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Ramachandran M, Hamouda M, Cui CL, Moghaddam M, Zarrintan S, Lane JS, Malas MB. Investigation of the Weekend Effect on Peri-Operative Complications and Mortality Following Carotid Revascularization. J Vasc Surg 2024:S0741-5214(24)01480-0. [PMID: 38942398 DOI: 10.1016/j.jvs.2024.06.163] [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: 03/28/2023] [Revised: 06/15/2024] [Accepted: 06/21/2024] [Indexed: 06/30/2024]
Abstract
OBJECTIVE Outcomes for weekend surgical interventions are associated with higher rates of mortality and complications compared to weekday interventions. While prior investigations have reported the 'weekend effect' for carotid endarterectomy (CEA), this association remains unclear for Transcarotid Artery Revascularization (TCAR) and Transfemoral Carotid Artery Stenting (TFCAS). We investigated the weekend effect for all three carotid revascularization methods. METHODS We queried the Vascular Quality Initiative (VQI) for patients undergoing CEA, TCAR, and TFCAS between 2016-2022. Chi-square and logistic regression modeling analyzed outcomes including in-hospital stroke, death, MI, and 30-day mortality by weekend vs. weekday intervention. Backward stepwise regression was utilized to identify significant confounding variables and were ultimately included in each final logistic regression model. Logistic regression of outcomes was substratified by symptomatic status. Secondary multivariable analysis compared outcomes between the three revascularization methods by weekend vs. weekday interventions. RESULTS 155,962 procedures were analyzed including 103,790 CEA, 31,666 TCAR and 20,506 TFCAS. Of these, 1988 CEA, 246 TCAR and 820 TFCAS received weekend interventions. Logistic regression demonstrated no significant differences for TCAR, and increased odds of in-hospital stroke/death/MI for CEA [OR:1.31,(1.04-1.65)] and TFCAS [OR:1.46,(1.09-1.96)] weekend procedures. Asymptomatic TCAR patients had nearly triple the odds of 30-day mortality [OR:2.85,(1.06-7.68), P=0.038]. Similarly, odds of in-hospital death were nearly tripled for asymptomatic CEA [OR:2.89,(1.30-6.43), P=0.009] and asymptomatic TFCAS [OR:2.78,(1.34-5.76), P=0.006] patients. Secondary analysis demonstrated that CEA and TCAR had no significant differences for all outcomes. TFCAS was associated with increased odds of stroke and death compared to CEA and TCAR. CONCLUSION In this observational cohort study, we found that weekend carotid revascularization is associated with increased odds of complications and mortality. Furthermore, asymptomatic weekend patients perform worse in the CEA and TFCAS procedural groups. Among the three revascularization methods, TFCAS is associated with the highest odds of perioperative stroke and mortality. As such, our findings suggest that TFCAS procedures should be avoided over the weekend, in favor of CEA or TCAR. In patients who are poor candidates for CEA, TCAR offers the lowest morbidity and mortality for weekend procedures.
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Affiliation(s)
- Mokhshan Ramachandran
- Center for Learning and Excellence in Vascular and Endovascular Research (CLEVER), Department of Surgery, Division of Vascular & Endovascular Surgery, UC San Diego, San Diego, California
| | - Mohammed Hamouda
- Center for Learning and Excellence in Vascular and Endovascular Research (CLEVER), Department of Surgery, Division of Vascular & Endovascular Surgery, UC San Diego, San Diego, California
| | - Christina L Cui
- Division of Vascular and Endovascular Surgery, Duke Health Systems, Durham, NC
| | - Marjan Moghaddam
- Center for Learning and Excellence in Vascular and Endovascular Research (CLEVER), Department of Surgery, Division of Vascular & Endovascular Surgery, UC San Diego, San Diego, California
| | - Sina Zarrintan
- Center for Learning and Excellence in Vascular and Endovascular Research (CLEVER), Department of Surgery, Division of Vascular & Endovascular Surgery, UC San Diego, San Diego, California
| | - John S Lane
- Center for Learning and Excellence in Vascular and Endovascular Research (CLEVER), Department of Surgery, Division of Vascular & Endovascular Surgery, UC San Diego, San Diego, California
| | - Mahmoud B Malas
- Center for Learning and Excellence in Vascular and Endovascular Research (CLEVER), Department of Surgery, Division of Vascular & Endovascular Surgery, UC San Diego, San Diego, California,.
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Caron E, Yadavalli SD, Manchella M, Jabbour G, Mandigers TJ, Gomez-Mayorga JL, Bloch RA, Davis RB, Wang GJ, Nolan BA, Schermerhorn ML. Outcomes of carotid revascularization stratified by procedure in eGFR<30 and dialysis patients. J Vasc Surg 2024:S0741-5214(24)01252-7. [PMID: 38906431 DOI: 10.1016/j.jvs.2024.06.008] [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: 04/09/2024] [Revised: 06/04/2024] [Accepted: 06/07/2024] [Indexed: 06/23/2024]
Abstract
OBJECTIVE Renal failure is a predictor of adverse outcomes in carotid revascularization. There has been debate regarding the benefit of revascularization in patients with severe CKD or on dialysis. METHODS VQI patients undergoing TCAR, tfCAS, or CEA between 2016 and 2023 with eGFR <30 ml/min/1.73m2 or on dialysis were included. Patients were divided into cohorts based on procedure. Additional analyses were performed for patients on dialysis only and by symptomatology. Primary outcomes were perioperative stroke/death/MI (SDM). Secondary outcomes included perioperative death, stroke, MI, CNI and stroke/death. Inverse probability of treatment weighting (IPW) was performed based on treatment assignment to TCAR, tfCAS, and CEA patients and adjusted for demographics, comorbidities, and pre-op symptoms. Chi-square and multivariable logistic regression analysis were used to evaluate the association of procedure with perioperative outcomes in the weighted cohort. Five-year survival was evaluated using Kaplan-Meier and weighted Cox regression. RESULTS In the weighted cohort, 13,851 patients with eGFR of <30 (2,506 on dialysis) underwent TCAR (3,639, dialysis 704), tfCAS (1,975, 393) or CEA (8,237, 1,409) during the study period. Compared with TCAR, CEA had higher odds of stroke/death/MI (2.8% vs 3.6%, aOR 1.27 [1.00,1.61], p=.049), and MI (0.7% vs 1.5%, aOR 2.00 [1.31,3.05], p=.001)... Compared to TCAR, rates of SDM (2.8%vs5.8%), stroke (1.2%vs2.6%), death (0.9%vs2,4%)were all higher for tfCAS. In asymptomatic patients CEA patients had higher odds of MI (0.7% vs 1.3%, aOR 1.85[1.15, 2.97]p=.011) and CNI (0.3% vs 1.9%, aOR 7.23[3.28, 15.9] p<.001). Like the primary analysis, asymptomatic tfCAS patients demonstrated higher odds of death, and stroke/death. Symptomatic CEA patients demonstrated no difference in stroke, death or stroke/death. While tfCAS patients demonstrated higher odds of death, stroke, MI, stroke/death, and SDM. In both groups, 5-year survival was similar for TCAR and CEA (eGFR <30: 75.1% vs 74.2%, aHR1.06, p=.3) and lower for tfCAS (eGFR <30: 75.1% vs 70.4%, aHR1.44, p<.001) CONCLUSION: CEA and TCAR had similar odds of stroke and death and are both a reasonable choice in this population; however, TCAR may be better in patients with increased risk of MI. Additionally, tfCAS patients were more likely to have worse outcomes after weighting for symptom status. Finally, while patients with reduced eGFR have worse outcomes than their healthy peers, this analysis shows that the majority of patients survive long enough to benefit from the potential stroke risk reduction provided by all revascularization procedures.
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Affiliation(s)
- Elisa Caron
- Divisions of Vascular and Endovascular Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston MA
| | - Sai Divya Yadavalli
- Divisions of Vascular and Endovascular Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston MA
| | - Mohit Manchella
- Divisions of Vascular and Endovascular Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston MA
| | - Gabriel Jabbour
- Divisions of Vascular and Endovascular Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston MA
| | - Tim J Mandigers
- Divisions of Vascular and Endovascular Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston MA
| | - Jorge L Gomez-Mayorga
- Divisions of Vascular and Endovascular Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston MA
| | - Randall A Bloch
- Division of General Surgery, St Elizabeth's Medical Center, Boston University, Boston MA
| | - Roger B Davis
- Division of General Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston MA
| | - Grace J Wang
- Division of Vascular Surgery and Endovascular Therapy, Department of Surgery, Hospital of the University of Pennsylvania, Philadelphia, PA
| | - Brian A Nolan
- Division of Vascular and Endovascular Therapy, Department of Surgery, Maine Medical Center, Portland, ME
| | - Marc L Schermerhorn
- Divisions of Vascular and Endovascular Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston MA.
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Straus S, Yadavalli SD, Allievi S, Sanders A, Davis RB, Malas MB, Wang GJ, Kashyap VS, Cronenwett J, Motaganahalli RL, Nolan B, Eldrup-Jorgensen J, Schermerhorn M. Seven years of the transcarotid artery revascularization surveillance project, comparison to transfemoral stenting and endarterectomy. J Vasc Surg 2024:S0741-5214(24)01227-8. [PMID: 38821431 DOI: 10.1016/j.jvs.2024.05.048] [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: 03/05/2024] [Revised: 05/18/2024] [Accepted: 05/21/2024] [Indexed: 06/02/2024]
Abstract
OBJECTIVE This study utilizes the latest data from the Vascular Quality Initiative (VQI), which now encompasses over 50,000 transcarotid artery revascularization (TCAR) procedures, to offer a sizeable dataset for comparing the effectiveness and safety of TCAR, transfemoral carotid artery stenting (tfCAS), and carotid endarterectomy (CEA). Given this substantial dataset, we are now able to compare outcomes overall and stratified by symptom status across revascularization techniques. METHODS Utilizing VQI data from September 2016 to August 2023, we conducted a risk-adjusted analysis by applying inverse probability of treatment weighting to compare in-hospital outcomes between TCAR vs tfCAS, CEA vs tfCAS, and TCAR vs CEA. Our primary outcome measure was in-hospital stroke/death. Secondary outcomes included myocardial infarction and cranial nerve injury. RESULTS A total of 50,068 patients underwent TCAR, 25,361 patients underwent tfCAS, and 122,737 patients underwent CEA. TCAR patients were older, more likely to have coronary artery disease, chronic kidney disease, and undergo coronary artery bypass grafting/percutaneous coronary intervention as well as prior contralateral CEA/CAS compared with both CEA and tfCAS. TfCAS had higher odds of stroke/death when compared with TCAR (2.9% vs 1.6%; adjusted odds ratio [aOR], 1.84; 95% confidence interval [CI], 1.65-2.06; P < .001) and CEA (2.9% vs 1.3%; aOR, 2.21; 95% CI, 2.01-2.43; P < .001). CEA had slightly lower odds of stroke/death compared with TCAR (1.3% vs 1.6%; aOR, 0.83; 95% CI, 0.76-0.91; P < .001). TfCAS had lower odds of cranial nerve injury compared with TCAR (0.0% vs 0.3%; aOR, 0.00; 95% CI, 0.00-0.00; P < .001) and CEA (0.0% vs 2.3%; aOR, 0.00; 95% CI, 0.0-0.0; P < .001) as well as lower odds of myocardial infarction compared with CEA (0.4% vs 0.6%; aOR, 0.67; 95% CI, 0.54-0.84; P < .001). CEA compared with TCAR had higher odds of myocardial infarction (0.6% vs 0.5%; aOR, 1.31; 95% CI, 1.13-1.54; P < .001) and cranial nerve injury (2.3% vs 0.3%; aOR, 9.42; 95% CI, 7.78-11.4; P < .001). CONCLUSIONS Although tfCAS may be beneficial for select patients, the lower stroke/death rates associated with CEA and TCAR are preferred. When deciding between CEA and TCAR, it is important to weigh additional procedural factors and outcomes such as myocardial infarction and cranial nerve injury, particularly when stroke/death rates are similar. Additionally, evaluating subgroups that may benefit from one procedure over another is essential for informed decision-making and enhanced patient care in the treatment of carotid stenosis.
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Affiliation(s)
- Sabrina Straus
- Department of Surgery, Division of Vascular and Endovascular Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA; Department of Surgery, Division of Vascular and Endovascular Surgery, UC San Diego (UCSD), San Diego, CA
| | - Sai Divya Yadavalli
- Department of Surgery, Division of Vascular and Endovascular Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA
| | - Sara Allievi
- Department of Surgery, Division of Vascular and Endovascular Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA; Department of Vascular Surgery, Fondazione IRCCS Cà Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Andrew Sanders
- Department of Surgery, Division of Vascular and Endovascular Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA
| | - Roger B Davis
- Department of Surgery, Division of Vascular and Endovascular Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA
| | - Mahmoud B Malas
- Department of Surgery, Division of Vascular and Endovascular Surgery, UC San Diego (UCSD), San Diego, CA
| | - Grace J Wang
- Division of Vascular Surgery and Endovascular Therapy, Department of Surgery, Hospital of the University of Pennsylvania, Philadelphia, PA
| | - Vikram S Kashyap
- Frederik Meijer Heart and Vascular Institute, Corewell Health, Grand Rapids, MI
| | - Jack Cronenwett
- Section of Vascular Surgery, Dartmouth Medical School, Lebanon, NH
| | - Raghu L Motaganahalli
- Division of Vascular Surgery, Department of Surgery, Indiana University School of Medicine, Indianapolis, IN
| | - Brian Nolan
- Division of Vascular and Endovascular Therapy, Department of Surgery, Maine Medical Center, Portland, ME
| | - Jens Eldrup-Jorgensen
- Division of Vascular and Endovascular Therapy, Department of Surgery, Maine Medical Center, Portland, ME
| | - Marc Schermerhorn
- Department of Surgery, Division of Vascular and Endovascular Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA.
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Sultan S, Acharya Y, Dulai M, Tawfick W, Hynes N, Wijns W, Soliman O. Redefining postoperative hypertension management in carotid surgery: a comprehensive analysis of blood pressure homeostasis and hyperperfusion syndrome in unilateral vs. bilateral carotid surgeries and implications for clinical practice. Front Surg 2024; 11:1361963. [PMID: 38638141 PMCID: PMC11025470 DOI: 10.3389/fsurg.2024.1361963] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2023] [Accepted: 03/20/2024] [Indexed: 04/20/2024] Open
Abstract
Background This study evaluates the implications of blood pressure homeostasis in bilateral vs. unilateral carotid surgeries, focusing on the incidence of postoperative hypertension, hyperperfusion syndrome, and stroke as primary outcomes. It further delves into the secondary outcomes encompassing major adverse cardiovascular events and all-cause mortality. Methods Spanning two decades (2002-2023), this comprehensive retrospective research encompasses 15,369 carotid referrals, out of which 1,230 underwent carotid interventions. A subset of 690 patients received open carotid procedures, with a 10-year follow-up, comprising 599 unilateral and 91 bilateral surgeries. The Society for Vascular Surgery Carotid Reporting Standards underpin our methodological approach for data collection. Both univariate and multivariate analyses were utilized to identify factors associated with postoperative hypertension using the Statistical Package for the Social Sciences (SPSS) Version 22 (SPSS®, IBM® Corp., Armonk, N.Y., USA). Results A marked acute elevation in blood pressure was observed in patients undergoing both unilateral and bilateral carotid surgeries (p < 0.001). Smoking (OR: 1.183, p = 0.007), hyperfibrinogenemia (OR: 0.834, p = 0.004), emergency admission (OR: 1.192, p = 0.005), severe ipsilateral carotid stenosis (OR: 1.501, p = 0.022), and prior ipsilateral interventions (OR: 1.722, p = 0.003) emerged as significant factors that correlates with postoperative hypertension in unilateral surgeries. Conversely, in bilateral procedures, gender, emergency admissions (p = 0.012), and plaque morphology (p = 0.035) significantly influenced postoperative hypertension. Notably, 2.2% of bilateral surgery patients developed hyperperfusion syndrome, culminating in hemorrhagic stroke within 30 days. Intriguingly, postoperative stage II hypertension was identified as an independent predictor of neurological deficits post-secondary procedure in bilateral CEA cases (p = 0.004), attributable to hyperperfusion syndrome. However, it did not independently predict myocardial infarction or mortality outcomes. The overall 30-day stroke rate stood at 0.90%. Lowest incidence of post operative hypertension or any complications were observed in eversion carotid endartrertomy. Conclusion The study identifies postoperative hypertension as a crucial independent predictor of perioperative stroke following bilateral carotid surgery. Moreover, the study elucidates the significant impact of bilateral CEA on the development of post-operative hyperperfusion syndrome or stroke, as compared to unilateral CEA. Currently almost 90% of our carotid practice is eversion carotid endartrerectomy.
