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Park JK, Woo SY, Park YJ, Kim DI, Kim GM, Seo WK, Jung JW, Jeon P, Kim KH, Kim YW, Yang SS. The Impact of age and outcomes of high-risk patients on carotid revascularization. Vascular 2024; 32:596-602. [PMID: 36794829 DOI: 10.1177/17085381231155035] [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] [Indexed: 02/17/2023]
Abstract
OBJECTIVES To validate the accuracy of high-risk criteria for carotid endarterectomy (CEA) and analyze the correlation between age and outcome of CEA and carotid artery stenting (CAS) in risk groups. METHODS We reviewed a prospectively managed vascular surgery database in a single tertiary referral center, and 2482 internal carotid arteries (ICAs) had undergone carotid revascularization from November 1994 to December 2021. To validate high-risk criteria for CEA, patients were classified as high risk (Hr) and normal risk (Nr). Subgroup analysis was performed with patients older or younger than 75 years to investigate the relationship between age and outcome in each group. Primary endpoints were 30-day outcomes including stroke, death, stroke/death, myocardial infraction (MI), and major adverse cardiovascular events (MACEs). RESULTS A total of 2345 ICAs in 2256 patients were enrolled. The number of patients in the Hr group was 543 (24%) and the number in the Nr group was 1713 (76%). CEA and CAS were performed on 1384 (61%) and 872 (39%) patients, respectively. The 30-day stroke/death rate was higher with CAS than CEA in both the Hr (1.1% vs. 3.9%, p = 0.032) and Nr (1.2% vs. 6.9%, p < 0.001) groups. In unmatched logistic regression analysis of the Nr group (n = 1778), the rate of 30-day stroke/death (OR, 5.575; 95% CI, 2.922-10.636; p < 0.001) was higher for CAS than CEA. In propensity score matching of the Nr group, the rate of 30-day stroke/death (OR, 5.165; 95% CI, 2.391-11.155; p < 0.001) was also higher for CAS than CEA. In the age <75 subgroup of the Hr group (n = 428), CAS was associated with higher 30-day stroke/death (OR, 14.089; 95% CI, 1.314-151.036; p = 0.029). In the age ≥75 subgroup of the Hr (n = 139), there was no difference in 30-day stroke/death between CEA and CAS. In the age <75 subgroup of the Nr group (n = 1318), 30-day stroke/death (OR, 6.300; 95% CI, 2.797-14.193; p < 0.001) was higher in CAS. In the age ≥75 subgroup of the Nr group (n = 460), 30-day stroke/death (OR, 6.468; 95% CI, 1.862-22.471; p = 0.003) was higher in CAS. CONCLUSIONS In patients older than 75 years in the Hr group, there were relatively poor 30-day treatment outcomes in both CEA and CAS. Alternative treatment is needed that can expect better outcomes in older high-risk patients. In the Nr group, CEA has a significant benefit compared with CAS, and CEA should be recommended more to these patients.
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Affiliation(s)
- Joon-Kee Park
- Division of Vascular Surgery, Department of Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Shin-Young Woo
- Division of Vascular Surgery, Department of Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Yang-Jin Park
- Division of Vascular Surgery, Department of Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Dong-Ik Kim
- Division of Vascular Surgery, Department of Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Gyeong-Moon Kim
- Department of Neurology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Woo-Keun Seo
- Department of Neurology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Jong-Won Jung
- Department of Neurology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Pyoung Jeon
- Department of Radiology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Keon-Ha Kim
- Department of Radiology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Young-Wook Kim
- Division of Vascular Surgery, Department of Surgery, Kangbuk Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Shin-Seok Yang
- Division of Vascular Surgery, Department of Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
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Sakowitz S, Bakhtiyar SS, Khoraminejad B, Ebrahimian S, Madrigal J, Benharash P, Wu J. Thyroid surgery outcomes in octogenarians: A national analysis. Surgery 2023:S0039-6060(23)00053-3. [PMID: 37055292 DOI: 10.1016/j.surg.2023.02.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2023] [Revised: 01/25/2023] [Accepted: 02/06/2023] [Indexed: 04/15/2023]
Abstract
BACKGROUND The incidence of thyroid pathology increases with age. Yet octogenarians may face increased rates of complications after thyroid surgery. Using a nationally representative cohort, we evaluated the outcomes of thyroidectomy among octogenarians. METHODS All patients ≥55 years who underwent inpatient thyroidectomy were identified using the 2010 to 2020 National Readmissions Database. Patients ≥80 years were classified as octogenarians (others: nonoctogenarians). Multivariable models were built to evaluate independent associations between octogenarians and key clinical and financial outcomes. RESULTS Of 120,164 hospitalizations, 9,163 (7.6%) were octogenarians. The proportion of octogenarians undergoing thyroidectomy increased from 7.7% (2010) to 8.7% (2020) (nptrend <0.001). Octogenarians were more frequently female (72.1 vs 70.5%, P < .001), presented with a higher Elixhauser comorbidity index (3 [2-4] vs 2 [1-3], P < .001), and more commonly faced thyroid cancer (41.3 vs 32.7%, P < .001). After risk adjustment, octogenarians were associated with greater odds of experiencing any perioperative complication (adjusted odds ratio 1.36, 95% confidence interval 1.25-1.48). Octogenarians were further linked with greater odds of respiratory (adjusted odds ratio 1.82, 95% confidence interval 1.52-2.17) and renal complications (adjusted odds ratio 1.90, 95% confidence interval 1.45-2.49), dysphagia (adjusted odds ratio 1.51, 95% confidence interval 1.33-1.72), laryngeal edema (adjusted odds ratio 2.03, 95% confidence interval 1.30-3.18), vocal cord paralysis (adjusted odds ratio 1.79, 95% confidence interval 1.53-2.09), and stridor (adjusted odds ratio 1.42, 95% confidence interval 1.01-2.00). No difference in hypocalcemia was observed. Furthermore, octogenarians demonstrated an increased likelihood of in-hospital mortality (adjusted odds ratio 6.34, 95% confidence interval 3.11-12.53), hospitalization expenditures (+$910, 95% confidence interval +$420-1,400), and nonelective readmission within 30 days of discharge (adjusted odds ratio 1.54, 95% confidence interval 1.32-1.79). CONCLUSION Octogenarians are associated with greater morbidity after thyroidectomy. Patients ≥80 years should be counseled about increased perioperative risk when discussing surgical versus nonsurgical treatments for thyroid disease.
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Affiliation(s)
- Sara Sakowitz
- Cardiovascular Outcomes Research Laboratories, University of California, Los Angeles, CA. https://twitter.com/sarasakowitz
| | - Syed Shahyan Bakhtiyar
- Cardiovascular Outcomes Research Laboratories, University of California, Los Angeles, CA; Department of Surgery, University of Colorado, Aurora, CO. https://twitter.com/Aortologist
| | - Baran Khoraminejad
- Cardiovascular Outcomes Research Laboratories, University of California, Los Angeles, CA
| | - Shayan Ebrahimian
- Cardiovascular Outcomes Research Laboratories, University of California, Los Angeles, CA
| | - Josef Madrigal
- Cardiovascular Outcomes Research Laboratories, University of California, Los Angeles, CA; Department of Surgery, University of California, Los Angeles, CA
| | - Peyman Benharash
- Cardiovascular Outcomes Research Laboratories, University of California, Los Angeles, CA; Department of Surgery, University of California, Los Angeles, CA
| | - James Wu
- Cardiovascular Outcomes Research Laboratories, University of California, Los Angeles, CA; Department of Surgery, University of California, Los Angeles, CA.
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Leung YYR, Bera K, Urriza Rodriguez D, Dardik A, Mas JL, Simonte G, Rerkasem K, Howard DP. Safety of Carotid Endarterectomy for Symptomatic Stenosis by Age: Meta-Analysis With Individual Patient Data. Stroke 2023; 54:457-467. [PMID: 36647921 PMCID: PMC9855737 DOI: 10.1161/strokeaha.122.040819] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2022] [Accepted: 12/06/2022] [Indexed: 01/18/2023]
Abstract
BACKGROUND There is uncertainty whether elderly patients with symptomatic carotid stenosis have higher rates of adverse events following carotid endarterectomy. In trials, recurrent stroke risk on medical therapy alone increased with age, whereas operative stroke risk was not related. Few octogenarians were included in trials and there has been no systematic analysis of all study types. We aimed to evaluate the safety of carotid endarterectomy in symptomatic elderly patients, particularly in octogenarians. METHODS We did a systematic review and meta-analysis of studies (from January 1, 1980 through March 1, 2022) reporting post carotid endarterectomy risk of stroke, myocardial infarction, and death in patients with symptomatic carotid stenosis. We included observational studies and interventional arms of randomized trials if the outcome rates (or the raw data to calculate these) were provided. Individual patient data from 4 prospective cohorts enabled multivariate analysis. RESULTS Of 47 studies (107 587 patients), risk of perioperative stroke was 2.04% (1.94-2.14) in octogenarians (390 strokes/19 101 patients) and 1.85% (1.75-1.95) in nonoctogenarians (1395/75 537); P=0.046. Perioperative death was 1.09% (0.94-1.25) in octogenarians (203/18 702) and 0.53% (0.48-0.59) in nonoctogenarians (392/73 327); P<0.001. Per 5-year age increment, a linear increase in perioperative stroke, myocardial infarction, and death were observed; P=0.04 to 0.002. However, during the last 3 decades, perioperative stroke±death has declined significantly in octogenarians (7.78% [5.58-10.55] before year 2000 to 2.80% [2.56-3.04] after 2010); P<0.001. In Individual patient data multivariate-analysis (5111 patients), age ≥85 years was independently associated with perioperative stroke (P<0.001) and death (P=0.005). Yet, survival was similar for octogenarians versus nonoctogenarians at 1-year (95.0% [93.2-96.5] versus 97.5% [96.4-98.6]; P=0.08), as was 5-year stroke risk (11.93% [9.98-14.16]) versus 12.78% [11.65-13.61]; P=0.24). CONCLUSIONS We found a modest increase in perioperative risk with age in symptomatic patients undergoing carotid endarterectomy. As stroke risk increases with age when on medical therapy alone, our findings support selective urgent intervention in symptomatic elderly patients.
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Affiliation(s)
- Ya Yuan Rachel Leung
- Wolfson Centre for Prevention of Stroke and Dementia, Nuffield Department of Clinical Neurosciences, University of Oxford, UK (Y.Y.R.L., D.P.J.H.)
| | - Kasia Bera
- Department of Vascular Surgery, Oxford University Hospitals NHS Trust, UK (K.B., D.U.R., D.P.J.H.)
| | - Daniel Urriza Rodriguez
- Department of Vascular Surgery, Oxford University Hospitals NHS Trust, UK (K.B., D.U.R., D.P.J.H.)
| | - Alan Dardik
- Yale Department of Surgery, Departments of Surgery and Cellular and Molecular Physiology, Yale School of Medicine, New Haven, CT (A.D.)
- Department of Surgery, VA Connecticut Healthcare System, West Haven (A.D.)
| | - Jean-Louis Mas
- Department of Neurology, GHU Paris, Hôpital Sainte-Anne, Université Paris-Cité, Inserm, France (J.-L.M.)
| | - Gioele Simonte
- Vascular and Endovascular Surgery Unit, Santa Maria della Misericordia, University of Perugia, Italy (G.S.)
| | - Kittipan Rerkasem
- Environmental - Occupational Health Sciences and Non-Communicable Diseases Research Group, Research Institute for Health Sciences, Chiang Mai University, Thailand (K.R.)
- Clinical Surgical Research Center, Department of Surgery, Faculty of Medicine, Chiang Mai University, Thailand (K.R.)
| | - Dominic P.J. Howard
- Wolfson Centre for Prevention of Stroke and Dementia, Nuffield Department of Clinical Neurosciences, University of Oxford, UK (Y.Y.R.L., D.P.J.H.)
- Department of Vascular Surgery, Oxford University Hospitals NHS Trust, UK (K.B., D.U.R., D.P.J.H.)
