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Musialek P, Rosenfield K, Siddiqui AH, Grunwald IQ. Carotid Stenosis and Stroke: Medicines, Stents, Surgery-"Wait-and-See" or Protect? Thromb Haemost 2024. [PMID: 36170885 DOI: 10.1055/a-1952-1159] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/14/2022]
Affiliation(s)
- Piotr Musialek
- Department of Cardiac and Vascular Diseases, Jagiellonian University, Krakow, Poland
- John Paul II Hospital Stroke Thrombectomy-Capable Centre, Krakow, Poland
| | - Kenneth Rosenfield
- Division of Cardiology, Vascular Medicine and Intervention Section, Massachusetts General Hospital, Boston, United States
| | - Adnan H Siddiqui
- Departments of Neurosurgery and Radiology, School of Medicine and Biomedical Sciences, University at Buffalo, State University of New York, Buffalo, New York, United States
- Jacobs Institute, Buffalo, New York, United States
- Department of Neurosurgery, Gates Vascular Institute Kaleida Health, Buffalo, New York, United States
| | - Iris Q Grunwald
- Department of Radiology, Ninewells Hospital, Chair of Neuroradiology, University of Dundee, Dundee, Scotland, United Kingdom
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Teter K, Willems L, Harish K, Negash B, Warle M, Rockman C, Torres J, Ishida K, Jacobowitz G, Garg K, Maldonado T. Optimal medical therapy is lacking in patients undergoing intervention for symptomatic carotid artery stenosis and protects against larger areas of cerebral infarction. Vascular 2024:17085381241262927. [PMID: 38876778 DOI: 10.1177/17085381241262927] [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: 06/16/2024]
Abstract
OBJECTIVES Carotid interventions are indicated for both patients with symptomatic and a subset of patients with severe asymptomatic carotid artery stenosis (CAS). Symptomatic CAS accounts for up to 12%-25% of overall carotid interventions, but predictors of symptomatic presentation remain poorly defined. The aim of this study was to identify factors associated with symptomatic CAS in our patient population. METHODS Between January 2015 and February 2022, an institutional retrospective cohort study of prospectively collected data on patients undergoing interventions for CAS was performed. Procedures included carotid endarterectomy (CEA), transcarotid artery revascularization (TCAR), and transfemoral carotid artery stenting (TF-CAS). Demographic data, comorbidities, procedural details, and anatomic features from various imaging modalities were collected. Comparisons were made between symptomatic (symptoms within the prior 6 months) and asymptomatic patients. RESULTS During the study period, 279 patients who underwent intervention for symptomatic CAS were paired with a randomly selected cohort of 300 patients who underwent intervention for asymptomatic CAS from a total patient cohort of 1143 patients undergoing interventions for asymptomatic CAS. Demographic data did not differ between groups. Patients with symptomatic CAS more frequently had prior TIA/stroke (>6 months remote to the current event), but less frequently had coronary artery disease or chronic kidney disease and were less likely to receive adequate medical management including antihypertensive agents, lipid-lowering agents, and anti-platelet therapy. On multivariate analysis, remote prior TIA/stroke and lack of anti-platelet therapy remained significant. Among symptomatic patients presenting with stroke, lack of anti-platelet therapy was associated with an overall larger area of parenchymal involvement. No difference was observed with single versus dual anti-platelet therapy. Furthermore, symptomatic patients were more likely to have ulcerated plaques (30.9% vs 18%, p < .001), and symptomatic patients with ulcerated plaques more frequently had less than 50% compared to moderate/severe CAS. Nine patients who presented with symptoms had mild CAS and underwent intervention. CONCLUSIONS Symptomatic CAS was associated with a history of remote prior symptoms and lack of anti-platelet therapy at time of presentation. Furthermore, symptomatic patients not on anti-platelet agents were more likely to have a greater area of parenchymal involvement when presenting with stroke and symptomatic patients with ulcerated plaques were more likely to have mild CAS, suggesting the role of plaque instability in symptomatic presentation. These findings underscore the importance of appropriate medical management and adherence in all patients with CAS and perhaps a role for more frequent surveillance in those with potentially unstable plaque morphology.
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Affiliation(s)
| | - Loes Willems
- Radbound University Medical Center, Nijmegen, The Netherlands
| | | | | | - Michiel Warle
- Radbound University Medical Center, Nijmegen, The Netherlands
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Daolio RM, Zanin LFS, Flumignan CDQ, Cassola N, Guedes Neto HJ, Santos JEM, Amorim JE, Nakano LCU, Flumignan RLG. Accuracy of duplex ultrasonography versus angiotomography for the diagnosis of extracranial internal carotid stenosis. Rev Col Bras Cir 2024; 51:e20243632. [PMID: 38896635 PMCID: PMC11185060 DOI: 10.1590/0100-6991e-20243632-en] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2023] [Accepted: 02/09/2024] [Indexed: 06/21/2024] Open
Abstract
INTRODUCTION Internal carotid artery (ICA) stenosis causes about 15% of ischemic strokes. Duplex ultrasonography (DUS) is the first line of investigation of ICA stenosis, but its accuracy varies in the literature and it is usual to complement the study with another more accurate exam when faced with significant stenosis. There is a lack of studies that compare DUS with angiotomography (CTA) in the present literature. METHODS we performed an accuracy study, which compared DUS to CTA of patients in a tertiary hospital with a maximum interval of three months between tests. Patients were selected retrospectively, and two independent and certified vascular surgeons evaluated each image in a masked manner. When there was discordance, a third evaluator was summoned. We evaluated the diagnostic accuracy of ICA stenosis of 50-94% and 70-94%. RESULTS we included 45 patients and 84 arteries after inclusion and exclusion criteria applied. For the 50-94% stenosis range, DUS accuracy was 69%, sensitivity 89%, and specificity 63%. For the 70-94% stenosis range, DUS accuracy was 84%, sensitivity 61%, and specificity 93%. There was discordance between CTA evaluators with a change from clinical to surgical management in at least 37.5% of the conflicting reports. CONCLUSION DUS had an accuracy of 69% for stenoses of 50-94% and 84% for stenoses of 70-94% of the ICA. The CTA analysis depended directly on the evaluator with a change in clinical conduct in more than 37% of cases.
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Affiliation(s)
- Raul Muffato Daolio
- - Universidade Federal de São Paulo, Departamento de Cirurgia, Disciplina de Cirurgia Vascular e Endovascular - São Paulo - SP - Brasil
| | - Luiz Fernando Santetti Zanin
- - Universidade Federal de São Paulo, Departamento de Cirurgia, Disciplina de Cirurgia Vascular e Endovascular - São Paulo - SP - Brasil
| | | | - Nicolle Cassola
- - Universidade Federal de São Paulo, Departamento de Cirurgia, Disciplina de Cirurgia Vascular e Endovascular - São Paulo - SP - Brasil
| | - Henrique Jorge Guedes Neto
- - Universidade Federal de São Paulo, Departamento de Cirurgia, Disciplina de Cirurgia Vascular e Endovascular - São Paulo - SP - Brasil
| | | | - Jorge Eduardo Amorim
- - Universidade Federal de São Paulo, Departamento de Cirurgia, Disciplina de Cirurgia Vascular e Endovascular - São Paulo - SP - Brasil
| | - Luís Carlos Uta Nakano
- - Universidade Federal de São Paulo, Departamento de Cirurgia, Disciplina de Cirurgia Vascular e Endovascular - São Paulo - SP - Brasil
| | - Ronald Luiz Gomes Flumignan
- - Universidade Federal de São Paulo, Departamento de Cirurgia, Disciplina de Cirurgia Vascular e Endovascular - São Paulo - SP - Brasil
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Nguyen D, D'Andrea M, Joule D, Kulwin J, Rojas C, Zhou W. Barriers to Antiplatelet and Statin Adherence Following Major Vascular Intervention. Ann Vasc Surg 2024; 106:360-368. [PMID: 38821476 DOI: 10.1016/j.avsg.2024.03.026] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2024] [Revised: 03/12/2024] [Accepted: 03/21/2024] [Indexed: 06/02/2024]
Abstract
BACKGROUND Antiplatelets and statins therapies are associated with improved cardiovascular outcomes following major vascular intervention. Many vascular surgery institutions are reporting improved prescribing rates for aspirin (ASA), P2Y12 antagonists, and statins. Nevertheless, there remains limited publication describing rates and patient-perceived barriers for postoperative adherence. The purpose of this study is to investigate patient nonadherence to antiplatelet and statin therapies following major vascular intervention. METHODS A retrospective review of patients who underwent major vascular intervention at a single academic center was performed. The prescribing rates of ASA, P2Y12 antagonists, and statins were reviewed. Postoperative adherence, defined as consistent intake as prescribed, was evaluated at 1, 3, 6, 9, and 12 months using electronic documentation of both follow-up clinic appointments and phone call assessments, then corroborated with pharmacy fulfilment records. Patient-reported barriers to medication adherence were also examined. RESULTS A total of 101 subjects underwent major vascular intervention between January 2020 and July 2020, 98% of whom were discharged on at least 1 antiplatelet or statin agent. Approximately 90% of patients were discharged with ASA, 32% with a P2Y12 antagonist, and 96% with a statin. All patients who maintained adherence up to 6 months continued to report adherence at 9 and 12 months. Consistent adherence at 12 months was documented in 76% of patients on ASA, 81% on P2Y12 antagonism therapy, and 73% on statins. New adverse drug reactions represented the most common barrier to achieving adherence (37% [n = 20]). Preoperative therapy with ASA, P2Y12 antagonists, and statins were all independently predictive of postoperative adherence to the same regimen (P ≤ 0.001). The female gender was also associated with higher rates of adherence to postoperative P2Y12 antagonism therapy (P ≤ 0.05). CONCLUSIONS The current prescribing rates for antiplatelet and statin agents are promising, but postoperative nonadherence remains a multifaceted issue.
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Affiliation(s)
- Daniel Nguyen
- The University of Arizona College of Medicine - Tucson, Tucson, AZ.
| | - Melissa D'Andrea
- The University of Arizona College of Medicine - Tucson, Tucson, AZ
| | - Dylan Joule
- The University of Arizona College of Medicine - Tucson, Tucson, AZ
| | - Jeremy Kulwin
- The University of Arizona College of Medicine - Tucson, Tucson, AZ
| | - Connie Rojas
- Genome Center, The University of California, Davis, CA
| | - Wei Zhou
- The University of Arizona College of Medicine - Tucson, Tucson, AZ; Division of Vascular Surgery and Endovascular Therapy, The University of Arizona Department of Surgery, Tucson, AZ.
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Hirota S, Yoshimura M, Cho J, Hayashi T, Kaneoka A, Ito K, Kiyokawa J, Yamamoto S. Stenting for subclavian steal phenomenon to restore cerebral perfusion due to acute carotid occlusion following carotid endarterectomy: a case report. J Med Case Rep 2024; 18:226. [PMID: 38715146 PMCID: PMC11077806 DOI: 10.1186/s13256-024-04546-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2024] [Accepted: 04/08/2024] [Indexed: 05/12/2024] Open
Abstract
BACKGROUND Perioperative symptomatic carotid artery occlusion after carotid endarterectomy is a rare complication. In this study, we present a case of symptomatic acute carotid artery occlusion that occurred after carotid endarterectomy in a patient with coexistent subclavian artery steal phenomenon, which was successfully treated with subclavian artery stenting. CASE PRESENTATION A 57-year-old East Asian female presented with stenosis in the left common carotid artery and left subclavian artery along with subclavian steal. The proximal segment of the left anterior cerebral artery was hypoplastic, and the posterior communicating arteries on both sides were well-developed. Left internal carotid artery stenosis progressed during the follow-up examination; therefore, left carotid endarterectomy was performed. On the following day, symptoms of cerebral perfusion deficiency appeared due to occlusion of the left carotid artery. The stenotic origin of the left common carotid artery and the suspected massive thrombus in the left carotid artery posed challenges to carotid revascularization. Therefore, left subclavian artery stenting for the subclavian steal phenomenon was determined to be the best option for restoring cerebral blood flow to the whole brain. Her symptoms improved after the procedure, and the postprocedural workup revealed improved cerebral blood flow. CONCLUSION Subclavian artery stenting is safe and may be helpful in patients with cerebral perfusion deficiency caused by intractable acute carotid occlusion coexisting with the subclavian steal phenomenon. Revascularization of asymptomatic subclavian artery stenosis is generally not recommended. However, cerebral circulatory insufficiency as a comorbidity may be worth considering.
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Affiliation(s)
- Shin Hirota
- Department of Neurosurgery, Tsuchiura Kyodo General Hospital, 4-1-1 Otsuno, Tsuchiura-shi, Ibaraki, 300-0028, Japan.
| | - Masataka Yoshimura
- Department of Neurosurgery, Tsuchiura Kyodo General Hospital, 4-1-1 Otsuno, Tsuchiura-shi, Ibaraki, 300-0028, Japan
| | - Junshi Cho
- Department of Neurosurgery, Tsuchiura Kyodo General Hospital, 4-1-1 Otsuno, Tsuchiura-shi, Ibaraki, 300-0028, Japan
| | - Toshihiko Hayashi
- Department of Neurosurgery, Tsuchiura Kyodo General Hospital, 4-1-1 Otsuno, Tsuchiura-shi, Ibaraki, 300-0028, Japan
| | - Azumi Kaneoka
- Department of Neurosurgery, Tsuchiura Kyodo General Hospital, 4-1-1 Otsuno, Tsuchiura-shi, Ibaraki, 300-0028, Japan
| | - Kei Ito
- Department of Neurosurgery, Tsuchiura Kyodo General Hospital, 4-1-1 Otsuno, Tsuchiura-shi, Ibaraki, 300-0028, Japan
| | - Juri Kiyokawa
- Department of Neurosurgery, Tsuchiura Kyodo General Hospital, 4-1-1 Otsuno, Tsuchiura-shi, Ibaraki, 300-0028, Japan
| | - Shinji Yamamoto
- Department of Neurosurgery, Tsuchiura Kyodo General Hospital, 4-1-1 Otsuno, Tsuchiura-shi, Ibaraki, 300-0028, Japan
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Huang Y, Xie X, Huang G, Lu W, Hong S, Chen Y, Lin Y, Fu W, Hong X, Wang L. Long-term outcomes of endovascular therapy for right subclavian artery occlusive lesions: A multi-center experience. Vascular 2024:17085381241247613. [PMID: 38631687 DOI: 10.1177/17085381241247613] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/19/2024]
Abstract
OBJECTIVE To review our multi-institutional experience with endovascular therapy for right subclavian artery occlusive disease and to evaluate the long-term outcomes. METHODS We retrospectively evaluated all patients with right subclavian artery stenosis and occlusive disease who underwent endovascular therapy between March 2014 and September 2022 at two institutions. Patient baseline demographics, lesion characteristics, treatment strategies, and in-hospital and follow-up outcomes were prospectively collected and retrospectively analyzed. RESULTS Between March 2014 and September 2022, 73 patients underwent endovascular treatment at the two institutions. The dominant cause of lesions in this cohort was atherosclerosis. Three different types of lesions were summarized, and the corresponding endovascular strategies were performed. 66 patients (90.4%) underwent successful endovascular treatment, and 62 patients (84.9%) underwent balloon-expandable stent deployment. The mean perioperative in-hospital stay was 4.0 days (range, 3-6 days). Two patients died due to myocardial infarction, and one died of cerebral hemorrhage resulting from a traffic accident within 30 days of the intervention. The median follow-up time was 31.6 months (range, 12-96 months). No complications, including death, stroke, stent fractures, or migration, were noted in any patient during the follow-up period. The overall complication rate was 7/73 (9.6%), and 5/7 (6.9%) of the complications required reintervention. CONCLUSIONS Endovascular treatment of right subclavian artery lesions is safe, effective, and technically achievable. The reasonable use of balloon-expandable stents can achieve satisfactory outcomes with accurate orientation and promising patency.