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Affiliation(s)
- Sherif Sultan
- Department of Vascular and Endovascular Surgery, Western Vascular Institute, University Hospital Galway, University of Galway, Galway, Ireland
- Department of Vascular Surgery and Endovascular Surgery, Galway Clinic, Royal College of Surgeons in Ireland and University of Galway, Galway Affiliated Hospital, Doughiska, Ireland
- CORRIB-CURAM-Vascular Group, University of Galway, Galway, Ireland
- The Euro Heart Foundation, Amsterdam, Netherlands
| | - Yogesh Acharya
- Department of Vascular and Endovascular Surgery, Western Vascular Institute, University Hospital Galway, University of Galway, Galway, Ireland
- Department of Vascular Surgery and Endovascular Surgery, Galway Clinic, Royal College of Surgeons in Ireland and University of Galway, Galway Affiliated Hospital, Doughiska, Ireland
| | - Makinder Dulai
- Department of Vascular and Endovascular Surgery, Western Vascular Institute, University Hospital Galway, University of Galway, Galway, Ireland
- Department of Vascular Surgery and Endovascular Surgery, Galway Clinic, Royal College of Surgeons in Ireland and University of Galway, Galway Affiliated Hospital, Doughiska, Ireland
| | - Wael Tawfick
- Department of Vascular and Endovascular Surgery, Western Vascular Institute, University Hospital Galway, University of Galway, Galway, Ireland
- CORRIB-CURAM-Vascular Group, University of Galway, Galway, Ireland
| | - Niamh Hynes
- Department of Vascular Surgery and Endovascular Surgery, Galway Clinic, Royal College of Surgeons in Ireland and University of Galway, Galway Affiliated Hospital, Doughiska, Ireland
- CORRIB-CURAM-Vascular Group, University of Galway, Galway, Ireland
| | - William Wijns
- CORRIB-CURAM-Vascular Group, University of Galway, Galway, Ireland
- The Euro Heart Foundation, Amsterdam, Netherlands
| | - Osama Soliman
- CORRIB-CURAM-Vascular Group, University of Galway, Galway, Ireland
- The Euro Heart Foundation, Amsterdam, Netherlands
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Koh EY, Pineau SH, Dias CG, Al Rstum Z, Tanaka A, Keyhani A, Keyhani K, Wang SK. Fixed compared to mobile imaging arms for transcarotid artery revascularization. Vascular 2024; 32:407-411. [PMID: 36260023 DOI: 10.1177/17085381221135702] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
OBJECTIVE Transcarotid artery revascularization (TCAR) is a new surgical option for carotid artery stenosis. While this procedure is optimally performed in hybrid operating rooms (OR), it is currently unclear whether it could be safely performed using portable, C-arm fluoroscopy with equivalent results. The aim of this study is to determine whether there are differences in intraoperative and perioperative outcomes stratified by imaging modality. METHODS A retrospective review of all TCAR procedures attempted within our health system was performed, capturing all cases between September 2017 and May 2022. Procedures were divided into 2 cohorts, based on whether they were performed in a hybrid OR or with portable, C-arm in a standard OR. Patient demographics, intraoperative results, and postoperative outcomes were compared using univariate strategies. RESULTS A total of 503 patients were included for review, of which 422 were performed in a hybrid OR (84%) and 81 were performed using a portable C-arm (16%). Intraoperatively, an increased estimated blood loss (47.7 ± 54.7 vs 26.1 ± 26.9 mLs, p < 0.01) and operative time was found in the cases performed in a hybrid OR. However, the fluoroscopy time was lower (4.0 ± 2.6 vs 5.2 ± 5.8 min, p = 0.01) in the setting of advanced intraoperative imaging. Postoperatively, we found no differences with respect to myocardial infarction (0.2% vs. 0%, p > 0.99), stroke (2.4% vs. 2.5%, p = 0.96), or death (0.7% vs. 2.5%, p = 0.15) between groups. CONCLUSIONS While there are some intraoperative variabilities between TCAR performed in hybrid versus standard ORs, postoperative outcomes are comparable. Therefore, the lack of a hybrid room should not be a deterrent to the adoption of TCAR.
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Affiliation(s)
- Ezra Y Koh
- Division of Vascular Surgery, Department of Cardiothoracic and Vascular Surgery, McGovern Medical School at The University of Texas Health Science Center at Houston (UTHealth), Houston, TX, USA
| | - Sylvestre H Pineau
- Division of Vascular Surgery, Department of Cardiothoracic and Vascular Surgery, McGovern Medical School at The University of Texas Health Science Center at Houston (UTHealth), Houston, TX, USA
| | - Christina G Dias
- Division of Vascular Surgery, Department of Cardiothoracic and Vascular Surgery, McGovern Medical School at The University of Texas Health Science Center at Houston (UTHealth), Houston, TX, USA
| | - Zain Al Rstum
- Division of Vascular Surgery, Department of Cardiothoracic and Vascular Surgery, McGovern Medical School at The University of Texas Health Science Center at Houston (UTHealth), Houston, TX, USA
| | - Akiko Tanaka
- Division of Vascular Surgery, Department of Cardiothoracic and Vascular Surgery, McGovern Medical School at The University of Texas Health Science Center at Houston (UTHealth), Houston, TX, USA
| | - Arash Keyhani
- Division of Vascular Surgery, Department of Cardiothoracic and Vascular Surgery, McGovern Medical School at The University of Texas Health Science Center at Houston (UTHealth), Houston, TX, USA
| | - Kourosh Keyhani
- Division of Vascular Surgery, Department of Cardiothoracic and Vascular Surgery, McGovern Medical School at The University of Texas Health Science Center at Houston (UTHealth), Houston, TX, USA
| | - S Keisin Wang
- Division of Vascular Surgery, Department of Cardiothoracic and Vascular Surgery, McGovern Medical School at The University of Texas Health Science Center at Houston (UTHealth), Houston, TX, USA
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Mezzetto L, Mastrorilli D, Zanetti E, Scoccia E, Pecoraro B, Sboarina A, Mantovani A, Veraldi GF. Clinical risk factors and features on computed tomography angiography in high-risk carotid artery plaque in patients with type 2 diabetes. INT ANGIOL 2024; 43:280-289. [PMID: 38470152 DOI: 10.23736/s0392-9590.24.05154-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/13/2024]
Abstract
BACKGROUND High-risk carotid artery plaque (HPR) is associated with a markedly increased risk of ischemic stroke. The aims of this study were: 1) to examine the prevalence of HRP in a cohort of asymptomatic adults with type 2 diabetes (T2D); 2) to investigate the relationship between HRP, established cardiovascular risk factors and computed tomography angiography (CTA) profile; and 3) to assess whether the presence of HRP is associated with an increased risk of major adverse cardiovascular events (MACE). METHODS This was a retrospective cohort study of T2D asymptomatic patients who underwent carotid endarterectomy (CEA) from January 2018 to July 2021. The carotid atherosclerotic plaque (CAP) was assessed for the presence of ulceration, the presence of lipids, fibrosis, thrombotic deposits, hemorrhage, neovascularization, and inflammation. A CAP presenting at least five of these histological features was defined as a HRP (Group A); in all other cases it was defined as a mild to moderate heterogeneous plaque and no-HRP (Group B). CTA features included the presence of rim sign consisting of thin peripheral adventitial calcification (<2 mm) and internal soft plaque (≥2 mm), NASCET percent diameter stenosis, maximum plaque thickness, ulceration, calcification, and intraluminal thrombus were recorded. Binary logistic regression with Uni- and Multivariate was used to evaluate possible predictors for HRP while multivariable Cox Proportional Hazards was used to assess independent predictors for MACE. RESULTS One hundred eighty-five asymptomatic patients (mean age 73±8 years, 131 men), undergoing carotid endarterectomy, were included. Of these, 124 (67%) had HRP, and the 61 (33%) did not. Diabetic complications (OR 2.4, 95% CI: 1.1-5.1, P=0.01), NASCET stenosis ≥75% (OR 2.4, 95% CI: 1.2-3.7, P=0.02) and carotid RIM sign (OR 4.3, 95% CI: 3.9-7.3, P<0.001) were independently associated with HRP. However, HRP was not associated with a higher risk of MACE (freedom from MACE at 5 years: HRP 83.4% vs. non HRP 87.8%, P=0.72) or a reduction of survival (5-year survival estimates: HRP 96.4% vs. non HRP: 94.6%, P=0.76). CONCLUSIONS A high prevalence of HRP (67%) was observed in asymptomatic and elderly T2D patients. Independent predictors of HRP were diabetic complications, NASCET stenosis ≥75% and carotid RIM sign (OR 4.3, 95% CI: 3.9-7.3, P<0.001). HRP was not associated with an increased risk of MACE during a mean follow-up of 39±24 years.
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Affiliation(s)
- Luca Mezzetto
- Department of Vascular Surgery, University Hospital and Trust of Verona, University of Verona School of Medicine, Verona, Italy
| | - Davide Mastrorilli
- Department of Vascular Surgery, University Hospital and Trust of Verona, University of Verona School of Medicine, Verona, Italy -
| | - Elisa Zanetti
- Department of Vascular Surgery, University Hospital and Trust of Verona, University of Verona School of Medicine, Verona, Italy
| | - Enrico Scoccia
- Section of Endocrinology, Diabetes and Metabolism, Department of Medicine, University and Azienda Ospedaliera Universitaria Integrata of Verona, Verona, Italy
| | - Barbara Pecoraro
- Section of Endocrinology, Diabetes and Metabolism, Department of Medicine, University and Azienda Ospedaliera Universitaria Integrata of Verona, Verona, Italy
| | - Andrea Sboarina
- Department of Surgery, Dentistry, Pediatrics and Gynecology, University of Verona, Verona, Italy
| | - Alessandro Mantovani
- Section of Endocrinology, Diabetes and Metabolism, Department of Medicine, University and Azienda Ospedaliera Universitaria Integrata of Verona, Verona, Italy
| | - Gian F Veraldi
- Department of Vascular Surgery, University Hospital and Trust of Verona, University of Verona School of Medicine, Verona, Italy
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7
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Liesker DJ, Gareb B, Köhlen BT, Donners SJA, de Borst GJ, Zeebregts CJ, Saleem BR. Similar long-term outcomes for venous, bovine pericardial, and polyester patches for primary carotid endarterectomy. World J Surg 2024; 48:758-766. [PMID: 38323728 DOI: 10.1002/wjs.12090] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2023] [Accepted: 01/15/2024] [Indexed: 02/08/2024]
Abstract
BACKGROUND Currently, the type of patch used for carotid endarterectomy closure depends on the preference of the operating surgeon. Various materials are available, including autologous venous patches, bovine pericardial patches (BPP), and synthetic patches. The purpose of this study was to compare the long-term outcomes. METHODS All patients who underwent primary carotid endarterectomy with patch angioplasty using a venous, bovine, or polyester patch between 2010 and 2020 at two high-volume medical centers were included in this retrospective analysis on largely prospectively collected data. Study endpoints included long-term ipsilateral transient ischemic attack or cerebrovascular accident, restenosis, reintervention, and all-cause mortality. Cox proportional hazard models were fitted to assess the effect of patch type to each outcome. RESULTS In total, 1481 CEAs were performed with a follow-up of 32 (13-65) months. Venous patch was used in 309 patients (20.9%), BPP in 1000 patients (67.5%), and polyester patch in 172 patients (11.6%). A preoperative symptomatic carotid artery stenosis of >50% was observed in 91.9% (n = 284) of the patients who received a venous patch, 92.1% (n = 921) of the patients who received BPP, and 90.7% (n = 156) of the patients who received a polyester patch (p = 0.799). Only in selected patients with an asymptomatic stenosis of >70% surgery was considered. Multivariable analyses showed no significant differences between the three patch types regarding long-term outcomes after adjusting for confounders. CONCLUSIONS In patients undergoing primary carotid endarterectomy, the use of venous, bovine pericardial, or polyester patches seems equally safe and durable in terms of comparability in long-term outcomes.
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Affiliation(s)
- David J Liesker
- Department of Surgery (Division of Vascular Surgery), University Medical Center Groningen, University of Groningen, Groningen, Netherlands
| | - Barzi Gareb
- Department of Oral and Maxillofacial Surgery, University Medical Center Groningen, University of Groningen, Groningen, Netherlands
| | - Bart T Köhlen
- Department of Surgery (Division of Vascular Surgery), University Medical Center Utrecht, Utrecht, Netherlands
| | - Simone J A Donners
- Department of Surgery (Division of Vascular Surgery), University Medical Center Utrecht, Utrecht, Netherlands
| | - Gert J de Borst
- Department of Surgery (Division of Vascular Surgery), University Medical Center Utrecht, Utrecht, Netherlands
| | - Clark J Zeebregts
- Department of Surgery (Division of Vascular Surgery), University Medical Center Groningen, University of Groningen, Groningen, Netherlands
| | - Ben R Saleem
- Department of Surgery (Division of Vascular Surgery), University Medical Center Groningen, University of Groningen, Groningen, Netherlands
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8
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Oliveira TF, Centellas CDR, Dalio MB, Joviliano EE. Short term outcomes of carotid surgery: the real-world experience of a single teaching center. J Vasc Bras 2024; 23:e20230033. [PMID: 38433985 PMCID: PMC10903515 DOI: 10.1590/1677-5449.202300332] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2023] [Accepted: 11/27/2023] [Indexed: 03/05/2024] Open
Abstract
Background Surgical treatment of symptomatic extracranial carotid stenosis is well established for preventing neurological events and should adhere to optimal quality standards. However, there is growing concern as to whether results of controlled trials are replicable in real-world settings. Objectives To assess a symptomatic carotid stenosis population that underwent surgery and its short-term outcomes in a real-world context at a professional training center. Methods Observational study using data collected from medical records from January 2012 to January 2023. Patients undergoing operations for other carotid diseases and with concomitant heart surgery were excluded. Results A total of 70 patients undergoing angioplasty or carotid endarterectomy were included. Population subsets undergoing angioplasty or endarterectomy were similar. Differences in anesthetic modality and a longer operative time in the carotid endarterectomy subgroup were statistically significant. There were 4 cases of stroke, only 3 of which (2 minor and 1 major) were related to the index lesion. Thus, the rate of major operation-related stroke was 1.43% and the rate of any lesion-related stroke was 4.29%. There was 1 case of AMI in the angioplasty group and there were no deaths in the sample. The overall rate of major adverse cardiovascular events was 5.71%. There were no statistical differences between the endarterectomy and angioplasty groups regarding the main outcomes. Conclusions The rates of outcomes of ischemic stroke, acute myocardial infarction, death, and major adverse cardiovascular events at this center are in line with the rates reported by randomized controlled trials, demonstrating the feasibility of carotid surgery in centers with teaching programs.
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Affiliation(s)
- Tércio Ferreira Oliveira
- Universidade de São Paulo - USP, Faculdade de Medicina de Ribeirão Preto, Ribeirão Preto, SP, Brasil.
| | | | - Marcelo Bellini Dalio
- Universidade de São Paulo - USP, Faculdade de Medicina de Ribeirão Preto, Ribeirão Preto, SP, Brasil.
| | - Edwaldo Edner Joviliano
- Universidade de São Paulo - USP, Faculdade de Medicina de Ribeirão Preto, Ribeirão Preto, SP, Brasil.
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9
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Squizzato F, Piazza M, Turcatel A, Colacchio EC, Grego F, Antonello M. Effect of plaque morphological characteristics on the outcomes of carotid artery stenting. THE JOURNAL OF CARDIOVASCULAR SURGERY 2023; 64:561-569. [PMID: 38015553 DOI: 10.23736/s0021-9509.23.12763-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/29/2023]
Abstract
Carotid artery stenting (CAS) represents today an accepted option for the treatment of severe carotid artery stenosis. The evolution of materials, techniques, perioperative medical management and patients' selection, has allowed to progressively reduce CAS complications. However, the main drawback of CAS is still represented by the risk of cerebral embolization, that may occur during several steps of the procedure and also in the early postoperative period. Preoperative carotid plaque morphological characteristics may have a great role in determining the risk of embolization during CAS. This review summarizes the current knowledge on carotid plaque characteristics that may influence the risk of complication during CAS. This information may be important for the optimization of CAS patients' selection and adaptation of the materials and techniques.
