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Greco A, Occhipinti G, Giacoppo D, Agnello F, Laudani C, Spagnolo M, Mauro MS, Rochira C, Finocchiaro S, Mazzone PM, Faro DC, Landolina D, Ammirabile N, Imbesi A, Raffo C, Capodanno D. Antithrombotic Therapy for Primary and Secondary Prevention of Ischemic Stroke: JACC State-of-the-Art Review. J Am Coll Cardiol 2023; 82:1538-1557. [PMID: 37793752 DOI: 10.1016/j.jacc.2023.07.025] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/20/2023] [Revised: 07/05/2023] [Accepted: 07/12/2023] [Indexed: 10/06/2023]
Abstract
Stroke is a devastating condition with significant morbidity and mortality worldwide. Antithrombotic therapy plays a crucial role in both primary and secondary prevention of stroke events. Single or dual antiplatelet therapy is generally preferred in cases of large-artery atherosclerosis and small-vessel disease, whereas anticoagulation is recommended in conditions of blood stasis or hypercoagulable states that mostly result in red thrombi. However, the benefit of antithrombotic therapies must be weighed against the increased risk of bleeding, which can pose significant challenges in the pharmacological management of this condition. This review provides a comprehensive summary of the currently available evidence on antithrombotic therapy for ischemic stroke and outlines an updated therapeutic algorithm to support physicians in tailoring the strategy to the individual patient and the underlying mechanism of stroke.
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Affiliation(s)
- Antonio Greco
- Division of Cardiology, Azienda Ospedaliero-Universitaria Policlinico "G. Rodolico-San Marco," University of Catania, Catania, Italy. https://twitter.com/AGrecoMD
| | - Giovanni Occhipinti
- Division of Cardiology, Azienda Ospedaliero-Universitaria Policlinico "G. Rodolico-San Marco," University of Catania, Catania, Italy
| | - Daniele Giacoppo
- Division of Cardiology, Azienda Ospedaliero-Universitaria Policlinico "G. Rodolico-San Marco," University of Catania, Catania, Italy
| | - Federica Agnello
- Division of Cardiology, Azienda Ospedaliero-Universitaria Policlinico "G. Rodolico-San Marco," University of Catania, Catania, Italy
| | - Claudio Laudani
- Division of Cardiology, Azienda Ospedaliero-Universitaria Policlinico "G. Rodolico-San Marco," University of Catania, Catania, Italy
| | - Marco Spagnolo
- Division of Cardiology, Azienda Ospedaliero-Universitaria Policlinico "G. Rodolico-San Marco," University of Catania, Catania, Italy
| | - Maria Sara Mauro
- Division of Cardiology, Azienda Ospedaliero-Universitaria Policlinico "G. Rodolico-San Marco," University of Catania, Catania, Italy
| | - Carla Rochira
- Division of Cardiology, Azienda Ospedaliero-Universitaria Policlinico "G. Rodolico-San Marco," University of Catania, Catania, Italy
| | - Simone Finocchiaro
- Division of Cardiology, Azienda Ospedaliero-Universitaria Policlinico "G. Rodolico-San Marco," University of Catania, Catania, Italy
| | - Placido Maria Mazzone
- Division of Cardiology, Azienda Ospedaliero-Universitaria Policlinico "G. Rodolico-San Marco," University of Catania, Catania, Italy
| | - Denise Cristiana Faro
- Division of Cardiology, Azienda Ospedaliero-Universitaria Policlinico "G. Rodolico-San Marco," University of Catania, Catania, Italy
| | - Davide Landolina
- Division of Cardiology, Azienda Ospedaliero-Universitaria Policlinico "G. Rodolico-San Marco," University of Catania, Catania, Italy
| | - Nicola Ammirabile
- Division of Cardiology, Azienda Ospedaliero-Universitaria Policlinico "G. Rodolico-San Marco," University of Catania, Catania, Italy
| | - Antonino Imbesi
- Division of Cardiology, Azienda Ospedaliero-Universitaria Policlinico "G. Rodolico-San Marco," University of Catania, Catania, Italy
| | - Carmelo Raffo
- Division of Cardiology, Azienda Ospedaliero-Universitaria Policlinico "G. Rodolico-San Marco," University of Catania, Catania, Italy
| | - Davide Capodanno
- Division of Cardiology, Azienda Ospedaliero-Universitaria Policlinico "G. Rodolico-San Marco," University of Catania, Catania, Italy.
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Ozaki S, Akimoto T, Iida Y, Miyake S, Suzuki R, Shimohigoshi W, Hori S, Suenaga J, Shimizu N, Nakai Y, Sakata K, Yamamoto T. Complications and outcomes of carotid artery stenting in high-risk cases. J Stroke Cerebrovasc Dis 2023; 32:107329. [PMID: 37657401 DOI: 10.1016/j.jstrokecerebrovasdis.2023.107329] [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: 03/02/2023] [Revised: 05/21/2023] [Accepted: 08/24/2023] [Indexed: 09/03/2023] Open
Abstract
OBJECTIVES Carotid artery stenting is sometimes adapted for some at-risk cases; however, appropriate treatment timing with stroke onset is controversial. This study aims to identify factors that have an impact on complications and outcomes, especially in patients at high risk. MATERIALS AND METHODS We examined the characteristics of 152 consecutive patients treated by carotid artery stenting between January 2018 and March 2022 and retrospectively analyzed the risk factors for complications and poor outcomes (modified-Rankin-Scale deterioration), such as patient background, carotid artery stenting risks (access route tortuosity, severe calcification, vulnerable plaque, estimated glomerular filtration rate <30 mL/min/1.73 m2, etc.), characteristics of the stenosis, details of treatment, and treatment timing. RESULTS The average North American Symptomatic Carotid Endarterectomy Trial criteria score was 68.3% and the lesion length was 20.5±9.7mm. Among patients, 107 (70.4%) had a carotid artery stenting risk. In high-risk carotid artery stenting cases, symptomatic complications occurred in 32 (30.0%), and the 90-day modified Rankin scale score deteriorated in 15 cases (14.0%). Multivariate analysis showed that cases with triple antithrombotic therapy (p=0.003), stenting within 7 days (p=0.0032), and after 28+ days (p=0.0035) of stroke onset were independently associated factors for complications. CONCLUSIONS This study showed that among risk factors, triple antithrombotic therapy in particular was a risk factor for perioperative complications. Carotid artery stenting for patients with stroke after 28 days of onset affects the prognosis. Therefore, although further study is warranted, waiting more than one month for treatment in patients requiring carotid artery stenting is a potential risk.
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Affiliation(s)
- So Ozaki
- Department of Neurosurgery, Yokohama City University Medical Center, 4-57 Urafune, Minami, Yokohama 2320024, Japan
| | - Taisuke Akimoto
- Department of Neurosurgery, Yokohama City University Medical Center, 4-57 Urafune, Minami, Yokohama 2320024, Japan; Department of Neurosurgery, Yokohama City University Graduate School of Medicine, 3-9 Fukuura, Kanazawa, Yokohama 2360004, Japan.
| | - Yu Iida
- Department of Neurosurgery, Yokohama City University Graduate School of Medicine, 3-9 Fukuura, Kanazawa, Yokohama 2360004, Japan
| | - Shigeta Miyake
- Department of Neurosurgery, Yokohama Brain and Spine Center, 1-2-1, Takigashira, Isogo, Yokohama, Kanagawa 2350012, Japan
| | - Ryosuke Suzuki
- Department of Neurosurgery, Yokohama City University Graduate School of Medicine, 3-9 Fukuura, Kanazawa, Yokohama 2360004, Japan
| | - Wataru Shimohigoshi
- Department of Neurosurgery, Yokohama City University Medical Center, 4-57 Urafune, Minami, Yokohama 2320024, Japan
| | - Satoshi Hori
- Department of Neurosurgery, Yokohama City University Medical Center, 4-57 Urafune, Minami, Yokohama 2320024, Japan; Department of Neurosurgery, Yokohama City University Graduate School of Medicine, 3-9 Fukuura, Kanazawa, Yokohama 2360004, Japan
| | - Jun Suenaga
- Department of Neurosurgery, Yokohama City University Graduate School of Medicine, 3-9 Fukuura, Kanazawa, Yokohama 2360004, Japan
| | - Nobuyuki Shimizu
- Department of Neurosurgery, Yokohama City University Graduate School of Medicine, 3-9 Fukuura, Kanazawa, Yokohama 2360004, Japan
| | - Yasunobu Nakai
- Department of Neurosurgery, Yokohama City University Graduate School of Medicine, 3-9 Fukuura, Kanazawa, Yokohama 2360004, Japan; Department of Neurosurgery, Yokohama Brain and Spine Center, 1-2-1, Takigashira, Isogo, Yokohama, Kanagawa 2350012, Japan
| | - Katsumi Sakata
- Department of Neurosurgery, Yokohama City University Medical Center, 4-57 Urafune, Minami, Yokohama 2320024, Japan
| | - Tetsuya Yamamoto
- Department of Neurosurgery, Yokohama City University Graduate School of Medicine, 3-9 Fukuura, Kanazawa, Yokohama 2360004, Japan
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Fukutome K, Shiba M, Aketa S, Mitsui T, Shiraishi Y, Hayami H, Murakami Y, Matsuoka R, Tei R, Shin Y, Motoyama Y. Case report: Usefulness of angioscopy in determining antiplatelet drug reduction after carotid artery stenting. Front Neurol 2023; 14:1152173. [PMID: 37731855 PMCID: PMC10507256 DOI: 10.3389/fneur.2023.1152173] [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: 01/27/2023] [Accepted: 08/14/2023] [Indexed: 09/22/2023] Open
Abstract
We report a case in which neointima was confirmed by angioscopy and antiplatelet drug administration was reduced 2 months after carotid artery stenting (CAS). A patient in their 80s was scheduled to undergo resection for renal cancer; however, he also had right cervical internal carotid artery stenosis. Because this was a risk for general anesthesia, CAS was performed after first starting dual antiplatelet therapy. Urologically, early reduction of antiplatelet drugs was necessary for a nephrectomy. Although no obvious neointima could be identified on ultrasound 2 months after CAS, thin neointima was observed using angioscopy. Based on the above results, we reduced the antiplatelet drug administration, and then the nephrectomy was performed. Ultimately, no cerebral infarction occurred in the perioperative or postoperative periods. Angioscopy allows for visual confirmation of thin neointima. If sufficient neointima can be confirmed, antiplatelet drug reduction can be performed more safely and reliably.
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Affiliation(s)
- Kenji Fukutome
- Department of Neurosurgery, Osaka Police Hospital, Osaka, Japan
| | - Mikio Shiba
- Cardiovascular Division, Osaka Police Hospital, Osaka, Japan
| | - Shuta Aketa
- Department of Neurosurgery, Osaka Police Hospital, Osaka, Japan
| | - Takaaki Mitsui
- Department of Neurosurgery, Osaka Police Hospital, Osaka, Japan
| | - Yuki Shiraishi
- Department of Neurosurgery, Osaka Police Hospital, Osaka, Japan
| | | | | | - Ryuta Matsuoka
- Department of Neurosurgery, Osaka Police Hospital, Osaka, Japan
| | - Rinsei Tei
- Department of Neurosurgery, Osaka Police Hospital, Osaka, Japan
| | - Yasushi Shin
- Department of Neurosurgery, Osaka Police Hospital, Osaka, Japan
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Bass TA, Abbott JD, Mahmud E, Parikh SA, Aboulhosn J, Ashwath ML, Baranowski B, Bergersen L, Chaudry HI, Coylewright M, Denktas AE, Gupta K, Gutierrez JA, Haft J, Hawkins BM, Herrmann HC, Kapur NK, Kilic S, Lesser J, Lin CH, Mendirichaga R, Nkomo VT, Park LG, Phoubandith DR, Quader N, Rich MW, Rosenfield K, Sabri SS, Shames ML, Shernan SK, Skelding KA, Tamis-Holland J, Thourani VH, Tremmel JA, Uretsky S, Wageman J, Welt F, Whisenant BK, White CJ, Yong CM, Mendes LA, Arrighi JA, Breinholt JP, Day J, Dec GW, Denktas AE, Drajpuch D, Faza N, Francis SA, Hahn RT, Housholder-Hughes SD, Khan SS, Kondapaneni MD, Lee KS, Lin CH, Hussain Mahar J, McConnaughey S, Niazi K, Pearson DD, Punnoose LR, Reejhsinghani RS, Ryan T, Silvestry FE, Solomon MA, Spicer RL, Weissman G, Werns SW. 2023 ACC/AHA/SCAI advanced training statement on interventional cardiology (coronary, peripheral vascular, and structural heart interventions): A report of the ACC Competency Management Committee. J Thorac Cardiovasc Surg 2023; 166:e73-e123. [PMID: 37269254 DOI: 10.1016/j.jtcvs.2023.04.024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 06/05/2023]
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Jia L, Hua Y, Jiao L, Ma Y, Xing Y, Wang L, Hui P, Pan X, Fang Y, Peng T, Meng X, Zhu H, Wu C, Yan Y, Han B, Yang J, Zhang N, Zhang K, Xu D. Effects of plaque characteristics and artery hemodynamics on the residual stenosis after carotid artery stenting. J Vasc Surg 2023; 78:430-437.e4. [PMID: 37076105 DOI: 10.1016/j.jvs.2023.03.500] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2023] [Revised: 03/20/2023] [Accepted: 03/21/2023] [Indexed: 04/21/2023]
Abstract
OBJECTIVE Carotid artery stenting (CAS) has become an alternative strategy to carotid endarterectomy for carotid artery stenosis. Residual stenosis was an independent risk factor for restenosis, with the latter affecting the long-term outcomes of CAS. This multicenter study aimed to evaluate the echogenicity of plaques and hemodynamic alteration by color duplex ultrasound (CDU) examination and investigate their effects on the residual stenosis after CAS. METHODS From June 2018 to June 2020, 454 patients (386 males and 68 females) with a mean age of 67.2 ± 7.9 years, who underwent CAS from 11 advanced stroke centers in China were enrolled. One week before recanalization, CDU was used to evaluate the responsible plaques, including the morphology (regular or irregular), echogenicity of the plaques (iso-, hypo-, or hyperechoic) and calcification characteristics (without calcification, superficial calcification, inner calcification, and basal calcification). One week after CAS, the alteration of diameter and hemodynamic parameters were evaluated by CDU, and the occurrence and degree of residual stenosis were determined. In addition, magnetic resonance imaging was performed before and during the 30-day postprocedural period to identify new ischemic cerebral lesions. RESULTS The rate of composite complications, including cerebral hemorrhage, symptomatic new ischemic cerebral lesions, and death after CAS, was 1.54% (7/454 cases). The rate of residual stenosis after CAS was 16.3% (74/454 cases). After CAS, both the diameter and peak systolic velocity (PSV) improved in the preprocedural 50% to 69% and 70% to 99% stenosis groups (P < .05). Compared with the groups without residual stenosis and with <50% residual stenosis, the PSV of all three segments of stent in the 50% to 69% residual stenosis group were the highest, and the difference in the midsegment of stent PSV was the largest (P < .05). Logistic regression analysis showed that preprocedural severe (70% to 99%) stenosis (odds ratio [OR], 9.421; P = .032), hyperechoic plaques (OR, 3.060; P = .006) and plaques with basal calcification (OR, 1.885; P = .049) were independent risk factors for residual stenosis after CAS. CONCLUSIONS Patients with hyperechoic and calcified plaques of the carotid stenosis are at a high risk of residual stenosis after CAS. CDU is an optimal, simple and noninvasive imaging method to evaluate plaque echogenicity and hemodynamic alterations during the perioperative period of CAS, which can help surgeons to select the optimal strategies and prevent the occurrence of residual stenosis.
