1
|
Piechocki M, Przewłocki T, Pieniążek P, Trystuła M, Podolec J, Kabłak-Ziembicka A. A Non-Coronary, Peripheral Arterial Atherosclerotic Disease (Carotid, Renal, Lower Limb) in Elderly Patients-A Review: Part I-Epidemiology, Risk Factors, and Atherosclerosis-Related Diversities in Elderly Patients. J Clin Med 2024; 13:1471. [PMID: 38592280 PMCID: PMC10935176 DOI: 10.3390/jcm13051471] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2024] [Revised: 02/23/2024] [Accepted: 02/29/2024] [Indexed: 04/10/2024] Open
Abstract
Atherosclerosis is a generalized and progressive disease. Ageing is a key risk factor for atherosclerosis progression that is associated with the increased incidence of ischemic events in supplied organs, including stroke, coronary events, limb ischemia, or renal failure. Cardiovascular disease is the leading cause of death and major disability in adults ≥ 75 years of age. Atherosclerotic occlusive disease affects everyday activity and quality of life, and it is associated with reduced life expectancy. Although there is evidence on coronary artery disease management in the elderly, there is insufficient data on the management in older patients presented with atherosclerotic lesions outside the coronary territory. Despite this, trials and observational studies systematically exclude older patients, particularly those with severe comorbidities, physical or cognitive dysfunctions, frailty, or residence in a nursing home. This results in serious critical gaps in knowledge and a lack of guidance on the appropriate medical treatment and referral for endovascular or surgical interventions. Therefore, we attempted to gather data on the prevalence, risk factors, and management strategies in patients with extra-coronary atherosclerotic lesions.
Collapse
Affiliation(s)
- Marcin Piechocki
- Department of Vascular and Endovascular Surgery, The St. John Paul II Hospital, Prądnicka 80, 31-202 Krakow, Poland; (M.P.); (P.P.); (M.T.)
- Department of Cardiac and Vascular Diseases, Institute of Cardiology, Jagiellonian University Medical College, św. Anny 12, 31-007 Krakow, Poland;
| | - Tadeusz Przewłocki
- Department of Cardiac and Vascular Diseases, Institute of Cardiology, Jagiellonian University Medical College, św. Anny 12, 31-007 Krakow, Poland;
- Department of Interventional Cardiology, The St. John Paul II Hospital, Prądnicka 80, 31-202 Krakow, Poland;
| | - Piotr Pieniążek
- Department of Vascular and Endovascular Surgery, The St. John Paul II Hospital, Prądnicka 80, 31-202 Krakow, Poland; (M.P.); (P.P.); (M.T.)
- Department of Cardiac and Vascular Diseases, Institute of Cardiology, Jagiellonian University Medical College, św. Anny 12, 31-007 Krakow, Poland;
| | - Mariusz Trystuła
- Department of Vascular and Endovascular Surgery, The St. John Paul II Hospital, Prądnicka 80, 31-202 Krakow, Poland; (M.P.); (P.P.); (M.T.)
| | - Jakub Podolec
- Department of Interventional Cardiology, The St. John Paul II Hospital, Prądnicka 80, 31-202 Krakow, Poland;
- Department of Interventional Cardiology, Institute of Cardiology, Jagiellonian University Medical College, św. Anny 12, 31-007 Krakow, Poland
| | - Anna Kabłak-Ziembicka
- Department of Interventional Cardiology, Institute of Cardiology, Jagiellonian University Medical College, św. Anny 12, 31-007 Krakow, Poland
- Noninvasive Cardiovascular Laboratory, The St. John Paul II Hospital, Prądnicka 80, 31-202 Krakow, Poland
| |
Collapse
|
2
|
Nishimoto T, Oka F, Okazaki K, Sadahiro H, Oku T, Ishihara H. Safety of Tailored Transfemoral Carotid Artery Stenting for Symptomatic Elderly Patients: A Single Center Observational Study. World Neurosurg 2024; 181:e1038-e1046. [PMID: 37967746 DOI: 10.1016/j.wneu.2023.11.031] [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: 10/03/2023] [Revised: 11/07/2023] [Accepted: 11/08/2023] [Indexed: 11/17/2023]
Abstract
OBJECTIVE Transfemoral carotid artery stenting (TFCAS) in symptomatic elderly patients (≥70 years old) may have a high periprocedural stroke rate. This study was performed to examine whether tailored TFCAS for symptomatic elderly patients is as safe as that for symptomatic nonelderly patients. METHODS The subjects were 185 patients with symptomatic internal carotid artery stenosis. Tailored TFCAS including postoperative management was performed based on preoperative examinations of vascular anatomy, plaque imaging, platelet aggregation activity, and cerebral hemodynamic impairment. The major 30-day perioperative stroke rates were examined. RESULTS The patients included 51 (27.6%) <70 (group Y) and 134 (72.4%) ≥70 (group E) years old. Group E included significantly more cases with an elongated aortic arch, tortuous target lesion, and longer plaques (all P < 0.05). Among all cases, 181 (97.8%) procedures were performed as per preoperative planning. Group E had more frequent use of a proximal embolic protection device and a closed-cell or dual-layer micromesh stent (all P < 0.05). Seven patients (3.8%) had major stroke. Rates of major ischemic stroke (2.0% vs. 3.0%, P = 1.00) and intracranial hemorrhage (2.0% vs. 0.8%, P = 0.48) were low and did not differ significantly between groups Y and E. CONCLUSIONS Symptomatic elderly patients have several unfavorable factors. However, tailored TFCAS for each patient based on preoperative examinations in symptomatic elderly patients may be as safe as that in symptomatic nonelderly patients.
