1
|
Loufopoulos G, Manaki V, Tasoudis P, Meintanopoulos AS, Kouvelos G, Ntaios G, Spanos K. New Ischemic Cerebral Lesions in Postprocedural Magnetic Resonance Imaging in Carotid Artery Stenting Versus Carotid Endarterectomy: A Systematic Review and Meta-Analysis. Ann Vasc Surg 2024; 106:297-311. [PMID: 38825067 DOI: 10.1016/j.avsg.2024.05.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2024] [Revised: 05/12/2024] [Accepted: 05/15/2024] [Indexed: 06/04/2024]
Abstract
BACKGROUND Recent randomized controlled trials (RCTs) have demonstrated similar outcomes in terms of ischemic stroke incidence after carotid endarterectomy (CEA) or carotid artery stenting (CAS) in asymptomatic carotid disease, while CEA seems to be the first option for symptomatic carotid disease. The aim of this meta-analysis is to assess the incidence of silent cerebral microembolization detected by magnetic resonance imaging (MRI) following these procedures. METHODS A systematic search was conducted using PubMed, Scopus, and Cochrane databases, including comparative studies involving symptomatic or asymptomatic patients undergoing either CEA or CAS and reporting on new cerebral ischemic lesions in postoperative MRI. The primary outcome was the newly detected cerebral ischemic lesions. Pooled effect estimates for all outcomes were calculated using the random-effects model. Prespecified random effects metaregression and subgroup analysis were conducted to examine the impact of moderator variables on the presence of new cerebral ischemic lesions. RESULTS 25 studies reporting on a total of 1827 CEA and 1500 CAS interventions fulfilled the eligibility criteria. The incidence of new cerebral ischemic lesions was significantly lower after CEA compared to CAS, regardless of the time of MRI assessment (first 24 hours; OR: 0.33, 95% CI: 0.17-0.64, P < 0.001), (the first 72 hours, OR: 0.25, 95% CI 0.18-0.36, P < 0.001), (generally within a week after the operation; OR: 0.24, 95% CI: 0.17-0.34, P < 0.001). Also, the rate of stroke (OR: 0.38, 95% CI: 0.23-0.63, P < 0.001) and the presence of contralateral new cerebral ischemic lesions (OR: 0.16, 95% CI 0.08-0.32, P < 0.001) were less frequent after CEA. Subgroup analysis based on the study design and the use of embolic protection device during CAS showed consistently lower rates of new lesions after CEA. CONCLUSIONS CEA demonstrates significant lower rates of new silent cerebral microembolization, as detected by MRI in postoperative period compared with CAS.
Collapse
Affiliation(s)
- Georgios Loufopoulos
- Cardiothoracic and Vascular Surgery Working Group, Society of Junior Doctors, Athens, Greece; Department of Surgery, Saint Imier Hospital, Saint Imier, Switzerland.
| | - Vasiliki Manaki
- Cardiothoracic and Vascular Surgery Working Group, Society of Junior Doctors, Athens, Greece; Department of Vascular Surgery, Aristotle University of Thessaloniki, AHEPA University General Hospital, Thessaloniki, Greece
| | - Panagiotis Tasoudis
- Cardiothoracic and Vascular Surgery Working Group, Society of Junior Doctors, Athens, Greece; Division of Cardiothoracic Surgery, Department of Surgery, School of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, NC
| | | | - George Kouvelos
- Faculty of Medicine, Department of Vascular Surgery, University Hospital of Larissa, School of Health Sciences, University of Thessaly, Larissa, Greece
| | - George Ntaios
- Faculty of Medicine, Department of Internal Medicine, University Hospital of Larissa, School of Health Sciences, University of Thessaly, Larissa, Greece
| | - Konstantinos Spanos
- Faculty of Medicine, Department of Vascular Surgery, University Hospital of Larissa, School of Health Sciences, University of Thessaly, Larissa, Greece
| |
Collapse
|
2
|
Knappich C, Bohmann B, Kirchhoff F, Lohe V, Naher S, Kallmayer M, Eckstein HH, Kuehnl A. Use of an embolic protection device during carotid artery stenting is associated with lower periprocedural risk. J Neurointerv Surg 2024:jnis-2024-021722. [PMID: 38906691 DOI: 10.1136/jnis-2024-021722] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2024] [Accepted: 05/25/2024] [Indexed: 06/23/2024]
Abstract
OBJECTIVE To investigate associations between individual embolic protection device (EPD) use and respective center policy with periprocedural outcomes after carotid artery stenting (CAS). METHODS This analysis is based on the nationwide German statutory quality assurance database and was funded by Germany's Federal Joint Committee Innovation Fund (G-BA Innovationsfonds, 01VSF19016 ISAR-IQ). According to their policy towards EPD use, hospitals were categorized as routine EPD (>90%), selective EPD (10-90%), or sporadic EPD (<10%) centers. Primary study outcome was in-hospital stroke or death. Univariate and multivariate regression analyses were performed. RESULTS Overall, 19 302 patients who had undergone CAS between 2013 and 2016 were included. The highest in-hospital stroke or death rate was found in sporadic EPD centers, followed by selective and routine EPD centers (3.1% vs 2.9% vs 1.8%; P<0.001). Across the whole cohort, EPD use was associated with a lower in-hospital stroke or death rate (OR=0.60; 95% CI 0.50 to 0.72). In the multivariate regression analysis, EPD use was independently associated with a lower in-hospital stroke rate (aOR=0.66; 95% CI 0.46 to 0.94). Regarding center policy, routine EPD centers showed a significantly lower in-hospital mortality compared with sporadic EPD centers (aOR=0.44; 95% CI 0.22 to 0.88). CONCLUSIONS In a contemporary real-world cohort with low risk of selection bias, EPD use was associated with a lower in-hospital risk of stroke. A center policy of routine EPD use was associated with lower mortality. These data support routine use of EPD during CAS to enhance patient safety.
Collapse
Affiliation(s)
- Christoph Knappich
- Department for Vascular and Endovascular Surgery, Klinikum rechts der Isar, Technical University of Munich, Munich, Germany
| | - Bianca Bohmann
- Department for Vascular and Endovascular Surgery, Klinikum rechts der Isar, Technical University of Munich, Munich, Germany
| | - Felix Kirchhoff
- Department for Vascular and Endovascular Surgery, Klinikum rechts der Isar, Technical University of Munich, Munich, Germany
| | - Vanessa Lohe
- Department for Vascular and Endovascular Surgery, Klinikum rechts der Isar, Technical University of Munich, Munich, Germany
| | - Shamsun Naher
- Department for Vascular and Endovascular Surgery, Klinikum rechts der Isar, Technical University of Munich, Munich, Germany
| | - Michael Kallmayer
- Department for Vascular and Endovascular Surgery, Klinikum rechts der Isar, Technical University of Munich, Munich, Germany
| | - Hans-Henning Eckstein
- Department for Vascular and Endovascular Surgery, Klinikum rechts der Isar, Technical University of Munich, Munich, Germany
| | - Andreas Kuehnl
- Department for Vascular and Endovascular Surgery, Klinikum rechts der Isar, Technical University of Munich, Munich, Germany
| |
Collapse
|
3
|
Gorgulu S, Sahin M, Norgaz NT, Pala S, Sarı M, Yalcin AA, Sipahi I. Carotid artery stenting without embolic protection: A randomized multicenter trial (the CASWEP trial). Interv Neuroradiol 2023; 29:419-425. [PMID: 35469509 PMCID: PMC10399495 DOI: 10.1177/15910199221094388] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2022] [Accepted: 03/24/2022] [Indexed: 12/24/2022] Open
Abstract
BACKGROUND Carotid artery stenting (CAS) with a carotid protection device (CPD) has become the standard practice in patients with severe carotid stenosis and high surgical risk. However, the clinical efficacy and safety of CPDs are still controversial issues. We aimed to compare the clinical outcomes of the CAS without CPD with CAS combined with CPD. METHODS This is a multicenter randomized prospective study registered with http://clinicaltrials.gov (NCT02781181). After the exclusion, 279 patients were enrolled (139 patients in the CAS with CPD group and 140 patients in the CAS without CPD group). The primary outcome was a combination of peri-procedural in-hospital transient ischemic attack (TIA), ipsilateral stroke, or death. The secondary outcome was new ischemic brain lesions on post-procedural diffusion-weighted magnetic resonance imaging (DW-MRI). RESULTS Two patients died in CAS without CPD group, one patient died in CAS with CPD group. TIA was only seen in patients who underwent CAS under protection (n = 5). The combined primary outcome of TIA, ipsilateral stroke, and death rate was not different between groups (5.7% vs. 2.8%; p = 0.254). New defects were noted on the post-procedural DW-MRI in 28% of patients in the CPD group and 27% of patients in the no CPD group (p = 0.881). CONCLUSIONS This study suggests that CAS without CPD is not associated with higher rates of peri-procedural TIA, stroke, and death or new ischemic brain lesions on post-procedural DW-MRI compared to CAS with CPD in selected symptomatic and asymptomatic patients with significant carotid artery stenosis provided that there is no visible thrombus.
Collapse
Affiliation(s)
- Sevket Gorgulu
- Department of Cardiology, Acibadem University Medical Faculty, Istanbul, Turkey
| | - Muslum Sahin
- Department of Cardiology, Istinye University Medical Faculty, Istanbul, Turkey
| | | | - Selçuk Pala
- Department of Cardiology, University of Health Sciences, Kartal Kosuyolu High Speciality Educational and Research Hospital, Istanbul, Turkey
| | - Munevver Sarı
- Department of Cardiology, University of Health Sciences, Kartal Kosuyolu High Speciality Educational and Research Hospital, Istanbul, Turkey
| | - Ahmet Arif Yalcin
- Department of Cardiology, University of Health Sciences, Mehmet Akif Ersoy Chest and Cardiovascular Surgery Training and Research Hospital, Istanbul, Turkey
| | | |
Collapse
|
4
|
Ahmet Y, Murat Y. Evaluation of the association between silent ischemic lesions and stent design in carotid stenting applications. REVISTA DA ASSOCIACAO MEDICA BRASILEIRA (1992) 2023; 69:e20221437. [PMID: 37222323 DOI: 10.1590/1806-9282.20221437] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/10/2023] [Accepted: 02/23/2023] [Indexed: 05/25/2023]
Abstract
OBJECTIVE Minor ischemic events and silent ischemic lesions are more common in carotid stenting than in endarterectomy. These silent ischemic lesions are also associated with stroke risk and cognitive impairment, so it is important to understand the factors that increase the risk and develop strategies to reduce the risk. We aimed to evaluate the association between carotid stent design and silent ischemic lesion development. METHODS The files of the patients who underwent carotid stenting between January 2020 and April 2022 were scanned. Patients with diffusion MR images taken within the postoperative 24 h were included in the study, while those undergoing acute stent placement were excluded. The patients were divided into two groups: those with open-cell stents and those with closed-cell stents. RESULTS A total of 65 patients, including 39 patients undergoing open-cell stenting and 26 patients undergoing closed-cell stenting, were included in the study. There was no significant difference in demographic data and vascular risk factors between the groups. New ischemic lesions were detected in 29 (74.4%) patients in the open-cell stent group and 10 (38.4%) patients in the closed-cell stent group and were significantly higher in the open-cell group. There was no significant difference between the two groups in terms of major and minor ischemic events and stent restenosis at the 3-month follow-up. CONCLUSION The rate of new ischemic lesion development was found to be significantly higher in carotid stent procedures performed with an open-cell Protégé stent than in those performed with a closed-cell Wallstent stent.
