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Ristow AVB, Massière B, Meirelles GV, Casella IB, Morales MM, Moreira RCR, Procópio RJ, Oliveira TF, de Araujo WJB, Joviliano EE, de Oliveira JCP. Brazilian Angiology and Vascular Surgery Society Guidelines for the treatment of extracranial cerebrovascular disease. J Vasc Bras 2024; 23:e20230094. [PMID: 39099701 PMCID: PMC11296686 DOI: 10.1590/1677-5449.202300942] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2023] [Accepted: 10/16/2023] [Indexed: 08/06/2024] Open
Abstract
Extracranial cerebrovascular disease has been the subject of intense research throughout the world, and is of paramount importance for vascular surgeons. This guideline, written by the Brazilian Society of Angiology and Vascular Surgery (SBACV), supersedes the 2015 guideline. Non-atherosclerotic carotid artery diseases were not included in this document. The purpose of this guideline is to bring together the most robust evidence in this area in order to help specialists in the treatment decision-making process. The AGREE II methodology and the European Society of Cardiology system were used for recommendations and levels of evidence. The recommendations were graded from I to III, and levels of evidence were classified as A, B, or C. This guideline is divided into 11 chapters dealing with the various aspects of extracranial cerebrovascular disease: diagnosis, treatments and complications, based on up-to-date knowledge and the recommendations proposed by SBACV.
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Affiliation(s)
- Arno von Buettner Ristow
- Pontifícia Universidade Católica do Rio de Janeiro – PUC-RIO, Disciplina de Cirurgia Vascular e Endovascular, Rio de Janeiro, RJ, Brasil.
- Sociedade Brasileira de Angiologia e de Cirurgia Vascular – SBACV-RJ, Rio de Janeiro, RJ, Brasil.
| | - Bernardo Massière
- Pontifícia Universidade Católica do Rio de Janeiro – PUC-RIO, Disciplina de Cirurgia Vascular e Endovascular, Rio de Janeiro, RJ, Brasil.
- Sociedade Brasileira de Angiologia e de Cirurgia Vascular – SBACV-RJ, Rio de Janeiro, RJ, Brasil.
| | - Guilherme Vieira Meirelles
- Sociedade Brasileira de Angiologia e de Cirurgia Vascular – SBACV-SP, São Paulo, SP, Brasil.
- Universidade Estadual de Campinas – UNICAMP, Hospital das Clínicas, Disciplina de Cirurgia do Trauma, Campinas, SP, Brasil.
| | - Ivan Benaduce Casella
- Sociedade Brasileira de Angiologia e de Cirurgia Vascular – SBACV-SP, São Paulo, SP, Brasil.
- Universidade de São Paulo – USP, Faculdade de Medicina, São Paulo, SP, Brasil.
| | - Marcia Maria Morales
- Sociedade Brasileira de Angiologia e de Cirurgia Vascular – SBACV-SP, São Paulo, SP, Brasil.
- Associação Portuguesa de Beneficência de São José do Rio Preto, Serviço de Cirurgia Vascular, São José do Rio Preto, SP, Brasil.
| | - Ricardo Cesar Rocha Moreira
- Sociedade Brasileira de Angiologia e de Cirurgia Vascular – SBACV-PR, Curitiba, PR, Brasil.
- Pontifícia Universidade Católica do Paraná – PUC-PR, Hospital Cajurú, Serviço de Cirurgia Vascular, Curitiba, PR, Brasil.
| | - Ricardo Jayme Procópio
- Universidade Federal de Minas Gerais – UFMG, Hospital das Clínicas, Setor de Cirurgia Endovascular, Belo Horizonte, MG, Brasil.
- Universidade Federal de Minas Gerais – UFMG, Faculdade de Medicina, Belo Horizonte, MG, Brasil.
- Sociedade Brasileira de Angiologia e de Cirurgia Vascular – SBACV-MG, Belo Horizonte, MG, Brasil.
| | - Tércio Ferreira Oliveira
- Sociedade Brasileira de Angiologia e de Cirurgia Vascular – SBACV-SE, Aracajú, SE, Brasil.
- Universidade de São Paulo – USP, Faculdade de Medicina de Ribeirão Preto – FMRP, Ribeirão Preto, SP, Brasil.
| | - Walter Jr. Boim de Araujo
- Sociedade Brasileira de Angiologia e de Cirurgia Vascular – SBACV-PR, Curitiba, PR, Brasil.
- Universidade Federal do Paraná – UFPR, Hospital das Clínicas – HC, Curitiba, PR, Brasil.
| | - Edwaldo Edner Joviliano
- Sociedade Brasileira de Angiologia e de Cirurgia Vascular – SBACV-SP, São Paulo, SP, Brasil.
- Universidade de São Paulo – USP, Faculdade de Medicina de Ribeirão Preto – FMRP, Ribeirão Preto, SP, Brasil.
| | - Júlio Cesar Peclat de Oliveira
- Sociedade Brasileira de Angiologia e de Cirurgia Vascular – SBACV-SP, São Paulo, SP, Brasil.
- Universidade Federal do Estado do Rio de Janeiro – UNIRIO, Departamento de Cirurgia, Rio de Janeiro, RJ, Brasil.
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Naylor R, Rantner B, Ancetti S, de Borst GJ, De Carlo M, Halliday A, Kakkos SK, Markus HS, McCabe DJH, Sillesen H, van den Berg JC, Vega de Ceniga M, Venermo MA, Vermassen FEG, Esvs Guidelines Committee, Antoniou GA, Bastos Goncalves F, Bjorck M, Chakfe N, Coscas R, Dias NV, Dick F, Hinchliffe RJ, Kolh P, Koncar IB, Lindholt JS, Mees BME, Resch TA, Trimarchi S, Tulamo R, Twine CP, Wanhainen A, Document Reviewers, Bellmunt-Montoya S, Bulbulia R, Darling RC, Eckstein HH, Giannoukas A, Koelemay MJW, Lindström D, Schermerhorn M, Stone DH. Editor's Choice - European Society for Vascular Surgery (ESVS) 2023 Clinical Practice Guidelines on the Management of Atherosclerotic Carotid and Vertebral Artery Disease. Eur J Vasc Endovasc Surg 2023; 65:7-111. [PMID: 35598721 DOI: 10.1016/j.ejvs.2022.04.011] [Citation(s) in RCA: 211] [Impact Index Per Article: 211.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2022] [Accepted: 04/20/2022] [Indexed: 01/17/2023]
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Kakkos SK, Vega de Ceniga M, Naylor R. A Systematic Review and Meta-analysis of Peri-Procedural Outcomes in Patients Undergoing Carotid Interventions Following Thrombolysis. Eur J Vasc Endovasc Surg 2021; 62:340-349. [PMID: 34266765 DOI: 10.1016/j.ejvs.2021.06.003] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2021] [Revised: 06/01/2021] [Accepted: 06/03/2021] [Indexed: 10/20/2022]
Abstract
OBJECTIVE To evaluate the safety of carotid artery stenting (CAS) and carotid endarterectomy (CEA) after thrombolytic therapy (TT). DATA SOURCES Medline, Scopus, and Cochrane databases. REVIEW METHODS Systematic review and meta-analysis of studies involving patients who underwent CEA/CAS after TT. RESULTS In 25 studies (n = 147 810 patients), 2 557 underwent CEA (n = 2 076) or CAS (n = 481) following TT. After CEA, the pooled peri-procedural stroke/death rate was 5.2% (95% confidence interval [CI] 3.3 - 7.5) and intracranial haemorrhage (ICH) was 3.4% (95% CI 1.7 - 5.6). After CAS, the pooled peri-procedural stroke/death rate was 14.9% (95% CI 11.9 - 18.2) and ICH was 5.5% (95% CI 3.7 - 7.7). In case control studies comparing CEA outcomes in patients receiving TT vs. no TT, peri-procedural death/stroke was non-significantly higher after TT (4.3% vs. 1.5%; odds ratio [OR] 2.34, 95% CI 0.74 - 7.47), but ICH was significantly higher after TT (2.2% vs. 0.12%; OR 7.82, 95% CI 4.07 - 15.02), as was local haematoma formation (3.6% vs. 2.26%; OR 1.17, 95% CI 1.17 - 2.33). In case control studies comparing CAS outcomes in patients receiving TT vs. no TT, peri-procedural stroke/death was significantly higher after TT (5.2% vs. 1.5%; OR 8.49, 95% CI 2.12 - 33.95) as was ICH (5.4% vs. 0.7%; OR 7.48, 95% CI 4.69 - 11.92). Meta-regression analysis demonstrated an inverse association between the time interval from intravenous (IV) TT to undergoing CEA and the risk of peri-procedural stroke/death (p = .032). Peri-operative stroke/death was 13.0% when CEA was performed three days after TT and 10.6% when performed four days after TT, with the risk reducing to within the currently accepted 6% threshold after six-seven days had elapsed. CONCLUSION Peri-procedural ICH and local haematoma were significantly more frequent in patients undergoing CEA after TT (vs. no TT), although there were no randomised comparisons. Peri-procedural hazards were also significantly higher for CAS after TT. The inverse relationship between timing to CEA and peri-procedural stroke/death mandates careful patient selection and suggests that it may be safer to defer CEA for six-seven days after TT.
