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Petkoska D, Zafirovska B, Vasilev I, Saylors E, Sachar R, Kedev S. Transradial carotid artery stenting using double layer micromesh stent and novel post-dilation balloon with integrated embolic protection. CARDIOVASCULAR REVASCULARIZATION MEDICINE 2024; 63:43-51. [PMID: 38267286 DOI: 10.1016/j.carrev.2024.01.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2023] [Revised: 12/02/2023] [Accepted: 01/09/2024] [Indexed: 01/26/2024]
Abstract
OBJECTIVES The highest rate of embolization during carotid artery stenting occurs during post-dilation. We evaluated the ability of the Paladin system (Contego Medical, Raleigh, NC), a novel PTA balloon with an integrated 40-ɥm pore filter, to collect microemboli that may pass into the cerebral circulation when used during post-dilation. METHODS 25 symptomatic patients underwent transradial CAS using the Paladin system in conjunction with the Roadsaver (Terumo Corporation, Tokyo, Japan) micromesh stent. No additional embolic protection was used. The Paladin filters were collected following the procedure and preserved in formalin for histological analysis. The contents were evaluated for particle count and size. Subjects were followed for 30 days and evaluated for major cardiac adverse events (death, stroke and MI). Secondary endpoints included procedure success, device success, access site complications according to EASY score classification, major vascular or ischemic complications at follow up and in-stent restenosis rate evaluated with duplex ultrasound. RESULTS Mean age of patients was 68,5 years. Type 2 aortic arch was present in 77 % of patients and type 1 and type 3 in 12 % and 11 % of patients respectively. Procedural and device success was obtained in all cases without complications. The 30-day MAE rate was 0 %. Twenty-three filters underwent histological analysis. Microscopic debris was present in 100 % of filters, and 75 % of particles were less than 100ɥm in size. The mean number of particles per filter was 3352 ± 1567 (IQR 4300-2343), and the mean number of particles between 40-100ɥm per filter was 2499 ± 1240 (IQR 3227-1575). CONCLUSION CAS through radial approach can be safely and effectively performed using the IEP technology Paladin device and double-layer micromesh Roadsaver stent. This strategy can simplify the procedure and decrease peri-procedural complications and procedural time.
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Affiliation(s)
- Danica Petkoska
- University Clinic of Cardiology, Medical Faculty, University Ss. Cyril and Methodius, Skopje, Macedonia
| | - Biljana Zafirovska
- University Clinic of Cardiology, Medical Faculty, University Ss. Cyril and Methodius, Skopje, Macedonia
| | - Ivan Vasilev
- University Clinic of Cardiology, Medical Faculty, University Ss. Cyril and Methodius, Skopje, Macedonia
| | | | - Ravish Sachar
- North Carolina Heart and Vascular, UNC-REX Healthcare, University of North Carolina, Raleigh, NC, USA
| | - Sasko Kedev
- University Clinic of Cardiology, Medical Faculty, University Ss. Cyril and Methodius, Skopje, Macedonia.
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Kedev S. Carotid artery interventions - endarterectomy versus stenting. ASIAINTERVENTION 2023; 9:172-179. [PMID: 37736202 PMCID: PMC10509610 DOI: 10.4244/aij-d-23-00009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/07/2023] [Accepted: 06/02/2023] [Indexed: 09/23/2023]
Abstract
Current management of patients with carotid artery stenosis is based on well-established guidelines, including surgical procedures - carotid endarterectomy (CEA) and endovascular carotid artery stenting (CAS) - and optimal medical treatment alone. Outcomes in the postprocedural period after CAS and CEA are similar, suggesting strong clinical durability for both treatments. Recent advances, which include the emergence of novel endovascular treatment tools and techniques, combined with more recent randomised trial data shed new light on optimal patient selection and treatment in contemporary practice. Improved, modern technologies including enhanced embolic protection devices and dual-layered micromesh stents yield better outcomes and should result in further improvements in CAS. In centres of excellence, nowadays, the majority of patients with severe carotid artery stenosis can be successfully treated with either CEA or CAS.
