1
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Fries F. [Stent angioplasty for internal carotid artery stenosis]. RADIOLOGIE (HEIDELBERG, GERMANY) 2024; 64:694-698. [PMID: 38700713 DOI: 10.1007/s00117-024-01306-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 04/17/2024] [Indexed: 08/28/2024]
Abstract
BACKGROUND Stent angioplasty of carotid stenosis has become established as a safe and efficient treatment method alongside carotid endarterectomy due to developments in stent design and refinement of interventional techniques. Today, the protocol for stent angioplasty is largely standardized. OBJECTIVE The aim of this article is to provide sound insight into the development and current practice of stent angioplasty. Particular attention is paid to technical implementation and periprocedural management.
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Affiliation(s)
- Frederik Fries
- Klinik für Diagnostische und Interventionelle Neuroradiologie, Universitätsklinikum des Saarlandes, Kirrberger Straße, 66421, Homburg/Saar, Deutschland.
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2
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Milazzo N, Da Ros V, Diomedi M, Menozzi R, Pezzini A, Ruggiero M, Simonetti L, Zini A, Romano DG, Napoletano R, Vallone S, Bigliardi G, Plebani M, Cappellari M, Cristaudo C, Mangiafico S, Toni D, Consoli A. Current trends in antiplatelet strategies for emergent carotid stenting in acute tandem occlusions: a web-based, nationwide survey in the Italian neurovascular community. Neurol Sci 2024:10.1007/s10072-024-07722-2. [PMID: 39158771 DOI: 10.1007/s10072-024-07722-2] [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: 05/07/2024] [Accepted: 07/29/2024] [Indexed: 08/20/2024]
Abstract
BACKGROUND Although a benefit from mechanical thrombectomy has been proven, the best treatment strategy for tandem occlusions (TOs) remains unclear. We conducted a survey that aimed to investigate the trends of pharmacological strategy in the setting of emergent carotid stenting for TOs in the Italian neuro-endovascular community. METHODS We administered a 13-multiple choice-questions survey to the Chiefs of the centers participating to the Italian Registry of Endovascular Thrombectomy in Acute Stroke (IRETAS), focused on the technical aspects and on the management of the antiplatelet therapy for emergent carotid tenting in TOs. An internal coherence control was performed by the coordinating investigator. RESULTS We obtained responses from 56/66 centers (84.8%). The main results of the survey showed that most of the center treat TOs using a retrograde approach, deploying a closed-cell stent. A single antiplatelet therapy is preferred at the moment of the deployment of the stent. CONCLUSIONS This survey showed that the current practice regarding the acute management of TOs, in particular the antiplatelet therapy, remains heterogeneous in the Italian neurovascular community. Specific evidences are urgently needed in order to achieve a consensus on the acute management of TOs.
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Affiliation(s)
- Nicola Milazzo
- Diagnostic and Interventional Neuroradiology, Foch Hopital, Suresnes, France.
- UFR Simon Veil Santé, University of Versailles Saint-Quentin-en-Yvelines (UVSQ), Montigny-Le-Bretonneux, France.
- Maurizio Bufalini Hospital, Cesena, Italy.
| | - Valerio Da Ros
- Department of Biomedicine and Prevention, University of Rome Tor Vergata, Rome, Italy
| | - Marina Diomedi
- Stroke Unit, Department of Biomedicine and Prevention, University of Rome Tor Vergata, Rome, Italy
| | - Roberto Menozzi
- Diagnostic Department, Neuroradiology Unit, Parma University Hospital, Parma, Italy
| | - Alessandro Pezzini
- Stroke Care Program Department of Emergency, Parma University Hospital, Parma, Italy
| | | | - Luigi Simonetti
- IRCCS Istituto delle Scienze Neurologiche di Bologna, Neuroradiology Unit, Maggiore Hospital, Bologna, Italy
| | - Andrea Zini
- Department of Neurology and Stroke Center, IRCCS Istituto delle Scienze Neurologiche di Bologna, Maggiore Hospital, Bologna, Italy
| | - Daniele Giuseppe Romano
- Department of Interventional Radiology and Neuroradiology, University Hospital of Salerno, Salerno, Italy
| | - Rosa Napoletano
- Stroke Unit, Department of Medical Sciences, University Hospital of Salerno, Salerno, Italy
| | - Stefano Vallone
- Baggiovara Hospital, Azienda Ospedaliero-Universitaria di Modena, NeuroradiologyModena, Italy
| | - Guido Bigliardi
- Neurology Clinic - Stroke Unit, Baggiovara Hospital, Azienda Ospedaliero-Universitaria di Modena, Modena, Italy
| | - Mauro Plebani
- Department of Neuroradiology, Azienda Ospedaliera Universitaria Integrata, Verona, Italy
| | - Manuel Cappellari
- Stroke Unit, Azienda Ospedaliera Universitaria Integrata, Verona, Italy
| | | | - Salvatore Mangiafico
- Interventional Neuroradiology Consultant at IRCCS Neuromed, Pozzilli (IS), and Adjunct Professor of Interventional Neuroradiology at Tor Vergata University, Sapienza University and S. Andrea Hospital, Rome, Italy
| | - Danilo Toni
- Emergency Department Stroke Unit, Department of Human Neurosciences, Sapienza University of Rome, Rome, Italy
| | - Arturo Consoli
- Diagnostic and Interventional Neuroradiology, Foch Hopital, Suresnes, France
- UFR Simon Veil Santé, University of Versailles Saint-Quentin-en-Yvelines (UVSQ), Montigny-Le-Bretonneux, France
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3
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Gorgulu S, Sahin M, Norgaz NT, Pala S, Sarı M, Yalcin AA, Sipahi I. Carotid artery stenting without embolic protection: A randomized multicenter trial (the CASWEP trial). Interv Neuroradiol 2023; 29:419-425. [PMID: 35469509 PMCID: PMC10399495 DOI: 10.1177/15910199221094388] [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: 01/08/2022] [Accepted: 03/24/2022] [Indexed: 12/24/2022] Open
Abstract
BACKGROUND Carotid artery stenting (CAS) with a carotid protection device (CPD) has become the standard practice in patients with severe carotid stenosis and high surgical risk. However, the clinical efficacy and safety of CPDs are still controversial issues. We aimed to compare the clinical outcomes of the CAS without CPD with CAS combined with CPD. METHODS This is a multicenter randomized prospective study registered with http://clinicaltrials.gov (NCT02781181). After the exclusion, 279 patients were enrolled (139 patients in the CAS with CPD group and 140 patients in the CAS without CPD group). The primary outcome was a combination of peri-procedural in-hospital transient ischemic attack (TIA), ipsilateral stroke, or death. The secondary outcome was new ischemic brain lesions on post-procedural diffusion-weighted magnetic resonance imaging (DW-MRI). RESULTS Two patients died in CAS without CPD group, one patient died in CAS with CPD group. TIA was only seen in patients who underwent CAS under protection (n = 5). The combined primary outcome of TIA, ipsilateral stroke, and death rate was not different between groups (5.7% vs. 2.8%; p = 0.254). New defects were noted on the post-procedural DW-MRI in 28% of patients in the CPD group and 27% of patients in the no CPD group (p = 0.881). CONCLUSIONS This study suggests that CAS without CPD is not associated with higher rates of peri-procedural TIA, stroke, and death or new ischemic brain lesions on post-procedural DW-MRI compared to CAS with CPD in selected symptomatic and asymptomatic patients with significant carotid artery stenosis provided that there is no visible thrombus.
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Affiliation(s)
- Sevket Gorgulu
- Department of Cardiology, Acibadem University Medical Faculty, Istanbul, Turkey
| | - Muslum Sahin
- Department of Cardiology, Istinye University Medical Faculty, Istanbul, Turkey
| | | | - Selçuk Pala
- Department of Cardiology, University of Health Sciences, Kartal Kosuyolu High Speciality Educational and Research Hospital, Istanbul, Turkey
| | - Munevver Sarı
- Department of Cardiology, University of Health Sciences, Kartal Kosuyolu High Speciality Educational and Research Hospital, Istanbul, Turkey
| | - Ahmet Arif Yalcin
- Department of Cardiology, University of Health Sciences, Mehmet Akif Ersoy Chest and Cardiovascular Surgery Training and Research Hospital, Istanbul, Turkey
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Calo P, Oberhuber A, Görtz H. Patient Selection Criteria and Procedural Standardization for Carotid Artery Stenting-A Single Center Experience. J Clin Med 2023; 12:jcm12103534. [PMID: 37240640 DOI: 10.3390/jcm12103534] [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: 04/18/2023] [Revised: 04/26/2023] [Accepted: 05/16/2023] [Indexed: 05/28/2023] Open
Abstract
The gold standard for the treatment of carotid artery stenosis is the carotid endarterectomy (CEA). According to current guidelines, carotid artery stenting (CAS) is an alternative. Randomized control trials (RCTs) show significantly higher rates of peri-interventional strokes after CAS compared to CEA. However, these trials were usually characterized by a great heterogeneity in the CAS procedure. In this retrospective analysis from 2012 to 2020, 202 symptomatic and asymptomatic patients were treated with CAS. Patients were carefully pre-selected according to anatomical and clinical criteria. In all cases, the same steps and material were used. All interventions were performed by five experienced vascular surgeons. Primary endpoints of this study were perioperative death and stroke. Asymptomatic carotid stenosis was present in 77% of the patients and symptomatic in 23%. The mean age was 66 years. The average degree of stenosis was 81%. The CAS technical success rate was 100%. Periprocedural complications occurred in 1.5% of cases, including one major stroke (0.5%) and two minor strokes (1%). The results of this study indicate that through a strict patient selection based on anatomical and clinical criteria, CAS can be performed with very low complication rates. Furthermore, standardization of the materials and the procedure itself is crucial.
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Affiliation(s)
- Paolo Calo
- Department of Vascular Surgery, Bonifatius Hospital Lingen, 49808 Lingen, Germany
| | - Alexander Oberhuber
- Department of Vascular and Endovascular Surgery, University Hospital Muenster, 48149 Muenster, Germany
| | - Hartmut Görtz
- Department of Vascular Surgery, Bonifatius Hospital Lingen, 49808 Lingen, Germany
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Reddy VPK, Mulimani NM. Comparison of the Outcome and Efficacy of Single-Layer versus Dual-Layer Mesh Stent among Carotid Stenosis Patients Attending a Tertiary Care Setting—A Prospective Observational Study. JOURNAL OF CLINICAL INTERVENTIONAL RADIOLOGY ISVIR 2022. [DOI: 10.1055/s-0042-1759799] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022] Open
Abstract
Abstract
Introduction The effect of stent design whether single-layer or double-layer on long-term durability of carotid artery stenting (CAS) is unknown. The aim of this article was to compare the clinical outcome and efficacy of single-layer versus dual-layer mesh stent for CAS among carotid stenosis patients.
Methods A prospective observational study was conducted among 41 consecutive patients, who underwent CAS procedures between November 2019 and November 2021. Procedural data and outcomes for patients treated with the single-layer stent (n = 19patients) and double-layer stent (n = 22) were compared. Procedural efficacy and complications were considered as primary outcome variable. SPSS version 22 was used for statistical analysis.
Results Mean age of study population in dual-layer stents group was 63.86 ± 11.08 years and it was 61.47 ± 8.26 years in single-layer stent group. There was no statistically significant difference between two groups with age, stenosis, side of stenosis, prestenting angioplasty, and poststenting angioplasty (p-value >0.05). Out of 22 participants with dual-layer stent, only one (4.5%) participant experienced five episodes of transient ischemic attack in last 1 month. Both clinical and associated complaints were more in dual-layer group compared with single layer. One (5.26%) participant in single-layer group had reclusion/restenosis at 30 days. Majority in single-(57.8%) and double-layer (63.64%) stents group showed modified Rankin Scale score of 0.
Conclusion Restenosis after CAS occurred less frequently in patients treated with double-layer mesh when compared with single-layer stent. However, both stents were equally effective at preventing peri procedural complications.
