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Loufopoulos G, Manaki V, Tasoudis P, Meintanopoulos AS, Kouvelos G, Ntaios G, Spanos K. New Ischemic Cerebral Lesions in Postprocedural Magnetic Resonance Imaging in Carotid Artery Stenting Versus Carotid Endarterectomy: A Systematic Review and Meta-Analysis. Ann Vasc Surg 2024; 106:297-311. [PMID: 38825067 DOI: 10.1016/j.avsg.2024.05.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2024] [Revised: 05/12/2024] [Accepted: 05/15/2024] [Indexed: 06/04/2024]
Abstract
BACKGROUND Recent randomized controlled trials (RCTs) have demonstrated similar outcomes in terms of ischemic stroke incidence after carotid endarterectomy (CEA) or carotid artery stenting (CAS) in asymptomatic carotid disease, while CEA seems to be the first option for symptomatic carotid disease. The aim of this meta-analysis is to assess the incidence of silent cerebral microembolization detected by magnetic resonance imaging (MRI) following these procedures. METHODS A systematic search was conducted using PubMed, Scopus, and Cochrane databases, including comparative studies involving symptomatic or asymptomatic patients undergoing either CEA or CAS and reporting on new cerebral ischemic lesions in postoperative MRI. The primary outcome was the newly detected cerebral ischemic lesions. Pooled effect estimates for all outcomes were calculated using the random-effects model. Prespecified random effects metaregression and subgroup analysis were conducted to examine the impact of moderator variables on the presence of new cerebral ischemic lesions. RESULTS 25 studies reporting on a total of 1827 CEA and 1500 CAS interventions fulfilled the eligibility criteria. The incidence of new cerebral ischemic lesions was significantly lower after CEA compared to CAS, regardless of the time of MRI assessment (first 24 hours; OR: 0.33, 95% CI: 0.17-0.64, P < 0.001), (the first 72 hours, OR: 0.25, 95% CI 0.18-0.36, P < 0.001), (generally within a week after the operation; OR: 0.24, 95% CI: 0.17-0.34, P < 0.001). Also, the rate of stroke (OR: 0.38, 95% CI: 0.23-0.63, P < 0.001) and the presence of contralateral new cerebral ischemic lesions (OR: 0.16, 95% CI 0.08-0.32, P < 0.001) were less frequent after CEA. Subgroup analysis based on the study design and the use of embolic protection device during CAS showed consistently lower rates of new lesions after CEA. CONCLUSIONS CEA demonstrates significant lower rates of new silent cerebral microembolization, as detected by MRI in postoperative period compared with CAS.
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Affiliation(s)
- Georgios Loufopoulos
- Cardiothoracic and Vascular Surgery Working Group, Society of Junior Doctors, Athens, Greece; Department of Surgery, Saint Imier Hospital, Saint Imier, Switzerland.
| | - Vasiliki Manaki
- Cardiothoracic and Vascular Surgery Working Group, Society of Junior Doctors, Athens, Greece; Department of Vascular Surgery, Aristotle University of Thessaloniki, AHEPA University General Hospital, Thessaloniki, Greece
| | - Panagiotis Tasoudis
- Cardiothoracic and Vascular Surgery Working Group, Society of Junior Doctors, Athens, Greece; Division of Cardiothoracic Surgery, Department of Surgery, School of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, NC
| | | | - George Kouvelos
- Faculty of Medicine, Department of Vascular Surgery, University Hospital of Larissa, School of Health Sciences, University of Thessaly, Larissa, Greece
| | - George Ntaios
- Faculty of Medicine, Department of Internal Medicine, University Hospital of Larissa, School of Health Sciences, University of Thessaly, Larissa, Greece
| | - Konstantinos Spanos
- Faculty of Medicine, Department of Vascular Surgery, University Hospital of Larissa, School of Health Sciences, University of Thessaly, Larissa, Greece
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Knappich C, Bohmann B, Kirchhoff F, Lohe V, Naher S, Kallmayer M, Eckstein HH, Kuehnl A. Use of an embolic protection device during carotid artery stenting is associated with lower periprocedural risk. J Neurointerv Surg 2024:jnis-2024-021722. [PMID: 38906691 DOI: 10.1136/jnis-2024-021722] [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: 03/20/2024] [Accepted: 05/25/2024] [Indexed: 06/23/2024]
Abstract
OBJECTIVE To investigate associations between individual embolic protection device (EPD) use and respective center policy with periprocedural outcomes after carotid artery stenting (CAS). METHODS This analysis is based on the nationwide German statutory quality assurance database and was funded by Germany's Federal Joint Committee Innovation Fund (G-BA Innovationsfonds, 01VSF19016 ISAR-IQ). According to their policy towards EPD use, hospitals were categorized as routine EPD (>90%), selective EPD (10-90%), or sporadic EPD (<10%) centers. Primary study outcome was in-hospital stroke or death. Univariate and multivariate regression analyses were performed. RESULTS Overall, 19 302 patients who had undergone CAS between 2013 and 2016 were included. The highest in-hospital stroke or death rate was found in sporadic EPD centers, followed by selective and routine EPD centers (3.1% vs 2.9% vs 1.8%; P<0.001). Across the whole cohort, EPD use was associated with a lower in-hospital stroke or death rate (OR=0.60; 95% CI 0.50 to 0.72). In the multivariate regression analysis, EPD use was independently associated with a lower in-hospital stroke rate (aOR=0.66; 95% CI 0.46 to 0.94). Regarding center policy, routine EPD centers showed a significantly lower in-hospital mortality compared with sporadic EPD centers (aOR=0.44; 95% CI 0.22 to 0.88). CONCLUSIONS In a contemporary real-world cohort with low risk of selection bias, EPD use was associated with a lower in-hospital risk of stroke. A center policy of routine EPD use was associated with lower mortality. These data support routine use of EPD during CAS to enhance patient safety.
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Affiliation(s)
- Christoph Knappich
- Department for Vascular and Endovascular Surgery, Klinikum rechts der Isar, Technical University of Munich, Munich, Germany
| | - Bianca Bohmann
- Department for Vascular and Endovascular Surgery, Klinikum rechts der Isar, Technical University of Munich, Munich, Germany
| | - Felix Kirchhoff
- Department for Vascular and Endovascular Surgery, Klinikum rechts der Isar, Technical University of Munich, Munich, Germany
| | - Vanessa Lohe
- Department for Vascular and Endovascular Surgery, Klinikum rechts der Isar, Technical University of Munich, Munich, Germany
| | - Shamsun Naher
- Department for Vascular and Endovascular Surgery, Klinikum rechts der Isar, Technical University of Munich, Munich, Germany
| | - Michael Kallmayer
- Department for Vascular and Endovascular Surgery, Klinikum rechts der Isar, Technical University of Munich, Munich, Germany
| | - Hans-Henning Eckstein
- Department for Vascular and Endovascular Surgery, Klinikum rechts der Isar, Technical University of Munich, Munich, Germany
| | - Andreas Kuehnl
- Department for Vascular and Endovascular Surgery, Klinikum rechts der Isar, Technical University of Munich, Munich, Germany
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Spiliopoulos S, Blanc R, Gandini R, Müller-Hülsbeck S, Reith W, Moschovaki-Zeiger O. CIRSE Standards of Practice on Carotid Artery Stenting. Cardiovasc Intervent Radiol 2024; 47:705-716. [PMID: 38683353 PMCID: PMC11164804 DOI: 10.1007/s00270-024-03707-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/07/2023] [Accepted: 03/06/2024] [Indexed: 05/01/2024]
Abstract
BACKGROUND Carotid artery stenting has been used effectively to treat internal carotid artery stenosis since 1989 (Mathias et al. in World J Surg. 25(3):328-34, 2001), with refined and expanded techniques and tools presently delivering outstanding results in percutaneous endoluminal treatment of carotid artery stenosis. PURPOSE This CIRSE Standards of Practice document is directed at interventional radiologists and details the guidelines for carotid artery stenting, as well as the different implementation techniques. In addition to updating all previously published material on the different clinical indications, it will provide all technical details reflective of European practice for carotid artery stenting. CIRSE Standards of Practice documents do not aim to implement a standard of clinical patient care, but rather to provide a realistic strategy and best practices for the execution of this procedure. METHODS The writing group, which was established by the CIRSE Standards of Practice Committee, consisted of five clinicians with internationally recognised expertise in carotid artery stenting procedures. The writing group reviewed existing literature on carotid artery stenting procedures, performing a pragmatic evidence search using PubMed to select relevant publications in the English language from 2006 to 2022. RESULTS Carotid artery stenting has an established role in the management of internal carotid artery stenosis; this Standards of Practice document provides up-to-date recommendations for its safe performance.
