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Squizzato F, Piazza M, Turcatel A, Colacchio EC, Grego F, Antonello M. Effect of plaque morphological characteristics on the outcomes of carotid artery stenting. THE JOURNAL OF CARDIOVASCULAR SURGERY 2023; 64:561-569. [PMID: 38015553 DOI: 10.23736/s0021-9509.23.12763-7] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/29/2023]
Abstract
Carotid artery stenting (CAS) represents today an accepted option for the treatment of severe carotid artery stenosis. The evolution of materials, techniques, perioperative medical management and patients' selection, has allowed to progressively reduce CAS complications. However, the main drawback of CAS is still represented by the risk of cerebral embolization, that may occur during several steps of the procedure and also in the early postoperative period. Preoperative carotid plaque morphological characteristics may have a great role in determining the risk of embolization during CAS. This review summarizes the current knowledge on carotid plaque characteristics that may influence the risk of complication during CAS. This information may be important for the optimization of CAS patients' selection and adaptation of the materials and techniques.
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Affiliation(s)
- Francesco Squizzato
- Division of Vascular and Endovascular Surgery, Department of Cardiac, Thoracic Vascular Sciences and Public Health, School of Medicine, University of Padua, Padua, Italy -
| | - Michele Piazza
- Division of Vascular and Endovascular Surgery, Department of Cardiac, Thoracic Vascular Sciences and Public Health, School of Medicine, University of Padua, Padua, Italy
| | - Alessandra Turcatel
- Division of Vascular and Endovascular Surgery, Department of Cardiac, Thoracic Vascular Sciences and Public Health, School of Medicine, University of Padua, Padua, Italy
| | - Elda C Colacchio
- Division of Vascular and Endovascular Surgery, Department of Cardiac, Thoracic Vascular Sciences and Public Health, School of Medicine, University of Padua, Padua, Italy
| | - Franco Grego
- Division of Vascular and Endovascular Surgery, Department of Cardiac, Thoracic Vascular Sciences and Public Health, School of Medicine, University of Padua, Padua, Italy
| | - Michele Antonello
- Division of Vascular and Endovascular Surgery, Department of Cardiac, Thoracic Vascular Sciences and Public Health, School of Medicine, University of Padua, Padua, Italy
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MRI Outcomes Achieved by Simple Flow Blockage Technique in Symptomatic Carotid Artery Stenosis Stenting. J Pers Med 2022; 12:jpm12101564. [PMID: 36294703 PMCID: PMC9604835 DOI: 10.3390/jpm12101564] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2022] [Revised: 09/14/2022] [Accepted: 09/16/2022] [Indexed: 11/30/2022] Open
Abstract
In this study, we aimed to determine the frequency and clinical impact of new ischemic lesions detected with diffusion-weighted-imaging-MRI (DWI-MRI) as well as the clinical outcomes after carotid artery stenting (CAS) using the simple flow blockage technique (SFB). This is a retrospective study with data extraction from a monocentric prospective clinical registry (from 2017 to 2019) of consecutive patients admitted for symptomatic cervical ICA stenosis or web. Herein, patients benefited from DWI-MRI before and within 48 h of CAS for symptomatic ICA stenosis or web. The primary endpoint was the frequency of new DWI-MRI ischemic lesions and the secondary (composite) endpoint was the rate of mortality, symptomatic stroke or acute coronary syndrome within 30 days of the procedure. All of the 82 CAS procedures were successfully performed. Among the 33 patients (40.2%) with new DWI-MRI ischemic lesions, 30 patients were asymptomatic (90.9%). Irregular carotid plaque surface with (n = 13, 44.8%) or without ulceration (n = 12, 60.0%) was associated with higher rates of new DWI-MRI lesions by comparison to patients with a regular plaque (n = 7, 25%) (p = 0.048) using the univariate analysis. Less than half of this CAS cohort using the SFB technique had new ischemic lesions detected with DWI-MRI. Among these patients, more than 90% were asymptomatic. Irregularity of the plaque seems to increase the risk of peri-procedural DWI-MRI lesions.
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Gong W, Zhang X, Meng Z, Liu F, Li G, Xiao J, Liu P, Sun Y, Liu T, Wang H, Zhang Y, Wang N. Factors Influencing the Outcome of Symptomatic Intracranial Artery Stenosis With Hemodynamic Impairment After Short and Long-Term Stent Placement. Front Neurol 2022; 13:682694. [PMID: 35655616 PMCID: PMC9152452 DOI: 10.3389/fneur.2022.682694] [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: 03/19/2021] [Accepted: 04/20/2022] [Indexed: 11/13/2022] Open
Abstract
Objective Stent placement is a feasible approach worldwidely for patients with symptomatic intracranial artery stenosis (sICAS) and hemodynamic impairment (HI) who are at high risk of recurrent stroke after medical treatment. Exploration of factors associated with poor outcomes after stent placement could help develop better individualized therapeutic strategies. Methods This study conducted a post-hoc analysis of a prospective, multicenter registry study of stent use for sICAS with HI in China. Patient and clinical demographics, and stenotic lesion images were analyzed using univariate and multivariate Cox regression to the time until any endpoints or the end of the follow-up period. The short-term endpoint included any transient ischemic attack (TIA), stroke, or death within 1 month after stent placement. The long-term endpoints included the short-term endpoints and any TIA or stroke in the region of the affected artery that occurred more than 1 month after stent placement. Results Two hundred and ninety two patients were included, with 13 short-term and 39 long-term endpoints. Multivariate Cox regression analysis revealed that lesions at the arterial origin or bifurcation (Hazard Ratio (HR) = 7.52; 95% CI, 1.89-29.82; p = 0.004) were significantly associated with higher short-term risk. Baseline renal insufficiency reduced the risk (HR = 0.08; 95% CI: 0.01-0.68; p = 0.021). Factors significantly associated with higher long-term risk included irregular or ulcerated plaques at the lesion (HR = 2.15; 95% CI: 1.07-4.33; p = 0.031). Subgroup analyses indicated that higher risk occurred in the older age group (age>59 years, HR = 3.73, 95% CI: 1.27-10.97, p = 0.017), and not in the younger group (age≤59 years, HR = 1.12, 95% CI: 0.42-3.03, p = 0.822). Conclusion Irregular or ulcerated plaques in older patients and lesions at the arterial opening or bifurcation were more likely to result in adverse endpoints for stent placement during long or short -term follow-up. Investigation of these factors might facilitate the development of individualized therapeutic strategies for this population. Clinical Trial Registration http://www.clinicaltrials.gov, identifier: NCT01968122.