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Affiliation(s)
- Stavros K Kakkos
- Department of Vascular Surgery, University Hospital of Patras, Patras, Greece.
| | - Melina Vega de Ceniga
- Department of Angiology and Vascular Surgery, Hospital de Galdakao-Usansolo, Galdakao and Biocruces Bizkaia Health Research Institute, Barakaldo, Spain
| | - Ross Naylor
- Leicester Vascular Institute, Glenfield Hospital, Leicester, UK
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Bagley JH, Priest R. Carotid Revascularization: Current Practice and Future Directions. Semin Intervent Radiol 2020; 37:132-139. [PMID: 32419725 DOI: 10.1055/s-0040-1709154] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
Carotid stenosis is responsible for approximately 15% of ischemic strokes. Carotid revascularization significantly decreases patients' stroke risk. Carotid endarterectomy has first-line therapy for moderate-to-severe carotid stenosis after a series of pivotal randomized controlled trials were published almost 30 years ago. Revascularization with carotid stenting has become a popular and effective alternative in a select subpopulation of patients. We review the current state of the literature regarding revascularization indications, patient selection, advantages of each revascularization approach, timing of intervention, and emerging interventional techniques, such as transcarotid artery revascularization.
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Affiliation(s)
- Jacob H Bagley
- Department of Neurological Surgery, Oregon Health and Science University, Portland, Oregon
| | - Ryan Priest
- Dotter Department of Interventional Radiology, Oregon Health and Science University, Portland, Oregon
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Brinster CJ, Sternbergh WC. Safety of urgent carotid endarterectomy following thrombolysis. THE JOURNAL OF CARDIOVASCULAR SURGERY 2020; 61:149-158. [PMID: 32225134 DOI: 10.23736/s0021-9509.20.11179-0] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
INTRODUCTION Acute ischemic stroke is a leading cause of morbidity and mortality worldwide, and the incidence of ischemic stroke is predicted to increase in coming years. Carotid atherosclerotic occlusive disease accounts for up to 20% of all ischemic strokes, and mounting evidence suggests that, in the setting of an acute ischemic stroke due to carotid disease, earlier treatment with carotid intervention results in better outcomes. In patients with acute ischemic stroke, systemic or intravenous thrombolysis (IVT) has revolutionized ischemic stroke therapy, and intravenous tissue plasminogen activator (tPA) has become the principal treatment for acute ischemic stroke when administered within 3 to 4.5 hours of neurologic symptom onset. Given these trends in acute ischemic stroke therapy, vascular specialists are increasingly asked to perform carotid intervention following IVT, but reports in the literature examining outcomes in this circumstance are scarce, and the data regarding the appropriate interval from IVT to carotid endarterectomy (CEA) remains controversial. EVIDENCE ACQUISITION Literature searches were performed in PubMed (MEDLINE) and Ovid examining journal articles published between January 1st, 1998 and September 30th, 2019. The search terms used were: "urgent carotid endarterectomy," "carotid endarterectomy" AND "thrombolysis," "acute stroke and thrombolysis," "timing of carotid endarterectomy," and various combinations of these terms. EVIDENCE SYTNHESIS A total of 21 published reports detailing outcomes in 1165 patients have been published to date, with an average interval from IVT to CEA of 7.1 days, a cumulative 30-day stroke and death rate of 4.1% (0-18%) and a mean frequency of intracranial hemorrhage of 2.6% (0-18%). The aggregate data from the 21 reported series suggest that CEA can be performed safely within the first 14 days after the onset of neurologic symptoms in patients receiving antecedent IVT, however, data regarding the safety of urgent CEA within 48 to 72 hours of thrombolysis is conflicting, with some series reporting excellent results and others showing an increased risk of ICH, stroke, and/or death in these select patients. CONCLUSIONS Given the trend toward expedited treatment of acute ischemic stroke with subsequent transfer to regional referral centers, vascular specialists will be confronted with an increasing number of patients who may require urgent CEA after antecedent IVT. Further study is warranted to clearly delineate the appropriate interval from IVT to CEA and, specifically, to establish the safety of CEA with 72 hours of tPA administration.
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Affiliation(s)
- Clayton J Brinster
- Section of Vascular Surgery, Department of Surgery, Ochsner Clinic Foundation, New Orleans, LA, USA -
| | - W Charles Sternbergh
- Section of Vascular Surgery, Department of Surgery, Ochsner Clinic Foundation, New Orleans, LA, USA
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Vellimana AK, Washington CW, Yarbrough CK, Pilgram TK, Hoh BL, Derdeyn CP, Zipfel GJ. Thrombolysis is an Independent Risk Factor for Poor Outcome After Carotid Revascularization. Neurosurgery 2019; 83:922-930. [PMID: 29136204 DOI: 10.1093/neuros/nyx551] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2015] [Accepted: 10/02/2017] [Indexed: 12/14/2022] Open
Abstract
BACKGROUND Thrombolysis is the standard of care for acute ischemic stroke patients presenting in the appropriate time window. Studies suggest that the risk of recurrent ischemia is lower if carotid revascularization is performed early after the index event. The safety of early carotid revascularization in this patient population is unclear. OBJECTIVE To evaluate the safety of carotid revascularization in patients who received thrombolysis for acute ischemic stroke. METHODS The Nationwide Inpatient Sample database was queried for patients admitted through the emergency room with a primary diagnosis of carotid stenosis and/or occlusion. Each patient was reviewed for administration of thrombolysis, carotid endarterectomy, (CEA) or carotid angioplasty and stenting (CAS). Primary endpoints were intracerebral hemorrhage (ICH), postprocedural stroke (PPS), poor outcome, and in-hospital mortality. Potential risk factors were examined using univariate and multivariate analyses. RESULTS A total of 310 257 patients were analyzed. Patients who received tissue plasminogen activator (tPA) and underwent either CEA or CAS had a significantly higher risk of developing an ICH or PPS than patients who underwent either CEA or CAS without tPA administration. The increased risk of ICH or PPS in tPA-treated patients who underwent carotid revascularization diminished with time, and became similar to patients who underwent carotid revascularization without tPA administration by 7 d after thrombolysis. Patients who received tPA and underwent CEA or CAS also had higher odds of poor outcome and in-hospital mortality. CONCLUSION Thrombolysis is a strong risk factor for ICH, PPS, poor outcome, and in-hospital mortality in patients with carotid stenosis/occlusion who undergo carotid revascularization. The increased risk of ICH or PPS due to tPA declines with time after thrombolysis. Delaying carotid revascularization in these patients may therefore be appropriate. This delay, however, will expose these patients to the risk of recurrent stroke. Future studies are needed to determine the relative risks of these 2 adverse events.
