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Coelho A, Peixoto J, Mansilha A, Naylor AR, de Borst GJ. Timing of Carotid Intervention in Symptomatic Carotid Artery Stenosis: A Systematic Review and Meta-Analysis. Eur J Vasc Endovasc Surg 2021; 63:3-23. [PMID: 34953681 DOI: 10.1016/j.ejvs.2021.08.021] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2021] [Revised: 07/05/2021] [Accepted: 08/13/2021] [Indexed: 12/29/2022]
Abstract
OBJECTIVE This review aimed to analyse the timing of carotid endarterectomy (CEA) and carotid artery stenting (CAS) after the index event as well as 30 day outcomes at varying time periods within 14 days of symptom onset. METHODS A systematic review was performed according to the Preferred Reporting Items for Systematic reviews and Meta-analysis statement, comprising an online search of the Medline and Cochrane databases. Methodical quality assessment of the included studies was performed. Endpoints included procedural stroke and/or death stratified by delay from the index event and surgical technique (CEA/CAS). RESULTS Seventy-one studies with 232 952 symptomatic patients were included. Overall, 34 retrospective analyses of prospective databases, nine prospective, three RCT, three case control, and 22 retrospective studies were included. Compared with CEA, CAS was associated with higher 30 day stroke (OR 0.70; 95% CI 0.58 - 0.85) and mortality rates (OR 0.41; 95% CI 0.31 - 0.53) when performed ≤ 2 days of symptom onset. Patients undergoing CEA/CAS were analysed in different time frames (≤ 2 vs. 3 - 14 and ≤ 7 vs. 8 - 14 days). Expedited CEA (vs. 3 - 14 days) presented a sampled 30 day stroke rate of 1.4%; 95% CI 0.9 - 1.8 vs. 1.8%; 95% CI 1.8 - 2.0, with no statistically significant difference. Expedited CAS (vs. 3 - 14 days) was associated with no difference in stroke rate but statistically significantly higher mortality rate (OR 2.76; 95% CI 1.39 - 5.50). CONCLUSION At present, CEA is safer than transfemoral CAS within 2/7 days of symptom onset. Also, considering absolute rates, expedited CEA complies with the accepted thresholds in international guidelines. The ideal timing for performing CAS (when indicated against CEA) is not yet defined. Additional granular data and standard reporting of timing of intervention will facilitate future monitoring.
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Affiliation(s)
- Andreia Coelho
- Department of Angiology and Vascular Surgery, Centro Hospitalar Universitário do Porto, Portugal; Department of Surgery and Physiology, Faculdade Medicina da Universidade do Porto, Portugal
| | - João Peixoto
- Department of Surgery and Physiology, Faculdade Medicina da Universidade do Porto, Portugal; Department of Angiology and Vascular Surgery, Centro Hospitalar Vila Nova de Gaia/Espinho, Portugal
| | - Armando Mansilha
- Department of Surgery and Physiology, Faculdade Medicina da Universidade do Porto, Portugal
| | | | - Gert J de Borst
- Department of Vascular Surgery, University Medical Centre Utrecht, the Netherlands.
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Squizzato F, Xodo A, Taglialavoro J, Zavatta M, Grego F, Antonello M, Piazza M. Early outcomes of routine delayed shunting in carotid endarterectomy for symptomatic patients. THE JOURNAL OF CARDIOVASCULAR SURGERY 2021; 62:573-581. [PMID: 34308613 DOI: 10.23736/s0021-9509.21.11845-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
BACKGROUND The role of shunting during carotid endarterectomy (CEA) in symptomatic patients is unclear. The aim was to evaluate early outcomes of CEA with routine "delayed" shunt insertion, for patients with symptomatic carotid stenosis. METHODS we conducted a single-center retrospective review of symptomatic patients undergoing CEA (2009-2020). All CEAs were performed under general anesthesia using a standardized technique, based on delayed routine shunt insertion after plaque removal. Primary endpoints were 30-days mortality and stroke. A logistic regression was performed to identify clinical and procedural factors predictors of post-operative stroke. A literature systematic review was conducted using the terms "carotid endarterectomy" "stroke", "transient ischemic attack", "symptomatic carotid stenosis", and "shunt". RESULTS two-hundred-sixty-three CEAs were performed for TIA (n=178, 47%) or acute ischemic stroke (n=85, 32%). Mean delay of surgery was 6±19 days, and early CEA (<48 hours) was performed in 98 cases (37%). Conventional CEA was performed in 171 patients (67%), eversion CEA in 83 (33%). Early (30-days) mortality was 0.3%. Stroke/death rate was 2.3%. Female sex (OR 5.14, 95%CI 1.32-24.93; P=.023), use of anticoagulants (OR 10.57, 95%CI 2.67-51.86; P=.001), preoperative stroke (OR 5.34, 95%CI 1.62-69.21; P=.006), and the presence of preoperative CT/MRI cerebral ischemic lesions (OR 5.96, 95%CI 1.52-28.59; P=.013) were associated with early neurological complications. Statin medication (OR 0.18, 95%CI 0.04-0.71; P=.019) and CEA timing <2 days (OR 0.14, 95%CI 0.03-0.55; P=.005) were protective from postoperative stroke. CEA outcomes were independent from time period (P=.201) and operator's volume (P=.768). Four studies described the CEA outcomes with routine shunting in symptomatic patients, with a large variability in the selection of patients, surgical technique, and description of the results. CONCLUSIONS Routine delayed shunting after plaque removal seems to be a safe and effective technique, that contributed to maintain a low complication rate in neurologically symptomatic patients. Statin use and expedited timing were associated with improved outcomes using this technique.