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Affiliation(s)
- Stavros Spiliopoulos
- Interventional Radiology Unit, 2nd Department of Radiology, National and Kapodistrian University of Athens, "Attikon" University General Hospital, Athens, Greece.
| | - Raphaël Blanc
- Department of Interventional Neuroradiology, Foundation Rothschild Hospital, Paris, France
| | - Roberto Gandini
- Diagnostic and Interventional Radiology/Neuroradiology, University of Rome "Tor Vergata", Rome, Italy
| | - Stefan Müller-Hülsbeck
- Diagnostic and Interventional Radiology/Neuroradiology, DIAKO Hospital, Flensburg, Germany
| | - Wolfgang Reith
- Department of Neuroradiology, Saarland University, Homberg, Germany
| | - Ornella Moschovaki-Zeiger
- Interventional Radiology Unit, 2nd Department of Radiology, National and Kapodistrian University of Athens, "Attikon" University General Hospital, Athens, Greece
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Shimohigoshi W, Akimoto T, Ozaki S, Fushimi S, Takagi R, Kawasaki T, Uramaru K, Tatezuki J, Manaka H, Nakai Y, Sakata K, Yamamoto T. Safety and Risk Factors of Carotid Artery Stenting with Simple Distal Filter Protection: A Single-Center Retrospective Study. JOURNAL OF NEUROENDOVASCULAR THERAPY 2024; 18:155-163. [PMID: 38911486 PMCID: PMC11189783 DOI: 10.5797/jnet.oa.2023-0096] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/15/2023] [Accepted: 03/09/2024] [Indexed: 06/25/2024]
Abstract
Objective Carotid artery stenting embolic protection devices offer various options, among which distal filter protection is the simplest and easiest to handle. However, compared to balloon protection systems, distal filter protection has more embolic complications. Therefore, we explored the risk factors of distal filter protection, intending to achieve a safer carotid artery stenting. This retrospective study was conducted to identify prognostic factors following carotid artery stenting with only distal filter protection from July 2010 to June 2021. Methods Information on patient background, procedures and devices, and complications was collected using medical records. The data pertaining to 187 patients were analyzed after excluding the data of patients in whom other protection devices (8 cases) were used. We used FilterWire EZ as the first choice for embolic protection device and SpiderFX when the patients had difficult-to-cross lesions. Results The patients' mean age was 71.9 ± 6.9 years, and 72 (38.5%) were symptomatic. Symptomatic (odds ratio: 2.02, p = 0.035) and difficult-to-cross lesions (odds ratio: 3.63, p = 0.0013) were factors independently associated with symptomatic complications. Conclusion This retrospective single-center study established independent prognostic factors for carotid artery stenting with distal filter protection. For patients with symptomatic lesions and severe stenosis or bends that are difficult to pass through, it is necessary to be careful when performing carotid artery stenting with distal filter protection.
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Affiliation(s)
- Wataru Shimohigoshi
- Department of Neurosurgery, Yokohama City University Medical Center, Yokohama, Kanagawa, Japan
| | - Taisuke Akimoto
- Department of Neurosurgery, Yokohama City University Medical Center, Yokohama, Kanagawa, Japan
- Department of Neurosurgery, Yokohama City University Graduate School of Medicine, Yokohama, Kanagawa, Japan
| | - So Ozaki
- Department of Neurosurgery, Yokohama City University Medical Center, Yokohama, Kanagawa, Japan
- Department of Neurosurgery, Yokohama City University Graduate School of Medicine, Yokohama, Kanagawa, Japan
| | - Shuto Fushimi
- Department of Neurosurgery, Yokohama City University Medical Center, Yokohama, Kanagawa, Japan
- Department of Neurosurgery, Yokohama City University Graduate School of Medicine, Yokohama, Kanagawa, Japan
| | - Ryosuke Takagi
- Department of Neurosurgery, Yokohama City University Medical Center, Yokohama, Kanagawa, Japan
| | - Takafumi Kawasaki
- Department of Neurosurgery, Yokohama City University Medical Center, Yokohama, Kanagawa, Japan
| | - Koichi Uramaru
- Department of Neurosurgery, Yokohama City University Medical Center, Yokohama, Kanagawa, Japan
- Department of Neurosurgery, Yokohama City University Graduate School of Medicine, Yokohama, Kanagawa, Japan
| | - Junya Tatezuki
- Department of Neurosurgery, Yokohama City University Medical Center, Yokohama, Kanagawa, Japan
| | - Hiroshi Manaka
- Department of Neurosurgery, Yokohama City University Medical Center, Yokohama, Kanagawa, Japan
| | - Yasunobu Nakai
- Department of Neurosurgery, Yokohama City University Graduate School of Medicine, Yokohama, Kanagawa, Japan
| | - Katsumi Sakata
- Department of Neurosurgery, Yokohama City University Medical Center, Yokohama, Kanagawa, Japan
| | - Tetsuya Yamamoto
- Department of Neurosurgery, Yokohama City University Graduate School of Medicine, Yokohama, Kanagawa, Japan
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Giannopoulos S, Sagris M, Giannopoulos S, Tzoumas A, Kokkinidis DG, Texakalidis P, Koutsias G, Volteas P, Jing L, Malgor RD. Embolic protection devices for carotid artery stenting: A network meta-analysis. Vascular 2024; 32:447-457. [PMID: 36394946 DOI: 10.1177/17085381221140616] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/17/2024]
Abstract
OBJECTIVES Carotid artery stenting (CAS) is an alternative treatment option for patients at high risk for carotid endarterectomy (CEA) but has been correlated with increased risk for distal embolization and periprocedural stroke despite the use of adjunctive embolic protection devices (EPD). This study compared four types of EPDs and their intra and periprocedural related complications. METHODS A systematic review of the literature was conducted in PubMed/Medline to identify studies that investigated the outcomes of CAS with adjuvant use of EPDs, including Proximal Balloon (PB), Distal Filter (DF), and Distal Balloon (DB) strategy. Continuous flow reversal performed via transcarotid approach by a commercially available device as an embolic protection strategy was intentionally excluded based on its distinct procedural characteristics and lack of availability outside of the United States. This network meta-analysis was performed according to the PRISMA (Preferred Reporting Items for Systematic reviews and Meta-Analyses) guidelines. RESULTS Overall, 45 studies, consisting of 7600 participants satisfied the predetermined search criteria and were included in this network meta-analysis. Overall, 13 studies provided data regarding the number of patients with new ischemic lesions detected in the DW-MRI. DF (OR: 3.15; 95% CI: 1.54-6.44; p = 0.002) and DB (OR: 2.28; 95% CI: 1.58-3.29; p < 0.001) were associated with higher odds of new ischemic lesions compared to PB on DW-MRI imaging. No statistical difference was identified between DB versus DF groups (OR: 1.48; 95% CI: 0.73-2.59; p = 0.317). 36 and 27 studies reported on periprocedural stroke and transient ischemic attack (TIA) rates, respectively, showing similar odds of neurologic adverse events between all three groups. CONCLUSIONS PB deployment during CAS is superior to DF and DB in preventing distal embolization phenomena. However, no statistically significant difference in TIA and stroke rate was found among any of the analyzed EPD groups. Further research is warranted to investigate the association of embolic phenomena on imaging after CAS with clinically significant neurologic deficits.
