1
|
Loufopoulos G, Manaki V, Tasoudis P, Meintanopoulos AS, Kouvelos G, Ntaios G, Spanos K. New Ischemic Cerebral Lesions in Postprocedural Magnetic Resonance Imaging in Carotid Artery Stenting Versus Carotid Endarterectomy: A Systematic Review and Meta-Analysis. Ann Vasc Surg 2024; 106:297-311. [PMID: 38825067 DOI: 10.1016/j.avsg.2024.05.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2024] [Revised: 05/12/2024] [Accepted: 05/15/2024] [Indexed: 06/04/2024]
Abstract
BACKGROUND Recent randomized controlled trials (RCTs) have demonstrated similar outcomes in terms of ischemic stroke incidence after carotid endarterectomy (CEA) or carotid artery stenting (CAS) in asymptomatic carotid disease, while CEA seems to be the first option for symptomatic carotid disease. The aim of this meta-analysis is to assess the incidence of silent cerebral microembolization detected by magnetic resonance imaging (MRI) following these procedures. METHODS A systematic search was conducted using PubMed, Scopus, and Cochrane databases, including comparative studies involving symptomatic or asymptomatic patients undergoing either CEA or CAS and reporting on new cerebral ischemic lesions in postoperative MRI. The primary outcome was the newly detected cerebral ischemic lesions. Pooled effect estimates for all outcomes were calculated using the random-effects model. Prespecified random effects metaregression and subgroup analysis were conducted to examine the impact of moderator variables on the presence of new cerebral ischemic lesions. RESULTS 25 studies reporting on a total of 1827 CEA and 1500 CAS interventions fulfilled the eligibility criteria. The incidence of new cerebral ischemic lesions was significantly lower after CEA compared to CAS, regardless of the time of MRI assessment (first 24 hours; OR: 0.33, 95% CI: 0.17-0.64, P < 0.001), (the first 72 hours, OR: 0.25, 95% CI 0.18-0.36, P < 0.001), (generally within a week after the operation; OR: 0.24, 95% CI: 0.17-0.34, P < 0.001). Also, the rate of stroke (OR: 0.38, 95% CI: 0.23-0.63, P < 0.001) and the presence of contralateral new cerebral ischemic lesions (OR: 0.16, 95% CI 0.08-0.32, P < 0.001) were less frequent after CEA. Subgroup analysis based on the study design and the use of embolic protection device during CAS showed consistently lower rates of new lesions after CEA. CONCLUSIONS CEA demonstrates significant lower rates of new silent cerebral microembolization, as detected by MRI in postoperative period compared with CAS.
Collapse
Affiliation(s)
- Georgios Loufopoulos
- Cardiothoracic and Vascular Surgery Working Group, Society of Junior Doctors, Athens, Greece; Department of Surgery, Saint Imier Hospital, Saint Imier, Switzerland.
| | - Vasiliki Manaki
- Cardiothoracic and Vascular Surgery Working Group, Society of Junior Doctors, Athens, Greece; Department of Vascular Surgery, Aristotle University of Thessaloniki, AHEPA University General Hospital, Thessaloniki, Greece
| | - Panagiotis Tasoudis
- Cardiothoracic and Vascular Surgery Working Group, Society of Junior Doctors, Athens, Greece; Division of Cardiothoracic Surgery, Department of Surgery, School of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, NC
| | | | - George Kouvelos
- Faculty of Medicine, Department of Vascular Surgery, University Hospital of Larissa, School of Health Sciences, University of Thessaly, Larissa, Greece
| | - George Ntaios
- Faculty of Medicine, Department of Internal Medicine, University Hospital of Larissa, School of Health Sciences, University of Thessaly, Larissa, Greece
| | - Konstantinos Spanos
- Faculty of Medicine, Department of Vascular Surgery, University Hospital of Larissa, School of Health Sciences, University of Thessaly, Larissa, Greece
| |
Collapse
|
2
|
Bellomo TR, DeCarlo C, Lella SK, Jessula S, Feldman Z, Romero JM, Eagleton MJ, Dua A, Zacharias N. Complications of Carotid Interventions for Symptomatic Lesions after Systemic Thrombolysis. Ann Vasc Surg 2024; 106:377-385. [PMID: 38821470 DOI: 10.1016/j.avsg.2024.04.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2023] [Revised: 03/21/2024] [Accepted: 04/01/2024] [Indexed: 06/02/2024]
Abstract
BACKGROUND Series detailing complications after carotid endarterectomy (CEA) and transfemoral carotid stenting (tfCAS) for patients presenting with neurologic symptoms that are treated with systemic thrombolysis (ST) are sparse. We sought to determine if treatment with ST was associated with a higher rate of post-carotid intervention complications. METHODS A multispecialty, institutional, prospectively maintained database was queried for symptomatic patients treated with CEA or tfCAS from 2007 to 2019. The primary outcomes of interest were bleeding complications (access/wound complications, hematuria, intracranial hemorrhage) or need for reintervention, stroke, and death. We compared rates of these outcomes between patients who were and were not treated with ST. To adjust for preoperative patient factors and confounding variables, propensity scores for assignment to ST and non-ST were calculated. RESULTS There were 1,139 patients included (949 [82%] CEA and 190 [17%] tfCAS. All treated lesions were symptomatic (550 [48%] stroke, 603 [52%] transient ischemic attack). Fifty-six patients (5%) were treated with ST. Fifteen of 56 patients also underwent catheter-based intervention for stroke. ST was administered 0 to 1 day preoperatively in 21 (38%) patients, 2 to 6 days preoperatively in 27 (48%) patients, and greater than 6 days preoperatively in 8 (14%) patients. ST patients were more likely to present with stroke (93% vs. 45%; P < 0.001) and have higher preoperative Rankin scores. Unadjusted rate of bleeding/return to operating room was 3% for ST group and 3% for non-ST group (P = 0.60). Unadjusted rate of stroke was 4% for ST group and 3% for the non-ST group (P = 0.91), while perioperative mortality was 5% for ST group and 1% for non-ST group (P = 0.009). After adjusting for patient factors, preoperative antiplatelet/anticoagulation, and operative factors, ST was not associated with an increased odds of perioperative bleeding/return to the operating room (odds ratio 0.37; 95% confidence interval: 0.02-1.63; P = 0.309) or stroke (odds ratio 0.62; 95% confidence interval: 0.16-2.40; P = 0.493). CONCLUSIONS ST does not convey a higher risk of complications after CEA or tfCAS. After controlling for other factors, patients that received ST had similar rates of local complications and stroke when compared to non-ST patients. Early carotid intervention is safe in patients that have received ST, and delays should be avoided in symptomatic patients given the high risk of recurrent stroke.
Collapse
Affiliation(s)
- Tiffany R Bellomo
- Division of Vascular and Endovascular Surgery, Massachusetts General Hospital, Boston, MA.
| | - Charles DeCarlo
- Division of Vascular and Endovascular Surgery, Massachusetts General Hospital, Boston, MA
| | - Srihari K Lella
- Division of Vascular and Endovascular Surgery, Massachusetts General Hospital, Boston, MA
| | - Samuel Jessula
- Division of Vascular and Endovascular Surgery, Massachusetts General Hospital, Boston, MA
| | - Zachary Feldman
- Division of Vascular and Endovascular Surgery, Massachusetts General Hospital, Boston, MA
| | - Javier M Romero
- Division of Neuroradiology, Massachusetts General Hospital, Boston, MA
| | - Matthew J Eagleton
- Division of Vascular and Endovascular Surgery, Massachusetts General Hospital, Boston, MA
| | - Anahita Dua
- Division of Vascular and Endovascular Surgery, Massachusetts General Hospital, Boston, MA
| | - Nikolaos Zacharias
- Division of Vascular and Endovascular Surgery, Massachusetts General Hospital, Boston, MA
| |
Collapse
|
3
|
Rosen R, Bodnar M, Randolph J, Bailey CJ, Nickel C, Katsoulakis E, Mifsud M. Risk, prevention, screening and management of carotid artery stenosis in head & neck cancer patients-An evidence based review. Oral Oncol 2024; 156:106876. [PMID: 38908097 DOI: 10.1016/j.oraloncology.2024.106876] [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: 01/11/2024] [Revised: 05/12/2024] [Accepted: 05/28/2024] [Indexed: 06/24/2024]
Abstract
Our review aims to clarify the incidence of carotid artery stenosis, risks of development, screening, management, and primary prevention strategies documented in the literature after radiation therapy for head and neck cancers. The high prevalence of carotid stenosis after radiation therapy for head and neck cancers has made surveillance and risk stratification critical. In addition to general cardiovascular risk factors such as smoking, diabetes, and dyslipidemia, risk factors for carotid artery stenosis after head and neck radiation included total plaque score, radiotherapy use and dosage, length of time after radiotherapy, and age greater than 50. Cancer subtype, namely nasopharyngeal cancer, may be correlated with increased risk as well, though contrasting results have been found. Interestingly, however, no significant relationship has been found between radiotherapy dose and stroke risk. Surgical management of post-radiation carotid stenosis is similar to that of stenosis unrelated to radiation, with carotid endarterectomy considered to be the gold standard treatment and carotid artery stenting being an acceptable, less-invasive alternative. Medical management of these patients has not been well-studied, but antiplatelet therapy, statins, and blood pressure control may be beneficial. The mainstay of screening for radiation-induced stenosis has been Doppler ultrasound, with measurement of changes in the intima-media thickness being a primary marker of disease development. A literature review was carried out using the MeSH terms "Carotid Artery Stenosis," "Head and Neck Neoplasms," and "Radiotherapy."
Collapse
Affiliation(s)
| | | | - Jackson Randolph
- Georgetown University Medical Center, Department of Otolaryngology-Head and Neck Surgery, USA
| | - Charles J Bailey
- University of South Florida Morsani College of Medicine, Division of Vascular & Endovascular Surgery, USA
| | - Christopher Nickel
- University of South Florida Morsani College of Medicine, Department of Otolaryngology-Head and Neck Surgery, USA
| | - Evangelia Katsoulakis
- University of South Florida Morsani College of Medicine, Department of Radiation Oncology, USA
| | - Matthew Mifsud
- University of South Florida Morsani College of Medicine, Department of Otolaryngology-Head and Neck Surgery, USA.
| |
Collapse
|
4
|
Squizzato F, Zivelonghi C, Menegolo M, Xodo A, Colacchio EC, De Massari C, Grego F, Piazza M, Antonello M. A systematic review and meta-analysis on the outcomes of carotid endarterectomy after intravenous thrombolysis for acute ischemic stroke. J Vasc Surg 2024:S0741-5214(24)01682-3. [PMID: 39159889 DOI: 10.1016/j.jvs.2024.08.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2024] [Revised: 07/18/2024] [Accepted: 08/03/2024] [Indexed: 08/21/2024]
Abstract
BACKGROUNDS Intravenous thrombolysis (IVT) is the mainstay of treatment for patients presenting with acute ischemic stroke, while carotid endarterectomy (CEA) is indicated in patients with symptomatic carotid stenosis. However, the impact of prior IVT on the outcomes of CEA (IVT-CEA) is not clear. The aim of this study was to determine whether IVT may create additional stroke and death risk for CEA, compared to CEA performed in the absence of a history of recent IVT, and to determine the optimal timing for CEA after IVT METHODS: We conducted a systematic review and metanalysis on studies comparing the outcomes of IVT-CEA versus CEA, using Medline, Embase and Cochrane databases. RESULTS We included 11 retrospective comparative studies, in which 135644 patients underwent CEA and 2070 underwent IVT-CEA. The pooled rate of perioperative stroke was 4.2% in the IVT-CEA group and 1.3% in the CEA group (OR 0.44, 95% CI 0.12-1.58, p =.21), with a high heterogenicity (I2 = 93%). The rate of stroke/death was 5.9% in patients undergoing IVT-CEA 1.9% in those receiving CEA only (OR 0.42, 95% CI 0.15-1.14, I2 = 92%, p=.09); after exclusion of studies including TIA as presenting symptom, stroke/death risk was 3.6% in IVT-CEA and 3.0% in CEA (OR 1.42, 95%CI 0.80-2.53, I2=50%, p=.11). The risk of stoke decreased with a delay in the performance of CEA (p=.268). Using results of the meta-regression, the calculated delay of CEA that allows for a <6% risk was 4.6 days. Compared to CEA, patients undergoing IVT-CEA had a significantly higher risk of ICH (2.5% vs 0.1% OR 0.11, 95% CI 0.06-0.21, I2 = 28%, p < .001) and neck haematoma requiring reintervention (3.6% vs 2.3%, OR 0.61, 95% CI 0.43-0.85, I2 = 0%, p = .003). CONCLUSION In patients presenting with an acute ischemic stroke, CEA can be safely performed after a prior endovenous thrombolysis, maintaining a stroke/death risk <6%. After IVT, CEA should be deferred for at least 5 days to minimize the risk for ICH and neck bleeding.
Collapse
Affiliation(s)
| | - Cecilia Zivelonghi
- Department of Neurology and Stroke Unit, Verona University Hospital, Verona, Italy
| | - Mirko Menegolo
- Vascular and Endovascular Surgery Division, Padua University, Padua, Italy
| | - Andrea Xodo
- Vascular and Endovascular Surgery Division, "San Bortolo" Hospital, AULSS8 Berica, Vicenza, Italy
| | | | - Chiara De Massari
- Vascular and Endovascular Surgery Division, Padua University, Padua, Italy
| | - Franco Grego
- Vascular and Endovascular Surgery Division, Padua University, Padua, Italy
| | - Michele Piazza
- Vascular and Endovascular Surgery Division, Padua University, Padua, Italy
| | - Michele Antonello
- Vascular and Endovascular Surgery Division, Padua University, Padua, Italy
| |
Collapse
|
5
|
Tresson P, Lo S, Rivoire E, Cho TH, Millon A, Long A. Long-term mortality and morbidity after carotid endarterectomy for symptomatic and asymptomatic carotid stenosis. Ann Vasc Surg 2024:S0890-5096(24)00463-1. [PMID: 39116939 DOI: 10.1016/j.avsg.2024.07.085] [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: 04/10/2024] [Revised: 07/08/2024] [Accepted: 07/17/2024] [Indexed: 08/10/2024]
Abstract
OBJECTIVES To investigate whether the occurrence of ischemic stroke due to carotid stenosis is a marker of the severity of atherosclerotic disease and of an excess risk of cardiovascular morbidity and mortality, and of all-cause mortality, after carotid endarterectomy. METHODS Patients who had undergone a carotid endarterectomy (CEA) from June 2015 to august 2016 were included. Patients were classified into two groups, namely symptomatic and asymptomatic. Neurological event, myocardial infarction and death during early follow-up were monitored. Major adverse cardiovascular events (MACE), major limb events (MALE), and all-cause mortality were compared for patients with a CEA for an asymptomatic carotid stenosis versus those with a symptomatic stenosis. RESULTS Among the 190 patients included, 86 (51%) had a CEA for an asymptomatic stenosis and 84 (49%) for a symptomatic stenosis. During the first 30 days, the rate of all-cause death or ischemic stroke was similar in both groups (1%, p=0.986). After 30 days, there were a total of 35 MACE (21.3%) and 15 MALE (9.1%) during mean follow-up of 53 (22.6) months. Overall cardiovascular morbidity and mortality was 30.4%, and did not differ between groups (p=0.565). New ischemic stroke occurred in 11 patients (9.1%) and was significantly more frequent in the asymptomatic group (9 (14.8%) vs 2 (3.6%) in the symptomatic group, (OR: 4.96; CI 95% [1.04-23.77]; p = 0.013)). Overall all-cause mortality was 24% in both groups (p=0.93) CONCLUSION: The occurrence of ischemic stroke of carotid origin prior to revascularization does not appear to be associated with an excess risk of cardiovascular morbidity or mortality or all-cause mortality after surgery.
Collapse
Affiliation(s)
- Philippe Tresson
- Hospices Civils de Lyon, Hôpital Louis Pradel, Service de Chirurgie Vasculaire et Endovasculaire, Bron cedex, F-69500.
| | - Stéphane Lo
- Hospices Civils de Lyon, Hôpital Edouard Herriot, Service de Médecine Interne et de Médecine Vasculaire, Lyon cedex, F-69003; Université de Lyon, University Claude Bernard Lyon 1, Lyon, France
| | - Emeraude Rivoire
- Hospices Civils de Lyon, Hôpital Edouard Herriot, Service de Médecine Interne et de Médecine Vasculaire, Lyon cedex, F-69003; Université de Lyon, University Claude Bernard Lyon 1, Lyon, France
| | - Tae-Hee Cho
- Department of Vascular Neurology, Hospices Civils de Lyon, Université Lyon 1, France. CarMeN, INSERM-U1060, INRA-U1397, INSA-Lyon, Université Lyon 1, France
| | - Antoine Millon
- Hospices Civils de Lyon, Hôpital Louis Pradel, Service de Chirurgie Vasculaire et Endovasculaire, Bron cedex, F-69500; Université de Lyon, University Claude Bernard Lyon 1, Lyon, France
| | - Anne Long
- Hospices Civils de Lyon, Hôpital Edouard Herriot, Service de Médecine Interne et de Médecine Vasculaire, Lyon cedex, F-69003; Université de Lyon, University Claude Bernard Lyon 1, Lyon, France
| |
Collapse
|
6
|
Smith J, Margalit D, Golledge J, Nastasi D, Nohria A, McDowell L. Carotid Artery Stenosis and Ischemic Stroke in Patients With Head and Neck Cancer Treated With Radiation Therapy: A Critical Review. Int J Radiat Oncol Biol Phys 2024; 119:1437-1454. [PMID: 38583496 DOI: 10.1016/j.ijrobp.2024.03.044] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2023] [Revised: 03/21/2024] [Accepted: 03/27/2024] [Indexed: 04/09/2024]
Abstract
The purpose of this review is to summarize the literature on carotid artery stenosis (CAS) and ischemic stroke (IS) in patients with head and neck cancer (HNC) treated with radiation therapy (RT) to guide assessment, screening, and management strategies. Patients treated with RT for HNC are at an elevated risk of developing CAS, with published meta-analyses demonstrating that CAS >50% occurs in approximately 25% of patients. Previous research suggests a 10-year cumulative incidence of stroke between 5.7% and 12.5%. Cardiovascular disease (CVD) risk prediction tools such as Qstroke, QRISK-2, and Framingham risk score perform poorly for predicting IS for patients with HNC who received RT. Duplex ultrasound is the most common imaging modality to assess CAS, but controversy remains as to the utility of screening asymptomatic individuals. Only 3 of the 5 major HNC survivorship guidelines acknowledge RT as a risk factor for CAS or IS, while only 1 makes a specific recommendation on screening for CAS (American Head and Neck Society). Within the general population, only 1 CVD guideline discusses RT as a risk factor for CAS (Society for Vascular Surgery). Clinicians involved in the care of patients with HNC treated with RT should be aware of the increased risk of CAS and IS and the challenges in risk prediction. Although there is a lack of evidence to make firm recommendations, HNC survivorship recommendations should ensure HNC survivors and primary care providers are informed of these risks and the importance of assessment and management of CVD risk factors. Future studies are required to refine risk prediction models in patients with HNC and to determine those most likely to benefit from targeted screening and initiation of early preventative strategies.