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Affiliation(s)
- Francesco Squizzato
- Vascular and Endovascular Surgery Division, Department Of Cardiac, Thoracic Vascular Sciences and Public Health, School of Medicine, Padova University, Padua, Italy
| | - Andrea Xodo
- Vascular and Endovascular Surgery Division, Department Of Cardiac, Thoracic Vascular Sciences and Public Health, School of Medicine, Padova University, Padua, Italy
| | - Jacopo Taglialavoro
- Vascular and Endovascular Surgery Division, Department Of Cardiac, Thoracic Vascular Sciences and Public Health, School of Medicine, Padova University, Padua, Italy
| | - Marco Zavatta
- Vascular and Endovascular Surgery Division, Department Of Cardiac, Thoracic Vascular Sciences and Public Health, School of Medicine, Padova University, Padua, Italy
| | - Franco Grego
- Vascular and Endovascular Surgery Division, Department Of Cardiac, Thoracic Vascular Sciences and Public Health, School of Medicine, Padova University, Padua, Italy
| | - Michele Antonello
- Vascular and Endovascular Surgery Division, Department Of Cardiac, Thoracic Vascular Sciences and Public Health, School of Medicine, Padova University, Padua, Italy
| | - Michele Piazza
- Vascular and Endovascular Surgery Division, Department Of Cardiac, Thoracic Vascular Sciences and Public Health, School of Medicine, Padova University, Padua, Italy -
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Fernandes e Fernandes J, Mendes Pedro L, Gonçalves I. The conundrum of asymptomatic carotid stenosis-determinants of decision and evidence. ANNALS OF TRANSLATIONAL MEDICINE 2020; 8:1279. [PMID: 33178811 PMCID: PMC7607137 DOI: 10.21037/atm-2020-cass-12] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/29/2020] [Accepted: 04/24/2020] [Indexed: 01/27/2023]
Abstract
Management of asymptomatic carotid disease continues to challenge medical practice and present evidence is often conflicting. Stroke is a significant burden in Public Health and 11% to 15% appear as first neurologic event associated with asymptomatic carotid stenosis. Randomized trials provided support for Guidelines and Recommendations to intervene on asymptomatic stenosis, but at a known cost of a high number of unnecessary operations. Conflicting evidence from natural history studies and the widespread use of proper medical management including risk factors control, lowering-lipid drugs and strict control of arterial hypertension have reduced the incidence of strokes associated to asymptomatic carotid disease challenging established practice. Need to identify vulnerable lesions prone to develop thromboembolic brain events and also vulnerable patients at a higher risk of stroke is necessary and essential to further improve effectiveness of our interventions. After review of published literature on natural history of asymptomatic carotid stenosis, diagnostic methods to identify plaque vulnerability and present-day results of both endarterectomy and stenting, a strategy for management of asymptomatic carotid stenosis is suggested aiming to reduce unnecessary interventions and effectively contribute to stroke prevention.
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Affiliation(s)
- José Fernandes e Fernandes
- Department of Surgery and Vascular Surgery, Faculty of Medicine University of Lisbon, Lisbon, Portugal
- Santa Maria University Hospital, Lisbon Academic Medical Center, Lisbon, Portugal
- Senior Consultant Vascular Surgeon, Cardiovascular Institute/Hospital da Luz Torres de Lisboa, Lisbon, Portugal
| | - Luis Mendes Pedro
- Senior Consultant Vascular Surgeon, Cardiovascular Institute/Hospital da Luz Torres de Lisboa, Lisbon, Portugal
- Department of Vascular Surgery, Faculty of Medicine University of Lisbon, Lisbon, Portugal
- Vascular Surgery Department, Santa Maria University Hospital, Lisbon Academic Medical Center, Lisbon, Portugal
| | - Isabel Gonçalves
- Cardiology Department, Skåne University Hospital and Clinical Sciences Malmö, Lund University, Sweden
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Editor's Choice – Prognostic Role of Pre-Operative Symptom Status in Carotid Endarterectomy: A Systematic Review and Meta-Analysis. Eur J Vasc Endovasc Surg 2020; 59:516-524. [DOI: 10.1016/j.ejvs.2020.01.022] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2019] [Revised: 12/16/2019] [Accepted: 01/16/2020] [Indexed: 01/10/2023]
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Early Outcomes of Routine Delayed Shunting in Carotid Endarterectomy for Asymptomatic Patients. Eur J Vasc Endovasc Surg 2018; 56:334-341. [DOI: 10.1016/j.ejvs.2018.06.030] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2018] [Accepted: 06/11/2018] [Indexed: 11/19/2022]
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Risk Factors Associated with Ipsilateral Ischemic Events Following Carotid Endarterectomy for Carotid Artery Stenosis. World Neurosurg 2016; 89:611-9. [DOI: 10.1016/j.wneu.2015.11.049] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2015] [Revised: 11/10/2015] [Accepted: 11/12/2015] [Indexed: 11/20/2022]
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Clinical Outcomes after Carotid Endarterectomy in Patients with Contralateral Carotid Occlusion. Ann Vasc Surg 2016; 32:83-7. [DOI: 10.1016/j.avsg.2015.10.035] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2015] [Revised: 09/15/2015] [Accepted: 10/23/2015] [Indexed: 11/18/2022]
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Low Socioeconomic Status is an Independent Risk Factor for Survival After Abdominal Aortic Aneurysm Repair and Open Surgery for Peripheral Artery Disease. Eur J Vasc Endovasc Surg 2015; 50:615-22. [DOI: 10.1016/j.ejvs.2015.07.006] [Citation(s) in RCA: 37] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2015] [Accepted: 07/03/2015] [Indexed: 11/21/2022]
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Armario P, Pinto X, Soler C, Cardona P. [Secondary prevention of ischemic non cardioembolic stroke]. CLINICA E INVESTIGACION EN ARTERIOSCLEROSIS : PUBLICACION OFICIAL DE LA SOCIEDAD ESPANOLA DE ARTERIOSCLEROSIS 2015; 27:287-300. [PMID: 25771074 DOI: 10.1016/j.arteri.2015.01.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/06/2014] [Revised: 01/15/2015] [Accepted: 01/16/2015] [Indexed: 06/04/2023]
Abstract
Stroke patients are at high risk for recurrence or new occurrence of other cardiovascular events or cardiovascular mortality. It is estimated that a high percentage of non-cardioembolic ischemic stroke can be prevented by a suitable modification of lifestyle (diet and exercise), reducing blood pressure (BP) with antihypertensive medication, platelet aggregation inhibitors, statins and high intake reducing consumption of. Unfortunately the degree of control of the different risk factors in secondary prevention of stroke is low. The clinical practice guidelines show clear recommendations with corresponding levels of evidence, but only if implemented in a general way they will get a better primary and secondary stroke prevention.