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Affiliation(s)
| | - Navin M. Mulimani
- Department of Interventional Radiology, Dr KLEs Prabhakar Kore Hospital & MRC, Belagavi, Karnataka, India
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6
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Hammad M, Alkinani MH, Gupta BB, Abd El-Latif AA. Myocardial infarction detection based on deep neural network on imbalanced data. MULTIMEDIA SYSTEMS 2022; 28:1373-1385. [DOI: 10.1007/s00530-020-00728-8] [Citation(s) in RCA: 26] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/09/2020] [Accepted: 12/01/2020] [Indexed: 09/02/2023]
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Hajiyev K, Hellstern V, Cimpoca A, Wendl C, Bäzner H, Henkes H, von Gottberg P. Carotid Artery Stenting in Patients with Symptomatic and Asymptomatic Stenosis: In-Hospital Clinical Outcomes at a Single Neurovascular Center. J Clin Med 2022; 11:jcm11082086. [PMID: 35456179 PMCID: PMC9031352 DOI: 10.3390/jcm11082086] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2022] [Revised: 03/18/2022] [Accepted: 04/05/2022] [Indexed: 02/05/2023] Open
Abstract
Background: Carotid artery stenting (CAS) is a minimally invasive and proven percutaneous procedure that is widely used to treat patients with symptomatic and asymptomatic carotid artery stenosis. The purpose of this study was to characterize the in-hospital outcomes of symptomatic and asymptomatic patients undergoing CAS at a single neurovascular center. Methods: The study was conducted as a retrospective analysis of 1158 patients (asymptomatic, n = 636; symptomatic, n = 522; male, n = 816; median age, 71 years; NASCET method, 70–99% stenosis, n = 830) who underwent CAS between May 2009 and December 2020. In-hospital neurological outcomes, adverse reactions to iodinated contrast media, acute myocardial infarction, intraprocedural complications, and access-site issues were evaluated. The primary endpoints were disabling stroke (including disabling cerebral hyperperfusion syndrome [CHS]) and all in-hospital deaths. Results: A carotid stent could not be deployed in one patient due to calcified plaques (technical failure rate of 0.09%). Four patients (0.3%) experienced in-hospital, stroke-associated death, while five patients (0.4%) died from non-stroke-related causes. All stroke-associated deaths occurred in the symptomatic group and were due to CHS. The disabling stroke rate was 0.9% overall (n = 10; 0.5% versus 1.3% in asymptomatic versus symptomatic patients, respectively). Nineteen patients (1.6%) reached the in-hospital primary endpoint. More patients in the symptomatic group achieved this endpoint than in the asymptomatic group (2.5% versus 0.9%, respectively; p = 0.060). Conclusions: An evaluation was conducted on the in-hospital outcomes of 1158 patients at a single center who underwent CAS and was performed by trained physicians who were supervised by a senior neurovascular interventionist with over 20 years of experience, confirming the excellent safety profile of this procedure with a low rate of complications.
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Affiliation(s)
- Kamran Hajiyev
- Neuroradiologische Klinik, Klinikum Stuttgart, D-70174 Stuttgart, Germany; (V.H.); (A.C.); (H.H.); (P.v.G.)
- Correspondence:
| | - Victoria Hellstern
- Neuroradiologische Klinik, Klinikum Stuttgart, D-70174 Stuttgart, Germany; (V.H.); (A.C.); (H.H.); (P.v.G.)
| | - Alexandru Cimpoca
- Neuroradiologische Klinik, Klinikum Stuttgart, D-70174 Stuttgart, Germany; (V.H.); (A.C.); (H.H.); (P.v.G.)
| | - Christina Wendl
- Institut für Röntgendiagnostik, Zentrum für Neuroradiologie, Fakultät für Medizin, Universität Regensburg, D-93053 Regensburg, Germany;
| | - Hansjörg Bäzner
- Neurologische Klinik, Klinikum Stuttgart, D-70174 Stuttgart, Germany;
| | - Hans Henkes
- Neuroradiologische Klinik, Klinikum Stuttgart, D-70174 Stuttgart, Germany; (V.H.); (A.C.); (H.H.); (P.v.G.)
- Medizinische Fakultät, University Duisburg-Essen, D-47057 Duisburg, Germany
| | - Philipp von Gottberg
- Neuroradiologische Klinik, Klinikum Stuttgart, D-70174 Stuttgart, Germany; (V.H.); (A.C.); (H.H.); (P.v.G.)
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8
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Management of atherosclerotic extracranial carotid artery stenosis. Lancet Neurol 2022; 21:273-283. [DOI: 10.1016/s1474-4422(21)00359-8] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2020] [Revised: 09/30/2021] [Accepted: 10/08/2021] [Indexed: 02/05/2023]
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Poorthuis MH, Herings RA, Dansey K, Damen JA, Greving JP, Schermerhorn ML, de Borst GJ. External Validation of Risk Prediction Models to Improve Selection of Patients for Carotid Endarterectomy. Stroke 2022; 53:87-99. [PMID: 34634926 PMCID: PMC8712365 DOI: 10.1161/strokeaha.120.032527] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
BACKGROUND AND PURPOSE The net benefit of carotid endarterectomy (CEA) is determined partly by the risk of procedural stroke or death. Current guidelines recommend CEA if 30-day risks are <6% for symptomatic stenosis and <3% for asymptomatic stenosis. We aimed to identify prediction models for procedural stroke or death after CEA and to externally validate these models in a large registry of patients from the United States. METHODS We conducted a systematic search in MEDLINE and EMBASE for prediction models of procedural outcomes after CEA. We validated these models with data from patients who underwent CEA in the American College of Surgeons National Surgical Quality Improvement Program (2011-2017). We assessed discrimination using C statistics and calibration graphically. We determined the number of patients with predicted risks that exceeded recommended thresholds of procedural risks to perform CEA. RESULTS After screening 788 reports, 15 studies describing 17 prediction models were included. Nine were developed in populations including both asymptomatic and symptomatic patients, 2 in symptomatic and 5 in asymptomatic populations. In the external validation cohort of 26 293 patients who underwent CEA, 702 (2.7%) developed a stroke or died within 30-days. C statistics varied between 0.52 and 0.64 using all patients, between 0.51 and 0.59 using symptomatic patients, and between 0.49 to 0.58 using asymptomatic patients. The Ontario Carotid Endarterectomy Registry model that included symptomatic status, diabetes, heart failure, and contralateral occlusion as predictors, had C statistic of 0.64 and the best concordance between predicted and observed risks. This model identified 4.5% of symptomatic and 2.1% of asymptomatic patients with procedural risks that exceeded recommended thresholds. CONCLUSIONS Of the 17 externally validated prediction models, the Ontario Carotid Endarterectomy Registry risk model had most reliable predictions of procedural stroke or death after CEA and can inform patients about procedural hazards and help focus CEA toward patients who would benefit most from it.
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Affiliation(s)
| | - Reinier A.R. Herings
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
| | - Kirsten Dansey
- Division of Vascular and Endovascular Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, US
| | - Johanna A.A. Damen
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
| | - Jacoba P. Greving
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
| | - Marc L. Schermerhorn
- Division of Vascular and Endovascular Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, US
| | - Gert J. de Borst
- Department of Vascular Surgery, University Medical Center Utrecht, Utrecht, The Netherlands
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Advanced vasospasm in carotid stenting using the distal filter-type embolic protection device: A case report. JOURNAL OF SURGERY AND MEDICINE 2021. [DOI: 10.28982/josam.1000878] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
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Foo M, Ren Y, Gajera J, Barras CD, Kok HK, Jhamb A, Abbouchie H, Maingard J, Brooks DM, Asadi H. CaRotid Artery Filtering Technique (CRAFT): A Technique for Carotid Artery Stenting with Intrinsic Embolic Protection. Neurointervention 2021; 16:260-266. [PMID: 34689457 PMCID: PMC8561041 DOI: 10.5469/neuroint.2021.00353] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2021] [Accepted: 10/06/2021] [Indexed: 11/24/2022] Open
Abstract
Purpose Carotid artery stenting (CAS) is an established treatment for symptomatic carotid artery stenosis as an alternative to carotid endarterectomy. A variety of techniques and devices have been devised to minimise periprocedural stroke risk using either proximal or distal embolic protection. This study presents a method of embolic protection during CAS–the CaRotid Artery Filtering Technique (CRAFT). Materials and Methods The CRAFT technique employs aspects of both proximal and distal embolic protection. The CASPER RX stent (MicroVention, Tustin, CA, USA), which is a double-layered, closed-cell, micromesh nitinol stent, is deployed across the carotid artery stenosis with the assistance of a FlowGate balloon guide catheter (Stryker Neurovascular, Fremont, CA, USA). The partially deployed stent acts as a distal filter while the balloon guide is deflated midway during stent deployment to prevent distal plaque embolisation, followed by completion of stent deployment and angioplasty. Results A total of 94 patients underwent CAS using the CRAFT technique between June 2016 and March 2021. Successful stent deployment was achieved in all patients. Preliminary results demonstrated acute stent occlusion in 6 patients (6.4%) and distal embolic stroke in 5 patients (5.3%). The median procedural fluoroscopy time was 34 minutes with an interquartile range of 22 to 55 minutes. Conclusion The CRAFT technique of CAS presented by this study can be applied in the treatment of symptomatic carotid artery stenosis in both emergency and elective procedure settings with a high technical success and low distal embolic stroke risk.
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Affiliation(s)
- Michelle Foo
- Department of Radiology, Austin Hospital, Melbourne, Vic, Australia
| | - Yifan Ren
- Department of Radiology, Austin Hospital, Melbourne, Vic, Australia
| | - Jay Gajera
- Department of Radiology, Alfred Health, Melbourne, Vic, Australia
| | - Christen D Barras
- South Australian Health and Medical Research Institute, University of Adelaide, Adelaide, SA, Australia.,Department of Radiology, Royal Adelaide Hospital, Adelaide, SA, Australia
| | - Hong Kuan Kok
- Interventional Radiology Service, Department of Radiology, Northern Health, Melbourne, Vic, Australia.,School of Medicine, Faculty of Health, Deakin University, Waurn Ponds, Vic, Australia
| | - Ashu Jhamb
- Interventional Radiology Service, Department of Radiology, St Vincent's Hospital, Melbourne, Vic, Australia
| | | | - Julian Maingard
- School of Medicine, Faculty of Health, Deakin University, Waurn Ponds, Vic, Australia.,Interventional Neuroradiology Service, Department of Radiology, Monash Health, Melbourne, Vic, Australia
| | - Duncan Mark Brooks
- Department of Radiology, Austin Hospital, Melbourne, Vic, Australia.,Stroke Theme, The Florey Institute of Neuroscience and Mental Health, University of Melbourne, Melbourne, Vic, Australia
| | - Hamed Asadi
- Department of Radiology, Austin Hospital, Melbourne, Vic, Australia.,School of Medicine, Faculty of Health, Deakin University, Waurn Ponds, Vic, Australia.,Interventional Radiology Service, Department of Radiology, St Vincent's Hospital, Melbourne, Vic, Australia.,Interventional Neuroradiology Service, Department of Radiology, Monash Health, Melbourne, Vic, Australia.,Stroke Theme, The Florey Institute of Neuroscience and Mental Health, University of Melbourne, Melbourne, Vic, Australia
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12
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Müller MD, Bonati LH. Carotid artery stenosis – Current evidence and treatment recommendations. CLINICAL AND TRANSLATIONAL NEUROSCIENCE 2021. [DOI: 10.1177/2514183x211001654] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Background: Carotid artery stenosis is an important cause for stroke. Carotid endarterectomy (CEA) reduces the risk of stroke in patients with symptomatic carotid stenosis and to some extent in patients with asymptomatic carotid stenosis. More than 20 years ago, carotid artery stenting (CAS) emerged as an endovascular treatment alternative to CEA. Objective and Methods: This review summarises the available evidence from randomised clinical trials in patients with symptomatic as well as in patients with asymptomatic carotid stenosis. Results: CAS is associated with a higher risk of death or any stroke between randomisation and 30 days after treatment than CEA (odds ratio (OR) = 1.74, 95% CI 1.3 to 2.33, p < 0.0001). In a pre-defined subgroup analysis, the OR for stroke or death within 30 days after treatment was 1.11 (95% CI 0.74 to 1.64) in patients <70 years old and 2.23 (95% CI 1.61 to 3.08) in patients ≥70 years old, resulting in a significant interaction between patient age and treatment modality (interaction p = 0.007). The combination of death or any stroke up to 30 days after treatment or ipsilateral stroke during follow-up also favoured CEA (OR = 1.51, 95% CI 1.24 to 1.85, p < 0.0001). In asymptomatic patients, there is a non-significant increase in death or stroke occurring within 30 days of treatment with CAS compared to CEA (OR = 1.72, 95% CI 1.00 to 2.97, p = 0.05). The risk of peri-procedural death or stroke or ipsilateral stroke during follow-up did not differ significantly between treatments (OR = 1.27, 95% CI 0.87 to 1.84, p = 0.22). Discussion and Conclusion: In symptomatic patients, randomised evidence has consistently shown CAS to be associated with a higher risk of stroke or death within 30 days of treatment than CEA. This extra risk is mostly attributed to an increase in strokes occurring on the day of the procedure in patients ≥70 years. In asymptomatic patients, there may be a small increase in the risk of stroke or death within 30 days of treatment with CAS compared to CEA, but the currently available evidence is insufficient and further data from ongoing randomised trials are needed.