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Affiliation(s)
- Lingyun Jia
- Department of Vascular Ultrasonography, Xuanwu Hospital, Capital Medical University, Beijing, China; Beijing Diagnostic Center of Vascular Ultrasound, Beijing, China; Center of Vascular Ultrasonography, Beijing Institute of Brain Disorders, Collaborative Innovation Center for Brain Disorders, Capital Medical University, Beijing, China
| | - Yang Hua
- Department of Vascular Ultrasonography, Xuanwu Hospital, Capital Medical University, Beijing, China; Beijing Diagnostic Center of Vascular Ultrasound, Beijing, China; Center of Vascular Ultrasonography, Beijing Institute of Brain Disorders, Collaborative Innovation Center for Brain Disorders, Capital Medical University, Beijing, China.
| | - Liqun Jiao
- Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Yan Ma
- Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Yingqi Xing
- Department of Vascular Ultrasonography, Xuanwu Hospital, Capital Medical University, Beijing, China; Beijing Diagnostic Center of Vascular Ultrasound, Beijing, China; Center of Vascular Ultrasonography, Beijing Institute of Brain Disorders, Collaborative Innovation Center for Brain Disorders, Capital Medical University, Beijing, China; Department of Neurology, The First Hospital of Jilin University, Changchun, China
| | - Lijuan Wang
- Department of Neurology, The First Hospital of Jilin University, Changchun, China
| | - Pinjing Hui
- Department of Carotid and Cerebrovascular Ultrasonography, The First Affiliated Hospital of Soochow University, Soochow, China
| | - Xiaofang Pan
- Department of Ultrasonography, Dalian Municipal Central Hospital Affiliated of Dalian Medical University, Dalian, China
| | - Yalan Fang
- Department of Ultrasonography, The First Affiliated Hospital of Shanxi Medical University, Taiyuan, China
| | - Tao Peng
- Department of Ultrasonography, The Second People's Hospital of Liaocheng, Liaocheng, China
| | - Xuan Meng
- Neurovascular Function Department, Lanzhou University Second Hospital, Lanzhou, China
| | - Haohui Zhu
- Department of Ultrasonography, Henan Provincial Hospital, Zhengzhou, China
| | - Chunxia Wu
- Department of Ultrasonography, Liaocheng Brain Hospital, Liaocheng, China
| | - Yuanyuan Yan
- Department of Ultrasonography, Zhengzhou Central Hospital, Zhengzhou, China
| | - Bing Han
- Department of Ultrasonography, Weihai Municipal Hospital, Weihai, China
| | - Jie Yang
- Department of Vascular Ultrasonography, Xuanwu Hospital, Capital Medical University, Beijing, China; Beijing Diagnostic Center of Vascular Ultrasound, Beijing, China
| | - Nan Zhang
- Department of Vascular Ultrasonography, Xuanwu Hospital, Capital Medical University, Beijing, China; Beijing Diagnostic Center of Vascular Ultrasound, Beijing, China
| | - Ke Zhang
- Department of Vascular Ultrasonography, Xuanwu Hospital, Capital Medical University, Beijing, China; Beijing Diagnostic Center of Vascular Ultrasound, Beijing, China
| | - Duo Xu
- Department of Vascular Ultrasonography, Xuanwu Hospital, Capital Medical University, Beijing, China; Beijing Diagnostic Center of Vascular Ultrasound, Beijing, China
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Bass TA, Abbott JD, Mahmud E, Parikh SA, Aboulhosn J, Ashwath ML, Baranowski B, Bergersen L, Chaudry HI, Coylewright M, Denktas AE, Gupta K, Gutierrez JA, Haft J, Hawkins BM, Herrmann HC, Kapur NK, Kilic S, Lesser J, Lin CH, Mendirichaga R, Nkomo VT, Park LG, Phoubandith DR, Quader N, Rich MW, Rosenfield K, Sabri SS, Shames ML, Shernan SK, Skelding KA, Tamis-Holland J, Thourani VH, Tremmel JA, Uretsky S, Wageman J, Welt F, Whisenant BK, White CJ, Yong CM. 2023 ACC/AHA/SCAI Advanced Training Statement on Interventional Cardiology (Coronary, Peripheral Vascular, and Structural Heart Interventions): A Report of the ACC Competency Management Committee. JACC Cardiovasc Interv 2023; 16:1239-1291. [PMID: 37115166 DOI: 10.1016/j.jcin.2023.04.011] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 04/29/2023]
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7
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Twine CP, Kakkos SK, Aboyans V, Baumgartner I, Behrendt CA, Bellmunt-Montoya S, Jilma B, Nordanstig J, Saratzis A, Reekers JA, Zlatanovic P, Antoniou GA, de Borst GJ, Bastos Gonçalves F, Chakfé N, Coscas R, Dias NV, Hinchliffe RJ, Kolh P, Lindholt JS, Mees BME, Resch TA, Trimarchi S, Tulamo R, Vermassen FEG, Wanhainen A, Koncar I, Fitridge R, Matsagkas M, Valgimigli M. Editor's Choice - European Society for Vascular Surgery (ESVS) 2023 Clinical Practice Guidelines on Antithrombotic Therapy for Vascular Diseases. Eur J Vasc Endovasc Surg 2023; 65:627-689. [PMID: 37019274 DOI: 10.1016/j.ejvs.2023.03.042] [Citation(s) in RCA: 36] [Impact Index Per Article: 36.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2023] [Accepted: 03/03/2023] [Indexed: 04/05/2023]
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8
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Bass TA, Abbott JD, Mahmud E, Parikh SA, Aboulhosn J, Ashwath ML, Baranowski B, Bergersen L, Chaudry HI, Coylewright M, Denktas AE, Gupta K, Gutierrez JA, Haft J, Hawkins BM, Herrmann HC, Kapur NK, Kilic S, Lesser J, Lin CH, Mendirichaga R, Nkomo VT, Park LG, Phoubandith DR, Quader N, Rich MW, Rosenfield K, Sabri SS, Shames ML, Shernan SK, Skelding KA, Tamis-Holland J, Thourani VH, Tremmel JA, Uretsky S, Wageman J, Welt F, Whisenant BK, White CJ, Yong CM. 2023 ACC/AHA/SCAI Advanced Training Statement on Interventional Cardiology (Coronary, Peripheral Vascular, and Structural Heart Interventions): A Report of the ACC Competency Management Committee. J Am Coll Cardiol 2023; 81:1386-1438. [PMID: 36801119 DOI: 10.1016/j.jacc.2022.11.002] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/18/2023]
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Shahbazian N, Doyle MG, Forbes TL, Amon CH. A modeling framework for computational simulations of thoracic endovascular aortic repair. INTERNATIONAL JOURNAL FOR NUMERICAL METHODS IN BIOMEDICAL ENGINEERING 2023; 39:e3578. [PMID: 35107881 DOI: 10.1002/cnm.3578] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/12/2021] [Accepted: 01/29/2022] [Indexed: 05/12/2023]
Abstract
Thoracic endovascular aortic repair (TEVAR) is a minimally invasive treatment for thoracic aortic conditions including aneurysms and is associated with a number of postoperative stent graft related complications. Computational simulations of TEVAR have the potential to predict surgical outcomes and complications preoperatively. When using simulations for stent graft design and prediction of complications in a population, it is difficult to generalize patient-specific TEVAR computational models due to patient variability. This study proposes a novel modeling framework for creating realistic population-based computational models of TEVAR focused on aneurysms that allow for developing various clinically relevant geometric configurations and scenarios that are not easily attainable with limited patient data. The framework includes a methodology for developing population-based thoracic aortic geometries and defining age-dependent aortic tissue material models, as well as detailed steps and boundary conditions for finite element modeling of stent graft deployment during TEVAR. The simulation framework is illustrated for predicting the formation of a bird-beak configuration, a wedge-shaped gap at the proximal end of the deployed stent graft in TEVAR that leads to incomplete seal. A baseline TEVAR simulation model was developed along with three simulations in which the value of aortic curvature, aortic arch angle, or aortic tissue properties varied from the baseline model. Analyzing the length and angle of the bird-beak configuration in each case shows that the bird-beak size is sensitive to different values of the aortic geometry highlighting the importance of using realistic parameter values.
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Affiliation(s)
- Negin Shahbazian
- Department of Mechanical and Industrial Engineering, University of Toronto, Toronto, Ontario, Canada
| | - Matthew G Doyle
- Department of Mechanical and Industrial Engineering, University of Toronto, Toronto, Ontario, Canada
- Department of Surgery, Division of Vascular Surgery, Peter Munk Cardiac Centre, University Health Network, University of Toronto, Toronto, Ontario, Canada
| | - Thomas L Forbes
- Department of Surgery, Division of Vascular Surgery, Peter Munk Cardiac Centre, University Health Network, University of Toronto, Toronto, Ontario, Canada
| | - Cristina H Amon
- Department of Mechanical and Industrial Engineering, University of Toronto, Toronto, Ontario, Canada
- Institute of Biomedical Engineering, University of Toronto, Toronto, Ontario, Canada
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Bass TA, Abbott JD, Mahmud E, Parikh SA, Aboulhosn J, Ashwath ML, Baranowski B, Bergersen L, Chaudry HI, Coylewright M, Denktas AE, Gupta K, Gutierrez JA, Haft J, Hawkins BM, Herrmann HC, Kapur NK, Kilic S, Lesser J, Huie LC, Mendirichaga R, Nkomo VT, Park LG, Phoubandith DR, Quader N, Rich MW, Rosenfield K, Sabri SS, Shames ML, Shernan SK, Skelding KA, Tamis-Holland J, Thourani VH, Tremmel JA, Uretsky S, Wageman J, Welt F, Whisenant BK, White CJ, Yong CM. 2023 ACC/AHA/SCAI Advanced Training Statement on Interventional Cardiology (Coronary, Peripheral Vascular, and Structural Heart Interventions): A Report of the ACC Competency Management Committee. Circ Cardiovasc Interv 2023; 16:e000088. [PMID: 36795800 DOI: 10.1161/hcv.0000000000000088] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/18/2023]
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11
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Heib A, Chang H, Rockman C, Patel V, Jacobowitz G, Barfield M, Siracuse JJ, Faries P, Lamparello PJ, Cayne N, Maldonado T, Garg K. Periprocedural P2Y 12 inhibitors improve perioperative outcomes after carotid stenting by primarily decreasing strokes. J Vasc Surg 2023; 77:795-803. [PMID: 36328140 DOI: 10.1016/j.jvs.2022.10.038] [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: 05/26/2022] [Revised: 09/25/2022] [Accepted: 10/03/2022] [Indexed: 11/05/2022]
Abstract
OBJECTIVE The continuation of antiplatelet agents in the periprocedural period around carotid stenting (CAS) procedures is felt to be mandatory to minimize the risk of periprocedural stroke. However, the optimal antiplatelet regimen is unclear, with some advocating dual antiplatelet therapy, and others supporting the use of P2Y12 inhibitors alone. The objective of this study was to evaluate the periprocedural effect of P2Y12 inhibitors for CAS. METHODS The Vascular Quality Initiative was used from years 2007 to 2020. All transcarotid artery revascularization (TCAR) and transfemoral carotid artery stenting (TF-CAS) procedures were included. Patients were stratified based on perioperative use of P2Y12 inhibitors as well as symptomatic status. Primary end points were perioperative neurological events (strokes and transient ischemic attacks). Secondary end points were mortality and myocardial infarction. RESULTS A total of 31,036 CAS procedures were included for analysis, with 49.8% TCAR and 50.2% TF-CAS cases; 63.8% of patients were male and 82.3% of patients were on a P2Y12 inhibitor. P2Y12 inhibitor use was more common in males, asymptomatic patients, those older than 70 years, and concurrent statin use. P2Y12 inhibitors were more likely to be used in TCAR cases than in TF-CAS cases (87.3% vs 76.8%; P < .001). The rate of periprocedural neurological events in the whole cohort was 2.6%. Patients on P2Y12 inhibitors were significantly less likely to experience a periprocedural neurological event (2.3% vs 3.9%; P < .001) and mortality (0.6% vs 2.1%; P < .001) than those who were not on a P2Y12 inhibitor. There was no effect on the rates of myocardial infarction. On multivariate analysis, both symptomatic and asymptomatic patients on P2Y12 inhibitors were significantly less likely to develop perioperative neurological events. Additionally, the use of P2Y12 inhibitors demonstrated an independent significant effect in reducing of the rate of perioperative stroke (odds ratio, 0.29; 95% confidence interval, 0.25-0.33). Finally, additional analysis of the types of P2Y12 inhibitors used revealed that all seemed to be equally effective in decreasing the periprocedural neurological event rate. CONCLUSIONS The use of perioperative P2Y12 inhibitors seems to markedly decrease the perioperative neurological event rate with TCAR and TF-CAS in both symptomatic and asymptomatic patients and should be strongly considered. Patients with contraindications to P2Y12 inhibitors may not be appropriate candidates for any CAS procedure. Additionally, alternative types of P2Y12 inhibitors seem to be equally effective as clopidogrel. Finally, an analysis of the Vascular Quality Initiative demonstrates that, even for TCAR cases, only 87.3% of patients seem to be on P2Y12 inhibitors in the periprocedural period, leaving room for significant improvement.
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Affiliation(s)
- Adele Heib
- Albert Einstein College of Medicine/Montefiore Medical Center, Bronx, NY
| | - Heepeel Chang
- Division of Vascular and Endovascular Surgery, Westchester Medical Center/New York Medical College, Valhalla, NY
| | - Caron Rockman
- Division of Vascular and Endovascular Surgery, Department of Surgery, NYU Langone Medical Center, New York, NY
| | - Virendra Patel
- Division of Cardiac, Thoracic, and Vascular Surgery, New York Presbyterian/Columbia University Irving Medical Center/Columbia University College of Physicians and Surgeons, New York, NY
| | - Glenn Jacobowitz
- Division of Vascular and Endovascular Surgery, Department of Surgery, NYU Langone Medical Center, New York, NY
| | - Michael Barfield
- Division of Vascular and Endovascular Surgery, Department of Surgery, NYU Langone Medical Center, New York, NY
| | - Jeffrey J Siracuse
- Division of Vascular and Endovascular Surgery, Department of Surgery, Boston Medical Center, Boston, MA
| | - Peter Faries
- Division of Vascular and Endovascular Surgery, Department of Surgery, The Mount Sinai Hospital, New York, NY
| | - Patrick J Lamparello
- Division of Vascular and Endovascular Surgery, Department of Surgery, NYU Langone Medical Center, New York, NY
| | - Neal Cayne
- Division of Vascular and Endovascular Surgery, Department of Surgery, NYU Langone Medical Center, New York, NY
| | - Thomas Maldonado
- Division of Vascular and Endovascular Surgery, Department of Surgery, NYU Langone Medical Center, New York, NY
| | - Karan Garg
- Division of Vascular and Endovascular Surgery, Department of Surgery, NYU Langone Medical Center, New York, NY.
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Simonte G, Guglielmini G, Falcinelli E, Isernia G, Mezzasoma AM, Gresele P, Lenti M. High-on-treatment platelet reactivity predicts adverse outcome after carotid artery stenting: A prospective study. Thromb Res 2023; 222:117-123. [PMID: 36640567 DOI: 10.1016/j.thromres.2022.12.015] [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: 08/31/2022] [Revised: 12/15/2022] [Accepted: 12/22/2022] [Indexed: 12/29/2022]
Abstract
BACKGROUND AND PURPOSE High-on-treatment platelet reactivity (HTPR) has been established as a predictor of major adverse cardiovascular events (MACE) in patients undergoing percutaneous coronary interventions on dual antiplatelet therapy (DAPT), but no data are available on its predictive value in patients on DAPT after carotid artery stenting (CAS). We aimed to evaluate the possible association between HTPR in patients on aspirin plus clopidogrel therapy after CAS and subsequent MACE. METHODS All consecutive patients treated with CAS in a single institution were enrolled in a prospective clinical study. HTPR was evaluated with 5 different laboratory assays carried out just before CAS. MACE incidence (cerebral ischemia, myocardial infarction, stent thrombosis, acute limb ischemia and vascular death) was evaluated at 30 days and thereafter at yearly visits. RESULTS A total of 300 patients were enrolled in the study, and eight were then excluded because blood samples resulted unsuitable for the laboratory testing or CAS aborted for technical problems. Median follow-up was 5.8 years and during this period 47 MACE occurred. HTPR detected by multiplate electronic aggregometry (MEA) and the VASP phosphorylation assay (VASP) were associated with a significantly enhanced risk of MACE (p = 0.048 and p = 0.038, respectively). However, HTPR to three tests (HTPR3) was more strongly predictive of increased risk of a vascular event at follow up (p = 0.005) at bivariate analysis and also at Cox regression multivariate analysis (p = 0.002). CONCLUSIONS HTPR to three different assays (mainly to VASP + PFA P2Y+ VerifyNow) in patients on DAPT after CAS has predictive value for subsequent MACE. Prospective studies to assess whether platelet function testing-guided antiplatelet therapy is superior to standard DAPT in patient undergoing CAS should be considered.