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Affiliation(s)
- Wentao Gong
- Department of Neurology, The Affiliated Hospital of Qingdao University, Qingdao, China
| | - Xianjun Zhang
- Department of Neurology, The Affiliated Hospital of Qingdao University, Qingdao, China
| | - Zhen Meng
- Department of Interventional Operating Room, The Affiliated Hospital of Qingdao University, Qingdao, China
| | - Feifei Liu
- Department of General Medicine, The Affiliated Hospital of Qingdao University, Qingdao, China
| | - Guangwen Li
- Department of Neurology, The Affiliated Hospital of Qingdao University, Qingdao, China
| | - Juan Xiao
- Department of Evidence-Based Medicine, The Second Hospital of Shandong University, Jinan, China
| | - Peng Liu
- Department of Neurology, The Affiliated Hospital of Qingdao University, Qingdao, China
| | - Yujie Sun
- Department of Neurology, The Affiliated Hospital of Qingdao University, Qingdao, China
| | - Tonghui Liu
- Department of Neurology, The Affiliated Hospital of Qingdao University, Qingdao, China
| | - Hongxia Wang
- Department of Neurology, The Affiliated Hospital of Qingdao University, Qingdao, China
| | - Yong Zhang
- Department of Neurology, The Affiliated Hospital of Qingdao University, Qingdao, China
| | - Naidong Wang
- Department of Neurology, The Affiliated Hospital of Qingdao University, Qingdao, China
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Rots ML, Meershoek AJ, Bonati LH, den Ruijter HM, de Borst GJ. Editor's Choice – Predictors of New Ischaemic Brain Lesions on Diffusion Weighted Imaging After Carotid Stenting and Endarterectomy: A Systematic Review. Eur J Vasc Endovasc Surg 2019; 58:163-174. [DOI: 10.1016/j.ejvs.2019.04.016] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2018] [Revised: 04/09/2019] [Accepted: 04/14/2019] [Indexed: 12/16/2022]
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Swerdlow NJ, Jones DW, Pothof AB, O'Donnell TF, Liang P, Li C, Wyers MC, Schermerhorn ML. Three-dimensional image fusion is associated with lower radiation exposure and shorter time to carotid cannulation during carotid artery stenting. J Vasc Surg 2019; 69:1111-1120. [DOI: 10.1016/j.jvs.2018.07.038] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2018] [Accepted: 07/09/2018] [Indexed: 12/12/2022]
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Traenka C, Engelter ST, Brown MM, Dobson J, Frost C, Bonati LH. Silent brain infarcts on diffusion-weighted imaging after carotid revascularisation: A surrogate outcome measure for procedural stroke? A systematic review and meta-analysis. Eur Stroke J 2019; 4:127-143. [PMID: 31259261 DOI: 10.1177/2396987318824491] [Citation(s) in RCA: 32] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2018] [Accepted: 12/20/2018] [Indexed: 12/13/2022] Open
Abstract
Aim To investigate whether lesions on diffusion-weighted imaging (DWI+) after carotid artery stenting (CAS) or endarterectomy (CEA) might provide a surrogate outcome measure for procedural stroke. Materials and Methods Systematic MedLine® database search with selection of all studies published up to the end of 2016 in which DWI scans were obtained before and within seven days after CAS or CEA. The correlation between the underlying log odds of stroke and of DWI+ across all treatment groups (i.e. CAS or CEA groups) from included studies was estimated using a bivariate random effects logistic regression model. Relative risks of DWI+ and stroke in studies comparing CAS vs. CEA were estimated using fixed-effect Mantel-Haenszel models. Results We included data of 4871 CAS and 2099 CEA procedures (85 studies). Across all treatment groups (CAS and CEA), the log odds for DWI+ was significantly associated with the log odds for clinically manifest stroke (correlation coefficient 0.61 (95% CI 0.27 to 0.87), p = 0.0012). Across all carotid artery stenting groups, the correlation coefficient was 0.19 (p = 0.074). There were too few CEA groups to reliably estimate a correlation coefficient in this subset alone. In 19 studies comparing CAS vs. CEA, the relative risks (95% confidence intervals) of DWI+ and stroke were 3.83 (3.17-4.63, p < 0.00001) and 2.38 (1.44-3.94, p = 0.0007), respectively. Discussion This systematic meta-analysis demonstrates a correlation between the occurrence of silent brain infarcts on diffusion-weighted imaging and the risk of clinically manifest stroke in carotid revascularisation procedures. Conclusion Our findings strengthen the evidence base for the use of DWI as a surrogate outcome measure for procedural stroke in carotid revascularisation procedures. Further randomised studies comparing treatment effects on DWI lesions and clinical stroke are needed to fully establish surrogacy.
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Affiliation(s)
- Christopher Traenka
- Stroke Center and Department of Neurology, University Hospital Basel and University of Basel, Basel, Switzerland.,Neurorehabilitation Unit, University of Basel and University Center for Medicine of Aging and Rehabilitation, Felix Platter Hospital, Basel, Switzerland
| | - Stefan T Engelter
- Stroke Center and Department of Neurology, University Hospital Basel and University of Basel, Basel, Switzerland.,Neurorehabilitation Unit, University of Basel and University Center for Medicine of Aging and Rehabilitation, Felix Platter Hospital, Basel, Switzerland
| | - Martin M Brown
- Stroke Research Group, Department of Brain Repair & Rehabilitation, UCL Institute of Neurology, London, UK
| | - Joanna Dobson
- Department of Medical Statistics, Faculty of Epidemiology and Population Health, London School of Hygiene and Tropical Medicine, London, UK
| | - Chris Frost
- Department of Medical Statistics, Faculty of Epidemiology and Population Health, London School of Hygiene and Tropical Medicine, London, UK
| | - Leo H Bonati
- Stroke Center and Department of Neurology, University Hospital Basel and University of Basel, Basel, Switzerland.,Stroke Research Group, Department of Brain Repair & Rehabilitation, UCL Institute of Neurology, London, UK
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Quantitative analysis and predictors of embolic filter debris load during carotid artery stenting in asymptomatic patients. J Vasc Surg 2018; 68:109-117. [DOI: 10.1016/j.jvs.2017.09.055] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2017] [Accepted: 09/25/2017] [Indexed: 12/28/2022]
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8
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Jones DW, Brott TG, Schermerhorn ML. Trials and Frontiers in Carotid Endarterectomy and Stenting. Stroke 2018; 49:1776-1783. [PMID: 29866753 DOI: 10.1161/strokeaha.117.019496] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2017] [Revised: 04/19/2018] [Accepted: 04/30/2018] [Indexed: 11/16/2022]
Affiliation(s)
- Douglas W Jones
- From the Division of Vascular and Endovascular Surgery, Boston Medical Center, Boston University School of Medicine, MA (D.W.J.)
| | - Thomas G Brott
- Department of Neurology, Mayo Clinic, Jacksonville, FL (T.G.B.)
| | - Marc L Schermerhorn
- Division of Vascular and Endovascular Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA (M.L.S.).
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Tayal R, Khakwani MZ, Lesar B, Sinclair M, Emporelli A, Spektor V, Cohen M, Wasty N. Takeoff orientation of the major aortic arch branches irrespective of arch type: Ramifications for brachiocephalic interventions including carotid stenting. SAGE Open Med 2018; 6:2050312118776717. [PMID: 29780588 PMCID: PMC5952282 DOI: 10.1177/2050312118776717] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2018] [Accepted: 04/18/2018] [Indexed: 11/17/2022] Open
Abstract
Background: Our previous work demonstrating great ease and predictability of cannulation of the major aortic arch branches with an upwardly pointing 3DR catheter, irrespective of aortic arch type, led us to hypothesize that centering or “cresting” of these vessels must occur along the superior most aspect of the aortic arch in a curvilinear fashion. Methods: We retrospectively analyzed 111 computed tomographic scans of the chest and thoracic aorta with intravenous contrast performed at our hospital between April 2011 and May 2012 utilizing TeraRecon image reconstruction software. Four studies were excluded due to poor image quality and/or surgical changes to native aortic architecture. Results: Of the 107 studies included, 104 (97.2%) demonstrated centering of the major aortic arch branches on a curvilinear line “cresting” the superior most aspect of the aortic arch irrespective of arch type. Of the three studies that did not demonstrate this “cresting,” two were found to have aberrant right subclavian arteries associated with a type I aortic arch, and one had an aberrant right common carotid associated with a type II aortic arch. Conclusion: Operators engaging major aortic arch branches need to be mindful of the fact that these vessels are indeed centered on a line “cresting” along the superior most aspect of the aortic arch, and any algorithm that, by taking this information into account, reduces catheter manipulation in the aortic arch could potentially result in a reduction in distal atheroembolic events.
