of stroke and TIA to radiographic ischemia suggests that MRI ischemia could serve as a surrogate measure of periprocedural risk.
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Affiliation(s)
- Sung-Min Cho
- From the Cerebrovascular Center, Neurological Institute (S.-M.C., K.U.), and Medicine Institute (A.D.), Cleveland Clinic, Cleveland, OH; Case Western Reserve University (V.P.), Cleveland, OH; School of Medicine (A.V.H.), Universidad Peruana de Ciencias Aplicadas (UPC), Lima, Peru; and University of Connecticut/Hartford Hospital Evidence-Based Practice Center (A.V.H.)
| | - Abhishek Deshpande
- From the Cerebrovascular Center, Neurological Institute (S.-M.C., K.U.), and Medicine Institute (A.D.), Cleveland Clinic, Cleveland, OH; Case Western Reserve University (V.P.), Cleveland, OH; School of Medicine (A.V.H.), Universidad Peruana de Ciencias Aplicadas (UPC), Lima, Peru; and University of Connecticut/Hartford Hospital Evidence-Based Practice Center (A.V.H.)
| | - Vinay Pasupuleti
- From the Cerebrovascular Center, Neurological Institute (S.-M.C., K.U.), and Medicine Institute (A.D.), Cleveland Clinic, Cleveland, OH; Case Western Reserve University (V.P.), Cleveland, OH; School of Medicine (A.V.H.), Universidad Peruana de Ciencias Aplicadas (UPC), Lima, Peru; and University of Connecticut/Hartford Hospital Evidence-Based Practice Center (A.V.H.)
| | - Adrian V Hernandez
- From the Cerebrovascular Center, Neurological Institute (S.-M.C., K.U.), and Medicine Institute (A.D.), Cleveland Clinic, Cleveland, OH; Case Western Reserve University (V.P.), Cleveland, OH; School of Medicine (A.V.H.), Universidad Peruana de Ciencias Aplicadas (UPC), Lima, Peru; and University of Connecticut/Hartford Hospital Evidence-Based Practice Center (A.V.H.)
| | - Ken Uchino
- From the Cerebrovascular Center, Neurological Institute (S.-M.C., K.U.), and Medicine Institute (A.D.), Cleveland Clinic, Cleveland, OH; Case Western Reserve University (V.P.), Cleveland, OH; School of Medicine (A.V.H.), Universidad Peruana de Ciencias Aplicadas (UPC), Lima, Peru; and University of Connecticut/Hartford Hospital Evidence-Based Practice Center (A.V.H.).
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Markus HS, Larsson SC, Kuker W, Schulz UG, Ford I, Rothwell PM, Clifton A. Stenting for symptomatic vertebral artery stenosis: The Vertebral Artery Ischaemia Stenting Trial. Neurology 2017; 89:1229-1236. [PMID: 28835400 PMCID: PMC5606920 DOI: 10.1212/wnl.0000000000004385] [Citation(s) in RCA: 86] [Impact Index Per Article: 12.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2017] [Accepted: 06/05/2017] [Indexed: 11/15/2022] Open
Abstract
Objective: To compare in the Vertebral Artery Ischaemia Stenting Trial (VIST) the risks and benefits of vertebral angioplasty and stenting with best medical treatment (BMT) alone for symptomatic vertebral artery stenosis. Methods: VIST was a prospective, randomized, open-blinded endpoint clinical trial performed in 14 hospitals in the United Kingdom. Participants with symptomatic vertebral stenosis ≥50% were randomly assigned (1:1) to vertebral angioplasty/stenting plus BMT or to BMT alone with randomization stratified by site of stenosis (extracranial vs intracranial). Because of slow recruitment and cessation of funding, recruitment was stopped after 182 participants. Follow-up was a minimum of ≥1 year for each participant. Results: Three patients did not contribute any follow-up data and were excluded, leaving 91 patients in the stent group and 88 in the medical group. Mean follow-up was 3.5 (interquartile range 2.1–4.7) years. Of 61 patients who were stented, stenosis was extracranial in 48 (78.7%) and intracranial in 13 (21.3%). No periprocedural complications occurred with extracranial stenting; 2 strokes occurred during intracranial stenting. The primary endpoint of fatal or nonfatal stroke occurred in 5 patients in the stent group vs 12 in the medical group (hazard ratio 0.40, 95% confidence interval 0.14–1.13, p = 0.08), with an absolute risk reduction of 25 strokes per 1,000 person-years. The hazard ratio for stroke or TIA was 0.50 (p = 0.05). Conclusions: Stenting in extracranial stenosis appears safe with low complication rates. Large phase 3 trials are required to determine whether stenting reduces stroke risk. ISRCTN.com identifier: ISRCTN95212240. Classification of evidence: This study provides Class I evidence that for patients with symptomatic vertebral stenosis, angioplasty with stenting does not reduce the risk of stroke. However, the study lacked the precision to exclude a benefit from stenting.
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Affiliation(s)
- Hugh S Markus
- From the Stroke Research Group (H.S.M., S.C.L.), Department of Clinical Neurosciences, University of Cambridge, Cambridge Biomedical Campus; Nuffield Department of Clinical Neurosciences (W.K., U.G.S., P.M.R.), John Radcliffe Hospital, University of Oxford; Robertson Centre for Biostatistics (I.F.), University of Glasgow; and Department of Neuroradiology (A.C.), St. George's Hospital, London, UK.
| | - Susanna C Larsson
- From the Stroke Research Group (H.S.M., S.C.L.), Department of Clinical Neurosciences, University of Cambridge, Cambridge Biomedical Campus; Nuffield Department of Clinical Neurosciences (W.K., U.G.S., P.M.R.), John Radcliffe Hospital, University of Oxford; Robertson Centre for Biostatistics (I.F.), University of Glasgow; and Department of Neuroradiology (A.C.), St. George's Hospital, London, UK
| | - Wilhelm Kuker
- From the Stroke Research Group (H.S.M., S.C.L.), Department of Clinical Neurosciences, University of Cambridge, Cambridge Biomedical Campus; Nuffield Department of Clinical Neurosciences (W.K., U.G.S., P.M.R.), John Radcliffe Hospital, University of Oxford; Robertson Centre for Biostatistics (I.F.), University of Glasgow; and Department of Neuroradiology (A.C.), St. George's Hospital, London, UK
| | - Ursula G Schulz
- From the Stroke Research Group (H.S.M., S.C.L.), Department of Clinical Neurosciences, University of Cambridge, Cambridge Biomedical Campus; Nuffield Department of Clinical Neurosciences (W.K., U.G.S., P.M.R.), John Radcliffe Hospital, University of Oxford; Robertson Centre for Biostatistics (I.F.), University of Glasgow; and Department of Neuroradiology (A.C.), St. George's Hospital, London, UK
| | - Ian Ford
- From the Stroke Research Group (H.S.M., S.C.L.), Department of Clinical Neurosciences, University of Cambridge, Cambridge Biomedical Campus; Nuffield Department of Clinical Neurosciences (W.K., U.G.S., P.M.R.), John Radcliffe Hospital, University of Oxford; Robertson Centre for Biostatistics (I.F.), University of Glasgow; and Department of Neuroradiology (A.C.), St. George's Hospital, London, UK
| | - Peter M Rothwell
- From the Stroke Research Group (H.S.M., S.C.L.), Department of Clinical Neurosciences, University of Cambridge, Cambridge Biomedical Campus; Nuffield Department of Clinical Neurosciences (W.K., U.G.S., P.M.R.), John Radcliffe Hospital, University of Oxford; Robertson Centre for Biostatistics (I.F.), University of Glasgow; and Department of Neuroradiology (A.C.), St. George's Hospital, London, UK
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Fridman S, Saposnik G, Sposato LA. Visual Aids for Improving Patient Decision Making in Severe Symptomatic Carotid Stenosis. J Stroke Cerebrovasc Dis 2017; 26:2888-2892. [PMID: 28797613 DOI: 10.1016/j.jstrokecerebrovasdis.2017.07.011] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2017] [Revised: 07/08/2017] [Accepted: 07/11/2017] [Indexed: 10/19/2022] Open
Abstract
BACKGROUND Because of the large amount of information to process and the limited time of a clinical consult, choosing between carotid endarterectomy (CEA) and carotid angioplasty with stenting (CAS) can be confusing for patients with severe symptomatic internal carotid stenosis (ICA). GOAL We aim to develop a visual aid tool to help clinicians and patients in the decision-making process of selecting between CEA and CAS. MATERIALS AND METHODS Based on pooled analysis from randomized controlled trials including patients with symptomatic and severe ICA (SSICA), we generated visual plots comparing CEA with CAS for 3 prespecified postprocedural time points: (1) any stroke or death at 4 months, and (2) any stroke or death in the first 30 days and ipsilateral stroke thereafter at 5 years and (3) at 10 years. RESULTS A total of 4574 participants (2393 assigned to CAS, and 2361 to CEA) were included in the analyses. For every 100 patients with SSICA, 6 would develop any stroke or death in the CEA group compared with 9 undergoing CAS at 4 months (hazard ratio [HR] 1.53; 95%CI 1.20-1.95). At 5 years, 7 patients in the CEA group would develop any periprocedural stroke or death and ipsilateral stroke thereafter versus 12 undergoing CAS (HR 1.72; 95%CI 1.24-2.39), compared with 10 patients in the CEA and 13 in the CAS groups at 10 years (HR 1.17; 95%CI 0.82-1.66). CONCLUSION Visual aids presented in this study could potentially help patients with severe symptomatic internal carotid stenosis to better weigh the risks and benefits of CEA versus CAS as a function of time, allowing for the prioritization of personal preferences, and should be prospectively assessed.