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Affiliation(s)
- Francesco Squizzato
- Division of Vascular and Endovascular Surgery, Department of Cardiac, Thoracic Vascular Sciences and Public Health, School of Medicine, University of Padua, Padua, Italy -
| | - Michele Piazza
- Division of Vascular and Endovascular Surgery, Department of Cardiac, Thoracic Vascular Sciences and Public Health, School of Medicine, University of Padua, Padua, Italy
| | - Alessandra Turcatel
- Division of Vascular and Endovascular Surgery, Department of Cardiac, Thoracic Vascular Sciences and Public Health, School of Medicine, University of Padua, Padua, Italy
| | - Elda C Colacchio
- Division of Vascular and Endovascular Surgery, Department of Cardiac, Thoracic Vascular Sciences and Public Health, School of Medicine, University of Padua, Padua, Italy
| | - Franco Grego
- Division of Vascular and Endovascular Surgery, Department of Cardiac, Thoracic Vascular Sciences and Public Health, School of Medicine, University of Padua, Padua, Italy
| | - Michele Antonello
- Division of Vascular and Endovascular Surgery, Department of Cardiac, Thoracic Vascular Sciences and Public Health, School of Medicine, University of Padua, Padua, Italy
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10
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Bramucci A, Fontana A, Massoni CB, Vecchiati E, Freyrie A, Tusini N. Dual- vs single-layer stents for endovascular treatment of symptomatic and asymptomatic internal carotid artery stenosis. CARDIOVASCULAR REVASCULARIZATION MEDICINE 2023; 57:34-40. [PMID: 37365106 DOI: 10.1016/j.carrev.2023.06.016] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2023] [Revised: 05/20/2023] [Accepted: 06/16/2023] [Indexed: 06/28/2023]
Abstract
BACKGROUNDS Plaque protrusion is a common event among carotid artery stenting (CAS) patients and increases ischemic complication risk. Dual-layer stents (DLS) with micromesh technology may offer greater plaque protection compared to single-layer stents (SLS), but few data are available. The aim of the study is to compare clinical outcomes at 12 months for asymptomatic and symptomatic patients treated for primary CAS with DLS or SLS in a high-volume center. METHODS A retrospective analysis of consecutive symptomatic and asymptomatic patients treated with primary CAS for internal carotid artery (ICA) stenosis, with either DLS or SLS between 2015 and 2019, was performed. Primary endpoints included rates of ipsilateral transient ischemic attacks (TIA)/stroke and death within 1-year from CAS. Secondary endpoints included patency rates and survival according to stent type. RESULTS Of the 301 patients who met inclusion criteria (74.8 % male; 73.6 mean age ± 8.7 years), most patients were asymptomatic (77.4 %). Among all patients DLS was most frequently deployed (66 %); also, among asymptomatic (62 %) and symptomatic patients (81 %), p < 0.01. Symptomatic patients had less comorbidities and severe disease than asymptomatic patients. Six peri-operative strokes were recorded and, within 1 year, 2 additional strokes were registered among symptomatic patients treated with SLS. No post-operative strokes were encountered in the DLS group (p = 0.04) among symptomatic patients. Higher rates of TIA were observed among asymptomatic patients treated with DLS compared to SLS while rates of TIA were reduced among symptomatic patients treated with DLS. There were no differences in patency rates for DLS and SLS in symptomatic and asymptomatic patients. Primary patency was similar among DLS stent types but differed among SLS stent types (p = 0.01). At a mean follow-up of 27 months ±17.6, survival was comparable between DLS and SLS groups (p = 0.98). CONCLUSION CAS with DLS seems to reduce the risk of post-procedural stroke for symptomatic patients compared to SLS whilst the choice of stent did not influence ipsilateral TIA, survival or patency rates. These data require confirmation from larger, randomized, prospective studies.
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Affiliation(s)
- Alberto Bramucci
- Vascular Surgery, Department of Medicine and Surgery, University of Parma, Parma, Italy.
| | - Antonio Fontana
- Vascular Surgery, AO Reggio Emilia, Arcispedale S. Maria Nuova, Reggio Emilia, Italy.
| | | | - Enrico Vecchiati
- Vascular Surgery, AO Reggio Emilia, Arcispedale S. Maria Nuova, Reggio Emilia, Italy.
| | - Antonio Freyrie
- Vascular Surgery, Department of Medicine and Surgery, University of Parma, Parma, Italy.
| | - Nicola Tusini
- Vascular Surgery, AO Reggio Emilia, Arcispedale S. Maria Nuova, Reggio Emilia, Italy.
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11
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Zarrintan S, Elsayed N, Patel RJ, Clary B, Goodney PP, Malas MB. Propensity-Score Matched Analysis of Three Years Survival of Trans Carotid Artery Revascularization Versus Carotid Endarterectomy in the Vascular Quality Initiative Medicare-Linked Database. Ann Surg 2023; 278:559-567. [PMID: 37436847 DOI: 10.1097/sla.0000000000006009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/14/2023]
Abstract
OBJECTIVE Carotid endarterectomy (CEA) remains the gold standard procedure for carotid revascularization. Transfemoral carotid artery stenting (TFCAS) was introduced as a minimally invasive alternative procedure in patients who are at high risk for surgery. However, TFCAS was associated with an increased risk of stroke and death compared to CEA. BACKGROUND Transcarotid artery revascularization (TCAR) has outperformed TFCAS in several prior studies and has shown similar perioperative and 1-year outcomes compared with CEA. We aimed to compare the 1-year and 3-year outcomes of TCAR versus CEA in the Vascular Quality Initiative (VQI)-Medicare-Linked [Vascular Implant Surveillance and Interventional Outcomes Network (VISION)] database. METHODS The VISION database was queried for all patients undergoing CEA and TCAR between September 2016 to December 2019. The primary outcome was 1-year and 3-year survival. One-to-one propensity-score matching (PSM) without replacement was used to produce 2 well-matched cohorts. Kaplan-Meier estimates, and Cox regression was used for analyses. Exploratory analyses compared stroke rates using claims-based algorithms for comparison. RESULTS A total of 43,714 patients underwent CEA and 8089 patients underwent TCAR during the study period. Patients in the TCAR cohort were older and were more likely to have severe comorbidities. PSM produced two well-matched cohorts of 7351 pairs of TCAR and CEA. In the matched cohorts, there were no differences in 1-year death [hazard ratio (HR)=1.13; 95% CI, 0.99-1.30; P =0.065]. At 3-years, TCAR was associated with slight increased risk of death (HR=1.16; 95% CI, 1.04-1.30; P =0.008). When stratifying by initial symptomatic presentation, the increased 3-year death associated with TCAR persisted only in symptomatic patients (HR=1.33; 95% CI, 1.08-1.63; P =0.008). Exploratory analyses of postoperative stroke rates using administrative sources suggested that validated measures of claims-based stroke ascertainment are necessary. CONCLUSIONS In this large multi-institutional PSM analysis with robust Medicare-linked follow-up for survival analysis, the rate of death at 1 year was similar in TCAR and CEA regardless of symptomatic status. The slight increase in the risk of 3-year death in symptomatic patients undergoing TCAR is likely confounded by more severe comorbidities despite matching. A randomized controlled trial comparing TCAR to CEA is necessary to further determine the role of TCAR in standard-risk patients requiring carotid revascularization.
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Affiliation(s)
- Sina Zarrintan
- Department of Surgery, UC San Diego, San Diego, CA
- Center for Learning and Excellence in Vascular and Endovascular Research (CLEVER), UC San Diego, San Diego, CA
| | - Nadin Elsayed
- Department of Surgery, UC San Diego, San Diego, CA
- Center for Learning and Excellence in Vascular and Endovascular Research (CLEVER), UC San Diego, San Diego, CA
| | - Rohini J Patel
- Department of Surgery, UC San Diego, San Diego, CA
- Center for Learning and Excellence in Vascular and Endovascular Research (CLEVER), UC San Diego, San Diego, CA
| | - Bryan Clary
- Department of Surgery, UC San Diego, San Diego, CA
| | - Philip P Goodney
- Dartmouth Institute for Health Policy and Clinical Practice, Geisel School of Medicine at Dartmouth, Lebanon, NH
- Section of Vascular Surgery, Department of Surgery, Dartmouth-Hitchcock Medical Center, Lebanon, NH
| | - Mahmoud B Malas
- Department of Surgery, UC San Diego, San Diego, CA
- Center for Learning and Excellence in Vascular and Endovascular Research (CLEVER), UC San Diego, San Diego, CA
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12
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Davidovic L, Zlatanovic P, Dragas M, Dimic A, Mutavdzic P, Koncar I, Trailovic R, Ducic S, Mitrovic A, Ilic A. The influence of gender on 30-day adverse clinical outcomes in patients undergoing carotid surgery. THE JOURNAL OF CARDIOVASCULAR SURGERY 2023; 64:504-512. [PMID: 37335278 DOI: 10.23736/s0021-9509.23.12633-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/21/2023]
Abstract
BACKGROUND We aimed to further evaluate sex differences of perioperative and 30-day complications after carotid surgery in patients with both asymptomatic and symptomatic carotid artery stenosis. METHODS This was a single-center prospective cohort study including 2013 consecutive patients, who were treated surgically due to extracranial carotid artery stenosis and prospectively followed. Patients who underwent carotid artery stenting and who were treated conservatively were excluded. The primary endpoints for this study were hospital stroke/transitory ischemic attack (TIA) and overall survival rates. Secondary outcomes included all other hospital adverse events, 30-day stroke/TIA, and 30-day mortality rates. RESULTS Hospital mortality was higher in female patients with symptomatic carotid stenosis (3% vs. 0.5%, P=0.018). Bleeding requiring re-intervention occurred more often in female patients with both asymptomatic (1.5% vs. 0.4%, P=0.045) and symptomatic carotid stenosis (2.4% vs. 0.2%, P=0.022). 30-day stroke/TIA and mortality rates were higher in female patients with both asymptomatic (stroke/TIA 4.4% vs. 2.5%, P=0.041; mortality 3.3% vs. 1.6%, P=0.046) and symptomatic carotid stenosis (stroke/TIA 8.3% vs. 4.2%, P=0.040; mortality 4.1% vs. 0.7%, P=0.006). After adjusting for all confounding factors, female gender remained an important predicting factor for 30-day stroke/TIA in asymptomatic (OR=1.4, 95%CI 1.0-4.7, P=0.041) and symptomatic patients (OR=1.7, 95%CI 1.1-5.3, P=0.040), as well as for 30-day all-cause mortality in patients with asymptomatic (OR=1.5, 95%CI 1.1-4.1, P=0.030) and symptomatic carotid artery disease (OR=1.2, 95%CI 1.0-5.2, P=0.048). CONCLUSIONS Female gender is important predicting factor for stroke/TIA and all-cause mortality, both perioperative and during the first 30 days after carotid surgery.
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Affiliation(s)
- Lazar Davidovic
- Clinic for Vascular and Endovascular Surgery, Clinical Center of Serbia, Belgrade, Serbia
- Medical Faculty, University of Belgrade, Belgrade, Serbia
| | - Petar Zlatanovic
- Clinic for Vascular and Endovascular Surgery, Clinical Center of Serbia, Belgrade, Serbia -
| | - Marko Dragas
- Clinic for Vascular and Endovascular Surgery, Clinical Center of Serbia, Belgrade, Serbia
- Medical Faculty, University of Belgrade, Belgrade, Serbia
| | - Andreja Dimic
- Clinic for Vascular and Endovascular Surgery, Clinical Center of Serbia, Belgrade, Serbia
- Medical Faculty, University of Belgrade, Belgrade, Serbia
| | - Perica Mutavdzic
- Clinic for Vascular and Endovascular Surgery, Clinical Center of Serbia, Belgrade, Serbia
- Medical Faculty, University of Belgrade, Belgrade, Serbia
| | - Igor Koncar
- Clinic for Vascular and Endovascular Surgery, Clinical Center of Serbia, Belgrade, Serbia
- Medical Faculty, University of Belgrade, Belgrade, Serbia
| | - Ranko Trailovic
- Clinic for Vascular and Endovascular Surgery, Clinical Center of Serbia, Belgrade, Serbia
- Medical Faculty, University of Belgrade, Belgrade, Serbia
| | - Stefan Ducic
- Clinic for Vascular and Endovascular Surgery, Clinical Center of Serbia, Belgrade, Serbia
| | - Aleksandar Mitrovic
- Clinic for Vascular and Endovascular Surgery, Clinical Center of Serbia, Belgrade, Serbia
| | - Anica Ilic
- Clinic for Vascular and Endovascular Surgery, Clinical Center of Serbia, Belgrade, Serbia
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13
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Squizzato F, Piazza M, Forcella E, Colacchio EC, Fedrigo M, Angelini A, Grego F, Antonello M. Impact of Carotid Stent Design on Embolic Filter Debris Load During Carotid Artery Stenting. Stroke 2023; 54:2534-2541. [PMID: 37593847 DOI: 10.1161/strokeaha.123.043117] [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: 03/02/2023] [Accepted: 08/01/2023] [Indexed: 08/19/2023]
Abstract
BACKGROUND The carotid stent design may influence the risk of embolization during carotid artery stenting. The aim of the study was to assess this risk by comparing the quantity of embolized material captured by filters during carotid artery stenting, using different stent designs. METHODS We conducted a single-center retrospective study of patients undergoing carotid artery stenting for asymptomatic carotid stenosis >70% (2010-2022) in a tertiary academic hospital (Padua University Hospital, Italy). Carotid stents were classified according to their design as open-cell (OCS), closed-cell (CCS), or micromesh stents (MMS). A distal filter protection was used in all patients, and the amount of captured embolized particles was semiautomatically analyzed using a dedicated software (Image-Pro Plus, Media Cybernetics). Primary end point was embolic filter debris (EFD) load, defined as the ratio of the filter area covered by particulate material to the total filter area. Secondary end points were 30 days major stroke and death. RESULTS Four-hundred-eighty-one carotid artery stentings were included; 171 (35%) using an OCS, 68 (14%) a CCS, and 242 (50%) a MMS. Thirty-days mortality was 0.2% (n=1) and major stroke rate was 0.2% (P=0.987). Filters of patients receiving MMS were more likely to be free from embolized material (OCS, 30%; CCS, 13%; MMS, 41%; P<0.001) and had a lower EFD load (OCS, 9.1±14.5%; CCS, 7.9±14.0%; MMS, 5.0±9.1%; P<0.001) compared with other stent designs. After stratification by plaque characteristics, MMS had a lower EFD load in cases of hypoechogenic plaque (OCS, 13.4±9.9%; CCS, 10.9±8.7%; MMS, 6.5±13.1%; P<0.001), plaque length>15 mm (OC, 10.2±15.3; CC, 8.6±12.4; MM, 8.2±13.6; P<0.001), and preoperative ipsilateral asymptomatic ischemic cerebral lesion (OCS, 12.9±16.8%; CCS, 8.7±19.5%; MMS, 5.4±9.7%; P<0.001). After multivariate linear regression, use of MMS was associated with lower EFD load (P=0.038). CONCLUSIONS The use of MMS seems to be associated with a lower embolization rate and EFD load, especially in hypoechogenic and long plaques and in patients with a preoperative evidence of asymptomatic ischemic cerebral lesion.
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Affiliation(s)
- Francesco Squizzato
- Section of Vascular and Endovascular Surgery (F.S., M.P., E.F., E.C.C., F.G., M.A.), Department of Cardiac Thoracic Vascular Sciences and Public Health, University of Padua, Italy
| | - Michele Piazza
- Section of Vascular and Endovascular Surgery (F.S., M.P., E.F., E.C.C., F.G., M.A.), Department of Cardiac Thoracic Vascular Sciences and Public Health, University of Padua, Italy
| | - Edoardo Forcella
- Section of Vascular and Endovascular Surgery (F.S., M.P., E.F., E.C.C., F.G., M.A.), Department of Cardiac Thoracic Vascular Sciences and Public Health, University of Padua, Italy
| | - Elda Chiara Colacchio
- Section of Vascular and Endovascular Surgery (F.S., M.P., E.F., E.C.C., F.G., M.A.), Department of Cardiac Thoracic Vascular Sciences and Public Health, University of Padua, Italy
| | - Marny Fedrigo
- Section of Cardio Thoracic and Vascular Pathology (A.A., M.F.), Department of Cardiac Thoracic Vascular Sciences and Public Health, University of Padua, Italy
| | - Annalisa Angelini
- Section of Cardio Thoracic and Vascular Pathology (A.A., M.F.), Department of Cardiac Thoracic Vascular Sciences and Public Health, University of Padua, Italy
| | - Franco Grego
- Section of Vascular and Endovascular Surgery (F.S., M.P., E.F., E.C.C., F.G., M.A.), Department of Cardiac Thoracic Vascular Sciences and Public Health, University of Padua, Italy
| | - Michele Antonello
- Section of Vascular and Endovascular Surgery (F.S., M.P., E.F., E.C.C., F.G., M.A.), Department of Cardiac Thoracic Vascular Sciences and Public Health, University of Padua, Italy
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14
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Ratner M, Rockman C, Chang H, Johnson W, Sadek M, Maldonado T, Cayne N, Jacobowitz G, Siracuse JJ, Garg K. Young patients undergoing carotid stenting procedures have an increased rate of procedural failure at 1-year follow-up. J Vasc Surg 2023; 78:695-701.e2. [PMID: 37211144 DOI: 10.1016/j.jvs.2023.05.023] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2023] [Revised: 05/09/2023] [Accepted: 05/13/2023] [Indexed: 05/23/2023]
Abstract
OBJECTIVE The outcomes of patients with premature cerebrovascular disease (age ≤55 years) who undergo carotid artery stenting are not well-defined. Our study objective was to analyze the outcomes of younger patients undergoing carotid stenting. METHODS The Society for Vascular Surgery Vascular Quality Initiative was queried for transfemoral carotid artery stenting (TF-CAS) and transcarotid artery revascularization (TCAR) procedures between 2016 and 2020. Patients were stratified based on age ≤55 or >55 years. Primary endpoints were periprocedural stroke, death, myocardial infarction (MI), and composite outcomes. Secondary endpoints included procedural failure (defined as ipsilateral restenosis ≥80% or occlusion) and reintervention rates. RESULTS Of the 35,802 patients who underwent either TF-CAS or TCAR, 2912 (6.1%) were ≤55 years. Younger patients were less likely than older patients to have coronary disease (30.5% vs 50.2%; P < .001), diabetes (31.5% vs 37.9%; P < .001), and hypertension (71.8% vs 89.8%; P < .001), but were more likely to be female (45% vs 35.4%; P < .001) and active smokers (50.9% vs 24.0%; P < .001) Younger patients were also more likely to have had a prior transient ischemic attack or stroke than older patients (70.7% vs 56.9%; P < .001). TF-CAS was more frequently performed in younger patients (79.7% vs 55.4%; P < .001). In the periprocedural period, younger patients were less likely to have a MI than older patients (0.3% vs 0.7%; P < .001), but there was no significant difference in the rates of periprocedural stroke (1.5% vs 2.0%; P = .173) and composite outcomes of stroke/death (2.6% vs 2.7%; P = .686) and stroke/death/MI (2.9% vs 3.2%; P = .353) between our two cohorts. The mean follow-up was 12 months regardless of age. During follow-up, younger patients were significantly more likely to experience significant (≥80%) restenosis or occlusion (4.7% vs 2.3%; P = .001) and to undergo reintervention (3.3% vs 1.7%; P < .001). However, there was no statistical difference in the frequency of late strokes between younger and older patients (3.8% vs 3.2%; P = .129). CONCLUSIONS Patients with premature cerebrovascular disease undergoing carotid artery stenting are more likely to be African American, female, and active smokers than their older counterparts. Young patients are also more likely to present symptomatically. Although periprocedural outcomes are similar, younger patients have higher rates of procedural failure (significant restenosis or occlusion) and reintervention at 1-year follow-up. However, the clinical implication of late procedural failure is unknown, given that we found no significant difference in the rate of stroke at follow-up. Until further longitudinal studies are completed, clinicians should carefully consider the indications for carotid stenting in patients with premature cerebrovascular disease, and those who do undergo stenting may require close follow-up.