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Affiliation(s)
- Rajiv Tayal
- Divisions of Cardiology and Radiology, Cardiac Catheterization Lab, Newark Beth Israel Medical Center, Newark, NJ, USA
| | - M Zain Khakwani
- Divisions of Cardiology and Radiology, Cardiac Catheterization Lab, Newark Beth Israel Medical Center, Newark, NJ, USA
| | - Benjamin Lesar
- Divisions of Cardiology and Radiology, Cardiac Catheterization Lab, Newark Beth Israel Medical Center, Newark, NJ, USA
| | - Michael Sinclair
- Divisions of Cardiology and Radiology, Cardiac Catheterization Lab, Newark Beth Israel Medical Center, Newark, NJ, USA
| | - Afroditi Emporelli
- Divisions of Cardiology and Radiology, Cardiac Catheterization Lab, Newark Beth Israel Medical Center, Newark, NJ, USA
| | - Vadim Spektor
- Divisions of Cardiology and Radiology, Cardiac Catheterization Lab, Newark Beth Israel Medical Center, Newark, NJ, USA
| | - Marc Cohen
- Divisions of Cardiology and Radiology, Cardiac Catheterization Lab, Newark Beth Israel Medical Center, Newark, NJ, USA
| | - Najam Wasty
- Divisions of Cardiology and Radiology, Cardiac Catheterization Lab, Newark Beth Israel Medical Center, Newark, NJ, USA
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Lin C, Tang X, Shi Z, Zhang L, Yan D, Niu C, Zhou M, Wang L, Fu W, Guo D. Serum tumor necrosis factor α levels are associated with new ischemic brain lesions after carotid artery stenting. J Vasc Surg 2018; 68:771-778. [PMID: 29567026 DOI: 10.1016/j.jvs.2017.11.085] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2017] [Accepted: 11/13/2017] [Indexed: 10/17/2022]
Abstract
OBJECTIVE New diffusion-weighted imaging (DWI) lesions on magnetic resonance imaging (MRI) after carotid artery stenting (CAS) are associated with an increased risk of future cerebrovascular events. Therefore, we evaluated the association between the expression levels of serum inflammatory markers and new DWI lesions after CAS and the presence of intraplaque hemorrhage (IPH). We also explored the mechanisms underlying this association. METHODS A total of 225 inpatients with severe carotid artery stenosis were consecutively enrolled in this cohort study. Serum inflammatory marker levels were detected in all patients by enzyme-linked immunosorbent assay. In the final analysis, 128 patients who underwent CAS and received pretreatment and post-treatment MRI scans were enrolled. DWI was performed to detect new ischemia brain lesions. T1-weighted, T2-weighted, and time-of-flight sequences were also conducted to identify IPH. RESULTS Serum tumor necrosis factor α (TNF-α) levels were significantly higher in symptomatic patients as well as in IPH+ patients identified by carotid MRI. New DWI lesions were identified in 50% of patients after CAS. Univariate analysis showed that DWI+ patients after CAS exhibited older mean age, higher mean TNF-α levels, and more IPH on preoperative MRI and were less likely to have right carotid stenosis than DWI- patients. Multivariate logistic regression analyses revealed that serum TNF-α concentrations were associated with new DWI lesions after CAS (odds ratio, 1.245; 95% confidence interval, 1.068-1.451; P = .005). Finally, the specificity and sensitivity of serum TNF-α levels in predicting DWI+ patients after CAS were 0.828 and 0.453, respectively. CONCLUSIONS Higher serum TNF-α levels are associated with a higher likelihood of new DWI lesions after CAS and the presence of IPH. Therefore, TNF-α is a potentially valuable predictor of acute ischemic cerebral lesions after CAS and the presence of IPH.
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Affiliation(s)
- Changpo Lin
- Institute of Vascular Surgery, Department of Vascular Surgery, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Xiao Tang
- Institute of Vascular Surgery, Department of Vascular Surgery, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Zhenyu Shi
- Institute of Vascular Surgery, Department of Vascular Surgery, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Lu Zhang
- Institute of Vascular Surgery, Department of Vascular Surgery, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Dong Yan
- Institute of Vascular Surgery, Department of Vascular Surgery, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Cong Niu
- Department of Physiology and Pathophysiology, Fudan University Shanghai Medical College, Shanghai, China
| | - Min Zhou
- Institute of Vascular Surgery, Department of Vascular Surgery, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Lixin Wang
- Institute of Vascular Surgery, Department of Vascular Surgery, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Weiguo Fu
- Institute of Vascular Surgery, Department of Vascular Surgery, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Daqiao Guo
- Institute of Vascular Surgery, Department of Vascular Surgery, Zhongshan Hospital, Fudan University, Shanghai, China.
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Dong S, Peng Z, Tao Y, Huo Y, Zhou H. Metabolic syndrome is associated with increased risk of short-term post-procedural complications after carotid artery stenting. Neurol Sci 2017; 38:1933-1939. [DOI: 10.1007/s10072-017-3085-4] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2017] [Accepted: 07/31/2017] [Indexed: 12/30/2022]
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von Allmen R, Gahl B, Powell J. Editor's Choice – Incidence of Stroke Following Thoracic Endovascular Aortic Repair for Descending Aortic Aneurysm: A Systematic Review of the Literature with Meta-analysis. Eur J Vasc Endovasc Surg 2017; 53:176-184. [DOI: 10.1016/j.ejvs.2016.10.025] [Citation(s) in RCA: 51] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2016] [Accepted: 10/25/2016] [Indexed: 12/30/2022]
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Liu J, Xu ZQ, Cui M, Li L, Cheng Y, Zhou HD. Assessing risk factors for major adverse cardiovascular and cerebrovascular events during the perioperative period of carotid angioplasty with stenting patients. Exp Ther Med 2016; 12:1039-1047. [PMID: 27446318 PMCID: PMC4950788 DOI: 10.3892/etm.2016.3360] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2015] [Accepted: 05/18/2016] [Indexed: 11/16/2022] Open
Abstract
Carotid atherosclerotic stenosis is a risk factor for ischemic stroke. The rapid development of neuroimaging techniques had led to carotid angioplasty with stenting (CAS) becoming a useful, effective and minimally invasive method for the treatment of extracranial carotid artery stenosis. The aim of the present study was to identify independent risk factors to predict perioperative major adverse cerebral and cardiovascular events for CAS patients and establish a risk evaluation model. Consecutive patients treated with a standardized CAS procedure were enrolled in the present study. The patients included underwent independent neurological evaluation prior to and after the procedure and at 30 days. The rates of transient ischemic attack, stroke, myocardial infarction and mortality were recorded. A relative regression model was established to evaluate risk factors of perioperative major adverse cardiac and cerebrovascular events (MACCE). In total, 403 subjects treated with CAS were enrolled into the study at a baseline MACCE rate of 8.19%, whereas the overall stroke, myocardial infarction and mortality rate at 30 days was 3.97%. The multiple regression analysis revealed that certain factors significantly predicted the 30-day risk of treatment-related MACCE. These factors included age of ≥70 years, ulcerative plaque, severe carotid stenosis, bilateral carotid artery stenting and hemodynamic depression following CAS. The MACCE risk prediction model and risk score system were subsequently established. In conclusion, factors that significantly predicted the 30-day risk of MACCE of CAS included, age of ≥70 years, ulcerative plaque, severe carotid stenosis, bilateral carotid artery stenting and hemodynamic depression, with hemodynamic depression being a controllable factor. The established risk score system is therefore a potentially useful tool that can be employed in the prediction of MACCE after CAS.