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Affiliation(s)
- G Simonte
- Unit of Vascular Surgery, S. Maria della Misericordia Hospital, Perugia, Italy
| | - G Guglielmini
- Section of Internal and Cardiovascular Medicine, Department of Medicine and Surgery, University of Perugia, Perugia, Italy
| | - E Falcinelli
- Section of Internal and Cardiovascular Medicine, Department of Medicine and Surgery, University of Perugia, Perugia, Italy
| | - G Isernia
- Unit of Vascular Surgery, S. Maria della Misericordia Hospital, Perugia, Italy
| | - A M Mezzasoma
- Section of Internal and Cardiovascular Medicine, Department of Medicine and Surgery, University of Perugia, Perugia, Italy
| | - P Gresele
- Section of Internal and Cardiovascular Medicine, Department of Medicine and Surgery, University of Perugia, Perugia, Italy.
| | - M Lenti
- Unit of Vascular Surgery, S. Maria della Misericordia Hospital, Perugia, Italy
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13
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Teng L, Zhang Y, Fang J, Qu C, Li J, Shen C. Impact of residual stenosis on clinical outcomes when performing carotid artery stenting without postdilation. J Vasc Surg 2023; 77:182-190. [PMID: 35931400 DOI: 10.1016/j.jvs.2022.07.021] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2022] [Revised: 07/03/2022] [Accepted: 07/17/2022] [Indexed: 02/03/2023]
Abstract
OBJECTIVE Many centers consider postdilation if the final angiography after carotid artery stenting (CAS) shows residual stenosis of >30% to 40%. Postdilation has been demonstrated to potentially increase the risk of developing neurologic events. This study aimed to investigate the safety of CAS without postdilation regardless of the degree of residual stenosis. METHODS We retrospectively investigated 191 patients who underwent transfemoral CAS without postdilation intendedly. All cases underwent mild predilation and self-expanding stent implantation. We divided the patients into a residual stenosis of ≥40% group (n = 69 [36.1%]) and a residual stenosis of <40% group (n = 122 [63.9%]) according to their final angiography. We compared the procedural (within 30 days after CAS) and nonprocedural (afterward) adverse cardiovascular events and in-stent restenosis between the two groups. We also investigated the incidence of perioperative hemodynamic depression between the groups and the changes in residual stenosis over the follow-up time. RESULTS Patients in the residual stenosis of ≥40% group had a higher preoperative stenosis rate and a greater proportion of severely calcified lesions than those in the <40% group. There was one procedural cardiac death (0.5%), five strokes (2.6%), and four myocardial infarctions (2.1%). A total of 2.9% had stroke or death procedurally in the residual stenosis of ≥40% group and 3.2% in the residual stenosis of <40% group (P > .950). The median nonprocedural follow-up time was 22 months, with a total of six deaths and four strokes. The cumulative 2-year death or stroke rate was 6.2%, with 5.9% in the residual stenosis of ≥40% group versus 6.7% in the residual stenosis of <40% group (P = .507). There were two cases of in-stent restenosis in the residual stenosis of ≥40% group and three in the residual stenosis of <40% group (P = .927). The difference in the peak systolic velocity of the target lesion between groups at 3 months after CAS was no longer present, and residual stenosis stabilized at 10% to 20% at 6 months in both groups. The patients showed an association between increasing hemodynamic depression incidence and residual stenosis in a significantly graded response (P = .021). CONCLUSIONS Residual stenosis after carotid stenting without postdilation is not associated with a risk of postoperative adverse events. This study provides evidence for the feasibility of a no postdilation strategy for CAS.
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Affiliation(s)
- Lequn Teng
- National Center for Cardiovascular Disease, Chinese Academy of Medical Sciences, Fuwai Hospital, Beijing, China
| | - Yongbao Zhang
- National Center for Cardiovascular Disease, Chinese Academy of Medical Sciences, Fuwai Hospital, Beijing, China
| | - Jie Fang
- National Center for Cardiovascular Disease, Chinese Academy of Medical Sciences, Fuwai Hospital, Beijing, China
| | - Chengjia Qu
- National Center for Cardiovascular Disease, Chinese Academy of Medical Sciences, Fuwai Hospital, Beijing, China
| | - Jialiang Li
- National Center for Cardiovascular Disease, Chinese Academy of Medical Sciences, Fuwai Hospital, Beijing, China
| | - Chenyang Shen
- National Center for Cardiovascular Disease, Chinese Academy of Medical Sciences, Fuwai Hospital, Beijing, China.
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14
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Roh J, Baik SK, Yeom JA, Park KP, Ahn SH, Park MG. Usefulness of cone-beam computed tomography to predict residual stenosis after carotid artery stenting. Interv Neuroradiol 2022:15910199221143259. [PMID: 36523192 DOI: 10.1177/15910199221143259] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/17/2024] Open
Abstract
OBJECTIVES The long-term durability of carotid artery stenting (CAS) may be determined by various factors; however, residual stenosis is a known risk factor for in-stent restenosis. The authors of this article utilized cone-beam computed tomography (CBCT) in angiosuite to investigate plaque features affecting the character and quality of stent expansion after CAS. METHODS Forty-two CAS cases with both pre- and post-CAS CBCT evaluations were included in this retrospective analysis. Five features derived from pre-CAS images were tested: (1) eccentricity, (2) overballoon, (3) maximum plaque thickness, (4) calcification barrier, and (5) stenotic degree. For post-CAS CBCT, stent configuration was assessed if the stent was expanded and oval or round in shape as well as outward or inward in orientation. Variables were tested if they were associated with oval expansion, outward expansion, and 20% residual stenosis after CAS. RESULTS Oval or outward expansion is directly related to residual stenosis. The oval expansion was associated with maximum plaque thickness, and outward expansion was associated with the presence of a calcification barrier. Variables related to > 20% residual stenosis were the maximum plaque thickness, calcification barrier, and pre-CAS stenotic degree. CONCLUSIONS CBCT for carotid stenosis may provide valuable information about plaque features, especially calcification features that may interfere with the angioplasty effect, as well as the characteristics and quality of stent expansion. Residual stenosis > 20% was associated with calcification barrier, maximum plaque thickness, and pre-CAS stenotic degree.
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Affiliation(s)
- Jieun Roh
- Department of Radiology, 194197Pusan National University Yangsan Hospital, Yangsan-si, South Korea
| | - Seung Kug Baik
- Department of Radiology, 194197Pusan National University Yangsan Hospital, Yangsan-si, South Korea
| | - Jeong A Yeom
- Department of Radiology, 194197Pusan National University Yangsan Hospital, Yangsan-si, South Korea
| | - Kyung-Pil Park
- Department of Neurology, 194197Pusan National University Yangsan Hospital, Yangsan-si, South Korea
| | - Sung-Ho Ahn
- Department of Neurology, 194197Pusan National University Yangsan Hospital, Yangsan-si, South Korea
| | - Min-Gyu Park
- Department of Neurology, 194197Pusan National University Yangsan Hospital, Yangsan-si, South Korea
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15
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Sasaki N, Kotani Y, Ito Y, Noda S. Intra-arterial infusion of fasudil hydrochloride for cerebral vasospasm secondary to carotid artery stenting: illustrative case. JOURNAL OF NEUROSURGERY: CASE LESSONS 2022. [PMCID: PMC9379733 DOI: 10.3171/case2251] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
BACKGROUND Hypoperfusion due to intracranial cerebral vasospasm after carotid artery stenting (CAS) is rare. The authors presented a case of selective intraarterial infusion of fasudil hydrochloride for cerebral vasospasm after CAS. OBSERVATIONS A 73-year-old man received CAS for asymptomatic right cervical internal carotid artery stenosis. Twelve hours after CAS, disturbance of consciousness, left hemiplegia, and right conjugate deviation appeared in the patient. Head computed tomography angiography showed diffuse vasospasm of the right middle cerebral artery (MCA). The authors hypothesized that the cause of the symptoms was hypoperfusion due to intracranial cerebral vasospasm. Medical treatment was started; however, the focal symptoms worsened rapidly. Therefore, the authors decided to infuse fasudil intraarterially. This treatment resulted in a remarkable improvement in blood flow and gradual recovery from neurological symptoms. Head magnetic resonance angiography on the day after fasudil infusion showed improved visualization of the right MCA. The neurological symptoms almost completely disappeared 22 hours after fasudil infusion (40 hours after CAS). LESSONS As a complication after CAS, the possibility of hypoperfusion due to cerebral vasospasm should be considered. If symptoms due to hypoperfusion worsen even after medical treatment, intraarterial infusion of fasudil may be an effective option.
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Affiliation(s)
- Nozomi Sasaki
- Department of Neurosurgery, Chuno Kosei Hospital, Gifu-ken, Japan
| | - Yoshinori Kotani
- Department of Neurosurgery, Chuno Kosei Hospital, Gifu-ken, Japan
| | - Yohei Ito
- Department of Neurosurgery, Chuno Kosei Hospital, Gifu-ken, Japan
| | - Shinji Noda
- Department of Neurosurgery, Chuno Kosei Hospital, Gifu-ken, Japan
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16
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Al-Bayati AR, Nogueira RG, Haussen DC. Carotid Artery Stenting: Applications and Technical Considerations. Neurology 2021; 97:S137-S144. [PMID: 34785612 DOI: 10.1212/wnl.0000000000012802] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2020] [Accepted: 03/03/2021] [Indexed: 11/15/2022] Open
Abstract
PURPOSE OF THE REVIEW To examine current understanding of diverse etiologies of extracranial carotid disease, including clinical and imaging manifestations as well as treatment approaches. RECENT FINDINGS Increasing availability of advanced cerebrovascular imaging modalities continues to elucidate atherosclerotic and nonatherosclerotic carotid steno-occlusive disease as a common culprit of cerebral ischemia. Individualized treatment strategies targeting each etiologic subset would optimize preventive measures and minimize recurrence of cerebral ischemia. SUMMARY Ischemic stroke is a prominent cause of mortality and long-term disability worldwide. The magnified effect of carotid disease warrants constant and close inspection.
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Affiliation(s)
- Alhamza R Al-Bayati
- From the Department of Neurology and Radiology, Marcus Stroke & Neuroscience Center, Grady Memorial Hospital, Emory University School of Medicine, Atlanta, GA.
| | - Raul G Nogueira
- From the Department of Neurology and Radiology, Marcus Stroke & Neuroscience Center, Grady Memorial Hospital, Emory University School of Medicine, Atlanta, GA
| | - Diogo C Haussen
- From the Department of Neurology and Radiology, Marcus Stroke & Neuroscience Center, Grady Memorial Hospital, Emory University School of Medicine, Atlanta, GA
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17
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Higashiguchi S, Sadato A, Nakahara I, Matsumoto S, Hayakawa M, Adachi K, Hasebe A, Suyama Y, Omi T, Yamashiro K, Wakako A, Ishihara T, Kawazoe Y, Kumai T, Tanabe J, Suyama K, Watanabe S, Suzuki T, Hirose Y. Reduction of thromboembolic complications during the endovascular treatment of unruptured aneurysms by employing a tailored dual antiplatelet regimen using aspirin and prasugrel. J Neurointerv Surg 2021; 13:1044-1048. [PMID: 33632886 PMCID: PMC8526880 DOI: 10.1136/neurintsurg-2020-016994] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2020] [Revised: 01/05/2021] [Accepted: 01/09/2021] [Indexed: 12/25/2022]
Abstract
Background Thromboembolic complications (TECs) are frequent during the endovascular treatment of unruptured aneurysms. To prevent TECs, dual antiplatelet therapy using aspirin and clopidogrel is recommended for the perioperative period. In patients with a poor response, clopidogrel is a risk factor for TECs. To prevent TECs, our study assessed the stratified use of prasugrel. Methods Patients who underwent endovascular therapy for unruptured cerebral aneurysms from April 2017 to August 2019 were enrolled in this clinical study and given premedication with aspirin and clopidogrel for 2 weeks prior to the procedure. P2Y12 reaction units (PRU) were measured using the VerifyNow assay on the day before the procedure (tailored group). In subgroups with PRU <240, the clopidogrel dose was maintained (CPG subgroup). In subgroups with PRU ≥240, clopidogrel was changed to prasugrel (PSG subgroup). We compared the occurrence of TECs with retrospective consecutive cases from January 2015 to March 2017 without PRU assessments (non-tailored group). The frequency of TECs within 30 days was assessed as the primary endpoint. Results The tailored and non-tailored groups comprised 167 and 50 patients, respectively. TECs occurred in 11 (6.6%) and 8 (16%) patients in the tailored and non-tailored groups (P=0.048), respectively. The HR for TECs was significantly reduced in the tailored group (HR 0.3, 95% CI 0.11 to 0.81); P=0.017) compared with the non-tailored group. Conclusion The results suggest that tailored dual antiplatelet therapy medication with PRU significantly reduces the frequency of TECs without increasing hemorrhagic complications.
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Affiliation(s)
- Saeko Higashiguchi
- Department of Neurosurgery, Fujita Health University, Toyoake, Aichi, Japan
| | - Akiyo Sadato
- Department of Neurosurgery, Fujita Health University, Toyoake, Aichi, Japan
| | - Ichiro Nakahara
- Department of Comprehensive Strokology, Fujita Health University, Toyoake, Aichi, Japan
| | - Shoji Matsumoto
- Department of Comprehensive Strokology, Fujita Health University, Toyoake, Aichi, Japan
| | - Motoharu Hayakawa
- Department of Neurosurgery, Fujita Health University, Toyoake, Aichi, Japan
| | - Kazuhide Adachi
- Department of Neurosurgery, Fujita Health University, Toyoake, Aichi, Japan
| | - Akiko Hasebe
- Department of Comprehensive Strokology, Fujita Health University, Toyoake, Aichi, Japan
| | - Yoshio Suyama
- Department of Comprehensive Strokology, Fujita Health University, Toyoake, Aichi, Japan
| | - Tatsuo Omi
- Department of Neurosurgery, Fujita Health University, Toyoake, Aichi, Japan
| | - Kei Yamashiro
- Department of Neurosurgery, Fujita Health University, Toyoake, Aichi, Japan
| | - Akira Wakako
- Department of Neurosurgery, Fujita Health University, Toyoake, Aichi, Japan
| | - Takuma Ishihara
- Innovative and Clinical Research Promotion Center, Gifu University Hospital, Gifu, Gifu, Japan
| | - Yushi Kawazoe
- Department of Neurosurgery, Fujita Health University, Toyoake, Aichi, Japan
| | - Tadashi Kumai
- Department of Neurosurgery, Fujita Health University, Toyoake, Aichi, Japan
| | - Jun Tanabe
- Department of Comprehensive Strokology, Fujita Health University, Toyoake, Aichi, Japan
| | - Kenichiro Suyama
- Department of Comprehensive Strokology, Fujita Health University, Toyoake, Aichi, Japan
| | - Sadayoshi Watanabe
- Department of Comprehensive Strokology, Fujita Health University, Toyoake, Aichi, Japan
| | - Takeya Suzuki
- Department of Comprehensive Strokology, Fujita Health University, Toyoake, Aichi, Japan
| | - Yuichi Hirose
- Department of Neurosurgery, Fujita Health University, Toyoake, Aichi, Japan
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18
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DeCarlo C, Tanious A, Boitano LT, Mohebali J, Stone DH, Clouse WD, Conrad MF. Simultaneous treatment of common carotid lesions increases the risk of stroke and death after carotid artery stenting. J Vasc Surg 2021; 74:592-598.e1. [PMID: 33545307 DOI: 10.1016/j.jvs.2020.12.089] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2020] [Accepted: 12/21/2020] [Indexed: 11/29/2022]
Abstract
BACKGROUND Tandem carotid artery lesions that involve simultaneous internal carotid artery (ICA) and common carotid artery (CCA) stenoses present a complex clinical problem. Some studies have shown that the addition of a retrograde proximal intervention to treat a CCA lesion during a carotid endarterectomy (CEA) increases the risk of stroke and death. However, the stroke and death risks associated with a totally endovascular approach to tandem lesions is unknown and is the subject of this study. METHODS Vascular Study Group of New England data for the years 2005 to 2020 were queried for carotid artery stenting (CAS) procedures. Emergent and bilateral procedures, procedures for indications other than atherosclerosis, patients with prior ipsilateral CAS, ICA lesions with stenosis of less than 50%, and transcarotid procedures were excluded. The cohort was divided into tandem and isolated lesion groups. The primary outcome was the composite of stroke and death. Predictors of stroke or death were determined with multivariable logistic regression. RESULTS There were 2016 carotid arteries stented in 1950 patients-1881 (96%) with isolated lesions and 135 (4%) with tandem lesions. The mean patient age was 69.6 ± 9.0 years. Tandem lesions were more likely to be present in women (50.4% vs 33.0%; P < .001) and in patients with a prior carotid endarterectomy (45.9% vs 35.4%; P = .014). Other covariates were similar between the groups. Symptomatic lesions accounted for 42.3% of cases (isolated, 42.2% vs tandem, 43.0%; P = .86). Arteries in the tandem group more often required multiple stents to treat the ICA lesion (9.6% vs 5.2%; P = .027). ICA neuroprotection had similar outcomes in both groups (tandem: success 94.1%, failure 3.7%; isolated: success 96.3%, failure 1.8%; P = .29). The tandem group experienced a higher 30-day mortality (2.2% vs 0.6%; P = .039), more perioperative neurologic events (stroke or transient ischemic attack) (8.1% vs 2.0%; P < .001), and a higher incidence of stroke or death (5.9% vs 1.9%; P = .002). Predictors of the primary outcome in the multivariable model included treatment of tandem lesions (odds ratio [OR], 3.10; 95% confidence interval [CI], 1.39-6.89; P = .006), symptomatic lesions (OR, 2.24; 95% CI, 1.21-4.17; P = .010), chronic obstructive pulmonary disease (OR, 2.14; 95% CI, 1.17-3.92; P = .014), general anesthesia (OR, 3.34; 95% CI, 1.35-8.26; P = .009), and advancing age (OR, 1.05 per year; 95% CI, 1.01-1.09; P = .006). CONCLUSIONS The addition of endovascular treatment of tandem CCA lesions with CAS is associated with a three-fold increase in perioperative stroke and death and should be avoided if possible.