Collapse
Affiliation(s)
- Yabalak Ahmet
- Düzce Üniversitesi, Faculty of Medicine, Department of Neurology - Düzce, Turkey
| | - Yılmaz Murat
- Bolu Abant İzzet Baysal Üniversitesi, Faculty of Medicine, Department of Neurology - Bolu, Turkey
| |
Collapse
|
5
|
Wang SX, Marcaccio CL, Patel PB, Giles KA, Soden PA, Schermerhorn ML, Liang P. Distal embolic protection use during transfemoral carotid artery stenting is associated with improved in-hospital outcomes. J Vasc Surg 2023; 77:1710-1719.e6. [PMID: 36796592 DOI: 10.1016/j.jvs.2023.01.210] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2022] [Revised: 01/29/2023] [Accepted: 01/30/2023] [Indexed: 02/16/2023]
Abstract
OBJECTIVE Despite current guidelines recommending the use of distal embolic protection during transfemoral carotid artery stenting (tfCAS) to prevent periprocedural stroke, there remains significant variation in the routine use of distal filters. We sought to assess in-hospital outcomes in patients undergoing tfCAS with and without embolic protection using a distal filter. METHODS We identified all patients undergoing tfCAS in the Vascular Quality Initiative from March 2005 to December 2021 and excluded those who received proximal embolic balloon protection. We created propensity score-matched cohorts of patients who underwent tfCAS with and without attempted placement of a distal filter. Subgroup analyses of patients with failed vs successful filter placement and failed vs no attempt at filter placement were performed. In-hospital outcomes were assessed using log binomial regression, adjusted for protamine use. Outcomes of interest were composite stroke/death, stroke, death, myocardial infarction (MI), transient ischemic attack (TIA), and hyperperfusion syndrome. RESULTS Among 29,853 patients who underwent tfCAS, 28,213 (95%) had a filter attempted for distal embolic protection and 1640 (5%) did not. After matching, 6859 patients were identified. No attempted filter was associated with significantly higher risk of in-hospital stroke/death (6.4% vs 3.8%; adjusted relative risk [aRR], 1.72; 95% confidence interval [CI], 1.32-2.23; P < .001), stroke (3.7% vs 2.5%; aRR, 1.49; 95% CI, 1.06-2.08; P = .022), and mortality (3.5% vs 1.7%; aRR, 2.07; 95% CI, 1.42-3.020; P < .001). In a secondary analysis of patients who had failed attempt at filter placement vs successful filter placement, failed filter placement was associated with worse outcomes (stroke/death: 5.8% vs 2.7%; aRR, 2.10; 95% CI, 1.38-3.21; P = .001 and stroke: 5.3% vs 1.8%; aRR, 2.87; 95% CI, 1.78-4.61; P < .001). However, there were no differences in outcomes in patients with failed vs no attempted filter placement (stroke/death: 5.4% vs 6.2%; aRR, 0.99; 95% CI, 0.61-1.63; P = .99; stroke: 4.7% vs 3.7%; aRR, 1.40; 95% CI, 0.79-2.48; P = .20; death: 0.9% vs 3.4%; aRR, 0.35; 95% CI, 0.12-1.01; P = .052). CONCLUSIONS tfCAS performed without attempted distal embolic protection was associated with a significantly higher risk of in-hospital stroke and death. Patients undergoing tfCAS after failed attempt at filter placement have equivalent stroke/death to patients in whom no filter was attempted, but more than a two-fold higher risk of stroke/death compared with those with successfully placed filters. These findings support current Society for Vascular Surgery guidelines recommending routine use of distal embolic protection during tfCAS. If a filter cannot be placed safely, an alternative approach to carotid revascularization should be considered.
Collapse
Affiliation(s)
- Sophie X Wang
- Department of Surgery, Division of Vascular and Endovascular Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA
| | - Christina L Marcaccio
- Department of Surgery, Division of Vascular and Endovascular Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA
| | - Priya B Patel
- Department of Surgery, Division of Vascular and Endovascular Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA
| | - Kristina A Giles
- Department of Surgery, Division of Vascular Surgery, Maine Medical Center, Portland, ME
| | - Peter A Soden
- Department of Surgery, Division of Vascular Surgery, Brown University, Providence, RI
| | - Marc L Schermerhorn
- Department of Surgery, Division of Vascular and Endovascular Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA
| | - Patric Liang
- Department of Surgery, Division of Vascular and Endovascular Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA.
| |
Collapse
|
6
|
Razumovsky AY, Jahangiri FR, Balzer J, Alexandrov AV. ASNM and ASN joint guidelines for transcranial Doppler ultrasonic monitoring: An update. J Neuroimaging 2022; 32:781-797. [PMID: 35589555 DOI: 10.1111/jon.13013] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2022] [Revised: 04/27/2022] [Accepted: 05/10/2022] [Indexed: 11/26/2022] Open
Abstract
Today, it seems prudent to reconsider how ultrasound technology can be used for providing intraoperative neurophysiologic monitoring that will result in better patient outcomes and decreased length and cost of hospitalization. An extensive and rapidly growing literature suggests that the essential hemodynamic information provided by transcranial Doppler (TCD) ultrasonography neuromonitoring (TCDNM) would provide effective monitoring modality for improving outcomes after different types of vascular, neurosurgical, orthopedic, cardiovascular, and cardiothoracic surgeries and some endovascular interventional or diagnostic procedures, like cardiac catheterization or cerebral angiography. Understanding, avoiding, and preventing peri- or postoperative complications, including neurological deficits following abovementioned surgeries, endovascular intervention, or diagnostic procedures, represents an area of great public and economic benefit for society, especially considering the aging population. The American Society of Neurophysiologic Monitoring and American Society of Neuroimaging Guidelines Committees formed a joint task force and developed updated guidelines to assist in the use of TCDNM in the surgical and intensive care settings. Specifically, these guidelines define (1) the objectives of TCD monitoring; (2) the responsibilities and behaviors of the neurosonographer during monitoring; (3) instrumentation and acquisition parameters; (4) safety considerations; (5) contemporary rationale for TCDNM; (6) TCDNM perspectives; and (7) major recommendations.
Collapse
Affiliation(s)
| | | | - Jeffrey Balzer
- Department of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Andrei V Alexandrov
- Department of Neurology, The University of Tennessee Health Science Center, Memphis, Tennessee, USA
| |
Collapse
|
7
|
Advanced vasospasm in carotid stenting using the distal filter-type embolic protection device: A case report. JOURNAL OF SURGERY AND MEDICINE 2021. [DOI: 10.28982/josam.1000878] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
|
8
|
Müller MD, Bonati LH. Carotid artery stenosis – Current evidence and treatment recommendations. CLINICAL AND TRANSLATIONAL NEUROSCIENCE 2021. [DOI: 10.1177/2514183x211001654] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Background: Carotid artery stenosis is an important cause for stroke. Carotid endarterectomy (CEA) reduces the risk of stroke in patients with symptomatic carotid stenosis and to some extent in patients with asymptomatic carotid stenosis. More than 20 years ago, carotid artery stenting (CAS) emerged as an endovascular treatment alternative to CEA. Objective and Methods: This review summarises the available evidence from randomised clinical trials in patients with symptomatic as well as in patients with asymptomatic carotid stenosis. Results: CAS is associated with a higher risk of death or any stroke between randomisation and 30 days after treatment than CEA (odds ratio (OR) = 1.74, 95% CI 1.3 to 2.33, p < 0.0001). In a pre-defined subgroup analysis, the OR for stroke or death within 30 days after treatment was 1.11 (95% CI 0.74 to 1.64) in patients <70 years old and 2.23 (95% CI 1.61 to 3.08) in patients ≥70 years old, resulting in a significant interaction between patient age and treatment modality (interaction p = 0.007). The combination of death or any stroke up to 30 days after treatment or ipsilateral stroke during follow-up also favoured CEA (OR = 1.51, 95% CI 1.24 to 1.85, p < 0.0001). In asymptomatic patients, there is a non-significant increase in death or stroke occurring within 30 days of treatment with CAS compared to CEA (OR = 1.72, 95% CI 1.00 to 2.97, p = 0.05). The risk of peri-procedural death or stroke or ipsilateral stroke during follow-up did not differ significantly between treatments (OR = 1.27, 95% CI 0.87 to 1.84, p = 0.22). Discussion and Conclusion: In symptomatic patients, randomised evidence has consistently shown CAS to be associated with a higher risk of stroke or death within 30 days of treatment than CEA. This extra risk is mostly attributed to an increase in strokes occurring on the day of the procedure in patients ≥70 years. In asymptomatic patients, there may be a small increase in the risk of stroke or death within 30 days of treatment with CAS compared to CEA, but the currently available evidence is insufficient and further data from ongoing randomised trials are needed.
Collapse
Affiliation(s)
- Mandy D Müller
- Department of Neurology and Stroke Center, University Hospital Basel, University of Basel, Basel, Switzerland
- Department of Neurosurgery, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Leo H Bonati
- Department of Neurology and Stroke Center, University Hospital Basel, University of Basel, Basel, Switzerland
- Department of Brain Repair and Rehabilitation, Stroke Research Centre, UCL Institute of Neurology, University College London, London, UK
| |
Collapse
|
9
|
Nazari P, Golnari P, Hurley MC, Shaibani A, Ansari SA, Potts MB, Jahromi BS. Carotid Stenting without Embolic Protection Increases Major Adverse Events: Analysis of the National Surgical Quality Improvement Program. AJNR Am J Neuroradiol 2021; 42:1264-1269. [PMID: 34255736 DOI: 10.3174/ajnr.a7108] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2020] [Accepted: 01/26/2021] [Indexed: 11/07/2022]
Abstract
BACKGROUND AND PURPOSE Published data regarding embolic protection device efficacy is mixed, and its use during carotid artery stent placement remains variable. We, therefore, examined the frequency of embolic protection device use and its association with outcomes after carotid artery stent placement using a national quality improvement data base. MATERIALS AND METHODS Patients undergoing carotid artery stent placement with or without embolic protection devices were identified in the American College of Surgeons National Surgical Quality Improvement Program data base. The primary outcome was the incidence of major adverse cardiovascular events (defined as death, stroke, or myocardial infarction/arrhythmia) within 30 days. Propensity scoring was used to create 2 matching cohorts of patients using demographic and baseline variables. RESULTS Between 2011 and 2018, among 1200 adult patients undergoing carotid artery stent placement, 23.8% did not have embolic protection devices. There was no trend toward increased embolic protection device use with time. Patients without embolic protection device use received preoperative antiplatelets less frequently (90.6% versus 94.6%, P = .02), underwent more emergent carotid artery stent placement (7.2% versus 3.6%, P = .01), and had a higher incidence of major adverse cardiovascular events (OR = 1.81; 95% CI, 1.11-2.94) and stroke (OR = 3.31; 95% CI, 1.71-6.39). After compensating for baseline imbalances using propensity-matched cohorts (n = 261 for both), carotid artery stent placement without an embolic protection device remained associated with increased major adverse cardiovascular events (9.2% versus 4.2%; OR = 2.30; 95% CI, 1.10-4.80) and stroke (6.5% versus 1.5%; OR = 4.48; 95% CI, 1.49-13.49). CONCLUSIONS Lack of embolic protection device use during carotid artery stent placement is associated with a 4-fold increase in the likelihood of perioperative stroke. Nevertheless, nearly one-quarter of patients in the American College of Surgeons National Surgical Quality Improvement Program underwent unprotected carotid artery stent placement. Efforts targeting improved embolic protection device use during carotid artery stent placement are warranted.
Collapse
Affiliation(s)
- P Nazari
- From the Departments of Neurological Surgery and Radiology Northwestern Memorial Hospital, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - P Golnari
- From the Departments of Neurological Surgery and Radiology Northwestern Memorial Hospital, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - M C Hurley
- From the Departments of Neurological Surgery and Radiology Northwestern Memorial Hospital, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - A Shaibani
- From the Departments of Neurological Surgery and Radiology Northwestern Memorial Hospital, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - S A Ansari
- From the Departments of Neurological Surgery and Radiology Northwestern Memorial Hospital, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - M B Potts
- From the Departments of Neurological Surgery and Radiology Northwestern Memorial Hospital, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - B S Jahromi
- From the Departments of Neurological Surgery and Radiology Northwestern Memorial Hospital, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| |
Collapse
|
10
|
Lin CJ, Chang FC, Lin CJ, Liaw YC, Tu PC, Wang PN, Saver JL, Lee IH. Long-term cognitive and multimodal imaging outcomes after carotid artery stenting vs intensive medication alone for severe asymptomatic carotid stenosis. J Formos Med Assoc 2021; 121:134-143. [PMID: 33674231 DOI: 10.1016/j.jfma.2021.02.007] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2020] [Revised: 02/04/2021] [Accepted: 02/07/2021] [Indexed: 12/21/2022] Open
Abstract
BACKGROUND Severe carotid stenosis is associated with cognitive impairment, which may be attributed to asymptomatic microembolism and/or chronic hypoperfusion. We aim to evaluate the long-term cognitive and brain connectivity outcomes of carotid artery stenting (CAS) for asymptomatic ≥70% stenosis of the extracranial internal carotid artery (ICA). METHODS We conducted a non-randomized controlled study to compare intensive medical therapy alone (Med) or in combination with carotid artery stenting for the composite vascular events, neuropsychological, and multimodal magnetic resonance perfusion imaging and diffusion tensor imaging outcomes. RESULTS Sixty-nine patients were followed for a mean of 2.3 years (31 Med, 38 CAS) and 11 patients had composite vascular events of all-cause death, ischemic stroke, or myocardial infarction (6 Med vs 5 CAS). Forty-six asymptomatic subjects completed neuropsychological and multimodality imaging follow-ups (23 Med, 23 CAS). Compared to the Med group, the CAS group had a modest improvement of 12-item delayed verbal memory (8.9 ± 2.4 to 9.8 ± 2.7 vs 9.0 ± 2.1 to 8.9 ± 2.3, p = 0.04), but not in global cognition, attention or executive function, which was associated with increased structural connectivity of fractional anisotropy at the ipsilateral deep white matter. Importantly, the memory improvement was correlated with the perfusion increment at the ipsilateral middle cerebral artery territory. CONCLUSION For asymptomatic extracranial carotid steno-occlusion, successful carotid revascularization in addition to intensive medical treatment may potentially benefit cognitive reserve and connectivity strength which are partly attributed to restoration of non-critical hypoperfusion.