Collapse
Affiliation(s)
- Justin Smith
- Faculty of Medicine, University of Queensland, Brisbane, Australia; Department of Radiation Oncology, Princess Alexandra Hospital, Brisbane, Australia.
| | - Danielle Margalit
- Department of Radiation Oncology, Dana-Farber Cancer Institute/Brigham & Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Jonathan Golledge
- Queensland Research Centre for Peripheral Vascular Disease, College of Medicine and Dentistry, James Cook University, Townsville, Australia; The Department of Vascular and Endovascular Surgery, Townsville University Hospital, Townsville, Australia; The Australian Institute of Tropical Health and Medicine, Townsville, Australia
| | - Domenico Nastasi
- Department of Vascular Surgery, Gold Coast University Hospital, Gold Coast, Australia
| | - Anju Nohria
- Cardiovascular Division, Brigham and Women's Hospital, Boston, Massachusetts; Adult Survivorship Program, Dana Farber Cancer Institute, Boston, Massachusetts
| | - Lachlan McDowell
- Faculty of Medicine, University of Queensland, Brisbane, Australia; Department of Radiation Oncology, Princess Alexandra Hospital, Brisbane, Australia
| |
Collapse
|
7
|
Meschia JF. William M. Feinberg Lecture: Asymptomatic Carotid Stenosis: Current and Future Considerations. Stroke 2024; 55:2184-2192. [PMID: 38920049 PMCID: PMC11331494 DOI: 10.1161/strokeaha.124.046956] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2024] [Accepted: 06/04/2024] [Indexed: 06/27/2024]
Abstract
Asymptomatic high-grade carotid stenosis is an important therapeutic target for stroke prevention. For decades, the ACAS (Asymptomatic Carotid Atherosclerosis Study) and ACST (Asymptomatic Carotid Surgery Trial) trials provided most of the evidence supporting endarterectomy for patients with asymptomatic high-grade stenosis who were otherwise good candidates for surgery. Since then, transfemoral/transradial carotid stenting and transcarotid artery revascularization have emerged as alternatives to endarterectomy for revascularization. Advances in treatments against atherosclerosis have driven down the rates of stroke in patients managed without revascularization. SPACE-2 (Stent-Protected Angioplasty Versus Carotid Endarterectomy-2), a trial that included endarterectomy, stenting, and medical arms, failed to detect significant differences in stroke rates among treatment groups, but the study was stopped well short of its recruitment goal. CREST-2 (Carotid Revascularization and Medical Management for Asymptomatic Carotid Stenosis Trial) will be able to clarify whether revascularization by stenting or endarterectomy remains efficacious under conditions of intensive medical management. Transcarotid artery revascularization has a favorable periprocedural risk profile, but randomized trials comparing it to intensive medical management are lacking. Features like intraplaque hemorrhage on MRI and echolucency on B-mode ultrasonography can identify patients at higher risk of stroke with asymptomatic stenosis. High-grade stenosis with poor collaterals can cause hemispheric hypoperfusion, and unstable plaque can cause microemboli, both of which may be treatable risk factors for cognitive impairment. Evidence that there are patients with carotid stenosis who benefit cognitively from revascularization is presently lacking. New risk factors are emerging, like exposure to microplastics and nanoplastics. Strategies to limit exposure will be important without specific medical therapies.
Collapse
Affiliation(s)
- James F Meschia
- Department of Neurology, Mayo Clinic Florida, Jacksonville, FL
| |
Collapse
|
8
|
Suhail S, Tallarita T, Kanzafarova I, Lau J, Mansukhani S, Olatunji S, Calvin AD, Moustafa B, Manz J, Sen I. Ocular Ischemic Syndrome and the Role of Carotid Artery Revascularization. Ann Vasc Surg 2024; 105:165-176. [PMID: 38574808 DOI: 10.1016/j.avsg.2023.12.098] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2023] [Revised: 12/29/2023] [Accepted: 12/31/2023] [Indexed: 04/06/2024]
Abstract
BACKGROUND Ocular ischemic syndrome (OIS) is a rare presentation of atherosclerotic carotid artery stenosis that can result in permanent visual loss. This severely disabling syndrome remains under diagnosed and undertreated due to lack of awareness; especially since it requires expedited multidisciplinary care. The relevance of early diagnosis and treatment is increasing due to an increasing prevalence of cerebrovascular disease. METHODS The long-term visual and cerebrovascular outcomes following intervention for nonarteritic OIS, remain poorly described and were the objective of this concise review. We conducted a PubMed search to include all English language publications (cohort studies and case reports) between 2002 and 2023. RESULTS A total of 33 studies (479 patients) report the outcomes of treatment of OIS with carotid endarterectomy (CEA, 304 patients, 19 studies), and carotid artery stenting (CAS, 175 patients, 14 studies). Visual outcomes were improved or did not worsen in 447 patients (93.3%). No periprocedural stroke was reported. Worsening visual symptoms were rare (35 patients, 7.3%); they occurred in the immediate postoperative period secondary to ocular hypoperfusion (3 patients) and in the late postoperative period due to progression of systemic atherosclerotic disease. Symptomatic recurrence due to recurrent stenosis after CEA was reported in 1 patient (0.21%); this was managed successfully with CAS. None of these studies report the results of transcarotid artery revascularization, the long-term operative outcome or stroke rate. CONCLUSIONS OIS remains to be an underdiagnosed condition. Early diagnosis and prompt treatment are crucial in reversal or stabilization of OIS symptoms. An expedited multidisciplinary approach between vascular surgery and ophthalmology services is necessary to facilitate timely treatment and optimize outcome. If diagnosed early, both CEA and CAS have been associated with visual improvement and prevention of progressive visual loss.
Collapse
Affiliation(s)
- Shanzay Suhail
- Vascular and Endovascular Surgery, Mayo Clinic Health System, Eau Claire, WI.
| | - Tiziano Tallarita
- Vascular and Endovascular Surgery, Mayo Clinic Health System, Eau Claire, WI
| | | | - Jenny Lau
- Ophthalmology, Mayo Clinic Health System, Eau Claire, WI
| | | | | | - Andrew D Calvin
- Cardiovascular Medicine, Mayo Clinic Health System, Eau Claire, WI
| | | | - James Manz
- Neurologic Surgery Mayo Clinic Health System, Eau Claire, WI
| | - Indrani Sen
- Vascular and Endovascular Surgery, Mayo Clinic Health System, Eau Claire, WI.
| |
Collapse
|
9
|
Garagoli F, Chiabrando JG, Seropian IM, Lombardi M, Agatiello CR, Fernández Recalde ML, Vergallo R, Porto I, Bluro IM. Stroke risk after transcatheter aortic valve replacement in patients with carotid stenosis: A systematic review and meta-analysis. Int J Cardiol 2024; 408:132085. [PMID: 38702030 DOI: 10.1016/j.ijcard.2024.132085] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/07/2024] [Revised: 04/02/2024] [Accepted: 04/19/2024] [Indexed: 05/06/2024]
Abstract
BACKGROUND Stroke is a feared complication of transcatheter aortic valve replacement (TAVR). Patients undergoing TAVR typically have multiple comorbidities, such as carotid artery stenosis (CAS). We conducted the present meta-analysis to determine the risk of stroke and mortality following TAVR in patients with CAS. METHODS We searched PubMed/Medline, Scopus, ScienceDirect, and Cochrane Clinical Trials databases for clinical studies that compared CAS ≥50% and CAS ≥70% versus non-CAS TAVR population. The endpoints included the 30-day incidence of stroke or transient ischemic attack (TIA) and 30-day all-cause of mortality. RESULTS We identified seven studies that included 12,418 patients in the CAS group and 102,316 in the control group. CAS ≥50% was not associated with an increased risk of 30-day stroke or TIA after TAVR [risk ratio (RR): 1.38; 95% confidence interval (95% CI): 0.95-2.02; p = 0.09]. However, patients with CAS ≥70% had an increased risk of stroke or TIA (RR: 1.43; 95% CI: 1.02-2.01; p = 0.04). No difference in 30-day all-cause mortality was observed between CAS ≥50% or CAS ≥70% and control groups (RR: 1.09; 95% CI: 0.79-1.52; p = 0.59 and RR: 1.11; 95% CI: 0.85-1.45; p = 0.43, respectively). CONCLUSIONS CAS ≥70% was associated with an increased risk of stroke or TIA following TAVR compared with patients without CAS.
Collapse
Affiliation(s)
- Fernando Garagoli
- Department of Cardiology, Hospital Italiano de Buenos Aires, Buenos Aires, Argentina.
| | - Juan Guido Chiabrando
- Department of Interventional Cardiology, Sanatorio Anchorena, Buenos Aires, Argentina
| | - Ignacio Miguel Seropian
- Department of Interventional Cardiology, Hospital Italiano de Buenos Aires, Buenos Aires, Argentina
| | - Marco Lombardi
- Department of Internal Medicine and Medical Specialties (DIMI), Università di Genova, Largo R. Benzi, 10, 16132 Genova, Italy
| | - Carla Romina Agatiello
- Department of Interventional Cardiology, Hospital Italiano de Buenos Aires, Buenos Aires, Argentina
| | | | - Rocco Vergallo
- Department of Internal Medicine and Medical Specialties (DIMI), Università di Genova, Largo R. Benzi, 10, 16132 Genova, Italy; Cardiothoracic and Vascular Department (DICATOV), IRCCS Ospedale Policlinico San Martino, Viale Benedetto XV, 6, 16132 Genova, Italy
| | - Italo Porto
- Department of Internal Medicine and Medical Specialties (DIMI), Università di Genova, Largo R. Benzi, 10, 16132 Genova, Italy; Cardiothoracic and Vascular Department (DICATOV), IRCCS Ospedale Policlinico San Martino, Viale Benedetto XV, 6, 16132 Genova, Italy
| | - Ignacio Martín Bluro
- Department of Cardiology, Hospital Italiano de Buenos Aires, Buenos Aires, Argentina
| |
Collapse
|
10
|
Saicic S, Knappich C, Kallmayer M, Kirchhoff F, Bohmann B, Lohe V, Naher S, Böhm J, Lückerath S, Eckstein HH, Kuehnl A. Association of Centre Quality Certification with Characteristics of Patients, Management, and Outcomes Following Carotid Endarterectomy or Carotid Artery Stenting. J Clin Med 2024; 13:4407. [PMID: 39124674 PMCID: PMC11313300 DOI: 10.3390/jcm13154407] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2024] [Revised: 07/11/2024] [Accepted: 07/23/2024] [Indexed: 08/12/2024] Open
Abstract
Background: The aim of this study was to analyze the association between center quality certifications and patients' characteristics, clinical management, and outcomes after carotid revascularization. Methods: This study is a pre-planned sub-study of the ISAR-IQ project, which analyzes data from the Bavarian subset of the nationwide German statutory quality assurance carotid database. Hospitals were classified as to whether a certified vascular center (cVC) or a certified stroke unit (cSU) was present on-site or not. The primary outcome event was any stroke or death until discharge from the hospital. Results: In total, 31,793 cases were included between 2012 and 2018. The primary outcome rate in asymptomatic patients treated by CEA ranged from 0.7% to 1.5%, with the highest rate in hospitals with cVC but without cSU. The multivariable regression analysis revealed a significantly lower primary outcome rate in centers with cSU in asymptomatic patients (aOR 0.69; 95% CI 0.56-0.86; p < 0.001). In symptomatic patients needing emergency treatment, the on-site availability of a cSU was associated with a significantly lower primary outcome rate (aOR 0.56; 95% CI 0.40-0.80; p < 0.001), whereas the presence of a cVC was associated with higher risk (aOR 3.07; 95% CI 1.65-5.72). Conclusions: This study provides evidence of statistically significant better results in some sub-cohorts in certified centers. In centers with cSU, the risk of any stroke or death was significantly lower in asymptomatic patients receiving CEA or symptomatic patients treated by emergency CEA.
Collapse
Affiliation(s)
- Stefan Saicic
- Department for Vascular and Endovascular Surgery, University Hospital rechts der Isar, Technical University of Munich, 81675 Munich, Germany; (S.S.)
| | - Christoph Knappich
- Department for Vascular and Endovascular Surgery, University Hospital rechts der Isar, Technical University of Munich, 81675 Munich, Germany; (S.S.)
| | - Michael Kallmayer
- Department for Vascular and Endovascular Surgery, University Hospital rechts der Isar, Technical University of Munich, 81675 Munich, Germany; (S.S.)
| | - Felix Kirchhoff
- Department for Vascular and Endovascular Surgery, University Hospital rechts der Isar, Technical University of Munich, 81675 Munich, Germany; (S.S.)
| | - Bianca Bohmann
- Department for Vascular and Endovascular Surgery, University Hospital rechts der Isar, Technical University of Munich, 81675 Munich, Germany; (S.S.)
| | - Vanessa Lohe
- Department for Vascular and Endovascular Surgery, University Hospital rechts der Isar, Technical University of Munich, 81675 Munich, Germany; (S.S.)
| | - Shamsun Naher
- Department for Vascular and Endovascular Surgery, University Hospital rechts der Isar, Technical University of Munich, 81675 Munich, Germany; (S.S.)
| | - Julian Böhm
- Landesarbeitsgemeinschaft zur Datengestützten, Einrichtungsübergreifenden Qualitätssicherung in Bayern (LAG Bayern), 80331 Munich, Germany
| | - Sofie Lückerath
- Department for Vascular and Endovascular Surgery, University Hospital rechts der Isar, Technical University of Munich, 81675 Munich, Germany; (S.S.)
| | - Hans-Henning Eckstein
- Department for Vascular and Endovascular Surgery, University Hospital rechts der Isar, Technical University of Munich, 81675 Munich, Germany; (S.S.)
| | - Andreas Kuehnl
- Department for Vascular and Endovascular Surgery, University Hospital rechts der Isar, Technical University of Munich, 81675 Munich, Germany; (S.S.)
| |
Collapse
|
11
|
Hommery-Boucher X, Fortin W, Beaudoin N, Blair JF, Stevens LM, Elkouri S. Safety of Shunting Strategies During Carotid Endarterectomy: A Vascular Quality Initiative Data Analysis. Eur J Vasc Endovasc Surg 2024:S1078-5884(24)00628-2. [PMID: 39038509 DOI: 10.1016/j.ejvs.2024.07.021] [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: 11/19/2023] [Revised: 06/24/2024] [Accepted: 07/16/2024] [Indexed: 07/24/2024]
Abstract
OBJECTIVE This study aimed to evaluate in hospital outcomes after carotid endarterectomy (CEA) according to shunt usage, particularly in patients with contralateral carotid occlusion (CCO) or recent stroke. Data from CEAs registered in the Vascular Quality Initiative database between 2012 and 2020 were analysed, excluding surgeons with < 10 CEAs registered in the database, concomitant procedures, re-interventions, and incomplete data. METHODS Based on their rate of shunt use, participating surgeons were divided in three groups: non-shunters (< 5%), selective shunters (5 - 95%), and routine shunters (> 95%). Primary outcomes of in hospital stroke, death, and stroke and death rate (SDR) were analysed in symptomatic and asymptomatic patients. RESULTS A total of 113 202 patients met the study criteria, of whom 31 147 were symptomatic and 82 055 were asymptomatic. Of the 1 645 surgeons included, 12.1% were non-shunters, 63.6% were selective shunters, and 24.3% were routine shunters, with 10 557, 71 160, and 31 579 procedures in each group, respectively. In the univariable analysis, in hospital stroke (2.0% vs. 1.9% vs. 1.6%; p = .17), death (0.5% vs. 0.4% vs. 0.4%; p = .71), and SDR (2.2% vs. 2.1% vs. 1.8%; p = .23) were not statistically significantly different among the three groups in the symptomatic cohort. The asymptomatic cohort also did not show a statistically significant difference for in hospital stroke (0.9% vs. 1.0% vs. 0.9%; p = .55), death (0.2% vs. 0.2% vs. 0.2%; p = .64), and SDR (1.0% vs. 1.1% vs. 1.0%; p = .43). The multivariable model did not show a statistically significant difference for the primary outcomes between the three shunting cohorts. On subgroup analysis, the SDRs were not statistically significantly different for patients with CCO (3.3% vs. 2.5% vs. 2.4%; p = .64) and those presenting with a recent stroke (2.9% vs. 3.4% vs. 3.1%; p = .60). CONCLUSION No statistically significant differences were found between three shunting strategies for in hospital SDR, including in patients with CCO or recent stroke.
Collapse
Affiliation(s)
| | - William Fortin
- Hôpital du Sacré-Cœur de Montréal, Montreal, Quebec, Canada
| | - Nathalie Beaudoin
- Centre hospitalier de l'Université de Montréal (CHUM), Montreal, Quebec, Canada
| | - Jean-François Blair
- Centre hospitalier de l'Université de Montréal (CHUM), Montreal, Quebec, Canada
| | | | - Stéphane Elkouri
- Centre hospitalier de l'Université de Montréal (CHUM), Montreal, Quebec, Canada
| |
Collapse
|
12
|
Kallmayer M, Knappich C, Kirchhoff F, Bohmann B, Lohe V, Naher S, Eckstein HH, Kuehnl A. Determinants of Pre- and Post-Procedural Neurological Assessment, and Outcome of Carotid Endarterectomy or Stenting. J Clin Med 2024; 13:4177. [PMID: 39064217 PMCID: PMC11278376 DOI: 10.3390/jcm13144177] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2024] [Revised: 07/09/2024] [Accepted: 07/11/2024] [Indexed: 07/28/2024] Open
Abstract
Background: The German-Austrian guideline on the treatment of carotid stenosis recommends specialist neurological assessment (NA) before and after carotid endarterectomy (CEA) or carotid artery stenting (CAS). This study analyzes the determinants of NA and the association of NA with the perioperative rate of stroke or death. Materials and Methods: This study is a pre-planned sub-study of the ISAR-IQ project, which analyzes data from the nationwide German statutory quality assurance carotid database. Patients were classified as asymptomatic (group A), elective symptomatic (group B), and others (group C: emergency (C1), simultaneous operation (C2), and other indications (C3)). The primary outcome event (POE) of this study was any in-hospital stroke or death. Adjusted odds ratios for pre- and post-NA and the POE were calculated using multivariable regression analyses. Results: We analyzed 228,133 patients (54% asymptomatic, 68% male, mean age 72 years) undergoing CEA or CAS between 2012 and 2018. Age and sex were not associated with the likelihood of pre-NA or post-NA. The multivariable regression analysis showed an inverse association between pre-NA and POE (adjusted odds ratio (aOR) 0.47; 95% CI 0.44-0.51, p < 0.001), and a direct association of post-NA and POE (aOR 4.39; 95% CI 4.04-4.78, p < 0.001). Conclusions: Pre- and postinterventional specialist NA is strongly associated with the risk of any in-hospital stroke or death after CEA or CAS in Germany. A relevant confounding by indication or reversed causation cannot be ruled out. Nevertheless, to improve the quality assurance of treatment, the NA recommended in the guideline should be carried out consistently.