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Affiliation(s)
- Sasko Kedev
- University Clinic of Cardiology, Faculty of Medicine, Ss. Cyril and Methodius University, Skopje, Republic of North Macedonia
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Miccichè E, Condello F, Cao D, Azzano A, Ioppolo AM, Mangiameli A, Cremonesi A. Procedural embolic protection strategies for carotid artery stenting: current status and future prospects. Expert Rev Med Devices 2023; 20:373-391. [PMID: 37000987 DOI: 10.1080/17434440.2023.2198124] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/03/2023]
Abstract
INTRODUCTION Carotid artery angioplasty and stenting (CAS) is an established procedure to treat carotid artery stenosis for either primary or secondary prevention of stroke. Randomized clinical trials have shown an increased risk of periprocedural cerebrovascular events with CAS compared with carotid endarterectomy (CEA). Several strategies have been proposed to mitigate this risk, including alternative vascular access site, proximal/distal embolic protection devices, and dual-layer stents, among others. AREAS COVERED This review provides a general overview of current embolic protection strategies for CAS. The phases of the procedure which can affect the early risk of stroke and how to reduce it with novel techniques and devices have been discussed. EXPERT OPINION Innovations in device technologies have dramatically improved the safety and efficacy of CAS. To minimize the gap with surgery, a thorough, patient-oriented approach should be pursued. Endovascular technologies and techniques should be selected on an individual basis to address unique lesion characteristics and vascular anatomies. Meticulous pre-procedural planning, both clinical and anatomical, is needed to assess the embolic risk of each procedure. Only by having an in-depth understanding of the wide range of available endovascular devices and techniques, the operator will choose the most appropriate strategy to optimize CAS results.
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Fioretti V, Gerardi D, Luzi G, Stabile E. Proximal versus distal protection: dissecting clinical trials. Minerva Cardiol Angiol 2022; 70:727-737. [PMID: 36700668 DOI: 10.23736/s2724-5683.22.06233-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Abstract
Carotid artery stenting (CAS) is a valid alternative to conventional carotid endarterectomy for treatment of carotid artery stenosis. Distal embolization of atherosclerotic debris causing cerebrovascular accidents during CAS has been the most significant concern limiting widespread application of CAS technology. A variety of embolic protection devices (EPDs) with different mechanism of action, have been designed to minimize the risk of major embolization causing stroke and their use is recommended by current guidelines. Two general types of EPDs are available: proximal protection devices (PPDs) and distal protection devices (DPDs). However, there is no convincing clinical evidence of the clinical superiority of one device over another. This review will examine the different types of available devices and also innovative devices and techniques, including strengths and weaknesses of each, and present the available evidence and rationale for their routine use during CAS.
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Affiliation(s)
- Vincenzo Fioretti
- Division of Cardiology, Cardiovascular Department, San Carlo Regional Hospital, Potenza, Italy
| | - Donato Gerardi
- Division of Cardiology, Cardiovascular Department, San Carlo Regional Hospital, Potenza, Italy
| | - Giampaolo Luzi
- Division of Cardiac Surgery, Cardiovascular Department, San Carlo Regional Hospital, Potenza, Italy
| | - Eugenio Stabile
- Division of Cardiology, Cardiovascular Department, San Carlo Regional Hospital, Potenza, Italy -