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Affiliation(s)
- Ananth K Vellimana
- Department of Neurological Surgery, Washington University School of Medi-cine, St. Louis, Missouri
| | - Chad W Washington
- Department of Neurological Surgery, Washington University School of Medi-cine, St. Louis, Missouri
| | - Chester K Yarbrough
- Department of Neurological Surgery, Washington University School of Medi-cine, St. Louis, Missouri
| | - Thomas K Pilgram
- Mallinckrodt Institute of Radiology, Washington University School of Medicine, St. Louis, Missouri
| | - Brian L Hoh
- Department of Neurosurgery, University of Florida, Gainesville, Florida
| | - Colin P Derdeyn
- Department of Neurological Surgery, Washington University School of Medi-cine, St. Louis, Missouri.,Mallinckrodt Institute of Radiology, Washington University School of Medicine, St. Louis, Missouri
| | - Gregory J Zipfel
- Department of Neurological Surgery, Washington University School of Medi-cine, St. Louis, Missouri
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Fortin W, Chaput M, Elkouri S, Beaudoin N, Blair JF. Carotid endarterectomy after systemic thrombolysis in a stroke population. J Vasc Surg 2019; 71:1254-1259. [PMID: 31526691 DOI: 10.1016/j.jvs.2019.05.061] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2019] [Accepted: 05/25/2019] [Indexed: 12/22/2022]
Abstract
OBJECTIVE Vascular specialists are increasingly being requested to perform carotid endarterectomy (CEA) after intravenous thrombolysis (IVT) for stroke patients, raising concerns about hemorrhagic complications. Few case series and registry reports have assessed the question, and even fewer studies have included a control group. The aim of this study was to evaluate the overall outcome of patients undergoing CEA after IVT and to compare them with contemporary patients with CEA after simple stroke (non-IVT group). It also aimed to evaluate the differences in outcomes of stroke patients requiring CEA between nonvascular and vascular centers. METHODS The data of 169 consecutive patients who have undergone CEA after stroke in a single center was analyzed from January 2011 to December 2016, 27 of them (16%) having undergone previous IVT. A comparative analysis between the non-IVT and the IVT groups was performed. The time between stroke diagnosis and referral to a vascular specialist was also studied. RESULTS Age, sex, and cardiovascular comorbidities were similar in both groups. Median time between stroke and CEA was 13 days (Q1-Q3, 8-23 days), with 16 of the 27 patients (59%) in the IVT group undergoing CEA less than 14 days after the initial event. There were three intracranial hemorrhages (2.1%) in the non-IVT group versus one (3.7%) in the IVT group (P = NS). The overall 30-day combined stroke and death rate was 7.1% (6.3% in the non-IVT group vs 11.1% in the IVT group; P = .70). The incidence of postoperative cervical hematoma requiring reoperation was similar in both groups (2.1% vs 3.7%; P = NS). The median time between diagnosis of stroke and referral to a vascular specialist was higher for patients in nonvascular centers compared with vascular centers (3.5 days vs 1.0 day; P < .001), which translated to fewer patients referred from nonvascular centers undergoing surgery in the 14-day window period (38% vs 67%; P < .001). CONCLUSIONS In this retrospective analysis, CEA after IVT showed similar outcomes when compared with the overall CEA after stroke population. Stroke patients diagnosed in nonvascular centers were referred later than those in vascular centers and, although postoperative outcomes were similar, that was correlated with fewer patients undergoing surgery in a timely fashion.
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Affiliation(s)
- William Fortin
- Division of Vascular Surgery, Centre Hospitalier de l'Université de Montréal (CHUM), Montreal, Quebec, Canada; Division of Vascular Surgery, Hôpital Maisonneuve-Rosemont, Montreal, Quebec, Canada; Faculty of Medicine, Université de Montréal, Montreal, Quebec, Canada
| | - Miguel Chaput
- Division of Vascular Surgery, Hôpital Maisonneuve-Rosemont, Montreal, Quebec, Canada
| | - Stephane Elkouri
- Division of Vascular Surgery, Centre Hospitalier de l'Université de Montréal (CHUM), Montreal, Quebec, Canada
| | - Nathalie Beaudoin
- Division of Vascular Surgery, Centre Hospitalier de l'Université de Montréal (CHUM), Montreal, Quebec, Canada
| | - Jean-François Blair
- Division of Vascular Surgery, Centre Hospitalier de l'Université de Montréal (CHUM), Montreal, Quebec, Canada.
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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.
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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
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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.
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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
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Naylor AR, Ricco JB, de Borst GJ, Debus S, de Haro J, Halliday A, Hamilton G, Kakisis J, Kakkos S, Lepidi S, Markus HS, McCabe DJ, Roy J, Sillesen H, van den Berg JC, Vermassen F, Kolh P, Chakfe N, Hinchliffe RJ, Koncar I, Lindholt JS, Vega de Ceniga M, Verzini F, Archie J, Bellmunt S, Chaudhuri A, Koelemay M, Lindahl AK, Padberg F, Venermo M. Editor's Choice - Management of Atherosclerotic Carotid and Vertebral Artery Disease: 2017 Clinical Practice Guidelines of the European Society for Vascular Surgery (ESVS). Eur J Vasc Endovasc Surg 2018; 55:3-81. [PMID: 28851594 DOI: 10.1016/j.ejvs.2017.06.021] [Citation(s) in RCA: 797] [Impact Index Per Article: 132.8] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
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Gunka I, Krajickova D, Lesko M, Renc O, Raupach J, Jiska S, Lojik M, Chovanec V, Maly R. Safety of Early Carotid Endarterectomy after Intravenous Thrombolysis in Acute Ischemic Stroke. Ann Vasc Surg 2017; 44:353-360. [PMID: 28479465 DOI: 10.1016/j.avsg.2017.03.195] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2016] [Revised: 03/08/2017] [Accepted: 03/28/2017] [Indexed: 11/19/2022]
Abstract
BACKGROUND The timing of carotid endarterectomy (CEA) after intravenous thrombolysis (IVT) is still a controversial issue. The aim of this study was to assess the safety of early carotid interventions in patients treated with thrombolysis for acute ischemic stroke. METHODS A retrospective analysis was performed using prospectively collected data from consecutive patients who underwent CEA for symptomatic internal carotid artery stenosis within 14 days after the index neurological event during the period from January 2013 to July 2016. Patients who had undergone IVT before CEA were identified. The primary outcome measures were any stroke and death rate at 30 days, symptomatic intracerebral hemorrhage and surgical site bleeding requiring intervention. RESULTS A total of 93 patients were included for the final analysis. Among these, 13 (14.0%) patients had undergone IVT before CEA while 80 (86.0%) patients had CEA only. The median time interval between IVT and CEA was 2 days (range: 0-13). A subgroup of 6 patients underwent CEA within 24 hours of administration of IVT. The 30-day combined stroke and death rate was 7.7% (1 of 13) among patients undergoing IVT before CEA and 5.0% (4 of 80) among those undergoing CEA only (P = 0.690). In the IVT group, there were no cerebral hemorrhages or significant surgical site bleeding events requiring reintervention. CONCLUSIONS Our experience indicates that CEA performed early after IVT for acute ischemic stroke, aiming not only to reduce the risk of stroke recurrence but also to achieve neurological improvement by reperfusion of the ischemic penumbra, may be safe and can lead to favorable outcomes.