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Affiliation(s)
- Mandy D Müller
- Department of Neurology and Stroke Center, University Hospital Basel, University of Basel, Basel, Switzerland
- Department of Neurosurgery, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Leo H Bonati
- Department of Neurology and Stroke Center, University Hospital Basel, University of Basel, Basel, Switzerland
- Department of Brain Repair and Rehabilitation, Stroke Research Centre, UCL Institute of Neurology, University College London, London, UK
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13
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Nazari P, Golnari P, Hurley MC, Shaibani A, Ansari SA, Potts MB, Jahromi BS. Carotid Stenting without Embolic Protection Increases Major Adverse Events: Analysis of the National Surgical Quality Improvement Program. AJNR Am J Neuroradiol 2021; 42:1264-1269. [PMID: 34255736 DOI: 10.3174/ajnr.a7108] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2020] [Accepted: 01/26/2021] [Indexed: 11/07/2022]
Abstract
BACKGROUND AND PURPOSE Published data regarding embolic protection device efficacy is mixed, and its use during carotid artery stent placement remains variable. We, therefore, examined the frequency of embolic protection device use and its association with outcomes after carotid artery stent placement using a national quality improvement data base. MATERIALS AND METHODS Patients undergoing carotid artery stent placement with or without embolic protection devices were identified in the American College of Surgeons National Surgical Quality Improvement Program data base. The primary outcome was the incidence of major adverse cardiovascular events (defined as death, stroke, or myocardial infarction/arrhythmia) within 30 days. Propensity scoring was used to create 2 matching cohorts of patients using demographic and baseline variables. RESULTS Between 2011 and 2018, among 1200 adult patients undergoing carotid artery stent placement, 23.8% did not have embolic protection devices. There was no trend toward increased embolic protection device use with time. Patients without embolic protection device use received preoperative antiplatelets less frequently (90.6% versus 94.6%, P = .02), underwent more emergent carotid artery stent placement (7.2% versus 3.6%, P = .01), and had a higher incidence of major adverse cardiovascular events (OR = 1.81; 95% CI, 1.11-2.94) and stroke (OR = 3.31; 95% CI, 1.71-6.39). After compensating for baseline imbalances using propensity-matched cohorts (n = 261 for both), carotid artery stent placement without an embolic protection device remained associated with increased major adverse cardiovascular events (9.2% versus 4.2%; OR = 2.30; 95% CI, 1.10-4.80) and stroke (6.5% versus 1.5%; OR = 4.48; 95% CI, 1.49-13.49). CONCLUSIONS Lack of embolic protection device use during carotid artery stent placement is associated with a 4-fold increase in the likelihood of perioperative stroke. Nevertheless, nearly one-quarter of patients in the American College of Surgeons National Surgical Quality Improvement Program underwent unprotected carotid artery stent placement. Efforts targeting improved embolic protection device use during carotid artery stent placement are warranted.
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Affiliation(s)
- P Nazari
- From the Departments of Neurological Surgery and Radiology Northwestern Memorial Hospital, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - P Golnari
- From the Departments of Neurological Surgery and Radiology Northwestern Memorial Hospital, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - M C Hurley
- From the Departments of Neurological Surgery and Radiology Northwestern Memorial Hospital, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - A Shaibani
- From the Departments of Neurological Surgery and Radiology Northwestern Memorial Hospital, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - S A Ansari
- From the Departments of Neurological Surgery and Radiology Northwestern Memorial Hospital, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - M B Potts
- From the Departments of Neurological Surgery and Radiology Northwestern Memorial Hospital, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - B S Jahromi
- From the Departments of Neurological Surgery and Radiology Northwestern Memorial Hospital, Northwestern University Feinberg School of Medicine, Chicago, Illinois
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14
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Jang SH, Kwon DH, Han MK, Park H, Sohn SI, Choi H, Hong JH. Impact of statin pretreatment on the complications of carotid stenting in asymptomatic patients: observational study. BMC Neurol 2021; 21:75. [PMID: 33588788 PMCID: PMC7883458 DOI: 10.1186/s12883-021-02104-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2020] [Accepted: 02/02/2021] [Indexed: 11/10/2022] Open
Abstract
Background Carotid stenosis is a known risk factor for ischemic stroke, and carotid artery stenting is an effective preventive procedure. However, the stroke risk reduction for asymptomatic patients is small. Therefore, it is important to reduce the risk of complications, particularly in asymptomatic carotid stenosis. Statins are known to reduce the overall risk of periprocedural complications, although there is a lack of data focusing on asymptomatic patients. We aimed to investigate whether different doses of statin pretreatment can reduce periprocedural complications of carotid artery stenting (CAS) in patients with asymptomatic carotid artery stenosis. Methods Between July 2003 and June 2013, 276 consecutive patients received CAS for asymptomatic carotid stenosis. Periprocedural complications included the outcome of stroke, myocardial infarction, or death within 30 days of CAS. Statin pretreatment was categorized as no-statin (n = 87, 31.5%), standard-dose (< 40 mg, n = 139, 50.4%), and high-dose statin (≥40 mg, n = 50, 18.1%) according to the atorvastatin equivalent dose. The Cochran-Armitage (CA) trend test was performed to investigate the association of periprocedural complications with statin dose. Results The overall periprocedural complication rate was 3.3%. There was no significant difference in the risk of periprocedural complications between the three groups (no statin: n = 3 [3.4%]; standard-dose: n = 4 [2.9%]; high-dose n = 2 [4.0%] p = 0.923). The CA trend test did not demonstrate a trend in the proportion of periprocedural complications across increasing statin equivalent doses (p = 0.919). Conclusions Statin pretreatment before CAS showed neither absolute nor dose-dependent effects against periprocedural complications in asymptomatic patients undergoing CAS. Supplementary Information The online version contains supplementary material available at 10.1186/s12883-021-02104-z.
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Affiliation(s)
- Seong Hwa Jang
- Department of Neurology, Keimyung University Dongsan Hospital, Keimyung University School of Medicine, 1095 Dalgubeol-daero, Dalseo-gu, Daegu, 42601, South Korea
| | - Doo Hyuk Kwon
- Department of Neurology, Keimyung University Dongsan Hospital, Keimyung University School of Medicine, 1095 Dalgubeol-daero, Dalseo-gu, Daegu, 42601, South Korea
| | - Moon-Ku Han
- Department of Neurology, Seoul National University Bundang Hospital, Seoul National University School of Medicine, Seongnam, South Korea
| | - Hyungjong Park
- Department of Neurology, Keimyung University Dongsan Hospital, Keimyung University School of Medicine, 1095 Dalgubeol-daero, Dalseo-gu, Daegu, 42601, South Korea
| | - Sung-Il Sohn
- Department of Neurology, Keimyung University Dongsan Hospital, Keimyung University School of Medicine, 1095 Dalgubeol-daero, Dalseo-gu, Daegu, 42601, South Korea
| | - Huimahn Choi
- Department of Neurology and Neurosurgery, McGovern Medical School, University of Texas Health Science Center at Houston, Houston, TX, USA
| | - Jeong-Ho Hong
- Department of Neurology, Keimyung University Dongsan Hospital, Keimyung University School of Medicine, 1095 Dalgubeol-daero, Dalseo-gu, Daegu, 42601, South Korea.
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15
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Luo J, Li L, Wang T, Yang K, Feng Y, Yang R, Ma Y, Gao P, Yang B, Jiao L. Risk Factors of New Cerebral Infarctions After Endovascular Treatment for Basilar Artery Stenosis Based on High-Resolution Magnetic Resonance Imaging. Front Neurol 2021; 11:620031. [PMID: 33551976 PMCID: PMC7855455 DOI: 10.3389/fneur.2020.620031] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2020] [Accepted: 12/18/2020] [Indexed: 11/13/2022] Open
Abstract
Objective: The current study aims to analyze the risk factors of new cerebral infarctions in the distribution of basilar artery (BA) detected by diffusion-weighted imaging (DWI) after endovascular treatment in patients with severe BA stenosis. Methods: Data was collected from the electronic medical records of patients with severely atherosclerotic basilar artery stenosis (≥70%) who underwent endovascular treatment. The plaque characteristics, including the plaque distribution, plaque burden, plaque enhancement index, remodeling ratio, and stenosis degree, were evaluated qualitatively and quantitatively using high-resolution magnetic resonance imaging (HR-MRI) and digital subtraction angiography (DSA). The characteristics of the procedure, such as the type of treatment, balloon diameter, balloon length, stent diameter, and stent length, were analyzed. Results: A total of 107 patients with severe basilar artery stenosis (≥70%) who underwent endovascular treatment were enrolled. The study participants included 77 men and 30 women, with an average age of 61.6 ± 8.1 years. The rate of postoperative new cerebral infarctions was 55.1% (59/107), of which 74.6% (44/59) were caused by artery-to-artery embolism, 6.8% (4/59) due to perforator occlusion, and 18.6% (11/59) were caused by a mixed mechanism. Twelve of 59 patients had ischemic events, with nine cases of stroke and three cases of transient ischemic attacks (TIA). The plaque burden in the DWI-positive group was significantly larger than that in the DWI-negative group (3.7% vs. -8.5%, p = 0.016). Positive remodeling was more common in the DWI-positive group than in the DWI-negative group (35.6% vs. 16.7%, p = 0.028). Smoking was inversely correlated with the rate of new cerebral infarctions (odds ratio, 0.394; 95% confidence interval, 0.167-0.926; p = 0.033). Conclusion: The plaque characteristics are not associated with new cerebral infarctions in the distribution of BA, although a large plaque burden and positive remodeling are more likely to appear in patients with new cerebral infarctions after BA stenting, which warrants further studies with a larger sample size. As for smoking, the inverse correlation with new cerebral infarctions in the BA territory needs large-scale prospective randomized controlled trials to verify.
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Affiliation(s)
- Jichang Luo
- China International Neuroscience Institute (China-INI), Beijing, China.,Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Long Li
- China International Neuroscience Institute (China-INI), Beijing, China.,Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Tao Wang
- China International Neuroscience Institute (China-INI), Beijing, China.,Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Kun Yang
- Department of Evidence-Based Medicine, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Yao Feng
- China International Neuroscience Institute (China-INI), Beijing, China.,Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Renjie Yang
- China International Neuroscience Institute (China-INI), Beijing, China.,Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Yan Ma
- China International Neuroscience Institute (China-INI), Beijing, China.,Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Peng Gao
- China International Neuroscience Institute (China-INI), Beijing, China.,Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, Beijing, China.,Department of Interventional Neuroradiology, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Bin Yang
- China International Neuroscience Institute (China-INI), Beijing, China.,Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Liqun Jiao
- China International Neuroscience Institute (China-INI), Beijing, China.,Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, Beijing, China.,Department of Interventional Neuroradiology, Xuanwu Hospital, Capital Medical University, Beijing, China
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16
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Howard VJ, Algra A, Howard G, Bonati LH, de Borst GJ, Bulbulia R, Calvet D, Eckstein HH, Fraedrich G, Greving JP, Halliday A, Hendrikse J, Jansen O, Brown MM, Mas JL, Ringleb PA, Brott TG. Absence of Consistent Sex Differences in Outcomes From Symptomatic Carotid Endarterectomy and Stenting Randomized Trials. Stroke 2021; 52:416-423. [PMID: 33493046 PMCID: PMC9136999 DOI: 10.1161/strokeaha.120.030184] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND AND PURPOSE CREST (Carotid Revascularization Endarterectomy Versus Stenting Trial) reported a higher periprocedural risk for any stroke, death, or myocardial infarction for women randomized to carotid artery stenting (CAS) compared with women randomized to carotid endarterectomy (CEA). No difference in risk by treatment was detected for women relative to men in the 4-year primary outcome. We aimed to conduct a pooled analysis among symptomatic patients in large randomized trials to provide more precise estimates of sex differences in the CAS-to-CEA risk for any stroke or death during the 120-day periprocedural period and ipsilateral stroke thereafter. METHODS Data from the Carotid Stenosis Trialists' Collaboration included outcomes from symptomatic patients in EVA-3S (Endarterectomy Versus Angioplasty in Patients With Symptomatic Severe Carotid Stenosis), SPACE (Stent-Protected Angioplasty Versus Carotid Endarterectomy in Symptomatic Patients), ICSS (International Carotid Stenting Study), and CREST. The primary outcome was any stroke or death within 120 days after randomization and ipsilateral stroke thereafter. Event rates and relative risks were estimated using Poisson regression; effect modification by sex was assessed with a sex-by-treatment-by-trial interaction term, with significant interaction defined a priori as P≤0.10. RESULTS Over a median 2.7 years of follow-up, 433 outcomes occurred in 3317 men and 1437 women. The CAS-to-CEA relative risk of the primary outcome was significantly lower for women compared with men in 1 trial, nominally lower in another, and nominally higher in the other two. The sex-by-treatment-by-trial interaction term was significant (P=0.065), indicating heterogeneity among trials. Contributors to this heterogeneity are primarily differences in periprocedural period. When the trials are nevertheless pooled, there were no significant sex differences in risk in any follow-up period. CONCLUSIONS There were significant differences between trials in the magnitude of sex differences in treatment effect (CAS-to-CEA relative risk), indicating pooling data from these trials to estimate sex differences might not be valid. Whether sex is acting as an effect modifier of the CAS-to-CEA treatment effect in symptomatic patients remains uncertain. Registration: URL: https://www.clinicaltrials.gov; Unique identifier: NCT00190398 (EVA-3S) and NCT00004732 (CREST). URL: https://www.isrctn.com; Unique identifier: ISRCTN57874028 (SPACE) and ISRCTN25337470 (ICSS).
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Affiliation(s)
- Virginia J Howard
- Department of Epidemiology (V.J.H.), School of Public Health, University of Alabama at Birmingham
| | - Ale Algra
- Department of Neurology and Neurosurgery, Brain Center Rudolf Magnus and Julius Center for Health Sciences and Primary Care (A.A.), and Julius Centre for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht University, the Netherlands
| | - George Howard
- Department of Biostatistics (G.H.), School of Public Health, University of Alabama at Birmingham
| | - Leo H Bonati
- Department of Brain Repair and Rehabilitation, Stroke Research Centre, University College of London Queen Square Institute of Neurology, University College London, United Kingdom (L.H.B., M.M.B.)