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Affiliation(s)
- Sebastian Fridman
- Department of Clinical Neurological Sciences, Western University, London, Ontario, Canada.
| | - Gustavo Saposnik
- Stroke Outcomes Research Center, Division of Neurology, Department of Medicine, St. Michael's Hospital and Institute of Health Policy, Management and Evaluation, Faculty of Medicine, University of Toronto, Institute for Clinical Evaluative Sciences, Toronto, Ontario, Canada; Li Ka Shing Knowledge Institute, Toronto, Ontario, Canada
| | - Luciano A Sposato
- Department of Clinical Neurological Sciences, Western University, London, Ontario, Canada; Stroke, Dementia & Heart Disease Laboratory, Western University, London, Ontario, Canada; Department of Anatomy and Cell Biology, Schulich School of Medicine and Dentistry, London, ON, Canada; Department of Epidemiology and Biostatistics, Schulich School of Medicine and Dentistry, London, ON, Canada
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Volkers EJ, Greving JP, Hendrikse J, Algra A, Kappelle LJ, Becquemin JP, Bonati LH, Brott TG, Bulbulia R, Calvet D, Eckstein HH, Fraedrich G, Gregson J, Halliday A, Howard G, Jansen O, Roubin GS, Brown MM, Mas JL, Ringleb PA. Body mass index and outcome after revascularization for symptomatic carotid artery stenosis. Neurology 2017; 88:2052-2060. [PMID: 28446644 DOI: 10.1212/wnl.0000000000003957] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2016] [Accepted: 03/01/2017] [Indexed: 12/31/2022] Open
Abstract
OBJECTIVE To determine whether the obesity paradox exists in patients who undergo carotid artery stenting (CAS) or carotid endarterectomy (CEA) for symptomatic carotid artery stenosis. METHODS We combined individual patient data from 2 randomized trials (Endarterectomy vs Angioplasty in Patients with Symptomatic Severe Carotid Stenosis and Stent-Protected Angioplasty vs Carotid Endarterectomy) and 3 centers in a third trial (International Carotid Stenting Study). Baseline body mass index (BMI) was available for 1,969 patients and classified into 4 groups: <20, 20-<25, 25-<30, and ≥30 kg/m2. Primary outcome was stroke or death, investigated separately for the periprocedural and postprocedural period (≤120 days/>120 days after randomization). This outcome was compared between different BMI strata in CAS and CEA patients separately, and in the total group. We performed intention-to-treat multivariable Cox regression analyses. RESULTS Median follow-up was 2.0 years. Stroke or death occurred in 159 patients in the periprocedural (cumulative risk 8.1%) and in 270 patients in the postprocedural period (rate 4.8/100 person-years). BMI did not affect periprocedural risk of stroke or death for patients assigned to CAS (ptrend = 0.39) or CEA (ptrend = 0.77) or for the total group (ptrend = 0.48). Within the total group, patients with BMI 25-<30 had lower postprocedural risk of stroke or death than patients with BMI 20-<25 (BMI 25-<30 vs BMI 20-<25; hazard ratio 0.72; 95% confidence interval 0.55-0.94). CONCLUSIONS BMI is not associated with periprocedural risk of stroke or death; however, BMI 25-<30 is associated with lower postprocedural risk than BMI 20-<25. These observations were similar for CAS and CEA.
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Affiliation(s)
- Eline J Volkers
- From the Department of Neurology and Neurosurgery, Brain Center Rudolf Magnus (E.J.V., A.A., L.J.K.), Julius Center for Health Sciences and Primary Care (E.J.V., J.P.G., A.A.), and Department of Radiology (J.H.), University Medical Center Utrecht, the Netherlands; IVPE (J.-P.B.), Hopital Privé Paul D'Egine Champigny, France; Department of Neurology and Stroke Center (L.H.B.), University Hospital Basel, Switzerland; Department of Brain Repair and Rehabilitation (L.H.B., M.M.B.), UCL Institute of Neurology, University College London, UK; Department of Neurology (T.G.B.), Mayo Clinic, Jacksonville, FL; Clinical Trial Service Unit and Epidemiological Studies Unit (R.B.), Oxford University, UK; Department of Neurology (D.C., J.-L.M.), Hôpital Sainte-Anne, Université Paris-Descartes, DHU Neurovasc Sorbonne Paris Cité, INSERM U894, Paris, France; Department of Vascular and Endovascular Surgery/Vascular Center (H.-H.E.), Klinikum rechts der Isar, Technical University Munich, Germany; Department of Vascular Surgery (G.F.), Medical University of Innsbruck, Austria; London School for Hygiene and Tropical Medicine (J.G.); Nuffield Department of Surgical Sciences (A.H.), John Radcliffe Hospital, Oxford, UK; Department of Biostatistics (G.H.), UAB School of Public Health, Birmingham, AL; Clinic for Radiology and Neuroradiology (O.J.), UKSH Campus Kiel, Germany; Cardiovascular Associates of the Southeast (G.S.R.), Birmingham, AL; and Department of Neurology (P.A.R.), University of Heidelberg Medical School, Germany.