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Affiliation(s)
- Yulong Huang
- Department of Vascular Surgery, Xiamen Branch of Zhongshan Hospital, Fudan University, Xiamen, China
| | - Xinsheng Xie
- Department of Vascular Surgery, Xiamen Branch of Zhongshan Hospital, Fudan University, Xiamen, China
| | - Guoqiang Huang
- Department of Radiology, Xiamen Branch of Zhongshan Hospital, Fudan University, Xiamen, China
| | - Weifeng Lu
- Department of Vascular Surgery, Xiamen Branch of Zhongshan Hospital, Fudan University, Xiamen, China
| | - Shichai Hong
- Department of Vascular Surgery, Xiamen Branch of Zhongshan Hospital, Fudan University, Xiamen, China
| | - Yihui Chen
- Department of Vascular Surgery, Xiamen Branch of Zhongshan Hospital, Fudan University, Xiamen, China
| | - Yue Lin
- Department of Vascular Surgery, Xiamen Branch of Zhongshan Hospital, Fudan University, Xiamen, China
| | - Weiguo Fu
- Department of Vascular Surgery, Xiamen Branch of Zhongshan Hospital, Fudan University, Xiamen, China
- Department of Vascular Surgery, Fudan University, Shanghai, China
- Institute of Vascular Surgery, Fudan University, Shanghai, China
| | - Xiang Hong
- Department of Vascular Surgery, Xiamen Branch of Zhongshan Hospital, Fudan University, Xiamen, China
| | - Lixin Wang
- Department of Vascular Surgery, Xiamen Branch of Zhongshan Hospital, Fudan University, Xiamen, China
- Department of Vascular Surgery, Fudan University, Shanghai, China
- Institute of Vascular Surgery, Fudan University, Shanghai, China
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Aggarwal A, Whitler C, Jain A, Patel H, Zughaib M. Carotid Artery Stenting Versus Carotid Artery Endarterectomy in Asymptomatic Severe Carotid Stenosis: An Updated Meta-Analysis. Cureus 2023; 15:e50506. [PMID: 38222218 PMCID: PMC10787384 DOI: 10.7759/cureus.50506] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/13/2023] [Indexed: 01/16/2024] Open
Abstract
Carotid artery stenting (CAS) and carotid artery endarterectomy (CEA) are revascularization options for the management of severe carotid disease in asymptomatic patients. We aimed to compare the peri-procedural outcomes of the two modalities. A systematic review of the databases PUBMED, EBSCO, and Cochrane Library was performed. All the studies that reported periprocedural outcomes (within 30 days) in asymptomatic carotid stenosis patients were included in the meta-analysis. Random effects models with inverse-variance weighting were used to estimate pooled risk ratios (RRs) to compare the outcomes. Fifteen studies (including seven randomized controlled trials) met the inclusion criteria. A total of 15251 patients were included, out of which 6419 (42%) underwent CAS and 8832 (57.9%) underwent CEA. There was no statistical difference in the primary composite outcome of death/stroke/myocardial infarction (MI) (RR 1.02, 95% CI [0.69-1.51], p 0.93). No difference was found in the secondary outcome of all-cause mortality. CAS was associated with a slightly lower risk of MI and cranial nerve palsy. CAS was associated with a slightly higher risk of stroke with no difference in the occurrence of disabling stroke or ipsilateral stroke. In general terms, the study confirms equipoise in the two treatment strategies with a higher risk of MI and cranial nerve palsy with CEA and a higher risk of non-disabling stroke with CAS.
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Affiliation(s)
- Ankita Aggarwal
- Cardiology, Ascension Providence Hospital - Southfield Campus, Southfield, USA
| | - Cameron Whitler
- Cardiology, Ascension Providence Hospital - Southfield Campus, Southfield, USA
| | - Anubhav Jain
- Cardiology, Ascension Genesys Hospital, Grand Blanc, USA
| | - Harshil Patel
- Cardiology, Ascension Providence Hospital - Southfield Campus, Southfield, USA
| | - Marcel Zughaib
- Cardiology, Ascension Providence Hospital - Southfield Campus, Southfield, USA
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Zarrintan S, Malas MB. What Is the Role of Transcarotid Artery Revascularization? Adv Surg 2023; 57:115-140. [PMID: 37536848 DOI: 10.1016/j.yasu.2023.04.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/05/2023]
Abstract
Carotid endarterectomy (CEA) is the gold-standard method of carotid revascularization in symptomatic patients with ≥50% and in asymptomatic patients with ≥70% stenosis. Transfemoral carotid artery stenting (TFCAS) has been associated with higher perioperative stroke rates compared to CEA in several studies. On the other hand, transcarotid artery revascularization (TCAR) has outperformed TFCAS in patients who are considered high risk for surgery. There is increasing data that supports TCAR as a safe and efficient technique with outcomes similar to those of CEA, but additional level-one studies are necessary to evaluate the long-term outcomes of TCAR in high- and standard-risk patients.
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Affiliation(s)
- Sina Zarrintan
- Department of Surgery, Division of Vascular and Endovascular Surgery, UC San Diego, San Diego, CA, USA; Center for Learning and Excellence in Vascular & Endovascular Research (CLEVER), UC San Diego, San Diego, CA, USA; Altman Center for Clinical and Translational Research, 9452 Medical Center Drive - LL2W 502A, La Jolla, CA 92037, USA
| | - Mahmoud B Malas
- Department of Surgery, Division of Vascular and Endovascular Surgery, UC San Diego, San Diego, CA, USA; Center for Learning and Excellence in Vascular & Endovascular Research (CLEVER), UC San Diego, San Diego, CA, USA; Altman Center for Clinical and Translational Research, 9452 Medical Center Drive - LL2W 502A, La Jolla, CA 92037, USA.
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Clezar CN, Flumignan CD, Cassola N, Nakano LC, Trevisani VF, Flumignan RL. Pharmacological interventions for asymptomatic carotid stenosis. Cochrane Database Syst Rev 2023; 8:CD013573. [PMID: 37565307 PMCID: PMC10401652 DOI: 10.1002/14651858.cd013573.pub2] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 08/12/2023]
Abstract
BACKGROUND Carotid artery stenosis is narrowing of the carotid arteries. Asymptomatic carotid stenosis is when this narrowing occurs in people without a history or symptoms of this disease. It is caused by atherosclerosis; that is, the build-up of fats, cholesterol, and other substances in and on the artery walls. Atherosclerosis is more likely to occur in people with several risk factors, such as diabetes, hypertension, hyperlipidaemia, and smoking. As this damage can develop without symptoms, the first symptom can be a fatal or disabling stroke, known as ischaemic stroke. Carotid stenosis leading to ischaemic stroke is most common in men older than 70 years. Ischaemic stroke is a worldwide public health problem. OBJECTIVES To assess the effects of pharmacological interventions for the treatment of asymptomatic carotid stenosis in preventing neurological impairment, ipsilateral major or disabling stroke, death, major bleeding, and other outcomes. SEARCH METHODS We searched the Cochrane Stroke Group trials register, CENTRAL, MEDLINE, Embase, two other databases, and three trials registers from their inception to 9 August 2022. We also checked the reference lists of any relevant systematic reviews identified and contacted specialists in the field for additional references to trials. SELECTION CRITERIA We included all randomised controlled trials (RCTs), irrespective of publication status and language, comparing a pharmacological intervention to placebo, no treatment, or another pharmacological intervention for asymptomatic carotid stenosis. DATA COLLECTION AND ANALYSIS We used standard Cochrane methodological procedures. Two review authors independently extracted the data and assessed the risk of bias of the trials. A third author resolved disagreements when necessary. We assessed the evidence certainty for key outcomes using GRADE. MAIN RESULTS We included 34 RCTs with 11,571 participants. Data for meta-analysis were available from only 22 studies with 6887 participants. The mean follow-up period was 2.5 years. None of the 34 included studies assessed neurological impairment and quality of life. Antiplatelet agent (acetylsalicylic acid) versus placebo Acetylsalicylic acid (1 study, 372 participants) may result in little to no difference in ipsilateral major or disabling stroke (risk ratio (RR) 1.08, 95% confidence interval (CI) 0.47 to 2.47), stroke-related mortality (RR 1.40, 95% CI 0.54 to 3.59), progression of carotid stenosis (RR 1.16, 95% CI 0.79 to 1.71), and adverse events (RR 0.81, 95% CI 0.41 to 1.59), compared to placebo (all low-certainty evidence). The effect of acetylsalicylic acid on major bleeding is very uncertain (RR 0.98, 95% CI 0.06 to 15.53; very low-certainty evidence). The study did not measure neurological impairment or quality of life. Antihypertensive agents (metoprolol and chlorthalidone) versus placebo The antihypertensive agent, metoprolol, may result in no difference in ipsilateral major or disabling stroke (RR 0.14, 95% CI 0.02 to1.16; 1 study, 793 participants) and stroke-related mortality (RR 0.57, 95% CI 0.17 to 1.94; 1 study, 793 participants) compared to placebo (both low-certainty evidence). However, chlorthalidone may slow the progression of carotid stenosis (RR 0.45, 95% CI 0.23 to 0.91; 1 study, 129 participants; low-certainty evidence) compared to placebo. Neither study measured neurological impairment, major bleeding, adverse events, or quality of life. Anticoagulant agent (warfarin) versus placebo The evidence is very uncertain about the effects of warfarin (1 study, 919 participants) on major bleeding (RR 1.19, 95% CI 0.97 to 1.46; very low-certainty evidence), but it may reduce adverse events (RR 0.89, 95% CI 0.81 to 0.99; low-certainty evidence) compared to placebo. The study did not measure neurological impairment, ipsilateral major or disabling stroke, stroke-related mortality, progression of carotid stenosis, or quality of life. Lipid-lowering agents (atorvastatin, fluvastatin, lovastatin, pravastatin, probucol, and rosuvastatin) versus placebo or no treatment Lipid-lowering agents may result in little to no difference in ipsilateral major or disabling stroke (atorvastatin, lovastatin, pravastatin, and rosuvastatin; RR 0.36, 95% CI 0.09 to 1.53; 5 studies, 2235 participants) stroke-related mortality (lovastatin and pravastatin; RR 0.25, 95% CI 0.03 to 2.29; 2 studies, 1366 participants), and adverse events (fluvastatin, lovastatin, pravastatin, probucol, and rosuvastatin; RR 0.76, 95% CI 0.53 to1.10; 7 studies, 3726 participants) compared to placebo or no treatment (all low-certainty evidence). The studies did not measure neurological impairment, major bleeding, progression of carotid stenosis, or quality of life. AUTHORS' CONCLUSIONS Although there is no high-certainty evidence to support pharmacological intervention, this does not mean that pharmacological treatments are ineffective in preventing ischaemic cerebral events, morbidity, and mortality. High-quality RCTs are needed to better inform the best medical treatment that may reduce the burden of carotid stenosis. In the interim, clinicians will have to use other sources of information.
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Affiliation(s)
- Caroline Nb Clezar
- Department of Surgery, Division of Vascular and Endovascular Surgery, Universidade Federal de São Paulo, São Paulo, Brazil
| | - Carolina Dq Flumignan
- Department of Surgery, Division of Vascular and Endovascular Surgery, Universidade Federal de São Paulo, São Paulo, Brazil
| | - Nicolle Cassola
- Department of Surgery, Division of Vascular and Endovascular Surgery, Universidade Federal de São Paulo, São Paulo, Brazil
| | - Luis Cu Nakano
- Department of Surgery, Division of Vascular and Endovascular Surgery, Universidade Federal de São Paulo, São Paulo, Brazil
| | - Virginia Fm Trevisani
- Medicina de Urgência and Rheumatology, Escola Paulista de Medicina, Universidade Federal de São Paulo and Universidade de Santo Amaro, São Paulo, Brazil
| | - Ronald Lg Flumignan
- Department of Surgery, Division of Vascular and Endovascular Surgery, Universidade Federal de São Paulo, São Paulo, Brazil
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Pini R, Gallitto E, Fronterrè S, Rocchi C, Lodato M, Shyti B, Faggioli G, Gargiulo M. Diagnosis and management of acute conditions of the extracranial carotid artery. Semin Vasc Surg 2023; 36:130-138. [PMID: 37330227 DOI: 10.1053/j.semvascsurg.2023.04.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2023] [Revised: 04/01/2023] [Accepted: 04/04/2023] [Indexed: 06/19/2023]
Abstract
Symptomatic carotid stenosis and carotid dissection are acute conditions of extracranial cerebrovascular vessels determining transient ischemic attack or stroke. Medical, surgical, or endovascular management are different options to treat these pathologies. This narrative review focused on the management, from symptoms to treatment, of the acute conditions of extracranial cerebrovascular vessels, including post-carotid revascularization stroke. Symptomatic carotid stenosis (> 50% according to North American Symptomatic Carotid Endarterectomy Trial criteria) with transient ischemic attack or stroke benefits from carotid revascularization-primarily with carotid endarterectomy associated with medical therapy-within 2 weeks from symptom onset to reduce the risk of stroke recurrence. Different from acute extracranial carotid dissection, medical management with antiplatelet or anticoagulant therapy can prevent new neurologic ischemic events, considering stenting only in case of symptom recurrence. Stroke after carotid revascularization can be associated with the following etiologies: carotid manipulation, plaque fragmentation, or clamping ischemia. Medical or surgical management is therefore influenced by the cause and timing of the neurologic events after carotid revascularization. Acute conditions of the extracranial cerebrovascular vessels include a heterogeneous group of pathologies and correct management can reduce symptom recurrence substantially.
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Affiliation(s)
- Rodolfo Pini
- Vascular Surgery Unit, Istituto di Ricovero e Cura a Carattere Scientifico University Hospital Policlinico S. Orsola, Via Massarenti 9, Bologna, 40138, Bologna, Italy.
| | - Enrico Gallitto
- Vascular Surgery Unit, Istituto di Ricovero e Cura a Carattere Scientifico University Hospital Policlinico S. Orsola, Via Massarenti 9, Bologna, 40138, Bologna, Italy; Vascular Surgery, University of Bologna, Il Dipartimento di Scienze Mediche e Chirurgiche, Bologna, Italy
| | - Sara Fronterrè
- Vascular Surgery, University of Bologna, Il Dipartimento di Scienze Mediche e Chirurgiche, Bologna, Italy
| | - Cristina Rocchi
- Vascular Surgery, University of Bologna, Il Dipartimento di Scienze Mediche e Chirurgiche, Bologna, Italy
| | - Marcello Lodato
- Vascular Surgery, University of Bologna, Il Dipartimento di Scienze Mediche e Chirurgiche, Bologna, Italy
| | - Betti Shyti
- Vascular Surgery, University of Bologna, Il Dipartimento di Scienze Mediche e Chirurgiche, Bologna, Italy
| | - Gianluca Faggioli
- Vascular Surgery Unit, Istituto di Ricovero e Cura a Carattere Scientifico University Hospital Policlinico S. Orsola, Via Massarenti 9, Bologna, 40138, Bologna, Italy; Vascular Surgery, University of Bologna, Il Dipartimento di Scienze Mediche e Chirurgiche, Bologna, Italy
| | - Mauro Gargiulo
- Vascular Surgery Unit, Istituto di Ricovero e Cura a Carattere Scientifico University Hospital Policlinico S. Orsola, Via Massarenti 9, Bologna, 40138, Bologna, Italy; Vascular Surgery, University of Bologna, Il Dipartimento di Scienze Mediche e Chirurgiche, Bologna, Italy
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11
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Calo P, Oberhuber A, Görtz H. Patient Selection Criteria and Procedural Standardization for Carotid Artery Stenting-A Single Center Experience. J Clin Med 2023; 12:jcm12103534. [PMID: 37240640 DOI: 10.3390/jcm12103534] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2023] [Revised: 04/26/2023] [Accepted: 05/16/2023] [Indexed: 05/28/2023] Open
Abstract
The gold standard for the treatment of carotid artery stenosis is the carotid endarterectomy (CEA). According to current guidelines, carotid artery stenting (CAS) is an alternative. Randomized control trials (RCTs) show significantly higher rates of peri-interventional strokes after CAS compared to CEA. However, these trials were usually characterized by a great heterogeneity in the CAS procedure. In this retrospective analysis from 2012 to 2020, 202 symptomatic and asymptomatic patients were treated with CAS. Patients were carefully pre-selected according to anatomical and clinical criteria. In all cases, the same steps and material were used. All interventions were performed by five experienced vascular surgeons. Primary endpoints of this study were perioperative death and stroke. Asymptomatic carotid stenosis was present in 77% of the patients and symptomatic in 23%. The mean age was 66 years. The average degree of stenosis was 81%. The CAS technical success rate was 100%. Periprocedural complications occurred in 1.5% of cases, including one major stroke (0.5%) and two minor strokes (1%). The results of this study indicate that through a strict patient selection based on anatomical and clinical criteria, CAS can be performed with very low complication rates. Furthermore, standardization of the materials and the procedure itself is crucial.