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Qumsiyeh Y, Siada S, Yan Y, Dirks R, Ali A, Daneshvar M, O'Banion LA. Carotid endarterectomy is safe for octogenarians. J Vasc Surg 2023; 77:176-181. [PMID: 35940506 DOI: 10.1016/j.jvs.2022.07.169] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2022] [Revised: 07/18/2022] [Accepted: 07/25/2022] [Indexed: 02/03/2023]
Abstract
BACKGROUND Carotid endarterectomy (CEA) has demonstrated superior results in stroke risk reduction for patients with symptomatic and asymptomatic high-grade carotid stenosis. However, this benefit has long been questioned for the elderly and high-risk populations. In the present study, we aimed to provide high-volume, single-institution data with long-term follow-up examining the risk factors for postoperative stroke and stroke-free survival stratified by age for asymptomatic and symptomatic patients undergoing CEA. METHODS A single-institution retrospective review of 840 consecutive patients who had undergone CEA from 2011 to 2018 was performed, inclusive of both symptomatic and asymptomatic operative indications. The primary end point was perioperative stroke within 30 days of surgery. The secondary end points were late stroke, death, and myocardial infarction. Patients aged >80 years were compared with those aged <80 years to examine freedom from stroke and death. Statistically significant differences were defined as those with P < .05. RESULTS A total of 840 patients were evaluated with a median follow-up of 416 ± 1244 days. Of the 840 patients, 499 (59%) were men, and 604 (72%) were White. The mean age was 72 ± 9 years, with 202 (24%) aged ≥80 years. CEA was performed for symptomatic disease in 305 patients (36%), of whom 143 (47%) had had strokes and 162 (53%) had had transient ischemic attacks. The overall 30-day postoperative stroke rate was 1.0% (eight patients; 0.6% for asymptomatic and 1.6% for symptomatic; P = .147). Compared with younger patients, octogenarians had had a similar stroke rate after CEA (1.5% vs 0.8%; P = .407). Hispanic race was an independent risk factor for postoperative stroke. White race and preoperative statin use both appeared to be protective. Kaplan-Meier survival curves demonstrated decreased a 5-year stroke-free survival in patients aged ≥80 years (P = .031). However, overall, the estimated 5-year survival was similar to the U.S. general population across both age groups. CONCLUSIONS CEA for octogenarians is safe and effective for both symptomatic and asymptomatic populations with excellent 30-day outcomes and long-term survival mirroring that of the general population.
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Affiliation(s)
- Yazen Qumsiyeh
- Division of Vascular Surgery, Department of Surgery, University of California, San Francisco-Fresno, Fresno, CA.
| | - Sammy Siada
- Division of Vascular Surgery, Department of Surgery, University of California, San Francisco-Fresno, Fresno, CA
| | - Yueqi Yan
- Biostatistics and Data Support Center, University of California, Merced, CA
| | - Rachel Dirks
- Division of Vascular Surgery, Department of Surgery, University of California, San Francisco-Fresno, Fresno, CA
| | - Amna Ali
- Division of Vascular Surgery, Department of Surgery, University of California, San Francisco-Fresno, Fresno, CA
| | - Meelod Daneshvar
- Division of Vascular Surgery, Department of Surgery, University of California, San Francisco-Fresno, Fresno, CA
| | - Leigh Ann O'Banion
- Division of Vascular Surgery, Department of Surgery, University of California, San Francisco-Fresno, Fresno, CA
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5
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Nantakool S, Chuatrakoon B, Orrapin S, Leung R, Howard DPJ, Rerkasem A, Derraik JGB, Rerkasem K. Influences of age and gender on operative risks following carotid endarterectomy: A systematic review and meta-analysis. PLoS One 2023; 18:e0285540. [PMID: 37163559 PMCID: PMC10171679 DOI: 10.1371/journal.pone.0285540] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2022] [Accepted: 04/25/2023] [Indexed: 05/12/2023] Open
Abstract
OBJECTIVES This review aims to undertake a comprehensive review of the literature and investigate associations of age and gender on 30 days post carotid endarterectomy (CEA) and up to 5 years post CEA stroke, death, and combined stroke and death. DESIGN A systematic review and meta-analysis. METHODS Three main electronic databases including the Cochrane Library, MEDLINE, and Embase were searched from their inception to July 2022. Studies examining operative risks (i.e., stroke, death, and combined stroke and death following CEA) linked to age or gender were included. Two independent reviewers were responsible for study selection, quality assessment, and data extraction. Odds ratio (OR) and 95% confidence interval (CI) of all outcomes were calculated. RESULTS 44609 studies were retrieved from the search. There were 127 eligible studies (80 studies of age, 72 studies of gender, 25 studies of age and gender) for pooling in the meta-analysis. With regards to stroke and death risks within 30 days post CEA; patients aged ≥75 had higher death (OR 1.38; 95% CI 1.10-1.75) than patients aged <75. Patients aged ≥80 had higher stroke risk (OR 1.17; 95% CI 1.07-1.27) and death risk (OR 1.85; 95% CI 1.48-2.30) particular in asymptomatic patients (OR 2.4; 95% CI 1.56-3.81). Pooled effect estimates by gender, at 30 days post CEA, showed that female was associated with increased risk of stroke (OR 1.28; 95% CI 1.16-1.40), with more risk in asymptomatic female patients (OR 1.51; 95% CI 1.14-1.99). CONCLUSIONS This meta-analysis highlights that older people is associated with increased stroke risk, particularly asymptomatic octogenarians who had higher likelihood of death within 30 days post CEA. In addition, female especially those with asymptomatic carotid stenosis had greater likelihood of stroke within 30 days post CEA surgery.
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Affiliation(s)
- Sothida Nantakool
- Research Institute for Health Sciences, Environmental-Occupational Health Sciences and Non Communicable Diseases Research Group (EOHS and NCD Research Group), Chiang Mai University, Chiang Mai, Thailand
| | - Busaba Chuatrakoon
- Faculty of Associated Medical Sciences, Department of Physical Therapy, Chiang Mai University, Chiang Mai, Thailand
| | - Saritphat Orrapin
- Faculty of Medicine, Department of Surgery, Division of Vascular Surgery, Thammasat University (Rangsit Campus), Pathum Thani, Thailand
| | - Rachel Leung
- Nuffield Department of Clinical Neurosciences, Centre for Prevention of Stroke and Dementia, University of Oxford, Oxford, United Kingdom
| | - Dominic P J Howard
- Nuffield Department of Clinical Neurosciences, Centre for Prevention of Stroke and Dementia, University of Oxford, Oxford, United Kingdom
| | - Amaraporn Rerkasem
- Research Institute for Health Sciences, Environmental-Occupational Health Sciences and Non Communicable Diseases Research Group (EOHS and NCD Research Group), Chiang Mai University, Chiang Mai, Thailand
| | - José G B Derraik
- Research Institute for Health Sciences, Environmental-Occupational Health Sciences and Non Communicable Diseases Research Group (EOHS and NCD Research Group), Chiang Mai University, Chiang Mai, Thailand
- Liggins Institute, University of Auckland, Auckland, New Zealand
- Department of Women's and Children's Health, Uppsala University, Uppsala, Sweden
- Faculty of Medical and Health Sciences, Department of Paediatrics, Child and Youth Health, University of Auckland, Auckland, New Zealand
| | - Kittipan Rerkasem
- Research Institute for Health Sciences, Environmental-Occupational Health Sciences and Non Communicable Diseases Research Group (EOHS and NCD Research Group), Chiang Mai University, Chiang Mai, Thailand
- Faculty of Medicine, Department of Surgery, Chiang Mai University, Chiang Mai, Thailand
- Faculty of Medicine, Clinical Surgical Research Center, Chiang Mai University, Chiang Mai, Thailand
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Mandelbaum AD, Hadaya J, Ulloa JG, Patel R, McCallum JC, De Virgilio C, Benharash P. Impact of Frailty on Clinical Outcomes after Carotid Artery Revascularization. Ann Vasc Surg 2021; 74:111-121. [PMID: 33556528 DOI: 10.1016/j.avsg.2020.12.039] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2020] [Revised: 12/17/2020] [Accepted: 12/17/2020] [Indexed: 01/23/2023]
Abstract
BACKGROUND Frailty has been increasingly recognized as an important risk factor for vascular procedures. To assess the impact of frailty on clinical outcomes and resource utilization in patients undergoing carotid revascularization using a national cohort. METHODS The 2005-2017 National Inpatient Sample was used to identify patients who underwent carotid endarterectomy (CEA) or carotid stenting (CAS). Patients were classified as frail using diagnosis codes defined by the Johns Hopkins Adjusted Clinical Groups frailty indicator. Multivariable regression was used to evaluate associations between frailty and in-hospital mortality, postoperative stroke, myocardial infarction (MI), hospitalization costs, and length of stay (LOS). RESULTS Of 1,426,343 patients undergoing carotid revascularization, 59,158 (4.2%) were identified as frail. Among frail patients, 79.4% underwent CEA and 20.6% underwent CAS. Compared to CEA, a greater proportion of patients undergoing CAS were frail (6.0% vs. 3.8%, P < 0.001). Compared to the nonfrail cohort, frail patients had higher rates of mortality (2.2% vs. 0.5%, P < 0.001), postoperative stroke (2.6% vs. 1.0%, P < 0.001), MI (2.2% vs. 0.8%, P < 0.001), and stroke/death (4.4% vs. 1.4%, P < 0.001). After adjustment, frailty was associated with increased odds of mortality (AOR = 1.59, 95% CI: 1.30-1.80, P < 0.001), stroke (AOR = 1.66, 95% CI: 1.38-1.83 P < 0.001), MI (AOR = 1.51, 95% CI: 1.29-1.72, P < 0.001), and stroke/death (AOR = 1.62, 95% CI: 1.45-1.81, P < 0.001). Furthermore, frailty was associated with increased hospitalization costs (β = +$5,980, 95% CI: $5,490-$6,470, P < 0.001) and LOS (β = +2.6 days, 95% CI: 2.4-2.8, P < 0.001). CONCLUSIONS Frailty is associated with adverse outcomes and greater resource use for those undergoing carotid revascularization. Risk models should include an assessment of frailty to guide management and improve outcomes for these high-risk patients.
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Affiliation(s)
- Ava D Mandelbaum
- Cardiovascular Outcomes Research Laboratories (CORELAB), Division of Cardiac Surgery, David Geffen School of Medicine, University of California Los Angeles, Los Angeles, CA
| | - Joseph Hadaya
- Cardiovascular Outcomes Research Laboratories (CORELAB), Division of Cardiac Surgery, David Geffen School of Medicine, University of California Los Angeles, Los Angeles, CA
| | - Jesus G Ulloa
- Division of Vascular Surgery, David Geffen School of Medicine, University of California Los Angeles, Los Angeles, CA
| | - Rhusheet Patel
- Division of Vascular Surgery, David Geffen School of Medicine, University of California Los Angeles, Los Angeles, CA
| | - John C McCallum
- Department of Surgery, Harbor UCLA Medical Center, Torrance, CA
| | | | - Peyman Benharash
- Cardiovascular Outcomes Research Laboratories (CORELAB), Division of Cardiac Surgery, David Geffen School of Medicine, University of California Los Angeles, Los Angeles, CA.
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Rocha-Neves J, Pereira-Macedo J, Ferreira A, Dias-Neto M, Andrade JP, Mansilha AA. Impact of intraoperative neurologic deficits in carotid endarterectomy under regional anesthesia. SCAND CARDIOVASC J 2021; 55:180-186. [PMID: 33487041 DOI: 10.1080/14017431.2021.1874509] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
OBJECTIVE Patients undergoing carotid endarterectomy (CEA) may experiment neurologic deficits during the carotid cross-clamping due to secondary cerebral hypoperfusion. An associated risk of postoperative stroke incidence is also well established. This work aimed to assess the postoperative adverse events related to neurologic deficits in the awake test after clamping and to determine its predictive factors. Methods. From January 2012 to January 2018, 79 patients from a referral hospital that underwent CEA with regional anesthesia for carotid stenosis and manifested neurologic deficits were gathered. Consecutively selected controls (n = 85) were submitted to the same procedure without developing neurological changes. Postoperative complications such as stroke, myocardial infarction, all-cause death, and Clavien-Dindo classification were assessed 30 days after the procedure. Univariate and binary logistic regressions were performed for data assessment. Results. Patients with clamping associated neurologic deficits were significantly more obese than the control group (aOR = 9.30; 95% CI: 2.57-33.69; p = .01). Lower degree of ipsilateral stenosis and higher degree of contralateral stenosis were independently related to clamping intolerance (aOR = 0.70; 95% CI: 0.49-0.99; p = .047 and aOR = 1.30; 95% CI: 1.06-1.50; p = .009, respectively). Neurologic deficits were a main 30-day stroke predictor (aOR = 4.30; 95% CI: 1.10-16.71; p = .035). Conclusions. Neurologic deficits during carotid clamping are a predictor of perioperative stroke. Body mass index > 30 kg/m2, a lower degree of ipsilateral stenosis, and a higher degree of contralateral stenosis are independent predictors of neurologic deficits and, therefore, might play a role in the prevention of procedure-related stroke.