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Affiliation(s)
- Molly Ratner
- Division of Vascular Surgery, Department of Surgery, New York University Langone Medical Center, New York, NY
| | - Caron Rockman
- Division of Vascular Surgery, Department of Surgery, New York University Langone Medical Center, New York, NY
| | - Heepeel Chang
- Division of Vascular Surgery, Department of Surgery, Westchester Medical Center, Valhalla, NY
| | - William Johnson
- Division of Vascular Surgery, Department of Surgery, New York University Langone Medical Center, New York, NY
| | - Mikel Sadek
- Division of Vascular Surgery, Department of Surgery, New York University Langone Medical Center, New York, NY
| | - Thomas Maldonado
- Division of Vascular Surgery, Department of Surgery, New York University Langone Medical Center, New York, NY
| | - Neal Cayne
- Division of Vascular Surgery, Department of Surgery, New York University Langone Medical Center, New York, NY
| | - Glenn Jacobowitz
- Division of Vascular Surgery, Department of Surgery, New York University Langone Medical Center, New York, NY
| | - Jeffrey J Siracuse
- Division of Vascular and Endovascular Surgery, Department of Surgery, Boston Medical Center, Boston, MA
| | - Karan Garg
- Division of Vascular Surgery, Department of Surgery, New York University Langone Medical Center, New York, NY.
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15
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Ratner M, Garg K, Chang H, Johnson W, Sadek M, Maldonado T, Cayne N, Siracuse J, Jacobowitz G, Rockman C. Young patients undergoing carotid endarterectomy have increased rates of recurrent disease and late neurological events. J Vasc Surg 2023; 78:123-130. [PMID: 36870458 DOI: 10.1016/j.jvs.2023.02.011] [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: 12/15/2022] [Revised: 02/19/2023] [Accepted: 02/21/2023] [Indexed: 03/06/2023]
Abstract
OBJECTIVES There are few data regarding outcomes of patients with premature cerebrovascular disease (age ≤55 years) who undergo carotid endarterectomy (CEA). The objective of this study was to analyze the demographics, presentation, perioperative and later outcomes of younger patients undergoing CEA. METHODS The Society for Vascular Surgery Vascular Quality Initiative was queried for CEA cases between 2012 and 2022. Patients were stratified based on age of less than 55 or age greater than 55 years. Primary end points were periprocedural stroke, death, myocardial infarction, and composite outcomes. Secondary end points included restenosis (≥80%) or occlusion, late neurological events and reintervention. RESULTS Of 120,549 patients undergoing CEA, 7009 (5.5%) were 55 years old or younger (mean age, 51.3 years). Younger patients were more likely to be African American (7.7% vs 4.5%; P < .001), female (45.2% vs 38.9%; P < .001), and active smokers (57.3% vs 24.1%; P < .001). They were less likely than older patients to have hypertension (82.5% vs 89.7%; P < .001), coronary artery disease (25.0% vs 27.3%; P < .001), and congestive heart failure (7.8% vs 11.4%; P < .001). Younger patients were significantly less likely than older patients to be on aspirin, anticoagulation, statins, or beta-blockers, but were more likely to be taking P2Y12 inhibitors (37.2 vs 33.7%; P < .001). Younger patients were more likely to present with symptomatic disease (35.1% vs 27.6%; P < .001) and were more likely to undergo nonelective CEA (19.2% vs 12.8%; P < .001). Younger and older patients had similar rates of perioperative stroke/death (2% vs 2%; P = NS) and postoperative neurological events (1.9% vs 1.8%; P = NS). However, younger patients had lower rates of overall postoperative complications compared with their older counterparts (3.7% vs 4.7%; P < .001). Of these patients, 72.6% had recorded follow-up (mean, 13 months). During follow-up, younger patients were significantly more likely than older patients to experience a late failure, defined as significant restenosis (≥80%) or complete occlusion of the operated artery (2.4% vs 1.5%; P < .001) and were more likely to experience any neurological event (3.1% vs 2.3%; P < .001). Reintervention rates did not significantly differ between the two cohorts. After controlling for covariates using a logistic regression model, age 55 years or younger was independently associated with increased odds of late restenosis or occlusion (odds ratio, 1.591; 95% confidence interval, 1.221-2.073; P < .001) as well as late neurological events (odds ratio, 1.304; 95% confidence interval, 1.079-1.576; P = .006). CONCLUSIONS Young patients undergoing CEA are more likely to be African American, female, and active smokers. They are more likely to present symptomatically and undergo nonelective CEA. Although perioperative outcomes are similar, younger patients are more likely to experience carotid occlusion or restenosis as well as subsequent neurological events, during a relatively short follow-up period. These data suggest that younger CEA patients may require more diligent follow-up, as well as a continued aggressive approach to medical management of atherosclerosis to prevent future events related to the operated artery, given the particularly aggressive nature of premature atherosclerosis.
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Affiliation(s)
- Molly Ratner
- New York University Langone Medical Center, Department of Surgery, Division of Vascular Surgery, New York, NY
| | - Karan Garg
- New York University Langone Medical Center, Department of Surgery, Division of Vascular Surgery, New York, NY
| | - Heepeel Chang
- Westchester Medical Center, Department of Surgery, Division of Vascular Surgery, Valhalla, NY
| | - William Johnson
- New York University Langone Medical Center, Department of Surgery, Division of Vascular Surgery, New York, NY
| | - Mikel Sadek
- New York University Langone Medical Center, Department of Surgery, Division of Vascular Surgery, New York, NY
| | - Thomas Maldonado
- New York University Langone Medical Center, Department of Surgery, Division of Vascular Surgery, New York, NY
| | - Neal Cayne
- New York University Langone Medical Center, Department of Surgery, Division of Vascular Surgery, New York, NY
| | - Jeffrey Siracuse
- Boston Medical Center, Department of Surgery, Division of Vascular and Endovascular Surgery, Boston, MA
| | - Glenn Jacobowitz
- New York University Langone Medical Center, Department of Surgery, Division of Vascular Surgery, New York, NY
| | - Caron Rockman
- New York University Langone Medical Center, Department of Surgery, Division of Vascular Surgery, New York, NY.
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Desantis C, Zacà S, Wiesel P, Mastrangelo G, Pulli R, Angiletta D. Sex-Related Outcomes in Asymptomatic Patients Undergoing Carotid Artery Stenting. J Endovasc Ther 2023:15266028231172356. [PMID: 37190763 DOI: 10.1177/15266028231172356] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/17/2023]
Abstract
PURPOSE Aim of the study was to evaluate the influence of sex in asymptomatic patients undergoing carotid artery stenting (CAS). MATERIALS AND METHODS A retrospective observational study was conducted from January 2006 to December 2020. A total of 438 consecutive patients with asymptomatic carotid artery stenosis >70% underwent transfemoral CAS and were stratified in males (M) and females (F). Periprocedural 30-day outcomes were: stroke, death, and myocardial infarction (MI). Follow-up outcomes were: death and stroke rates (primary) and freedom from restenosis (FFR) and reintervention rates (secondary). Follow-up data were analyzed at 1, 5, and 10 years. Data were analyzed with χ2 test and Fisher's exact test and follow-up outcomes with Kaplan-Meier curves. The log-rank test was used to determine differences between the groups and univariate analysis to identify the association between risk factors and intraoperative details with mortality and restenosis rates. RESULTS A total of 462 procedures were performed (M: n=321, 69.4%), in which 24 CAS were bilateral (5.5%). Mean age was 71.9±7.6 years (M: 72.1±7.8; F: 71.7±7.3). Periprocedural outcomes were: stroke rate 2.2% (n=10; M: n=5, 1.6%; F: n=5, 3.5%; p=0.176), mortality rate 0.6% (M: n=3, p=0.334), and stroke/death rate 2.8% (n=13; M: n=8, 2.5%; F: n=5, 3.5%; p=0.528); no cardiac events (MI) were recorded. A not-disabling (minor) stroke was detected in 3 males (0.9%), while a disabling (major) stroke was reported in 7 patients (1.7%) of whom 5 were ischemic events (M: n=2, 0.6%; F: n=3, 2.2%) and 2 were cerebral hemorrhages (F: 1.3%, p=0.046). Mean follow-up was 73.66±40.83 months (M: 72.66; F: 76.01; p=0.246). Overall survival rate was 96.1% (95% confidence interval [CI]: 93-98), 81.8% (95% CI: 77-86), and 45.5% (95% CI: 38-53) at 1, 5, and 10 years, respectively (p=0.236). The overall stroke rate was 0.3% (freedom from stroke [FFS]: 99.7%; 95% CI: 98-100), 0.9% (FFS: 99%; 95% CI: 98-100), and 4.3% (FFS: 95.7%; 95% CI: 89-98; M: n=6; F: n=2; p=0.774). Stroke-related mortality rate was 0.7% (FFS: 99.3%; 95% CI: 97-100) and 2.9% (FFS: 97.1%; 95% CI: 91-99) at 5 and 10 years, respectively, without differences between the groups (M: n=4; F: n=2; p=0.763). Overall FFR rate was 97.4% (95% CI: 95-99), 93.4% (95% CI: 90-96), and 89.5% (95% CI: 84-93; p=0.322). Two severe symptomatic restenosis (>70%, M) required a new endovascular revascularization. CONCLUSION The sex variable does not influence outcomes of CAS in asymptomatic patients at short- and long-term follow-up, although females show a worst incidence of periprocedural major strokes. Carotid artery stenting may be safely proposed when a careful patient selection is applied. CLINICAL IMPACT The sex variable has been advocated as a considerable factor that could influence the outcomes of transfemoral carotid artery stenting (CAS). Literature data are contrasting, even if different papers mainly reported that CAS is associated to worst outcomes in female patients. Our study shows that the sex-variable does not influence outcomes of CAS in asymptomatic patients at short and long-term follow-up, although females had a worst incidence of periprocedural major strokes. CAS may be safely proposed when a careful patient selection is applied.
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Affiliation(s)
- Claudio Desantis
- Vascular and Endovascular Surgery-Department of Emergency and Organs Transplantation, "Aldo Moro" University of Bari School of Medicine, Bari, Italy
| | - Sergio Zacà
- Vascular and Endovascular Surgery-Department of Emergency and Organs Transplantation, "Aldo Moro" University of Bari School of Medicine, Bari, Italy
| | - Paola Wiesel
- Vascular and Endovascular Surgery-Department of Emergency and Organs Transplantation, "Aldo Moro" University of Bari School of Medicine, Bari, Italy
| | - Giovanni Mastrangelo
- Vascular and Endovascular Surgery-Department of Emergency and Organs Transplantation, "Aldo Moro" University of Bari School of Medicine, Bari, Italy
| | - Raffaele Pulli
- Vascular and Endovascular Surgery-Department of Emergency and Organs Transplantation, "Aldo Moro" University of Bari School of Medicine, Bari, Italy
| | - Domenico Angiletta
- Vascular and Endovascular Surgery-Department of Emergency and Organs Transplantation, "Aldo Moro" University of Bari School of Medicine, Bari, Italy
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Xodo A, Barbui F, Desole A, Pilon F, Zaramella M, Milite D. Bypass and other modified reconstruction techniques for 'challenging' carotid cases: A comparison with conventional endarterectomy. Vascular 2023:17085381231174946. [PMID: 37172198 DOI: 10.1177/17085381231174946] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/14/2023]
Abstract
OBJECTIVE Standard carotid endarterectomy (CEA) is usually performed with patch closure or eversion. However, sometimes a 'modified' carotid artery revascularization (MCAR) technique is required if the lesion is complex, extended and anatomically or technically challenging. MCAR is defined as carotid artery bypass; otherwise, it is the combination of common carotid artery (CCA) primary suture or patch angioplasty, associated with internal carotid artery (ICA) patch closure or eversion. The aim of this study was to evaluate the outcomes of MCAR during complex carotid procedures, comparing them with standard CEA. METHODS A retrospective analysis of asymptomatic patients who underwent CEA during a 16-year period (June 2005 to June 2021) was performed. Patients were divided into three different groups: ECEA (eversion CEA), PCEA (CEA with patch angioplasty) and MCAR. Primary endpoints were relevant neurological complication rate (RNCR), death within 30 days, freedom from ipsilateral stroke, reintervention rates and freedom from carotid artery restenosis. RESULTS A total of 1,752 patients were included (ECEA: 699; PCEA: 948; MCAR: 105) in the study. Patients treated with MCAR were significantly older and had a higher SVS score for arterial hypertension compared with ECEA and PCEA groups. A long plaque in the CCA was the most common indication for MCAR (40.1%); inadequate distal plaque-end or distal dissection (25.7%) was the second most prevalent indication. Overall perioperative RNCR, defined as minor and major stroke, was 0.7% (ECEA: 0.4%; PCEA: 0.7%; MCAR: 1.9%; p = 0.22), without any significant difference among the three groups. However, patients treated with MCAR had a significantly higher rate of global central neurological complications (defined as transient ischaemic attack, minor stroke and major stroke) than the other cohorts (ECEA: 0.7%; PCEA: 1.2%; MCAR: 3.8%; p = 0.02). One patient (0.05%) died perioperatively of a major cerebral infarction. Long-term follow-up (66.7 ± 43.9) showed a significantly lower rate of freedom from ipsilateral stroke for the MCAR group (96.8%) compared with ECEA and PCEA groups (99.8% and 98.9%, respectively, p = 0.03). Similar reintervention rates (ECEA: 2.7%; PCEA: 3.3%; MCAR: 3.8%; p = 0.74) and freedom from carotid restenosis rates (ECEA: 1.3%; PCEA: 2.6%; MCAR: 1.9%; p = 0.16) were observed. CONCLUSIONS Patients who underwent ICA revascularization with MCAR showed risks of perioperative death, major or minor stroke (<2%), reintervention rates and carotid restenosis rates that are comparable with PCEA or ECEA groups. Nevertheless, the MCAR group showed a significantly higher rate of global central neurological complications (considering together TIA, minor stroke and major stroke) than patients treated with standard CEA. MCAR techniques appear to be effective alternatives to standard CEAs, with an acceptable surgical risk. However, these should be performed mainly in selected cases, for example, in complex anatomy (detected in a non-negligible percentage of patients by preoperative imaging), or in the case of unexpected intraoperative technical issues.