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Affiliation(s)
- Juan Liu
- Department of Neurology and Center for Clinical Neuroscience, Daping Hospital, Third Military Medical University, Chongqing 400042, P.R. China
| | - Zhi-Qiang Xu
- Department of Neurology and Center for Clinical Neuroscience, Daping Hospital, Third Military Medical University, Chongqing 400042, P.R. China
| | - Min Cui
- Department of Neurology and Center for Clinical Neuroscience, Daping Hospital, Third Military Medical University, Chongqing 400042, P.R. China
| | - Ling Li
- Department of Neurology and Center for Clinical Neuroscience, Daping Hospital, Third Military Medical University, Chongqing 400042, P.R. China
| | - Yong Cheng
- Department of Neurology and Center for Clinical Neuroscience, Daping Hospital, Third Military Medical University, Chongqing 400042, P.R. China
| | - Hua-Dong Zhou
- Department of Neurology and Center for Clinical Neuroscience, Daping Hospital, Third Military Medical University, Chongqing 400042, P.R. China
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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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Abstract
PURPOSE To describe a direct percutaneous carotid access technique for carotid artery stenting (CAS) that circumvents the potential for embolization that can occur during catheter manipulation in the aortic arch during femoral access. TECHNIQUE After inducing anesthesia, an ultrasound transducer is placed at the base of the neck above the clavicle. A 21-G, 7-cm needle from a micropuncture introducer is used for single-wall puncture of the common carotid artery (CCA). A 0.018-inch guidewire is inserted into the needle for placement of a 4-F, 10-cm introducer. After placing a 0.035-inch angled guidewire in the external carotid artery, the 4-F introducer is exchanged for the closure device sheath (preclose technique). A regular 6-F introducer is then placed inside the closure device sheath, and a low dose (2000 units) of heparin is administered for the brief CAS procedure, which is performed under cerebral protection. After a successful procedure is confirmed, the protection device is retrieved, and the closure device is applied to seal the puncture. CONCLUSION This approach has a low rate of neurological and access site complications. Percutaneous direct carotid access could extend the indications for CAS to include difficult anatomies, high-risk patients, and certain emergent situations that warrant easy and rapid access to the CCA.
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Vincent S, Eberg M, Eisenberg MJ, Filion KB. Meta-Analysis of Randomized Controlled Trials Comparing the Long-Term Outcomes of Carotid Artery Stenting Versus Endarterectomy. Circ Cardiovasc Qual Outcomes 2015; 8:S99-108. [DOI: 10.1161/circoutcomes.115.001933] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
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Gensicke H, van der Worp HB, Nederkoorn PJ, Macdonald S, Gaines PA, van der Lugt A, Mali WPTM, Lyrer PA, Peters N, Featherstone RL, de Borst GJ, Engelter ST, Brown MM, Bonati LH. Ischemic brain lesions after carotid artery stenting increase future cerebrovascular risk. J Am Coll Cardiol 2015; 65:521-9. [PMID: 25677309 PMCID: PMC4323145 DOI: 10.1016/j.jacc.2014.11.038] [Citation(s) in RCA: 92] [Impact Index Per Article: 10.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/29/2014] [Revised: 11/05/2014] [Accepted: 11/11/2014] [Indexed: 11/13/2022]
Abstract
Background Brain lesions on diffusion-weighted imaging (DWI) are frequently found after carotid artery stenting (CAS), but their clinical relevance remains unclear. Objectives This study sought to investigate whether periprocedural ischemic DWI lesions after CAS or carotid endarterectomy (CEA) are associated with an increased risk of recurrent cerebrovascular events. Methods In the magnetic resonance imaging (MRI) substudy of ICSS (International Carotid Stenting Study), 231 patients with symptomatic carotid stenosis were randomized to undergo CAS (n = 124) or CEA (n = 107). MRIs were performed 1 to 7 days before and 1 to 3 days after treatment. The primary outcome event was stroke or transient ischemic attack in any territory occurring between the post-treatment MRI and the end of follow-up. Time to occurrence of the primary outcome event was compared between patients with (DWI+) and without (DWI–) new DWI lesions on the post-treatment scan in the CAS and CEA groups separately. Results Median time of follow-up was 4.1 years (interquartile range: 3.0 to 5.2). In the CAS group, recurrent stroke or transient ischemic attack occurred more often among DWI+ patients (12 of 62) than among DWI– patients (6 of 62), with a cumulative 5-year incidence of 22.8% (standard error [SE]: 7.1%) and 8.8% (SE: 3.8%), respectively (unadjusted hazard ratio: 2.85; 95% confidence interval: 1.05 to 7.72; p = 0.04). In DWI+ and DWI– patients, 8 and 2 events, respectively, occurred within 6 months after treatment. In the CEA group, there was no difference in recurrent cerebrovascular events between DWI+ and DWI– patients. Conclusions Ischemic brain lesions discovered on DWI after CAS seem to be a marker of increased risk for recurrent cerebrovascular events. Patients with periprocedural DWI lesions might benefit from more aggressive and prolonged antiplatelet therapy after CAS. (A Randomised Comparison of the Risks, Benefits and Cost Effectiveness of Primary Carotid Stenting With Carotid Endarterectomy: International Carotid Stenting Study; ISRCTN25337470)
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Affiliation(s)
- Henrik Gensicke
- Department of Neurology and Stroke Center, University Hospital Basel, Basel, Switzerland
| | - H Bart van der Worp
- Department of Neurology and Neurosurgery, Brain Center Rudolf Magnus, University Medical Center Utrecht, Utrecht, the Netherlands
| | - Paul J Nederkoorn
- Department of Neurology, Academic Medical Center, Amsterdam, the Netherlands
| | - Sumaira Macdonald
- Department of Radiology, Freeman Hospital, Newcastle-upon-Tyne, United Kingdom
| | - Peter A Gaines
- Sheffield Vascular Institute, Northern General Hospital, Sheffield, United Kingdom
| | - Aad van der Lugt
- Department of Radiology, Erasmus MC, University Medical Center Rotterdam, Rotterdam, the Netherlands
| | - Willem P Th M Mali
- Department of Radiology, University Medical Center Utrecht, Utrecht, the Netherlands
| | - Philippe A Lyrer
- Department of Neurology and Stroke Center, University Hospital Basel, Basel, Switzerland
| | - Nils Peters
- Department of Neurology and Stroke Center, University Hospital Basel, Basel, Switzerland
| | - Roland L Featherstone
- Department of Brain Repair and Rehabilitation, UCL Institute of Neurology, Queen Square, London, United Kingdom
| | - Gert J de Borst
- Department of Vascular Surgery, University Medical Center Utrecht, Utrecht, the Netherlands
| | - Stefan T Engelter
- Department of Neurology and Stroke Center, University Hospital Basel, Basel, Switzerland
| | - Martin M Brown
- Department of Brain Repair and Rehabilitation, UCL Institute of Neurology, Queen Square, London, United Kingdom
| | - Leo H Bonati
- Department of Neurology and Stroke Center, University Hospital Basel, Basel, Switzerland; Department of Brain Repair and Rehabilitation, UCL Institute of Neurology, Queen Square, London, United Kingdom.
