1
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Karatas M, Parsova KE, Keskin M, Ocal L, Doğan S, Keles N. Prognostic value of serum albumin to creatinine ratio in patients undergoing carotid artery stenting. INT ANGIOL 2024; 43:290-297. [PMID: 38577708 DOI: 10.23736/s0392-9590.24.05112-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/06/2024]
Abstract
BACKGROUND We aimed to investigate the prognostic value of serum albumin-to-creatinine ratio (sACR) in carotid artery stenting (CAS) patients regarding in-hospital and 5-year outcomes. METHODS This is a retrospective study. Baseline characteristics were compared between patients by admission albumin to creatinine ratio and categorized accordingly: T1, T2 and T3. 609 patients were included in the study. Serum albumin and creatinine levels at hospital admission were used to calculate the sACR. The primary endpoint was all-cause mortality. MACE consisted of stroke, transient ischemic attack (TIA), myocardial infarction (MI) and death. All follow-up data were obtained from electronic medical records or by interview. The study was terminated after 60 months of follow-up. RESULTS Serum albumin levels were found to be significantly lower in T1, while creatinine was found to be significantly higher in T1. T1 has the lowest sACR while T3 has the highest. In hospital, ipsilateral stroke, major stroke, MI and death were significantly higher in T1. In long-term outcomes, ipsilateral stroke, major stroke, and death were significantly higher in T1. CONCLUSIONS Low sACR values at hospital admission was independently associated with in-hospital and long-term mortality and major stroke in patients underwent CAS.
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Affiliation(s)
- Mesut Karatas
- Department of Cardiology, Kartal Kosuyolu Yuksek Ihtisas Training and Research Hospital, University of Health Sciences, Istanbul, Türkiye
| | - Kemal E Parsova
- Department of Cardiology, Medicana Atasehir Hospital, Istanbul, Türkiye
| | - Muhammed Keskin
- Department of Cardiology, Faculty of Medicine, Bahcesehir University, Istanbul, Türkiye
| | - Lutfi Ocal
- Department of Cardiology, Kartal Kosuyolu Yuksek Ihtisas Training and Research Hospital, University of Health Sciences, Istanbul, Türkiye
| | | | - Nursen Keles
- Department of Cardiology, Dr. Siyami Ersek Thoracic and Cardiovascular Surgery Training and Research Hospital, University of Health Sciences, Istanbul, Türkiye
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2
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Ramazanoglu L, Kalyoncu Aslan I, Bugrul A, Onal Y, Velioglu M, Topcuoglu OM, Gozke E. Prediction of Bleeding by the PRECISE-DAPT Score in Patients with Carotid Artery Stenting. Cardiovasc Intervent Radiol 2023; 46:574-578. [PMID: 37012393 DOI: 10.1007/s00270-023-03419-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/27/2022] [Accepted: 03/11/2023] [Indexed: 04/05/2023]
Abstract
PURPOSE The predicting bleeding complications in patients undergoing stent implantation and the subsequent dual antiplatelet therapy (PRECISE-DAPT) score predicts the risk of bleeding in patients with dual antiplatelet therapy (DAPT) after percutaneous coronary interventions (PCIs). Patients with carotid artery stenting (CAS) are also treated with DAPT. In this study, we aimed to investigate the performance of the PRECISE-DAPT score in predicting bleeding in patients with CAS. METHODS Patients who had CAS between January 2018 and December 2020 were retrospectively enrolled. The PRECISE-DAPT score was calculated for each patient. The patients were divided into two groups based on their PRECISE-DAPT score: low < 25 and high ≥ 25. Bleeding and ischemia complications and laboratory data among the two groups were compared. RESULTS A total of 120 patients with a mean age of 67.3 ± 9.7 years were included. Forty-three patients had high PRECISE-DAPT scores, and 77 patients had low PRECISE-DAPT scores. Six patients developed bleeding events during the six-month follow-up, and five of them were in the PRECISE DAPT score ≥ 25 group. The difference between the two groups regarding bleeding events at six months was significant (P = 0.022). CONCLUSION The PRECISE-DAPT score might be used for predicting the bleeding risk in patients with CAS, and the bleeding rate was significantly higher in patients with a PRECISE-DAPT score ≥ 25.
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Affiliation(s)
- Leyla Ramazanoglu
- Department of Neurology, University of Health Sciences Fatih Sultan Mehmet Training and Research Hospital, Istanbul, Turkey.
| | - Isil Kalyoncu Aslan
- Department of Neurology, University of Health Sciences Fatih Sultan Mehmet Training and Research Hospital, Istanbul, Turkey
| | - Ahmet Bugrul
- Meram Faculty of Medicine, Department of Neurology, Necmettin Erbakan University, Konya, Turkey
| | - Yilmaz Onal
- Department of Radiology, University of Health Sciences Fatih Sultan Mehmet Training and Research Hospital, Istanbul, Turkey
| | - Murat Velioglu
- Department of Radiology, University of Health Sciences Fatih Sultan Mehmet Training and Research Hospital, Istanbul, Turkey
| | | | - Eren Gozke
- Department of Neurology, University of Health Sciences Fatih Sultan Mehmet Training and Research Hospital, Istanbul, Turkey
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3
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Chan V, Rheaume AR, Chow MM. Impact of frailty on 30-day death, stroke, or myocardial infarction in severe carotid stenosis: Endarterectomy versus stenting. Clin Neurol Neurosurg 2022; 222:107469. [DOI: 10.1016/j.clineuro.2022.107469] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2022] [Revised: 10/06/2022] [Accepted: 10/06/2022] [Indexed: 11/03/2022]
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4
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Meschia JF, Brott TG. Lessons From ACST-2. Stroke 2022; 53:e145-e149. [PMID: 35227079 PMCID: PMC8960366 DOI: 10.1161/strokeaha.121.037269] [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: 12/24/2022]
Abstract
The recent 130-center, international, second ACST trial (Asymptomatic Carotid Surgery Trial) involving 3625 patients found that regardless of whether a patient underwent stenting or endarterectomy, the periprocedural risk of disabling or fatal stroke was about 1% and the 5-year estimated risk of nonprocedural disabling or fatal stroke was 2.5%. With advances in technique, technology, and patient selection, stenting done by appropriately trained and experienced operators can achieve safety and efficacy comparable to endarterectomy for asymptomatic patients. The ongoing CREST-2 trial (Carotid Revascularization and Medical Management for Asymptomatic Carotid Stenosis Trial) will clarify whether revascularization, by either stenting or endarterectomy, remains an important therapeutic goal in the setting of modern intensive medical therapy.
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Affiliation(s)
- James F Meschia
- Vascular Neurology Division, Department of Neurology, Mayo Clinic, Jacksonville, FL
| | - Thomas G Brott
- Vascular Neurology Division, Department of Neurology, Mayo Clinic, Jacksonville, FL
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5
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Štěchovský C, Hájek P, Roland R, Horváth M, Veselka J. Long-term changes after carotid stenting assessed by intravascular ultrasound and near-infrared spectroscopy. Cardiovasc Diagn Ther 2021; 11:1180-1189. [PMID: 35070788 PMCID: PMC8748489 DOI: 10.21037/cdt-21-160] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2021] [Accepted: 09/29/2021] [Indexed: 08/22/2023]
Abstract
BACKGROUND Long-term effect of carotid stenting (CAS) on the stabilization of the plaque is almost unrecognized. Vascular healing and remodeling might seal the atherosclerotic plaque with neointimal hyperplasia decreasing the vulnerability. We aimed to assess long-term change in the lipid signal, stent and luminal dimensions and restenosis after CAS with the intravascular ultrasound (IVUS) and near-infrared spectroscopy (NIRS) imaging. METHODS We performed follow-up angiography and NIRS-IVUS imaging of 58 carotid stents in 52 patients. Median time from CAS to the follow-up examination was 31 months (range, 5-56). The lipid signal of the stented segment was calculated from a NIRS-derived chemogram (a spectroscopic map) as the lipid core burden index (LCBI, a dimensionless number from 0 to 1,000). Planimetric and volumetric measurements from IVUS were performed to assess change in minimal stent area (MSA), minimal luminal area (MLA), stent and luminal volume, late stent expansion and percentage in-stent restenosis (ISR) volume. RESULTS During the follow-up period, the mean (±SD) LCBI significantly decreased from 32±56 to 17±27 (P=0.002). The mean stent volume significantly increased from 717±302 to 1,019±429 mm3 (P<0.001) with mean stent expansion 43%±24%. The mean luminal volume increased from 717±302 to 760±359 mm3 (P=0.025) due to ISR encroaching 26%±15% of the stent volume. CONCLUSIONS Lipid signal decreased during the follow-up period suggesting stabilization of the plaque. Late stent expansion was balanced with neointimal hyperplasia. TRIAL REGISTRATION The trial is registered under clinicaltrials.gov NCT03141580.
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Affiliation(s)
| | - Petr Hájek
- Department of Cardiology, Second Faculty of Medicine, Charles University, University Hospital Motol, Prague, Czech Republic
| | - Robert Roland
- Department of Cardiology, Second Faculty of Medicine, Charles University, University Hospital Motol, Prague, Czech Republic
| | - Martin Horváth
- Department of Cardiology, Second Faculty of Medicine, Charles University, University Hospital Motol, Prague, Czech Republic
| | - Josef Veselka
- Department of Cardiology, Second Faculty of Medicine, Charles University, University Hospital Motol, Prague, Czech Republic
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6
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Lv P, Ji A, Zhang R, Guo D, Tang X, Lin J. Circumferential degree of carotid calcification is associated with new ischemic brain lesions after carotid artery stenting. Quant Imaging Med Surg 2021; 11:2669-2676. [PMID: 34079732 DOI: 10.21037/qims-20-1244] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
Abstract
Background The relationship between plaque calcification and new ischemic brain lesions after carotid artery stenting (CAS) remains controversial. The purpose of this study was to determine if the circumferential degree of carotid calcification is associated with new ischemic brain lesions on diffusion-weighted imaging (DWI) after CAS. Methods A total of 96 patients with carotid stenosis of ≥50% who underwent CAS were enrolled in the study. All patients underwent preoperative carotid computed tomography (CT), and preoperative and postoperative brain MRI. The brain MRI sequences included T1WI, T2WI, T2-fluid-attenuated inversion recovery (FLAIR), and DWI. The location, circumferential degree, volume, percentage volume, maximum density, mean density, Agatston score of carotid calcification, and total plaque volume were assessed and compared between patients with and without new ischemic brain lesions after CAS. Univariate and multivariate analyses were performed to evaluate predictors of new ischemic brain lesions. Results All of the 96 patients (67.8±6.8 years of age, 83.3% men) were included in the analysis. New ischemic brain lesions on DWI were observed in 40 patients (41.7%). Patients with new ischemic brain lesions after CAS had a larger circumferential degree of calcification than those without new ischemic brain lesions (P<0.001). There was only a possible trend toward significance for the percentage volume of calcification between the two groups with and without new brain ischemic lesions (P=0.07). No significant differences were found regarding the location (P=0.18), volume (P=0.37), maximum density (P=0.44), mean density (P=0.39), Agatston score (P=0.28), and total plaque volume (P=0.33) of carotid calcification between the DWI+ and DWI- groups. In the multivariate analysis, an increased risk of new ischemic brain lesions was observed in patients with a high score for the circumferential degree of calcification [score 3; odds ratio (OR): 10.7, P<0.001; score 4, OR: 11.7, P=0.038]. Conclusions The circumferential degree of carotid calcification was associated with new ischemic brain lesions after CAS. CAS should be avoided if possible for carotid stenosis with large circumferential calcified plaques.