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Affiliation(s)
- Pedro Armario
- Servicio de Atención Integrada Riesgo Vascular, Hospital Moisés Broggi-Consorci Sanitari Integral, Sant Joan Despí, Barcelona, España; Servicio de Medicina Interna, Hospital Moisés Broggi-Consorci Sanitari Integral, Sant Joan Despí, Barcelona, España.
| | - Xavier Pinto
- Tratamiento de la Dislipemia en la Prevención Secundaria del Ictus, Unidad de Lípidos y Riesgo Vascular, Servicio de Medicina Interna, Hospital Universitario de Bellvitge, l'Hospitalet de Llobregat, Barcelona, España
| | - Cristina Soler
- Unidad de Lípidos i Arteriosclerosis, Servicio de Medicina Interna, Hospital de Sta Caterina, Salt, Girona, España
| | - Pere Cardona
- Unidad de Ictus y Enfermedades Cerebrovasculares, Servicio de Neurología, Hospital Universitario de Bellvitge, l'Hospitalet de Llobregat, Barcelona, España
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Gates L, Botta R, Schlosser F, Goodney P, Fokkema M, Schermerhorn M, Sarac T, Indes J. Characteristics that define high risk in carotid endarterectomy from the Vascular Study Group of New England. J Vasc Surg 2015; 62:929-36. [PMID: 26054590 DOI: 10.1016/j.jvs.2015.04.398] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2014] [Accepted: 04/17/2015] [Indexed: 11/28/2022]
Abstract
OBJECTIVE The Stenting with Angioplasty and Protection in Patients at High Risk for Endarterectomy (SAPPHIRE) trial compared carotid endarterectomy (CEA) to carotid artery stenting (CAS) among high-risk patients using a model of risk that has not been validated by previous publications. The objective of our study was to determine the accuracy of this high-risk model and to determine the true risk factors that result in patients being at high risk for CEA. METHODS Prospectively collected data for 3098 CEAs between 2003 and 2011 at 20 Vascular Surgery Group of New England (VSGNE) centers were used. SAPPHIRE general inclusion criteria and primary outcomes were assessed. Factors that were associated with the primary outcome by analysis of variance (P < .10) and not linearly dependent, as determined by a Pearson correlation analysis, were further assessed for an independent association by multivariate logistic regression. A risk index model was developed for these significant predictors to accurately define high-risk CEA. RESULTS The average patient age was 69.9 ± 9.5 years, 60% were male, and 45.7% were asymptomatic. The 1-year composite outcome event rate, defined as postoperative myocardial infarction and stroke or death, was 14.2%. Multivariate analysis (P < .05) found the following independently significant risk factors: age in years (95% confidence interval [CI], 1.0-1.1; P < .001), preadmission living in a nursing home (95% CI, 1.2-6.6; P = .020), congestive heart failure (95% CI, 1.4-2.8; P < .001), diabetes mellitus (DM; 95% CI, 1.1-1.3; P < .001), chronic obstructive pulmonary disease (95% CI, 1.2-1.5; P < .001), any previous cerebrovascular disease (95% CI, 1.1-1.9; P = .003), and contralateral internal carotid artery stenosis (95% CI, 1.0-1.2; P = .001). Three of the SAPPHIRE high-risk criteria-abnormal stress test, recurrent stenosis after CEA, and previous radiotherapy to the neck-were not independently associated with an adverse outcome. Independently significant risk factors not included in the SAPPHIRE criteria are inclusion of ages <80 years, preadmission living in a nursing home, DM, contralateral carotid stenosis, and any previous cerebrovascular accident. The risk index predictors are age in years (40-49: 0 points; 50-59: 2 points; 60-69: 4 points; 70-79: 6 points; 80-89: 8 points), living in a nursing home (4 points), any cardiovascular disease (2 points), congestive heart failure (5 points), chronic obstructive pulmonary disease (3 points), DM (2 points), degree of contralateral stenosis (<50%: 0 points; 50%-69%: 1 point; 70%-near occlusion: 2 points; occlusion: 3 points). High-risk CEA is defined as >13 points, representing adverse outcome rate of 22.5%. CONCLUSIONS SAPPHIRE and other previously reported high-risk CAS inclusion criteria do not include all of the factors found to be independently associated with outcomes. Further studies are required to determine whether CAS is inferior to CEA in high-risk patients using a validated model of risk. In addition, this preoperative assessment includes novel criteria that can be used to stratify risks.