Collapse
Affiliation(s)
| | | | | | | | | | | | | | - Andreas Kuehnl
- Department for Vascular and Endovascular Surgery, Klinikum rechts der Isar, Technical University of Munich, 81675 Munich, Germany; (M.K.)
| |
Collapse
|
13
|
Yagshyyev S, Haney B, Li Y, Papatheodorou N, Zetzmann K, Meyer A, Meyer S, Lang W, Rother U. Independent Factors Influencing Changes in Baroreceptor Sensitivity after Carotid Endarterectomy. Ann Vasc Surg 2024; 108:393-402. [PMID: 39019257 DOI: 10.1016/j.avsg.2024.06.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2024] [Revised: 06/09/2024] [Accepted: 06/11/2024] [Indexed: 07/19/2024]
Abstract
BACKGROUND Carotid endarterectomy (CEA) is a well-established standard therapy for patients with symptomatic or asymptomatic high-grade carotid stenosis. The aim of carotid endarterectomy is to decrease the risk of stroke and avoid relevant functional loss. However, carotid endarterectomy is known to be associated with hemodynamic dysregulation. In this study we compared eversion CEA (E-CEA) and conventional CEA (C-CEA) regarding postoperative blood pressure values as well as preoperative and postoperative baroreceptor sensitivity in the first 7 days after surgery. The aim was to find possible factors influencing changes in baroreceptor sensitivity. METHODS Patients (111 patients were enrolled, of which 50 patients received C-CEA and 61 patients E-CEA) were prospectively enrolled in this study. For the measurement of baroreceptor sensitivity, a noninvasive Finometer measuring device from Finapres Medical System B.V. (Amsterdam, The Netherlands) was used. Measurements were performed 1 day before surgery (PRE), directly after surgery (F1), on day 1 (F2), day 2 (F3), and on day 7 (F4) postoperatively. RESULTS Postoperative blood pressure values were significantly higher in the E-CEA group on the day of surgery (F1) (P < 0.001) and on day 1 (F2) (P < 0.001). From day 2 (F3, F4) postoperatively, no significant difference was found between the 2 groups. The invasive blood pressure measurement in the postoperative recovery room showed significantly higher systolic blood pressure values in the E-CEA group (P = 0.001). The need of acute antihypertensive therapy was significantly higher in the recovery room in the E-CEA group (P = 0.020). With regard to changes in baroreceptor sensitivity, significantly lower baroreceptor sensitivity (BRS) values were recorded in the E-CEA group at 1 day (F2) postoperatively (P = 0.005). The regression analysis showed that the applied surgical technique and the patient's age were significant factors influencing changes in baroreceptor sensitivity. CONCLUSIONS In this study we could confirm higher blood pressure levels after E-CEA in the first 2 days after surgery. Additionally, we identified 22 factors possibly influencing baroreceptor sensitivity: surgical technique and age. Based on the data obtained in this study, hemodynamic dysregulation after CEA (E-CEA, C-CEA) is temporary and short-term. Already after the second postoperative day, there was no significant difference between the E-CEA and E-CEA groups, this effect remained stable after 7 days.
Collapse
Affiliation(s)
- Shatlyk Yagshyyev
- Department of Vascular Surgery, University Hospital Erlangen, Friedrich-Alexander-Universität Erlangen-Nürnberg (FAU), Erlangen, Germany
| | - Briain Haney
- Department of Vascular Surgery, University Hospital Erlangen, Friedrich-Alexander-Universität Erlangen-Nürnberg (FAU), Erlangen, Germany
| | - Yi Li
- Department of Vascular Surgery, University Hospital Erlangen, Friedrich-Alexander-Universität Erlangen-Nürnberg (FAU), Erlangen, Germany
| | - Nikolaos Papatheodorou
- Department of Vascular Surgery, University Hospital Erlangen, Friedrich-Alexander-Universität Erlangen-Nürnberg (FAU), Erlangen, Germany
| | - Katharina Zetzmann
- Department of Vascular Surgery, University Hospital Erlangen, Friedrich-Alexander-Universität Erlangen-Nürnberg (FAU), Erlangen, Germany
| | - Alexander Meyer
- Department of Vascular Surgery, Helios Klinikum Berlin-Buch, Berlin, Germany; Medical School Berlin, Berlin, Germany
| | - Sebastian Meyer
- Department of Medical Informatics, Biometry and Epidemiology, Friedrich-Alexander-Universität Erlangen-Nürnberg, Erlangen, Germany
| | - Werner Lang
- Department of Vascular Surgery, University Hospital Erlangen, Friedrich-Alexander-Universität Erlangen-Nürnberg (FAU), Erlangen, Germany
| | - Ulrich Rother
- Department of Vascular Surgery, University Hospital Erlangen, Friedrich-Alexander-Universität Erlangen-Nürnberg (FAU), Erlangen, Germany.
| |
Collapse
|
14
|
Gonzalez-Urquijo M, Gómez-Gutiérrez OA, Hinojosa-Gonzalez DE, Reijnen MMPJ, van den Berg JC, Vegas DH, Marine L, Lozano-Balderas G, Fabiani MA. Survey-Based Assessment of the Quality of Reporting Guidelines of Carotid Artery Stenosis. Ann Vasc Surg 2024; 108:426-436. [PMID: 39004276 DOI: 10.1016/j.avsg.2024.05.019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2024] [Revised: 05/18/2024] [Accepted: 05/26/2024] [Indexed: 07/16/2024]
Abstract
BACKGROUND No evaluation of the quality of different carotid guidelines using validated scales has been performed to date. The present study aims to analyze 3 carotid stenosis guidelines, apprizing their quality and reporting using validated tools. METHODS A survey-based assessment of the quality of the European Society for Vascular Surgery (ESVS) 2023, European Stroke Organisation (ESO) 2021, and the Society for Vascular Surgery (SVS) 2021 carotid stenosis guidelines, was performed by 43 vascular surgeons, cardiologists, neurologist or interventional radiologists using 2 validated appraisal tools for quality and reporting guidelines, the AGREE II instrument and the RIGHT statement. RESULTS Using the AGREE II tool, the ESVS, SVS, and ESO guidelines had overall quality scores of 87.3%, 79.4%, and 82.9%, respectively (P = 0.001) The ESVS and ESO had better scores in the scope and purpose domain, and the SVS in the clarity of presentation domain. In the RIGHT statement, the ESVS, SVS, and ESO guidelines had overall quality scores of 84.0.7%, 74.3%, and 79.0%, respectively (P = 0.001). All 3 guidelines stood out for their methodology for search of evidence and formulating evidence-based recommendations. On the contrary, were negatively evaluated mostly in the cost and resource implications in formulating the recommendations. CONCLUSIONS The 2023 ESVS carotid stenosis guideline was the best evaluated among the 3 guidelines, with scores over 5% higher than the other 2 guidelines. Efforts should be made by guideline writing committees to take the AGREE II and RIGHT statements into account in the development of future guidelines to produce high-quality recommendations.
Collapse
Affiliation(s)
- Mauricio Gonzalez-Urquijo
- Tecnologico de Monterrey, School of Medicine and Health Sciences, Monterrey, Nuevo León, México; Departamento de Cirugía Vascular y Endovascular, Escuela de Medicina, Pontificia Universidad Catolica de Chile, Santiago, Chile
| | | | | | - Michel M P J Reijnen
- Department of Surgery, Rijnstate, Arnhem, and Multi-Modality Medical Imaging Group, TechMed Centre, University of Twente, Enschede, The Netherlands
| | - Jos C van den Berg
- Centro Vascolare Ticino, Ospedale Regionale di Lugano, sede Civico, Lugano, Switzerland; Universitätsinstitut für Diagnostische, Interventionelle und Pädiatrische Radiologie, Inselspital, Universitätsspital Bern, Bern, Switzerland
| | | | - Leopoldo Marine
- Departamento de Cirugía Vascular y Endovascular, Escuela de Medicina, Pontificia Universidad Catolica de Chile, Santiago, Chile
| | - Gerardo Lozano-Balderas
- Tecnologico de Monterrey, School of Medicine and Health Sciences, Monterrey, Nuevo León, México
| | - Mario Alejandro Fabiani
- Tecnologico de Monterrey, School of Medicine and Health Sciences, Monterrey, Nuevo León, México.
| |
Collapse
|
15
|
Kök M, de Heide EJ, Hellegering J, van der Laan MJ, Mazuri A, Uyttenboogaart M, Bokkers RPH, Zeebregts CJ. Carotid Stenosis in Logistic Restraints Optimizing Treatment of Significant Carotid Artery Stenosis in Times of Logistic Restraints as a Result of COVID-19 Pandemic. Ann Vasc Surg 2024; 108:498-507. [PMID: 39009113 DOI: 10.1016/j.avsg.2024.05.020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2024] [Revised: 05/20/2024] [Accepted: 05/25/2024] [Indexed: 07/17/2024]
Abstract
BACKGROUND COVID-19 confronted medical care with many challenges. During the pandemic, several resources were limited resulting in renouncing or postponing medical care like carotid endarterectomy (CEA) for patients with significant carotid artery stenosis. Although according to international guidelines CEA is the first choice, carotid artery stenting (CAS) could potentially be a reasonable alternative especially during logistical restraints. PURPOSE To evaluate outcomes of CAS versus CEA before, during and after the COVID-19 pandemic. Our hypothesis was that a CAS first approach yielded comparable outcomes compared to a CEA first approach. METHODS Retrospective analysis of consecutive patients with significant carotid artery stenosis treated with CEA or CAS between September 2018 and March 2023. Each consecutive period of 1.5 year marked a new (treatment) period: pre-COVID (CEA first strategy), during COVID (CAS first strategy) and post-COVID (patient-tailored approach). Primary outcome was the composite endpoint of stroke, transient ischemic attack or death within 30 days. Secondary outcome consisted of the rate of technical success, cerebral hyperperfusion syndrome, myocardial infarction or other cardiac complications needing intervention, bleeding of the surgical site needing intervention, nerve palsy, unintended IC admission, pseudoaneurysm, restenosis, or occlusion. RESULTS A total of 318 patients were included. Out of 137 patients treated with CEA, 55, 36 and 46 were treated pre-COVID, during COVID and post-COVID, respectively. Out of 181 CAS procedures, 38, 59 and 84, respectively, were performed in each time period. Primary outcome occurred in 5.5%, 0% and 2.2% in the CEA group and 0%, 1.7% and 3.6% in the CAS group (P = 0.27; P = 1.00; P = 1.00, respectively). Overall technical success was 100% for CEA and 99.4% for CAS (P = 1.00). Rate of restenosis was the only secondary outcome measure which was significantly better after CAS compared to CEA in the pre- and post-COVID period (CEA vs. CAS, 12.7% vs. 7.9%, and 23.9% vs. 4.8% with a P-value of 0.03 and 0.03, respectively). Hospital presentation to treatment interval did not differ significantly during the pandemic. CONCLUSIONS Outcomes were comparable between CAS versus CEA in patients with significant carotid artery stenosis before, during and after the COVID-19 pandemic. CAS showed better results in terms of other complications (i.e., restenosis rate) in the pre- and post-COVID period compared to CEA. Our results may support a CAS first approach when no relevant contra-indications exist without exposing the patient to complications associated with an open surgical approach. Discussion in a multidisciplinary team is advised.
Collapse
Affiliation(s)
- Mert Kök
- Division of Vascular Surgery, Departments of Surgery, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Erik-Jan de Heide
- Departments of Radiology, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Joyce Hellegering
- Division of Vascular Surgery, Departments of Surgery, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Maarten J van der Laan
- Division of Vascular Surgery, Departments of Surgery, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Aryan Mazuri
- Departments of Radiology, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Maarten Uyttenboogaart
- Departments of Radiology, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands; Departments of Neurology, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Reinoud P H Bokkers
- Departments of Radiology, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Clark J Zeebregts
- Division of Vascular Surgery, Departments of Surgery, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands.
| |
Collapse
|
16
|
Lengyel B, Vecsey-Nagy M, Peter C, Varga A, Kovats T, Bayerle P, Sotonyi P, Banga PV. The Circle of Willis Status Influences Neurological Complications of Carotid Endarterectomy with Contralateral Carotid Occlusion. Ann Vasc Surg 2024; 108:410-418. [PMID: 39009123 DOI: 10.1016/j.avsg.2024.05.021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2024] [Revised: 05/15/2024] [Accepted: 05/31/2024] [Indexed: 07/17/2024]
Abstract
BACKGROUND To evaluate the impact of anatomical variations in the Circle of Willis (CoW) on immediate neurological events (INEs) after carotid endarterectomy (CEA) without shunting in patients with contralateral carotid occlusion (CCO). METHODS Single-center retrospective study. Patient's demographic and clinical outcomes data were prospectively collected. CoW segments were reviewed retrospectively. Between January 2013 and May 2018, 2090 patients underwent CEA under general anesthesia, CCO was found in 113 (5.4%) patients. CoW segments were classified as normal, hypoplastic (diameter ˂0.8 mm), or absent based on computed tomography angiography. We studied the CoW segments as 2 collateral networks connecting the basilar artery and the ipsilateral middle cerebral artery: a short semicircle (first segment of the ipsilateral posterior cerebral artery [P1] and posterior communicating artery [Pcom] segment) and a long semicircle (contralateral P1, Pcom, and both first segments of the anterior cerebri artery (A1) anterior communicating artery (Acom)). INE was defined as any transient ischemic attack or stroke diagnosed immediately after the procedure. RESULTS Out of the 113 patients, 46 underwent endarterectomy with shunting. We further excluded 16 patients from the assessment of the CoW due to unavailability or inadequate quality of computed tomography angiography. Of the 113 patients, 2 had strokes, 1 with shunting that occurred hrs after surgery. Besides the other stroke case, 4 INE were observed, all without the use of a shunt. Of the 51 patients with CoW assessment, 10 (19.6%) had a complete CoW, while 21 (41.2%) patients had only 1 semicircle intact (10 short and 11 long intact semicircles), and none of these patients experienced an INE. A total of 20 (39%) patients had both the long and short semicircles incomplete, of which 4 (7.8%) cases had an INE. In all INE cases, at least 1 of the Pcom was absent or hypoplastic. The absence of both Pcom was a strong predictor of incident INE [odds ratio = 11.10 (confidence interval: 1.04-118.60)] for INE. CONCLUSIONS Patients with CCO and insufficient CoW collateral flow support are at an increased risk of INE, including stroke, in the absence of shunt protection during CEA cross-clamping. Shunting should always be considered when the collateral flow between the ipsilateral middle cerebral artery and the basilar artery is compromised in CCO patients.
Collapse
Affiliation(s)
- Balazs Lengyel
- Cardiovascular Center, Semmelweis University, Budapest, Hungary
| | | | - Csongor Peter
- Cardiovascular Center, Semmelweis University, Budapest, Hungary
| | - Andrea Varga
- Cardiovascular Center, Semmelweis University, Budapest, Hungary
| | - Tamas Kovats
- Health Services Management Training Centre, Semmelweis University, Budapest, Hungary
| | - Patrik Bayerle
- Cardiovascular Center, Semmelweis University, Budapest, Hungary
| | - Peter Sotonyi
- Cardiovascular Center, Semmelweis University, Budapest, Hungary
| | | |
Collapse
|
17
|
Galyfos G, Charalampopoulos G, Karagiannis G, Liasis N, Koncar I, Siogkas P, Fotiadis D, Filis K, Sigala F. Factors Associated with High-Risk Plaque Characteristics Among Patients with Medium to Severe Carotid Artery Stenosis. Ann Vasc Surg 2024; 108:325-332. [PMID: 39009116 DOI: 10.1016/j.avsg.2024.05.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2024] [Revised: 04/29/2024] [Accepted: 05/14/2024] [Indexed: 07/17/2024]
Abstract
BACKGROUND There has been a large discussion in literature regarding the proper management of asymptomatic patients with significant carotid artery stenosis. This study aims to identify potential risk factors associated with high-risk carotid plaques. METHODS This is a retrospective study based on a prospective database. Eligible patients had medium to severe symptomatic or asymptomatic carotid stenosis (≥50%, North American Symptomatic Carotid Endarterectomy Trial criteria). This study will analyze patients recruited by our institution as part of the multicenter TAXINOMISIS project (NCT03495830). According to protocol, all patients underwent a colored Duplex ultrasound examination and a magnetic resonance angiography at baseline. Carotid plaques were classified according to Gray-Weale ultrasonographic criteria (types I-V). Main outcomes included the occurrence of symptoms, the high/low echogenicity of the plaque, the existence of intraplaque hemorrhage and the existence of lipidic/necrotic core. Secondary, risk factors associated with the aforementioned outcomes were evaluated. RESULTS A total of 62 patients (mean age: 68.7 ± 9.3 years, 66.1% males, 24.2% symptomatic) were recruited by our department. Mean carotid stenosis was 70.81% ± 13.53%. In multivariate regression analysis, C-reactive protein > 2 mg/l was strongly associated with symptomatic stenosis (odds ratio [OR] = 9.92 [1.12-88.178]; P = 0.039), and low high-density lipoprotein levels (<1200 mmol/l) were associated with lipidic/necrotic plaque core (OR = 16.88 [1.10-259.30]; P = 0.043). Low high-density lipoprotein levels (OR = 7.22 [1.00-51.95], P = 0.049) and HbA1c >7% (OR = 0.08 [0.01-0.93], P = 0.044) were associated with type III/IV plaques whereas HgAbc1 >7% (OR = 14.26 [1.21-168.34], P = 0.035) was associated with type V plaques. CONCLUSIONS This preliminary study has revealed some potential risk factors associated with unstable carotid plaques. These data could help the future development of prognostic models for early detection patients that could benefit from further intervention.
