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Monaco F, Licheri M, Labanca R, Russetti F, Oriani A, Melissano G, Chiesa R, Barucco G. Association of Impedance Aggregometry-Measured Platelet Aggregation With Thromboembolic Events in Patients Who Undergo Carotid Endarterectomy: A Pilot Study. J Cardiothorac Vasc Anesth 2024; 38:771-779. [PMID: 38320918 DOI: 10.1053/j.jvca.2023.12.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/16/2023] [Revised: 11/29/2023] [Accepted: 12/01/2023] [Indexed: 02/08/2024]
Abstract
OBJECTIVES The aim of the current study was to assess the relationship among thrombin receptor activator peptide 6 (TRAP test), adenosine-5'-diphosphate (ADP test), arachidonic acid (ASPI test), and stroke/transient ischemic attack (TIA), using the multiple electrode aggregometry (Multiplate) in patients undergoing carotid thromboendarterectomy (CEA). DESIGN A retrospective study. SETTING Vascular surgery operating rooms of a university hospital. PARTICIPANTS One hundred thirty-one out of 474 patients undergoing CEA between November 2020 and October 2022. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS A preoperative blood sample of all enrolled patients was analyzed using the Multiplate analyzer. Receiver operating characteristics curves, were generated to test the ability of TRAP, ADP, and ASPI in discriminating perioperative thromboembolic stroke/TIA. A logistic LASSO regression model was used to identify factors independently associated with stroke/TIA. Eight patients experienced a perioperative stroke/TIA. Although all the platelet functional assays showed excellent predictive performance, an ADP value exceeding 72 U showed the highest specificity (87%) and sensitivity (68%) in discriminating patients who had a perioperative thromboembolic stroke/TIA, with a negative predictive value of 99% and a positive predictive value of 15%. After LASSO regression, an ADP >72 U and the need for a shunt during CEA were the only 2 variables independently associated with perioperative stroke/TIA. CONCLUSION Because the ADP test was independently associated with perioperative stroke/TIA, the assessment of platelet reactivity using Multiplate may offer potential utility in monitoring patients undergoing CEA.
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Affiliation(s)
- Fabrizio Monaco
- Department of Anesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, Milan, Italy.
| | - Margherita Licheri
- Department of Anesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Rosa Labanca
- Department of Anesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Federica Russetti
- Department of Anesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Alessandro Oriani
- Department of Anesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Germano Melissano
- Department of Vascular Surgery, IRCCS San Raffaele Scientific Institute, Milan, Italy; Vita-Salute San Raffaele University, Milan, Italy
| | - Roberto Chiesa
- Department of Vascular Surgery, IRCCS San Raffaele Scientific Institute, Milan, Italy; Vita-Salute San Raffaele University, Milan, Italy
| | - Gaia Barucco
- Department of Anesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, Milan, Italy
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Han T, Tang H, Lin C, Zhu J, Shen Y, Yan D, Zhao Z, Lin J, Gao B, Si Y, Wei X, Tang X, Guo D, Fu W. One month follow-up of carotid endarterectomy with in-hospital preoperative aspirin monotherapy and postoperative dual antiplatelet therapy in asymptomatic and symptomatic patients: A multi-center study. Heliyon 2024; 10:e24755. [PMID: 38322935 PMCID: PMC10844113 DOI: 10.1016/j.heliyon.2024.e24755] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2023] [Revised: 12/15/2023] [Accepted: 01/12/2024] [Indexed: 02/08/2024] Open
Abstract
Background There is currently no consensus regarding the optimal perioperative antiplatelet strategy for carotid artery surgery. This multicentre study aimed to analyse the association between preoperative aspirin monotherapy following postoperative dual antiplatelet therapy (DAPT) and the risk for stroke and death after carotid endarterectomy (CEA). Methods This cohort study included 821 patients with carotid artery stenosis who underwent CEA. Primary outcomes included any stroke or death up to the one-month postoperative follow-up. Multilevel multivariate regression analyses and descriptive statistics were performed. Results Patients were predominantly male (53 %), with a mean age of 66.2 years. The primary outcome occurred in 1.6 % of patients. Univariate and multivariate analyses revealed that patients with chronic obstructive pulmonary disease (COPD) exhibited a high risk for stroke or death (P = 0.011). The occurrence of any local complications in the neck was accompanied by an increase in diastolic blood pressure (DBP) (P = 0.007). Patients with a high systolic blood pressure (SBP) (P = 0.002) experienced a longer operative duration. The length of hospital stay was longer in the patients with COPD (P = 0.020), minor stroke (P = 0.011), and major stroke (P = 0.001). A positive linear correlation was found between SBP and operative duration in the overall population (β 0.4 [95 % confidence interval (CI) 0.1-0.7]; P = 0.002). The resultant curve for DBP and any local complications in the neck exhibited a two-stage change and one breakpoint in the entire population (k = 68 mmHg, <68; odds ratio [OR] 0.9 [95 % CI 0.7-1.1], P = 0.461; ≥68: OR 1.1 [95 % CI 1.0-1.1], P = 0.003). Conclusions Preoperative aspirin monotherapy and postoperative DAPT were safe and effective antiplatelet treatments for patients who underwent CEA.
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Affiliation(s)
- Tonglei Han
- Department of Vascular Surgery, Zhongshan Hospital, Fudan University, Shanghai, 200030, China
| | - Hanfei Tang
- Department of Vascular Surgery, Zhongshan Hospital, Fudan University, Shanghai, 200030, China
| | - Changpo Lin
- Department of Vascular Surgery, Zhongshan Hospital, Fudan University, Shanghai, 200030, China
| | - Jiaqi Zhu
- Department of Vascular Surgery, Zhongshan Hospital, Fudan University, Shanghai, 200030, China
| | - Yang Shen
- Department of Vascular Surgery, Zhongshan Hospital, Fudan University, Shanghai, 200030, China
| | - Dong Yan
- Department of Vascular Surgery, Zhongshan Hospital, Fudan University, Shanghai, 200030, China
| | - Zhiqing Zhao
- Department of Vascular Surgery, Changhai Hospital, The PLA Naval Medical University, Shanghai, 200433, China
| | - Jiang Lin
- Department of Radiology, Zhongshan Hospital, Fudan University and Shanghai Institute of Medical Imaging, Shanghai, 200030, China
| | - Bin Gao
- Department of Vascular Surgery, Zhongshan Hospital, Fudan University, Shanghai, 200030, China
| | - Yi Si
- Department of Vascular Surgery, Zhongshan Hospital, Fudan University, Shanghai, 200030, China
| | - Xiaolong Wei
- Department of Vascular Surgery, Changhai Hospital, The PLA Naval Medical University, Shanghai, 200433, China
| | - Xiao Tang
- Department of Vascular Surgery, Zhongshan Hospital, Fudan University, Shanghai, 200030, China
| | - Daqiao Guo
- Department of Vascular Surgery, Zhongshan Hospital, Fudan University, Shanghai, 200030, China
| | - Weiguo Fu
- Department of Vascular Surgery, Zhongshan Hospital, Fudan University, Shanghai, 200030, China
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Yaghi S, Albin C, Chaturvedi S, Savitz SI. Roundtable of Academia and Industry for Stroke Prevention: Prevention and Treatment of Large-Vessel Disease. Stroke 2024; 55:226-235. [PMID: 38134259 DOI: 10.1161/strokeaha.123.043910] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2023]
Affiliation(s)
- Shadi Yaghi
- Alpert Medical School at Brown University, Providence, RI (S.Y.)
| | | | | | - Sean I Savitz
- Institute for Stroke and Cerebrovascular Disease, University of Texas Health Science Center, Houston (S.I.S.)
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Offiah C, Tierney S, Egan B, Collins RD, Ryan DJ, McCarthy AJ, Smith DR, Mahon J, Boyle E, Delaney H, O 'Donohoe R, Hurley A, Walsh RA, Murphy SM, Bogdanova-Mihaylova P, O 'Dowd S, Kelly MJ, Omer T, Coughlan T, O'Neill D, Martin M, Murphy SJX, McCabe DJH. Frequency of inter-specialty consensus decisions and adherence to advice following discussion at a weekly neurovascular multidisciplinary meeting. Ir J Med Sci 2023; 192:3051-3062. [PMID: 37081289 PMCID: PMC10119010 DOI: 10.1007/s11845-023-03319-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2022] [Accepted: 02/13/2023] [Indexed: 04/22/2023]
Abstract
BACKGROUND/AIMS Data are limited on the frequency of 'consensus decisions' between sub-specialists attending a neurovascular multidisciplinary meeting (MDM) regarding management of patients with extracranial carotid/vertebral stenoses and post-MDM 'adherence' to such advice. METHODS This prospective audit/quality improvement project collated prospectively-recorded data from a weekly Neurovascular/Stroke Centre MDM documenting the proportion of extracranial carotid/vertebral stenosis patients in whom 'consensus management decisions' were reached by neurologists, vascular surgeons, stroke physicians-geriatricians and neuroradiologists. Adherence to MDM advice was analysed in asymptomatic carotid stenosis (ACS), symptomatic carotid stenosis (SCS), 'indeterminate symptomatic status stenosis' (ISS) and vertebral artery stenosis (VAS) patients, including intervals between index event to MDM + / - intervention. RESULTS One hundred fifteen patients were discussed: 108 with carotid stenosis and 7 with VAS. Consensus regarding management was noted in 96.5% (111/115): 100% with ACS and VAS, 96.2% with SCS and 92.9% with ISS. Adherence to MDM management advice was 96.4% (107/111): 100% in ACS, ISS and VAS patients; 92% (46/50) in SCS patients. The median interval from index symptoms to revascularisation in 50-99% SCS patients was 12.5 days (IQR: 9-18.3 days; N = 26), with a median interval from MDM to revascularisation of 5.5 days (IQR: 1-7 days). Thirty patients underwent revascularisation. Two out of twenty-nine patients (6.9%) with either SCS or ISS had a peri-procedural ipsilateral ischaemic stroke, with no further strokes/deaths during 3-months follow-up. CONCLUSIONS The high frequency of inter-specialty consensus regarding management and adherence to proposed treatment supports a collaborative/multidisciplinary model of care in patients with extracranial arterial stenoses. Service development should aim to shorten times between MDM discussion-intervention and optimise prevention of stroke/death.