Collapse
Affiliation(s)
- Takuma Nishimoto
- Department of Neurosurgery, Yamaguchi University School of Medicine, Ube, Yamaguchi, Japan.
| | - Fumiaki Oka
- Department of Neurosurgery, Yamaguchi University School of Medicine, Ube, Yamaguchi, Japan
| | - Koki Okazaki
- Department of Neurosurgery, Yamaguchi University School of Medicine, Ube, Yamaguchi, Japan
| | - Hirokazu Sadahiro
- Department of Neurosurgery, Yamaguchi University School of Medicine, Ube, Yamaguchi, Japan
| | - Takayuki Oku
- Department of Neurosurgery, Yamaguchi University School of Medicine, Ube, Yamaguchi, Japan
| | - Hideyuki Ishihara
- Department of Neurosurgery, Yamaguchi University School of Medicine, Ube, Yamaguchi, Japan
| |
Collapse
|
3
|
Vascular Anatomy and Not Age is Responsible for Increased Risk of Complications in Symptomatic Elderly Patients Undergoing Carotid Artery Stenting. World Neurosurg 2019; 128:e513-e521. [PMID: 31048049 DOI: 10.1016/j.wneu.2019.04.187] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2019] [Revised: 04/22/2019] [Accepted: 04/23/2019] [Indexed: 11/22/2022]
Abstract
BACKGROUND Various studies have suggested that age ≥80 years is associated with a higher rate of complications after carotid artery stenting (CAS). The Buffalo Risk Assessment Scale (BRASS) predicts complications in symptomatic patients undergoing CAS. Application of the BRASS has shown the ability to improve patient selection. We used the BRASS system to evaluate whether the higher rate of complications associated with CAS in the elderly is related to vascular anatomy. METHODS A retrospective review of CAS was performed at our institution over 7 years. Demographic information, anatomic characteristics, BRASS categorization, and outcome measures were compared between elderly (≥80 years) and younger patients (<80 years). RESULTS The study included 447 patients: 335 patients (75%) <80 years and 112 patients (25%) ≥80 years. There were significantly more elderly patients in the high-risk BRASS category (P < 0.01), and more young patients in the low-risk BRASS category (P = 0.04). The complication rates in the 2 groups were similar. Older patients were more likely to harbor complex vascular anatomy: they had significantly higher rates of types II and III aortic arches (P = 0.01 and P < 0.01, respectively), higher percentage of tortuous carotid vessels (P < 0.01), and higher rates of hostile anatomy for deployment of distal embolic protection devices (P = 0.02). CONCLUSIONS Complex vascular anatomy, rather than age, is the key factor behind the higher CAS-associated complication rate in the elderly. Complications can be avoided through proper patient selection and stratifying patients based on anatomic characteristics, which can be achieved through the BRASS scoring system.