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Affiliation(s)
- Lindsay Gates
- Department of Vascular Surgery, Yale University School of Medicine, New Haven, Conn.
| | - Robert Botta
- Department of Vascular Surgery, Yale University School of Medicine, New Haven, Conn
| | - Felix Schlosser
- Department of Vascular Surgery, Yale University School of Medicine, New Haven, Conn
| | - Philip Goodney
- Department of Vascular Surgery, Dartmouth-Hitchcock Medical Center, Lebanon, NH
| | - Margriet Fokkema
- Department of Vascular and Endovascular Surgery, Beth Israel Deaconess Medical Center, Boston, Mass
| | - Marc Schermerhorn
- Department of Vascular and Endovascular Surgery, Beth Israel Deaconess Medical Center, Boston, Mass
| | - Timur Sarac
- Department of Vascular Surgery, Yale University School of Medicine, New Haven, Conn
| | - Jeffrey Indes
- Department of Vascular Surgery, Yale University School of Medicine, New Haven, Conn
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Chen Y, Song G, Jiao L, Wang Y, Ma Y, Ling F. A study of carotid endarterectomy in a Chinese population: Initial experience at a single center. Clin Neurol Neurosurg 2014; 126:88-92. [DOI: 10.1016/j.clineuro.2014.08.025] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2014] [Revised: 08/19/2014] [Accepted: 08/23/2014] [Indexed: 10/24/2022]
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Paraskevas KI, Veith FJ. The indications of carotid artery stenting in symptomatic patients may need to be reconsidered. Ann Vasc Surg 2014; 29:154-9. [PMID: 25305422 DOI: 10.1016/j.avsg.2014.08.010] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2014] [Revised: 08/26/2014] [Accepted: 08/29/2014] [Indexed: 10/24/2022]
Abstract
According to the 2011 and the 2014 updated American Heart Association/American Stroke Association Guidelines, carotid artery stenting (CAS) is indicated as an alternative to carotid endarterectomy (CEA) for the management of symptomatic carotid patients. According to these recommendations, CAS is preferred to CEA in symptomatic patients with specific technical, anatomic, or physiological characteristics that render these individuals at "high risk" for surgery (e.g., contralateral carotid occlusion, previous neck irradiation, recurrent carotid stenosis, and so forth). This article presents emerging data suggesting that most of these criteria do not comprise contraindications for CEA. In fact, CEA is associated with similar (or even better) outcomes compared with CAS in many such "high-risk" patients. Based on these results, the indications of CAS in symptomatic patients may need to be reconsidered.
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Affiliation(s)
| | - Frank J Veith
- Division of Vascular Surgery, New York University Langone Medical Center, New York, NY; Division of Vascular Surgery, The Cleveland Clinic, Cleveland, OH
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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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Cervical Carotid Disease: Carotid Endarterectomy and Stenting. World Neurosurg 2014; 81:257-60. [DOI: 10.1016/j.wneu.2013.01.085] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2012] [Accepted: 01/19/2013] [Indexed: 11/18/2022]
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Samson RH, Cline JL, Showalter DP, Lepore MR, Nair DG. Contralateral carotid artery occlusion is not a contraindication to carotid endarterectomy even if shunts are not routinely used. J Vasc Surg 2013; 58:935-40. [PMID: 24075103 DOI: 10.1016/j.jvs.2013.04.011] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2013] [Revised: 04/04/2013] [Accepted: 04/05/2013] [Indexed: 11/25/2022]
Abstract
OBJECTIVE Although controversial, carotid artery stenting (CAS) has been proposed as being safer than carotid endarterectomy (CEA) for patients with a contralateral internal carotid occlusion (CCO). Arguably, with a CCO, CAS should be even safer than CEA if a shunt is not used. Accordingly, we reviewed our experience with 2183 CEAs performed routinely without a shunt to evaluate the risk of CEA performed in a subset of 147 patients with a CCO. METHODS Between 1988 and 2011, 147 CEAs (111 men [75%], 36 women [25%]) were routinely performed without a shunt despite CCO. Of these patients, 76% were asymptomatic. CEAs were performed by seven surgeons using standard techniques (not eversion), with patients under general anesthesia and blood pressure maintained at >130 mm Hg. All patients received heparin (7500 U), and protamine reversal was routine. Median cross-clamp time was 20 minutes (range, 14-40 minutes). RESULTS Three neurologic events occurred ≤ 30 days (2.0%). One transient ischemic attack (TIA) occurred immediately, and one occurred on the first postoperative day due to occlusion of the endarterectomy site. One patient sustained an immediate stroke and died of a large computed tomography-documented atheroembolic shower. CONCLUSIONS Our data demonstrate the safety of CEA in the presence of a CCO, even when performed without a shunt. It is unlikely that the stroke or delayed TIA could be attributed to nonshunting or CCO. Even if so, the stroke and death rates would be lower than those previously reported for patients undergoing CEA in the presence of a CCO. This may be due to short cross-clamp times, careful technique, general anesthesia, and blood pressure support. Given these low adverse event rates, our experience refutes the assumption that patients with a CCO are at such a high risk for CEA that the only alternative is CAS.
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Affiliation(s)
- Russell H Samson
- Sarasota Vascular Specialists, affiliated with Florida State University Medical School, Sarasota, Fla
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Ullery BW, Orlova K, Shang EK, Jackson BM, Wang GJ, Fairman RM, Woo EY. Results of carotid angioplasty and stenting are equivalent for critical versus high-grade lesions in patients deemed high risk for carotid endarterectomy. J Surg Res 2013; 185:21-6. [PMID: 23953786 DOI: 10.1016/j.jss.2013.07.027] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2013] [Revised: 07/11/2013] [Accepted: 07/12/2013] [Indexed: 10/26/2022]
Abstract
BACKGROUND To examine outcomes of carotid angioplasty and stenting (CAS) in patients with critical carotid stenosis who are deemed high risk for carotid endarterectomy. METHODS Medical records were retrospectively analyzed for patients undergoing CAS between September 2002 and March 2011 at a single institution. Patients were classified as having either critical (≥ 90%) or high-grade (70%-89%) carotid stenosis based on angiography. The primary composite end point was stroke, myocardial infarction, or death from any cause during the periprocedural period or any ipsilateral stroke during the follow-up period. RESULTS A total of 245 patients underwent 257 CAS procedures during the study period. Fifty-one percentage (n = 130) of cases involved critical stenosis (66.2% male; mean age, 71 ± 10 y), with the remaining group (n = 127) involving high-grade stenosis (67.7% male; mean age, 71 ± 9 y). Symptomatic carotid disease was present in 25% of the critical stenosis and 31% of the high-grade stenosis groups (P = 0.33). Chronic obstructive pulmonary disease was more commonly found in the high-grade stenosis group (20% versus 8%, P = 0.01). No difference was observed between the groups relative to other baseline demographic characteristics, presence of contralateral carotid occlusion, stent diameter or length, maximum balloon diameter or length, use of embolic protection device, or procedural duration. Technical success was achieved in all cases. There was no difference in the need to predilate before the introduction of the filter or stent based on the degree of stenosis. We found no difference in the primary composite end point between the high-grade or critical stenosis groups (7.1% versus 7.7%, P = 0.74), or there were no differences between the individual components of the composite end point. Mid-term survival was similar between the two groups at a mean follow-up period of 2.4 y. CONCLUSIONS Despite concerns regarding the potential for increased neurologic complications, our data demonstrate that patients with high-grade and critical stenosis are able to safely undergo CAS and achieve similar periprocedural outcomes and mid-term prognosis.