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Grants
- Meath Foundation, Vascular Neurology Research Foundation,
- The Adelaide Health Foundation Ireland, Enterprise Ireland-Innovation Partnership Programme
- Trinity College Dublin Innovation Bursary, The Meath Foundation, Ireland, Joint Irish Institute of Clinical Neuroscience/Merck Serono Fellowship in Neuroscience Grant, The Vascular Neurology Research Foundation Ireland, Bayer HealthCare, Ireland and Verum
- The Meath Foundation, Ireland; The Adelaide Health Foundation, Ireland; The Vascular Neurology Research Foundation Ireland; the Enterprise Ireland-Innovation Partnership Programme (co-funded by the European Regional Development Fund); and by unrestricted e
- University of Dublin, Trinity College
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Affiliation(s)
- Chika Offiah
- Dept. of Neurology, Tallaght University Hospital (TUH) / The Adelaide and Meath Hospital, Dublin, incorporating the National Children's Hospital (AMNCH), Dublin, Ireland
- Stroke Service, Tallaght University Hospital (TUH) / The Adelaide and Meath Hospital, Dublin, incorporating the National Children's Hospital (AMNCH), Dublin, Ireland
| | - Sean Tierney
- Dept. of Vascular Surgery, Tallaght University Hospital (TUH) / The Adelaide and Meath Hospital, Dublin, incorporating the National Children's Hospital (AMNCH), Dublin, Ireland
| | - Bridget Egan
- Dept. of Vascular Surgery, Tallaght University Hospital (TUH) / The Adelaide and Meath Hospital, Dublin, incorporating the National Children's Hospital (AMNCH), Dublin, Ireland
| | - Ronán D Collins
- Stroke Service, Tallaght University Hospital (TUH) / The Adelaide and Meath Hospital, Dublin, incorporating the National Children's Hospital (AMNCH), Dublin, Ireland
- Dept. of Age-Related Health Care, Tallaght University Hospital (TUH) / The Adelaide and Meath Hospital, Dublin, incorporating the National Children's Hospital (AMNCH), Dublin, Ireland
| | - Daniel J Ryan
- Stroke Service, Tallaght University Hospital (TUH) / The Adelaide and Meath Hospital, Dublin, incorporating the National Children's Hospital (AMNCH), Dublin, Ireland
- Dept. of Age-Related Health Care, Tallaght University Hospital (TUH) / The Adelaide and Meath Hospital, Dublin, incorporating the National Children's Hospital (AMNCH), Dublin, Ireland
| | - Allan J McCarthy
- Dept. of Neurology, Tallaght University Hospital (TUH) / The Adelaide and Meath Hospital, Dublin, incorporating the National Children's Hospital (AMNCH), Dublin, Ireland
- Stroke Service, Tallaght University Hospital (TUH) / The Adelaide and Meath Hospital, Dublin, incorporating the National Children's Hospital (AMNCH), Dublin, Ireland
| | - Deirdre R Smith
- Dept. of Neurology, Tallaght University Hospital (TUH) / The Adelaide and Meath Hospital, Dublin, incorporating the National Children's Hospital (AMNCH), Dublin, Ireland
- Vascular Neurology Research Foundation, Tallaght University Hospital (TUH) / The Adelaide and Meath Hospital, Dublin, incorporating the National Children's Hospital (AMNCH), Dublin, Ireland
| | - James Mahon
- Stroke Service, Tallaght University Hospital (TUH) / The Adelaide and Meath Hospital, Dublin, incorporating the National Children's Hospital (AMNCH), Dublin, Ireland
- Dept. of Age-Related Health Care, Tallaght University Hospital (TUH) / The Adelaide and Meath Hospital, Dublin, incorporating the National Children's Hospital (AMNCH), Dublin, Ireland
| | - Emily Boyle
- Dept. of Vascular Surgery, Tallaght University Hospital (TUH) / The Adelaide and Meath Hospital, Dublin, incorporating the National Children's Hospital (AMNCH), Dublin, Ireland
| | - Holly Delaney
- Dept. of Radiology, Tallaght University Hospital (TUH) / The Adelaide and Meath Hospital, Dublin, incorporating the National Children's Hospital (AMNCH), Dublin, Ireland
| | - Rory O 'Donohoe
- Dept. of Radiology, Tallaght University Hospital (TUH) / The Adelaide and Meath Hospital, Dublin, incorporating the National Children's Hospital (AMNCH), Dublin, Ireland
| | - Alison Hurley
- Dept. of Radiology, Tallaght University Hospital (TUH) / The Adelaide and Meath Hospital, Dublin, incorporating the National Children's Hospital (AMNCH), Dublin, Ireland
| | - Richard A Walsh
- Dept. of Neurology, Tallaght University Hospital (TUH) / The Adelaide and Meath Hospital, Dublin, incorporating the National Children's Hospital (AMNCH), Dublin, Ireland
| | - Sinead M Murphy
- Dept. of Neurology, Tallaght University Hospital (TUH) / The Adelaide and Meath Hospital, Dublin, incorporating the National Children's Hospital (AMNCH), Dublin, Ireland
- Stroke Service, Tallaght University Hospital (TUH) / The Adelaide and Meath Hospital, Dublin, incorporating the National Children's Hospital (AMNCH), Dublin, Ireland
- Academic Unit of Neurology, School of Medicine, Trinity College Dublin, Dublin, Ireland
| | - Petya Bogdanova-Mihaylova
- Dept. of Neurology, Tallaght University Hospital (TUH) / The Adelaide and Meath Hospital, Dublin, incorporating the National Children's Hospital (AMNCH), Dublin, Ireland
| | - Sean O 'Dowd
- Dept. of Neurology, Tallaght University Hospital (TUH) / The Adelaide and Meath Hospital, Dublin, incorporating the National Children's Hospital (AMNCH), Dublin, Ireland
| | - Mark J Kelly
- Dept. of Neurology, Tallaght University Hospital (TUH) / The Adelaide and Meath Hospital, Dublin, incorporating the National Children's Hospital (AMNCH), Dublin, Ireland
- Stroke Service, Tallaght University Hospital (TUH) / The Adelaide and Meath Hospital, Dublin, incorporating the National Children's Hospital (AMNCH), Dublin, Ireland
| | - Taha Omer
- Dept. of Neurology, Tallaght University Hospital (TUH) / The Adelaide and Meath Hospital, Dublin, incorporating the National Children's Hospital (AMNCH), Dublin, Ireland
- Stroke Service, Tallaght University Hospital (TUH) / The Adelaide and Meath Hospital, Dublin, incorporating the National Children's Hospital (AMNCH), Dublin, Ireland
| | - Tara Coughlan
- Stroke Service, Tallaght University Hospital (TUH) / The Adelaide and Meath Hospital, Dublin, incorporating the National Children's Hospital (AMNCH), Dublin, Ireland
- Dept. of Age-Related Health Care, Tallaght University Hospital (TUH) / The Adelaide and Meath Hospital, Dublin, incorporating the National Children's Hospital (AMNCH), Dublin, Ireland
| | - Desmond O'Neill
- Stroke Service, Tallaght University Hospital (TUH) / The Adelaide and Meath Hospital, Dublin, incorporating the National Children's Hospital (AMNCH), Dublin, Ireland
- Dept. of Age-Related Health Care, Tallaght University Hospital (TUH) / The Adelaide and Meath Hospital, Dublin, incorporating the National Children's Hospital (AMNCH), Dublin, Ireland
| | - Mary Martin
- Dept. of Geriatric and Stroke Medicine, Naas General Hospital, Naas, Ireland
| | - Stephen J X Murphy
- Dept. of Neurology, Tallaght University Hospital (TUH) / The Adelaide and Meath Hospital, Dublin, incorporating the National Children's Hospital (AMNCH), Dublin, Ireland
- Stroke Service, Tallaght University Hospital (TUH) / The Adelaide and Meath Hospital, Dublin, incorporating the National Children's Hospital (AMNCH), Dublin, Ireland
| | - Dominick J H McCabe
- Dept. of Neurology, Tallaght University Hospital (TUH) / The Adelaide and Meath Hospital, Dublin, incorporating the National Children's Hospital (AMNCH), Dublin, Ireland.
- Stroke Service, Tallaght University Hospital (TUH) / The Adelaide and Meath Hospital, Dublin, incorporating the National Children's Hospital (AMNCH), Dublin, Ireland.
- Vascular Neurology Research Foundation, Tallaght University Hospital (TUH) / The Adelaide and Meath Hospital, Dublin, incorporating the National Children's Hospital (AMNCH), Dublin, Ireland.
- Dept. of Clinical Neurosciences, Royal Free Campus, UCL Queen Square Institute of Neurology, London, UK.
- Academic Unit of Neurology, School of Medicine, Trinity College Dublin, Dublin, Ireland.
- Vascular Neurology Research Foundation, c/o Department of Neurology, Tallaght University Hospital /AMNCH, Tallaght, Dublin, 24, Ireland.
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Twine CP, Kakkos SK, Aboyans V, Baumgartner I, Behrendt CA, Bellmunt-Montoya S, Jilma B, Nordanstig J, Saratzis A, Reekers JA, Zlatanovic P, Antoniou GA, de Borst GJ, Bastos Gonçalves F, Chakfé N, Coscas R, Dias NV, Hinchliffe RJ, Kolh P, Lindholt JS, Mees BME, Resch TA, Trimarchi S, Tulamo R, Vermassen FEG, Wanhainen A, Koncar I, Fitridge R, Matsagkas M, Valgimigli M. Editor's Choice - European Society for Vascular Surgery (ESVS) 2023 Clinical Practice Guidelines on Antithrombotic Therapy for Vascular Diseases. Eur J Vasc Endovasc Surg 2023; 65:627-689. [PMID: 37019274 DOI: 10.1016/j.ejvs.2023.03.042] [Citation(s) in RCA: 36] [Impact Index Per Article: 36.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2023] [Accepted: 03/03/2023] [Indexed: 04/05/2023]
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Manunga J, Pedersen C, Stanberry L, Pai A, Skeik N, Sullivan TM. Impact of Continued Clopidogrel use on Outcomes of Patients undergoing Carotid Endarterectomy. J Vasc Surg 2023:S0741-5214(23)01058-3. [PMID: 37086820 DOI: 10.1016/j.jvs.2023.04.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2023] [Revised: 04/10/2023] [Accepted: 04/11/2023] [Indexed: 04/24/2023]
Abstract
OBJECTIVES To evaluate the use of clopidogrel at the time of carotid endarterectomy (CEA) and its association with postoperative complications. METHODS Single institution, retrospective review of a prospective database. RESULTS From 2010 to 2017, CEA was performed in 1066 consecutive patients (median age 73 years, 66% men). The indications for operation included ≥70% asymptomatic stenosis (458, 43%), prior stroke (314, 29%), and transient cerebral or retinal ischemia (294, 28%). At the time of operation, 509 (48%) patients were taking aspirin alone, 441 (41%) were taking clopidogrel (374 in combination with aspirin, 67 as sole therapy), 83 (8%) were on no documented antiplatelet medication, and 33 (3%) were taking warfarin (with therapeutic INR). The likelihood of clopidogrel use at the time of operation was higher for patients with a history of symptomatic carotid disease (p=0.002). Over the study period, clopidogrel use increased from 31.9% in 2010 to, 56.8% in 2017 that corresponds to 11% 95%CI (6, 15) increase annually. Postoperative strokes occurred in 15 patients (overall incidence 1.4%), the majority of which were minor (12/15, 80%). Six strokes occurred in patients taking aspirin alone (6/509, 1.2%), 2 in patients on clopidogrel and aspirin (2/441, 0.5%), 2 in patients taking clopidogrel alone (2/67, 2.9%), 3 in patients on no documented antiplatelet medication (3/83, 3.6%), and 2 in those taking warfarin (one of which was secondary to a fatal intracranial hemorrhage within 30 d of discharge; 2/33, 6.1%). The 30-day mortality rate was 0.03% (3/1066); the risk for the combined endpoint of any stroke, death or myocardial infarction (MI) was 2.3% (25/1066), and the risk for major stroke, death, or MI was 1.2%. There was no apparent association between clopidogrel use and the incidence of postoperative bleeding (p=0.59) or any other postoperative complication (stroke, death, MI, cranial nerve injury, p=0.15). CONCLUSIONS Clopidogrel use in our CEA practice has increased over time and has not been associated with an increased risk of postoperative complications, including bleeding. These data suggest that clopidogrel should not be discontinued prior to CEA, and should be considered as part of 'optimal medical therapy' in patients undergoing CEA.
