1
|
Tekieli L, Dzierwa K, Grunwald IQ, Mazurek A, Urbanczyk-Zawadzka M, Wiewiorka L, Banys RP, Dabrowski W, Podlasek A, Weglarz E, Stefaniak J, Nizankowski RT, Musialek P. Outcomes in acute carotid-related stroke eligible for mechanical reperfusion: SAFEGUARD-STROKE Registry. THE JOURNAL OF CARDIOVASCULAR SURGERY 2024; 65:231-248. [PMID: 39007556 DOI: 10.23736/s0021-9509.24.13093-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 07/16/2024]
Abstract
BACKGROUND Carotid-related strokes (CRS) are largely unresponsive to intravenous thrombolysis and are often large and disabling. Little is known about contemporary CRS referral pathways and proportion of eligible patients who receive emergency mechanical reperfusion (EMR). METHODS Referral pathways, serial imaging, treatment data, and neurologic outcomes were evaluated in consecutive CRS patients presenting over 18 months in catchment area of a major carotid disease referral center with proximal-protected CAS expertise, on-site neurology, and stroke thrombectomy capability (Acute Stroke of CArotid Artery Bifurcation Origin Treated With Use oF the MicronEt-covered CGUARD Stent - SAFEGUARD-STROKE Registry; companion to SAFEGUARD-STROKE Study NCT05195658). RESULTS Of 101 EMR-eligible patients (31% i.v.-thrombolyzed, 39.5% women, age 39-89 years, 94.1% ASPECTS 9-10, 90.1% pre-stroke mRS 0-1), 57 (56.4%) were EMR-referred. Referrals were either endovascular (Comprehensive Stroke Centre, CSC, 21.0%; Stroke Thrombectomy-Capable CAS Centre, STCC, 70.2%) or to vascular surgery (VS, 1.8%), with >1 referral attempt in 7.0% patients (CSC/VS or VS/CSC or CSC/VS/STCC). Baseline clinical and imaging characteristics were not different between EMR-treated and EMR-untreated patients. EMR was delivered to 42.6% eligible patients (emergency carotid surgery 0%; STCC rejections 0%). On multivariable analysis, non-tandem CRS was a predictor of not getting referred for EMR (OR 0.36; 95%CI 0.14-0.93, P=0.03). Ninety-day neurologic status was profoundly better in EMR-treated patients; mRS 0-2 (83.7% vs. 34.5%); mRS 3-5 (11.6% vs. 53.4%), mRS 6 (4.6% vs. 12.1%); P<0.001 for all. CONCLUSIONS EMR-treatment substantially improves CRS neurologic outcomes but only a minority of EMR-eligible patients receive EMR. To increase the likelihood of brain-saving treatment, EMR-eligible stroke referral and management pathways, including those for CSC/VS-rejected patients, should involve stroke thrombectomy-capable centres with endovascular carotid treatment expertise.
Collapse
Affiliation(s)
- Lukasz Tekieli
- Stroke Thrombectomy-Capable Center, St. John Paul II Hospital, Krakow, Poland -
- Department of Cardiac and Vascular Diseases, Jagiellonian University Medical College, Krakow, Poland -
- Department of Interventional Cardiology, Jagiellonian University Medical College, Krakow, Poland -
| | - Karolina Dzierwa
- Cardiovascular Imaging Laboratory, St. John Paul II Hospital, Krakow, Poland
| | - Iris Q Grunwald
- Division of Imaging Science and Technology, School of Medicine, University of Dundee, Dundee, UK
- Department of Radiology, University of Dundee Ninewells Hospital, Dundee, UK
| | - Adam Mazurek
- Stroke Thrombectomy-Capable Center, St. John Paul II Hospital, Krakow, Poland
- Department of Cardiac and Vascular Diseases, Jagiellonian University Medical College, Krakow, Poland
| | | | - Lukasz Wiewiorka
- Department of Radiology, St. John Paul II Hospital, Krakow, Poland
| | - R Pawel Banys
- Department of Radiology, St. John Paul II Hospital, Krakow, Poland
| | - Wladyslaw Dabrowski
- Department of Interventional Cardiology, Jagiellonian University Medical College, Krakow, Poland
| | - Anna Podlasek
- Tayside Innovation MedTech Ecosystem (TIME), University of Dundee, Dundee, UK
- Precison Imaging Beacon, Radiological Sciences, University of Nottingham, Nottingham, UK
| | - Ewa Weglarz
- Department of Interventional Cardiology, Jagiellonian University Medical College, Krakow, Poland
- Department of Nursing, Faculty of Health Sciences, Jagiellonian University Medical College, Krakow, Poland
| | - Justyna Stefaniak
- Department of Bioinformatics and Telemedicine, Jagiellonian University Medical College, Krakow, Poland
| | - Rafal T Nizankowski
- Quality Promotion in Healthcare, Sano Center for Computational Medicine, Krakow, Poland
| | - Piotr Musialek
- Stroke Thrombectomy-Capable Center, St. John Paul II Hospital, Krakow, Poland
- Department of Cardiac and Vascular Diseases, Jagiellonian University Medical College, Krakow, Poland
| |
Collapse
|
2
|
Kazantsev AN, Korotkikh AV, Unguryan VM, Belov YV. Update in Carotid Disease. Curr Probl Cardiol 2023; 48:101676. [PMID: 36828045 DOI: 10.1016/j.cpcardiol.2023.101676] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2023] [Revised: 02/17/2023] [Accepted: 02/17/2023] [Indexed: 02/24/2023]
Abstract
This review of the literature analyzes publications over the past five years on various problems associated with carotid endarterectomy: 1. Is the eversion or classical technique of surgery with plastic repair of the reconstruction area with a patch more effective? 2. Carotid endarterectomy or carotid angioplasty with stenting is more optimal? 3. When should brain revascularization be performed after the development of ischemic stroke? 4. Should a temporary shunt be used to protect the brain during carotid endarterectomy? 5. How to prevent and treat different types of intraoperative ischemic strokes? 6. What tactics of treatment of patients with combined lesions of the carotid and coronary arteries is more effective? 7. What are the causes and methods of elimination of restenosis of the internal carotid artery known? 8. Is carotid endarterectomy safe in old age?
Collapse
Affiliation(s)
- Anton Nikolaevich Kazantsev
- Kostroma Regional Clinical Hospital named after Korolev E.I., Kostroma, Russian Federation; Kostroma oncological dispensary, Kostroma, Russian Federation.
| | - Alexander Vladimirovich Korotkikh
- Clinic of Cardiac Surgery of the Amur State Medical Academy of the Ministry of Health of Russia, Blagoveshchensk, Russian Federation
| | | | - Yuriy Vladimirovich Belov
- First Moscow State Medical University named after Sechenov, Moscow, Russian Federation; Federal State Budgetary Scientific Institution Russian Scientific Center for Surgery named after Academician B.V. Petrovsky, Moscow, Russian Federation
| |
Collapse
|
3
|
Hebert D, Elder TA, Adel JG. Emergent carotid endarterectomy and mechanical thrombectomy in tandem occlusion. Surg Neurol Int 2022; 13:521. [DOI: 10.25259/sni_740_2022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2022] [Accepted: 10/03/2022] [Indexed: 11/13/2022] Open
Abstract
Background:
Acute tandem occlusions, or occlusions of the extracranial portion of the internal carotid artery (ICA) with concurrent thromboembolism of the intracranial ICA or middle cerebral artery, poses a major clinical challenge, with patients suffering worse outcomes compared to those with single occlusions. Management of these lesions generally includes a combination of mechanical thrombectomy (MT) of the intracranial occlusion and stenting of the extracranial carotid lesion. In this manuscript, we describe a successful surgical method for achieving revascularization of tandem occlusions in the rare circumstance that the proximal lesion cannot be crossed endovascularly to gain intracranial access.