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Affiliation(s)
- Brant W Ullery
- Division of Vascular Surgery and Endovascular Therapy, Department of Surgery, University of Pennsylvania, Philadelphia, Pennsylvania
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Serrone JC, Andaluz N, Brink V, Zuccarello M, Ware SL. Systemic infusion and local irrigation with argatroban effective in preventing clot formation during carotid endarterectomy in a patient with heparin-induced thrombocytopenia. World Neurosurg 2013; 80:222.e15-8. [PMID: 23321376 DOI: 10.1016/j.wneu.2013.01.037] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2011] [Revised: 12/13/2012] [Accepted: 01/10/2013] [Indexed: 10/27/2022]
Abstract
BACKGROUND A therapeutic dilemma exists when patients with symptomatic carotid stenosis and concomitant heparin-induced thrombocytopenia (HIT) are advised to urgently undergo carotid endarterectomy (CEA) with heparin therapy. METHODS After a 63-year-old man with HIT and multiple medical comorbidities underwent emergent coronary artery bypass grafting, postoperative imaging revealed plaque at the origin of the left internal carotid artery with 80%-99% stenosis and minimal contralateral internal carotid artery disease. During the patient's evaluation to undergo CEA for symptomatic high-grade carotid stenosis, enzyme-linked immunosorbent assay revealed persistent platelet factor 4 antibodies. RESULTS The endarterectomy was successfully performed while the patient received argatroban, both as a continuous infusion and intermittent irrigation during dissection of the plaque. Postoperatively, the drip was continued for 24 hours, and the patient was discharged day 2 on a daily dose of 325 mg of aspirin. At the 6-month examination, Doppler ultrasound revealed normal anterograde velocities with no evidence of stenosis, and the patient noted no subsequent ischemic events. CONCLUSIONS We now recommend systemic intravenous and local argatroban irrigation to prevent thromboembolic complications in CEA cases with HIT and renal insufficiency. Bivalirudin for both systemic intravenous use and local irrigation may be safer in patients without renal insufficiency because of its shorter half-life.
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Affiliation(s)
- Joseph C Serrone
- Department of Neurosurgery, University of Cincinnati College of Medicine and Comprehensive Stroke Center at University of Cincinnati Neuroscience Institute, Cincinnati, Ohio, USA
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Matsumura JS, Gray W, Chaturvedi S, Yamanouchi D, Peng L, Verta P. Results of carotid artery stenting with distal embolic protection with improved systems: Protected Carotid Artery Stenting in Patients at High Risk for Carotid Endarterectomy (PROTECT) trial. J Vasc Surg 2012; 55:968-976.e5. [DOI: 10.1016/j.jvs.2011.10.120] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2011] [Revised: 09/21/2011] [Accepted: 10/17/2011] [Indexed: 10/14/2022]
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Buszman PP, Szymański R, Dębiński M, Milewski K, Król M, Nowakowski P, Kiesz RS, Radvany MG, Wiernek S, Wiernek B, Buszman PE. Long-term results of cephalad arteries percutanoeus transluminal angioplasty with stent implantation (The CAPTAS registry). Catheter Cardiovasc Interv 2012; 79:532-40. [PMID: 22311860 DOI: 10.1002/ccd.23391] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/13/2010] [Revised: 09/19/2011] [Accepted: 10/02/2011] [Indexed: 11/12/2022]
Abstract
INTRODUCTION Carotid artery stenting (CAS) has become an alternative to carotid endarterectomy. Moreover, percutaneous transluminal angioplasty (PTA) allows other cephalad arteries revascularization. The aim of this study was to evaluate late outcomes of cephalad arteries PTA. METHODS This is an international multicenter registry of 434 consecutive patients in which 497 PTAs were performed. Patients with symptomatic >50% stenosis or asymptomatic >70% stenosis were enrolled. Stenting of 577 internal carotid arteries (ICA) and 13 common carotid arteries was performed, 20.7% procedures were complex in which bilateral carotid stenoses or carotid and vertebral arteries stenoses were revascularized at one stage. In 15.9% patients, one-stage coronary intervention was carried out. Distal protection devices were used in 69.6% of cases. PTAs were divided into high (n = 330) and low (n = 167) risk of major adverse coronary and cerebral events (MACCE). RESULTS At 30 days, there were 15 (3.5%) cases of MACCE [0.9% deaths, 2.1% strokes, and 0.9% myocardial infarction (MI)]. TIAs were observed in 15 (3.9%) patients. There was no significant difference in stroke incidence between procedures with or without neuroprotection (1.8 vs. 3%; P = 0.66) as well as in MACCE occurrence between high and low-risk groups (4.3 vs. 2%; P = 0.34). Bilateral stenoses increased while hypertension decreased the risk of MACCE. Left ICA lesions increased the risk of cerebrovascular accidents (CVA). At 4 years (1-11 years), the mortality rate was 11.5%, 6% of patients had stroke, and 3% MIs. Restenosis occurred in 3%. There was a trend toward higher mortality rate (13.3 vs. 6.9%; P = 0.07) and MACCE risk in high-risk group (23.5 vs.14.7% P = 0.06). Age > 65 y.o. and stent length < 24 mm increased, while the statin therapy on admission decreased the risk of long-term death. Structural valve disease and stent length <30 mm increased the risk of MACCE, while implantation of Acculink stent decreased the risk of CVA. CONCLUSIONS CAS is safe and successful procedure with low early and long-term adverse events. Special attention should be put on patients with bilateral and left ICA stenoses. If possible, longer stents should be applied.