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Affiliation(s)
- Peng Lv
- Department of Radiology, Zhongshan Hospital, Fudan University and Shanghai Institute of Medical Imaging, Shanghai, China
| | - Aihua Ji
- Department of Radiology, Beijing Jishuitan Hospital, Beijing, China
| | - Ranying Zhang
- Department of Radiology, Zhongshan Hospital, Fudan University and Shanghai Institute of Medical Imaging, Shanghai, China
| | - Daqiao Guo
- Department of Vascular Surgery, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Xiao Tang
- Department of Vascular Surgery, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Jiang Lin
- Department of Radiology, Zhongshan Hospital, Fudan University and Shanghai Institute of Medical Imaging, Shanghai, China
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7
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Xin W, Yang S, Li Q, Yang X. Endarterectomy versus stenting for the prevention of periprocedural stroke or death in patients with symptomatic or asymptomatic carotid stenosis: a meta-analysis of 10 randomized trials. ANNALS OF TRANSLATIONAL MEDICINE 2021; 9:256. [PMID: 33708883 PMCID: PMC7940891 DOI: 10.21037/atm-20-4620] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Background The incidence of stroke or death in carotid endarterectomy (CEA) versus carotid artery stenting (CAS) cannot be estimated accurately. We aimed to compare periprocedural stroke or death in patients with symptomatic or asymptomatic carotid artery stenosis (CS) treated with CEA versus CAS. Methods Ten randomized trials (with ≥100 randomized patients per trial) compared the relative effectiveness of CAS and CEA for the prevention of stroke or death. Results In the symptomatic group during the periprocedural period, the results showed that the risk of death or any stroke [risk ratio (RR): 0.627; 95% CI: 0.497-0.792; P<0.001] and the risk of any stroke (RR: 0.654; 95% CI: 0.522-0.820; P<0.001) were significantly greater with CAS than with CEA. The difference in the risk of periprocedural stroke was mostly attributed to nondisabling stroke (RR: 0.407; 95% CI: 0.264-0.627; P<0.001), which was driven especially by ipsilateral ischemic stroke (RR: 0.649; 95% CI: 0.494-0.851; P=0.002) and bradycardia or hypotension (RR: 0.105; 95% CI: 0.051-0.217; P<0.001). However, we found that the CEA group had a higher rate of myocardial infarction than the CAS group (RR: 2.496; P=0.025). Meanwhile, ipsilateral stenosis >70% increased the incidence of periprocedural death or stroke for post-CEA patients (RR: 2.166, 95% CI: 1.112 to 4.220, P=0.023), but no risk factors were identified for post-CAS. Regarding the asymptomatic group, the results demonstrated that patients randomized to CEA had a significantly reduced risk of periprocedural stroke (RR: 0.518; 95% CI: 0.281-0.954; P=0.035), which seems to be driven by periprocedural minor stroke (RR: 0.482; 95% CI: 0.231-0.982; P=0.046). Conclusions Among patients with symptomatic CS, CEA was associated with reduced rates of periprocedural stroke and periprocedural nondisabling stroke. Among patients with asymptomatic CS, the rates of minor stroke and stroke in general were higher with stenting than with CEA. Based on the current data, CEA is more beneficial than CAS for 30-day stroke prevention.
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Affiliation(s)
- Wenqiang Xin
- Department of Neurosurgery, Tianjin Medical University General Hospital, Tianjin, China
| | - Shixue Yang
- Department of Neurosurgery, Tianjin Medical University General Hospital, Tianjin, China
| | - Qifeng Li
- Department of Neurosurgery, Tianjin Medical University General Hospital, Tianjin, China
| | - Xinyu Yang
- Department of Neurosurgery, Tianjin Medical University General Hospital, Tianjin, China
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8
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Óriás VI, Szöllősi D, Gyánó M, Veres DS, Nardai S, Csobay-Novák C, Nemes B, Kiss JP, Szigeti K, Osváth S, Sótonyi P, Ruzsa Z. Initial evidence of a 50% reduction of contrast media using digital variance angiography in endovascular carotid interventions. Eur J Radiol Open 2020; 7:100288. [PMID: 33294499 PMCID: PMC7683322 DOI: 10.1016/j.ejro.2020.100288] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2020] [Revised: 11/03/2020] [Accepted: 11/04/2020] [Indexed: 12/29/2022] Open
Abstract
Digital Variance Angiography (DVA) is a novel medical image processing method. DVA provides better image quality than Digital Subtraction Angiography (DSA). The quality reserve of DVA allows the reduction of contrast agents in angiography.
Purpose In previous clinical studies Digital Variance Angiography (DVA) provided higher signal-to-noise ratio (SNR) and better image quality than Digital Subtraction Angiography (DSA). Our aim was to investigate whether this quality reserve of DVA provides an opportunity for the reduction of iodinated contrast media (ICM) in carotid X-ray angiography (CXA). Method Our prospective study enrolled 26 patients (67.0 ± 8.1 years) undergoing carotid percutaneous transluminal angioplasty. The SNR of DSA and DVA image pairs obtained by a standard (100 %, 6 mL ICM) or a low-dose (50 %, 3 mL ICM) protocol were compared. Visual evaluation of all images was performed by five specialists using a 5-grade rating scale. The quality of DSA100 and DVA50 videos was also compared. Results DVA provided more than two-fold SNR, the median SNRDVA/SNRDSA ratio was 2.06 (100 %) and 2.25 (50 %). In the visual evaluation, the DVA100 score (3.73 ± 0.06) was significantly higher than the DSA100 score (3.52 ± 0.07, Wilcoxon p < 0.001), and the DVA50 score (3.64 ± 0.13) was also significantly higher than the DSA50 score (3.01 ± 0.17, Wilcoxon p < 0.001). While the low-dose protocol significantly decreased the DSA score (Mann-Whitney p < 0.01, DSA100 vs DSA50), it had no effect on the DVA score (DVA100 vs DVA50). There was no statistical difference between the DSA100 and DVA50 scores. Evaluators preferred the diagnostic value of DVA50 to DSA100 videos in 61% of comparisons, the interrater agreement was 69 % (Fleiss’ kappa 0.35, p < 0.001) Conclusions Our data show that DVA allows a substantial (50 %) ICM reduction in CXA without affecting the quality and diagnostic value of angiograms.
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Affiliation(s)
- Viktor I Óriás
- Kinepict Health Ltd, 1026, Júlia u 11, Budapest, Hungary.,Bács-Kiskun County Hospital, 6000, Nyíri út 38, Kecskemét, Hungary.,The Heart and Vascular Center, Semmelweis University, 1122, Városmajor utca 68, Budapest, Hungary
| | - Dávid Szöllősi
- Kinepict Health Ltd, 1026, Júlia u 11, Budapest, Hungary.,Department of Biophysics and Radiation Biology, Semmelweis University, 1094, Tűzoltó u 37-47, Budapest, Hungary
| | - Marcell Gyánó
- Kinepict Health Ltd, 1026, Júlia u 11, Budapest, Hungary.,The Heart and Vascular Center, Semmelweis University, 1122, Városmajor utca 68, Budapest, Hungary
| | - Dániel S Veres
- Department of Biophysics and Radiation Biology, Semmelweis University, 1094, Tűzoltó u 37-47, Budapest, Hungary
| | - Sándor Nardai
- The Heart and Vascular Center, Semmelweis University, 1122, Városmajor utca 68, Budapest, Hungary
| | - Csaba Csobay-Novák
- The Heart and Vascular Center, Semmelweis University, 1122, Városmajor utca 68, Budapest, Hungary
| | - Balázs Nemes
- The Heart and Vascular Center, Semmelweis University, 1122, Városmajor utca 68, Budapest, Hungary
| | - János P Kiss
- Kinepict Health Ltd, 1026, Júlia u 11, Budapest, Hungary
| | - Krisztián Szigeti
- Kinepict Health Ltd, 1026, Júlia u 11, Budapest, Hungary.,Department of Biophysics and Radiation Biology, Semmelweis University, 1094, Tűzoltó u 37-47, Budapest, Hungary
| | - Szabolcs Osváth
- Kinepict Health Ltd, 1026, Júlia u 11, Budapest, Hungary.,Department of Biophysics and Radiation Biology, Semmelweis University, 1094, Tűzoltó u 37-47, Budapest, Hungary
| | - Péter Sótonyi
- The Heart and Vascular Center, Semmelweis University, 1122, Városmajor utca 68, Budapest, Hungary
| | - Zoltán Ruzsa
- Bács-Kiskun County Hospital, 6000, Nyíri út 38, Kecskemét, Hungary.,The Heart and Vascular Center, Semmelweis University, 1122, Városmajor utca 68, Budapest, Hungary
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9
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Zheng L, Li J, Liu H, Guo H, Zhao L, Bai H, Yan Z, Qu Y. Perioperative Blood Pressure Control in Carotid Artery Stenosis Patients With Carotid Angioplasty Stenting: A Retrospective Analysis of 173 Cases. Front Neurol 2020; 11:567623. [PMID: 33193006 PMCID: PMC7661555 DOI: 10.3389/fneur.2020.567623] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2020] [Accepted: 09/30/2020] [Indexed: 01/03/2023] Open
Abstract
Background: Carotid angioplasty stenting (CAS) is a currently widely used surgical treatment of carotid artery stenosis. However, the influences of the perioperative blood pressure (BP) on patients' prognosis remain unclear. Objective: The present study was designed to explore the effects of different perioperative BP control strategies on CAS patients' prognosis. Methods: One hundred seventy-three consecutive patients admitted between January 2016 and April 2019 were reviewed retrospectively. The outcomes of patients with different systolic BP (<120, 120–130, and >130 mmHg) before CAS and within 24 h after CAS were compared. The primary outcomes were the incidence of secondary cerebral infarction (CI) and intracranial hemorrhage (ICH) after CAS. The secondary outcome was the incidence of unfavorable discharge and in-hospital death. The unfavorable discharge was defined as modified Rankin Scale (mRS) score 3–5 at discharge. Results: There was no significant difference between the incidences of ICH (P = 0.803) and CI (P = 0.410) in patients with different BP before CAS. The patients with post-CAS BP values of >130 mmHg had a 37.67-fold increased risk (95% CI: 6.79–209.01) of ICH compared with others, while no significant difference was observed on the incidence of CI (P = 0.174) among patients with different post-CAS BP values. The patients with post-CAS BP values of >130 mmHg also had a significantly higher incidence of unfavorable discharge (P = 0.002) and in-hospital death (P = 0.001) compared with others. Conclusion: High BP (>130 mmHg) within 24 h after CAS significantly increases the risks of secondary cerebral hemorrhage, unfavorable discharge, and in-hospital death. Thus, the BP should be controlled below 130 mmHg in the first 24 h after CAS.