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Affiliation(s)
- Igor Gunka
- Department of Surgery, Faculty of Medicine in Hradec Králové, University Hospital Hradec Kralové, Charles University, Hradec Kralove, Czech Republic.
| | - Dagmar Krajickova
- Department of Neurology, Faculty of Medicine in Hradec Králové, University Hospital Hradec Kralové, Charles University, Hradec Kralove, Czech Republic
| | - Michal Lesko
- Department of Surgery, Faculty of Medicine in Hradec Králové, University Hospital Hradec Kralové, Charles University, Hradec Kralove, Czech Republic
| | - Ondrej Renc
- Department of Radiology, Faculty of Medicine in Hradec Králové, University Hospital Hradec Kralové, Charles University, Hradec Kralove, Czech Republic
| | - Jan Raupach
- Department of Radiology, Faculty of Medicine in Hradec Králové, University Hospital Hradec Kralové, Charles University, Hradec Kralove, Czech Republic
| | - Stanislav Jiska
- Department of Surgery, Faculty of Medicine in Hradec Králové, University Hospital Hradec Kralové, Charles University, Hradec Kralove, Czech Republic
| | - Miroslav Lojik
- Department of Radiology, Faculty of Medicine in Hradec Králové, University Hospital Hradec Kralové, Charles University, Hradec Kralove, Czech Republic
| | - Vendelin Chovanec
- Department of Radiology, Faculty of Medicine in Hradec Králové, University Hospital Hradec Kralové, Charles University, Hradec Kralove, Czech Republic
| | - Radovan Maly
- First Department of Internal Medicine-Cardioangiology, Faculty of Medicine in Hradec Králové, University Hospital Hradec Kralové, Charles University, Hradec Kralove, Czech Republic
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Gunka I, Krajickova D, Lesko M, Jiska S, Raupach J, Lojik M, Maly R. Emergent Carotid Thromboendarterectomy for Acute Symptomatic Occlusion of the Extracranial Internal Carotid Artery. Vasc Endovascular Surg 2017; 51:176-182. [DOI: 10.1177/1538574416674641] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background: Strokes secondary to acute internal carotid artery (ICA) occlusion are associated with an extremely poor prognosis. The best treatment approach in this setting is still unknown. The aim of our study was to evaluate the efficacy, safety, and outcomes of emergent surgical revascularization of acute extracranial ICA occlusion in patients with minor to severe ischemic stroke. Methods: A retrospective analysis was performed using prospectively collected data of consecutive patients who underwent carotid thromboendarterectomy for symptomatic acute ICA occlusion during the period from January 2013 to December 2015. Primary outcomes were disability at 90 days assessed by the modified Rankin Scale (mRS) and neurological deficit at discharge assessed using the National Institute of Health Stroke Scale (NIHSS). Secondary outcomes were the recanalization rate, 30-day overall mortality, and any intracerebral bleeding. Results: During the study period, a total of 6 patients (5 men and 1 woman) with a median age of 64 years (range: 58-84 years) underwent emergent reconstruction for acute symptomatic ICA occlusion within a median of 5.4 hours (range: 2.9-12.0 hours) after symptoms onset. The median presenting NIHSS score was 10.5 points (range: 4-21). Before surgery, 4 patients (66.7%) had been treated by systemic recombinant tissue plasminogen activator lysis. The median time interval between initiation of intravenous thrombolysis and carotid thromboendarterectomy was 117.5 minutes (range: 65-140 minutes). Patency of the ICA was achieved in all patients. On discharge, the median NIHSS score was 2 points (range: 0-11 points). There was no postoperative intracerebral hemorrhage and zero 30-day mortality rate. At 3 months, 5 patients (83.3%) had a good clinical outcome (mRS ≤ 2). Conclusion: Patients presenting with minor to severe ischemic stroke syndromes due to isolated extracranial ICA occlusion may benefit from emergent carotid revascularization. Thorough preoperative neuroimaging is essential to aid in selecting eligible candidates for acute surgical intervention.
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Affiliation(s)
- Igor Gunka
- Department of Surgery, University Hospital and Faculty of Medicine Hradec Kralove, Charles University in Prague, Hradec Kralove, Czech Republic
| | - Dagmar Krajickova
- Department of Neurology, University Hospital and Faculty of Medicine Hradec Kralove, Charles University in Prague, Hradec Kralove, Czech Republic
| | - Michal Lesko
- Department of Surgery, University Hospital and Faculty of Medicine Hradec Kralove, Charles University in Prague, Hradec Kralove, Czech Republic
| | - Stanislav Jiska
- Department of Surgery, University Hospital and Faculty of Medicine Hradec Kralove, Charles University in Prague, Hradec Kralove, Czech Republic
| | - Jan Raupach
- Department of Radiology, University Hospital and Faculty of Medicine Hradec Kralove, Charles University in Prague, Hradec Kralove, Czech Republic
| | - Miroslav Lojik
- Department of Radiology, University Hospital and Faculty of Medicine Hradec Kralove, Charles University in Prague, Hradec Kralove, Czech Republic
| | - Radovan Maly
- 1st Department of Internal Medicine—Cardioangiology, University Hospital and Faculty of Medicine Hradec Kralove, Charles University in Prague, Hradec Kralove, Czech Republic
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Naylor AR. Medical treatment strategies to reduce perioperative morbidity and mortality after carotid surgery. Semin Vasc Surg 2017; 30:17-24. [DOI: 10.1053/j.semvascsurg.2017.04.006] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/17/2023]
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14
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Abstract
The '6-month' threshold for treating symptomatic patients is obsolete. There is compelling evidence that the highest-risk period for stroke (after suffering a transient ischemic attack) is the first 2 weeks, especially the first few days, and that carotid endarterectomy (CEA) confers maximal benefit when performed early. Despite well-documented anxieties, there is increasing evidence that CEA can be performed safely within the first 7 days after onset of symptoms, although risks may be higher when performed within 48 h. The role for carotid artery stenting in the hyperacute period remains uncertain. Centers performing carotid artery stenting within 14 days of symptom onset with risks equivalent to CEA should be encouraged to continue and help others to achieve similar outcomes. For the majority, however, CEA will probably remain the safer option. 'Best medical therapy' and risk factor modification should be started as soon as a transient ischemic attack is suspected, while the early introduction of dual antiplatelet therapy may reduce recurrent events prior to CEA, without increasing perioperative bleeding complications.
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Affiliation(s)
- A Ross Naylor
- a The Department of Vascular Surgery at Leicester Royal Infirmary, Leicester, UK
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15
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Yamamoto Y, Okazaki T, Yoda K, Tada Y, Nagahiro S. Successful Emergency Carotid Endarterectomy after Thrombolysis with Intravenous Recombinant Tissue-Type Plasminogen Activator. THE JOURNAL OF MEDICAL INVESTIGATION 2016; 63:300-4. [DOI: 10.2152/jmi.63.300] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Affiliation(s)
- Yoko Yamamoto
- Department of Neurosurgery, Tokushima Prefectural Miyoshi Hospital
| | | | - Keishi Yoda
- Department of Neurosurgery, Tokushima Prefectural Miyoshi Hospital
| | - Yoshiteru Tada
- Department of Neurosurgery, Institute of Biomedical Biosciences, Tokushima University Graduate School
| | - Shinji Nagahiro
- Department of Neurosurgery, Institute of Biomedical Biosciences, Tokushima University Graduate School
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Azzini C, Gentile M, De Vito A, Traina L, Sette E, Fainardi E, Mascoli F, Casetta I. Very Early Carotid Endarterectomy After Intravenous Thrombolysis. Eur J Vasc Endovasc Surg 2015; 51:482-6. [PMID: 26712132 DOI: 10.1016/j.ejvs.2015.11.006] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2015] [Accepted: 11/11/2015] [Indexed: 10/22/2022]
Abstract
OBJECTIVE/BACKGROUND The timing of carotid endarterectomy (CEA) after thrombolysis is still a matter of debate. The aim of this study was to analyse a cohort of patients undergoing urgent endarterectomy after intravenous thrombolysis for acute ischaemic stroke. METHODS This was an observational study. Prospective databases were reviewed and matched to identify patients who underwent CEA early after intravenous thrombolysis (2009-14). The focus was carotid surgery performed within 12 hours of stroke onset in patients with a high grade (≥70%) symptomatic carotid stenosis, associated with vulnerable plaques or stroke in evolution, and evidence of a significant salvageable ischaemic penumbra on perfusion computed tomography scan. Demographic and clinical information, as well as data on relevant outcomes were extracted. RESULTS Thirty four consecutive stroke patients who underwent CEA within 2 weeks of thrombolysis for acute ischaemic stroke and ipsilateral high grade carotid stenosis were identified. In 11 patients the surgical procedure was performed within 12 hours of the onset of symptoms. All patients showed a clinical improvement after combined treatment. The 3 month outcome was favourable (modified Rankin Scale ≤ 2) in 10 patients. No haemorrhagic complications were registered. There was neither peri-operative stroke nor stroke within 3 months of surgery. One patient died from acute myocardial infarction 3 days after intervention. CONCLUSION This experience suggests that very early CEA after thrombolysis, aimed at removing the source of potential embolisation and restoring blood flow, may be safe and can lead to a favourable outcome.