Collapse
Affiliation(s)
- Chun-Jen Lin
- Division of Cerebrovascular Diseases, Neurological Institute, Taipei Veterans General Hospital, Taiwan; School of Medicine, National Yang-Ming University, Taipei, Taiwan
| | - Feng-Chi Chang
- School of Medicine, National Yang-Ming University, Taipei, Taiwan; Department of Radiology, Taipei Veterans General Hospital, Taiwan
| | - Chung-Jung Lin
- School of Medicine, National Yang-Ming University, Taipei, Taiwan; Department of Radiology, Taipei Veterans General Hospital, Taiwan
| | - Yi-Chia Liaw
- Division of Cerebrovascular Diseases, Neurological Institute, Taipei Veterans General Hospital, Taiwan
| | - Pei-Chi Tu
- Department of Medical Research, Taipei Veterans General Hospital, Taiwan; Institute of Philosophy of Mind and Cognition, National Yang-Ming University, Taipei, Taiwan
| | - Pei-Ning Wang
- Division of Cerebrovascular Diseases, Neurological Institute, Taipei Veterans General Hospital, Taiwan; School of Medicine, National Yang-Ming University, Taipei, Taiwan
| | | | - I-Hui Lee
- Division of Cerebrovascular Diseases, Neurological Institute, Taipei Veterans General Hospital, Taiwan; Institute of Brain Science, Brain Research Center, National Yang-Ming University, Taipei, Taiwan.
| |
Collapse
|
11
|
Clinical situations requiring radial or brachial access during carotid artery stenting. ADVANCES IN INTERVENTIONAL CARDIOLOGY 2020; 16:410-417. [PMID: 33598013 PMCID: PMC7863832 DOI: 10.5114/aic.2020.101765] [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: 04/30/2020] [Accepted: 06/29/2020] [Indexed: 11/17/2022] Open
Abstract
Introduction Radial or brachial access may be preferred in the case of severe peripheral artery disease (PAD) or difficult aortic arch anatomy during carotid artery stenting (CAS). Aim To evaluate the clinical conditions indicating potential benefit from non-femoral access as well as feasibility and safety of transradial/transbrachial access (TRA/TBA) as an alternative approach for CAS. Material and methods Since 2013, 67 patients (mean age: 70 years old, 44 men, 42% symptomatic) were selected for CAS with the TRA/TBA approach. The composite endpoint was stroke/death/myocardial infarction within 30 days of the procedure and compared to the propensity score matched transfemoral approach (TFA) group. Clinical (including neurological) examination and Doppler ultrasonography were performed before the procedure, at discharge and at 30 days. Results CAS with TRA/TBA was successful in 63/67 patients. Transfemoral access was not feasible due to PAD in 35 (52.2%) patients, bovine arch in 10 (14.9%), obesity (BMI > 35 kg/m2) in 9 (13.4%), severe degenerative disease of the spine in 7 (10.5%), arch type III in 5 (7.5%) and excessive subclavian stent protrusion in 1 (1.5%) patient. Mean NASCET carotid artery stenosis was reduced from 81% to 9% (p < 0.001). The composite endpoint occurred in 3 (4.8%) cases and it was not statistically significantly different from the matched TFA group (6.3%; p = 0.697). No access site complications requiring surgical intervention or blood transfusion developed. Conclusions Transradial and transbrachial CAS may be an effective and safe procedure, and it may constitute a viable alternative to the femoral approach in patients with severe PAD, difficult aortic arch anatomy or obesity.
Collapse
|
12
|
Schubert T, Rivera-Rivera L, Roldan-Alzate A, Consigny D, Leitner L, Strother C, Aagaard-Kienitz B. Achievable aspiration flow rates with large balloon guide catheters during carotid artery stenting. CVIR Endovasc 2020; 3:65. [PMID: 32910271 PMCID: PMC7483693 DOI: 10.1186/s42155-020-00134-1] [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: 03/29/2020] [Accepted: 06/23/2020] [Indexed: 11/24/2022] Open
Abstract
Background Emergency carotid artery stenting (CAS) is a frequent endovascular procedure, especially in combination with intracranial thrombectomy. Balloon guide catheters are frequently used in these procedures. Our aim was to determine if mechanical aspiration through the working lumen of a balloon occlusion catheter during the steps of a carotid stenting procedure achieve flow rates that may lead to internal carotid artery (ICA) flow reversal which consecutively may prevent distal embolism. Methods Aspiration experiments were conducted using a commercially available aspiration pump. Aspiration flow rates/min with 6 different types of carotid stents inserted into a balloon guide catheter were measured. Measurements were repeated three times with increasing pressure in the phantom. To determine if the achieved aspiration flow rates were similar to physiologic values, flow rates in the ICA and external carotid artery (ECA) in 10 healthy volunteers were measured using 4D-flow MRI. Results Aspiration flow rates ranged from 25 to 82 mL/min depending on the stent model. The pressure in the phantom had a significant influence on the aspiration volume. Mean blood flow volumes in volunteers were 210 mL/min in the ICA and 101 mL/min in the ECA. Conclusions Based on the results of this study, flow reversal in the ICA during common carotid artery occlusion is most likely achieved with the smallest diameter stent sheath and the stent model with the shortest outer stent sheath maximum diameter. This implies that embolic protection during emergency CAS through aspiration is most effective with these models.
Collapse
Affiliation(s)
- Tilman Schubert
- Department of Radiology, University of Wisconsin-Madison, Madison, WI, USA. .,Department of Neuroradiology, Zurich University Hospital, Zurich, Switzerland.
| | | | - Alejandro Roldan-Alzate
- Department of Radiology, University of Wisconsin-Madison, Madison, WI, USA.,Department of Mechanical Engineering, University of Wisconsin-Madison, Madison, WI, USA.,Department of Biomedical Engineering, University of Wisconsin-Madison, Madison, WI, USA
| | - Daniel Consigny
- Department of Radiology, University of Wisconsin-Madison, Madison, WI, USA
| | - Lorenz Leitner
- Department of Neuro-Urology, Balgrist University Hospital, Zurich, Switzerland
| | - Charles Strother
- Department of Radiology, University of Wisconsin-Madison, Madison, WI, USA
| | - Beverly Aagaard-Kienitz
- Department of Radiology, University of Wisconsin-Madison, Madison, WI, USA.,Department of Neurological Surgery, University of Wisconsin-Madison, Madison, WI, USA
| |
Collapse
|
13
|
Hanaoka Y, Koyama JI, Yamazaki D, Miyaoka Y, Fujii Y, Nakamura T, Ogiwara T, Ito K, Horiuchi T. Transradial Approach as the Primary Vascular Access with a 6-Fr Simmons Guiding Sheath for Anterior Circulation Interventions: A Single-Center Case Series of 130 Consecutive Patients. World Neurosurg 2020; 138:e597-e606. [PMID: 32165342 DOI: 10.1016/j.wneu.2020.03.003] [Citation(s) in RCA: 29] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2019] [Revised: 02/29/2020] [Accepted: 03/02/2020] [Indexed: 10/24/2022]
Abstract
OBJECTIVE In coronary intervention, the transradial approach (TRA) is increasingly used as the primary vascular access because of its numerous advantages over the transfemoral approach. However, in neurointerventions, conventional TRA with a straight-shaped guiding system is used as an alternative vascular access because transradial carotid cannulation can be technically challenging for right common carotid artery (CCA) lesions with steep angulation to the right subclavian artery or left CCA lesions with a nonbovine origin. The purpose of the present study was to evaluate the feasibility and safety of TRA as the primary vascular access with a pre-shaped Simmons guiding sheath for anterior circulation interventions. METHODS Between June 2018 and September 2019, 130 consecutive patients (75 carotid artery stenting and 55 cerebral aneurysm coiling cases) who underwent TRA as the primary vascular access were included in this study. A 6-Fr Simmons guiding sheath was introduced into the target CCA by selecting a cannulation technique based on preprocedural image assessment. We retrospectively analyzed the carotid cannulation success, procedural success, and periprocedural or vascular access site complications. RESULTS Carotid cannulation (69 right CCA, 6 left CCA with a bovine origin, and 55 left CCA with a nonbovine origin) and the subsequent procedure were successfully performed for all 130 patients without periprocedural or vascular access site complications. CONCLUSIONS TRA with a 6-Fr Simmons guiding sheath for anterior circulation interventions is highly successful and safe for all target CCAs and aortic arch types. This method can be utilized as the primary vascular access for anterior circulation interventions.
Collapse
Affiliation(s)
- Yoshiki Hanaoka
- Department of Neurosurgery, Shinshu University School of Medicine, Matsumoto, Nagano, Japan
| | - Jun-Ichi Koyama
- Neurointervention Center, Shinshu University Hospital, Matsumoto, Nagano, Japan
| | - Daisuke Yamazaki
- Department of Neurosurgery, Shinshu University School of Medicine, Matsumoto, Nagano, Japan
| | - Yoshinari Miyaoka
- Department of Neurosurgery, Shinshu University School of Medicine, Matsumoto, Nagano, Japan
| | - Yu Fujii
- Department of Neurosurgery, Shinshu University School of Medicine, Matsumoto, Nagano, Japan
| | - Takuya Nakamura
- Department of Neurosurgery, Shinshu University School of Medicine, Matsumoto, Nagano, Japan
| | - Toshihiro Ogiwara
- Department of Neurosurgery, Shinshu University School of Medicine, Matsumoto, Nagano, Japan
| | - Kiyoshi Ito
- Department of Neurosurgery, Shinshu University School of Medicine, Matsumoto, Nagano, Japan
| | - Tetsuyoshi Horiuchi
- Department of Neurosurgery, Shinshu University School of Medicine, Matsumoto, Nagano, Japan.
| |
Collapse
|
14
|
Müller MD, Lyrer P, Brown MM, Bonati LH. Carotid artery stenting versus endarterectomy for treatment of carotid artery stenosis. Cochrane Database Syst Rev 2020; 2:CD000515. [PMID: 32096559 PMCID: PMC7041119 DOI: 10.1002/14651858.cd000515.pub5] [Citation(s) in RCA: 35] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
BACKGROUND Carotid artery stenting is an alternative to carotid endarterectomy for the treatment of atherosclerotic carotid artery stenosis. This review updates a previous version first published in 1997 and subsequently updated in 2004, 2007, and 2012. OBJECTIVES To assess the benefits and risks of stenting compared with endarterectomy in people with symptomatic or asymptomatic carotid stenosis. SEARCH METHODS We searched the Cochrane Stroke Group Trials Register (last searched August 2018) and the following databases: CENTRAL, MEDLINE, Embase, and Science Citation Index to August 2018. We also searched ongoing trials registers (August 2018) and reference lists, and contacted researchers in the field. SELECTION CRITERIA Randomised controlled trials (RCTs) comparing stenting with endarterectomy for symptomatic or asymptomatic atherosclerotic carotid stenosis. In addition, we included RCTs comparing carotid artery stenting with medical therapy alone. DATA COLLECTION AND ANALYSIS One review author selected trials for inclusion, assessed trial quality and risk of bias, and extracted data. A second review author independently validated trial selection and a third review author independently validated data extraction. We calculated treatment effects as odds ratios (OR) and 95% confidence intervals (CI), with endarterectomy as the reference group. We quantified heterogeneity using the I² statistic and used GRADE to assess the overall certainty of evidence. MAIN RESULTS We included 22 trials involving 9753 participants. In participants with symptomatic carotid stenosis, compared with endarterectomy stenting was associated with a higher risk of periprocedural death or stroke (the primary safety outcome; OR 1.70, 95% CI 1.31 to 2.19; P < 0.0001, I² = 5%; 10 trials, 5396 participants; high-certainty evidence); and periprocedural death, stroke, or myocardial infarction (OR 1.43, 95% CI 1.14 to 1.80; P = 0.002, I² = 0%; 6 trials, 4861 participants; high-certainty evidence). The OR for the primary safety outcome was 1.11 (95% CI 0.74 to 1.64) in participants under 70 years old and 2.23 (95% CI 1.61 to 3.08) in participants 70 years old or more (interaction P = 0.007). There was a non-significant increase in periprocedural death or major or disabling stroke with stenting (OR 1.36, 95% CI 0.97 to 1.91; P = 0.08, I² = 0%; 7 trials, 4983 participants; high-certainty evidence). Compared with endarterectomy, stenting was associated with lower risks of myocardial infarction (OR 0.47, 95% CI 0.24 to 0.94; P = 0.03, I² = 0%), cranial nerve palsy (OR 0.09, 95% CI 0.06 to 0.16; P < 0.00001, I² = 0%), and access site haematoma (OR 0.32, 95% CI 0.15 to 0.68; P = 0.003, I² = 27%). The combination of periprocedural death or stroke or ipsilateral stroke during follow-up (the primary combined safety and efficacy outcome) favoured endarterectomy (OR 1.51, 95% CI 1.24 to 1.85; P < 0.0001, I² = 0%; 8 trials, 5080 participants; high-certainty evidence). The rate of ipsilateral stroke after the periprocedural period did not differ between treatments (OR 1.05, 95% CI 0.75 to 1.47; P = 0.77, I² = 0%). In participants with asymptomatic carotid stenosis, there was a non-significant increase in periprocedural death or stroke with stenting compared with endarterectomy (OR 1.72, 95% CI 1.00 to 2.97; P = 0.05, I² = 0%; 7 trials, 3378 participants; moderate-certainty evidence). The risk of periprocedural death or stroke or ipsilateral stroke during follow-up did not differ significantly between treatments (OR 1.27, 95% CI 0.87 to 1.84; P = 0.22, I² = 0%; 6 trials, 3315 participants; moderate-certainty evidence). Moderate or higher carotid artery restenosis (50% or greater) or occlusion during follow-up was more common after stenting (OR 2.00, 95% CI 1.12 to 3.60; P = 0.02, I² = 44%), but the difference in risk of severe restenosis was not significant (70% or greater; OR 1.26, 95% CI 0.79 to 2.00; P = 0.33, I² = 58%; low-certainty evidence). AUTHORS' CONCLUSIONS Stenting for symptomatic carotid stenosis is associated with a higher risk of periprocedural stroke or death than endarterectomy. This extra risk is mostly attributed to an increase in minor, non-disabling strokes occurring in people older than 70 years. Beyond the periprocedural period, carotid stenting is as effective in preventing recurrent stroke as endarterectomy. However, combining procedural safety and long-term efficacy in preventing recurrent stroke still favours endarterectomy. In people with asymptomatic carotid stenosis, there may be a small increase in the risk of periprocedural stroke or death with stenting compared with endarterectomy. However, CIs of treatment effects were wide and further data from randomised trials in people with asymptomatic stenosis are needed.