Methods:
Despite using our institution’s standard protocol for achieving revascularization of such lesions, the extracranial occlusion could not be crossed endovascularly, and the case was converted to an emergent carotid endarterectomy (CEA) in the operating room. Once the endarterectomy was complete, intraoperative MT was performed before cervical incision closure to revascularization.
Results:
The patient recovered well postoperatively and was discharged with NIHSS of 2 due to minor facial palsy and minor dysarthria. Thirty-day follow-up revealed resolution of the prior neurologic deficits and an mRS of 1.
Conclusion:
Emergent CEA should be considered in the rare circumstance of being unable to cross the cervical occlusion during management of acute ischemic stroke with tandem occlusion.
Collapse
Affiliation(s)
- Danielle Hebert
- Department of General Surgery, Central Michigan University College of Medicine, Michigan, United States
| | - Theresa A. Elder
- Department of Neurological Surgery, University Hospitals Cleveland Medical Center, Cleveland, Ohio, United States
| | - Joseph G. Adel
- Department of Neuroscience, Ascension St. Mary’s Hospital, Saginaw, Michigan, United States
| |
Collapse
|
4
|
Angle N, Loja M, Angle A, Alam DABNM M, Gerstch JH. Outcomes of Preferential Early Carotid Endarterectomy Following Recent Stroke. Ann Vasc Surg 2022; 83:26-34. [DOI: 10.1016/j.avsg.2022.02.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2021] [Revised: 02/02/2022] [Accepted: 02/14/2022] [Indexed: 11/25/2022]
|
5
|
AbuRahma AF, Avgerinos ED, Chang RW, Darling RC, Duncan AA, Forbes TL, Malas MB, Perler BA, Powell RJ, Rockman CB, Zhou W. The Society for Vascular Surgery implementation document for management of extracranial cerebrovascular disease. J Vasc Surg 2021; 75:26S-98S. [PMID: 34153349 DOI: 10.1016/j.jvs.2021.04.074] [Citation(s) in RCA: 60] [Impact Index Per Article: 20.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2021] [Accepted: 04/28/2021] [Indexed: 12/24/2022]
Affiliation(s)
- Ali F AbuRahma
- Department of Surgery, West Virginia University-Charleston Division, Charleston, WV.
| | - Efthymios D Avgerinos
- Division of Vascular Surgery, University of Pittsburgh School of Medicine, UPMC Hearrt & Vascular Institute, Pittsburgh, Pa
| | - Robert W Chang
- Vascular Surgery, Permanente Medical Group, San Francisco, Calif
| | | | - Audra A Duncan
- Division of Vascular & Endovascular Surgery, University of Western Ontario, London, Ontario, Canada
| | - Thomas L Forbes
- Division of Vascular & Endovascular Surgery, University of Western Ontario, London, Ontario, Canada
| | - Mahmoud B Malas
- Vascular & Endovascular Surgery, University of California San Diego, La Jolla, Calif
| | - Bruce Alan Perler
- Division of Vascular Surgery & Endovascular Therapy, Johns Hopkins, Baltimore, Md
| | | | - Caron B Rockman
- Division of Vascular Surgery, New York University Langone, New York, NY
| | - Wei Zhou
- Division of Vascular Surgery, University of Arizona, Tucson, Ariz
| |
Collapse
|
6
|
Symptomatic Common Carotid Free-Floating Thrombus in a COVID-19 Patient, Case Report and Literature Review. Ann Vasc Surg 2021; 73:122-128. [PMID: 33689754 PMCID: PMC7955774 DOI: 10.1016/j.avsg.2021.02.008] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2021] [Revised: 02/19/2021] [Accepted: 02/22/2021] [Indexed: 11/20/2022]
Abstract
Carotid free-floating thrombus is an uncommon entity that usually presents with neurologic symptoms. Crescendo transient ischemic attack is an accepted indication for urgent carotid endarterectomy. COVID-19 is associated with severe thromboembolic complications. We report the case of a 61-year-old man who developed, 2 weeks after the diagnosis of COVID-19, crescendo transient ischemic attack, complicating a large intraluminal floating thrombus within the right common carotid artery. A carotid thromboendarterectomy under local anesthesia, with patch closure was immediately performed without complications. We conducted a literature review to identify cases of common carotid artery thrombus related to COVID-19. Carotid free-floating thrombus in the common carotid artery is exceptional. However, since the beginning of the COVID-19 pandemic, 15 cases have been published.
Collapse
|
7
|
Fereydooni A, Gorecka J, Xu J, Schindler J, Dardik A. Carotid Endarterectomy and Carotid Artery Stenting for Patients With Crescendo Transient Ischemic Attacks: A Systematic Review. JAMA Surg 2020; 154:1055-1063. [PMID: 31483458 DOI: 10.1001/jamasurg.2019.2952] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
Importance Thromboembolic stroke attributable to an ipsilateral carotid artery plaque is a leading cause of disability in the United States and a major source of morbidity. Randomized clinical trials have demonstrated the efficacy of carotid endarterectomy and carotid stenting at minimizing stroke risk in patients with minor stroke and transient ischemic attack. However, there is no consensus on guidelines for medical management and the timing of revascularization in patients with multiple recurrent episodes of transient ischemic attack over hours or days, an acute neurological event known as crescendo transient ischemic attack. Objective To review the management of and timing of intervention in patients presenting with crescendo transient ischemic attack. Evidence Review This systematic review included all English-language articles published from January 1, 1985, to January 1, 2019, available from PubMed (MEDLINE) and Google Scholar. Articles were excluded if they did not include analysis of patients with symptoms, did not report the timing of intervention after crescendo transient ischemic attack, or mixed analysis of patients with stroke in evolution with patients with crescendo transient ischemic attack. The quality of the evidence was assessed with the modified rating from the Oxford Centre for Evidence-based Medicine. Observations Patients with crescendo transient ischemic attack were found to have a higher risk of stroke or death after carotid endarterectomy compared with patients with a single transient ischemic attack or stable stroke. With medical therapy alone, a considerable number of patients with crescendo transient ischemic attack experience a completed stroke within several months and have a poor prognosis without intervention. Urgent carotid endarterectomy, typically performed within 48 hours of initial presentation, is beneficial in carefully selected patients. There have been several reports of operative treatment within the first 24 hours of presentation; however, review of these reports does not show any additional benefit from emergency treatment. Carotid artery stenting is reserved only for selected patients with prohibitive surgical risk for endarterectomy. The literature does not clearly support any additional benefit of intravenous heparin therapy over mono or dual antiplatelet therapy prior to carotid endarterectomy. Conclusions and Relevance Crescendo transient ischemic attack is best managed with optimal medical management as well as urgent carotid endarterectomy within 2 days of presentation. Surgical endarterectomy appears to be preferred because of the increased embolic potential of bifurcation plaque, whereas stenting is an option for patients with contraindications for surgery. With ongoing advances in cerebrovascular imaging and medical treatment of stroke, there is a need for better evidence to determine the optimal timing and preoperative medical management of patients with crescendo transient ischemic attack.