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Affiliation(s)
- Longlong Zheng
- Department of Neurosurgery, Tangdu Hospital, The Fourth Military Medical University, Xi'an, China
| | - Jiang Li
- Department of Neurosurgery, Tangdu Hospital, The Fourth Military Medical University, Xi'an, China
| | - Haixiao Liu
- Department of Neurosurgery, Tangdu Hospital, The Fourth Military Medical University, Xi'an, China
| | - Hao Guo
- Department of Neurosurgery, Tangdu Hospital, The Fourth Military Medical University, Xi'an, China
| | - Lei Zhao
- Department of Neurosurgery, Tangdu Hospital, The Fourth Military Medical University, Xi'an, China
| | - Hao Bai
- Department of Neurosurgery, Tangdu Hospital, The Fourth Military Medical University, Xi'an, China
| | - Zhongjun Yan
- Department of Neurosurgery, Tangdu Hospital, The Fourth Military Medical University, Xi'an, China
| | - Yan Qu
- Department of Neurosurgery, Tangdu Hospital, The Fourth Military Medical University, Xi'an, China
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10
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Arthur AS, Abecassis IJ, Abi-Aad KR, Albuquerque FC, Almefty RO, Aoun RJN, Barrow DL, Bederson J, Bendok BR, Ducruet AF, Fanous AA, Fennell VS, Flores BC, Griessenauer CJ, Kim LJ, Levitt MR, Mack WJ, Mascitelli J, Min E, Mocco J, Morr S, Nerva JD, Richards AE, Schirmer CM, See AP, Snyder KV, Tian F, Walcott BP, Welz ME. Vascular. Oper Neurosurg (Hagerstown) 2020; 17:S76-S118. [PMID: 31099843 DOI: 10.1093/ons/opz088] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2019] [Accepted: 02/05/2019] [Indexed: 11/12/2022] Open
Affiliation(s)
- Adam S Arthur
- Department of Neurosurgery, University of Tennessee Health Science Center, Memphis, Tennessee.,Semmes-Murphey Neurologic and Spine Institute, Memphis, Tennessee
| | - I Josh Abecassis
- Department of Neurological Surgery, University of Washington School of Medicine, Seattle, Washington
| | - Karl R Abi-Aad
- Department of Neurological Surgery, Mayo Clinic, Phoenix, Arizona.,Precision Neuro-therapeutics Innovation Lab, Mayo Clinic, Phoenix, Arizona.,Neurosurgery Simulation and Innovation Lab, Mayo Clinic, Phoenix, Arizona
| | - Felipe C Albuquerque
- Department of Neurosurgery, Barrow Neurological Institute, St Joseph's Hospital and Medical Center, Phoenix, Arizona
| | - Rami O Almefty
- Department of Neurosurgery, Barrow Neurological Institute, St Joseph's Hospital and Medical Center, Phoenix, Arizona
| | - Rami James N Aoun
- Department of Neurological Surgery, Mayo Clinic, Phoenix, Arizona.,Precision Neuro-therapeutics Innovation Lab, Mayo Clinic, Phoenix, Arizona.,Neurosurgery Simulation and Innovation Lab, Mayo Clinic, Phoenix, Arizona.,Department of Otolaryngology, Mayo Clinic, Phoenix Arizona.,Department of Radiology, Mayo Clinic, Phoenix, Arizona
| | - Daniel L Barrow
- Department of Neurosurgery, Emory University School of Medicine, Atlanta, Georgia.,Department of Ophthalmalogy, Emory University School of Medicine, Atlanta, Georgia.,Department of Radiology, Emory University School of Medicine, Atlanta, Georgia
| | - Joshua Bederson
- Department of Neurosurgery, Mount Sinai Medical Center, New York, New York
| | - Bernard R Bendok
- Department of Neurological Surgery, Mayo Clinic, Phoenix, Arizona.,Precision Neuro-therapeutics Innovation Lab, Mayo Clinic, Phoenix, Arizona.,Neurosurgery Simulation and Innovation Lab, Mayo Clinic, Phoenix, Arizona.,Department of Otolaryngology, Mayo Clinic, Phoenix Arizona.,Department of Radiology, Mayo Clinic, Phoenix, Arizona
| | - Andrew F Ducruet
- Department of Neurosurgery, Barrow Neurological Institute, St Joseph's Hospital and Medical Center, Phoenix, Arizona
| | - Andrew A Fanous
- Department of Neurosurgery, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, State University of New York, Buffalo, New York.,Department of Radiology, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, State University of New York, Buffalo, New York.,Department of Neurology, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, State University of New York, Buffalo, New York.,Department of Neurosurgery, Gates Vascular Institute at Kaleida Health, Buffalo, New York.,Toshiba Stroke and Vascular Research Center, University at Buffalo, State University of New York, Buffalo, New York
| | - Vernard S Fennell
- Department of Neurosurgery, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, State University of New York, Buffalo, New York.,Department of Radiology, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, State University of New York, Buffalo, New York.,Department of Neurology, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, State University of New York, Buffalo, New York.,Department of Neurosurgery, Gates Vascular Institute at Kaleida Health, Buffalo, New York.,Toshiba Stroke and Vascular Research Center, University at Buffalo, State University of New York, Buffalo, New York
| | - Bruno C Flores
- Department of Neurosurgery, Barrow Neurological Institute, St Joseph's Hospital and Medical Center, Phoenix, Arizona
| | - Christoph J Griessenauer
- Department of Neurosurgery and Neuroscience Institute, Geisinger Health System, Wilkes-Barre, Pennsylvania
| | - Louis J Kim
- Department of Neurological Surgery, University of Washington School of Medicine, Seattle, Washington.,Department of Radiology, University of Washington School of Medicine, Seattle, Washington
| | - Michael R Levitt
- Department of Neurological Surgery, University of Washington School of Medicine, Seattle, Washington.,Department of Radiology, University of Washington School of Medicine, Seattle, Washington.,Department of Mechanical Engineering, University of Washington School of Medicine, Seattle, Washington
| | - William J Mack
- Department of Neurosurgery, Keck School of Medicine, University of Southern California, Los Angeles, California
| | - Justin Mascitelli
- Department of Neurosurgery, Mount Sinai Medical Center, New York, New York
| | - Elliott Min
- Department of Neurosurgery, Keck School of Medicine, University of Southern California, Los Angeles, California
| | - J Mocco
- Department of Neurosurgery, Mount Sinai Medical Center, New York, New York
| | - Simon Morr
- Department of Neurosurgery, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, State University of New York, Buffalo, New York.,Department of Radiology, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, State University of New York, Buffalo, New York.,Department of Neurology, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, State University of New York, Buffalo, New York.,Department of Neurosurgery, Gates Vascular Institute at Kaleida Health, Buffalo, New York.,Toshiba Stroke and Vascular Research Center, University at Buffalo, State University of New York, Buffalo, New York
| | - John D Nerva
- Department of Neurological Surgery, University of Washington School of Medicine, Seattle, Washington
| | | | - Clemens M Schirmer
- Department of Neurosurgery and Neuroscience Institute, Geisinger Health System, Wilkes-Barre, Pennsylvania
| | - Alfred P See
- Department of Neurosurgery, Barrow Neurological Institute, St Joseph's Hospital and Medical Center, Phoenix, Arizona
| | - Kenneth V Snyder
- Department of Neurosurgery, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, State University of New York, Buffalo, New York.,Department of Radiology, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, State University of New York, Buffalo, New York.,Department of Neurology, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, State University of New York, Buffalo, New York.,Department of Neurosurgery, Gates Vascular Institute at Kaleida Health, Buffalo, New York.,Toshiba Stroke and Vascular Research Center, University at Buffalo, State University of New York, Buffalo, New York
| | - Fucheng Tian
- Department of Neurological Surgery, Mayo Clinic, Phoenix, Arizona.,Precision Neuro-therapeutics Innovation Lab, Mayo Clinic, Phoenix, Arizona.,Neurosurgery Simulation and Innovation Lab, Mayo Clinic, Phoenix, Arizona
| | - Brian P Walcott
- Department of Neurosurgery, Keck School of Medicine, University of Southern California, Los Angeles, California
| | - Matthew E Welz
- Department of Neurological Surgery, Mayo Clinic, Phoenix, Arizona.,Precision Neuro-therapeutics Innovation Lab, Mayo Clinic, Phoenix, Arizona.,Neurosurgery Simulation and Innovation Lab, Mayo Clinic, Phoenix, Arizona
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Abstract
Interventional neuroradiology (INR) has evolved from a hybrid mixture of daring radiologists and iconoclastic neurosurgeons into a multidisciplinary specialty, which has become indispensable for cerebrovascular and neurological centers worldwide. This manuscript traces the origins of INR and describes its evolution to the present day. The focus will be on cerebrovascular disorders including aneurysms, stroke, brain arteriovenous malformations, dural arteriovenous fistulae, and atherosclerotic disease, both intra- and extracranial. Also discussed are cerebral vasospasm, venolymphatic malformations of the head and neck, tumor embolization, idiopathic intracranial hypertension, inferior petrosal venous sinus sampling for Cushing's disease, and spinal interventions. Pediatric INR has not been included and deserves a separate, dedicated review.
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12
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The utility of adjunctive electroencephalography while performing transcarotid artery revascularization. JOURNAL OF VASCULAR SURGERY CASES INNOVATIONS AND TECHNIQUES 2019; 5:456-460. [PMID: 31737803 PMCID: PMC6848990 DOI: 10.1016/j.jvscit.2019.09.008] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/06/2019] [Accepted: 09/12/2019] [Indexed: 11/20/2022]
Abstract
Transcarotid artery revascularization (TCAR) has been used as an alternative to carotid endarterectomy and transfemoral carotid artery stenting. Although TCAR has been associated with a decrease in perioperative strokes compared with transfemoral carotid artery stenting, little is known about the safety of cerebral blood during flow reversal or the value of adjunctive electroencephalography (EEG) monitoring in performing TCAR. We describe two cases of EEG changes in patients undergoing TCAR. These cases highlight the use of adjunctive EEG and provide examples of test clamping to assess for compromised collateral cerebral blood flow in patients undergoing TCAR.
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13
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Spiliopoulos S, Vasiniotis Kamarinos N, Reppas L, Palialexis K, Brountzos E. Carotid artery stenting: an update. Curr Opin Cardiol 2019; 34:616-620. [PMID: 31436557 DOI: 10.1097/hco.0000000000000679] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
PURPOSE OF REVIEW To present the latest evidence about carotid artery stenting (CAS) including indications, safety, efficacy, and available equipment. RECENT FINDINGS The micromesh stent, a new stent design which offers excellent flexibility and embolic protection, has been associated with promising outcomes. SUMMARY CAS has emerged as a minimally invasive treatment method for carotid artery stenosis with comparable outcomes with surgical management. The implementation of new technology combined with operator experience has led to a paradigm shift; however, to date, no robust evidence exists about patient and lesion selection. Many studies are underway to clarify the technical aspects of CAS as well as the optimal treatment of carotid artery stenosis for each patient population.
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Affiliation(s)
- Stavros Spiliopoulos
- Interventional Radiology Unit, 2nd Department of Radiology, School of Medicine, National and Kapodistrian University of Athens, Attikon University General Hospital, Athens, Greece
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14
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Baradaran H, Gupta A, Anzai Y, Mushlin AI, Kamel H, Pandya A. Cost Effectiveness of Assessing Ultrasound Plaque Characteristics to Risk Stratify Asymptomatic Patients With Carotid Stenosis. J Am Heart Assoc 2019; 8:e012739. [PMID: 31645165 PMCID: PMC6898827 DOI: 10.1161/jaha.119.012739] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Abstract
Background Imaging may play an important role in identifying high‐risk plaques in patients who have carotid disease and who could benefit from surgical revascularization. We sought to evaluate the cost effectiveness of a decision‐making rule based on the ultrasound imaging assessment of plaque echolucency in patients with asymptomatic carotid stenosis. Methods and Results We used a decision‐analytic model to project lifetime quality‐adjusted life years and costs for 5 stroke prevention strategies: (1) medical therapy only; (2) revascularization if both plaque echolucency and stenosis progression to >90% are present; (3) revascularization only if plaque echolucency is present; (4) revascularization only if stenosis progression >90% is present; or (5) either plaque echolucency or stenosis progression is present. Risks of clinical events, costs, and quality‐of‐life values were estimated based on published sources and the analysis was conducted from a healthcare system perspective for asymptomatic patients with 70% to 89% carotid stenosis at presentation. Patients who did not undergo revascularization had the highest stroke events (17.6%) and lowest life‐years (8.45), while those who underwent revascularization on the basis of either presence of plaque echolucency on ultrasound or progression of carotid stenosis had the lowest stroke events (12.0%) and longest life‐years (14.41). The either plaque echolucency or progression‐based revascularization group had an incremental cost‐effectiveness ratio of $110 000/quality‐adjusted life years compared with the plaque echolucency‐based strategy, which had an incremental cost‐effectiveness ratio of $29 000/quality‐adjusted life years compared with the joint echolucency and progression‐based strategy. Conclusions Plaque echolucency on ultrasound can be a cost‐effective tool to identify patients with asymptomatic carotid artery stenosis most likely to benefit from carotid endarterectomy.