Collapse
Affiliation(s)
- Mandy D Müller
- University Hospital BaselDepartment of Neurology and Stroke CenterPetersgraben 4BaselSwitzerland4031
| | - Philippe Lyrer
- University Hospital BaselDepartment of Neurology and Stroke CenterPetersgraben 4BaselSwitzerland4031
| | - Martin M Brown
- UCL Institute of NeurologyDepartment of Brain Repair & RehabilitationBox 6, The National HospitalQueen SquareLondonUKWC1N 3BG
| | - Leo H Bonati
- University Hospital BaselDepartment of Neurology and Stroke CenterPetersgraben 4BaselSwitzerland4031
- UCL Institute of NeurologyDepartment of Brain Repair & RehabilitationBox 6, The National HospitalQueen SquareLondonUKWC1N 3BG
| | | |
Collapse
|
15
|
Müller MD, von Felten S, Algra A, Becquemin JP, Brown M, Bulbulia R, Calvet D, Eckstein HH, Fraedrich G, Halliday A, Hendrikse J, Gregson J, Howard G, Jansen O, Mas JL, Brott TG, Ringleb PA, Bonati LH. Immediate and Delayed Procedural Stroke or Death in Stenting Versus Endarterectomy for Symptomatic Carotid Stenosis. Stroke 2019; 49:2715-2722. [PMID: 30355202 DOI: 10.1161/strokeaha.118.020684] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background and Purpose- Stenting for symptomatic carotid stenosis (carotid artery stenting [CAS]) carries a higher risk of procedural stroke or death than carotid endarterectomy (CEA). It is unclear whether this extra risk is present both on the day of procedure and within 1 to 30 days thereafter and whether clinical risk factors differ between these periods. Methods- We analyzed the risk of stroke or death occurring on the day of procedure (immediate procedural events) and within 1 to 30 days thereafter (delayed procedural events) in 4597 individual patients with symptomatic carotid stenosis who underwent CAS (n=2326) or CEA (n=2271) in 4 randomized trials. Results- Compared with CEA, patients treated with CAS were at greater risk for immediate procedural events (110 versus 42; 4.7% versus 1.9%; odds ratio, 2.6; 95% CI, 1.9-3.8) but not for delayed procedural events (59 versus 46; 2.5% versus 2.0%; odds ratio, 1.3; 95% CI, 0.9-1.9; interaction P=0.006). In patients treated with CAS, age increased the risk for both immediate and delayed events while qualifying event severity only increased the risk of delayed events. In patients treated with CEA, we found no risk factors for immediate events while a higher level of disability at baseline and known history of hypertension were associated with delayed procedural events. Conclusions- The increased procedural stroke or death risk associated with CAS compared with CEA was caused by an excess of events occurring on the day of procedure. This finding demonstrates the need to enhance the procedural safety of CAS by technical improvements of the procedure and increased operator skill. Higher age increased the risk for both immediate and delayed procedural events in CAS, mechanisms of which remain to be elucidated. Clinical Trial Registration- URL: https://clinicaltrials.gov . Unique identifier: NCT00190398. URL: http://www.isrctn.com . Unique identifier: ISRCTN57874028. URL: http://www.isrctn.com . Unique identifier: ISRCTN25337470. URL: https://clinicaltrials.gov . Unique identifier: NCT00004732.
Collapse
Affiliation(s)
- Mandy D Müller
- From the Department of Neurology and Stroke Center (M.D.M., L.H.B.), University Hospital Basel, University of Basel, Switzerland
| | - Stefanie von Felten
- Department of Clinical Research, Clinical Trial Unit (S.v.F.), University Hospital Basel, University of Basel, Switzerland
| | - Ale Algra
- Department of Neurology and Neurosurgery, Brain Center Rudolf Magnus and Julius Center for Health Sciences and Primary Care (A.A.), University Medical Center Utrecht, the Netherlands
| | - Jean-Pierre Becquemin
- Vascular Institute Paris East, Hôpital privé Paul D'Egine, Ramsay Group, France (J.-P.B.)
| | - Martin Brown
- Department of Brain Repair and Rehabilitation, UCL Institute of Neurology, University College London, United Kingdom (M.B., L.H.B.)
| | - Richard Bulbulia
- MRC Population Health Research Unit, Clinical Trial Service Unit and Epidemiological Studies Unit, Nuffield Department of Population Health, Oxford University, United Kingdom (R.B.)
| | - David Calvet
- Department of Neurology, Hôpital Sainte-Anne, Université Paris-Descartes, DHU Neurovasc Sorbonne Paris Cité, INSERM U894, France (D.C., J.-L.M.)
| | - Hans-Henning Eckstein
- Department of Vascular and Endovascular Surgery, Klinikum rechts der Isar, Technical University of Munich, Germany (H.-H.E.)
| | - Gustav Fraedrich
- Department of Vascular Surgery, Medical University of Innsbruck, Austria (G.F.)
| | - Alison Halliday
- Nuffield Department of Surgical Sciences, John Radcliffe Hospital, Oxford, United Kingdom (A.H.)
| | - Jeroen Hendrikse
- Department of Radiology (J.H.), University Medical Center Utrecht, the Netherlands
| | - John Gregson
- Department of Medical Statistics, London School of Hygiene and Tropical Medicine, United Kingdom (J.G.)
| | - George Howard
- Department of Biostatistics, UAB School of Public Health, Birmingham, AL (G.H.)
| | - Olav Jansen
- Clinic for Radiology and Neuroradiology, UKSH Campus Kiel, Germany (O.J.)
| | - Jean-Louis Mas
- Department of Neurology, Hôpital Sainte-Anne, Université Paris-Descartes, DHU Neurovasc Sorbonne Paris Cité, INSERM U894, France (D.C., J.-L.M.)
| | - Thomas G Brott
- Department of Neurology, Mayo Clinic, Jacksonville, FL (T.G.B.)
| | - Peter A Ringleb
- Department of Neurology, University of Heidelberg Medical School, Germany (P.A.R.)
| | - Leo H Bonati
- From the Department of Neurology and Stroke Center (M.D.M., L.H.B.), University Hospital Basel, University of Basel, Switzerland.,Department of Brain Repair and Rehabilitation, UCL Institute of Neurology, University College London, United Kingdom (M.B., L.H.B.)
| | | |
Collapse
|
16
|
Yerasi C, Heuser RR. You Can but Should You? Alternatives When Embolic Protection Is Difficult in Carotid Stenting. J Endovasc Ther 2019; 26:425. [DOI: 10.1177/1526602819844800] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Affiliation(s)
- Charan Yerasi
- Creighton University School of Medicine, Phoenix, AZ, USA
| | - Richard R. Heuser
- St Luke’s Hospital, University of Arizona College of Medicine, Phoenix, AZ, USA
| |
Collapse
|
17
|
Lamanna A, Maingard J, Barras CD, Kok HK, Handelman G, Chandra RV, Thijs V, Brooks DM, Asadi H. Carotid artery stenting: Current state of evidence and future directions. Acta Neurol Scand 2019; 139:318-333. [PMID: 30613950 DOI: 10.1111/ane.13062] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2018] [Revised: 12/18/2018] [Accepted: 01/03/2019] [Indexed: 11/29/2022]
Abstract
Both carotid endarterectomy (CEA) and carotid artery stenting (CAS) are common treatments for carotid artery stenosis. Several randomized controlled trials (RCTs) have compared CEA to CAS in the treatment of carotid artery stenosis. These studies have suggested that CAS is more strongly associated with periprocedural stroke; however, CEA is more strongly associated with myocardial infarction. Published long-term outcomes report that CAS and CEA are similar. A reduction in complications associated with CAS has also been demonstrated over time. The symptomatic status of the patient and history of previous CEA or cervical radiotherapy are significant factors when deciding between CEA or CAS. Numerous carotid artery stents are available, varying in material, shape and design but with minimal evidence comparing stent types. The role of cerebral protection devices is unclear. Dual antiplatelet therapy is typically prescribed to prevent in-stent thrombosis, and however, evidence comparing periprocedural and postprocedural antiplatelet therapy is scarce, resulting in inconsistent guidelines. Several RCTs are underway that will aim to clarify some of these uncertainties. In this review, we summarize the development of varying techniques of CAS and studies comparing CAS to CEA as treatment options for carotid artery stenosis.
Collapse
Affiliation(s)
- Anthony Lamanna
- Interventional Radiology Service, Department of Radiology Austin Hospital Melbourne Victoria Australia
| | - Julian Maingard
- Interventional Radiology Service, Department of Radiology Austin Hospital Melbourne Victoria Australia
| | - Christen D. Barras
- South Australian Health and Medical Research Institute Adelaide South Australia Australia
- The University of Adelaide Adelaide South Australia Australia
| | - Hong Kuan Kok
- Interventional Radiology ServiceNorthern Hospital Radiology Melbourne, Victoria Australia
- School of Medicine, Faculty of HealthDeakin University Waurn Ponds Victoria Australia
| | - Guy Handelman
- Education and Research CentreBeaumont Hospital Dublin Ireland
- Department of RadiologyRoyal Victoria Hospital Belfast UK
| | - Ronil V. Chandra
- Department of ImagingMonash Health Melbourne Victoria Australia
- Interventional Neuroradiology Unit, Monash ImagingMonash Health Melbourne Victoria Australia
| | - Vincent Thijs
- Stroke Division, The Florey Institute of Neuroscience & Mental HealthUniversity of Melbourne Melbourne Victoria Australia
- The University of Melbourne Melbourne Victoria Australia
- Department of NeurologyAustin Health Melbourne Victoria Australia
| | - Duncan Mark Brooks
- Interventional Radiology Service, Department of Radiology Austin Hospital Melbourne Victoria Australia
- Interventional Neuroradiology Service, Department of RadiologyAustin Hospital Melbourne Victoria Australia
| | - Hamed Asadi
- Interventional Radiology Service, Department of Radiology Austin Hospital Melbourne Victoria Australia
- School of Medicine, Faculty of HealthDeakin University Waurn Ponds Victoria Australia
- Department of ImagingMonash Health Melbourne Victoria Australia
- Interventional Neuroradiology Unit, Monash ImagingMonash Health Melbourne Victoria Australia
- Interventional Neuroradiology Service, Department of RadiologyAustin Hospital Melbourne Victoria Australia
| |
Collapse
|
18
|
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.
Collapse
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
| |
Collapse
|
19
|
Bashir Q, Baig AA. Carotid Revascularization with and without the Use of an Embolic Protection Device: A Single-Center Experience from Pakistan. INTERVENTIONAL NEUROLOGY 2018; 7:378-388. [PMID: 30410515 DOI: 10.1159/000489711] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/13/2018] [Accepted: 04/28/2018] [Indexed: 11/19/2022]
Abstract
Background To assess the safety and clinical efficacy of carotid artery stenting with and without an embolic protection device (EPD) in both symptomatic and asymptomatic carotid disease cases. Methods Retrospective data of 55 symptomatic (≥50% occlusion by digital subtraction angiography [DSA], ≥70% by ultrasound, computed tomography angiography [CTA], and magnetic resonance angiography [MRA]) and asymptomatic (≥60% by DSA, ≥70% by ultrasound, ≥80% by CTA and MRA) carotid disease cases undergoing carotid stenting/angioplasty revascularization from February 2014 to October 2017 was reviewed. All symptomatic patients either experienced recurrent transient ischemic attacks or one or more stroke attacks. An EPD protocol was designed for its selective use based on plaque morphologies and working diameters. The primary end points at 30 days of follow-up were a periprocedural incidence of any stroke, myocardial infarction or death, and ipsilateral stroke during the follow-up period. Results Of the 55 cases, 39 were males and 16 females; mean age was 64.8 years. Fifty-one patients (92.7%) were symptomatic, with a mean stenosis of 80.1%. EPD was used in only 11 cases (20%). Minor stroke rate during the first 30 postoperative days was 1.8% (1 case) with EPD; no myocardial infarction or mortality. No stroke occurred during the median 1.5 years' follow-up. Conclusion Based on our single-center experience and findings of a relatively small sample size, carotid revascularization with stenting and angioplasty without EPD in experienced hands was found to be safe and efficacious. In addition, it proves cost-effective for patients by limiting the use of unnecessary disposables. These results are comparable to those reported in major trials and are well within the complication thresholds suggested in current guidelines. These results also show promise and illustrate the need for a larger, randomized controlled trial in order to thoroughly address this aspect of carotid revascularization.