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Morgan CE, Lee CJ, Chin JA, Eskandari MK, Morasch MD, Rodriguez HE, Helenowski IB, Kibbe MR. High-Risk Anatomic Variables and Plaque Characteristics in Carotid Artery Stenting. Vasc Endovascular Surg 2014; 48:452-9. [DOI: 10.1177/1538574414551577] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Objectives: To determine anatomic and plaque-related risk factors for patients undergoing carotid artery stenting. Methods: A retrospective review of patients from a prospectively maintained database undergoing carotid artery stenting at our institution between 2001 and 2010 was performed. Preoperative imaging studies (ie, ultrasound, computed tomography angiography, magnetic resonance angiography, and angiograms) were reviewed for specific anatomic criteria and plaque characteristics. Primary outcomes included 30-day stroke or transient ischemic attack (TIA). Secondary outcomes included 30-day death and myocardial infarction (MI). Statistical significance was assumed for P = .05. Results: Imaging was reviewed for 381 carotid arteries in 375 patients. There were 14 (3.7%) perioperative neurologic events, which included 8 TIA and 6 strokes. Thirty-day mortality and MI were 0.5% and 0.75%, respectively. Degree of internal carotid artery stenosis was associated with primary outcomes ( P = .03), and the presence of arch calcification trended toward an increase in primary outcomes ( P = .07). However, arch type, ostial involvement, tandem lesions, and plaque calcification did not correlate with primary outcomes. Differences were noted between the sexes, with females having more common carotid artery tortuosity than males (34% vs 27%, P = .04). Females also had a trend toward more plaque calcification and more severe arch calcification than males. These differences did not translate to differences in perioperative neurologic events. Conclusion: Our data suggest that degree of internal carotid artery stenosis and aortic arch calcification may be associated with increased perioperative neurologic risk during carotid stenting, but arch type is not.
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Affiliation(s)
- Courtney E. Morgan
- Department of Surgery, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Cheong J. Lee
- Department of Surgery, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Jason A. Chin
- Department of Surgery, Yale University School of Medicine, New Haven, CT, USA
| | - Mark K. Eskandari
- Department of Surgery, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Mark D. Morasch
- Department of Vascular Surgery, St Vincent Healthcare, Billings, MT, USA
| | - Heron E. Rodriguez
- Department of Surgery, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Irene B. Helenowski
- Department of Surgery, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
- Department of Preventative Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Melina R. Kibbe
- Department of Surgery, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
- Department of Vascular Surgery, Jesse Brown Veterans Affairs Medical Center, Chicago, IL, USA
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Huang KL, Chang YJ, Chang CH, Chang TY, Liu CH, Hsieh IC, Wong HF, Wai YY, Chen YW, Yip BS, Lee TH. Impact of coexisting coronary artery disease on the occurrence of cerebral ischemic lesions after carotid stenting. PLoS One 2014; 9:e94280. [PMID: 24732408 PMCID: PMC3986076 DOI: 10.1371/journal.pone.0094280] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2013] [Accepted: 03/14/2014] [Indexed: 11/19/2022] Open
Abstract
Background Coronary artery disease (CAD) may coexist with extracranial carotid artery stenosis (ECAS), but the influence of CAD on procedure-related complications after carotid artery stenting (CAS) has not been well investigated. The study aimed to determine the impact of CAD on the occurrence of peri-CAS cerebral ischemic lesions on diffusion-weighted imaging (DWI) scanning. Methods Coronary angiography was performed within six months before CAS. DWI scanning was repetitively done within 1 week before and after CAS. Clinical outcome measures were stroke, angina, myocardial infarction and death within 30 days. Results Among 126 patients (69.5±9.0 years) recruited for unilateral protected CAS, 33 (26%) patients had peri-CAS DWI-positive lesions. CAD was noted in 79% (26 in 33) and 48% (45 in 93) of patients with and without peri-CAS DWI-positive lesions (OR, 4.0; 95% CI, 1.6–10.0; P = .0018), and the number of concomitant CAD on coronary angiography was positively correlated with the risk for peri-CAS DWI-positive lesions (P = .0032). In patients with no CAD (n = 55), asymptomatic CAD (n = 41) and symptomatic CAD (n = 30), the occurrence rates of peri-CAS DWI-positive lesions were 13%, 41% and 30% (P = .0048), and the peri-CAS stroke rates were 2%, 7% and 0% (P = .2120). Conclusions The severity of morphological CAD and the presence of either symptomatic or asymptomatic CAD are associated with the occurrence of peri-CAS cerebral ischemic lesions.
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Affiliation(s)
- Kuo-Lun Huang
- Stroke Center and Department of Neurology, Linkou Chang Gung Memorial Hospital, Taoyuan, Taiwan
- College of Medicine, Chang Gung University, Taoyuan, Taiwan
| | - Yeu-Jhy Chang
- Stroke Center and Department of Neurology, Linkou Chang Gung Memorial Hospital, Taoyuan, Taiwan
- College of Medicine, Chang Gung University, Taoyuan, Taiwan
| | - Chien-Hung Chang
- Stroke Center and Department of Neurology, Linkou Chang Gung Memorial Hospital, Taoyuan, Taiwan
- College of Medicine, Chang Gung University, Taoyuan, Taiwan
- Department of Electrical Engineering, Chang Gung University, Taoyuan, Taiwan
| | - Ting-Yu Chang
- Stroke Center and Department of Neurology, Linkou Chang Gung Memorial Hospital, Taoyuan, Taiwan
- College of Medicine, Chang Gung University, Taoyuan, Taiwan
| | - Chi-Hung Liu
- Stroke Center and Department of Neurology, Linkou Chang Gung Memorial Hospital, Taoyuan, Taiwan
- College of Medicine, Chang Gung University, Taoyuan, Taiwan
| | - I-Chang Hsieh
- College of Medicine, Chang Gung University, Taoyuan, Taiwan
- Department of Internal Medicine, Section of Cardiology, Linkou Chang Gung Memorial Hospital, Taoyuan, Taiwan
| | - Ho-Fai Wong
- College of Medicine, Chang Gung University, Taoyuan, Taiwan
- Department of Medical Imaging and Intervention, Linkou Chang Gung Memorial Hospital, Taoyuan, Taiwan
| | - Yau-Yau Wai
- College of Medicine, Chang Gung University, Taoyuan, Taiwan
- Department of Medical Imaging and Intervention, Linkou Chang Gung Memorial Hospital, Taoyuan, Taiwan
| | - Yu-Wei Chen
- Department of Neurology, Landseed Hospital, Taoyuan, Taiwan
- Department of Neurology, National Taiwan University Hospital, Taipei City, Taiwan
- Department of Computer Science and Information Engineering, National Central University, Zhongli City, Taiwan
| | - Bak-Sau Yip
- Department of Neurology, National Taiwan University Hospital Hsinchu Branch, Hsinchu, Taiwan
| | - Tsong-Hai Lee
- Stroke Center and Department of Neurology, Linkou Chang Gung Memorial Hospital, Taoyuan, Taiwan
- College of Medicine, Chang Gung University, Taoyuan, Taiwan
- * E-mail:
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Staubach S, Hein-Rothweiler R, Hochadel M, Segerer M, Zahn R, Jung J, Rieß G, Seggewiß H, Schneider A, Fürste T, Gottkehaskamp C, Mudra H. Predictors of minor versus major stroke during carotid artery stenting: results from the carotid artery stenting (CAS) registry of the Arbeitsgemeinschaft Leitende Kardiologische Krankenhausärzte (ALKK). Clin Res Cardiol 2014; 103:345-51. [DOI: 10.1007/s00392-013-0657-z] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/10/2013] [Accepted: 12/16/2013] [Indexed: 11/28/2022]