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Affiliation(s)
- Paolo Calo
- Department of Vascular Surgery, Bonifatius Hospital Lingen, 49808 Lingen, Germany
| | - Alexander Oberhuber
- Department of Vascular and Endovascular Surgery, University Hospital Muenster, 48149 Muenster, Germany
| | - Hartmut Görtz
- Department of Vascular Surgery, Bonifatius Hospital Lingen, 49808 Lingen, Germany
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12
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Haywood NS, Ratcliffe SJ, Zheng X, Mao J, Farivar BS, Tracci MC, Malas MB, Goodney PP, Clouse WD. Operative and long-term outcomes of combined and staged carotid endarterectomy and coronary bypass. J Vasc Surg 2023; 77:1424-1433.e1. [PMID: 36681256 PMCID: PMC10353412 DOI: 10.1016/j.jvs.2023.01.015] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2022] [Revised: 12/31/2022] [Accepted: 01/10/2023] [Indexed: 01/19/2023]
Abstract
OBJECTIVE Optimal temporal surgical management of significant carotid stenosis and coronary artery disease remains unknown. Carotid endarterectomy (CEA) and coronary artery bypass (CABG) are performed concurrently (CCAB) or in a staged (CEA-CABG or CABG-CEA) approach. Using the Vascular Quality Initiative-Vascular Implant Surveillance and Interventional Outcomes Coordinated Registry Network-Medicare-linked dataset, this study compared operative and long-term outcomes after CCAB and staged approaches. METHODS The Vascular Quality Initiative-Vascular Implant Surveillance and Interventional Outcomes Coordinated Registry Network dataset was used to identify CEAs from 2011 to 2018 with combined CABG or CABG within 45 days preceding or after CEA. Patients were stratified based on concurrent or staged approach. Primary outcomes were stroke, myocardial infarction (MI), all-cause mortality, stroke and death as composite (SD) and all as composite within 30 days from the last procedure as well as in the long term. Univariate analysis and risk-adjusted analysis using inverse propensity weighting were performed. Kaplan-Meier curves of stroke, MI, and death were created and compared. RESULTS There were 1058 patients included: 643 CCAB and 415 staged (309 CEA-CABG and 106 CABG-CEA). Compared with staged patients, those undergoing CCAB had a higher preoperative rate of congestive heart failure (24.8% vs 18.4%; P = .01) and decreased renal function (14.9% vs 8.5%; P < .01), as well as fewer prior neurological events (23.5% vs 31.4%; P < .01). Patients undergoing CCAB had similar weighted rate of 30-day stroke (4.6% vs 4.1%; P = .72), death (7.0% vs 5.0%; P = .32), and composite outcomes (stroke and death, 9.8% vs 8.5%; P = .56; stroke, death, and MI, 14.7% vs 17.4%; P = .31), but a lower weighted rate of MI (5.5% vs 11.5%; P < .01) vs the staged cohort. Long-term adjusted risks of stroke (hazard ratio [HR], 0.85; 95% confidence interval [CI], 0.54-1.36; P = .51) and mortality (HR, 1.02; 95% CI, 0.76-1.36; P=.91) were similar between groups, but higher risk of MI long-term was seen in those staged (HR, 1.49; 95% CI, 1.07-2.08; P = .02). CONCLUSIONS In patients undergoing CCAB or staged open revascularization for carotid stenosis and coronary artery disease, the staged approach had an increased risk of postoperative cardiac event, but the short- and long-term rates of stroke and mortality seem to be comparable. Adverse cardiovascular event risk is high between operations when staged and should be a consideration when selecting an approach. Although factors leading to staged sequencing performance need further clarity, CCAB seems to be safe and should be considered an equally reasonable option.
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Affiliation(s)
- Nathan S Haywood
- Department of Vascular and Endovascular Surgery, University of Virginia, Charlottesville, VA
| | - Sarah J Ratcliffe
- Department of Biostatistics, University of Virginia, Charlottesville, VA
| | - Xinyan Zheng
- Population Health Sciences, Weill Cornell Medicine, New York, NY
| | - Jialin Mao
- Population Health Sciences, Weill Cornell Medicine, New York, NY
| | - Behzad S Farivar
- Department of Vascular and Endovascular Surgery, University of Virginia, Charlottesville, VA
| | - Margaret C Tracci
- Department of Vascular and Endovascular Surgery, University of Virginia, Charlottesville, VA
| | - Mahmoud B Malas
- Department of Vascular and Endovascular Surgery, University of California San Diego, San Diego, CA
| | - Philip P Goodney
- Department of Vascular and Endovascular Surgery, Dartmouth-Hitchcock Medical Center, Lebanon, NH
| | - W Darrin Clouse
- Department of Vascular and Endovascular Surgery, University of Virginia, Charlottesville, VA.
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13
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Şimsek Z, Alizade E, Abdurahmanova İ, Güner A, Zehir R, Pala S. Serum sortilin as a predictor of stroke in patients with intermediate carotid artery stenosis. Vascular 2023; 31:317-324. [PMID: 35403511 DOI: 10.1177/17085381211067051] [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: 11/15/2022]
Abstract
BACKGROUND Sortilin was an important molecular protein involved in the pathogenesis of atherosclerosis. Besides, serum sortilin was associated with adverse cerebrovascular events. Atherosclerotic stenosis in the carotid artery is a major etiology for ischemic stroke. The risk of stroke in patients with intermediate carotid artery stenosis (CAS) was unknown. Hence, the aim of the present study was to evaluate the relationship between serum sortilin levels and stroke in patients with intermediate CAS. METHODS A total of 195 intermediate CAS patients were included in this cross-sectional study. The patients were divided into two groups as symptomatic (N = 95) and asymptomatic (N = 100) patients. Patients with a transient ischemic attack (TIA), retinal ischemic event, or ischemic stroke resulting from the narrowed carotid artery were considered to be symptomatic. Serum sortilin concentrations were measured using the enzyme-linked immunosorbent assay. RESULTS Serum sortilin level was significantly higher in the symptomatic group than in the severe asymptomatic group (1.53 ± 0.25 ng/mL vs 1.34 ± 0.19 ng/mL, p < 0.001). Besides, high serum sortilin levels (odds ratio = 4.91, 95% confidence intervals 1.24-19.51, p = 0.023) were identified as independent predictors of symptomatic carotid plaque. In the receiver operating characteristic curve analysis, serum sortilin levels higher than 1.34 ng/mL predicted stroke/TIA with a sensitivity of 66.3% and a specificity of 67% (AUC = 0.725, p < 0.001). CONCLUSIONS Serum sortilin level is increased in the presence of symptomatic intermediate CAS and may have clinical value in the management of patients with carotid artery disease.
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Affiliation(s)
- Zeki Şimsek
- Cardiology Department, 111350Kartal Kosuyolu Heart Research and Training Hospital, Istanbul, Turkey
| | - Elnur Alizade
- Cardiology Department, 111350Kartal Kosuyolu Heart Research and Training Hospital, Istanbul, Turkey
| | - İlahe Abdurahmanova
- Department of Cardiology, Ministry of Emergency Situation of the Republic of Azerbaijan, Baku, Azerbaijan
| | - Ahmet Güner
- Department of Cardiology, 187456Mehmet Akif Ersoy Thoracic and Cardiovascular Surgery Training and Research Hospital, Istanbul, Turkey
| | - Regayip Zehir
- Cardiology Department, 111350Kartal Kosuyolu Heart Research and Training Hospital, Istanbul, Turkey
| | - Selçuk Pala
- Cardiology Department, 111350Kartal Kosuyolu Heart Research and Training Hospital, Istanbul, Turkey
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14
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Erben Y, Brott TG. The Challenge of Preventing Carotid Artery Stroke in Properly Medically Managed Patients: Lessons From SPACE-2. J Vasc Surg 2023; 77:1575-1577. [PMID: 36893947 DOI: 10.1016/j.jvs.2023.02.018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2023] [Accepted: 02/23/2023] [Indexed: 03/09/2023]
Affiliation(s)
- Young Erben
- Division of Vascular and Endovascular Surgery, Mayo Clinic, Jacksonville, FL.
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15
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Pizzarelli G, Gennai S, Leone N, Covic T, Moratto R, Silingardi R. Transcranial Doppler detects micro emboli in patients with asymptomatic carotid stenoses undergoing endarterectomy. J Vasc Surg 2023; 77:811-817.e2. [PMID: 36243263 DOI: 10.1016/j.jvs.2022.10.003] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2022] [Revised: 09/28/2022] [Accepted: 10/03/2022] [Indexed: 11/06/2022]
Abstract
OBJECTIVE The objective of this study was to assess the primary endpoint defined as the detection of micro-embolic signals (MES) by the use of transcranial Doppler (TCD) in patients with asymptomatic carotid stenosis (≥70%) scheduled for carotid endarterectomy. The secondary endpoint consisted of testing the association of MES with stenosis severity, histopathological, and ultrasound characteristics. METHODS This was a single-center, single-arm, prospective, observational trial. Computed tomography angiography and ultrasound assessment (Geroulakos classification) were mandatory as well as being under best medical therapy. MES number and characteristics were investigated in Holter mode TCD-X device with a standard 1.5 MHz probe. The time points of evaluation were: 24 hours preoperative, 24 hours postoperative, and 30 days postoperative. The histopathological analysis was performed according to the modified American Heart Association classification. One-way analysis of variance tested MES differences over time. Univariable and multivariable logistic regression tested variables potentially associated with MES. RESULTS A total of 120 patients demonstrated a significant reduction of the mean number of MES (3.35 ± 10.04 and 0.82 ± 2.39; pre- and post-carotid endarterectomy, respectively), becoming undetectable at 30 days (P = .001). Hypoechogenic plaques assessed by ultrasound were a significant risk factor for MES (P = .001). The features of plaque vulnerability, such as hemorrhagic component (P = .011), neovascularization (P = .025), signs of inflammation (P = .027), and rupture of the fibrous cap (P = .002) were predictors of MES. Cap rupture was the only predictor in the multivariate analysis (odds ratio, 5.98; P = .030). The stenosis severity was not associated with MES (P = .95) CONCLUSIONS: Patients under best medical therapy had a preoperative embolic activity becoming no more detectable after surgery. Both ultrasound and histologic markers of vulnerability were predictors of MES, and stenosis severity was not associated. TCD gives better insight into the real embolic risk, and future studies should evaluate clinical results coming from its implementation with standard imaging techniques. CLINICALTRIAL gov registration number NCT05134493.
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Affiliation(s)
- Ginevra Pizzarelli
- Department of Vascular Surgery, Ospedale Civile di Baggiovara, Azienda Ospedaliero-Universitaria di Modena, University of Modena and Reggio Emilia, Modena, Italy
| | - Stefano Gennai
- Department of Vascular Surgery, Ospedale Civile di Baggiovara, Azienda Ospedaliero-Universitaria di Modena, University of Modena and Reggio Emilia, Modena, Italy
| | - Nicola Leone
- Department of Vascular Surgery, Ospedale Civile di Baggiovara, Azienda Ospedaliero-Universitaria di Modena, University of Modena and Reggio Emilia, Modena, Italy.
| | - Tea Covic
- Department of Vascular Surgery, Ospedale Civile di Baggiovara, Azienda Ospedaliero-Universitaria di Modena, University of Modena and Reggio Emilia, Modena, Italy
| | - Roberto Moratto
- Department of Vascular Surgery, Ospedale Civile di Baggiovara, Azienda Ospedaliero-Universitaria di Modena, University of Modena and Reggio Emilia, Modena, Italy
| | - Roberto Silingardi
- Department of Vascular Surgery, Ospedale Civile di Baggiovara, Azienda Ospedaliero-Universitaria di Modena, University of Modena and Reggio Emilia, Modena, Italy
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16
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Kallmayer MA, Knappich C, Karlas A, Trenner M, Kuehnl A, Eckstein HH. External Validity of Randomised Controlled Trials on Carotid Revascularisation: Trial Populations May Not Always Reflect Patients in Clinical Practice. Eur J Vasc Endovasc Surg 2022; 64:452-460. [PMID: 35987505 DOI: 10.1016/j.ejvs.2022.07.044] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2021] [Revised: 06/26/2022] [Accepted: 07/26/2022] [Indexed: 01/12/2023]
Abstract
OBJECTIVE The external validity of randomised controlled trials (RCTs) and their transferability to clinical practice is under investigated. This study aimed to analyse the exclusion criteria of recent carotid RCTs comparing carotid endarterectomy (CEA) and carotid artery stenting, and to assess the eligibility of consecutive clinical practice cohorts to those RCTs. METHODS An analysis of the clinical and anatomical exclusion criteria of RCTs for asymptomatic (SPACE-2, ACST-2, CREST-1, and CREST-2) and symptomatic carotid stenosis (SPACE-1, CREST-1, ICSS, and EVA-3S) was performed. Two hundred consecutive asymptomatic and 200 consecutive symptomatic patients, treated by CEA, or transfemoral or transcarotid artery stenting at a tertiary referral university centre were assessed for their potential eligibility for each corresponding RCT. RCT patient data were pooled and differences from the clinical practice cohort analysed. Statistics were descriptive and comparative using Fisher's exact and t tests. RESULTS The number of clinical and anatomical exclusion criteria differed widely between RCTs. Potential eligibility rates of the clinical practice cohort for RCTs with regard to asymptomatic carotid stenosis were 80.5% (ACST-2), 79.5% (SPACE-2), 47% (CREST-1), and 20% (CREST-2). For RCTs on symptomatic carotid stenosis the eligibility rates were 89% (ICSS), 86.5% (EVA-3S), 64% (SPACE-1), and 39% (CREST-1). Both clinical practice cohorts were older by about three years and patients were more often male vs. the RCTs. Furthermore, a history of smoking (asymptomatic patients), hypertension (symptomatic patients), and atrial fibrillation was diagnosed more often, whereas hypercholesterolaemia and coronary heart disease (asymptomatic patients) were less prevalent. More clinical practice patients were on antiplatelets, anticoagulants, and lipid lowering drugs. Symptomatic clinical practice patients presented more often with retinal ischaemia and less often with minor hemispheric strokes than patients in the RCTs. CONCLUSION The external validity of contemporary carotid RCTs varies considerably. Patients in routine clinical practice differ from RCT populations with respect to age, comorbidities, and medication. These data are of interest for clinicians and guideline authors and may be relevant for the design of future comparative trials.
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Affiliation(s)
- Michael A Kallmayer
- Department for Vascular and Endovascular Surgery, Klinikum rechts der Isar, Technical University of Munich (TUM), Munich, Germany
| | - Christoph Knappich
- Department for Vascular and Endovascular Surgery, Klinikum rechts der Isar, Technical University of Munich (TUM), Munich, Germany
| | - Angelos Karlas
- Department for Vascular and Endovascular Surgery, Klinikum rechts der Isar, Technical University of Munich (TUM), Munich, Germany
| | - Matthias Trenner
- Department for Vascular and Endovascular Surgery, Klinikum rechts der Isar, Technical University of Munich (TUM), Munich, Germany
| | - Andreas Kuehnl
- Department for Vascular and Endovascular Surgery, Klinikum rechts der Isar, Technical University of Munich (TUM), Munich, Germany
| | - Hans-Henning Eckstein
- Department for Vascular and Endovascular Surgery, Klinikum rechts der Isar, Technical University of Munich (TUM), Munich, Germany.
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Prevalence of Symptomatic Nonstenotic Carotid Disease Using Simultaneous Non-Contrast Angiography and Intraplaque Hemorrhage Imaging for MR Screen Protocol. Diagnostics (Basel) 2022; 12:diagnostics12102321. [PMID: 36292010 PMCID: PMC9600452 DOI: 10.3390/diagnostics12102321] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2022] [Revised: 09/20/2022] [Accepted: 09/21/2022] [Indexed: 11/26/2022] Open
Abstract
Background: To determine the prevalence of symptomatic nonstenotic carotid disease (SyNC) using simultaneous non-contrast angiography and intraplaque hemorrhage (SNAP) imaging for patients with acute stroke as an MR screen protocol and to assess imaging findings of carotid plaques. Patients and Methods: From May 2020 to October 2021, 2459 patients with suspected acute neurological symptoms were evaluated with brain diffusion-weighted imaging (DWI) and carotid SNAP imaging. We analyzed the degree of stenosis and intraplaque hemorrhage (IPH) using SNAP imaging. Prevalence of SyNC and risk factors for stroke in patients with SyNC were determined. We performed subgroup multivariate analysis between SyNC and other etiologies of stroke (non-SyNC). Results: Of 4608 carotid arteries in 2304 patients enrolled in this study, 454 (9.9%) plaques (both lesions in 128 patients) were found on SNAP imaging. Of these plaques, 353 (77.8%) showed stenosis of <50%. Of plaques with <50% stenosis, 47 (13.3%) patients had a territorial acute focal infarction. Seventeen (36.2%) were classified with embolic stroke of undetermined source (ESUS) and SyNC. High maximal wall thickness and carotid IPH were identified as influencing factors for SyNC. Conclusion: For patients with <50% stenosis and territorial infarction, SyNC is a relatively important source of stroke. Especially, high maximal wall thickness and carotid IPH are important risk factors for SyNC.
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Abstract
Transcarotid artery revascularization (TCAR) is a novel carotid stenting method that avoids the manipulation of the aortic arch and uses a flow-reversal neuroprotection system that effectively reduces the risk of embolic events during carotid intervention. Studies have shown a lower risk of stroke or death compared with the transfemoral carotid stenting approach, and an equivalent risk of stroke or death compared with traditional carotid endarterectomy. TCAR has added benefits of lower risk of myocardial infarction, cranial nerve injuries, and shorter operative times compared with endarterectomy. TCAR has become widely adopted by vascular surgeons in the United States for the treatment of patients with high-risk medical comorbidities and those with challenging surgical anatomy.
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Affiliation(s)
- Patric Liang
- Beth Israel Deaconess Medical Center, Division of Vascular and Endovascular Surgery, Harvard Medical School, 110 Francis Street, Suite 5B, Boston, MA 02215, USA
| | - Marc L Schermerhorn
- Beth Israel Deaconess Medical Center, Division of Vascular and Endovascular Surgery, Harvard Medical School, 110 Francis Street, Suite 5B, Boston, MA 02215, USA.