Collapse
Affiliation(s)
- George Galyfos
- Vascular Unit, First Department of Propedeutic Surgery, National and Kapodistrian University of Athens, Athens, Greece.
| | - Georgios Charalampopoulos
- Vascular Unit, First Department of Propedeutic Surgery, National and Kapodistrian University of Athens, Athens, Greece
| | - Georgios Karagiannis
- Vascular Unit, First Department of Propedeutic Surgery, National and Kapodistrian University of Athens, Athens, Greece
| | - Nikolaos Liasis
- Vascular Unit, First Department of Propedeutic Surgery, National and Kapodistrian University of Athens, Athens, Greece
| | - Igor Koncar
- Clinic of Vascular and Endovascular Surgery, University Clinical Centre of Serbia, Belgrade, Serbia
| | - Panagiotis Siogkas
- Unit of Medical Technology and Intelligent Information Systems, Department of Materials Science and Engineering, University of Ioannina, Ioannina, Greece
| | - Dimitrios Fotiadis
- Unit of Medical Technology and Intelligent Information Systems, Department of Materials Science and Engineering, University of Ioannina, Ioannina, Greece
| | - Konstantinos Filis
- Vascular Unit, First Department of Propedeutic Surgery, National and Kapodistrian University of Athens, Athens, Greece
| | - Frangeska Sigala
- Vascular Unit, First Department of Propedeutic Surgery, National and Kapodistrian University of Athens, Athens, Greece
| |
Collapse
|
18
|
Clemente Gouveia de Gramilho GM, Pereira-Macedo J, Dias LRP, Dias Ferreira AR, Myrcha P, Alves Vieira Andrade JP, Rocha-Neves JMPD. Brain natriuretic peptide is a long-term cardiovascular predictor in carotid endarterectomy. Acta Chir Belg 2024:1-7. [PMID: 38975870 DOI: 10.1080/00015458.2024.2377889] [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: 04/05/2024] [Accepted: 07/04/2024] [Indexed: 07/09/2024]
Abstract
BACKGROUND In noncardiac surgery, several biomarkers are known to play a role in predicting long-term complications, such as major adverse cardiovascular events (MACE), myocardial infarction, or death. Carotid endarterectomy (CEA) is considered a low to medium-risk surgery for carotid stenosis aimed at preventing stroke events. Brain natriuretic peptide (BNP) is a biomarker with potential prognostic value regarding MACE. Since its role in patients undergoing CEA is unknown, this study aims to assess the potential role of BNP as a short and long-term predictor of all-cause mortality and MACE in patients undergoing CEA. METHODS From a prospective database, patients who underwent CEA under regional anesthesia (RA) at a tertiary hospital center were enrolled, and a post hoc analysis was conducted. Patients on which BNP levels were measured up to fifteen days before surgery, and two groups based on the BNP threshold (200 pg/mL) were defined and compared. Kaplan Meier survival curves and adjusted hazard ratios (aHR) were assessed by multivariable Cox regression. The primary outcome was the incidence of long-term MACE and all-cause mortality. Secondary outcomes included the incidence of AMI and AHF. RESULTS A total of 89 patients were evaluated. The mean age of the cohort was 71.2 ± 8.7 years, with 71 (79.8%) males, and presented a median follow-up of 30 [13.5-46.4] months. BNP > 200 pg/mL has demonstrated positive predictive value for MACE (aHR: 5.569, confidence interval (CI): 2.441-12.7, p < 0.001) and all-cause mortality (aHR: 3.469, CI: 1.315-9.150, p = 0.018). CONCLUSION BNP has been demonstrated to independently predict long-term all-cause mortality, MACE and AMI following CEA. It serves as a low-cost, ready-to-use biomarker, although further studies are necessary.
Collapse
Affiliation(s)
| | - Juliana Pereira-Macedo
- Faculdade de Medicina da Universidade do Porto, Porto, Portugal
- Department of Surgery, Unidade Local de Saúde do Médio Ave, Vila Nova de Famalicão, Portugal
- RISE@Heath, Porto, Portugal
| | - Lara Romana Pereira Dias
- Department of Angiology and Vascular Surgery, Unidade Local de Saúde de São João, Porto, Portugal
| | - Ana Rita Dias Ferreira
- Intensive Care Medicine Department, Centro Hospitalar Universitário de São João, Porto, Portugal
| | - Piotr Myrcha
- Department of General and Vascular Surgery, Faculty of Medicine, Medical University of Warsaw, Warsaw, Poland
- Department of General, Vascular and Oncological Surgery, Brodnowski Hospital, Warsaw, Poland
| | - José Paulo Alves Vieira Andrade
- RISE@Heath, Porto, Portugal
- Unit of Anatomy, Department of Biomedicine, Faculty of Medicine, University of Porto, Porto, Portugal
| | - João Manuel Palmeira da Rocha-Neves
- RISE@Heath, Porto, Portugal
- Department of Angiology and Vascular Surgery, Unidade Local de Saúde de São João, Porto, Portugal
- Unit of Anatomy, Department of Biomedicine, Faculty of Medicine, University of Porto, Porto, Portugal
| |
Collapse
|
19
|
Qiu K, Liu X, Jia Z, Zhao L, Shi H, Liu S. Comparing Transbrachial and Transradial as Alternatives to Transfemoral Access for Large-Bore Neuro Stenting: Insights From a Propensity-Matched Study. Acad Radiol 2024:S1076-6332(24)00431-8. [PMID: 38991867 DOI: 10.1016/j.acra.2024.06.042] [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] [Revised: 06/26/2024] [Accepted: 06/26/2024] [Indexed: 07/13/2024]
Abstract
RATIONALE AND OBJECTIVES This study aimed to evaluate the safety and effectiveness of transbrachial access (TBA) and transradial access (TRA) compared to transfemoral access (TFA) for large-bore neuro stenting (≥7 F). METHODS From January 2019 to January 2024, 4752 patients received large-bore neuro stenting in our center. The primary outcomes were procedural metrics. Safety outcomes were significant access site complications, including substantial hematoma, pseudoaneurysm, artery occlusion, and complications requiring treatment (medicine, intervention, or surgery). After propensity score matching with a ratio of 1:1:2 (TBA: TRA: TFA), adjusting for age, gender, aortic arch type, and neuro stenting as covariates, outcomes were compared between groups. RESULTS 46 TBA, 46 TRA and 92 TFA patients were enrolled. The mean age was 67.8 ± 11.2 years, comprising 127 (69.0%) carotid artery stenting and 57 (31.0%) vertebral artery stenting. The rates of technical success (TBA: 100%, TRA: 95.7%, TFA: 100%) and significant access site complications (TBA: 4.3%, TRA: 6.5%, TFA: 1.1%) were comparable between the groups (P > 0.05). Compared to TFA, the TRA cohort exhibited significant delays in angiosuite arrival to puncture time (14 vs. 8 min, P = 0.039), puncture to angiography completion time (19 vs. 11 min, P = 0.027), and procedural duration (42 vs. 29 min, P = 0.031). There were no substantial differences in procedural time metrics between TBA (10, 14, and 31 min, respectively) and TFA. CONCLUSION TBA and TRA as the primary access for large-bore neuro stenting are safe and effective. Procedural delays in TRA may favor TBA as the first-line alternative access to TFA.
Collapse
Affiliation(s)
- Kai Qiu
- Department of Interventional Radiology, The First Affiliated Hospital with Nanjing Medical University, Nanjing 210029, China
| | - Xinglong Liu
- Department of Interventional Radiology, The First Affiliated Hospital with Nanjing Medical University, Nanjing 210029, China
| | - Zhenyu Jia
- Department of Interventional Radiology, The First Affiliated Hospital with Nanjing Medical University, Nanjing 210029, China
| | - Linbo Zhao
- Department of Interventional Radiology, The First Affiliated Hospital with Nanjing Medical University, Nanjing 210029, China
| | - Haibin Shi
- Department of Interventional Radiology, The First Affiliated Hospital with Nanjing Medical University, Nanjing 210029, China
| | - Sheng Liu
- Department of Interventional Radiology, The First Affiliated Hospital with Nanjing Medical University, Nanjing 210029, China.
| |
Collapse
|
20
|
Björck M, Boyle JR, Loftus I. Quality, Diversity, Science, and Education: The Pillars of the European Journal of Vascular and Endovascular Surgery and the European Society for Vascular Surgery. Eur J Vasc Endovasc Surg 2024:S1078-5884(24)00573-2. [PMID: 38992803 DOI: 10.1016/j.ejvs.2024.07.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2024] [Accepted: 07/08/2024] [Indexed: 07/13/2024]
Affiliation(s)
- Martin Björck
- Department of Surgical Sciences, Uppsala University, Uppsala, Sweden; Institute of Clinical Medicine, University of Tartu, Tartu, Estonia.
| | - Jonathan R Boyle
- Cambridge Vascular Unit, Cambridge University Hospitals NHS Trust and Department of Surgery, University of Cambridge, Cambridge, UK
| | - Ian Loftus
- Department of Vascular Surgery, St Georges NHS Foundation Trust, London, UK
| |
Collapse
|
21
|
Pakizer D, Kozel J, Elmers J, Feber J, Michel P, Školoudík D, Sirimarco G. Diagnostics Accuracy of Magnetic Resonance Imaging in Detection of Atherosclerotic Plaque Characteristics in Carotid Arteries Compared to Histology: A Systematic Review. J Magn Reson Imaging 2024. [PMID: 38981139 DOI: 10.1002/jmri.29522] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2024] [Revised: 06/12/2024] [Accepted: 06/17/2024] [Indexed: 07/11/2024] Open
Abstract
Carotid plaque composition represents one of the main risk factors of future ischemic stroke. MRI provides excellent soft tissue contrast that can distinguish plaque characteristics. Our objective was to analyze the diagnostic accuracy of MRI imaging in the detection of carotid plaque characteristics compared to histology in patients with symptomatic and asymptomatic carotid atherosclerosis through a systematic review. After prospective registration in PROSPERO (ID CRD42022329690), Medline Ovid, Embase.com, Cochrane Library, and Web of Science Core were searched without any search limitation up to May 27, 2022 to identify eligible articles. Of the 8168 studies, 53 (37 × 1.5 T MRI, 17 × 3 T MRI) evaluated MRI accuracy in the detection of 13 specific carotid plaque characteristics in 169 comparisons. MRI demonstrated high diagnostic accuracy for detection of calcification (3 T MRI: mean sensitivity 92%/mean specificity 90%; 1.5 T MRI: mean sensitivity 81%/mean specificity 91%), fibrous cap (1.5 T: 89%/87%), unstable plaque (1.5 T: 89%/87%), intraplaque hemorrhage (1.5 T: 86%/88%), and lipid-rich necrotic core (1.5 T: 89%/79%). MRI also proved to have a high level of tissue discrimination for the carotid plaque characteristics investigated, allowing potentially for a better risk assessment and follow-up of patients who may benefit from more aggressive treatments. These results emphasize the role of MRI as the first-line imaging modality for comprehensive assessment of carotid plaque morphology, particularly for unstable plaque. EVIDENCE LEVEL: 2 TECHNICAL EFFICACY: Stage 2.
Collapse
Affiliation(s)
- David Pakizer
- Centre for Health Research, Department of Clinical Neurosciences, Faculty of Medicine, University of Ostrava, Ostrava, Czech Republic
| | - Jiří Kozel
- Centre for Health Research, Department of Clinical Neurosciences, Faculty of Medicine, University of Ostrava, Ostrava, Czech Republic
| | - Jolanda Elmers
- Medical Library, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland
| | - Janusz Feber
- Centre for Health Research, Department of Clinical Neurosciences, Faculty of Medicine, University of Ostrava, Ostrava, Czech Republic
- Division of Nephrology, Department of Pediatrics, Children's Hospital of Eastern Ontario, University of Ottawa, Ottawa, Ontario, Canada
| | - Patrik Michel
- Stroke Center, Service of Neurology, Department of Clinical Neurosciences, Lausanne University Hospital, Lausanne, Switzerland
| | - David Školoudík
- Centre for Health Research, Department of Clinical Neurosciences, Faculty of Medicine, University of Ostrava, Ostrava, Czech Republic
| | - Gaia Sirimarco
- Stroke Center, Service of Neurology, Department of Clinical Neurosciences, Lausanne University Hospital, Lausanne, Switzerland
- Neurology Unit, Department of Internal Medicine, Riviera Chablais Hospital, Rennaz, Switzerland
| |
Collapse
|
22
|
Manuel MR, Francisco M. Reply. AJNR Am J Neuroradiol 2024; 45:E21. [PMID: 38902007 DOI: 10.3174/ajnr.a8341] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/22/2024]
Affiliation(s)
| | - Moniche Francisco
- Institute of Biomedicine of SevilleIBiS/Hospital Universitario Virgen del Rocío/CSIC/Universidad de SevillaSeville, Spain
| |
Collapse
|
23
|
Aarli SJ, Thomassen L, Logallo N, Kvistad CE, Næss H, Fromm A. Prolonged and repeated microemboli detection in acute ischemic stroke - The Norwegian Microemboli in Acute Stroke Study (NOR-MASS). J Stroke Cerebrovasc Dis 2024; 33:107849. [PMID: 38972617 DOI: 10.1016/j.jstrokecerebrovasdis.2024.107849] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2024] [Revised: 06/29/2024] [Accepted: 07/02/2024] [Indexed: 07/09/2024] Open
Abstract
OBJECTIVES Cerebral microemboli can be detected by transcranial Doppler monitoring (TCDM) and may elucidate stroke etiology, the effect of preventive therapy, and the risk of stroke recurrence. Microemboli detection is usually performed for up to 60 minutes, but due to temporal variability, microembolization may be missed if the monitoring time is too short. We aimed to assess the time course of microembolization in acute ischemic stroke and explore the utility of prolonged and repeated microemboli detection. MATERIALS AND METHODS Patients with suspected ischemic stroke and symptom onset within 24 hours were examined with bilateral, stationary TCDM for one hour followed by unilateral, ambulatory TCDM for two hours. Unilateral TCDM was repeated for the following two days and after three months. RESULTS We included 47 patients, of which 41 had ischemic stroke, five had transient ischemic attack, and one had amaurosis fugax. Microemboli were detected in 60 % of patients. The occurrence was highest within 24 hours after onset and significantly lower at three months. Prolonged and repeated microemboli detection yielded only one additional microemboli-positive patient. Hence, patients who initially were microemboli negative tended to remain negative. We could not demonstrate an association between microemboli occurrence and clinical outcome or stroke recurrence. CONCLUSIONS Microembolic signals are frequent within 24 hours after ischemic stroke onset, but prolonged and repeated microemboli detection did not increase the yield of MES positive patients. CLINICAL TRIAL REGISTRATION-URL http://www. CLINICALTRIALS gov. Unique identifier: NCT03543319.
Collapse
Affiliation(s)
- Sander Johan Aarli
- Department of Neurology, Haukeland University Hospital, Bergen, Norway; Department of Clinical Medicine, University of Bergen, Bergen, Norway.
| | - Lars Thomassen
- Department of Neurology, Haukeland University Hospital, Bergen, Norway; Department of Clinical Medicine, University of Bergen, Bergen, Norway
| | - Nicola Logallo
- Department of Neurosurgery, Haukeland University Hospital, Bergen, Norway
| | - Christopher Elnan Kvistad
- Department of Neurology, Haukeland University Hospital, Bergen, Norway; Department of Clinical Medicine, University of Bergen, Bergen, Norway
| | - Halvor Næss
- Department of Neurology, Haukeland University Hospital, Bergen, Norway; Department of Clinical Medicine, University of Bergen, Bergen, Norway
| | - Annette Fromm
- Department of Neurology, Haukeland University Hospital, Bergen, Norway
| |
Collapse
|
24
|
Wang T, Sun X, Wang X, Feng Y, Yang K, Wang J, Xu R, Gong H, Luo J, Dmytriw AA, Jiao L, Ma Y. Carotid revascularisation versus medical treatment for asymptomatic carotid artery stenosis. Cochrane Database Syst Rev 2024; 7:CD015499. [PMID: 38967132 PMCID: PMC11225108 DOI: 10.1002/14651858.cd015499] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 07/06/2024]
Abstract
OBJECTIVES This is a protocol for a Cochrane Review (intervention). The objectives are as follows: To compare the safety and efficacy of carotid revascularisation plus best medical treatment with best medical treatment alone in people with asymptomatic carotid artery stenosis.
Collapse
Affiliation(s)
- Tao Wang
- Department of Neurosurgery, Xuanwu Hospital, China International Neuroscience Institute, Capital Medical University, National Center for Neurological Disorders, Beijing, China
| | - Xinyi Sun
- Department of Neurosurgery, Xuanwu Hospital, China International Neuroscience Institute, Capital Medical University, National Center for Neurological Disorders, Beijing, China
| | - Xue Wang
- Medical Library, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Yiding Feng
- Department of Neurosurgery, Xuanwu Hospital, China International Neuroscience Institute, Capital Medical University, National Center for Neurological Disorders, Beijing, China
| | - Kun Yang
- Department of Evidence-based Medicine, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Jie Wang
- Department of Neurosurgery, Xuanwu Hospital, China International Neuroscience Institute, Capital Medical University, National Center for Neurological Disorders, Beijing, China
| | - Ran Xu
- Department of Neurosurgery, Xuanwu Hospital, China International Neuroscience Institute, Capital Medical University, National Center for Neurological Disorders, Beijing, China
| | - Haozhi Gong
- Department of Neurosurgery, Xuanwu Hospital, China International Neuroscience Institute, Capital Medical University, National Center for Neurological Disorders, Beijing, China
| | - Jichang Luo
- Department of Neurosurgery, Xuanwu Hospital, China International Neuroscience Institute, Capital Medical University, National Center for Neurological Disorders, Beijing, China
| | - Adam A Dmytriw
- Neuroendovascular Program, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Liqun Jiao
- Department of Neurosurgery, Xuanwu Hospital, China International Neuroscience Institute, Capital Medical University, National Center for Neurological Disorders, Beijing, China
- Department of Interventional Neuroradiology, Xuanwu Hospital, China International Neuroscience Institute, Capital Medical University, National Center for Neurological Disorders, Beijing, China
| | - Yan Ma
- Department of Neurosurgery, Xuanwu Hospital, China International Neuroscience Institute, Capital Medical University, National Center for Neurological Disorders, Beijing, China
| |
Collapse
|
25
|
Gao X, Guo J, Pan D, Gu Y. Treatment Strategies for Asymptomatic Carotid Stenosis: A Systematic Review and Bayesian Network Meta-Analysis. Oper Neurosurg (Hagerstown) 2024:01787389-990000000-01241. [PMID: 38967441 DOI: 10.1227/ons.0000000000001251] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2024] [Accepted: 04/23/2024] [Indexed: 07/06/2024] Open
Abstract
BACKGROUND AND OBJECTIVES To compare the safety and efficacy of carotid endarterectomy (CEA), carotid stenting (CAS), and optimal medical therapy (OMT) in patients with asymptomatic carotid stenosis. METHODS Relevant randomized controlled trials were researched with PubMed, Web of Science, and the Cochrane Library databases. Fixed-effects model and random-effects model were used to estimate the relative risks and the hazard ratios (HRs). The results of the probabilistic analysis were reported as surfaces under the cumulative ranking curve. RESULTS Eight randomized controlled trials were included. Data from 10 348 patients (CEA: n = 4758; CAS: n = 3919; OMT: n = 1673) were evaluated. Compared with the previous OMT, CEA, CAS, and the current OMT (c-OMT) were all effective in reducing the risk of stroke (CEA: HR, 0.52; CI, 0.40-0.66; CAS: HR, 0.58; CI, 0.42-0.81; c-OMT: HR, 0.40; CI, 0.15-0.94); CEA and CAS reduced the risk of ipsilateral stroke (CEA: HR, 0.41; CI, 0.28-0.59; CAS: HR, 0.51; CI, 0.31-0.84), and the risk of fatal or disabling stroke (CEA: HR, 0.59; CI, 0.43-0.81; CAS: HR, 0.57; CI, 0.34-0.95). Regarding reducing the risk of stroke, only CEA was statistically significant in patients with any degree of stenosis compared with the previous medical treatment (<80%: HR, 0.48; CI, 0.33%-0.70%; 80%-99%: HR, 0.53; CI, 0.38-0.73). CONCLUSION In the treatment of asymptomatic carotid stenosis, the perioperative outcomes of CAS were similar to that of CEA; CEA, CAS, and c-OMT shared similar long-term outcomes; and CEA and CAS may be more effective in patients with high levels of asymptomatic stenosis.