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Affiliation(s)
- Andrea Xodo
- Division of Vascular and Endovascular Surgery, "San Bortolo" Hospital, Vicenza, Italy
| | - Federico Barbui
- Division of Vascular and Endovascular Surgery, "San Bortolo" Hospital, Vicenza, Italy
| | - Alessandro Desole
- Division of Vascular and Endovascular Surgery, "San Bortolo" Hospital, Vicenza, Italy
| | - Fabio Pilon
- Division of Vascular and Endovascular Surgery, "San Bortolo" Hospital, Vicenza, Italy
| | | | - Domenico Milite
- Division of Vascular and Endovascular Surgery, "San Bortolo" Hospital, Vicenza, Italy
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Martin GH, Leckie K, Dakour-Aridi H, Saqib NU, Motaganahalli RL, Keyhani A, Keyhani K, Wang SK. Fate of Hemodialysis Patients Undergoing Transcarotid Revascularization. Vasc Endovascular Surg 2023; 57:215-221. [PMID: 36428225 DOI: 10.1177/15385744221143215] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
INTRODUCTION Carotid revascularization in patients with end-stage renal disease (ESRD) continues to be a controversial topic, as life expectancy is poor, thus, preventing the recouperation of cumulative stroke-risk reduction in the postoperative period. We performed this primarily descriptive analysis of the results of transcarotid revascularization (TCAR) in renal failure patients. METHODS A retrospective review of two independent carotid revascularization databases maintained at two large health systems were performed to capture all consecutive TCAR procedures. Patients were classified as either (1) ESRD or (2) preserved renal function (PRF) and compared with standard univariate techniques, where appropriate. RESULTS From December 2015 to April 2022, 851 consecutive TCARs were attempted at our participating facilities. Of these, 27 were performed in ESRD patients (all hemodialysis). These patients were younger and presented with a higher Charlson Comorbidity Index. The incidence of a high anatomic risk criterion as defined for the Centers for Medicare and Medicaid Services (CMS) were similar between groups, as was the incidence of a symptomatic carotid lesion. There were no differences between the groups in terms of intraoperative characteristics and the postoperative medication management were grossly similar by renal function. In the 30-day perioperative period, there were no stroke, death, or myocardial infarction in the 27 ESRD patients treated with TCAR. The mean duration of follow-up in the ESRD cohort was 15.0 months. During this time, there was no ipsilateral stroke events, one contralateral stroke, and one MI. All 27 carotid stents remained patent during this period. Six patients perished after TCAR at a mean interval of 12.2 months after TCAR. CONCLUSION Survival is poor after carotid revascularization via the TCAR technique on intermediate follow-up. Careful patient selection is required to identify those who will survive to collect on the cumulative stroke-risk reduction afforded by carotid intervention.
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Affiliation(s)
- Gordon H Martin
- Department of Cardiothoracic and Vascular Surgery, 12339McGovern Medical School at The University of Texas Health Science Center at Houston (UTHealth), Houston, TX, USA
| | - Katherin Leckie
- Division of Vascular Surgery, Department of Surgery, 12250Indiana University School of Medicine, Indianapolis, IN, USA
| | - Hanaa Dakour-Aridi
- Division of Vascular Surgery, Department of Surgery, 12250Indiana University School of Medicine, Indianapolis, IN, USA
| | - Naveed U Saqib
- Department of Cardiothoracic and Vascular Surgery, 12339McGovern Medical School at The University of Texas Health Science Center at Houston (UTHealth), Houston, TX, USA
| | - Raghu L Motaganahalli
- Division of Vascular Surgery, Department of Surgery, 12250Indiana University School of Medicine, Indianapolis, IN, USA
| | - Arash Keyhani
- Department of Cardiothoracic and Vascular Surgery, 12339McGovern Medical School at The University of Texas Health Science Center at Houston (UTHealth), Houston, TX, USA
| | - Kourosh Keyhani
- Department of Cardiothoracic and Vascular Surgery, 12339McGovern Medical School at The University of Texas Health Science Center at Houston (UTHealth), Houston, TX, USA
| | - S Keisin Wang
- Department of Cardiothoracic and Vascular Surgery, 12339McGovern Medical School at The University of Texas Health Science Center at Houston (UTHealth), Houston, TX, USA
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Squizzato F, Spertino A, Lupia M, Grego F, Gerosa G, Tarantini G, Piazza M, Antonello M. Prevalence, risk factors, and clinical effect of coronary artery disease in patients with asymptomatic bilateral carotid stenosis. J Vasc Surg 2023; 77:1182-1191.e1. [PMID: 36464015 DOI: 10.1016/j.jvs.2022.11.063] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2022] [Revised: 11/22/2022] [Accepted: 11/23/2022] [Indexed: 12/03/2022]
Abstract
OBJECTIVE In the present report, we have described the prevalence, risk factors, and clinical effects of coronary artery disease (CAD) for patients with asymptomatic bilateral carotid stenosis. METHODS We conducted a single-center, retrospective cohort study of consecutive patients referred for bilateral carotid stenosis >70% (2014-2021). All the patients had undergone systematic coronary angiography. Depending on the anatomic and clinical characteristics, the patients had undergone combined carotid endarterectomy (CEA) plus coronary artery bypass grafting, coronary percutaneous intervention followed by CEA or carotid artery stenting (CAS), or staged bilateral CEA with cardiac best medical therapy. The cumulative 30-day stroke/myocardial infarction (MI) rate after cardiac and bilateral carotid interventions and long-term survival and freedom from cardiovascular mortality were assessed. RESULTS A total of 167 patients with bilateral carotid stenosis >70% had undergone preoperative coronary angiography, identifying severe CAD in 108 patients (65.1%). Echocardiographic abnormalities (odds ratio [OR], 2.07; 95% confidence interval [CI], 1.03-5.78; P = .04) and prior coronary intervention (OR, 11.94; 95% CI, 2.99-63.81; P = .001) were significantly associated with severe CAD. CAD was treatable in 91 patients (84%) and untreatable in 17 (16%). The cumulative MI rate was 4.8%; 5.6% for the patients with severe CAD and 1.7% for those without severe CAD (P = .262). The cumulative stroke rate was 1.8%; 1.8% for those with severe CAD and 1.7% for those without severe CAD (P = 1.00). The overall stroke/MI rate was 6.6%; 8.3% for those with severe CAD and 3.3% for patients without severe CAD (P = .33). Patients with severe CAD deemed untreatable for coronary bypass or percutaneous intervention had a higher risk of perioperative stroke/MI (OR, 1.24; 95% CI, 1.00-2.83; P = .04). At 10 years, overall survival was 67.1% (95% CI, 57%-79%), and freedom from cardiovascular mortality was 78.5% (95% CI, 69%-89%). Patients with untreatable CAD maintained a higher risk of 10-year mortality (hazard ratio, 5.5; 95% CI, 1.6-19.9; P < .01). CONCLUSIONS In the present study, the prevalence of CAD in patients with bilateral carotid stenosis was high, especially for those with abnormal echocardiographic findings. CAD was potentially treatable in 80% of patients, and staged or simultaneous CAD treatment was performed with an acceptable stroke/MI complication rate for these patients. The presence of untreatable CAD was associated with worsened early and long-term outcomes, questioning the benefit of carotid interventions for this subset of patients.
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Affiliation(s)
- Francesco Squizzato
- Division of Vascular and Endovascular Surgery, Department of Cardiac, Thoracic, Vascular Sciences and Public Health, University of Padua, Padua, Italy.
| | - Andrea Spertino
- Division of Vascular and Endovascular Surgery, Department of Cardiac, Thoracic, Vascular Sciences and Public Health, University of Padua, Padua, Italy
| | - Mario Lupia
- Division of Vascular and Endovascular Surgery, Department of Cardiac, Thoracic, Vascular Sciences and Public Health, University of Padua, Padua, Italy
| | - Franco Grego
- Division of Vascular and Endovascular Surgery, Department of Cardiac, Thoracic, Vascular Sciences and Public Health, University of Padua, Padua, Italy
| | - Gino Gerosa
- Division of Cardiac Surgery, Department of Cardiac, Thoracic, Vascular Sciences and Public Health, University of Padua, Padua, Italy
| | - Giuseppe Tarantini
- Interventional Cardiology Unit, Division of Cardiology, Department of Cardiac, Thoracic, Vascular Sciences and Public Health, University of Padua, Padua, Italy
| | - Michele Piazza
- Division of Vascular and Endovascular Surgery, Department of Cardiac, Thoracic, Vascular Sciences and Public Health, University of Padua, Padua, Italy
| | - Michele Antonello
- Division of Vascular and Endovascular Surgery, Department of Cardiac, Thoracic, Vascular Sciences and Public Health, University of Padua, Padua, Italy
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Leckie K, Tanaka A, Dakour-Aridi H, Motaganahalli RL, George MJ, Keyhani A, Keyhani K, Wang SK. Predictors of 30-Day Stroke and Death After Transcarotid Revascularization. J Surg Res 2023; 283:146-151. [PMID: 36410230 DOI: 10.1016/j.jss.2022.10.028] [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: 05/03/2022] [Revised: 09/26/2022] [Accepted: 10/17/2022] [Indexed: 11/19/2022]
Abstract
INTRODUCTION Much of the previous robust analyses of the results associated with transcarotid revascularization (TCAR) derives from industry-sponsored trials or the Vascular Quality Initiative (VQI). This investigation was performed to identify preoperative predictors of 30-day stroke and death using institutional databases. METHODS A retrospective analysis was performed of carotid revascularization databases created at two high-volume TCAR centers and maintained independently of the VQI carotid module between December 2015 and December 2021. The primary outcome of interest was a composite of perioperative (30-day) stroke and death. Univariate regression analyses, followed by multivariate regression analyses, were performed to identify potential predictors of adverse events. RESULTS During the study period, 750 TCAR procedures were performed at our combined health systems, resulting in 24 (3.2%) individuals who experienced either stroke and/or death in the perioperative period. Of these, we observed nine (1.2%) mortality events and 18 (2.4%) strokes. On univariate analysis, candidate protectors of stroke/death were found to be coronary artery disease (odds ratio [OR], 0.43; 95% confidence interval [CI], 0.18-1.01; P = 0.05) and protamine reversal (0.51; 0.21-1.21; P = 0.15). Candidate predictors of the primary outcome were anticoagulant usage (3.03; 1.26-7.24; P = 0.01), postprocedural debris in the filter (2.30; 0.97-5.43; P = 0.06), symptomatic carotid lesion (2.03; 0.90-4.50), and cardiac arrhythmia (1.98; 0.80-4.03; P = 0.14). On multivariate analysis, two predictors remained, cardiac arrhythmia (4.21; 1.10-16.16; P = 0.04) and symptomatic carotid lesion (14.49; 1.80-116.94; P = 0.01). CONCLUSIONS A symptomatic carotid lesion, and to a lesser extent cardiac arrhythmia, are strong predictors of 30-day stroke/death after TCAR. Surgeons should be cognizant of the increased risk of adverse events in the perioperative period in these patients.
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Affiliation(s)
- Katherin Leckie
- Division of Vascular Surgery, Department of Surgery, Indiana University School of Medicine, Indianapolis, Indiana
| | - Akiko Tanaka
- Division of Vascular Surgery, Department of Cardiothoracic and Vascular Surgery, McGovern Medical School at The University of Texas Health Science Center at Houston (UTHealth), Houston, Texas
| | - Hanaa Dakour-Aridi
- Division of Vascular Surgery, Department of Surgery, Indiana University School of Medicine, Indianapolis, Indiana
| | - Raghu L Motaganahalli
- Division of Vascular Surgery, Department of Surgery, Indiana University School of Medicine, Indianapolis, Indiana
| | - Mitchell J George
- Division of Vascular Surgery, Department of Cardiothoracic and Vascular Surgery, McGovern Medical School at The University of Texas Health Science Center at Houston (UTHealth), Houston, Texas
| | - Arash Keyhani
- Division of Vascular Surgery, Department of Cardiothoracic and Vascular Surgery, McGovern Medical School at The University of Texas Health Science Center at Houston (UTHealth), Houston, Texas
| | - Kourosh Keyhani
- Division of Vascular Surgery, Department of Cardiothoracic and Vascular Surgery, McGovern Medical School at The University of Texas Health Science Center at Houston (UTHealth), Houston, Texas
| | - S Keisin Wang
- Division of Vascular Surgery, Department of Cardiothoracic and Vascular Surgery, McGovern Medical School at The University of Texas Health Science Center at Houston (UTHealth), Houston, Texas.
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Mert B, Mert FTİ, Boyacıoglu K, Sahin İ, Özkaynak B. Carotid artery bypass versus endarterectomy as an alternative treatment of carotid artery stenosis: A propensity score matching analysis. J Stroke Cerebrovasc Dis 2023; 32:106888. [PMID: 36476510 DOI: 10.1016/j.jstrokecerebrovasdis.2022.106888] [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: 08/11/2022] [Revised: 11/07/2022] [Accepted: 11/08/2022] [Indexed: 12/09/2022] Open
Abstract
OBJECTIVES The main focus of this study is to evaluate the reliability and durability of saphenous vein bypass grafting from common carotid artery to internal carotid artery (CBG) asan alternative treatment of patients with carotid artery stenosis. METHODS 459 patients with carotid artery stenosis underwent initial carotid endarterectomy (CEA) or CBG between 2009 and 2019. Propensity score matching was performed, and outcomes of two different surgical procedures were analyzed. RESULTS Outcomes of the 142 pairs of matched patients were investigated. There were no significant differences in the preoperative characteristics of these matched groups. Overall mean time of follow-up was 91.364 ± 3.265 months. Mortality rate during the follow-up period was 18.309% (26 patients) in the CEA group, and 11.971% (17 patients) in the CBG group. Stroke was encountered in 8 patients in the CEA group (5.63%), and 3 patients in the CBG group (2.11%) during follow-up. Restenosis was detected in 11 patients in the CEA group (7.75%), and 3 patients in the CBG group (3.52%) during follow-up. There were no significant differences in the survival, stroke - free survival, and restenosis - free survival distributions of both groups. CONCLUSIONS In carotid artery stenosis, it is reasonable to consider CBG as an alternative surgical option when adequate disease-free inflow (common carotid artery) and outflow (distal internal carotid artery) segments are present.
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Affiliation(s)
- Bülent Mert
- Department of Cardiovascular Surgery, University of Health Sciences, Bagcilar Training and Research Hospital, İstanbul, Turkey
| | - Fatma Tugba İlal Mert
- Department of Cardiovascular Surgery, University of Health Sciences, Kanuni Sultan Suleyman Training and Research Hospital, İstanbul, Turkey
| | - Kamil Boyacıoglu
- Department of Cardiovascular Surgery, University of Health Sciences, Bagcilar Training and Research Hospital, İstanbul, Turkey
| | - İrfan Sahin
- Department of Cardiology, University of Health Sciences, Bagcilar Training and Research Hospital, İstanbul, Turkey
| | - Berk Özkaynak
- Department of Cardiovascular Surgery, University of Health Sciences, Bagcilar Training and Research Hospital, İstanbul, Turkey.
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Jovanovic A, Jonsson M, Roy J, Eriksson J, Mutavdzic P, Trailovic R, Koncar I. Comparison of Methods for Monitoring Intra-operative Cerebral Perfusion in Patients Undergoing Carotid Endarterectomy with Selective Shunting: A Systematic Review and Network Meta-Analysis of Randomised Controlled Trials and Cohort Studies. Eur J Vasc Endovasc Surg 2023; 65:233-243. [PMID: 38807326 DOI: 10.1016/j.ejvs.2022.08.025] [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: 02/13/2022] [Revised: 08/03/2022] [Accepted: 08/21/2022] [Indexed: 11/26/2022]
Abstract
OBJECTIVE This study aimed to analyse the influence of different methods of monitoring cerebral perfusion (MCP) on stroke, death, and use of intraluminal shunt during carotid endarterectomy (CEA). METHODS A systematic review and network meta-analysis was conducted and registered in the PROSPERO registry (CRD42021246360). Medline, Embase, CENTRAL, and Web of Science were searched. Randomised controlled trials (RCTs) and cohort studies with > 50 participants that compared clinical outcomes for different MCP in patients undergoing CEA were included. Papers reporting one or a combination of two of the following MCPs were included in the analysis: awake testing (AT), near infrared spectroscopy (NIRS), electroencephalography (EEG), somatosensory evoked potential (SSEP), motor evoked potential (MEP), transcranial Doppler (TCD), and stump pressure (SP). A random effects network meta-analysis was performed using a binomial likelihood function with a specified logit link for peri-operative stroke or death and shunting as outcomes. Near infrared spectroscopy was excluded due to the lack of studies that could be used for statistical analysis. RESULTS Of 1 834 publications, 17 studies (15 cohort studies and two RCTs) including 21 538 participants were incorporated in the quantitative analysis. Electroencephalography was used in the largest number of participants (7 429 participants, six studies), while AT was used in the highest number of studies (10 studies). All monitoring modalities had worse outcomes with respect to stroke or death when compared with AT, with ORs ranging between 1.3 (95% credible interval [CrI] 0.2 - 10.9) for SSEP + MEP and 3.1 (CrI 0.3 - 35.0) for patients monitored with a combination of EEG and TCD. However, the wide CrI indicated that there is no statistically significant difference between the monitoring methods. Patients monitored with a combination of EEG and TCD had the lowest odds of being shunted, while SP had the highest odds of being shunted, also with no statistically significant difference. CONCLUSION There is a lack of high quality data on this topic in the literature. The present study showed no significant difference between monitoring methods investigated in the network meta-analysis.
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Affiliation(s)
- Aleksa Jovanovic
- Institute of Epidemiology, Faculty of Medicine, University of Belgrade, Belgrade, Serbia
| | - Magnus Jonsson
- Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden; Department of Vascular Surgery, Karolinska University Hospital, Stockholm, Sweden
| | - Joy Roy
- Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden; Department of Vascular Surgery, Karolinska University Hospital, Stockholm, Sweden
| | - Julia Eriksson
- Division of Biostatistics, Institute of Environmental Medicine, Karolinska Institutet, Stockholm, Sweden
| | - Perica Mutavdzic
- Faculty of Medicine, University of Belgrade, Belgrade, Serbia; Clinic for Vascular and Endovascular Surgery, Serbian Clinical Centre, Belgrade, Serbia
| | - Ranko Trailovic
- Faculty of Medicine, University of Belgrade, Belgrade, Serbia; Clinic for Vascular and Endovascular Surgery, Serbian Clinical Centre, Belgrade, Serbia
| | - Igor Koncar
- Faculty of Medicine, University of Belgrade, Belgrade, Serbia; Clinic for Vascular and Endovascular Surgery, Serbian Clinical Centre, Belgrade, Serbia.