Collapse
Affiliation(s)
- Qasim Bashir
- Department of Neurointervention, Bahria Town Hospital, Lahore, Pakistan.,Department of Clinical and Interventional Neurology, CMH Lahore Medical College, Lahore, Pakistan
| | | |
Collapse
|
20
|
Staged carotid artery stenting in patients with severe carotid stenosis: Multicenter experience. J Clin Neurosci 2018; 53:74-78. [PMID: 29685407 DOI: 10.1016/j.jocn.2018.04.007] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2018] [Accepted: 04/08/2018] [Indexed: 11/24/2022]
Abstract
Cerebral hyperperfusion syndrome (CHS) is serious complication after carotid artery stenting (CAS) caused by decreased cerebral vasoreactivity (CVR) due to long standing hypoperfusion of the brain. We hypothesized that partial dilatation of carotid stenosis would allow the recovery of CVR, and prevent CHS when definitive angioplasty with stent is performed afterward. In this study, we aimed to evaluate the safety and efficacy of staged CAS in patients with severe carotid artery stenosis with evident hemodynamic compromise in regard to preventing hyperperfusion syndrome. From January 2005 to February 2016, 53 patients with 55 severe carotid artery stenosis lesions showing decreased CVR and/or cerebral basal flow at the perfusion studies underwent staged CAS in three institutes. The procedure consisted of initial partial balloon angioplasty (BA), recovery period, and delayed definitive stenting (DS). We analyzed immediate results, complications, recoil and CHS related to staged CAS. We experienced no symptomatic manifestation of CHS except self-limited headache after the procedures. The median of intervals between BA and DS stages were 10 days. There was no case of severe recoil during the interval between BA and DS stage. Where perfusion imaging data was available, hyperperfusion was present in three and one patients after BA and DS stage, respectively, with no clinical symptom of CHS. In conclusion, staged CAS was feasible in patients with severe carotid artery stenosis and hemodynamic compromise, without inducing severe complication of CHS such as intracranial hemorrhage.
Collapse
|
21
|
Cho YD, Kim SE, Lim JW, Choi HJ, Cho YJ, Jeon JP. Protected versus Unprotected Carotid Artery Stenting : Meta-Analysis of the Current Literature. J Korean Neurosurg Soc 2018; 61:458-466. [PMID: 29631386 PMCID: PMC6046577 DOI: 10.3340/jkns.2017.0202.001] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2017] [Accepted: 09/08/2017] [Indexed: 11/27/2022] Open
Abstract
Objective To compare peri-operative any symptomatic stroke after carotid angioplasty and stenting (CAS), based on the application or absence of a cerebral protection device. Methods A systematic literature review using PubMed, Embase, and the Cochrane Central was done across an online data base from January 1995 to October 2016. Procedures which were performed due to carotid dissection or aneurysm, procedures using covered stents or conducted in an emergency, were excluded. The primary endpoint was perioperative any symptomatic stroke within 30 days after the procedure. A fixed effect model was used in cases of heterogeneity less than 50%. Results In the 25 articles included in this study, the number of stroke events was 326 (2.0%) in protected CAS and 142 (3.4%) in unprotected CAS. The use of cerebral protection device significantly decreased stroke after CAS (odds ratio [OR] 0.633, 95% confidence interval [CI] 0.479–0.837, p=0.001). In the publication bias analysis, Egger’s regression test disclosed that the intercept was -0.317 (95% CI -1.015–0.382, p=0.358). Regarding symptomatic patients (four studies, 539 CAS procedures), the number of stroke was six (1.7%) in protected CAS and 11 (5.7%) in unprotected CAS. The protective effect against stroke events by cerebral protection device did not have a statistical significance (OR 0.455, 95% CI 0.151–1.366, p=0.160). Conclusion The use of protection device significantly decreased stroke after CAS. However, its efficacy was not demonstrated in symptomatic patients. Routine use of protection device during CAS should be critically assessed before mandatory use.
Collapse
Affiliation(s)
- Young Dae Cho
- Department of Radiology, Seoul National University College of Medicine, Seoul, Korea
| | - Sung-Eun Kim
- Department of Emergency Medicine, Seoul Emergency Operations Center, Seoul, Korea
| | - Jeong Wook Lim
- Department of Neurosurgery, Chungnam National University College of Medicine, Daejeon, Korea
| | - Hyuk Jai Choi
- Department of Neurosurgery, Hallym University College of Medicine, Chuncheon, Korea
| | - Yong Jun Cho
- Department of Neurosurgery, Hallym University College of Medicine, Chuncheon, Korea
| | - Jin Pyeong Jeon
- Department of Neurosurgery, Hallym University College of Medicine, Chuncheon, Korea.,Institute of New Frontier Research, Hallym University College of Medicine, Chuncheon, Korea
| |
Collapse
|
22
|
Abstract
OBJECTIVES The aim of this study was to analyze the association between intraprocedural and periprocedural variables and in-hospital stroke or death rate after carotid artery stenting. BACKGROUND In Germany, all open surgical and endovascular procedures on the extracranial carotid artery must be documented in a statutory nationwide quality assurance database. METHODS A total of 13,086 carotid artery stenting procedures for asymptomatic (63.9%) or symptomatic carotid stenosis (mean age 69.7 years, 69.7% men) between 2009 and 2014 were recorded. The following variables were analyzed: stent design, stent material, neurophysiological monitoring, periprocedural antiplatelet medication, and use of an embolic protection device. The primary outcome was in-hospital stroke or death. Major stroke or death, any stroke, and death, all until discharge, were secondary outcomes. Adjusted relative risks (RRs) were assessed using multilevel multivariable regression analyses. RESULTS The primary outcome occurred in 2.4% of the population (1.7% in asymptomatic and 3.7% in symptomatic patients). The multivariable analysis showed an independent association between the use of an embolic protection device and lower in-hospital rates of stroke or death (adjusted RR: 0.65; 95% confidence interval [CI]: 0.50 to 0.85), major stroke or death (adjusted RR: 0.60; 95% CI: 0.43 to 0.84), and stroke (adjusted RR: 0.57; 95% CI: 0.43 to 0.77). Regarding the occurrence of in-hospital death, there was no significant association (adjusted RR: 0.78; 95% CI: 0.46 to 1.35). None of the outcomes was associated with stent design, stent material, neurophysiological monitoring, or antiplatelet medication. CONCLUSIONS The use of an embolic protection device was independently associated with lower in-hospital risk for stroke or death, major stroke or death, and stroke.
Collapse
|
23
|
Vinogradov RA, Zebelyan AA. [Risk stratification in carotid artery stenting]. Khirurgiia (Mosk) 2018:93-95. [PMID: 29460887 DOI: 10.17116/hirurgia2018293-95] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Affiliation(s)
- R A Vinogradov
- Research Institute - Ochapovsky Regional Clinical Hospital # 1 of Healthcare Ministry of the Krasnodar Territory, Krasnodar, Russia
| | - A A Zebelyan
- Kuban State Medical University of Healthcare Ministry of the Russian Federation, Krasnodar, Russia
| |
Collapse
|
24
|
Abstract
Carotid artery stenting (CAS) has been recommended as an alternative treatment to carotid endarterectomy for patients with significant carotid stenosis. Only a few studies have analyzed clinical/anatomical and technical variables that affect perioperative outcomes of CAS. Following a comprehensive Medline search, it was reported that clinical factors, including age of >80 years, chronic renal failure, diabetes mellitus, symptomatic indications, and procedures performed within 2 weeks of transient ischemic attack symptoms, are associated with high perioperative stroke and death rates. They also highlighted that angiographic variables, e.g., ulcerated and calcified plaques, left carotid intervention, >90% stenosis, >10-mm target lesion length, ostial involvement, type III aortic arch, and >60°-angulated internal carotid and common carotid arteries, are predictors of increased stroke rates. Technical factors associated with increased perioperative risk of stroke include percutaneous transluminal angioplasty (PTA) without embolic protection devices, PTA before stent placement, and the use of multiple stents. This review describes the most widely quoted data in defining various predictors of perioperative stroke and death after CAS. (This is a review article based on the invited lecture of the 45th Annual Meeting of Japanese Society for Vascular Surgery.)
Collapse
Affiliation(s)
- Ali F AbuRahma
- Department of Surgery, West Virginia University, Charleston, West Virginia, USA
| |
Collapse
|
25
|
Cho SM, Deshpande A, Pasupuleti V, Hernandez AV, Uchino K. Radiographic and symptomatic brain ischemia in CEA and CAS: A systematic review and meta-analysis. Neurology 2017; 89:1977-1984. [PMID: 29021357 DOI: 10.1212/wnl.0000000000004626] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2017] [Accepted: 08/21/2017] [Indexed: 01/17/2023] Open
Abstract
OBJECTIVE In a systematic review, we compared ratio of new periprocedural radiographic brain ischemia (RBI) to the number of strokes and TIAs among patients undergoing carotid endarterectomy (CEA) and carotid artery stenting (CAS). METHODS We searched 5 databases for entries related to brain ischemia in CEA or CAS from inception through September 2015. We included articles with CEA or CAS and systematic performance of preprocedural and postprocedural brain MRI and reporting of RBI and stroke incidence. We calculated a symptomatic risk ratio of number of strokes and TIAs to RBI. Random effects models were used. RESULTS Fifty-nine studies (5,431 participants) met the inclusion criteria. There were 22 cohorts in CEA, 34 in CAS with distal protection, 8 in CAS with proximal protection, 9 in CAS without protection, and 9 in CAS with unspecified devices. Overall, 30.7% (95% confidence interval [CI] 26.6%-34.7%) had RBI, while 3.2% (95% CI 2.6%-3.8%) had clinical strokes or TIAs, with a stroke and TIA to RBI weighted ratio of 0.18 (95% CI 0.15-0.22). CEA had lower incidence of RBI compared to CAS (13.0% vs 37.4%) and also lower number of strokes and TIAs (1.8% vs 4.1%). The stroke and TIA to RBI ratio did not differ across 5 different types of carotid interventions (p = 0.58). CONCLUSIONS One in 5 persons with periprocedural radiographic brain ischemia during CEA and CAS had strokes and TIAs. The stable ratio of stroke and TIA to radiographic ischemia suggests that MRI ischemia could serve as a surrogate measure of periprocedural risk.
Collapse
Affiliation(s)
- Sung-Min Cho
- From the Cerebrovascular Center, Neurological Institute (S.-M.C., K.U.), and Medicine Institute (A.D.), Cleveland Clinic, Cleveland, OH; Case Western Reserve University (V.P.), Cleveland, OH; School of Medicine (A.V.H.), Universidad Peruana de Ciencias Aplicadas (UPC), Lima, Peru; and University of Connecticut/Hartford Hospital Evidence-Based Practice Center (A.V.H.)
| | - Abhishek Deshpande
- From the Cerebrovascular Center, Neurological Institute (S.-M.C., K.U.), and Medicine Institute (A.D.), Cleveland Clinic, Cleveland, OH; Case Western Reserve University (V.P.), Cleveland, OH; School of Medicine (A.V.H.), Universidad Peruana de Ciencias Aplicadas (UPC), Lima, Peru; and University of Connecticut/Hartford Hospital Evidence-Based Practice Center (A.V.H.)
| | - Vinay Pasupuleti
- From the Cerebrovascular Center, Neurological Institute (S.-M.C., K.U.), and Medicine Institute (A.D.), Cleveland Clinic, Cleveland, OH; Case Western Reserve University (V.P.), Cleveland, OH; School of Medicine (A.V.H.), Universidad Peruana de Ciencias Aplicadas (UPC), Lima, Peru; and University of Connecticut/Hartford Hospital Evidence-Based Practice Center (A.V.H.)
| | - Adrian V Hernandez
- From the Cerebrovascular Center, Neurological Institute (S.-M.C., K.U.), and Medicine Institute (A.D.), Cleveland Clinic, Cleveland, OH; Case Western Reserve University (V.P.), Cleveland, OH; School of Medicine (A.V.H.), Universidad Peruana de Ciencias Aplicadas (UPC), Lima, Peru; and University of Connecticut/Hartford Hospital Evidence-Based Practice Center (A.V.H.)
| | - Ken Uchino
- From the Cerebrovascular Center, Neurological Institute (S.-M.C., K.U.), and Medicine Institute (A.D.), Cleveland Clinic, Cleveland, OH; Case Western Reserve University (V.P.), Cleveland, OH; School of Medicine (A.V.H.), Universidad Peruana de Ciencias Aplicadas (UPC), Lima, Peru; and University of Connecticut/Hartford Hospital Evidence-Based Practice Center (A.V.H.).
| |
Collapse
|
26
|
Zerebrale Protektion bei endovaskulären Prozeduren. ZEITSCHRIFT FUR HERZ THORAX UND GEFASSCHIRURGIE 2017. [DOI: 10.1007/s00398-017-0141-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
|
27
|
Watanabe H, Saito N, Nagata Y, Yamamoto E, Nakatsuma K, Bingyuan B, Watanabe S, Tazaki J, Kimura T, Inoue K. A novel guidewire-integrated embolic protection filter device with a handy-folding system: In vitro and in vivo performance assessment. Catheter Cardiovasc Interv 2017; 92:E9-E14. [PMID: 28940984 DOI: 10.1002/ccd.27315] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/26/2016] [Revised: 06/07/2017] [Accepted: 08/07/2017] [Indexed: 11/06/2022]
Abstract
OBJECTIVES We developed a novel guidewire-integrated filter device with a handy-folding system (IFD: Inoue filter device). In vitro and in vivo studies were conducted to evaluate the feasibilityof the IFD. BACKGROUND Although distal atheromatous and thrombotic embolizations remain unresolved critical issues during catheter interventions, distal protection devices are infrequently used partly because of reduced lower maneuverability. METHODS In the in vitro experiment, we created an experimental circulation model composed of silicone latex tubes, a reservoir, and a roller pump. After the filter device was deployed in the tube, polystyrene fluorescent microspheres were injected and the capture rate was calculated. Ten trials were performed using the IFD and Spider FX. In the in vivo study, five independent operators deployed, and they retrieved the IFD in swine common iliac and internal carotid arteries. The procedural success rate as well as the delivery and retrieval time was evaluated. RESULTS In the in vitro study, the mean capture rate was 94% and 35% in the IFD and Spider groups, respectively. In the in vivo study, all procedures were successful, with no complications. The mean delivery time was 281 ± 87 s and 194 ± 67 s and the mean retrieval time was 24 ± 9 and 13 ±1 s in the left internal carotid and the left common iliac arteries, respectively. CONCLUSION Although further studies and improvements are required, the study results indicate that the IFD is feasible.