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Affiliation(s)
- Charles DeCarlo
- Division of Vascular and Endovascular Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, Mass.
| | - Adam Tanious
- Division of Vascular and Endovascular Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, Mass
| | - Laura T Boitano
- Division of Vascular and Endovascular Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, Mass
| | - Jahan Mohebali
- Division of Vascular and Endovascular Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, Mass
| | - David H Stone
- Section of Vascular Surgery, Dartmouth-Hitchcock Medical Center, Lebanon, NH
| | - W Darrin Clouse
- Division of Vascular and Endovascular Surgery, University of Virginia, Charlottesville VA
| | - Mark F Conrad
- Division of Vascular and Endovascular Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, Mass
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19
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Tao Y, Hua Y, Jia L, Jiao L, Liu B. Risk Factors for Residual Stenosis After Carotid Artery Stenting. Front Neurol 2021; 11:606924. [PMID: 33584505 PMCID: PMC7876267 DOI: 10.3389/fneur.2020.606924] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2020] [Accepted: 12/21/2020] [Indexed: 11/13/2022] Open
Abstract
Background and purpose: Stent residual stenosis is an independent risk factor for restenosis after stenting. This study aimed to analyze the factors influencing residual stenosis after carotid artery stenting (CAS). Methods: A total of 570 patients who underwent CAS with 159 closed-loop stents (CLS) and 411 open-loop stents (OLS) from January 2013 to January 2016 were retrospectively enrolled in this study. Carotid stenosis location in the common carotid artery or in internal carotid artery, plaque size, and features (regular or irregular morphology; with or without calcification), degree of carotid artery stenosis, and stent expansion rate were detected by carotid duplex ultrasonography. Residual stenosis was defined as a stenosis rate ≥30% after CAS, as detected by digital subtraction angiography. A logistic regression analysis was used to analyze residual stenosis risk factors. Results: The overall incidence of residual stenosis was 22.8% (130/570 stents). The incidence of residual stenosis in the CLS group was higher than that in the OLS group (29.5 vs. 20.2%, χ2 = 5.71, P = 0.017). The logistic regression analysis showed that CLS [odds ratio (OR), 1.933; 95% confidence interval (CI), 1.009-3.702], irregular plaques (OR, 4.237; 95% CI, 2.391-7.742), and plaques with calcification (OR, 2.370; 95% CI, 1.337-4.199) were independent risk factors for residual stenosis after CAS. In addition, a high radial expansion rate of stent was a protective factor for residual stenosis (OR, 0.171; 95% CI, 0.123-0.238). The stenosis location and stent length did not impact the occurrence of residual stenosis. After 1-year follow-up, the incidence of restenosis in the residual stenosis group was higher than that in the group without residual stenosis (13.1 vs. 2.0%, χ2 = 28.05, P < 0.001). Conclusions: The findings of this study suggest that plaque morphology, echo characteristics (with calcification), and stents type influence residual stenosis.
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Affiliation(s)
- Yunlu Tao
- Department of Vascular Ultrasonography, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Yang Hua
- Department of Vascular Ultrasonography, Xuanwu Hospital, Capital Medical University, Beijing, China.,Center of Vascular Ultrasonography, Beijing Institute of Brain Disorders, Beijing, China
| | - Lingyun Jia
- Department of Vascular Ultrasonography, Xuanwu Hospital, Capital Medical University, Beijing, China.,Center of Vascular Ultrasonography, Beijing Institute of Brain Disorders, Beijing, China
| | - Liqun Jiao
- Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Beibei Liu
- Department of Vascular Ultrasonography, Xuanwu Hospital, Capital Medical University, Beijing, China
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Veselka J, Hajek P, Štěchovský C, Horváth M, Adlová R, Roland R, Homolová I, Hansvenclová E, Zimolová P. Long-term survival of carotid stenting patients with regard to single- or double-vessel carotid artery disease: a propensity score matching analysis. Arch Med Sci 2021; 17:849-855. [PMID: 34336012 PMCID: PMC8314408 DOI: 10.5114/aoms.2020.98167] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/03/2020] [Accepted: 07/18/2020] [Indexed: 01/22/2023] Open
Abstract
INTRODUCTION There is lack of long-term data outside of controlled clinical trials in carotid artery stenting (CAS). In this study, we compared the short-term outcome, long-term survival, and rate of re-interventions for restenosis in patients after CAS, related to the extent of carotid atherosclerosis classified as single-vessel (unilateral) or double-vessel (bilateral) carotid artery disease. MATERIAL AND METHODS We retrospectively evaluated 599 patients with significant carotid artery stenosis, who underwent 763 CAS procedures, and used the propensity score to match 226 pairs (452 patients) in the single- or double-vessel carotid disease. RESULTS There was no significant difference in the occurrence of in-hospital major adverse events (3.5% vs. 3.1% of patients in the double-vessel carotid group vs. the single-vessel carotid group; p = 1) The mean follow-up was 6.1 ±4.0 years, and a total of 181 (40%) deaths occurred during 2759 patient-years, which translates into 7.8 and 5.3 deaths per 100 patient-years in the double-vessel carotid group and the single-vessel carotid group, respectively (p < 0.01). The survival in the double-vessel carotid group vs. the single-vessel carotid group at 10 years was 46% (95% CI: 38-54%) vs. 55% (95% CI: 47-63%) (p < 0.01). Twenty-four (11%) patients and 6 (3%) patients underwent re-interventions for restenosis in the double-vessel and the single-vessel carotid disease group, respectively (p < 0.01). CONCLUSIONS Patients with CAS and significant double-vessel carotid artery disease had similar peri-procedural risk, but had a worse long-term survival, and a higher rate of re-interventions for restenosis compared to the single-vessel carotid artery disease patients.
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Affiliation(s)
- Josef Veselka
- Department of Cardiology, 2 Medical School, Charles University, University Hospital Motol, Prague, Czech Republic
| | - Petr Hajek
- Department of Cardiology, 2 Medical School, Charles University, University Hospital Motol, Prague, Czech Republic
| | - Cyril Štěchovský
- Department of Cardiology, 2 Medical School, Charles University, University Hospital Motol, Prague, Czech Republic
| | - Martin Horváth
- Department of Cardiology, 2 Medical School, Charles University, University Hospital Motol, Prague, Czech Republic
| | - Radka Adlová
- Department of Cardiology, 2 Medical School, Charles University, University Hospital Motol, Prague, Czech Republic
| | - Robert Roland
- Department of Cardiology, 2 Medical School, Charles University, University Hospital Motol, Prague, Czech Republic
| | - Ingrid Homolová
- Department of Cardiology, 2 Medical School, Charles University, University Hospital Motol, Prague, Czech Republic
| | - Eva Hansvenclová
- Department of Cardiology, 2 Medical School, Charles University, University Hospital Motol, Prague, Czech Republic
| | - Petra Zimolová
- Department of Cardiology, 2 Medical School, Charles University, University Hospital Motol, Prague, Czech Republic
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Horev A, Zlotnik Y, Borodetsky V, Biederko R, Star M, Zvenigorodsky V, Shelef I, Ifergane G. Adjunctive treatment with low dose intra-arterial eptifibatide and intravenous aspirin during carotid stenting: A case series. J Clin Neurosci 2020; 84:29-32. [PMID: 33485594 DOI: 10.1016/j.jocn.2020.11.048] [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: 09/11/2020] [Revised: 11/03/2020] [Accepted: 11/27/2020] [Indexed: 11/26/2022]
Abstract
PURPOSE According to most guidelines, medical protocol for carotid stenting includes the administration of oral Aspirin and Clopidogrel at least four days before the procedure, with intraprocedural intravenous (IV) heparin. Some publications have also reported the safety of adding glycoprotein 2b/3a inhibitors to the protocol. In this retrospective study, we evaluate the safety of a new medication protocol that includes IV aspirin and intra-arterial Eptifibatide (glycoprotein 2b/3a inhibitor) during carotid stenting. All patients who underwent carotid stenting at Soroka University Medical Center between January 2015 and May 2020 were included (emergent cases were excluded). We divided patients into two groups-patients treated under the standard protocol, and patients treated under the new protocol. In the latter, patients received both the standard protocol regimen, as well as 150 mg IV aspirin immediately before stenting, and a slow intra-arterial injection of 2-3 mg Eptifibatide (glycoprotein 2b/3a antagonist) immediately after stenting. Forty-four patients were treated according to the standard protocol (group 1), and 41 patients were treated according to the new protocol (group 2). In group 1, six patients had complications, while in group 2, no complications of any kind were noted (p = 0.027). The safety and possible efficacy of this novel protocol was preliminarily demonstrated in the present study. Future studies are needed to prove the safety and efficacy of a specific drug regimen that will further reduce the complication rates of carotid stenting.
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Affiliation(s)
- Anat Horev
- Neurology Department, Soroka University Medical Center, Beer-Sheva, Israel.
| | - Yair Zlotnik
- Neurology Department, Soroka University Medical Center, Beer-Sheva, Israel
| | | | - Ron Biederko
- Research Institute, Soroka University Medical Center, Beer-Sheva, Israel
| | - Michael Star
- Neurology Department, Soroka University Medical Center, Beer-Sheva, Israel
| | | | - Ilan Shelef
- Radiology Institute, Soroka University Medical Center, Beer-Sheva, Israel
| | - Gal Ifergane
- Neurology Department, Soroka University Medical Center, Beer-Sheva, Israel
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Liang P, O'Donnell TFX, Cronenwett JL, Malas MB, Eldrup-Jorgensen J, Kashyap VS, Wang GJ, Motaganahalli RL, Nolan BW, Schermerhorn ML. Vascular Quality Initiative risk score for 30-day stroke or death following transcarotid artery revascularization. J Vasc Surg 2020; 73:1665-1674. [PMID: 33091519 DOI: 10.1016/j.jvs.2020.10.023] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2020] [Accepted: 10/06/2020] [Indexed: 11/30/2022]
Abstract
OBJECTIVE Transcarotid artery revascularization (TCAR) using a flow-reversal neuroprotection system has gained popularity for the endovascular treatment of carotid artery atherosclerotic disease owing to its lower risk of stroke or death compared with transfemoral carotid artery stenting. However, specific risk factors associated with stroke or death complications after TCAR have yet to be defined. METHODS All patients undergoing TCAR for the treatment of asymptomatic or symptomatic atherosclerotic carotid disease were identified between September 2016 and September 2019 in the Vascular Quality Initiative TCAR Surveillance Project. Our primary outcome was 30-day stroke or death. We created a risk model for 30-day stroke or death using multivariable fractional polynomials and internally validated the model using bootstrapping. RESULTS During the study period 7633 patients underwent TCAR, of which 4089 (53.6%) were treated for symptomatic and 3544 (46.4%) for asymptomatic disease. The average age of patients undergoing TCAR was 73.3 ± 9.1 years and 63.7% were male. Stroke or death events within 30 days of the index operation occurred in 153 patients (2.0%). Factors independently associated with a higher odds of 30-day stroke or death included the severity of presenting stroke symptoms (cortical transient ischemic attack, odds ratio [OR], 2.17 [95% confidence interval (CI), 1.21-3.90; P = .009]; stroke, OR, 3.30; 95% CI, 2.25-4.85; P < .001), advancing age (OR, 1.03 per year; 95% CI, 1.01-1.06; P = .003), and history of unstable angina or myocardial infarction within the past 6 months (OR, 2.20; 95% CI, 1.29-3.77; P = .004), moderate or severe congestive heart failure (OR, 2.44; 95% CI, 1.31-4.55; P = .005), chronic obstructive pulmonary disease (on medications, OR, 1.61 [95% CI, 1.06-2.43; P = .024]; on home oxygen, OR, 2.52 [95% CI, 1.44-4.41; P = .001]), and prior ipsilateral carotid endarterectomy (OR, 1.56; 95% CI, 1.09-2.25; P = .016), whereas preoperative P2Y12 use was associated with a lower odds of 30-day stroke or death (OR, 0.57; 95% CI, 0.39-0.85; P = .005). A 30-point risk prediction model created based on these criteria produced a C statistic of 0.72 and Hosmer-Lemeshow goodness of fit of 0.97. Internal validation demonstrated good discrimination with a bias corrected area under the receiver operating characteristic curve of 0.70 with a calibration slope of 1.00. CONCLUSIONS This Vascular Quality Initiative TCAR risk score calculator can be used to estimate the risk of stroke or death within 30 days of the procedure. Because TCAR is commonly used to treat patients with high surgical risk for carotid endarterectomy, this risk score will help to guide treatment decisions in patients being considered for TCAR.
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Affiliation(s)
- Patric Liang
- Division of Vascular and Endovascular Surgery, Department of Surgery, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, Mass
| | - Thomas F X O'Donnell
- Division of Vascular and Endovascular Surgery, Department of Surgery, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, Mass; Department of Surgery, Massachusetts General Hospital and Harvard Medical School, Boston, Mass
| | - Jack L Cronenwett
- Section of Vascular Surgery and The Dartmouth Institute, Dartmouth-Hitchcock Medical Center, Lebanon, NH
| | - Mahmoud B Malas
- Division of Vascular and Endovascular Surgery, Department of Surgery, University of California San Diego Health System, San Diego, Calif
| | - Jens Eldrup-Jorgensen
- Division of Vascular and Endovascular Surgery, Department of Surgery, Maine Medical Center, Portland, Me
| | - Vikram S Kashyap
- Division of Vascular and Surgery and Endovascular Therapy, Department of Surgery, University Hospitals Cleveland Medical Center, Cleveland, Ohio
| | - Grace J Wang
- Division of Vascular Surgery and Endovascular Therapy, Department of Surgery, Hospital of the University of Pennsylvania, Philadelphia, Pa
| | - Raghu L Motaganahalli
- Division of Vascular Surgery, Department of Surgery, Indiana University School of Medicine, Indianapolis, Ind
| | - Brian W Nolan
- Division of Vascular and Endovascular Surgery, Department of Surgery, Maine Medical Center, Portland, Me
| | - Marc L Schermerhorn
- Division of Vascular and Endovascular Surgery, Department of Surgery, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, Mass.