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19
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Gao J, Li W, Zhu J, Liu Y, Tian H. Ultrasound Evaluation of Subclavian Artery and Internal Thoracic Artery Before Coronary Artery Bypass Grafting as Part of Preoperative Vascular Assessment. Acad Radiol 2022; 30:911-918. [PMID: 35820976 DOI: 10.1016/j.acra.2022.06.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2022] [Revised: 06/04/2022] [Accepted: 06/13/2022] [Indexed: 11/01/2022]
Abstract
RATIONALE AND OBJECTIVES Noninvasive diagnostic imaging of subclavian artery (SCA) and internal thoracic artery (ITA) is crucial to the patients planning to use ITA for coronary artery bypass grafting (CABG). The guidelines have not yet provided guidance on screening high-risk groups. The present study aimed to evaluate the contribution of ultrasonography in the assessment of SCA and ITA, especially for the patients referred for CABG who planned to use ITA graft. MATERIALS AND METHODS Patients diagnosed with multivessel coronary heart disease were enrolled and some of them planned CABG. Bilateral SCAs and ITAs were routinely evaluated by color Doppler ultrasound (CDUS) before operation. The luminal diameter and the peak systolic velocity of the proximal and distal parts of SCA and ITA were measured. Depending on the Doppler waveform, the lumen narrowing rate was calculated. RESULTS The final analysis was carried out in 572 patients. Thirty-five patients had moderate (50%-69%), severe (70%-99%) stenosis or occlusion in the SCA (left-sided in 21 and right-sided in 14). One patient had severe proximal stenosis in left ITA and one patient had no flow in left ITA due to the occlusion in left SCA. One patient had anatomic variation of isolated right aortic arch with aberrant left SCA. All of those cases were confirmed with multidetector computed tomography angiography. CONCLUSION CDUS could be used for the evaluation of SCA and ITA before CABG as part of presurgical vascular assessment and provide an import basis for the imaging diagnosis and surgical plan.
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Affiliation(s)
- Junxue Gao
- Department of Ultrasound, Peking University People's Hospital, No.11 Xizhimen South Street, Beijing 100044, China
| | - Wenxue Li
- Department of Ultrasound, Peking University People's Hospital, No.11 Xizhimen South Street, Beijing 100044, China
| | - Jiaan Zhu
- Department of Ultrasound, Peking University People's Hospital, No.11 Xizhimen South Street, Beijing 100044, China.
| | - Yuejie Liu
- Department of Ultrasound, Peking University People's Hospital, No.11 Xizhimen South Street, Beijing 100044, China
| | - Hui Tian
- Department of Ultrasound, Peking University People's Hospital, No.11 Xizhimen South Street, Beijing 100044, China
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20
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Bhattacharya R, Zekavat SM, Haessler J, Fornage M, Raffield L, Uddin MM, Bick AG, Niroula A, Yu B, Gibson C, Griffin G, Morrison AC, Psaty BM, Longstreth WT, Bis JC, Rich SS, Rotter JI, Tracy RP, Correa A, Seshadri S, Johnson A, Collins MPH JM, Hayden KM, Madsen TE, Ballantyne CM, Jaiswal S, Ebert BL, Kooperberg C, Manson JE, Whitsel EA, Natarajan P, Reiner AP. Clonal Hematopoiesis Is Associated With Higher Risk of Stroke. Stroke 2022; 53:788-797. [PMID: 34743536 PMCID: PMC8885769 DOI: 10.1161/strokeaha.121.037388] [Citation(s) in RCA: 69] [Impact Index Per Article: 34.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2021] [Accepted: 10/25/2021] [Indexed: 12/28/2022]
Abstract
BACKGROUND AND PURPOSE Clonal hematopoiesis of indeterminate potential (CHIP) is a novel age-related risk factor for cardiovascular disease-related morbidity and mortality. The association of CHIP with risk of incident ischemic stroke was reported previously in an exploratory analysis including a small number of incident stroke cases without replication and lack of stroke subphenotyping. The purpose of this study was to discover whether CHIP is a risk factor for ischemic or hemorrhagic stroke. METHODS We utilized plasma genome sequence data of blood DNA to identify CHIP in 78 752 individuals from 8 prospective cohorts and biobanks. We then assessed the association of CHIP and commonly mutated individual CHIP driver genes (DNMT3A, TET2, and ASXL1) with any stroke, ischemic stroke, and hemorrhagic stroke. RESULTS CHIP was associated with an increased risk of total stroke (hazard ratio, 1.14 [95% CI, 1.03-1.27]; P=0.01) after adjustment for age, sex, and race. We observed associations with CHIP with risk of hemorrhagic stroke (hazard ratio, 1.24 [95% CI, 1.01-1.51]; P=0.04) and with small vessel ischemic stroke subtypes. In gene-specific association results, TET2 showed the strongest association with total stroke and ischemic stroke, whereas DMNT3A and TET2 were each associated with increased risk of hemorrhagic stroke. CONCLUSIONS CHIP is associated with an increased risk of stroke, particularly with hemorrhagic and small vessel ischemic stroke. Future studies clarifying the relationship between CHIP and subtypes of stroke are needed.
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Affiliation(s)
- Romit Bhattacharya
- Cardiovascular Research Center, Massachusetts General Hospital, Boston, MA
- Program in Medical and Population Genetics and the Cardiovascular Disease Initiative, Broad Institute of Harvard and MIT, Cambridge, MA
- Department of Medicine, Harvard Medical School, Boston, MA
| | - Seyedeh M. Zekavat
- Cardiovascular Research Center, Massachusetts General Hospital, Boston, MA
- Program in Medical and Population Genetics and the Cardiovascular Disease Initiative, Broad Institute of Harvard and MIT, Cambridge, MA
- Yale School of Medicine, New Haven, CT
| | - Jeffrey Haessler
- Division of Public Health Sciences, Fred Hutchinson Cancer Research Center, Seattle, WA
| | - Myriam Fornage
- Brown Foundation Institute of Molecular Medicine, McGovern Medical School, The University of Texas Health Science Center at Houston, Houston, TX
- Human Genetics Center, Department of Epidemiology, Human Genetics, and Environmental Sciences, School of Public Health, The University of Texas Health Science Center at Houston, Houston, Texas, USA
| | - Laura Raffield
- Department of Genetics, University of North Carolina at Chapel Hill, Chapel Hill, NC
| | - Md Mesbah Uddin
- Cardiovascular Research Center, Massachusetts General Hospital, Boston, MA
- Program in Medical and Population Genetics and the Cardiovascular Disease Initiative, Broad Institute of Harvard and MIT, Cambridge, MA
| | - Alexander G. Bick
- Division of Genetic Medicine, Department of Medicine, Vanderbilt University Medical Center, Nashville, TN
| | - Abhishek Niroula
- Program in Medical and Population Genetics and the Cardiovascular Disease Initiative, Broad Institute of Harvard and MIT, Cambridge, MA
- Department of Laboratory Medicine, Lund University, Lund, Sweden
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, MA
| | - Bing Yu
- Human Genetics Center, Department of Epidemiology, Human Genetics, and Environmental Sciences, School of Public Health, The University of Texas Health Science Center at Houston, Houston, Texas, USA
| | - Christopher Gibson
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, MA
| | - Gabriel Griffin
- Department of Pathology, Brigham and Women’s Hospital, Boston, MA
- Epigenomics Program, Broad Institute of MIT and Harvard, Cambridge, MA
| | - Alanna C. Morrison
- Human Genetics Center, Department of Epidemiology, Human Genetics, and Environmental Sciences, School of Public Health, The University of Texas Health Science Center at Houston, Houston, Texas, USA
| | - Bruce M. Psaty
- Cardiovascular Health Research Unit, Departments of Medicine, Epidemiology, and Health Services, University of Washington, Seattle, WA
| | | | - Joshua C. Bis
- Cardiovascular Health Research Unit, Department of Medicine, University of Washington, Seattle, WA
| | - Stephen S. Rich
- Center for Public Health Genomics, University of Virginia, Charlottesville, VA
| | - Jerome I. Rotter
- The Institute for Translational Genomics and Population Sciences, Department of Pediatrics, The Lundquist Institute at Harbor-UCLA Medical Center, Torrance, CA USA
| | - Russell P. Tracy
- Department of Pathology and Laboratory Medicine, University of Vermont College of Medicine, Burlington
| | - Adolfo Correa
- Jackson Heart Study, University of Mississippi Medical Center, Jackson, MS, USA
| | - Sudha Seshadri
- Glenn Biggs Institute for Alzheimer’s & Neurodegenerative Diseases, University of Texas Health Sciences Center, San Antonio, TX 78229
- Boston University and the NHLBI’s Framingham Heart Study, Boston, MA, 02215, USA
- Department of Neurology, Boston University School of Medicine, Boston, MA, 02118, USA
| | - Andrew Johnson
- Boston University and the NHLBI’s Framingham Heart Study, Boston, MA, 02215, USA
- Population Sciences Branch, Division of Intramural Research, National Heart, Lung and Blood Institute, Framingham, MA 01702
| | - Jason M. Collins MPH
- Department of Epidemiology, University of North Carolina, Gillings School of Global Public Health, Chapel Hill, NC
| | - Kathleen M. Hayden
- Department of Social Sciences and Health Policy, Wake Forest School of Medicine, Winston-Salem, NC, USA
| | - Tracy E. Madsen
- Departments of Emergency Medicine and Epidemiology, Brown University
| | | | - Siddhartha Jaiswal
- Department of Pathology, Stanford University School of Medicine, Stanford, CA
| | - Benjamin L. Ebert
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, MA
- Howard Hughes Medical Institute, Boston, MA
| | - Charles Kooperberg
- Division of Public Health Sciences, Fred Hutchinson Cancer Research Center, Seattle, WA
| | - JoAnn E. Manson
- Department of Medicine, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA
| | - Eric A. Whitsel
- Population Sciences Branch, Division of Intramural Research, National Heart, Lung and Blood Institute, Framingham, MA 01702
- Department of Medicine, School of Medicine, University of North Carolina, Chapel Hill, NC
| | | | - Pradeep Natarajan
- Cardiovascular Research Center, Massachusetts General Hospital, Boston, MA
- Program in Medical and Population Genetics and the Cardiovascular Disease Initiative, Broad Institute of Harvard and MIT, Cambridge, MA
- Department of Medicine, Harvard Medical School, Boston, MA
| | - Alexander P. Reiner
- Department of Epidemiology, University of Washington, Seattle, WA 98109, USA
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21
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Ultrasound-guided intermediate cervical plexus block for postoperative analgesia in patients undergoing carotid endarterectomy under general anesthesia: a case-control study. JOURNAL OF CONTEMPORARY MEDICINE 2022. [DOI: 10.16899/jcm.1051240] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
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22
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Nasr B, Crespy V, Penasse E, Gaudry M, Rosset E, Feugier P, Gouëffic Y, Maurel B, Hostalrich A, Alric P, Sadaghianloo N, Settembre N, Chevallier J, Ben Ahmed S, Gouny P, Steinmetz E. Late Outcomes of Carotid Artery Stenting for Radiation Therapy-Induced Carotid Stenosis. J Endovasc Ther 2022; 29:921-928. [PMID: 35012391 DOI: 10.1177/15266028211068757] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
PURPOSE Carotid artery stenting (CAS) appears as a promising alternative treatment to carotid endarterectomy for radiation therapy (RT)-induced carotid stenosis. However, this is based on a poor level of evidence studies (small sample size, primarily single institution reports, few long-term data). The purpose of this study was to report the long-term outcomes of a multicentric series of CAS for RT-induced stenosis. METHODS All CAS for RT-induced stenosis performed in 11 French academic institutions from 2005 to 2017 were collected in this retrospective study. Patient demographics, clinical risk factors, elapsed time from RT, clinical presentation and imaging parameters of carotid stenosis were preoperatively gathered. Long-term outcomes were determined by clinical follow-up and duplex ultrasound. The primary endpoint was the occurrence of cerebrovascular events during follow-up. Secondary endpoints included perioperative morbidity and mortality rate, long-term mortality rate, primary patency, and target lesion revascularization. RESULTS One hundred and twenty-one CAS procedures were performed in 112 patients. The mean interval between irradiation and CAS was 15 ± 12 years. In 31.4% of cases, the lesion was symptomatic. Mean follow-up was 42.5 ± 32.6 months (range 1-141 months). The mortality rate at 5 years was 23%. The neurologic event-free survival and the in-stent restenosis rates at 5 years were 87.8% and 38.9%, respectively. Diabetes mellitus (p=0.02) and single postoperative antiplatelet therapy (p=0.001) were found to be significant predictors of in-stent restenosis. Freedom from target lesion revascularization was 91.9% at 5 years. CONCLUSION This study showed that CAS is an effective option for RT-induced stenosis in patients not favorable to carotid endarterectomy. The CAS was associated with a low rate of neurological events and reinterventions at long-term follow-up.
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Affiliation(s)
- Bahaa Nasr
- CHU Brest, Hôpital Cavale Blanche, Brest, France
| | | | | | | | - Eugenio Rosset
- CHU Clermont-Ferrand, Hôpital Gabriel Montpied, Clermont-Ferrand, France
| | | | - Yann Gouëffic
- Centre Casculaire, Groupe Hospitalier Paris Saint Joseph, Paris, France
| | | | | | - Pierre Alric
- CHU Montpellier, Hôpital Lapeyronie, Montpellier, France
| | | | | | | | | | - Pierre Gouny
- CHU Brest, Hôpital Cavale Blanche, Brest, France
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23
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Gaisenok OV, Rezvaya AA. [A comparative analysis of the clinical and anamnestic status of patients with chronic occlusion of the carotid arteries based on the data of observational registries]. Zh Nevrol Psikhiatr Im S S Korsakova 2022; 122:33-41. [PMID: 36582159 DOI: 10.17116/jnevro202212212233] [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: 12/31/2022]
Abstract
OBJECTIVE To study the clinical and anamnestic status of patients with chronic carotid artery occlusion (CCAO) based on the analysis of risk factors, demographic and clinical and anatomical characteristics, the dynamics of the disease; to evaluate ongoing drug therapy, the incidence of strokes (MI) and deaths (according to the local registry compared with the results of other observational studies). MATERIAL AND METHODS PubMed and eLibrary searches for a systematic review were performed from October 24 to December 10, 2021 independently by two investigators. Out of 870 articles, based on inclusion/exclusion criteria, 8 studies were selected and included in the systematic review. RESULTS A comparative analysis of the clinical and anamnestic status of patients with CCAO according to the present review showed the following data on the prevalence of the main risk factors/diseases: hypertension - 79.1%; male gender - 83.7%; smoking - 46%; diabetes mellitus - 30.5%. Of the entire of own Duplex registry group (n=2548), 7 patients were identified with CCAO (0.27%). All patients were male (mean age 71.3±9.4 years). Endpoints were recorded in 5 of 7 participants during the follow-up period (8.9 years): 5 deaths, 2 fatal MI, 1 non-fatal MI, 1 myocardial infarction. A significant impact of the fact of MI on the survival of patients was confirmed using the standard log-rank test (p=0.02 and the Cox-Mendel test (p=0.04). The incidence of MI during the prospective follow-up according to the analyzed studies ranged from 4.3% (within a month of follow-up) to 42.8% (with a follow-up of 8.9 years), and averaged 12%. CONCLUSIONS A comparative analysis of the clinical and anamnestic status of patients with CCAO based on data from observational registers showed that the probability of detecting this pathology is associated with age and male gender. Data obtained from prospective observation of patients with CCAO in our own study show that the development of MI is one of the main factors affecting the survival of this category of patients.
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Affiliation(s)
- O V Gaisenok
- United Hospital with Outpatient Department of the Administrative Department of the President of the Russian Federation, Moscow, Russia
| | - A A Rezvaya
- Central State Medical Academy of the Administrative Department of the President of the Russian Federation, Moscow, Russia
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24
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Klimontov VV, Koroleva EA, Khapaev RS, Korbut AI, Lykov AP. Carotid Artery Disease in Subjects with Type 2 Diabetes: Risk Factors and Biomarkers. J Clin Med 2021; 11:72. [PMID: 35011813 PMCID: PMC8745306 DOI: 10.3390/jcm11010072] [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: 11/14/2021] [Revised: 12/17/2021] [Accepted: 12/22/2021] [Indexed: 02/07/2023] Open
Abstract
Carotid atherosclerosis (CA) and, especially, carotid artery stenosis (CAS), are associated with a high risk of cardiovascular events in subjects with type 2 diabetes (T2D). In this study, we aimed to identify risk factors and biomarkers of subclinical CA and CAS in T2D individuals. High-resolution ultrasonography of carotid arteries was performed in 389 patients. Ninety-five clinical parameters were evaluated, including diabetic complications and comorbidities; antihyperglycemic, hypolipidemic, and antihypertensive therapy; indices of glycemic control and glucose variability (GV); lipid panels; estimated glomerular filtration rate (eGFR); albuminuria; blood cell count; and coagulation. Additionally, serum levels of calponin-1, relaxin, L-citrulline, and matrix metalloproteinase-2 and -3 (MMP-2, -3) were measured by ELISA. In univariate analysis, older age, male sex, diabetes duration, GV, diabetic retinopathy, chronic kidney disease, coronary artery disease, peripheral artery disease, and MMP-3 were associated with subclinical CA. In addition to these factors, long-term arterial hypertension, high daily insulin doses, eGFR, and L-citrulline were associated with CAS. In multivariate logistic regression, age, male sex, BMI, GV, and eGFR predicted CA independently; male sex, BMI, diabetes duration, eGFR, and L-citrulline were predictors of CAS. These results can be used to develop screening and prevention programs for CA and CAS in T2D subjects.