Collapse
Affiliation(s)
- Hiroki Watanabe
- Department of Cardiovascular Medicine, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - Naritatsu Saito
- Department of Cardiovascular Medicine, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | | | - Erika Yamamoto
- Department of Cardiovascular Medicine, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - Kenji Nakatsuma
- Department of Cardiovascular Medicine, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - Bao Bingyuan
- Department of Cardiovascular Medicine, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - Shin Watanabe
- Department of Cardiovascular Medicine, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - Junichi Tazaki
- Department of Cardiovascular Medicine, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - Takeshi Kimura
- Department of Cardiovascular Medicine, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | | |
Collapse
|
28
|
Maggio P, Altamura C, Lupoi D, Paolucci M, Altavilla R, Tibuzzi F, Passarelli F, Arpesani R, Di Giambattista G, Grasso RF, Luppi G, Fiacco F, Silvestrini M, Pasqualetti P, Vernieri F. The Role of White Matter Damage in the Risk of Periprocedural Diffusion-Weighted Lesions after Carotid Artery Stenting. Cerebrovasc Dis Extra 2017; 7:1-8. [PMID: 28125807 PMCID: PMC5340215 DOI: 10.1159/000452717] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2016] [Accepted: 10/10/2016] [Indexed: 12/27/2022] Open
Abstract
Background White matter hyperintensities (WMH) are a common finding in aged individuals affected by carotid artery disease and are a risk factor for first-ever and recurrent stroke. We investigated if white matter damage increases the risk of brain microembolism during carotid artery stenting (CAS), as evaluated by the appearance of new areas of restricted diffusion on diffusion-weighted images (DWI). Methods We evaluated 47 patients with severe internal carotid artery (ICA) stenosis undergoing CAS, comparing preprocedural clinical, ultrasound and radiological characteristics. WMH volume was computed on FLAIR images before CAS. After CAS, the DWI scan was looked over for areas of restricted diffusion (DWI lesions). A first univariate analysis was adopted to compare groups according to the occurrence of DWI lesions. Then, the variable DWI lesion was modelled by means of a logistic regression model. Results Seventeen patients developed at least 1 DWI lesion after CAS. Compared with non-DWI, DWI patients were more commonly treated in the left ICA (p = 0.007) and had a more severe WMH damage (p = 0.027). Indeed, the risk of a DWI lesion was higher in left versus right stenosis (OR = 9.0, 95% CI 1.9-42.7, p = 0.005) and increased for each log-unit of WMH lesion load (OR = 7.05, 95% CI 1.07-46.49, p = 0.042). A WMH lesion load of at least 5.25 cm3 had a 50% probability of occurrence of a new DWI lesion. Conclusions Treated side and preexisting white matter damage are risk conditions for brain microembolism during CAS. This should be taken into account to optimize severe carotid artery disease management.
Collapse
Affiliation(s)
- Paola Maggio
- Neurology Unit, ASST Bergamo Est, Azienda Ospedaliera Bolognini, Seriate, Italy
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|
29
|
Binning MJ, Maxwell CR, Stofko D, Zerr M, Maghazehe K, Liebman K, Hakma Z, Lewis-Diaz C, Veznedaroglu E. Carotid Artery Angioplasty and Stenting Without Distal Embolic Protection Devices. Neurosurgery 2017; 80:60-64. [PMID: 27471973 DOI: 10.1227/neu.0000000000001367] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2015] [Accepted: 05/26/2016] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Embolic protection devices are used during carotid artery stenting procedures to reduce risk of distal embolization. Although this is a standard procedural recommendation, no studies have shown superiority of these devices over unprotected stenting procedures. OBJECTIVE To assess the periprocedural outcome and durability of carotid artery stenting without embolic protection devices and poststent angioplasty. METHODS We performed a retrospective chart review of 174 carotid angioplasty stent procedures performed at our institution. One hundred sixty-six patients underwent angioplasty and stenting without distal protection devices or poststent angioplasty. Complications related to stenting, including procedural complications, postoperative stroke and/or myocardial infarction, and stent restenosis were analyzed. RESULTS One hundred thirty-five stents (78%) were performed in symptomatic patients, whereas 22% of stents were placed for asymptomatic internal carotid artery stenosis. The degree of stenosis was 80% or greater in 75% of patients and 90% or greater in 55% of patients. Following the stenting procedure, the 24-hour and 30-day rate of transient ischemic attack, intracranial hemorrhage, or ischemic stroke was 0. Three (2%) patients had a perioperative, non-ST elevation myocardial infarction. Five patients (2.8%) required treatment for restenosis (>50% stenosis from baseline), 1 of which was symptomatic. CONCLUSION Our data show that carotid artery stenting without the use of embolic protection devices and without postangioplasty stenting, in experienced hands, can be performed safely. Furthermore, this technique does not result in a higher degree of in-stent restenosis than series in which poststenting angioplasty is performed.
Collapse
Affiliation(s)
| | | | | | - Myra Zerr
- Capital Health Regional Medical Center and Capital Institutes for Neurosciences, Trenton and Pennington, New Jersey
| | - Kamyar Maghazehe
- Capital Health Regional Medical Center and Capital Institutes for Neurosciences, Trenton and Pennington, New Jersey
| | | | - Zakaria Hakma
- Drexel Neurosciences Institute, Philadelphia, Pennsylvania
| | - Cynthia Lewis-Diaz
- Capital Health Regional Medical Center and Capital Institutes for Neurosciences, Trenton and Pennington, New Jersey
| | | |
Collapse
|
30
|
Abstract
Atherosclerotic carotid stenosis accounts for about 15% of ischemic strokes. Carotid endarterectomy reduces the risk of stroke in patients with severe carotid stenosis. Carotid artery stenting has emerged as a potentially less invasive alternative to carotid endarterectomy. However, randomized clinical trials in patients with symptomatic stenosis have shown that carotid artery stenting is associated with a higher risk of peri-procedural stroke compared with carotid endarterectomy. Carotid artery stenting is associated with a lower risk of peri-procedural myocardial infarction and local complications (cranial nerve palsies, access site hematoma) and appears to be as durable as carotid endarterectomy in terms of long-term protection against ipsilateral stroke and risk of restenosis. The main risk factors for peri-procedural stroke in patients treated with carotid artery stenting are age >70 years and high burden of white-matter lesions on brain imaging. Patients with asymptomatic carotid stenosis receiving modern medical treatment have a low risk (<1%/year) of ipsilateral stroke and it is uncertain whether the benefit of revascularization still justifies the procedural risk of stroke or death. In particular, the small excess of procedural risk of stroke associated with carotid artery stenting (compared with carotid endarterectomy) may offset the small benefit (if any) of carotid endarterectomy versus medical therapy in unselected patients. Randomized clinical trials are ongoing to solve this issue.
Collapse
Affiliation(s)
- David Calvet
- Centre Hospitalier Sainte-Anne, Université Paris-Descartes, INSERM U894, DHU Neurovasc-Paris Sorbonne, Paris, France
| | - Jean-Louis Mas
- Centre Hospitalier Sainte-Anne, Université Paris-Descartes, INSERM U894, DHU Neurovasc-Paris Sorbonne, Paris, France jl.mas@ch-sainte-anne
| |
Collapse
|
31
|
Aytac E, Gürkaş E, Akpinar CK, Saleem MA, Qureshi AI. Subclinical ischemic events in patients undergoing carotid artery stent placement: comparison of proximal and distal protection techniques. J Neurointerv Surg 2016; 9:933-936. [PMID: 27698230 DOI: 10.1136/neurintsurg-2016-012661] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2016] [Revised: 09/14/2016] [Accepted: 09/15/2016] [Indexed: 12/20/2022]
Abstract
OBJECTIVE To determine the relative effectiveness of proximal and distal protection in prevention of cerebral ischemic events during carotid artery stent (CAS) placement using diffusion-weighted MRI (DW-MRI). METHODS We analyzed data from patients who had undergone DW-MRI before and within 24 hours of CAS for symptomatic internal carotid artery (ICA) stenosis (with last ischemic events within 3 months). The study was performed prospectively; patients were not randomized, and were treated either with a proximal balloon occlusion system (Mo.Ma; Invatec, Roncadelle, Italy) or filter-type distal protection device (Spider device; ev3, Plymouth, Minnesota, USA). RESULTS Of the 45 patients (mean age±SD: 66.9±9.8 years; 73.3% were men) who underwent CAS, 19 had proximal protection and 26 distal protection. New ischemic lesions were detected in 26/45 patients on DW-MRI scans obtained within 24 hours after CAS. The proportion of patients with new lesions on DW-MRI at 24 hours was not different between the two groups (47.4% vs 65.4% for proximal and distal protection, respectively). The mean number of new ischemic lesions on post-CAS DW-MRI was non-significantly higher in patients who underwent CAS with distal protection (2.80±3.54 for proximal protection vs 4.96±5.11 for distal protection; p=0.12). The proportion of patients with new lesions >1 cm did not differ between the two groups (5.3% for proximal protection vs 11.5% for distal protection; p=0.62). There was no difference in the rates of ischemic stroke between patients who underwent CAS treatment using proximal and distal protection (5.3% vs 7.7%; p=1.000). CONCLUSIONS We found a relatively high rate of new ischemic lesions in patients undergoing CAS with cerebral protection. There was no difference in the proportion of patients with new lesions between patients treated using distal protection and those treated using proximal protection.
Collapse
Affiliation(s)
- Emrah Aytac
- Ankara Numune Training and Research Hospital, Neurology Clinic, Ankara, Turkey.,Zeenat Qureshi Stroke Institute, St Cloud, Minnesota, USA
| | - Erdem Gürkaş
- Ankara Numune Training and Research Hospital, Neurology Clinic, Ankara, Turkey
| | | | | | | |
Collapse
|
32
|
Plessers M, Van Herzeele I, Hemelsoet D, Vingerhoets G, Vermassen F. Perioperative Embolization Load and S-100β Do Not Predict Cognitive Outcome after Carotid Revascularization. Ann Vasc Surg 2016; 36:175-181. [DOI: 10.1016/j.avsg.2016.02.044] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2015] [Revised: 02/19/2016] [Accepted: 02/23/2016] [Indexed: 11/27/2022]
|
33
|
Doig D, Turner EL, Dobson J, Featherstone RL, Lo RTH, Gaines PA, Macdonald S, Bonati LH, Clifton A, Brown MM. Predictors of Stroke, Myocardial Infarction or Death within 30 Days of Carotid Artery Stenting: Results from the International Carotid Stenting Study. Eur J Vasc Endovasc Surg 2016; 51:327-34. [PMID: 26602322 PMCID: PMC4786052 DOI: 10.1016/j.ejvs.2015.08.013] [Citation(s) in RCA: 42] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2014] [Accepted: 08/18/2015] [Indexed: 10/25/2022]
Abstract
OBJECTIVES Stroke, myocardial infarction (MI), and death are complications of carotid artery stenting (CAS). The effect of baseline patient demographic factors, processes of care, and technical factors during CAS on the risk of stroke, MI, or death within 30 days of CAS in the International Carotid Stenting Study (ICSS) were investigated. METHODS In ICSS, suitable patients with recently symptomatic carotid stenosis > 50% were randomly allocated to CAS or endarterectomy. Factors influencing the risk of stroke, MI, or death within 30 days of CAS were examined in a regression model for the 828 patients randomized to CAS in whom the procedure was initiated. RESULTS Of the patients, 7.4% suffered stroke, MI, or death within 30 days of CAS. Independent predictors of risk were age (risk ratio [RR] 1.17 per 5 years of age, 95% CI 1.01-1.37), a right-sided procedure (RR 0.54, 95% CI 0.32-0.91), aspirin and clopidogrel in combination prior to CAS (compared with any other antiplatelet regimen, RR 0.59, 95% CI 0.36-0.98), smoking status, and the severity of index event. In patients in whom a stent was deployed, use of an open-cell stent conferred higher risk than use of a closed-cell stent (RR 1.92, 95% CI 1.11-3.33). Cerebral protection device (CPD) use did not modify the risk. CONCLUSIONS Selection of patients for CAS should take into account symptoms, age, and side of the procedure. The results favour the use of closed-cell stents. CPDs in ICSS did not protect against stroke.