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Affiliation(s)
- Stefanos Giannopoulos
- Division of Vascular and Endovascular Surgery, Department of Surgery, Stony Brook University Hospital, Stony Brook, NY, USA
| | | | - Spyridon Giannopoulos
- First Department of Surgery, National and Kapodistrian University of Athens, Laikon General Hospital, Athens, Greece
| | - Andreas Tzoumas
- Department of Medicine, University of Cincinnati Health, Cincinnati, OH, USA
| | - Damianos G Kokkinidis
- Section of Cardiovascular Medicine, Yale University/Yale New Haven Hospital, New Haven, CT, USA
| | - Pavlos Texakalidis
- Department of Neurosurgery, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - George Koutsias
- Aristotle University of Thessaloniki, Division of Vascular Surgery, 2(nd) Department of Surgery, Thessaloniki, Greece
| | - Panagiotis Volteas
- Division of Vascular and Endovascular Surgery, Department of Surgery, Stony Brook University Hospital, Stony Brook, NY, USA
| | - Li Jing
- Division of Vascular and Endovascular Surgery, Department of Surgery, Stony Brook University Hospital, Stony Brook, NY, USA
| | - Rafael D Malgor
- Division of Vascular Surgery and Endovascular Therapy, University of Colorado, Anschutz Medical Center, Aurora, CO, USA
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Gabrielli R, Siani A, Smedile G, Rizzo AR, Accrocca F, Bartoli S. Carotid Artery Stenting versus Carotid Endarterectomy in Terms of Neuroprotection DW-MRI Detected and Neuropsychological Assessment Impairment. Ann Vasc Surg 2024; 98:68-74. [PMID: 37392855 DOI: 10.1016/j.avsg.2023.05.046] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2023] [Revised: 05/28/2023] [Accepted: 05/31/2023] [Indexed: 07/03/2023]
Abstract
BACKGROUND Carotid artery stenting (CAS) versus carotid endarterectomy (CEA) is well issue known, but the purpose of this study is to compare CAS versus CEA in terms of asymptomatic Diffusion-weighted magnetic resonance imaging (DW-MRI) demonstrated microembolic scattering of infarction and neuropsychological assessment impairment. METHODS We performed a prospective, observational, cohort study on 211 consecutive carotid revascularizations at our institution. Patients were divided into 2 different cohorts: CEA was performed in n = 116 patients (Group A); CAS was performed in n = 95 (Group B). Adverse events were collected at 30 days and 6 months postoperative. Differences in terms of DW-MRI demonstrated microembolic scattering of infarction were analyzed and considered significative for P ≤ 0.05. Secondary objectives were: major and minor stroke, neuropsychological assessment impairment, death, myocardial infarction (MI). RESULTS CEA was associated with a significative decreased rate of asymptomatic DW-MRI demonstrated microembolic scattering of infarction (13.8% vs. 51%; P = 0.0001) and of 6 months neuropsychological assessments impairment (0.8 vs. 7.4) (P = 0.04) in asymptomatic patients. There was no significant difference between 2 groups in terms of comorbidities. Stroke rates were similar at 30 days (1.7% CEA vs. 4.1% CAS) and 6 months (2.6% CEA vs. 5.3% CAS P = 0.32). There were no differences in terms of central neurological events, death, transient ischemic attack, MI between the groups. The composite end point of stroke/death/MI at 6 months postoperatively was 2.6% vs. 6.3% (P = 0.19). CONCLUSIONS According to these results, CEA achieved better outcomes compared to patients treated by CAS with distal filter in terms of asymptomatic microembolic event and impairment National Institutes of Health Stroke Scale scale and neuropsychological assessments. Limitations of the study lead to limited conclusions only in the specific population and not generalized. Further, comparative randomized studies are warranted.
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Affiliation(s)
- Roberto Gabrielli
- Unit of Vascular, Endovascular and Emergency Vascular Surgery, "S. Eugenio" Hospital, Rome, Italy.
| | - Andrea Siani
- Unit of Vascular, Endovascular and Emergency Vascular Surgery, "S. Eugenio" Hospital, Rome, Italy
| | - Gianluca Smedile
- Unit of Vascular, Endovascular and Emergency Vascular Surgery, "S. Eugenio" Hospital, Rome, Italy
| | - Anna Rita Rizzo
- Unit of Vascular, Endovascular and Emergency Vascular Surgery, "S. Eugenio" Hospital, Rome, Italy
| | - Federico Accrocca
- Unit of Vascular, Endovascular and Emergency Vascular Surgery, "S. Eugenio" Hospital, Rome, Italy
| | - Stefano Bartoli
- Unit of Vascular, Endovascular and Emergency Vascular Surgery, "S. Eugenio" Hospital, Rome, Italy
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Zughaib MT, Chowdhury M, Assaf AD, Aldaoud M, Zughaib ME. Mobile Atheroma in the Left Internal Carotid Artery: A Case of Impending Doom! Cureus 2023; 15:e51181. [PMID: 38283505 PMCID: PMC10811432 DOI: 10.7759/cureus.51181] [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: 12/27/2023] [Indexed: 01/30/2024] Open
Abstract
A 69-year-old male presented for evaluation of a carotid bruit. Carotid ultrasound demonstrated the unique finding of a large, highly mobile atheroma in the proximal left internal carotid artery. The presence of a mobile atheroma confers an even higher risk of stroke, so this presentation posed a dilemma in terms of endovascular versus open surgical management strategies. In patients with carotid artery disease, the risk of stroke is related to plaque rupture and distal embolization. The patient underwent successful carotid stenting without periprocedural complications. Our case reports the unusual occurrence of a highly mobile atheroma as the initial presentation of carotid artery disease treated safely with percutaneous carotid artery stenting.
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Affiliation(s)
- Marc T Zughaib
- Department of Cardiology, Ascension Providence Hospital - Michigan State University College of Human Medicine, Southfield, USA
| | - Medhat Chowdhury
- Department of Cardiology, Ascension Providence Hospital - Michigan State University College of Human Medicine, Southfield, USA
| | - Andrew D Assaf
- Department of Cardiology, Ascension Providence Hospital - Michigan State University College of Human Medicine, Southfield, USA
| | - Mathhar Aldaoud
- Department of Cardiology, Ascension Providence Hospital - Michigan State University College of Human Medicine, Southfield, USA
| | - Marcel E Zughaib
- Department of Cardiology, Ascension Providence Hospital - Michigan State University College of Human Medicine, Southfield, USA
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Miccichè E, Condello F, Cao D, Azzano A, Ioppolo AM, Mangiameli A, Cremonesi A. Procedural embolic protection strategies for carotid artery stenting: current status and future prospects. Expert Rev Med Devices 2023; 20:373-391. [PMID: 37000987 DOI: 10.1080/17434440.2023.2198124] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/03/2023]
Abstract
INTRODUCTION Carotid artery angioplasty and stenting (CAS) is an established procedure to treat carotid artery stenosis for either primary or secondary prevention of stroke. Randomized clinical trials have shown an increased risk of periprocedural cerebrovascular events with CAS compared with carotid endarterectomy (CEA). Several strategies have been proposed to mitigate this risk, including alternative vascular access site, proximal/distal embolic protection devices, and dual-layer stents, among others. AREAS COVERED This review provides a general overview of current embolic protection strategies for CAS. The phases of the procedure which can affect the early risk of stroke and how to reduce it with novel techniques and devices have been discussed. EXPERT OPINION Innovations in device technologies have dramatically improved the safety and efficacy of CAS. To minimize the gap with surgery, a thorough, patient-oriented approach should be pursued. Endovascular technologies and techniques should be selected on an individual basis to address unique lesion characteristics and vascular anatomies. Meticulous pre-procedural planning, both clinical and anatomical, is needed to assess the embolic risk of each procedure. Only by having an in-depth understanding of the wide range of available endovascular devices and techniques, the operator will choose the most appropriate strategy to optimize CAS results.
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Cappuzzo JM, Monteiro A, Waqas M, Baig AA, Popoola DO, Almayman F, Khawar WI, Farkash ZG, Davies JM, Siddiqui AH, Levy EI, Snyder KV. Carotid Artery Stenting Using the Walrus Balloon Guide Catheter With Flow Reversal for Proximal Embolic Protection: Technical Description and Single-Center Case Series. Oper Neurosurg (Hagerstown) 2023; 24:11-16. [PMID: 36251417 DOI: 10.1227/ons.0000000000000442] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2022] [Accepted: 07/12/2022] [Indexed: 01/06/2023] Open
Abstract
BACKGROUND The use of modern transfemoral balloon guide catheters (BGC) for flow reversal during carotid artery stenting is scarcely described in the literature but represents a promising and efficient technique for embolic protection. OBJECTIVE To describe a flow-reversal technique using the Walrus BGC (Q'Apel Medical Inc.) and report our center's experience. METHODS We performed a retrospective analysis of data for consecutive patients aged 18 years or older who underwent elective carotid artery stenting with the use of flow reversal through the Walrus BGC between July 2020 and September 2021. Patient characteristics, procedural details, and clinical follow-up were evaluated. RESULTS One hundred and five patients were included. Mean age was 69.8 ± 9.4 years, and 36 (34.3%) were women. The most common comorbidities were hyperlipidemia (76.2%) and hypertension (57.1%). Fifty-nine (56.2%) patients were symptomatic. Ninety-nine (94.3%) patients had stenosis ≥70%. Contralateral stenosis ≥50% was present in 44 patients (41.9%). Distal filters were used after flow reversal was established in 90 patients (85.7%). Angioplasty was performed in 85 patients (80.9%). Stenting was successful in 100% of cases. No periprocedural transient ischemic attacks (TIAs) or strokes occurred. Stroke occurred in 2 patients (1.9%) during the 30-day follow-up period, resulting in 1 (0.9%) death. CONCLUSION In our experience, this technique was safe, feasible, and efficient, with 100% technical success and no periprocedural thromboembolic complications. More extensive studies are needed to establish the role of proximal protection with flow reversal using modern BGCs.