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Liesker DJ, Gareb B, Looman RS, Donners SJA, de Borst GJ, Zeebregts CJ, Saleem BR. Patch angioplasty during carotid endarterectomy using different materials has similar clinical outcomes. J Vasc Surg 2023; 77:559-566.e1. [PMID: 36208708 DOI: 10.1016/j.jvs.2022.09.027] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2022] [Revised: 09/26/2022] [Accepted: 09/29/2022] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Patch angioplasty during carotid endarterectomy (CEA) is commonly used to treat carotid artery stenosis. However, the choice of which patch to use remains a matter of debate. Autologous venous material has disadvantages such as wound-related problems at the harvest site and a prolonged intervention time. These limitations can be bypassed when synthetic or biological patches are used. Both materials have been associated with divergent advantages and disadvantages. Therefore, the aim of our study was to compare the long-term follow-up outcomes in patients who underwent CEA and closure with either a bovine pericardial patch (BPP) or polyester patch. METHODS A retrospective cohort study was conducted including all patients who underwent primary CEA and closure with a BPP or a polyester patch between January 2010 and December 2020 at our tertiary referral center. In 2015, the BPP was introduced as an alternative for polyester. The primary outcome was the occurrence of transient ischemic attack (TIA) or cerebrovascular accident (CVA) during follow-up and secondary outcomes included restenosis, reintervention, all-cause mortality, and patch infection. Cox proportional hazard models were used and hazard ratios with 95% confidence intervals were used to predict these outcomes. RESULTS We included 417 CEA patients; 254 patients (61%) received a BPP and 163 received (39%) a polyester patch. The mean age was 70.2 ± 8.7 years and 67% were male. The median follow-up time was 15 months (range, 12-27 months) for BPP and 42 months (range, 16-60 months) for polyester (P < .001). Postoperative hematoma (≤30 days) was significantly lower in the BPP cohort (2% BPP vs 6% polyester; P = .047). No other significant differences on short-term outcomes were found. Univariable Cox regression analyses showed no significant differences between the effect estimates of polyester and BPP on TIA or CVA (P = .106), restenosis (P = .211), reintervention (P = .549), or all-cause mortality (P = .158). No significant differences were found after adjusting for confounders in the multivariable analyses: TIA or CVA (P = .939), restenosis (P = .057), reintervention (P = .193) and all-cause mortality (P = .742). Three patients with a polyester patch had patch infection compared with none of the patients in the group who received a BPP. CONCLUSIONS This large retrospective study showed comparable safety and durability of both BPP and polyester suggesting that both patch types can be safely applied for CEA with patch angioplasty. Patch infection was rare and was absent in the BPP group.
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Affiliation(s)
- David J Liesker
- Department of Surgery (Division of Vascular Surgery), University Medical Center Groningen, University of Groningen, Groningen, the Netherlands.
| | - Barzi Gareb
- Department of Surgery Oral and Maxillofacial Surgery, University Medical Center Groningen, University of Groningen, Groningen, the Netherlands
| | - Rick S Looman
- Department of Surgery (Division of Vascular Surgery), University Medical Center Groningen, University of Groningen, Groningen, the Netherlands
| | - Simone J A Donners
- Department of Surgery (Division of Vascular Surgery), University Medical Center Utrecht, Utrecht, the Netherlands
| | - Gert J de Borst
- Department of Surgery (Division of Vascular Surgery), University Medical Center Utrecht, Utrecht, the Netherlands
| | - Clark J Zeebregts
- Department of Surgery (Division of Vascular Surgery), University Medical Center Groningen, University of Groningen, Groningen, the Netherlands
| | - Ben R Saleem
- Department of Surgery (Division of Vascular Surgery), University Medical Center Groningen, University of Groningen, Groningen, the Netherlands
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Long-Term Results of Autologous Bifurcated Carotid Artery Reconstructions. Ann Vasc Surg 2023; 92:93-103. [PMID: 36639097 DOI: 10.1016/j.avsg.2022.12.090] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2022] [Revised: 12/17/2022] [Accepted: 12/26/2022] [Indexed: 01/12/2023]
Abstract
BACKGROUND Carotid bifurcation revascularization using interposition grafts is rare. While internal carotid artery (ICA) revascularization is regarded as mandatory, the external carotid artery (ECA) is severed in most instances. Long-term results of an autologous bifurcated carotid artery reconstruction are discussed. METHODS Single-center, retrospective analysis of a consecutive series of patients treated at an academic vascular surgery center. RESULTS From December 2006 to November 2019, fifty-one patients underwent reconstruction of the carotid artery using an autologous bifurcated interposition graft (38 males, 75%; median age: 68.7 years; interquartile range [IQR]: 60.2-76.5). Thirty-eight patients were asymptomatic (74.5%). Indication for reconstruction was recurrent carotid stenosis unfavorable for endovascular treatment/redo patch plasty (n = 32, symptomatic: n = 7), carotid aneurysm (n = 11, symptomatic: n = 5), neck tumor with vascular involvement (n = 7), trauma (n = 1). Nonreversed valve depleted saphenous vein y-graft from the groin was used in 49 (94.2%) and reversed cubital vein bifurcation in 3 (5.8%) procedures. The median ICA cross-clamp time was 15 min (IQR: 13-20 min). In four procedures (7.7%), a shunt was inserted because of a significant decrease of cerebral perfusion. In one patient, additional intraoperative stent placement of a proximal common carotid artery (CCA) stenosis was performed. Six patients suffered from ischemic neurological deficits (11.5%), all but 1 recovered with no or moderate symptoms. After a median follow-up of 5.2 years (IQR: 1.1-8.7 years), 7 significant asymptomatic stenoses (13.5%) and 2 occlusions (3.8%, one symptomatic) of the ICA, two significant asymptomatic CCA stenoses (3.8%), five significant stenoses (9.6%) and 7 asymptomatic occlusions (13.5%) of the ECA were observed. This prompted 7 re-redo-interventions in 5 patients. Twenty-eight patients (54.9%) died after a median follow-up of 3.3 years (IQR: 0.5-5.6 years). Two of these patients died due to conditions related to the performed carotid artery reconstruction. CONCLUSIONS Autologous bifurcated carotid artery interposition graft provides results comparable to other complex ICA revascularizations. Overall survival in this heterogeneous patient cohort is poor. Due to the high risk of stroke and poor long-term outcome, this procedure should be reserved for symptomatic patients with no other option for revascularization.
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Short- and Mid-Term Outcomes of Stenting in Patients with Isolated Distal Internal Carotid Artery Stenosis or Post-Surgical Restenosis. J Clin Med 2022; 11:jcm11195640. [PMID: 36233508 PMCID: PMC9571211 DOI: 10.3390/jcm11195640] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2022] [Revised: 09/20/2022] [Accepted: 09/21/2022] [Indexed: 12/24/2022] Open
Abstract
The aim was to evaluate the outcome of stenting in patients with isolated distal internal carotid artery (ICA) stenosis or post-surgical restenosis, as no data are currently available in the literature. Sixty-six patients (men, N = 53; median age: 66 [IQR, 61–73] years) with ≥50% distal ICA (re)stenosis were included in this single-center retrospective study. The narrowest part of the (re)stenosis was at least 20 mm from the bifurcation in all patients. Patients were divided into two etiological groups, atherosclerotic (AS, N = 40) and post-surgical restenotic (RES, N = 26). Postprocedural neurological events were observed in two patients (5%) in the AS group and in two patients (7.7%) in the RES group. The median follow-up time was 40 (IQR, 18–86) months. Three patients (7.5%) in the AS group had an in-stent restenosis (ISR) ≥ 50%, but none in the RES group. Three patients (7.5%) in the AS group and seven patients (26.9%) in the RES group died. None of the deaths in the RES group were directly related to stenting itself. The early neurological complication rate of stenting due to distal ICA (re)stenoses is acceptable. However, the mid-term mortality rate of stenting for distal ICA post-surgical restenoses is high, indicating the vulnerability of this subgroup.
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George MJ, Husman R, Dakour-Aridi H, Tanaka A, Madison M, Motaganahalli R, Leckie K, Wang SK. Dual Institutional Experience with Transcarotid Artery Revascularization. Vasc Endovascular Surg 2022; 57:35-40. [DOI: 10.1177/15385744221127846] [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]
Abstract
Introduction Transcarotid artery revascularization (TCAR) is a hybrid open and endovascular technique to treat carotid stenosis. The purpose of this study is to present a large cohort of patients who underwent TCAR at 2 high-volume TCAR health systems. Methods This study was a retrospective chart review of all instances of TCAR within the Memorial Hermann Health System and Indiana University Health, from December 2015-January 2022, using the ENROUTE Neuroprotection Device (Silk Road Medical, Sunnyvale, CA). We report patient demographics, intraoperative metrics, 30-day results and long-term results. Results In all, 750 patients underwent TCAR in the designated time period. Average patient age was 73 years, with 68% being male. Overall, 53.9% of patients had coronary artery disease, 45.4% had diabetes, and 36.9% were symptomatic. Technical success was achieved in 98.8% of patients with conversion to open endarterectomy in 1.1%. Average reverse flow time was 9.1 minutes with length of stay greater than 1 day 38%. Ipsilateral stroke rate within 30 days was 2.3% and long-term cumulative stroke rate was 3.0%. Death within 30 days occurred in 1.2% of patients and in 5.9% over long-term follow up. In all, 1% of patients required reintervention. Conclusions TCAR is a safe and effective treatment modality for carotid artery stenotic disease. Its outcomes are similar to historical results associated with carotid endarterectomy, long considered the gold standard.
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Affiliation(s)
- Mitchell J George
- Department of Cardiothoracic and Vascular Surgery, McGovern Medical School at The University of Texas Health Science Center at Houston (UTHealth), Houston, TX, USA
| | - Regina Husman
- Department of Cardiothoracic and Vascular Surgery, McGovern Medical School at The University of Texas Health Science Center at Houston (UTHealth), Houston, TX, USA
| | - Hanaa Dakour-Aridi
- Department of Surgery, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Akiko Tanaka
- Department of Cardiothoracic and Vascular Surgery, McGovern Medical School at The University of Texas Health Science Center at Houston (UTHealth), Houston, TX, USA
| | - Mackenzie Madison
- Department of Surgery, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Raghu Motaganahalli
- Department of Surgery, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Katherin Leckie
- Department of Surgery, Indiana University School of Medicine, Indianapolis, IN, USA
| | - S Keisin Wang
- Department of Cardiothoracic and Vascular Surgery, McGovern Medical School at The University of Texas Health Science Center at Houston (UTHealth), Houston, TX, USA
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Joviliano EE, Ribeiro MS, Sobreira ML, Moura R, Geiger MA, Guillamon AT, Regina de Oliveira Raymundo S, Miquelin DG, Hafner L, Almeida MJ, Oliveira TF, Dalio MB, Yoshida WB. Short-term outcomes of transfemoral carotid artery stenting and carotid endarterectomy in symptomatic patients: data from a multicentric prospective registry in Brazil. Ann Vasc Surg 2022; 85:41-48. [PMID: 35589029 DOI: 10.1016/j.avsg.2022.04.053] [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: 12/28/2021] [Revised: 04/05/2022] [Accepted: 04/25/2022] [Indexed: 11/01/2022]
Abstract
BACKGROUND Transfemoral carotid artery stenting (TF-CAS) and carotid endarterectomy (CEA) are alternative strategies for stroke prevention in patients with atherosclerotic carotid disease. Since their main objective is to prevent future ischemic events, regular reassessment of the outcomes is mandatory for providing the best therapy. OBJECTIVE The purpose of this study was to describe the practice and the outcomes of TF-CAS and CEA in symptomatic patients in public university hospitals in Brazil, using data from a prospective multicentric registry. METHODS Prospective 8-year observational study of patients with symptomatic carotid artery atherosclerotic disease that underwent TF-CAS and CEA in five public university hospitals affiliated with the RHEUNI (Registry Project of Vascular Disease in the Public University Hospitals of São Paulo). All consecutive procedures were included. The indications for the procedures were determined by each surgeon's individual discretion, in accordance with a preoperative risk evaluation. The outcome measures were any 30-day follow-up death, stroke, myocardial infarction (MI), and their combined outcome (major adverse cardiovascular events - MACE). The registration of the study was made at clinicaltrials.gov NCT02538276. RESULTS From January 2012 through December 2019, 376 consecutive and symptomatic patients were included in the study records. There were 152 TF-CAS procedures (40.4%) and 224 CEA procedures (59.5%). All completed the 30-day follow-up period. Occurrence of death (TR-CAS: 0.66% x CEA: 0.66%, P=0.99), stroke (TF-CAS: 4.61% x CEA: 4.46%, P=0.99), and MI (TF-CAS: 0.66% x CEA: 0%, P=0.403) was similar in both groups, without statistically significant differences. MACE rate did not differ in both groups (TF-CAS: 5.92% x CEA: 4.46%, P=0.633). CONCLUSIONS Data from a prospective registry of five Brazilian university hospitals showed that transfemoral carotid artery stenting and carotid endarterectomy in symptomatic patients had similar 30-day perioperative rates of death, stroke, and myocardial infarction and their combination.
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Affiliation(s)
| | | | | | - Regina Moura
- University Hospital of Botucatu Medical School - São Paulo State University
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Micheel A, Konietschke F, Hinterseher I, Kapahnke S, Bürger M, Raude B, Schawe L, Omran S, Greiner A, Frese JP. Perioperative risk prediction using the POSSUM and V-POSSUM models in symptomatic carotid stenosis. VASA 2022; 51:150-157. [DOI: 10.1024/0301-1526/a000997] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
Summary: Background: This study aimed to evaluate risk factors for adverse outcomes and perioperative stroke and death in patients with symptomatic carotid stenosis undergoing open endarterectomy (CEA). The second objective was to assess the predictive value of the POSSUM and V-POSSUM models for predicting morbidity and mortality from CEA in symptomatic carotid stenosis. Patients and methods: A retrospective observational study of all patients admitted to a single center who underwent CEA for symptomatic carotid stenosis was performed. 320 patients from 1999 to 2013 were included. Postoperative complications, 30-day survival, and stroke rates were recorded. The observed outcomes were compared to the POSSUM and V-POSSUM expected mortality (observed to expected ratio (O:E)). Results: The mean age was 68.1±10.0 years. 215 patients were male (67%). Risk factors for surgical complications were: age, with a higher risk in both groups of less than 60 years and more than 75 years of age (p=0.04), a higher ASA score (p=0.04), and hyperlipidemia (p=0.017). Risk factors for the combined endpoint stroke or death were a higher ASA category (p<0.001), stroke as indication for CEA (p 0.022), and a high degree of stenosis (p=0.019). For POSSUM predicted mortality, there was a good O:E ratio in the two lowest risk groups, but a 2-fold overprediction of death or stroke in the two high-risk strata. The area under the curve (AUC) was 0.58 (95% CI: 0.43–0.73). The V-POSSUM showed a better fit in the high-risk groups, but an underprediction of mortality in the low-risk strata. Conclusions: Age and comorbid conditions are risk factors for adverse outcomes after CEA. The V-POSSUM model is better than POSSUM to predict postoperative death and stroke after CEA in patients with symptomatic carotid stenosis and a high preoperative physiological score. In patients with low physiological scores, both POSSUM and V-POSSUM show a limited predictive value.