- Department of Neurology, Stroke Center (L.H.B.), University Hospital Basel, University of Basel, Switzerland
- Department of Clinical Research (L.H.B.), University Hospital Basel, University of Basel, Switzerland
| | - Gert J de Borst
- Department of Vascular Surgery (G.J.d.B.), and Julius Centre for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht University, the Netherlands
| | - Richard Bulbulia
- Clinical Trial Service Unit and Epidemiological Studies Unit (R.B.), Nuffield Department of Population Health, University of Oxford, United Kingdom
- Medical Research Council Population Health Research Unit (R.B.), Nuffield Department of Population Health, University of Oxford, United Kingdom
| | - David Calvet
- Department of Neurology, Hopital Sainte-Anne, Universite Paris-Descartes, DHU Neurovasc Sorbonne Paris Cite, INSERM U894, France (D.C., J.-L.M.)
| | - Hans-Henning Eckstein
- Department of Vascular and Endovascular Surgery/Vascular Center, Klinikum rechts der Isar der Technischen Universitat Munchen, Munich, Germany (H.-H.E.)
| | - Gustav Fraedrich
- Department of Vascular Surgery, Medical University of Innsbruck, Austria (G.F.)
| | - Jacoba P Greving
- Department of Epidemiology (J.P.G.), and Julius Centre for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht University, the Netherlands
| | - Alison Halliday
- Nuffield Department of Surgical Sciences, John Radcliffe Hospital, Oxford, United Kingdom (A.H.)
| | - Jeroen Hendrikse
- Department of Radiology, University Medical Center Utrecht, the Netherlands (J.H.)
| | - Olav Jansen
- Department of Radiology and Neuroradiology, UKSH Campus Kiel, Germany (O.J.)
| | - Martin M Brown
- Department of Brain Repair and Rehabilitation, Stroke Research Centre, University College of London Queen Square Institute of Neurology, University College London, United Kingdom (L.H.B., M.M.B.)
| | - Jean-Louis Mas
- Department of Neurology, Hopital Sainte-Anne, Universite Paris-Descartes, DHU Neurovasc Sorbonne Paris Cite, INSERM U894, France (D.C., J.-L.M.)
| | - Peter A Ringleb
- Department of Neurology, University of Heidelberg Medical School, Germany (P.A.R.)
| | - Thomas G Brott
- Department of Neurology, Mayo Clinic, Jacksonville, FL (T.G.B.)
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17
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Carvalho P, Coelho A, Mansilha A. Effectiveness and safety of dual-layer stents in carotid artery disease: a systematic review. INT ANGIOL 2020; 40:97-104. [PMID: 33337115 DOI: 10.23736/s0392-9590.20.04553-8] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
INTRODUCTION Carotid artery stenting (CAS) has emerged as a minimally invasive alternative to carotid endarterectomy (CEA) in atherosclerotic carotid artery disease, even though the risk for procedural stroke after CAS remains significantly higher. Recently, in order to reduce embolic cerebral events after CAS, a new generation of dual-layer stents (DLS) has been developed. This review aimed to perform a detailed analysis of the available evidence on safety and efficacy of DLS in both symptomatic and asymptomatic atherosclerotic carotid artery stenosis. EVIDENCE ACQUISITION A systematic review was conducted according to the recommendations of the Preferred Reporting Items for Systematic Reviews and Meta-Analyses statement. The primary endpoint was the 30-day rate of myocardial infarction (MI), stroke and death. Secondary outcomes included rate and timing of stent occlusion/restenosis. EVIDENCE SYNTHESIS A total of 20 articles with 1193 patients were included. Thirty-day MI ranged from 0-5%, 30-day stroke ranged from 0-10.5% and 30-day mortality ranged from 0-10%. Stent occlusion rate ranged from 0-52.4%, the majority of which occurred intraprocedurally (N.=50; 61.7%), in emergency treated patients. The incidence of new ipsilateral cerebral ischemic lesions after CAS with DLS was reported in five studies, ranging from 5.5-37%. CONCLUSIONS Despite the theoretic advantage of reducing the risk for procedural embolic events when compared to conventional stents, high quality evidence is scarce. Also, safety issues regarding DLS in the emergency setting have been raised, particularly for thrombotic complications. Additional data from well-designed Randomized Controlled Trials are needed to assert the true value of DLS.
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Affiliation(s)
| | - Andreia Coelho
- Faculty of Medicine, University of Porto, Porto, Portugal.,Department of Angiology and Vascular Surgery, Hospital Center of Vila Nova de Gaia/Espinho, Vila Nova de Gaia, Portugal
| | - Armando Mansilha
- Faculty of Medicine, University of Porto, Porto, Portugal.,Department of Angiology and Vascular Surgery, University Hospital Center of São João, Porto, Portugal
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18
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Ziapour B, Schermerhorn ML, Iafrati MD, Suarez LB, TourSavadkohi S, Salehi P. A systematic review and meta-analysis of predilation and postdilation in transfemoral carotid artery stenting. J Vasc Surg 2020; 72:346-355.e1. [DOI: 10.1016/j.jvs.2019.11.044] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2019] [Accepted: 11/23/2019] [Indexed: 12/28/2022]
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19
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Abdullayev N, Maus V, Mpotsaris A, Henning TD, Goertz L, Borggrefe J, Chang DH, Onur OA, Liebig T, Schlamann M, Kabbasch C. Comparative analysis of CGUARD embolic prevention stent with Casper-RX and Wallstent for the treatment of carotid artery stenosis. J Clin Neurosci 2020; 75:117-121. [PMID: 32173154 DOI: 10.1016/j.jocn.2020.03.008] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2019] [Revised: 11/28/2019] [Accepted: 03/08/2020] [Indexed: 10/24/2022]
Abstract
Stent protected Angioplasty of extracranial carotid artery stenosis using the dual-layered CGUARD stent is a novel treatment option. In this study we evaluate the feasibility and the safety of the CGUARD in symptomatic and asymptomatic patients in comparison to Casper-RX and Wallstent. This is a multi-center study of consecutive patients treated with the CGUARD, Casper-RX and Wallstent at two German high volume neurovascular centers between April 2017 and May 2018. Patient characteristics, neuroimaging data and angiographic outcome were retrospectively analyzed. The primary end points of the study were acute occlusion of the carotid stent and symptomatic intracerebral hemorrhage (sICH). Carotid artery stenting was performed in 76 patients; of those 26 (34%) were treated with the CGUARD, 25 (33%) with Casper-RX, and 25 (33%) with Wallstent. In 58/76 (76%) cases carotid artery stenosis was symptomatic with a median baseline National Institutes of Health Stroke Scale of 4. Angioplasty and stenting as part of a mechanical thrombectomy for acute ischemic stroke was performed in 25/76 (33%) patients. Baseline patient characteristics were similar between the treatment groups, except for a higher portion of scheduled cases in the Casper-RX group. There were no significant differences in the rate of acute in stent occlusions (CGUARD, 2/26 (8%); Casper-RX, 1/25(4%); Wallstent, 1/25 (4%)) and postinterventional sICH (1/26 (4%), 0/25(0%), 0/25 (0%)). Clinical outcome at discharge did not differ between groups. Treatment of carotid artery stenosis using CGUARD is feasible with a good safety profile comparable to that of Casper-RX and Wallstent.
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Affiliation(s)
- N Abdullayev
- Institute for Diagnostic and Interventional Radiology, University Cologne, Faculty of Medicine and University Hospital Cologne, Kerpener Straße 62, 50937, Cologne, Germany.
| | - V Maus
- Institute of Diagnostic and Interventional Radiology, Neuroradiology and Nuclear Medicine, Knappschaftskrankenhaus Bochum, Ruhr University Bochum, In der Schornau 23-25, 44892 Bochum, Germany
| | - A Mpotsaris
- Department of Neuroradiology, RWTH Aachen, Pauwelsstraße 30, 52074 Aachen, Germany
| | - T D Henning
- Department of Radiology, Krankenhaus der Barmherzigen Brüder Trier, Nordallee 1, 54292 Trier, Germany
| | - L Goertz
- Department of Neurosurgery, University Hospital of Cologne, Kerpener Straße 62, 50937 Cologne, Germany
| | - J Borggrefe
- Institute for Diagnostic and Interventional Radiology, University Cologne, Faculty of Medicine and University Hospital Cologne, Kerpener Straße 62, 50937, Cologne, Germany
| | - D H Chang
- Department of Radiology, University Hospital of Heidelberg, Im Neuenheimer Feld 672, 69120 Heidelberg, Germany
| | - O A Onur
- Department of Neurology, University Hospital of Cologne, Kerpener Straße 62, 50937 Cologne, Germany
| | - T Liebig
- Institute of Neuroradiology, University Hospital Munich (LMU), Marchioninistraße 15, 81377 Munich, Germany
| | - M Schlamann
- Institute for Diagnostic and Interventional Radiology, University Cologne, Faculty of Medicine and University Hospital Cologne, Kerpener Straße 62, 50937, Cologne, Germany
| | - C Kabbasch
- Institute for Diagnostic and Interventional Radiology, University Cologne, Faculty of Medicine and University Hospital Cologne, Kerpener Straße 62, 50937, Cologne, Germany
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20
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de Vries EE, Meershoek AJA, Vonken EJ, den Ruijter HM, van den Berg JC, de Borst GJ. A meta-analysis of the effect of stent design on clinical and radiologic outcomes of carotid artery stenting. J Vasc Surg 2019; 69:1952-1961.e1. [PMID: 31159989 DOI: 10.1016/j.jvs.2018.11.017] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2018] [Accepted: 11/10/2018] [Indexed: 11/25/2022]
Abstract
OBJECTIVE Procedural characteristics, including stent design, may influence the outcome of carotid artery stenting (CAS). A thorough comparison of the effect of stent design on outcome of CAS is thus warranted to allow for optimal evidence-based clinical decision making. This study sought to evaluate the effect of stent design on clinical and radiologic outcomes of CAS. METHODS A systematic search was conducted in MEDLINE, Embase, and Cochrane databases in May 2018. Included were articles reporting on the occurrence of clinical short- and intermediate-term major adverse events (MAEs; any stroke or death) or radiologic adverse events (new ischemic lesions on postprocedural magnetic resonance diffusion-weighted imaging [MR-DWI], restenosis, or stent fracture) in different stent designs used to treat carotid artery stenosis. Random effects models were used to calculate combined overall effect sizes. Metaregression was performed to identify the effect of specific stents on MAE rates. RESULTS From 2654 unique identified articles, two randomized, controlled trials and 66 cohort studies were eligible for analysis (including 46,728 procedures). Short-term clinical MAE rates were similar for patients treated with open cell vs closed cell or hybrid stents. Use of an Acculink stent was associated with a higher risk of short-term MAE compared with a Wallstent (risk ratio [RR], 1.51; P = .03), as was true for use of Precise stent vs Xact stent (RR, 1.55; P < .001). Intermediate-term clinical MAE rates were similar for open vs closed cell stents. Use of open cell stents predisposed to a 25% higher chance (RR, 1.25; P = .03) of developing postprocedural new ischemic lesions on MR-DWI. No differences were observed in the incidence of restenosis, stent fracture, or intraprocedural hemodynamic depression with respect to different stent design. CONCLUSIONS Stent design is not associated with short- or intermediate-term clinical MAE rates in patients undergoing CAS. Furthermore, the division in open and closed cell stent design might conceal true differences in single stent efficacy. Nevertheless, open cell stenting resulted in a significantly higher number of subclinical postprocedural new ischemic lesions detected on MR-DWI compared with closed cell stenting. An individualized patient data meta-analysis, including future studies with prospective homogenous study design, is required to adequately correct for known risk factors and to provide definite conclusions with respect to carotid stent design for specific subgroups.
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Affiliation(s)
- Evelien E de Vries
- Department of Vascular Surgery, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Armelle J A Meershoek
- Department of Vascular Surgery, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Evert J Vonken
- Department of Radiology, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Hester M den Ruijter
- Experimental Cardiology Laboratory, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Jos C van den Berg
- Centro Vascolare Ticino, Ospedale Regionale di Lugano, Lugano, Switzerland; Universitätsinstitut für Diagnostische, Interventionelle und Pädiatrische Radiologie, Inselspital, University of Bern, Bern, Switzerland
| | - Gert J de Borst
- Department of Vascular Surgery, University Medical Center Utrecht, Utrecht, The Netherlands.