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Affiliation(s)
- João Rocha-Neves
- Department of Angiology and Vascular Surgery, Centro Hospitalar Universitário de São João, Porto, Portugal.,Department of Biomedicine - Unity of Anatomy, Faculdade de Medicina da Universidade do Porto, Porto, Portugal.,Department of Surgery and Physiology, Faculdade de Medicina da Universidade do Porto, Porto, Portugal
| | - Juliana Pereira-Macedo
- Department of Angiology and Vascular Surgery, Centro Hospitalar Universitário de São João, Porto, Portugal
| | - André Ferreira
- Department of Biomedicine - Unity of Anatomy, Faculdade de Medicina da Universidade do Porto, Porto, Portugal.,Department of Ophthalmology, Centro Hospitalar Universitário do Porto, Porto, Portugal
| | - Marina Dias-Neto
- Department of Angiology and Vascular Surgery, Centro Hospitalar Universitário de São João, Porto, Portugal.,Department of Surgery and Physiology, Faculdade de Medicina da Universidade do Porto, Porto, Portugal.,Cardiovascular R&D Unit, Faculdade de Medicina da Universidade do Porto, Porto, Portugal
| | - José P Andrade
- Department of Biomedicine - Unity of Anatomy, Faculdade de Medicina da Universidade do Porto, Porto, Portugal.,Center for Health Technology and Services Research (CINTESIS), Porto, Portugal
| | - Armando A Mansilha
- Department of Angiology and Vascular Surgery, Centro Hospitalar Universitário de São João, Porto, Portugal.,Department of Surgery and Physiology, Faculdade de Medicina da Universidade do Porto, Porto, Portugal.,Cardiovascular R&D Unit, Faculdade de Medicina da Universidade do Porto, Porto, Portugal
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8
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Johnson NW, Smoll NR, Tan C, Brooks CE. Trainee surgeons and patient outcomes in carotid endarterectomy: a retrospective cohort study. ANZ J Surg 2020; 90:1710-1715. [PMID: 32815260 DOI: 10.1111/ans.16209] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2019] [Revised: 05/31/2020] [Accepted: 07/07/2020] [Indexed: 11/30/2022]
Abstract
BACKGROUND In Australia and New Zealand, more than 2000 carotid endarterectomies are performed annually. The major morbidities arising from this procedure are post-operative stroke, cranial nerve injury and death. Carotid endarterectomy surgery is a key component of the vascular surgical training programme. We assessed the impact of having a surgical trainee perform a major component of this procedure on the post-operative rates of stroke, cranial nerve injury and mortality. METHODS We performed a retrospective cohort study of vascular surgical patients undergoing carotid endarterectomy, with data obtained from the Australasian Vascular Audit database between January 2010 and December 2014. The dataset comprised of 6528 carotid endarterectomies performed during this time. The collected data were stratified into two categories - consultant-led cases, and those in which trainee surgeons performed at least a major component of the surgery under consultant supervision. The results were analysed for differences in post-operative stroke, cranial nerve injury and inpatient mortality. Differences between groups were assessed using multivariate analysis, adjusting for potentially confounding covariables. RESULTS On multivariate analysis, there was no statistically significant difference in the rates of post-operative stroke (odds ratio (OR) 0.88, 95% confidence interval (CI) 0.57-1.36, P = 0.55), cranial nerve injury (OR 0.68, 95% CI 0.39-1.21, P = 0.19) or inpatient mortality (OR 0.78, 95% CI 0.29-2.13, P = 0.63) between the two cohorts. CONCLUSION Having surgical trainees perform components of carotid endarterectomies under supervision is not associated with an increased rate of post-operative stroke, cranial nerve injury or mortality.
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Affiliation(s)
- Nicholas W Johnson
- Department of Surgery, Peninsula Health, Melbourne, Victoria, Australia.,Department of Surgery, Alfred Health, Melbourne, Victoria, Australia
| | - Nicholas R Smoll
- School of Population and Global Health, University of Melbourne, Melbourne, Victoria, Australia
| | - Christianne Tan
- Department of Surgery, Peninsula Health, Melbourne, Victoria, Australia
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9
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Hobbs LK, Ramdon A, Roddy SP, Hnath JC, Yeh CC, Darling RC. Outcomes for carotid endarterectomy in nonagenarians. J Vasc Surg 2019; 71:96-103. [PMID: 31611107 DOI: 10.1016/j.jvs.2019.07.083] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2019] [Accepted: 07/26/2019] [Indexed: 11/27/2022]
Abstract
OBJECTIVE Carotid endarterectomy (CEA) is a well-established procedure with prospective randomized data demonstrating the benefit of stroke prevention. With the aging of the population, there are limited data published for nonagenarians, especially for asymptomatic stenosis. This study investigated 30-day morbidity and mortality as well as late survival in symptomatic and asymptomatic nonagenarians with severe carotid stenosis undergoing CEA. METHODS A retrospective review was conducted of a single vascular surgery group's registry involving multiple hospitals between November 1994 and June 2017 for all primary CEAs of patients ≥90 years old at the time of surgery. The exclusion criterion was redo surgery or bilateral CEAs. Demographic data, sex, symptoms, risk factors, and postoperative complications were analyzed. Survival analysis was conducted using SPSS software (IBM Corp, Armonk, NY) for the specific end point 30-day morbidity or mortality and late survival. RESULTS There were 77 patients (44 male [57%]) who underwent CEA for symptomatic (44 [57%]) and asymptomatic (33 [43%]) internal carotid artery stenosis with a median age of 92 years; 23 women were symptomatic compared with 21 men, and 23 men were asymptomatic compared with 10 women. Symptomatic patients included amaurosis fugax (n = 3), stroke (n = 16), and transient ischemic attack (n = 25). CEAs were performed using the eversion technique under cervical block with selective shunting. The 30-day morbidity included one (2.3%) nonfatal myocardial infarction and one (2.3%) ischemic stroke in the symptomatic group compared with one (3%) patient having a nonfatal myocardial infarction and none with ischemic stroke in the asymptomatic group. One patient of the symptomatic group required return to the operating room for hematoma evacuation. The 30-day mortality was 2.3% in the symptomatic group compared with 6.1% in the asymptomatic group. There was no statistical difference in survival based on sex (P = .444). The symptomatic and asymptomatic groups had similar median survival of 27.7 months and 29.4 months (P = .987), respectively. CONCLUSIONS The aging population adds increasing difficulty in decision-making for surgical intervention on carotid stenosis. CEA in nonagenarians is associated with reasonably low 30-day rates of ischemic stroke and myocardial infarction in our small study. However, enthusiasm for asymptomatic CEA in this population must be tempered by low survival rates.
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Affiliation(s)
- Laura K Hobbs
- The Vascular Group, Albany Medical College, Albany Medical Center Hospital, Albany, NY
| | - Andre Ramdon
- The Vascular Group, Albany Medical College, Albany Medical Center Hospital, Albany, NY
| | - Sean P Roddy
- The Vascular Group, Albany Medical College, Albany Medical Center Hospital, Albany, NY
| | - Jeffrey C Hnath
- The Vascular Group, Albany Medical College, Albany Medical Center Hospital, Albany, NY
| | - Chin-Chin Yeh
- The Vascular Group, Albany Medical College, Albany Medical Center Hospital, Albany, NY
| | - R Clement Darling
- The Vascular Group, Albany Medical College, Albany Medical Center Hospital, Albany, NY.
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10
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Carotid endarterectomy for asymptomatic carotid stenosis is safe in octogenarians. J Vasc Surg 2019; 71:518-524. [PMID: 31471235 DOI: 10.1016/j.jvs.2019.05.054] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2019] [Accepted: 05/19/2019] [Indexed: 12/12/2022]
Abstract
OBJECTIVE Carotid endarterectomy (CEA) is the gold standard to prevent a recurrent stroke in symptomatic patients with carotid stenosis. However, in the modern era, the benefit of CEA in asymptomatic octogenarian patients has come into question. This study investigates real-world outcomes of CEA in asymptomatic octogenarians. METHODS Patients who underwent CEA for asymptomatic carotid stenosis were identified in the American College of Surgeons National Surgical Quality Improvement Program CEA-targeted database from 2012 to 2017. They were stratified into two groups: octogenarians (≥80 years old) and younger patients (<80 years old). The 30-day outcomes evaluated included mortality and major morbidities such as stroke, cardiac events, pulmonary, and renal dysfunction. Multivariable logistic regression was used for data analysis. RESULTS We identified 13,846 patients with asymptomatic carotid stenosis who underwent an elective CEA including 2509 octogenarians and 11,337 younger patients. Octogenarians were more likely to be female and less likely to be diabetic or smokers compared with younger patients. There was no difference in preoperative use of statins or antiplatelet therapy. Examination of 30-day outcomes revealed that octogenarians had slightly higher mortality (1.2% vs 0.5%; odds ratio, 2.1; 95% confidence interval, 1.3-3.4; P < .01), and a higher risk of return to the operating room (3.3% vs 2.3%; odds ratio, 1.4; 95% confidence interval, 1.1-1.9; P = .01). However, there was no difference between octogenarians and younger patients in adverse cardiac events or pulmonary, renal, or wound complications. Twenty-five octogenarian and 138 younger patients suffered from periprocedural stroke at a similar rate (1.0% vs 1.2%; P = .54). Stroke/death occurred for 51 of 2509 patients (2.0%) in the older group and 184 of 11,337 patients (1.6%) in the younger group, a difference that was not significant (P = .15). CONCLUSIONS The 30-day outcomes of CEA in octogenarians are comparable with those in younger patients. Although the octogenarians had slightly higher mortality than younger patients, the absolute risk of mortality was still low at 1.2%. Therefore, CEA is safe in asymptomatic carotid stenosis in octogenarians. Overall life expectancy and preoperative functional status, rather than age, should be the major determinants in the decision to operate.