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Affiliation(s)
- Justin M Cappuzzo
- Department of Neurosurgery, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, Buffalo, New York, USA.,Department of Neurosurgery, Gates Vascular Institute at Kaleida Health, Buffalo, New York, USA
| | - Andre Monteiro
- Department of Neurosurgery, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, Buffalo, New York, USA.,Department of Neurosurgery, Gates Vascular Institute at Kaleida Health, Buffalo, New York, USA
| | - Muhammad Waqas
- Department of Neurosurgery, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, Buffalo, New York, USA.,Department of Neurosurgery, Gates Vascular Institute at Kaleida Health, Buffalo, New York, USA
| | - Ammad A Baig
- Department of Neurosurgery, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, Buffalo, New York, USA.,Department of Neurosurgery, Gates Vascular Institute at Kaleida Health, Buffalo, New York, USA
| | - Daniel O Popoola
- Jacobs School of Medicine, University at Buffalo, Buffalo, New York, USA
| | - Faisal Almayman
- Department of Neurosurgery, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, Buffalo, New York, USA.,Department of Neurosurgery, Gates Vascular Institute at Kaleida Health, Buffalo, New York, USA
| | - Wasiq I Khawar
- Department of Neurosurgery, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, Buffalo, New York, USA
| | - Zoe G Farkash
- Department of Neurosurgery, Gates Vascular Institute at Kaleida Health, Buffalo, New York, USA
| | - Jason M Davies
- Department of Neurosurgery, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, Buffalo, New York, USA.,Department of Neurosurgery, Gates Vascular Institute at Kaleida Health, Buffalo, New York, USA.,Department of Bioinformatics, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, Buffalo, New York, USA.,Canon Stroke and Vascular Research Center, University at Buffalo, Buffalo, New York, USA.,Jacobs Institute, Buffalo, New York, USA
| | - Adnan H Siddiqui
- Department of Neurosurgery, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, Buffalo, New York, USA.,Department of Neurosurgery, Gates Vascular Institute at Kaleida Health, Buffalo, New York, USA.,Canon Stroke and Vascular Research Center, University at Buffalo, Buffalo, New York, USA.,Jacobs Institute, Buffalo, New York, USA.,Department of Radiology, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, Buffalo, New York, USA
| | - Elad I Levy
- Department of Neurosurgery, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, Buffalo, New York, USA.,Department of Neurosurgery, Gates Vascular Institute at Kaleida Health, Buffalo, New York, USA.,Canon Stroke and Vascular Research Center, University at Buffalo, Buffalo, New York, USA.,Jacobs Institute, Buffalo, New York, USA.,Department of Radiology, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, Buffalo, New York, USA
| | - Kenneth V Snyder
- Department of Neurosurgery, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, Buffalo, New York, USA.,Department of Neurosurgery, Gates Vascular Institute at Kaleida Health, Buffalo, New York, USA.,Canon Stroke and Vascular Research Center, University at Buffalo, Buffalo, New York, USA.,Jacobs Institute, Buffalo, New York, USA
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Levy BR, Waqas M, Monteiro A, Cappuzzo JM, Baig AA, Khawar WI, Davies JM, Snyder KV, Siddiqui AH, Riina HA, Levy EI. Not a trifecta: complementary use of carotid artery revascularization techniques in the era of hybrid neurosurgery. J Neurosurg 2023; 138:199-204. [PMID: 35561689 DOI: 10.3171/2022.4.jns22420] [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: 02/18/2022] [Accepted: 04/05/2022] [Indexed: 01/04/2023]
Abstract
OBJECTIVE Carotid stenosis is currently treated by carotid endarterectomy (CEA), carotid artery stenting (CAS), or transcarotid artery revascularization (TCAR). This study sought to add to the literature by providing real-world data comparing the safety and effectiveness associated with the performance of these carotid revascularization techniques by dual-trained neurosurgeons. METHODS The authors performed a retrospective review of carotid stenosis databases at two US centers. Patients treated by CEA, transfemoral CAS, or TCAR for atherosclerotic carotid artery disease were included. Clinical outcomes were compared at 30 days after the procedure. RESULTS Seven hundred eighty patients were included (583 with CAS, 165 with CEA, and 32 with TCAR). Overall, 486 patients (62.3%) were men, and 393 (50.4%) had left-sided carotid stenosis. Most patients (n = 617, 79.1%) had symptomatic disease. Among the three treatment groups, there were no statistically significant differences with respect to 30-day ischemic events (CAS 3.8%, CEA 1.8%, TCAR 6.3%; p = 0.267) or 30-day mortality rates (CAS 3.6%, CEA 2.4%, TCAR 3.1%; p = 0.857). Male sex had significantly lower odds of 30-day transient ischemic attack (TIA) or stroke in both univariable (p = 0.024) and multivariable (p = 0.023) regression models. Increasing age had significantly higher odds of 30-day mortality on univariable (p = 0.006) and multivariable (p = 0.003) regression. Patients with the occurrence of 30-day TIA or stroke also had significantly higher odds of 30-day mortality on univariable (p < 0.001) and multivariable (p < 0.001) regression. CONCLUSIONS This real-world experience reflects the current practice of hybrid neurosurgery at two high-volume tertiary care centers and suggests that all three treatment modalities have comparable safety and effectiveness if patients are properly selected.
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Affiliation(s)
- Bennett R Levy
- 1George Washington University School of Medicine and Health Sciences, Washington, DC
| | - Muhammad Waqas
- 2Department of Neurosurgery, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, New York.,3Department of Neurosurgery, Gates Vascular Institute at Kaleida Health, Buffalo, New York
| | - Andre Monteiro
- 2Department of Neurosurgery, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, New York.,3Department of Neurosurgery, Gates Vascular Institute at Kaleida Health, Buffalo, New York
| | - Justin M Cappuzzo
- 2Department of Neurosurgery, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, New York.,3Department of Neurosurgery, Gates Vascular Institute at Kaleida Health, Buffalo, New York
| | - Ammad A Baig
- 2Department of Neurosurgery, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, New York.,3Department of Neurosurgery, Gates Vascular Institute at Kaleida Health, Buffalo, New York
| | - Wasiq I Khawar
- 3Department of Neurosurgery, Gates Vascular Institute at Kaleida Health, Buffalo, New York
| | - Jason M Davies
- 2Department of Neurosurgery, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, New York.,3Department of Neurosurgery, Gates Vascular Institute at Kaleida Health, Buffalo, New York.,4Department of Bioinformatics, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, New York.,5Canon Stroke and Vascular Research Center, University at Buffalo, New York.,6Jacobs Institute, Buffalo, New York
| | - Kenneth V Snyder
- 2Department of Neurosurgery, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, New York.,3Department of Neurosurgery, Gates Vascular Institute at Kaleida Health, Buffalo, New York.,5Canon Stroke and Vascular Research Center, University at Buffalo, New York.,6Jacobs Institute, Buffalo, New York
| | - Adnan H Siddiqui
- 2Department of Neurosurgery, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, New York.,3Department of Neurosurgery, Gates Vascular Institute at Kaleida Health, Buffalo, New York.,5Canon Stroke and Vascular Research Center, University at Buffalo, New York.,6Jacobs Institute, Buffalo, New York.,7Department of Radiology, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, New York; and
| | - Howard A Riina
- 8Department of Neurological Surgery, New York University Langone Medical Center, New York, New York
| | - Elad I Levy
- 2Department of Neurosurgery, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, New York.,3Department of Neurosurgery, Gates Vascular Institute at Kaleida Health, Buffalo, New York.,5Canon Stroke and Vascular Research Center, University at Buffalo, New York.,6Jacobs Institute, Buffalo, New York.,7Department of Radiology, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, New York; and
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11
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Fioretti V, Gerardi D, Luzi G, Stabile E. Proximal versus distal protection: dissecting clinical trials. Minerva Cardiol Angiol 2022; 70:727-737. [PMID: 36700668 DOI: 10.23736/s2724-5683.22.06233-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Abstract
Carotid artery stenting (CAS) is a valid alternative to conventional carotid endarterectomy for treatment of carotid artery stenosis. Distal embolization of atherosclerotic debris causing cerebrovascular accidents during CAS has been the most significant concern limiting widespread application of CAS technology. A variety of embolic protection devices (EPDs) with different mechanism of action, have been designed to minimize the risk of major embolization causing stroke and their use is recommended by current guidelines. Two general types of EPDs are available: proximal protection devices (PPDs) and distal protection devices (DPDs). However, there is no convincing clinical evidence of the clinical superiority of one device over another. This review will examine the different types of available devices and also innovative devices and techniques, including strengths and weaknesses of each, and present the available evidence and rationale for their routine use during CAS.