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Affiliation(s)
- Anita Micheel
- Charité – Universitätsmedizin Berlin, Corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Department of Vascular Surgery, Berlin, Germany
- Department of Internal Medicine, Bundeswehr-Zentralkrankenhaus, Koblenz, Germany
| | - Frank Konietschke
- Charité – Universitätsmedizin Berlin, Corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Institute of Medical Biometrics and Clinical Epidemiology, Berlin, Germany
| | - Irene Hinterseher
- Charité – Universitätsmedizin Berlin, Corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Department of Vascular Surgery, Berlin, Germany
- Department of Vascular Surgery, Medizinische Hochschule Brandenburg Theodor-Fontane – Campus Neuruppin, Neuruppin, Germany
| | - Sebastian Kapahnke
- Charité – Universitätsmedizin Berlin, Corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Department of Vascular Surgery, Berlin, Germany
| | - Matthias Bürger
- Charité – Universitätsmedizin Berlin, Corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Department of Vascular Surgery, Berlin, Germany
| | - Ben Raude
- Charité – Universitätsmedizin Berlin, Corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Department of Vascular Surgery, Berlin, Germany
| | - Larissa Schawe
- Charité – Universitätsmedizin Berlin, Corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Department of Vascular Surgery, Berlin, Germany
| | - Safwan Omran
- Charité – Universitätsmedizin Berlin, Corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Department of Vascular Surgery, Berlin, Germany
| | - Andreas Greiner
- Charité – Universitätsmedizin Berlin, Corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Department of Vascular Surgery, Berlin, Germany
| | - Jan Paul Frese
- Charité – Universitätsmedizin Berlin, Corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Department of Vascular Surgery, Berlin, Germany
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Tanaka A, Madison MK, Motaganahalli RL, Fajardo A, Husman R, Keyhani A, Keyhani K, Wang SK. Transcarotid Artery Revascularization is Safe in Necks Hostile for Carotid Endarterectomy. J Vasc Surg 2022; 76:961-966. [DOI: 10.1016/j.jvs.2022.04.030] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2022] [Accepted: 04/04/2022] [Indexed: 10/18/2022]
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Garg K, Chang H, Siracuse JJ, Jacobowitz GR, Torres J, Veith FJ, Patel VI, Maldonado TS, Sadek M, Cayne NS, Rockman CB. Severity of stenosis in symptomatic patients undergoing carotid interventions may influence perioperative neurologic events. J Vasc Surg 2022; 76:741-749.e1. [PMID: 35272001 DOI: 10.1016/j.jvs.2022.02.044] [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: 10/05/2021] [Accepted: 02/06/2022] [Indexed: 10/18/2022]
Abstract
OBJECTIVE Carotid artery plaque burden, indirectly measured by the degree of stenosis, quantifies future embolic risk. In natural history studies, patients with moderate degrees of stenosis have a lower stroke risk than those with severe stenosis. However, patients with symptomatic carotid stenosis who have experienced TIA or stroke are found to have both moderate and severe degrees of stenosis. We sought to examine the association carotid artery stenosis severity with outcomes in symptomatic patients undergoing carotid interventions including carotid endarterectomy (CEA), transfemoral carotid artery stenting (CAS) and transcervical carotid artery revascularization (TCAR). METHODS The Society for Vascular Surgery Quality Initiative database was queried for all patients undergoing CAS, CEA and TCAR between 2003 and 2020. Patients were stratified into two groups based on the severity of stenosis - non-severe (0 - 69%) and severe (≥ 70%). Primary endpoints were periprocedural neurologic events (strokes and transient ischemic attacks (TIAs)). Secondary endpoints were periprocedural death, myocardial infarction (MI) and composite outcomes of stroke/death and stroke/death/MI per reporting standards for carotid interventions. RESULTS Of 29,614 symptomatic patients included in the analysis, 5,296 (17.9%) patients underwent TCAR, 7,844 (26.5%) underwent CAS, and 16,474 (55.6%) underwent CEA for symptomatic carotid artery stenosis. In the CEA cohort, the neurologic event rate was similarly significantly lower in patients with severe stenosis when compared to those with non-severe stenosis (2.6% vs. 3.2%, P=.024). In the TCAR cohort, the periprocedural neurologic even rate was lower in patients with severe stenosis when compared to those with non-severe stenosis (3% vs. 4.3%, P=.033). There was no similar difference noted in the CAS cohort, with periprocedural neurologic event rates of 3.8% in the severe group versus 3.5% in the non-severe group (P=.518). On multivariable analysis, severe stenosis was associated with significantly decreased odds of post procedural neurologic events in patients undergoing CEA (odds ratio [OR] 0.75, 95% confidence interval [CI], 0.6 - 0.92; P=.007) and TCAR (OR .83; CI, .69 - 0.99; P=.039), but not CAS. CONCLUSION Severe carotid stenosis as opposed to more moderate degrees of stenosis was associated with decreased rates of periprocedural stroke and TIAs in symptomatic patients undergoing TCAR and CEA, but not CAS. The finding of increased rates of periprocedural neurologic events in symptomatic patients with lesser degrees of stenosis undergoing TCAR and CEA warrants further evaluation with a particular focus on plaque morphology and brain physiology, and their inherent risks with carotid revascularization procedures.
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Affiliation(s)
- Karan Garg
- Division of Vascular and Endovascular Surgery, Department of Surgery, New York University Langone Medical Center, New York, NY, 10016.
| | - Heepeel Chang
- Division of Vascular and Endovascular Surgery, Department of Surgery, New York University Langone Medical Center, New York, NY, 10016
| | - Jeffrey J Siracuse
- Division of Vascular and Endovascular Surgery, Boston University School of Medicine, Boston Medical Center, Boston, MA 02210
| | - Glenn R Jacobowitz
- Division of Vascular and Endovascular Surgery, Department of Surgery, New York University Langone Medical Center, New York, NY, 10016
| | - Jose Torres
- Department of Neurology, New York University Langone Medical Center, New York, NY, 10016
| | - Frank J Veith
- Division of Vascular and Endovascular Surgery, Department of Surgery, New York University Langone Medical Center, New York, NY, 10016
| | - Virendra I Patel
- Division of Cardiac, Thoracic, and Vascular Surgery, New York Presbyterian / Columbia University Irving Medical Center / Columbia University College of Physicians and Surgeons, New York, NY 10032
| | - Thomas S Maldonado
- Division of Vascular and Endovascular Surgery, Department of Surgery, New York University Langone Medical Center, New York, NY, 10016
| | - Mikel Sadek
- Division of Vascular and Endovascular Surgery, Department of Surgery, New York University Langone Medical Center, New York, NY, 10016
| | - Neal S Cayne
- Division of Vascular and Endovascular Surgery, Department of Surgery, New York University Langone Medical Center, New York, NY, 10016
| | - Caron B Rockman
- Division of Vascular and Endovascular Surgery, Department of Surgery, New York University Langone Medical Center, New York, NY, 10016
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Nguyen DT, Vokó B, Nyárádi BB, Munkácsi T, Bérczi Á, Vokó Z, Dósa E. Restenosis rates in patients with ipsilateral carotid endarterectomy and contralateral carotid artery stenting. PLoS One 2022; 17:e0262735. [PMID: 35148323 PMCID: PMC8836368 DOI: 10.1371/journal.pone.0262735] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2021] [Accepted: 01/04/2022] [Indexed: 11/28/2022] Open
Abstract
Purpose We aimed to evaluate the long-term outcome of carotid endarterectomy (CEA) and carotid artery stenting (CAS) in patients who underwent both procedures on different sides. Methods In this single-center retrospective study (2001–2019), 117 patients (men, N = 78; median age at CEA, 64.4 [interquartile range {IQR}, 57.8–72.2] years; median age at CAS, 68.8 [IQR, 61.0–76.0] years) with ≥50% internal carotid artery stenosis who had CEA on one side and CAS on the other side were included. The risk of restenosis was estimated by treatment adjusted for patient and lesion characteristics. Results Neurological symptoms were significantly more common (41.9% vs 16.2%, P<0.001) and patients had a significantly shorter mean duration of smoking (30.2 [standard deviation {SD}, 22.2] years vs 31.8 [SD, 23.4] years, P<0.001), hypertension (10.1 [SD, 9.8] years vs 13.4 [SD, 9.1] years, P<0.001), hyperlipidemia (3.6 [SD, 6.6] years vs 5.0 [SD, 7.3] years, P = 0.001), and diabetes mellitus (3.9 [SD, 6.9] years vs 5.7 [SD, 8.9] years, P<0.001) before CEA compared to those before CAS. While the prevalence of heavily calcified stenoses on the operated side (25.6% vs 6.8%, P<0.001), the incidence of predominantly echogenic/echogenic plaques (53.0% vs 70.1%, P = 0.011) and suprabulbar lesions (1.7% vs 22.2%, P<0.001) on the stented side was significantly higher. Restenosis rates were 10.4% at 1 year, 22.3% at 5 years, and 33.7% at the end of the follow-up (at 11 years) for CEA, while these were 11.4%, 14.7%, and 17.2%, respectively, for CAS. Cox regression analysis revealed a significantly higher risk of restenosis (hazard ratio [HR], 1.80; 95% confidence interval [CI], 1.05–3.10; P = 0.030) for CEA compared to that for CAS. After adjusting for relevant confounding factors (smoking, hypertension, diabetes mellitus, calcification severity, plaque echogenicity, and lesion location), the estimate effect size materially did not change, although it did not remain statistically significant (HR, 1.85; 95% CI, 0.95–3.60; P = 0.070). Conclusion Intra-patient comparison of CEA and CAS in terms of restenosis tilts the balance toward CAS.
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Affiliation(s)
- Dat Tin Nguyen
- Heart and Vascular Center, Semmelweis University, Budapest, Hungary
- Hungarian Vascular Radiology Research Group, Budapest, Hungary
| | - Boldizsár Vokó
- Heart and Vascular Center, Semmelweis University, Budapest, Hungary
| | | | - Tamás Munkácsi
- Heart and Vascular Center, Semmelweis University, Budapest, Hungary
| | - Ákos Bérczi
- Heart and Vascular Center, Semmelweis University, Budapest, Hungary
- Hungarian Vascular Radiology Research Group, Budapest, Hungary
| | - Zoltán Vokó
- Center for Health Technology Assessment, Semmelweis University, Budapest, Hungary
| | - Edit Dósa
- Heart and Vascular Center, Semmelweis University, Budapest, Hungary
- Hungarian Vascular Radiology Research Group, Budapest, Hungary
- * E-mail:
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Ghamraoui AK, Chang H, Maldonado TS, Ricotta JJ. Clopidogrel Versus Ticagrelor for Antiplatelet Therapy in Transcarotid Artery Revascularization (TCAR) in the Society for Vascular Surgery Vascular Quality Initiative. J Vasc Surg 2021; 75:1652-1660. [PMID: 34920001 DOI: 10.1016/j.jvs.2021.11.060] [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: 06/21/2021] [Accepted: 11/11/2021] [Indexed: 01/24/2023]
Abstract
OBJECTIVE Transcarotid artery revascularization (TCAR) with dynamic flow reversal is a hybrid technique for operative management of carotid artery stenosis. Dual antiplatelet therapy is recommended for patients undergoing TCAR; however, nonresponders to these medications may be predisposed to perioperative thromboembolic complications. Prevalent in up to 44-66% of patients taking clopidogrel, high on-treatment platelet reactivity (HTPR) may thus be responsible for a portion of adverse cerebrovascular events in TCAR. A previous single-institution study has demonstrated the use of ticagrelor as a viable alternative to clopidogrel for antiplatelet therapy in patients undergoing TCAR; however, large-scale comparisons between clopidogrel and ticagrelor are needed to confirm the safety of ticagrelor outside of highly selected patients and providers. METHODS Data from patients enrolled in the Society for Vascular Surgery Vascular Quality Initiative undergoing TCAR with a perioperative antiplatelet therapy regimen including either clopidogrel or ticagrelor from January 2015 to March 2021 were analyzed and compared. Multivariable logistic regression and propensity score matching were used to evaluate the primary 30-day outcomes of stroke, major bleeding event, and combined stroke/myocardial infarction (MI)/death rate while adjusting for baseline characteristics of the patients. RESULTS A total of 11973 patients underwent TCAR with a dual antiplatelet therapy regimen that included clopidogrel versus 426 patients with ticagrelor. Compared to clopidogrel, patients on ticagrelor were significantly more likely to have coronary artery disease (51% vs 66% [P = <.001]), particularly unstable angina or MI within 6 months (3% vs 9% [P = <.001]), and more likely to have insulin-dependent diabetes mellitus (14% vs 19% [P = <.001]). The unadjusted 30-day rates of stroke, major bleeding, and combined stroke/MI/death were not statistically significant among both groups (1.3% vs 0.5% [P = .14], 2.4% vs 1.4% [P = .18], and 1.9% vs 1.6% [P = .71], respectively). After multivariable adjustment and propensity matching, these remained statistically insignificant. CONCLUSIONS Despite a substantially higher medical risk in patients undergoing TCAR with ticagrelor, 30-day rates of stroke, major bleeding events, and combined stroke/MI/death were similar between patients on ticagrelor and clopidogrel as part of adjunctive antiplatelet therapy. Randomized prospective trials, and studies with larger sample sizes and longer follow-up will be needed to better examine the outcome differences in TCAR between these two medications.
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Affiliation(s)
- Ahmed K Ghamraoui
- Charles E. Schmidt College of Medicine, Florida Atlantic University, Boca Raton, FL, USA
| | - Heepeel Chang
- Westchester Medical Center, New York Medical College, Valhalla, NY, USA
| | - Thomas S Maldonado
- The Schwartz Buckely Professor of Surgery, NYU Langone Health, New York, NY, USA; Director of the Venous Thromboembolic Center and Aortic Center, NYU Langone Medical Center, New York, NY, USA
| | - Joseph J Ricotta
- National Director of Vascular Surgery and Endovascular Therapy, Tenet Healthcare Corporation, Delray Medical Center, Delray Beach, FL, USA; Professor of Surgery and Program Director, Vascular Surgery Fellowship, Charles E. Schmidt College of Medicine, Florida Atlantic University, Boca Raton, FL, USA
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Aspalter M, Enzmann FK, Hölzenbein TJ, Hitzl W, Primavesi F, Algayerova L, Nierlich P, Kartnig C, Seitelberger R, Linni K. Preoperative anxiety as predictor of perioperative clinical events following carotid surgery: a prospective observational study. Perioper Med (Lond) 2021; 10:53. [PMID: 34876216 PMCID: PMC8653535 DOI: 10.1186/s13741-021-00223-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2021] [Accepted: 09/30/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Psychological factors like anxiety and depression are recognised to play a causal role in the development of cardiovascular disease and they may also influence outcome after vascular surgery procedures. The aim of this study was to investigate the association of anxiety and depression with postoperative outcome following elective carotid surgery. METHODS Single centre prospective observational study of patients treated for asymptomatic carotid artery stenosis at an academic vascular surgery centre. Preoperative anxiety and depression were evaluated using self-reporting questionnaires: Spielberger State-Trait Anxiety Inventory (STAI-S/-T) and Hospital Anxiety and Depression Scale (HADS-A/-D). Postoperative morbidity and mortality were assessed with the primary composite endpoint of stroke, myocardial infarction (MI) and death. Standard reporting guidelines for carotid disease were applied. RESULTS From June 2012 to November 2015, 393 carotid endarterectomies (CEA) were performed at our institution. Out of those, 98 asymptomatic patients were available for analysis (78% male; median age, 71.1 years). Median scores of self-reporting questionnaires did not differ from published data of the general population (STAI-T, trait component, median, 36; IQR, 31-42.75; STAI-S, state component, median, 38; IQR, 32-43; HADS-A median, 6; IQR, 3-8; HADS-D median, 4; IQR, 2-7). Cardiovascular risk factors were similar in anxious and non-anxious patients. The composite endpoint of stroke, MI and death occurred significantly more often in patients presenting with a preoperative HADS-A score higher than 6 (10.5%, 95% CI, 3-25; p =.020). CONCLUSIONS The present study indicates that preoperative anxiety is associated with the occurrence of intra- and postoperative neurological events in patients undergoing CEA. Patients who had a preoperative HADS-A score of 6 or less had a very low probability of experiencing these complications.