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Affiliation(s)
- C Azzini
- Unità Operativa di Neurologia, Azienda Ospedaliera-Universitaria, Ferrara, Via Aldo Moro 8, 44124 Ferrara-Cona, Italy
| | - M Gentile
- Unità Operativa di Clinica Neurologica, Dipartimento di Scienze Biomediche e Chirurgico-Specialistiche, Università di Ferrara, Via Aldo Moro 8, 44124 Ferrara-Cona, Italy
| | - A De Vito
- Unità Operativa di Neurologia, Azienda Ospedaliera-Universitaria, Ferrara, Via Aldo Moro 8, 44124 Ferrara-Cona, Italy
| | - L Traina
- Unità Operativa di Chirurgia Vascolare, Azienda Ospedaliera-Universitaria, Ferrara, Via Aldo Moro 8, 44124 Ferrara-Cona, Italy
| | - E Sette
- Unità Operativa di Neurologia, Azienda Ospedaliera-Universitaria, Ferrara, Via Aldo Moro 8, 44124 Ferrara-Cona, Italy
| | - E Fainardi
- Unità Operativa di Neuroradiologia, Azienda Ospedaliera-Universitaria, Ferrara, Via Aldo Moro 8, 44124 Ferrara-Cona, Italy
| | - F Mascoli
- Unità Operativa di Chirurgia Vascolare, Azienda Ospedaliera-Universitaria, Ferrara, Via Aldo Moro 8, 44124 Ferrara-Cona, Italy
| | - I Casetta
- Unità Operativa di Clinica Neurologica, Dipartimento di Scienze Biomediche e Chirurgico-Specialistiche, Università di Ferrara, Via Aldo Moro 8, 44124 Ferrara-Cona, Italy.
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17
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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.
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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
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Early carotid artery stenting for symptomatic carotid artery stenosis. Acta Neurochir (Wien) 2015; 157:1873-8. [PMID: 26335754 DOI: 10.1007/s00701-015-2548-8] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2015] [Accepted: 08/11/2015] [Indexed: 10/23/2022]
Abstract
BACKGROUND The aim of present study was to assess safety and efficacy of early carotid artery stent (CAS) in patients with symptomatic carotid artery stenosis compared with delayed CAS. METHODS This retrospective study was approved by the institutional review board, and the requirement to obtain written informed consent was waived. Outcomes of 206 patients with symptomatic carotid stenosis who were treated by CAS were analyzed. According to CAS timing from last symptom, patients were divided into early (within 2 weeks, 74 [35.0 %]) and delayed (after 2 weeks, 112 [64.1 %]) group by CAS timing from the last symptom. Procedural complication and early (≤30 days of CAS) event (ipsilateral stroke or any death) for safety, and late (31 days to 1 year of CAS) event for efficacy of CAS preventing further stroke were evaluated. The two groups were compared using Cox proportional hazard analysis. RESULTS No difference was found in procedural complication between the groups (early 2 [2.7 %] vs. delayed group 7 [5.3 %], hazard ratio [HR] 0.61, 95 % confidence interval [CI] 0.123-2.979, p = 0.537). In the early group, however, early event developed more frequently than in the late group (9 [12.2 %] vs. 1 [0.8 %], HR 16.05, 95 % CI 1.991-129.438, p = 0.009). The late event rate showed no difference between the two groups (4 [5.4 %] vs. 4 [3.0 %], HR 2.09, 95 % CI 0.484-8.989, p = 0.324). CONCLUSIONS Early CAS is not safe during periprocedural period, compared with late CAS. In CAS for symptomatic carotid stenosis, delayed CAS should be considered.
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Bazan HA, Zea N, Jennings B, Smith TA, Vidal G, Sternbergh WC. Urgent carotid intervention is safe after thrombolysis for minor to moderate acute ischemic stroke. J Vasc Surg 2015; 62:1529-38. [PMID: 26412434 DOI: 10.1016/j.jvs.2015.07.082] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2015] [Accepted: 07/21/2015] [Indexed: 01/01/2023]
Abstract
OBJECTIVE Carotid intervention shortly after an acute neurologic ischemic event is being performed more frequently in stroke centers to reduce the risk of recurrent stroke. Thrombolysis with recombinant tissue plasminogen activator (tPA) is offered to select patients with ischemic stroke symptoms who present within 4.5 hours. However, there is a paucity of data as to whether tPA followed by urgent carotid endarterectomy (CEA) or carotid artery stenting (CAS) has an increased risk of complications, particularly intracerebral hemorrhage (ICH). We sought to determine the periprocedural complications of urgently performed CEA or CAS following tPA. METHODS From January 2009 to January 2015, 762 patients underwent carotid interventions (CEA, n = 440; CAS, n = 322) at a tertiary referral center and 165 patients (21.6%) underwent an urgent CEA or CAS during the index hospitalization for an acute transient ischemic attack or stroke. We compared the effect of intravenous tPA on 30-day complications, including ICH. The χ(2) and Fisher exact tests were used to determine significance between groups. RESULTS During the 6-year period, 165 patients underwent urgent carotid interventions (CEA, n = 135; CAS, n = 30) for acute neurologic symptoms. Of these, 19% (31 patients [CEA, n = 25; CAS, n = 6]) had tPA for an acute stroke; the remaining (134 patients [CEA, n = 110; CAS, n = 24]) fell outside of the tPA time window. Most strokes were minor or moderate with a mean National Institutes of Health Stroke Scale (NIHSS) score of 6.6 (range, 0-19). The mean time to intervention for both groups was 2.4 days (0-15 days). The 30-day stroke, death, and myocardial infarction rates were 9.7% (3 of 31) for the tPA group compared with 4.5% (6 of 134) for the no-tPA group (P = .37). Including bleeding complications in these 30-day outcomes, there was no difference between the tPA (3 of 31) and the no-tPA cohorts (8 of 134; P = .43). In the tPA group, there were one ICH, one neck hematoma/death, and an additional death; in the no-tPA group, there were one ICH, two neck hematomas, one stroke, two myocardial infarctions, one ICH/death, and one additional death. No significant increased rates of bleeding were noted within the tPA group (2 of 31) compared with the no-tPA group (4 of 134; P = .32). Moreover, in the tPA cohort, more than half of the patients (17 of 31) underwent revascularization within 72 hours (CEA = 13; CAS = 4) with outcomes similar to those who underwent revascularization after 72 hours. CONCLUSIONS Thrombolysis followed by urgent CEA or CAS is not associated with an increased risk of complications in select patients who present with acute neurologic symptoms. Selection of patients is important; there was no ICH and only one death in each group for patients with minor to moderate ischemic stroke (NIHSS score <10).