Collapse
Affiliation(s)
- Arash Fereydooni
- Department of Surgery, Yale School of Medicine, Yale University, New Haven, Connecticut
| | - Jolanta Gorecka
- Department of Surgery, Yale School of Medicine, Yale University, New Haven, Connecticut
| | - Jianbiao Xu
- Department of Surgery, Yale School of Medicine, Yale University, New Haven, Connecticut
| | - Joseph Schindler
- Department of Neurology, Yale School of Medicine, Yale University, New Haven, Connecticut
| | - Alan Dardik
- Department of Surgery, Yale School of Medicine, Yale University, New Haven, Connecticut
| |
Collapse
|
8
|
Gunka I, Krajickova D, Lesko M, Renc O, Raupach J, Jiska S, Lojik M, Chovanec V, Hudak A, Maly R. Outcomes of Urgent Carotid Endarterectomy for Crescendo Transient Ischemic Attacks and Stroke in Evolution. Ann Vasc Surg 2019; 61:185-192. [PMID: 31394223 DOI: 10.1016/j.avsg.2019.05.061] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2019] [Revised: 05/27/2019] [Accepted: 05/29/2019] [Indexed: 11/26/2022]
Abstract
BACKGROUND Carotid endarterectomy (CEA) after an unstable neurological presentation is still a controversial issue. The aim of this study was to evaluate outcomes of urgent (≤48 hr) CEA in patients with crescendo transient ischemic attack (cTIA) or stroke in evolution (SIE). METHODS A retrospective analysis was performed using prospectively collected data from all consecutive neurologically unstable patients who underwent urgent CEA during the period from January 2013 to November 2018. End points were 30-day any stroke and death rate, symptomatic intracerebral hemorrhage (ICH), myocardial infarction (MI), surgical site bleeding requiring intervention, National Institutes of Health Stroke Scale (NIHSS) score variation, and functional outcome at 90 days assessed by the modified Rankin scale (mRS). Patients were evaluated according to clinical presentation (cTIA or SIE). RESULTS A total of 46 neurologically unstable patients with cTIA (20 patients; 43.5%) and SIE (26 patients; 56.5%) were included. The 30-day risk of any stroke or death was 10.0% (2 of 20) in the cTIA group and 7.7% (2 of 26) in the SIE group. No symptomatic ICH or MI was detected after surgery in either study group. A total of 2 patients (4.3%; 1 cTIA, 1 SIE) underwent reoperation for surgical site bleeding. In patients with SIE, the mean NIHSS score on admission was 9.85 ± 5.12. Postoperatively, 22 (84.6%) of the 26 patients with SIE had clinical improvement of their neurological deficit, 3 (11.5%) patients had no change, and 1 (3.8%) patient died. On discharge, the mean NIHSS score was 4.31 ± 6.09 points and was significantly improved compared with NIHSS scores at admission (P < 0.001). At 3 months, 21 patients (80.8%) with SIE had a good clinical outcome (mRS ≤ 2). CONCLUSIONS Urgent CEA in neurologically unstable patients can be performed with acceptable perioperative risks. Moreover, in well-selected patients with SIE, urgent CEA may be associated with significantly improved final functional outcomes.
Collapse
Affiliation(s)
- Igor Gunka
- Department of Surgery, University Hospital Hradec Kralove, Charles University, Faculty of Medicine in Hradec Kralove, Hradec Kralove, Czech Republic.
| | - Dagmar Krajickova
- Department of Neurology, University Hospital Hradec Kralove, Charles University, Faculty of Medicine in Hradec Kralove, Hradec Kralove, Czech Republic
| | - Michal Lesko
- Department of Surgery, University Hospital Hradec Kralove, Charles University, Faculty of Medicine in Hradec Kralove, Hradec Kralove, Czech Republic
| | - Ondrej Renc
- Department of Radiology, University Hospital Hradec Kralove, Charles University, Faculty of Medicine in Hradec Kralove, Hradec Kralove, Czech Republic
| | - Jan Raupach
- Department of Radiology, University Hospital Hradec Kralove, Charles University, Faculty of Medicine in Hradec Kralove, Hradec Kralove, Czech Republic
| | - Stanislav Jiska
- Department of Surgery, University Hospital Hradec Kralove, Charles University, Faculty of Medicine in Hradec Kralove, Hradec Kralove, Czech Republic
| | - Miroslav Lojik
- Department of Radiology, University Hospital Hradec Kralove, Charles University, Faculty of Medicine in Hradec Kralove, Hradec Kralove, Czech Republic
| | - Vendelin Chovanec
- Department of Radiology, University Hospital Hradec Kralove, Charles University, Faculty of Medicine in Hradec Kralove, Hradec Kralove, Czech Republic
| | - Alexander Hudak
- Department of Surgery, University Hospital Hradec Kralove, Charles University, Faculty of Medicine in Hradec Kralove, Hradec Kralove, Czech Republic
| | - Radovan Maly
- 1st Department of Internal Medicine - Cardioangiology, University Hospital Hradec Kralove, Charles University, Faculty of Medicine in Hradec Kralove, Hradec Kralove, Czech Republic
| |
Collapse
|
9
|
Savardekar AR, Narayan V, Patra DP, Spetzler RF, Sun H. Timing of Carotid Endarterectomy for Symptomatic Carotid Stenosis: A Snapshot of Current Trends and Systematic Review of Literature on Changing Paradigm towards Early Surgery. Neurosurgery 2019; 85:E214-E225. [DOI: 10.1093/neuros/nyy557] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2018] [Accepted: 01/31/2019] [Indexed: 11/14/2022] Open
Abstract
Abstract
Carotid revascularization has been recommended as the maximally beneficial treatment for stroke prevention in patients with recently symptomatic carotid stenosis (SCS). The appropriate timing for performing carotid endarterectomy (CEA) within the first 14 d after the occurrence of the index event remains controversial. We aim to provide a snapshot of the pertinent current literature related to the timing of CEA for patients with SCS. A systematic review of literature was conducted to study the timing of CEA for SCS. The guidelines of the Preferred Reporting Items for Systematic Reviews and Meta-analysis (PRISMA) were followed. A total of 63 articles were identified as relevant to this topic. A summary of 15 articles favoring urgent CEA (within 48 h) for SCS within 48 h of index event and 9 articles not favoring urgent CEA is presented. A consensus is still to be achieved on the ideal timing of CEA for SCS within the 14-d window presently prescribed. The current literature suggests that patients who undergo urgent CEA (within 48 h) after nondisabling stroke as the index event have an increased periprocedural risk as compared to those who had transient ischemic attack (TIA) as the index event. Further prospective studies and clinical trials studying this question with separate groups classified as per the index event are required to shed more light on the subject. The current literature points to a changing paradigm towards early carotid surgery, specifically targeted within 48 h if the index event is TIA, and within 7 d if the index event is stroke.
Collapse
Affiliation(s)
- Amey R Savardekar
- Department of Neurosurgery, Louisiana State University Health Sciences Center, Shreveport, Louisiana
| | - Vinayak Narayan
- Department of Neurosurgery, Louisiana State University Health Sciences Center, Shreveport, Louisiana
| | - Devi P Patra
- Department of Neurosurgery, Louisiana State University Health Sciences Center, Shreveport, Louisiana
| | - Robert F Spetzler
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona
| | - Hai Sun
- Department of Neurosurgery, Louisiana State University Health Sciences Center, Shreveport, Louisiana
| |
Collapse
|
10
|
Knappich C, Kuehnl A, Tsantilas P, Schmid S, Breitkreuz T, Kallmayer M, Zimmermann A, Eckstein HH. Patient characteristics and in-hospital outcomes of emergency carotid endarterectomy and carotid stenting after stroke in evolution. J Vasc Surg 2018; 68:436-444.e6. [DOI: 10.1016/j.jvs.2017.10.085] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2017] [Accepted: 10/26/2017] [Indexed: 11/30/2022]
|
11
|
|
12
|
Nakagawa N, Fukawa N, Tsuji K, Nakano N, Murakami S, Nagatsuka K, Kato A. Urgent Carotid Artery Stenting for Carotid-Related Stroke-in-Evolution. Oper Neurosurg (Hagerstown) 2018; 14:9-15. [PMID: 29253285 DOI: 10.1093/ons/opx073] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2016] [Accepted: 03/08/2017] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND Stroke-in-evolution (SIE) is a major outcome determinant in patients with acute ischemic stroke. The benefit of surgery for treatment of carotid artery-related SIE remains controversial. OBJECTIVE To retrospectively evaluate the use of carotid artery stenting (CAS) as a possible alternative treatment in patients with carotid-related SIE. METHODS Ten patients with carotid-related SIE were treated with CAS from May 2005 to December 2014. The mean initial National Institutes of Health Stroke Scale (NIHSS) score was 5.4 ± 4.4. Two patients had total occlusion of the internal carotid artery, and 8 had severe stenosis. The mean interval from symptom onset to clinical deterioration was 2.9 ± 2.9 d. The mean NIHSS score after deterioration was 14.3 ± 4.5. In the hemodynamic assessment using perfusion imaging, the ipsilateral cerebral hemodynamics was impaired in 7 of 8 patients. RESULTS All patients underwent urgent CAS in the acute phase of SIE. Seven patients underwent CAS using flow reversal with or without distal protection. No procedure-related complications occurred in any patients, although 1 patient developed aspiration pneumonia. The mean NIHSS score 7 d after CAS was 4.8 ± 2.3. Six patients (60%) had a modified Rankin scale score of 0 to 2 at discharge. CONCLUSION Urgent CAS for carotid-related SIE with hemodynamic impairment appears to be an effective method for achieving good clinical outcomes.