| | - Jacoba P Greving
- From the Department of Neurology and Neurosurgery, Brain Center Rudolf Magnus (E.J.V., A.A., L.J.K.), Julius Center for Health Sciences and Primary Care (E.J.V., J.P.G., A.A.), and Department of Radiology (J.H.), University Medical Center Utrecht, the Netherlands; IVPE (J.-P.B.), Hopital Privé Paul D'Egine Champigny, France; Department of Neurology and Stroke Center (L.H.B.), University Hospital Basel, Switzerland; Department of Brain Repair and Rehabilitation (L.H.B., M.M.B.), UCL Institute of Neurology, University College London, UK; Department of Neurology (T.G.B.), Mayo Clinic, Jacksonville, FL; Clinical Trial Service Unit and Epidemiological Studies Unit (R.B.), Oxford University, UK; Department of Neurology (D.C., J.-L.M.), Hôpital Sainte-Anne, Université Paris-Descartes, DHU Neurovasc Sorbonne Paris Cité, INSERM U894, Paris, France; Department of Vascular and Endovascular Surgery/Vascular Center (H.-H.E.), Klinikum rechts der Isar, Technical University Munich, Germany; Department of Vascular Surgery (G.F.), Medical University of Innsbruck, Austria; London School for Hygiene and Tropical Medicine (J.G.); Nuffield Department of Surgical Sciences (A.H.), John Radcliffe Hospital, Oxford, UK; Department of Biostatistics (G.H.), UAB School of Public Health, Birmingham, AL; Clinic for Radiology and Neuroradiology (O.J.), UKSH Campus Kiel, Germany; Cardiovascular Associates of the Southeast (G.S.R.), Birmingham, AL; and Department of Neurology (P.A.R.), University of Heidelberg Medical School, Germany
| | - Jeroen Hendrikse
- From the Department of Neurology and Neurosurgery, Brain Center Rudolf Magnus (E.J.V., A.A., L.J.K.), Julius Center for Health Sciences and Primary Care (E.J.V., J.P.G., A.A.), and Department of Radiology (J.H.), University Medical Center Utrecht, the Netherlands; IVPE (J.-P.B.), Hopital Privé Paul D'Egine Champigny, France; Department of Neurology and Stroke Center (L.H.B.), University Hospital Basel, Switzerland; Department of Brain Repair and Rehabilitation (L.H.B., M.M.B.), UCL Institute of Neurology, University College London, UK; Department of Neurology (T.G.B.), Mayo Clinic, Jacksonville, FL; Clinical Trial Service Unit and Epidemiological Studies Unit (R.B.), Oxford University, UK; Department of Neurology (D.C., J.-L.M.), Hôpital Sainte-Anne, Université Paris-Descartes, DHU Neurovasc Sorbonne Paris Cité, INSERM U894, Paris, France; Department of Vascular and Endovascular Surgery/Vascular Center (H.-H.E.), Klinikum rechts der Isar, Technical University Munich, Germany; Department of Vascular Surgery (G.F.), Medical University of Innsbruck, Austria; London School for Hygiene and Tropical Medicine (J.G.); Nuffield Department of Surgical Sciences (A.H.), John Radcliffe Hospital, Oxford, UK; Department of Biostatistics (G.H.), UAB School of Public Health, Birmingham, AL; Clinic for Radiology and Neuroradiology (O.J.), UKSH Campus Kiel, Germany; Cardiovascular Associates of the Southeast (G.S.R.), Birmingham, AL; and Department of Neurology (P.A.R.), University of Heidelberg Medical School, Germany
| | - Ale Algra
- From the Department of Neurology and Neurosurgery, Brain Center Rudolf Magnus (E.J.V., A.A., L.J.K.), Julius Center for Health Sciences and Primary Care (E.J.V., J.P.G., A.A.), and Department of Radiology (J.H.), University Medical Center Utrecht, the Netherlands; IVPE (J.-P.B.), Hopital Privé Paul D'Egine Champigny, France; Department of Neurology and Stroke Center (L.H.B.), University Hospital Basel, Switzerland; Department of Brain Repair and Rehabilitation (L.H.B., M.M.B.), UCL Institute of Neurology, University College London, UK; Department of Neurology (T.G.B.), Mayo Clinic, Jacksonville, FL; Clinical Trial Service Unit and Epidemiological Studies Unit (R.B.), Oxford University, UK; Department of Neurology (D.C., J.-L.M.), Hôpital Sainte-Anne, Université Paris-Descartes, DHU Neurovasc Sorbonne Paris Cité, INSERM U894, Paris, France; Department of Vascular and Endovascular Surgery/Vascular Center (H.-H.E.), Klinikum rechts der Isar, Technical University Munich, Germany; Department of Vascular Surgery (G.F.), Medical University of Innsbruck, Austria; London School for Hygiene and Tropical Medicine (J.G.); Nuffield Department of Surgical Sciences (A.H.), John Radcliffe Hospital, Oxford, UK; Department of Biostatistics (G.H.), UAB School of Public Health, Birmingham, AL; Clinic for Radiology and Neuroradiology (O.J.), UKSH Campus Kiel, Germany; Cardiovascular Associates of the Southeast (G.S.R.), Birmingham, AL; and Department of Neurology (P.A.R.), University of Heidelberg Medical School, Germany
| | - L Jaap Kappelle
- From the Department of Neurology and Neurosurgery, Brain Center Rudolf Magnus (E.J.V., A.A., L.J.K.), Julius Center for Health Sciences and Primary Care (E.J.V., J.P.G., A.A.), and Department of Radiology (J.H.), University Medical Center Utrecht, the Netherlands; IVPE (J.-P.B.), Hopital Privé Paul D'Egine Champigny, France; Department of Neurology and Stroke Center (L.H.B.), University Hospital Basel, Switzerland; Department of Brain Repair and Rehabilitation (L.H.B., M.M.B.), UCL Institute of Neurology, University College London, UK; Department of Neurology (T.G.B.), Mayo Clinic, Jacksonville, FL; Clinical Trial Service Unit and Epidemiological Studies Unit (R.B.), Oxford University, UK; Department of Neurology (D.C., J.-L.M.), Hôpital Sainte-Anne, Université Paris-Descartes, DHU Neurovasc Sorbonne Paris Cité, INSERM U894, Paris, France; Department of Vascular and Endovascular Surgery/Vascular Center (H.-H.E.), Klinikum rechts der Isar, Technical University Munich, Germany; Department of Vascular Surgery (G.F.), Medical University of Innsbruck, Austria; London School for Hygiene and Tropical Medicine (J.G.); Nuffield Department of Surgical Sciences (A.H.), John Radcliffe Hospital, Oxford, UK; Department of Biostatistics (G.H.), UAB School of Public Health, Birmingham, AL; Clinic for Radiology and Neuroradiology (O.J.), UKSH Campus Kiel, Germany; Cardiovascular Associates of the Southeast (G.S.R.), Birmingham, AL; and Department of Neurology (P.A.R.), University of Heidelberg Medical School, Germany
| | - Jean-Pierre Becquemin
- From the Department of Neurology and Neurosurgery, Brain Center Rudolf Magnus (E.J.V., A.A., L.J.K.), Julius Center for Health Sciences and Primary Care (E.J.V., J.P.G., A.A.), and Department of Radiology (J.H.), University Medical Center Utrecht, the Netherlands; IVPE (J.-P.B.), Hopital Privé Paul D'Egine Champigny, France; Department of Neurology and Stroke Center (L.H.B.), University Hospital Basel, Switzerland; Department of Brain Repair and Rehabilitation (L.H.B., M.M.B.), UCL Institute of Neurology, University College London, UK; Department of Neurology (T.G.B.), Mayo Clinic, Jacksonville, FL; Clinical Trial Service Unit and Epidemiological Studies Unit (R.B.), Oxford University, UK; Department of Neurology (D.C., J.-L.M.), Hôpital Sainte-Anne, Université Paris-Descartes, DHU Neurovasc Sorbonne Paris Cité, INSERM U894, Paris, France; Department of Vascular and Endovascular Surgery/Vascular Center (H.-H.E.), Klinikum rechts der Isar, Technical University Munich, Germany; Department of Vascular Surgery (G.F.), Medical University of Innsbruck, Austria; London School for Hygiene and Tropical Medicine (J.G.); Nuffield Department of Surgical Sciences (A.H.), John Radcliffe Hospital, Oxford, UK; Department of Biostatistics (G.H.), UAB School of Public Health, Birmingham, AL; Clinic for Radiology and Neuroradiology (O.J.), UKSH Campus Kiel, Germany; Cardiovascular Associates of the Southeast (G.S.R.), Birmingham, AL; and Department of Neurology (P.A.R.), University of Heidelberg Medical School, Germany
| | - Leo H Bonati
- From the Department of Neurology and Neurosurgery, Brain Center Rudolf Magnus (E.J.V., A.A., L.J.K.), Julius Center for Health Sciences and Primary Care (E.J.V., J.P.G., A.A.), and Department of Radiology (J.H.), University Medical Center Utrecht, the Netherlands; IVPE (J.-P.B.), Hopital Privé Paul D'Egine Champigny, France; Department of Neurology and Stroke Center (L.H.B.), University Hospital Basel, Switzerland; Department of Brain Repair and Rehabilitation (L.H.B., M.M.B.), UCL Institute of Neurology, University College London, UK; Department of Neurology (T.G.B.), Mayo Clinic, Jacksonville, FL; Clinical Trial Service Unit and Epidemiological Studies Unit (R.B.), Oxford University, UK; Department of Neurology (D.C., J.-L.M.), Hôpital Sainte-Anne, Université Paris-Descartes, DHU Neurovasc Sorbonne Paris Cité, INSERM U894, Paris, France; Department of Vascular and Endovascular Surgery/Vascular Center (H.-H.E.), Klinikum rechts der Isar, Technical University Munich, Germany; Department of Vascular Surgery (G.F.), Medical University of Innsbruck, Austria; London School for Hygiene and Tropical Medicine (J.G.); Nuffield Department of Surgical Sciences (A.H.), John Radcliffe Hospital, Oxford, UK; Department of Biostatistics (G.H.), UAB School of Public Health, Birmingham, AL; Clinic for Radiology and Neuroradiology (O.J.), UKSH Campus Kiel, Germany; Cardiovascular Associates of the Southeast (G.S.R.), Birmingham, AL; and Department of Neurology (P.A.R.), University of Heidelberg Medical School, Germany