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Yun WS, Kwun WH, Suh BY. The early and mid-term results of carotid artery stenting in high-risk patients. JOURNAL OF THE KOREAN SURGICAL SOCIETY 2011; 80:283-8. [PMID: 22066049 PMCID: PMC3204673 DOI: 10.4174/jkss.2011.80.4.283] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/22/2010] [Accepted: 08/12/2010] [Indexed: 11/30/2022]
Abstract
PURPOSE This study aimed to investigate early and mid-term outcomes of carotid artery stenting (CAS). METHODS We retrospectively reviewed 111 patients who were treated for carotid stenosis between October 2004 and December 2009 (42 CASs and 69 carotid endarterectomies [CEAs]). RESULTS CAS group was older than CEA group (70 years vs. 67 years, P = 0.001). Coronary artery disease and high lesion above the 2nd cervical vertebral body were more common in CAS group (29% vs. 13%, P = 0.002; 4% vs. 24%, P = 0.004). The 30-days stroke rate was higher in CAS group (10% vs. 1% in CEA group, P = 0.067, Fisher's exact test). New brain lesions on diffusion-weighted magnetic resonance imaging were more common in CAS group (48% vs. 20% in CEA group, P = 0.002, chi-square test). The 1-, 3-year freedom from stroke were 91%, 84% in CAS group and 99%, 99% in CEA group (P = 0.007, log-rank test). Univariate analysis showed that female gender and age > 70 years were related with postprocedural neurological complications (P = 0.046 and P = 0.007, log-rank test). However, none were independent risk factors on multivariate analysis. CONCLUSION In our series, the rates of peri-procedural neurological complications in CAS group were significantly high. These results suggest that more experience and restricted patient selection will be needed for CAS.
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Affiliation(s)
- Woo-Sung Yun
- Department of Surgery, Yeungnam University College of Medicine, Daegu, Korea
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Gonzalez A, Drummond M, McCord S, Garrett HE. Carotid endarterectomy for treatment of in-stent restenosis. J Vasc Surg 2011; 54:1167-9. [DOI: 10.1016/j.jvs.2011.04.009] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2011] [Revised: 03/31/2011] [Accepted: 04/04/2011] [Indexed: 11/25/2022]
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Brott TG, Halperin JL, Abbara S, Bacharach JM, Barr JD, Bush RL, Cates CU, Creager MA, Fowler SB, Friday G, Hertzberg VS, McIff EB, Moore WS, Panagos PD, Riles TS, Rosenwasser RH, Taylor AJ. 2011 ASA/ACCF/AHA/AANN/AANS/ACR/ASNR/CNS/SAIP/SCAI/SIR/SNIS/SVM/SVS Guideline on the Management of Patients With Extracranial Carotid and Vertebral Artery Disease. J Am Coll Cardiol 2011; 57:e16-94. [PMID: 21288679 DOI: 10.1016/j.jacc.2010.11.006] [Citation(s) in RCA: 194] [Impact Index Per Article: 14.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
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Brott TG, Halperin JL, Abbara S, Bacharach JM, Barr JD, Bush RL, Cates CU, Creager MA, Fowler SB, Friday G, Hertzberg VS, McIff EB, Moore WS, Panagos PD, Riles TS, Rosenwasser RH, Taylor AJ. 2011 ASA/ACCF/AHA/AANN/AANS/ACR/ASNR/CNS/SAIP/SCAI/SIR/SNIS/SVM/SVS guideline on the management of patients with extracranial carotid and vertebral artery disease. Stroke 2011; 42:e464-540. [PMID: 21282493 DOI: 10.1161/str.0b013e3182112cc2] [Citation(s) in RCA: 96] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
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Brott TG, Halperin JL, Abbara S, Bacharach JM, Barr JD, Bush RL, Cates CU, Creager MA, Fowler SB, Friday G, Hertzberg VS, McIff EB, Moore WS, Panagos PD, Riles TS, Rosenwasser RH, Taylor AJ. 2011 ASA/ACCF/AHA/AANN/AANS/ACR/ASNR/CNS/SAIP/SCAI/SIR/SNIS/SVM/SVS guideline on the management of patients with extracranial carotid and vertebral artery disease. A report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines, and the American Stroke Association, American Association of Neuroscience Nurses, American Association of Neurological Surgeons, American College of Radiology, American Society of Neuroradiology, Congress of Neurological Surgeons, Society of Atherosclerosis Imaging and Prevention, Society for Cardiovascular Angiography and Interventions, Society of Interventional Radiology, Society of NeuroInterventional Surgery, Society for Vascular Medicine, and Society for Vascular Surgery. Circulation 2011; 124:e54-130. [PMID: 21282504 DOI: 10.1161/cir.0b013e31820d8c98] [Citation(s) in RCA: 59] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
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Chiriano J, Abou-Zamzam AM, Nguyen K, Molkara AM, Zhang WW, Bianchi C, Teruya TH. Preoperative Carotid Duplex Findings Predict Carotid Stump Pressures During Endarterectomy in Symptomatic But Not Asymptomatic Patients. Ann Vasc Surg 2010; 24:1038-44. [DOI: 10.1016/j.avsg.2010.05.014] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2010] [Revised: 05/05/2010] [Accepted: 05/21/2010] [Indexed: 11/30/2022]
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Raabe RD, Burr RB, Short R. One-year Cognitive Outcomes Associated with Carotid Artery Stent Placement. J Vasc Interv Radiol 2010; 21:983-8; quiz 989. [DOI: 10.1016/j.jvir.2010.03.011] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2009] [Revised: 03/09/2010] [Accepted: 03/12/2010] [Indexed: 10/19/2022] Open