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Affiliation(s)
- Jesse Manunga
- Section of Vascular and Endovascular Surgery, Minneapolis Heart Institute at Abbott Northwestern Hospital; Minneapolis Heart Institute foundation.
| | - Christopher Pedersen
- Section of Vascular and Endovascular Surgery, Minneapolis Heart Institute at Abbott Northwestern Hospital
| | | | - Akila Pai
- Division of Vascular and Endovascular Surgery, The Mount Sinai Hospital
| | - Nedaa Skeik
- Section of Vascular and Endovascular Surgery, Minneapolis Heart Institute at Abbott Northwestern Hospital; Minneapolis Heart Institute foundation
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Chaturvedi S. Diagnosis and Management of Large Artery Atherosclerosis. Continuum (Minneap Minn) 2023; 29:486-500. [PMID: 37039406 DOI: 10.1212/con.0000000000001212] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/12/2023]
Abstract
OBJECTIVE Ischemic stroke due to large vessel atherosclerosis is a significant cause of stroke globally. With the aging population, the number of people with atherosclerotic stroke will increase in the coming decades. This article reviews the recent developments in the assessment and treatment of extracranial and intracranial atherosclerotic disease. LATEST DEVELOPMENTS More intensive dual antiplatelet therapy can now be recommended for patients with transient ischemic attack or stroke. More stringent blood pressure and lipid control is also advised. The need for carotid revascularization will likely decrease in the coming decades because of advances in multimodal medical therapy; in particular, the role of revascularization for treating asymptomatic carotid stenosis is controversial. Patients with symptomatic intracranial stenosis should receive intensive medical therapy. Interest in high-resolution carotid plaque imaging is growing. ESSENTIAL POINTS The prevention of stroke due to large vessel atherosclerosis has improved owing to advances in medical therapies. The role of carotid revascularization is unclear for many patient subgroups.
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Patel RJ, Marmor R, Dakour H, Elsayed N, Ramachandran M, Malas MB. Dual Antiplatelet Therapy Is Associated with Increased Risk of Bleeding and Decreased Risk of Stroke Following Carotid Endarterectomy. Ann Vasc Surg 2023; 88:191-198. [PMID: 35921978 PMCID: PMC10238168 DOI: 10.1016/j.avsg.2022.07.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2022] [Revised: 06/22/2022] [Accepted: 07/07/2022] [Indexed: 11/27/2022]
Abstract
BACKGROUND Despite many patients undergoing carotid endarterectomy (CEA) being on dual antiplatelet therapy (DAPT) for cardiac or neurologic indications, the impact of such therapy on perioperative outcomes remains unclear. We aim to compare rates of postoperative bleeding, stroke and major adverse events (stroke, death or MI) among patients on Aspirin alone (ASAA) versus DAPT (Clopidogrel and Aspirin). METHODS Patients undergoing CEA for carotid artery stenosis between 2010 and 2021 in the Vascular Quality Initiative (VQI) were included. We excluded patients undergoing concomitant or re-do operations or patients with missing antiplatelet information. Propensity score matching was performed between the 2 groups ASAA and DAPT based on age, sex, race, presenting symptoms, major comorbidities [hypertension, diabetes and coronary artery disease (CAD)], degree of ipsilateral stenosis, presence of contralateral occlusion, as well as preoperative medications. Intergroup differences between the treatment groups and differences in perioperative outcomes were tested with the McNemar's test for categorical variables and paired t-test or Wilcoxon matched-pairs signed-rank test for continuous variables where appropriate. Relative risks with 95% confidence intervals were estimated as the ratio of the probability of the outcome event in the patients treated within each treatment group. RESULTS A total of 125,469 patients were included [ASAA n = 82,920 (66%) and DAPT n = 42,549 (34%)]. Patients on DAPT were more likely to be symptomatic, had higher rates of CAD, prior percutaneous coronary intervention or coronary artery bypass grafting, and higher rates of diabetes. After propensity score matching, the DAPT group had an increased rate of bleeding complications (RR: 1.6: 1.4-1.8, P < 0.001) as compared with those on ASAA despite being more likely to receive both drains and protamine. In addition, patients on DAPT had a slight decrease in the risk of in-hospital stroke as compared with patients on ASAA (RR: 0.80: 0.7-0.9, P = 0.001). CONCLUSIONS This large multi-institutional study demonstrates a modest decrease in the risk of in-hospital stroke for patients on DAPT undergoing CEA as compared with those on ASAA. This small benefit is at the expense of a significant increase in the risk of perioperative bleeding events incurred by those on DAPT at the time of CEA. This analysis suggests avoiding DAPT when possible, during CEA.
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Affiliation(s)
- Rohini J Patel
- Division of Vascular and Endovascular Surgery, University of California San Diego, San Diego, CA
| | - Rebecca Marmor
- Division of Vascular Surgery and Endovascular Therapy, The Johns Hopkins University, Baltimore, MD
| | - Hanaa Dakour
- Division of Vascular Surgery, Indiana University, Indianapolis, IN
| | - Nadin Elsayed
- Division of Vascular and Endovascular Surgery, University of California San Diego, San Diego, CA
| | - Mokhshan Ramachandran
- Division of Vascular and Endovascular Surgery, University of California San Diego, San Diego, CA
| | - Mahmoud B Malas
- Division of Vascular and Endovascular Surgery, University of California San Diego, San Diego, CA.
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9
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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: 205] [Impact Index Per Article: 205.0] [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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10
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Wu J, Fang C, Wei L, Liu Y, Xu H, Wang X, Yuan L, Wu X, Xu Y, Zhang A. Spotlight on clinical strategies of Chronic Internal Carotid Artery Occlusion: Endovascular interventions and external-intracarotid bypasses compared to conservative treatment. Front Surg 2022; 9:971066. [PMID: 36425889 PMCID: PMC9679017 DOI: 10.3389/fsurg.2022.971066] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2022] [Accepted: 10/18/2022] [Indexed: 10/11/2023] Open
Abstract
Chronic internal carotid artery occlusion (CICAO) has high prevalence and incidence rates, and patients with CICAO can be completely asymptomatic, experience a devastating stroke or die. It is important to note that CICAO causes cerebrovascular accidents. Currently, the external carotid-internal carotid (EC-IC) bypass technique is used to treat CICAO. However, many clinical studies showed that EC-IC bypass was not beneficial for many patients with CICAO. Meanwhile, endovascular intervention treatment options for CICAO are evolving, and an increasing number of patients are undergoing endovascular intervention therapy. Accordingly, a review comparing both techniques is warranted. For this review, we searched PubMed and collected relevant case study reports comparing endovascular interventional therapy and internal and external cervical bypass surgeries to provide strategies for clinical treatment.
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Affiliation(s)
- Junnan Wu
- Department of Emergency, Dongyang Hospital Affiliated to Wenzhou Medical University, Jinhua, China
| | - Chaoyou Fang
- Department of Neurosurgery, Shanghai General Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China
| | - Lingying Wei
- Department of Emergency, Dongyang Hospital Affiliated to Wenzhou Medical University, Jinhua, China
| | - Yibo Liu
- Department of Neurosurgery, The Second Affiliated Hospital, School of Medicine, Zhejiang University, Shanghai, China
- Clinical Research Center for Neurological Diseases of Zhejiang Province, Hangzhou, China
| | - Houshi Xu
- Department of Neurosurgery, Shanghai General Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China
| | - Xiaoyu Wang
- Department of Neurosurgery, The Second Affiliated Hospital, School of Medicine, Zhejiang University, Shanghai, China
- Clinical Research Center for Neurological Diseases of Zhejiang Province, Hangzhou, China
| | - Ling Yuan
- Department of Neurosurgery, Shanghai General Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China
| | - Xiaoya Wu
- Department of Emergency, Dongyang Hospital Affiliated to Wenzhou Medical University, Jinhua, China
| | - Yuanzhi Xu
- Department of Neurosurgery, Huashan Hospital, School of Medicine, Fudan University, Shanghai, China
| | - Anke Zhang
- Department of Neurosurgery, The Second Affiliated Hospital, School of Medicine, Zhejiang University, Shanghai, China
- Clinical Research Center for Neurological Diseases of Zhejiang Province, Hangzhou, China
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11
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Donners SJA, Mekke JM, van Hattum ES, Toorop RJ, de Borst GJ. Editor's Choice - Risk of Bleeding Complications With Different Peri-Operative Antithrombotic Regimens During Carotid Endarterectomy: a National Registry Analysis. Eur J Vasc Endovasc Surg 2022; 64:444-451. [PMID: 36031046 DOI: 10.1016/j.ejvs.2022.08.020] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2022] [Revised: 08/09/2022] [Accepted: 08/12/2022] [Indexed: 01/12/2023]
Abstract
OBJECTIVE Antithrombotic therapy is one of the cornerstones of the prevention of (recurrent) ocular or cerebral ischaemic events in patients with carotid artery stenosis. Randomised controlled trials on antithrombotic therapy for patients with minor ischaemic stroke and transient ischaemic attack (TIA) have recommended dual antiplatelet therapy (DAPT) in the three weeks following the index event. However, these trials excluded patients undergoing carotid revascularisation. To date, the optimal antithrombotic therapy during the peri-operative period of carotid endarterectomy (CEA) remains unclear. METHODS Symptomatic and asymptomatic patients with carotid artery stenosis undergoing primary CEA from the Dutch Audit for Carotid Interventions registry between June 2013 and December 2020 were eligible for inclusion. The primary outcome was defined as post-operative cervical bleeding needing re-intervention or intracranial haemorrhage during the first 30 days following CEA. The secondary outcomes were ischaemic stroke or TIA or all cause mortality during the first 30 days following CEA. Descriptive statistics and multiple logistic regressions analyses were applied, with acetylsalicylic acid (ASA) as the reference value. RESULTS A total of 12 317 patients were included. In the peri-operative phase, 31.0% of patients were treated with ASA, 32.4% with clopidogrel, 11.1% with ASA plus clopidogrel, 10.4% with ASA plus dipyridamole, 10.3% with vitamin K antagonist, and 4.8% with direct acting oral anticoagulants therapy. After multiple logistic regression analysis, no association was seen with the primary outcome in ASA plus clopidogrel (odds ratio [OR] 0.81; confidence interval [CI] 0.58 - 1.13; p = .23), and ASA plus dipyridamole (OR 0.69; CI 0.47 - 1.00; p = .059). Both the DAPT therapies were not associated with the secondary outcome. CONCLUSION The effectiveness and safety of DAPT did not differ from single antiplatelet therapy (SAPT) in patients undergoing CEA and further evaluation is needed in prospective studies. Considering additional data from the literature and guideline recommendations, DAPT should be started immediately after stroke until 30 days after CEA followed by SAPT, due to a possible reduction in the risk of recurrence.
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Affiliation(s)
- Simone J A Donners
- Department of Vascular Surgery, Division of Surgical Specialties, University Medical Centre Utrecht, Utrecht University, Utrecht, the Netherlands
| | - Joost M Mekke
- Department of Vascular Surgery, Division of Surgical Specialties, University Medical Centre Utrecht, Utrecht University, Utrecht, the Netherlands
| | - Eline S van Hattum
- Department of Vascular Surgery, Division of Surgical Specialties, University Medical Centre Utrecht, Utrecht University, Utrecht, the Netherlands
| | - Raechel J Toorop
- Department of Vascular Surgery, Division of Surgical Specialties, University Medical Centre Utrecht, Utrecht University, Utrecht, the Netherlands
| | - Gert J de Borst
- Department of Vascular Surgery, Division of Surgical Specialties, University Medical Centre Utrecht, Utrecht University, Utrecht, the Netherlands.