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Powers CJ, Hirsch JA, Hussain MS, Patsalides AT, Blackham KA, Narayanan S, Lee SK, Fraser JF, Bulsara KR, Prestigiacomo CJ, Gandhi CD, Abruzzo T, Do HM, Meyers PM, Albuquerque FC, Frei D, Kelly ME, Pride GL, Jayaraman MV. Standards of practice and reporting standards for carotid artery angioplasty and stenting. J Neurointerv Surg 2013; 6:87-90. [PMID: 24198273 DOI: 10.1136/neurintsurg-2013-011013] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Affiliation(s)
- Ciaran J Powers
- Department of Neurosurgery, Wexner Medical Center, Columbus, Ohio, USA
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Sfyroeras GS, Moulakakis KG, Markatis F, Antonopoulos CN, Antoniou GA, Kakisis JD, Brountzos EN, Liapis CD. Results of carotid artery stenting with transcervical access. J Vasc Surg 2013; 58:1402-7. [PMID: 24074938 DOI: 10.1016/j.jvs.2013.07.111] [Citation(s) in RCA: 39] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2013] [Revised: 07/12/2013] [Accepted: 07/26/2013] [Indexed: 02/06/2023]
Abstract
OBJECTIVE Carotid artery stenting (CAS) is usually performed with femoral access; however, this access may be impeded by anatomic limitations. Moreover, many embolic events happen during aortic arch catheterization. To overcome these problems, transcervical access to the carotid artery can be used as an alternative approach for CAS. METHODS An electronic search of the literature using PubMed was performed. All studies reporting the results of CAS using the transcervical approach were retrieved and analyzed. RESULTS The analysis included 12 studies reporting the results of 739 CAS procedures performed in 722 patients (mean age, 75.5 years). Of 533 lesions reported, 235 (44%) were symptomatic, with no data regarding symptomatic status available for 206 lesions. Two techniques were used: direct CAS with transcervical access (filter protected or unprotected) in 250 patients and CAS with transcervical access under reversed flow (with arteriovenous shunt in most cases) in 489 patients. Local anesthesia was used in 464 of 739 procedures (63%), and the remaining were performed under general anesthesia or cervical block. Technical success was 96.3% for 579 procedures with available data (558 successful procedures and 21 failures: inability to cross the lesion, 10; dissection, 5; failure of predilatation, 1; stent thrombosis, 1; patient agitation, 1; and no data, 3). The incidence of conversion to open repair was 3.0% (20 of 579 procedures: 18 carotid endarterectomies and two common carotid-internal carotid bypass grafts). Stroke occurred in eight patients (two fatal) and a fatal myocardial infarction in one patient. The incidence of stroke, myocardial infarction, and death was 1.1%, 0.14%, and 0.41%, respectively. The incidence of stroke was 1.2% (3 of 250) in direct CAS with transcervical access and 1.02% (5 of 489) in CAS under reversed flow (P > .05). Transient ischemic attack occurred in 20 patients (2.7%). Local complications were encountered in 17 of 579 CAS (2.9%), comprising 15 hematomas and two patients with transient laryngeal palsy. CONCLUSIONS CAS with the transcervical approach is a safe procedure with low incidence of stroke and complications. It can be used as an alternative to femoral access in patients with unfavorable aortoiliac or aortic arch anatomy.
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Affiliation(s)
- George S Sfyroeras
- Department of Vascular Surgery, Attikon University Hospital, Athens, Greece.
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Kwon SM, Cheong JH, Lee SK, Park DW, Kim JM, Kim CH. Risk factors for developing large emboli following carotid artery stenting. J Korean Neurosurg Soc 2013; 53:155-60. [PMID: 23634265 PMCID: PMC3638268 DOI: 10.3340/jkns.2013.53.3.155] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2012] [Revised: 12/10/2012] [Accepted: 02/25/2013] [Indexed: 11/27/2022] Open
Abstract
Objective The introduction and development of the embolic protecting device (EPD) has resulted in a decreased rate of stroke after carotid artery stenting (CAS). The authors performed a retrospective study to investigate the risk factors for developing large emboli after CAS which can lead to ischemic events. Methods A total of 35 consecutive patients who underwent CAS between January 2009 and March 2012 were included in this study. Patients were divided into two groups including those with small emboli (group A; grade 1, 2) and those with large emboli (group B; grade 3, 4). The size and number of emboli were assigned one of four grades (1=no clots, 2=1 or 2 small clots, 3=more than 3 small clots, 4=large clots) by microscopic observation of the EPD after CAS. We compared demographic characteristics, medical history, and angiographic findings of each group. Results Thirty-five patients underwent CAS, and technical success was achieved in all cases. Twenty-three patients were included in group A and 12 patients in group B. Our results demonstrated that advanced age [odds ratio (OR) 1.24; 95% confidence interval (CI) 1.01-1.52; p=0.044] and smoking (OR 42.06; CI 2.828-625.65, p=0.006) were independent risk factors for developing large emboli after CAS. Conclusion In patients with carotid artery stenosis treated with CAS, advanced age and smoking increased the number and size of emboli. Although use of an EPD is controversial, it may be useful in CAS in patients with risk factors for large emboli in order to reduce the risk of ischemic events.
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Affiliation(s)
- Sae Min Kwon
- Department of Neurosurgery, Hanyang University Guri Hospital, Guri, Korea
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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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Siddiqui AH, Natarajan SK, Hopkins LN, Levy EI. Carotid artery stenting for primary and secondary stroke prevention. World Neurosurg 2012; 76:S40-59. [PMID: 22182271 DOI: 10.1016/j.wneu.2011.06.019] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2011] [Accepted: 06/09/2011] [Indexed: 11/19/2022]
Abstract
BACKGROUND Carotid artery disease is a major cause of the disability and mortality associated with strokes. Ischemic stroke remains the major cause of adult disability and third-leading cause of adult mortality, and carotid revascularization currently remains the principal surgical tool in the prophylaxis of this disease. METHODS The literature representing the current body of evidence for carotid revascularization and the authors' current practices in the management of this disease are summarized in this review. RESULTS We provide an evidence-based narration of the development and current status of carotid artery stenting (CAS) by reviewing 1) the evidence for carotid revascularization from early carotid endarterectomy (CEA) trials; 2) the randomized trials comparing CEA and CAS, with a special emphasis on the recently published results of the Carotid Revascularization Endarterectomy versus Stenting Trial (CREST), which have been a "game-changer," tipping the balance towards accepting CAS as a safe, equally effective, and durable alternative to CEA for all patients requiring carotid revascularization; and 3) the technical advances in CAS after enrollment of patients in the CREST. CONCLUSIONS CAS and CEA are complementary procedures. Judicious selection of the procedure is made on a case-by-case basis.