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Affiliation(s)
- Vincenzo Fioretti
- Division of Cardiology, Cardiovascular Department, San Carlo Regional Hospital, Potenza, Italy
| | - Donato Gerardi
- Division of Cardiology, Cardiovascular Department, San Carlo Regional Hospital, Potenza, Italy
| | - Giampaolo Luzi
- Division of Cardiac Surgery, Cardiovascular Department, San Carlo Regional Hospital, Potenza, Italy
| | - Eugenio Stabile
- Division of Cardiology, Cardiovascular Department, San Carlo Regional Hospital, Potenza, Italy -
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12
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Cremonesi A, Cao D, Condello F, Carvalho de Campos Martins E. From surgical clamping to endovascular flow arrest/reversal: the concept behind the system. Minerva Cardiol Angiol 2022; 70:709-718. [PMID: 36468764 DOI: 10.23736/s2724-5683.22.06178-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Carotid artery lesions are frequently composed of friable, thrombotic, ulcerated and/or hemorrhagic materials which can embolize during surgical or endovascular interventions. The use of embolic protection devices (EPD) during carotid angioplasty and stenting (CAS) has been proven to be associated with a reduction of the embolic load. Many studies indicate that the clinical results of CAS are comparable with the best surgical series, when EPD are routinely applied. The proximal EPD work by interrupting or reversing the blood flow in the common carotid artery/internal carotid artery (CCA/ICA). Once established the endovascular flow arrest/reversal, these systems have the advantages of promoting a protected crossing of the lesion and blocking both macro-emboli and micro-emboli. Moreover, proximal neuroprotection implies no manipulation of the device in the distal ICA, neither during device deployment nor during device retrieval, and reduces the risk of arterial spasm, dissection, or intimal damage. The choice between transfemoral and transcervical proximal EPD should account for different factors: local availability, operator expertise, and patient characteristics including anatomical features precluding flow arrest/reversal (e.g., incomplete circle of Willis), femoral access (e.g., unfavorable aortic arch anatomy), or transcervical access (e.g., diseased CCA).
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Affiliation(s)
- Alberto Cremonesi
- Interventional Cardiovascular Unit, Humanitas Gavazzeni Hospital, Bergamo, Italy - .,Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, Milan, Italy -
| | - Davide Cao
- Interventional Cardiovascular Unit, Humanitas Gavazzeni Hospital, Bergamo, Italy.,Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, Milan, Italy
| | - Francesco Condello
- Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, Milan, Italy.,IRCCS Humanitas Research Hospital, Rozzano, Milan, Italy
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13
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Foo M, Ren Y, Gajera J, Barras CD, Kok HK, Jhamb A, Abbouchie H, Maingard J, Brooks DM, Asadi H. CaRotid Artery Filtering Technique (CRAFT): A Technique for Carotid Artery Stenting with Intrinsic Embolic Protection. Neurointervention 2021; 16:260-266. [PMID: 34689457 PMCID: PMC8561041 DOI: 10.5469/neuroint.2021.00353] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2021] [Accepted: 10/06/2021] [Indexed: 11/24/2022] Open
Abstract
Purpose Carotid artery stenting (CAS) is an established treatment for symptomatic carotid artery stenosis as an alternative to carotid endarterectomy. A variety of techniques and devices have been devised to minimise periprocedural stroke risk using either proximal or distal embolic protection. This study presents a method of embolic protection during CAS–the CaRotid Artery Filtering Technique (CRAFT). Materials and Methods The CRAFT technique employs aspects of both proximal and distal embolic protection. The CASPER RX stent (MicroVention, Tustin, CA, USA), which is a double-layered, closed-cell, micromesh nitinol stent, is deployed across the carotid artery stenosis with the assistance of a FlowGate balloon guide catheter (Stryker Neurovascular, Fremont, CA, USA). The partially deployed stent acts as a distal filter while the balloon guide is deflated midway during stent deployment to prevent distal plaque embolisation, followed by completion of stent deployment and angioplasty. Results A total of 94 patients underwent CAS using the CRAFT technique between June 2016 and March 2021. Successful stent deployment was achieved in all patients. Preliminary results demonstrated acute stent occlusion in 6 patients (6.4%) and distal embolic stroke in 5 patients (5.3%). The median procedural fluoroscopy time was 34 minutes with an interquartile range of 22 to 55 minutes. Conclusion The CRAFT technique of CAS presented by this study can be applied in the treatment of symptomatic carotid artery stenosis in both emergency and elective procedure settings with a high technical success and low distal embolic stroke risk.
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Affiliation(s)
- Michelle Foo
- Department of Radiology, Austin Hospital, Melbourne, Vic, Australia
| | - Yifan Ren
- Department of Radiology, Austin Hospital, Melbourne, Vic, Australia
| | - Jay Gajera
- Department of Radiology, Alfred Health, Melbourne, Vic, Australia
| | - Christen D Barras
- South Australian Health and Medical Research Institute, University of Adelaide, Adelaide, SA, Australia.,Department of Radiology, Royal Adelaide Hospital, Adelaide, SA, Australia
| | - Hong Kuan Kok
- Interventional Radiology Service, Department of Radiology, Northern Health, Melbourne, Vic, Australia.,School of Medicine, Faculty of Health, Deakin University, Waurn Ponds, Vic, Australia
| | - Ashu Jhamb
- Interventional Radiology Service, Department of Radiology, St Vincent's Hospital, Melbourne, Vic, Australia
| | | | - Julian Maingard
- School of Medicine, Faculty of Health, Deakin University, Waurn Ponds, Vic, Australia.,Interventional Neuroradiology Service, Department of Radiology, Monash Health, Melbourne, Vic, Australia
| | - Duncan Mark Brooks
- Department of Radiology, Austin Hospital, Melbourne, Vic, Australia.,Stroke Theme, The Florey Institute of Neuroscience and Mental Health, University of Melbourne, Melbourne, Vic, Australia
| | - Hamed Asadi
- Department of Radiology, Austin Hospital, Melbourne, Vic, Australia.,School of Medicine, Faculty of Health, Deakin University, Waurn Ponds, Vic, Australia.,Interventional Radiology Service, Department of Radiology, St Vincent's Hospital, Melbourne, Vic, Australia.,Interventional Neuroradiology Service, Department of Radiology, Monash Health, Melbourne, Vic, Australia.,Stroke Theme, The Florey Institute of Neuroscience and Mental Health, University of Melbourne, Melbourne, Vic, Australia
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14
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Saber H, Colby GP. Commentary: Stenting in High-Grade Internal Carotid Artery Stenosis: 2-Dimensional Operative Video. Oper Neurosurg (Hagerstown) 2021; 21:E289-E290. [PMID: 34245151 DOI: 10.1093/ons/opab209] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2021] [Accepted: 05/04/2021] [Indexed: 11/12/2022] Open
Affiliation(s)
- Hamidreza Saber
- Department of Radiology, David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, California, USA
| | - Geoffrey P Colby
- Department of Radiology, David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, California, USA.,Department of Neurosurgery, David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, California, USA
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15
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Transcervical carotid artery revascularization: A systematic review and meta-analysis of outcomes. J Vasc Surg 2021; 74:657-665.e12. [PMID: 33864829 DOI: 10.1016/j.jvs.2021.03.032] [Citation(s) in RCA: 19] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2020] [Accepted: 03/14/2021] [Indexed: 11/21/2022]
Abstract
OBJECTIVE Carotid artery stenosis is considered a determinant factor for cerebrovascular events, estimated to be the cause of 10% to 20% of all ischemic strokes. Transcervical carotid artery revascularization (TCAR) has been offered as an alternative to transfemoral carotid artery stenting and carotid endarterectomy to treat carotid artery stenosis. METHODS We performed a systematic review and meta-analysis of prospective and retrospective studies reporting the outcomes of patients who had undergone TCAR for carotid artery stenosis. The incidence of periprocedural adverse events was calculated. RESULTS A total of 45 studies with 14,588 patients met the predefined eligibility criteria and were included in the present meta-analysis. The technical success rate was 99% (95% confidence interval [CI], 98%-99%). The reasons for technical failure included an inability to cross the lesion and/or failure to deploy the stent. Access site complications occurred in 2% of all cases (95% CI, 1%-2%; 30 studies). Overall, the incidence of cranial nerve (CN) injuries was very rare, with only 33 of 8994 patients experiencing neurologic deficits attributed to CN involvement. Bleeding complications were reported by 20 studies and occurred in 2% (95% CI, 1%-3%) of all cases. The overall periprocedural all-cause mortality and stroke rate was 0.5% and 1.3%, respectively. In-stent restenosis was observed in 4 of 260 patients (1.5%; 7 studies), and early (30-day) reocclusion or acute thrombosis of the target lesion occurred in 12 of 1243 patients (∼1%; 11 studies). CONCLUSIONS The results from the present study have provided significant evidence that TCAR is a very promising and safe carotid revascularization approach with favorable technical success rates associated with low periprocedural stroke and CN injury rates.