Collapse
Affiliation(s)
- D Doig
- Institute of Neurology, University College London, UK
| | - E L Turner
- Department of Biostatistics and Bioinformatics, Duke University, Durham, NC, USA; Duke Global Health Institute, Duke University, Durham, NC, USA
| | - J Dobson
- Department of Medical Statistics, London School of Hygiene and Tropical Medicine, UK
| | | | - R T H Lo
- University Medical Centre, Utrecht, The Netherlands
| | - P A Gaines
- Sheffield Vascular Institute, Sheffield, UK
| | - S Macdonald
- Freeman Hospital, Newcastle Acute Hospitals NHS Foundation Trust, Newcastle, UK
| | - L H Bonati
- Institute of Neurology, University College London, UK; Department of Neurology and Stroke Unit, University Hospital Basel, Switzerland
| | | | - M M Brown
- Institute of Neurology, University College London, UK.
| |
Collapse
|
34
|
Affiliation(s)
- Mahmoud Malas
- a Johns Hopkins Medical Institutions , Baltimore , MD , USA
| | - Tammam Obeid
- a Johns Hopkins Medical Institutions , Baltimore , MD , USA
| |
Collapse
|
35
|
Doig D, Hobson BM, Müller M, Jäger HR, Featherstone RL, Brown MM, Bonati LH, Richards T. Carotid Anatomy Does Not Predict the Risk of New Ischaemic Brain Lesions on Diffusion-Weighted Imaging after Carotid Artery Stenting in the ICSS-MRI Substudy. Eur J Vasc Endovasc Surg 2016; 51:14-20. [PMID: 26481656 PMCID: PMC4711310 DOI: 10.1016/j.ejvs.2015.08.012] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2014] [Accepted: 08/18/2015] [Indexed: 12/17/2022]
Abstract
INTRODUCTION The International Carotid Stenting Study (ICSS, ISRCTN25337470) randomized patients with recently symptomatic carotid artery stenosis > 50% to carotid artery stenting (CAS) or endarterectomy. CAS increased the risk of new brain lesions visible on diffusion-weighted magnetic resonance imaging (DWI-MRI) more than endarterectomy in the ICSS-MRI Substudy. The predictors of new post-stenting DWI lesions were assessed in these patients. METHODS ICSS-MRI Substudy patients allocated to CAS were studied. Baseline or pre-stenting catheter angiograms were rated to determine carotid anatomy. Baseline patient demographics and the influence of plaque length, plaque morphology, internal carotid angulation, and external or common carotid atheroma were examined in negative binomial regression models. RESULTS A total of 115 patients (70% male, average age 70.4) were included; 50.4% had at least one new DWI-MRI-positive lesion following CAS. Independent risk factors increasing the number of new lesions were a left-sided stenosis (incidence risk ratio [IRR] 1.59, 95% CI 1.04-2.44, p = .03), age (IRR 2.10 per 10-year increase in age, 95% CI 1.61-2.74, p < .01), male sex (IRR 2.83, 95% CI 1.72-4.67, p < .01), hypertension (IRR 2.04, 95% CI 1.25-3.33, p < .01) and absence of cardiac failure (IRR 6.58, 95% CI 1.23-35.07, p = .03). None of the carotid anatomical features significantly influenced the number of post-procedure lesions. CONCLUSION Carotid anatomy seen on pre-stenting catheter angiography did not predict of the number of ischaemic brain lesions following CAS.
Collapse
Affiliation(s)
- D Doig
- Institute of Neurology, University College London, UK
| | - B M Hobson
- University College London Medical School, UK
| | - M Müller
- University of Basel, Basel, Switzerland
| | - H R Jäger
- Institute of Neurology, University College London, UK
| | | | - M M Brown
- Institute of Neurology, University College London, UK.
| | - L H Bonati
- Institute of Neurology, University College London, UK; Department of Neurology and Stroke Unit, University Hospital Basel, Basel, Switzerland
| | - T Richards
- Division of Surgery and Interventional Science, University College London, UK
| |
Collapse
|
36
|
Borhani Haghighi A, Yousefi S, Bahramali E, Kokabi S, Heydari ST, Shariat A, Nikseresht A, Ashjazadeh N, Izadi S, Petramfar P, Poursadegh M, Rahimi Jaberi A, Emami S, Agheli H, Nemati R, Yaghoubi E, Abdi MH, Panahandeh M, Heydari M, Safari A, Basir M, Cruz-Flores S, Edgell R. Demographic and Technical Risk Factors of 30-Day Stroke, Myocardial Infarction, and/or Death in Standard- and High-Risk Patients Who Underwent Carotid Angioplasty and Stenting. INTERVENTIONAL NEUROLOGY 2015; 3:165-73. [PMID: 26279663 DOI: 10.1159/000430923] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
BACKGROUND Carotid angioplasty and stenting (CAS) is an accepted treatment to prevent stroke in patients with carotid artery stenosis. The purpose of this study is to identify risk factors for major complications after CAS. MATERIALS AND METHODS This is a prospective study that was conducted at Shiraz University of Medical Sciences in southern Iran from March 2011 to June 2014. Consecutive patients undergoing CAS were enrolled. Both standard- and high-risk patients for endarterectomy were enrolled. Demographic data, atherosclerotic risk factors, site of stenosis, degree of stenosis, and data regarding technical factors were recorded. Thirty-day stroke, myocardial infarction, and/or death were considered as the composite primary outcomes of the study. RESULTS A total of 251 patients were recruited (mean age: 71.1 ± 9.6 years; male: 65.3%). Of these, 178 (70.9%) were symptomatic, 73 (29.1%) were diabetic, 129 (51.4%) were hyperlipidemic, 165 (65.7%) were hypertensive, and 62 (24.7%) patients were smokers. CAS was performed for left internal carotid artery (ICA) in 113 (45.4%) patients. Fourteen (5.6%) patients had sequential bilateral stenting. Mean stenosis of operated ICA was 80.2 ± 13.8%. An embolic protection device was used in 203 (96.2%) patients. Pre- and postdilation were performed in 39 (18.5%) and 182 (86.3%) patients, respectively. Composite outcomes were observed in 3.6% of patients (3.2% stroke, 0% myocardial infarction, and 1.2% death). Left-sided lesions and the presence of diabetes mellitus were significantly associated with poor short-term outcome (p = 0.025 and p = 0.020, respectively). CONCLUSION There was a higher risk of short-term major complications in diabetic patients and for left carotid artery intervention.
Collapse
Affiliation(s)
- Afshin Borhani Haghighi
- Clinical Neurology Research Center, Shiraz University of Medical Sciences, Fasa, Iran ; Department of Neurology, Shiraz University of Medical Sciences, Fasa, Iran
| | - Samaneh Yousefi
- Noncommunicable Diseases Research Center, Fasa University of Medical Sciences, Fasa, Iran
| | - Ehsan Bahramali
- Cardiology Department, Faculty of Medicine, Fasa University of Medical Sciences, Fasa, Iran
| | - Safoora Kokabi
- Transgenic Technology Research Center, Shiraz University of Medical Sciences, Fasa, Iran
| | - Seyed Taghi Heydari
- Health Policy Research Center, Shiraz University of Medical Sciences, Fasa, Iran
| | - Abdolhamid Shariat
- Clinical Neurology Research Center, Shiraz University of Medical Sciences, Fasa, Iran ; Department of Neurology, Shiraz University of Medical Sciences, Fasa, Iran
| | - Alireza Nikseresht
- Clinical Neurology Research Center, Shiraz University of Medical Sciences, Fasa, Iran ; Department of Neurology, Shiraz University of Medical Sciences, Fasa, Iran
| | - Nahid Ashjazadeh
- Clinical Neurology Research Center, Shiraz University of Medical Sciences, Fasa, Iran ; Department of Neurology, Shiraz University of Medical Sciences, Fasa, Iran
| | - Sadegh Izadi
- Clinical Neurology Research Center, Shiraz University of Medical Sciences, Fasa, Iran ; Department of Neurology, Shiraz University of Medical Sciences, Fasa, Iran
| | - Peyman Petramfar
- Clinical Neurology Research Center, Shiraz University of Medical Sciences, Fasa, Iran ; Department of Neurology, Shiraz University of Medical Sciences, Fasa, Iran
| | - Maryam Poursadegh
- Clinical Neurology Research Center, Shiraz University of Medical Sciences, Fasa, Iran ; Department of Neurology, Shiraz University of Medical Sciences, Fasa, Iran
| | - Abbas Rahimi Jaberi
- Clinical Neurology Research Center, Shiraz University of Medical Sciences, Fasa, Iran ; Department of Neurology, Shiraz University of Medical Sciences, Fasa, Iran
| | - Sajjad Emami
- Department of Neurology, Faculty of Medicine, Jahrom University of Medical Sciences, Jahrom, Iran
| | - Hamid Agheli
- Shahidzadeh Hospital, Behbahan, Bushehr University of Medical Sciences, Bushehr, Iran
| | - Reza Nemati
- Department of Neurology, Faculty of Medicine, Bushehr University of Medical Sciences, Bushehr, Iran
| | - Ehsan Yaghoubi
- Department of Neurology, Faculty of Medicine, Yasuj University of Medical Sciences, Yasuj, Iran
| | - Mohammad Hosein Abdi
- Motaharri Hospital, Marvdasht, Rafsanjan University of Medical Sciences, Rafsanjan, Iran
| | - Majid Panahandeh
- Ordibehesht Hospital, Shiraz, Fasa University of Medical Sciences, Fasa, Iran
| | - Moslem Heydari
- Department of Neurology, Faculty of Medicine, Rafsanjan University of Medical Sciences, Rafsanjan, Iran
| | - Anahid Safari
- Department of Pharmacology, Kazeroon Azad University, Kazeroon, Iran
| | - Marziyeh Basir
- Student Research Committee, Fasa University of Medical Sciences, Fasa, Iran
| | | | - Randal Edgell
- Department of Neurology, Saint Louis University, Saint Louis, Mo., USA ; Department of Psychiatry, Saint Louis University, Saint Louis, Mo., USA
| |
Collapse
|
37
|
Mahmoud KD, Lennon RJ, Holmes DR. Event Rates in Randomized Clinical Trials Evaluating Cardiovascular Interventions and Devices. Am J Cardiol 2015; 116:355-63. [PMID: 26048853 DOI: 10.1016/j.amjcard.2015.04.045] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/20/2015] [Revised: 04/30/2015] [Accepted: 04/30/2015] [Indexed: 10/23/2022]
Abstract
Randomized clinical trials (RCTs) are considered the gold standard for evidence-based medicine. However, an accurate estimation of the event rate is crucial for their ability to test clinical hypotheses. Overestimation of event rates reduces the required sample size but can compromise the statistical power of the RCT. Little is known about the prevalence, extent, and impact of overestimation of event rates. The latest RCTs on 10 preselected topics in the field of cardiovascular interventions and devices were selected, and actual primary event rates in the control group were compared with their respective event rate estimations. We also assessed what proportion of the nonsignificant RCTs was truly able to exclude a relevant treatment effect. A total of 27 RCTs randomizing 19,436 patients were included. The primary event rate in the control group was overestimated in 20 of the 27 RCTs (74.1%) resulting in a substantial relative difference between observed and estimated event rates (mean -22.9%, 95% confidence interval -33.5% to -12.2%; median -16.3%, 95% confidence interval -30.3% to -6.5%). Event rates were particularly overestimated in RCTs on biodegradable polymer drug-eluting coronary stents and renal artery stenting. Of the 14 single end point superiority trials with nonsignificant results, only 3 (21.4%) actually resulted in truly negative conclusions. In conclusion, event rates in RCTs evaluating cardiovascular interventions and devices are frequently overestimated. This under-reported phenomenon has fundamental impact on the design of RCTs and can have an adverse impact on the statistical power of these trials to answer important questions about therapeutic strategies.