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Müller MD, Gregson J, McCabe DJH, Nederkoorn PJ, van der Worp HB, de Borst GJ, Cleveland T, Wolff T, Engelter ST, Lyrer PA, Brown MM, Bonati LH. Stent Design, Restenosis and Recurrent Stroke After Carotid Artery Stenting in the International Carotid Stenting Study. Stroke 2019; 50:3013-3020. [PMID: 31547798 DOI: 10.1161/strokeaha.118.024076] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
Background and Purpose- Open-cell carotid artery stents are associated with a higher peri-procedural stroke risk than closed-cell stents. However, the effect of stent design on long-term durability of carotid artery stenting (CAS) is unknown. We compared the medium- to long-term risk of restenosis and ipsilateral stroke between patients treated with open-cell stents versus closed-cell stents in the ICSS (International Carotid Stenting Study). Methods- Patients with symptomatic carotid stenosis were randomized to CAS or endarterectomy and followed with duplex ultrasound for a median of 4.0 years. We analyzed data from patients with completed CAS procedures, known stent design, and available ultrasound follow-up. The primary outcome, moderate or higher restenosis (≥50%) was defined as a peak systolic velocity of >1.3 m/s on ultrasound or occlusion of the treated internal carotid artery and analyzed with interval-censored models. Results- Eight hundred fifty-five patients were allocated to CAS. Seven hundred fourteen patients with completed CAS and known stent design were included in the current analysis. Of these, 352 were treated with open-cell and 362 with closed-cell stents. Moderate or higher restenosis occurred significantly less frequently in patients treated with open-cell (n=113) than closed-cell stents (n=154; 5-year risks were 35.5% versus 46.0%; unadjusted hazard ratio, 0.68; 95% CI, 0.53-0.88). There was no significant difference in the risk of severe restenosis (≥70%) after open-cell stenting (n=27) versus closed-cell stenting (n=43; 5-year risks, 8.6% versus 12.7%; unadjusted hazard ratio, 0.63; 95% CI, 0.37-1.05). The risk of ipsilateral stroke beyond 30 days after treatment was similar with open-cell and closed-cell stents (hazard ratio, 0.78; 95% CI, 0.35-1.75). Conclusions- Moderate or higher restenosis after CAS occurred less frequently in patients treated with open-cell stents than closed-cell stents. However, both stent designs were equally effective at preventing recurrent stroke during follow-up. Clinical Trial Registration- URL: http://www.isrctn.com/. Unique identifier: ISRCTN25337470.
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Affiliation(s)
- Mandy D Müller
- From the Department of Neurology and Stroke Center (M.D.M., S.T.E., P.A.L., L.H.B.)
| | - John Gregson
- Department of Medical Statistics, London School of Hygiene and Tropical Medicine, United Kingdom (J.G.)
| | - Dominick J H McCabe
- Vascular Neurology Research Foundation, Department of Neurology and Stroke Service, The Adelaide and Meath Hospital, Dublin, incorporating the National Children's Hospital, Dublin/Tallaght University Hospital, Ireland; Irish Center for Vascular Biology, Ireland; Academic Unit of Neurology, School of Medicine, Trinity College Dublin, Ireland (D.J.H.M.).,Department of Clinical Neurosciences, Royal Free Campus (D.J.H.M.), UCL Institute of Neurology, London, United Kingdom
| | - Paul J Nederkoorn
- Department of Neurology, Amsterdam University Medical Center, the Netherlands (P.J.N.)
| | - H Bart van der Worp
- Department of Neurology and Neurosurgery, Brain Center Rudolf Magnus (H.B.v.d.W.), University Medical Center Utrecht, Utrecht University, the Netherlands
| | - Gert J de Borst
- Department of Vascular Surgery (G.J.d.B.), University Medical Center Utrecht, Utrecht University, the Netherlands
| | - Trevor Cleveland
- Sheffield Vascular Institute, Sheffield Teaching Hospitals NHS Foundation Trust, United Kingdom (T.C.)
| | - Thomas Wolff
- Department of Vascular Surgery (T.W.), University of Basel, Switzerland
| | - Stefan T Engelter
- From the Department of Neurology and Stroke Center (M.D.M., S.T.E., P.A.L., L.H.B.).,University Hospital Basel and Neurorehabilitation Unit, University Center for Medicine of Aging and Rehabilitation Basel, Felix Platter Hospital (S.T.E.), University of Basel, Switzerland
| | - Philippe A Lyrer
- From the Department of Neurology and Stroke Center (M.D.M., S.T.E., P.A.L., L.H.B.)
| | | | - Leo H Bonati
- From the Department of Neurology and Stroke Center (M.D.M., S.T.E., P.A.L., L.H.B.).,Stroke Research Center, Department of Brain Repair and Rehabilitation (L.H.B.), UCL Institute of Neurology, London, United Kingdom
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22
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Müller MD, von Felten S, Algra A, Becquemin JP, Brown M, Bulbulia R, Calvet D, Eckstein HH, Fraedrich G, Halliday A, Hendrikse J, Gregson J, Howard G, Jansen O, Mas JL, Brott TG, Ringleb PA, Bonati LH. Immediate and Delayed Procedural Stroke or Death in Stenting Versus Endarterectomy for Symptomatic Carotid Stenosis. Stroke 2019; 49:2715-2722. [PMID: 30355202 DOI: 10.1161/strokeaha.118.020684] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background and Purpose- Stenting for symptomatic carotid stenosis (carotid artery stenting [CAS]) carries a higher risk of procedural stroke or death than carotid endarterectomy (CEA). It is unclear whether this extra risk is present both on the day of procedure and within 1 to 30 days thereafter and whether clinical risk factors differ between these periods. Methods- We analyzed the risk of stroke or death occurring on the day of procedure (immediate procedural events) and within 1 to 30 days thereafter (delayed procedural events) in 4597 individual patients with symptomatic carotid stenosis who underwent CAS (n=2326) or CEA (n=2271) in 4 randomized trials. Results- Compared with CEA, patients treated with CAS were at greater risk for immediate procedural events (110 versus 42; 4.7% versus 1.9%; odds ratio, 2.6; 95% CI, 1.9-3.8) but not for delayed procedural events (59 versus 46; 2.5% versus 2.0%; odds ratio, 1.3; 95% CI, 0.9-1.9; interaction P=0.006). In patients treated with CAS, age increased the risk for both immediate and delayed events while qualifying event severity only increased the risk of delayed events. In patients treated with CEA, we found no risk factors for immediate events while a higher level of disability at baseline and known history of hypertension were associated with delayed procedural events. Conclusions- The increased procedural stroke or death risk associated with CAS compared with CEA was caused by an excess of events occurring on the day of procedure. This finding demonstrates the need to enhance the procedural safety of CAS by technical improvements of the procedure and increased operator skill. Higher age increased the risk for both immediate and delayed procedural events in CAS, mechanisms of which remain to be elucidated. Clinical Trial Registration- URL: https://clinicaltrials.gov . Unique identifier: NCT00190398. URL: http://www.isrctn.com . Unique identifier: ISRCTN57874028. URL: http://www.isrctn.com . Unique identifier: ISRCTN25337470. URL: https://clinicaltrials.gov . Unique identifier: NCT00004732.
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Affiliation(s)
- Mandy D Müller
- From the Department of Neurology and Stroke Center (M.D.M., L.H.B.), University Hospital Basel, University of Basel, Switzerland
| | - Stefanie von Felten
- Department of Clinical Research, Clinical Trial Unit (S.v.F.), University Hospital Basel, University of Basel, Switzerland
| | - Ale Algra
- Department of Neurology and Neurosurgery, Brain Center Rudolf Magnus and Julius Center for Health Sciences and Primary Care (A.A.), University Medical Center Utrecht, the Netherlands
| | - Jean-Pierre Becquemin
- Vascular Institute Paris East, Hôpital privé Paul D'Egine, Ramsay Group, France (J.-P.B.)
| | - Martin Brown
- Department of Brain Repair and Rehabilitation, UCL Institute of Neurology, University College London, United Kingdom (M.B., L.H.B.)
| | - Richard Bulbulia
- MRC Population Health Research Unit, Clinical Trial Service Unit and Epidemiological Studies Unit, Nuffield Department of Population Health, Oxford University, United Kingdom (R.B.)
| | - David Calvet
- Department of Neurology, Hôpital Sainte-Anne, Université Paris-Descartes, DHU Neurovasc Sorbonne Paris Cité, INSERM U894, France (D.C., J.-L.M.)
| | - Hans-Henning Eckstein
- Department of Vascular and Endovascular Surgery, Klinikum rechts der Isar, Technical University of Munich, Germany (H.-H.E.)
| | - Gustav Fraedrich
- Department of Vascular Surgery, Medical University of Innsbruck, Austria (G.F.)
| | - Alison Halliday
- Nuffield Department of Surgical Sciences, John Radcliffe Hospital, Oxford, United Kingdom (A.H.)
| | - Jeroen Hendrikse
- Department of Radiology (J.H.), University Medical Center Utrecht, the Netherlands
| | - John Gregson
- Department of Medical Statistics, London School of Hygiene and Tropical Medicine, United Kingdom (J.G.)
| | - George Howard
- Department of Biostatistics, UAB School of Public Health, Birmingham, AL (G.H.)
| | - Olav Jansen
- Clinic for Radiology and Neuroradiology, UKSH Campus Kiel, Germany (O.J.)
| | - Jean-Louis Mas
- Department of Neurology, Hôpital Sainte-Anne, Université Paris-Descartes, DHU Neurovasc Sorbonne Paris Cité, INSERM U894, France (D.C., J.-L.M.)
| | - Thomas G Brott
- Department of Neurology, Mayo Clinic, Jacksonville, FL (T.G.B.)
| | - Peter A Ringleb
- Department of Neurology, University of Heidelberg Medical School, Germany (P.A.R.)
| | - Leo H Bonati
- From the Department of Neurology and Stroke Center (M.D.M., L.H.B.), University Hospital Basel, University of Basel, Switzerland.,Department of Brain Repair and Rehabilitation, UCL Institute of Neurology, University College London, United Kingdom (M.B., L.H.B.)
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Batchelder AJ, Saratzis A, Ross Naylor A. Editor's Choice - Overview of Primary and Secondary Analyses From 20 Randomised Controlled Trials Comparing Carotid Artery Stenting With Carotid Endarterectomy. Eur J Vasc Endovasc Surg 2019; 58:479-493. [PMID: 31492510 DOI: 10.1016/j.ejvs.2019.06.003] [Citation(s) in RCA: 46] [Impact Index Per Article: 9.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2018] [Revised: 05/30/2019] [Accepted: 06/05/2019] [Indexed: 12/19/2022]
Abstract
OBJECTIVES The aim of this review was to carry out primary and secondary analyses of 20 randomised controlled trials (RCTs) comparing carotid endarterectomy (CEA) with carotid artery stenting (CAS). METHODS A systematic review and meta-analysis of data from 20 RCTs (126 publications) was carried out. RESULTS Compared with CEA, the 30 day death/stroke rate was significantly higher after CAS in seven RCTs involving 3467 asymptomatic patients (odds ratio [OR] 1.64, 95% confidence interval [CI] 1.02-2.64) and in 10 RCTs involving 5797 symptomatic patients (OR 1.71, 95% CI 1.38-2.11). Excluding procedural risks, late ipsilateral stroke was about 4% at 9 years for both CEA and CAS, i.e., CAS was durable. Reducing procedural death/stroke after CAS may be achieved through better case selection, e.g., performing CEA in (i) symptomatic patients aged > 70 years; (ii) interventions within 14 days of symptom onset; and (iii) situations where stroke risk after CAS is predicted to be higher (segmental/remote plaques, plaque length > 13 mm, heavy burden of white matter lesions [WMLs], where two or more stents might be needed). New WMLs were significantly more common after CAS (52% vs. 17%) and were associated with higher rates of late stroke/transient ischaemic attack (23% vs. 9%), but there was no evidence that new WMLs predisposed towards late cognitive impairment. Restenoses were more common after CAS (10%) but did not increase late ipsilateral stroke. Restenoses (70%-99%) after CEA were associated with a small but significant increase in late ipsilateral stroke (OR 3.87, 95% CI 1.96-7.67; p < .001). CONCLUSIONS CAS confers higher rates of 30 day death/stroke than CEA. After 30 days, ipsilateral stroke is virtually identical for CEA and CAS. Key issues to be resolved include the following: (i) Will newer stent technologies and improved cerebral protection allow CAS to be performed < 14 days after symptom onset with risks similar to CEA? (ii) What is the optimal volume of CAS procedures to maintain competency? (iii) How to deliver better risk factor control and best medical treatment? (iv) Is there a role for CEA/CAS in preventing/reversing cognitive impairment?
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Affiliation(s)
| | | | - A Ross Naylor
- The Leicester Vascular Institute, Glenfield Hospital, Leicester, UK.