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Affiliation(s)
| | - Ajay Gupta
- Department of Radiology Weill Cornell Medical College New York NY
| | - Yoshimi Anzai
- Department of Radiology University of Utah Salt Lake City UT
| | - Alvin I Mushlin
- Department of Healthcare Policy and Research Weill Cornell Medical College New York NY
| | - Hooman Kamel
- Department of Neurology Weill Cornell Medical College New York NY
| | - Ankur Pandya
- Department of Health Policy and Management Harvard T.H. Chan School of Public Health Boston MA
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15
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Corcione N, Pepe M, Ferraro P, Morello A, Conte S, Avellino R, Cavarretta E, Carulli E, Biondi-Zoccai G, Giordano A. Impact of Tirofiban on Serum Troponin Changes in Patients Undergoing Carotid Artery Stenting: A Propensity Matched Analysis. Ann Vasc Surg 2019; 64:151-156.e2. [PMID: 31629846 DOI: 10.1016/j.avsg.2019.09.011] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2019] [Revised: 08/31/2019] [Accepted: 09/01/2019] [Indexed: 02/05/2023]
Abstract
BACKGROUND The optional periprocedural antithrombotic management for carotid artery stenting (CAS) is still debated. METHODS We aimed to compare the procedural and 1-month outlook of patients undergoing CAS with tirofiban as parenteral antiplatelet therapy. We retrospectively compared patients receiving tirofiban during CAS versus those undergoing CAS without tirofiban, using propensity score matching. Ancillary antithrombotic therapy included in all patients aspirin, clopidogrel, and unfractioned heparin. The primary outcome was the change in serum troponin from baseline to postprocedural peak levels. A total of 30 patients undergoing CAS were included, 15 receiving tirofiban on top of heparin and dual oral antiplatelet therapy (DAPT) and 15 receiving only heparin and DAPT. Bail-out use of tirofiban was an exclusion criterion. RESULTS Baseline troponin was 3.00 (0.06; 5.20) ng/mL in the tirofiban group vs. 4.6 (0.02; 13.10) ng/mL in the no-tirofiban group (P = 0.229), and postprocedural peak 3.5 (0.06; 5.50) ng/mL vs. 6.30 (0.09; 28.40) ng/mL (P = 0.191). Peak-baseline difference in troponin was lower in the tirofiban group than in the no-tirofiban group: 0.3 (0.00; 1.7) ng/mL vs. 1.3 (0.01; 10.00) ng/mL (P = 0.044); the relative peak-baseline change in troponin was analogously different: 24.3% (0%; 44.7%) vs. 50% (21.3%; 80.0%) (P = 0.039). No case of death, myocardial infarction, stroke, or transient ischemic attack occurred during in-hospital stay or at 1-month follow-up. CONCLUSIONS Tirofiban during CAS might provide periprocedural myocardial protection and reduce myocardial injury as determined by serial troponin measurements.
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Affiliation(s)
- Nicola Corcione
- Unità Operativa di Interventistica Cardiovascolare, Presidio Ospedaliero Pineta Grande, Castel Volturno, Italy
| | - Martino Pepe
- U.O. di Cardiologia Universitaria, Policlinico di Bari, Bari, Italy.
| | - Paolo Ferraro
- Unità Operativa di Emodinamica, Casa di Salute Santa Lucia, San Giuseppe Vesuviano, Italy
| | - Alberto Morello
- Unità Operativa di Interventistica Cardiovascolare, Presidio Ospedaliero Pineta Grande, Castel Volturno, Italy
| | - Sirio Conte
- Unità Operativa di Emodinamica, Casa di Salute Santa Lucia, San Giuseppe Vesuviano, Italy
| | - Raffaella Avellino
- Unità Operativa di Interventistica Cardiovascolare, Presidio Ospedaliero Pineta Grande, Castel Volturno, Italy; Unità Operativa di Emodinamica, Casa di Salute Santa Lucia, San Giuseppe Vesuviano, Italy
| | - Elena Cavarretta
- Department of Medico-Surgical Sciences and Biotechnologies, Sapienza University of Rome, Latina, Italy; Mediterranea Cardiocentro, Napoli, Italy
| | - Eugenio Carulli
- U.O. di Cardiologia Universitaria, Policlinico di Bari, Bari, Italy
| | - Giuseppe Biondi-Zoccai
- Department of Medico-Surgical Sciences and Biotechnologies, Sapienza University of Rome, Latina, Italy; Mediterranea Cardiocentro, Napoli, Italy
| | - Arturo Giordano
- Unità Operativa di Interventistica Cardiovascolare, Presidio Ospedaliero Pineta Grande, Castel Volturno, Italy
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16
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Vieira-Leite C, Mosqueira AJ, Arias-Rivas S, Rodríguez-Yáñez M, Pumar JM. Results of a Single Center's Stenting Procedure for the Treatment of Carotid Stenosis. World Neurosurg 2019; 133:e487-e491. [PMID: 31542440 DOI: 10.1016/j.wneu.2019.09.065] [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: 07/11/2019] [Revised: 09/11/2019] [Accepted: 09/12/2019] [Indexed: 10/26/2022]
Abstract
BACKGROUND Stenting may be a safer alternative to endarterectomy for treating carotid artery stenosis (CAS), but its long-term efficacy is uncertain. There is a lack of long-term and noncontrolled clinical trial data that reflects "real-world" CAS. This study aimed to analyze the long-term efficacy and safety of our center's CAS procedure. METHODS We retrospectively analyzed our database of patients who underwent CAS. Patient demographic data, previous risk factors, diagnostic and procedural information, and clinical and image follow-up data were collected from up to 1 year after treatment. RESULTS Overall, 187 patients were analyzed. Our patient population largely comprised higher-risk patients compared with the patient populations of randomized controlled trials. We had more symptomatic (n = 145, 77.5%) than asymptomatic patients (n = 42, 22.5%), and 49% of patients had >90% stenosis. By the 30-day follow-up, there were 10 major adverse events (5.3%) observed in 8 patients (4.2%), including 7 strokes (3 ischemic and 4 hemorrhagic) and 3 deaths. By the 1-year follow-up, 6 strokes and 5 deaths occurred in 9 patients (4.8%), and color Doppler control showed that 87.6% of patients had stenosis-free stents. CONCLUSIONS Despite our high-risk population group, there were high rates of successful stent placement, low complication rates, good clinical outcomes, and low rates of stenting restenosis.
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Affiliation(s)
- Cecília Vieira-Leite
- Department of Radiology, Santiago de Compostela University Hospital, Santiago de Compostela, Spain.
| | - Antonio Jesús Mosqueira
- Department of Radiology, Santiago de Compostela University Hospital, Santiago de Compostela, Spain
| | - Susana Arias-Rivas
- Department of Neurology, Santiago de Compostela University Hospital, Santiago de Compostela, Spain
| | - Manuel Rodríguez-Yáñez
- Department of Neurology, Santiago de Compostela University Hospital, Santiago de Compostela, Spain
| | - Jose Manuel Pumar
- Department of Radiology, Santiago de Compostela University Hospital, Santiago de Compostela, Spain
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17
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Otite FO, Khandelwal P, Malik AM, Chaturvedi S. National Patterns of Carotid Revascularization Before and After the Carotid Revascularization Endarterectomy vs Stenting Trial (CREST). JAMA Neurol 2019; 75:51-57. [PMID: 29204653 DOI: 10.1001/jamaneurol.2017.3496] [Citation(s) in RCA: 26] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/23/2023]
Abstract
Importance The Carotid Revascularization Endarterectomy vs Stenting Trial (CREST) showed greater safety of carotid artery stenting (CAS) in patients younger than 70 years and carotid endarterectomy (CEA) in those older than 70 years. It is unknown how the result of CREST has influenced carotid revascularization choices in the United States. Objective To evaluate national patterns in CAS performance in patients older than 70 years in the post-CREST (2011-2014) compared with the pre-CREST (2007-2010) era. Design, Setting, and Participants All adults older than 70 years undergoing carotid revascularization in the United States from 2007 to 2014 were retrospectively identified from the 2007-2014 National Inpatient Sample using International Classification of Disease, Ninth Revision procedural codes. From 61 324 882 unweighted hospitalizations contained in the 2007-2014 National Inpatient Sample, 494 733 weighted carotid revascularization admissions in adults older than 70 years were identified using International Classification of Disease, Ninth Revision procedural codes. Main Outcomes and Measures The proportion of CAS performed in all age groups over time was estimated and multivariable-adjusted models were used to compare the odds of receiving CAS in the pre-CREST with those in the post-CREST era in adults older than 70 years. Results A total of 41.8% of all patients were women, and mean (SE) age at presentation was 78.1 (0.03) years. A total of 16.3% of CAS and 10.1% of CEA procedures were performed in patients with symptomatic stenosis. The proportion of patients older than 70 years receiving CAS increased from 11.9% in the pre-CREST to 13.8% in the post-CREST era (P = .005). In multivariable models, the odds of receiving CAS increased by 13% in all patients older than 70 years in the post-CREST compared with the pre-CREST period (odds ratio [OR], 1.13, 95% CI, 1.00-1.28, P = .04), including symptomatic women (OR, 1.31, 1.05-1.65, P = .02). Symptomatic stenosis (OR 1.39; 95% CI, 1.27-1.52; P < .001), congestive heart failure (OR, 1.48; 95% CI, 1.35-1.63; P < .001), and peripheral vascular disease (OR, 1.35; 95% CI, 1.27-1.43; P < .001) were associated with higher odds of CAS; comorbid hypertension (OR, 0.70; 95% CI, 0.66-0.74; P < .001), smoking (OR, 0.84; 95% CI, 0.78-0.91; P < .001), and weekend admission (OR, 0.77; 95% CI, 0.68-0.88; P < .001) were negatively associated with the odds of CAS. Conclusions and Relevance Despite concerns for higher periprocedural complications with CAS in elderly patients, the odds of CAS increased in the post-CREST compared with pre-CREST era in patients older than 70 years, including symptomatic women.
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Affiliation(s)
- Fadar Oliver Otite
- Department of Neurology, University of Miami Miller School of Medicine, Miami, Florida
| | - Priyank Khandelwal
- Department of Neurology, University of Miami Miller School of Medicine, Miami, Florida
| | - Amer M Malik
- Department of Neurology, University of Miami Miller School of Medicine, Miami, Florida
| | - Seemant Chaturvedi
- Department of Neurology, University of Miami Miller School of Medicine, Miami, Florida
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18
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Shibata MA, Harada-Shiba M, Shibata E, Tosa H, Matoba Y, Hamaoka H, Iinuma M, Kondo Y. Crude α-Mangostin Suppresses the Development of Atherosclerotic Lesions in Apoe-Deficient Mice by a Possible M2 Macrophage-Mediated Mechanism. Int J Mol Sci 2019; 20:ijms20071722. [PMID: 30959963 PMCID: PMC6480575 DOI: 10.3390/ijms20071722] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2019] [Revised: 04/01/2019] [Accepted: 04/03/2019] [Indexed: 12/14/2022] Open
Abstract
Lifestyle choices play a significant role in the etiology of atherosclerosis. Male Apoe−/− mice that develop spontaneous atherosclerotic lesions were fed 0%, 0.3%, and 0.4% mangosteen extracts, composed largely of α-mangostin (MG), for 17 weeks. Body weight gains were significantly decreased in both MG-treated groups compared to the control, but the general condition remained good throughout the study. The levels of total cholesterol (decreased very-low-density lipoprotein in lipoprotein profile) and triglycerides decreased significantly in the MG-treated mice in conjunction with decreased hepatic HMG-CoA synthase and Fatty acid transporter. Additionally, increased serum lipoprotein lipase activity and histopathology further showed a significant reduction in atherosclerotic lesions at both levels of MG exposure. Real-time PCR analysis for macrophage indicators showed a significant elevation in the levels of Cd163, an M2 macrophage marker, in the lesions of mice receiving 0.4% MG. However, the levels of Nos2, associated with M1 macrophages, showed no change. In addition, quantitative immunohistochemical analysis of macrophage subtypes showed a tendency for increased M2 populations (CD68+/CD163+) in the lesions of mice given 0.4% MG. In further analysis of the cytokine-polarizing macrophage subtypes, the levels of Interleukin13 (Il13), associated with M2 polarization, were significantly elevated in lesions exposed to 0.4% MG. Thus, MG could suppress the development of atherosclerosis in Apoe−/− mice, possibly through an M2 macrophage-mediated mechanism.