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11
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Evaluation and comparison of postoperative outcomes of octogenarians and non-octogenarians undergoing carotid endarterectomy. Eur Surg 2019. [DOI: 10.1007/s10353-019-0584-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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12
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Wong EH, Smith M, Fish B, Jani P, Palme CE, Smith MC, Riffat F. Thyroidectomy in octogenarians is not associated with poorer postoperative outcomes. Head Neck 2019; 41:2500-2506. [DOI: 10.1002/hed.25712] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2018] [Revised: 12/20/2018] [Accepted: 02/05/2019] [Indexed: 11/10/2022] Open
Affiliation(s)
- Eugene H. Wong
- Department of Otolaryngology; Westmead Hospital; Westmead New South Wales Australia
- Sydney Medical School; University of Sydney; Camperdown New South Wales Australia
| | - Murray Smith
- Department of Otolaryngology; Westmead Hospital; Westmead New South Wales Australia
| | - Brian Fish
- Department of Otolaryngology; Addenbrooke's Hospital; Cambridge United Kingdom
| | - Piyush Jani
- Department of Otolaryngology; Addenbrooke's Hospital; Cambridge United Kingdom
| | - Carsten E. Palme
- Department of Otolaryngology; Westmead Hospital; Westmead New South Wales Australia
- Sydney Medical School; University of Sydney; Camperdown New South Wales Australia
| | - Mark C. Smith
- Department of Otolaryngology; Westmead Hospital; Westmead New South Wales Australia
- Sydney Medical School; University of Sydney; Camperdown New South Wales Australia
| | - Faruque Riffat
- Department of Otolaryngology; Westmead Hospital; Westmead New South Wales Australia
- Sydney Medical School; University of Sydney; Camperdown New South Wales Australia
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Blay E, Balogun Y, Nooromid MJ, Eskandari MK. Early Carotid Endarterectomy after Acute Stroke Yields Excellent Outcomes: An Analysis of the Procedure-Targeted ACS-NSQIP. Ann Vasc Surg 2019; 57:194-200. [PMID: 30690159 DOI: 10.1016/j.avsg.2018.10.023] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2018] [Revised: 10/08/2018] [Accepted: 10/15/2018] [Indexed: 11/18/2022]
Abstract
BACKGROUND Recurrent ischemic events have been associated with delayed carotid endarterectomy (CEA) for patients who present with acute strokes. As such, earlier intervention has been advocated to preserve cerebral function and expedient rehabilitation. We sought to determine the differences in 30-day postoperative major adverse clinical events (MACEs) for patients who undergo early (≤7 days) and delayed (>7 days) CEA after acute stroke. METHODS Our sample consisted of patients captured in the CEA-targeted American College of Surgeons National Surgical Quality Improvement Program data set between 2011 and 2015. The primary outcome was 30-day postoperative MACEs (death, stroke, or myocardial infarction [MI]). Differences in postoperative MACEs were determined between early and delayed CEA treatment. In addition, multivariable analyses were done to determine the association between various patient factors and postoperative complications after CEA for patients who presented with acute strokes. RESULTS A total of 3,427 patients were identified who underwent CEA for acute stroke in the CEA-targeted files between 2011 and 2015. Overall, perioperative rates of 30-day death, stroke, or MI were 1.30% (n = 43), 2.74% (n = 94), and 0.96% (n = 33), respectively. There were no differences in 30-day postoperative death, stroke, or MI for early or delayed CEA after acute strokes. On multivariable analysis, independent predictors for postoperative MACEs in patients with acute stroke were age ≥80 years (OR 2.41; 95% CI [1.15-5.06]), preoperative beta-blocker use (OR 2.11; 95% CI [1.13-3.93]), and operative time > 150 min (OR 2.39; 95% CI [0.82-4.98]). CONCLUSIONS There are no differences in postoperative 30-day death, stroke, or MI in early and delayed CEA after an acute stroke. These results substantiate the recommendation for early (<7 days) CEA after acute strokes.
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Affiliation(s)
- Eddie Blay
- Surgical Outcomes and Quality Improvement Center (SOQIC), Department of Surgery and Center for Healthcare Studies, Feinberg School of Medicine, Northwestern University, Chicago, IL; Department of Surgery, Temple University Hospital, Philadelphia, PA.
| | - Yetunde Balogun
- Department of Surgery, Temple University Hospital, Philadelphia, PA
| | - Michael J Nooromid
- Division of Vascular Surgery, Department of Surgery, Northwestern University, Chicago, IL
| | - Mark K Eskandari
- Division of Vascular Surgery, Department of Surgery, Northwestern University, Chicago, IL
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14
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Abstract
As the population ages, surgical decision-making in vascular surgery has become more complex. Older patients may not have been offered vascular surgical intervention in the past because of prohibitive physiologic demands and poor health. Patients now have more aggressive management of vascular risk factors with medications, such as statin therapy, and less invasive endovascular or hybrid treatment options. Outcomes in elderly patients may not be comparable with younger patients for entities such as aortic aneurysm repair, carotid endarterectomy, or lower extremity revascularization. Despite this, desirable outcomes can be successfully achieved and should be offered to carefully selected elderly individuals.
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Affiliation(s)
- Pegge M Halandras
- Department of Vascular Surgery and Endovascular Surgery, Loyola University Chicago, Stritch School of Medicine, 2160 South First Avenue, EMS Building 110, Room 3220, Maywood, IL 60153, USA.
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15
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Tyagi SC, Dougherty MJ, Fukuhara S, Troutman DA, Pineda DM, Zheng H, Calligaro KD. Low carotid stump pressure as a predictor for ischemic symptoms and as a marker for compromised cerebral reserve in octogenarians undergoing carotid endarterectomy. J Vasc Surg 2018; 68:445-450. [PMID: 29482876 DOI: 10.1016/j.jvs.2017.11.076] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2017] [Accepted: 11/10/2017] [Indexed: 11/19/2022]
Abstract
BACKGROUND Carotid artery occlusive disease can cause stroke by embolization, thrombosis, and hypoperfusion. The majority of strokes secondary to cervical carotid atherosclerosis are believed to be of embolic etiology. However, cerebral hypoperfusion could be an important factor in perioperative stroke. We retrospectively reviewed the stump pressure (SP) of carotid endarterectomy (CEA) of patients at Pennsylvania Hospital to identify whether physiologic perfusion differences account for differences in perioperative stroke rates, particularly in octogenarians. METHODS We conducted a retrospective review of our prospectively maintained database for CEA performed between 1992 and 2015. SP was measured and recorded for 1190 patients. A low SP was defined as systolic pressure <50 mm Hg. Shunts were used only for patients under general anesthesia with SP <50 mm Hg, for awake patients with neurologic changes with carotid clamping, and in some patients with recent stroke. RESULTS Symptomatic patients were more likely to have SP <50 mm Hg compared with asymptomatic patients (35.6% vs 26.2%; P = .0015). Patients having SP <50 mm Hg had a higher postoperative stroke rate compared with patients with SP >50 mm Hg (2.9% vs 0.9%; P = .0174). Octogenarians were more likely to have a lower SP compared with patients younger than 80 years (35.7% vs 27.7%; P = .0328). Symptomatic patients with low SP were at highest risk for perioperative stroke (6.4% vs 1.2%; P = .001) compared with patients without these factors. CONCLUSIONS SP is a marker for decreased cerebrovascular reserve and along with symptomatic status identifies those at highest risk for periprocedural stroke with CEA. Whereas patients older than 80 years may benefit from carotid intervention, they are likely to be at somewhat elevated stroke risk because of higher prevalence of low SP, and shunting does not eliminate this risk.
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Affiliation(s)
- Sam C Tyagi
- Section of Vascular Surgery, Pennsylvania Hospital, Philadelphia, Pa
| | | | - Shinichi Fukuhara
- Section of Vascular Surgery, Pennsylvania Hospital, Philadelphia, Pa
| | | | - Danielle M Pineda
- Section of Vascular Surgery, Pennsylvania Hospital, Philadelphia, Pa
| | - Hong Zheng
- Section of Vascular Surgery, Pennsylvania Hospital, Philadelphia, Pa
| | - Keith D Calligaro
- Section of Vascular Surgery, Pennsylvania Hospital, Philadelphia, Pa
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16
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Vinogradov RA, Pykhteev VS, Martirosova KI, Lashevich KA. [Perioperative complications prognosis in carotid endarterectomy]. Khirurgiia (Mosk) 2018:82-85. [PMID: 29376964 DOI: 10.17116/hirurgia2018182-85] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/07/2023]
Affiliation(s)
- R A Vinogradov
- Research Institute - Ochapovsky Regional Clinical Hospital # 1, Krasnodar, Russia; Kuban State Medical University of Healthcare Ministry of the Russian Federation, Krasnodar, Russia
| | - V S Pykhteev
- Kuban State Medical University of Healthcare Ministry of the Russian Federation, Krasnodar, Russia
| | - K I Martirosova
- Pirogov Russian National Research Medical University of Healthcare Ministry of the Russian Federation, Moscow, Russia
| | - K A Lashevich
- Kuban State Medical University of Healthcare Ministry of the Russian Federation, Krasnodar, Russia
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17
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Pastuszak Ż, Koźniewska E, Stępień A, Piusińska-Macoch A, Czernicki Z, Koszewski W. Importance rating of risk factors of ischemic stroke in patients over 85 years old in the polish population. Neurol Neurochir Pol 2017; 52:88-93. [PMID: 29196059 DOI: 10.1016/j.pjnns.2017.11.007] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2017] [Accepted: 11/09/2017] [Indexed: 10/18/2022]
Abstract
INTRODUCTION The European population is aging and the number of elderly patients suffering from ischemic brain stroke increases. A better knowledge of the correlation between the risk factors and the course of the disease in old people may be useful for planning medical care and prophylactic strategies. AIM This prospective study aimed to perform a demographic and clinical analysis of the etiology of ischemic stroke, survival rate and severity of post-stroke disability in patients who developed ischemic stroke at the age of over 85 years in the Polish population. METHOD The study group consisted of 159 patients over 85 years old with ischemic stroke. The prevalence of risk factors such as sex, hypertension, hyperlipidemia, atrial fibrillation, heart failure and diabetes was evaluated. The outcome was assessed using the Barthel scale and the National Institutes of Health Stroke Scale. RESULTS The most common risk factors of ischemic stroke were hypertension and atrial fibrillation. Patients with atrial fibrillation had a more severe course of ischemic stroke. CONCLUSION The course of brain stroke in the Polish population is more severe in patients over 85 years old than in younger ones. The key risk factor in this group is atrial fibrillation.
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Affiliation(s)
- Żanna Pastuszak
- Department of Neurosurgery, Mossakowski Medical Research Centre, Polish Academy of Sciences, ul. Pawińskiego 5, 02-106 Warsaw, Poland.
| | - Ewa Koźniewska
- Department of Neurosurgery, Mossakowski Medical Research Centre, Polish Academy of Sciences, ul. Pawińskiego 5, 02-106 Warsaw, Poland
| | - Adam Stępień
- Department of Neurology, Military Institute of Medicine, ul. Szaserów 128, 04-141 Warsaw, Poland
| | - Anna Piusińska-Macoch
- Department of Neurology, Military Institute of Medicine, ul. Szaserów 128, 04-141 Warsaw, Poland
| | - Zbigniew Czernicki
- Department of Neurosurgery, Second Faculty of the Medical University of Warsaw, ul. Cegłowska 80, 01-809 Warsaw, Poland
| | - Waldemar Koszewski
- Department of Neurosurgery, Second Faculty of the Medical University of Warsaw, ul. Cegłowska 80, 01-809 Warsaw, Poland
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Nanto M, Goto Y, Yamamoto H, Tanigawa S, Takado M, Ogawa T, Nakahara Y. Periprocedural Outcomes of Carotid Artery Stenting in Elderly Patients. J Stroke Cerebrovasc Dis 2017; 27:103-107. [PMID: 28919313 DOI: 10.1016/j.jstrokecerebrovasdis.2017.08.010] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2017] [Revised: 08/02/2017] [Accepted: 08/10/2017] [Indexed: 11/25/2022] Open
Abstract
BACKGROUND Carotid artery stenting has emerged as an alternative to carotid endarterectomy especially in patients with high risk of carotid endarterectomy. Older age (≥80 years old) was recognized as one of the high risk factors of carotid endarterectomy. However, the association between older age and increased risk of adverse events for carotid artery stenting has been reported. The purpose of this study was to evaluate the association between age and periprocedural outcomes after carotid artery stenting. METHODS A total of 126 symptomatic and asymptomatic cases of carotid artery stenosis were treated with tailored carotid artery stenting. The type of stents and embolic protection devices were chosen according to clinical and morphologic characteristics of the patients. Procedural, imaging, and clinical outcomes were retrospectively assessed and compared between the elderly patients group (≥80 years old) and the non-elderly patients group (<80 years old). RESULTS Clinical and morphologic characteristics except for dyslipidemia were not significantly different between the 2 groups. Periprocedural neurologic complications were not significantly different between the 2 groups (P = .095). Minor stroke occurred more frequently in the elderly patients group (P = .021). However, the frequency of major stroke was not significantly different between the 2 groups (P = 1). Presence of new ischemic lesions on postprocedural examination was not significantly different between the 2 groups (P = .84). Myocardial infarction and death did not occur in either group. CONCLUSIONS Carotid artery stenting can be performed safely in elderly patients, comparable with non-elderly patients.