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Fassaert LM, de Borst GJ. Technical improvements in carotid revascularization based on the mechanism of procedural stroke. THE JOURNAL OF CARDIOVASCULAR SURGERY 2019; 60:313-324. [PMID: 30827087 DOI: 10.23736/s0021-9509.19.10918-4] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
The benefit of carotid revascularization in patients with severe carotid artery stenosis is hampered by the risk of stroke due to the intervention itself. The risk of periprocedural strokes is higher for carotid artery stenting (CAS) as compared to carotid endarterectomy (CEA). Over the past years, the pathophysiological mechanism responsible for periprocedural stroke seems to unfold step by step. Initially, all procedural strokes were thought to be the result of technical errors during surgical repair: cerebral ischemia due to clamping time of the carotid artery, cerebral embolization of atherosclerotic debris due to manipulation of the atheroma or thrombosis of the artery. Following improvements in surgical techniques, technical skills, new intraoperative monitoring technologies such as angioscopy, and the results of the first large clinical randomized controlled trials (RCT) it was believed that most periprocedural strokes were of thromboembolic nature, while a large part of these caused by technical error. Nowadays, analyses of underlying pathophysiological mechanisms of procedural stroke make a clinically relevant distinction between intra-procedural and postprocedural strokes. Intra-procedural stroke is defined as hypoperfusion due to clamping (CEA) or dilatation (CAS) and embolization from the carotid plaque (both CEA and CAS). Postprocedural stroke can be caused by thrombo-embolisation but seems to have a primarily hemodynamic origin. Besides thrombotic occlusion of the carotid artery, cerebral hyperperfusion syndrome (CHS) due to extensively increased cerebral revascularization is the most reported pathophysiological mechanism of postprocedural stroke. Multiple technical improvements have attempted to lower the risk of periprocedural stroke. The introduction of antiplatelet therapy (APT) has significantly reduced the risk of thromboembolic events in patients with carotid stenosis. Over the years, recommendations regarding APT changed. While for a long time APT was discontinued prior to surgery because of a fear of increased bleeding risk, nowadays continuation of APT during carotid intervention (aspirin monotherapy or even dual APT including clopidogrel) is found to be safe and effective. In CAS patients, dual APT up to three months' postprocedural is considered best. Stent design and cerebral protection devices (CPD) for CAS procedure are continuously under development. Trials have suggested a benefit of closed-cell stent design over open-cell stent design in order to reduce procedural stroke, while the benefit of CPD during stenting is still a matter of debate. Although CPD reduce the risk of procedural stroke, a higher number of new ischemic brain lesions detected on diffusion weighted imaging was found in patients treated with CPD. In patients undergoing CEA under general anesthesia, adequate use of cerebral monitoring (EEG and transcranial Doppler [TCD]) has reduced the number of intraoperative stroke by detecting embolization and thereby guiding the surgeon to adjust his technique or to selectively shunt the carotid artery. In addition, TCD is able to adequately identify and exclude patients at risk for CHS. For CAS, the additional value of periprocedural cerebral monitoring to prevent strokes needs urgent attention. In conclusion, this review provides an overview of the pathophysiological mechanism of stroke following carotid revascularization (both CAS and CEA) and of the technical improvements that have contributed to reducing this stroke risk.
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Affiliation(s)
- Leonie M Fassaert
- Department of Vascular Surgery, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
| | - Gert J de Borst
- Department of Vascular Surgery, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands -
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25
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Beppu M, Mineharu Y, Imamura H, Adachi H, Sakai C, Tani S, Arimura K, Tokunaga S, Sakai N. Postoperative in-stent protrusion is an important predictor of perioperative ischemic complications after carotid artery stenting. J Neuroradiol 2018. [DOI: 10.1016/j.neurad.2018.02.009] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
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Texakalidis P, Giannopoulos S, Kokkinidis DG, Lanzino G. Effect of Open- vs Closed-Cell Stent Design on Periprocedural Outcomes and Restenosis After Carotid Artery Stenting: A Systematic Review and Comprehensive Meta-analysis. J Endovasc Ther 2018; 25:523-533. [DOI: 10.1177/1526602818783505] [Citation(s) in RCA: 26] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/30/2023]
Abstract
Purpose:To compare periprocedural complications and in-stent restenosis rates associated with open- vs closed-cell stent designs used in carotid artery stenting (CAS). Methods: A systematic search was conducted to identify all randomized and observational studies published in English up to October 31, 2017, that compared open- vs closed-cell stent designs in CAS. Identified studies were included if they reported the following outcomes: stroke, transient ischemic attack (TIA), myocardial infarction (MI), hemodynamic depression, new ischemic lesions detected on imaging, and death within 30 days, as well as the incidence of in-stent restenosis. A random-effects model meta-analysis was employed. Model results are reported as the odds ratio (OR) and 95% confidence interval (CI). The I2 statistic was used to assess heterogeneity. Results: Thirty-three studies (2 randomized trials) comprising 20, 291 patients (mean age 71.3±3.0 years; 74.6% men) were included. Patients in the open-cell stent group had a statistically significant lower risk of restenosis ⩾40% (OR 0.42, 95% CI 0.19 to 0.92; I2=0%) and ⩾70% (OR 0.23, 95% CI 0.10 to 0.52; I2=0%) at a mean follow-up of 24 months. No statistically significant differences were identified for periprocedural stroke, TIA, new ischemic lesions, MI, hemodynamic depression, or death within 30 days after CAS. Sensitivity analysis of the 2 randomized controlled trials only did not point to any significant differences either. Conclusion: Use of open-cell stent design in CAS is associated with a decreased risk for restenosis when compared to the closed-cell stent, without significant differences in periprocedural outcomes.
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Affiliation(s)
- Pavlos Texakalidis
- Department of Neurologic Surgery, Mayo Clinic, Rochester, MN, USA
- Aristotle University of Thessaloniki, Greece
| | | | - Damianos G. Kokkinidis
- Department of Medicine, Jacobi Medical Center, Albert Einstein College of Medicine, Bronx, NY, USA
| | - Giuseppe Lanzino
- Department of Neurologic Surgery, Mayo Clinic, Rochester, MN, USA
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27
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Quantitative analysis and predictors of embolic filter debris load during carotid artery stenting in asymptomatic patients. J Vasc Surg 2018; 68:109-117. [DOI: 10.1016/j.jvs.2017.09.055] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2017] [Accepted: 09/25/2017] [Indexed: 12/28/2022]
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28
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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: 12] [Impact Index Per Article: 2.0] [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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Wodarg F, Turner EL, Dobson J, Ringleb PA, Mali WP, Fraedrich G, Chatellier G, Bequemin JP, Brown MM, Algra A, Mas JL, Jansen O, Bonati LH. Influence of stent design and use of protection devices on outcome of carotid artery stenting: a pooled analysis of individual patient data. J Neurointerv Surg 2018; 10:1149-1154. [PMID: 29674483 DOI: 10.1136/neurintsurg-2017-013622] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2017] [Revised: 03/07/2018] [Accepted: 03/13/2018] [Indexed: 11/03/2022]
Abstract
BACKGROUND AND PURPOSE Carotid artery stenting is an alternative to endarterectomy for the treatment of symptomatic carotid stenosis but was associated with a higher risk of procedural stroke or death in randomized controlled trials (RCTs). Technical aspects of treatment may partly explain these results. The purpose of this analysis was to investigate the influence of technical aspects such as stent design or the use of protection devices, as well as clinical variables, on procedural risk. METHODS We pooled data of 1557 individual patients receiving stent treatment in three large RCTs comparing stenting versus endarterectomy for symptomatic carotid stenosis. The primary outcome event was any procedural stroke or death occurring within 30 days after stenting. RESULTS Procedural stroke or death occurred significantly more often with the use of open-cell stents (61/595 patients, 10.3%) than with closed-cell stents (58/962 patients, 6.0%; RR 1.76; 95% CI 1.23 to 2.52; P=0.002). Procedural stroke or death occurred in 76/950 patients (8.0%) treated with protection devices (predominantly distal filters) and in 43/607 (7.1%) treated without protection devices (RR 1.10; 95% CI 0.71 to 1.70; P=0.67). Clinical variables predicting the primary outcome event were age, severity of the qualifying event, history of prior stroke, and level of disability at baseline. The effect of stent design remained similar after adjustment for these variables. CONCLUSIONS In symptomatic carotid stenosis, the use of stents with a closed-cell design is independently associated with a lower risk of procedural stroke or death compared with open-cell stents. Filter-type protection devices do not appear to reduce procedural risk.
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Affiliation(s)
- Fritz Wodarg
- Department of Radiology and Neuroradiology, University Hospital Kiel, Kiel, Germany
| | - Elisabeth L Turner
- Department of Medical Statistics, London School of Hygiene and Tropical Medicine, London, UK
| | - Joanna Dobson
- Department of Medical Statistics, London School of Hygiene and Tropical Medicine, London, UK
| | - Peter A Ringleb
- Department of Neurology, University Hospital Heidelberg, Heidelberg, Germany
| | - Willem P Mali
- Department of Radiology, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Gustav Fraedrich
- Department of Vascular Surgery, Medical University, Innsbruck, Austria
| | - Gilles Chatellier
- Clinical Research Unit, Hôpital Européen Georges Pompidou, Université René Descartes, Paris, France
| | - Jean-Pierre Bequemin
- Department of Vascular, Cardiac and Thoracic Surgery, Hôpital Henri Mondor, Université Paris XII, Paris, France
| | - Martin M Brown
- Stroke Research Centre, UCL Institute of Neurology, London, UK
| | - Ale Algra
- Brain Center Rudolf Magnus, Department of Neurology and Neurosurgery and Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Jean-Louis Mas
- Department of Neurology, Hôpital Sainte-Anne, Université Paris-Descartes, INSERM U894, DHU Neurovasc-Paris Sorbonne, Paris, France
| | - Olav Jansen
- Department of Radiology and Neuroradiology, University Hospital Kiel, Kiel, Germany
| | - Leo H Bonati
- Stroke Research Centre, UCL Institute of Neurology, London, UK.,Department of Neurology and Stroke Center, University of Basel Hospital, Basel, Switzerland
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Abstract
OBJECTIVES The aim of this study was to analyze the association between intraprocedural and periprocedural variables and in-hospital stroke or death rate after carotid artery stenting. BACKGROUND In Germany, all open surgical and endovascular procedures on the extracranial carotid artery must be documented in a statutory nationwide quality assurance database. METHODS A total of 13,086 carotid artery stenting procedures for asymptomatic (63.9%) or symptomatic carotid stenosis (mean age 69.7 years, 69.7% men) between 2009 and 2014 were recorded. The following variables were analyzed: stent design, stent material, neurophysiological monitoring, periprocedural antiplatelet medication, and use of an embolic protection device. The primary outcome was in-hospital stroke or death. Major stroke or death, any stroke, and death, all until discharge, were secondary outcomes. Adjusted relative risks (RRs) were assessed using multilevel multivariable regression analyses. RESULTS The primary outcome occurred in 2.4% of the population (1.7% in asymptomatic and 3.7% in symptomatic patients). The multivariable analysis showed an independent association between the use of an embolic protection device and lower in-hospital rates of stroke or death (adjusted RR: 0.65; 95% confidence interval [CI]: 0.50 to 0.85), major stroke or death (adjusted RR: 0.60; 95% CI: 0.43 to 0.84), and stroke (adjusted RR: 0.57; 95% CI: 0.43 to 0.77). Regarding the occurrence of in-hospital death, there was no significant association (adjusted RR: 0.78; 95% CI: 0.46 to 1.35). None of the outcomes was associated with stent design, stent material, neurophysiological monitoring, or antiplatelet medication. CONCLUSIONS The use of an embolic protection device was independently associated with lower in-hospital risk for stroke or death, major stroke or death, and stroke.
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Symptomatic carotid stenosis: is stenting as safe and effective as carotid endarterectomy? Curr Opin Neurol 2018; 30:22-27. [PMID: 28002121 DOI: 10.1097/wco.0000000000000409] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
PURPOSE OF REVIEW Reviewing current evidence on carotid artery stenting (CAS) compared with carotid endarterectomy (CEA) in the prevention of ipsilateral stroke in patients with a symptomatic carotid stenosis. RECENT FINDINGS Randomized clinical trials and registries have consistently shown that CAS is associated with a higher risk of procedural stroke or death and a lower risk of procedural myocardial infarction and local complications compared with CEA. Both procedures are equally effective to prevent late recurrent ipsilateral stroke and are associated with similar low risk of restenosis.Individual patient data analyses of the Carotid Stenosis Trialists' Collaboration recently showed that CAS is as safe and as effective in patients younger than 70. SUMMARY Although CEA remains the standard treatment in patients with recently symptomatic carotid stenosis, CAS is a safe and effective alternative option in patients younger than 70 and can be also considered when a contraindication to CEA exists.
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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: 803] [Impact Index Per Article: 133.8] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
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Udesh R, Solanki P, Mehta A, Gleason T, Wechsler L, Thirumala PD. Carotid artery stenosis as an independent risk factor for perioperative strokes following mitral valve surgical intervention. J Neurol Sci 2017; 382:170-184. [PMID: 29055498 DOI: 10.1016/j.jns.2017.10.004] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2017] [Revised: 09/04/2017] [Accepted: 10/04/2017] [Indexed: 11/25/2022]
Abstract
OBJECTIVE To examine the role of carotid stenosis (CS) and other independent risk factors of perioperative stroke following either mitral valve repair or replacement. METHODS Using data from the National Inpatient Sample (NIS) database for analysis, all patients who underwent either mitral valve repair or replacement were identified using ICD-9 codes. RESULTS A total of 79,583 patients who underwent either mitral valve replacement or repair were studied. 3.39% of the total cohort developed perioperative stroke. With a mean age of 62.78±0.23, there was a statistically significant amount of stroke cases in age ranges 65-74 and 75-84 (p<0.05). Risk stratification was done using Van Walraven (VWR) scoring and the cohort had a mean of 2.73±0.06. The following independent predictors were found to be significant: age, female gender, moderate and high VWR risk, both symptomatic and asymptomatic CS, atrial fibrillation, previous h/o smoking, and other cardiac valve procedures performed, and congestive heart failure (CHF). CONCLUSION CS is a significant risk factor for perioperative strokes following mitral valve surgery. Further prospective clinical studies are needed that look into risk stratification of patients for better patient selection and the question of whether carotid revascularization procedures will be beneficial in reducing stroke rates.