| | - Thomas G Brott
- From the Department of Neurology and Neurosurgery, Brain Center Rudolf Magnus (E.J.V., A.A., L.J.K.), Julius Center for Health Sciences and Primary Care (E.J.V., J.P.G., A.A.), and Department of Radiology (J.H.), University Medical Center Utrecht, the Netherlands; IVPE (J.-P.B.), Hopital Privé Paul D'Egine Champigny, France; Department of Neurology and Stroke Center (L.H.B.), University Hospital Basel, Switzerland; Department of Brain Repair and Rehabilitation (L.H.B., M.M.B.), UCL Institute of Neurology, University College London, UK; Department of Neurology (T.G.B.), Mayo Clinic, Jacksonville, FL; Clinical Trial Service Unit and Epidemiological Studies Unit (R.B.), Oxford University, UK; Department of Neurology (D.C., J.-L.M.), Hôpital Sainte-Anne, Université Paris-Descartes, DHU Neurovasc Sorbonne Paris Cité, INSERM U894, Paris, France; Department of Vascular and Endovascular Surgery/Vascular Center (H.-H.E.), Klinikum rechts der Isar, Technical University Munich, Germany; Department of Vascular Surgery (G.F.), Medical University of Innsbruck, Austria; London School for Hygiene and Tropical Medicine (J.G.); Nuffield Department of Surgical Sciences (A.H.), John Radcliffe Hospital, Oxford, UK; Department of Biostatistics (G.H.), UAB School of Public Health, Birmingham, AL; Clinic for Radiology and Neuroradiology (O.J.), UKSH Campus Kiel, Germany; Cardiovascular Associates of the Southeast (G.S.R.), Birmingham, AL; and Department of Neurology (P.A.R.), University of Heidelberg Medical School, Germany
| | - Richard Bulbulia
- From the Department of Neurology and Neurosurgery, Brain Center Rudolf Magnus (E.J.V., A.A., L.J.K.), Julius Center for Health Sciences and Primary Care (E.J.V., J.P.G., A.A.), and Department of Radiology (J.H.), University Medical Center Utrecht, the Netherlands; IVPE (J.-P.B.), Hopital Privé Paul D'Egine Champigny, France; Department of Neurology and Stroke Center (L.H.B.), University Hospital Basel, Switzerland; Department of Brain Repair and Rehabilitation (L.H.B., M.M.B.), UCL Institute of Neurology, University College London, UK; Department of Neurology (T.G.B.), Mayo Clinic, Jacksonville, FL; Clinical Trial Service Unit and Epidemiological Studies Unit (R.B.), Oxford University, UK; Department of Neurology (D.C., J.-L.M.), Hôpital Sainte-Anne, Université Paris-Descartes, DHU Neurovasc Sorbonne Paris Cité, INSERM U894, Paris, France; Department of Vascular and Endovascular Surgery/Vascular Center (H.-H.E.), Klinikum rechts der Isar, Technical University Munich, Germany; Department of Vascular Surgery (G.F.), Medical University of Innsbruck, Austria; London School for Hygiene and Tropical Medicine (J.G.); Nuffield Department of Surgical Sciences (A.H.), John Radcliffe Hospital, Oxford, UK; Department of Biostatistics (G.H.), UAB School of Public Health, Birmingham, AL; Clinic for Radiology and Neuroradiology (O.J.), UKSH Campus Kiel, Germany; Cardiovascular Associates of the Southeast (G.S.R.), Birmingham, AL; and Department of Neurology (P.A.R.), University of Heidelberg Medical School, Germany
| | - David Calvet
- From the Department of Neurology and Neurosurgery, Brain Center Rudolf Magnus (E.J.V., A.A., L.J.K.), Julius Center for Health Sciences and Primary Care (E.J.V., J.P.G., A.A.), and Department of Radiology (J.H.), University Medical Center Utrecht, the Netherlands; IVPE (J.-P.B.), Hopital Privé Paul D'Egine Champigny, France; Department of Neurology and Stroke Center (L.H.B.), University Hospital Basel, Switzerland; Department of Brain Repair and Rehabilitation (L.H.B., M.M.B.), UCL Institute of Neurology, University College London, UK; Department of Neurology (T.G.B.), Mayo Clinic, Jacksonville, FL; Clinical Trial Service Unit and Epidemiological Studies Unit (R.B.), Oxford University, UK; Department of Neurology (D.C., J.-L.M.), Hôpital Sainte-Anne, Université Paris-Descartes, DHU Neurovasc Sorbonne Paris Cité, INSERM U894, Paris, France; Department of Vascular and Endovascular Surgery/Vascular Center (H.-H.E.), Klinikum rechts der Isar, Technical University Munich, Germany; Department of Vascular Surgery (G.F.), Medical University of Innsbruck, Austria; London School for Hygiene and Tropical Medicine (J.G.); Nuffield Department of Surgical Sciences (A.H.), John Radcliffe Hospital, Oxford, UK; Department of Biostatistics (G.H.), UAB School of Public Health, Birmingham, AL; Clinic for Radiology and Neuroradiology (O.J.), UKSH Campus Kiel, Germany; Cardiovascular Associates of the Southeast (G.S.R.), Birmingham, AL; and Department of Neurology (P.A.R.), University of Heidelberg Medical School, Germany
| | - Hans-Henning Eckstein
- From the Department of Neurology and Neurosurgery, Brain Center Rudolf Magnus (E.J.V., A.A., L.J.K.), Julius Center for Health Sciences and Primary Care (E.J.V., J.P.G., A.A.), and Department of Radiology (J.H.), University Medical Center Utrecht, the Netherlands; IVPE (J.-P.B.), Hopital Privé Paul D'Egine Champigny, France; Department of Neurology and Stroke Center (L.H.B.), University Hospital Basel, Switzerland; Department of Brain Repair and Rehabilitation (L.H.B., M.M.B.), UCL Institute of Neurology, University College London, UK; Department of Neurology (T.G.B.), Mayo Clinic, Jacksonville, FL; Clinical Trial Service Unit and Epidemiological Studies Unit (R.B.), Oxford University, UK; Department of Neurology (D.C., J.-L.M.), Hôpital Sainte-Anne, Université Paris-Descartes, DHU Neurovasc Sorbonne Paris Cité, INSERM U894, Paris, France; Department of Vascular and Endovascular Surgery/Vascular Center (H.-H.E.), Klinikum rechts der Isar, Technical University Munich, Germany; Department of Vascular Surgery (G.F.), Medical University of Innsbruck, Austria; London School for Hygiene and Tropical Medicine (J.G.); Nuffield Department of Surgical Sciences (A.H.), John Radcliffe Hospital, Oxford, UK; Department of Biostatistics (G.H.), UAB School of Public Health, Birmingham, AL; Clinic for Radiology and Neuroradiology (O.J.), UKSH Campus Kiel, Germany; Cardiovascular Associates of the Southeast (G.S.R.), Birmingham, AL; and Department of Neurology (P.A.R.), University of Heidelberg Medical School, Germany
| | - Gustav Fraedrich
- From the Department of Neurology and Neurosurgery, Brain Center Rudolf Magnus (E.J.V., A.A., L.J.K.), Julius Center for Health Sciences and Primary Care (E.J.V., J.P.G., A.A.), and Department of Radiology (J.H.), University Medical Center Utrecht, the Netherlands; IVPE (J.-P.B.), Hopital Privé Paul D'Egine Champigny, France; Department of Neurology and Stroke Center (L.H.B.), University Hospital Basel, Switzerland; Department of Brain Repair and Rehabilitation (L.H.B., M.M.B.), UCL Institute of Neurology, University College London, UK; Department of Neurology (T.G.B.), Mayo Clinic, Jacksonville, FL; Clinical Trial Service Unit and Epidemiological Studies Unit (R.B.), Oxford University, UK; Department of Neurology (D.C., J.-L.M.), Hôpital Sainte-Anne, Université Paris-Descartes, DHU Neurovasc Sorbonne Paris Cité, INSERM U894, Paris, France; Department of Vascular and Endovascular Surgery/Vascular Center (H.-H.E.), Klinikum rechts der Isar, Technical University Munich, Germany; Department of Vascular Surgery (G.F.), Medical University of Innsbruck, Austria; London School for Hygiene and Tropical Medicine (J.G.); Nuffield Department of Surgical Sciences (A.H.), John Radcliffe Hospital, Oxford, UK; Department of Biostatistics (G.H.), UAB School of Public Health, Birmingham, AL; Clinic for Radiology and Neuroradiology (O.J.), UKSH Campus Kiel, Germany; Cardiovascular Associates of the Southeast (G.S.R.), Birmingham, AL; and Department of Neurology (P.A.R.), University of Heidelberg Medical School, Germany
| | - John Gregson