Collapse
Affiliation(s)
- Nobuhiro Nakagawa
- Department of Neurosurgery, Kindai University Hospital, Osaka, Japan
| | - Norihito Fukawa
- Department of Neurosurgery, Kindai University Hospital, Osaka, Japan
| | - Kiyoshi Tsuji
- Department of Neurosurgery, Kindai University Hospital, Osaka, Japan
| | - Naoki Nakano
- Department of Neurosurgery, Kindai University Hospital, Osaka, Japan
| | - Saori Murakami
- Department of Neurosurgery, Kindai University Hospital, Osaka, Japan
| | | | - Amami Kato
- Department of Neurosurgery, Kindai University Hospital, Osaka, Japan
| |
Collapse
|
13
|
Vasconcelos V, Cassola N, da Silva EMK, Baptista‐Silva JCC. Immediate versus delayed treatment for recently symptomatic carotid artery stenosis. Cochrane Database Syst Rev 2016; 9:CD011401. [PMID: 27611108 PMCID: PMC6457772 DOI: 10.1002/14651858.cd011401.pub2] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
Abstract
BACKGROUND The timing of surgery for recently symptomatic carotid artery stenosis remains controversial. Early cerebral revascularization may prevent a disabling or fatal ischemic recurrence, but it may also increase the risk of hemorrhagic transformation, or of dislodging a thrombus. This review examined the randomized controlled evidence that addressed whether the increased risk of recurrent events outweighed the increased benefit of an earlier intervention. OBJECTIVES To assess the risks and benefits of performing very early cerebral revascularization (within two days) compared with delayed treatment (after two days) for people with recently symptomatic carotid artery stenosis. SEARCH METHODS We searched the Cochrane Stroke Group Trials Register in January 2016, the Cochrane Central Register of Controlled Trials (CENTRAL; The Cochrane Library 2016, Issue 1), MEDLINE (1948 to 26 January 2016), EMBASE (1974 to 26 January 2016), LILACS (1982 to 26 January 2016), and trial registers (from inception to 26 January 2016). We also handsearched conference proceedings and journals, and searched reference lists. There were no language restrictions. We contacted colleagues and pharmaceutical companies to identify further studies and unpublished trials. SELECTION CRITERIA All completed, truly randomized trials (RCT) that compared very early cerebral revascularization (within two days) with delayed treatment (after two days) for people with recently symptomatic carotid artery stenosis. DATA COLLECTION AND ANALYSIS We independently selected trials for inclusion according to the above criteria, assessed risk of bias for each trial, and performed data extraction. We utilized an intention-to-treat analysis strategy. MAIN RESULTS We identified one RCT that involved 40 participants, and addressed the timing of surgery for people with recently symptomatic carotid artery stenosis. It compared very early surgery with surgery performed after 14 days of the last symptomatic event. The overall quality of the evidence was very low, due to the small number of participants from only one trial, and missing outcome data. We found no statistically significant difference between the effects of very early or delayed surgery in reducing the combined risk of stroke and death within 30 days of surgery (risk ratio (RR) 3.32; confidence interval (CI) 0.38 to 29.23; very low-quality evidence), or the combined risk of perioperative death and stroke (RR 0.47; CI 0.14 to 1.58; very low-quality evidence). To date, no results are available to confirm the optimal timing for surgery. AUTHORS' CONCLUSIONS There is currently no high-quality evidence available to support either very early or delayed cerebral revascularization after a recent ischemic stroke. Hence, further randomized trials to identify which patients should undergo very urgent revascularization are needed. Future studies should stratify participants by age group, sex, grade of ischemia, and degree of stenosis. Currently, there is one ongoing RCT that is examining the timing of cerebral revascularization.
Collapse
Affiliation(s)
- Vladimir Vasconcelos
- Universidade Federal de São PauloDepartment of Vascular SurgeryRua Borges Lagoa, 754São PauloBrazil04038‐001
| | - Nicolle Cassola
- Universidade Federal de São PauloDepartment of Vascular SurgeryRua Borges Lagoa, 754São PauloBrazil04038‐001
| | - Edina MK da Silva
- Universidade Federal de São PauloEmergency Medicine and Evidence Based MedicineRua Borges Lagoa 564 cj 64Vl. ClementinoSão PauloSão PauloBrazil04038‐000
| | - Jose CC Baptista‐Silva
- Universidade Federal de São PauloEvidence Based Medicine, Cochrane BrazilRua Borges Lagoa, 564, cj 124São PauloSão PauloBrazil04038‐000
| | | |
Collapse
|
14
|
Loftus IM, Paraskevas KI, Naylor AR. Urgent Carotid Endarterectomy Does Not Increase Risk and Will Prevent More Strokes. Angiology 2016; 68:469-471. [PMID: 27535948 DOI: 10.1177/0003319716664286] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Ian M Loftus
- 1 St George's Vascular Institute, St George's Healthcare NHS Trust, London, United Kingdom
| | - Kosmas I Paraskevas
- 2 Northern Vascular Centre, Freeman Hospital, Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle-upon-Tyne, United Kingdom
| | - A Ross Naylor
- 3 Division of Cardiovascular Sciences, Department of Vascular Surgery, Vascular Research Group, Leicester Royal Infirmary, Leicester, United Kingdom
| |
Collapse
|
15
|
Yang B, Fung A, Pac-Soo C, Ma D. Vascular surgery-related organ injury and protective strategies: update and future prospects. Br J Anaesth 2016; 117:ii32-ii43. [DOI: 10.1093/bja/aew211] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/30/2023] Open
|
16
|
De Rango P, Brown MM, Chaturvedi S, Howard VJ, Jovin T, Mazya MV, Paciaroni M, Manzone A, Farchioni L, Caso V. Summary of Evidence on Early Carotid Intervention for Recently Symptomatic Stenosis Based on Meta-Analysis of Current Risks. Stroke 2015; 46:3423-36. [DOI: 10.1161/strokeaha.115.010764] [Citation(s) in RCA: 55] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2015] [Accepted: 09/14/2015] [Indexed: 12/16/2022]
Abstract
Background and Purpose—
This study aimed to assess the evidence on the periprocedural (<30 days) risks of carotid intervention in relation to timing of procedure in patients with recently symptomatic carotid stenosis.