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Affiliation(s)
- Masa-Aki Shibata
- Department of Anatomy and Cell Biology, Osaka Medical College, 2-7 Daigaku-machi, Takatsuki, Osaka 569-8686, Japan.
| | - Mariko Harada-Shiba
- Department of Molecular Innovation in Lipidology, National Cerebral & Cardiovascular Center Research Institute, Suita, Osaka 565-8565, Japan.
| | - Eiko Shibata
- Department of Molecular Innovation in Lipidology, National Cerebral & Cardiovascular Center Research Institute, Suita, Osaka 565-8565, Japan.
| | | | - Yoshinobu Matoba
- Ecoresource Institute Co., Ltd., Minokamo, Gifu 505-0042, Japan.
| | - Hitomi Hamaoka
- Department of Anatomy and Cell Biology, Osaka Medical College, 2-7 Daigaku-machi, Takatsuki, Osaka 569-8686, Japan.
| | | | - Yoichi Kondo
- Department of Anatomy and Cell Biology, Osaka Medical College, 2-7 Daigaku-machi, Takatsuki, Osaka 569-8686, Japan.
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19
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Pucciarelli A, Arcari A, Popusoi G, Cioppa A, Salemme L, Iacovelli F, Napolitano G, Esposito G, Tesorio T, Stabile E. Incidence and predictors of acute kidney injury in patients undergoing proximal protected carotid artery stenting. EUROINTERVENTION 2018; 14:e360-e366. [PMID: 29633937 DOI: 10.4244/eij-d-17-00308] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
AIMS Many studies have analysed the occurrence of acute kidney injury (AKI) after percutaneous coronary intervention (PCI) but there are limited data relating to AKI risk in patients undergoing carotid artery stenting (CAS). The aim of this study was to determine the incidence and predictors of AKI in patients undergoing proximal protected CAS. METHODS AND RESULTS We analysed 456 patients undergoing proximal protected CAS. A binomial multivariate logistic model was developed including patients' clinical and angiographic/procedural characteristics. AKI (defined as an sCr increase ≥0.3 mg/dl or ≥1.5-fold sCr increase from baseline or more than 50% increase from baseline, within 48 hours post procedure) occurred in 155 patients (34%). AKI patients were more frequently affected by hypertension, diabetes, dyslipidaemia and anaemia, and presented lower renal function at baseline. Higher contrast volume to creatinine clearance ratio (2.40±1.44 vs. 2.08±1.15; p=0.01), lower post-procedural mean arterial pressure (MAP) (94.3±17.7 vs. 99.6±18.5 mmHg; p=0.003) and a more frequent post-procedural systolic pressure drop (∆SBP >50 mmHg) (23.9% vs. 14.3%, p=0.01) were observed in the AKI group of patients. At multivariate analysis, independent predictors of AKI were ∆SBP >50 mmHg, diabetes mellitus and dyslipidaemia. CONCLUSIONS AKI can occur quite frequently after proximal protected CAS and is related to clinical and procedural features. These data should be confirmed in larger registries or randomised trials.
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20
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Safety of Stenting and Endarterectomy for Asymptomatic Carotid Artery Stenosis: A Meta-Analysis of Randomised Controlled Trials. Eur J Vasc Endovasc Surg 2018; 55:614-624. [DOI: 10.1016/j.ejvs.2018.02.020] [Citation(s) in RCA: 31] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2017] [Accepted: 02/12/2018] [Indexed: 11/20/2022]
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21
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Tanaka H, Watanabe Y, Nakamura H, Takahashi H, Arisawa A, Fujiwara T, Matsuo C, Tomiyama N. Multiple blood flow measurements before and after carotid artery stenting via phase-contrast magnetic resonance imaging: An observational study. PLoS One 2018; 13:e0195099. [PMID: 29641548 PMCID: PMC5895018 DOI: 10.1371/journal.pone.0195099] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2017] [Accepted: 03/18/2018] [Indexed: 11/19/2022] Open
Abstract
After carotid artery stenting, the procurement of information about blood flow redistribution among brain-feeding arteries and its time trend is essential to understanding a patient’s physiological background and to determine their care regimen. Cerebral blood flow has been measured twice following carotid artery stenting in few previous studies, with some discrepancies in the results. The purpose of this study was to measure cerebral blood flow at multiple time points after carotid artery stenting, and to elucidate the time trend of cerebral blood flow and redistribution among arteries. Blood flow rates in 11 subjects were measured preoperatively, at one day, one week, and about three months, respectively after carotid artery stenting by using phase-contrast magnetic resonance imaging. The target vessels were the bilateral internal carotid arteries, the basilar artery, and the bilateral middle cerebral arteries. Lumen was semi-automatically defined using an algorithm utilizing pulsatility. The results showed that blood flow rates in the stented internal carotid artery and the ipsilateral middle cerebral artery increased following carotid artery stenting. Blood flow rates in the contralateral internal carotid artery and the basilar artery gradually declined, and they were lower than the preoperative values at three months after stenting. The sum of blood flow rates of the bilateral internal carotid arteries and the basilar artery increased after carotid artery stenting, and then decreased over the next three months. There was no significant change in the blood flow rate in the contralateral middle cerebral artery. From these results, it was concluded that redistribution among the bilateral internal carotid arteries and the basilar artery occurs after carotid artery stenting, and that it takes months thereafter to reach another equilibrium.
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Affiliation(s)
- Hisashi Tanaka
- Department of Radiology, Osaka University Graduate School of Medicine, Suita, Osaka, Japan
- * E-mail:
| | - Yoshiyuki Watanabe
- Department of Radiology, Osaka University Graduate School of Medicine, Suita, Osaka, Japan
| | - Hajime Nakamura
- Department of Neurosurgery, Osaka University Graduate School of Medicine, Suita, Osaka, Japan
| | - Hiroto Takahashi
- Department of Radiology, Osaka University Graduate School of Medicine, Suita, Osaka, Japan
| | - Atsuko Arisawa
- Department of Radiology, Osaka University Graduate School of Medicine, Suita, Osaka, Japan
| | - Takuya Fujiwara
- Department of Radiology, Osaka University Graduate School of Medicine, Suita, Osaka, Japan
| | - Chisato Matsuo
- Department of Radiology, Osaka University Graduate School of Medicine, Suita, Osaka, Japan
| | - Noriyuki Tomiyama
- Department of Radiology, Osaka University Graduate School of Medicine, Suita, Osaka, Japan
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22
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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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23
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Abstract
PURPOSE OF REVIEW To summarize why there are polarized opinions regarding the management of patients with asymptomatic carotid disease and whether it is possible to identify patients who might benefit from carotid interventions. RECENT FINDINGS Carotid Revascularization Endarterectomy Versus Stenting Trial and Asymptomatic Carotid Trial 1 (ACT-1) recently concluded that outcomes after carotid endarterectomy and carotid stenting were not significantly different in asymptomatic patients and that procedural risks were below the accepted 3% threshold. However, systematic reviews suggest that Carotid Revascularization Endarterectomy Versus Stenting Trial/ACT-1 results may not be generalizable into routine practice. In parallel, meta-analyses suggest that stroke rates on medical therapy may be declining, suggesting that Asymptomatic Carotid Atherosclerosis Study/Asymptomatic Carotid Surgery Trial data, which have underpinned every practice guideline since 1995, are too historical for use in 2017. A recent review has, however, identified a number of clinical/imaging features that may be associated with higher rates of stroke on medical therapy. SUMMARY The majority of surgeons/interventionists are unlikely to accept radical changes in practice until new randomized trials confirm that the risk of stroke on modern medical therapy is significantly lower than that previously accepted. In the interim, it would be preferable to target interventions into a smaller cohort who present with clinical/imaging features that might render them 'higher risk for stroke' on medical therapy.
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Kwon HJ, Park JH, Lee JH, Jeong HS, Song HJ, Kim J, Kim M, Kwon IS, Seong IW. Low Common Carotid Artery Systolic Occlusion Pressure and Symptomatic Carotid Artery Stenosis Are Associated with Development of Neurologic Intolerance during Proximal Protected Carotid Artery Stenting. Korean Circ J 2018; 48:217-226. [PMID: 29557108 PMCID: PMC5861314 DOI: 10.4070/kcj.2017.0031] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2017] [Revised: 11/06/2017] [Accepted: 12/06/2017] [Indexed: 12/28/2022] Open
Abstract
Background and Objectives Neurologic intolerance (NI) is defined as the occurrence of neurological symptoms during carotid artery stenting (CAS). Because NI is inevitable problem, it may be helpful to anticipate its occurrence. So, we studied factors associated with NI during proximal protected CAS. Methods We retrospectively analyzed all consecutive patients underwent proximal protected CAS from August 2012 to January 2017. Results We included total 123 patients (109 males, 72±8 years old). The total procedure time was 43±12 minutes, and mean occlusion time was 4.8±1.2 minutes. We divided CAS patients into 2 groups according to presence of NI; neurologic tolerance (NT; n=74, 60%) and NI (n=49, 40%) groups. After the univariate analysis, symptomatic carotid artery stenosis (p=0.003), absence of anterior communicating artery (p=0.015) and low common carotid artery occlusion pressure (CCAOP, p<0.001) were associated with NI. After the multivariate analysis, NI was significantly associated with symptomatic carotid artery stenosis (odds ratio [OR], 5.549; p=0.014) and systolic CCAOP≤42 mmHg (OR, 6.461; p<0.001). In NI group, 43 patients (88%) recovered right after the balloon deflation and 2 patients were normalized within 2 hours. However, 1 had major stroke and 3 had minor strokes in 4 patients with persistent NI ≥24 hours. Conclusions About 40% showed NI during the CAS. Most of them (88%, 43 of 49 patients) recovered after the balloon deflation, but stroke incidence was significantly higher in NI group. Symptomatic carotid artery stenosis and systolic CCAOP ≤42 mmHg were significantly associated with the development of NI during proximal protected CAS.
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Affiliation(s)
- Hee Jin Kwon
- Division of Cardiology, Department of Internal Medicine, Chungnam National University Hospital, Chungnam National University School of Medicine, Daejeon, Korea
| | - Jae Hyeong Park
- Division of Cardiology, Department of Internal Medicine, Chungnam National University Hospital, Chungnam National University School of Medicine, Daejeon, Korea
| | - Jae Hwan Lee
- Division of Cardiology, Department of Internal Medicine, Chungnam National University Hospital, Chungnam National University School of Medicine, Daejeon, Korea.