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Langhoff R, Petrov I, Kedev S, Milosevic Z, Schmidt A, Scheinert D, Schofer J, Sievert H, Sedgewick G, Saylors E, Sachar R, Cremonesi A, Micari A. PERFORMANCE 1 study: Novel carotid stent system with integrated post-dilation balloon and embolic protection device. Catheter Cardiovasc Interv 2022; 100:1090-1099. [PMID: 36229946 PMCID: PMC10092178 DOI: 10.1002/ccd.30410] [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: 01/31/2022] [Revised: 07/13/2022] [Accepted: 09/06/2022] [Indexed: 11/11/2022]
Abstract
OBJECTIVES The PERFORMANCE I study was designed to evaluate the safety and feasibility of the Neuroguard IEP® System, a novel carotid stent system with an integrated embolic filter and post-dilatation balloon, to treat clinically significant carotid artery stenosis. BACKGROUND The risk of major adverse events during carotid artery stenting is comparable to carotid endarterectomy, however, the risk of minor stroke remains higher with stenting. METHODS In total, 67 patients undergoing carotid artery stenting were enrolled at nine centers in Europe. Follow-up assessments included neurological exams, duplex ultrasound, 12-lead electrocardiogram, and cardiac enzyme analysis. The primary endpoint was the 30-day composite rate of stroke, death, and myocardial infarctions versus a prespecified performance goal. Secondary endpoints included procedure success, device success, and target lesion revascularization. RESULTS The study population was predominantly male (74.6%) with a mean age of 69.3 ± 8.9 years and 67% of subjects met at least one criterion placing them at an elevated risk for adverse events following carotid endarterectomy. All patients were treated successfully with the study device. There were no deaths or strokes within 30 days of the index procedure. One subject (1.5%) experienced a non-ST elevation myocardial infarction at day 17. The primary endpoint was met with a 30-day major adverse events rate of 1.5% (1/67). Through 12-month follow-up, there were no strokes, neurological deaths, target lesion revascularizations, or instances of in-stent-restenosis. CONCLUSIONS Results from this study demonstrate the Neuroguard IEP system is safe and feasible with a stroke/death rate of 0% at 30 days. A large pivotal study is currently underway.
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Affiliation(s)
- Ralf Langhoff
- Department for Angiology, Brandenburg Medical School Theodor Fontane, Campus Clinic Brandenburg, Center for Internal Medicine I, Berlin, Germany.,Department of Angiology, Sankt-Gertrauden-Krankenhaus, Berlin, Germany
| | - Ivo Petrov
- Cardiology and Angiology Department at Acibadem City Clinic Cardiovascular Center, Sofia, Bulgaria
| | - Sasko Kedev
- University Clinic of Cardiology Medical Faculty University "Ss. Cyril and Methodius" Skopje, Skopje, Macedonia
| | - Zoran Milosevic
- Department of Diagnostic and Interventional Neuroradiology, University Medical Centre Ljubljana, Ljubljana, Slovenia
| | - Andrej Schmidt
- Clinic for Angiology, University Hospital Leipzig, Leipzig, Germany
| | - Dierk Scheinert
- Clinic for Angiology, University Hospital Leipzig, Leipzig, Germany
| | | | - Horst Sievert
- CardioVascular Center Frankfurt (CVC), Frankfurt, Germany
| | | | | | - Ravish Sachar
- Contego Medical, Inc, Raleigh, North Carolina, USA.,UNC-Rex Healthcare, Raleigh, North Carolina, USA
| | | | - Antonio Micari
- Department of Cardiology, University of Messina, Messina, Italy