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OCAK Ö, CELİK H, VARISLI B. Hypoglossal Nerve Palsy after Carotid Endarterectomy: Case Report. JOURNAL OF EMERGENCY MEDICINE CASE REPORTS 2020. [DOI: 10.33706/jemcr.573739] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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Öcal L, Küp A, Çelik M, Cerşit S, Keskin M, Havan N, Gürsoy MO, Şahin M, Eren H, Koyuncu A, Uslu A, Yılmaz F, Yazıcıoğlu MV, Türkmen MM. What should be the Optimal Carotid Stent Opening Rate Without Post-Dilation? J Stroke Cerebrovasc Dis 2020; 29:105155. [PMID: 32912494 DOI: 10.1016/j.jstrokecerebrovasdis.2020.105155] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2020] [Revised: 06/25/2020] [Accepted: 07/11/2020] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND There is not a widely accepted optimal rate of stent opening in patients underwent carotid artery stenting. In this study we evaluated the effect of carotid stent opening rate (CSOR) without performing post-dilation on in-hospital and long-term outcomes. METHODS A total of 825 patient patients underwent carotid artery stenting without post-dilation enrolled to the study. The patients divided into two groups according to their final CSOR (50% ≤ Post-stent deployment (SD) <80% and 80% ≤ Post-SD ≤ 100%). In-hospital and 3-year outcomes were compared between the groups. RESULTS During hospitalization, the rate of ipsilateral stroke, major stroke and transient ischemic attacks were similar between the groups (respectively; 6.2% vs. 4.1, P = 0.190; 1.5% vs. 1.8, P = 0.811; 1.5% vs. 1.9%, P = 0.683). The 3-year Kaplan-Meier overall survival rates for the first and second groups were 87.6% and 84.4%, respectively (log rank test P = 0.426). The 3-year Kaplan-Meier overall cumulative ipsilateral stroke rates for the first and second groups were 88.0% and 88.6%, respectively (log rank test P = 0.409) CONCLUSION: Our study demonstrated that a CSOR higher than 50% without performing a post-dilation might be an effective therapeutic approach since there was not a significant difference regarding outcomes between the patients with a 50% ≤ Post-SD <80% and 80% ≤ Post-SD ≤ 100%. The need for post-stent balloon dilation might have been eliminated due to subsequent stent self-expansion.
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Affiliation(s)
- Lütfi Öcal
- Cardiology, Health Sciences University, Kartal Koşuyolu Heart Training and Research Hospital, Istanbul, Turkey
| | - Ayhan Küp
- Cardiology, Health Sciences University, Kartal Koşuyolu Heart Training and Research Hospital, Istanbul, Turkey
| | - Mehmet Çelik
- Cardiology, Health Sciences University, Kartal Koşuyolu Heart Training and Research Hospital, Istanbul, Turkey
| | - Sinan Cerşit
- Cardiology, Health Sciences University, Kartal Koşuyolu Heart Training and Research Hospital, Istanbul, Turkey
| | - Muhammed Keskin
- Cardiology, Health Sciences University, Sultan Abdulhamid Han Training and Research Hospital, Istanbul, Turkey.
| | - Nuri Havan
- Radiology, Health Sciences University, Kartal Koşuyolu Heart Training and Research Hospital, Istanbul, Turkey
| | - Mustafa Ozan Gürsoy
- Cardiology, Katip Çelebi University, Atatürk Training and Research Hospital, Izmir, Turkey
| | - Müslüm Şahin
- Cardiology, VM Pendik Medical Park Hospital, Istanbul, Turkey
| | - Hayati Eren
- Cardiology, Elbistan State Hospital, Kahramanmaraş, Turkey
| | - Atilla Koyuncu
- Cardiology, Health Sciences University, Bakırköy Training and Research Hospital, Istanbul, Turkey
| | - Abdulkadir Uslu
- Cardiology, Health Sciences University, Kartal Koşuyolu Heart Training and Research Hospital, Istanbul, Turkey
| | - Fatih Yılmaz
- Cardiology, Health Sciences University, Kartal Koşuyolu Heart Training and Research Hospital, Istanbul, Turkey
| | - Mehmet Vefik Yazıcıoğlu
- Cardiology, Health Sciences University, Kartal Koşuyolu Heart Training and Research Hospital, Istanbul, Turkey
| | - Mehmet Muhsin Türkmen
- Cardiology, Health Sciences University, Kartal Koşuyolu Heart Training and Research Hospital, Istanbul, Turkey
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Sirignano P, Stabile E, Mansour W, Capoccia L, Faccenna F, Intrieri F, Ferri M, Saccà S, Sponza M, Mortola P, Ronchey S, Grillo P, Chiappa R, Losa S, Setacci F, Pirrelli S, Taurino M, Ruffino MA, Udini M, Palombo D, Ippoliti A, Montelione N, Setacci C, de Donato G, Ruggeri M, Speziale F. 1-Month Results From a Prospective Experience on CAS Using CGuard Stent System. JACC Cardiovasc Interv 2020; 13:2170-2177. [DOI: 10.1016/j.jcin.2020.05.026] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/04/2020] [Revised: 05/08/2020] [Accepted: 05/12/2020] [Indexed: 12/26/2022]
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Langhoff R, Schofer J, Scheinert D, Schmidt A, Sedgewick G, Saylors E, Sachar R, Sievert H, Zeller T. Double Filtration During Carotid Artery Stenting Using a Novel Post-Dilation Balloon With Integrated Embolic Protection. JACC Cardiovasc Interv 2020; 12:395-403. [PMID: 30784647 DOI: 10.1016/j.jcin.2018.11.039] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/24/2018] [Revised: 11/20/2018] [Accepted: 11/28/2018] [Indexed: 11/19/2022]
Abstract
OBJECTIVES This study evaluated the safety and performance of the Paladin System, a novel angioplasty balloon with an integrated embolic protection filter designed to increase embolic protection during post-dilation. BACKGROUND The risk of major adverse events during carotid artery stenting (CAS) is equivalent to carotid endarterectomy. However, the risk of minor stroke remains higher with CAS. Much of this risk occurs during post-stent dilation. METHODS A total of 106 patients were enrolled in 5 centers in Germany. The study's primary endpoint was all-cause death, myocardial infarction, and stroke at 30 days post-procedure. Pre- and post-procedural diffusion-weighted magnetic resonance imaging evaluated new ischemic lesions in 30 subjects. Filter histomorphometric analysis was performed in 23 patients. Retrospective analyses compared outcome rates to historical controls. RESULTS Device and procedural success rates were 100%. The combined major adverse event rate (death, myocardial infarction, and stroke) at discharge and at 30 days was 0% and 1.0%, respectively. The single adverse event was a stroke, which occurred at day 12 and was believed unrelated to the device or procedure. New ischemic lesions were found in 11 (36.7%) patients in the diffusion-weighted magnetic resonance imaging subset. New ipsilateral lesions were seen in 9 (30.0%) patients. Mean lesion volume per patient was 0.010 cm3. Debris was present in all filters, and approximately 90% of captured particles were <100 μm. CONCLUSIONS Use of the Paladin System for post-stent dilation during CAS appears safe, and it may effectively decrease the number of embolic particles reaching the brain, which may help reduce the risk of procedure-related stroke. (A Multi-Center Study to Evaluate Acute Safety and Clinical Performance of Paladin® Carotid Post-Dilation Balloon System With Integrated Embolic Protection; NCT02501148).
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Affiliation(s)
- Ralf Langhoff
- Department of Angiology, Sankt Gertrauden Krankenhaus GmbH, Berlin, Germany.
| | - Joachim Schofer
- Department of Cardiology, Medical Care Center Prof. Mathey, Prof. Schofer, Hamburg, Germany
| | - Dierk Scheinert
- Clinic for Angiology, University Hospital Leipzig, Leipzig, Germany
| | - Andrej Schmidt
- Clinic for Angiology, University Hospital Leipzig, Leipzig, Germany
| | | | | | - Ravish Sachar
- Heart and Vascular Services, UNC REX Healthcare, Raleigh, North Carolina
| | - Horst Sievert
- CardioVascular Center Frankfurt, Frankfurt am Main, Germany; Anglia Ruskin University, Chelmsford, United Kingdom
| | - Thomas Zeller
- Department of Angiology, Universitats Herzzentrum Freiburg-Bad Krozingen, Bad Krozingen, Germany
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Prospective multicentre study of carotid artery stenting using the MER™ Stent - the OCEANUS study - 30-day and one-year follow-up results. ADVANCES IN INTERVENTIONAL CARDIOLOGY 2019; 16:1-9. [PMID: 32368230 PMCID: PMC7189137 DOI: 10.5114/aic.2019.91364] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2019] [Accepted: 10/03/2019] [Indexed: 12/24/2022] Open
Abstract
Introduction Constant technological progress in the field of carotid stenting translates into improved short- and long-term results of endovascular treatment. The introduction of a new generation, self-expanding, open-cell stent has provided a new treatment option in endovascular management of carotid stenosis. Aim To evaluate 30-day and 1-year clinical outcomes of non-consecutive patients with high risk of carotid endarterectomy, who underwent 5F cylinder-tapered MER™ open-cell carotid stent implantation. Material and methods It was a single-arm, prospective study conducted in four experienced catheterisation centres. The use of embolic protection devices was mandatory. The primary endpoint was stroke in 30-day follow-up. The secondary endpoints were 30-day and 1-year cumulative incidence of death, stroke and myocardial infarction, 1-year target vessel revascularisation, procedural success (residual stenosis ≤ 30%), restenosis rate (%DS ≥ 50%), and Serious Adverse Device Effect (SADE) rate in 1-year follow-up. Results In total 100 patients were recruited for the study, with the majority being males (n = 61). The mean age was 68.3 ±8.2 years, and most of the patients were asymptomatic (n = 56). In 55 (55%) patients direct stenting was performed, with the use of proximal protection devices in 19 (19%) patients. Mean internal carotid artery/common carotid artery stenosis before and after stent implantation was 81.98 ±9.15% and 12.52 ±8.70%, respectively (p < 0.001). Procedural success was achieved in all cases. One ischaemic stroke was observed at 30 days (1%, primary endpoint). At 1-year follow-up two myocardial infarctions and three deaths occurred with no additional stroke. Conclusions The OCEANUS study indicated the safety and efficacy of the MER™ stent during 30-day and 1-year follow-up in both symptomatic and asymptomatic patients. The majority of patients were event-free. However, larger cohort studies are needed to evaluate MER™ stents in detail.
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Kuwabara M, Nakahara T, Mitsuhara T, Shimonaga K, Hosogai M, Kurisu K, Sakamoto S. Transient Cerebral Vasospasm After Carotid Artery Stenting: A Case Report and Literature Review. World Neurosurg 2019; 135:107-111. [PMID: 31837494 DOI: 10.1016/j.wneu.2019.11.151] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2019] [Accepted: 11/25/2019] [Indexed: 11/15/2022]
Abstract
BACKGROUND Cerebral embolism after carotid artery stenting (CAS) is a well-known complication, but cerebral ischemia owing to cerebral vasospasm after CAS is rare and has seldom been reported. We describe a patient with transient ischemic complications owing to reversible cerebral vasospasm of the middle cerebral artery after CAS. CASE DESCRIPTION A 74-year-old man presented with right hemiparesis caused by acutely scattered brain infarction in the left cerebral hemisphere. Magnetic resonance angiography showed severe stenosis of the left cervical internal carotid artery origin. CAS under a distal filter protection was performed without any intraprocedural complications, but 12 hours later, the patient had aphasia and Gerstmann syndrome. Urgent magnetic resonance imaging revealed no evidence of an intracranial hemorrhage or new cerebral infarction. However, magnetic resonance angiography showed diffuse vasospasm of the left middle cerebral artery. His symptoms and imaging findings improved gradually with conservative treatment. The patient was discharged without new neurologic deficit or recurrent attack 3 weeks after CAS. CONCLUSIONS In a patient with delayed neurologic symptoms after CAS, the possibility of cerebral vasospasm should be kept in mind to select appropriate treatment.
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Affiliation(s)
- Masashi Kuwabara
- Department of Neurosurgery, Graduate School of Biomedical and Health Sciences, Hiroshima University, Hiroshima, Japan.
| | - Toshinori Nakahara
- Department of Neurosurgery, Hiroshima City Asa Hospital, Hiroshima, Japan
| | - Takafumi Mitsuhara
- Department of Neurosurgery, Graduate School of Biomedical and Health Sciences, Hiroshima University, Hiroshima, Japan
| | - Koji Shimonaga
- Department of Neurosurgery, Hiroshima City Asa Hospital, Hiroshima, Japan
| | - Masahiro Hosogai
- Department of Neurosurgery, Hiroshima City Asa Hospital, Hiroshima, Japan
| | - Kaoru Kurisu
- Department of Neurosurgery, Graduate School of Biomedical and Health Sciences, Hiroshima University, Hiroshima, Japan
| | - Shigeyuki Sakamoto
- Department of Neurosurgery, Graduate School of Biomedical and Health Sciences, Hiroshima University, Hiroshima, Japan
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Sacks D, Farrell MB, Katzen BT, Lally M, Matsumura JS, Merrill N. Snapshot of current carotid artery stenting practice and accreditation in the USA. BMJ Open Qual 2019; 8:e000671. [PMID: 31673643 PMCID: PMC6797390 DOI: 10.1136/bmjoq-2019-000671] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2019] [Revised: 09/16/2019] [Accepted: 09/21/2019] [Indexed: 11/29/2022] Open
Abstract
Objective The aim of this exploratory study was to compare the performance of carotid artery stenting (CAS) best practices between Intersocietal Accreditation Commission (IAC) accredited facilities and non-accredited facilities certified by the Centers for Medicare and Medicaid Services (CMS). Methods A random, anonymous survey was sent to CMS and IAC accredited facilities querying facility routine performance of 16 CAS procedure components found in published guidelines and utilised during clinical trials. Results There were 28 responses (response rate=17%). Significant differences were found between the CMS and the IAC facilities for four of 16 procedure measures: determination of modified Rankin Scale score prior to stenting (p=0.012, 95% CI 20% to 80%), accurate measurement of per cent stenosis using electronic callipers (p=0.005, 95% CI 24% to 84%), confirmation of anticoagulation with activated clotting time greater than 250 s prior to crossing the lesion (p=0.03, 95% CI 7% to 69%), and comparison of facility outcomes to accepted benchmarks for stroke and death (p=0.03, 95% CI 7% to 69%). Overall, IAC facilities performed all 16 procedures more frequently (97%) than CMS facilities (66%) (p<0.001, 95% CI 24% to 36%). Conclusions Although the sample size was small, the results demonstrated IAC accredited facilities are more likely to follow best practices, to use quantitative tools to select appropriate patients, and quantitively measure patient-centred clinical outcomes compared with CMS certified facilities. The findings raise the question as to the value of CMS certification versus IAC accreditation as a requirement for reimbursement.
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Affiliation(s)
- David Sacks
- Department of Radiology/Interventional Radiology, The Reading Hospital and Medical Center, West Reading, Pennsylvania, USA
| | - Mary Beth Farrell
- Research, Intersocietal Accreditation Commission, Ellicott City, Maryland, USA
| | | | - Mary Lally
- Intersocietal Accreditation Commission, Ellicott City, Maryland, USA
| | - Jon S Matsumura
- Department of Surgery, Division of Vascular Surgery, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin, USA
| | - Nancy Merrill
- Intersocietal Accreditation Commission, Ellicott City, Maryland, USA
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Yao X, Dai Z, Zhang X, Gao J, Xu G, Cai Y, Li Z. Carotid Geometry as a Predictor of In-Stent Neointimal Hyperplasia - A Computational Fluid Dynamics Study. Circ J 2019; 83:1472-1479. [PMID: 31061352 DOI: 10.1253/circj.cj-18-1152] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
BACKGROUND Carotid angioplasty and stenting (CAS) is emerging as an alternative treatment for carotid stenosis, but neointimal hyperplasia (NIH) remains a drawback of this treatment strategy. This study aimed to evaluate the effect of variations of carotid bifurcation geometry on local hemodynamics and NIH.Methods and Results:Hemodynamic and geometric effects on NIH were compared between 2 groups, by performing computational fluid dynamics (CFD) simulations both on synthetic models and patient-specific models. In the idealized models, multiple regression analysis revealed a significant negative relationship between internal carotid artery (ICA) angle and the local hemodynamics. In the patient-derived models, which were reconstructed from digital subtraction angiography (DSA) of 25 patients with bilateral CAS, a low time-average wall shear stress (TAWSS) and a high oscillatory shear index (OSI) were often found at the location of NIH. Larger difference values of the OSI percentage area (10.56±20.798% vs. -5.87±18.259%, P=0.048) and ECA/CCA diameter ratio (5.64±12.751% vs. -3.59±8.697%, P=0.047) were detected in the NIH-asymmetric group than in the NIH-symmetric group. CONCLUSIONS Changes in carotid bifurcation geometry can make apparent differences in hemodynamic distribution and lead to bilateral NIH asymmetry. It may therefore be reasonable to consider certain geometric variations as potential local risk factors for NIH.