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Affiliation(s)
- Reshmi Udesh
- Department of Neurological Surgery, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Pawan Solanki
- Department of Neurological Surgery, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Amol Mehta
- Department of Neurological Surgery, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Thomas Gleason
- Department of Cardiothoracic Surgery, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Lawrence Wechsler
- Department of Neurology, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Parthasarathy D Thirumala
- Department of Neurological Surgery, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA; Department of Neurology, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA.
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Bennett KM, Hoch JR, Scarborough JE. Predictors of 30-day postoperative major adverse clinical events after carotid artery stenting: An analysis of the procedure-targeted American College of Surgeons National Surgical Quality Improvement Program. J Vasc Surg 2017; 66:1093-1099. [DOI: 10.1016/j.jvs.2017.04.039] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2017] [Accepted: 04/10/2017] [Indexed: 10/19/2022]
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Hertzer NR. The Current Status of Carotid Endarterectomy Part II: Randomized Trials versus Angioplasty and Stenting. Ann Vasc Surg 2017; 43:24-40. [DOI: 10.1016/j.avsg.2017.04.005] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2017] [Accepted: 04/10/2017] [Indexed: 10/19/2022]
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Musiałek P, Hopkins LN, Siddiqui AH. One swallow does not a summer make but many swallows do: accumulating clinical evidence for nearly-eliminated peri-procedural and 30-day complications with mesh-covered stents transforms the carotid revascularisation field. ADVANCES IN INTERVENTIONAL CARDIOLOGY 2017; 13:95-106. [PMID: 28798779 PMCID: PMC5545669 DOI: 10.5114/pwki.2017.69012] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2017] [Accepted: 07/10/2017] [Indexed: 02/07/2023] Open
Abstract
Atherosclerotic carotid artery stenosis (CS) continues to be a common cause of acute ischaemic stroke. Optimised medical therapy (OMT), the first-line treatment modality in CS, may reduce or delay - but it does not abolish - CS-related strokes. As per current AHA/ASA and ESC/ESVS/ESO guidelines, carotid artery stenting (CAS) is a less-invasive alternative to carotid endarterectomy (CEA) for CS revascularisation in primary and secondary stroke prevention. Ten-year follow-up from the CREST trial in patients with symptomatic and asymptomatic CS confirmed equipoise of CAS and CEA in the primary endpoint. Nevertheless CAS - using a widely open-cell, first-generation stent and first-generation (distal/filter) neuroprotection - has been criticised for its relative excess of (mostly minor) strokes by 30 days, a significant proportion of which were post-procedural. Atherosclerotic plaque protrusion through conventional carotid stent struts, confirmed on intravascular imaging, has been implicated as a leading mechanism of the relative excess of strokes with CAS vs. CEA, including delayed strokes with CAS. Different designs of mesh-covered carotid stents have been developed to prevent plaque prolapse. Several multi-centre/multi-specialty clinical studies with CGurad MicroNet-Covered Embolic Prevention Stent System (EPS) and RoadSaver/Casper were recently published and included routine DW-MRI cerebral imaging peri-procedurally and at 30 days (CGuard EPS). Data from more than 550 patients in mesh-covered carotid stent clinical studies to-date show an overall 30-day complication rate of ~1% with near-elimination of post-procedural events. While more (and long-term) evidence is still anticipated, these results - taken together with optimised intra-procedural neuroprotection in CAS (increased use of proximal systems including trans-carotid dynamic flow reversal) and the positive 12-month mesh-covered stent data reports in 2017 - are transforming the carotid revascularisation field today. Establishing effective algorithms to identify the asymptomatic subjects at stroke risk despite OMT, and large-scale studies with mesh-covered stents including long-term clinical and duplex ultrasound outcomes, are the next major goals.
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Affiliation(s)
- Piotr Musiałek
- Department of Cardiac and Vascular Diseases, Jagiellonian University, School of Medicine, John Paul II Hospital, Krakow, Poland
| | - L. Nelson Hopkins
- Departments of Neurosurgery and Radiology, School of Medicine and Biomedical Sciences, University at Buffalo, State University of New York, Jacobs Institute, Gates Vascular Institute Kaleida Health, Buffalo, New York, USA
| | - Adnan H. Siddiqui
- Departments of Neurosurgery and Radiology, School of Medicine and Biomedical Sciences, University at Buffalo, State University of New York, Jacobs Institute, Gates Vascular Institute Kaleida Health, Buffalo, New York, USA
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Yilmaz U, Körner H, Mühl-Benninghaus R, Simgen A, Kraus C, Walter S, Behnke S, Faßbender K, Reith W, Unger MM. Acute Occlusions of Dual-Layer Carotid Stents After Endovascular Emergency Treatment of Tandem Lesions. Stroke 2017; 48:2171-2175. [PMID: 28679854 DOI: 10.1161/strokeaha.116.015965] [Citation(s) in RCA: 43] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2016] [Revised: 06/08/2017] [Accepted: 06/12/2017] [Indexed: 11/16/2022]
Abstract
BACKGROUND AND PURPOSE A new generation of carotid artery stents that uses a second micromesh layer to reduce embolic events during carotid artery stenting has recently been introduced. The purpose of this study was to compare acute occlusion rates of these new dual-layer stents with those of single-layer stents in the setting of emergency carotid artery stenting with intracranial mechanical thrombectomy in acute ischemic stroke. METHODS Consecutive patients with acute tandem (intra- and extracranial) lesions of the anterior circulation who were endovascularly treated at our institution were identified from our registry of neuroendovascular interventions. Clinical, angiographic, and neuroimaging data were analyzed. End points included acute occlusions of the carotid stents (within 72 hours after stenting) and symptomatic intracerebral hemorrhage. RESULTS Forty-seven patients were included. Dual-layer stents (n=20) had a significantly higher rate of acute occlusions than single-layer stents (n=27; 45% versus 3.7%; P=0.001; odds ratio, 21.3; 95% confidence interval, 2.4-188.4). There were no significant differences in the rates of patients who had any antiplatelet or dual antiplatelet medication before admission, in the rates of postinterventional symptomatic intracerebral hemorrhage, the mean National Institutes of Health Stroke Scale scores at admission, or the modified Rankin Scale scores at discharge. CONCLUSIONS The recently introduced dual-layer stents have a higher risk of acute occlusion compared with single-layer stents in the treatment of acute stroke.
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Affiliation(s)
- Umut Yilmaz
- From the Department of Neuroradiology (U.Y., H.K., R.M.-B., A.S., C.K., W.R.) and Department of Neurology (S.W., S.B., K.F., M.M.U.), Saarland University Hospital, Homburg, Germany.
| | - Heiko Körner
- From the Department of Neuroradiology (U.Y., H.K., R.M.-B., A.S., C.K., W.R.) and Department of Neurology (S.W., S.B., K.F., M.M.U.), Saarland University Hospital, Homburg, Germany
| | - Ruben Mühl-Benninghaus
- From the Department of Neuroradiology (U.Y., H.K., R.M.-B., A.S., C.K., W.R.) and Department of Neurology (S.W., S.B., K.F., M.M.U.), Saarland University Hospital, Homburg, Germany
| | - Andreas Simgen
- From the Department of Neuroradiology (U.Y., H.K., R.M.-B., A.S., C.K., W.R.) and Department of Neurology (S.W., S.B., K.F., M.M.U.), Saarland University Hospital, Homburg, Germany
| | - Catherine Kraus
- From the Department of Neuroradiology (U.Y., H.K., R.M.-B., A.S., C.K., W.R.) and Department of Neurology (S.W., S.B., K.F., M.M.U.), Saarland University Hospital, Homburg, Germany
| | - Silke Walter
- From the Department of Neuroradiology (U.Y., H.K., R.M.-B., A.S., C.K., W.R.) and Department of Neurology (S.W., S.B., K.F., M.M.U.), Saarland University Hospital, Homburg, Germany
| | - Stefanie Behnke
- From the Department of Neuroradiology (U.Y., H.K., R.M.-B., A.S., C.K., W.R.) and Department of Neurology (S.W., S.B., K.F., M.M.U.), Saarland University Hospital, Homburg, Germany
| | - Klaus Faßbender
- From the Department of Neuroradiology (U.Y., H.K., R.M.-B., A.S., C.K., W.R.) and Department of Neurology (S.W., S.B., K.F., M.M.U.), Saarland University Hospital, Homburg, Germany
| | - Wolfgang Reith
- From the Department of Neuroradiology (U.Y., H.K., R.M.-B., A.S., C.K., W.R.) and Department of Neurology (S.W., S.B., K.F., M.M.U.), Saarland University Hospital, Homburg, Germany
| | - Marcus M Unger
- From the Department of Neuroradiology (U.Y., H.K., R.M.-B., A.S., C.K., W.R.) and Department of Neurology (S.W., S.B., K.F., M.M.U.), Saarland University Hospital, Homburg, Germany
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Wabnitz AM, Turan TN. Symptomatic Carotid Artery Stenosis: Surgery, Stenting, or Medical Therapy? CURRENT TREATMENT OPTIONS IN CARDIOVASCULAR MEDICINE 2017; 19:62. [PMID: 28677035 PMCID: PMC5496976 DOI: 10.1007/s11936-017-0564-0] [Citation(s) in RCA: 30] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
Symptomatic carotid artery disease is a significant cause of ischemic stroke, and these patients are at high risk for recurrent vascular events. Patients with symptoms of stroke or transient ischemic attack attributable to a significantly stenotic vessel (70–99% luminal narrowing) should be treated with intensive medical therapy. Intensive medical therapy is a combination of pharmacologic and lifestyle interventions consistent with best-known practices as follows: initiation of antiplatelet agent or anticoagulation if medically indicated, high potency statin medication, blood pressure control with goal blood pressure of greater than 140/90, Mediterranean-style diet, exercise, and smoking cessation. Further, patients who have extracranial culprit lesions should be considered for revascularization with either carotid endarterectomy or carotid angioplasty and stenting depending on several factors including the patient’s anatomy, age, gender, and procedural risk. Based on current evidence, patients with symptomatic intracranial stenosis should be managed with intensive medical therapy, including the use of dual antiplatelet therapy with aspirin and clopidogrel for the first 90 days following the ischemic event. While the literature has shown a stronger benefit of revascularization of extracranial symptomatic disease among certain subgroups of patients with greater than 70% stenosis, there is less benefit from revascularization with endarterectomy in patients with moderate stenosis of 50–69% if the surgeon’s risk of perioperative stroke or death rate is greater than 6%.
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Affiliation(s)
- Ashley M Wabnitz
- Division of Neurology, Medical University of South Carolina, 19 Hagood Ave, Harborview Office Tower Suite 501, Charleston, SC, 29425-8050, USA.
| | - Tanya N Turan
- Division of Neurology, Medical University of South Carolina, 19 Hagood Ave, Harborview Office Tower Suite 501, Charleston, SC, 29425-8050, USA
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Factors affecting cardiovascular and cerebrovascular complications of carotid artery stenting in Northern Michigan: A retrospective study. CARDIOVASCULAR REVASCULARIZATION MEDICINE 2017; 18:S18-S21. [DOI: 10.1016/j.carrev.2017.03.023] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2017] [Revised: 03/15/2017] [Accepted: 03/22/2017] [Indexed: 11/21/2022]
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Feng GH, Li HP, Li QL, Fu Y, Huang RB. Red blood cell distribution width and ischaemic stroke. Stroke Vasc Neurol 2017; 2:172-175. [PMID: 28989807 PMCID: PMC5628378 DOI: 10.1136/svn-2017-000071] [Citation(s) in RCA: 53] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2017] [Revised: 04/28/2017] [Accepted: 05/07/2017] [Indexed: 12/14/2022] Open
Abstract
The red blood cell distribution width (RDW) is a measure of red blood cell (RBC) size heterogeneity, which is easily calculated by dividing the SD of erythrocyte volumes for the mean corpuscular volume. Recent reporter suggested that, besides haematological diseases and anaemia, many human disorders may be closely associated with the elevated RDW. A literature review has revealed the RDW may be closely related to the development of ischaemic stroke, carotid artery atherosclerosis and cerebral embolism. Higher RDW could independently predict adverse outcomes in patients in these conditions.