Collapse
Affiliation(s)
- Xinyi Gao
- Department of Vascular Surgery, Xuanwu Hospital, Capital Medical University, Beijing, China
| | | | | | | |
Collapse
|
26
|
Kirchhoff F, Knappich C, Kallmayer M, Bohmann B, Lohe V, Tsantilas P, Naher S, Eckstein HH, Kühnl A. Determinants of prehospital and in-hospital delay in patients with symptomatic carotid stenosis and their influence on the outcome after elective carotid endarterectomy. Stroke Vasc Neurol 2024:svn-2024-003098. [PMID: 38969509 DOI: 10.1136/svn-2024-003098] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2024] [Accepted: 05/13/2024] [Indexed: 07/07/2024] Open
Abstract
BACKGROUND This study analyses the determinants of prehospital (index event to admission) and in-hospital delay (admission to carotid endarterectomy (CEA)). In addition, the analysis addresses the association between prehospital or in-hospital delay and outcomes after CEA for symptomatic patients in German hospitals. MATERIALS AND METHODS This retrospective analysis is based on the nationwide German statutory quality assurance database. 55 437 patients were included in the analysis. Prehospital delay was grouped as follows: 180-15, 14-8, 7-3, 2-0 days or 'in-hospital index event'. In-hospital delay was divided into: 0-1, 2-3 and >3 days. The primary outcome event (POE) was in-hospital stroke or death. Univariate and multivariable regression analyses were performed for statistical analysis. The slope of the linear regression line is given as the β-value, and the rate parameter of the logistic regression is given as the adjusted OR (aOR). RESULTS Prehospital delay was 0-2 days in 34.9%, 3-14 days in 29.5% and >14 days in 18.6%. Higher age (β=-1.08, p<0.001) and a more severe index event (transitory ischaemic attack: β=-4.41, p<0.001; stroke: β=-6.05, p<0.001, Ref: amaurosis fugax) were determinants of shorter prehospital delay. Higher age (β=0.28, p<0.001) and female sex (β=0.09, p=0.014) were associated with a longer in-hospital delay. Index event after admission (aOR 1.23, 95% CI: 1.04 to 1.47) and an intermediate in-hospital delay of 2-3 days (aOR 1.15, 95% CI: 1.00 to 1.33) were associated with an increased POE risk. CONCLUSIONS This study revealed that older age, higher American Society of Anesthesiology (ASA) stage, increasing severity of symptoms and ipsilateral moderate stenosis were associated with shorter prehospital delay. Non-specific symptoms were associated with a longer prehospital delay. Regarding in-hospital delay, older age, higher ASA stage, contralateral occlusion, preprocedural examination by a neurologist and admission on Fridays or Saturdays were associated with lagged treatment. A very short (<2 days) prehospital and intermediate in-hospital delay (2-3 days) were associated with increased risk of perioperative stroke or death.
Collapse
Affiliation(s)
- Felix Kirchhoff
- Clinic and Policlinic for Vascular and Endovascular Surgery, Hospital Rechts der Isar, Technical University of Munich, Munich, Germany
| | - Christoph Knappich
- Clinic and Policlinic for Vascular and Endovascular Surgery, Hospital Rechts der Isar, Technical University of Munich, Munich, Germany
| | - Michael Kallmayer
- Clinic and Policlinic for Vascular and Endovascular Surgery, Hospital Rechts der Isar, Technical University of Munich, Munich, Germany
| | - Bianca Bohmann
- Clinic and Policlinic for Vascular and Endovascular Surgery, Hospital Rechts der Isar, Technical University of Munich, Munich, Germany
| | - Vanessa Lohe
- Clinic and Policlinic for Vascular and Endovascular Surgery, Hospital Rechts der Isar, Technical University of Munich, Munich, Germany
| | | | - Shamsun Naher
- Clinic and Policlinic for Vascular and Endovascular Surgery, Hospital Rechts der Isar, Technical University of Munich, Munich, Germany
| | - Hans-Henning Eckstein
- Clinic and Policlinic for Vascular and Endovascular Surgery, Hospital Rechts der Isar, Technical University of Munich, Munich, Germany
| | - Andreas Kühnl
- Clinic and Policlinic for Vascular and Endovascular Surgery, Hospital Rechts der Isar, Technical University of Munich, Munich, Germany
| |
Collapse
|
27
|
Jaafar N, Alsop DC. Arterial Spin Labeling: Key Concepts and Progress Towards Use as a Clinical Tool. Magn Reson Med Sci 2024; 23:352-366. [PMID: 38880616 PMCID: PMC11234948 DOI: 10.2463/mrms.rev.2024-0013] [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: 02/06/2024] [Accepted: 05/15/2024] [Indexed: 06/18/2024] Open
Abstract
Arterial spin labeling (ASL), a non-invasive MRI technique, has emerged as a valuable tool for researchers that can measure blood flow and related parameters. This review aims to provide a qualitative overview of the technical principles and recent developments in ASL and to highlight its potential clinical applications. A growing literature demonstrates impressive ASL sensitivity to a range of neuropathologies and treatment responses. Despite its potential, challenges persist in the translation of ASL to widespread clinical use, including the lack of standardization and the limited availability of comprehensive training. As experience with ASL continues to grow, the final stage of translation will require moving beyond single site observational studies to multi-site experience and measurement of the added contribution of ASL to patient care and outcomes.
Collapse
Affiliation(s)
- Narjes Jaafar
- Department of Radiology, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, MA, USA
| | - David C. Alsop
- Department of Radiology, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, MA, USA
| |
Collapse
|
28
|
Huo R, Yuan W, Xu H, Yang D, Qiao H, Han H, Wang T, Liu Y, Yuan H, Zhao X. Investigating the Association of Carotid Atherosclerotic Plaque MRI Features and Silent Stroke After Carotid Endarterectomy. J Magn Reson Imaging 2024; 60:138-149. [PMID: 38018669 DOI: 10.1002/jmri.29115] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2023] [Revised: 10/04/2023] [Accepted: 10/05/2023] [Indexed: 11/30/2023] Open
Abstract
BACKGROUND The predictive value of carotid plaque characteristics for silent stroke (SS) after carotid endarterectomy (CEA) is unclear. OBJECTIVE To investigate the associations between carotid plaque characteristics and postoperative SS in patients undergoing CEA. STUDY TYPE Prospective. POPULATION One hundred fifty-three patients (mean age: 65.4 ± 7.9 years; 126 males) with unilateral moderate-to-severe carotid stenosis (evaluated by CT angiography) referred for CEA. FIELD STRENGTH/SEQUENCE 3 T, brain-MRI:T2-PROPELLER, T1-/T2-FLAIR, diffusion weighted imaging (DWI) and T2*, carotid-MRI:black-blood T1-/T2W, 3D TOF, Simultaneous Non-contrast Angiography intraplaque hemorrhage. ASSESSMENT Patients underwent carotid-MRI within 1-week before CEA, and brain-MRI within 48-hours pre-/post-CEA. The presence and size (volume, maximum-area-percentage) of carotid lipid-rich necrotic core (LRNC), intraplaque hemorrhage (Type-I/Type-II IPH) and calcification were evaluated on carotid-MR images. Postoperative SS was assessed from pre-/post-CEA brain DWI. Patients were divided into moderate-carotid-stenosis (50%-69%) and severe-carotid-stenosis (70%-99%) groups and the associations between carotid plaque characteristics and SS were analyzed. STATISTICAL TESTS Independent t test, Mann-Whitney U-test, chi-square test and logistic regressions (OR: odds ratio, CI: confidence interval). P value <0.05 was considered statistically significant. RESULTS SS was found in 8 (16.3%) of the 49 patients with moderate-carotid-stenosis and 21 (20.2%) of the 104 patients with severe-carotid-stenosis. In patients with severe-carotid-stenosis, those with SS had significantly higher IPH (66.7% vs. 39.8%) and Type-I IPH (66.7% vs. 38.6%) than those without. The presence of IPH (OR 3.030, 95% CI 1.106-8.305) and Type-I IPH (OR 3.187, 95% CI 1.162-8.745) was significantly associated with SS. After adjustment, the associations of SS with presence of IPH (OR 3.294, 95% CI 1.122-9.669) and Type-I IPH (OR 3.633, 95% CI 1.216-10.859) remained significant. Moreover, the volume of Type-II IPH (OR 1.014, 95% CI 1.001-1.028), and maximum-area-percentage of Type-II IPH (OR 1.070, 95% CI 1.002-1.142) and LRNC (OR 1.030, 95% CI 1.000-1.061) were significantly associated with SS after adjustment. No significant (P range: 0.203-0.980) associations were found between carotid plaque characteristics and SS in patients with moderate-carotid-stenosis. DATA CONCLUSIONS In patients with unilateral severe-carotid-stenosis, carotid vulnerable plaque MR features, particularly presence and size of IPH, might be effective predictors for SS after CEA. EVIDENCE LEVEL 2 TECHNICAL EFFICACY: Stage 2.
Collapse
Affiliation(s)
- Ran Huo
- Department of Radiology, Peking University Third Hospital, Beijing, China
| | - Wanzhong Yuan
- Department of Neurosurgery, Peking University Third Hospital, Beijing, China
| | - Huimin Xu
- Department of Radiology, Peking University Third Hospital, Beijing, China
| | - Dandan Yang
- Department of Radiology, Beijing Geriatric Hospital, Beijing, China
| | - Huiyu Qiao
- Center for Biomedical Imaging Research, Department of Biomedical Engineering, School of Medicine, Tsinghua University, Beijing, China
| | - Hualu Han
- Center for Biomedical Imaging Research, Department of Biomedical Engineering, School of Medicine, Tsinghua University, Beijing, China
| | - Tao Wang
- Department of Neurosurgery, Peking University Third Hospital, Beijing, China
| | - Ying Liu
- Department of Radiology, Peking University Third Hospital, Beijing, China
| | - Huishu Yuan
- Department of Radiology, Peking University Third Hospital, Beijing, China
| | - Xihai Zhao
- Center for Biomedical Imaging Research, Department of Biomedical Engineering, School of Medicine, Tsinghua University, Beijing, China
| |
Collapse
|
29
|
Sterpetti AV, Gabriele R, Dimarzo L. Asymptomatic Carotid Stenosis. Ann Vasc Surg 2024; 104:255-257. [PMID: 38599482 DOI: 10.1016/j.avsg.2024.02.019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2024] [Accepted: 02/28/2024] [Indexed: 04/12/2024]
Affiliation(s)
| | | | - Luca Dimarzo
- Department of Vascular Surgery, Sapienza University; Rome, Italy
| |
Collapse
|
30
|
Woźniak A, Satała J, Gorzelak‐Pabiś P, Pawlos A, Broncel M, Kaźmierski P, Woźniak E. OxLDL as a prognostic biomarker of plaque instability in patients qualified for carotid endarterectomy. J Cell Mol Med 2024; 28:e18459. [PMID: 39039803 PMCID: PMC11263466 DOI: 10.1111/jcmm.18459] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2023] [Revised: 04/18/2024] [Accepted: 05/16/2024] [Indexed: 07/24/2024] Open
Abstract
Atherosclerotic plaque instability increases the risk of stroke. As such, determining the nature of an instability atherosclerotic plaque may speed up qualification for carotid endarterectomy (CEA), thus reducing the risk of acute vascular events. The aim of the study was to determine the diagnostic value of oxidized LDL cholesterol (ox-LDL), matrix metalloproteinase 9 (MMP-9) and 8-hydroxy-2'-deoxyguanosine (8-OHdG) in serum as a prognostic markers of instability atherosclerotic plaques. Serum was collected from 67 patients who underwent CEA in accordance with the qualification criteria. The levels of ox-LDL, MMP-9 and 8-OHdG were assessed by ELISA. The predictive value of the markers was determined based on an ROC curve, and the cut-off points with the highest sensitivity and specificity were determined. Patients with unstable atherosclerotic plaque had significantly higher serum ox-LDL, MMP-9 and 8-OHdG values. It was found that in patients before CEA, ox-LDL >31.4 ng/mL was associated with an 82.5% probability of unstable atherosclerotic plaque, MMP-9 >113.1 ng/mL with 78.6%, and 8-OHdG >2.15 ng/mL with 64.7%. Multivariate regression analysis found ox-LDL to be an independent factor associated with plaque instability. Patients with unstable plaques tend to have higher serum levels of ox-LDL, MMP-9 and 8-OHdG compared to those with stable plaques. The optimal cut-off point for ox-LDL (AUC 0.86, p <0.0001) was 31.14 ng/mL, with 91.18% sensitivity and 78.79% specificity. The high sensitivity and specificity of ox-LDL suggests that it can be used as an independent marker of plaque instability.
Collapse
Affiliation(s)
- Agnieszka Woźniak
- Department of Internal Diseases and Clinical Pharmacology, Laboratory of Tissue ImmunopharmacologyMedical University of LodzLodzPoland
| | - Joanna Satała
- Department of Internal Diseases and Clinical Pharmacology, Laboratory of Tissue ImmunopharmacologyMedical University of LodzLodzPoland
| | - Paulina Gorzelak‐Pabiś
- Department of Internal Diseases and Clinical Pharmacology, Laboratory of Tissue ImmunopharmacologyMedical University of LodzLodzPoland
| | - Agnieszka Pawlos
- Department of Internal Diseases and Clinical Pharmacology, Laboratory of Tissue ImmunopharmacologyMedical University of LodzLodzPoland
| | - Marlena Broncel
- Department of Internal Diseases and Clinical Pharmacology, Laboratory of Tissue ImmunopharmacologyMedical University of LodzLodzPoland
| | - Piotr Kaźmierski
- Department of Vascular, General, and Oncologic SurgeryMedical University of LodzLodzPoland
| | - Ewelina Woźniak
- Department of Internal Diseases and Clinical Pharmacology, Laboratory of Tissue ImmunopharmacologyMedical University of LodzLodzPoland
| |
Collapse
|
31
|
Knappich C, Bohmann B, Kirchhoff F, Lohe V, Naher S, Kallmayer M, Eckstein HH, Kuehnl A. Use of an embolic protection device during carotid artery stenting is associated with lower periprocedural risk. J Neurointerv Surg 2024:jnis-2024-021722. [PMID: 38906691 DOI: 10.1136/jnis-2024-021722] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2024] [Accepted: 05/25/2024] [Indexed: 06/23/2024]
Abstract
OBJECTIVE To investigate associations between individual embolic protection device (EPD) use and respective center policy with periprocedural outcomes after carotid artery stenting (CAS). METHODS This analysis is based on the nationwide German statutory quality assurance database and was funded by Germany's Federal Joint Committee Innovation Fund (G-BA Innovationsfonds, 01VSF19016 ISAR-IQ). According to their policy towards EPD use, hospitals were categorized as routine EPD (>90%), selective EPD (10-90%), or sporadic EPD (<10%) centers. Primary study outcome was in-hospital stroke or death. Univariate and multivariate regression analyses were performed. RESULTS Overall, 19 302 patients who had undergone CAS between 2013 and 2016 were included. The highest in-hospital stroke or death rate was found in sporadic EPD centers, followed by selective and routine EPD centers (3.1% vs 2.9% vs 1.8%; P<0.001). Across the whole cohort, EPD use was associated with a lower in-hospital stroke or death rate (OR=0.60; 95% CI 0.50 to 0.72). In the multivariate regression analysis, EPD use was independently associated with a lower in-hospital stroke rate (aOR=0.66; 95% CI 0.46 to 0.94). Regarding center policy, routine EPD centers showed a significantly lower in-hospital mortality compared with sporadic EPD centers (aOR=0.44; 95% CI 0.22 to 0.88). CONCLUSIONS In a contemporary real-world cohort with low risk of selection bias, EPD use was associated with a lower in-hospital risk of stroke. A center policy of routine EPD use was associated with lower mortality. These data support routine use of EPD during CAS to enhance patient safety.
Collapse
Affiliation(s)
- Christoph Knappich
- Department for Vascular and Endovascular Surgery, Klinikum rechts der Isar, Technical University of Munich, Munich, Germany
| | - Bianca Bohmann
- Department for Vascular and Endovascular Surgery, Klinikum rechts der Isar, Technical University of Munich, Munich, Germany
| | - Felix Kirchhoff
- Department for Vascular and Endovascular Surgery, Klinikum rechts der Isar, Technical University of Munich, Munich, Germany
| | - Vanessa Lohe
- Department for Vascular and Endovascular Surgery, Klinikum rechts der Isar, Technical University of Munich, Munich, Germany
| | - Shamsun Naher
- Department for Vascular and Endovascular Surgery, Klinikum rechts der Isar, Technical University of Munich, Munich, Germany
| | - Michael Kallmayer
- Department for Vascular and Endovascular Surgery, Klinikum rechts der Isar, Technical University of Munich, Munich, Germany
| | - Hans-Henning Eckstein
- Department for Vascular and Endovascular Surgery, Klinikum rechts der Isar, Technical University of Munich, Munich, Germany
| | - Andreas Kuehnl
- Department for Vascular and Endovascular Surgery, Klinikum rechts der Isar, Technical University of Munich, Munich, Germany
| |
Collapse
|
32
|
Maimaitiaili S, Tang C, Liu C, Lv X, Chen Z, Zhang M, Cai J, Liang Z, Zhao B, Zhang W, Qiao T. Alterations in brain morphology and functional connectivity mediate cognitive decline in carotid atherosclerotic stenosis. Front Aging Neurosci 2024; 16:1395911. [PMID: 38974904 PMCID: PMC11225314 DOI: 10.3389/fnagi.2024.1395911] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2024] [Accepted: 05/27/2024] [Indexed: 07/09/2024] Open
Abstract
Background Patients with carotid atherosclerotic stenosis (CAS) often have varying degrees of cognitive decline. However, there is little evidence regarding how brain morphological and functional abnormalities impact the cognitive decline in CAS patients. This study aimed to determine how the brain morphological and functional changes affected the cognitive decline in patients with CAS. Methods The brain morphological differences were analyzed using surface and voxel-based morphometry, and the seed-based whole-brain functional connectivity (FC) abnormalities were analyzed using resting-state functional magnetic resonance imaging. Further, mediation analyses were performed to determine whether and how morphological and FC changes affect cognition in CAS patients. Results The CAS-MCI (CAS patients with mild cognitive impairment) group performed worse in working memory, verbal fluency, and executive time. Cortical thickness (CT) of the left postcentral and superiorparietal were significantly reduced in CAS-MCI patients. The gray matter volume (GMV) of the right olfactory, left temporal pole (superior temporal gyrus) (TPOsup.L), left middle temporal gyrus (MTG.L), and left insula (INS.L) were decreased in the CAS-MCI group. Besides, decreased seed-based FC between TPOsup.L and left precuneus, between MTG.L and TPOsup.L, and between INS.L and MTG.L, left middle frontal gyrus, as well as Superior frontal gyrus, were found in CAS-MCI patients. Mediation analyses demonstrated that morphological and functional abnormalities fully mediated the association between the maximum degree of carotid stenosis and cognitive function. Conclusion Multiple brain regions have decreased GMV and CT in CAS-MCI patients, along with disrupted seed-based FC. These morphological and functional changes play a crucial role in the cognitive impairment in CAS patients.