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Reiff T, Eckstein HH, Mansmann U, Jansen O, Fraedrich G, Mudra H, Böckler D, Böhm M, Debus ES, Fiehler J, Mathias K, Ringelstein EB, Schmidli J, Stingele R, Zahn R, Zeller T, Niesen WD, Barlinn K, Binder A, Glahn J, Hacke W, Ringleb PA, Macharzina RR, Lechner G, Menz C, Schonhardt S, Weinbeck M, Greb O, Otto D, Winker T, Berger H, Poppert H, Kühnl A, Pütz V, Haase K, Bodechtel U, Weiss N, Bergert H, Meyne J, Groß J, Kruse M, Gerdes B, Reinbold WD, Wuttig H, Maier-Hasselmann A, Segerer M, Fuchs HH, Gass S, Groden C, Niedergethmann M, Griebe M, Rosenkranz M, Beck J, Thomalla G, Zeumer HH, Jauß M, Kneist W, Kneist M, Staudacher T, Bernhard A, Jost P, Prey N, Knippschild J, Kastrup O, Köhrmann M, Frank B, Bongers V, Hoffmann J, Kniemeyer HW, Knauth M, Wasser K, Stojanovic T, Emmert H, Tacke J, Schwalbe B, Nam EM, van Lengerich U, Lowens S, Gröschel K, Uphaus T, Gröschel S, Boor S, Dorweiler B, Schmid E, Henkes H, Hupp T, Singer O, Hamann G, Wagner-Heck M, Kerth-Krick S, Kilic M, Huppert P, Niederkorn K, Fruhwirth J, Klein G, Pulkowski U, Jöster K, Wacks JH, Kloppmann E, Vatankhah B, Hopf-Jensen S, Stolze H, Müller-Hülsbeck S, Walluscheck KP, Schmitt HM, Grüger A, Seemann J, Tilahun B, Dichgans M, Wollenweber FA, Dörr A, Zollver A, Gäbel G, Hedtmann G, Kollmar R, Claus D, Petermann C, Kirsch S, Bosnjak B, Heiß J, Mühling H, Wunderlich S, Sabisch PN, Gahn G, Storck M, Arnold S, Fischer U, Gralla J, von Mering M, Dißmann R, Kirsch D, Schmidauer C, Waldenberger P, Furtner M, Kazarians H, Breuer P, Arning C, Rieper J, Schmidt G, Arnold M, Schroth G, Weise J, Zanow J, Mayer T, Töpper R, Gross-Fengels W, Daum H, Dittrich R, Ritter M, Kasprzak B, Torsello G, Pohlmann C, Brüning R, Breuer P, Crispin A, Hofmann M, Müller T, Blessing E, Möhlenbruch M, Ludwig I, Amiri H. Carotid endarterectomy or stenting or best medical treatment alone for moderate-to-severe asymptomatic carotid artery stenosis: 5-year results of a multicentre, randomised controlled trial. Lancet Neurol 2022; 21:877-888. [PMID: 36115360 DOI: 10.1016/s1474-4422(22)00290-3] [Citation(s) in RCA: 31] [Impact Index Per Article: 15.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2022] [Revised: 06/28/2022] [Accepted: 06/30/2022] [Indexed: 10/14/2022]
Abstract
BACKGROUND The optimal treatment for patients with asymptomatic carotid artery stenosis is under debate. Since best medical treatment (BMT) has improved over time, the benefit of carotid endarterectomy (CEA) or carotid artery stenting (CAS) is unclear. Randomised data comparing the effect of CEA and CAS versus BMT alone are absent. We aimed to directly compare CEA plus BMT with CAS plus BMT and both with BMT only. METHODS SPACE-2 was a multicentre, randomised, controlled trial at 36 study centres in Austria, Germany, and Switzerland. We enrolled participants aged 50-85 years with asymptomatic carotid artery stenosis at the distal common carotid artery or the extracranial internal carotid artery of at least 70%, according to European Carotid Surgery Trial criteria. Initially designed as a three-arm trial including one group for BMT alone (with a randomised allocation ratio of 2·9:2·9:1), the SPACE-2 study design was amended (due to slow recruitment) to become two substudies with two arms each comparing CEA plus BMT with BMT alone (SPACE-2a) and CAS plus BMT with BMT alone (SPACE-2b); in each case in a 1:1 randomisation. Participants and clinicians were not masked to allocation. The primary efficacy endpoint was the cumulative incidence of any stroke or death from any cause within 30 days or any ipsilateral ischaemic stroke within 5 years. The primary safety endpoint was any stroke or death from any cause within 30 days after CEA or CAS. The primary analysis was by intention-to treat, which included all randomly assigned patients in SPACE-2, SPACE-2a, and SPACE-2b, analysed using meta-analysis of individual patient data. We did two-step hierarchical testing to first show superiority of CEA and CAS to BMT alone then to assess non-inferiority of CAS to CEA. Originally, we planned to recruit 3640 patients; however, the study had to be stopped prematurely due to insufficient recruitment. This report presents the primary analysis at 5-year follow-up. This trial is registered with ISRCTN, number ISRCTN78592017. FINDINGS 513 patients across SPACE-2, SPACE-2a, and SPACE-2b were recruited and surveyed between July 9, 2009, and Dec 12, 2019, of whom 203 (40%) were allocated to CEA plus BMT, 197 (38%) to CAS plus BMT, and 113 (22%) to