Collapse
|
4
|
Mohammadian R, Sharifipour E, Taheraghdam A, Mansourizadeh R, Altafi D, Fattahzadeh G, Sariaslani P, Yousefshahi P, Ebrahimzadeh K, Vahedian M, Golzari SEJ. Efficacy of carotid artery stenting on stroke prevention of octogenarians. Clin Neurol Neurosurg 2018; 173:187-193. [PMID: 30165319 DOI: 10.1016/j.clineuro.2018.08.027] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2018] [Revised: 07/15/2018] [Accepted: 08/20/2018] [Indexed: 11/16/2022]
Abstract
OBJECTIVES Octogenarians account for a third of ischemic stroke (IS) patients and applying endovascular carotid artery stenting (CAS), as a secondary prevention, in these patients is challenging. The aim of this study was to evaluate peri-procedural and long term clinical and angiographic impact of CAS on octogenarians. PATIENTS AND METHODS In a prospective study, 102 patients aged over 80 years old with symptomatic internal carotid artery (ICA) stenosis presenting by non-disabling IS or transient ischemic attack and having undergone CAS were evaluated prospectively from January 2012 to July 2016. All patients received standard stroke care during the study follow up period. Peri-procedural complication, cerebrovascular accidents, restenosis in target vessel and mortality rate were recorded and the collected data were analyzed to evaluate safety and durability of CAS in octogenarians. RESULTS 48 (47.06%) males and 54 (52.9%) females with the mean age of 83.39 ± 2.53 (range, 80-88) years were followed in a mean period of 24.5 ± 14.1 months (6-50 months). Success rate of CAS was 100%; whereas, the peri-procedural complication rate was 5.8% (only one patient experienced acute ischemic stroke during the procedure). Restenosis and recurrent cerebrovascular accidents were observed in 3.9% and 9.8% of the cases, respectively. Recurrent cerebrovascular accident leading to death was seen in 2.9% of the cases. The median patient event-free survival was 20 months. CONCLUSION Endovascular CAS seems to be a safe and durable method for secondary prevention in ischemic stroke following symptomatic carotid artery stenosis in octogenarians.
Collapse
Affiliation(s)
- Reza Mohammadian
- Institute of Neuroradiology University Hospital of Zurich, Neuroscience Research Center, Tabriz University of Medical Sciences, Tabriz, Iran
| | - Ehsan Sharifipour
- Neuroscience Research Center of Qom University of Medical Sciences, Iran.
| | | | - Reza Mansourizadeh
- Institute of Neuroradiology University Hospital of Zurich, Neuroscience Research Center, Tabriz University of Medical Sciences, Tabriz, Iran
| | - Davar Altafi
- Neurologist, Ardebil University of Medical Sciences, Iran
| | | | | | | | | | - Mostafa Vahedian
- Clinical Research and Development Center (CRDC), Qom University of Medical Sciences, Qom, Iran
| | - Samad E J Golzari
- Research Center for Evidence Based Medicine, Tabriz University of Medical Sciences, Tabriz, Iran; Road Traffic Injury Research Center, Health Management and Safety Promotion Research Institute, Tabriz University of Medical Sciences, Tabriz, Iran
| |
Collapse
|
5
|
Mesh-covered (Roadsaver) stent as a new treatment modality for symptomatic or high-risk carotid stenosis. ADVANCES IN INTERVENTIONAL CARDIOLOGY 2017; 13:130-134. [PMID: 28798783 PMCID: PMC5545667 DOI: 10.5114/pwki.2017.68139] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2016] [Accepted: 12/18/2016] [Indexed: 11/17/2022] Open
Abstract
Introduction Prevention of periprocedural stroke has a crucial role in carotid artery stenting (CAS) procedures. Aim To assess retrospectively 30-day safety and effectiveness of 41 procedures of internal and common carotid artery stenting using the Roadsaver double nitinol layer micromesh stent in 40 non-consecutive patients with symptomatic or high-risk carotid artery stenosis. Material and methods The patients were men (n = 31) and women (n = 9); mean age was 67.8 ±7.9 years. Femoral access was used in 39 cases, whereas radial access was used in 2. Proximal (n = 27) or distal (n = 14) embolic neuroprotection was used. Results The Roadsaver stents (nominal diameter 7, 8 or 9 mm, length 25 or 30 mm) were implanted successfully in all cases. One minor stroke occurred after common carotid artery intubation with a guiding catheter (before stent deployment) and one transient postprocedural ischemic attack (TIA) of the ipsilateral cerebral hemisphere was observed. Internal/common carotid artery stenosis severity was evaluated by duplex Doppler. Maximal peak systolic velocity (PSV) before CAS was in the range: 2.0–7.0 m/s, mean: 3.9 ±1.0 m/s, at 24–48 h after stenting mean PSV was 1.1 ±0.4 m/s (p < 0.05), and at 30 days 1.1 ±0.3 m/s (p < 0.05). Maximal end-diastolic velocity (EDV) was 0.85–3.5 m/s, mean 1.4 ±0.5 m/s, at 24–48 h after stenting mean EDV was 0.3 ±0.1 m/s (p < 0.05), and at 30 days 0.4 ±0.1 m/s (p < 0.05). No restenosis or thrombosis was observed. Angiographic stenosis decreased from 82.9 ±9.1% (range: 61–97%) to 19.3 ±7.3% (range: 0–34%) (p < 0.05). Conclusions The CAS using the Roadsaver stent seems to be safe and effective. Further studies involving larger patient populations and longer follow-up are needed.