- From the Department of Neurology and Neurosurgery, Brain Center Rudolf Magnus (E.J.V., A.A., L.J.K.), Julius Center for Health Sciences and Primary Care (E.J.V., J.P.G., A.A.), and Department of Radiology (J.H.), University Medical Center Utrecht, the Netherlands; IVPE (J.-P.B.), Hopital Privé Paul D'Egine Champigny, France; Department of Neurology and Stroke Center (L.H.B.), University Hospital Basel, Switzerland; Department of Brain Repair and Rehabilitation (L.H.B., M.M.B.), UCL Institute of Neurology, University College London, UK; Department of Neurology (T.G.B.), Mayo Clinic, Jacksonville, FL; Clinical Trial Service Unit and Epidemiological Studies Unit (R.B.), Oxford University, UK; Department of Neurology (D.C., J.-L.M.), Hôpital Sainte-Anne, Université Paris-Descartes, DHU Neurovasc Sorbonne Paris Cité, INSERM U894, Paris, France; Department of Vascular and Endovascular Surgery/Vascular Center (H.-H.E.), Klinikum rechts der Isar, Technical University Munich, Germany; Department of Vascular Surgery (G.F.), Medical University of Innsbruck, Austria; London School for Hygiene and Tropical Medicine (J.G.); Nuffield Department of Surgical Sciences (A.H.), John Radcliffe Hospital, Oxford, UK; Department of Biostatistics (G.H.), UAB School of Public Health, Birmingham, AL; Clinic for Radiology and Neuroradiology (O.J.), UKSH Campus Kiel, Germany; Cardiovascular Associates of the Southeast (G.S.R.), Birmingham, AL; and Department of Neurology (P.A.R.), University of Heidelberg Medical School, Germany
| | - Alison Halliday
- From the Department of Neurology and Neurosurgery, Brain Center Rudolf Magnus (E.J.V., A.A., L.J.K.), Julius Center for Health Sciences and Primary Care (E.J.V., J.P.G., A.A.), and Department of Radiology (J.H.), University Medical Center Utrecht, the Netherlands; IVPE (J.-P.B.), Hopital Privé Paul D'Egine Champigny, France; Department of Neurology and Stroke Center (L.H.B.), University Hospital Basel, Switzerland; Department of Brain Repair and Rehabilitation (L.H.B., M.M.B.), UCL Institute of Neurology, University College London, UK; Department of Neurology (T.G.B.), Mayo Clinic, Jacksonville, FL; Clinical Trial Service Unit and Epidemiological Studies Unit (R.B.), Oxford University, UK; Department of Neurology (D.C., J.-L.M.), Hôpital Sainte-Anne, Université Paris-Descartes, DHU Neurovasc Sorbonne Paris Cité, INSERM U894, Paris, France; Department of Vascular and Endovascular Surgery/Vascular Center (H.-H.E.), Klinikum rechts der Isar, Technical University Munich, Germany; Department of Vascular Surgery (G.F.), Medical University of Innsbruck, Austria; London School for Hygiene and Tropical Medicine (J.G.); Nuffield Department of Surgical Sciences (A.H.), John Radcliffe Hospital, Oxford, UK; Department of Biostatistics (G.H.), UAB School of Public Health, Birmingham, AL; Clinic for Radiology and Neuroradiology (O.J.), UKSH Campus Kiel, Germany; Cardiovascular Associates of the Southeast (G.S.R.), Birmingham, AL; and Department of Neurology (P.A.R.), University of Heidelberg Medical School, Germany
| | - George Howard
- From the Department of Neurology and Neurosurgery, Brain Center Rudolf Magnus (E.J.V., A.A., L.J.K.), Julius Center for Health Sciences and Primary Care (E.J.V., J.P.G., A.A.), and Department of Radiology (J.H.), University Medical Center Utrecht, the Netherlands; IVPE (J.-P.B.), Hopital Privé Paul D'Egine Champigny, France; Department of Neurology and Stroke Center (L.H.B.), University Hospital Basel, Switzerland; Department of Brain Repair and Rehabilitation (L.H.B., M.M.B.), UCL Institute of Neurology, University College London, UK; Department of Neurology (T.G.B.), Mayo Clinic, Jacksonville, FL; Clinical Trial Service Unit and Epidemiological Studies Unit (R.B.), Oxford University, UK; Department of Neurology (D.C., J.-L.M.), Hôpital Sainte-Anne, Université Paris-Descartes, DHU Neurovasc Sorbonne Paris Cité, INSERM U894, Paris, France; Department of Vascular and Endovascular Surgery/Vascular Center (H.-H.E.), Klinikum rechts der Isar, Technical University Munich, Germany; Department of Vascular Surgery (G.F.), Medical University of Innsbruck, Austria; London School for Hygiene and Tropical Medicine (J.G.); Nuffield Department of Surgical Sciences (A.H.), John Radcliffe Hospital, Oxford, UK; Department of Biostatistics (G.H.), UAB School of Public Health, Birmingham, AL; Clinic for Radiology and Neuroradiology (O.J.), UKSH Campus Kiel, Germany; Cardiovascular Associates of the Southeast (G.S.R.), Birmingham, AL; and Department of Neurology (P.A.R.), University of Heidelberg Medical School, Germany
| | - Olav Jansen
- From the Department of Neurology and Neurosurgery, Brain Center Rudolf Magnus (E.J.V., A.A., L.J.K.), Julius Center for Health Sciences and Primary Care (E.J.V., J.P.G., A.A.), and Department of Radiology (J.H.), University Medical Center Utrecht, the Netherlands; IVPE (J.-P.B.), Hopital Privé Paul D'Egine Champigny, France; Department of Neurology and Stroke Center (L.H.B.), University Hospital Basel, Switzerland; Department of Brain Repair and Rehabilitation (L.H.B., M.M.B.), UCL Institute of Neurology, University College London, UK; Department of Neurology (T.G.B.), Mayo Clinic, Jacksonville, FL; Clinical Trial Service Unit and Epidemiological Studies Unit (R.B.), Oxford University, UK; Department of Neurology (D.C., J.-L.M.), Hôpital Sainte-Anne, Université Paris-Descartes, DHU Neurovasc Sorbonne Paris Cité, INSERM U894, Paris, France; Department of Vascular and Endovascular Surgery/Vascular Center (H.-H.E.), Klinikum rechts der Isar, Technical University Munich, Germany; Department of Vascular Surgery (G.F.), Medical University of Innsbruck, Austria; London School for Hygiene and Tropical Medicine (J.G.); Nuffield Department of Surgical Sciences (A.H.), John Radcliffe Hospital, Oxford, UK; Department of Biostatistics (G.H.), UAB School of Public Health, Birmingham, AL; Clinic for Radiology and Neuroradiology (O.J.), UKSH Campus Kiel, Germany; Cardiovascular Associates of the Southeast (G.S.R.), Birmingham, AL; and Department of Neurology (P.A.R.), University of Heidelberg Medical School, Germany
| | - Gary S Roubin
- From the Department of Neurology and Neurosurgery, Brain Center Rudolf Magnus (E.J.V., A.A., L.J.K.), Julius Center for Health Sciences and Primary Care (E.J.V., J.P.G., A.A.), and Department of Radiology (J.H.), University Medical Center Utrecht, the Netherlands; IVPE (J.-P.B.), Hopital Privé Paul D'Egine Champigny, France; Department of Neurology and Stroke Center (L.H.B.), University Hospital Basel, Switzerland; Department of Brain Repair and Rehabilitation (L.H.B., M.M.B.), UCL Institute of Neurology, University College London, UK; Department of Neurology (T.G.B.), Mayo Clinic, Jacksonville, FL; Clinical Trial Service Unit and Epidemiological Studies Unit (R.B.), Oxford University, UK; Department of Neurology (D.C., J.-L.M.), Hôpital Sainte-Anne, Université Paris-Descartes, DHU Neurovasc Sorbonne Paris Cité, INSERM U894, Paris, France; Department of Vascular and Endovascular Surgery/Vascular Center (H.-H.E.), Klinikum rechts der Isar, Technical University Munich, Germany; Department of Vascular Surgery (G.F.), Medical University of Innsbruck, Austria; London School for Hygiene and Tropical Medicine (J.G.); Nuffield Department of Surgical Sciences (A.H.), John Radcliffe Hospital, Oxford, UK; Department of Biostatistics (G.H.), UAB School of Public Health, Birmingham, AL; Clinic for Radiology and Neuroradiology (O.J.), UKSH Campus Kiel, Germany; Cardiovascular Associates of the Southeast (G.S.R.), Birmingham, AL; and Department of Neurology (P.A.R.), University of Heidelberg Medical School, Germany
| | - Martin M Brown
- From the Department of Neurology and Neurosurgery, Brain Center Rudolf Magnus (E.J.V., A.A., L.J.K.), Julius Center for Health Sciences and Primary Care (E.J.V., J.P.G., A.A.), and Department of Radiology (J.H.), University Medical Center Utrecht, the Netherlands; IVPE (J.-P.B.), Hopital Privé Paul D'Egine Champigny, France; Department of Neurology and Stroke Center (L.H.B.), University Hospital Basel, Switzerland; Department of Brain Repair and Rehabilitation (L.H.B., M.M.B.), UCL Institute of Neurology, University College London, UK; Department of Neurology (T.G.B.), Mayo Clinic, Jacksonville, FL; Clinical Trial Service Unit and Epidemiological Studies Unit (R.B.), Oxford University, UK; Department of Neurology (D.C., J.-L.M.), Hôpital Sainte-Anne, Université Paris-Descartes, DHU Neurovasc Sorbonne Paris Cité, INSERM U894, Paris, France; Department of Vascular and Endovascular Surgery/Vascular Center (H.-H.E.), Klinikum rechts der Isar, Technical University Munich, Germany; Department of Vascular Surgery (G.F.), Medical University of Innsbruck, Austria; London School for Hygiene and Tropical Medicine (J.G.); Nuffield Department of Surgical Sciences (A.H.), John Radcliffe Hospital, Oxford, UK; Department of Biostatistics (G.H.), UAB School of Public Health, Birmingham, AL; Clinic for Radiology and Neuroradiology (O.J.), UKSH Campus Kiel, Germany; Cardiovascular Associates of the Southeast (G.S.R.), Birmingham, AL; and Department of Neurology (P.A.R.), University of Heidelberg Medical School, Germany