BMT alone. Median follow-up was 59·9 months (IQR 46·6-60·0). The cumulative incidence of any stroke or death from any cause within 30 days or any ipsilateral ischaemic stroke within 5 years (primary efficacy endpoint) was 2·5% (95% CI 1·0-5·8) with CEA plus BMT, 4·4% (2·2-8·6) with CAS plus BMT, and 3·1% (1·0-9·4) with BMT alone. Cox proportional-hazard testing showed no difference in risk for the primary efficacy endpoint for CEA plus BMT versus BMT alone (hazard ratio [HR] 0·93, 95% CI 0·22-3·91; p=0·93) or for CAS plus BMT versus BMT alone (1·55, 0·41-5·85; p=0·52). Superiority of CEA or CAS to BMT was not shown, therefore non-inferiority testing was not done. In both the CEA group and the CAS group, five strokes and no deaths occurred in the 30-day period after the procedure. During the 5-year follow-up period, three ipsilateral strokes occurred in both the CAS plus BMT and BMT alone group, with none in the CEA plus BMT group. INTERPRETATION CEA plus BMT or CAS plus BMT were not found to be superior to BMT alone regarding risk of any stroke or death within 30 days or ipsilateral stroke during the 5-year observation period. Because of the small sample size, results should be interpreted with caution. FUNDING German Federal Ministry of Education and Research (BMBF) and German Research Foundation (DFG).
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Affiliation(s)
- Tilman Reiff
- Department of Neurology, University Hospital of Heidelberg, Heidelberg, Germany.
| | - Hans-Henning Eckstein
- Department for Vascular and Endovascular Surgery, Klinikum rechts der Isar, Technical University of Munich, Munich, Germany
| | - Ulrich Mansmann
- Institute of Medical Informatics, Biometry and Epidemiology, Ludwig-Maximilians-Universität München, Munich, Germany
| | - Olav Jansen
- Department of Radiology and Neuroradiology, UKSH Campus Kiel, Kiel, Germany
| | - Gustav Fraedrich
- Department of Vascular Surgery, University Hospital of Innsbruck, Innsbruck, Austria
| | - Harald Mudra
- Department of Cardiology, München Klinik, Klinikum Neuperlach, Munich, Germany
| | - Dittmar Böckler
- Department of Vascular and Endovascular Surgery, University Hospital of Heidelberg, Heidelberg, Germany
| | - Michael Böhm
- Department of Internal Medicine, University Hospital of Homburg/Saar, Homburg, Germany
| | - E Sebastian Debus
- Department of Vascular Surgery, University Hospital of Hamburg, Hamburg, Germany
| | - Jens Fiehler
- Department of Neuroradiology, University Hospital of Hamburg, Hamburg, Germany
| | - Klaus Mathias
- Department of Radiology, Klinikum Dortmund, Dortmund, Germany
| | | | - Jürg Schmidli
- Department of Vascular Surgery, University Hospital of Bern, Bern, Switzerland
| | - Robert Stingele
- Department of Neurology, DRK-Kliniken Berlin, Berlin, Germany
| | - Ralf Zahn
- Department of Internal Medicine, Klinikum Ludwigshafen, Ludwigshafen, Germany
| | - Thomas Zeller
- Department of Angiology, University Heart-Center Freiburg-Bad Krozingen, Bad Krozingen, Germany
| | - Wolf-Dirk Niesen
- Department of Neurology, University Hospital Freiburg, Freiburg, Germany
| | - Kristian Barlinn
- Department of Neurology, University Hospital of Dresden, Dresden, Germany
| | - Andreas Binder
- Department of Neurology, UKSH Campus Kiel, Kiel, Germany
| | - Jörg Glahn
- Department of Neurology, Johannes Wesling Klinikum, Minden, Germany
| | - Werner Hacke
- Department of Neurology, University Hospital of Heidelberg, Heidelberg, Germany
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White CJ, Brott TG, Gray WA, Heck D, Jovin T, Lyden SP, Metzger DC, Rosenfield K, Roubin G, Sachar R, Siddiqui A. Carotid Artery Stenting. J Am Coll Cardiol 2022; 80:155-170. [DOI: 10.1016/j.jacc.2022.05.007] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/02/2022] [Revised: 05/04/2022] [Accepted: 05/05/2022] [Indexed: 11/29/2022]