Collapse
|
38
|
Leal Lorenzo J. Pasado, presente y futuro de la angioplastia y stent carotídeo. ANGIOLOGIA 2015. [DOI: 10.1016/j.angio.2014.08.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
|
39
|
Abstract
Carotid artery stenting is a less invasive alternative to endarterectomy to treat symptomatic carotid stenosis. Clinical trials showed a higher periprocedural risk of nondisabling stroke with stenting, and a higher periprocedural risk of myocardial infarction, cranial nerve palsy, and access site hematoma with endarterectomy. The excess in procedure-related strokes with stenting is mainly seen in patients aged 70 and over. After the procedural period, stenting and endarterectomy are equally effective in preventing stroke and recurrent carotid stenosis in the medium to long term. The choice of stenting versus endarterectomy should take into account risks of both procedures in individual patients.
Collapse
Affiliation(s)
- Leo Bonati
- Department of Neurology, Stroke Center, University Hospital Basel, Petersgraben 4, Basel CH-4031, Switzerland.
| |
Collapse
|
40
|
Grunwald IQ, Reith W, Kühn AL, Balami JS, Karp K, Fassbender K, Walter S, Papanagiotou P, Krick C. Proximal protection with the Gore PAES can reduce DWI lesion size in high-grade stenosis during carotid stenting. EUROINTERVENTION 2015; 10:271-6. [PMID: 24531258 DOI: 10.4244/eijv10i2a45] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
AIMS The aim was to determine the incidence of new ischaemic lesions on diffusion-weighted MR imaging (DWI) in a non-randomised cohort of patients after protected and unprotected carotid artery stent placement using the Parodi Anti-Emboli System (PAES). METHODS AND RESULTS A retrospective review was conducted on 269 patients who received DWI prior to, and 24-72 hours after, stent placement. All patients were enrolled in one centre. Forty patients stented with the PAES device were matched with 229 patients stented without protection (control group). New diffusion restriction on DWI was detected in 25.8% (PAES) versus 32.3% (control group); p=0.64. On average there were 0.7 lesions (PAES) versus 0.8 lesions (control group) per patient. The area of lesions was 1.7 (PAES) versus 5.6 mm2. In a subanalysis of patients (32 PAES, 148 non-protected) with >80% stenosis, the area of restricted diffusion was less when proximal protection was used (p<0.05). The number and area of DWI lesions did not differ on the contralateral, non-stented side. When the PAES system was used, patients were more likely not to have any lesion at all (p=0.028). CONCLUSIONS In high-grade stenosis, the use of the Gore PAES device significantly reduced the area of new DWI lesions and patients were more likely not to have any new DWI lesion at all.
Collapse
Affiliation(s)
- Iris Quasar Grunwald
- Postgraduatate Medical Institute (PMI), Anglia Ruskin University, Chelmsford, Essex, and Southend University Hospital, Essex, United Kingdom
| | | | | | | | | | | | | | | | | |
Collapse
|
41
|
Abstract
Stroke is the third leading cause of death in developed nations. Up to 88% of strokes are ischemic in nature. Extracranial carotid artery atherosclerotic disease is the third leading cause of ischemic stroke in the general population and the second most common nontraumatic cause among adults younger than 45 years. This article provides comprehensive, evidence-based recommendations for the management of extracranial atherosclerotic disease, including imaging for screening and diagnosis, medical management, and interventional management.
Collapse
Affiliation(s)
- Yinn Cher Ooi
- Department of Neurosurgery, University of California, Los Angeles
| | - Nestor R. Gonzalez
- Department of Neurosurgery and Radiology, University of California, Los Angeles, 100 UCLA Med Plaza Suite# 219, Los Angeles, CA 90095, +1(310)825-5154
| |
Collapse
|
42
|
Kuliha M, Roubec M, Procházka V, Jonszta T, Hrbáč T, Havelka J, Goldírová A, Langová K, Herzig R, Školoudík D. Randomized clinical trial comparing neurological outcomes after carotid endarterectomy or stenting. Br J Surg 2014; 102:194-201. [DOI: 10.1002/bjs.9677] [Citation(s) in RCA: 37] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2014] [Revised: 07/02/2014] [Accepted: 09/19/2014] [Indexed: 11/10/2022]
Abstract
Abstract
Background
Silent infarction in the brain can be detected in around 34 per cent of patients after carotid endarterectomy (CEA) and 54 per cent after carotid angioplasty and stenting (CAS). This study compared the risk of new infarctions in the brain in patients undergoing CEA or CAS.
Methods
Consecutive patients with internal carotid artery (ICA) stenosis exceeding 70 per cent were screened for inclusion in this prospective study. Patients with indications for intervention, and eligible for both methods, were allocated randomly to CEA or CAS. Neurological examination, cognitive function tests and MRI of the brain were undertaken before and 24 h after intervention.
Results
Of 150 randomized patients, 73 (47 men; mean age 64·9(7·1) years) underwent CEA and 77 (58 men; 66·4(7·5) years) had CAS. New infarctions on MRI were found more frequently after CAS (49 versus 25 per cent; P = 0·002). Lesion volume was also significantly greater after CAS (P = 0·010). Multiple logistic regression analyses identified intervention in the right ICA as the only independent predictor of brain infarction (odds ratio 2·10, 95 per cent c.i. 1·03 to 4·25; P = 0·040). Stroke or transient ischaemic attack occurred in one patient after CEA and in two after CAS. No significant differences were found in cognitive test results between the groups.
Conclusion
These data confirm a higher risk of silent infarction in the brain on MRI after CAS in comparison with CEA, but without measurable change in cognitive function. Registration number: NCT01591005 (http://www.clinicaltrials.gov).
Collapse
Affiliation(s)
- M Kuliha
- Departments of Neurology, University Hospital Ostrava, Ostrava, Czech Republic
| | - M Roubec
- Departments of Neurology, University Hospital Ostrava, Ostrava, Czech Republic
| | - V Procházka
- Departments of Radiology, University Hospital Ostrava, Ostrava, Czech Republic
| | - T Jonszta
- Departments of Radiology, University Hospital Ostrava, Ostrava, Czech Republic
| | - T Hrbáč
- Departments of Neurosurgery, Comprehensive Stroke Centre, University Hospital Ostrava, Ostrava, Czech Republic
| | - J Havelka
- Departments of Radiology, University Hospital Ostrava, Ostrava, Czech Republic
| | - A Goldírová
- Departments of Neurology, University Hospital Ostrava, Ostrava, Czech Republic
- Department of Nursing, Faculty of Health Sciences, Palacký University, Olomouc, Czech Republic
| | - K Langová
- Department of Biophysics, Faculty of Medicine and Dentistry, Institute of Molecular and Translational Medicine, Palacký University, Olomouc, Czech Republic
| | - R Herzig
- Department of Neurosurgery, Comprehensive Stroke Centre, Military University Hospital, Prague, Czech Republic
| | - D Školoudík
- Departments of Neurology, University Hospital Ostrava, Ostrava, Czech Republic
- Department of Nursing, Faculty of Health Sciences, Palacký University, Olomouc, Czech Republic
| |
Collapse
|
43
|
Safety and efficacy assessment of carotid artery stenting in a high-risk population in a single-centre registry. ADVANCES IN INTERVENTIONAL CARDIOLOGY 2014; 10:258-63. [PMID: 25489319 PMCID: PMC4252323 DOI: 10.5114/pwki.2014.46767] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2014] [Revised: 10/20/2014] [Accepted: 11/04/2014] [Indexed: 11/18/2022] Open
Abstract
Introduction Ischaemic stroke is the primary cause of long-term disability and the third most common cause of death. Internal carotid artery stenosis is an important risk factor for stroke and transient ischaemic attack (TIA). European Society of Cardiology (ESC) and American Heart Association (AHA) guidelines allow carotid artery stenting (CAS) as an alternative to endarterectomy in centres with low rates of death or stroke. Aim To assess the safety and efficacy of CAS in a single-centre observation. Material and methods We performed a retrospective analysis of all patients treated with CAS between March 2008 and July 2012. Clinical data and outcomes in both asymptomatic and symptomatic patients were analysed. Results A total of 214 consecutive patients were included in the registry. Symptomatic patients accounted for 57% of the study group and were more likely to have a history of stroke and/or TIA that occurred more than 6 months before the procedure (50% vs. 8%, p < 0.001). Asymptomatic patients were more likely to have a history of coronary artery disease (88% vs. 61%, p < 0.001), and the rates of previous acute coronary syndrome and revascularisation were also higher in this group (58% vs. 41% and 71% vs. 52%, respectively, both p < 0.05). The symptomatic group had higher incidence of stroke in periprocedural and 30-day observation (4% vs. 0%, p < 0.05). There was no difference in incidence of adverse events in long-term observation. Conclusions Carotid artery stenting is a safe and efficacious procedure. Every centre performing CAS should monitor the rate of periprocedural complications.
Collapse
|
44
|
Abstract
Symptomatic extracranial internal carotid artery stenosis poses a high short-time risk of ischemic cerebral stroke, as high as 20% to 30% in the first three months. Timely performed carotid endarterectomy (CEA) has been shown to be highly effective in reducing this risk although, in recent years, there has been great interest in replacing this procedure with less invasive carotid angioplasty and stenting (CAS). In this update we review recent studies and provide recommendations regarding the indications, methods and timing of surgical intervention as well as the anaesthetic management of CEA, and we report on recently published randomized controlled trials comparing CEA to CAS. We also provide recommendations regarding the sometime neglected but important medical management of patients undergoing carotid intervention, including antithrombotic and antihypertension therapy, lipid lowering agents, assistance with smoking cessation, and diabetes control.
Collapse
|
45
|
Abstract
Carotid artery stenting (CAS) has achieved clinical equipoise with carotid endarterectomy (CEA), as evidenced by 2 large U.S. randomized clinical trials, multiple pivotal registry trials, and 2 multispecialty guideline documents endorsed by 14 professional societies. The largest randomized trial conducted in patients at average surgical risk of CEA, CREST (Carotid Revascularization Endarterectomy Versus Stenting Trial) found no difference between CAS and CEA for the combined endpoint of stroke, death, and myocardial infarction (MI) after 4 years of follow-up. The largest randomized trial comparing CAS and CEA in patients at increased surgical risk, SAPPHIRE (Stenting and Angioplasty with Protection in Patients at High Risk for Endarterectomy), looked at 1-year stroke, death, and MI incidence and found no difference in symptomatic patients, but a significantly better outcome in asymptomatic patients for CAS (9.9% vs. 21.5%; p = 0.02). Given that >70% of carotid revascularization procedures are performed in asymptomatic patients for primary prevention of stroke, it is incumbent upon clinicians to demonstrate that revascularization has an incremental benefit over highly effective modern medical therapy alone.
Collapse
|
46
|
Kedev S. Transradial carotid artery stenting: examining the alternatives when femoral access is unavailable. Interv Cardiol 2014. [DOI: 10.2217/ica.14.36] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
|
47
|
Alaraj A, Wallace A, Dashti R, Patel P, Aletich V. Balloons in endovascular neurosurgery: history and current applications. Neurosurgery 2014; 74 Suppl 1:S163-90. [PMID: 24402485 DOI: 10.1227/neu.0000000000000220] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022] Open
Abstract
The use of balloons in the field of neurosurgery is currently an essential part of our clinical practice. The field has evolved over the last 40 years since Serbinenko used balloons to test the feasibility of occluding cervical vessels for intracranial pathologies. Since that time, indications have expanded to include sacrificing cervical and intracranial vessels with detachable balloons, supporting the coil mass in wide-necked aneurysms (balloon remodeling technique), and performing intracranial and cervical angioplasty for atherosclerotic disease, as well as an adjunct to treat arteriovenous malformations. With the rapid expansion of endovascular technologies, it appears that the indications and uses for balloons will continue to expand. In this article, we review the history of balloons, the initial applications, the types of balloons available, and the current applications available for endovascular neurosurgeons.
Collapse
Affiliation(s)
- Ali Alaraj
- Department of Neurosurgery, College of Medicine, University of Illinois at Chicago. Chicago, Illinois
| | | | | | | | | |
Collapse
|
48
|
Patel RAG. State of the art in carotid artery stenting: trial data, technical aspects, and limitations. J Cardiovasc Transl Res 2014; 7:446-57. [PMID: 24771314 DOI: 10.1007/s12265-014-9567-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/17/2014] [Accepted: 04/13/2014] [Indexed: 10/25/2022]
Abstract
The volume of carotid artery stenting (CAS) safety and efficacy data has grown exponentially over the last decade. Recent comparative data with carotid endarterectomy, the utility of embolic protection devices, peri-procedural medications, basic technical aspects of CAS, developments in carotid stent design, potential complications of CAS, and complication risk factors are discussed in this review.
Collapse
Affiliation(s)
- Rajan A G Patel
- John Ochsner Heart & Vascular Institute, Ochsner Medical Center, 1514 Jefferson Hwy., New Orleans, LA, 70121, USA,
| |
Collapse
|
49
|
Nakagawa I, Wada T, Park HS, Nishimura F, Yamada S, Nakagawa H, Kichikawa K, Nakase H. Platelet inhibition by adjunctive cilostazol suppresses the frequency of cerebral ischemic lesions after carotid artery stenting in patients with carotid artery stenosis. J Vasc Surg 2014; 59:761-7. [DOI: 10.1016/j.jvs.2013.09.011] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2013] [Revised: 09/05/2013] [Accepted: 09/06/2013] [Indexed: 11/25/2022]
|
50
|
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]
|