Collapse
|
6
|
Fanous AA, Natarajan SK, Jowdy PK, Dumont TM, Mokin M, Yu J, Goldstein A, Wach MM, Budny JL, Hopkins LN, Snyder KV, Siddiqui AH, Levy EI. High-Risk Factors in Symptomatic Patients Undergoing Carotid Artery Stenting With Distal Protection. Neurosurgery 2015; 77:531-42; discussion 542-3. [DOI: 10.1227/neu.0000000000000871] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
Abstract
BACKGROUND:
Demographics and vascular anatomy may play an important role in predicting periprocedural complications in symptomatic patients undergoing carotid artery stenting (CAS).
OBJECTIVE:
To predict factors associated with increased risk of complications in symptomatic patients undergoing CAS and to devise a CAS scoring system that predicts such complications in this patient population.
METHODS:
A retrospective study was conducted that included patients who underwent CAS for symptomatic carotid stenosis during a 3-year period. Demographics and anatomic characteristics were subsequently correlated with 30-day outcome measures.
RESULTS:
A total of 221 patients were included in the study. The cumulative rate of periprocedural complications was 7.2%, including stroke (3.2%), myocardial infarction (3.2%), and death (1.4%). Renal disease increased the risk of all complications. National Institutes of Health Stroke Scale score ≥10 at presentation, difficult femoral access, and diseased calcified aortic arch increased the risk of stroke and all complications. Type III aortic arch correlated with increased risk of stroke. Pseudo-occlusion and concentric calcification of the carotid artery increased the risk of myocardial infarction, death, and all complications. Carotid tortuosity and anatomy hostile to the deployment of distal protection devices increased the risk of stroke, myocardial infarction, death, and all complications.
CONCLUSION:
Our results suggest that CAS should be avoided in patients with multiple anatomic risk factors. High presenting National Institutes of Health Stroke Scale score and renal disease also increase the complication risk. The CAS scoring system devised here is simple, reproducible, and clinically valuable in predicting complications risk in symptomatic patients undergoing CAS.
Collapse
Affiliation(s)
- Andrew A. Fanous
- Department of Neurosurgery, School of Medicine and Biomedical Sciences
- Department of Neurosurgery, Gates Vascular Institute, Kaleida Health, Buffalo, New York
| | - Sabareesh K. Natarajan
- Department of Neurosurgery, School of Medicine and Biomedical Sciences
- Department of Neurosurgery, Gates Vascular Institute, Kaleida Health, Buffalo, New York
| | - Patrick K. Jowdy
- Department of Neurosurgery, School of Medicine and Biomedical Sciences
- Department of Neurosurgery, Gates Vascular Institute, Kaleida Health, Buffalo, New York
| | - Travis M. Dumont
- Department of Neurosurgery, School of Medicine and Biomedical Sciences
- Department of Neurosurgery, Gates Vascular Institute, Kaleida Health, Buffalo, New York
- Division of Neurosurgery, Department of Surgery, University of Arizona, Tucson, Arizona
| | - Maxim Mokin
- Department of Neurosurgery, School of Medicine and Biomedical Sciences
- Department of Neurosurgery, Gates Vascular Institute, Kaleida Health, Buffalo, New York
- Department of Neurosurgery, University of South Florida, Tampa, Florida
| | | | - Adam Goldstein
- Department of Neurosurgery, School of Medicine and Biomedical Sciences
- Department of Neurosurgery, Gates Vascular Institute, Kaleida Health, Buffalo, New York
| | - Michael M. Wach
- Department of Neurosurgery, School of Medicine and Biomedical Sciences
- Department of Neurosurgery, Gates Vascular Institute, Kaleida Health, Buffalo, New York
| | - James L. Budny
- Department of Neurosurgery, School of Medicine and Biomedical Sciences
- Department of Neurosurgery, Gates Vascular Institute, Kaleida Health, Buffalo, New York
| | - L. Nelson Hopkins
- Department of Neurosurgery, School of Medicine and Biomedical Sciences
- Department of Neurosurgery, Gates Vascular Institute, Kaleida Health, Buffalo, New York
- Department of Radiology, School of Medicine and Biomedical Sciences
- Toshiba Stroke and Vascular Research Center, University at Buffalo, State University of New York, Buffalo, New York
- Jacobs Institute, Buffalo, New York
| | - Kenneth V. Snyder
- Department of Neurosurgery, School of Medicine and Biomedical Sciences
- Department of Neurosurgery, Gates Vascular Institute, Kaleida Health, Buffalo, New York