| | - Jean-Louis Mas
- From the Department of Neurology and Neurosurgery, Brain Center Rudolf Magnus (E.J.V., A.A., L.J.K.), Julius Center for Health Sciences and Primary Care (E.J.V., J.P.G., A.A.), and Department of Radiology (J.H.), University Medical Center Utrecht, the Netherlands; IVPE (J.-P.B.), Hopital Privé Paul D'Egine Champigny, France; Department of Neurology and Stroke Center (L.H.B.), University Hospital Basel, Switzerland; Department of Brain Repair and Rehabilitation (L.H.B., M.M.B.), UCL Institute of Neurology, University College London, UK; Department of Neurology (T.G.B.), Mayo Clinic, Jacksonville, FL; Clinical Trial Service Unit and Epidemiological Studies Unit (R.B.), Oxford University, UK; Department of Neurology (D.C., J.-L.M.), Hôpital Sainte-Anne, Université Paris-Descartes, DHU Neurovasc Sorbonne Paris Cité, INSERM U894, Paris, France; Department of Vascular and Endovascular Surgery/Vascular Center (H.-H.E.), Klinikum rechts der Isar, Technical University Munich, Germany; Department of Vascular Surgery (G.F.), Medical University of Innsbruck, Austria; London School for Hygiene and Tropical Medicine (J.G.); Nuffield Department of Surgical Sciences (A.H.), John Radcliffe Hospital, Oxford, UK; Department of Biostatistics (G.H.), UAB School of Public Health, Birmingham, AL; Clinic for Radiology and Neuroradiology (O.J.), UKSH Campus Kiel, Germany; Cardiovascular Associates of the Southeast (G.S.R.), Birmingham, AL; and Department of Neurology (P.A.R.), University of Heidelberg Medical School, Germany
| | - Peter A Ringleb
- From the Department of Neurology and Neurosurgery, Brain Center Rudolf Magnus (E.J.V., A.A., L.J.K.), Julius Center for Health Sciences and Primary Care (E.J.V., J.P.G., A.A.), and Department of Radiology (J.H.), University Medical Center Utrecht, the Netherlands; IVPE (J.-P.B.), Hopital Privé Paul D'Egine Champigny, France; Department of Neurology and Stroke Center (L.H.B.), University Hospital Basel, Switzerland; Department of Brain Repair and Rehabilitation (L.H.B., M.M.B.), UCL Institute of Neurology, University College London, UK; Department of Neurology (T.G.B.), Mayo Clinic, Jacksonville, FL; Clinical Trial Service Unit and Epidemiological Studies Unit (R.B.), Oxford University, UK; Department of Neurology (D.C., J.-L.M.), Hôpital Sainte-Anne, Université Paris-Descartes, DHU Neurovasc Sorbonne Paris Cité, INSERM U894, Paris, France; Department of Vascular and Endovascular Surgery/Vascular Center (H.-H.E.), Klinikum rechts der Isar, Technical University Munich, Germany; Department of Vascular Surgery (G.F.), Medical University of Innsbruck, Austria; London School for Hygiene and Tropical Medicine (J.G.); Nuffield Department of Surgical Sciences (A.H.), John Radcliffe Hospital, Oxford, UK; Department of Biostatistics (G.H.), UAB School of Public Health, Birmingham, AL; Clinic for Radiology and Neuroradiology (O.J.), UKSH Campus Kiel, Germany; Cardiovascular Associates of the Southeast (G.S.R.), Birmingham, AL; and Department of Neurology (P.A.R.), University of Heidelberg Medical School, Germany
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Abstract
In the past decade, the definition of stroke has been revised and major advances have been made for its treatment and prevention. For acute ischaemic stroke, the addition of endovascular thrombectomy of proximal large artery occlusion to intravenous alteplase increases functional independence for a further fifth of patients. The benefits of aspirin in preventing early recurrent ischaemic stroke are greater than previously recognised. Other strategies to prevent recurrent stroke now include direct oral anticoagulants as an alternative to warfarin for atrial fibrillation, and carotid stenting as an alternative to endarterectomy for symptomatic carotid stenosis. For acute intracerebral haemorrhage, trials are ongoing to assess the effectiveness of acute blood pressure lowering, haemostatic therapy, minimally invasive surgery, anti-inflammation therapy, and neuroprotection methods. Pharmacological and stem-cell therapies promise to facilitate brain regeneration, rehabilitation, and functional recovery. Despite declining stroke mortality rates, the global burden of stroke is increasing. A more comprehensive approach to primary prevention of stroke is required that targets people at all levels of risk and is integrated with prevention strategies for other diseases that share common risk factors.
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Affiliation(s)
- Graeme J Hankey
- School of Medicine & Pharmacology, The University of Western Australia, Perth, WA, Australia; Department of Neurology, Sir Charles Gairdner Hospital, Perth, WA, Australia; Western Australian Neuroscience Research Institute (WANRI), Perth, WA, Australia.
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Zhao W, Meng R, Ma C, Hou B, Jiao L, Zhu F, Wu W, Shi J, Duan Y, Zhang R, Zhang J, Sun Y, Zhang H, Ling F, Wang Y, Feng W, Ding Y, Ovbiagele B, Ji X. Safety and Efficacy of Remote Ischemic Preconditioning in Patients With Severe Carotid Artery Stenosis Before Carotid Artery Stenting: A Proof-of-Concept, Randomized Controlled Trial. Circulation 2017; 135:1325-1335. [PMID: 28174194 DOI: 10.1161/circulationaha.116.024807] [Citation(s) in RCA: 99] [Impact Index Per Article: 14.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/06/2016] [Accepted: 01/26/2017] [Indexed: 11/16/2022]
Abstract
BACKGROUND Remote ischemic preconditioning (RIPC) can inhibit recurrent ischemic events effectively in patients with acute or chronic cerebral ischemia. However, it is still unclear whether RIPC can impede ischemic injury after carotid artery stenting (CAS) in patients with severe carotid artery stenosis. METHODS Subjects with severe carotid artery stenosis were recruited in this randomized controlled study, and assigned to RIPC, sham, and no intervention (control) groups. All subjects received standard medical therapy. Subjects in the RIPC and sham groups underwent RIPC and sham RIPC twice daily, respectively, for 2 weeks before CAS. Plasma neuron-specific enolase and S-100B were used to evaluate safety, hypersensitive C-reactive protein, and new ischemic diffusion-weighted imaging lesions were used to determine treatment efficacy. The primary outcomes were the presence of ≥1 newly ischemic brain lesions on diffusion-weighted imaging within 48 hours after stenting and clinical events within 6 months after stenting. RESULTS We randomly assigned 189 subjects in this study (63 subjects in each group). Both RIPC and sham RIPC procedures were well tolerated and completed with high compliance (98.41% and 95.24%, respectively). Neither plasma neuron-specific enolase levels nor S-100B levels changed significantly before and after treatment. No severe adverse event was attributed to RIPC and sham RIPC procedures. The incidence of new diffusion-weighted imaging lesions in the RIPC group (15.87%) was significantly lower than in the sham group (36.51%; relative risk, 0.44; 96% confidence interval, 0.20-0.91; P<0.01) and the control group (41.27%; relative risk, 0.39; 96% confidence interval, 0.21-0.82; P<0.01). The volumes of lesions were smaller in the RIPC group than in the control and sham groups (P<0.01 each). Ischemic events that occurred after CAS were 1 transient ischemic attack in the RIPC group, 2 strokes in the control group, and 2 strokes and 1 transient ischemic attack in the sham group, but these results were not significantly different among the 3 groups (P=0.597). CONCLUSIONS RIPC is safe in patients undergoing CAS, which may be able to decrease ischemic brain injury secondary to CAS. However, the mechanisms and effects of RIPC on clinical outcomes in this cohort of patients need further investigation. CLINICAL TRIAL REGISTRATION URL: http://www.clinicaltrials.gov. Unique identifier: NCT01654666.