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- Department of Vascular Surgery, Division of Surgical Specialties, University Medical Centre Utrecht, Utrecht University, Utrecht, the Netherlands
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Cruz Silva J, Constâncio V, Lima P, Anacleto G, Fonseca M. Effect of Chronic Antiplatelet and Anticoagulant Medication in Neck Haematoma and Perioperative Outomes After Carotid Endarterectomy. Ann Vasc Surg 2022; 88:199-209. [PMID: 36116744 DOI: 10.1016/j.avsg.2022.08.018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2022] [Revised: 08/01/2022] [Accepted: 08/04/2022] [Indexed: 11/18/2022]
Abstract
OBJECTIVES A retrospective analysis of neck haematoma, stroke and mortality after symptomatic and asymptomatic carotid endarterectomy (CEA) was conducted, in order to determine the most appropriate perioperative medication for these patients. Thirty-day outcomes of moderate and severe neck bleeding were also investigated. METHODS Patients undergoing CEA in a Vascular Surgery department were analysed (2015-2019). Pre-procedure antithrombotic medication (from the 5-days prior to surgery) was identified. End point predictors were identified by univariate and multivariable analyses and adjusted for confounders. RESULTS A total of 304 CEA were included. Almost half of the included patients (49.67%) were under low-dose aspirin, 17.55% other single antiplatelet agent, 12.59% dual antiplatelet therapy, 8.61% anticoagulation and 10.92% no antithrombotic therapy. There was 8.22% rate of important haematoma, including 4.93% severe (requiring surgical exploration) hematomas and a 30-day all-stroke incidence of 2.94% in symptomatic and 1.79% asymptomatic patients (p=.51). When compared to aspirin, severe haematoma was more prevalent with single clopidogrel or triflusal (RR 4.25, p=.11), dual antiplatelet group (RR 11.84, p=.002) and anticoagulation (RR 8.604, p=.02). Dual antiaggregation and anticoagulation did not confer post-operative stroke protection compared to single aspirin in either symptomatic or asymptomatic patients. Non-significant higher intra-hospital mortality was noted in no medication, dual antiplatelet and anticoagulation groups in contrast to aspirin. Severe neck bleeding was associated with increased congestive heart failure (9.26-fold, p=.03) and longer hospital stay (11.20±24.69 days versus 3.18±4.79 with no bleeding, p<.001), with a tendency for higher hospital readmission at 30-days (4.66-fold, p=.13). Mortality and stroke rates were similar. CONCLUSIONS Double antiaggregation and anticoagulation did not confer better perioperative outcomes after elective CEA in our study. These regimens were associated with increased risk of neck haematoma, especially severe bleeding, with similar rates of neurologic events in both symptomatic and asymptomatic patients and no mortality benefit. Monotherapy with aspirin appears to be the safest perioperative antithrombotic regimen for elective CEA.
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Affiliation(s)
- Joana Cruz Silva
- Angiology and Vascular Surgery Department, Centro Hospitalar e Universitário de Coimbra, Coimbra, Portugal.
| | - Vânia Constâncio
- Angiology and Vascular Surgery Department, Centro Hospitalar e Universitário de Coimbra, Coimbra, Portugal
| | - Pedro Lima
- Angiology and Vascular Surgery Department, Centro Hospitalar e Universitário de Coimbra, Coimbra, Portugal
| | - Gabriel Anacleto
- Angiology and Vascular Surgery Department, Centro Hospitalar e Universitário de Coimbra, Coimbra, Portugal
| | - Manuel Fonseca
- Angiology and Vascular Surgery Department, Centro Hospitalar e Universitário de Coimbra, Coimbra, Portugal
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13
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Perioperative Medical Management for Symptomatic Carotid Artery Interventions. CURRENT TREATMENT OPTIONS IN CARDIOVASCULAR MEDICINE 2022. [DOI: 10.1007/s11936-022-00966-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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14
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Qureshi AI, Huang W, Lobanova I, Ishfaq MF, French BR, Siddiq F, Gomez CR. Clopidogrel Bolus is Inferior to Sustained Clopidogrel Pretreatment in Patients Undergoing Carotid Artery Stent Placement. Neurosurgery 2022; 90:717-724. [PMID: 35271515 DOI: 10.1227/neu.0000000000001899] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2021] [Accepted: 12/05/2021] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Clopidogrel bolus is an option used before carotid artery stent (CAS) placement when sustained clopidogrel pretreatment is not used. OBJECTIVE To compare the effect of clopidogrel bolus (450 mg administered ≥4 hours) with sustained clopidogrel pretreatment (48 hours or greater) before CAS among patients recruited in the Carotid Revascularization Endarterectomy versus Stenting Trial. METHODS We compared the rates of primary end point (either any stroke, myocardial infarction, or death during the periprocedural period or any ipsilateral stroke within 4 years) between patients who received clopidogrel bolus and those who received sustained clopidogrel pretreatment using Cox proportional hazards analysis after adjusting for age, sex, symptomatic status, and initial severity of stenosis (≥70% vs <70%) over 4 years. RESULTS The rate of periprocedural stroke (7.3% vs 3.4%, P = .03) and primary end point (11.3% vs 5.9%, P = .02) was significantly higher among patients who received clopidogrel bolus. The risk of primary end point was significantly higher in patients who received clopidogrel bolus (hazards ratio 1.9, 95% CI 1.1-3.4, P = .02) after adjusting for potential confounders. The overall mean (±standard deviation) primary end point-free survival based on Kaplan-Meier analysis was 7.0 ± 0.2 years for patients who received clopidogrel bolus and 8.9 ± 0.1 years for those who received sustained clopidogrel pretreatment (log-rank test P = .011). CONCLUSION Clopidogrel bolus was associated with higher rates of adverse outcomes compared with sustained clopidogrel pretreatment in patients who underwent CAS. Therefore, clopidogrel bolus may not be equivalent to sustained clopidogrel pretreatment.
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Affiliation(s)
- Adnan I Qureshi
- Zeenat Qureshi Stroke Institutes and Department of Neurology, University of Missouri, Columbia, Missouri, USA
| | - Wei Huang
- Zeenat Qureshi Stroke Institutes and Department of Neurology, University of Missouri, Columbia, Missouri, USA
| | - Iryna Lobanova
- Zeenat Qureshi Stroke Institutes and Department of Neurology, University of Missouri, Columbia, Missouri, USA
| | - M Fawad Ishfaq
- Department of Neurology, University of Missouri, Columbia, Missouri, USA
| | - Brandi R French
- Department of Neurology, University of Missouri, Columbia, Missouri, USA
| | - Farhan Siddiq
- Division of Neurosurgery, University of Missouri, Columbia, Missouri, USA
| | - Camilo R Gomez
- Department of Neurology, University of Missouri, Columbia, Missouri, USA
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15
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Rantner B, de Borst GJ. Mirror Mirror on the Wall, Which Is the Most Protective Antithrombotic Therapy of Them All? Eur J Vasc Endovasc Surg 2022; 63:556. [DOI: 10.1016/j.ejvs.2022.01.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2021] [Revised: 01/11/2022] [Accepted: 01/11/2022] [Indexed: 11/03/2022]
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16
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Ku JC, Taslimi S, Zuccato J, Pasarikovski CR, Nasr N, Chechik O, Chisci E, Bissacco D, Larrue V, Rabinovich Y, Michelagnoli S, Settembrini PG, Priola SM, Cusimano MD, Yang VXD, Macdonald RL. Peri-Operative Outcomes of Carotid Endarterectomy are Not Improved on Dual Antiplatelet Therapy vs. Aspirin Monotherapy: A Systematic Review and Meta-Analysis. Eur J Vasc Endovasc Surg 2022; 63:546-555. [PMID: 35241374 DOI: 10.1016/j.ejvs.2021.12.037] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2021] [Revised: 12/01/2021] [Accepted: 12/28/2021] [Indexed: 12/27/2022]
Abstract
OBJECTIVE A systematic review and meta-analysis of the peri-operative outcomes of carotid endarterectomy (CEA) on dual antiplatelet therapy (DAPT) vs. aspirin monotherapy was carried out, to determine optimal peri-operative management with these antiplatelet agents. DATA SOURCES The Web of Science, Pubmed, and Embase databases were searched from inception to July 2021. The corresponding authors of excluded articles were contacted to obtain additional data for possible inclusion. REVIEW METHODS The main outcomes included ischaemic complications (stroke, transient ischaemic attack [TIA], and transcranial Doppler [TCD] measured micro-emboli), haemorrhagic complications (haemorrhagic stroke, neck haematoma, and re-operation for bleeding), and composite outcomes. Pooled estimates using odds ratios (ORs) were combined using a random or fixed effects model based on the results of the chi square test and calculation of I2. RESULTS In total, 47 411 patients were included in 11 studies, with 14 345 (30.2%) receiving DAPT and 33 066 (69.7%) receiving aspirin only. There was no significant difference in the rates of peri-operative stroke (OR 0.87, 95% confidence interval [CI] 0.72 - 1.05) and TIA (OR 0.78, 95% CI 0.52 - 1.17) despite a significant reduction in TCD measured micro-emboli (OR 0.19, 95% CI 0.10 - 0.35) in the DAPT compared with the aspirin monotherapy group. Subgroup analysis did not reveal any significant difference in ischaemic stroke risk between patients with asymptomatic and symptomatic carotid artery stenosis. DAPT was associated with an increased risk of neck haematoma (OR 2.79, 95% CI 1.87 - 4.18) and re-operation for bleeding (OR 1.98, 95% CI 1.77 - 2.23) vs. aspirin. Haemorrhagic stroke was an under reported outcome in the literature. CONCLUSION This meta-analysis found that CEA while on DAPT increased the risk of haemorrhagic complications, with similar rates of ischaemic complications, vs. aspirin monotherapy. This suggests that the risks of performing CEA on DAPT outweigh the benefits, even in patients with symptomatic carotid stenosis. The overall quality of studies was low, and improved reporting of CEA outcomes in the literature is necessary.