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Affiliation(s)
- Vadim V. Klimontov
- Research Institute of Clinical and Experimental Lymphology—Branch of the Institute of Cytology and Genetics, Siberian Branch of Russian Academy of Sciences (RICEL—Branch of IC&G SB RAS), 630060 Novosibirsk, Russia; (E.A.K.); (R.S.K.); (A.I.K.); (A.P.L.)
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25
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Abstract
This article focuses on the inpatient evaluation and management of ischemic stroke and transient ischemic attack (TIA). We describe foundational principles including quality metrics, TIA, and stroke as emergencies, TIA/minor stroke management, and standard assessments before discussing tailored evaluation and management strategies by stroke type.
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Affiliation(s)
- Lauren Patrick
- Department of Neurology, Division of Neurovascular, University of California San Francisco, 505 Parnassus Avenue, M-830, San Francisco, CA 94143, USA; Weill Institute for Neuroscience, San Francisco, CA, USA
| | - Cathra Halabi
- Department of Neurology, Division of Neurovascular, University of California San Francisco, 505 Parnassus Avenue, M-830, San Francisco, CA 94143, USA; Weill Institute for Neuroscience, San Francisco, CA, USA.
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26
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Ruka E, Lesur O, Gingras M, Buruian M, Voisine É, Marzouk M, Dagenais F, Voisine P. Relationship Between the Degree of Carotid Stenosis and the Risk of Stroke in Patients Undergoing Cardiac Surgery. Can J Cardiol 2021; 38:347-354. [PMID: 34808321 DOI: 10.1016/j.cjca.2021.11.007] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2020] [Revised: 11/11/2021] [Accepted: 11/12/2021] [Indexed: 11/02/2022] Open
Abstract
BACKGROUND The impact of carotid stenosis (CS) in patients undergoing cardiac surgery remains controversial. The aim of this study was to evaluate the association between carotid stenosis and stroke and/or transient ischemic attack (TIA) in patients undergoing cardiac surgery on cardiopulmonary bypass. METHODS This is a retrospective cohort study including patients undergoing cardiac surgery on cardiopulmonary bypass between January 2006 and March 2018 at the Quebec Heart and Lung Institute. Data of patients' preoperative demographic characteristics, operative and postoperative variables were taken from a computerized database and patients' charts. Univariate and multivariate analyses were performed. RESULTS A total of 20,241 patients were included in the study. Among those who had received preoperative carotid ultrasound, 516 (2.6% of the total population) had unilateral or bilateral CS ≥50%. Categorized levels of carotid stenosis severity were identified as independent risk factors for post-operative stroke and/or transient ischemic attack occurrence. There was an almost three-fold increased risk of post-operative neurologic events in 80-99% CS vs. less severe 50-79% CS [OR 2.91; IC95% (1.30-6.54)] suggesting that the degree of severity of CS is potentially a strong independent predictor of post-operative neurologic events. CONCLUSIONS CS is an independent risk factor of post-operative stroke and/or TIA. This study suggests for the first time that the risk of stroke increases with the degree of severity of CS, with the greatest risk being for CS between 80-99%. The strength of this relationship and potential causality effect should be further explored in a prospective study focusing on this most at risk population.
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Affiliation(s)
- Emmeline Ruka
- Quebec Heart and Lung Institute, Québec, Canada; Faculty of Medicine, University of Sherbrooke, Québec, Canada
| | - Olivier Lesur
- Faculty of Medicine, University of Sherbrooke, Québec, Canada
| | | | | | | | | | - François Dagenais
- Quebec Heart and Lung Institute, Québec, Canada; Faculty of Medicine, Laval University, Québec, Canada
| | - Pierre Voisine
- Quebec Heart and Lung Institute, Québec, Canada; Faculty of Medicine, Laval University, Québec, Canada.
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Yu J, Zhou Y, Yang Q, Liu X, Huang L, Yu P, Chu S. Machine learning models for screening carotid atherosclerosis in asymptomatic adults. Sci Rep 2021; 11:22236. [PMID: 34782634 PMCID: PMC8593081 DOI: 10.1038/s41598-021-01456-3] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2021] [Accepted: 10/25/2021] [Indexed: 11/29/2022] Open
Abstract
Carotid atherosclerosis (CAS) is a risk factor for cardiovascular and cerebrovascular events, but duplex ultrasonography isn’t recommended in routine screening for asymptomatic populations according to medical guidelines. We aim to develop machine learning models to screen CAS in asymptomatic adults. A total of 2732 asymptomatic subjects for routine physical examination in our hospital were included in the study. We developed machine learning models to classify subjects with or without CAS using decision tree, random forest (RF), extreme gradient boosting (XGBoost), support vector machine (SVM) and multilayer perceptron (MLP) with 17 candidate features. The performance of models was assessed on the testing dataset. The model using MLP achieved the highest accuracy (0.748), positive predictive value (0.743), F1 score (0.742), area under receiver operating characteristic curve (AUC) (0.766) and Kappa score (0.445) among all classifiers. It’s followed by models using XGBoost and SVM. In conclusion, the model using MLP is the best one to screen CAS in asymptomatic adults based on the results from routine physical examination, followed by using XGBoost and SVM. Those models may provide an effective and applicable method for physician and primary care doctors to screen asymptomatic CAS without risk factors in general population, and improve risk predictions and preventions of cardiovascular and cerebrovascular events in asymptomatic adults.
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Affiliation(s)
- Jian Yu
- Department of Endocrinology, Affiliated Hospital of Guilin Medical University, Guilin, Guangxi, China
| | - Yan Zhou
- Department of Respiratory and Critical Care Medicine, Affiliated Hospital of Guilin Medical University, Guilin, Guangxi, China.,Laboratory of Respiratory Disease, Affiliated Hospital of Guilin Medical University, Guilin, 541001, Guangxi, China
| | - Qiong Yang
- Department of Endocrinology, Affiliated Hospital of Guilin Medical University, Guilin, Guangxi, China
| | - Xiaoling Liu
- Department of Endocrinology, Affiliated Hospital of Guilin Medical University, Guilin, Guangxi, China
| | - Lili Huang
- Department of Endocrinology, Affiliated Hospital of Guilin Medical University, Guilin, Guangxi, China
| | - Ping Yu
- Department of Endocrinology, Affiliated Hospital of Guilin Medical University, Guilin, Guangxi, China
| | - Shuyuan Chu
- Laboratory of Respiratory Disease, Affiliated Hospital of Guilin Medical University, Guilin, 541001, Guangxi, China.
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28
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Cui CL, Zarrintan S, Marmor RA, Nichols J, Cajas-Monson L, Malas M. Performance of Carotid Revascularization Procedures as Modified by Sex. Ann Vasc Surg 2021; 81:171-182. [PMID: 34752853 DOI: 10.1016/j.avsg.2021.08.051] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2021] [Revised: 08/27/2021] [Accepted: 08/31/2021] [Indexed: 11/25/2022]
Abstract
BACKGROUND Current recommendations on carotid revascularization postulate that women have both increased perioperative risks, such as stroke and death, as well as reduced benefit from intervention. These recommendations do not include data on transcarotid artery revascularization (TCAR). This study strives to compare safety and benefits of TCAR, TFCAS (Transfemoral Carotid Artery Stenting), and CEA (Carotid Endarterectomy) with regard to patient sex. METHODS We performed retrospective analysis of the Society for Vascular Surgery (SVS) Vascular Quality Initiative (VQI) CEA and stenting registries, as well as TCAR Surveillance Project data. We compared outcomes after TCAR, TFCAS, and CEA based on sex. The primary outcome was the rate of in-hospital stroke or death. Secondary outcomes included in-hospital stroke, death, transient ischemic attack (TIA), myocardial infarction (MI), stroke/death/MI, stroke/TIA, and recurrent ipsilateral stroke and/or death at 1-year of follow-up. RESULTS A total of 75,538 patients were included, of which 28,960 (38.3%) were female and 46,578 (61.7%) were male. TFCAS females had more than 2 times higher odds of stroke/death (OR:2.85, 95%CI: 2.21-3.67, P < 0.001) and stroke/death/MI (OR:2.23, 95%CI:1.75-2.83, P < 0.001) when compared to CEA females. Odds of TIA were also higher in both TFCAS females (OR:2.01, 95%CI:1.19-3.42, P = 0.010) and TCAR females (OR:1.91, 95%CI:1.09-3.35, P = .023) when compared to CEA females. However, only TFCAS females experienced increased odds of stroke/TIA (OR:1.96, 95%CI:1.45-2.65, P < 0.001) when compared to CEA females. TFCAS males had almost twice the odds of stroke/death (OR:1.74, 95%CI:1.39-2.16, P < 0.001) and 44% higher odds of stroke/death/MI (OR:1.44, 95%CI:1.19-1.75, P < 0.001), and more than 3-times increased odds of death (OR:3.45, 95%CI:2.53-4.71, P < 0.001) when compared to CEA males. Odds of in-hospital stroke were comparable between TFCAS and CEA after adjusting for covariates. TCAR males have half the odds of MI when compared to CEA males (OR:0.52, 95%CI:0.34-0.80, P = 0.003). At 1-year TCAR had comparable risk of stroke/death while TFCAS had increased risk of stroke/death when compared to CEA among both males and females. CONCLUSION TCAR performed similarly to CEA in both sexes regardless of symptomatic status. Stroke/death and stroke/death/MI rates were similar in symptomatic and asymptomatic males and females treated by CEA or TCAR. The 1-year outcomes of TCAR were also comparable to CEA in both sexes. It seems that TCAR may be a safe alternative to CEA particularly in women when surgical risk prohibits CEA and while TFCAS is associated with substantial adverse outcomes.
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29
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Simsek Z, Alizade E, Güner A, Zehir R. Correlation between serum sortilin levels and severity of extracranial carotid artery stenosis. Int J Clin Pract 2021; 75:e14733. [PMID: 34387924 DOI: 10.1111/ijcp.14733] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/15/2021] [Accepted: 08/10/2021] [Indexed: 12/21/2022] Open
Abstract
OBJECTIVE Atherosclerosis is a chronic inflammatory vascular condition characterised by intimal thickening with cholesterol accumulation and macrophage foam cell infiltration causing plaque formation at the site of the injured vessel wall. This condition is a major contributor to carotid artery stenosis (CAS). Sortilin, a member of the mammalian vacuolar protein sorting 10 protein family, promotes uptake of low-density lipoprotein particles into macrophages with consequent foam cell formation independent of the low-density lipoprotein receptor, and thereby, accelerates atherosclerotic plaque formation and progression. We investigated the correlation between serum sortilin levels and the severity of extracranial CAS. MATERIALS AND METHODS The study included 149 patients who underwent carotid angiography for suspected carotid artery disease. The North American Symptomatic Carotid Endarterectomy Trial 2011 criteria were used to determine the degree of CAS. Serum sortilin concentrations were measured using the enzyme-linked immunosorbent assay. RESULTS Serum sortilin levels were significantly higher in the severe CAS than in the non-severe CAS group (2.71 ± 0.71 ng/mL vs 1.63 ± 0.57 ng/mL, P < .001). Receiver operating characteristic curve analysis showed that serum sortilin levels >1.66 ng/mL predicted severe CAS with sensitivity of 83.49% and specificity of 56.76%. CONCLUSION Current data suggest that prediction of severe CAS may serve as an atherosclerosis biomarker and significantly contribute to research on disease progression in atherosclerosis, as well as in other arterial diseases. Sortilin may be a potential therapeutic target owing to its role in the pathogenesis of atherosclerotic carotid artery disease.
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Affiliation(s)
- Zeki Simsek
- Cardiology Department, Kartal Kosuyolu Heart Research and Training Hospital, Istanbul, Turkey
| | - Elnur Alizade
- Cardiology Department, Kartal Kosuyolu Heart Research and Training Hospital, Istanbul, Turkey
| | - Ahmet Güner
- Department of Cardiology, Mehmet Akif Ersoy Thoracic and Cardiovascular Surgery Training and Research Hospital, Istanbul, Turkey
| | - Regayip Zehir
- Cardiology Department, Kartal Kosuyolu Heart Research and Training Hospital, Istanbul, Turkey
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von Gottberg P, Hellstern V, Wendl C, Wolf ME, Niehaus L, Bäzner H, Henkes H. Combined Anticoagulation and Antiaggregation in Acute Cervical Artery Dissection. J Clin Med 2021; 10:jcm10194580. [PMID: 34640598 PMCID: PMC8509613 DOI: 10.3390/jcm10194580] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2021] [Revised: 09/21/2021] [Accepted: 09/27/2021] [Indexed: 11/21/2022] Open
Abstract
Cervical artery dissection (CAD) is a frequent cause of stroke in young adults. Previous studies investigating the efficiency of anticoagulation (AC) versus antiplatelet therapy (AT) found an insignificant difference. We therefore retrospectively evaluated a combination of AC plus AT in patients with acute CAD regarding safety and efficacy. Twenty-eight patients with CAD and minor neurological symptoms/no major infarction received either single (n = 14) or dual AT (n = 14) combined with AC. Angiographic follow-up during hospitalization, 4-8 weeks and 3–6 months after CAD focused on occlusion, residual stenosis, and functional recanalization. Possible adverse events were surveyed. We compared the AC plus AT group to 22 patients with acute CAD treated with AC or AT. Compared to preceding AC-/AT-only studies, AC plus single or dual AT resulted in more frequent, faster recanalization. Frequency and severity of adverse events was comparable. No major adverse events or death occurred. Preceding works on conservative treatment of CAD are discussed and compared to this study. Considerations are given to pathophysiology and the dynamic of CAD. Combining AC plus AT in CAD may result in more reliable recanalization in a shorter time. The risk for adverse events appears similar to treatment with only AC or AT.
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Affiliation(s)
- Philipp von Gottberg
- Neuroradiologische Klinik, Klinikum Stuttgart, 70174 Stuttgart, Germany; (V.H.); (H.H.)
- Correspondence: ; Tel.: +49-711-2783-4501
| | - Victoria Hellstern
- Neuroradiologische Klinik, Klinikum Stuttgart, 70174 Stuttgart, Germany; (V.H.); (H.H.)
| | - Christina Wendl
- Institut für Röntgendiagnostik, Zentrum für Neuroradiologie, Fakultät für Medizin der Universität Regensburg, 93053 Regensburg, Germany;
| | - Marc E. Wolf
- Neurologische Klinik, Klinikum Stuttgart, 70174 Stuttgart, Germany; (M.E.W.); (H.B.)
| | - Ludwig Niehaus
- Neurologische Fachklinik, Rems-Murr-Kliniken, 71364 Winnenden, Germany;
| | - Hansjörg Bäzner
- Neurologische Klinik, Klinikum Stuttgart, 70174 Stuttgart, Germany; (M.E.W.); (H.B.)
| | - Hans Henkes
- Neuroradiologische Klinik, Klinikum Stuttgart, 70174 Stuttgart, Germany; (V.H.); (H.H.)
- Medizinische Fakultät, Universität Duisburg-Essen, 45147 Essen, Germany
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Finamore F, Nieddu G, Rocchiccioli S, Spirito R, Guarino A, Formato M, Lepedda AJ. Apolipoprotein Signature of HDL and LDL from Atherosclerotic Patients in Relation with Carotid Plaque Typology: A Preliminary Report. Biomedicines 2021; 9:biomedicines9091156. [PMID: 34572342 PMCID: PMC8465382 DOI: 10.3390/biomedicines9091156] [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: 08/02/2021] [Revised: 08/30/2021] [Accepted: 08/31/2021] [Indexed: 12/14/2022] Open
Abstract
In the past years, it has become increasingly clear that the protein cargo of the different lipoprotein classes is largely responsible for carrying out their various functions, also in relation to pathological conditions, including atherosclerosis. Accordingly, detailed information about their apolipoprotein composition and structure may contribute to the revelation of their role in atherogenesis and the understanding of the mechanisms that lead to atherosclerotic degeneration and toward vulnerable plaque formation. With this aim, shotgun proteomics was applied to identify the apolipoprotein signatures of both high-density and low-density lipoproteins (HDL and LDL) plasma fractions purified from healthy volunteers and atherosclerotic patients with different plaque typologies who underwent carotid endarterectomy. By this approach, two proteins with potential implications in inflammatory, immune, and hemostatic pathways, namely, integrin beta-2 (P05107) and secretoglobin family 3A member 2 (Q96PL1), have been confirmed to belong to the HDL proteome. Similarly, the list of LDL-associated proteins has been enriched with 21 proteins involved in complement and coagulation cascades and the acute-phase response, which potentially double the protein species of LDL cargo. Moreover, differential expression analysis has shown protein signatures specific for patients with “hard” or “soft” plaques.