Methods—
A systematic literature review of studies published in the past 8 years reporting periprocedural stroke/death after carotid endarterectomy (CEA) and carotid stenting (CAS) related to the time between qualifying neurological symptoms and intervention was performed. Pooled estimates of periprocedural risk for patients treated within 0 to 48 hours, 0 to 7 days, and 0 to 15 days were derived with proportional meta-analyses and reported separately for patients with stroke and transient ischemic attack as index events.
Results—
Of 47 studies included, 35 were on CEA, 7 on CAS, and 5 included both procedures. The pooled risk of periprocedural stroke was 3.4% (95% confidence interval [CI], 2.6–4.3) after CEA and 4.8% (95% CI, 2.5–7.8) after CAS performed <15 days; stroke/death rates were 3.8% and 6.9% after CEA and CAS, respectively. Pooled periprocedural stroke risk was 3.3% (95% CI, 2.1–4.6) after CEA and 4.8% (95% CI, 2.5–7.8) after CAS when performed within 0 to 7 days. In hyperacute surgery (<48 hours), periprocedural stroke risk after CEA was 5.3% (95% CI, 2.8–8.4) but with relevant risk differences among patients treated after transient ischemic attack (2.7%; 95% CI, 0.5–6.9) or stroke (8.0%; 95% CI, 4.6–12.2) as index.
Conclusions—
CEA within 15 days from stroke/transient ischemic attack can be performed with periprocedural stroke risk <3.5%. CAS within the same period may carry a stroke risk of 4.8%. Similar periprocedural risks occur after CEA and CAS performed earlier, within 0 to 7 days. Carotid revascularization can be safely performed within the first week (0–7 days) after symptom onset.
Collapse
Affiliation(s)
- Paola De Rango
- From the Unit of Vascular and Endovascular Surgery, Department of Surgical and Biomedical Sciences (P.D.R., A.M., L.F.) and Stroke Unit, Division of Cardiovascular Medicine (M.P., V.C.), Hospital S.M. Misericordia, Perugia, Italy; Department of Brain Repair and Rehabilitation, UCL Institute of Neurology, University College London, London, United Kingdom (M.M.B.); Department of Neurology and Stroke Program, University of Miami Miller School of Medicine, FL (S.C.); Department of Epidemiology, School
| | - Martin M. Brown
- From the Unit of Vascular and Endovascular Surgery, Department of Surgical and Biomedical Sciences (P.D.R., A.M., L.F.) and Stroke Unit, Division of Cardiovascular Medicine (M.P., V.C.), Hospital S.M. Misericordia, Perugia, Italy; Department of Brain Repair and Rehabilitation, UCL Institute of Neurology, University College London, London, United Kingdom (M.M.B.); Department of Neurology and Stroke Program, University of Miami Miller School of Medicine, FL (S.C.); Department of Epidemiology, School
| | - Seemant Chaturvedi
- From the Unit of Vascular and Endovascular Surgery, Department of Surgical and Biomedical Sciences (P.D.R., A.M., L.F.) and Stroke Unit, Division of Cardiovascular Medicine (M.P., V.C.), Hospital S.M. Misericordia, Perugia, Italy; Department of Brain Repair and Rehabilitation, UCL Institute of Neurology, University College London, London, United Kingdom (M.M.B.); Department of Neurology and Stroke Program, University of Miami Miller School of Medicine, FL (S.C.); Department of Epidemiology, School
| | - Virginia J. Howard
- From the Unit of Vascular and Endovascular Surgery, Department of Surgical and Biomedical Sciences (P.D.R., A.M., L.F.) and Stroke Unit, Division of Cardiovascular Medicine (M.P., V.C.), Hospital S.M. Misericordia, Perugia, Italy; Department of Brain Repair and Rehabilitation, UCL Institute of Neurology, University College London, London, United Kingdom (M.M.B.); Department of Neurology and Stroke Program, University of Miami Miller School of Medicine, FL (S.C.); Department of Epidemiology, School
| | - Tudor Jovin
- From the Unit of Vascular and Endovascular Surgery, Department of Surgical and Biomedical Sciences (P.D.R., A.M., L.F.) and Stroke Unit, Division of Cardiovascular Medicine (M.P., V.C.), Hospital S.M. Misericordia, Perugia, Italy; Department of Brain Repair and Rehabilitation, UCL Institute of Neurology, University College London, London, United Kingdom (M.M.B.); Department of Neurology and Stroke Program, University of Miami Miller School of Medicine, FL (S.C.); Department of Epidemiology, School
| | - Michael V. Mazya
- From the Unit of Vascular and Endovascular Surgery, Department of Surgical and Biomedical Sciences (P.D.R., A.M., L.F.) and Stroke Unit, Division of Cardiovascular Medicine (M.P., V.C.), Hospital S.M. Misericordia, Perugia, Italy; Department of Brain Repair and Rehabilitation, UCL Institute of Neurology, University College London, London, United Kingdom (M.M.B.); Department of Neurology and Stroke Program, University of Miami Miller School of Medicine, FL (S.C.); Department of Epidemiology, School
| | - Maurizio Paciaroni
- From the Unit of Vascular and Endovascular Surgery, Department of Surgical and Biomedical Sciences (P.D.R., A.M., L.F.) and Stroke Unit, Division of Cardiovascular Medicine (M.P., V.C.), Hospital S.M. Misericordia, Perugia, Italy; Department of Brain Repair and Rehabilitation, UCL Institute of Neurology, University College London, London, United Kingdom (M.M.B.); Department of Neurology and Stroke Program, University of Miami Miller School of Medicine, FL (S.C.); Department of Epidemiology, School
| | - Alessandra Manzone
- From the Unit of Vascular and Endovascular Surgery, Department of Surgical and Biomedical Sciences (P.D.R., A.M., L.F.) and Stroke Unit, Division of Cardiovascular Medicine (M.P., V.C.), Hospital S.M. Misericordia, Perugia, Italy; Department of Brain Repair and Rehabilitation, UCL Institute of Neurology, University College London, London, United Kingdom (M.M.B.); Department of Neurology and Stroke Program, University of Miami Miller School of Medicine, FL (S.C.); Department of Epidemiology, School
| | - Luca Farchioni
- From the Unit of Vascular and Endovascular Surgery, Department of Surgical and Biomedical Sciences (P.D.R., A.M., L.F.) and Stroke Unit, Division of Cardiovascular Medicine (M.P., V.C.), Hospital S.M. Misericordia, Perugia, Italy; Department of Brain Repair and Rehabilitation, UCL Institute of Neurology, University College London, London, United Kingdom (M.M.B.); Department of Neurology and Stroke Program, University of Miami Miller School of Medicine, FL (S.C.); Department of Epidemiology, School
| | - Valeria Caso
- From the Unit of Vascular and Endovascular Surgery, Department of Surgical and Biomedical Sciences (P.D.R., A.M., L.F.) and Stroke Unit, Division of Cardiovascular Medicine (M.P., V.C.), Hospital S.M. Misericordia, Perugia, Italy; Department of Brain Repair and Rehabilitation, UCL Institute of Neurology, University College London, London, United Kingdom (M.M.B.); Department of Neurology and Stroke Program, University of Miami Miller School of Medicine, FL (S.C.); Department of Epidemiology, School
| |
Collapse
|
17
|
Low Socioeconomic Status is an Independent Risk Factor for Survival After Abdominal Aortic Aneurysm Repair and Open Surgery for Peripheral Artery Disease. Eur J Vasc Endovasc Surg 2015; 50:615-22. [DOI: 10.1016/j.ejvs.2015.07.006] [Citation(s) in RCA: 37] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2015] [Accepted: 07/03/2015] [Indexed: 11/21/2022]
|
18
|
AbuRahma A. Part Two: Against the Motion. Carotid Endarterectomy is not Safer than Stenting in the Hyperacute Period After Onset of Symptoms. Eur J Vasc Endovasc Surg 2015; 49:627-633. [DOI: 10.1016/j.ejvs.2015.03.035] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
|
19
|
Naylor AR, AbuRahma AF. Debate: Whether carotid endarterectomy is safer than stenting in the hyperacute period after onset of symptoms. J Vasc Surg 2015; 61:1642-51. [PMID: 26004334 DOI: 10.1016/j.jvs.2015.02.046] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
The carotid artery has been a regular battleground for debates regarding many issues, including appropriate management of symptomatic and asymptomatic lesions, the conduct, timing, and safety of such interventions, and now, whether endarterectomy or stenting is safer in the hyperacute period. Our discussants agree that, as a prophylactic procedure, a carotid intervention should occur early after index symptoms to prevent as many strokes as possible. However, which intervention is best?