| | - Hye Seon Jeong
- Department of Neurology, Chungnam National University Hospital, Chungnam National University School of Medicine, Daejeon, Korea
| | - Hee Jung Song
- Department of Neurology, Chungnam National University Hospital, Chungnam National University School of Medicine, Daejeon, Korea
| | - Jei Kim
- Department of Neurology, Chungnam National University Hospital, Chungnam National University School of Medicine, Daejeon, Korea
| | - Mijoo Kim
- Division of Cardiology, Department of Internal Medicine, Chungnam National University Hospital, Chungnam National University School of Medicine, Daejeon, Korea
| | - In Sun Kwon
- Clinical Trial Center, Chungnam National University Hospital, Chungnam National University School of Medicine, Daejeon, Korea
| | - In Whan Seong
- Division of Cardiology, Department of Internal Medicine, Chungnam National University Hospital, Chungnam National University School of Medicine, Daejeon, Korea
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Ohta T, Nakahara I, Matsumoto S, Ishibashi R, Miyata H, Nishi H, Watanabe S, Nagata I. Prediction of Cerebral Hyperperfusion After Carotid Artery Stenting by Cerebral Angiography and Single-Photon Emission Computed Tomography Without Acetazolamide Challenge. Neurosurgery 2017; 81:512-519. [DOI: 10.1093/neuros/nyx041] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2016] [Accepted: 01/17/2017] [Indexed: 11/14/2022] Open
Affiliation(s)
- Tsuyoshi Ohta
- Department of Neurosurgery, Kochi Health Sciences Center, Kochi City, Kochi Prefecture, Japan
| | - Ichiro Nakahara
- Department of Comprehensive Strokology, Fujita Health University School of Medicine, Toyoake City, Aichi Prefecture, Japan
| | - Shoji Matsumoto
- Department of Neurosurgery, Kokura Memorial Hospital, Kitakyushu City, Fukuoka Prefecture, Japan
| | - Ryota Ishibashi
- Department of Neurosurgery, Kokura Memorial Hospital, Kitakyushu City, Fukuoka Prefecture, Japan
| | - Haruka Miyata
- Department of Neurosurgery, Kokura Memorial Hospital, Kitakyushu City, Fukuoka Prefecture, Japan
| | - Hidehisa Nishi
- Department of Neurosurgery, Kokura Memorial Hospital, Kitakyushu City, Fukuoka Prefecture, Japan
| | - Sadayoshi Watanabe
- Department of Comprehensive Strokology, Fujita Health University School of Medicine, Toyoake City, Aichi Prefecture, Japan
| | - Izumi Nagata
- Department of Neurosurgery, Kokura Memorial Hospital, Kitakyushu City, Fukuoka Prefecture, Japan
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Shibata MA, Shibata E, Maemura K, Kondo Y, Harada-Shiba M. Pathological and molecular analyses of atherosclerotic lesions in ApoE-knockout mice. Med Mol Morphol 2017; 50:130-144. [PMID: 28247010 DOI: 10.1007/s00795-017-0154-y] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2016] [Accepted: 02/07/2017] [Indexed: 12/23/2022]
Abstract
The establishment of consistent and reliable methods for the analysis of atherosclerosis molecular pathways and for testing the efficiency of new therapeutics is of utmost importance. Here, we fed ApoE-knockout (KO) mice with high-fat diet to for 16 weeks to induce atherosclerosis. Atherosclerotic lesions in mice were methodically investigated using pathologic analyses and molecular biology tools. These lesions were histopathologically classified into three categories: early, progressive, and combined lesions. Immunohistochemical analyses showed that both F4/80 (macrophage marker) and tenascin-C are expressed in these lesions. Real-time PCR analysis conducted using formalin-fixed paraffin-embedded tissues with atherosclerotic lesions demonstrated an increase in the levels of many inflammatory chemokines, including Cxcl16, while antibody arrays performed using frozen atherosclerotic tissue samples showed elevated TIMP-1 expression. Subsequent immunohistochemical analyses showed that the expression of CXCL16, TIMP-1, MMP-9, MMP-8, and LOX-1 is localized in the atherosclerotic lesions. We confirmed that the expression of these proteins is localized to atherosclerotic lesion, which suggests their roles in the development of the lesions in ApoE-KO mice. Therefore, this mouse model represents an appropriate tool for elucidating molecular mechanisms underlying the development of atherosclerosis, and a model for the evaluation of therapeutic efficiency of novel drugs.
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Affiliation(s)
- Masa-Aki Shibata
- Department of Anatomy and Cell Biology, Division of Life Sciences, Osaka Medical College, 2-7, Daigaku-machi, Takatsuki, Osaka, 569-8686, Japan.
| | - Eiko Shibata
- Department of Molecular Innovation in Lipidology, National Cerebral and Cardiovascular Center Research Institute, 5-7-1, Fujishirodai, Suita, Osaka, 565-8565, Japan
| | - Kentaro Maemura
- Department of Anatomy and Cell Biology, Division of Life Sciences, Osaka Medical College, 2-7, Daigaku-machi, Takatsuki, Osaka, 569-8686, Japan
| | - Yoichi Kondo
- Department of Anatomy and Cell Biology, Division of Life Sciences, Osaka Medical College, 2-7, Daigaku-machi, Takatsuki, Osaka, 569-8686, Japan
| | - Mariko Harada-Shiba
- Department of Molecular Innovation in Lipidology, National Cerebral and Cardiovascular Center Research Institute, 5-7-1, Fujishirodai, Suita, Osaka, 565-8565, Japan
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Kouvelos G, Koutsoumpelis A, Arnaoutoglou E, Nassis C, Bouris V, Peroulis M, Papadopoulos G, Matsagkas M. The effect of increasing operator experience on procedure-related characteristics in patients undergoing carotid artery stenting. Vascular 2017; 25:488-496. [PMID: 28142887 DOI: 10.1177/1708538117691431] [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] [Indexed: 11/16/2022]
Abstract
Objectives To evaluate the efficacy and safety of carotid artery stenting for the treatment of severe carotid artery disease in our department and to investigate the effect of increasing operator experience on perioperative and procedure-related characteristics. Methods From January 2007 to February 2015 200 patients underwent 207 endovascular procedures for carotid artery stenosis. Of all, 113 arteries (56.5%) were symptomatic. Significant changes across time were calculated with the use of Change Point analysis using bootstrap and mean squared error estimates. Results The technical success was 98.6% (204/207 cases). Thirty-day neurological events included stroke in four patients (2%) and transient ischemic attack in two (1%). None of the patients died during the first 30 days. The most significant change of radiation duration occurred after the 33rd patient with a decrease from 25.31 min to 12.31 min, while for the total operative time that change occurred between the 31st and 33rd patient where mean operation time decreased from 88.89 min to 49.22 min. The most significant change of contrast media used occurred at the 40th patient with a decrease from 91.58 ml to 62 ml. During a mean follow-up period of 42 ± 20.02 months none of the patients experienced any cerebrovascular event. There was one case of significant recurrent stenosis, which was successfully treated by endovascular means. Conclusions Endovascular treatment of carotid artery stenosis performed in a single center with the use of a cerebral protection device seems to consist a safe therapeutic choice with acceptable results, within the referenced benchmarks proposed in the latest guidelines. Certain perioperative parameters such as the amount of contrast media used, the fluoroscopy and operation time, seem to decline overtime indicating increasing operator's experience. A number of performed cases above 40 was related to the significant decrease of those parameters and may represent the learning curve of the procedure.
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Affiliation(s)
- George Kouvelos
- 1 Department of Surgery, Vascular Surgery Unit, University of Ioannina, Medical School, Ioannina, Greece
| | - Andreas Koutsoumpelis
- 1 Department of Surgery, Vascular Surgery Unit, University of Ioannina, Medical School, Ioannina, Greece
| | - Eleni Arnaoutoglou
- 2 Department of Anesthesiology, University of Ioannina, Medical School, Ioannina, Greece
| | - Christos Nassis
- 3 Department of Neurology, Ioannina University Hospital, Ioannina, Greece
| | - Vasilios Bouris
- 1 Department of Surgery, Vascular Surgery Unit, University of Ioannina, Medical School, Ioannina, Greece
| | - Michalis Peroulis
- 1 Department of Surgery, Vascular Surgery Unit, University of Ioannina, Medical School, Ioannina, Greece
| | - George Papadopoulos
- 2 Department of Anesthesiology, University of Ioannina, Medical School, Ioannina, Greece
| | - Miltiadis Matsagkas
- 1 Department of Surgery, Vascular Surgery Unit, University of Ioannina, Medical School, Ioannina, Greece
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Borrelli MP, Setacci F, de Donato G, Galzerano G, Benevento D, Mele M, Rosadini D, Messina G, Setacci C. Patient Discomfort during Carotid Artery Stenting: A Comparison Study between Iodixanol versus Iopamidol. Ann Vasc Surg 2017; 39:167-172. [DOI: 10.1016/j.avsg.2016.04.018] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2016] [Revised: 03/24/2016] [Accepted: 04/24/2016] [Indexed: 10/21/2022]
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Chaturvedi S, Chimowitz M, Brown RD, Lal BK, Meschia JF. The urgent need for contemporary clinical trials in patients with asymptomatic carotid stenosis. Neurology 2016; 87:2271-2278. [PMID: 27683853 DOI: 10.1212/wnl.0000000000003267] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2016] [Accepted: 08/10/2016] [Indexed: 11/15/2022] Open
Abstract
Asymptomatic extracranial internal carotid artery atherosclerotic stenosis increases with age and is more common in men. Studies performed more than 2 decades ago showed that carotid endarterectomy reduced the rate of stroke in carefully selected patients with asymptomatic carotid stenosis compared with medical therapy in the long term. Those trials were completed more than 20 years ago and with advances in the treatment of atherosclerotic disease, the question has been raised to as to whether endarterectomy is still of value for patients with asymptomatic narrowing. Perioperative risk of carotid revascularization procedures has also declined. Due to improvements in both medical and surgical treatments for carotid artery stenosis, it is timely to reevaluate the efficacy of carotid intervention relative to medical treatment for patients with asymptomatic stenosis.
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Affiliation(s)
- Seemant Chaturvedi
- From the University of Miami Miller School of Medicine (S.C.), FL; Medical University of South Carolina (M.C.), Charleston; Mayo Clinic (R.D.B.), Rochester, MN; University of Maryland School of Medicine (B.K.L.), Baltimore; and Mayo Clinic (J.F.M.), Jacksonville, FL.
| | - Marc Chimowitz
- From the University of Miami Miller School of Medicine (S.C.), FL; Medical University of South Carolina (M.C.), Charleston; Mayo Clinic (R.D.B.), Rochester, MN; University of Maryland School of Medicine (B.K.L.), Baltimore; and Mayo Clinic (J.F.M.), Jacksonville, FL
| | - Robert D Brown
- From the University of Miami Miller School of Medicine (S.C.), FL; Medical University of South Carolina (M.C.), Charleston; Mayo Clinic (R.D.B.), Rochester, MN; University of Maryland School of Medicine (B.K.L.), Baltimore; and Mayo Clinic (J.F.M.), Jacksonville, FL
| | - Brajesh K Lal
- From the University of Miami Miller School of Medicine (S.C.), FL; Medical University of South Carolina (M.C.), Charleston; Mayo Clinic (R.D.B.), Rochester, MN; University of Maryland School of Medicine (B.K.L.), Baltimore; and Mayo Clinic (J.F.M.), Jacksonville, FL
| | - James F Meschia
- From the University of Miami Miller School of Medicine (S.C.), FL; Medical University of South Carolina (M.C.), Charleston; Mayo Clinic (R.D.B.), Rochester, MN; University of Maryland School of Medicine (B.K.L.), Baltimore; and Mayo Clinic (J.F.M.), Jacksonville, FL
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Siddiq F, Adil MM, Malik AA, Qureshi MH, Qureshi AI. Effect of Carotid Revascularization Endarterectomy Versus Stenting Trial Results on the Performance of Carotid Artery Stent Placement and Carotid Endarterectomy in the United States. Neurosurgery 2016; 77:726-32; discussion 732. [PMID: 26308633 DOI: 10.1227/neu.0000000000000905] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023] Open
Abstract
BACKGROUND CREST (Carotid Revascularization Endarterectomy Versus Stenting Trial) results, published in 2010, showed no difference in the rates of composite outcome (stroke, myocardial infarction, or death) between carotid artery stent placement (CAS) and carotid endarterectomy (CEA). OBJECTIVE To identify any changes in use and outcomes of CAS and CEA subsequent to the CREST results. METHODS We estimated the frequency of CAS and CEA procedures in the years 2009 (pre-CREST period) and 2011 (post-CREST period), using data from the National Inpatient Sample (NIS). Demographic and clinical characteristics and in-hospital outcomes of pre- and post-CREST CAS-treated and post-CREST CEA-treated patients were compared with pre-CREST CEA-treated patients. RESULTS A total of 225,191 patients underwent CEA or CAS in the pre- and post-CREST periods. The frequency of CAS among carotid revascularization procedures did not change after publication of the CREST results (12.3% vs. 12.7%, P = .9). In the pre-CREST period, the CAS group (compared with the CEA group) had higher rates of congestive heart failure (P < .001), coronary artery disease (P < .001), and renal failure (P < .001). The post-CREST CAS group had a higher frequency of atrial fibrillation (P = .003), congestive heart failure (P < .0001), coronary artery disease (P < .0001), and renal failure (P = .0001). Discharge with moderate to severe disability (P < .0001) and postprocedure neurological complications (P = .005) were more frequently reported in the post-CREST CAS group. After adjusting for age, sex, and risk factors, the odds ratio (OR) for moderate to severe disability was 1.0 (95% confidence interval [CI]: 0.8-1.2) in the pre-CREST CAS group and 1.4 (95% CI: 1.1-1.7) in the post-CREST CAS group compared with the reference group. The adjusted OR for neurological complications in the pre-CREST CAS group was 1.6 (95% CI: 1.2-2.1, P = .002), and 1.5 (95% CI: 1.1-2.0, P = .01) in the post-CREST CAS group. CONCLUSION The frequency of CAS and CEA for carotid artery stenosis has not changed after publication of the CREST. The demographics, pretreatment comorbidity profile, and in-hospital complication rates remained unchanged during the 2 time periods.