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Affiliation(s)
- Xinke Yao
- School of Biological Science & Medical Engineering, Southeast University
| | - Zhengze Dai
- Department of Neurology, Jinling Clinical College of Nanjing Medical University.,Department of Neurology, Nanjing Pukou Hospital
| | - Xu Zhang
- School of Biological Science & Medical Engineering, Southeast University
| | - Jie Gao
- Department of Neurology, Jinling Hospital, Medical School of Nanjing University
| | - Gelin Xu
- Department of Neurology, Jinling Clinical College of Nanjing Medical University.,Department of Neurology, Jinling Hospital, Medical School of Nanjing University
| | - Yan Cai
- School of Biological Science & Medical Engineering, Southeast University
| | - Zhiyong Li
- School of Biological Science & Medical Engineering, Southeast University.,School of Chemistry, Physics and Mechanical Engineering, Queensland University of Technology
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Luo N, Qi W, Tong W, Li C, Feng W, Meng B, Zhou X, Huang Y, Wen X, Jiang Y, Huang J, Lu J. Efficacy and Safety of a Novel Catheter for Transradial Cerebral Angiography. Ann Vasc Surg 2019; 60:236-245. [PMID: 31200041 DOI: 10.1016/j.avsg.2019.03.036] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2018] [Revised: 02/28/2019] [Accepted: 03/08/2019] [Indexed: 11/26/2022]
Abstract
BACKGROUND The goal of this study is to evaluate the safety and efficacy of a novel catheter for right radial artery approach cerebral angiography. METHODS Patients from the Neurology Department of The Second Affiliated Hospital of Guangxi Traditional Chinese Medical University who underwent diagnostic cerebral angiography of either the left vertebral artery dominant type or balanced type were enrolled in this study. RESULTS A total of 167 patients were treated between February 2016 and December 2017, of whom 44 were excluded based on study exclusion criteria and 123 were enrolled in the present analysis. Bilateral subclavian artery catheterization and bilateral common carotid artery catheterization were conducted successfully in all 123 patients. The success rate of selective catheterization of the left vertebral artery was 87.8% (108/123). The success rate of selective catheterization of the right vertebral artery using the novel catheter was 89.0% (73/82). The average fluoroscopy time was 6.5 ± 3.4 min, the average operation duration was 47 ± 3.7 (range 50-90) min, and the average dosage of contrast agent was 112.3 ± 8.1 mL. One patient exhibited an absence of pulse in the punctual radial artery after the removal of the arterial compression band, but there was no evidence of ischemia of the distal hand. One patient who was undergoing dual anti-platelet drug treatment suffered from bleeding at the puncture point when deflated for 2 hr after operation; this patient was re-pressurized and re-timed. CONCLUSIONS This novel catheter improved the success rate of selective left vertebral artery catheterization, and allowed for simplification of the relevant surgical steps. The controllability of this novel catheter was satisfactory, and its associated surgical risk was found to be low.
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Affiliation(s)
- Ning Luo
- Department of Neurology, Affiliated RuiKang Hospital of Guangxi University of Chinese Medicine, Nanning, People's Republic of China.
| | - Weiwei Qi
- Department of Neurology, First Affiliated Hospital of Sun Yat-Sen University, Guangzhou, People's Republic of China
| | - Wangxia Tong
- Department of Neurology, Affiliated RuiKang Hospital of Guangxi University of Chinese Medicine, Nanning, People's Republic of China
| | - Changhai Li
- Department of Neurology, Affiliated RuiKang Hospital of Guangxi University of Chinese Medicine, Nanning, People's Republic of China
| | - Wenyong Feng
- Department of Neurology, Affiliated RuiKang Hospital of Guangxi University of Chinese Medicine, Nanning, People's Republic of China
| | - Bing Meng
- Department of Neurology, Affiliated RuiKang Hospital of Guangxi University of Chinese Medicine, Nanning, People's Republic of China
| | - Xinmei Zhou
- Department of Neurology, Affiliated RuiKang Hospital of Guangxi University of Chinese Medicine, Nanning, People's Republic of China
| | - Yanhong Huang
- Department of Neurology, Affiliated RuiKang Hospital of Guangxi University of Chinese Medicine, Nanning, People's Republic of China
| | - Xiaodong Wen
- Department of Neurology, Affiliated RuiKang Hospital of Guangxi University of Chinese Medicine, Nanning, People's Republic of China
| | - Yuanjing Jiang
- Department of Neurology, Affiliated RuiKang Hospital of Guangxi University of Chinese Medicine, Nanning, People's Republic of China
| | - Jianmin Huang
- Department of Neurology, Affiliated RuiKang Hospital of Guangxi University of Chinese Medicine, Nanning, People's Republic of China
| | - Jianzheng Lu
- Department of Neurology, Affiliated RuiKang Hospital of Guangxi University of Chinese Medicine, Nanning, People's Republic of China
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Mazurek A, Partyka L, Trystula M, Jakala J, Proniewska K, Borratynska A, Tomaszewski T, Slezak M, Malinowski KP, Drazkiewicz T, Podolec P, Rosenfiled K, Musialek P. Highly-calcific carotid lesions endovascular management in symptomatic and increased-stroke-risk asymptomatic patients using the CGuard™ dual-layer carotid stent system: Analysis from the PARADIGM study. Catheter Cardiovasc Interv 2019; 94:149-156. [PMID: 30945420 DOI: 10.1002/ccd.28219] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/29/2019] [Revised: 03/13/2019] [Accepted: 03/23/2019] [Indexed: 11/08/2022]
Abstract
OBJECTIVES To assess feasibility, safety, angiographic, and clinical outcome of highly-calcific carotid stenosis (HCCS) endovascular management using CGuard™ dual-layer carotid stents. BACKGROUND HCCS has been a challenge to carotid artery stenting (CAS) using conventional stents. CGuard combines a high-radial-force open-cell frame conformability with MicroNet sealing properties. METHODS The PARADIGM study is prospectively assessing routine CGuard use in all-comer carotid revascularization patients; the focus of the present analysis is HCCS versus non-HCCS lesions. Angiographic HCCS (core laboratory evaluation) required calcific segment length to lesion length ≥2/3, minimal calcification thickness ≥3 mm, circularity (≥3 quadrants), and calcification severity grade ≥3 (carotid calcification severity scoring system [CCSS]; G0-G4). RESULTS One hundred and one consecutive patients (51-86 years, 54.4% symptomatic; 106 lesions) received CAS (16 HCCS and 90 non-HCCS); eight others (two HCCS) were treated surgically. CCSS evaluation was reproducible, with weighted kappa (95% CI) of 0.73 (0.58-0.88) and 0.83 (0.71-0.94) for inter- and intra-observer reproducibility respectively. HCCS postdilatation pressures were higher than those in non-HCCS; 22 (20-24) versus 20 (18-24) atm, p = .028; median (Q1-Q3). Angiography-optimized HCCS-CAS was feasible and free of contrast extravasation or clinical complications. Overall residual diameter stenosis was single-digit but it was higher in HCCS; 9 (4-17) versus 3 (1-7) %, p = .002. At 30 days and 12 months HCCS in-stent velocities were normal and there were no adverse clinical events. CONCLUSION CGuard HCCS endovascular management was feasible and safe. A novel algorithm to grade carotid artery calcification severity was reproducible and applicable in clinical study setting. Larger HCCS series and longer-term follow-up are warranted.
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Affiliation(s)
- Adam Mazurek
- Department of Cardiac & Vascular Diseases, John Paul II Hospital, Jagiellonian University Medical College, Krakow, Poland
| | - Lukasz Partyka
- KCRI Angiographic Core Laboratory and Data Management Division, Krakow, Poland
| | - Mariusz Trystula
- Department of Vascular Surgery, John Paul II Hospital, Krakow, Poland
| | - Jacek Jakala
- KCRI Angiographic Core Laboratory and Data Management Division, Krakow, Poland
| | - Klaudia Proniewska
- KCRI Angiographic Core Laboratory and Data Management Division, Krakow, Poland
| | - Anna Borratynska
- Neurology Inpatient and Outpatient Department, John Paul II Hospital, Krakow, Poland
| | - Tomasz Tomaszewski
- Neurology Inpatient and Outpatient Department, John Paul II Hospital, Krakow, Poland
| | - Magdalena Slezak
- Department of Vascular Surgery, John Paul II Hospital, Krakow, Poland
| | - Krzysztof P Malinowski
- Department of Vascular Surgery, John Paul II Hospital, Krakow, Poland.,Institute of Public Health, Faculty of Health Science, Jagiellonian University Medical College, Krakow, Poland
| | - Tomasz Drazkiewicz
- KCRI Angiographic Core Laboratory and Data Management Division, Krakow, Poland
| | - Piotr Podolec
- Department of Cardiac & Vascular Diseases, John Paul II Hospital, Jagiellonian University Medical College, Krakow, Poland
| | - Kenneth Rosenfiled
- Division of Cardiology, Massachusetts General Hospital, Boston, Massachusetts
| | - Piotr Musialek
- Department of Cardiac & Vascular Diseases, John Paul II Hospital, Jagiellonian University Medical College, Krakow, Poland
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Luo N, Qi W, Tong W, Meng B, Feng W, Zhou X, Wen X, Huang J. The Effect of Vascular Morphology on Selective Left Vertebral Artery Catheterization in Right-sided Radial Artery Cerebral Angiography. Ann Vasc Surg 2019; 56:62-72. [DOI: 10.1016/j.avsg.2018.08.112] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2018] [Revised: 08/30/2018] [Accepted: 08/31/2018] [Indexed: 11/24/2022]
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Carotid Artery Stenting for Symptomatic Internal Carotid Artery Stenosis Associated with Moyamoya Disease. World Neurosurg 2018; 123:76-80. [PMID: 30528525 DOI: 10.1016/j.wneu.2018.11.204] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2018] [Revised: 11/21/2018] [Accepted: 11/22/2018] [Indexed: 11/22/2022]
Abstract
BACKGROUND Surgical intervention in a case of internal carotid artery stenosis with moyamoya vessels has not been well described. We present a case with detailed description of the surgical procedure and perioperative management. CASE DESCRIPTION A 58-year-old man with symptomatic internal carotid artery stenosis had concurrent moyamoya vessels intracranially. He had motor weakness and numbness in the left upper extremity. Magnetic resonance imaging showed an ischemic lesion in the right frontal lobe and right chronic subdural hematoma. On day 18 after surgery for subdural hematoma, carotid artery stenting was performed under proximal balloon protection and distal filter protection. After carotid artery stenting, systolic blood pressure was maintained at <120 mm Hg. Hyperperfusion syndrome or hemorrhagic complication did not occur. The patient was discharged without any neurologic deficits. CONCLUSIONS In our patient with internal carotid artery stenosis with moyamoya vessels, strict control of blood pressure likely contributed to prevention of hyperperfusion syndrome or hemorrhagic complications.
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Dai Z, Li R, Zhao N, Han Y, Wang M, Zhang S, Bai Y, Li Z, Liang M, Xiao L, Ma M, Liu X, Xu G. Neutrophil to Lymphocyte Ratio as a Predictor of Restenosis After Angioplasty and Stenting for Asymptomatic Carotid Stenosis. Angiology 2018; 70:160-165. [PMID: 29940783 DOI: 10.1177/0003319718784805] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
The inflammatory response plays a vital role in the development of in-stent restenosis (ISR) after carotid angioplasty and stenting (CAS). The neutrophil to lymphocyte ratio (NLR) has been suggested as a sensitive inflammatory marker. We explored the association between NLR and ISR in CAS patients. A total of 427 patients who underwent CAS were enrolled. Neutrophil to lymphocyte ratio was measured before the procedure. Clinical examination and radiographic evaluation were performed at 6 months and annually after the procedure. In-stent restenosis was defined as ≥50% stenosis in the treated lesion. Cox regression was used to identify predictors of ISR after CAS. Of the 459 arteries (in 427 patients) with CAS, 72 (15.7%) were identified with ISR during a mean follow-up of 14.6 (19.1) months (range, 0.7-120.7 months). Increased NLR (≥2.13) was significantly related to ISR in patients with asymptomatic stenosis ( P = .001). However, significance was not observed in symptomatic stenosis. On multivariate analysis, baseline NLR ≥ 2.13 (hazard ratio [HR], 2.74; 95% confidence interval [CI], 1.46-5.14), smoking (HR, 1.99; 95% CI, 1.11-3.58), residual stenosis (HR, 1.12; 95% CI, 1.09-1.15), and baseline glucose level (HR, 1.01; 95% CI, 1.01-1.02) were associated with ISR. Elevated NLR may be a predictor of ISR after CAS for asymptomatic stenosis.
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Affiliation(s)
- Zhengze Dai
- Department of Neurology, Jinling Clinical College of Nanjing Medical University, Nanjing, Jiangsu, China
- Department of Neurology, Nanjing Pukou Hospital, Nanjing, Jiangsu, China
| | - Rongrong Li
- Department of Neurology, Jinling Hospital, Medical School of Nanjing University, Nanjing, Jiangsu, China
| | - Nan Zhao
- Department of Neurology, Jinling Hospital, Medical School of Nanjing University, Nanjing, Jiangsu, China
| | - Yunfei Han
- Department of Neurology, Jinling Hospital, Medical School of Nanjing University, Nanjing, Jiangsu, China
| | - Mengmeng Wang
- Department of Neurology, Jinling Hospital, Medical School of Nanjing University, Nanjing, Jiangsu, China
| | - Shuai Zhang
- Department of Neurology, Jinling Clinical College of Nanjing Medical University, Nanjing, Jiangsu, China
- Department of Neurology, The Affiliated Hospital of Yangzhou University, Yangzhou University, Yangzhou, Jiangsu, China
| | - Yongjie Bai
- Department of Neurology, Jinling Clinical College of Nanjing Medical University, Nanjing, Jiangsu, China
- Department of Neurology, First Affiliated Hospital, College of Clinical Medicine of Henan University of Science and Technology, Luoyang, Henan, China
| | - Zibao Li
- Department of Neurology, Jinling Clinical College of Nanjing Medical University, Nanjing, Jiangsu, China
| | - Meng Liang
- Department of Neurology, Jinling Hospital, Second Military Medical University, Nanjing, Jiangsu, China
| | - Lulu Xiao
- Department of Neurology, Jinling Clinical College of Nanjing Medical University, Nanjing, Jiangsu, China
- Department of Neurology, Jinling Hospital, Medical School of Nanjing University, Nanjing, Jiangsu, China
| | - Minmin Ma
- Department of Neurology, Jinling Clinical College of Nanjing Medical University, Nanjing, Jiangsu, China
- Department of Neurology, Jinling Hospital, Medical School of Nanjing University, Nanjing, Jiangsu, China
| | - Xinfeng Liu
- Department of Neurology, Jinling Clinical College of Nanjing Medical University, Nanjing, Jiangsu, China
- Department of Neurology, Jinling Hospital, Medical School of Nanjing University, Nanjing, Jiangsu, China
| | - Gelin Xu
- Department of Neurology, Jinling Clinical College of Nanjing Medical University, Nanjing, Jiangsu, China
- Department of Neurology, Jinling Hospital, Medical School of Nanjing University, Nanjing, Jiangsu, China
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Rosen AC, Soman S, Bhat J, Laird AR, Stephens J, Eickhoff SB, Fox PM, Long B, Dinishak D, Ortega M, Lane B, Wintermark M, Hitchner E, Zhou W. Convergence Analysis of Micro-Lesions (CAML): An approach to mapping of diffuse lesions from carotid revascularization. NEUROIMAGE-CLINICAL 2018; 18:553-559. [PMID: 29868451 PMCID: PMC5984594 DOI: 10.1016/j.nicl.2018.01.020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/18/2017] [Revised: 12/19/2017] [Accepted: 01/18/2018] [Indexed: 11/25/2022]
Abstract
Carotid revascularization (endarterectomy, stenting) prevents stroke; however, procedure-related embolization is common and results in small brain lesions easily identified by diffusion weighted magnetic resonance imaging (DWI). A crucial barrier to understanding the clinical significance of these lesions has been the lack of a statistical approach to identify vulnerable brain areas. The problem is that the lesions are small, numerous, and non-overlapping. Here we address this problem with a new method, the Convergence Analysis of Micro-Lesions (CAML) technique, an extension of the Anatomic Likelihood Analysis (ALE). The method combines manual lesion tracing, constraints based on known lesion patterns, and convergence analysis to represent regions vulnerable to lesions as probabilistic brain atlases. Two studies were conducted over the course of 12 years in an active, vascular surgery clinic. An analysis in an initial group of 126 patients at 1.5 T MRI was cross-validated in a second group of 80 patients at 3T MRI. In CAML, lesions were manually defined and center points identified. Brains were aligned according to side of surgery since this factor powerfully determines lesion distribution. A convergence based analysis, was performed on each of these groups. Results indicated the most consistent region of vulnerability was in motor and premotor cortex regions. Smaller regions common to both groups included the dorsolateral prefrontal cortex and medial parietal regions. Vulnerability of motor cortex is consistent with previous work showing changes in hand dexterity associated with these procedures. The consistency of CAML also demonstrates the feasibility of this new approach to characterize small, diffuse, non-overlapping lesions in patients with multifocal pathologies. Convergence Analysis of Micro-Lesions technique finds patterns in diffuse lesions. Lesions from carotid revascularization affect consistent brain targets. Motor cortex is the most vulnerable brain region to these lesions.