Collapse
Affiliation(s)
- A Ross Naylor
- Vascular Research Group, Division of Cardiovascular Sciences, Leicester Royal Infirmary, Leicester, United Kingdom.
| | - Ali F AbuRahma
- Division of Vascular Surgery & Endovascular Surgery, West Virginia University, Charleston, WVa.
| |
Collapse
|
20
|
Charmoille E, Brizzi V, Lepidi S, Sassoust G, Roullet S, Ducasse E, Midy D, Bérard X. Thirty-day outcome of delayed versus early management of symptomatic carotid stenosis. Ann Vasc Surg 2015; 29:977-84. [PMID: 25765637 DOI: 10.1016/j.avsg.2015.01.013] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2014] [Revised: 01/09/2015] [Accepted: 01/10/2015] [Indexed: 10/23/2022]
Abstract
BACKGROUND The aim of this study was to compare outcomes of early (<15 days) versus delayed carotid endarterectomy (CEA) in symptomatic patients. METHODS All CEA procedures performed for symptomatic carotid stenosis between January 2006 and May 2010 were retrospectively reviewed. Postoperative mortality (within 30 days), stroke, and myocardial infarction (MI) rates were analyzed in the early and delayed CEA groups. RESULTS During the study period, 149 patients were included. Carotid revascularization was performed within 15 days after symptom onset in 62 (41.6%) patients and longer than 15 days after symptom onset in 87 (58.4%) patients. The mean time lapse between onset of neurological symptoms and surgery was 9.3 days (range 1-15) in the early surgery group and 47.9 days (range 16-157) in the delayed surgery group. Thirty-day combined stroke and death rates were, respectively, 1.7% and 3.5% in the early and the delayed surgery groups. Thirty-day combined stroke, death, and MI rates were, respectively, 1.7% and 5.9% in the early and the delayed surgery groups. CONCLUSION During the study period, the reduction of the symptom-to-knife time in application to the carotid revascularization guidelines did not impact our outcomes suggesting that early CEA achieves 30-day mortality and morbidity rates at least equivalent to those of delayed CEA.
Collapse
Affiliation(s)
- Emilie Charmoille
- Vascular Surgery Department, Bordeaux University Hospital, Bordeaux, France; Bordeaux University, Bordeaux, France
| | - Vincenzo Brizzi
- Vascular Surgery Department, Bordeaux University Hospital, Bordeaux, France.
| | - Sandro Lepidi
- Vascular Surgery Department, Padova University Hospital, Padova, Italy
| | - Gérard Sassoust
- Vascular Surgery Department, Bordeaux University Hospital, Bordeaux, France
| | - Stéphanie Roullet
- Vascular Surgery Department, Bordeaux University Hospital, Bordeaux, France
| | - Eric Ducasse
- Vascular Surgery Department, Bordeaux University Hospital, Bordeaux, France; Bordeaux University, Bordeaux, France
| | - Dominique Midy
- Vascular Surgery Department, Bordeaux University Hospital, Bordeaux, France; Bordeaux University, Bordeaux, France
| | - Xavier Bérard
- Vascular Surgery Department, Bordeaux University Hospital, Bordeaux, France; Bordeaux University, Bordeaux, France
| |
Collapse
|
21
|
Merlini T, Péret M, Lhommet P, Debiais S, Marc G, Godard S, Martinez R, Enon B, Picquet J. Is Early Surgical Revascularization of Symptomatic Carotid Stenoses Safe? Ann Vasc Surg 2014; 28:1539-47. [DOI: 10.1016/j.avsg.2014.01.025] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2013] [Revised: 01/27/2014] [Accepted: 01/28/2014] [Indexed: 10/25/2022]
|
22
|
A Retrospective Study on Early Carotid Endarterectomy within 48 Hours after Transient Ischemic Attack and Stroke in Evolution. Ann Vasc Surg 2014; 28:227-38. [DOI: 10.1016/j.avsg.2013.02.015] [Citation(s) in RCA: 42] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2012] [Revised: 02/09/2013] [Accepted: 02/11/2013] [Indexed: 11/20/2022]
|
23
|
Mono ML, Steiger I, Findling O, Jung S, Reinert M, Galimanis A, Kuhlen D, Beck J, El-Koussy M, Brekenfeld C, Schroth G, Fischer U, Nedeltchev K, Mattle HP, Arnold M. Risk of very early recurrent cerebrovascular events in symptomatic carotid artery stenosis. J Neurosurg 2013; 119:1620-6. [DOI: 10.3171/2013.7.jns122128] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Object
The risk of recurrence of cerebrovascular events within the first 72 hours of admission in patients hospitalized with symptomatic carotid artery (CA) stenoses and the risks and benefits of emergency CA intervention within the first hours after the onset of symptoms are not well known. Therefore, the authors aimed to assess 1) the ipsilateral recurrence rate within 72 hours of admission, in the period from 72 hours to 7 days, and after 7 days in patients presenting with nondisabling stroke, transient ischemic attack (TIA), or amaurosis fugax (AF), and with an ipsilateral symptomatic CA stenosis of 50% or more, and 2) the risk of stroke in CA interventions within 48 hours of admission versus the risk in interventions performed after 48 hours.
Methods
Ninety-four patients were included in this study. These patients were admitted to hospital within 48 hours of a nondisabling stroke, TIA, or AF resulting from a symptomatic CA stenosis of 50% or more. The patients underwent carotid endarterectomy (85 patients) or CA stenting (9 patients). At baseline, the cardiovascular risk factors of the patients, the degree of symptomatic CA stenosis, and the type of secondary preventive treatment were assessed. The in-hospital recurrence rate of stroke, TIA, or AF ipsilateral to the symptomatic CA stenosis was determined for the first 72 hours after admission, from 72 hours to 7 days, and after 7 days. Procedure-related cerebrovascular events were also recorded.
Results
The median time from symptom onset to CA intervention was 5 days (interquartile range 3.00–9.25 days). Twenty-one patients (22.3%) underwent CA intervention within 48 hours after being admitted. Overall, 15 recurrent cerebrovascular events were observed in 12 patients (12.8%) in the period between admission and CA intervention: 3 strokes (2 strokes in progress and 1 stroke) (3.2%), 5 TIAs (5.3%), and 1 AF (1.1%) occurred within the first 72 hours (total 9.6%) of admission; 1 TIA (1.1%) occurred between 72 hours and 7 days, and 5 TIAs (5.3%) occurred after more than 7 days. The corresponding actuarial cerebrovascular recurrence rates were 11.4% (within 72 hours of admission), 2.4% (between 72 hours and 7 days), and 7.9% (after 7 days). Among baseline characteristics, no predictive factors for cerebrovascular recurrence were identified.
Procedure-related cerebrovascular events occurred at a rate of 4.3% (3 strokes and 1 TIA), and procedures performed within the first 48 hours and procedures performed after 48 hours had a similar frequency of these events (4.5% vs 4.1%, respectively; p = 0.896).