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Affiliation(s)
- Francesco Finamore
- Institute of Clinical Physiology, National Research Council, via Giuseppe Moruzzi 1, 56124 Pisa, Italy; (F.F.); (S.R.)
| | - Gabriele Nieddu
- Department of Biomedical Sciences, University of Sassari, Viale San Pietro 43, 07100 Sassari, Italy; (G.N.); (M.F.)
| | - Silvia Rocchiccioli
- Institute of Clinical Physiology, National Research Council, via Giuseppe Moruzzi 1, 56124 Pisa, Italy; (F.F.); (S.R.)
| | - Rita Spirito
- Centro Cardiologico Monzino, IRCCS, via Parea 4, 20138 Milano, Italy; (R.S.); (A.G.)
| | - Anna Guarino
- Centro Cardiologico Monzino, IRCCS, via Parea 4, 20138 Milano, Italy; (R.S.); (A.G.)
| | - Marilena Formato
- Department of Biomedical Sciences, University of Sassari, Viale San Pietro 43, 07100 Sassari, Italy; (G.N.); (M.F.)
| | - Antonio Junior Lepedda
- Department of Biomedical Sciences, University of Sassari, Viale San Pietro 43, 07100 Sassari, Italy; (G.N.); (M.F.)
- Correspondence:
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32
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Song D, Ireifej B, Seen T, Almas T, Sattar Y, Chadi Alraies M. Diagnosis and management of unilateral subclavian steal syndrome with bilateral carotid artery stenosis. Ann Med Surg (Lond) 2021; 68:102597. [PMID: 34377448 PMCID: PMC8329505 DOI: 10.1016/j.amsu.2021.102597] [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: 07/08/2021] [Revised: 07/25/2021] [Accepted: 07/25/2021] [Indexed: 01/22/2023] Open
Abstract
Subclavian steal syndrome is a rare phenomenon occurring from retrograde blood flow in the vertebral artery due to proximal stenosis in the subclavian artery. As a result, the arm gets blood supply from the vertebral artery at the expense of the vertebrobasilar system. The patient remains largely asymptomatic until there is an increase demand for blood supply to the arm, resulting in a constellation of symptoms including dizziness, vertigo, blurred vision, diplopia, headache, syncope, postural hypotension, neurologic deficits, and rarely, memory problems. The management approach depends on the severity of clinical symptoms but includes medical treatment, endovascular therapy and lifestyle modifications. Subclavian steal syndrome with concurrent carotid artery stenosis is only the second documented case, which makes it an extremely rare presentation or frequently unnoticed condition. Absence of symptoms does not rule out subclavian steal syndrome with bilateral carotid stenosis and should be considered in the differential in patients with high risk comorbidities with appropriate imaging and physical exam. The treatment depends on the severity of clinical symptoms but includes medical treatment, endovascular therapy and lifestyle modifications.
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Affiliation(s)
- David Song
- Icahn School of Medicine at Mount Sinai Elmhurst Hospital, Queens, NY, USA
| | - Branden Ireifej
- Icahn School of Medicine at Mount Sinai Elmhurst Hospital, Queens, NY, USA
| | - Tasur Seen
- Icahn School of Medicine at Mount Sinai Elmhurst Hospital, Queens, NY, USA
| | - Talal Almas
- Royal College of Surgeons in Ireland, Dublin, Ireland
| | - Yasar Sattar
- Icahn School of Medicine at Mount Sinai Elmhurst Hospital, Queens, NY, USA
| | - M Chadi Alraies
- Division of Interventional Cardiology, Detroit Medical Center, Detroit, MI, USA
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Ganji M, Nardi V, Prasad M, Jordan KL, Bois MC, Franchi F, Zhu XY, Tang H, Young MD, Lerman LO, Lerman A. Carotid Plaques From Symptomatic Patients Are Characterized by Local Increase in Xanthine Oxidase Expression. Stroke 2021; 52:2792-2801. [PMID: 34107737 DOI: 10.1161/strokeaha.120.032964] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
[Figure: see text].
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Affiliation(s)
- Morsaleh Ganji
- Department of Cardiovascular Medicine (M.G., V.N., M.P., F.F., M.D.Y., A.L.), Mayo Clinic, Rochester, MN
| | - Valentina Nardi
- Department of Cardiovascular Medicine (M.G., V.N., M.P., F.F., M.D.Y., A.L.), Mayo Clinic, Rochester, MN
| | - Megha Prasad
- Department of Cardiovascular Medicine (M.G., V.N., M.P., F.F., M.D.Y., A.L.), Mayo Clinic, Rochester, MN
| | - Kyra L Jordan
- Department of Nephrology and Hypertension (K.L.J., X.Y.Z., H.T., L.O.L.), Mayo Clinic, Rochester, MN
| | - Melanie C Bois
- Department of Laboratory Medicine and Pathology (M.C.B.), Mayo Clinic, Rochester, MN
| | - Federico Franchi
- Department of Cardiovascular Medicine (M.G., V.N., M.P., F.F., M.D.Y., A.L.), Mayo Clinic, Rochester, MN
| | - Xiang Y Zhu
- Department of Nephrology and Hypertension (K.L.J., X.Y.Z., H.T., L.O.L.), Mayo Clinic, Rochester, MN
| | - Hui Tang
- Department of Nephrology and Hypertension (K.L.J., X.Y.Z., H.T., L.O.L.), Mayo Clinic, Rochester, MN
| | - Melissa D Young
- Department of Cardiovascular Medicine (M.G., V.N., M.P., F.F., M.D.Y., A.L.), Mayo Clinic, Rochester, MN
| | - Lilach O Lerman
- Department of Nephrology and Hypertension (K.L.J., X.Y.Z., H.T., L.O.L.), Mayo Clinic, Rochester, MN
| | - Amir Lerman
- Department of Cardiovascular Medicine (M.G., V.N., M.P., F.F., M.D.Y., A.L.), Mayo Clinic, Rochester, MN
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Myasoedova VA, Saccu C, Chiesa M, Songia P, Alfieri V, Massaiu I, Valerio V, Moschetta D, Gripari P, Naliato M, Cavallotti L, Spirito R, Trabattoni P, Poggio P. Aortic Valve Sclerosis as an Important Predictor of Long-Term Mortality in Patients With Carotid Atheromatous Plaque Requiring Carotid Endarterectomy. Front Cardiovasc Med 2021; 8:653991. [PMID: 34124193 PMCID: PMC8193358 DOI: 10.3389/fcvm.2021.653991] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2021] [Accepted: 04/26/2021] [Indexed: 12/27/2022] Open
Abstract
Background: A strong association between aortic valve sclerosis (AVSc), the earliest manifestation of calcific aortic valve disease, and atherosclerosis exists. The aim of the study was to evaluate the predictive capabilities of AVSc on long-term all-cause mortality, in patients requiring carotid endarterectomy (CEA). Methods and Results: 806 consecutive CEA patients were enrolled. Preoperative echocardiography was used to assess AVSc. Computed tomography angiography was applied for plaque characterization. Kaplan-Meier curves, Cox linear regression, and area under the receiving operator characteristic (AUC) curve analyses were used to evaluate the predictive capability of AVSc. Overall, 348 of 541 patients had AVSc (64%). Age, diabetes, and estimated glomerular filtration rate (eGFR) were associated with AVSc. In the 5-year follow-up, AVSc group had a mortality rate of 16.7% while in no-AVSc group was 7.8%. Independent predictors of all-cause mortality were age, sex, eGFR, left ventricular ejection fraction, and AVSc. After adjustments, AVSc was associated with a significant increase in all-cause mortality risk (hazard ratio, HR = 1.9; 95%CI: 1.04–3.54; p = 0.038). We stratify our cohort based on carotid atheromatous plaque-type: soft, calcified, and mixed-fibrotic. In patients with mixed-fibrotic plaques, the mortality rate of AVSc patients was 15.5% compared to 2.4% in no-AVSc patients. In this group, AVSc was associated with an increased long-term all-cause mortality risk with an adjusted HR of 12.8 (95%CI: 1.71–96.35; p = 0.013), and the AUC, combing eGFR and AVSc was 0.77 (p < 0.001). Conclusions: Our findings indicate that AVSc together with eGFR may be used to improve long-term risk stratification of patients undergoing CEA surgery.
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Affiliation(s)
- Veronika A Myasoedova
- Unità per lo Studio delle Patologie Aortiche, Valvolari e Coronariche, Centro Cardiologico Monzino, Istituto di Ricovero e Cura a Carattere Scientifico, Milan, Italy
| | - Claudio Saccu
- Dipartimento di Chirurgia Cardiovascolare, Centro Cardiologico Monzino, Istituto di Ricovero e Cura a Carattere Scientifico, Milan, Italy
| | - Mattia Chiesa
- Bioinformatics and Artificial Intelligence Facility, Centro Cardiologico Monzino, Istituto di Ricovero e Cura a Carattere Scientifico, Milan, Italy
| | - Paola Songia
- Unità per lo Studio delle Patologie Aortiche, Valvolari e Coronariche, Centro Cardiologico Monzino, Istituto di Ricovero e Cura a Carattere Scientifico, Milan, Italy
| | - Valentina Alfieri
- Unità per lo Studio delle Patologie Aortiche, Valvolari e Coronariche, Centro Cardiologico Monzino, Istituto di Ricovero e Cura a Carattere Scientifico, Milan, Italy
| | - Ilaria Massaiu
- Unità per lo Studio delle Patologie Aortiche, Valvolari e Coronariche, Centro Cardiologico Monzino, Istituto di Ricovero e Cura a Carattere Scientifico, Milan, Italy
| | - Vincenza Valerio
- Unità per lo Studio delle Patologie Aortiche, Valvolari e Coronariche, Centro Cardiologico Monzino, Istituto di Ricovero e Cura a Carattere Scientifico, Milan, Italy.,Università degli Studi di Napoli Federico II, Dipartimento di Medicina Clinica e Chirurgia, Napoli, Italy
| | - Donato Moschetta
- Unità per lo Studio delle Patologie Aortiche, Valvolari e Coronariche, Centro Cardiologico Monzino, Istituto di Ricovero e Cura a Carattere Scientifico, Milan, Italy.,Department of Pharmacological and Biomolecular Sciences, University of Milan, Milan, Italy
| | - Paola Gripari
- Dipartimento di Imaging Cardiovascolare, Centro Cardiologico Monzino, Istituto di Ricovero e Cura a Carattere Scientifico, Milan, Italy
| | - Moreno Naliato
- Dipartimento di Chirurgia Cardiovascolare, Centro Cardiologico Monzino, Istituto di Ricovero e Cura a Carattere Scientifico, Milan, Italy
| | - Laura Cavallotti
- Dipartimento di Chirurgia Cardiovascolare, Centro Cardiologico Monzino, Istituto di Ricovero e Cura a Carattere Scientifico, Milan, Italy
| | - Rita Spirito
- Dipartimento di Chirurgia Cardiovascolare, Centro Cardiologico Monzino, Istituto di Ricovero e Cura a Carattere Scientifico, Milan, Italy
| | - Piero Trabattoni
- Dipartimento di Chirurgia Cardiovascolare, Centro Cardiologico Monzino, Istituto di Ricovero e Cura a Carattere Scientifico, Milan, Italy
| | - Paolo Poggio
- Unità per lo Studio delle Patologie Aortiche, Valvolari e Coronariche, Centro Cardiologico Monzino, Istituto di Ricovero e Cura a Carattere Scientifico, Milan, Italy
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Güner A, Çelik Ö, Topel Ç, Arif Yalçın A, Kalçık M, Uzun F, Altunova M, Örten M, Akman C, Güner EG, Ertürk M. The effect of complex vascular anatomy on silent new ischemic cerebral lesions in carotid artery stenting procedures (from the COMPLEX-CAS Trial). Vascular 2021; 30:292-300. [PMID: 33896290 DOI: 10.1177/17085381211010016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
BACKGROUND Carotid artery stenting is a minimally invasive, durable alternative treatment option, which is an alternative to the reference method, carotid endarterectomy, for patients with carotid artery stenosis; however, silent new ischemic cerebral lesions (SNICLs) after carotid artery stenting remain as a matter of concern. Hence, we aimed to assess the effect of complex vascular anatomy on silent new ischemic cerebral lesions in carotid artery stenting procedures. METHODS We prospectively evaluated 122 patients (mean age: 69.5 ± 7.1 years, male:83) who underwent carotid artery stenting for carotid artery revascularization. The patients having symptomatic transient ischemic attack or stroke after carotid artery stenting were excluded. The presence of a new hyperintense lesions on diffusion-weighted imaging without any neurological findings was considered as the SNICL. Patients were classified into two groups as DWI-positive and DWI-negative patients. RESULTS Among the study population, 32 patients (26.2%) had SNICLs. The DWI-positive group had a significantly higher common carotid artery (CCA)-internal carotid artery (ICA) angle, older age, more frequent history of stroke, a higher proportion of type III aortic arch, and longer fluoroscopy time than the DWI-negative group. High CCA-ICA angle was identified as one of the independent predictors of SNICL (OR (odds ratio) = 1.103 95%CI (confidence interval): (1.023-1.596); p = 0.034), and CCA-ICA angle higher than 34.5 degrees predicted SNICL with a sensitivity of 62.5% and a specificity of 62.2% (area under the curve: 0.680; 95% CI: 0.570 to 0.789; p = 0.003). CONCLUSIONS The higher CCA-ICA angle may predict pre-procedure SNICL risk in carotid artery stenting and may have clinical value in the management of patients with carotid artery stenosis.
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Affiliation(s)
- Ahmet Güner
- Department of Cardiology, Mehmet Akif Ersoy Thoracic and Cardiovascular Surgery Training and Research Hospital, Istanbul, Turkey
| | - Ömer Çelik
- Department of Cardiology, Mehmet Akif Ersoy Thoracic and Cardiovascular Surgery Training and Research Hospital, Istanbul, Turkey
| | - Çağdaş Topel
- Department of Radiology, Mehmet Akif Ersoy Thoracic and Cardiovascular Surgery Training and Research Hospital, Istanbul, Turkey
| | - Ahmet Arif Yalçın
- Department of Cardiology, Mehmet Akif Ersoy Thoracic and Cardiovascular Surgery Training and Research Hospital, Istanbul, Turkey
| | - Macit Kalçık
- Department of Cardiology, Faculty of Medicine, Hitit University, Çorum, Turkey
| | - Fatih Uzun
- Department of Cardiology, Mehmet Akif Ersoy Thoracic and Cardiovascular Surgery Training and Research Hospital, Istanbul, Turkey
| | - Mehmet Altunova
- Department of Cardiology, Mehmet Akif Ersoy Thoracic and Cardiovascular Surgery Training and Research Hospital, Istanbul, Turkey
| | - Murat Örten
- Department of Neurology, Mehmet Akif Ersoy Thoracic and Cardiovascular Surgery Training and Research Hospital, Istanbul, Turkey
| | - Cemalettin Akman
- Department of Cardiology, Mehmet Akif Ersoy Thoracic and Cardiovascular Surgery Training and Research Hospital, Istanbul, Turkey
| | - Ezgi Gültekin Güner
- Department of Cardiology, Mehmet Akif Ersoy Thoracic and Cardiovascular Surgery Training and Research Hospital, Istanbul, Turkey
| | - Mehmet Ertürk
- Department of Cardiology, Mehmet Akif Ersoy Thoracic and Cardiovascular Surgery Training and Research Hospital, Istanbul, Turkey
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Surgical therapy for chronic internal carotid artery occlusion: a systematic review and meta-analysis. Updates Surg 2021; 73:2065-2078. [PMID: 33864610 DOI: 10.1007/s13304-021-01055-x] [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: 02/10/2021] [Accepted: 04/12/2021] [Indexed: 10/21/2022]
Abstract
Chronic internal carotid artery occlusion (CICAO) significantly increases the risk of recurrent stroke. Given unfavorable outcomes, revascularization procedures are not generally recommended for CICAO. In the last several years, loads of studies reported successful surgical revascularization for CICAO with promising success rate and favorable short-term outcomes. Meanwhile, due to the lack of high-quality evidence, the safety and efficacy of revascularization procedures remain debatable. This systematic review aims to scrutinize current evidence for the applicability of revascularization for CICAO. We also investigated potential predictors of postoperative prognosis. We searched clinical studies on surgical treatment of CICAO on the Medline, Cochrane library, and Embase databases, published from Jan 1990 to Jan 2021. Surgical operation was restricted to bypass surgery, endarterectomy, endovascular therapy, and hybrid surgery. Controlled clinical studies were included for clinical outcomes. Large-sample single-arm studies were supplemented to assess complications and success rate. Co-primary endpoints were technical success rate and neurological function; secondary endpoints were recurrent stroke/cerebrovascular events, complications, and deaths within follow-up. This systematic review has been registered in PROSPERO (CRD42020181250). One RCT and 5 cohort studies with a total of 465 patients were included in this review. Seven single-arm studies were supplemented for assessing success rate and complications. Bypass surgery presented the highest graft patency of 96% and a low incidence of complications, but no benefits on neurological function, recurrent stroke, or deaths. Endovascular therapy (carotid stenting) was characterized by a relatively lower technical success rate, significant neurological function recovery, and nonsignificant reduction of cerebrovascular events and deaths. Hybrid surgery was considered as a potential treatment for CICAO because of a high technical success rate and significant neurological improvement. Endarterectomy is only suitable for short-segment occlusion. Prospective clinical trials should focus on carotid stenting and hybrid surgery for their significant capacity of improving neurologic function and potential capacity of reducing deaths and cerebrovascular events.