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Affiliation(s)
- Masataka Nanto
- Department of Neurosurgery, Kyoto Second Red Cross Hospital, Kyoto, Japan.
| | - Yudai Goto
- Department of Neurosurgery, Kyoto Graduate School of Medical Science Kyoto Prefectural University of Medicine, Kyoto, Japan
| | - Hiroyuki Yamamoto
- Department of Neurosurgery, Kyoto Graduate School of Medical Science Kyoto Prefectural University of Medicine, Kyoto, Japan
| | - Seisuke Tanigawa
- Department of Neurosurgery, Kyoto Graduate School of Medical Science Kyoto Prefectural University of Medicine, Kyoto, Japan
| | - Michiko Takado
- Department of Neurosurgery, Kyoto Graduate School of Medical Science Kyoto Prefectural University of Medicine, Kyoto, Japan
| | - Takahiro Ogawa
- Department of Neurosurgery, Kyoto Graduate School of Medical Science Kyoto Prefectural University of Medicine, Kyoto, Japan
| | - Yoshikazu Nakahara
- Department of Neurosurgery, Kyoto Second Red Cross Hospital, Kyoto, Japan
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Smithard DG. Stroke in Frail Older People. Geriatrics (Basel) 2017; 2:E24. [PMID: 31011034 PMCID: PMC6371123 DOI: 10.3390/geriatrics2030024] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2017] [Revised: 06/20/2017] [Accepted: 06/22/2017] [Indexed: 02/01/2023] Open
Abstract
The population is ageing, with the greatest proportional increase in those >80 years of age. Many of these people will be frail and at risk of stroke. Research has shown that the very old have much to benefit from hyperacute stroke intervention, but at the same time they suffer increased mortality. Their outcome following stroke and intervention is more often predicted by the presence of frailty rather than age alone. Intervention both in primary prevention and hyperacute stroke management needs to allow for preexisting morbidity and frailty in deciding what is and what is not appropriate, rather than an arbitrary decision on age. Frail older people are more likely to develop delirium and dysphagia combined with poor mouthcare and die, yet all of these issues are managed badly. An increased awareness of these complications of stroke in the frail older person is necessary.
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Affiliation(s)
- David G Smithard
- Department of Electronic and Digital Arts, University of Kent, Canterbury CT2 7NZ, UK.
- Clinical Gerontology, King's College Hospital, London SE5 9RS, UK.
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20
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Schneider JR, Jackson CR, Helenowski IB, Verta MJ, Wilkinson JB, Kim S, Hoel AW. A comparison of results of carotid endarterectomy in octogenarians and nonagenarians to younger patients from the Mid-America Vascular Study Group and the Society for Vascular Surgery Vascular Quality Initiative. J Vasc Surg 2017; 65:1643-1652. [DOI: 10.1016/j.jvs.2016.12.118] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2016] [Accepted: 12/21/2016] [Indexed: 11/26/2022]
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Schmid S, Tsantilas P, Knappich C, Kallmayer M, König T, Breitkreuz T, Zimmermann A, Kuehnl A, Eckstein HH. Risk of Inhospital Stroke or Death Is Associated With Age But Not Sex in Patients Treated With Carotid Endarterectomy for Asymptomatic or Symptomatic Stenosis in Routine Practice: Secondary Data Analysis of the Nationwide German Statutory Quality Assurance Database From 2009 to 2014. J Am Heart Assoc 2017; 6:JAHA.116.004764. [PMID: 28288976 PMCID: PMC5524011 DOI: 10.1161/jaha.116.004764] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/02/2022]
Abstract
Background Guideline recommendations on carotid endarterectomy are based predominantly on randomized, controlled trials, in which women or elderly patients are often under‐represented. This study analyzed the association of age and sex with the risk of in‐hospital stroke or death following carotid endarterectomy under routine conditions in Germany. Methods and Results Secondary data analysis using the Statutory German Quality Assurance Database on all carotid endarterectomy procedures (n=142 074) performed between 2009 and 2014. Primary outcome was any stroke or death until discharge; secondary outcomes were any in‐hospital stroke (alone), and death (alone). Descriptive statistics and multilevel multivariable regression analyses were applied. Patients were predominately male (68%), with mean age 71 years. Carotid stenosis was symptomatic in 40%. Primary outcome occurred in 1.8% of women and 1.9% of men. Multivariable regression analysis revealed that more‐advanced age was associated with a higher primary outcome rate (relative risk [RR] per 10‐year increase: 1.19; 95% CI, 1.14–1.24). Risk of death (alone) was associated with age (RR, 1.68; 95% CI, 1.54–1.84). Age was associated with the risk of stroke (alone; RR, 1.05; 95% CI, 1.00–1.11). Sex was not associated with primary outcome rate (1.01; 95% CI, 0.93–1.10), nor did it significantly modify the age effect. Conclusions This study shows that increasing age, but not sex, is associated with a higher risk of in‐hospital stroke or death following carotid endarterectomy under everyday conditions in Germany. Whereas the risk of death (alone) is significantly associated with age, the association between age and the risk of stroke (alone) can be considered of minor importance.
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Affiliation(s)
- Sofie Schmid
- Department of Vascular and Endovascular Surgery, Klinikum rechts der Isar Technical University of Munich, Germany
| | - Pavlos Tsantilas
- Department of Vascular and Endovascular Surgery, Klinikum rechts der Isar Technical University of Munich, Germany
| | - Christoph Knappich
- Department of Vascular and Endovascular Surgery, Klinikum rechts der Isar Technical University of Munich, Germany
| | - Michael Kallmayer
- Department of Vascular and Endovascular Surgery, Klinikum rechts der Isar Technical University of Munich, Germany
| | - Thomas König
- AQUA-Institut für angewandte Qualitätsförderung und Forschung im Gesundheitswesen GmbH, Göttingen, Germany
| | - Thorben Breitkreuz
- AQUA-Institut für angewandte Qualitätsförderung und Forschung im Gesundheitswesen GmbH, Göttingen, Germany
| | - Alexander Zimmermann
- Department of Vascular and Endovascular Surgery, Klinikum rechts der Isar Technical University of Munich, Germany
| | - Andreas Kuehnl
- Department of Vascular and Endovascular Surgery, Klinikum rechts der Isar Technical University of Munich, Germany
| | - Hans-Henning Eckstein
- Department of Vascular and Endovascular Surgery, Klinikum rechts der Isar Technical University of Munich, Germany
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The perioperative outcomes of eversion carotid endarterectomy in diabetic patients aged 80 years or older. J Vasc Surg 2016; 64:348-353. [PMID: 26993375 DOI: 10.1016/j.jvs.2016.01.052] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2015] [Accepted: 01/29/2016] [Indexed: 11/22/2022]
Abstract
BACKGROUND Uncertainty exists about the influence of advanced age and diabetes mellitus on the clinical effect of carotid endarterectomy (CEA). This study analyzed the perioperative (30-day) outcomes of CEA in diabetic patients aged ≥80 years. METHODS Data of 1872 consecutive patients who underwent 2125 primary eversion CEAs from 1990 to 2014 at our institution were prospectively stored in a vascular surgery registry. Risk factors, medication, and indication for surgery were recorded. The 354 patients (387 CEAs) aged ≥80 years formed the study base; of whom, 207 (219 CEAs) were diabetic and 147 (168 CEAs) were not. A neurologist assessed all patients preoperatively, on waking from the anesthesia, and before discharge from the hospital. All procedures were eversion CEA performed by the same surgeon under general anesthesia with routine electroencephalographic monitoring for selective shunting. RESULTS Diabetic patients were more likely to have arterial hypertension (P = .033), cardiac disease (P = .038), peripheral aneurysmal/atherosclerotic disease (P = .046), and contralateral carotid occlusion (P = .042) than their nondiabetic counterparts. Overall, there were no deaths, two (0.51%) perioperative strokes (both in diabetic patients), and 13 nonfatal cardiac complications (3.3%), of which 10 occurred in diabetic patients, but the difference failed to reach statistical significance. CONCLUSIONS Findings from this study show that CEA is safe and effective for stroke prevention in diabetic patients aged ≥80 years, with a negligible incidence of perioperative adverse events and no deaths.
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Abbott AL, Bladin CF, Levi CR, Chambers BR. What Should We Do with Asymptomatic Carotid Stenosis? Int J Stroke 2016; 2:27-39. [DOI: 10.1111/j.1747-4949.2007.00096.x] [Citation(s) in RCA: 77] [Impact Index Per Article: 9.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
The benefit of prophylactic carotid endarterectomy (CEA) for patients with asymptomatic severe carotid stenosis in the major randomised surgical studies was small, expensive and may now be absorbed by improvements in best practice medical intervention. Strategies to identify patients with high stroke risk are needed. If surgical intervention is to be considered the complication rates of individual surgeons should be available. Clinicians will differ in their interpretation of the same published data. Maintaining professional relationships with clinicians from different disciplines often involves compromise. As such, the management of a patient will, in part, depend on what kind of specialist the patient is referred to. The clinician's discussion with patients about this complex issue must be flexible to accommodate differing patient expectations. Ideally, patients prepared to undergo surgical procedures should be monitored in a trial setting or as part of an audited review process to increase our understanding of current practice outcomes.
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Affiliation(s)
- Anne L. Abbott
- National Stroke Research Institute, Austin Health, Melbourne, Vic. 3081, Australia
- The University of Melbourne, Melbourne, Vic., Australia
- Department of Neuroscience, Box Hill Hospital, Nelson Road, Box Hill, Melbourne Vic., 3128, Australia
- Neurology Department, Austin Health, Melbourne, Vic., Australia
| | - Christopher F. Bladin
- Department of Neuroscience, Box Hill Hospital, Nelson Road, Box Hill, Melbourne Vic., 3128, Australia
| | - Christopher R. Levi
- Department of Neuroscience, John Hunter Hospital, Lookout Road, Lambton Heights, Newcastle, NSW, 2035, Australia
| | - Brian R. Chambers
- National Stroke Research Institute, Austin Health, Melbourne, Vic. 3081, Australia
- The University of Melbourne, Melbourne, Vic., Australia
- Neurology Department, Austin Health, Melbourne, Vic., Australia
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Carotid Endarterectomy or Stenting in Octogenarians in a Monocentric Experience. Ann Vasc Surg 2016; 33:132-7. [DOI: 10.1016/j.avsg.2015.10.039] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2015] [Revised: 09/30/2015] [Accepted: 10/02/2015] [Indexed: 11/24/2022]
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De Rango P, Simonte G, Farchioni L, Cieri E, Manzone A, Parlani G, Lenti M, Verzini F. Safety of Carotid Revascularization in Symptomatic Patients with less than 70 Years. Ann Vasc Surg 2016; 32:73-82. [PMID: 26802293 DOI: 10.1016/j.avsg.2015.10.024] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2015] [Revised: 10/07/2015] [Accepted: 10/10/2015] [Indexed: 11/29/2022]
Abstract
BACKGROUND Age is a main risk factor for stroke and perioperative risk. This study aims to analyze the effect of age by symptomatic status in young patients receiving carotid revascularization. METHODS Consecutive carotid revascularization procedures performed during the period 2001-2009 were reviewed. Patients were analyzed by age using the 70-year threshold as suggested by trials. Primary end point was perioperative stroke or death rate. Secondary end points included survival and late stroke incidence at 6 years. RESULTS A total of 2,196 procedures (1,080 by carotid artery stenting [CAS] and 1,116 by carotid endarterectomy [CEA]) were analyzed. Symptomatic patients (n = 684) showed higher perioperative stroke or death risks (24 of 684 [3.5%] versus 29 of 1,512 [1.9%], odds ratio [OR] 1.8; 95% confidence interval [CI] 1.07-3.22; P = 0.034) and lower 6-year survival (74% vs. 82%, P < 0.0001) or freedom from late stroke (93% vs. 97%, P = 0.001) when compared with asymptomatic patients with similar differences detected within CEA or CAS procedure. Overall 949 procedures were in patients with 70 years or less at the time of intervention (500 CEA and 449 CAS); 282 were in patients symptomatic for minor stroke or transient ischemic attack within 6 months before revascularization. For young symptomatic patients, primary end point rates were <2.5% after both CEA and CAS procedure. Perioperative stroke or death rates were 2.4% in symptomatic versus 1.5% in asymptomatic (4 of 170 vs. 5 of 330; OR 1.57; 95% CI 0.42-5.91; P = 0.50) within the CEA group and 1.8% in symptomatic versus 1.2% in asymptomatic (2 of 112 vs. 4 of 337; OR 1.51; 95% CI 0.27-8.38; P = 0.64) within the CAS group. At 6 years, symptomatic young patients showed survival (89.5% vs. 89%, P = 0.76) and freedom from late stroke (97% vs. 98%, P = 0.56) rates comparable to those found in asymptomatic patients, with similar incidences after CAS or CEA procedure. CONCLUSIONS Outcomes after carotid revascularization are related to patients' age. At younger ages (<70 years), after carotid revascularization, symptomatic patients show low perioperative risks of stroke or death, comparable with those in asymptomatic patients. The same, 2.5% or lower, threshold for perioperative stroke or death risk related to asymptomatic carotid procedures must be applied today to symptomatic patients when younger than age of 70 years.