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Affiliation(s)
- Jerry C Ku
- Division of Neurosurgery, University of Toronto, Toronto, ON, Canada
| | - Shervin Taslimi
- Division of Neurosurgery, Department of Surgery, Kingston General Hospital, Toronto, ON, Canada.
| | - Jeffrey Zuccato
- Division of Neurosurgery, University of Toronto, Toronto, ON, Canada
| | | | | | - Ofir Chechik
- Sackler Faculty of Medicine, Tel-Aviv Medical Centre, Tel Aviv University, Israel
| | - Emiliano Chisci
- Department of Surgery, Vascular and Endovascular Surgery Unit, "San Giovanni di Dio" Hospital, Florence, Italy
| | - Daniele Bissacco
- School of Vascular Surgery, Università degli Studi di Milano, Milan, Italy
| | | | - Yefim Rabinovich
- Sackler Faculty of Medicine, Tel-Aviv Medical Centre, Tel Aviv University, Israel
| | - Stefano Michelagnoli
- Department of Surgery, Vascular and Endovascular Surgery Unit, "San Giovanni di Dio" Hospital, Florence, Italy
| | | | - Stefano M Priola
- Division of Neurosurgery, Health Sciences North, Sudbury, ON, Canada
| | - Michael D Cusimano
- Division of Neurosurgery, University of Toronto, Toronto, ON, Canada; Division of Neurosurgery, St. Michael's Hospital, Toronto, ON, Canada
| | - Victor X D Yang
- Division of Neurosurgery, University of Toronto, Toronto, ON, Canada; Division of Neurosurgery, Sunnybrook Hospital, Toronto, ON, Canada
| | - R Loch Macdonald
- Department of Neurological Surgery, University of California San Francisco, Fresno Campus, Fresno, CA, USA
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17
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Martinez-Gutierrez JC, Roy AT, D'Amato S, Berkman JM, Montes D, Kimball CA, Rordorf GA, Chibnik LB, Romero JM, Silverman SB. Preoperative antithrombotic treatment in acutely symptomatic carotid artery stenosis. J Stroke Cerebrovasc Dis 2022; 31:106396. [PMID: 35219972 DOI: 10.1016/j.jstrokecerebrovasdis.2022.106396] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2022] [Accepted: 02/04/2022] [Indexed: 10/19/2022] Open
Abstract
OBJECTIVES Early recurrence of cerebral ischemia in acutely symptomatic carotid artery stenosis can precede revascularization. The optimal antithrombotic regimen for this high-risk population is not well established. Although antiplatelet agents are commonly used, there is limited evidence for the use of anticoagulants. We sought to understand the safety and efficacy of short-term preoperative anticoagulants in secondary prevention of recurrent cerebral ischemic events from acutely symptomatic carotid stenosis in patients awaiting carotid endarterectomy (CEA). MATERIALS AND METHODS A retrospective query of a prospective single institution registry of carotid revascularization was performed. Patients who presented with acute ischemic stroke or transient ischemic attack (TIA) attributable to an ipsilateral internal carotid artery stenosis (ICA) were included. Antiplatelet (AP) only and anticoagulation (AC) treatment arms were compared. The primary outcome was a composite of preoperative recurrent ischemic stroke or TIA. The primary safety outcome was symptomatic intracranial hemorrhage. RESULTS Out of 443 CEA patients, 342 were in the AC group and 101 in the AP group. Baseline characteristics between groups (AC vs AP) were similar apart from age (71±10.5 vs 73±9.5, p=0.04), premorbid modified Rankin scale (mRS) score (1.0±1.2 vs 1.4±1.3, p=0.03) and stroke as presenting symptom (65.8 vs 53.5%, p=0.02). Patients in the AC group had a lower incidence of recurrent stroke/TIA (3.8 vs 10.9%, p=0.006). One patient had symptomatic intracranial hemorrhage in the AC group, and none in the AP group. In multivariate analysis controlling for age, premorbid mRS, stroke severity, degree of stenosis, presence of intraluminal thrombus (ILT) and time to surgery, AC was protective (OR 0.30, p=0.007). This effect persisted in the cohort exclusively without ILT (OR 0.23, p=0.002). CONCLUSIONS Short term preoperative anticoagulation in patients with acutely symptomatic carotid stenosis appears safe and effective compared to antiplatelet agents alone in the prevention of recurrent cerebral ischemic events while awaiting CEA.
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Affiliation(s)
- Juan Carlos Martinez-Gutierrez
- Department of Neurosurgery, UTHealth McGovern Medical School, 6400 Fannin ST, Houston, TX 77030, United States; Department of Neurology, Brigham and Women's Hospital, Boston, MA, United States; Department of Neurology, Massachusetts General Hospital, 55 Fruit St, Boston, MA 02114, United States.
| | - Alexis T Roy
- Department of Neurology, Brigham and Women's Hospital, Boston, MA, United States; Department of Neurology, Massachusetts General Hospital, 55 Fruit St, Boston, MA 02114, United States
| | - Salvatore D'Amato
- Department of Neurosurgery, UTHealth McGovern Medical School, 6400 Fannin ST, Houston, TX 77030, United States; Department of Neurology, Brigham and Women's Hospital, Boston, MA, United States; Department of Neurology, Massachusetts General Hospital, 55 Fruit St, Boston, MA 02114, United States
| | - Jillian M Berkman
- Department of Neurology, Brigham and Women's Hospital, Boston, MA, United States; Department of Neurology, Massachusetts General Hospital, 55 Fruit St, Boston, MA 02114, United States
| | - Daniel Montes
- Department of Radiology, Massachusetts General Hospital, Boston, MA, United States
| | - Cheryl A Kimball
- Department of Neurology, Massachusetts General Hospital, 55 Fruit St, Boston, MA 02114, United States
| | - Guy A Rordorf
- Department of Neurology, Massachusetts General Hospital, 55 Fruit St, Boston, MA 02114, United States
| | - Lori B Chibnik
- Department of Neurology, Massachusetts General Hospital, 55 Fruit St, Boston, MA 02114, United States; Department of Epidemiology, Harvard T.H. Chan School of Public Health, Boston, MA, United States
| | - Javier M Romero
- Department of Radiology, Massachusetts General Hospital, Boston, MA, United States
| | - Scott B Silverman
- Department of Neurology, Massachusetts General Hospital, 55 Fruit St, Boston, MA 02114, United States.
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18
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Schultz-Lebahn A, Nissen PH, Pedersen TF, Tang M, Hvas AM. Platelet function assessed by ROTEM ® platelet in patients receiving antiplatelet therapy during cardiac and vascular surgery. Scandinavian Journal of Clinical and Laboratory Investigation 2021; 82:18-27. [PMID: 34890293 DOI: 10.1080/00365513.2021.2012820] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
Patients undergoing coronary artery bypass graft (CABG) surgery or carotid endarterectomy (CEA) continue antiplatelet therapy perioperatively, which may increase bleeding risk. We aimed to investigate whether Rotational thromboelastometry (ROTEM®) platelet, a newly marketed platelet function analysis, would detect antiplatelet therapy in CABG and CEA patients; whether detection of reduced platelet function was associated with increased bleeding; and whether ex vivo desmopressin increased platelet function. We included 20 CABG patients continuing aspirin and 20 CEA patients continuing clopidogrel (n = 1) or clopidogrel and aspirin (n = 19). Platelet function was analyzed with ROTEM® platelet and light transmission aggregometry (LTA). According to the lower reference limit, ROTEM® platelet managed to detect aspirin, but clopidogrel detection was inadequate compared to LTA. Using a previously published cut-off for bleeding risk, 6 (30%) patients receiving aspirin and 4 (21%) patients receiving both clopidogrel and aspirin demonstrated platelet function below this cut-off. One of the four CEA patients below the cut-off died from intracerebral hemorrhage postoperatively. CABG patients below (n = 6) and above (n = 14) the cut-off did not differ in chest tube output (median [range]: 373 ml [250-900] vs. 368 ml [195-820]). Ex vivo addition of desmopressin did not increase platelet function. In conclusion, ROTEM® platelet does reveal aspirin treatment whereas clopidogrel treatment is most often overlooked. Due to low bleeding in the study population, it was not possible to conclude on the association with bleeding risk.
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Affiliation(s)
- Anna Schultz-Lebahn
- Department of Clinical Biochemistry, Aarhus University Hospital, Aarhus, Denmark
| | - Peter H Nissen
- Department of Clinical Biochemistry, Aarhus University Hospital, Aarhus, Denmark.,Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
| | - Troels Fogh Pedersen
- Department of Cardiothoracic and Vascular Surgery, Aarhus University Hospital, Aarhus, Denmark
| | - Mariann Tang
- Department of Cardiothoracic and Vascular Surgery, Aarhus University Hospital, Aarhus, Denmark
| | - Anne-Mette Hvas
- Department of Clinical Biochemistry, Aarhus University Hospital, Aarhus, Denmark.,Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
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Al-Bayati AR, Nogueira RG, Haussen DC. Carotid Artery Stenting: Applications and Technical Considerations. Neurology 2021; 97:S137-S144. [PMID: 34785612 DOI: 10.1212/wnl.0000000000012802] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2020] [Accepted: 03/03/2021] [Indexed: 11/15/2022] Open
Abstract
PURPOSE OF THE REVIEW To examine current understanding of diverse etiologies of extracranial carotid disease, including clinical and imaging manifestations as well as treatment approaches. RECENT FINDINGS Increasing availability of advanced cerebrovascular imaging modalities continues to elucidate atherosclerotic and nonatherosclerotic carotid steno-occlusive disease as a common culprit of cerebral ischemia. Individualized treatment strategies targeting each etiologic subset would optimize preventive measures and minimize recurrence of cerebral ischemia. SUMMARY Ischemic stroke is a prominent cause of mortality and long-term disability worldwide. The magnified effect of carotid disease warrants constant and close inspection.
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Affiliation(s)
- Alhamza R Al-Bayati
- From the Department of Neurology and Radiology, Marcus Stroke & Neuroscience Center, Grady Memorial Hospital, Emory University School of Medicine, Atlanta, GA.
| | - Raul G Nogueira
- From the Department of Neurology and Radiology, Marcus Stroke & Neuroscience Center, Grady Memorial Hospital, Emory University School of Medicine, Atlanta, GA
| | - Diogo C Haussen
- From the Department of Neurology and Radiology, Marcus Stroke & Neuroscience Center, Grady Memorial Hospital, Emory University School of Medicine, Atlanta, GA
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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
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21
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Cilostazol Addition to Aspirin could not Reduce the Neurological Deterioration in TOAST Subtypes: ADS Post-Hoc Analysis. J Stroke Cerebrovasc Dis 2020; 30:105494. [PMID: 33278804 DOI: 10.1016/j.jstrokecerebrovasdis.2020.105494] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2020] [Revised: 11/15/2020] [Accepted: 11/20/2020] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND Our previous trial acute dual study (ADS) reported that dual antiplatelet therapy (DAPT) using cilostazol and aspirin did not reduce the rate of short-term neurological worsening in non-cardioembolic stroke patients. Present post-hoc analysis investigated whether the impact of combined cilostazol and aspirin differed among stroke subtypes and factors associated with neurological deterioration and/or stroke recurrence. METHODS Using the ADS registry, the rate of neurological deterioration, defined as clinical worsening and/or recurrent stroke, including transient ischemic attack was calculated. Stroke subtypes included large-artery atherosclerosis (LAA), small vessel occlusion (SVO), other determined etiology (Others), and undetermined etiology of stroke (Undetermined). RESULTS Data of 1022 patients were analyzed. Deterioration was seen in 104 (10%) patients, and the rates were not markedly different between patients treated with DAPT vs. aspirin in any stroke subtypes: LAA, 19% vs. 11%, (p=0.192); SVO, 10% vs. 10% (p=1.000); Others, 6% vs. 6% (p=1.000); Undetermined, 11% vs. 8% (p=0.590). Diabetes mellitus was the independent factor associated with deterioration (odds ratio 4.360, 95% confidence interval 1.139-16.691, p=0.032) in the LAA group. Age (1.030 [1.004-1.057], p=0.026), systolic blood pressure (1.012 [1.003-1.022], p=0.010), and infarct size (2.550 [1.488-4.371], p=0.001) were associated with deterioration in SVO group, and intracranial stenosis/occlusion was associated with it in the Undetermined group (3.744 [1.138-12.318], p=0.030). CONCLUSIONS Combined cilostazol and aspirin did not reduce the rate of short-term neurological deterioration in any clinical stroke subtype. The characteristics of patients whose condition deteriorates in the acute period may differ based on the stroke subtypes.
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Abstract
Despite the completion of several multi-center trials, the management of carotid stenosis remains in flux. Key questions include the role of intensive medical management in the treatment of asymptomatic carotid stenosis. In addition, identification of patients with symptomatic stenosis who will most benefit from carotid revascularization remains a priority. The role of newer imaging techniques such as carotid plaque analysis with magnetic resonance imaging is also challenging current treatment paradigms. These topics are explored in this topical update.