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Affiliation(s)
- Farhan Siddiq
- *Zeenat Qureshi Stroke Research Center, Departments of Neurosurgery and Neurology, University of Minnesota, Minnesota; ‡Department of Neurology, Ochsner Clinic Foundation and Ochsner Neuroscience Institute, New Orleans, Louisiana
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Stabile E, Giugliano G, Cremonesi A, Bosiers M, Reimers B, Setacci C, Cao P, Schmidt A, Sievert H, Peeters P, Nikas D, Sannino A, de Donato G, Parlani G, Castriota F, Hornung M, Rubino P, Esposito G, Tesorio T. Impact on outcome of different types of carotid stent: results from the European Registry of Carotid Artery Stenting. EUROINTERVENTION 2016; 12:e265-70. [DOI: 10.4244/eijv12i2a41] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Affiliation(s)
- Eugenio Stabile
- Department of Advanced Biomedical Sciences, University of Naples Federico II, Naples, Italy
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Wayangankar S, Kapadia S, Bajzer C. Carotid Artery Stenting: 2016 and Beyond. CARDIOVASCULAR INNOVATIONS AND APPLICATIONS 2016. [DOI: 10.15212/cvia.2016.0015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
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Hye RJ, Voeks JH, Malas MB, Tom M, Longson S, Blackshear JL, Brott TG. Anesthetic type and risk of myocardial infarction after carotid endarterectomy in the Carotid Revascularization Endarterectomy versus Stenting Trial (CREST). J Vasc Surg 2016; 64:3-8.e1. [PMID: 26994949 DOI: 10.1016/j.jvs.2016.01.047] [Citation(s) in RCA: 44] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2015] [Accepted: 01/26/2016] [Indexed: 11/28/2022]
Abstract
OBJECTIVE Carotid endarterectomy (CEA) is usually performed under general anesthesia (GA), although some advocate regional anesthesia (RA) to reduce hemodynamic instability and allow neurologic monitoring and selective shunting. RA does not reduce risk of periprocedural stroke or death, although some series show a reduction in myocardial infarction (MI). We investigated the association of anesthesia type and periprocedural MI among patients receiving GA or RA for CEA and patients undergoing carotid artery stenting (CAS) in the Carotid Revascularization Endarterectomy versus Stenting Trial (CREST). METHODS Between 2000 and 2008, 1151 patients underwent CEA (anesthetic type available for 1149 patients), and 1123 patients underwent CAS ≤30 days of randomization in CREST. CEA patients were categorized by anesthetic type (GA vs RA). CREST defined protocol MI as chest pain or electrocardiogram change plus biomarker evidence of MI, and total MI was defined as protocol MI plus biomarker-positive (+)-only MI. The incidence of protocol MI and total MI in patients undergoing CEA under GA and RA were compared with those undergoing CAS. Other study end points were similarly compared. Differences in baseline characteristics and periprocedural events were evaluated among the three groups. Logistic regression, adjusting for age and symptomatic status, was used to assess group differences. RESULTS The three groups had similar demographic risk factors, except for prevalence of symptomatic carotid stenosis, which was lowest in the CEA-RA group (P = .03). Of the 111 patients in the CEA-RA group, no protocol MIs occurred and only two biomarker+-only MIs, for an overall incidence of 1.8%, similar to the 1.7% overall incidence in patients undergoing CAS. In contrast, the combined incidence of protocol and biomarker+-only MIs in the 1038 patients in the CEA-GA group was significantly higher at 3.4% (P = .04), twice the risk of protocol MI and biomarker+-only MI compared with those undergoing CAS (odds ratio [OR], 2.01; 95% confidence interval [CI], 1.14-3.54). Direct comparison of the MI incidence between CEA-RA and CEA-GA showed no statistical difference. Patients undergoing CEA-GA had lower odds of a periprocedural stroke (OR, 0.48; 95% CI, 0.28-0.79) and stroke or death (OR, 0.46; 95% CI, 0.27-0.76) compared with those undergoing CAS but were not significantly different from those undergoing CEA-RA. CONCLUSIONS Patients in CREST undergoing CEA-RA had a similar risk of periprocedural MI as those undergoing CAS, whereas the risk for CEA-GA was twice that compared with patients undergoing CAS. Nevertheless, because periprocedural MI is one of the few variables favoring CAS over CEA and has been associated with decreased long-term survival, RA should be seriously considered for patients undergoing CEA.
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Affiliation(s)
- Robert J Hye
- Department of Vascular Surgery, Kaiser Permanente, San Diego, Calif
| | - Jenifer H Voeks
- Department of Neurology, Medical University of South Carolina, Charleston, SC
| | - Mahmoud B Malas
- Department of Vascular and Endovascular Surgery, Johns Hopkins University, Baltimore, Md
| | - MeeLee Tom
- Department of Surgery, New Jersey Medical School, Rutgers/The State University of New Jersey, Newark, NJ
| | - Sonni Longson
- Department of Vascular Surgery, Kaiser Permanente, San Diego, Calif
| | | | - Thomas G Brott
- Department of Surgery, New Jersey Medical School, Rutgers/The State University of New Jersey, Newark, NJ; Department of Neurology, Mayo Clinic, Jacksonville, Fla.
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Giordano A, Ferraro P, Corcione N, Messina S, Maresca G, Coscioni E, Biondi-Zoccai G. Successful treatment of recurrent carotid in-stent restenosis and drug-eluting balloon failure with a coronary bioresorbable vascular scaffold: A case report. Int J Surg Case Rep 2016; 21:78-82. [PMID: 26945488 PMCID: PMC4802336 DOI: 10.1016/j.ijscr.2016.02.035] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2015] [Revised: 02/23/2016] [Accepted: 02/24/2016] [Indexed: 02/05/2023] Open
Abstract
INTRODUCTION Carotid in-stent restenosis is associated with substantial risk of recurrent restenosis, even after drug-eluting balloon usage. PRESENTATION OF CASE We hereby report the case of a patient with recurrent carotid in-stent restenosis and drug-eluting balloon failure treated with a coronary bioresorbable vascular scaffold, achieving a satisfactory acute and long-term result, as disclosed by duplex ultrasound scan performed more than 1 year after the procedure. DISCUSSION/CONCLUSION While awaiting for external validation, this clinical vignette supports expanding the armamentarium of endovascular specialists focusing on carotid artery disease, while providing further proof of the safety and efficacy of current bioresorbable vascular scaffolds.
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Affiliation(s)
- Arturo Giordano
- Unità Operativa di Interventistica Cardiovascolare, Presidio Ospedaliero Pineta Grande, Castel Volturno, Italy; Unità Operativa di Emodinamica, Casa di Salute Santa Lucia, San Giuseppe Vesuviano, Italy
| | - Paolo Ferraro
- Unità Operativa di Interventistica Cardiovascolare, Presidio Ospedaliero Pineta Grande, Castel Volturno, Italy; Unità Operativa di Emodinamica, Casa di Salute Santa Lucia, San Giuseppe Vesuviano, Italy
| | - Nicola Corcione
- Unità Operativa di Interventistica Cardiovascolare, Presidio Ospedaliero Pineta Grande, Castel Volturno, Italy; Unità Operativa di Emodinamica, Casa di Salute Santa Lucia, San Giuseppe Vesuviano, Italy
| | - Stefano Messina
- Unità Operativa di Interventistica Cardiovascolare, Presidio Ospedaliero Pineta Grande, Castel Volturno, Italy; Unità Operativa di Emodinamica, Casa di Salute Santa Lucia, San Giuseppe Vesuviano, Italy
| | - Gennaro Maresca
- Unità Operativa di Interventistica Cardiovascolare, Presidio Ospedaliero Pineta Grande, Castel Volturno, Italy; Unità Operativa di Emodinamica, Casa di Salute Santa Lucia, San Giuseppe Vesuviano, Italy
| | - Enrico Coscioni
- Division of Cardiac Surgery, San Giovanni di Dio e Ruggì D'Aragona Hospital, Salerno, Italy
| | - Giuseppe Biondi-Zoccai
- Department of Medico-Surgical Sciences and Biotechnologies, Sapienza University of Rome, Latina, Italy; Department of AngioCardioNeurology, IRCCS Neuromed, Pozzilli, Italy.
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Biondi-Zoccai G, Frati G, Coscioni E, Giordano A. Commentary: Cilostazol and Carotid Stenting: A Merry Marriage? J Endovasc Ther 2016; 23:196-8. [PMID: 26763261 DOI: 10.1177/1526602815619405] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Affiliation(s)
- Giuseppe Biondi-Zoccai
- Department of Medico-Surgical Sciences and Biotechnologies, Sapienza University of Rome, Latina, Italy Eleonora Lorillard Spencer Cenci Foundation, Rome, Italy
| | - Giacomo Frati
- Department of Medico-Surgical Sciences and Biotechnologies, Sapienza University of Rome, Latina, Italy Department of AngioCardioNeurology, IRCCS Neuromed, Pozzilli, Italy
| | - Enrico Coscioni
- Division of Cardiac Surgery, San Giovanni di Dio e Ruggi D'Aragona Hospital, Salerno, Italy
| | - Arturo Giordano
- Unità Operativa di Interventistica Cardiovascolare, Presidio Ospedaliero Pineta Grande, Castel Volturno, Italy Unità Operativa di Emodinamica, Casa di Salute Santa Lucia, San Giuseppe Vesuviano, Italy
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Egron S, Kütting M, Marzelle J, Becquemin JP, Schmitz-Rode T, Steinseifer U. What can be done for cerebral embolic protection in TAVI? Analysis in the light of 10 years' experience with protected carotid artery stenting. Expert Rev Med Devices 2016; 13:15-29. [PMID: 26567610 DOI: 10.1586/17434440.2015.1120666] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
In the last 30 years, development of minimally invasive percutaneous procedures to treat cardiovascular defects has been thriving. Although these techniques present obvious advantages, like avoiding cardiopulmonary bypass, the passage of catheter systems and the deployment of devices in the blood circulation can cause particle embolization that may result in stroke. In carotid artery stenting, cerebral embolic protection devices (CEPD) such as filtering membranes have been available for already 10 years. In transcatheter aortic valve implantation (TAVI), the development of CEPD is starting and three membrane-based devices are in clinical trials. There are controversial discussions about the efficacy of CEPD in TAVI. The experience with CEPD in carotid artery stenting can help to understand some of the technical issues and shortcomings of current devices and thereby ultimately reduce cerebral complication risks during TAVI procedures.