- Department of Radiology, School of Medicine and Biomedical Sciences
- Toshiba Stroke and Vascular Research Center, University at Buffalo, State University of New York, Buffalo, New York
- Department of Neurology, School of Medicine and Biomedical Sciences
| | - Adnan H. Siddiqui
- Department of Neurosurgery, School of Medicine and Biomedical Sciences
- Department of Neurosurgery, Gates Vascular Institute, Kaleida Health, Buffalo, New York
- Department of Radiology, School of Medicine and Biomedical Sciences
- Toshiba Stroke and Vascular Research Center, University at Buffalo, State University of New York, Buffalo, New York
- Jacobs Institute, Buffalo, New York
| | - Elad I. Levy
- Department of Neurosurgery, School of Medicine and Biomedical Sciences
- Department of Neurosurgery, Gates Vascular Institute, Kaleida Health, Buffalo, New York
- Department of Radiology, School of Medicine and Biomedical Sciences
- Toshiba Stroke and Vascular Research Center, University at Buffalo, State University of New York, Buffalo, New York
| |
Collapse
|
7
|
Morr S, Lin N, Siddiqui AH. Carotid artery stenting: current and emerging options. MEDICAL DEVICES-EVIDENCE AND RESEARCH 2014; 7:343-55. [PMID: 25349483 PMCID: PMC4208632 DOI: 10.2147/mder.s46044] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Carotid artery stenting technologies are rapidly evolving. Options for endovascular surgeons and interventionists who treat occlusive carotid disease continue to expand. We here present an update and overview of carotid stenting devices. Evidence supporting carotid stenting includes randomized controlled trials that compare endovascular stenting to open surgical endarterectomy. Carotid technologies addressed include the carotid stents themselves as well as adjunct neuroprotective devices. Aspects of stent technology include bare-metal versus covered stents, stent tapering, and free-cell area. Drug-eluting and cutting balloon indications are described. Embolization protection options and new direct carotid access strategies are reviewed. Adjunct technologies, such as intravascular ultrasound imaging and risk stratification algorithms, are discussed. Bare-metal and covered stents provide unique advantages and disadvantages. Stent tapering may allow for a more fitted contour to the caliber decrement between the common carotid and internal carotid arteries but also introduces new technical challenges. Studies regarding free-cell area are conflicting with respect to benefits and associated risk; clinical relevance of associated adverse effects associated with either type is unclear. Embolization protection strategies include distal filter protection and flow reversal. Though flow reversal was initially met with some skepticism, it has gained wider acceptance and may provide the advantage of not crossing the carotid lesion before protection is established. New direct carotid access techniques address difficult anatomy and incorporate sophisticated flow-reversal embolization protection techniques. Carotid stenting is a new and exciting field with rapidly advancing technologies. Embolization protection, low-risk deployment, and lesion assessment and stratification are active areas of research. Ample room remains for further innovations and developments.
Collapse
Affiliation(s)
- Simon Morr
- Department of Neurosurgery, School of Medicine and Biomedical Sciences, Buffalo, NY, USA ; Department of Neurosurgery, Gates Vascular Institute, Kaleida Health, Buffalo, NY, USA
| | - Ning Lin
- Department of Neurosurgery, School of Medicine and Biomedical Sciences, Buffalo, NY, USA ; Department of Neurosurgery, Gates Vascular Institute, Kaleida Health, Buffalo, NY, USA
| | - Adnan H Siddiqui
- Department of Neurosurgery, School of Medicine and Biomedical Sciences, Buffalo, NY, USA ; Department of Radiology, School of Medicine and Biomedical Sciences, Buffalo, NY, USA ; Toshiba Stroke and Vascular Research Center, University at Buffalo, State University of New York, Buffalo, NY, USA ; Department of Neurosurgery, Gates Vascular Institute, Kaleida Health, Buffalo, NY, USA ; Jacobs Institute, Buffalo, NY, USA
| |
Collapse
|
8
|
Jimenez-Gomez E, Cano Sánchez A, Oteros Fernández R, Valenzuela Alvarado S, Bravo-Rodriguez F, Delgado Acosta F. Unprotected carotid artery stenting in symptomatic elderly patients: a single-center experience. J Neurointerv Surg 2014; 7:341-5. [DOI: 10.1136/neurintsurg-2014-011131] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2014] [Accepted: 03/14/2014] [Indexed: 11/04/2022]
|