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Affiliation(s)
- Wenbo Zhao
- From Department of Neurology, Xuanwu Hospital, Capital Medical University, Beijing, China (W.Z., R.M., W.W., J.Z., Y.S., Y.W.); Department of Surgical Intensive Care Unit, Beijing Anzhen Hospital, Capital Medical University, China (C.M.); Department of Intensive Care Unit, Shanxian Central Hospital, Heze, China (B.H.); Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, Beijing, China (L.J., F.Z., H.Z., F.L., X.J.); China-America Joint Institution of Neuroscience, Xuanwu Hospital, Capital Medical University, Beijing, China (J.S., Y.D.); Department of Nuclear Medicine, Xuanwu Hospital, Capital Medical University, Beijing, China (R.Z.); Department of Neurology, Medical University of South Carolina, Charleston (W.F., B.O.); and Department of Neurosurgery, Wayne State University, Detroit, MI (Y.D.)
| | - Ran Meng
- From Department of Neurology, Xuanwu Hospital, Capital Medical University, Beijing, China (W.Z., R.M., W.W., J.Z., Y.S., Y.W.); Department of Surgical Intensive Care Unit, Beijing Anzhen Hospital, Capital Medical University, China (C.M.); Department of Intensive Care Unit, Shanxian Central Hospital, Heze, China (B.H.); Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, Beijing, China (L.J., F.Z., H.Z., F.L., X.J.); China-America Joint Institution of Neuroscience, Xuanwu Hospital, Capital Medical University, Beijing, China (J.S., Y.D.); Department of Nuclear Medicine, Xuanwu Hospital, Capital Medical University, Beijing, China (R.Z.); Department of Neurology, Medical University of South Carolina, Charleston (W.F., B.O.); and Department of Neurosurgery, Wayne State University, Detroit, MI (Y.D.)
| | - Chun Ma
- From Department of Neurology, Xuanwu Hospital, Capital Medical University, Beijing, China (W.Z., R.M., W.W., J.Z., Y.S., Y.W.); Department of Surgical Intensive Care Unit, Beijing Anzhen Hospital, Capital Medical University, China (C.M.); Department of Intensive Care Unit, Shanxian Central Hospital, Heze, China (B.H.); Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, Beijing, China (L.J., F.Z., H.Z., F.L., X.J.); China-America Joint Institution of Neuroscience, Xuanwu Hospital, Capital Medical University, Beijing, China (J.S., Y.D.); Department of Nuclear Medicine, Xuanwu Hospital, Capital Medical University, Beijing, China (R.Z.); Department of Neurology, Medical University of South Carolina, Charleston (W.F., B.O.); and Department of Neurosurgery, Wayne State University, Detroit, MI (Y.D.)
| | - Baojun Hou
- From Department of Neurology, Xuanwu Hospital, Capital Medical University, Beijing, China (W.Z., R.M., W.W., J.Z., Y.S., Y.W.); Department of Surgical Intensive Care Unit, Beijing Anzhen Hospital, Capital Medical University, China (C.M.); Department of Intensive Care Unit, Shanxian Central Hospital, Heze, China (B.H.); Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, Beijing, China (L.J., F.Z., H.Z., F.L., X.J.); China-America Joint Institution of Neuroscience, Xuanwu Hospital, Capital Medical University, Beijing, China (J.S., Y.D.); Department of Nuclear Medicine, Xuanwu Hospital, Capital Medical University, Beijing, China (R.Z.); Department of Neurology, Medical University of South Carolina, Charleston (W.F., B.O.); and Department of Neurosurgery, Wayne State University, Detroit, MI (Y.D.)
| | - Liqun Jiao
- From Department of Neurology, Xuanwu Hospital, Capital Medical University, Beijing, China (W.Z., R.M., W.W., J.Z., Y.S., Y.W.); Department of Surgical Intensive Care Unit, Beijing Anzhen Hospital, Capital Medical University, China (C.M.); Department of Intensive Care Unit, Shanxian Central Hospital, Heze, China (B.H.); Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, Beijing, China (L.J., F.Z., H.Z., F.L., X.J.); China-America Joint Institution of Neuroscience, Xuanwu Hospital, Capital Medical University, Beijing, China (J.S., Y.D.); Department of Nuclear Medicine, Xuanwu Hospital, Capital Medical University, Beijing, China (R.Z.); Department of Neurology, Medical University of South Carolina, Charleston (W.F., B.O.); and Department of Neurosurgery, Wayne State University, Detroit, MI (Y.D.)
| | - Fengshui Zhu
- From Department of Neurology, Xuanwu Hospital, Capital Medical University, Beijing, China (W.Z., R.M., W.W., J.Z., Y.S., Y.W.); Department of Surgical Intensive Care Unit, Beijing Anzhen Hospital, Capital Medical University, China (C.M.); Department of Intensive Care Unit, Shanxian Central Hospital, Heze, China (B.H.); Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, Beijing, China (L.J., F.Z., H.Z., F.L., X.J.); China-America Joint Institution of Neuroscience, Xuanwu Hospital, Capital Medical University, Beijing, China (J.S., Y.D.); Department of Nuclear Medicine, Xuanwu Hospital, Capital Medical University, Beijing, China (R.Z.); Department of Neurology, Medical University of South Carolina, Charleston (W.F., B.O.); and Department of Neurosurgery, Wayne State University, Detroit, MI (Y.D.)
| | - Weijuan Wu
- From Department of Neurology, Xuanwu Hospital, Capital Medical University, Beijing, China (W.Z., R.M., W.W., J.Z., Y.S., Y.W.); Department of Surgical Intensive Care Unit, Beijing Anzhen Hospital, Capital Medical University, China (C.M.); Department of Intensive Care Unit, Shanxian Central Hospital, Heze, China (B.H.); Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, Beijing, China (L.J., F.Z., H.Z., F.L., X.J.); China-America Joint Institution of Neuroscience, Xuanwu Hospital, Capital Medical University, Beijing, China (J.S., Y.D.); Department of Nuclear Medicine, Xuanwu Hospital, Capital Medical University, Beijing, China (R.Z.); Department of Neurology, Medical University of South Carolina, Charleston (W.F., B.O.); and Department of Neurosurgery, Wayne State University, Detroit, MI (Y.D.)
| | - Jingfei Shi
- From Department of Neurology, Xuanwu Hospital, Capital Medical University, Beijing, China (W.Z., R.M., W.W., J.Z., Y.S., Y.W.); Department of Surgical Intensive Care Unit, Beijing Anzhen Hospital, Capital Medical University, China (C.M.); Department of Intensive Care Unit, Shanxian Central Hospital, Heze, China (B.H.); Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, Beijing, China (L.J., F.Z., H.Z., F.L., X.J.); China-America Joint Institution of Neuroscience, Xuanwu Hospital, Capital Medical University, Beijing, China (J.S., Y.D.); Department of Nuclear Medicine, Xuanwu Hospital, Capital Medical University, Beijing, China (R.Z.); Department of Neurology, Medical University of South Carolina, Charleston (W.F., B.O.); and Department of Neurosurgery, Wayne State University, Detroit, MI (Y.D.)
| | - Yunxia Duan
- From Department of Neurology, Xuanwu Hospital, Capital Medical University, Beijing, China (W.Z., R.M., W.W., J.Z., Y.S., Y.W.); Department of Surgical Intensive Care Unit, Beijing Anzhen Hospital, Capital Medical University, China (C.M.); Department of Intensive Care Unit, Shanxian Central Hospital, Heze, China (B.H.); Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, Beijing, China (L.J., F.Z., H.Z., F.L., X.J.); China-America Joint Institution of Neuroscience, Xuanwu Hospital, Capital Medical University, Beijing, China (J.S., Y.D.); Department of Nuclear Medicine, Xuanwu Hospital, Capital Medical University, Beijing, China (R.Z.); Department of Neurology, Medical University of South Carolina, Charleston (W.F., B.O.); and Department of Neurosurgery, Wayne State University, Detroit, MI (Y.D.)