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Affiliation(s)
- Allyson C Rosen
- Palo Alto Veterans Affairs Health Care System, Palo Alto, CA 94304, United States; Department of Psychiatry, Stanford University, Stanford, CA 94305, United States.
| | - Salil Soman
- Palo Alto Veterans Affairs Health Care System, Palo Alto, CA 94304, United States; Harvard Medical School, Beth Israel Deaconess Medical Center, Department of Radiology, Boston, MA 00215, United States
| | - Jyoti Bhat
- Palo Alto Veterans Affairs Health Care System, Palo Alto, CA 94304, United States; Palo Alto Veterans Institute for Research, Palo Alto, CA 94304, United States
| | - Angela R Laird
- Department of Physics, School of Integrated Science and Humanity, Florida International University, Miami, FL 33199, United States
| | - Jeffrey Stephens
- Palo Alto Veterans Affairs Health Care System, Palo Alto, CA 94304, United States
| | - Simon B Eickhoff
- Institute of Systems Neuroscience, Medical Faculty, Heinrich Heine University Düsseldorf, Düsseldorf, Germany; Institute of Neuroscience and Medicine, Brain & Behaviour (INM-7), Research Centre Jülich, Jülich, Germany
| | - P Mickle Fox
- Research Imaging Institute, The University of Texas Health Science Center at San Antonio, TX 78229, United States
| | - Becky Long
- Department of Surgery, Stanford University, Stanford, CA 94305, United States; Department of Surgery, Texas Tech University Health Science Center El Paso, TX 79905, United States
| | - David Dinishak
- Palo Alto University, Redwood City, CA 94063, United States
| | - Mario Ortega
- Department of Neurology, Washington University School of Medicine, St. Louis, MO 63110, United States
| | - Barton Lane
- Palo Alto Veterans Affairs Health Care System, Palo Alto, CA 94304, United States; Department of Radiology, Stanford University, Stanford, CA 94305, United States
| | - Max Wintermark
- Palo Alto Veterans Affairs Health Care System, Palo Alto, CA 94304, United States; Department of Radiology, Stanford University, Stanford, CA 94305, United States
| | - Elizabeth Hitchner
- Palo Alto Veterans Affairs Health Care System, Palo Alto, CA 94304, United States; Department of Vascular Surgery, Stanford University, Stanford, CA 94305, United States
| | - Wei Zhou
- Palo Alto Veterans Affairs Health Care System, Palo Alto, CA 94304, United States; Department of Vascular Surgery, Stanford University, Stanford, CA 94305, United States; Department of Surgery, Tucson, AZ 85724-5066, United States
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Dai Z, Gao J, Li S, Li R, Chen Z, Liang M, Liu X, Xu G. Mean Platelet Volume as a Predictor for Restenosis After Carotid Angioplasty and Stenting. Stroke 2018; 49:872-876. [PMID: 29559579 DOI: 10.1161/strokeaha.117.019748] [Citation(s) in RCA: 27] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2017] [Revised: 01/18/2018] [Accepted: 02/16/2018] [Indexed: 01/08/2023]
Affiliation(s)
- Zhengze Dai
- From the Department of Neurology, Jinling Clinical College of Nanjing Medical University, China (Z.D., Z.C., X.L., G.X.); Department of Neurology, Nanjing Pukou Hospital, China (Z.D.); Department of Neurology, Jinling Hospital, Medical School of Nanjing University, China (J.G., R.L., X.L., G.X.); Department of Neurology, Jinling Hospital, Southern Medical University, Nanjing, China (S.L.); Department of Neurology, Jiangsu Province Hospital of Traditional Chinese Medicine, Nanjing, China (Z.C.); and
| | - Jie Gao
- From the Department of Neurology, Jinling Clinical College of Nanjing Medical University, China (Z.D., Z.C., X.L., G.X.); Department of Neurology, Nanjing Pukou Hospital, China (Z.D.); Department of Neurology, Jinling Hospital, Medical School of Nanjing University, China (J.G., R.L., X.L., G.X.); Department of Neurology, Jinling Hospital, Southern Medical University, Nanjing, China (S.L.); Department of Neurology, Jiangsu Province Hospital of Traditional Chinese Medicine, Nanjing, China (Z.C.); and
| | - Shun Li
- From the Department of Neurology, Jinling Clinical College of Nanjing Medical University, China (Z.D., Z.C., X.L., G.X.); Department of Neurology, Nanjing Pukou Hospital, China (Z.D.); Department of Neurology, Jinling Hospital, Medical School of Nanjing University, China (J.G., R.L., X.L., G.X.); Department of Neurology, Jinling Hospital, Southern Medical University, Nanjing, China (S.L.); Department of Neurology, Jiangsu Province Hospital of Traditional Chinese Medicine, Nanjing, China (Z.C.); and
| | - Rongrong Li
- From the Department of Neurology, Jinling Clinical College of Nanjing Medical University, China (Z.D., Z.C., X.L., G.X.); Department of Neurology, Nanjing Pukou Hospital, China (Z.D.); Department of Neurology, Jinling Hospital, Medical School of Nanjing University, China (J.G., R.L., X.L., G.X.); Department of Neurology, Jinling Hospital, Southern Medical University, Nanjing, China (S.L.); Department of Neurology, Jiangsu Province Hospital of Traditional Chinese Medicine, Nanjing, China (Z.C.); and
| | - Zhaoyao Chen
- From the Department of Neurology, Jinling Clinical College of Nanjing Medical University, China (Z.D., Z.C., X.L., G.X.); Department of Neurology, Nanjing Pukou Hospital, China (Z.D.); Department of Neurology, Jinling Hospital, Medical School of Nanjing University, China (J.G., R.L., X.L., G.X.); Department of Neurology, Jinling Hospital, Southern Medical University, Nanjing, China (S.L.); Department of Neurology, Jiangsu Province Hospital of Traditional Chinese Medicine, Nanjing, China (Z.C.); and
| | - Meng Liang
- From the Department of Neurology, Jinling Clinical College of Nanjing Medical University, China (Z.D., Z.C., X.L., G.X.); Department of Neurology, Nanjing Pukou Hospital, China (Z.D.); Department of Neurology, Jinling Hospital, Medical School of Nanjing University, China (J.G., R.L., X.L., G.X.); Department of Neurology, Jinling Hospital, Southern Medical University, Nanjing, China (S.L.); Department of Neurology, Jiangsu Province Hospital of Traditional Chinese Medicine, Nanjing, China (Z.C.); and
| | - Xinfeng Liu
- From the Department of Neurology, Jinling Clinical College of Nanjing Medical University, China (Z.D., Z.C., X.L., G.X.); Department of Neurology, Nanjing Pukou Hospital, China (Z.D.); Department of Neurology, Jinling Hospital, Medical School of Nanjing University, China (J.G., R.L., X.L., G.X.); Department of Neurology, Jinling Hospital, Southern Medical University, Nanjing, China (S.L.); Department of Neurology, Jiangsu Province Hospital of Traditional Chinese Medicine, Nanjing, China (Z.C.); and
| | - Gelin Xu
- From the Department of Neurology, Jinling Clinical College of Nanjing Medical University, China (Z.D., Z.C., X.L., G.X.); Department of Neurology, Nanjing Pukou Hospital, China (Z.D.); Department of Neurology, Jinling Hospital, Medical School of Nanjing University, China (J.G., R.L., X.L., G.X.); Department of Neurology, Jinling Hospital, Southern Medical University, Nanjing, China (S.L.); Department of Neurology, Jiangsu Province Hospital of Traditional Chinese Medicine, Nanjing, China (Z.C.); and
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Tsujimoto M, Enomoto Y, Miyai M, Egashira Y, Iwama T. Optimal platelet function test for in-stent tissue protrusion following carotid artery stenting. J Int Med Res 2018; 46:1866-1875. [PMID: 29552932 PMCID: PMC5991223 DOI: 10.1177/0300060518762949] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/02/2022] Open
Abstract
Purpose To determine the best platelet function test for in-stent tissue protrusion following carotid artery stenting (CAS). Methods Patients who underwent CAS were recruited prospectively in this observational study. Combination of aspirin 100 mg/day and clopidogrel 75 mg/day was administered for a minimum of 7 days prior to procedure. Platelet aggregation was measured by light transmittance aggregometry (LTA) following stimulation by adenosine diphosphate (ADP), collagen, and thrombin receptor activating peptide (TRAP) and by the point of care assay, VerifyNow which measures aspirin and thienopyridine reaction units. Results In-stent tissue protrusion with maximum projection area of ≥1 mm2 was detected by optical coherence tomography (OCT) in 10/28 (36%) patients. Baseline characteristics were not significantly different between the two in-stent size groups (i.e., ≥1 mm2 vs. <1 mm2) but after stimulation by collagen at 10 and 20 μg/ml, platelet reactivity as measured by LTA was significantly higher in the ≥1 mm2 group compared with the <1 mm2 group. No other differences in platelet function were detected. Conclusions Collagen-induced platelet reactivity was related to in-stent tissue protrusion size following CAS.
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Affiliation(s)
- Masanori Tsujimoto
- 1 Department of Neurosurgery, 73882 Daiyukai General Hospital, Sakura, Ichinomiya city, Aichi, Japan.,2 Department of Neurosurgery, Gifu University Graduate School of Medicine, Yanagido, Gifu city, Gifu, Japan
| | - Yukiko Enomoto
- 2 Department of Neurosurgery, Gifu University Graduate School of Medicine, Yanagido, Gifu city, Gifu, Japan
| | - Masafumi Miyai
- 2 Department of Neurosurgery, Gifu University Graduate School of Medicine, Yanagido, Gifu city, Gifu, Japan
| | - Yusuke Egashira
- 2 Department of Neurosurgery, Gifu University Graduate School of Medicine, Yanagido, Gifu city, Gifu, Japan
| | - Toru Iwama
- 2 Department of Neurosurgery, Gifu University Graduate School of Medicine, Yanagido, Gifu city, Gifu, Japan
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Yamauchi K, Enomoto Y, Otani K, Egashira Y, Iwama T. Prediction of hyperperfusion phenomenon after carotid artery stenting and carotid angioplasty using quantitative DSA with cerebral circulation time imaging. J Neurointerv Surg 2017; 10:576-579. [DOI: 10.1136/neurintsurg-2017-013259] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2017] [Revised: 08/08/2017] [Accepted: 08/16/2017] [Indexed: 11/04/2022]
Abstract
BackgroundHyperperfusion syndrome after carotid interventions has a low incidence but it can lead to morbidity and mortality.ObjectiveTo evaluate the usefulness of quantitative DSA for predicting hyperperfusion phenomenon (HPP) after carotid artery stenting and angioplasty.MethodsThirty-three consecutive patients with carotid stenosis treated with carotid artery stenting or angioplasty between February 2014 and August 2016 were included. Color-coded digital subtraction angiograms showing the time to maximum contrast intensity of each image pixel were obtained from conventional DSA before and after procedures. The cerebral circulation time (CCT) was defined as the difference in the relative time to maximum intensity between arterial and venous regions of interest set on the angiograms. HPP was diagnosed straight after the procedure with qualitative 123I-IMP single-photon emission CT (SPECT). Cut-off points for detecting HPP for preprocedural CCT and periprocedural change of CCT were assessed by receiver operating characteristic analysis using 123I-IMP SPECT as reference standard.Results123I-IMP SPECT showed HPP in 4 of 33 patients. In these 4 patients, preprocedural prolongation of CCT (13.0±6.1 vs 7.2±1.3 s; p<0.001) was seen compared with patients without HPP as well as larger periprocedural changes of CCT (5.9±5.7 vs 0.5±1.3 s; p<0.001). The optimal cut-off points of preprocedural CCT and change of CCT for predicting HPP were 8.0 s (100% sensitivity, 69% specificity) and 3.2 s (75% sensitivity, 100% specificity), respectively.ConclusionsPreprocedural prolongation and greater periprocedural change of CCT are associated with the occurrence of HPP. Periprocedural evaluation of CCT may be useful for predicting HPP.
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Chong AB, Taylor M, Schubert G, Vassar M. Interventional Radiology Clinical Practice Guideline Recommendations for Neurovascular Disorders Are Not Based on High-Quality Systematic Reviews. AJNR Am J Neuroradiol 2017; 38:759-765. [PMID: 28154125 DOI: 10.3174/ajnr.a5079] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2016] [Accepted: 11/22/2016] [Indexed: 12/21/2022]
Abstract
BACKGROUND In recent years, clinical practice guidelines have been criticized for biased interpretations of research evidence, and interventional radiology is no exception. PURPOSE Our aim was to evaluate the methodologic quality and transparency of reporting in systematic reviews used as evidence in interventional radiology clinical practice guidelines for neurovascular disorders from the Society of Interventional Radiology. DATA SOURCES Our sources were 9 neurovascular disorder clinical practice guidelines from the Society of Interventional Radiology. STUDY SELECTION We selected 65 systematic reviews and meta-analyses. DATA ANALYSIS A Measurement Tool to Assess Systematic Reviews (AMSTAR) and Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) tools were used to assess the methodologic quality and reporting transparency of systematic reviews. Radial plots were created on the basis of average scores for PRISMA and AMSTAR items. DATA SYNTHESIS On the basis of AMSTAR scores, 3 (4.62%) reviews were high-quality, 28 reviews (43.08%) were moderate-quality, and 34 reviews (52.31%) were low-quality, with an average quality score of 3.66 (34.32%; minimum, 0%; maximum, 81.82%). The average PRISMA score was 18.18 (69.41%). LIMITATIONS We were unable to obtain previous versions for 8 reviews, 7 of which were from the Cochrane Database of Systematic Reviews. CONCLUSIONS The methodologic quality of systematic reviews needs to be improved. Although reporting clarity was much better than the methodologic quality, it still has room for improvement. The methodologic quality and transparency of reporting did not vary much among clinical practice guidelines. This study can also be applied to other medical specialties to examine the quality of studies used as evidence in their own clinical practice guidelines.
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Affiliation(s)
- A B Chong
- From the Oklahoma State University Center for Health Sciences, Tulsa, Oklahoma
| | - M Taylor
- From the Oklahoma State University Center for Health Sciences, Tulsa, Oklahoma
| | - G Schubert
- From the Oklahoma State University Center for Health Sciences, Tulsa, Oklahoma
| | - M Vassar
- From the Oklahoma State University Center for Health Sciences, Tulsa, Oklahoma.