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Illuminati G, Ricco JB, Greco C, Mangieri E, Calio' F, Ceccanei G, Pacilè M, Schiariti M, Tanzilli G, Barillà F, Paravati V, Mazzesi G, Miraldi F, Tritapepe L. Systematic Preoperative Coronary Angiography and Stenting Improves Postoperative Results of Carotid Endarterectomy in Patients with Asymptomatic Coronary Artery Disease: A Randomised Controlled Trial. Eur J Vasc Endovasc Surg 2010; 39:139-45. [DOI: 10.1016/j.ejvs.2009.11.015] [Citation(s) in RCA: 47] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2009] [Accepted: 11/15/2009] [Indexed: 10/20/2022]
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Morales MM, Anacleto A, Buchdid MA, Simeoni PRB, Ledesma S, Cêntola C, Anacleto JC, Aldrovani M, Piccinato CE. Morphological and hemodynamic patterns of carotid stenosis treated by endarterectomy with patch closure versus stenting: a duplex ultrasound study. Clinics (Sao Paulo) 2010; 65:1315-23. [PMID: 21340221 PMCID: PMC3020343 DOI: 10.1590/s1807-59322010001200015] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/26/2010] [Accepted: 09/27/2010] [Indexed: 11/23/2022] Open
Abstract
OBJECTIVES A duplex ultrasound study was performed to investigate morphological and hemodynamic patterns of carotid stenoses treated by endarterectomy with patch closure versus stenting. MATERIALS AND METHOD Twenty-nine carotid stenoses were treated with stenting and 65 with patch closure. Duplex ultrasound parameters (luminal diameter, mm; peak systolic velocity and end-diastolic velocity, cm/s) were measured 24 hours after the procedures and also at 12 months post-procedure. Residual stenoses (immediately postprocedure) and restenoses (within 12 months of procedure) were defined as narrowings of ≥ 50% on duplex ultrasound examination. RESULTS In stented patients, the luminal diameter of the proximal internal carotid artery increased in the interval between the 24-hour and 12-month post-procedure studies, while in the patch closure patients, the diameter decreased. Carotid hemodynamics normalized immediately after both patching and stenting and remained relatively stable thereafter up to 12 months. No statistically elevated flow velocities (in the absence of residual stenosis or restenosis) were observed in the patched or stented carotid arteries. No significant differences in residual stenosis rates were observed between the stenting group (3 cases, 10.34%) and the patch closure group (1 case, 1.53%, P = 0.08). At 12 months, 2 stenting patients (6.88%) and 2 patch closure patients (3.07%) had $50% restenosis (P = 0.58). One case of late stroke due to restenosis was observed in the stenting group; the patient died 12 months postoperatively, before receiving new intervention. CONCLUSION Measurements over time in luminal diameter signalized differences in arterial remodeling mechanisms between patched and stented carotids. Both stenting and patch closure were associated with carotid patency and flow restoration. This study does not support a general approach to new velocity criteria indiscriminately applied to stented or patched carotids.
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Gray WA, Chaturvedi S, Verta P. Thirty-Day Outcomes for Carotid Artery Stenting in 6320 Patients From 2 Prospective, Multicenter, High-Surgical-Risk Registries. Circ Cardiovasc Interv 2009; 2:159-66. [PMID: 20031712 DOI: 10.1161/circinterventions.108.823013] [Citation(s) in RCA: 105] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background—
The American Heart Association has established guidelines for acceptable 30-day death and stroke rates for patients with severe carotid disease undergoing standard-risk carotid endarterectomy: <3% for asymptomatic lesions and <6% for symptomatic lesions. To date, carotid artery stenting has not demonstrated these outcomes in multicenter, prospective assessments of high-surgical-risk patients.
Methods and Results—
Data from 2 prospective, multicenter (280 US sites, 672 operators), postmarket surveillance studies in high-surgical-risk patients were analyzed: 2145 patients from the Emboshield and Xact Post Approval Carotid Stent Trial (EX) and 4175 patients from the Carotid ACCULINK/ACCUNET Post Approval Trial to Uncover Rare Events (C2). Both studies had pre- and postprocedure neurological evaluation and independent adjudication of neurological events. The overall 30-day death and stroke rate was 4.1% (95% CI, 3.3% to 5.0%) for EX and 3.4% (95% CI, 2.9% to 4.0%) for C2. In the population comparable with American Heart Association guidelines (<80 years), the combined 30-day death and stroke rate was 5.3% (95% CI, 3.6% to 7.4%) for symptomatic patients and 2.9% (95% CI, 2.4% to 3.4%) for asymptomatic patients, independent of unfavorable risk factors (anatomic or physiologic); in patients ≥80 years, this rate was 10.5% (95% CI, 6.3% to 16.0%) and 4.4% (95% CI, 3.3% to 5.7%), respectively. In subjects with anatomic features unfavorable for surgery, the 30-day death and stroke rates were 1.7% (95% CI, 0.0% to 8.9%) and 2.7% (95% CI, 1.3% to 4.9%) for symptomatic and asymptomatic cohorts, respectively, independent of age.