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16
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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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17
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Imamura H, Sakai N, Matsumoto Y, Yamagami H, Terada T, Fujinaka T, Yoshimura S, Sugiu K, Ishii A, Matsumaru Y, Izumi T, Oishi H, Higashi T, Iihara K, Kuwayama N, Ito Y, Nakamura M, Hyodo A, Ogasawara K. Clinical trial of carotid artery stenting using dual-layer CASPER stent for carotid endarterectomy in patients at high and normal risk in the Japanese population. J Neurointerv Surg 2020; 13:524-529. [PMID: 32934139 PMCID: PMC8142440 DOI: 10.1136/neurintsurg-2020-016250] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2020] [Revised: 08/27/2020] [Accepted: 08/30/2020] [Indexed: 02/03/2023]
Abstract
BACKGROUND The dual-layer nitinol CASPER stent was designed to prevent plaque prolapse into its strut and periprocedural stroke. OBJECTIVE To conduct a clinical trial for government approval of the device in patients at either high or normal risk for carotid endarterectomy (CEA). METHODS Eligible patients had ≥50% symptomatic stenosis or ≥80% asymptomatic stenosis according to the North American Symptomatic Carotid Endarterectomy Trial methods (peak systolic velocity 130 and 230 cm/s on ultrasonography, respectively). The primary endpoint was the lack of major adverse events (MAEs), defined as death, stroke, and myocardial infarction within 30 days, and ipsilateral stroke within 1 year. The performance goal was set at 90.5%. MAE rates were also compared between the CEA high- and normal-risk groups. RESULTS 140 carotid artery stenting procedures, including 40% of patients at high risk and 60% at normal risk for CEA, were performed in 13 institutes. MAEs occurred in two cases (one intraprocedural and one postprocedural stroke), and the MAE rate was 1.4%. The non-MAE rate was 98.6% according to Kaplan-Meier analysis, which was superior to the previously set performance goal. The deployment success, target lesion revascularization (TLR), in-stent restenosis, and cerebrovascular event rates were 99.3%, 2.4%, 8.5%, and 7.2%, respectively. The MAE rate in patients with normal CEA risk was 1.2%, which was similar to the high-risk CEA group, with no significant difference due to the small number of MAEs. CONCLUSIONS The MAE rate following use of the CASPER stent was low (1.4%). The MAE, deployment success, TLR, in-stenosis, and cerebrovascular event rates were similar to those of previous reports.
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Affiliation(s)
- Hirotoshi Imamura
- Department of Neurosurgery, Kobe City Medical Center General Hospital, Kobe, Japan
| | - Nobuyuki Sakai
- Department of Neurosurgery, Kobe City Medical Center General Hospital, Kobe, Japan
| | - Yasushi Matsumoto
- Department of Neuroendovascular Therapy, Kohnan Hospital, Sendai, Japan
| | - Hiroshi Yamagami
- Division of Stroke Care Unit, National Cerebral and Cardiovascular Center, Suita, Japan
| | - Tomoaki Terada
- Department of Neurosurgery, Showa University Fujigaoka Hospital, Yokohama, Japan
| | - Toshiyuki Fujinaka
- Department of Neurosurgery, National Hospital Organization Osaka National Hospital, Osaka, Japan
| | - Shinichi Yoshimura
- Department of Neurosurgery, Hyogo College of Medicine, Nishinomiya, Japan
| | - Kenji Sugiu
- Department of Neurosurgery, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, Okayama, Japan
| | - Akira Ishii
- Department of Neurosugery, Kyoto University, Kyoto, Japan
| | - Yuji Matsumaru
- Division of Stroke prevention and treatment, Department of Neurosurgery, Faculty of Medicine, University of Tsukuba, Tsukuba, Japan
| | - Takashi Izumi
- Department of Neurosurgery, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Hidenori Oishi
- Department of Neurosurgery, Juntendo University, Faculty of Medicine, Tokyo, Japan
| | - Toshio Higashi
- Department of Neurosurgery, Fukuoka University School of Medicine, Fukuoka, Japan
| | - Koji Iihara
- Department of Neurosurgery, Kyushu University, Graduate School of Medical Sciences, Fukuoka, Japan
| | - Naoya Kuwayama
- Department of Neurosurgery, University of Toyama, Toyama, Japan
| | - Yasushi Ito
- Department of Neurosurgery, Shinrakuen Hospital, Niigata, Japan
| | | | - Akio Hyodo
- Department of Neurosurgery, Dokkyo Medical University Koshigaya Hospital, Koshigaya, Japan
| | - Kuniaki Ogasawara
- Department of Neurosurgery, Iwate Medical University, Morioka, Japan
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18
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Giannopoulos S, Armstrong EJ. WIRION™ embolic protection system for carotid artery stenting and lower extremity endovascular intervention. Future Cardiol 2020; 16:527-538. [PMID: 32253940 DOI: 10.2217/fca-2020-0023] [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] Open
Abstract
Aim: To summarize all available literature regarding the Wirion™ embolic protection system (EPS) and present examples from our center. Materials & methods: A review of literture was performed about the utilization of Wirion EPS. Results: One study was identified investigating the outcomes of Wirion during carotid artery stenting. The study demonstrated 98.3% procedural success with stroke occurring in only 2.5%. Two single arm studies were identified investigating the efficacy of the Wirion filter during lower extremity endovascular interventions. The reported device success ranged from 95.1 to 97.3%. Conclusion: While carotid artery stenting should always be performed with adjunctive EPS in order to decrease the risk of cerebrovascular accidents, the routine use of EPS in femorpopliteal interventions remains an active area of investigation.
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Affiliation(s)
- Stefanos Giannopoulos
- Division of Cardiology, Rocky Mountain Regional VA Medical Center, University of Colorado, Denver, CO 80045, USA
| | - Ehrin J Armstrong
- Division of Cardiology, Rocky Mountain Regional VA Medical Center, University of Colorado, Denver, CO 80045, USA
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19
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Kokkinidis DG, Chaitidis N, Giannopoulos S, Texakalidis P, Haider MN, Aronow HD, Giri JS, Armstrong EJ. Presence of Contralateral Carotid Occlusion Is Associated With Increased Periprocedural Stroke Risk Following CEA but Not CAS: A Meta-analysis and Meta-regression Analysis of 43 Studies and 96,658 Patients. J Endovasc Ther 2020; 27:334-344. [PMID: 32066317 DOI: 10.1177/1526602820904163] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Purpose: To investigate the prognostic role of contralateral carotid artery occlusion (CCO) in perioperative outcomes of patients undergoing carotid artery endarterectomy (CEA) vs carotid artery stenting (CAS). Materials and Methods: The PubMed, Scopus, and Cochrane databases were searched up to September 2018 to identify observational or randomized studies that compared outcomes of carotid revascularization in patients with vs without CCO. Forty-three studies (46 arms) comprising 96,658 patients were selected (75,857 CEA and 20,801 CAS). The CCO group included 9258 patients. Heterogeneity was assessed with the Higgins I2 test. I2>75% indicated significant heterogeneity. A random effects model was used to account for heterogeneity among studies. The results were reported as the odds ratios (ORs) with the 95% confidence intervals (CIs). Meta-regression analysis examined potential confounders. Publication bias was quantified by the Egger method. Results: Carotid revascularization in patients with CCO was associated with an increased risk of 30-day mortality (OR 1.75, 95% CI 1.38 to 2.23, p<0.001; I2=0%), stroke (OR 1.77, 95% CI 1.41 to 2.22, p<0.001; I2=46%), transient ischemic attack (TIA) (OR 2.10, 95% CI 1.34 to 3.27, p=0.001; I2=15%), and the composite endpoint of stroke/death (OR 1.78, 95% CI 1.54 to 2.05, p<0.001; I2=0%). No difference was noted in the risk of perioperative myocardial infarction (OR 0.81, 95% CI 0.50 to 1.31; p=0.388; I2=0%). Subgroup analysis demonstrated that CEA in patients with CCO was associated with an increased risk of stroke (OR 2.07, 95% CI 1.72 to 2.49, p<0.001; I2=14%), death (OR 1.80, 95% CI 1.55 to 2.10, p<0.001; I2=0%), TIA (OR 2.18, 95% CI 1.38 to 3.45, p<0.001; I2=13%), and stroke/death (OR 1.80, 95% CI 1.55 to 2.10, p<0.001; I2=0%), whereas CCO patients who were treated with CAS were at an increased risk for death (OR 1.65, 95% CI 1.07 to 2.60, p=0.023; I2=0%) but not stroke (OR 0.94, 95% CI 0.61 to 1.47; p=0.080; I2=31%) or TIA (OR 1.18, 95% CI 0.18 to 7.55; p=0.861; I2=43%). The meta-regression analysis did not find any significant association for any of the outcomes, and there was no evidence of publication bias. Conclusion: Carotid revascularization outcomes are adversely affected by the presence of CCO. Patients with CCO have a significantly higher risk of periprocedural stroke, death, and TIA. CEA in patients with CCO is associated with an increased risk of perioperative stroke, death, TIA, and death/stroke, while CAS in the presence of a CCO is associated with an increased risk of periprocedural death but not stroke or TIA.