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Affiliation(s)
- Rakhee Lalla
- Department of Neurology, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Prashant Raghavan
- Department of Radiology, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Seemant Chaturvedi
- Department of Neurology, University of Maryland School of Medicine, Baltimore, MD, USA
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Fereydooni A, Gorecka J, Xu J, Schindler J, Dardik A. Carotid Endarterectomy and Carotid Artery Stenting for Patients With Crescendo Transient Ischemic Attacks: A Systematic Review. JAMA Surg 2020; 154:1055-1063. [PMID: 31483458 DOI: 10.1001/jamasurg.2019.2952] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
Importance Thromboembolic stroke attributable to an ipsilateral carotid artery plaque is a leading cause of disability in the United States and a major source of morbidity. Randomized clinical trials have demonstrated the efficacy of carotid endarterectomy and carotid stenting at minimizing stroke risk in patients with minor stroke and transient ischemic attack. However, there is no consensus on guidelines for medical management and the timing of revascularization in patients with multiple recurrent episodes of transient ischemic attack over hours or days, an acute neurological event known as crescendo transient ischemic attack. Objective To review the management of and timing of intervention in patients presenting with crescendo transient ischemic attack. Evidence Review This systematic review included all English-language articles published from January 1, 1985, to January 1, 2019, available from PubMed (MEDLINE) and Google Scholar. Articles were excluded if they did not include analysis of patients with symptoms, did not report the timing of intervention after crescendo transient ischemic attack, or mixed analysis of patients with stroke in evolution with patients with crescendo transient ischemic attack. The quality of the evidence was assessed with the modified rating from the Oxford Centre for Evidence-based Medicine. Observations Patients with crescendo transient ischemic attack were found to have a higher risk of stroke or death after carotid endarterectomy compared with patients with a single transient ischemic attack or stable stroke. With medical therapy alone, a considerable number of patients with crescendo transient ischemic attack experience a completed stroke within several months and have a poor prognosis without intervention. Urgent carotid endarterectomy, typically performed within 48 hours of initial presentation, is beneficial in carefully selected patients. There have been several reports of operative treatment within the first 24 hours of presentation; however, review of these reports does not show any additional benefit from emergency treatment. Carotid artery stenting is reserved only for selected patients with prohibitive surgical risk for endarterectomy. The literature does not clearly support any additional benefit of intravenous heparin therapy over mono or dual antiplatelet therapy prior to carotid endarterectomy. Conclusions and Relevance Crescendo transient ischemic attack is best managed with optimal medical management as well as urgent carotid endarterectomy within 2 days of presentation. Surgical endarterectomy appears to be preferred because of the increased embolic potential of bifurcation plaque, whereas stenting is an option for patients with contraindications for surgery. With ongoing advances in cerebrovascular imaging and medical treatment of stroke, there is a need for better evidence to determine the optimal timing and preoperative medical management of patients with crescendo transient ischemic attack.
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Affiliation(s)
- Arash Fereydooni
- Department of Surgery, Yale School of Medicine, Yale University, New Haven, Connecticut
| | - Jolanta Gorecka
- Department of Surgery, Yale School of Medicine, Yale University, New Haven, Connecticut
| | - Jianbiao Xu
- Department of Surgery, Yale School of Medicine, Yale University, New Haven, Connecticut
| | - Joseph Schindler
- Department of Neurology, Yale School of Medicine, Yale University, New Haven, Connecticut
| | - Alan Dardik
- Department of Surgery, Yale School of Medicine, Yale University, New Haven, Connecticut
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Naylor AR, McCabe DJH. New Data and the Covid-19 Pandemic Mandate a Rethink of Antiplatelet Strategies in Patients With TIA or Minor Stroke Associated With Atherosclerotic Carotid Stenosis. Eur J Vasc Endovasc Surg 2020; 59:861-865. [PMID: 32362487 PMCID: PMC7183953 DOI: 10.1016/j.ejvs.2020.04.024] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2020] [Revised: 04/09/2020] [Accepted: 04/16/2020] [Indexed: 11/30/2022]
Affiliation(s)
- A R Naylor
- Leicester Vascular Institute, Glenfield Hospital, Leicester, UK.
| | - D J H McCabe
- Department of Neurology and Stroke Service, The Adelaide and Meath Hospital, Incorporating the National Children's Hospital - Tallaght University Hospital, Dublin, Ireland; Academic Unit of Neurology, School of Medicine, Trinity College Dublin, Ireland
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Lessons Learned Establishing a 24/7 Rapid Access TIA Service. Eur J Vasc Endovasc Surg 2020; 59:514-515. [DOI: 10.1016/j.ejvs.2020.01.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2019] [Accepted: 01/08/2020] [Indexed: 11/20/2022]
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Jiang QL, Wang PJ, Liu HX, Huang LL, Kang XK. Dual versus Single Antiplatelet Therapy in Carotid Artery Endarterectomy: Direct Comparison of Complications Related to Antiplatelet Therapy. World Neurosurg 2020; 135:e598-e609. [PMID: 31870823 DOI: 10.1016/j.wneu.2019.12.070] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2019] [Revised: 12/11/2019] [Accepted: 12/12/2019] [Indexed: 10/25/2022]
Abstract
BACKGROUND Dual and single antiplatelet therapies are routinely used in carotid artery endarterectomy (CEA). However, the efficacy and safety of these therapies are controversial. The present study aimed to comprehensively compare the clinical outcomes between dual and single antiplatelet therapies in CEA. METHODS This study retrieved available academic studies evaluating the complications related to antiplatelet therapy between dual and single antiplatelet therapies in CEA from the databases of ScienceDirect, the Cochrane Library, EMBASE, and PubMed. References to previous reviews and related clinical trials were manually checked to retrieve potential literature that was not included in our electronic search results. RESULTS A total of 10 articles (1 randomized controlled trial, 9 non-randomized controlled trials) were included in the study. The overall number of patients in the dual antiplatelet group was 14,280, and the number of patients in the single antiplatelet group was 125,850. The results revealed that the single antiplatelet group had a lower incidence of 30-day death (rate difference [RD] 0.002; 95% confidence interval [CI] 0.000-0.003; P = 0.014), neck hematoma (odds ratio [OR] 2.120; 95% CI 1.431-3.142; P < 0.001), myocardial infarction (RD 0.004; 95% CI 0.001-0.007; P = 0.003), and major bleeding (RD 0.005; 95% CI 0.002-0.008; P < 0.001). Meanwhile, the single antiplatelet group was associated with a shorter operation time (weighted mean difference 4.000; 95% CI= 2.564-5.436; P < 0.001). However, there was no significant difference in the rate of postoperative transient ischemic attack (P = 0.215), stroke (P = 0.130), or length of stay (P = 0.563). CONCLUSIONS Based on current evidence, using single antiplatelet therapy in CEA may reduce operation time and the incidences of 30-day death, neck hematoma, major bleeding, and myocardial infarction without increasing the risks of transient ischemic attack, stroke, or a longer operation time.
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Affiliation(s)
- Qun-Long Jiang
- Department of Neurosurgery, Liaocheng People's Hospital, Liaocheng, Shandong, R.P. China
| | - Pei-Jian Wang
- Department of Neurosurgery, Liaocheng People's Hospital, Liaocheng, Shandong, R.P. China
| | - Hui-Xin Liu
- Department of Medical Examination, Liaocheng People's Hospital, Liaocheng, Shandong, R.P. China
| | - Li-Li Huang
- Department of Endocrinology, Liaocheng People's Hospital, Liaocheng, Shandong, R.P. China
| | - Xiao-Kui Kang
- Department of Neurosurgery, Liaocheng People's Hospital, Liaocheng, Shandong, R.P. China.
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Militsakh O, Lydiatt W, Lydiatt D, Interval E, Lindau R, Coughlin A, Panwar A. Development of Multimodal Analgesia Pathways in Outpatient Thyroid and Parathyroid Surgery and Association With Postoperative Opioid Prescription Patterns. JAMA Otolaryngol Head Neck Surg 2019; 144:1023-1029. [PMID: 30027221 DOI: 10.1001/jamaoto.2018.0987] [Citation(s) in RCA: 53] [Impact Index Per Article: 10.6] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
Abstract
Importance Prescription opioid use contributes to drug-related adverse effects and risk for dependence and abuse. Multimodal analgesia (MMA) has been shown to be useful in reducing opioid use following orthopedic, gynecologic, and colorectal surgery, but adoption in head and neck surgery has lagged. Recently, we published findings related to the feasibility of MMA protocols in same-day thyroid, parathyroid, and parotid surgery. However, whether such strategies lead to effective and durable reduction in frequency of opioid prescriptions, and affect physician prescribing practices, remains unclear. Objective To observe trends in adoption and adherence to institutional MMA protocols following thyroid and parathyroid surgery, and to assess the association of institutional multimodal (nonopioid) analgesia protocols with opioid use and physician prescribing patterns following outpatient thyroid and parathyroid surgery. Design, Setting, and Participants Cohort study at a head and neck surgery service at a tertiary care hospital of prescription patterns and retrospective review of patient medical records following implementation of an optional institutional MMA protocol in 2015, based on preoperative administration of acetaminophen, nonsteroidal anti-inflammatory drugs (NSAIDs), and gabapentin, and postoperative use of acetaminophen and ibuprofen for analgesia after thyroid and parathyroid surgery. There were 528 adult patients who underwent thyroid and parathyroid surgery between January 1, 2015, and June 30, 2017. Main Outcomes and Measures We report on adherence to the MMA protocol over the study period as measure of physician buy-in and adoption of the technique. The frequency of opioid use and physician prescription patterns following thyroid and parathyroid surgery is reported over the study period to study the association of the available MMA pathway with these variables. Results A total of 528 patients (mean [SD] age, 53.1 [15.7] years; 80.3% female) underwent outpatient thyroid and parathyroid surgery. The frequency of postoperative opioid prescriptions decreased during the study period (16 of 122 [13.1%] in 2015, 22 of 244 [9.0%] in 2016, 3 of 162 [1.9%] in 2017). Adherence to the MMA protocol increased (0 of 122 cases in 2015, 106 of 244 [43.4%] cases in 2016, 142 of 162 [87.7%] cases in 2017), with reduced likelihood of opioid prescription on discharge (2017 vs 2015 odds ratio, 0.13; 95% CI, 0.04-0.44). Only 1 postoperative hematoma was recorded in the study cohort, and 352 (66.7%) patients achieved same-day discharge, whereas 176 (33.3%) maintained outpatient status but received overnight observation prior to discharge. Conclusions and Relevance Adoption and adherence to the MMA protocol increased substantially over the study period for patients undergoing thyroid and parathyroid surgery and was associated with a simultaneous significant decline in prescription of postoperative opioid analgesics. Use of nonopioid multimodal agents, incorporating NSAIDs, was safe and did not lead to increased incidence of bleeding. Availability of effective nonopioid MMA pathways may favorably influence physician prescribing practices and avoid unnecessary opioid prescriptions.