Conclusions—
Outcomes for carotid artery stenting in nonoctogenarian high-surgical-risk patients have improved since the pivotal Food and Drug Administration approval trials, and have achieved American Heart Association standards in both symptomatic and asymptomatic lesions.
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Affiliation(s)
- William A. Gray
- From the Center for Interventional Vascular Therapy (W.A.G.), Columbia University, New York, NY; Department of Neurology and Stroke Program (S.C.), Wayne State University, Detroit, Mich; and Abbott Vascular (P.V.), Endovascular Global Clinical Science, Santa Clara, Calif
| | - Seemant Chaturvedi
- From the Center for Interventional Vascular Therapy (W.A.G.), Columbia University, New York, NY; Department of Neurology and Stroke Program (S.C.), Wayne State University, Detroit, Mich; and Abbott Vascular (P.V.), Endovascular Global Clinical Science, Santa Clara, Calif
| | - Patrick Verta
- From the Center for Interventional Vascular Therapy (W.A.G.), Columbia University, New York, NY; Department of Neurology and Stroke Program (S.C.), Wayne State University, Detroit, Mich; and Abbott Vascular (P.V.), Endovascular Global Clinical Science, Santa Clara, Calif
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Rerkasem K, Rothwell PM. Temporal Trends in the Risks of Stroke and Death due to Endarterectomy for Symptomatic Carotid Stenosis: An Updated Systematic Review. Eur J Vasc Endovasc Surg 2009; 37:504-11. [PMID: 19297217 DOI: 10.1016/j.ejvs.2009.01.011] [Citation(s) in RCA: 35] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2008] [Accepted: 01/21/2009] [Indexed: 11/29/2022]
Affiliation(s)
- K Rerkasem
- Vascular Surgery Division, Department of Surgery, Faculty of Medicine, Chiang Mai University, Chiang Mai, Thailand
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Abstract
BACKGROUND AND PURPOSE Recent advances in stroke treatment created a need for a consensus statement by industry experts detailing elements of quality stroke care. In 2005, the brain attack coalition published recommendations outlining elements constituting the highest level of stroke care, the comprehensive stroke center. Unlike primary level stroke care, comprehensive center recommendations have not resulted in creation of a corresponding national certification process-largely owing to difficulties in establishing quality metrics. The authors proposed 13 comprehensive quality measures and assessed them at a tertiary referral, teaching hospital in Houston, Texas. METHODS Proposed metrics were derived from the 2005 brain attack coalition's comprehensive center guidelines. Outcomes measures included morbidity and mortality rates for stroke, cerebral aneurysm, carotid endarerectomy, and stent patients. Process measures included timeliness of brain imaging interpretation, timeliness and consideration of antiplatelet treatment regimes for carotid stent patients, and documentation of National Institutes of Health Stroke Score. Metrics were defined by international classification of disease codes with accompanying inclusion and exclusion criteria. RESULTS Internal quality was benchmarked against Primary Stroke Center, research literature, and University Health Consortium rates. Baseline data revealed significant opportunities for improvement in the categories of imaging interpretation timeliness and National Institutes of Health Stroke Score documentation. All other measures fell within expected ranges. CONCLUSIONS Assessment of quality outcomes is the basis for disease-specific certification. Institutions that claim comprehensive capabilities must demonstrate high standards of performance on uniform validated quality metrics. The authors demonstrate the feasibility of operationalizing the metrics outlined in Brain Attack Coalition's comprehensive stroke center recommendations.
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Unnikrishnan M, Siddappa S, Anto R, Babu V, Paul B, Kapilamoorthy TR, Sivasankaran S, Sandhyamani S, Sreedhar R, Radhakrishnan K. Experiences with carotid endarterectomy at Sree Chitra Tirunal Institute. Ann Indian Acad Neurol 2008; 11:170-8. [PMID: 19893664 PMCID: PMC2771972 DOI: 10.4103/0972-2327.42937] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2008] [Revised: 07/03/2008] [Accepted: 07/08/2008] [Indexed: 11/22/2022] Open
Abstract
Background: Atherosclerotic carotid artery disease poses a grave threat to cerebral circulation, leading to a stroke with its devastating sequelae, if left untreated. Carotid endarterectomy has a proven track record with compelling evidence in stroke prevention. Objectives: a) To confirm that carotid endarterectomy (CEA) is safe and effective in preventing stroke at both short and long term. b) to demonstrate long term patency of internal carotid artery when arteriotomy repair is performed using autologous saphenous vein patch. Materials and Methods: During ten years, from September 1997 to February 2008, thirty nine patients who underwent consecutive carotid endarterectomy at our institute, form the basis of this report. Their age ranged from thirty to seventy eight years, with a mean age of 56. There were four women in this cohort. Thirty seven patients were symptomatic with >70% stenosis and two were asymptomatic with >80% stenosis, incidentally detected. Imaging included Duplex scan and MRA for carotid territory and brain, and non-invasive cardiac assessment. Co-morbidities included smoking, hypertension, diabetes, and coronary artery disease. Carotid Endarterectomy was performed under general anaesthesia, using carotid shunt and vein patch arteriotomy repair. Results: All the patients made satisfactory recovery, without major adverse cerebral events in this series. Morbidities included Transient Ischemic Attack (TIA) in two, needing only medications in one, and carotid stenting in the other. Minor morbidities included neck hematoma in two and transient hypoglossal paresis in three patients. Yearly follow-up included duplex scan assessment for all the patients. Two patients died of contralateral stroke, two of myocardial events and two were lost to follow up. Thirty three patients are well and free of the disease during the follow up of three to 120 months. Conclusion: Carotid endarterectomy provided near total freedom from adverse cerebral events and its catastrophic sequelae, leading to excellent outcome, both short as well as long term.
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Moussa ID. The CABARNET trial more evidence...but what's next? Catheter Cardiovasc Interv 2008; 71:961-2. [PMID: 18500701 DOI: 10.1002/ccd.21626] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
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