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Affiliation(s)
- Adnan H Siddiqui
- Department of Neurosurgery, School of Medicine and Biomedical Sciences, University at Buffalo, State University of New York, Buffalo, New York, USA.
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Christopoulos D, Philippov E. The results of a simplified technique for safe carotid stenting in the elderly. J Vasc Surg 2011; 54:1637-42. [DOI: 10.1016/j.jvs.2011.06.025] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2011] [Revised: 05/31/2011] [Accepted: 06/06/2011] [Indexed: 10/17/2022]
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Kablak-Ziembicka A, Przewłocki T. Commentary: Carotid artery stenting drawbacks: microembolic ischemic cerebral lesions--do they matter? J Endovasc Ther 2011; 18:527-30. [PMID: 21861742 DOI: 10.1583/11-3400c.1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/17/2022]
Affiliation(s)
- Anna Kablak-Ziembicka
- Department of Cardiac and Vascular Diseases, The John Paul II Hospital, Jagiellonian University School of Medicine, Krakow, Poland.
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Powell S, deFreitas D. Carotid artery stenting in the nation: the influence of hospital and physician volume on outcomes. Vasc Endovascular Surg 2011; 45:205; author reply 206-7. [PMID: 21382837 DOI: 10.1177/1538574410376448] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
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Nedeltchev K, Pattynama PM, Biaminoo G, Diehm N, Jaff MR, Hopkins LN, Ramee S, van Sambeek M, Talen A, Vermassen F, Cremonesi A. Standardized definitions and clinical endpoints in carotid artery and supra-aortic trunk revascularization trials. Catheter Cardiovasc Interv 2011; 76:333-44. [PMID: 20506555 DOI: 10.1002/ccd.22560] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Abstract
BACKGROUND Endovascular therapy has emerged as a promising alternative to open surgery for stroke prevention in patients with obstructive disease of the supra-aortic arteries. Although most previous studies have used similar safety and efficacy endpoints, differences in definitions, timing of assessments, and standards of reporting have hampered direct comparisons across various trials. METHODS AND RESULTS The DEFINE group, an informal collaboration of multidisciplinary physicians, involved in the therapy of patients with obstructive disease of the supra-aortic arteries in Europe and the United States reviewed the current literature and, after extensive correspondence and meetings, proposed the definitions outlined in the present manuscript. Three meetings including all authors of the manuscript, along with representatives of the United States Food and Drug Administration (FDA) and commercial device manufacturers were held in Barcelona, Spain, in May 2008, in Munich, Germany, in July 2008, and in New York in November 2008. The proposed definitions encompass baseline clinical and anatomic characteristics, clinical and radiologic outcomes, complications, standards of reporting, and timing of assessment. CONCLUSIONS Considering the broad consensus between the multidisciplinary scientific members and the regulatory authorities, the proposed definitions are expected to find adoption in future clinical investigations. These definitions can be applied to both endovascular and open surgery trials and will allow reliable comparisons between these two revascularization methods.
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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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Chaer RA, Shen J, Rao A, Cho JS, Abu Hamad G, Makaroun MS. Cerebral reserve is decreased in elderly patients with carotid stenosis. J Vasc Surg 2010; 52:569-74; discussion 574-5. [PMID: 20620003 DOI: 10.1016/j.jvs.2010.04.021] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2009] [Revised: 04/05/2010] [Accepted: 04/06/2010] [Indexed: 10/19/2022]
Abstract
OBJECTIVES Octogenarians and even patients over 70 years old have unexplained poor outcomes with carotid angioplasty and stenting (CAS). We sought to evaluate whether older patients may have compromised intracranial collaterals and cerebral reserve and be intolerant to otherwise clinically silent emboli generated during CAS. METHODS One thousand twenty-four cerebral blood flow (CBF) studies performed between 1991 and 2001 with stable xenon computed tomography scans (Xe/CT) were reviewed. CBF was measured before and after 1 gm intravenous acetazolamide (ACZ), a cerebral vasodilator. The normal response to ACZ is an increase in CBF. In areas of significant compromise of cerebral reserve (CR), CBF drops, representing a "steal" phenomenon. CBF changes were categorized as normal or abnormal and correlated with age, gender, cerebral symptoms, and with intracranial, carotid, or vertebral artery disease. Logistic regression was used to determine the effect of age on CR in the entire group and a subgroup of 179 patients with significant carotid stenosis of >50%. RESULTS Nine hundred sixteen studies were suitable for analysis. Carotid occlusion was predictive of decreased reserve (OR, 3.9; P = .03) regardless of age. There was also a trend toward lower reserve with severe carotid stenosis >70% (OR, 3) and in women (OR, 1.8; P = .08). Age >or=70 had no effect on reserve in the overall heterogeneous population with and without carotid disease and neither did a history of stroke, carotid, or intracranial stenosis. However, in 179 patients with significant carotid stenosis, age >or=70 was predictive of poor reserve (OR, 2.7; P = .03) and so was the presence of peripheral vascular disease (OR, 3.7; P = .03). A trend toward decreased reserve was also seen in women (OR, 2.3; P = .08). CONCLUSIONS Age >or=70 is associated with poor cerebral reserve in patients with significant carotid stenosis as measured by CBF response to an ACZ challenge. Thus, patients >or=70 may be more sensitive to minor cerebral emboli, which may be one factor explaining their higher risk of stroke during CAS.
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Affiliation(s)
- Rabih A Chaer
- University of Pittsburgh Medical Center, Division of Vascular Surgery, Pittsburgh, PA 15213, USA.
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Massière B, Ristow AV, Vieira RD, Cury JM, Gress M, Vescovi A, Peixoto C, Marques MA. Angioplastia carotídea com reversão do fluxo em octogenários: relato de caso. J Vasc Bras 2010. [DOI: 10.1590/s1677-54492010000300017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
Pacientes octogenários submetidos à angioplastia carotídea apresentam maior incidência de eventos neurológicos quando comparados a grupos de pacientes mais jovens e a grupos da mesma faixa etária submetidos à endarterectomia carotídea. A maior taxa de complicações pode ser explicada por fatores anatômicos e anatomopatológicos que aumentam a dificuldade técnica e o risco de ateroembolismo do procedimento endovascular. O procedimento foi realizado no centro cirúrgico, com o paciente em decúbito dorsal e sob anestesia geral. Realizamos acesso cirúrgico transverso limitado, na base do pescoço à direita, com dissecção, identificação e reparo da artéria carótida comum e veia jugular interna. Foram administradas 10.000 U de heparina e puncionada a carótida comum pela técnica de Seldinger com introdução de bainha 8F em sentido cranial. Na sequência, foi puncionada a veia jugular interna com instalação de bainha 8F em sentido caudal. Em seguida, ambas as bainhas foram conectadas, utilizando-se um segmento de equipo de soro. A carótida comum foi fechada por cadarço duplo de silicone e o fluxo retrógrado pela carótida interna foi estabelecido. Subsequentemente, foi introduzido fio guia 0.014 x 190 cm com cruzamento da lesão, realizando-se angioplastia com balão 5 x 20 mm e em seguida stent (Wallstent® 7 x 50 - Boston Scientific) foi introduzido, posicionado e liberado. A angioplastia carotídea com reversão de fluxo, por via transcervical, constitui estratégia de proteção cerebral custo-eficiente e com menor potencial emboligênico em pacientes octogenários com anatomia desfavorável.