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Affiliation(s)
- Damianos G Kokkinidis
- Division of Cardiology, Rocky Mountain Regional VA Medical Center, University of Colorado, Denver, CO, USA.,Department of Medicine, Jacobi Medical Center, Albert Einstein College of Medicine, Bronx, NY, USA
| | - Nikos Chaitidis
- Department of Medicine, Jacobi Medical Center, Albert Einstein College of Medicine, Bronx, NY, USA
| | - Stefanos Giannopoulos
- Division of Cardiology, Rocky Mountain Regional VA Medical Center, University of Colorado, Denver, CO, USA
| | - Pavlos Texakalidis
- Division of Neurological Surgery, Emory University Hospital, Atlanta, GA, USA
| | - Moosa N Haider
- Vascular Center and Division of Cardiovascular Medicine, University of California, Davis, Sacramento, CA, USA
| | - Herbert D Aronow
- The Warren Alpert Medical School of Brown University and Lifespan Cardiovascular Institute, Providence, RI, USA
| | - Jay S Giri
- Penn Cardiovascular Outcomes, Quality, & Evaluative Research Center, Cardiovascular Medicine Division, Department of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Ehrin J Armstrong
- Division of Cardiology, Rocky Mountain Regional VA Medical Center, University of Colorado, Denver, CO, USA
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Contractor T, Co ML, Cooper JM, Mandapati R, Abudayyeh I. Management of inadvertent lead placement in the left ventricle via a patent foramen ovale: A multidisciplinary approach. HeartRhythm Case Rep 2020; 6:89-93. [PMID: 32099797 PMCID: PMC7026559 DOI: 10.1016/j.hrcr.2019.10.020] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Affiliation(s)
| | - Michael Lawrenz Co
- Loma Linda University Medical Center, Loma Linda, California
- Address reprint requests and correspondence: Dr Michael Lawrenz Co, Loma Linda University Medical Center, 11234 Anderson Street, Loma Linda, CA 92354.
| | | | - Ravi Mandapati
- Loma Linda University Medical Center, Loma Linda, California
| | - Islam Abudayyeh
- Loma Linda University Medical Center, Loma Linda, California
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21
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Shinozaki N, Murakami T, Ohno Y, Nakano M, Fujii T, Nakazawa G, Yoshimachi F, Ikari Y. Effect of high-dose strong statin for preventing periprocedural ischemic complications of carotid artery stenting. Heart Vessels 2020; 35:762-768. [PMID: 31925501 DOI: 10.1007/s00380-019-01552-5] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/01/2019] [Accepted: 12/27/2019] [Indexed: 11/28/2022]
Abstract
Statin therapy has been shown to induce carotid atherosclerotic plaque regression and reduce the periprocedural ischemic complications of carotid artery stenting (CAS). This study assessed the safety and usefulness of pretreatment using a high-dose strong statin (HDSS) to reduce the periprocedural ischemic complications of CAS. We analyzed 117 carotid lesions treated by CAS that were evaluated with magnetic resonance imaging (MRI) within 48 h after the procedure. For 67 lesions, an HDSS (rosuvastatin 20 mg or atorvastatin 40 mg daily) were prescribed from at least 14 days before CAS to at least 14 days after procedure (HDSS group). Clinical and angiographic data, as well as in-hospital outcomes, of the HDSS group were retrospectively compared with 50 lesions with conventional treatment without an HDSS (non-HDSS group). There were no significant differences in the baseline clinical and procedural characteristics between the two groups. There was no side effect related to the HDSS. Stroke rates were similar between the two groups (3.0% in HDSS group vs 8.0% in non-HDSS group, p = 0.22). All were minor strokes. Compared to the non-HDSS group, the HDSS group had a lower frequency of new lesions on diffusion-weighted imaging (DWI) with MRI (25.4% vs 44.0%, p = 0.0345). New ipsilateral DWI-positive rate in the HDSS group was significantly lower than in the non-HDSS group (16.4% vs 34.0%, p = 0.0275). Nonipsilateral (contralateral or posterior circulation) DWI-positive rates were similar between the two groups (13.4% vs 20.0%, p = 0.34). Pretreatment with an HDSS might reduce the periprocedural ischemic complications of CAS.
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Affiliation(s)
- Norihiko Shinozaki
- Department of Cardiology, Tokai University School of Medicine, 143 Shimokasuya, Isehara, Kanagawa, Japan.
| | - Tsutomu Murakami
- Department of Cardiology, Tokai University School of Medicine, 143 Shimokasuya, Isehara, Kanagawa, Japan
| | - Yohei Ohno
- Department of Cardiology, Tokai University School of Medicine, 143 Shimokasuya, Isehara, Kanagawa, Japan
| | - Masataka Nakano
- Department of Cardiology, Tokai University School of Medicine, 143 Shimokasuya, Isehara, Kanagawa, Japan
| | - Toshiharu Fujii
- Department of Cardiology, Tokai University School of Medicine, 143 Shimokasuya, Isehara, Kanagawa, Japan
| | - Gaku Nakazawa
- Department of Cardiology, Tokai University School of Medicine, 143 Shimokasuya, Isehara, Kanagawa, Japan
| | - Fuminobu Yoshimachi
- Department of Cardiology, Tokai University School of Medicine, 143 Shimokasuya, Isehara, Kanagawa, Japan
| | - Yuji Ikari
- Department of Cardiology, Tokai University School of Medicine, 143 Shimokasuya, Isehara, Kanagawa, Japan
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22
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Kim HJ, Rho MH. Massive Cerebral Microemboli after Protected Carotid Artery Angioplasty and Stenting Using a Distal Filter Embolic Protection Device for a Vulnerable Plaque with a Lipid Rich Necrotic Core and Intraplaque Hemorrhage: A Case Report. JOURNAL OF THE KOREAN SOCIETY OF RADIOLOGY 2020; 81:739-745. [PMID: 36238616 PMCID: PMC9431912 DOI: 10.3348/jksr.2020.81.3.739] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/10/2019] [Revised: 09/17/2019] [Accepted: 09/27/2019] [Indexed: 11/21/2022]
Abstract
A major concern associated with carotid artery angioplasty and stenting (CAS) is a periprocedural distal cerebral embolization. To prevent distal embolization, embolic protection devices (EPDs) have been developed. However, the risk of cerebral embolism after protected CAS in patents with a vulnerable plaque is controversial and either a silent or a symptomatic stroke can occur despite the use of EPDs. Here, we report a case of a massive cerebral microemboli after a protected CAS using a distal filter EPD for a vulnerable plaque with a lipid rich necrotic core and intraplaque hemorrhage.
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Affiliation(s)
- Hae-Jung Kim
- Department of Radiology, Kangbuk Samsung Hospital, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Myung-Ho Rho
- Department of Radiology, Kangbuk Samsung Hospital, Sungkyunkwan University School of Medicine, Seoul, Korea
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23
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Morr S, Vakharia K, Fanous AA, Waqas M, Siddiqui AH. Utility of Intravascular Ultrasound During Carotid Angioplasty and Stenting with Proximal Protection. Cureus 2019; 11:e4935. [PMID: 31431840 PMCID: PMC6695231 DOI: 10.7759/cureus.4935] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
Abstract
Carotid artery stenting (CAS) is an established treatment for patients at high-risk for endarterectomy. Patients who undergo CAS have been shown to have periprocedural microembolic events on transcranial Doppler ultrasonography. Flow reversal is often applied in these situations to prevent distal emboli and concurrently allow blood to flush into the common carotid artery. Patients who demonstrate soft plaque morphology that may embolize distally during CAS benefit from flow reversal. Even so, the all-stroke risk in these patients is nearly 1.4%. High-risk patients typically have more difficult plaque morphology; flow reversal decreases the rate of distal emboli but does not offer the intraprocedural visualization seen with intravascular ultrasound (IVUS). In this paper, we illustrate potential periprocedural outcomes associated with stenting of the stenotic carotid bifurcation under flow reversal and how IVUS influenced endovascular management. Three high-risk patients who underwent CAS with direct common carotid artery cutdown approaches due to common carotid ostia disease with flow-reversal proximal embolic protection also had intraprocedural IVUS performed to evaluate plaque morphology and stability before the protection system was removed. Case 1 illustrates no intraluminal thrombus on IVUS, requiring no further intervention after stent placement. Case 2 demonstrates intraluminal thrombus on IVUS requiring a second stent to stabilize plaque. Case 3 shows the inadequate resolution of thrombus after a second stent, which was addressed with balloon angioplasty. In our experience, using IVUS as an adjunct to CAS under proximal embolic protection helped demonstrate plaque morphology and plaque fragmentation after stent placement. These cases illustrate the potential benefit of allowing stabilization of the plaque before flow reversal is stopped.