Collapse
Affiliation(s)
- Subinuer Maimaitiaili
- Department of Vascular Surgery, Nanjing Drum Tower Hospital, Affiliated Hospital of Medical School, Nanjing University, Nanjing, China
| | - Chen Tang
- Department of Vascular Surgery, Nanjing Drum Tower Hospital, Affiliated Hospital of Medical School, Nanjing University, Nanjing, China
| | - Cheng Liu
- Department of Vascular Surgery, Nanjing Drum Tower Hospital, Affiliated Hospital of Medical School, Nanjing University, Nanjing, China
| | - Xiaochen Lv
- Department of Vascular Surgery, Nanjing Drum Tower Hospital, Affiliated Hospital of Medical School, Nanjing University, Nanjing, China
| | - Zhipeng Chen
- Department of Vascular Surgery, Nanjing Drum Tower Hospital, Affiliated Hospital of Medical School, Nanjing University, Nanjing, China
| | - Mengqiang Zhang
- Department of Vascular Surgery, Nanjing Drum Tower Hospital, Affiliated Hospital of Medical School, Nanjing University, Nanjing, China
| | - Jing Cai
- Department of Vascular Surgery, Nanjing Drum Tower Hospital, Affiliated Hospital of Medical School, Nanjing University, Nanjing, China
| | - Zishun Liang
- Department of Vascular Surgery, Nanjing Drum Tower Hospital, Affiliated Hospital of Medical School, Nanjing University, Nanjing, China
| | - Biao Zhao
- Department of Vascular Surgery, Nanjing Drum Tower Hospital, Affiliated Hospital of Medical School, Nanjing University, Nanjing, China
| | - Wen Zhang
- Department of Radiology, Nanjing Drum Tower Hospital, Affiliated Hospital of Medical School, Nanjing University, Nanjing, China
| | - Tong Qiao
- Department of Vascular Surgery, Nanjing Drum Tower Hospital, Affiliated Hospital of Medical School, Nanjing University, Nanjing, China
| |
Collapse
|
33
|
Caron E, Yadavalli SD, Manchella M, Jabbour G, Mandigers TJ, Gomez-Mayorga JL, Bloch RA, Davis RB, Wang GJ, Nolan BA, Schermerhorn ML. Outcomes of carotid revascularization stratified by procedure in patients with an estimated glomerular filtration rate of <30 and dialysis patients. J Vasc Surg 2024:S0741-5214(24)01252-7. [PMID: 38906431 DOI: 10.1016/j.jvs.2024.06.008] [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: 04/09/2024] [Revised: 06/04/2024] [Accepted: 06/07/2024] [Indexed: 06/23/2024]
Abstract
OBJECTIVE Renal failure is a predictor of adverse outcomes in carotid revascularization. There has been debate regarding the benefit of revascularization in patients with severe chronic kidney disease or on dialysis. METHODS Patients in the Vascular Quality Initiative undergoing transcarotid artery revascularization (TCAR), transfemoral carotid artery stenting (tfCAS), or CEA between 2016 and 2023 with an estimated glomerular filtration rate (eGFR) of <30 mL/min/1.73 m2 or on dialysis were included. Patients were divided into cohorts based on procedure. Additional analyses were performed for patients on dialysis only and by symptomatology. Primary outcomes were perioperative stroke/death/myocardial infarction (MI) (SDM). Secondary outcomes included perioperative death, stroke, MI, cranial nerve injury, and stroke/death. Inverse probability of treatment weighting was performed based on treatment assignment to TCAR, tfCAS, and CEA patients and adjusted for demographics, comorbidities, and preoperative symptoms. The χ2 test and multivariable logistic regression analysis were used to evaluate the association of procedure with perioperative outcomes in the weighted cohort. Five-year survival was evaluated using Kaplan-Meier and weighted Cox regression. RESULTS In the weighted cohort, 13,851 patients with an eGFR of <30 (2506 on dialysis) underwent TCAR (3639; 704 on dialysis), tfCAS (1975; 393 on dialysis), or CEA (8237; 1409 on dialysis) during the study period. Compared with TCAR, CEA had higher odds of SDM (2.8% vs 3.6%; adjusted odds ratio [aOR], 1.27; 95% confidence interval [CI], 1.00-1.61; P = .049), and MI (0.7% vs 1.5%; aOR, 2.00; 95% CI, 1.31-3.05; P = .001). Compared with TCAR, rates of SDM (2.8% vs 5.8%), stroke (1.2% vs 2.6%), and death (0.9% vs 2.4%) were all higher for tfCAS. In asymptomatic patients CEA patients had higher odds of MI (0.7% vs 1.3%; aOR, 1.85; 95% CI, 1.15-2.97; P = .011) and cranial nerve injury (0.3% vs 1.9%; aOR, 7.23; 95% CI, 3.28-15.9; P < .001). Like in the primary analysis, asymptomatic tfCAS patients demonstrated higher odds of death and stroke/death. Symptomatic CEA patients demonstrated no difference in stroke, death, or stroke/death. Although tfCAS patients demonstrated higher odds of death, stroke, MI, stroke/death, and SDM. In both groups, the 5-year survival was similar for TCAR and CEA (eGFR <30, 75.1% vs 74.2%; aHR, 1.06; P = .3) and lower for tfCAS (eGFR <30, 75.1% vs 70.4%; aHR, 1.44; P < .001). CONCLUSIONS CEA and TCAR had similar odds of stroke and death and are both a reasonable choice in this population; however, TCAR may be better in patients with an increased risk of MI. Additionally, tfCAS patients were more likely to have worse outcomes after weighting for symptom status. Finally, although patients with a reduced eGFR have worse outcomes than their healthy peers, this analysis shows that the majority of patients survive long enough to benefit from the potential stroke risk reduction provided by all revascularization procedures.
Collapse
Affiliation(s)
- Elisa Caron
- Divisions of Vascular and Endovascular Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA
| | - Sai Divya Yadavalli
- Divisions of Vascular and Endovascular Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA
| | - Mohit Manchella
- Divisions of Vascular and Endovascular Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA
| | - Gabriel Jabbour
- Divisions of Vascular and Endovascular Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA
| | - Tim J Mandigers
- Divisions of Vascular and Endovascular Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA
| | - Jorge L Gomez-Mayorga
- Divisions of Vascular and Endovascular Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA
| | - Randall A Bloch
- Division of General Surgery, St Elizabeth's Medical Center, Boston University, Boston, MA
| | - Roger B Davis
- Division of General Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA
| | - Grace J Wang
- Division of Vascular Surgery and Endovascular Therapy, Department of Surgery, Hospital of the University of Pennsylvania, Philadelphia, PA
| | - Brian A Nolan
- Division of Vascular and Endovascular Therapy, Department of Surgery, Maine Medical Center, Portland, ME
| | - Marc L Schermerhorn
- Divisions of Vascular and Endovascular Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA.
| |
Collapse
|
34
|
Bloch RA, Ellias SD, Caron E, Prushik SG, Shean KE, Conrad MF. Real-world use of medical therapy in moderate asymptomatic carotid stenosis. J Vasc Surg 2024:S0741-5214(24)01216-3. [PMID: 38906434 DOI: 10.1016/j.jvs.2024.05.037] [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: 04/11/2024] [Revised: 05/14/2024] [Accepted: 05/15/2024] [Indexed: 06/23/2024]
Abstract
OBJECTIVE Despite level 1 evidence demonstrating the benefit of carotid endarterectomy for the prevention of stroke in patients with severe asymptomatic carotid stenosis (ACS), there has been a trend toward recommending optimal medical therapy (OMT) alone. This recommendation has been promulgated based on the observation that modern advances in OMT reduce the overall stroke risk in the general population, but the success of this treatment strategy is dependent on patient and provider adherence. In current practice, patients with moderate ACS are nearly all treated with OMT alone. The objective of this study was to evaluate adherence to OMT in a cohort of patients with moderate ACS undergoing treatment with OMT alone. METHODS Consecutive carotid duplex ultrasound examinations were reviewed for the years 2019 and 2020. Those with moderate (50%-69%) ACS based on Society for Vascular Surgery guidelines were included in the study. Patients were assessed for OMT at the time of the index duplex, the first follow-up visit, and at each subsequent follow-up visit until the end of the study. OMT was defined as abstinence from smoking, aspirin or other antiplatelet use, and statin or other lipid-lowering therapy. Patients were stratified based on their ability to achieve OMT, and each component was evaluated to identify shortfalls in therapy. RESULTS A total of 323 duplex ultrasound examinations with moderate ACS in 255 patients were identified. Of the 255 patients, 143 (56.1%) were on OMT at the time of the first duplex; that number increased to 163 (63.9%) by the first follow-up visit and 175 (68.6%) by the completion of the study. There were 112 (43.9%) patients who were not on OMT at the time of the index duplex, 43 (38.4%) of whom achieved OMT over a median follow-up time of 2.7 years. By the end of follow-up, 86 (76.8%) were taking aspirin or another antiplatelet medication, 93 (83.0%) were on statin or other lipid-lowering therapy, and 74 (66.1%) were abstinent from smoking. Pre-duplex smoking was independently associated with failure to achieve OMT (hazard ratio: 0.452, P = .017). CONCLUSIONS Among patients with moderate ACS who were not previously on OMT, the rate of OMT achievement is poor. Although advances in lipid management through statin therapy have been praised for their role in improving the effectiveness of OMT, smoking cessation represents an important target for improving uptake and as a result effectiveness of OMT.
Collapse
Affiliation(s)
- Randall A Bloch
- Division of Vascular and Endovascular Surgery, St. Elizabeth's Medical Center, Boston University School of Medicine, Boston, MA
| | - Samia D Ellias
- Division of Vascular and Endovascular Surgery, St. Elizabeth's Medical Center, Boston University School of Medicine, Boston, MA
| | - Elisa Caron
- Division of Vascular and Endovascular Surgery, St. Elizabeth's Medical Center, Boston University School of Medicine, Boston, MA
| | - Scott G Prushik
- Division of Vascular and Endovascular Surgery, St. Elizabeth's Medical Center, Boston University School of Medicine, Boston, MA
| | - Katie E Shean
- Division of Vascular and Endovascular Surgery, St. Elizabeth's Medical Center, Boston University School of Medicine, Boston, MA
| | - Mark F Conrad
- Division of Vascular and Endovascular Surgery, St. Elizabeth's Medical Center, Boston University School of Medicine, Boston, MA.
| |
Collapse
|
35
|
Sándor ÁD, Czinege Z, Szabó A, Losoncz E, Tóth K, Mihály Z, Sótonyi P, Merkely B, Székely A. Cerebrovascular dysregulation and postoperative cognitive alterations after carotid endarterectomy. GeroScience 2024:10.1007/s11357-024-01237-6. [PMID: 38877342 DOI: 10.1007/s11357-024-01237-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2024] [Accepted: 06/01/2024] [Indexed: 06/16/2024] Open
Abstract
There are controversial data about the effect of carotid endarterectomy regarding postoperative cognitive function. Our aim was to analyze the effect of cerebral tissue saturation monitored by near-infrared spectroscopy (NIRS) on cognitive function. Perioperative data of 103 asymptomatic patients undergoing elective carotid surgery under general anesthesia were analyzed. Preoperatively and 3 months after the operation, MMSE (Mini Mental State Examination) and MoCA (Montreal Cognitive Assessment) tests were conducted. For cerebral monitoring, NIRS was used, and the lowest rSO2 value and the degree of desaturation were calculated. Cognitive changes were defined as one standard deviation change from the preoperative test scores, defined as postoperative neurocognitive decline (PNCD) and cognitive improvement (POCI). PNCD was found in 37 patients (35.92%), and POCI was found in 18 patients (17.47%). Female gender, patients with diabetes, and the degree of desaturation were independently associated with PNCD. The degree of desaturation during the cross-clamp period negatively correlated with the change in the MoCA scores (R = - 0.707, p = 0.001). The 15.5% desaturation ratio had 86.5% sensitivity and 78.8% specificity for discrimination. For POCI, a desaturation of less than 12.65% had 72.2% sensitivity and 67.1% specificity. POCI was associated with lower preoperative MOCA scores and a lower degree of desaturation. We found a significant relation between the change of postoperative cognitive function proven by the MoCA test and cerebral tissue saturation during the clamping period in patients undergoing carotid endarterectomy.
Collapse
Affiliation(s)
- Ágnes Dóra Sándor
- Department of Anesthesiology and Intensive Therapy, Semmelweis University, Budapest, Hungary
| | - Zsófia Czinege
- Department of Vascular and Endovascular Surgery, Semmelweis University, Budapest, Hungary
| | - András Szabó
- Doctoral School of Theoretical and Translational Medicine, Semmelweis University, Budapest, Hungary
| | - Eszter Losoncz
- Doctoral School of Theoretical and Translational Medicine, Semmelweis University, Budapest, Hungary
| | - Krisztina Tóth
- Doctoral School of Theoretical and Translational Medicine, Semmelweis University, Budapest, Hungary
| | - Zsuzsanna Mihály
- Department of Vascular and Endovascular Surgery, Semmelweis University, Budapest, Hungary
| | - Péter Sótonyi
- Department of Vascular and Endovascular Surgery, Semmelweis University, Budapest, Hungary
| | - Béla Merkely
- Heart and Vascular Center, Semmelweis University, Budapest, Hungary
| | - Andrea Székely
- Department of Anesthesiology and Intensive Therapy, Semmelweis University, Budapest, Hungary.
| |
Collapse
|
36
|
Daolio RM, Zanin LFS, Flumignan CDQ, Cassola N, Guedes Neto HJ, Santos JEM, Amorim JE, Nakano LCU, Flumignan RLG. Accuracy of duplex ultrasonography versus angiotomography for the diagnosis of extracranial internal carotid stenosis. Rev Col Bras Cir 2024; 51:e20243632. [PMID: 38896635 PMCID: PMC11185060 DOI: 10.1590/0100-6991e-20243632-en] [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: 07/28/2023] [Accepted: 02/09/2024] [Indexed: 06/21/2024] Open
Abstract
INTRODUCTION Internal carotid artery (ICA) stenosis causes about 15% of ischemic strokes. Duplex ultrasonography (DUS) is the first line of investigation of ICA stenosis, but its accuracy varies in the literature and it is usual to complement the study with another more accurate exam when faced with significant stenosis. There is a lack of studies that compare DUS with angiotomography (CTA) in the present literature. METHODS we performed an accuracy study, which compared DUS to CTA of patients in a tertiary hospital with a maximum interval of three months between tests. Patients were selected retrospectively, and two independent and certified vascular surgeons evaluated each image in a masked manner. When there was discordance, a third evaluator was summoned. We evaluated the diagnostic accuracy of ICA stenosis of 50-94% and 70-94%. RESULTS we included 45 patients and 84 arteries after inclusion and exclusion criteria applied. For the 50-94% stenosis range, DUS accuracy was 69%, sensitivity 89%, and specificity 63%. For the 70-94% stenosis range, DUS accuracy was 84%, sensitivity 61%, and specificity 93%. There was discordance between CTA evaluators with a change from clinical to surgical management in at least 37.5% of the conflicting reports. CONCLUSION DUS had an accuracy of 69% for stenoses of 50-94% and 84% for stenoses of 70-94% of the ICA. The CTA analysis depended directly on the evaluator with a change in clinical conduct in more than 37% of cases.
Collapse
Affiliation(s)
- Raul Muffato Daolio
- - Universidade Federal de São Paulo, Departamento de Cirurgia, Disciplina de Cirurgia Vascular e Endovascular - São Paulo - SP - Brasil
| | - Luiz Fernando Santetti Zanin
- - Universidade Federal de São Paulo, Departamento de Cirurgia, Disciplina de Cirurgia Vascular e Endovascular - São Paulo - SP - Brasil
| | | | - Nicolle Cassola
- - Universidade Federal de São Paulo, Departamento de Cirurgia, Disciplina de Cirurgia Vascular e Endovascular - São Paulo - SP - Brasil
| | - Henrique Jorge Guedes Neto
- - Universidade Federal de São Paulo, Departamento de Cirurgia, Disciplina de Cirurgia Vascular e Endovascular - São Paulo - SP - Brasil
| | | | - Jorge Eduardo Amorim
- - Universidade Federal de São Paulo, Departamento de Cirurgia, Disciplina de Cirurgia Vascular e Endovascular - São Paulo - SP - Brasil
| | - Luís Carlos Uta Nakano
- - Universidade Federal de São Paulo, Departamento de Cirurgia, Disciplina de Cirurgia Vascular e Endovascular - São Paulo - SP - Brasil
| | - Ronald Luiz Gomes Flumignan
- - Universidade Federal de São Paulo, Departamento de Cirurgia, Disciplina de Cirurgia Vascular e Endovascular - São Paulo - SP - Brasil
| |
Collapse
|
37
|
Paraskevas KI, AbuRahma AF. A comparison of the 2022 Society for Vascular Surgery and the 2023 European Society for Vascular Surgery guidelines for the management of patients with asymptomatic and symptomatic carotid stenosis. J Vasc Surg 2024; 79:1272-1275. [PMID: 38310980 DOI: 10.1016/j.jvs.2024.01.210] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2023] [Revised: 01/20/2024] [Accepted: 01/28/2024] [Indexed: 02/06/2024]
Affiliation(s)
| | - Ali F AbuRahma
- Department of Surgery, Charleston Area Medical Center/West Virginia University, Charleston, WV
| |
Collapse
|
38
|
Altreuther M, Seternes A, Saltnes T, Myrbø N, Vikan K, Nilsen LH, Feng T. Antithrombotic and Lipid Lowering Therapy is Associated With Improved Survival After Vascular Surgery: A Population Based Study From Norway. Eur J Vasc Endovasc Surg 2024; 67:988-994. [PMID: 37866794 DOI: 10.1016/j.ejvs.2023.10.019] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2023] [Revised: 09/18/2023] [Accepted: 10/18/2023] [Indexed: 10/24/2023]
Abstract
OBJECTIVE This population based retrospective cohort study aimed to investigate the association between combined treatment with lipid lowering drugs and antiplatelet or anticoagulation therapy and long term survival following vascular surgery in Norway. METHODS The study included all patients who were registered for the treatment of carotid stenosis, abdominal aortic aneurysm (AAA), and atherosclerotic lower extremity arterial disease (LEAD) in the Norwegian Registry for Vascular Surgery between 2015 and 2019 and who were discharged alive. Clinical and medication details were retrieved from the register. Survival was assessed with Kaplan-Meier analysis and a multivariable Cox regression model. Stratification was according to treatment group, patient sex, and if patients received the recommended medications or not. Recommended medications were defined as lipid lowering drugs, usually statins, and antiplatelets, or sometimes anticoagulants, when comorbidity indicated anticoagulation therapy. RESULTS In total, 15 810 patients had LEAD, 4 080 patients AAA, and 2 194 patients had carotid stenosis. In all treatment groups, survival was superior for patients who used the recommended medications upon discharge. The difference was greatest in patients with LEAD with mean survival periods of 4.33 (95% CI 4.29 - 4.36) and 3.7 (95% CI 3.64 - 3.77) years in patients discharged with and without the recommended medications, respectively (p < .001). The mean survival periods were 4.67 (95% CI 4.61 - 4.73) and 4.34 (95% CI 4.24 - 4.44) years in patients with AAA discharged with and without the recommended medications, respectively (p < .001). Cox regression analysis showed a statistically significantly lower mortality rate for patients discharged with the recommended medications for LEAD (HR 0.58; p < .001) and AAA (HR 0.57; p < .001). CONCLUSION The recommended medications were associated with improved survival in all treatment groups and both sexes. The survival difference was statistically significant in patients with LEAD and AAA. Patients with LEAD had the greatest improvement; therefore, the recommended secondary prophylaxis is especially important in these patients.