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Affiliation(s)
- Sandrine Egron
- a Department of Cardiovascular Engineering , Institute of Applied Medical Engineering AME, Helmholtz Institute , Aachen , Germany
| | - Maximilian Kütting
- a Department of Cardiovascular Engineering , Institute of Applied Medical Engineering AME, Helmholtz Institute , Aachen , Germany
| | - Jean Marzelle
- b Department of Vascular Surgery , Henri Mondor Hospital , Créteil , France
| | | | - Thomas Schmitz-Rode
- a Department of Cardiovascular Engineering , Institute of Applied Medical Engineering AME, Helmholtz Institute , Aachen , Germany
| | - Ulrich Steinseifer
- a Department of Cardiovascular Engineering , Institute of Applied Medical Engineering AME, Helmholtz Institute , Aachen , Germany
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Paraskevas KI, Veith FJ. Carotid Artery Stenting (CAS) Outcomes May Vary between Operators and/or Institutions. The Results from Centers of CAS Excellence May Not Be Generalizable. Ann Vasc Surg 2015; 29:1491-2. [PMID: 26362617 DOI: 10.1016/j.avsg.2015.06.095] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2015] [Accepted: 06/28/2015] [Indexed: 11/28/2022]
Affiliation(s)
- Kosmas I Paraskevas
- Division of Cardiovascular Sciences, St. George's Vascular Institute, St. George's Hospital University of London, London, UK.
| | - Frank J Veith
- Division of Vascular Surgery, New York University Langone Medical Center, New York, NY; Division of Vascular Surgery, The Cleveland Clinic, Cleveland, OH
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Horváth M, Hájek P, Štěchovský C, Honěk J, Veselka J. Intravascular Near-Infrared Spectroscopy: A Possible Tool for Optimizing the Management of Carotid Artery Disease. Int J Angiol 2015; 24:198-204. [PMID: 26417188 PMCID: PMC4572008 DOI: 10.1055/s-0035-1558644] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022] Open
Abstract
Stroke is the second most common cause of morbidity and mortality in the Western nations. It is estimated that approximately one-fifth of all strokes or transient ischemic attacks are caused by carotid artery disease. Thus, treatment of carotid artery disease as a mean of stroke prevention is extremely important. Since the introduction of carotid endarterectomy, debate has persisted over the treatment strategy for carotid artery disease. Current recommendations have many potential flaws because they are often based on older trials performed before the introduction of modern pharmacotherapy and are mostly based on the angiographic degree of stenosis, without an emphasis on the pathophysiology of the disease. Most carotid events are caused by rupture or distal embolization of the content of an unstable atherosclerotic plaque with a large lipid pool. Thus, it is plausible that the information regarding the composition of the atherosclerotic plaque could play an important role in deciding on a treatment strategy. In this review article, we provide information about near-infrared spectroscopy, a new invasive imaging modality, which seems to be capable of providing such information.
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Affiliation(s)
- Martin Horváth
- Department of Cardiology, Charles University in Prague, 2nd Faculty of Medicine and Motol University Hospital, Prague, Czech Republic
| | - Petr Hájek
- Department of Cardiology, Charles University in Prague, 2nd Faculty of Medicine and Motol University Hospital, Prague, Czech Republic
| | - Cyril Štěchovský
- Department of Cardiology, Charles University in Prague, 2nd Faculty of Medicine and Motol University Hospital, Prague, Czech Republic
| | - Jakub Honěk
- Department of Cardiology, Charles University in Prague, 2nd Faculty of Medicine and Motol University Hospital, Prague, Czech Republic
| | - Josef Veselka
- Department of Cardiology, Charles University in Prague, 2nd Faculty of Medicine and Motol University Hospital, Prague, Czech Republic
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Nomura M, Mori K, Seki S. Perforation of superior thyroid artery by guidewire during carotid artery stenting. Neuroradiol J 2015; 28:329-32. [PMID: 26246105 DOI: 10.1177/1971400915594928] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
BACKGROUND AND AIM Although carotid artery stenting (CAS) has become a common treatment for carotid artery stenosis, some complications occur related to the procedures. Perforation of an external carotid artery (ECA) branch is a rare complication. CASE DESCRIPTION An 83-year-old man presented with gait disturbance and dysarthria. MRI demonstrated a fresh cerebral infarction in the watershed territory of the left cerebrum and severe stenosis of the left internal carotid artery (ICA). He underwent CAS for the left ICA stenosis. After the procedure, the patient complained of discomfort of the throat. Swelling of the neck was observed and angiography showed extravasation of contrast medium from the superior thyroid artery. The patient was immediately sedated and intubated. Strict control of the blood pressure was continued. Two days after CAS, the tracheal tube was extracted. He was discharged without deficit on the 17th post-stenting day. CONCLUSION Injury of ECA branches is a potential complication when a guidewire is inserted during advancement of the materials. It may be life threatening due to associated respiratory problems. Once bleeding from the ECA is suspected, close observation of the patient's neck and respiration and immediate intervention are necessary.
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Affiliation(s)
- Motohiro Nomura
- Department of Neurosurgery, Yokohama Sakae Kyosai Hospital, Japan
| | - Kentaro Mori
- Department of Neurosurgery, Yokohama Sakae Kyosai Hospital, Japan
| | - Shunsuke Seki
- Department of Neurosurgery, Yokohama Sakae Kyosai Hospital, Japan
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Gupta A, Mushlin AI, Kamel H, Navi BB, Pandya A. Cost-Effectiveness of Carotid Plaque MR Imaging as a Stroke Risk Stratification Tool in Asymptomatic Carotid Artery Stenosis. Radiology 2015; 277:763-72. [PMID: 26098459 DOI: 10.1148/radiol.2015142843] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
PURPOSE To evaluate the cost-effectiveness of a decision-making rule based on the magnetic resonance (MR) imaging assessment of intraplaque hemorrhage (IPH) in patients with asymptomatic carotid artery stenosis. MATERIALS AND METHODS Two competing stroke prevention strategies were compared: (a) an intensive medical therapy-based management strategy versus (b) an imaging-based strategy in which the subset of patients with asymptomatic carotid artery stenosis with IPH on MR images would undergo immediate carotid endarterectomy in addition to ongoing intensive medical therapy. Patients in the medical therapy-only group could undergo carotid endarterectomy only with substantial carotid artery stenosis disease progression. Lifetime quality-adjusted life years (QALYs) and costs were modeled for patients with asymptomatic carotid artery stenosis with 70%-89% and 50%-69% carotid artery stenosis at presentation. Risks of stroke and complications from carotid endarterectomy, costs, and quality of life values were estimated from published sources. RESULTS The medical therapy-based strategy had a lower life expectancy (12.65 years vs 12.95 years), lower lifetime QALYs (9.96 years vs 10.05 years), and lower lifetime costs ($13 699 vs $15 297) when compared with the MR imaging IPH-based strategy. The incremental cost-effectiveness ratio (ICER) for the MR imaging IPH strategy compared with the medical therapy-based strategy was $16 000 per QALY by using a base-case 70-year-old patient. When using starting patient ages of 60 and 80 years, the ICERs for the MR imaging IPH strategy were $3100 per QALY and $73 000 per QALY, respectively. The ICERs for the MR imaging IPH strategy were slightly higher at all ages for 50%-69% stenosis but remained below a willingness-to-pay threshold of $100 000 per QALY for starting ages of 60 and 70 years. CONCLUSION MR imaging IPH can be used as a cost-effective tool to identify patients with asymptomatic carotid artery stenosis most likely to benefit from carotid endarterectomy.
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Affiliation(s)
- Ajay Gupta
- From the Departments of Radiology (A.G.), Neurology (H.K., B.B.N.), and Healthcare Policy and Research (A.I.M., A.P.), Weill Cornell Medical College, 1300 York Ave, New York, NY 10065
| | - Alvin I Mushlin
- From the Departments of Radiology (A.G.), Neurology (H.K., B.B.N.), and Healthcare Policy and Research (A.I.M., A.P.), Weill Cornell Medical College, 1300 York Ave, New York, NY 10065
| | - Hooman Kamel
- From the Departments of Radiology (A.G.), Neurology (H.K., B.B.N.), and Healthcare Policy and Research (A.I.M., A.P.), Weill Cornell Medical College, 1300 York Ave, New York, NY 10065
| | - Babak B Navi
- From the Departments of Radiology (A.G.), Neurology (H.K., B.B.N.), and Healthcare Policy and Research (A.I.M., A.P.), Weill Cornell Medical College, 1300 York Ave, New York, NY 10065
| | - Ankur Pandya
- From the Departments of Radiology (A.G.), Neurology (H.K., B.B.N.), and Healthcare Policy and Research (A.I.M., A.P.), Weill Cornell Medical College, 1300 York Ave, New York, NY 10065
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Štěchovský C, Hájek P, Horváth M, Špaček M, Veselka J. Near-infrared spectroscopy combined with intravascular ultrasound in carotid arteries. Int J Cardiovasc Imaging 2015; 32:181-8. [PMID: 26044524 DOI: 10.1007/s10554-015-0687-x] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/08/2015] [Accepted: 05/29/2015] [Indexed: 12/22/2022]
Abstract
Limited insights into the pathophysiology of the atherosclerotic carotid stenosis are available in vivo. We conducted a prospective study to assess safety and feasibility of intravascular ultrasound (IVUS) combined with near-infrared spectroscopy (NIRS) in carotid arteries. In addition, we described the size and the distribution of lipid rich plaques in significant atherosclerotic carotid stenoses. In a prospective single centre study 45 consecutive patients (mean age 66 ± 8 years) with symptomatic (≥50 %) or asymptomatic (≥70 %) stenosis of internal carotid artery (ICA) amendable to carotid stenting were enrolled. A 40 mm long NIRS-IVUS pullback through the stenosis was performed. IVUS and NIRS data were analyzed to assess minimal luminal area (MLA), plaque burden (PB), remodeling index (RI), calcifications, lipid core burden index (LCBI), maximal LCBI in any 4 mm segment of the artery (LCBImx) and LCBI in the 4 mm segment at the site of minimal luminal area (LCBImxMLA). NIRS-IVUS pullbacks were safely performed without overt clinical events. LCBImx was significantly higher than LCBImxMLA (369.1 ± 221.1 vs. 215.7 ± 2589; p = 0.004). Conversely, PB was significantly larger at the site of MLA (87.4 ± 4.8 % vs. 58.3 ± 18.2 %; p < 0001). Distance of the NIRS-IVUS frame with the highest LCBI from the site of MLA was 6.5 ± 7.7 mm. Eighty percent of frames with maximal LCBI were localized within 10 mm from the site of MLA and 67 % proximally to or at the site of MLA. This study suggested safety and feasibility of the NIRS-IVUS imaging of the carotid stenosis and provided insights on the distribution of lipids in the carotid stenosis. Lipid rich plaques were more often located in the sites with a milder stenosis and smaller plaque burden than at the site of MLA.
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Affiliation(s)
- Cyril Štěchovský
- Department of Cardiology, 2nd Medical School, Charles University, Motol University Hospital, V Uvalu 84, 150 06, Prague 5, Czech Republic.
| | - Petr Hájek
- Department of Cardiology, 2nd Medical School, Charles University, Motol University Hospital, V Uvalu 84, 150 06, Prague 5, Czech Republic
| | - Martin Horváth
- Department of Cardiology, 2nd Medical School, Charles University, Motol University Hospital, V Uvalu 84, 150 06, Prague 5, Czech Republic
| | - Miloslav Špaček
- Department of Cardiology, 2nd Medical School, Charles University, Motol University Hospital, V Uvalu 84, 150 06, Prague 5, Czech Republic
| | - Josef Veselka
- Department of Cardiology, 2nd Medical School, Charles University, Motol University Hospital, V Uvalu 84, 150 06, Prague 5, Czech Republic
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Chaturvedi S, Sacco RL. How Recent Data Have Impacted the Treatment of Internal Carotid Artery Stenosis. J Am Coll Cardiol 2015; 65:1134-43. [DOI: 10.1016/j.jacc.2014.12.045] [Citation(s) in RCA: 38] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/17/2014] [Revised: 12/27/2014] [Accepted: 12/30/2014] [Indexed: 11/29/2022]
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Affiliation(s)
- A. Ross Naylor
- From the Department of Vascular Surgery, Vascular Research Group, Division of Cardiovascular Sciences, Leicester Royal Infirmary, Leicester, United Kingdom
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