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Affiliation(s)
- Simon Morr
- Neurosurgery, New York-Presbyterian Hospital-Columbia and Cornell, New York, USA
| | - Kunal Vakharia
- Neurosurgery, Gates Vascular Institute/Kaleida Health, Buffalo, USA
| | - Andrew A Fanous
- Neurosciences, INOVA Medical Group Neurosurgery, Alexandria, USA
| | - Muhammad Waqas
- Neurosurgery, Gates Vascular Institute/Kaleida Health, Buffalo, USA
| | - Adnan H Siddiqui
- Neurosurgery, Jacobs School of Medicine and Biomedical Sciences, Buffalo, USA
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24
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Yerasi C, Heuser RR. You Can but Should You? Alternatives When Embolic Protection Is Difficult in Carotid Stenting. J Endovasc Ther 2019; 26:425. [DOI: 10.1177/1526602819844800] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Affiliation(s)
- Charan Yerasi
- Creighton University School of Medicine, Phoenix, AZ, USA
| | - Richard R. Heuser
- St Luke’s Hospital, University of Arizona College of Medicine, Phoenix, AZ, USA
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25
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Texakalidis P, Chaitidis N, Giannopoulos S, Giannopoulos S, Machinis T, Jabbour P, Rivet D, Reavey-Cantwell J, Rangel-Castilla L. Carotid Revascularization in Older Adults: A Systematic Review and Meta-Analysis. World Neurosurg 2019; 126:656-663.e1. [DOI: 10.1016/j.wneu.2019.02.030] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2018] [Revised: 02/04/2019] [Accepted: 02/06/2019] [Indexed: 11/24/2022]
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26
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Texakalidis P, Giannopoulos S, Kokkinidis DG, Charisis N, Kakkar A, Jabbour P, Rangel-Castilla L, Armstrong EJ, Reavey-Cantwell J. Direct Transcervical Access vs the Transfemoral Approach for Carotid Artery Stenting: A Systematic Review and Meta-Analysis. J Endovasc Ther 2019; 26:219-227. [PMID: 30821193 DOI: 10.1177/1526602819833370] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/19/2023]
Abstract
PURPOSE To examine the safety profile of transcervical access (TCA) in comparison with the transfemoral approach (TFA) in carotid artery stenting. MATERIALS AND METHODS A systematic review and meta-analysis was performed according to current guidelines. Eleven eligible studies including 11,592 patients (10,736 in the TFA group and 856 in the TCA group) were identified through a search of the PubMed, Scopus, and Cochrane databases up to October 2018. A random effects model meta-analysis was conducted, and the I2 statistic was used to assess heterogeneity. Publication bias was assessed using funnel plots and quantified using the Egger method. RESULTS The TFA group had a statistically significantly higher risk of periprocedural (30-day) stroke compared with the TCA group (OR 1.98, 95% CI 1.08 to 3.63, p=0.027; I2=0%). Also, patients in the TFA group had a significantly higher risk of developing new ischemic lesions (OR 2.97, 95% CI 1.48 to 5.96, p=0.002; I2=0%) on diffusion-weighted magnetic resonance imaging (DW-MRI). No differences in terms of transient ischemic attack (OR 1.50, 95% CI 0.73 to 3.10, p=0.268; I2=5.9%), myocardial infarction (OR 0.64, 95% CI 0.30 to 1.35; p=0.242; I2=0%), local hematoma (OR 0.53, 95% CI 0.12 to 2.25, p=0.389; I2=0%), or mortality (OR 1.35, 95% CI 0.62 to 2.92, p=0.449; I2=0%) were identified between the groups. CONCLUSION TCA is associated with a significantly lower risk for periprocedural stroke and DW-MRI ischemic lesions compared with TFA. Other periprocedural outcomes were similar between the groups.
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Affiliation(s)
- Pavlos Texakalidis
- 1 Department of Neurosurgery, School of Medicine, Emory University, Atlanta, GA, USA
| | | | - Damianos G Kokkinidis
- 3 Department of Medicine, Jacobi Medical Center, Albert Einstein College of Medicine, Bronx, NY, USA
| | | | - Amit Kakkar
- 5 Department of Cardiology, Jacobi Medical Center, Albert Einstein College of Medicine, Bronx, NY, USA
| | - Pascal Jabbour
- 6 Department of Neurosurgery, Thomas Jefferson University, Philadelphia, PA, USA
| | | | - Ehrin J Armstrong
- 8 Division of Cardiology, Denver VA Medical Center, University of Colorado, Denver, CO, USA
| | - John Reavey-Cantwell
- 9 Department of Neurosurgery, Virginia Commonwealth University, Richmond, VA, USA
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27
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Dargazanli C, Mahmoudi M, Cappucci M, Collemiche FL, Labreuche J, Habza O, Gascou G, Lefèvre PH, Eker O, Mourand I, Gaillard N, Charif M, Derraz I, Arquizan C, Costalat V. Angiographic Patterns and Outcomes Achieved by Proximal Balloon Occlusion in Symptomatic Carotid Artery Stenosis Stenting. Clin Neuroradiol 2019; 30:363-372. [DOI: 10.1007/s00062-019-00770-8] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2018] [Accepted: 02/15/2019] [Indexed: 11/30/2022]
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28
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Editorial comment: sandwich carotid stenting: too much of a good thing? Eur Radiol 2018; 29:75-76. [PMID: 30377792 DOI: 10.1007/s00330-018-5806-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2018] [Revised: 09/14/2018] [Accepted: 09/27/2018] [Indexed: 02/05/2023]
Abstract
This editorial comment refers to the article "Detection of in-stent protrusion (ISP) by intravascular ultrasound during carotid stenting: usefulness of stent-in-stent placement for ISP" by Okazaki T et al Eur Radiol., July 2018.
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29
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Texakalidis P, Lu VM, Yolcu Y, Kerezoudis P, Alvi MA, Parney IF, Fogelson JL, Bydon M. Impact of Powdered Vancomycin on Preventing Surgical Site Infections in Neurosurgery: A Systematic Review and Meta-analysis. Neurosurgery 2018; 84:569-580. [DOI: 10.1093/neuros/nyy288] [Citation(s) in RCA: 26] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2018] [Accepted: 06/05/2018] [Indexed: 01/21/2023] Open
Affiliation(s)
- Pavlos Texakalidis
- Department of Neurologic Surgery, Mayo Clinic, Rochester, Minnesota
- Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Victor M Lu
- Department of Neurologic Surgery, Mayo Clinic, Rochester, Minnesota
- Mayo Clinic Neuro-Informatics Laboratory, Mayo Clinic, Rochester, Minnesota
| | - Yagiz Yolcu
- Department of Neurologic Surgery, Mayo Clinic, Rochester, Minnesota
- Mayo Clinic Neuro-Informatics Laboratory, Mayo Clinic, Rochester, Minnesota
| | - Panagiotis Kerezoudis
- Department of Neurologic Surgery, Mayo Clinic, Rochester, Minnesota
- Mayo Clinic Neuro-Informatics Laboratory, Mayo Clinic, Rochester, Minnesota
| | - Mohammed Ali Alvi
- Department of Neurologic Surgery, Mayo Clinic, Rochester, Minnesota
- Mayo Clinic Neuro-Informatics Laboratory, Mayo Clinic, Rochester, Minnesota
| | - Ian F Parney
- Department of Neurologic Surgery, Mayo Clinic, Rochester, Minnesota
| | | | - Mohamad Bydon
- Department of Neurologic Surgery, Mayo Clinic, Rochester, Minnesota
- Mayo Clinic Neuro-Informatics Laboratory, Mayo Clinic, Rochester, Minnesota
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