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Haensig M, Kuntze T, Gonzalez-Lopez D, Lapp H, Lauten P, Owais T. Thromboembolic complications in transfemoral aortic valve implantation due to aortic wall thrombus and shaggy aorta syndrome. Eur J Cardiothorac Surg 2021; 60:253-260. [PMID: 33637994 DOI: 10.1093/ejcts/ezab093] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/09/2020] [Revised: 01/13/2021] [Accepted: 01/22/2021] [Indexed: 11/13/2022] Open
Abstract
OBJECTIVES Aortic wall thrombus (AWT) can affect suitability to endovascular repair, while its most aggressive entity is better known as shaggy aorta syndrome. Primary objective was to study the procedural and clinical outcome with regard to atherothrombotic AWT in transfemoral aortic valve implantation. METHODS In a retrospective, single-centre analysis, a qualitative 0-10 AWT score classification system was used. The most severely affected aortic area in computed tomography angiography cross-section was assessed for the number of affected segments, thrombus type, thickness, area and circumference. Primary endpoints were 30-day mortality, neurologic, renal and pulmonary events and signs of solid organ infarction. RESULTS Between November 2017 and September 2019, 604 patients underwent transfemoral transcatheter aortic valve implantation in our institution. Computed tomography-guided analysis revealed AWT in 11.3% and shaggy aorta syndrome in 6 patients (1.0% with 83.3% male). AWT was mainly present in the descending thoracic and abdominal aorta and was associated with acute renal failure (11.8% vs 3.2%, P ≤ 0.001) and a seven-fold increased rate of disabling peri-interventional stroke (4.4% vs 0.6%, P ≤ 0.001). In all patients with disabling peri-interventional stroke a balloon-expandable prosthesis was used (P ≤ 0.001). In case of shaggy aorta, mortality was more than six-fold increased (2.8% vs 16.7%, P = 0.046). CONCLUSIONS Severe and irregular thrombus of the descending thoracic and abdominal aorta has been strongly associated with acute respiratory failure and peri-interventional stroke in transfemoral aortic valve implantation, being more likely using balloon-expandable devices. Our results imply important changes with regard to device design and present international transcatheter aortic valve implantation guidelines.
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Affiliation(s)
- Martin Haensig
- Department of Cardiothoracic Surgery, Central Clinic Hospital of Bad Berka, Bad Berka, Germany
| | - Thomas Kuntze
- Department of Cardiothoracic Surgery, Central Clinic Hospital of Bad Berka, Bad Berka, Germany
| | - David Gonzalez-Lopez
- Department of Cardiothoracic Surgery, Central Clinic Hospital of Bad Berka, Bad Berka, Germany
| | - Harald Lapp
- Department of Cardiology and Internal Medicine, Central Clinic Hospital of Bad Berka, Bad Berka, Germany
| | - Philipp Lauten
- Department of Cardiology and Internal Medicine, Central Clinic Hospital of Bad Berka, Bad Berka, Germany
| | - Tamer Owais
- Department of Cardiothoracic Surgery, Central Clinic Hospital of Bad Berka, Bad Berka, Germany.,Department of Cardiothoracic Surgery, Cairo University, Cairo, Egypt
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Lal BK, Roubin GS, Rosenfield K, Heck D, Jones M, Jankowitz B, Jovin T, Chaturvedi S, Dabus G, White CJ, Gray W, Matsumura J, Katzen BT, Hopkins LN, Mayorga-Carlin M, Sorkin JD, Howard G, Meschia JF, Brott TG. Quality Assurance for Carotid Stenting in the CREST-2 Registry. J Am Coll Cardiol 2020; 74:3071-3079. [PMID: 31856962 DOI: 10.1016/j.jacc.2019.10.032] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/17/2019] [Revised: 10/03/2019] [Accepted: 10/15/2019] [Indexed: 10/25/2022]
Abstract