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Affiliation(s)
- Paola De Rango
- Unit of Vascular Surgery, Hospital S. M. Misericordia, Department of Surgery and Biomedical Science, University of Perugia, Perugia, Italy.
| | - Gioele Simonte
- Unit of Vascular Surgery, Hospital S. M. Misericordia, Department of Surgery and Biomedical Science, University of Perugia, Perugia, Italy
| | - Luca Farchioni
- Unit of Vascular Surgery, Hospital S. M. Misericordia, Department of Surgery and Biomedical Science, University of Perugia, Perugia, Italy
| | - Enrico Cieri
- Unit of Vascular Surgery, Hospital S. M. Misericordia, Department of Surgery and Biomedical Science, University of Perugia, Perugia, Italy
| | - Alessandra Manzone
- Unit of Vascular Surgery, Hospital S. M. Misericordia, Department of Surgery and Biomedical Science, University of Perugia, Perugia, Italy
| | - Giovanbattista Parlani
- Unit of Vascular Surgery, Hospital S. M. Misericordia, Department of Surgery and Biomedical Science, University of Perugia, Perugia, Italy
| | - Massimo Lenti
- Unit of Vascular Surgery, Hospital S. M. Misericordia, Department of Surgery and Biomedical Science, University of Perugia, Perugia, Italy
| | - Fabio Verzini
- Unit of Vascular Surgery, Hospital S. M. Misericordia, Department of Surgery and Biomedical Science, University of Perugia, Perugia, Italy
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Evaluación de la seguridad de la endarterectomía carotídea en nuestro servicio. ANGIOLOGIA 2015. [DOI: 10.1016/j.angio.2014.11.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
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Contemporary results of carotid endarterectomy in “normal-risk” patients from the Society for Vascular Surgery Vascular Registry. J Vasc Surg 2015. [DOI: 10.1016/j.jvs.2015.05.003] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
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Ballotta E, Toniato A, Da Roit A, Lorenzetti R, Piatto G, Baracchini C. Carotid endarterectomy for asymptomatic carotid stenosis in the very elderly. J Vasc Surg 2015; 61:382-8. [DOI: 10.1016/j.jvs.2014.07.090] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2014] [Accepted: 07/22/2014] [Indexed: 10/24/2022]
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Kang JL, Chung TK, Lancaster RT, Lamuraglia GM, Conrad MF, Cambria RP. Outcomes after carotid endarterectomy: is there a high-risk population? A National Surgical Quality Improvement Program report. J Vasc Surg 2014; 49:331-8, 339.e1; discussion 338-9. [PMID: 19216952 DOI: 10.1016/j.jvs.2008.09.018] [Citation(s) in RCA: 42] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2008] [Revised: 09/11/2008] [Accepted: 09/11/2008] [Indexed: 10/21/2022]
Abstract
OBJECTIVE Carotid endarterectomy (CEA) is the standard treatment of carotid stenosis for symptomatic and asymptomatic patients. Carotid angioplasty and stenting (CAS), however, has been proposed as alternative therapy for patients deemed at high-risk for CEA. This study examined 30-day adjudicated outcomes in a contemporary series of CEAs and assessed the validity of criteria used to define a potential high-risk patient population for CEA. METHODS Patients undergoing isolated CEA in private sector hospitals between Jan 1, 2005, and Dec 31, 2006, were identified using the prospectively gathered National Surgical Quality Improvement Program database. The primary study end points were 30-day stroke and death rates. Demographic, preoperative, and intraoperative variables were examined using multivariate models to identify variables associated with the study end points. Variables used to define systemic "high-risk" patients in the Stenting and Angioplasty with Protection in Patients at High Risk for Endarterectomy (SAPPHIRE) study (active cardiac disease, severe chronic obstructive pulmonary disease, and octogenarian status) were examined individually and in composite fashion for association with study endpoints. RESULTS Of the 3949 CEAs performed, 59% were in men, 30% were "high-risk" (19% age >80), and 43% had a previous neurologic event. The 30-day stroke rate was 1.6%, the death rate was 0.7%, and combined stroke/death rate was 2.2%. Multivariate analysis showed that intraoperative transfusion (odds ratio [OR], 5.95; 95% confidence interval [CI], 1.71-20.66; P = .005), prior major stroke (OR, 5.34; 95% CI, 2.96-9.64; P < .0001), shorter height (surrogate for small artery size; OR, 1.09; 95% CI, 1.02-1.16; P = .010), and increased anesthesia time (OR, 1.02; 95% CI, 1.00-1.03; P = .008) were predictive of stroke. Critical limb ischemia (OR, 12.72; 95% CI, 3.49-46.40; P < .0001) and poor functional status (OR, 7.05; 95% CI, 2.95-16.82; P < .0001) were independent correlates of death. Systemic high-risk variables, either combined or individually, did not increase risk of stroke or death on multivariate analysis. CONCLUSION CEA is associated with favorable 30-day outcomes across a spectrum of patient comorbidity features including octogenarian status. Anatomic and technical features are the important predictors of perioperative stroke, whereas critical limb ischemia and poor functional status are important predictors of death for patients undergoing CEA. These data refute the concept that CAS is preferred for patients deemed high-risk by virtue of systemic comorbidities.
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Affiliation(s)
- Jeanwan L Kang
- Department of Surgery, Division of Vascular and Endovascular Surgery, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts 02114, USA.
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Salomon du Mont L, Ravelojaona M, Puyraveau M, Al Sayed M, Ritucci E, Rinckenbach S. Carotid endarterectomy in octogenarian: short- and midterm results. Ann Vasc Surg 2013; 28:917-23. [PMID: 24786194 DOI: 10.1016/j.avsg.2013.09.006] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2012] [Revised: 09/09/2013] [Accepted: 09/11/2013] [Indexed: 11/17/2022]
Abstract
BACKGROUND Randomized controlled trials that have established recommendations for carotid surgery have excluded patients >79 years of age, and in our day to day practice, patients in this age group are becoming more common. We sought to analyze the outcomes of carotid endarterectomy (CEA) in octogenarians, determine the risk factors of morbidity and mortality, and evaluate the midterm survey of these patients. METHODS Age was the only selection criteria for inclusion in this study. We compared symptomatic and asymptomatic populations and retrospectively analyzed the CEA results performed in patients ≥80 years of age in each group. We calculated the combined ipsilateral stroke/death for each group. RESULTS In the 6-year study period (2002-2007), 132 CEAs were performed in 118 octogenarians. The mean age was 83.2 years (range: 80-93), and there were 70 men (59.3%) and 48 women (40.6%). In this study group, 37.9% of patients were symptomatic and 62.1% were asymptomatic; the rate of internal carotid stenosis was 81.6% (standard deviation: ±8.5%). The combined ipsilateral stroke/death rate was 3.79% (4 deaths and 1 stroke): 2% in the symptomatic patients and 4.88% in the asymptomatic patients. No differences were found between the groups' combined ipsilateral stroke/death rate (P > 0.05), but there were significant more patients with coronary artery disease and peripheral artery disease in the asymptomatic patients. A contralateral significant internal carotid stenosis was a risk factor of combined ipsilateral stroke and death (P = 0.024). The mean duration of follow-up was 3.8 ± 2.0 years, and 73% ± 5% of the patients were alive at 3 years. CONCLUSION The good immediate results and good probability of survival at 3 years after surgery conveys a real benefit of this surgery in this age group, but patients should be selected on a case by case basis. In our experience, the presence of bilateral lesions should be a significant influence criterion in the preoperative risk assessment. Other evaluation criteria, such as cardiac status, are needed to optimize the selection of asymptomatic patients in particular.
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Affiliation(s)
| | - Mihary Ravelojaona
- Vascular Surgery Unit, University Hospital of Besancon, Besancon, France
| | - Marc Puyraveau
- Clinical Research Methods Center, University Hospital of Besancon, Besancon, France
| | - Mazen Al Sayed
- Vascular Surgery Unit, University Hospital of Besancon, Besancon, France
| | - Enzo Ritucci
- Vascular Surgery Unit, University Hospital of Besancon, Besancon, France
| | - Simon Rinckenbach
- Vascular Surgery Unit, University Hospital of Besancon, Besancon, France; University of Franche Comte, EA4268 INSERM, Besancon, France
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Deutsch L, Haller B, Söllner H, Storck M, Eckstein HH. Trends und Ergebnisse der Karotischirurgie in Deutschland 2003–2011. GEFÄSSCHIRURGIE 2013. [DOI: 10.1007/s00772-013-1229-2] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
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Safety and Efficacy of Carotid Endarterectomy in Octogenarians. Ann Vasc Surg 2013; 27:736-42. [DOI: 10.1016/j.avsg.2012.09.020] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2012] [Revised: 08/29/2012] [Accepted: 09/10/2012] [Indexed: 11/21/2022]
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Dzierwa K, Pieniazek P, Tekieli L, Musialek P, Przewlocki T, Kablak-Ziembicka A, Kosobucka-Peszat R, Machnik R, Trystula M, Podolec P. Carotid artery stenting according to the “tailored CAS” algorithm performed in the very elderly patients: The thirty day outcome. Catheter Cardiovasc Interv 2013; 82:681-8. [PMID: 23825008 DOI: 10.1002/ccd.25025] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/11/2012] [Revised: 03/12/2013] [Accepted: 05/10/2013] [Indexed: 11/07/2022]
Affiliation(s)
- Karolina Dzierwa
- Department of Cardiac and Vascular Diseases, Institute of Cardiology, Jagiellonian University Medical College, John Paul II hospital, Krakow, Poland
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Reichmann BL, van Lammeren GW, Moll FL, de Borst GJ. Is age of 80 years a threshold for carotid revascularization? Curr Cardiol Rev 2012; 7:15-21. [PMID: 22294970 PMCID: PMC3131710 DOI: 10.2174/157340311795677716] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/16/2010] [Revised: 10/16/2010] [Accepted: 01/07/2011] [Indexed: 11/22/2022] Open
Abstract
Background and purpose: Carotid Angioplasty and Stenting (CAS) has emerged as an alternative to Carotid Endarterectomy (CEA) in treatment of carotid stenotic disease. With increasing life expectancy clinicians are more often confronted with patients of higher age. Octogenarians were often excluded from randomized trials comparing CAS to CEA because they were considered high-risk for revascularization. Conflicting results on the peri-procedural outcome of carotid revascularization in these patients have been reported. In order to objectively evaluate whether age above 80 years should be an upper limit for indicating carotid revascularization we systematically reviewed the currently available literature. Methods: Literature was systematically reviewed between January 2000 and June 2010 using Pubmed and Embase, to identify all relevant studies concerning CAS and CEA in octogenarians. Inclusion criteria were 1) reporting outcome on either CEA or CAS; and 2) data subanalysis on treatment outcome by age. The 30-day Major Adverse Event (MAE) rate (disabling stroke, myocardial infarction or death) was extracted as well as demographic features of included patients. Results: After exclusion of 23 articles, 46 studies were included in this review, 18 involving CAS and 28 involving CEA. A total of 2.963 CAS patients and 14.365 CEA patients with an age >80 years were reviewed. The MAE rate was 6.9% (range 1.6 - 24.0%) following CAS and 4.2% (range 0 – 8.8%) following CEA. A separate analysis in this review included the results of one major registry 140.376 patients) analyzing CEA in octogenarians only reporting on 30-day mortality and not on neurological or cardiac adverse events. When these data were included the MAE following CEA is 2.4% (range 0 – 8.8%) Conclusions: MAE rates after CEA in octogenarians are comparable with the results of large randomized trials in younger patients. Higher complication rates are described for CAS in octogenarians. In general, age > 80 years is not an absolute cut off point to exclude patients from carotid surgery. In our opinion, CEA should remain the golden standard in the treatment of significant carotid artery stenoses, even in the very elderly.