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Affiliation(s)
- Hernan A Bazan
- Section of Vascular/Endovascular Surgery, Department of Surgery, Ochsner Clinic, New Orleans, La.
| | - Nicolas Zea
- Section of Vascular/Endovascular Surgery, Department of Surgery, Ochsner Clinic, New Orleans, La
| | - Bethany Jennings
- Stroke/Vascular Neurology, Department of Neurology, Ochsner Clinic, New Orleans, La
| | - Taylor A Smith
- Section of Vascular/Endovascular Surgery, Department of Surgery, Ochsner Clinic, New Orleans, La
| | - Gabriel Vidal
- Stroke/Vascular Neurology, Department of Neurology, Ochsner Clinic, New Orleans, La
| | - W Charles Sternbergh
- Section of Vascular/Endovascular Surgery, Department of Surgery, Ochsner Clinic, New Orleans, La
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Tsivgoulis G, Safouris A, Alexandrov AV. Safety of intravenous thrombolysis for acute ischemic stroke in specific conditions. Expert Opin Drug Saf 2015; 14:845-64. [DOI: 10.1517/14740338.2015.1032242] [Citation(s) in RCA: 38] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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21
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Rathenborg L, Venermo M, Troëng T, Jensen L, Vikatmaa P, Wahlgren C, Ijäs P, Björck M, Kragsterman B. Editor's Choice - Safety of Carotid Endarterectomy After Intravenous Thrombolysis for Acute Ischaemic Stroke: A Case-Controlled Multicentre Registry Study. Eur J Vasc Endovasc Surg 2014; 48:620-5. [DOI: 10.1016/j.ejvs.2014.09.004] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2014] [Accepted: 09/08/2014] [Indexed: 10/24/2022]
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22
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Mandavia R, Qureshi M, Dharmarajah B, Head K, Davies A. Safety of Carotid Intervention Following Thrombolysis in Acute Ischaemic Stroke. Eur J Vasc Endovasc Surg 2014; 48:505-12. [DOI: 10.1016/j.ejvs.2014.08.012] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2014] [Accepted: 08/06/2014] [Indexed: 10/24/2022]
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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]
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Vellimana AK, Yarbrough CK, Blackburn S, Strom RG, Pilgram TK, Lee JM, Grubb RL, Rich KM, Chicoine MR, Dacey RG, Derdeyn CP, Zipfel GJ. Intravenous tissue-type plasminogen activator therapy is an independent risk factor for symptomatic intracerebral hemorrhage after carotid endarterectomy. Neurosurgery 2014; 74:254-61. [PMID: 24335814 PMCID: PMC4097004 DOI: 10.1227/neu.0000000000000261] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Carotid endarterectomy (CEA) for symptomatic carotid artery stenosis and intravenous tissue-type plasminogen activator (IV-tPA) for acute ischemic stroke are proven therapies; however, the safety of CEA in stroke patients who recently received IV-tPA has not been established. OBJECTIVE To evaluate the safety of CEA in stroke patients who recently received IV-tPA. METHODS A retrospective review of patients who underwent CEA for symptomatic carotid artery stenosis was performed. The primary end point was postoperative symptomatic intracerebral hemorrhage (sICH). A univariate analysis of potential risk factors for sICH, including IV-tPA therapy, timing of CEA, degree of stenosis, and stroke severity, was performed. Factors with a value of P < .1 on univariate analysis were tested further. RESULTS Among 142 patients, 3 suffered sICH after CEA: 2 of 11 patients treated with IV-tPA (18.2%) and 1 of 131 patients not treated with IV-tPA (0.8%). Both IV-tPA patients suffering sICH underwent CEA within 3 days of tPA administration. On univariate analysis, IV-tPA (P = .02), female sex (P = .09), shorter time between ischemic event and CEA (P = .06), and lower mean arterial pressure during the first 48 hours of admission (P = .08) were identified as risk factors for sICH. On multivariate analysis, IV-tPA was the only significant risk factor (P = .002 by stepwise logistic regression; P = .03 by nominal logistic regression). CONCLUSION This study indicates that IV-tPA is an independent risk factor for sICH after CEA. This suggests that CEA should be pursued cautiously in patients who recently received IV-tPA. Early surgery may be associated with an increased risk for sICH. ABBREVIATIONS CEA, carotid endarterectomyIV-tPA, intravenous recombinant tissue-type plasminogen activatorMAP, mean arterial pressureNASCET, North American Symptomatic Carotid Endarterectomy TrialNIHSS, National Institutes of Health Stroke ScaleNINDS, National Institute of Neurological Disorders and StrokesICH, symptomatic intracerebral hemorrhageTIA, transient ischemic attack.
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Affiliation(s)
- Ananth K. Vellimana
- Department of Neurological Surgery, Washington University School of Medicine, St. Louis, Missouri, USA
| | - Chester K. Yarbrough
- Department of Neurological Surgery, Washington University School of Medicine, St. Louis, Missouri, USA
| | - Spiros Blackburn
- Department of Neurological Surgery, Washington University School of Medicine, St. Louis, Missouri, USA
- Mallinckrodt Institute of Radiology, Washington University School of Medicine, St. Louis, Missouri, USA
| | - Russell G. Strom
- Department of Neurological Surgery, Washington University School of Medicine, St. Louis, Missouri, USA
| | - Thomas K. Pilgram
- Mallinckrodt Institute of Radiology, Washington University School of Medicine, St. Louis, Missouri, USA
| | - Jin-Moo Lee
- Department of Neurology, Washington University School of Medicine, St. Louis, Missouri, USA
| | - Robert L. Grubb
- Department of Neurological Surgery, Washington University School of Medicine, St. Louis, Missouri, USA
| | - Keith M. Rich
- Department of Neurological Surgery, Washington University School of Medicine, St. Louis, Missouri, USA
| | - Michael R. Chicoine
- Department of Neurological Surgery, Washington University School of Medicine, St. Louis, Missouri, USA
| | - Ralph G. Dacey
- Department of Neurological Surgery, Washington University School of Medicine, St. Louis, Missouri, USA
| | - Colin P. Derdeyn
- Department of Neurological Surgery, Washington University School of Medicine, St. Louis, Missouri, USA
- Mallinckrodt Institute of Radiology, Washington University School of Medicine, St. Louis, Missouri, USA
- Department of Neurology, Washington University School of Medicine, St. Louis, Missouri, USA
| | - Gregory J. Zipfel
- Department of Neurological Surgery, Washington University School of Medicine, St. Louis, Missouri, USA
- Department of Neurology, Washington University School of Medicine, St. Louis, Missouri, USA
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Koraen-Smith L, Troëng T, Björck M, Kragsterman B, Wahlgren CM, Kragsterman B, Hager J, Wellander E, Nordanstig J, Sigvant B, Björses K, Wigelius A, Asplund K, Appelros P, Bjarne D, Engberg W, von Euler M, Norrving B, Stegmayr B, Térent A, Wallin S, Ytterberg M. Urgent Carotid Surgery and Stenting May Be Safe After Systemic Thrombolysis for Stroke. Stroke 2014; 45:776-80. [DOI: 10.1161/strokeaha.113.003763] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Affiliation(s)
- Linn Koraen-Smith
- From the Department of Vascular Surgery, Karolinska Institute and Karolinska University Hospital, Stockholm, Sweden (L.K.-S., C.-M.W.); Department of Surgery, Blekinge Hospital, Karlskrona, Sweden (T.T.); and Department of Surgical Sciences, Section of Vascular Surgery, Uppsala University, Uppsala, Sweden (T.T., M.B., B.K.)
| | - Thomas Troëng
- From the Department of Vascular Surgery, Karolinska Institute and Karolinska University Hospital, Stockholm, Sweden (L.K.-S., C.-M.W.); Department of Surgery, Blekinge Hospital, Karlskrona, Sweden (T.T.); and Department of Surgical Sciences, Section of Vascular Surgery, Uppsala University, Uppsala, Sweden (T.T., M.B., B.K.)
| | - Martin Björck
- From the Department of Vascular Surgery, Karolinska Institute and Karolinska University Hospital, Stockholm, Sweden (L.K.-S., C.-M.W.); Department of Surgery, Blekinge Hospital, Karlskrona, Sweden (T.T.); and Department of Surgical Sciences, Section of Vascular Surgery, Uppsala University, Uppsala, Sweden (T.T., M.B., B.K.)
| | - Björn Kragsterman
- From the Department of Vascular Surgery, Karolinska Institute and Karolinska University Hospital, Stockholm, Sweden (L.K.-S., C.-M.W.); Department of Surgery, Blekinge Hospital, Karlskrona, Sweden (T.T.); and Department of Surgical Sciences, Section of Vascular Surgery, Uppsala University, Uppsala, Sweden (T.T., M.B., B.K.)
| | - Carl-Magnus Wahlgren
- From the Department of Vascular Surgery, Karolinska Institute and Karolinska University Hospital, Stockholm, Sweden (L.K.-S., C.-M.W.); Department of Surgery, Blekinge Hospital, Karlskrona, Sweden (T.T.); and Department of Surgical Sciences, Section of Vascular Surgery, Uppsala University, Uppsala, Sweden (T.T., M.B., B.K.)