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Nazari P, Golnari P, Hurley MC, Shaibani A, Ansari SA, Potts MB, Jahromi BS. Carotid Stenting without Embolic Protection Increases Major Adverse Events: Analysis of the National Surgical Quality Improvement Program. AJNR Am J Neuroradiol 2021; 42:1264-1269. [PMID: 34255736 DOI: 10.3174/ajnr.a7108] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2020] [Accepted: 01/26/2021] [Indexed: 11/07/2022]
Abstract
BACKGROUND AND PURPOSE Published data regarding embolic protection device efficacy is mixed, and its use during carotid artery stent placement remains variable. We, therefore, examined the frequency of embolic protection device use and its association with outcomes after carotid artery stent placement using a national quality improvement data base. MATERIALS AND METHODS Patients undergoing carotid artery stent placement with or without embolic protection devices were identified in the American College of Surgeons National Surgical Quality Improvement Program data base. The primary outcome was the incidence of major adverse cardiovascular events (defined as death, stroke, or myocardial infarction/arrhythmia) within 30 days. Propensity scoring was used to create 2 matching cohorts of patients using demographic and baseline variables. RESULTS Between 2011 and 2018, among 1200 adult patients undergoing carotid artery stent placement, 23.8% did not have embolic protection devices. There was no trend toward increased embolic protection device use with time. Patients without embolic protection device use received preoperative antiplatelets less frequently (90.6% versus 94.6%, P = .02), underwent more emergent carotid artery stent placement (7.2% versus 3.6%, P = .01), and had a higher incidence of major adverse cardiovascular events (OR = 1.81; 95% CI, 1.11-2.94) and stroke (OR = 3.31; 95% CI, 1.71-6.39). After compensating for baseline imbalances using propensity-matched cohorts (n = 261 for both), carotid artery stent placement without an embolic protection device remained associated with increased major adverse cardiovascular events (9.2% versus 4.2%; OR = 2.30; 95% CI, 1.10-4.80) and stroke (6.5% versus 1.5%; OR = 4.48; 95% CI, 1.49-13.49). CONCLUSIONS Lack of embolic protection device use during carotid artery stent placement is associated with a 4-fold increase in the likelihood of perioperative stroke. Nevertheless, nearly one-quarter of patients in the American College of Surgeons National Surgical Quality Improvement Program underwent unprotected carotid artery stent placement. Efforts targeting improved embolic protection device use during carotid artery stent placement are warranted.
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Affiliation(s)
- P Nazari
- From the Departments of Neurological Surgery and Radiology Northwestern Memorial Hospital, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - P Golnari
- From the Departments of Neurological Surgery and Radiology Northwestern Memorial Hospital, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - M C Hurley
- From the Departments of Neurological Surgery and Radiology Northwestern Memorial Hospital, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - A Shaibani
- From the Departments of Neurological Surgery and Radiology Northwestern Memorial Hospital, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - S A Ansari
- From the Departments of Neurological Surgery and Radiology Northwestern Memorial Hospital, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - M B Potts
- From the Departments of Neurological Surgery and Radiology Northwestern Memorial Hospital, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - B S Jahromi
- From the Departments of Neurological Surgery and Radiology Northwestern Memorial Hospital, Northwestern University Feinberg School of Medicine, Chicago, Illinois
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Çelik Ö, Güner A, Kalçık M, Güler A, Demir AR, Demir Y, Uygur B, Şahin AA, Topel Ç, Ertürk M. The predictive value of CHADS2 score for subclinical cerebral ischemia after carotid artery stenting (from the PREVENT-CAS trial). Catheter Cardiovasc Interv 2021; 97:301-309. [PMID: 33085162 DOI: 10.1002/ccd.29344] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/18/2020] [Revised: 09/10/2020] [Accepted: 10/08/2020] [Indexed: 11/09/2022]
Abstract
BACKGROUND Carotid artery stenting (CAS) is being increasingly used as an alternative revascularization procedure to carotid endarterectomy; however, subclinical ischemic cerebral lesions after CAS remain as a matter of concern. Hence, we aimed to assess the clinical utility of the CHADS2 score in predicting subclinical ischemic events after CAS. METHODS We prospectively evaluated 107 patients (mean age: 70.4 ± 6.6 years, male:77) who underwent CAS for carotid artery revascularization. The patients having symptomatic transient ischemic attack or stroke after CAS were excluded. The presence of new hyperintense lesion on diffusion-weighted imaging (DWI) without any neurological findings was considered as silent ischemia. Patients were classified into two groups as DWI-positive and DWI-negative patients. RESULTS Among study population, 28 patients (26.2%) had subclinical embolism. The DWI-positive group had a significantly higher CHADS2 scores, older age, more frequent history of stroke, higher proportion of type III aortic arch, and longer fluoroscopy time than the DWI-negative group. Increased CHADS2 score was identified as one of the independent predictors of silent embolism (OR = 5.584; 95%CI: 1.516-20.566; p = .010), and CHADS2 score higher than 2.5 predicted subclinical cerebral ischemia with a sensitivity of 72% and a specificity of 71% (AUC: 0.793; 95% CI: 0.696 - 0.890; p < .001). CONCLUSIONS CHADS2 score was able to predict the risk of periprocedural subclinical ischemic events in CAS and might be of clinical value in the management of patients with carotid artery stenosis.
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Affiliation(s)
- Ömer Çelik
- Department of Cardiology, University of Health Sciences Turkey, Mehmet Akif Ersoy Thoracic and Cardiovascular Surgery Training and Research Hospital, Istanbul, Turkey
| | - Ahmet Güner
- Department of Cardiology, University of Health Sciences Turkey, Mehmet Akif Ersoy Thoracic and Cardiovascular Surgery Training and Research Hospital, Istanbul, Turkey
| | - Macit Kalçık
- Department of Cardiology, Faculty of Medicine, Hitit University, Çorum, Turkey
| | - Arda Güler
- Department of Cardiology, University of Health Sciences Turkey, Mehmet Akif Ersoy Thoracic and Cardiovascular Surgery Training and Research Hospital, Istanbul, Turkey
| | - Ali Rıza Demir
- Department of Cardiology, University of Health Sciences Turkey, Mehmet Akif Ersoy Thoracic and Cardiovascular Surgery Training and Research Hospital, Istanbul, Turkey
| | - Yusuf Demir
- Department of Cardiology, University of Health Sciences Turkey, Mehmet Akif Ersoy Thoracic and Cardiovascular Surgery Training and Research Hospital, Istanbul, Turkey
| | - Begum Uygur
- Department of Cardiology, University of Health Sciences Turkey, Mehmet Akif Ersoy Thoracic and Cardiovascular Surgery Training and Research Hospital, Istanbul, Turkey
| | - Ahmet Anıl Şahin
- Department of Cardiology, University of Health Sciences Turkey, Mehmet Akif Ersoy Thoracic and Cardiovascular Surgery Training and Research Hospital, Istanbul, Turkey
| | - Çağdaş Topel
- Department of Radiology, Mehmet Akif Ersoy Thoracic and Cardiovascular Surgery Training and Research Hospital, Istanbul, Turkey
| | - Mehmet Ertürk
- Department of Cardiology, University of Health Sciences Turkey, Mehmet Akif Ersoy Thoracic and Cardiovascular Surgery Training and Research Hospital, Istanbul, Turkey
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Callen A, Narvid J, Chen X, Gregath T, Meisel K. Neurovascular disease, diagnosis, and therapy: Cervical and intracranial atherosclerosis, vasculitis, and vasculopathy. HANDBOOK OF CLINICAL NEUROLOGY 2021; 176:249-266. [PMID: 33272399 DOI: 10.1016/b978-0-444-64034-5.00023-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
Stroke is a leading cause of death, disability, and financial burden in the United States. Perhaps more than any other disease process, the rapidity with which the diagnosis and treatment of stroke are successfully achieved is paramount to the reduction of its associated morbidity and mortality. Steno-occlusive intracranial vascular disease, the most notorious culprit of cerebral ischemia and/or hemorrhage, traces its etiology to native and embolic atherosclerosis as well as various forms of vascular inflammation, insult, and dysfunction. Distinguishing between these causes is a critical first step in the diagnosis and treatment of a patient presenting with cerebrovascular compromise. In this chapter, we delineate the clinical and imaging features of cervical and intracranial atherosclerosis, vasculitis, and vasculopathy, along with the evidence behind the treatments which comprise their current-day standard of care. The modern imaging armamentarium is diverse and complex, with contrast-enhanced and non-contrast MR angiography, CT angiography, digital subtraction angiography, and ultrasound; each playing an important role in providing rapid insight into the patient's disease process. Understanding these imaging techniques and their application in the acute setting is critical for the provider caring for stroke patients.
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Affiliation(s)
- Andrew Callen
- Department of Radiology, University of Colorado, Boulder, CO, United States
| | - Jared Narvid
- Department of Radiology, University of California San Francisco, San Francisco, CA, United States
| | - Xiaolin Chen
- Department of Neurosurgery, Peking University International Hospital, Beijing, China
| | - Trevor Gregath
- Department of Neurology, Bryan Health, Lincoln, NE, United States
| | - Karl Meisel
- Department of Neurology, University of California San Francisco, San Francisco, CA, United States.
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Abstract
PURPOSE OF REVIEW Surgical vascular intervention is an important tool in reducing the risk of stroke. This article examines the evidence for using the available options. RECENT FINDINGS Carotid endarterectomy is an effective treatment option for reducing the risk of stroke in appropriately selected patients. Patients should be stratified for future stroke risk based on both the degree of stenosis and the presence of symptoms referable to the culprit lesion. Carotid stenting is also useful in reducing stroke risk, again in carefully selected patients. Because of the publication of significant data regarding both carotid endarterectomy and carotid artery stenting in the last several years, selection can be far more personalized and refined for individual patients based on demographics, sex, patient preference, and medical comorbidities. Routine extracranial-intracranial bypass surgery remains unproven as a therapeutic option for large vessel occlusion in reducing the incidence of ischemic stroke although some carefully screened patient populations remaining at high risk may benefit; procedural risks and pathology related to alterations in blood flow dynamics are challenges to overcome. Indirect revascularization remains an appropriate solution for carefully selected patients with cerebral large vessel steno-occlusive disease, and multiple variations of surgical technique are patient specific. Indirect revascularization may benefit from clinical trials with larger patient populations for validation in specific pathologies and offers the advantages of lower surgical complication rates and reduced risk of pathologic responses to altered cerebral flow dynamics. SUMMARY Surgical solutions to reduce stroke risk provide important alternatives in appropriately selected patients and should be considered in addition to medical management and lifestyle modification for optimizing patient outcomes.
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In-hospital clinical outcomes of transcatheter aortic valve replacement in patients with concomitant carotid artery stenosis: Insights from the national inpatient sample. IJC HEART & VASCULATURE 2020; 31:100621. [PMID: 32939395 PMCID: PMC7479274 DOI: 10.1016/j.ijcha.2020.100621] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2020] [Revised: 08/12/2020] [Accepted: 08/16/2020] [Indexed: 11/23/2022]
Abstract
Background Carotid artery stenosis (CAS) is a common occurrence in elderly patients undergoing transcatheter aortic valve replacement (TAVR). We conducted a retrospective study to identify the impact of CAS on in-hospital outcomes following TAVR. Methods We queried the National Inpatient Sample (NIS) for 2016–2017 and identified patients who underwent TAVR with concomitant CAS using the ICD-10 codes. The primary endpoint of our study was in-hospital mortality and acute ischemic stroke. Results We identified 80,740 TAVR-related hospitalizations. Of these, 6.9% (N = 5555) patients had concomitant CAS. The mean age for CAS patients was 80 ± 7.4 years. Females were represented equally in both groups. Traditional comorbidities like dyslipidemia [78.3% (N = 4350) vs. 68.2% (N = 51261); P < 0.001] and peripheral arterial disease [27.4% (N = 1525) vs. 12.7% (N = 9526); P < 0.001] were more frequently observed among CAS patients. Patients with CAS had higher rates of previous stroke [17.5% (N = 970) vs. 11.8% (N = 8902); P < 0.001] and CABG 23.8% (N = 1320) vs. 18.6% (N = 14022); P < 0.001]. Other cardiovascular risk factors were similar between the two groups. Moreover, no differences in in-hospital outcomes including mortality [odds ratio (OR): 1.35, CI: 0.48–3.83; P = 0.57] were observed in the propensity matched cohort. Conclusions Our study did not find any major differences in outcomes in the CAS group following TAVR; however, a more detailed randomized controlled study with long-term follow-up of these patients is needed.
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Huang Y, Ma X, Li M, Dong H, Wan Y, Zhu J. Carotid contrast-enhanced ultrasonographic assessment of disease activity in Takayasu arteritis. Eur Heart J Cardiovasc Imaging 2020; 20:789-795. [PMID: 30590495 DOI: 10.1093/ehjci/jey197] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/13/2018] [Revised: 11/13/2018] [Accepted: 11/23/2018] [Indexed: 11/14/2022] Open
Abstract
AIMS To investigate the usefulness of carotid contrast-enhanced ultrasound (CEUS) in assessment of disease activity in patients with Takayasu arteritis (TA). METHODS AND RESULTS After screening 219 CEUS records from 124 consecutive patients followed at our clinic between October 2014 and May 2018, data were analysed from 159 carotid CEUS from 86 patients diagnosed with Type I TA. Patients were categorized based on disease activity according to National Institutes of Health criteria into two groups: active disease group (92 CEUS) and non-active disease group (67 CEUS). The enhanced intensity of carotid artery wall: (i) was higher in active disease group than in non-active disease group (3.09 ± 1.67 dB vs. 1.44 ± 1.29 dB, P < 0.0001, respectively); and (ii) had a high predictive value for TA disease activity with area under the curve (AUC) of 86.3% [95% confidence interval (CI) 79.7-92.9], sensitivity of 88.0%, and specificity of 79.1%. The latter AUC was not significantly affected (P > 0.05) when erythrocyte sedimentation rate, C-reactive protein level, or arterial wall thickness were added to assessment of disease activity in TA. CONCLUSION Carotid vascularization by CEUS, as sole inflammatory marker, had a high predictive value for disease activity in Type I TA.
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Affiliation(s)
- Yanli Huang
- Department of Ultrasonography, The First Affiliated Hospital of Dalian Medical University, No 222, Zhongshan Road, Xigang District, Dalian, China
| | - Xiaohui Ma
- Department of Vascular Surgery, Chinese PLA General Hospital, Fuxing Road 28, Haidian District, Beijing, China
| | - Min Li
- Department of Ultrasonography, Chinese PLA General Hospital, Fuxing Road 28, Haidian District, Beijing, China
| | - Huiwu Dong
- Department of Ultrasonography, Chinese PLA General Hospital, Fuxing Road 28, Haidian District, Beijing, China
| | - Yuehua Wan
- Department of Rheumatology, Chinese PLA General Hospital, Fuxing Road 28, Haidian District, Beijing, China
| | - Jian Zhu
- Department of Rheumatology, Chinese PLA General Hospital, Fuxing Road 28, Haidian District, Beijing, China
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Soenens G, Moreels N, Vermassen F, De Herdt V, Hemelsoet D, Van Herzeele I. Evolution of surgical treatment of carotid artery stenosis: a single center observational study. Acta Chir Belg 2020; 120:301-309. [PMID: 30995167 DOI: 10.1080/00015458.2019.1607489] [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: 12/24/2022]
Abstract
Background: In 2009 and 2011 respectively ESVS and AHA/ASA guidelines recommended to operate patients with a symptomatic carotid artery stenosis within 14 days. This study aimed primarily to determine if an academic hospital has implemented these international guidelines about indication and timing of surgical treatment of carotid stenosis. Second, the influence of referral from another hospital on time from symptoms to surgery and the influence of time between neurological event and surgery on 30-day complication rate was studied. Third, the number of asymptomatic carotid artery lesions treated surgically was also evaluated in both periods.Methods: Retrospective study to compare patients with significant atherosclerotic carotid stenosis who underwent carotid endarterectomy (CEA) or carotid artery stenting (CAS) in 2005-2006 versus patients treated in 2014-2016. Demographic data, treatment characteristics, interval between symptom and surgery and 30-day outcomes were collected.Results: In 2005-2006 38.1% (59/155) of the patients were treated for symptomatic carotid artery stenosis, in 2014-2016 this increased to 66.5% (121/182) (p < .001, 95% CI: 0.179-0.383). Median time from neurological symptom to surgery in symptomatic patients decreased from 30 to 13 d (p <.001, 95% CI: 1.476-2.763). Early surgery did not increase the 30-day postoperative complications (p = .19, 95% CI: 0.987-1.003). Referral from another hospital almost doubled the time interval between symptoms and surgery in 2014-2016 (p <.001, 95% CI: 1.386-2.827).Conclusions: Since the publication of the international guidelines, patients with symptomatic carotid artery stenosis were preferably surgically treated within 2 weeks at an academic institution. The number of treated asymptomatic carotid stenoses was drastically reduced.