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Qureshi AI, Chaudhry SA, Majidi S, Grigoryan M, Rodriguez GJ, Suri MFK. Population-based estimates of neuroendovascular procedures: results of a state-wide study. Neuroepidemiology 2012; 39:125-30. [PMID: 22890506 DOI: 10.1159/000337163] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2012] [Accepted: 02/10/2012] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND The Brain Attack Coalition identified the availability of neuroendovascular procedures as an essential component of a comprehensive stroke center. OBJECTIVE To provide population-based estimates of neuroendovascular procedures. METHODS State-wide estimates of cervicocerebral angiograms, endovascular ischemic stroke treatments, carotid angioplasty and stent placements, intracranial angioplasty and stent placements, endovascular treatment of intracranial aneurysms, and endovascular treatment of intracranial arteriovenous malformations (AVMs) were obtained. We calculated the annual incidence rates of various neuroendovascular and neurosurgical procedures (per 100,000 persons). For the denominator, total persons in each year were categorized in 10-year age intervals. RESULTS The incidence of carotid endarterectomy (387.6 per 100,000 persons) and carotid stent placement (34.7 per 100,000 persons) peaked at 75-84 years. The incidence of aneurysm embolization also peaked in that population bracket (67.9 per 100,000 persons), yet there was a dramatic reduction in the incidence of surgical aneurysm treatment (3.6 per 100,000 persons) in those aged 75-84 years. There was a prominent reduction in the incidence of all procedures in the population aged ≥85 years, except for intravenous/intra-arterial thrombolytic use in ischemic stroke. The incidence of ischemic stroke increased almost by 50% in the population aged ≥85 years compared to those aged 75-84 years. However, the incidence of endovascular procedures for acute ischemic stroke decreased from 22.8 per 100,000 persons in the population aged 75-84 years to 13.2 per 100,000 persons in the population aged ≥85 years. CONCLUSIONS A marked disproportion of neuroendovascular procedures performed and disease prevalence was noted in persons aged ≥85 years, an increasing segment of the population according to recent Census.
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Affiliation(s)
- Adnan I Qureshi
- Zeenat Qureshi Stroke Research Center, University of Minnesota, Minneapolis, MN 55455, USA.
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De Rango P, Lenti M, Simonte G, Cieri E, Giordano G, Caso V, Isernia G, Cao P. No benefit from carotid intervention in fatal stroke prevention for >80-year-old patients. Eur J Vasc Endovasc Surg 2012; 44:252-9. [PMID: 22819739 DOI: 10.1016/j.ejvs.2012.06.006] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2012] [Accepted: 06/13/2012] [Indexed: 10/28/2022]
Abstract
BACKGROUND Invasive management of patients ≥80 years of age with carotid stenosis may be questionable. The higher likelihood of stroke needs to be balanced with the increased perioperative risk and the reduced life expectancy of this ageing population. The purpose of this study was to evaluate the clinical relevance of carotid stenosis revascularisation in octogenarians. METHODS All patients ≥80 years of age who received carotid revascularisation in 2001-2010 were reviewed for perioperative and 5-year outcomes. The experience was comprehensive of carotid endarterectomy (CEA) and carotid stenting (CAS) performed during the training frame when age was not a contraindication for this procedure. Mortality rates were compared to those of octogenarians of the same geographical territory according to all-cause and stroke-related mortality national statistics datasets. RESULTS A total of 348 procedures performed in ≥80-year-old patients (272 males) were reviewed: 162 (46.6%) were by CAS and 169 (48.6%) were for symptomatic disease. Perioperative stroke/death rate was 5.5% and was non-significantly higher for symptomatic disease (7.1% vs. 3.9% asymptomatic; p = 0.24), after CAS (6.2% vs. 4.8% CEA; p = 0.64) and in females (6.6% vs. 5.1% males; p = 0.57). At median follow-up of 36.18 months, 95 deaths and 21 new ischaemic strokes (12 fatal) occurred with 5-year Kaplan-Meier freedom from stroke of 84.8% (78.7%, symptomatic vs. 90.3% asymptomatic; p = 0.003). According to national datasets, in 80-85-year-old resident population 5-year mortality was 29.9% (23.4% females, 40.6% males) and ischaemic stroke-related mortality was 14.9% (16.8% females, 13.0% males). Corresponding figures from treated population showed a 5-year mortality of 49.4%, higher in males (39.5% females, 52.5% males) and ischaemic stroke-related mortality of 20.2%, higher in females (40.0% females, 15.6% males). Comparing data from the study population with residents' figures, ischaemic stroke-related mortality hazard was significantly higher in the study females: odds ratio (OR) 3.2, 95% confidence interval (CI) 1.16-9.17; p = 0.029 (for males: OR 0.97, 95%CI 0.89-1.10; p = 0.99). CONCLUSIONS Despite perioperative stroke/death risks being lower compared with CAS, the benefit of surgical carotid revascularisation in old patients remains controversial due to limited life expectancy and high fatality of stroke in this ageing population. Invasive treatment of carotid stenosis may not be warranted in most patients ≥80 years of age with carotid stenosis, especially when female and asymptomatic.
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Affiliation(s)
- P De Rango
- Division of Vascular and Endovascular Surgery, Hospital S.M. Misericordia, Loc. S. Andrea delle Fratte, 06134 Perugia, Italy.
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Patel ST, Patil SV, Chamberlain RS. A United States Population-Based Study on Clinical Outcomes Following Primary Carotid Endarterectomy: Who and When? ACTA ACUST UNITED AC 2012. [DOI: 10.4236/ss.2012.312117] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
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O’Brien G, Martin Z, Haider N, Colgan M, O’Neill S, Moore D, Madhavan P. An analysis of vascular surgery in elderly patients to determine whether age affects treatment strategy. Ir J Med Sci 2011; 181:73-6. [DOI: 10.1007/s11845-011-0779-0] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2011] [Accepted: 10/18/2011] [Indexed: 10/15/2022]
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Outcomes of damage control laparotomy with open abdomen management in the octogenarian population. ACTA ACUST UNITED AC 2011; 70:616-21. [PMID: 21610351 DOI: 10.1097/ta.0b013e31820d19ed] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
BACKGROUND Controversy surrounds the role of abbreviated laparotomy and open abdomen (OA) in the octogenarian population in the acute care surgery model based on concern that the initial insult, combined with its sequelae, is beyond the physiologic reserve of these patients. As the population ages further, this dilemma will arise more frequently, requiring the analysis of futility or utility of OA in this demographic. METHODS The institutional review board approval was obtained to analyze retrospectively patients aged 80 years or older with OA from 1997 to 2009. Univariate, multivariate, and Kaplan-Meier analyses were used to evaluate the effects that demographics, comorbidities, and clinical factors had on in-hospital mortality and overall survival. RESULTS Sixty-seven patients (32 men and 35 women) were identified. Acute general surgery (including vascular procedures) was the most common indication for laparotomy (94%) with trauma a distant second (6%). Early definitive closure was obtained in 52% of patients with a 34% planned ventral hernia rate. Overall complication rate was 62% and overall in-hospital mortality was 37%. Multivariate analysis revealed congestive heart failure (odds ratio, 11.4; 95% confidence interval, 1.01-128.03) and acute renal failure (odds ratio, 11.8; 95% confidence interval, 2.00-69.12) correlated with in-hospital mortality. Of those surviving to hospital dismissal, 2-year survival was 66% with a 17-month median follow-up (range, 1-125 months). CONCLUSION There is utility in octogenarians undergoing aggressive surgical management that requires OA. These patients have high mortality rates, but long-term survival can be better than their peers with other chronic diseases if they survive the surgical insult. Patient selection should be based on preexisting comorbidities such as congestive heart failure and the development of acute renal failure. Despite the adequate long-term survival, most patients will leave the hospital with a hernia.
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GRIBAR JOHNJ, JIDDOU MONICA, CHOKSI NISHIT, ABBAS AMRE, BOWERS TERRY, KAZMIERCZAK CHRIS, TIMMS CHRIS, SAFIAN ROBERTD. Carotid Stenting in High-Risk Patients: Early and Late Outcomes. J Interv Cardiol 2011; 24:247-53. [DOI: 10.1111/j.1540-8183.2011.00635.x] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
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Sideso E, Walton J, Handa A. General or Local Anesthesia for Carotid Endarterectomy—The “Real-World” Experience. Angiology 2011; 62:609-13. [DOI: 10.1177/0003319711405507] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Perioperative complications from carotid endarterectomy (CEA) are the main drawbacks of the procedure. The aim of this study was to assess the complication rates in patients undergoing CEA under general anesthesia (GA) or regional anesthesia (local anesthesia [LA]) at our institution. Patients undergoing CEA at our regional vascular unit between 2000 and 2004 were included. Data were collated retrospectively from a prospective database. Follow-up was up to 62 months. In all, 383 endarterectomies were performed, 260 of which were under LA. Outcome measures included 30-day death (2.1%), stroke (1.8%), and combined stroke and death (2.8%). A 30-day incidence of stroke, death, and combined stroke and death was lower in the LA group. Incidence of myocardial infarction and transient ischemic attacks, and annual mortality were higher in the LA group. No significant difference was found between the 2 groups. In a unit where CEA is preferentially performed under LA, anesthesia technique failed to significantly influence outcome.
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Affiliation(s)
- E. Sideso
- Nuffield Department of Surgery, University of Oxford, John Radcliffe Hospital, Headley Way, Oxford, UK
- Nuffield Department of Medicine, University of Oxford, John Radcliffe Hospital, Headley Way, Oxford, UK
| | - J. Walton
- Nuffield Department of Surgery, University of Oxford, John Radcliffe Hospital, Headley Way, Oxford, UK
| | - Ashok Handa
- Nuffield Department of Surgery, University of Oxford, John Radcliffe Hospital, Headley Way, Oxford, UK
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Duschek N, Skrinjar E, Waldhör T, Vutuc C, Daniel G, Hübl W, Assadian A. N-terminal pro B-type natriuretic peptide (NT pro-BNP) is a predictor of long-term survival in male patients of 75 years and older with high-grade asymptomatic internal carotid artery stenosis. J Vasc Surg 2011; 53:1242-50. [PMID: 21215559 DOI: 10.1016/j.jvs.2010.10.123] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2010] [Revised: 10/27/2010] [Accepted: 10/27/2010] [Indexed: 11/25/2022]
Abstract
BACKGROUND Carotid endarterectomy (CEA) is commonly performed for asymptomatic high-grade internal carotid artery (ICA) stenosis to prevent stroke. However, despite advancing age of the society, for patients older than 75 years, there is no recommendation by the European guidelines for CEA, as this age group might not benefit from this intervention due to a limited life expectancy. OBJECTIVE We assessed N-terminal pro B-type natriuretic peptide (NT pro-BNP) as a predictive marker for long-term survival in this particular patient population in order to stratify patients for an improved surgical outcome. METHODS In a nonrandomized single-center clinical trial, we prospectively studied mortality rates of 205 consecutive patients (80 women, 125 men; mean age, 75 ± 10 years) with asymptomatic high-grade ICA stenosis in relation to preoperative plasma NT pro-BNP levels. We estimated cumulative survival over 5 years by Kaplan-Meier curves and established a proportional hazard-model by Cox regression. RESULTS In male patients, higher levels of preoperative NT pro-BNP levels were associated with a significantly increased long-term mortality. Those 75 years or older had the same survival rate as younger patients, if NT pro-BNP levels were low, making them thus eligible for CEA. CONCLUSIONS The results of our study suggest that preoperative plasma levels of NT pro-BNP are a valuable tool for the stratification of male patients. Male patients older than 75 years with low levels of NT pro-BNP should be referred for carotid revascularization, as they will most likely enjoy the benefit of surgery.