Collapse
Affiliation(s)
- Martin Altreuther
- Section of Vascular Surgery, Department of Surgery, Trondheim University Hospital, St Olavs Hospital, Trondheim, Norway; Department of Circulation and Medical Imaging, Norwegian University of Science and Technology, Trondheim, Norway; Norwegian Registry for Vascular surgery (NORKAR), Department of Medical Quality Registries, St Olavs hospital, Trondheim University Hospital, Trondheim, Norway.
| | - Arne Seternes
- Section of Vascular Surgery, Department of Surgery, Trondheim University Hospital, St Olavs Hospital, Trondheim, Norway; Department of Circulation and Medical Imaging, Norwegian University of Science and Technology, Trondheim, Norway
| | - Turi Saltnes
- Norwegian Registry for Vascular surgery (NORKAR), Department of Medical Quality Registries, St Olavs hospital, Trondheim University Hospital, Trondheim, Norway
| | - Nadia Myrbø
- Norwegian Registry for Vascular surgery (NORKAR), Department of Medical Quality Registries, St Olavs hospital, Trondheim University Hospital, Trondheim, Norway
| | - Kristin Vikan
- Norwegian Registry for Vascular surgery (NORKAR), Department of Medical Quality Registries, St Olavs hospital, Trondheim University Hospital, Trondheim, Norway
| | - Linn Hege Nilsen
- Norwegian Registry for Vascular surgery (NORKAR), Department of Medical Quality Registries, St Olavs hospital, Trondheim University Hospital, Trondheim, Norway
| | - Tingting Feng
- Norwegian Registry for Vascular surgery (NORKAR), Department of Medical Quality Registries, St Olavs hospital, Trondheim University Hospital, Trondheim, Norway
| |
Collapse
|
39
|
Wong KHF, Mouton R, Hinchliffe RJ. Epidemiology of tobacco smoking in patients undergoing elective vascular surgery in the UK. Anaesthesia 2024; 79:656-658. [PMID: 38444098 DOI: 10.1111/anae.16266] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/17/2024] [Indexed: 03/07/2024]
Affiliation(s)
- K H F Wong
- Bristol Medical School, University of Bristol, Bristol, UK
| | - R Mouton
- Bristol Medical School, University of Bristol, Bristol, UK
| | - R J Hinchliffe
- Bristol Medical School, University of Bristol, Bristol, UK
| |
Collapse
|
40
|
Bastos Gonçalves F, Mees B, Tulamo R. ESVS Guidelines App: Bringing Evidence Based Vascular Practice to your Pocket. Eur J Vasc Endovasc Surg 2024; 67:872-874. [PMID: 38485048 DOI: 10.1016/j.ejvs.2024.03.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2024] [Revised: 02/22/2024] [Accepted: 03/11/2024] [Indexed: 04/14/2024]
Affiliation(s)
- Frederico Bastos Gonçalves
- Hospital de Santa Marta, Unidade Local de Saúde São José, Centro Clínico; Académico de Lisboa, Lisbon, Portugal; NOVA Medical School|Faculdade de Ciências Médicas, NMS|FCM, Universidade Nova de Lisboa, Lisbon, Portugal; Hospital CUF Tejo, Lisbon, Portugal.
| | - Barend Mees
- Department of Vascular Surgery, Maastricht UMC, Maastricht, The Netherlands
| | - Riikka Tulamo
- Department of Vascular Surgery, Helsinki University Hospital and University of Helsinki, Helsinki, Finland
| |
Collapse
|
41
|
Spiliopoulos S, Blanc R, Gandini R, Müller-Hülsbeck S, Reith W, Moschovaki-Zeiger O. CIRSE Standards of Practice on Carotid Artery Stenting. Cardiovasc Intervent Radiol 2024; 47:705-716. [PMID: 38683353 PMCID: PMC11164804 DOI: 10.1007/s00270-024-03707-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/07/2023] [Accepted: 03/06/2024] [Indexed: 05/01/2024]
Abstract
BACKGROUND Carotid artery stenting has been used effectively to treat internal carotid artery stenosis since 1989 (Mathias et al. in World J Surg. 25(3):328-34, 2001), with refined and expanded techniques and tools presently delivering outstanding results in percutaneous endoluminal treatment of carotid artery stenosis. PURPOSE This CIRSE Standards of Practice document is directed at interventional radiologists and details the guidelines for carotid artery stenting, as well as the different implementation techniques. In addition to updating all previously published material on the different clinical indications, it will provide all technical details reflective of European practice for carotid artery stenting. CIRSE Standards of Practice documents do not aim to implement a standard of clinical patient care, but rather to provide a realistic strategy and best practices for the execution of this procedure. METHODS The writing group, which was established by the CIRSE Standards of Practice Committee, consisted of five clinicians with internationally recognised expertise in carotid artery stenting procedures. The writing group reviewed existing literature on carotid artery stenting procedures, performing a pragmatic evidence search using PubMed to select relevant publications in the English language from 2006 to 2022. RESULTS Carotid artery stenting has an established role in the management of internal carotid artery stenosis; this Standards of Practice document provides up-to-date recommendations for its safe performance.
Collapse
Affiliation(s)
- Stavros Spiliopoulos
- Interventional Radiology Unit, 2nd Department of Radiology, National and Kapodistrian University of Athens, "Attikon" University General Hospital, Athens, Greece.
| | - Raphaël Blanc
- Department of Interventional Neuroradiology, Foundation Rothschild Hospital, Paris, France
| | - Roberto Gandini
- Diagnostic and Interventional Radiology/Neuroradiology, University of Rome "Tor Vergata", Rome, Italy
| | - Stefan Müller-Hülsbeck
- Diagnostic and Interventional Radiology/Neuroradiology, DIAKO Hospital, Flensburg, Germany
| | - Wolfgang Reith
- Department of Neuroradiology, Saarland University, Homberg, Germany
| | - Ornella Moschovaki-Zeiger
- Interventional Radiology Unit, 2nd Department of Radiology, National and Kapodistrian University of Athens, "Attikon" University General Hospital, Athens, Greece
| |
Collapse
|
42
|
Trystula M, VAN Herzeele I, Kolvenbach R, Tekieli L, Fonteyne C, Mazurek A, Dzierwa K, Chmiel J, Lindsay J, Kwiatkowski T, Hydzik A, Oplawski M, Bederski K, Musialek P. Next-generation transcarotid artery revascularization: TransCarotid flOw Reversal Cerebral Protection And CGUARD MicroNET-Covered Embolic Prevention Stent System To Reduce Strokes - TOPGUARD Study. THE JOURNAL OF CARDIOVASCULAR SURGERY 2024; 65:181-194. [PMID: 39007552 DOI: 10.23736/s0021-9509.24.13121-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 07/16/2024]
Abstract
BACKGROUND Stent-assisted carotid artery revascularization employing surgical cutdown for transcervical access and dynamic flow reversal (TCAR) is gaining popularity. TCAR, despite maximized intra-procedural cerebral protection, shows a marked excess of 30-day neurologic complications in symptomatic vs. asymptomatic stenoses. The TCAR conventional single-layer stent (free-cell area 5.89mm2) inability to seal embologenic lesions may be particularly relevant after the flow reversal neuroprotection is terminated. METHODS We evaluated peri-procedural and 30-day major adverse cerebral and cardiac events (MACCE) of TCAR (ENROUTE, SilkRoad Medical) paired with MicroNET-covered neuroprotective stent (CGuard, InspireMD) in consecutive patients at elevated risk of complications with transfemoral/transradial filter-protected stenting (increased lesion-related and/or access-related risk). CGuard (MicroNET free cell area ≈0.02-0.03 mm2) has level-1 evidence for reducing intra- and abolishing post-procedural lesion-related cerebral embolism. RESULTS One hundred and six increased-risk patients (age 72 [61-76] years, median [Q1-Q3]; 60.4% symptomatic, 49.1% diabetic, 36.8% women, 61.3% left-sided index lesion) were enrolled in three vascular surgery centers. Angiographic stenosis severity was 81 (75-91)%, lesion length 21 (15-26)mm, increased-risk lesional characteristics 87.7%. Study stent use was 100% (no other stent types). 74.5% lesions were predilated; post-dilatation rate was 90.6%. Flow reversal duration was 8 (5-11)min. One stroke (0.9%) occurred in an asymptomatic patient prior to establishing neuroprotection (index lesion disruption with the sheath insertion wire); there were no other peri-procedural MACCE. No further adverse events occurred by 30-days. 30-day stent patency was 100% with normal velocities and absence of any in-stent material by Duplex Doppler. CONCLUSIONS Despite a high proportion of increased-risk lesions and clinically symptomatic patients in this study, TCAR employing the MicroNET-covered anti-embolic stent showed 30-day MACCE rate <1%. This suggests a clinical role for combining maximized intra-procedural prevention of cerebral embolism by dynamic flow reversal with anti-embolic stent prevention of peri- and post-procedural cerebral embolism (TOPGUARD NCT04547387).
Collapse
Affiliation(s)
- Mariusz Trystula
- Department of Vascular Surgery, St. John Paul II Hospital, Krakow, Poland
| | - Isabelle VAN Herzeele
- Department of Thoracic and Vascular Surgery, Ghent University Hospital, Ghent, Belgium
| | - Ralf Kolvenbach
- Department of Vascular Surgery, Sana Kliniken, Düsseldorf, Germany
| | - Lukasz Tekieli
- Department of Cardiac and Vascular Diseases, Jagiellonian University Medical College, Krakow, Poland
- Stroke Thrombectomy-Capable Center, St. John Paul II Hospital, Krakow, Poland
| | - Charlotte Fonteyne
- Department of Thoracic and Vascular Surgery, University of Ghent, Ghent, Belgium
| | - Adam Mazurek
- Department of Cardiac and Vascular Diseases, Jagiellonian University Medical College, Krakow, Poland
- Stroke Thrombectomy-Capable Center, St. John Paul II Hospital, Krakow, Poland
| | - Karolina Dzierwa
- Cardiovascular Imaging Laboratory, St. John Paul II Hospital, Krakow, Poland
| | - Jakub Chmiel
- Department of Cardiac and Vascular Diseases, Jagiellonian University Medical College, Krakow, Poland
- Stroke Thrombectomy-Capable Center, St. John Paul II Hospital, Krakow, Poland
| | | | - Tomasz Kwiatkowski
- Department of Vascular Surgery, St. John Paul II Hospital, Krakow, Poland
| | - Adam Hydzik
- Department of Vascular Surgery, St. John Paul II Hospital, Krakow, Poland
| | | | - Krzysztof Bederski
- Department of Thoracic Surgery, St. John Paul II Hospital, Krakow, Poland
| | - Piotr Musialek
- Department of Cardiac and Vascular Diseases, Jagiellonian University Medical College, Krakow, Poland -
- Stroke Thrombectomy-Capable Center, St. John Paul II Hospital, Krakow, Poland
| |
Collapse
|
43
|
Onalan A, Gurkas E, Kursad Akpinar C, Aykac O, Uysal Kocabas Z, Dogan H, Temel M, Ozcan Ozdemir A. Safety and effectiveness of anticoagulation in the management of acute stroke and transient ischemic attack due to intracranial and extracranial non-occlusive thrombus. J Clin Neurosci 2024; 124:47-53. [PMID: 38643651 DOI: 10.1016/j.jocn.2024.04.012] [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: 01/07/2024] [Revised: 04/04/2024] [Accepted: 04/10/2024] [Indexed: 04/23/2024]
Abstract
INTRODUCTION The awareness of nonocclusive thrombus has increased with the increasing frequency of imaging methods used for acute ischemic stroke; however, the best treatment for nonocclusive thrombi is still unknown. In this study, we examined how anticoagulants affect supra-aortic artery nonocclusive thrombus and clinical outcomes. MATERIALS AND METHODS This study included 52 patients with transient ischemic attack or stroke who were diagnosed with nonocclusive thrombi on computed tomography angiography at admission. Patients were treated with anticoagulant treatment and grouped according to treatment modality (either unfractionated heparin or low molecular weight heparin) and treatment duration. Primary safety outcome was major bleeding defined as immediate and clnically significant hemorrhage. Anticoagulant treatment was continued until the thrombus was resolved as determined by consecutive weekly computed tomography angiography controls. After thrombus resolution, treatment was directed according to the underlying etiology. Antiaggregation treatment was the preferred treatment after thrombus resolution for patients with no observed etiology. RESULTS The affected internal carotid arteries were most frequently located in the cervical segment (48 %). Complete resolution was achieved within 2 weeks in 50 patients (96 %). The involved vasculature included the following: the extracranial carotid artery segments (n = 26, 50 %), intracranial ICA segments (n = 10, 19 %), basilar artery segments (n = 8, 15 %) and MCA segments (n = 7, 13 %). The most common underlying pathologies were atherosclerosis (n = 17), atrial fibrillation (n = 17), undetermined embolic stroke (n = 8), dissection (n = 7), and malignancy (n = 2). No symptomatic intra- or extracranial bleeding complications due to anticoagulant use were observed in any patient during the study period. A good functional outcome (modified Rankin scale score 0-2) was achieved in 49 patients (94 %) at 3 months. There was no significant difference between treatment type and duration in terms of reinfarction (p = 0.97 and p = 0.78, respectively). CONCLUSION Anticoagulant treatment is safe and effective in symptomatic patients with intracranial or extracranial artery nonocclusive thrombus, regardless of the anticoagulant type, thrombus location and size.
Collapse
Affiliation(s)
- Aysenur Onalan
- University of Health Sciences, Kartal Dr. Lutfi Kirdar City Hospital, Istanbul, Turkey Department of Neurology, Stroke Center, Turkey.
| | - Erdem Gurkas
- University of Health Sciences, Kartal Dr. Lutfi Kirdar City Hospital, Istanbul, Turkey Department of Neurology, Stroke Center, Turkey
| | | | - Ozlem Aykac
- Eskisehir Osmangazi University, Department of Neurology, Stroke Center, Eskisehir, Turkey
| | - Zehra Uysal Kocabas
- Eskisehir Osmangazi University, Department of Neurology, Stroke Center, Eskisehir, Turkey
| | - Hasan Dogan
- Samsun University, Department of Neurology, Stroke Center, Samsun, Turkey
| | - Musa Temel
- Sanliurfa Mehmet Akif Inan Research Hospital, Department of Neurology, Sanliurfa, Turkey
| | - Atilla Ozcan Ozdemir
- Eskisehir Osmangazi University, Department of Neurology, Stroke Center, Eskisehir, Turkey
| |
Collapse
|
44
|
Clouse WD. No Answers. Just More Questions: Comment on Combined Coronary and Carotid Artery Disease: What to Operate on First? Or Both at the Same Time? J Cardiothorac Vasc Anesth 2024; 38:1423-1424. [PMID: 38555214 DOI: 10.1053/j.jvca.2023.10.039] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/27/2023] [Accepted: 10/30/2023] [Indexed: 04/02/2024]
Affiliation(s)
- W Darrin Clouse
- Divsion of Vascular and Endovascular Surgery, University of Virginia Health, Charlottesville, VA.
| |
Collapse
|
45
|
Sterpetti AV, Gabriele R, Borrelli V, Campagnol M, Iannone I, Costi U, Sapienza P, Dimarzo L. Clinical outcomes for patients with cardiovascular diseases before, during, and after the COVID19 pandemic. A pooled analysis of 600.000 patients. Curr Probl Cardiol 2024; 49:102540. [PMID: 38521287 DOI: 10.1016/j.cpcardiol.2024.102540] [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: 03/20/2024] [Accepted: 03/20/2024] [Indexed: 03/25/2024]
Abstract
BACKGROUND The unexpected virulence of the COVID19 pandemic brought to significant changes of generally accepted therapeutic approaches. The consequences of these changes were difficult to define during the pandemic period. METHODS We analyzed the National Registries including 97% of hospital admissions in Italy, regarding data describing number of operations for aortic valve implantation or repair, carotid and coronary revascularization, AAA repair, and lower limb arterial reconstruction performed in the period 2015 to 2019 and in the pandemic years 2020, 2021, and 2022. Primary outcomes were number and type of surgical procedures, 30-days operative mortality. RESULTS During the three years of the pandemic there was a statistically significant increase of the number of all-causes deaths in comparison with the mean of the previous five years (2015-2019). In Italy there was a total increase of all causes-deaths of 251.911 (+105900 in 2020; +66929 in 2021; and +79082 in 2022), and 73% of the excess of deaths was related with COVID19 infection and 27% occurred in COVID 19 negative patients. During the first year of the pandemic, worse clinical outcomes for hospitalized patients with CVD were registered. The medical system responded adequately and in the following two pandemic years clinical outcomes for hospitalized patients were similar with those of the pre-pandemic period. CONCLUSIONS The unexpected virulence of COVID19 pandemic determined worse clinical outcomes for patients with CVD during the first year. The adopted preventive measures allowed in the following two pandemic years improved clinical outcomes, similar with those of the pre-pandemic period.
Collapse
Affiliation(s)
| | | | | | | | | | | | | | - Luca Dimarzo
- Department of vascular endovascular surgery, Sapienza university Rome, Italy
| |
Collapse
|
46
|
Schwindt A, Kedev S, Vajda Z, Deloose K, Latacz P, Cvetic V, Müller-Hülsbeck S, Langhoff R. Comparative analysis of carotid artery stenting practice and outcomes across operator specialties: insights from a prespecified subanalysis of a large real-world patient cohort (ROADSAVER Study). THE JOURNAL OF CARDIOVASCULAR SURGERY 2024; 65:195-204. [PMID: 39007553 DOI: 10.23736/s0021-9509.24.13069-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 07/16/2024]
Abstract
BACKGROUND In contemporary clinical practice, carotid artery stenting (CAS) is increasingly becoming a multispecialty field, joining operators of various training backgrounds, which bring forth their unique expertise, patient management philosophies, and procedural preferences. The best practices and approaches, however, are still debated. Therefore, real-world insights on different operator preferences and related outcomes are of utmost value, yet still rather scarce in the available literature. METHODS Using the data collected in the ROADSAVER observational, European multicenter CAS study, a prespecified comparative analysis evaluating the impact of the operator's specialization was performed. We used major adverse event (MAE) rate at 30-day follow-up, defined as the cumulative incidence of any death or stroke, and its components as outcome measures. RESULTS A total of 1965 procedures were analyzed; almost half 878 (44.7%) were performed by radiologists (interventional/neuro), 717 (36.5%) by cardiologists or angiologists, and 370 (18.8%) by surgeons (vascular/neuro). Patients treated by surgeons were the oldest (72.9±8.5), while radiologists treated most symptomatic patients (58.1%) and more often used radial access (37.2%). The 30-day MAE incidence achieved by cardiologists/angiologists was 2.0%, radiologists 2.5%, and surgeons 1.9%; the observed differences in rates were statistically not-significant (P=0.7027), even when adjusted for baseline patient/lesion and procedural disparities across groups. The corresponding incidence rates for death from any cause were 1.0%, 0.8%, and 0.3%, P=0.4880, and for any stroke: 1.4%, 2.3%, and 1.9%, P=0.4477, respectively. CONCLUSIONS Despite the disparities in patient selection and procedural preferences, the outcomes achieved by different specialties in real-world, contemporary CAS practice remain similar when using modern devices and techniques.