Conclusions
The in-hospital recurrence of cerebrovascular events was quite low, but all recurrent strokes occurred within 72 hours. The risk of stroke associated with a CA intervention performed within the first 48 hours was not increased compared with that for later interventions. This raises the question of the optimal timing of CA intervention in symptomatic CA stenosis. To answer this question, more data are needed, preferably from large randomized trials.
Collapse
Affiliation(s)
| | | | | | | | | | | | - Dominique Kuhlen
- 5Department of Neurosurgery, Klinikum Rechts der Isar, Technical University Munich, Germany
| | | | - Marwan El-Koussy
- 3Neuroradiology, Inselspital, University Hospital Bern, Switzerland
| | - Caspar Brekenfeld
- 4Department of Neuroradiology, University Hospital Eppendorf, Hamburg; and
| | - Gerhard Schroth
- 3Neuroradiology, Inselspital, University Hospital Bern, Switzerland
| | | | | | | | | |
Collapse
|
24
|
Outcomes of urgent carotid endarterectomy for stable and unstable acute neurologic deficits. J Vasc Surg 2013; 59:440-6. [PMID: 24246539 DOI: 10.1016/j.jvs.2013.08.035] [Citation(s) in RCA: 45] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2013] [Revised: 08/19/2013] [Accepted: 08/20/2013] [Indexed: 12/23/2022]
Abstract
OBJECTIVE The aim of the study was to assess the outcomes of carotid endarterectomy (CEA) performed in an urgent setting on acutely symptomatic patients selected through a very simple protocol. METHODS From January 2002 to January 2012, 193 symptomatic patients underwent CEA. Of these, 90 presented with acute symptoms, and after a congruous carotid stenosis was identified, underwent urgent operations (group 1): 27 patients had transient ischemic attack (group 1A), 52 patients had mild to moderate stroke (group 1B), and 11 patients had stroke in evolution (group 1C). The remaining 103 patients with a nonrecent neurologic deficit were treated by elective surgery in the same period (group 2). End points were 30-day neurologic morbidity and mortality. RESULTS The median delay of urgent CEA (U-CEA) from deficit onset was 48 hours (interquartile range, 13-117 hours). Groups 1 and 2 were comparable in demographics. Acute patients showed a higher rate of stroke at presentation (70% vs 37%; P = .001) and of history of coronary artery disease (30% vs 13.5%; P = .007). Acute patients sustained six postoperative strokes (6.6%). Neurologic outcomes were correlated to clinical presentation: no strokes occurred in group 1A patients, and 5.8% group 1B patients and 27.3% group 1C patients had postoperative stroke (P < .01). Postoperative mortality was 4.4% for U-CEA: one fatal myocardial infarction, one intracranial hemorrhage, and two thromboembolic strokes. Elective patients sustained four postoperative strokes (3.9%), with one death (0.9%) as a consequence of hyperperfusion cerebral edema. U-CEAs performed ≤48 hours from symptom onset had a lower postoperative stroke rate than those performed >48 hours (4.4% vs 8.8%; P = .3). Among patients presenting with a stroke (group 1B), the National Institutes of Health Stroke Scale (NIHSS) assessment at discharge showed improvement in 79% (although only 25% had ≥4 points in reduction), stability in 17%, and deterioration in 4%. Patients with moderate stroke were slightly better in NIHSS improvement than those with mild stroke (median NIHSS variation at discharge, -3 vs -1; P = .001). CONCLUSIONS Our results with U-CEA confirm that this population has a higher risk profile compared with elective surgery. The type of acute presentation is correlated with perioperative risk. U-CEA was safe when performed on patients presenting with transient ischemic attack. An acceptable complication rate was achieved for patients with minor to moderate strokes. The poorest outcomes occurred in patients presenting with stroke in evolution: U-CEA in these patients should be offered with extreme caution, although we are aware that a conservative treatment may not grant a better prognosis.
Collapse
|
25
|
Color Doppler of the extracranial and intracranial arteries in the acute phase of cerebral ischemia. J Ultrasound 2013; 16:187-93. [PMID: 24432173 DOI: 10.1007/s40477-013-0036-7] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2013] [Accepted: 08/19/2013] [Indexed: 10/26/2022] Open
Abstract
Vascular imaging greatly improves the possibility of locating the site of vascular occlusion in patients with acute cerebrovascular disease. Different occlusive patterns may underlie the same clinical presentation, with different prognosis and different treatment: for this reason, a diagnostic tool able to identify quickly the status of the extra- and intracranial vessels is needed. Color Doppler ultrasound of the extracranial arteries is a reliable and accurate method able to localize and quantify the carotid artery stenosis. The ultrasound quantification of the degree of stenosis is based on both morphological and velocimetric criteria: B-mode, color or power Doppler and spectral analysis are used for this purpose. Also the analysis of the plaque is an integral part of the ultrasound examination: the B mode plaque characterization (structure and surface) plays an important role in the evaluation of risk of stroke. So color Doppler ultrasound is able to select patients who may require medical therapy, carotid endarterectomy or angioplasty and stenting. Transcranial color Doppler is an inexpensive, reliable, fast, non-invasive, bedside tool: in the acute phase of stroke, it is able to evaluate quickly the intracranial arteries and monitor the possible recanalization of occluded vessel ensuring the follow-up of dynamic lesions, such as the intracranial stenosis and occlusions.
Collapse
|
26
|
Bruls S, Desfontaines P, Defraigne JO, Sakalihasan N. Urgent Carotid Endarterectomy in Patients with Acute Neurological Symptoms: The Results of a Single Center Prospective Nonrandomized Study. AORTA : OFFICIAL JOURNAL OF THE AORTIC INSTITUTE AT YALE-NEW HAVEN HOSPITAL 2013; 1:110-6. [PMID: 26798682 DOI: 10.12945/j.aorta.2013.13-008] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/29/2013] [Accepted: 05/10/2013] [Indexed: 11/18/2022]
Abstract
BACKGROUND To evaluate the feasibility and the safety of performing urgent (within 24 hours) carotid endarterectomy in patients with carotid stenosis presenting with repetitive transient ischemic attacks or progressing stroke. METHODS Thirty consecutive patients underwent urgent carotid endarterectomy for repetitive transient ischemic attacks (N = 12) or progressing stroke (N = 18) according to the following criteria: two or more transient ischemic attacks or a fluctuating neurological deficit over a period of less than 24 hours (progressing stroke), no impairment of consciousness, no cerebral infarct larger than 1.5 cm in diameter on computed tomography and a carotid artery stenosis of 70% or more on the appropriate side, diagnosed by echodoppler ultrasonography and/or arteriography. Patients with cerebral hemorrhage were excluded. All patients were examined pre- and postoperatively by the same neurologist and surgery was performed by the same vascular surgeon. All the patients underwent a cerebral CT scan within 5 days after surgery. RESULTS There were 19 men and 11 women. The mean age was 71 ± 7.6 years. The time delay of surgery after the onset of transient ischemic attacks or progressing stroke averaged 19.4 ± 11.5 hours. For patients suffering progressive stroke, one developed a fatal ischemic stroke 24 hours after surgery, five showed no improvement of their neurological status after surgery, but none worsened. Twelve patients experienced significant improvement of their neurological status with an European Stroke Scale of 77.9 ± 25.2 at admission and 95.8 ± 4.6 at discharge, and all but one of those patients had a Barthel's index value over 85/100 at discharge. The 12 patients with repetitive transient ischemic attacks had an uneventful postoperative outcome. The mean duration of follow-up was 3.4 ± 1.2 years. No patient developed another transient ischemic attack or ischemic stroke during the follow-up period. CONCLUSIONS The results of our series documented the feasibility and the safety of performing urgent (within 24 hours) carotid endarterectomy in patients presenting with repetitive transient ischemic attacks or progressing stroke. This procedure seems to us to be justified by the fact that waiting for surgery may lead to the development of a more profound deficit or another stroke in these neurologically unstable patients whose only chance for neurological recovery is in the early phase.