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Omran J, Abdullah O, Abu-Fadel M, Gray WA, Firwana B, Drachman DE, Mahmud E, Aronow HD, White CJ, Al-Dadah AS. Hemorrhagic and ischemic outcomes of Heparin vs. Bivalirudin in carotid artery stenting: A meta-analysis of studies. Catheter Cardiovasc Interv 2017; 89:746-753. [PMID: 27526953 DOI: 10.1002/ccd.26685] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/05/2016] [Revised: 05/16/2016] [Accepted: 07/02/2016] [Indexed: 11/10/2022]
Abstract
INTRODUCTION Bivalirudin, has been shown to have comparable efficacy and better safety profile when compared to unfractionated heparin (UFH) in percutaneous coronary interventions. Bivalirudin's safety in carotid artery stenting (CAS) was associated with better outcomes than heparin in some studies. In this Meta analysis we examine the hemorrhagic and ischemic outcomes associated with Bivalirudin compared to UFH during CAS. METHODS A comprehensive literature search was conducted with the electronic databases MEDLINE, EMBASE, and CENTRAL. Random-effects meta-analysis method was used to pool risk ratio (RR) for both Heparin and Bivalirudin with 95% confidence interval (CI). Study outcomes included hemorrhagic complications; major/minor bleeding and intracranial hemorrhage (ICH) as well as ischemic complications including ischemic stroke, myocardial infarction, and 30 day mortality. RESULTS A total of four studies were included enrolling 7,784 patients. Compared to UFH, Bivalirudin was associated with significantly lower major bleeding events with a relative risk (RR) of 0.53 (95% CI: 0.35-0.80; I2 = 0%). Minor bleeding events were significantly lower in the Bivalirudin group with a RR of 0.41 (95% CI: 0.2-0.82; I2 = 0%). Looking into other outcomes, there were no significant differences between anticoagulation strategies in terms of ischemic stroke (RR 0.8, with 95% CI: 0.60-1.06), intracranial hemorrhage (RR 0.73 with 95% CI: 0.27-1.98), myocardial infarction (RR 1.01 with 95% CI: 0.59-1.73) or 30 day mortality (RR 0.83 with 95% CI: 0.47-1.47). CONCLUSION Compared to UFH, Bivalirudin is associated with lower bleeding risk when used during CAS. © 2016 Wiley Periodicals, Inc.
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Affiliation(s)
- Jad Omran
- Cardiovascular Medicine Department at the University of Missouri-Columbia School of Medicine, Columbia, Missouri
| | - Obai Abdullah
- Internal Medicine Department, University of Florida Collage of Medicine, Gainesville, Florida
| | - Mazen Abu-Fadel
- Internal Medicine Department, Section of Cardiovascular Disease, University of Oklahoma Health Sciences Center, Oklahoma City, Oklahoma
| | - William A Gray
- Department of Cardiology, Columbia University Medical Center, New York, New York
| | - Belal Firwana
- Department of Hematology and Oncology, University of Arkansas for Medical Sciences, Little Rock, Arkansas
| | - Douglas E Drachman
- Department of Cardiology, Massachusetts General Hospital, Boston, Massachusetts
| | - Ehtisham Mahmud
- Division of Cardiovascular Medicine, Sulpizio Cardiovascular Center, University of California-San Diego, La Jolla, California
| | - Herebert D Aronow
- Department of Cardiology, Lifespan Cardiovascular Institue, Providence, Rhode Island
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Effects of Obstructive Carotid Artery Disease on Ocular Circulation and the Safety of Carotid Artery Stenting. Heart Lung Circ 2017; 26:1069-1078. [PMID: 28162948 DOI: 10.1016/j.hlc.2016.11.020] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2016] [Revised: 10/19/2016] [Accepted: 11/24/2016] [Indexed: 11/23/2022]
Abstract
BACKGROUND The aims of this study were to examine the ophthalmic artery flow changes in patients with obstructive carotid artery disease, evaluate the orbital blood flow changes after carotid artery stenting and assess the safety of carotid stenting procedure by using transorbital colour and spectral Doppler sonography. METHODS Thirty-one consecutive patients scheduled for carotid stenting with severe internal carotid artery stenosis (>60%; the study group) and 30 control subjects were included. Ophthalmic artery (OA) Doppler sonography was performed in the control group and study group before and after stenting. Peak systolic velocity (PSV), end-diastolic velocity (EDV), pulsatility index (PI), and resistive index (RI) and systolic/diastolic ratio (S/D) in the ophthalmic artery were recorded. Statistical comparisons were made between controls and study group before stenting and before and after stenting in the study group. RESULTS Comparison between control and study group before stenting revealed a statistically significant decrease in OA PSV (51.5±14.5 vs. 39.7±19cm/sec, p= 0.008) and EDV (15.2±4.5 vs. 11.3±5.7cm/sec, p=0.004) in the study group. Differences in PI (1.3±0.14 vs. 1.36±0.4, p=0.47), RI (0.7±0.04 vs. 0.75±0.21, p=0.19), and S/D (3.5±0.6 vs. 3.6±1, p= 0.5) ratio were not statistically significant between groups. Peak systolic velocity (39.7±18.9 vs. 51.3±22.2cm/sec, p <0.001), RI (0.75±0.21 vs. 0.81±0.13, p=0.16) and S/D ratio (3.6±1 vs. 4.6±1.5, p= 0.001) were found to be significantly increased in the study group after stenting compared to baseline. There were no statistically significant differences in EDV and RI EDV(11.3±5.7 vs. 11.7±5.7cm/sec, p=0.66), PI (1.36±0.4 vs. 1.6±0.6, p =0.047) after stenting. CONCLUSIONS Ophthalmic artery flow parameters were significantly lower in patients with severe carotid artery stenosis compared to control, indicating compromised ocular blood flow in severe carotid stenosis. Flow indicators significantly improved after stent implantation suggesting the importance of revascularisation in restoring ocular blood flow and safety of carotid stenting.
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Barkat M, Hajibandeh S, Hajibandeh S, Torella F, Antoniou G. Systematic Review and Meta-analysis of Dual Versus Single Antiplatelet Therapy in Carotid Interventions. Eur J Vasc Endovasc Surg 2017; 53:53-67. [DOI: 10.1016/j.ejvs.2016.10.011] [Citation(s) in RCA: 37] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2016] [Accepted: 10/18/2016] [Indexed: 11/25/2022]
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Bosiers M, Deloose K, Torsello G, Scheinert D, Maene L, Peeters P, Müller-Hülsbeck S, Sievert H, Langhoff R, Bosiers M, Setacci C. The CLEAR-ROAD study: evaluation of a new dual layer micromesh stent system for the carotid artery. EUROINTERVENTION 2016; 12:e671-6. [PMID: 27180304 DOI: 10.4244/eijy16m05_04] [Citation(s) in RCA: 47] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Affiliation(s)
- Marc Bosiers
- Department of Vascular Surgery, A.Z. Sint-Blasius, Dendermonde, Belgium
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Tsujimoto M, Enomoto Y, Kokuzawa J, Iwama T. Diabetes mellitus and carotid artery plaques exhibiting high-intensity signals on MR angiography are related to increased platelet reactivity after carotid artery stenting. J Neurointerv Surg 2016; 9:106-110. [PMID: 27370776 PMCID: PMC5264231 DOI: 10.1136/neurintsurg-2016-012419] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2016] [Revised: 06/07/2016] [Accepted: 06/15/2016] [Indexed: 11/25/2022]
Abstract
Background Increased platelet reactivity after carotid artery stenting (CAS) may cause thromboembolic complications. Objective This study aimed to investigate the incidence of increased platelet reactivity after CAS and to determine the factors related to it. Methods Patients who underwent CAS were recruited prospectively. They received pre-procedural antiplatelet therapy comprising some combination of aspirin (100 mg/day), clopidogrel (75 mg/day), and/or cilostazol (200 mg/day) for a minimum of 7 days. ADP- and collagen-induced platelet aggregation were measured before and 4 days after CAS. Changes in platelet reactivity were reported as changes in the categorized platelet reactivity grade based on the effective dose 50%. Clinical characteristics of patients with and without increased platelet reactivity were compared. Results Among 38 consecutive patients who underwent CAS, 18 (47%) exhibited increased platelet reactivity. Diabetes mellitus (OR 15.0; 95% CI 2.1 to 106.5; p=0.007) and carotid artery plaques exhibiting high-intensity signals (HIS) on time-of-flight MR angiography (TOF-MRA) (OR 25.2; 95% CI 2.0 to 316.2; p=0.013) were independently associated with increased platelet reactivity in a multivariate analysis. Conclusions Increased platelet reactivity occurred in nearly half of the studied patients subjected to CAS and was independently associated with diabetes mellitus and carotid artery plaques exhibiting HIS on TOF-MRA.
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Affiliation(s)
- Masanori Tsujimoto
- Department of Neurosurgery, Gifu University Graduate School of Medicine, Gifu, Japan
| | - Yukiko Enomoto
- Department of Neurosurgery, Gifu University Graduate School of Medicine, Gifu, Japan
| | - Jouji Kokuzawa
- Department of Neurosurgery, Gifu University Graduate School of Medicine, Gifu, Japan
| | - Toru Iwama
- Department of Neurosurgery, Gifu University Graduate School of Medicine, Gifu, Japan
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Schofer J, Musiałek P, Bijuklic K, Kolvenbach R, Trystula M, Siudak Z, Sievert H. A Prospective, Multicenter Study of a Novel Mesh-Covered Carotid Stent: The CGuard CARENET Trial (Carotid Embolic Protection Using MicroNet). JACC Cardiovasc Interv 2016; 8:1229-1234. [PMID: 26292586 DOI: 10.1016/j.jcin.2015.04.016] [Citation(s) in RCA: 99] [Impact Index Per Article: 12.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/03/2015] [Accepted: 04/08/2015] [Indexed: 02/08/2023]
Abstract
OBJECTIVES This study sought to evaluate the feasibility of the CGuard Carotid Embolic Protective Stent system-a novel thin strut nitinol stent combined with a polyethylene terephthalate mesh covering designed to prevent embolic events from the target lesion in the treatment of carotid artery lesions in consecutive patients suitable for carotid artery stenting. BACKGROUND The risk of cerebral embolization persists throughout the carotid artery stenting procedure and remains during the stent healing period. METHODS A total of 30 consecutive patients (age 71.6 ± 7.6 years, 63% male) meeting the conventional carotid artery stenting inclusion criteria were enrolled in 4 centers in Germany and Poland. RESULTS The primary combined endpoint was the procedure success of the CGuard system and the number and volume of new lesions on the ipsilateral side assessed by diffusion-weighted magnetic resonance imaging at 48 h post-procedure and at 30 days. The secondary endpoint was 30-day major adverse cardiac or cerebrovascular events (death, stroke, or myocardial infarction). Protection devices were used in all procedures. Procedure success was 100%, with 0% procedural complications. The 30-day major adverse cardiac or cerebrovascular events rate was 0%. New ipsilateral ischemic lesions at 48 h occurred in 37.0% of patients and the average lesion volume was 0.039 ± 0.08 cm(3). The 30-day diffusion-weighted magnetic resonance imaging showed complete resolution of all but 1 periprocedural lesion and only 1 new minor (0.116 cm(3)) lesion in relation to the 48-h scan. CONCLUSIONS The use of the CGuard system in patients undergoing carotid artery stenting is feasible. In addition, the benefit of using CGuard may extend throughout the stent healing period.
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Affiliation(s)
- Joachim Schofer
- Medical Care Center, Hamburg University Cardiovascular Center, Hamburg, Germany.
| | - Piotr Musiałek
- Jagiellonian University Department of Cardiac and Vascular Diseases, John Paul II Hospital, Krakow, Poland
| | - Klaudija Bijuklic
- Medical Care Center, Hamburg University Cardiovascular Center, Hamburg, Germany
| | | | - Mariusz Trystula
- Jagiellonian University Department of Cardiac and Vascular Diseases, John Paul II Hospital, Krakow, Poland
| | - Zbigniew Siudak
- Jagiellonian University Department of Cardiac and Vascular Diseases, John Paul II Hospital, Krakow, Poland; Krakow Cardiovascular Research Institute, Krakow, Poland
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Shams T, Zaidat O, Yavagal D, Xavier A, Jovin T, Janardhan V. Society of Vascular and Interventional Neurology (SVIN) Stroke Interventional Laboratory Consensus (SILC) Criteria: A 7M Management Approach to Developing a Stroke Interventional Laboratory in the Era of Stroke Thrombectomy for Large Vessel Occlusions. INTERVENTIONAL NEUROLOGY 2016; 5:1-28. [PMID: 27610118 PMCID: PMC4934489 DOI: 10.1159/000443617] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
Brain attack care is rapidly evolving with cutting-edge stroke interventions similar to the growth of heart attack care with cardiac interventions in the last two decades. As the field of stroke intervention is growing exponentially globally, there is clearly an unmet need to standardize stroke interventional laboratories for safe, effective, and timely stroke care. Towards this goal, the Society of Vascular and Interventional Neurology (SVIN) Writing Committee has developed the Stroke Interventional Laboratory Consensus (SILC) criteria using a 7M management approach for the development and standardization of each stroke interventional laboratory within stroke centers. The SILC criteria include: (1) manpower: personnel including roles of medical and administrative directors, attending physicians, fellows, physician extenders, and all the key stakeholders in the stroke chain of survival; (2) machines: resources needed in terms of physical facilities, and angiography equipment; (3) materials: medical device inventory, medications, and angiography supplies; (4) methods: standardized protocols for stroke workflow optimization; (5) metrics (volume): existing credentialing criteria for facilities and stroke interventionalists; (6) metrics (quality): benchmarks for quality assurance; (7) metrics (safety): radiation and procedural safety practices.
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Affiliation(s)
- Tanzila Shams
- Texas Stroke Institute, HCA North Texas Division, Dallas-Fort Worth, Tex., USA
| | - Osama Zaidat
- Mercy Neuroscience and Stroke Center, Toledo, Ohio, USA
| | - Dileep Yavagal
- Jackson Memorial Hospital, University of Miami Health System, Miami, Fla., USA
| | - Andrew Xavier
- Detroit Medical Center, Wayne State University, Detroit, Mich., USA
| | - Tudor Jovin
- UPMC Stroke Institute, University of Pittsburgh Medical Center, Pittsburg, Pa., USA
| | - Vallabh Janardhan
- Texas Stroke Institute, HCA North Texas Division, Dallas-Fort Worth, Tex., USA
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Perioperative and follow-up results in carotid artery stenting with contralateral carotid occlusion. Jpn J Radiol 2016; 34:523-8. [PMID: 27230906 DOI: 10.1007/s11604-016-0554-2] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2016] [Accepted: 05/12/2016] [Indexed: 10/21/2022]
Abstract
PURPOSE Contralateral carotid occlusion (CCO) increases the risk of carotid endarterectomy (CEA). We determined the outcome of carotid angioplasty and stenting (CAS), an alternative to CEA, in the setting of CCO through an independent analysis of imaging and clinical outcome. MATERIALS AND METHODS Medical records of 26 consecutive patients with CCO who underwent CAS by a single operator using the same procedural protocol (with distal protection and closed-cell stents) were retrospectively evaluated. National Institutes of Health Stroke Scale (NIHSS) and Modified Rankin Scale (mRS) scores before and after CAS, periprocedural complications, and the restenosis rate were analyzed by independent stroke neurologists who were not involved in the care of the patients. RESULTS The median mRS score for the 26 patients was 1 (range 0-5) before and after CAS. All of the patients underwent clinical and imaging follow-up (mean 19.5 ± 14.3 and 11.6 ± 11.2 months, respectively). Thirty-day mortality/permanent morbidity rates were 0 %. One patient had hyperperfusion syndrome and was managed medically without sequelae; however, he had stent occlusion after 30 days, resulting in a decline in his mRS from 4 (preprocedure) to 5. Otherwise, there was no decline in mRS during the post-discharge follow-up. CONCLUSION According to an independent analysis of this single-operator series, CAS is safe and effective for the treatment of patients with CCO.
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