BACKGROUND The CREST-2 Registry (C2R) was approved by National Institute of Neurological Disorders and Stroke-National Institutes of Health in September 2014 with Centers for Medicare & Medicaid Services, U.S. Food and Drug Administration, and industry collaboration to enroll patients undergoing CAS. The registry credentials interventionists and promotes optimal patient selection, procedural-technique, and outcomes. OBJECTIVES This study reports periprocedural outcomes in a cohort of carotid artery stenting (CAS) performed for asymptomatic and symptomatic carotid stenosis. METHODS Asymptomatic patients with ≥70% and symptomatic patients with ≥50% carotid stenosis, ≤80 years of age, and at standard or high risk for carotid endarterectomy are eligible for enrollment. Interventionists are credentialed by a multispecialty committee that reviews experience, lesion selection, technique, and outcomes. The primary endpoint was a composite of stroke and death (S/D) in the 30-day periprocedural period. Myocardial infarction and access-site complications were assessed as secondary outcomes. RESULTS As of December 2018, 187 interventionists from 98 sites in the United States performed 2,219 CAS procedures in 2,141 patients with primary atherosclerosis (78 were bilateral). The mean age of the cohort was 68 years, 65% were male, and 92% were white; 1,180 (55%) were for asymptomatic disease, and 961 (45%) were for symptomatic disease. All U.S. Food and Drug Administration-approved stents and embolic protection devices were represented. The 30-day rate of S/D was 1.4% for asymptomatic, 2.8% for symptomatic, and 2.0% for all patients. CONCLUSIONS C2R is the first national registry for CAS cosponsored by federal and industry partners. CAS was performed by experienced operators using appropriate patient selection and optimal technique. In that setting, a broad group of interventionists achieved very low periprocedural S/D rates for asymptomatic and symptomatic patients.
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Affiliation(s)
- Brajesh K Lal
- Department of Vascular Surgery, University of Maryland, Baltimore, Maryland.
| | - Gary S Roubin
- Department of Cardiology, Cardiovascular Associates of the Southeast/Brookwood Baptist Medical Center, Birmingham, Alabama
| | - Kenneth Rosenfield
- Department of Cardiology, Massachusetts General Hospital, Boston, Massachusetts
| | - Donald Heck
- Department of Radiology, Novant Health Clinical Research, Winston-Salem, North Carolina
| | - Michael Jones
- Department of Cardiology, Baptist Health Lexington, Lexington, Kentucky
| | - Brian Jankowitz
- Department of Neurosurgery, UPMC Presbyterian University Hospital, Pittsburgh, Pennsylvania
| | - Tudor Jovin
- Department of Neurology, UPMC Presbyterian University Hospital, Pittsburgh, Pennsylvania
| | | | - Guilherme Dabus
- Department of Interventional Neuroradiology, Miami Cardiac and Vascular Institute at Baptist Hospital of Miami, Miami, Florida
| | | | - William Gray
- Department of Cardiology, Lankenau Medical Center, Wynnewood, Pennsylvania
| | - Jon Matsumura
- Department of Surgery, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin
| | - Barry T Katzen
- Department of Interventional Radiology, Miami Cardiac and Vascular Institute, Miami, Florida
| | | | | | - John D Sorkin
- Department of Biostatistics and Informatics, Baltimore VA Medical Center, Baltimore, Maryland
| | - George Howard
- Department of Biostatistics, University of Alabama at Birmingham, Birmingham, Alabama
| | | | - Thomas G Brott
- Department of Neurology, Mayo Clinic, Jacksonville, Florida
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Pieniążek P, Nowakowski P, Ziaja K, Kobayashi A, Uchto W, Sulżenko J, Machnik R, Tekieli Ł, Stańczyk D, Plens K, Zasada W, Dziewierz A, Ziaja D. Prospective multicentre study of carotid artery stenting using the MER™ Stent - the OCEANUS study - 30-day and one-year follow-up results. ADVANCES IN INTERVENTIONAL CARDIOLOGY 2020; 16:1-9. [PMID: 32368230 PMCID: PMC7189137 DOI: 10.5114/aic.2019.91364] [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: 08/09/2019] [Accepted: 10/03/2019] [Indexed: 12/24/2022] Open
Abstract