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Affiliation(s)
- Gang-Hua Feng
- Department of Neurology, The First People’s Hospital of Chenzhou, University of South China, Chenzhou, China
| | - Hai-Peng Li
- Department of Neurology, The First People’s Hospital of Chenzhou, University of South China, Chenzhou, China
| | - Qiu-Li Li
- Department of Neurology, The First People’s Hospital of Chenzhou, University of South China, Chenzhou, China
| | - Ying Fu
- Thyroid Medicine Department/Radionuclide Therapy Department (Ward 31), Hunan Provincial Tumor Hospital, The Affiliated Cancer Hospital of Xiangya School of Medicine, Central South University, Changsha, China
| | - Ren-Bin Huang
- Department of Neurology, The First People’s Hospital of Chenzhou, University of South China, Chenzhou, China
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Choices of Stent and Cerebral Protection in the Ongoing ACST-2 Trial: A Descriptive Study. Eur J Vasc Endovasc Surg 2017; 53:617-625. [DOI: 10.1016/j.ejvs.2016.12.034] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2016] [Accepted: 12/27/2016] [Indexed: 11/18/2022]
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Patient- and lesion-tailored algorithm of endovascular treatment for arterial occlusive disease of extracranial arteries supplying the brain: safety of the treatment at 30-day follow-up. ADVANCES IN INTERVENTIONAL CARDIOLOGY 2017; 13:53-61. [PMID: 28344618 PMCID: PMC5364283 DOI: 10.5114/aic.2017.66187] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2016] [Accepted: 10/12/2016] [Indexed: 11/17/2022] Open
Abstract
Introduction Although surgical endarterectomy remains the treatment of choice for carotid artery stenosis, stenting plays an important role as an alternative treatment modality, especially in high-risk patients. The actual safety profile associated with stenting procedures is probably better than that reported by randomized controlled trials. Aim To assess the safety of stent implantations in extracranial arteries supplying the brain, and also to identify risk factors associated with this procedure. Material and methods This was a post hoc analysis, with 30-day follow-up. We analyzed the results of treatment of 372 patients who underwent 408 procedures, 197 such procedures in asymptomatic, and 211 in symptomatic individuals. Stenting procedures were performed using a technique and armamentarium which were tailored to the type and anatomy of lesions. Results There were 6 (1.5%) strokes, including 2 (0.5%) major strokes, 1 ipsi- and 1 contralateral, and 4 (1.0%) minor strokes. In asymptomatic patients there was 1 (0.3%) minor stroke. Transient ischemic attacks occurred in 5 (1.2%) patients. There were 2 (0.5%) non-STEMI myocardial infarctions and 2 (0.5%) non-stroke related fatalities. Risk factors of these adverse events were diabetes mellitus, lesions localized in a tortuous segment of the artery, embolic material in the filter and bilateral stenoses of carotid arteries. Additional risk factors in asymptomatic patients were renal impairment and advanced coronary artery disease; and in symptomatic patients, grade 3 arterial hypertension, dislipidemia, cigarette smoking and lesions requiring predilatation. Conclusions Stenting procedures of extracranial arteries supplying the brain, which are tailored to the type and anatomy of lesions, seem to be relatively safe.
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Abstract
The superficial femoral artery is a complex artery subject to a unique set of biomechanical loading conditions in its course through the leg. Plain balloon angioplasty and balloon-expandable stents had unacceptably high rates of restenosis, necessitating target vessel revascularization. Nitinol alloy is well suited to provide the strength and flexibility needed of stents to withstand the external forces posed by the environment of the superficial femoral artery. Advances in stent technology with the addition of a slow-releasing antiproliferative agent and changes in scaffold design have shown promise in reducing the rates of stent fracture and in-stent restenosis.
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Affiliation(s)
- Ashwin Nathan
- Cardiovascular Medicine Division, Perelman Center, Hospital of the University of Pennsylvania, South Tower, 11th Floor, 3400 Civic Center Boulevard, Philadelphia, PA 19104, USA; Penn Cardiovascular Quality, Outcomes, and Evaluative Research Center, University of Pennsylvania, Philadelphia, PA, USA
| | - Taisei Kobayashi
- Cardiovascular Medicine Division, Perelman Center, Hospital of the University of Pennsylvania, South Tower, 11th Floor, 3400 Civic Center Boulevard, Philadelphia, PA 19104, USA; Penn Cardiovascular Quality, Outcomes, and Evaluative Research Center, University of Pennsylvania, Philadelphia, PA, USA
| | - Jay Giri
- Cardiovascular Medicine Division, Perelman Center, Hospital of the University of Pennsylvania, South Tower, 11th Floor, 3400 Civic Center Boulevard, Philadelphia, PA 19104, USA; Penn Cardiovascular Quality, Outcomes, and Evaluative Research Center, University of Pennsylvania, Philadelphia, PA, USA.
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Featherstone RL, Dobson J, Ederle J, Doig D, Bonati LH, Morris S, Patel NV, Brown MM. Carotid artery stenting compared with endarterectomy in patients with symptomatic carotid stenosis (International Carotid Stenting Study): a randomised controlled trial with cost-effectiveness analysis. Health Technol Assess 2016; 20:1-94. [PMID: 26979174 DOI: 10.3310/hta20200] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND Carotid artery stenting (CAS) is an alternative to carotid endarterectomy (CEA) for the treatment of carotid stenosis, but safety and long-term efficacy were uncertain. OBJECTIVE To compare the risks, benefits and cost-effectiveness of CAS versus CEA for symptomatic carotid stenosis. DESIGN International, multicentre, randomised controlled, open, prospective clinical trial. SETTING Hospitals at 50 centres worldwide. PARTICIPANTS Patients older than 40 years of age with symptomatic atheromatous carotid artery stenosis. INTERVENTIONS Patients were randomly allocated stenting or endarterectomy using a computerised service and followed for up to 10 years. MAIN OUTCOME MEASURES The primary outcome measure was the long-term rate of fatal or disabling stroke, analysed by intention to treat (ITT). Disability was assessed using the modified Rankin Scale (mRS). A cost-utility analysis estimating mean costs and quality-adjusted life-years (QALYs) was calculated over a 5-year time horizon. RESULTS A total of 1713 patients were randomised but three withdrew consent immediately, leaving 1710 for ITT analysis (853 were assigned to stenting and 857 were assigned to endarterectomy). The incidence of stroke, death or procedural myocardial infarction (MI) within 120 days of treatment was 8.5% in the CAS group versus 5.2% in the CEA group (72 vs. 44 events) [hazard ratio (HR) 1.69, 95% confidence interval (CI) 1.16 to 2.45; p = 0.006]. In the analysis restricted to patients who completed stenting, age independently predicted the risk of stroke, death or MI within 30 days of CAS (relative risk increase 1.17% per 5 years of age, 95% CI 1.01% to 1.37%). Use of an open-cell stent conferred higher risk than a closed-cell stent (relative risk 1.92, 95% CI 1.11 to 3.33), but use of a cerebral protection device did not modify the risk. CAS was associated with a higher risk of stroke in patients with an age-related white-matter changes score of 7 or more (HR 2.98, 95% CI 1.29 to 6.93; p = 0.011). After completion of follow-up with a median of 4.2 years, the number of patients with fatal or disabling stroke in the CAS and CEA groups (52 vs. 49), and the cumulative 5-year risk did not differ significantly (6.4% vs. 6.5%) (HR 1.06, 95% CI 0.72 to 1.57; p = 0.776). Stroke of any severity was more frequent in the CAS group (15.2% vs. 9.4% in the CEA group) (HR 1.712, 95% CI 1.280 to 2.300; p < 0.001). There was no significant difference in long-term rates of severe carotid restenosis or occlusion (10.8% in the CAS group vs. 8.6% in the CEA group) (HR 1.25, 95% CI 0.89 to 1.75; p = 0.20). There was no difference in the distribution of mRS scores at 1-year, 5-year or final follow-up. There were no differences in costs or QALYs between the treatments. LIMITATIONS Patients and investigators were not blinded to treatment allocation. Interventionists' experience of stenting was less than that of surgeons with endarterectomy. Data on costs of managing strokes were not collected. CONCLUSIONS The functional outcome after stenting is similar to endarterectomy, but stenting is associated with a small increase in the risk of non-disabling stroke. The choice between stenting and endarterectomy should take into account the procedural risks related to individual patient characteristics. Future studies should include measurement of cognitive function, assessment of carotid plaque morphology and identification of clinical characteristics that determine benefit from revascularisation. TRIAL REGISTRATION Current Controlled Trials ISRCTN25337470. FUNDING This project was funded by the National Institute for Health Research Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 20, No. 20. See the NIHR Journal Library website for further project information. Further funding was provided by the Medical Research Council, Stroke Association, Sanofi-Synthélabo and the European Union.
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Affiliation(s)
- Roland L Featherstone
- Department of Brain Repair and Rehabilitation, UCL Institute of Neurology, University College London, London, UK
| | - Joanna Dobson
- Department of Medical Statistics Unit, Faculty of Epidemiology and Population Health, London School of Hygiene and Tropical Medicine, London, UK
| | - Jörg Ederle
- Department of Brain Repair and Rehabilitation, UCL Institute of Neurology, University College London, London, UK
| | - David Doig
- Department of Brain Repair and Rehabilitation, UCL Institute of Neurology, University College London, London, UK
| | - Leo H Bonati
- Department of Brain Repair and Rehabilitation, UCL Institute of Neurology, University College London, London, UK.,Department of Neurology and Stroke Centre, University Hospital Basel, Basel University, Basel, Switzerland
| | - Stephen Morris
- Department of Applied Health Research, University College London, London, UK
| | - Nishma V Patel
- Department of Applied Health Research, University College London, London, UK
| | - Martin M Brown
- Department of Brain Repair and Rehabilitation, UCL Institute of Neurology, University College London, London, UK
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Brown MM, Spence JD. Latest Skirmishes in the Long-Term Battle Between Carotid Endarterectomy and Stenting. Stroke 2016; 47:2673-5. [PMID: 27633023 DOI: 10.1161/strokeaha.116.013272] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2016] [Accepted: 08/05/2016] [Indexed: 11/16/2022]
Affiliation(s)
- Martin M Brown
- From the Stroke Research Centre, Department of Brain Repair and Rehabilitation, UCL Institute of Neurology, the National Hospital for Neurology and Neurosurgery, London, United Kingdom (M.M.B.); and Stroke Prevention and Atherosclerosis Research Centre, Robarts Research Institute, Western University, London, ON, Canada (J.D.S.).
| | - J David Spence
- From the Stroke Research Centre, Department of Brain Repair and Rehabilitation, UCL Institute of Neurology, the National Hospital for Neurology and Neurosurgery, London, United Kingdom (M.M.B.); and Stroke Prevention and Atherosclerosis Research Centre, Robarts Research Institute, Western University, London, ON, Canada (J.D.S.)
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Incidence of New Ischaemic Brain Lesions After Carotid Artery Stenting with the Micromesh Roadsaver Carotid Artery Stent: A Prospective Single-Centre Study. Cardiovasc Intervent Radiol 2016; 39:1541-1549. [PMID: 27571985 DOI: 10.1007/s00270-016-1454-7] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/17/2016] [Accepted: 08/18/2016] [Indexed: 12/25/2022]
Abstract
AIMS Several randomized trials of patients with carotid stenosis show increased adverse neurological events with stenting versus endarterectomy in the 30-day post-procedure. This study examines the incidence of new ischaemic lesions in patients treated in our centre using the new Roadsaver stent. METHODS AND RESULTS Between September 2015 and January 2016, 23 consecutive patients (age 74.3 ± 7.3 years, 17.4 % female) underwent carotid artery stenting with the Roadsaver stent, a nitinol double-layer micromesh device. A distal protection device was used in all cases. Diffusion-weighted magnetic resonance imaging was performed 24 h before, and 24 h and 30 days after the procedure. The 24-h post-procedure imaging showed 15 new ipsilateral ischaemic lesions in 7 (30.4 %) patients: median volume 0.076 cm3 (interquartile range 0.065-0.146 cm3). All lesions were asymptomatic. The 30-day imaging showed complete resolution of all lesions and no new ischaemic lesions. Follow-up clinical and ultrasound examinations at 30 days and 6 months recorded no adverse cardiac or cerebrovascular events. CONCLUSIONS Protected stenting with micromesh Roadsaver stent showed good safety and efficacy in the treatment of carotid stenosis, with a low incidence of delayed embolic events and new ipsilateral ischaemic brain lesions. These preliminary results are encouraging, but need to be confirmed with larger populations.
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Musialek P, Mazurek A, Trystula M, Borratynska A, Lesniak-Sobelga A, Urbanczyk M, Banys RP, Brzychczy A, Zajdel W, Partyka L, Zmudka K, Podolec P. Novel PARADIGM in carotid revascularisation: Prospective evaluation of All-comer peRcutaneous cArotiD revascularisation in symptomatic and Increased-risk asymptomatic carotid artery stenosis using CGuard™ MicroNet-covered embolic prevention stent system. EUROINTERVENTION 2016; 12:e658-70. [DOI: 10.4244/eijy16m05_02] [Citation(s) in RCA: 60] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Affiliation(s)
- Piotr Musialek
- Jagiellonian University Department of Cardiac & Vascular Diseases, John Paul II Hospital, Krakow, Poland
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Verzini F. Commentary on 'Predictors of Stroke, Myocardial Infarction, or Death within 30 Days of Carotid Artery Stenting: Results from the International Carotid Stenting Study.' An Old Story (Not for Old Patients). Eur J Vasc Endovasc Surg 2016; 51:335. [PMID: 26810344 DOI: 10.1016/j.ejvs.2015.12.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2015] [Accepted: 12/12/2015] [Indexed: 11/20/2022]
Affiliation(s)
- F Verzini
- Unit of Vascular Surgery, Hospital S. Maria della Misericordia, University of Perugia, Perugia, Italy.
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