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Krylov VV, Luk'ianchikov VA. Cerebral revascularization for the treatment of patients with acute ischemic stroke. Zh Nevrol Psikhiatr Im S S Korsakova 2014; 114:46-52. [DOI: 10.17116/jnevro201411412246-52] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
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27
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Yong YP, Saunders J, Abisi S, Sprigg N, Varadhan K, MacSweeney S, Altaf N. Safety of carotid endarterectomy following thrombolysis for acute ischemic stroke. J Vasc Surg 2013; 58:1671-7. [DOI: 10.1016/j.jvs.2013.05.093] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2013] [Revised: 05/20/2013] [Accepted: 05/21/2013] [Indexed: 10/26/2022]
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Barroso B, Laurens B, Demasles S, Faik M, Ledoyer G. Early Carotid Artery Endarterectomy after Intravenous Thrombolysis Therapy. Int J Stroke 2013; 8:E28. [DOI: 10.1111/ijs.12072] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Affiliation(s)
- Bruno Barroso
- Stroke Unit, Department of Neurology, Hospital F. Mitterrand, Pau, France
| | - Brice Laurens
- Stroke Unit, Department of Neurology, Hospital F. Mitterrand, Pau, France
| | - Stéphanie Demasles
- Stroke Unit, Department of Neurology, Hospital F. Mitterrand, Pau, France
| | - Mohamed Faik
- Department of Vascular Surgery, Hospital F. Mitterrand, Pau, France
| | - Gael Ledoyer
- Department of Vascular Surgery, Hospital F. Mitterrand, Pau, France
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29
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Role of Carotid Endarterectomy Following Intravenous Thrombolysis. Eur J Vasc Endovasc Surg 2013; 45:578. [DOI: 10.1016/j.ejvs.2013.03.019] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2013] [Accepted: 03/20/2013] [Indexed: 11/19/2022]
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30
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Carotid Endarterectomy after Intravenous Thrombolysis for Acute Cerebral Ischaemic Attack: Is It Safe? Eur J Vasc Endovasc Surg 2013; 45:573-7. [DOI: 10.1016/j.ejvs.2013.02.020] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2012] [Accepted: 02/27/2013] [Indexed: 11/15/2022]
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31
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Reinert M, Mono ML, Kuhlen D, Mariani L, Barth A, Beck J, Andres RH, Gralla J, Wymann R, Schmidt J, Kauert C, Schroth G, Arnold M, Mattle HP, Raabe A, Fischer U. Restenosis after microsurgical non-patch carotid endarterectomy in 586 patients. Acta Neurochir (Wien) 2012; 154:423-31; discussion 431. [PMID: 22113556 PMCID: PMC3284671 DOI: 10.1007/s00701-011-1233-9] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2011] [Accepted: 11/09/2011] [Indexed: 11/19/2022]
Abstract
Background Carotid endarterectomy (CEA) reduces the risk of stroke in patients with symptomatic (>50%) and asymptomatic (>60%) carotid artery stenosis. Here we report the midterm results of a microsurgical non-patch technique and compare these findings to those in the literature. Methods From 1998 to 2009 we treated 586 consecutive patients with CEA. CEA was performed, under general anesthesia, with a surgical microscope using a non-patch technique. Somatosensory evoked potential and transcranial Doppler were continuously monitored. Cross-clamping was performed under EEG burst suppression and adaptive blood pressure increase. Follow-up was performed by an independent neurologist. Mortality at 30 days and morbidity such as major and minor stroke, peripheral nerve palsy, hematoma and cardiac complications were recorded. The restenosis rate was assessed using duplex sonography 1 year after surgery. Results A total of 439 (75%) patients had symptomatic and 147 (25%) asymptomatic stenosis; 49.7% of the stenoses were on the right-side. Major perioperative strokes occurred in five (0.9%) patients [n = 4 (0.9%) symptomatic; n = 1 (0.7%) asymptomatic patients]. Minor stroke was recorded in six (1%) patients [n = 4 (0.9%) symptomatic; n = 2 (1.3%) asymptomatic patients]. Two patients with symptomatic stenoses died within 1 month after surgery. Nine patients (1.5%) had reversible peripheral nerve palsies, and nine patients (1.5%) suffered a perioperative myocardial infarction. High-grade (>70%) restenosis at 1 year was observed in 19 (3.2%) patients [n = 12 (2.7%) symptomatic; n = 7 (4.7%) asymptomatic patients]. Conclusions The midterm rate of restenosis was low when using a microscope-assisted non-patch endarterectomy technique. The 30-day morbidity and mortality rate was comparable or lower than those in recently published surgical series.
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Carotid endarterectomy in the acute phase of stroke-in-evolution is safe and effective in selected patients. J Vasc Surg 2012; 55:701-7. [PMID: 22070936 DOI: 10.1016/j.jvs.2011.09.054] [Citation(s) in RCA: 35] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2011] [Revised: 09/12/2011] [Accepted: 09/13/2011] [Indexed: 11/22/2022]
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Hauck EF, Natarajan SK, Ohta H, Ogilvy CS, Hopkins LN, Siddiqui AH, Levy EI. Emergent endovascular recanalization for cervical internal carotid artery occlusion in patients presenting with acute stroke. Neurosurgery 2011; 69:899-907; discussion 907. [PMID: 21499144 DOI: 10.1227/neu.0b013e31821cfa52] [Citation(s) in RCA: 39] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Acute proximal (cervical) internal carotid artery (ICA) occlusion may cause ischemia of an entire hemisphere or no ischemia at all, depending on the presence of intracranial collaterals. OBJECTIVE To retrospectively analyze the clinical results for emergent endovascular carotid recanalization in patients with acute proximal (cervical) ICA occlusion and to assess predictors of recanalization and clinical, neurological, and functional outcome. METHODS Emergent endovascular revascularization was attempted in 22 patients presenting with acute stroke secondary to complete cervical ICA occlusion. Patients with pseudo-occlusion were excluded. Recanalization was assessed with the Thrombolysis in Myocardial Ischemia (TIMI) system: grade 0 (no flow) to grade 3 (normal flow). RESULTS The median age of the patients was 65 years; mean admission National Institutes of Health Stroke Scale (NIHSS) score was 14. Recanalization (TIMI grade 2/3) occurred in 17 patients (77.3%). Ten patients (45.5%) demonstrated significant clinical improvement during hospitalization (NIHSS improved ≥4 points). Fifty percent of patients had good outcomes (modified Rankin Scale ≤2) after a median follow-up of 3 months. Patient age <70 years and successful recanalization (TIMI grade 2/3) predicted a good outcome (P ≤ .01). Presence of atrial fibrillation, admission NIHSS score ≥20, and complete ICA occlusion at all levels (cervical, petrocavernous, and intracranial) were associated with poor outcomes (P ≤ .05). Patients with complete cervical ICA occlusion but partial distal preservation of the vessel were most likely to benefit from the intervention (recanalization in 88.2%; good outcome in 64.7%). CONCLUSION Attempts at emergent endovascular carotid recanalization for acute stroke are encouraged, particularly in younger patients with partial distal preservation of the ICA.