| | - Renling Zhang
- From Department of Neurology, Xuanwu Hospital, Capital Medical University, Beijing, China (W.Z., R.M., W.W., J.Z., Y.S., Y.W.); Department of Surgical Intensive Care Unit, Beijing Anzhen Hospital, Capital Medical University, China (C.M.); Department of Intensive Care Unit, Shanxian Central Hospital, Heze, China (B.H.); Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, Beijing, China (L.J., F.Z., H.Z., F.L., X.J.); China-America Joint Institution of Neuroscience, Xuanwu Hospital, Capital Medical University, Beijing, China (J.S., Y.D.); Department of Nuclear Medicine, Xuanwu Hospital, Capital Medical University, Beijing, China (R.Z.); Department of Neurology, Medical University of South Carolina, Charleston (W.F., B.O.); and Department of Neurosurgery, Wayne State University, Detroit, MI (Y.D.)
| | - Jing Zhang
- From Department of Neurology, Xuanwu Hospital, Capital Medical University, Beijing, China (W.Z., R.M., W.W., J.Z., Y.S., Y.W.); Department of Surgical Intensive Care Unit, Beijing Anzhen Hospital, Capital Medical University, China (C.M.); Department of Intensive Care Unit, Shanxian Central Hospital, Heze, China (B.H.); Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, Beijing, China (L.J., F.Z., H.Z., F.L., X.J.); China-America Joint Institution of Neuroscience, Xuanwu Hospital, Capital Medical University, Beijing, China (J.S., Y.D.); Department of Nuclear Medicine, Xuanwu Hospital, Capital Medical University, Beijing, China (R.Z.); Department of Neurology, Medical University of South Carolina, Charleston (W.F., B.O.); and Department of Neurosurgery, Wayne State University, Detroit, MI (Y.D.)
| | - Yongxin Sun
- From Department of Neurology, Xuanwu Hospital, Capital Medical University, Beijing, China (W.Z., R.M., W.W., J.Z., Y.S., Y.W.); Department of Surgical Intensive Care Unit, Beijing Anzhen Hospital, Capital Medical University, China (C.M.); Department of Intensive Care Unit, Shanxian Central Hospital, Heze, China (B.H.); Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, Beijing, China (L.J., F.Z., H.Z., F.L., X.J.); China-America Joint Institution of Neuroscience, Xuanwu Hospital, Capital Medical University, Beijing, China (J.S., Y.D.); Department of Nuclear Medicine, Xuanwu Hospital, Capital Medical University, Beijing, China (R.Z.); Department of Neurology, Medical University of South Carolina, Charleston (W.F., B.O.); and Department of Neurosurgery, Wayne State University, Detroit, MI (Y.D.)
| | - Hongqi Zhang
- From Department of Neurology, Xuanwu Hospital, Capital Medical University, Beijing, China (W.Z., R.M., W.W., J.Z., Y.S., Y.W.); Department of Surgical Intensive Care Unit, Beijing Anzhen Hospital, Capital Medical University, China (C.M.); Department of Intensive Care Unit, Shanxian Central Hospital, Heze, China (B.H.); Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, Beijing, China (L.J., F.Z., H.Z., F.L., X.J.); China-America Joint Institution of Neuroscience, Xuanwu Hospital, Capital Medical University, Beijing, China (J.S., Y.D.); Department of Nuclear Medicine, Xuanwu Hospital, Capital Medical University, Beijing, China (R.Z.); Department of Neurology, Medical University of South Carolina, Charleston (W.F., B.O.); and Department of Neurosurgery, Wayne State University, Detroit, MI (Y.D.)
| | - Feng Ling
- From Department of Neurology, Xuanwu Hospital, Capital Medical University, Beijing, China (W.Z., R.M., W.W., J.Z., Y.S., Y.W.); Department of Surgical Intensive Care Unit, Beijing Anzhen Hospital, Capital Medical University, China (C.M.); Department of Intensive Care Unit, Shanxian Central Hospital, Heze, China (B.H.); Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, Beijing, China (L.J., F.Z., H.Z., F.L., X.J.); China-America Joint Institution of Neuroscience, Xuanwu Hospital, Capital Medical University, Beijing, China (J.S., Y.D.); Department of Nuclear Medicine, Xuanwu Hospital, Capital Medical University, Beijing, China (R.Z.); Department of Neurology, Medical University of South Carolina, Charleston (W.F., B.O.); and Department of Neurosurgery, Wayne State University, Detroit, MI (Y.D.)
| | - Yuping Wang
- From Department of Neurology, Xuanwu Hospital, Capital Medical University, Beijing, China (W.Z., R.M., W.W., J.Z., Y.S., Y.W.); Department of Surgical Intensive Care Unit, Beijing Anzhen Hospital, Capital Medical University, China (C.M.); Department of Intensive Care Unit, Shanxian Central Hospital, Heze, China (B.H.); Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, Beijing, China (L.J., F.Z., H.Z., F.L., X.J.); China-America Joint Institution of Neuroscience, Xuanwu Hospital, Capital Medical University, Beijing, China (J.S., Y.D.); Department of Nuclear Medicine, Xuanwu Hospital, Capital Medical University, Beijing, China (R.Z.); Department of Neurology, Medical University of South Carolina, Charleston (W.F., B.O.); and Department of Neurosurgery, Wayne State University, Detroit, MI (Y.D.)
| | - Wuwei Feng
- From Department of Neurology, Xuanwu Hospital, Capital Medical University, Beijing, China (W.Z., R.M., W.W., J.Z., Y.S., Y.W.); Department of Surgical Intensive Care Unit, Beijing Anzhen Hospital, Capital Medical University, China (C.M.); Department of Intensive Care Unit, Shanxian Central Hospital, Heze, China (B.H.); Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, Beijing, China (L.J., F.Z., H.Z., F.L., X.J.); China-America Joint Institution of Neuroscience, Xuanwu Hospital, Capital Medical University, Beijing, China (J.S., Y.D.); Department of Nuclear Medicine, Xuanwu Hospital, Capital Medical University, Beijing, China (R.Z.); Department of Neurology, Medical University of South Carolina, Charleston (W.F., B.O.); and Department of Neurosurgery, Wayne State University, Detroit, MI (Y.D.)
| | - Yuchuan Ding
- From Department of Neurology, Xuanwu Hospital, Capital Medical University, Beijing, China (W.Z., R.M., W.W., J.Z., Y.S., Y.W.); Department of Surgical Intensive Care Unit, Beijing Anzhen Hospital, Capital Medical University, China (C.M.); Department of Intensive Care Unit, Shanxian Central Hospital, Heze, China (B.H.); Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, Beijing, China (L.J., F.Z., H.Z., F.L., X.J.); China-America Joint Institution of Neuroscience, Xuanwu Hospital, Capital Medical University, Beijing, China (J.S., Y.D.); Department of Nuclear Medicine, Xuanwu Hospital, Capital Medical University, Beijing, China (R.Z.); Department of Neurology, Medical University of South Carolina, Charleston (W.F., B.O.); and Department of Neurosurgery, Wayne State University, Detroit, MI (Y.D.)
| | - Bruce Ovbiagele
- From Department of Neurology, Xuanwu Hospital, Capital Medical University, Beijing, China (W.Z., R.M., W.W., J.Z., Y.S., Y.W.); Department of Surgical Intensive Care Unit, Beijing Anzhen Hospital, Capital Medical University, China (C.M.); Department of Intensive Care Unit, Shanxian Central Hospital, Heze, China (B.H.); Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, Beijing, China (L.J., F.Z., H.Z., F.L., X.J.); China-America Joint Institution of Neuroscience, Xuanwu Hospital, Capital Medical University, Beijing, China (J.S., Y.D.); Department of Nuclear Medicine, Xuanwu Hospital, Capital Medical University, Beijing, China (R.Z.); Department of Neurology, Medical University of South Carolina, Charleston (W.F., B.O.); and Department of Neurosurgery, Wayne State University, Detroit, MI (Y.D.)
| | - Xunming Ji
- From Department of Neurology, Xuanwu Hospital, Capital Medical University, Beijing, China (W.Z., R.M., W.W., J.Z., Y.S., Y.W.); Department of Surgical Intensive Care Unit, Beijing Anzhen Hospital, Capital Medical University, China (C.M.); Department of Intensive Care Unit, Shanxian Central Hospital, Heze, China (B.H.); Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, Beijing, China (L.J., F.Z., H.Z., F.L., X.J.); China-America Joint Institution of Neuroscience, Xuanwu Hospital, Capital Medical University, Beijing, China (J.S., Y.D.); Department of Nuclear Medicine, Xuanwu Hospital, Capital Medical University, Beijing, China (R.Z.); Department of Neurology, Medical University of South Carolina, Charleston (W.F., B.O.); and Department of Neurosurgery, Wayne State University, Detroit, MI (Y.D.).
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