Collapse
Affiliation(s)
- Samuel Bruls
- Department of Cardiovascular and Thoracic Surgery, University Hospital of Liege, Liege, Belgium
| | | | - Jean-Olivier Defraigne
- Department of Cardiovascular and Thoracic Surgery, University Hospital of Liege, Liege, Belgium
| | | |
Collapse
|
27
|
Gajin P, Radak D, Tanaskovic S, Babic S, Nenezic D. Urgent carotid endarterectomy in patients with acute neurological ischemic events within six hours after symptoms onset. Vascular 2013; 22:167-73. [DOI: 10.1177/1708538113478760] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
To analyze the outcome of urgent carotid endarterectomy (CEA) performed within less than six hours in patients with crescendo transient ischemic attack (TIA) and stroke in progression. From January 1998 to December 2008, 58 urgent CEAs were done for acute neurological ischemic events – 46 patients with crescendo TIA and 12 patients with stroke in progression. Brain computed tomography (CT) was done prior and after the surgery. Disability level was assessed prior to and after urgent CEA using modified Rankin scale. Median follow-up was 42.1 ± 16.6 months. In the early postoperative period stroke rate was 0% for the patients in crescendo TIA group while in patients with stroke in progression group 3 patients (25%) had positive postoperative brain CT, yet neurological status significantly improved. Mid-term stroke rate was 2.2% in crescendo TIA group and 8.3% in stroke in progression group. In the early postoperative period there were no lethal outcomes, mid-term mortality was 8.3% in stroke in progression while in crescendo TIA group lethal outcomes were not observed. In conclusion, based on our results urgent CEA is a safe and effective treatment option for patients with crescendo TIA and stroke in progression with acceptable rate of postoperative complications.
Collapse
|
28
|
|
29
|
Capoccia L, Sbarigia E, Speziale F, Toni D, Biello A, Montelione N, Fiorani P. The need for emergency surgical treatment in carotid-related stroke in evolution and crescendo transient ischemic attack. J Vasc Surg 2012; 55:1611-7. [PMID: 22364655 DOI: 10.1016/j.jvs.2011.11.144] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2011] [Revised: 10/25/2011] [Accepted: 11/12/2011] [Indexed: 11/26/2022]
|
30
|
Ricotta JJ, Aburahma A, Ascher E, Eskandari M, Faries P, Lal BK. Updated Society for Vascular Surgery guidelines for management of extracranial carotid disease. J Vasc Surg 2011; 54:e1-31. [PMID: 21889701 DOI: 10.1016/j.jvs.2011.07.031] [Citation(s) in RCA: 439] [Impact Index Per Article: 33.8] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2011] [Revised: 06/21/2011] [Accepted: 07/12/2011] [Indexed: 11/30/2022]
Affiliation(s)
- John J Ricotta
- Washington Hospital Center, Georgetown University School of Medicine, Washington, DC 20010, USA.
| | | | | | | | | | | |
Collapse
|
31
|
Leseche G, Alsac JM, Castier Y, Fady F, Lavallee PC, Mazighi M, Amarenco P. Carotid endarterectomy in the acute phase of crescendo cerebral transient ischemic attacks is safe and effective. J Vasc Surg 2011; 53:637-42. [PMID: 21129902 DOI: 10.1016/j.jvs.2010.09.055] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2010] [Revised: 09/14/2010] [Accepted: 09/15/2010] [Indexed: 10/18/2022]
|
32
|
Dorigo W, Pulli R, Nesi M, Alessi Innocenti A, Pratesi G, Inzitari D, Pratesi C. Urgent Carotid Endarterectomy in Patients with Recent/Crescendo Transient Ischaemic Attacks or Acute Stroke. Eur J Vasc Endovasc Surg 2011; 41:351-7. [PMID: 21196126 DOI: 10.1016/j.ejvs.2010.11.026] [Citation(s) in RCA: 33] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2010] [Accepted: 11/25/2010] [Indexed: 11/18/2022]
Affiliation(s)
- W Dorigo
- Department of Vascular Surgery, University of Florence, Florence, Italy.
| | | | | | | | | | | | | |
Collapse
|
33
|
Ferrero E, Ferri M, Viazzo A, Gaggiano A, Ferrero M, Maggio D, Berardi G, Pecchio A, Piazza S, Cumbo P, Nessi F. Early Carotid Surgery in Patients After Acute Ischemic Stroke: Is it Safe? A Retrospective Analysis in a Single Center Between Early and Delayed/Deferred Carotid Surgery on 285 Patients. Ann Vasc Surg 2010; 24:890-9. [DOI: 10.1016/j.avsg.2010.03.014] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2009] [Revised: 03/02/2010] [Accepted: 03/02/2010] [Indexed: 11/30/2022]
|
34
|
Rerkasem K, Rothwell PM. Systematic Review of the Operative Risks of Carotid Endarterectomy for Recently Symptomatic Stenosis in Relation to the Timing of Surgery. Stroke 2009; 40:e564-72. [PMID: 19661467 DOI: 10.1161/strokeaha.109.558528] [Citation(s) in RCA: 131] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background and Purpose—
Reliable data on the risk of carotid endarterectomy (CEA) in relation to timing of surgery are necessary to plan CEA most effectively, to adjust risks for case-mix, and to understand the mechanisms of operative stroke.
Methods—
We performed a systematic review of all studies published from 1980 to 2008 inclusive that reported the risk of stroke and death due to CEA in relation to the time between presenting symptom and surgery. Pooled estimates of risk by the time since the last event were obtained by Mantel–Haenszel meta-analysis.
Results—
Of 494 published operative series, only 47 stratified risk by timing of surgery. The pooled absolute risks of stroke and death after urgent CEA were high in patients with stroke-in-evolution (20.2%, 95% CI 12.0 to 28.4) and in patients with crescendo TIA (11.4%, 6.1 to 16.7), with no trends toward reduced risks in more recent studies. However, there was no significant difference between early and later CEA in neurologically stable patients with recent TIA or nondisabling stroke (<1 week versus ≥1 week, OR=1.2, 0.9 to 1.7,
P
=0.17; <2 weeks versus ≥2 weeks, OR=1.2, 0.9 to 1.6,
P
=0.13).
Conclusions—
Emergency endarterectomy for stroke-in-evolution has a high operative risk, but the risk may be somewhat lower in patients with crescendo TIA. Surgery in the first week in neurologically stable patients with TIA or minor stroke is not associated with a substantially higher operative risk than delayed surgery. More data are required on the risk and benefit of more urgent surgery for TIA and minor stroke and for early versus delayed surgery in patients with major nondisabling stroke.
Collapse
Affiliation(s)
- Kittipan Rerkasem
- From the Vascular Surgery Division, Department of Surgery, Faculty of Medicine (K.R.), Chiang Mai University, Chiang Mai, Thailand; and the Stroke Prevention Research Unit, University Department of Clinical Neurology (P.M.R.), John Radcliffe Hospital, Oxford, UK
| | - Peter M. Rothwell
- From the Vascular Surgery Division, Department of Surgery, Faculty of Medicine (K.R.), Chiang Mai University, Chiang Mai, Thailand; and the Stroke Prevention Research Unit, University Department of Clinical Neurology (P.M.R.), John Radcliffe Hospital, Oxford, UK
| |
Collapse
|
35
|
Dahl T, Ellekjær H. Carotisstenose – utredning og behandling. TIDSSKRIFT FOR DEN NORSKE LEGEFORENING 2009; 129:2374-7. [DOI: 10.4045/tidsskr.09.0274] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/02/2022] Open
|