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Affiliation(s)
- Nikolaus Duschek
- Department of General and Vascular Surgery, Wilhelminenspital, Vienna, Austria.
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Calvillo-King L, Xuan L, Zhang S, Tuhrim S, Halm EA. Predicting risk of perioperative death and stroke after carotid endarterectomy in asymptomatic patients: derivation and validation of a clinical risk score. Stroke 2010; 41:2786-94. [PMID: 21051669 DOI: 10.1161/strokeaha.110.599019] [Citation(s) in RCA: 50] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Abstract
BACKGROUND AND PURPOSE National guidelines on carotid endarterectomy (CEA) for asymptomatic patients state that the procedure should be performed with a ≤ 3% risk of perioperative death or stroke. We developed and validated a multivariate model of risk of death or stroke within 30 days of CEA for asymptomatic disease and a related clinical prediction rule. METHODS We analyzed asymptomatic cases in a population-based cohort of CEAs performed in Medicare beneficiaries in New York State. Medical records were abstracted for sociodemographics, neurologic history, disease severity, diagnostic imaging data, comorbidities, and deaths and strokes within 30 days of surgery. We used multivariate logistic regression to identify independent predictors of perioperative death or stroke. The CEA-8 clinical risk score was derived from the final model. RESULTS Among the 6553 patients, the mean age was 74 years, 55% were male, 62% had coronary artery disease, and 22% had a history of distant stroke or transient ischemic attack. The perioperative rate of death or stroke was 3.0%. Multivariable predictors of perioperative events were female sex (odds ratio [OR] = 1.5; 95% CI, 1.1 to 1.9), nonwhite race (OR = 1.8; 95% CI, 1.1 to 2.9), severe disability (OR = 3.7; 95% CI, 1.8 to 7.7), congestive heart failure (OR = 1.6; 95% CI, 1.1 to 2.4), coronary artery disease (OR = 1.6; 95% CI, 1.2 to 2.2), valvular heart disease (OR = 1.5; 95% CI, 1.1 to 2.3), a distant history of stroke or transient ischemic attack (OR = 1.5; 95% CI, 1.1 to 2.0), and a nonoperated stenosis ≥ 50% (OR = 1.8; 95% CI, 1.3 to 2.3). The CEA-8 risk score stratified patients with a predicted probability of death or stroke rate from 0.6% to 9.6%. CONCLUSIONS Several sociodemographic, neurologic severity, and comorbidity factors predicted the risk of perioperative death or stroke in asymptomatic patients. The CEA-8 risk score can help clinicians calculate a predicted probability of complications for an individual patient to help inform the decision about revascularization.
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Affiliation(s)
- Linda Calvillo-King
- Division of General Internal Medicine, University of Texas Southwestern Medical Center, Dallas, TX 75390-8889, USA
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Micari A, Stabile E, Cremonesi A, Vadalà G, Castriota F, Pernice V, Sorropago G, Rubino P, Biamino G. Carotid artery stenting in octogenarians using a proximal endovascular occlusion cerebral protection device: a multicenter registry. Catheter Cardiovasc Interv 2010; 76:9-15. [PMID: 20578188 DOI: 10.1002/ccd.22503] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
Abstract
BACKGROUND Carotid stenting (CAS) has been proposed as an alternative to carotid endoarterectomy also in elderly patients with discrepant results. However, the use of proximal neuroprotection devices have not been evaluated in octogenarians. PURPOSE The aim of this multicenter prospective registry was to demonstrate that CAS in octogenarians is safe and effective if performed in high-volume centers by experienced operators. METHODS From July 2005 to May 2009, a total of 198 octogenarians patients, in three different institutions, were included in this registry. All patients underwent CAS using proximal endovascular occlusion device (Mo.Ma. device Invatec, Roncadelle, Italy). An independent neurologist evaluated all patients. The primary endpoint was death and stroke rate at 30 days. RESULTS 198 octogenarians (135 men; mean age: 83.2 years) were included in the registry. 39.4% of the patients were symptomatic. Procedural success was 100%. In-hospital complications: Two minor and two major strokes (2.02%) occurred. No device-related complications and no serious access site complication were noted. Between discharge and 30-day follow-up, one patient died due to a cardiac arrest. The overall 30-day combined stroke/death rate was 2.52%, resulting in 1.61% event incidence in asymptomatic and 3.9% in symptomatic patients (P = ns). Logistic regression did not identify independent predictor of neurological events, except in the female gender. CONCLUSION This multicenter prospective registry shows that CAS performed with proximal flow blockage is safe and feasible also in octogenarians. Thirty days death/stroke rates are similar to those of the overall population and within the International guidelines.
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Affiliation(s)
- Antonio Micari
- Cardiology Unit, GVM Care and Research, Villa Maria Eleonora Hospital, Viale Regione Siciliana 1572, Palermo, Italy.
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Percutaneous image-guided biopsy in an elderly population. J Vasc Interv Radiol 2010; 21:96-100. [PMID: 20123195 DOI: 10.1016/j.jvir.2009.09.025] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2008] [Revised: 09/21/2009] [Accepted: 09/28/2009] [Indexed: 11/15/2022] Open
Abstract
PURPOSE To evaluate the safety, accuracy, and clinical use of image-guided biopsy results in an elderly (age >/=80 years) patient population. MATERIALS AND METHODS Image-guided biopsy results of 722 elderly patients were obtained from our image-guided biopsy database over a 5-year period. This retrospective study of the data yielded 616 cases. The accuracy and complication rates for the elderly population were compared with the remaining patients in the database who were younger than 80 years of age (n= 13,012). In addition, use of biopsy results for treatment was also evaluated against a group of randomly selected younger patients who were matched for type and location of biopsy. RESULTS Image-guided biopsy in both patient groups was characterized by a high accuracy rate (95% for the elderly patients vs 96.5% for others), but the accuracy rate was significantly higher in the nonelderly group (P = .0247). Image-guided biopsy in elderly patients did not carry a greater complication rate compared with younger patients for any major complication. Use of malignant biopsy results (ie, initiating any therapy) was significantly less common in elderly patients (58% underwent therapy) than in younger age groups. In patients aged 60-70 y, 100% initiated therapy; in patients aged 70-80 y, 95% underwent therapy. CONCLUSIONS Image-guided biopsy in elderly patients is a safe and accurate procedure. There is no greater risk of complication in elderly patients. Malignant diagnoses achieved by image-guided biopsy in elderly patients resulted less frequently in the initiation of therapy for malignancy.
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Chen RL, Balami JS, Esiri MM, Chen LK, Buchan AM. Ischemic stroke in the elderly: an overview of evidence. Nat Rev Neurol 2010; 6:256-65. [PMID: 20368741 DOI: 10.1038/nrneurol.2010.36] [Citation(s) in RCA: 164] [Impact Index Per Article: 11.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
Stroke mostly occurs in elderly people and patient outcomes after stroke are highly influenced by age. A better understanding of the causes of stroke in the elderly might have important practical implications not only for clinical management, but also for preventive strategies and future health-care policies. In this Review, we explore the evidence from both human and animal studies relating to the effect of old age-in terms of susceptibility, patient outcomes and response to treatment-on ischemic stroke. Several aging-related changes in the brain have been identified that are associated with an increase in vulnerability to ischemic stroke in the elderly. Furthermore, risk factor profiles for stroke and mechanisms of ischemic injury differ between young and elderly patients. Elderly patients with ischemic stroke often receive less-effective treatment and have poorer outcomes than younger individuals who develop this condition. Neuroprotective agents for ischemic stroke have been sought for decades but none has proved effective in humans. One contributing factor for this translational failure is that most preclinical studies have used young animals. Future research on ischemic stroke should consider age as a factor that influences stroke prevention and treatment, and should focus on the management of acute stroke in the elderly to reduce the incidence and improve outcomes in this vulnerable group.
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Affiliation(s)
- Ruo-Li Chen
- Nuffield Department of Medicine, University of Oxford, Headington, Oxford, UK
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White CJ. Stroke prevention: carotid stenting versus carotid endarterectomy. F1000 MEDICINE REPORTS 2010; 2. [PMID: 20948861 PMCID: PMC2948384 DOI: 10.3410/m2-24] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
Revascularization of the extracranial carotid arteries is a commonly performed surgical procedure to prevent stroke. Open surgery (i.e., carotid endarterectomy [CEA]) is a well-established stroke prevention procedure but is being ‘challenged' by a less invasive percutaneous procedure (i.e., carotid artery stent [CAS] placement). Clinical trials comparing CAS and CEA for average-surgical-risk patients have demonstrated mixed results, whereas the data for CAS compared with CEA in high-surgical-risk patients have demonstrated non-inferiority. The impending Carotid Revascularization Endarterectomy Versus Stenting Trial (CREST) results will have a major impact on the utility of CAS relative to CEA in average-surgical-risk patients.
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Affiliation(s)
- Christopher J White
- Department of Cardiovascular Diseases, Ochsner Clinic Foundation 1514 Jefferson Highway, New Orleans, LA 70121 USA
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Lichtman JH, Jones SB, Wang Y, Watanabe E, Allen NB, Fayad P, Goldstein LB. Postendarterectomy mortality in octogenarians and nonagenarians in the USA from 1993 to 1999. Cerebrovasc Dis 2009; 29:154-61. [PMID: 19955740 DOI: 10.1159/000262312] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2009] [Accepted: 09/11/2009] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Relatively little is known about trends in the utilization or outcomes of carotid endarterectomy (CEA) in the very elderly. We determined trends in the rates of CEA and perioperative (in-hospital and 30-day) and long-term (1-, 2-, 3-, 4- and 5-year) mortality in a US national sample of patients >or=80 years of age. METHODS All fee-for-service Medicare patients (80-89 and >or=90 years of age) who had a CEA [ICD-9-CM (International Classification of Diseases, Ninth Revision, Clinical Modification): 38.12] from 1993 to 1999 were identified using the Centers for Medicare and Medicaid Services Inpatient Standard Analytic Files. Demographic characteristics and comorbid conditions were determined using ICD-9-CM diagnostic codes within the year prior to the index hospitalization for CEA. RESULTS A total of 140,376 CEA were performed in patients aged 80-89 years and 6,446 in those aged >or=90 years during this 7-year period. The annual number of operations increased from 13,115 in 1993 to 21,582 in 1999 for octogenarians, and from 481 in 1993 to 1,257 in 1999 for nonagenarians. Perioperative mortality was 2.2% in octogenarians and 3.3% in nonagenarians. Long-term mortality increased by approximately 10% per year after the operation, and was 43% in octogenarians and 56% in nonagenarians at 5 years. Perioperative mortality rates remained relatively stable over the 7-year period for both age groups although comorbidities increased. CONCLUSIONS The number of CEA performed in the very elderly in the USA increased from 1993 to 1999. Perioperative mortality rates were high compared with trial results, while long-term survivorship was comparable to that of similarly-aged peers in the USA.
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Affiliation(s)
- Judith H Lichtman
- Section of Chronic Disease Epidemiology, Department of Epidemiology and Public Health, Yale University School of Medicine, New Haven, CT 06520-8034, USA. judith.lichtman @ yale.edu
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Ballotta E, Da Giau G, Ermani M, Meneghetti G, Saladini M, Manara R, Baracchini C. Early and long-term outcomes of carotid endarterectomy in the very elderly: An 18-year single-center study. J Vasc Surg 2009; 50:518-25. [DOI: 10.1016/j.jvs.2009.04.053] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2009] [Revised: 04/19/2009] [Accepted: 04/20/2009] [Indexed: 11/24/2022]
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Usman AA, Tang GL, Eskandari MK. Metaanalysis of Procedural Stroke and Death among Octogenarians: Carotid Stenting versus Carotid Endarterectomy. J Am Coll Surg 2009; 208:1124-31. [DOI: 10.1016/j.jamcollsurg.2009.02.043] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2009] [Revised: 02/06/2009] [Accepted: 02/09/2009] [Indexed: 10/20/2022]
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