Collapse
Affiliation(s)
- Arne Schwindt
- Department of Vascular Surgery, St. Franziskus-Hospital, Münster, Germany -
| | - Sasko Kedev
- Department of Cardiology, Faculty of Medicine, University Clinic of Cardiology, University of St. Cyril & Methodius, Skopje, Republic of North Macedonia
| | - Zsolt Vajda
- Neurovascular Unit, Moritz Kaposi Teaching Hospital, Kaposvár, Hungary
- Department of Radiology, Fejér County Szent György University Teaching Hospital, Székesfehérvár, Hungary
| | - Koen Deloose
- Department of Vascular Surgery, AZ-Sint Blasius, Dendermonde, Belgium
| | - Paweł Latacz
- Department of Vascular Surgery and Angiology, Brothers of Mercy St. John of God Hospital, Kraków, Poland
| | - Vladimir Cvetic
- Department of Cardiovascular Radiology, Clinic for Vascular and Endovascular Surgery, University Clinical Centre of Serbia, Belgrade, Serbia
| | - Stefan Müller-Hülsbeck
- Department of Diagnostic and Interventional Radiology and Neuroradiology, DIAKO Hospital gGmbH, Flensburg, Germany
| | - Ralf Langhoff
- Department of Angiology, Brandenburg Medical School Theodor Fontane, Campus Clinic Brandenburg, Brandenburg an der Havel and Sankt Gertrauden Hospital, Berlin, Germany
| |
Collapse
|
47
|
Ciaramella MA, Liang P, Hamdan AD, Wyers MC, Schermerhorn ML, Stangenberg L. Unplanned Stenting for Treatment of Distal Endpoint Issues During Carotid Endarterectomy. Eur J Vasc Endovasc Surg 2024; 67:1021-1022. [PMID: 38527518 DOI: 10.1016/j.ejvs.2024.03.030] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2023] [Revised: 03/04/2024] [Accepted: 03/21/2024] [Indexed: 03/27/2024]
Affiliation(s)
- Michael A Ciaramella
- Department of Surgery, Division of Vascular and Endovascular Surgery, Beth Israel Deaconess Medical Centre, Harvard Medical School, Boston, MA USA
| | - Patric Liang
- Department of Surgery, Division of Vascular and Endovascular Surgery, Beth Israel Deaconess Medical Centre, Harvard Medical School, Boston, MA USA
| | - Allen D Hamdan
- Department of Surgery, Division of Vascular and Endovascular Surgery, Beth Israel Deaconess Medical Centre, Harvard Medical School, Boston, MA USA
| | - Mark C Wyers
- Department of Surgery, Division of Vascular and Endovascular Surgery, Beth Israel Deaconess Medical Centre, Harvard Medical School, Boston, MA USA
| | - Marc L Schermerhorn
- Department of Surgery, Division of Vascular and Endovascular Surgery, Beth Israel Deaconess Medical Centre, Harvard Medical School, Boston, MA USA
| | - Lars Stangenberg
- Department of Surgery, Division of Vascular and Endovascular Surgery, Beth Israel Deaconess Medical Centre, Harvard Medical School, Boston, MA USA.
| |
Collapse
|
48
|
Tekieli L, Dzierwa K, Grunwald IQ, Mazurek A, Urbanczyk-Zawadzka M, Wiewiorka L, Banys RP, Dabrowski W, Podlasek A, Weglarz E, Stefaniak J, Nizankowski RT, Musialek P. Outcomes in acute carotid-related stroke eligible for mechanical reperfusion: SAFEGUARD-STROKE Registry. THE JOURNAL OF CARDIOVASCULAR SURGERY 2024; 65:231-248. [PMID: 39007556 DOI: 10.23736/s0021-9509.24.13093-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 07/16/2024]
Abstract
BACKGROUND Carotid-related strokes (CRS) are largely unresponsive to intravenous thrombolysis and are often large and disabling. Little is known about contemporary CRS referral pathways and proportion of eligible patients who receive emergency mechanical reperfusion (EMR). METHODS Referral pathways, serial imaging, treatment data, and neurologic outcomes were evaluated in consecutive CRS patients presenting over 18 months in catchment area of a major carotid disease referral center with proximal-protected CAS expertise, on-site neurology, and stroke thrombectomy capability (Acute Stroke of CArotid Artery Bifurcation Origin Treated With Use oF the MicronEt-covered CGUARD Stent - SAFEGUARD-STROKE Registry; companion to SAFEGUARD-STROKE Study NCT05195658). RESULTS Of 101 EMR-eligible patients (31% i.v.-thrombolyzed, 39.5% women, age 39-89 years, 94.1% ASPECTS 9-10, 90.1% pre-stroke mRS 0-1), 57 (56.4%) were EMR-referred. Referrals were either endovascular (Comprehensive Stroke Centre, CSC, 21.0%; Stroke Thrombectomy-Capable CAS Centre, STCC, 70.2%) or to vascular surgery (VS, 1.8%), with >1 referral attempt in 7.0% patients (CSC/VS or VS/CSC or CSC/VS/STCC). Baseline clinical and imaging characteristics were not different between EMR-treated and EMR-untreated patients. EMR was delivered to 42.6% eligible patients (emergency carotid surgery 0%; STCC rejections 0%). On multivariable analysis, non-tandem CRS was a predictor of not getting referred for EMR (OR 0.36; 95%CI 0.14-0.93, P=0.03). Ninety-day neurologic status was profoundly better in EMR-treated patients; mRS 0-2 (83.7% vs. 34.5%); mRS 3-5 (11.6% vs. 53.4%), mRS 6 (4.6% vs. 12.1%); P<0.001 for all. CONCLUSIONS EMR-treatment substantially improves CRS neurologic outcomes but only a minority of EMR-eligible patients receive EMR. To increase the likelihood of brain-saving treatment, EMR-eligible stroke referral and management pathways, including those for CSC/VS-rejected patients, should involve stroke thrombectomy-capable centres with endovascular carotid treatment expertise.
Collapse
Affiliation(s)
- Lukasz Tekieli
- Stroke Thrombectomy-Capable Center, St. John Paul II Hospital, Krakow, Poland -
- Department of Cardiac and Vascular Diseases, Jagiellonian University Medical College, Krakow, Poland -
- Department of Interventional Cardiology, Jagiellonian University Medical College, Krakow, Poland -
| | - Karolina Dzierwa
- Cardiovascular Imaging Laboratory, St. John Paul II Hospital, Krakow, Poland
| | - Iris Q Grunwald
- Division of Imaging Science and Technology, School of Medicine, University of Dundee, Dundee, UK
- Department of Radiology, University of Dundee Ninewells Hospital, Dundee, UK
| | - Adam Mazurek
- Stroke Thrombectomy-Capable Center, St. John Paul II Hospital, Krakow, Poland
- Department of Cardiac and Vascular Diseases, Jagiellonian University Medical College, Krakow, Poland
| | | | - Lukasz Wiewiorka
- Department of Radiology, St. John Paul II Hospital, Krakow, Poland
| | - R Pawel Banys
- Department of Radiology, St. John Paul II Hospital, Krakow, Poland
| | - Wladyslaw Dabrowski
- Department of Interventional Cardiology, Jagiellonian University Medical College, Krakow, Poland
| | - Anna Podlasek
- Tayside Innovation MedTech Ecosystem (TIME), University of Dundee, Dundee, UK
- Precison Imaging Beacon, Radiological Sciences, University of Nottingham, Nottingham, UK
| | - Ewa Weglarz
- Department of Interventional Cardiology, Jagiellonian University Medical College, Krakow, Poland
- Department of Nursing, Faculty of Health Sciences, Jagiellonian University Medical College, Krakow, Poland
| | - Justyna Stefaniak
- Department of Bioinformatics and Telemedicine, Jagiellonian University Medical College, Krakow, Poland
| | - Rafal T Nizankowski
- Quality Promotion in Healthcare, Sano Center for Computational Medicine, Krakow, Poland
| | - Piotr Musialek
- Stroke Thrombectomy-Capable Center, St. John Paul II Hospital, Krakow, Poland
- Department of Cardiac and Vascular Diseases, Jagiellonian University Medical College, Krakow, Poland
| |
Collapse
|
49
|
Ristow AVB, Massière B, Meirelles GV, Casella IB, Morales MM, Moreira RCR, Procópio RJ, Oliveira TF, de Araujo WJB, Joviliano EE, de Oliveira JCP. Brazilian Angiology and Vascular Surgery Society Guidelines for the treatment of extracranial cerebrovascular disease. J Vasc Bras 2024; 23:e20230094. [PMID: 39099701 PMCID: PMC11296686 DOI: 10.1590/1677-5449.202300942] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2023] [Accepted: 10/16/2023] [Indexed: 08/06/2024] Open
Abstract
Extracranial cerebrovascular disease has been the subject of intense research throughout the world, and is of paramount importance for vascular surgeons. This guideline, written by the Brazilian Society of Angiology and Vascular Surgery (SBACV), supersedes the 2015 guideline. Non-atherosclerotic carotid artery diseases were not included in this document. The purpose of this guideline is to bring together the most robust evidence in this area in order to help specialists in the treatment decision-making process. The AGREE II methodology and the European Society of Cardiology system were used for recommendations and levels of evidence. The recommendations were graded from I to III, and levels of evidence were classified as A, B, or C. This guideline is divided into 11 chapters dealing with the various aspects of extracranial cerebrovascular disease: diagnosis, treatments and complications, based on up-to-date knowledge and the recommendations proposed by SBACV.
Collapse
Affiliation(s)
- Arno von Buettner Ristow
- Pontifícia Universidade Católica do Rio de Janeiro – PUC-RIO, Disciplina de Cirurgia Vascular e Endovascular, Rio de Janeiro, RJ, Brasil.
- Sociedade Brasileira de Angiologia e de Cirurgia Vascular – SBACV-RJ, Rio de Janeiro, RJ, Brasil.
| | - Bernardo Massière
- Pontifícia Universidade Católica do Rio de Janeiro – PUC-RIO, Disciplina de Cirurgia Vascular e Endovascular, Rio de Janeiro, RJ, Brasil.
- Sociedade Brasileira de Angiologia e de Cirurgia Vascular – SBACV-RJ, Rio de Janeiro, RJ, Brasil.
| | - Guilherme Vieira Meirelles
- Sociedade Brasileira de Angiologia e de Cirurgia Vascular – SBACV-SP, São Paulo, SP, Brasil.
- Universidade Estadual de Campinas – UNICAMP, Hospital das Clínicas, Disciplina de Cirurgia do Trauma, Campinas, SP, Brasil.
| | - Ivan Benaduce Casella
- Sociedade Brasileira de Angiologia e de Cirurgia Vascular – SBACV-SP, São Paulo, SP, Brasil.
- Universidade de São Paulo – USP, Faculdade de Medicina, São Paulo, SP, Brasil.
| | - Marcia Maria Morales
- Sociedade Brasileira de Angiologia e de Cirurgia Vascular – SBACV-SP, São Paulo, SP, Brasil.
- Associação Portuguesa de Beneficência de São José do Rio Preto, Serviço de Cirurgia Vascular, São José do Rio Preto, SP, Brasil.
| | - Ricardo Cesar Rocha Moreira
- Sociedade Brasileira de Angiologia e de Cirurgia Vascular – SBACV-PR, Curitiba, PR, Brasil.
- Pontifícia Universidade Católica do Paraná – PUC-PR, Hospital Cajurú, Serviço de Cirurgia Vascular, Curitiba, PR, Brasil.
| | - Ricardo Jayme Procópio
- Universidade Federal de Minas Gerais – UFMG, Hospital das Clínicas, Setor de Cirurgia Endovascular, Belo Horizonte, MG, Brasil.
- Universidade Federal de Minas Gerais – UFMG, Faculdade de Medicina, Belo Horizonte, MG, Brasil.
- Sociedade Brasileira de Angiologia e de Cirurgia Vascular – SBACV-MG, Belo Horizonte, MG, Brasil.
| | - Tércio Ferreira Oliveira
- Sociedade Brasileira de Angiologia e de Cirurgia Vascular – SBACV-SE, Aracajú, SE, Brasil.
- Universidade de São Paulo – USP, Faculdade de Medicina de Ribeirão Preto – FMRP, Ribeirão Preto, SP, Brasil.
| | - Walter Jr. Boim de Araujo
- Sociedade Brasileira de Angiologia e de Cirurgia Vascular – SBACV-PR, Curitiba, PR, Brasil.
- Universidade Federal do Paraná – UFPR, Hospital das Clínicas – HC, Curitiba, PR, Brasil.
| | - Edwaldo Edner Joviliano
- Sociedade Brasileira de Angiologia e de Cirurgia Vascular – SBACV-SP, São Paulo, SP, Brasil.
- Universidade de São Paulo – USP, Faculdade de Medicina de Ribeirão Preto – FMRP, Ribeirão Preto, SP, Brasil.
| | - Júlio Cesar Peclat de Oliveira
- Sociedade Brasileira de Angiologia e de Cirurgia Vascular – SBACV-SP, São Paulo, SP, Brasil.
- Universidade Federal do Estado do Rio de Janeiro – UNIRIO, Departamento de Cirurgia, Rio de Janeiro, RJ, Brasil.
| |
Collapse
|
50
|
Straus S, Yadavalli SD, Allievi S, Sanders A, Davis RB, Malas MB, Wang GJ, Kashyap VS, Cronenwett J, Motaganahalli RL, Nolan B, Eldrup-Jorgensen J, Schermerhorn M. Seven years of the transcarotid artery revascularization surveillance project, comparison to transfemoral stenting and endarterectomy. J Vasc Surg 2024:S0741-5214(24)01227-8. [PMID: 38821431 DOI: 10.1016/j.jvs.2024.05.048] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2024] [Revised: 05/18/2024] [Accepted: 05/21/2024] [Indexed: 06/02/2024]
Abstract
OBJECTIVE This study utilizes the latest data from the Vascular Quality Initiative (VQI), which now encompasses over 50,000 transcarotid artery revascularization (TCAR) procedures, to offer a sizeable dataset for comparing the effectiveness and safety of TCAR, transfemoral carotid artery stenting (tfCAS), and carotid endarterectomy (CEA). Given this substantial dataset, we are now able to compare outcomes overall and stratified by symptom status across revascularization techniques. METHODS Utilizing VQI data from September 2016 to August 2023, we conducted a risk-adjusted analysis by applying inverse probability of treatment weighting to compare in-hospital outcomes between TCAR vs tfCAS, CEA vs tfCAS, and TCAR vs CEA. Our primary outcome measure was in-hospital stroke/death. Secondary outcomes included myocardial infarction and cranial nerve injury. RESULTS A total of 50,068 patients underwent TCAR, 25,361 patients underwent tfCAS, and 122,737 patients underwent CEA. TCAR patients were older, more likely to have coronary artery disease, chronic kidney disease, and undergo coronary artery bypass grafting/percutaneous coronary intervention as well as prior contralateral CEA/CAS compared with both CEA and tfCAS. TfCAS had higher odds of stroke/death when compared with TCAR (2.9% vs 1.6%; adjusted odds ratio [aOR], 1.84; 95% confidence interval [CI], 1.65-2.06; P < .001) and CEA (2.9% vs 1.3%; aOR, 2.21; 95% CI, 2.01-2.43; P < .001). CEA had slightly lower odds of stroke/death compared with TCAR (1.3% vs 1.6%; aOR, 0.83; 95% CI, 0.76-0.91; P < .001). TfCAS had lower odds of cranial nerve injury compared with TCAR (0.0% vs 0.3%; aOR, 0.00; 95% CI, 0.00-0.00; P < .001) and CEA (0.0% vs 2.3%; aOR, 0.00; 95% CI, 0.0-0.0; P < .001) as well as lower odds of myocardial infarction compared with CEA (0.4% vs 0.6%; aOR, 0.67; 95% CI, 0.54-0.84; P < .001). CEA compared with TCAR had higher odds of myocardial infarction (0.6% vs 0.5%; aOR, 1.31; 95% CI, 1.13-1.54; P < .001) and cranial nerve injury (2.3% vs 0.3%; aOR, 9.42; 95% CI, 7.78-11.4; P < .001). CONCLUSIONS Although tfCAS may be beneficial for select patients, the lower stroke/death rates associated with CEA and TCAR are preferred. When deciding between CEA and TCAR, it is important to weigh additional procedural factors and outcomes such as myocardial infarction and cranial nerve injury, particularly when stroke/death rates are similar. Additionally, evaluating subgroups that may benefit from one procedure over another is essential for informed decision-making and enhanced patient care in the treatment of carotid stenosis.
Collapse
Affiliation(s)
- Sabrina Straus
- Department of Surgery, Division of Vascular and Endovascular Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA; Department of Surgery, Division of Vascular and Endovascular Surgery, UC San Diego (UCSD), San Diego, CA
| | - Sai Divya Yadavalli
- Department of Surgery, Division of Vascular and Endovascular Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA
| | - Sara Allievi
- Department of Surgery, Division of Vascular and Endovascular Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA; Department of Vascular Surgery, Fondazione IRCCS Cà Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Andrew Sanders
- Department of Surgery, Division of Vascular and Endovascular Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA
| | - Roger B Davis
- Department of Surgery, Division of Vascular and Endovascular Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA
| | - Mahmoud B Malas
- Department of Surgery, Division of Vascular and Endovascular Surgery, UC San Diego (UCSD), San Diego, CA
| | - Grace J Wang
- Division of Vascular Surgery and Endovascular Therapy, Department of Surgery, Hospital of the University of Pennsylvania, Philadelphia, PA
| | - Vikram S Kashyap
- Frederik Meijer Heart and Vascular Institute, Corewell Health, Grand Rapids, MI
| | - Jack Cronenwett
- Section of Vascular Surgery, Dartmouth Medical School, Lebanon, NH
| | - Raghu L Motaganahalli
- Division of Vascular Surgery, Department of Surgery, Indiana University School of Medicine, Indianapolis, IN
| | - Brian Nolan
- Division of Vascular and Endovascular Therapy, Department of Surgery, Maine Medical Center, Portland, ME
| | - Jens Eldrup-Jorgensen
- Division of Vascular and Endovascular Therapy, Department of Surgery, Maine Medical Center, Portland, ME
| | - Marc Schermerhorn
- Department of Surgery, Division of Vascular and Endovascular Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA.
| |
Collapse
|