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Affiliation(s)
- Oleg Militsakh
- Department of Head and Neck Surgical Oncology, Methodist Estabrook Cancer Center, Nebraska Methodist Hospital, Omaha
| | - William Lydiatt
- Department of Head and Neck Surgical Oncology, Methodist Estabrook Cancer Center, Nebraska Methodist Hospital, Omaha
| | - Daniel Lydiatt
- Department of Head and Neck Surgical Oncology, Methodist Estabrook Cancer Center, Nebraska Methodist Hospital, Omaha
| | - Erik Interval
- Department of Head and Neck Surgical Oncology, Methodist Estabrook Cancer Center, Nebraska Methodist Hospital, Omaha
| | - Robert Lindau
- Department of Head and Neck Surgical Oncology, Methodist Estabrook Cancer Center, Nebraska Methodist Hospital, Omaha
| | - Andrew Coughlin
- Department of Head and Neck Surgical Oncology, Methodist Estabrook Cancer Center, Nebraska Methodist Hospital, Omaha
| | - Aru Panwar
- Department of Head and Neck Surgical Oncology, Methodist Estabrook Cancer Center, Nebraska Methodist Hospital, Omaha
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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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29
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Meershoek AJA, de Borst GJ. Timing of carotid intervention. Br J Surg 2019; 105:1231-1233. [PMID: 30133763 PMCID: PMC6099369 DOI: 10.1002/bjs.10950] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2018] [Accepted: 06/19/2018] [Indexed: 11/11/2022]
Abstract
Flimsy evidence
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Affiliation(s)
- A J A Meershoek
- Department of Vascular Surgery, University Medical Centre Utrecht, Room G04.129, PO Box 85500, 3508, GA, Utrecht, The Netherlands
| | - G J de Borst
- Department of Vascular Surgery, University Medical Centre Utrecht, Room G04.129, PO Box 85500, 3508, GA, Utrecht, The Netherlands
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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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Oltman J, Militsakh O, D'Agostino M, Kauffman B, Lindau R, Coughlin A, Lydiatt W, Lydiatt D, Smith R, Panwar A. Multimodal Analgesia in Outpatient Head and Neck Surgery: A Feasibility and Safety Study. JAMA Otolaryngol Head Neck Surg 2019; 143:1207-1212. [PMID: 29049548 DOI: 10.1001/jamaoto.2017.1773] [Citation(s) in RCA: 36] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/24/2023]
Affiliation(s)
- Justin Oltman
- College of Medicine, University of Nebraska Medical Center, Omaha
| | - Oleg Militsakh
- Department of Head and Neck Surgical Oncology, Estabrook Cancer Center, Nebraska Methodist Hospital, Omaha
| | - Mark D'Agostino
- Department of Anesthesiology, Nebraska Methodist Hospital, Omaha
| | - Brittany Kauffman
- Department of Head and Neck Surgical Oncology, Estabrook Cancer Center, Nebraska Methodist Hospital, Omaha
| | - Robert Lindau
- Department of Head and Neck Surgical Oncology, Estabrook Cancer Center, Nebraska Methodist Hospital, Omaha
| | - Andrew Coughlin
- Department of Head and Neck Surgical Oncology, Estabrook Cancer Center, Nebraska Methodist Hospital, Omaha
| | - William Lydiatt
- Department of Head and Neck Surgical Oncology, Estabrook Cancer Center, Nebraska Methodist Hospital, Omaha
| | - Daniel Lydiatt
- Department of Head and Neck Surgical Oncology, Estabrook Cancer Center, Nebraska Methodist Hospital, Omaha
| | - Russell Smith
- Department of Head and Neck Surgical Oncology, Estabrook Cancer Center, Nebraska Methodist Hospital, Omaha
| | - Aru Panwar
- Department of Head and Neck Surgical Oncology, Estabrook Cancer Center, Nebraska Methodist Hospital, Omaha
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Zimmermann A, Knappich C, Tsantilas P, Kallmayer M, Schmid S, Breitkreuz T, Storck M, Kuehnl A, Eckstein HH. Different perioperative antiplatelet therapies for patients treated with carotid endarterectomy in routine practice. J Vasc Surg 2018; 68:1753-1763. [DOI: 10.1016/j.jvs.2018.01.063] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2017] [Accepted: 01/27/2018] [Indexed: 11/17/2022]
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Ganesh A, Wong JH, Menon BK. Practice Current: How do you manage patients with a "hot carotid"? Neurol Clin Pract 2018; 8:527-536. [PMID: 30588383 PMCID: PMC6294534 DOI: 10.1212/cpj.0000000000000562] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2018] [Accepted: 09/11/2018] [Indexed: 12/20/2022]
Abstract
Patients presenting with acutely symptomatic carotid stenosis (a "hot carotid") are known to be at a high up-front risk of recurrent strokes. Uncertainties remain regarding the appropriate management of such patients in the acute period, particularly with respect to anti-thrombotic treatment as they await revascularisation with carotid endarterectomy (CEA) or angioplasty/stenting (CAS). Decision-making is further complicated when intraluminal thrombi are encountered on vessel imaging. Given these uncertainties, and the paucity of high-quality data in the literature, we sought expert opinion from around the globe on how to manage patients with a "hot carotid" as they await CEA/CAS, with a focus on anti-thrombotic treatment options. Similar questions were posed to the rest of our readership in an online survey, the results of which are also presented.
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Chaturvedi S. Treatment of a hot carotid: More fuel is needed to clarify the best treatments. Neurol Clin Pract 2018; 8:466-467. [PMID: 30588374 PMCID: PMC6294528 DOI: 10.1212/cpj.0000000000000561] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Affiliation(s)
- Seemant Chaturvedi
- Department of Neurology, University of Miami Miller School of Medicine, FL
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Jolobe OM. Mitigation of Stroke Risk in Nonvalvular Atrial Fibrillation Patients With High-Grade Carotid Artery Stenosis. Am J Med Sci 2018; 356:578-579. [DOI: 10.1016/j.amjms.2018.07.008] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2018] [Revised: 07/24/2018] [Accepted: 07/26/2018] [Indexed: 10/28/2022]
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Borioni R, Tomai F, De Persio G, Fratticci L, Tesori MC, Paciotti C, Garofalo M. Safety of carotid endarterectomy early after percutaneous coronary interventions. ITALIAN JOURNAL OF VASCULAR AND ENDOVASCULAR SURGERY 2018. [DOI: 10.23736/s1824-4777.18.01371-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
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Kragsterman B, Nordanstig A, Lindström D, Strömberg S, Thuresson M, Nordanstig J. Editor's Choice – Effect of More Expedited Carotid Intervention on Recurrent Ischaemic Event Rate: A National Audit. Eur J Vasc Endovasc Surg 2018; 56:467-474. [DOI: 10.1016/j.ejvs.2018.06.036] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2017] [Accepted: 06/18/2018] [Indexed: 11/27/2022]
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Saghir R, Humm G, Rix T. Haematomas after carotid endarterectomy can be reduced by direct pressure to the neck postoperatively. Ann R Coll Surg Engl 2018; 100:580-583. [PMID: 29909667 PMCID: PMC6214063 DOI: 10.1308/rcsann.2018.0109] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/17/2018] [Indexed: 11/22/2022] Open
Abstract
Introduction A recognised complication of carotid endarterectomy (CEA) is postoperative haematoma, which can threaten the airway. Previous studies have looked at medical methods of preventing this complication. This study aims to evaluate the impact of simple direct pressure postoperatively on the development of haematoma. Materials and methods From 2011 to 2016, 161 consecutive CEA were performed by a single surgeon or trainee under supervision. After 80 operations, the postoperative technique was altered, with additional pressure being applied by the surgeon to the skin incision from completion of suturing until each patient was awake in the recovery room. The rates of postoperative haematoma and other complications were compared between the pre- and post-intervention groups, as well as grade of surgeon, urgency of operation and antiplatelet/anticoagulant use. Results Post-carotid haematomas were eliminated in the post-intervention group (0/81); in the pre-intervention group 7/80 patients developed haematoma (P < 0.05). There were no significant differences in urgency of surgery, antiplatelet/anticoagulant use, grade of surgeon or other complications (stroke: 2/80 vs 0/81 P < 0.05), suggesting that this was not a learning curve effect. Discussion The results suggest that applying direct pressure helps to reduce oozing, provides time to monitor and identify additional bleeding and protects the wound from excessive strain that may be caused by coughing while the patient wakes up. We advise that the lead surgeon should apply such pressure to ensure precise and focal targeting, for maximum effect. Conclusion During recovery from CEA, focused and prolonged pressure by the operating surgeon is a highly effective method of reducing haematoma.
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Affiliation(s)
- R Saghir
- GKT School of Medicine, King’s College London, London, UK
| | - G Humm
- General Surgery Canterbury Hospital, Canterbury, Kent, UK
| | - T Rix
- Department of Vascular Surgery, East Kent Vascular Centre, Canterbury Hospital, Canterbury, UK
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Naylor AR. Only Time Will Tell! Eur J Vasc Endovasc Surg 2018; 56:475. [PMID: 30037738 DOI: 10.1016/j.ejvs.2018.06.061] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2018] [Accepted: 06/22/2018] [Indexed: 10/28/2022]
Affiliation(s)
- A Ross Naylor
- The Leicester Vascular Institute, Glenfield Hospital, Leicester, UK.
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Scoring system to predict early carotid restenosis after eversion endarterectomy by analysis of inflammatory markers. J Vasc Surg 2018; 68:118-127. [DOI: 10.1016/j.jvs.2017.09.054] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2017] [Accepted: 09/25/2017] [Indexed: 12/12/2022]
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Jones DW, Brott TG, Schermerhorn ML. Trials and Frontiers in Carotid Endarterectomy and Stenting. Stroke 2018; 49:1776-1783. [PMID: 29866753 DOI: 10.1161/strokeaha.117.019496] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2017] [Revised: 04/19/2018] [Accepted: 04/30/2018] [Indexed: 11/16/2022]
Affiliation(s)
- Douglas W Jones
- From the Division of Vascular and Endovascular Surgery, Boston Medical Center, Boston University School of Medicine, MA (D.W.J.)
| | - Thomas G Brott
- Department of Neurology, Mayo Clinic, Jacksonville, FL (T.G.B.)
| | - Marc L Schermerhorn
- Division of Vascular and Endovascular Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA (M.L.S.).
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Serra R, Barbetta A, Fugetto F, Licastro N, Aprea G, Petrella G, Danzi M, Rocca A, Compagna R, De Franciscis S, Amato B. Emergent treatment of carotid stenosis: an evidence-based systematic review. MINERVA CHIR 2018; 73:505-511. [PMID: 29806753 DOI: 10.23736/s0026-4733.18.07767-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
INTRODUCTION Stroke is one of the major causes of death in the world, but above all is the condition most associated with severe long-term disabilities. It is clear that this condition therefore requires the best therapeutic approach possible to minimize the consequences that this can lead to. The major issues concern the type of treatment to be used for revascularization (carotid endarterectomy [CEA] or stenting of the carotid artery [CAS]) and the timing of the treatment itself. Many studies have been conducted on this issue, but a definitive and unanimous verdict has not yet been reached on account of the great variety of results obtained from the various study group. The aim of this review is to analyze the latest scientific findings focused on revascularization following a symptomatic carotid stenosis (SCS). EVIDENCE ACQUISITION We searched all publications addressing treatments and timing of approach to SCS. Randomized trials, cohort studies and reviews were contemplated in order to give a breadth of clinical data. Medline and Science Direct were searched from January 2013 to April 2017. EVIDENCE SYNTHESIS Of the 819 records found, 76 matched our inclusion criteria. After reading the full-text articles, we decided to exclude 54 manuscripts because of the following reasons: 1) no innovative or important content; 2) insufficient data; 3) no clear potential biases or strategies to solve them; 4) no clear endpoints; and 5) inconsistent or arbitrary conclusions. The final set included 22 articles. CONCLUSIONS CEA is considered a less problematic method than CAS, especially for patients over the age of 75; CAS remains recommended in patients with a favorable anatomy or high surgical risks. Studies that showed more solid results seem to lead to the conclusion that optimal timing may be between 2 days and the end of the first week from the onset of symptoms in patients who are appropriate candidates for surgery.