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Affiliation(s)
- Erik F Hauck
- Department of Neurosurgery, University at Buffalo, State University of New York, Buffalo, NY, USA
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Sallustio F, Koch G, Rocco A, Rossi C, Pampana E, Gandini R, Meschini A, Diomedi M, Stanzione P, Di Legge S. Safety of early carotid artery stenting after systemic thrombolysis: a single center experience. Stroke Res Treat 2011; 2012:904575. [PMID: 21860810 PMCID: PMC3154777 DOI: 10.1155/2012/904575] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2011] [Accepted: 06/19/2011] [Indexed: 11/29/2022] Open
Abstract
Background. Patients with acute ischemic stroke due to internal carotid artery (ICA) disease are at high risk of early stroke recurrence. A combination of IV thrombolysis and early carotid artery stenting (CAS) may result in more effective secondary stroke prevention. Objective. We tested safety and durability of early CAS following IV thrombolysis in stroke patients with residual stenosis in the symptomatic ICA. Methods. Of consecutive patients treated with IV rtPA, those with residual ICA stenosis ≥70% or <70% with an ulcerated plaque underwent early CAS (>24 hours). The protocol included pre-rtPA MRI and MR angiography, and post-rtPA carotid ultrasound and CT angiography. Stroke severity was assessed by the NIH Stroke Scale (NIHSS). Three- and twelve-month stent patency was assessed by ultrasound. Twelve-month functional outcome was assessed by the modified Rankin Scale (mRS). Results. Of 145 consecutive IV rtPA-treated patients, 6 (4%) underwent early CAS. Median age was 76 (range 67-78) years, median NIHSS at stroke onset was 12 (range 9-16) and 7 (range 7-8) before CAS. Median onset-to-CAS time was 48 (range 30-94) hours. A single self-expandable stent was implanted to cover the entire lesion in all patients. The procedure was uneventful in all patients. After 12 months, all patients had stent patency, and the functional outcome was favourable (mRS ≤ 2) in all but 1 patient experiencing a recurrent stroke for new-onset atrial fibrillation. Conclusion. This small case series of a single centre suggests that early CAS may be considered a safe alternative to CEA after IV rtPA administration in selected patients at high risk of stroke recurrence.
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Affiliation(s)
- Fabrizio Sallustio
- Department of Clinical Neurological Sciences, Stroke Unit, Policlinico Tor Vergata, Viale Oxford 81, 00133 Rome, Italy
- I.R.C.C.S. Santa Lucia Foundation, Via Ardeatina 306, 00179 Rome, Italy
| | - Giacomo Koch
- Department of Clinical Neurological Sciences, Stroke Unit, Policlinico Tor Vergata, Viale Oxford 81, 00133 Rome, Italy
- I.R.C.C.S. Santa Lucia Foundation, Via Ardeatina 306, 00179 Rome, Italy
| | - Alessandro Rocco
- Department of Clinical Neurological Sciences, Stroke Unit, Policlinico Tor Vergata, Viale Oxford 81, 00133 Rome, Italy
| | - Costanza Rossi
- Department of Clinical Neurological Sciences, Stroke Unit, Policlinico Tor Vergata, Viale Oxford 81, 00133 Rome, Italy
| | - Enrico Pampana
- Department of Interventional Radiology, Policlinico Tor Vergata, Viale Oxford 81, 00133 Rome, Italy
| | - Roberto Gandini
- Department of Interventional Radiology, Policlinico Tor Vergata, Viale Oxford 81, 00133 Rome, Italy
| | - Alessandro Meschini
- Department of Interventional Radiology, Policlinico Tor Vergata, Viale Oxford 81, 00133 Rome, Italy
| | - Marina Diomedi
- Department of Clinical Neurological Sciences, Stroke Unit, Policlinico Tor Vergata, Viale Oxford 81, 00133 Rome, Italy
- I.R.C.C.S. Santa Lucia Foundation, Via Ardeatina 306, 00179 Rome, Italy
| | - Paolo Stanzione
- Department of Clinical Neurological Sciences, Stroke Unit, Policlinico Tor Vergata, Viale Oxford 81, 00133 Rome, Italy
- I.R.C.C.S. Santa Lucia Foundation, Via Ardeatina 306, 00179 Rome, Italy
| | - Silvia Di Legge
- Department of Clinical Neurological Sciences, Stroke Unit, Policlinico Tor Vergata, Viale Oxford 81, 00133 Rome, Italy
- I.R.C.C.S. Santa Lucia Foundation, Via Ardeatina 306, 00179 Rome, Italy
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Crozier JEM, Reid J, Welch GH, Muir KW, Stuart WP. Early carotid endarterectomy following thrombolysis in the hyperacute treatment of stroke. Br J Surg 2010; 98:235-8. [DOI: 10.1002/bjs.7306] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
Abstract
Abstract
Background
Thrombolysis with intravenous recombinant tissue plasminogen activator improves the probability of complete neurological recovery if given promptly following the onset of acute ischaemic stroke. Carotid endarterectomy (CEA) can reduce the risk of further embolic stroke in selected patients and is most effective within 14 days of the incident event. The safety of surgery so soon after thrombolysis is unknown. The aim of this study was to report the immediate outcomes of this management strategy early in the unit experience and to encourage pooling of data, recognizing that this will be an uncommon procedure even in busy stoke units with an active lysis programme.
Methods
Data were extracted from two prospectively collected databases, and included patient demographics, type of stroke, type and timing of surgical procedure, and immediate outcome. On presentation with a stroke, all patients underwent urgent computed tomography (CT) of the brain. Those eligible received thrombolysis according to the unit protocol. They underwent CT angiography 24 h after thrombolysis and patients with a severe carotid stenosis had surgery.
Results
Ten of a cohort of 450 patients who had received lysis underwent CEA. Seven of these were women and eight of the procedures were carried out under local anaesthetic. Surgery was performed a median of 8 (range 2–23) days after the index event; there were no major complications.
Conclusion
Few patients with acute stroke are eligible, but CEA performed soon after thrombolytic therapy for stroke appears to be safe.
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Affiliation(s)
- J E M Crozier
- Department of Vascular Surgery, Southern General Hospital, Glasgow, UK
| | - J Reid
- Department of Vascular Surgery, Southern General Hospital, Glasgow, UK
| | - G H Welch
- Department of Vascular Surgery, Southern General Hospital, Glasgow, UK
| | - K W Muir
- University of Glasgow, Division of Clinical Neurosciences, Institute of Neurological Sciences, Southern General Hospital, Glasgow, UK
| | - W P Stuart
- Department of Vascular Surgery, Southern General Hospital, Glasgow, UK
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Comment on “Early Carotid Endarterectomy after Intravenous Thrombolysis for Acute Ischaemic Stroke, Bartolia MA et al. May 2009”. Eur J Vasc Endovasc Surg 2009; 38:530; author reply 530-1. [DOI: 10.1016/j.ejvs.2009.05.026] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2009] [Accepted: 05/22/2009] [Indexed: 11/23/2022]
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Jackson AJ, Patel A, Renwick B, Ablett M, McMillan I. Spontaneous recanalization of a middle cerebral artery occlusion with subsequent carotid endarterectomy. J Vasc Surg 2009; 50:1493-5. [PMID: 19782507 DOI: 10.1016/j.jvs.2009.07.074] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2009] [Revised: 07/01/2009] [Accepted: 07/02/2009] [Indexed: 11/26/2022]
Abstract
We report the case of a 55-year-old man who presented with a left hemisphere stroke. The initial computed tomography scan demonstrated a cerebral infarct in association with a left middle cerebral artery occlusion. Carotid duplex ultrasound imaging revealed a surgical grade stenosis of the proximal left internal carotid artery; however, in view of the uncertain benefits of internal carotid endarterectomy in the face of ipsilateral middle cerebral artery occlusion, surgery was deferred. Subsequent surveillance by transcranial Doppler imaging and repeat computed tomography demonstrated spontaneous recanalization. The patient proceeded to carotid endarterectomy with no complications.
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