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Affiliation(s)
- Gilles Soenens
- Department of Thoracic and Vascular Surgery, Ghent University Hospital, Ghent, Belgium
| | - Nathalie Moreels
- Department of Thoracic and Vascular Surgery, Ghent University Hospital, Ghent, Belgium
| | - Frank Vermassen
- Department of Thoracic and Vascular Surgery, Ghent University Hospital, Ghent, Belgium
| | - Veerle De Herdt
- Department of Neurology, Ghent University Hospital, Ghent, Belgium
| | | | - Isabelle Van Herzeele
- Department of Thoracic and Vascular Surgery, Ghent University Hospital, Ghent, Belgium
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Usachev DY, Lukshin VA, Yakovlev SB, Shmigelsky AV, Pronin IN, Arustamyan SR, Belousova OB, Akhmedov AD, Shulgina AA, Sosnin AD, Shevchenko EV, Kulikov AS. [A 20-year experience in surgical treatment of steno-occlusive lesion of craniocervical arteries at the Burdenko Neurosurgical Center]. ZHURNAL VOPROSY NEĬROKHIRURGII IMENI N. N. BURDENKO 2020; 84:6-20. [PMID: 32649809 DOI: 10.17116/neiro2020840316] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
INTRODUCTION Surgical treatment of cerebral ischemia at the Burdenko Neurosurgical Center for the period from 1999 to 2019 is analyzed in the paper. The details of the treatment strategy in patients with steno-occlusive lesion of craniocervical arteries followed by cerebral ischemia developed over 20 years are discussed in the article. We have analyzed the features of surgical interventions on the major craniocervical arteries in a neurosurgical clinic and the results of this treatment. OBJECTIVE To demonstrate management of various lesions of major cerebral arteries in modern neurosurgical vascular hospital. MATERIAL AND METHODS In total, there were 3098 interventions on the major cerebral arteries in 2527 patients for this period. Mean age of patients ranged from 1.5 to 91 years (58±14 years). Interventions included open reconstructions of the carotid arteries (2031 surgeries), reconstructions of the vertebrobasilar arteries (135 surgeries), brain revascularization (658 surgeries), excision of the tumors of neurovascular bundle on the neck compressing carotid arteries (51 interventions). Endovascular interventions were performed in 223 cases and consisted of angioplasty and stenting of the extracranial segments of craniocervical arteries (185 surgeries), stenting of the intracranial arteries (30 surgeries) and endovascular thrombextraction (8 cases). Staged surgeries were performed in 541 patients (22.3%). RESULTS Favorable outcomes were obtained in 87.6% of cases, satisfactory results - in 9% of patients. Clinical deterioration due to long-term postoperative complications and recurrent strokes occurred in 2.9% of cases. Postoperative morbidity rate was 4.6%, persistent neurological deficit developed in 2.6% of cases. Mortality rate was 0.5%. CONCLUSION Surgical treatment of stenotic and occlusive lesion of the major cerebral arteries is an interdisciplinary problem. Solution of this issue is closely associated with technological progress, new discoveries in normal and pathological physiology, as well as clinical researches. Individualized choice of surgical approach is one the main modern trends of neurosurgical approach to this problem. At the same time, own surgical experience is the most important factor determining the results of arterial reconstructions.
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Affiliation(s)
| | - V A Lukshin
- Burdenko Neurosurgical Center, Moscow, Russia
| | | | | | - I N Pronin
- Burdenko Neurosurgical Center, Moscow, Russia
| | | | | | | | | | - A D Sosnin
- Burdenko Neurosurgical Center, Moscow, Russia
| | | | - A S Kulikov
- Burdenko Neurosurgical Center, Moscow, Russia
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Nezu T, Hosomi N. Usefulness of Carotid Ultrasonography for Risk Stratification of Cerebral and Cardiovascular Disease. J Atheroscler Thromb 2020; 27:1023-1035. [PMID: 32863299 PMCID: PMC7585913 DOI: 10.5551/jat.rv17044] [Citation(s) in RCA: 21] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
Carotid ultrasonography is useful for the assessments of the risk stratification for stroke or coronary artery disease, because it is a simple, repeatable, and noninvasive procedure. The carotid intima-media thickness (IMT), which is assessed using carotid ultrasonography, is a widely used surrogate marker for the severity of atherosclerosis. Several large clinical studies showed that increased carotid IMT is associated with the future stroke or cardiovascular events. In addition, in many clinical trials, it has been adopted for surrogate markers of clinical endpoints of medical intervention. Moreover, carotid ultrasonography allows the measurement of the presence and characteristics of plaques and the severity of carotid artery stenosis. The unstable morphology of plaque, such as hypoechoic, ulcer, and mobility, is associated with future ischemic stroke events. The screening tool of asymptomatic carotid artery stenosis is also important, although whether routine carotid ultrasonography assessment is recommended in the general population remains controversial. The screening of carotid artery stenosis using ultrasonography is essential for not only daily clinical settings but also management of patients with acute ischemic stroke. The patients with atherothrombotic stroke with severe internal carotid artery stenosis should be considered to surgical intervention, and duplex ultrasound approach is important to estimate for the severity of carotid stenosis. Physicians should keep in mind the usefulness of carotid ultrasonography for risk stratification of cerebral and cardiovascular disease based on various aspects. In addition, visual assessment or dynamic changes using carotid ultrasonography could provide the various and valuable insights in clinical settings.
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Affiliation(s)
- Tomohisa Nezu
- Department of Clinical Neuroscience and Therapeutics, Hiroshima University Graduate School of Biomedical and Health Sciences
| | - Naohisa Hosomi
- Department of Neurology, Chikamori Hospital.,Department of Disease Model, Research Institute of Radiation Biology and Medicine, Hiroshima University
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Fereydooni A, Gorecka J, Xu J, Schindler J, Dardik A. Carotid Endarterectomy and Carotid Artery Stenting for Patients With Crescendo Transient Ischemic Attacks: A Systematic Review. JAMA Surg 2020; 154:1055-1063. [PMID: 31483458 DOI: 10.1001/jamasurg.2019.2952] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
Importance Thromboembolic stroke attributable to an ipsilateral carotid artery plaque is a leading cause of disability in the United States and a major source of morbidity. Randomized clinical trials have demonstrated the efficacy of carotid endarterectomy and carotid stenting at minimizing stroke risk in patients with minor stroke and transient ischemic attack. However, there is no consensus on guidelines for medical management and the timing of revascularization in patients with multiple recurrent episodes of transient ischemic attack over hours or days, an acute neurological event known as crescendo transient ischemic attack. Objective To review the management of and timing of intervention in patients presenting with crescendo transient ischemic attack. Evidence Review This systematic review included all English-language articles published from January 1, 1985, to January 1, 2019, available from PubMed (MEDLINE) and Google Scholar. Articles were excluded if they did not include analysis of patients with symptoms, did not report the timing of intervention after crescendo transient ischemic attack, or mixed analysis of patients with stroke in evolution with patients with crescendo transient ischemic attack. The quality of the evidence was assessed with the modified rating from the Oxford Centre for Evidence-based Medicine. Observations Patients with crescendo transient ischemic attack were found to have a higher risk of stroke or death after carotid endarterectomy compared with patients with a single transient ischemic attack or stable stroke. With medical therapy alone, a considerable number of patients with crescendo transient ischemic attack experience a completed stroke within several months and have a poor prognosis without intervention. Urgent carotid endarterectomy, typically performed within 48 hours of initial presentation, is beneficial in carefully selected patients. There have been several reports of operative treatment within the first 24 hours of presentation; however, review of these reports does not show any additional benefit from emergency treatment. Carotid artery stenting is reserved only for selected patients with prohibitive surgical risk for endarterectomy. The literature does not clearly support any additional benefit of intravenous heparin therapy over mono or dual antiplatelet therapy prior to carotid endarterectomy. Conclusions and Relevance Crescendo transient ischemic attack is best managed with optimal medical management as well as urgent carotid endarterectomy within 2 days of presentation. Surgical endarterectomy appears to be preferred because of the increased embolic potential of bifurcation plaque, whereas stenting is an option for patients with contraindications for surgery. With ongoing advances in cerebrovascular imaging and medical treatment of stroke, there is a need for better evidence to determine the optimal timing and preoperative medical management of patients with crescendo transient ischemic attack.
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Affiliation(s)
- Arash Fereydooni
- Department of Surgery, Yale School of Medicine, Yale University, New Haven, Connecticut
| | - Jolanta Gorecka
- Department of Surgery, Yale School of Medicine, Yale University, New Haven, Connecticut
| | - Jianbiao Xu
- Department of Surgery, Yale School of Medicine, Yale University, New Haven, Connecticut
| | - Joseph Schindler
- Department of Neurology, Yale School of Medicine, Yale University, New Haven, Connecticut
| | - Alan Dardik
- Department of Surgery, Yale School of Medicine, Yale University, New Haven, Connecticut
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Singh N, Marko M, Ospel JM, Goyal M, Almekhlafi M. The Risk of Stroke and TIA in Nonstenotic Carotid Plaques: A Systematic Review and Meta-Analysis. AJNR Am J Neuroradiol 2020; 41:1453-1459. [PMID: 32646945 DOI: 10.3174/ajnr.a6613] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2020] [Accepted: 04/29/2020] [Indexed: 12/13/2022]
Abstract
BACKGROUND Severe carotid stenosis carries a high risk of stroke. However, the risk of stroke with nonstenotic carotid plaques (<50%) is increasingly recognized. PURPOSE We aimed to summarize the risk of TIA or stroke in patients with nonstenotic carotid plaques. DATA SOURCES We performed a comprehensive systematic review and meta-analysis in patients with acute ischemic stroke in whom carotid imaging was performed using MEDLINE and the Cochrane Database, including studies published up to December 2019. STUDY SELECTION Included studies had >10 patients with <50% carotid plaques on any imaging technique and reported the incidence or recurrence of ischemic stroke/TIA. High-risk plaque features and the risk of progression to stenosis >50% were extracted if reported. DATA SYNTHESIS We identified 31 studies reporting on the risk of ipsilateral stroke/TIA in patients with nonstenotic carotid plaques. Twenty-five studies (n = 13,428 participants) reported on first-ever stroke/TIA and 6 studies (n = 122 participants) reported on the recurrence of stroke/TIA. DATA ANALYSIS The incidence of first-ever ipsilateral stroke/TIA was 0.5/100 person-years. The risk of recurrent stroke/TIA was 2.6/100 person-years and increased to 4.9/100 person-years if intraplaque hemorrhage was present. The risk of progression to severe stenosis (>50%) was 2.9/100 person-years (8 studies, n = 448 participants). LIMITATIONS Included studies showed heterogeneity in reporting stroke etiology, the extent of stroke work-up, imaging modalities, and classification systems used for characterizing carotid stenosis. CONCLUSIONS The risk of recurrent stroke/TIA in nonstenotic carotid plaques is not negligible, especially in the presence of high-risk plaque features. Further research is needed to better define the significance of nonstenotic carotid plaques for stroke etiology.
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Affiliation(s)
- N Singh
- From the Departments of Clinical Neurosciences (N.S., M.M., J.M.O., M.G., M.A.), and Diagnostic Imaging (M.G., M.A.), Foothills Medical Center, University of Calgary, Calgary, Alberta, Canada
| | - M Marko
- From the Departments of Clinical Neurosciences (N.S., M.M., J.M.O., M.G., M.A.), and Diagnostic Imaging (M.G., M.A.), Foothills Medical Center, University of Calgary, Calgary, Alberta, Canada.,Department of Neurology (M.M.), Medical University of Vienna, Vienna, Austria
| | - J M Ospel
- From the Departments of Clinical Neurosciences (N.S., M.M., J.M.O., M.G., M.A.), and Diagnostic Imaging (M.G., M.A.), Foothills Medical Center, University of Calgary, Calgary, Alberta, Canada.,Department of Radiology (J.M.O.), University Hospital of Basel, Basel, Switzerland
| | - M Goyal
- From the Departments of Clinical Neurosciences (N.S., M.M., J.M.O., M.G., M.A.), and Diagnostic Imaging (M.G., M.A.), Foothills Medical Center, University of Calgary, Calgary, Alberta, Canada
| | - M Almekhlafi
- From the Departments of Clinical Neurosciences (N.S., M.M., J.M.O., M.G., M.A.), and Diagnostic Imaging (M.G., M.A.), Foothills Medical Center, University of Calgary, Calgary, Alberta, Canada
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Nana PN, Brotis AG, Spanos KT, Kouvelos GN, Matsagkas MI, Giannoukas AD. A systematic review and meta-analysis of carotid artery stenting using the transcervical approach. INT ANGIOL 2020; 39:372-380. [PMID: 32536113 DOI: 10.23736/s0392-9590.20.04434-x] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
Abstract
INTRODUCTION Carotid artery stenting (CAS) via a transcarotid revascularization (TCAR) approach has emerged as an alternative when carotid endarterectomy or conventional CAS is contraindicated. The present study was conducted to assess the feasibility and safety of TCAR in patients with carotid artery stenosis. EVIDENCE ACQUISITION A systematic review of the literature was performed, according to PRISMA guidelines (Preferred Reporting Items for Systematic reviews and Meta-Analyses), using PubMed, EMBASE and CENTRAL databases. The primary outcomes included technical success, perioperative neurological event, myocardial ischemic events, death and their composite. Operational duration, flow reversal time and any local procedure related complication (carotid dissection and cranial nerve injury) were also recorded. EVIDENCE SYNTHESIS Twenty-three studies were included, reporting on 3130 patients, undergoing TCAR. Thirty-five per cent of them were symptomatic. Technical success was 98% (95% CI: 0.97-0.99; P=0.11, I<sup>2</sup>=32%). Early (30-day) new neurological event rate was estimated at 2% (95% CI: 0.01-0.02; P=1.0, I<sup>2</sup>=0%, respectively) while early death rate was 1% (95% CI: 0.00-0.01; P=1.0, I<sup>2</sup>=0%). Myocardial ischemic (MI) event rate was 1% (95% CI, 0.00-0.01, P=0.97, I<sup>2</sup>=6.6%). The composite outcome of neurological event/MI/death at 30-day follow-up was 2% (95% CI: 0.01-0.02, P=0.79, I<sup>2</sup>=14%). Carotid dissection rate during the intervention was 2% (95% CI: 0.01-0.03, P=0.58, I<sup>2</sup>=2.9%) while the post-operatively detected cranial nerve injury rate was 1% (95% CI, 0.00-0.01, P=1.0, I<sup>2</sup>=0%). Regarding the technical aspects of the procedures, operational and flow reversal time were at 73.8 min and 13.7 min, respectively (95% CI: 68.2-79.3, P=0.18, I<sup>2</sup>=37.6% and 95% CI: 11.3-16.1, P=0.48, I<sup>2</sup>=0%, respectively). CONCLUSIONS TCAR is feasible with high technical success rate. The procedure presents low incidence of local complications, neurological events, myocardial complications and mortality during the early postoperative period and should be considered an acceptable alternative for patients treated for carotid artery stenosis.
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Affiliation(s)
- Petroula N Nana
- Department of Vascular Surgery, Faculty of Medicine, School of Health Sciences, University Hospital of Larissa, University of Thessaly, Larissa, Greece -
| | - Alexandros G Brotis
- Department of Neurosurgery, Faculty of Medicine, School of Health Sciences, University Hospital of Larissa, University of Thessaly, Larissa, Greece
| | - Konstantinos T Spanos
- Department of Vascular Surgery, Faculty of Medicine, School of Health Sciences, University Hospital of Larissa, University of Thessaly, Larissa, Greece
| | - George N Kouvelos
- Department of Vascular Surgery, Faculty of Medicine, School of Health Sciences, University Hospital of Larissa, University of Thessaly, Larissa, Greece
| | - Miltiadis I Matsagkas
- Department of Vascular Surgery, Faculty of Medicine, School of Health Sciences, University Hospital of Larissa, University of Thessaly, Larissa, Greece
| | - Athanasios D Giannoukas
- Department of Vascular Surgery, Faculty of Medicine, School of Health Sciences, University Hospital of Larissa, University of Thessaly, Larissa, Greece
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Dakour-Aridi H, Ramakrishnan G, Zarrintan S, Malas MB. Outcomes of transcarotid revascularization with dynamic flow reversal versus carotid endarterectomy in the TCAR Surveillance Project. Semin Vasc Surg 2020; 33:24-30. [DOI: 10.1053/j.semvascsurg.2020.10.001] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
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50
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Borghese O, Pisani A, Lapergue B, Di Centa I. Early Carotid Endarterectomy for Symptomatic Stenosis of Internal Carotid Artery in Patients Affected by Transient Ischemic Attack or Minor-to-Moderate Ischemic Acute Stroke: A Single-Center Experience. Ann Vasc Surg 2020; 65:232-239. [DOI: 10.1016/j.avsg.2019.10.088] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2019] [Revised: 10/28/2019] [Accepted: 10/28/2019] [Indexed: 01/01/2023]
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