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Affiliation(s)
- Raffaele Serra
- Interuniversity Center of Phlebolymphology (CIFL), Magna Græcia University, Catanzaro, Italy - .,Department of Medical and Surgical Sciences, Magna Græcia University, Catanzaro, Italy -
| | - Andrea Barbetta
- Interuniversity Center of Phlebolymphology (CIFL), Magna Græcia University, Catanzaro, Italy.,Department of Clinical Medicine and Surgery, Federico II University, Naples, Italy
| | - Francesco Fugetto
- Interuniversity Center of Phlebolymphology (CIFL), Magna Græcia University, Catanzaro, Italy
| | - Noemi Licastro
- Department of Medical and Surgical Sciences, Magna Græcia University, Catanzaro, Italy
| | - Giovanni Aprea
- Department of Clinical Medicine and Surgery, Federico II University, Naples, Italy
| | | | - Michele Danzi
- Department of Clinical Medicine and Surgery, Federico II University, Naples, Italy
| | - Aldo Rocca
- Department of Clinical Medicine and Surgery, Federico II University, Naples, Italy
| | - Rita Compagna
- Interuniversity Center of Phlebolymphology (CIFL), Magna Græcia University, Catanzaro, Italy.,Department of Clinical Medicine and Surgery, Federico II University, Naples, Italy
| | - Stefano De Franciscis
- Interuniversity Center of Phlebolymphology (CIFL), Magna Græcia University, Catanzaro, Italy.,Department of Medical and Surgical Sciences, Magna Græcia University, Catanzaro, Italy
| | - Bruno Amato
- Interuniversity Center of Phlebolymphology (CIFL), Magna Græcia University, Catanzaro, Italy.,Department of Clinical Medicine and Surgery, Federico II University, Naples, Italy
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Mistry EA, Khoury JC, Kleindorfer D. Carotid Endarterectomy and Concurrent Clopidogrel Use: National Practice Patterns in the United States. World Neurosurg 2018; 116:e315-e320. [PMID: 29747016 DOI: 10.1016/j.wneu.2018.04.199] [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: 03/12/2018] [Revised: 04/25/2018] [Accepted: 04/26/2018] [Indexed: 11/27/2022]
Abstract
BACKGROUND Patients with diagnoses of high-grade carotid stenosis are often placed on antiplatelet therapy and undergo carotid endarterectomy (CEA) during their hospital stay. There is intersurgeon variability in offering CEA to patients specifically on the potent antiplatelet agent clopidogrel. METHODS Utilizing the Premier database, data from adults with principal discharge diagnosis of stroke, transient ischemic attack (TIA), or carotid artery stenosis or occlusion without stroke/TIA (CAS) who had a CEA during the same hospital stay in 2014 were analyzed. Recent clopidogrel or aspirin use was defined as within 3 days before CEA. Univariate and multivariate analyses were used to examine the association of age, race, gender, symptomatic versus asymptomatic carotid stenosis, academic versus non-academic center, and regions of the United States with recent antiplatelet use before CEA. RESULTS There were 15,381 patients (median age, 71 years, interquartile range 65-78; 42% females) with stroke, TIA, or CAS who had a CEA during the same hospital stay in 2014 within the Premier databse. Of these, 2570 patients (16.7%) received clopidogrel, 4992 (32.5%) received aspirin but no clopidogrel, and 7819 (50.8%) received no clopidogrel/aspirin immediately before CEA. Younger patient age, treatment at a non-academic center, symptomatic carotid stenosis, and being in the Northeast or South were associated higher odds of being on clopidogrel therapy prior to CEA. CONCLUSIONS Across the United States, 1 in 6 patients was on clopidogrel therapy prior to undergoing a CEA. Patients with symptomatic carotid stenosis were most likely to be on clopidogrel therapy prior to their CEA. Future systematic analysis of differences in outcomes and safety events are needed.
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Affiliation(s)
- Eva A Mistry
- Department of Neurology and Rehabilitation Medicine, University of Cincinnati, Cincinnati, Ohio, USA.
| | - Jane C Khoury
- Division of Biostatistics and Epidemiology, Cincinnati Children's Medical Center, Cincinnati, Ohio, USA; Department of Pediatrics, University of Cincinnati of Cincinnati College of Medicine, Cincinnati, Ohio, USA
| | - Dawn Kleindorfer
- Department of Neurology and Rehabilitation Medicine, University of Cincinnati, Cincinnati, Ohio, USA
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Jolobe OM. Proposed rationale for anticoagulants in nonvalvular atrial fibrillation with zero CHA2DS2-Vasc score. Int J Cardiol 2018; 257:112. [DOI: 10.1016/j.ijcard.2017.10.030] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/04/2017] [Accepted: 10/06/2017] [Indexed: 11/25/2022]
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Schoellhammer L, Owen-Falkenberg A, Gottschalksen B, Shahidi S. Midt-Term Results after Fast-Track Prophylactic Carotid Surgery Program: The Risk of Overlooking Occult Cancer. J Stroke Cerebrovasc Dis 2018; 27:531-538. [DOI: 10.1016/j.jstrokecerebrovasdis.2017.10.001] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2017] [Accepted: 09/24/2017] [Indexed: 10/18/2022] Open
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Kisilevsky A, Gelb AW, Bustillo M, Flexman AM. Anaemia and red blood cell transfusion in intracranial neurosurgery: a comprehensive review. Br J Anaesth 2018; 120:988-998. [PMID: 29661416 DOI: 10.1016/j.bja.2017.11.108] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2017] [Revised: 11/08/2017] [Accepted: 11/30/2017] [Indexed: 01/04/2023] Open
Abstract
Both anaemia and blood transfusion are associated with poor outcomes in the neurosurgical population. Based on the available literature, the optimal haemoglobin concentration for neurologically injured patients appears to be in the range of 9.0-10.0 g dl-1, although the individual risks and benefits should be weighed. Several perioperative blood conservation strategies have been used successfully in neurosurgery, including correction of anaemia and coagulopathy, use of antifibrinolytics, and intraoperative cell salvage. Avoidance of non-steroidal anti-inflammatory drugs and starch-containing solutions is recommended given the potential for platelet dysfunction.
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Affiliation(s)
- A Kisilevsky
- Department of Anesthesiology, Pharmacology and Therapeutics, University of British Columbia, Vancouver General Hospital, Vancouver, BC, Canada
| | - A W Gelb
- Department of Anesthesia and Perioperative Care, University of California, San Francisco, CA, USA
| | - M Bustillo
- Department of Anesthesiology, Weill Cornell Medical College, New York Presbyterian Hospital, New York, NY, USA
| | - A M Flexman
- Department of Anesthesiology, Pharmacology and Therapeutics, University of British Columbia, Vancouver General Hospital, Vancouver, BC, Canada.
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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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Jolobe OM. The challenge of coprescription of antiplatelet therapy and oral anticoagulants. Am J Emerg Med 2017; 35:1782-1783. [DOI: 10.1016/j.ajem.2017.05.030] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2017] [Accepted: 05/21/2017] [Indexed: 11/29/2022] Open
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49
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Naylor AR, Vega de Ceniga M. Something Old, Something New, Something Borrowed, and Something Blue. Eur J Vasc Endovasc Surg 2017; 54:413-414. [PMID: 28888385 DOI: 10.1016/j.ejvs.2017.08.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2017] [Accepted: 08/01/2017] [Indexed: 11/17/2022]
Affiliation(s)
- A R Naylor
- Department of Vascular Surgery at Leicester Royal Infirmary, Leicester, UK.
| | - M Vega de Ceniga
- Department of Vascular Surgery Hospital de Galdakao-Usansolo, Galdakao, Bizkaia, Spain
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Kjørstad KE, Baksaas ST, Bundgaard D, Halbakken E, Hasselgård T, Jonung T, Jørgensen GT, Jørgensen JJ, Krog AH, Krohg-Sørensen K, Laxdal E, Mathisen SR, Oskarsson GV, Seljeskog S, Settemsdal I, Vetrhus M, Viddal BA, Wesche J, Aasgaard F, Mattsson E. Editor's Choice - The National Norwegian Carotid Study: Time from Symptom Onset to Surgery is too Long, Resulting in Additional Neurological Events. Eur J Vasc Endovasc Surg 2017; 54:415-422. [PMID: 28844552 DOI: 10.1016/j.ejvs.2017.07.013] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2016] [Accepted: 07/19/2017] [Indexed: 11/29/2022]
Abstract
OBJECTIVE/BACKGROUND The objective was to observe for 1 year all patients in Norway operated on for symptomatic carotid stenosis with respect to (i) the time from the index event to surgery and neurological events during this time; (ii) the level in the healthcare system causing delay of surgical treatment; and (iii) the possible relationship between peri-operative use of platelet inhibitors and neurological events while awaiting surgery. METHODS This was a prospective national multicentre study of a consecutive series of symptomatic patients. Patients were eligible for inclusion when referred for surgery. An index event was defined as the neurological event prompting contact with the healthcare system. All 15 departments in Norway performing carotid endarterectomy (CEA) participated. RESULTS Three hundred and seventy one patients were eligible for inclusion between 1 April 2014 and 31 March 2015, and 368 patients (99.2%) were included. Fifty-four percent of the patients contacted their general practitioner on the day of the index event. Primary healthcare referred 84.2% of the patients to hospital on the same day as examined. In hospital median time from admission to referral for vascular surgery was 3 days. Median time between referral to the operating unit and actual CEA was 5 days. Overall, 61.7% of the patients were operated on within 2 weeks of the index event. Twelve patients (3.3%) suffered a new neurological event while awaiting surgery. The percentage of patients on dual antiplatelet therapy was lower (25.0%) in this group than among the other patients (62.6%) (p = .008). The combined 30 day mortality and stroke rate was 3.8%. CONCLUSION This national study with almost complete inclusion and follow-up shows that the delays occur mainly at patient level and in hospital. The delay is associated with new neurological events. Dual antiplatelet therapy is associated with reduced risk of having a new neurological event before surgery.
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Affiliation(s)
- K E Kjørstad
- University Hospital of North Norway, Tromsø, Norway.
| | | | | | | | | | - T Jonung
- Haukeland University Hospital, University of Bergen, Bergen, Norway
| | | | - J J Jørgensen
- Oslo University Hospital, Oslo, Norway; University of Oslo, Oslo, Norway
| | - A H Krog
- Oslo University Hospital, Oslo, Norway; University of Oslo, Oslo, Norway
| | - K Krohg-Sørensen
- Oslo University Hospital, Oslo, Norway; University of Oslo, Oslo, Norway
| | - E Laxdal
- Haukeland University Hospital, University of Bergen, Bergen, Norway
| | | | | | - S Seljeskog
- Akershus University Hospital, Lørenskog, Norway
| | | | - M Vetrhus
- Stavanger University Hospital, Stavanger, Norway
| | - B A Viddal
- Stavanger University Hospital, Stavanger, Norway
| | - J Wesche
- University of Oslo, Oslo, Norway; Akershus University Hospital, Lørenskog, Norway
| | - F Aasgaard
- St. Olav's University Hospital, Trondheim, Norway
| | - E Mattsson
- St. Olav's University Hospital, Trondheim, Norway; Norwegian University of Science and Technology, Trondheim, Norway
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