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Affiliation(s)
| | | | | | | | - Marcus Gress
- Departamento de Cirurgia Vascular e Endovascular
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Setacci C, Chisci E, Setacci F, Iacoponi F, de Donato G, Rossi A. Siena Carotid Artery Stenting Score. Stroke 2010; 41:1259-65. [DOI: 10.1161/strokeaha.110.578583] [Citation(s) in RCA: 94] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Carlo Setacci
- From Department of Surgery, Vascular, and Endovascular Surgery Unit (C.S., E.C., F.S., G.d.D.), University of Siena, Siena, Italy; Department of Biomedical Sciences (F.I.), Applied Biology Section, University of Siena, Siena, Italy; Department of Neurological, Neurosurgical, and Behaviour Sciences (A.R.), University of Siena, Siena, Italy
| | - Emiliano Chisci
- From Department of Surgery, Vascular, and Endovascular Surgery Unit (C.S., E.C., F.S., G.d.D.), University of Siena, Siena, Italy; Department of Biomedical Sciences (F.I.), Applied Biology Section, University of Siena, Siena, Italy; Department of Neurological, Neurosurgical, and Behaviour Sciences (A.R.), University of Siena, Siena, Italy
| | - Francesco Setacci
- From Department of Surgery, Vascular, and Endovascular Surgery Unit (C.S., E.C., F.S., G.d.D.), University of Siena, Siena, Italy; Department of Biomedical Sciences (F.I.), Applied Biology Section, University of Siena, Siena, Italy; Department of Neurological, Neurosurgical, and Behaviour Sciences (A.R.), University of Siena, Siena, Italy
| | - Francesca Iacoponi
- From Department of Surgery, Vascular, and Endovascular Surgery Unit (C.S., E.C., F.S., G.d.D.), University of Siena, Siena, Italy; Department of Biomedical Sciences (F.I.), Applied Biology Section, University of Siena, Siena, Italy; Department of Neurological, Neurosurgical, and Behaviour Sciences (A.R.), University of Siena, Siena, Italy
| | - Gianmarco de Donato
- From Department of Surgery, Vascular, and Endovascular Surgery Unit (C.S., E.C., F.S., G.d.D.), University of Siena, Siena, Italy; Department of Biomedical Sciences (F.I.), Applied Biology Section, University of Siena, Siena, Italy; Department of Neurological, Neurosurgical, and Behaviour Sciences (A.R.), University of Siena, Siena, Italy
| | - Alessandro Rossi
- From Department of Surgery, Vascular, and Endovascular Surgery Unit (C.S., E.C., F.S., G.d.D.), University of Siena, Siena, Italy; Department of Biomedical Sciences (F.I.), Applied Biology Section, University of Siena, Siena, Italy; Department of Neurological, Neurosurgical, and Behaviour Sciences (A.R.), University of Siena, Siena, Italy
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Palombo G, Stella N, Faraglia V, Rizzo L, Fantozzi C, Bozzao A, Taurino M. Cervical Access for Filter-protected Carotid Artery Stenting: A Useful Tool to Reduce Cerebral Embolisation. Eur J Vasc Endovasc Surg 2010; 39:252-7. [DOI: 10.1016/j.ejvs.2009.11.011] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2009] [Accepted: 11/08/2009] [Indexed: 11/24/2022]
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Zarins CK, White RA, Diethrich EB, Shackelton RJ, Siami FS. Carotid revascularization using endarterectomy or stenting systems (CaRESS): 4-year outcomes. J Endovasc Ther 2009; 16:397-409. [PMID: 19702339 DOI: 10.1583/08-2685.1] [Citation(s) in RCA: 38] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
PURPOSE To examine the 4-year outcomes from Carotid Revascularization using Endarterectomy or Stenting Systems (CaRESS) in light of the current reimbursement guidelines for carotid artery stenting (CAS) from the Centers for Medicare and Medicaid Services (CMS). METHODS CaRESS was designed as a prospective, nonrandomized comparative cohort study of a broad-risk population of symptomatic and asymptomatic patients with carotid stenosis. In all, 397 patients (247 men; mean age 71 years, range 43-89) were enrolled and underwent carotid endarterectomy (CEA; n = 254) or protected CAS (n = 143). More than 90% of patients had >75% stenosis; two thirds were asymptomatic. The primary endpoints included (1) all-cause mortality, (2) any stroke, and (3) myocardial infarction (MI), as well as the composite endpoints of (4) death and any nonfatal stroke and (5) death, nonfatal stroke, and MI. The secondary endpoints were restenosis, repeat angiography, and carotid revascularization. All patients were classified with respect to surgical risk, symptom status, and stenosis grade based on criteria published by the CMS. In addition, separate analyses were performed comparing genders and octogenarians to those <80 years old. RESULTS No significant differences in the primary outcome measures were found between the CEA and CAS groups in the 4-year analysis. The incidences of any stroke at 4 years were 9.6% for CEA and 8.6% for CAS (p = 0.444); when combined with death, the composite death/nonfatal stroke rates were 26.5% for CEA versus 21.8% for CAS (p = 0.361). The composite endpoint of death, nonfatal stroke, and MI at 4 years was 27.0% in CEA versus 21.7% in CAS (p = 0.273) patients. The secondary endpoints of restenosis (p = 0.014) and repeat angiography (p = 0.052) were higher in the CAS arm. There were no differences in any of the subgroups stratified according the CMS guidelines or in the gender comparison. Four-year incidences of death/nonfatal stroke and death/nonfatal stroke/MI were higher in the CEA arm among patients <80 years of age (p = 0.049 and p = 0.030, respectively). There were no significant differences between these incidences in the octogenarian subgroup. CONCLUSION The risk of death or nonfatal stroke 4 years following CAS with distal protection is equivalent to CEA in a broad category of patients with carotid stenosis. There were no significant differences in stroke or mortality rates between high-risk and non-high-risk patients and no differences in outcomes between symptomatic and asymptomatic patients. After 4 years, CAS had a 2-fold higher restenosis rate compared to CEA. The risk of death/stroke or death/stroke/MI appears to be higher following CEA than CAS among patients <80 years of age, yet there is no statistically significant relationship between death, stroke, or MI among octogenarians.
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Howell GM, Makaroun MS, Chaer RA. Current Management of Extracranial Carotid Occlusive Disease. J Am Coll Surg 2009; 208:442-53. [DOI: 10.1016/j.jamcollsurg.2008.12.006] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2008] [Revised: 11/21/2008] [Accepted: 12/04/2008] [Indexed: 11/30/2022]
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Kastrup A, Schnaudigel S, Wasser K, Gröschel K. Carotid artery disease: Stenting versus endarterectomy. Curr Atheroscler Rep 2008; 10:391-7. [DOI: 10.1007/s11883-008-0061-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
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Gröschel K, Ernemann U, Schnaudigel S, Wasser K, Nägele T, Kastrup A. A risk score to predict ischemic lesions after protected carotid artery stenting. J Neurol Sci 2008; 273:112-5. [DOI: 10.1016/j.jns.2008.07.004] [Citation(s) in RCA: 30] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2008] [Revised: 07/02/2008] [Accepted: 07/03/2008] [Indexed: 12/01/2022]
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Gröschel K, Pilgram SM, Ernemann U, Schnaudigel S, Nägele T, Knauth M, Kastrup A. Aortic calcification on plain chest radiography predicts embolic complications during carotid artery stenting. Eur J Neurol 2008; 15:730-6. [DOI: 10.1111/j.1468-1331.2008.02183.x] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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