INTRODUCTION Constant technological progress in the field of carotid stenting translates into improved short- and long-term results of endovascular treatment. The introduction of a new generation, self-expanding, open-cell stent has provided a new treatment option in endovascular management of carotid stenosis. AIM To evaluate 30-day and 1-year clinical outcomes of non-consecutive patients with high risk of carotid endarterectomy, who underwent 5F cylinder-tapered MER™ open-cell carotid stent implantation. MATERIAL AND METHODS It was a single-arm, prospective study conducted in four experienced catheterisation centres. The use of embolic protection devices was mandatory. The primary endpoint was stroke in 30-day follow-up. The secondary endpoints were 30-day and 1-year cumulative incidence of death, stroke and myocardial infarction, 1-year target vessel revascularisation, procedural success (residual stenosis ≤ 30%), restenosis rate (%DS ≥ 50%), and Serious Adverse Device Effect (SADE) rate in 1-year follow-up. RESULTS In total 100 patients were recruited for the study, with the majority being males (n = 61). The mean age was 68.3 ±8.2 years, and most of the patients were asymptomatic (n = 56). In 55 (55%) patients direct stenting was performed, with the use of proximal protection devices in 19 (19%) patients. Mean internal carotid artery/common carotid artery stenosis before and after stent implantation was 81.98 ±9.15% and 12.52 ±8.70%, respectively (p < 0.001). Procedural success was achieved in all cases. One ischaemic stroke was observed at 30 days (1%, primary endpoint). At 1-year follow-up two myocardial infarctions and three deaths occurred with no additional stroke. CONCLUSIONS The OCEANUS study indicated the safety and efficacy of the MER™ stent during 30-day and 1-year follow-up in both symptomatic and asymptomatic patients. The majority of patients were event-free. However, larger cohort studies are needed to evaluate MER™ stents in detail.
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Affiliation(s)
- Piotr Pieniążek
- Department of Vascular Surgery Division on Endovascular Therapy, John Paul II Hospital, Krakow, Poland
- Department of Cardiac and Vascular Disease, Institute of Cardiology, Jagiellonian University, School of Medicine, Krakow, Poland
| | - Przemysław Nowakowski
- Department of Vascular Surgery, American Heart of Poland, Chrzanow, Poland
- University of Technology, Katowice, Poland
| | - Krzysztof Ziaja
- Department of General and Vascular Surgery, Angiology, and Phlebology, Medical University of Silesia, Katowice, Poland
| | - Adam Kobayashi
- Institute of Psychiatry and Neurology, 2 Department of Neurology, Warsaw, Poland
| | - Wojciech Uchto
- Department of Vascular Surgery, American Heart of Poland, Chrzanow, Poland
| | - Jakub Sulżenko
- Cardiocentre, University Hospital Kralovske Vinohrady and Third Faculty of Medicine, Charles University Prague, Czech Republic
| | - Roman Machnik
- Department of Vascular Surgery Division on Endovascular Therapy, John Paul II Hospital, Krakow, Poland
| | - Łukasz Tekieli
- Department of Vascular Surgery Division on Endovascular Therapy, John Paul II Hospital, Krakow, Poland
- Department of Interventional Cardiology, Institute of Cardiology, Jagiellonian University, Medical College, Krakow, Poland
| | - Dariusz Stańczyk
- Department of General and Vascular Surgery, Angiology, and Phlebology, Medical University of Silesia, Katowice, Poland
| | | | | | - Artur Dziewierz
- 2 Department of Cardiology, Institute of Cardiology, Jagiellonian University Medical College, Krakow, Poland
| | - Damian Ziaja
- Department of Physiotherapy, School of Health Science in Katowice, Medical University of Silesia, Katowice, Poland
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Mukherjee D, Roffi M. Minimizing Distal Embolization During Carotid Artery Stenting. JACC Cardiovasc Interv 2019; 12:404-405. [DOI: 10.1016/j.jcin.2018.12.024] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/06/2018] [Accepted: 12/18/2018] [Indexed: 10/27/2022]
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