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Affiliation(s)
- Manuela Aspalter
- Department of Cardiac, Vascular and Endovascular Surgery, Paracelsus Medical University, Müllner Hauptstraße 48, 5020, Salzburg, Austria.
| | - Florian K Enzmann
- Department of Cardiac, Vascular and Endovascular Surgery, Paracelsus Medical University, Müllner Hauptstraße 48, 5020, Salzburg, Austria
| | - Thomas J Hölzenbein
- Department of Cardiac, Vascular and Endovascular Surgery, Paracelsus Medical University, Müllner Hauptstraße 48, 5020, Salzburg, Austria
| | - Wolfgang Hitzl
- Research Office, Biostatistics, Paracelsus Medical University, Strubergasse 21, 5020, Salzburg, Austria.,Department of Ophthalmology and Optometry, Paracelsus Medical University Salzburg, Müllner Hauptstr. 48, 5020, Salzburg, Austria.,Research Program Experimental Ophthalmology and Glaucoma Research, Paracelsus Medical University, Muellner Hauptstrasse 48, 5020, Salzburg, Austria
| | - Florian Primavesi
- Department of Cardiac, Vascular and Endovascular Surgery, Paracelsus Medical University, Müllner Hauptstraße 48, 5020, Salzburg, Austria
| | - Lucia Algayerova
- Department of Cardiac, Vascular and Endovascular Surgery, Paracelsus Medical University, Müllner Hauptstraße 48, 5020, Salzburg, Austria
| | - Patrick Nierlich
- Department of Cardiac, Vascular and Endovascular Surgery, Paracelsus Medical University, Müllner Hauptstraße 48, 5020, Salzburg, Austria
| | - Christoph Kartnig
- Department of Psychiatry, Division of Psychosomatic Medicine, Paracelsus Medical University, Müllner Hauptstraße 48, 5020, Salzburg, Austria
| | - Reinald Seitelberger
- Department of Cardiac, Vascular and Endovascular Surgery, Paracelsus Medical University, Müllner Hauptstraße 48, 5020, Salzburg, Austria
| | - Klaus Linni
- Department of Cardiac, Vascular and Endovascular Surgery, Paracelsus Medical University, Müllner Hauptstraße 48, 5020, Salzburg, Austria
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Chang H, Rockman CB, Veith FJ, Kashyap VS, Jacobowitz GR, Sadek M, Garg K, Maldonado TS. Outcomes of transfemoral carotid artery stenting and transcarotid artery revascularization for restenosis after prior ipsilateral carotid endarterectomy. J Vasc Surg 2021; 75:561-571.e3. [PMID: 34506900 DOI: 10.1016/j.jvs.2021.07.245] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2021] [Accepted: 07/29/2021] [Indexed: 01/08/2023]
Abstract
OBJECTIVE Restenosis after carotid endarterectomy (CEA) poses unique therapeutic challenges, with no specific guidelines available on the operative approach. Traditionally, transfemoral carotid artery stenting (TfCAS) has been regarded as the preferred approach to treating restenosis after CEA. Recently, transcarotid artery revascularization with a flow-reversal neuroprotection system (TCAR) has gained popularity as an effective alternative treatment modality for de novo carotid artery stenosis. The aim of the present study was to compare the contemporary perioperative outcomes of TfCAS and TCAR in patients with prior ipsilateral CEA. METHODS The Vascular Quality Initiative database was reviewed for patients who had undergone TfCAS and TCAR for restenosis after prior ipsilateral CEA between January 2016 and August 2020. The primary outcome was the 30-day composite outcome of stroke and death. The secondary outcomes included 30-day stroke, transient ischemic attack (TIA), myocardial infarction (MI), death, and composite 30-day outcomes of stroke, death, and TIA, stroke and TIA, and stroke, death, and MI. Multivariable logistic regression models were used to evaluate the outcomes of interest after adjustment for potential confounders and baseline differences between cohorts. RESULTS Of 3508 patients, 1834 and 1674 had undergone TfCAS and TCAR, respectively. The TCAR cohort was older (mean age, 71.6 years vs 70.2 years; P < .001) and less likely to be symptomatic (27% vs 46%; P < .001), with a greater proportion taking aspirin (92% vs 88%; P = .001), a P2Y12 inhibitor (89% vs 80%; P < .001), and a statin (91% vs 87%; P = .002) compared with the TfCAS cohort. Perioperatively, the TCAR cohort had had lower 30-day composite outcomes of stroke/death (1.6% vs 2.7%; P = .025), stroke/death/TIA (1.8% vs 3.3%; P = .004), and stroke/death/MI (2.1% vs 3.2%; P = .048), primarily driven by lower rates of stroke (1.3% vs 2.3%; P = .031) and TIA (0.2% vs 0.7%; P = .031). Among asymptomatic patients, the incidence of stroke (0.6% vs 1.4%; P = .042) and the composite of stroke/TIA (0.8% vs 1.8%; P = .036) was significantly lower after TCAR than TfCAS, and TCAR was associated with a lower incidence of TIA (0% vs 1%; P = .038) among symptomatic patients. On adjusted analysis, the TCAR cohort had lower odds of TIA (adjusted odds ratio, 0.17; 95% confidence interval, 0.04-0.74; P = .019). CONCLUSIONS Among patients undergoing carotid revascularization for restenosis after prior ipsilateral CEA, TCAR was associated with decreased odds of 30-day TIA compared with TfCAS. However, the two treatment approaches were similarly safe in terms of the remaining perioperative outcomes, including stroke and death and stroke, death, and MI. Our results support the safety and efficacy of TCAR in this subset of patients deemed at high risk of reintervention.
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Affiliation(s)
- Heepeel Chang
- Division of Vascular and Endovascular Surgery, Department of Surgery, Westchester Medical Center, New York Medical College, Valhalla, NY
| | - Caron B Rockman
- Division of Vascular and Endovascular Surgery, Department of Surgery, New York University Langone Medical Center, New York, NY
| | - Frank J Veith
- Division of Vascular and Endovascular Surgery, Department of Surgery, New York University Langone Medical Center, New York, NY
| | - Vikram S Kashyap
- Division of Vascular Surgery and Endovascular Therapy, Department of Surgery, University Hospitals Cleveland Medical Center, Cleveland, Ohio
| | - Glenn R Jacobowitz
- Division of Vascular and Endovascular Surgery, Department of Surgery, New York University Langone Medical Center, New York, NY
| | - Mikel Sadek
- Division of Vascular and Endovascular Surgery, Department of Surgery, New York University Langone Medical Center, New York, NY
| | - Karan Garg
- Division of Vascular and Endovascular Surgery, Department of Surgery, New York University Langone Medical Center, New York, NY
| | - Thomas S Maldonado
- Division of Vascular and Endovascular Surgery, Department of Surgery, New York University Langone Medical Center, New York, NY.
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Zhang K, Ma Y, Shi Q, Wu J, Shen J, He Y, Zhang X, Jiao P, Li GS, Tang X, Petersen RH, Ng CSH, Fiorelli A, Novoa NM, Bedetti B, Levi Sandri GB, Hochwald S, Lerut T, Sihoe ADL, Barchi LC, Gilbert S, Waseda R, Toker A, Gonzalez-Rivas D, Fruscio R, Scarci M, Davoli F, Piessen G, Qiu B, Wang SD, Chen Y, Gao S. Developing the surgical technique reporting checklist and standards: a study protocol. Gland Surg 2021; 10:2591-2599. [PMID: 34527570 PMCID: PMC8411094 DOI: 10.21037/gs-21-312] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2021] [Accepted: 07/14/2021] [Indexed: 12/17/2022]
Abstract
BACKGROUND Standardized and transparent reporting of surgical technique is the cornerstone of effective dissemination, implementation and improvement. However, current reporting of surgical techniques is inadequate. The existing guidelines potentially applied to guide surgical technique reporting are with a minimal highlight of the surgical technique, lack requirements explaining what extent and dimensions need to be described in detail, or are unlikely to extrapolate to a wide range of surgical techniques. This study aims to formulate a rigorous protocol to develop a surgical technique reporting checklist and standards (SUPER) that defines what a clear, comprehensive and detailed surgical technique report should be contained. METHODS This protocol is designed following the classic guidance for developing reporting guidelines recommended by the EQUATOR network. RESULTS The development team will consist of surgeons (~80%), methodologists, and journal editors. The draft checklist sources will include a scoping review of existing reporting guidelines related to surgical technique, surgical technique articles from 15 top journals published in the last year, and brainstorming by the multidisciplinary development team. The final SUPER checklist will be formed after three rounds of Delphi surveys, one round of face-to-face meeting, and a month-long pilot test. The SUPER checklist will be published as open-access and be used in combination with existing reporting guidelines related to surgical techniques (e.g., IDEAL). This protocol will steer the SUPER checklist's development, allowing us to further elaborate surgical technique reporting for all surgical specialties, and enabling a more favorable experience for surgeons, nurses, medical students, residents, editors, and reviewers. TRIAL REGISTRATION This trial is registered at the EQUATOR network on December 18th, 2020. Available at: https://www.equator-network.org/library/reporting-guidelines-under-development/reporting-guidelines-under-development-for-other-study-designs/.
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Affiliation(s)
- Kaiping Zhang
- Editorial Office, AME Publishing Company, Hong Kong, China
- School of Public Health, Imperial College London, London, UK
| | - Yanfang Ma
- Evidence-Based Medicine Center, School of Basic Medical Sciences, Lanzhou University, Lanzhou, China
| | - Qianling Shi
- The First School of Clinical Medicine, Lanzhou University, Lanzhou, China
| | - Jinlin Wu
- Department of Cardiovascular Surgery, Guangdong Provincial People’s Hospital, Guangdong Academy of Medical Sciences, Guangdong, China
| | - Jianfei Shen
- Department of Cardiothoracic Surgery, Taizhou Hospital of Zhejiang Province Affiliated to Wenzhou Medical University, Linhai, China
| | - Yulong He
- The First School of Clinical Medicine, Lanzhou University, Lanzhou, China
| | - Xianzhuo Zhang
- The First School of Clinical Medicine, Lanzhou University, Lanzhou, China
| | - Panpan Jiao
- The First School of Clinical Medicine, Lanzhou University, Lanzhou, China
| | - Grace S. Li
- Editorial Office, AME Publishing Company, Hong Kong, China
| | - Xueqin Tang
- Editorial Office, AME Publishing Company, Hong Kong, China
| | | | - Calvin S. H. Ng
- The Chinese University of Hong Kong, Prince of Wales Hospital, Shatin, New Territories, Hong Kong, China
| | - Alfonso Fiorelli
- Thoracic Surgery Unit, University of Campania “Luigi Vanvitelli”, Naples, Italy
| | - Nuria M. Novoa
- Thoracic Surgery Service, University Hospital of Salamanca, Biomedical Institute of Salamanca, Salamanca, Spain
| | - Benedetta Bedetti
- Department of Thoracic Surgery, Helios Clinic Bonn/Rhein Sieg, Bonn, Germany
| | | | - Steven Hochwald
- Department of Surgical Oncology, Roswell Park Cancer Institute, Buffalo, NY, USA
| | - Toni Lerut
- Department of Thoracic Surgery, University Hospital Leuven, Leuven, Belgium
| | | | - Leandro Cardoso Barchi
- Digestive Surgery Division, Department of Gastroenterology, University of Sao Paulo School of Medicine, São Paulo, Brazil
| | - Sebastien Gilbert
- Division of Thoracic Surgery, Department of Surgery, The Ottawa Hospital, University of Ottawa, Ottawa, Canada
| | - Ryuichi Waseda
- Department of General Thoracic, Breast and Pediatric Surgery, Fukuoka University, Fukuoka, Japan
| | - Alper Toker
- Department of Cardiovascular and Thoracic Surgery, West Virginia University Heart and Vascular Institute, Morgantown, WV, USA
| | - Diego Gonzalez-Rivas
- Department of Thoracic Surgery and Lung Transplant, Coruña University Hospital, Minimally Invasive Thoracic Surgery Unit (UCTMI), Coruña, Spain
- Department of Thoracic Surgery, Shanghai Pulmonary Hospital, Tongji University School of Medicine, Shanghai, China
| | - Robert Fruscio
- Clinic of Obstetrics and Gynecology, San Gerardo Hospital, Monza, Italy
- Department of Medicine and Surgery, University of Milan-Bicocca, Milan, Italy
| | - Marco Scarci
- Department of Thoracic Surgery, S. Gerardo Hospital, Monza, Italy
| | - Fabio Davoli
- Department of Thoracic Surgery, AUSL Romagna, S. Maria delle Croci Teaching Hospital, Ravenna, Italy
| | - Guillaume Piessen
- University of Lille, Department of Digestive and Oncological Surgery, Claude Huriez University Hospital, Lille, France
| | - Bin Qiu
- Department of Thoracic Surgery, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | | | - Yaolong Chen
- World Health Organization (WHO) Collaborating Centre for Guideline Implementation and Knowledge Translation, Lanzhou, China
- Lanzhou University Institute of Health Data Science, Lanzhou, China
| | - Shugeng Gao
- Department of Thoracic Surgery, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
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Squizzato F, Xodo A, Taglialavoro J, Zavatta M, Grego F, Antonello M, Piazza M. Early outcomes of routine delayed shunting in carotid endarterectomy for symptomatic patients. THE JOURNAL OF CARDIOVASCULAR SURGERY 2021; 62:573-581. [PMID: 34308613 DOI: 10.23736/s0021-9509.21.11845-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
BACKGROUND The role of shunting during carotid endarterectomy (CEA) in symptomatic patients is unclear. The aim was to evaluate early outcomes of CEA with routine "delayed" shunt insertion, for patients with symptomatic carotid stenosis. METHODS we conducted a single-center retrospective review of symptomatic patients undergoing CEA (2009-2020). All CEAs were performed under general anesthesia using a standardized technique, based on delayed routine shunt insertion after plaque removal. Primary endpoints were 30-days mortality and stroke. A logistic regression was performed to identify clinical and procedural factors predictors of post-operative stroke. A literature systematic review was conducted using the terms "carotid endarterectomy" "stroke", "transient ischemic attack", "symptomatic carotid stenosis", and "shunt". RESULTS two-hundred-sixty-three CEAs were performed for TIA (n=178, 47%) or acute ischemic stroke (n=85, 32%). Mean delay of surgery was 6±19 days, and early CEA (<48 hours) was performed in 98 cases (37%). Conventional CEA was performed in 171 patients (67%), eversion CEA in 83 (33%). Early (30-days) mortality was 0.3%. Stroke/death rate was 2.3%. Female sex (OR 5.14, 95%CI 1.32-24.93; P=.023), use of anticoagulants (OR 10.57, 95%CI 2.67-51.86; P=.001), preoperative stroke (OR 5.34, 95%CI 1.62-69.21; P=.006), and the presence of preoperative CT/MRI cerebral ischemic lesions (OR 5.96, 95%CI 1.52-28.59; P=.013) were associated with early neurological complications. Statin medication (OR 0.18, 95%CI 0.04-0.71; P=.019) and CEA timing <2 days (OR 0.14, 95%CI 0.03-0.55; P=.005) were protective from postoperative stroke. CEA outcomes were independent from time period (P=.201) and operator's volume (P=.768). Four studies described the CEA outcomes with routine shunting in symptomatic patients, with a large variability in the selection of patients, surgical technique, and description of the results. CONCLUSIONS Routine delayed shunting after plaque removal seems to be a safe and effective technique, that contributed to maintain a low complication rate in neurologically symptomatic patients. Statin use and expedited timing were associated with improved outcomes using this technique.
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Affiliation(s)
- Francesco Squizzato
- Vascular and Endovascular Surgery Division, Department Of Cardiac, Thoracic Vascular Sciences and Public Health, School of Medicine, Padova University, Padua, Italy
| | - Andrea Xodo
- Vascular and Endovascular Surgery Division, Department Of Cardiac, Thoracic Vascular Sciences and Public Health, School of Medicine, Padova University, Padua, Italy
| | - Jacopo Taglialavoro
- Vascular and Endovascular Surgery Division, Department Of Cardiac, Thoracic Vascular Sciences and Public Health, School of Medicine, Padova University, Padua, Italy
| | - Marco Zavatta
- Vascular and Endovascular Surgery Division, Department Of Cardiac, Thoracic Vascular Sciences and Public Health, School of Medicine, Padova University, Padua, Italy
| | - Franco Grego
- Vascular and Endovascular Surgery Division, Department Of Cardiac, Thoracic Vascular Sciences and Public Health, School of Medicine, Padova University, Padua, Italy
| | - Michele Antonello
- Vascular and Endovascular Surgery Division, Department Of Cardiac, Thoracic Vascular Sciences and Public Health, School of Medicine, Padova University, Padua, Italy
| | - Michele Piazza
- Vascular and Endovascular Surgery Division, Department Of Cardiac, Thoracic Vascular Sciences and Public Health, School of Medicine, Padova University, Padua, Italy -
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Kahlberg A, Bilman V, Ardita V, Mascia D, Bertoglio L, Rinaldi E, Melissano G, Chiesa R. Contemporary Results of Carotid Artery Stenting Using Low-Profile Dual-Metal Layer Nitinol Micromesh Stents in Relation to Single-Layer Carotid Stents. J Endovasc Ther 2021; 28:726-736. [PMID: 34137659 DOI: 10.1177/15266028211025046] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
PURPOSE To evaluate patients characteristics, procedural details, perioperative outcomes, and midterm results of carotid artery stenting (CAS) performed with the Roadsaver/Casper stent (Terumo Corp, Tokyo, Japan) as compared to concurrent patients treated with other commercially available carotid stents. MATERIALS AND METHODS This is a single-center, retrospective, nonrandomized study including 200 consecutive patients who underwent a total of 205 elective CAS procedures due to severe internal carotid artery stenosis between April 2015 and December 2018. Procedural data and outcomes for patients treated with the Roadsaver/Casper stent implantation (100 procedures, in 97 patients) vs first-generation carotid stents implantations (90 procedures, in 88 patients) were compared. Fifteen patients were treated with CGuard carotid stent (InspireMD, Tel Aviv, Israel), and outcomes were reported separately. Primary endpoints were the occurrence of major adverse cerebrovascular events (MACE), including death, ipsilateral stroke, and transitory ischemic attack (TIA). Secondary endpoints were the rate of intrastent stenosis, the need for reintervention, and the occurrence of adverse cardiovascular events, including myocardial infarction, arrhythmias, and need for inotropic support. RESULTS No difference in demographics and preoperative risk factors were observed between patients treated with and without the Roadsaver/Casper stent. The mean procedure time was shorter in the Roadsaver/Casper group (40.7±16.9 vs 49.4±27.3 minutes; p=0.008), while radial percutaneous access was more frequent (24% vs 5%; p<0.001). The rate of stroke/TIA/death at 30 days was 3% in the Roadsaver group vs 1% in the first-generation stent group (p=0.623). The primary patencyrate was 100% and 93.4% at 1- and 3-year of follow-up in the Roadsaver/Casper groupand 99% and 94.3% in the other stent group, respectively (p=0.95). CONCLUSIONS In this real-world cohort of patients undergoing CAS, the Roadsaver/Casper stent was used to treat more symptomatic and vulnerable carotid plaques as compared to other carotid stents. Nevertheless, patients treated with this low-profile dual-layer micromesh stent showed low events rates at both 30 days and follow-up, similar to that observed for other stents.
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Affiliation(s)
- Andrea Kahlberg
- Department of Vascular Surgery, Vita-Salute University School of Medicine, San Raffaele Scientific Institute, Milan, Italy
| | - Victor Bilman
- Department of Vascular Surgery, Vita-Salute University School of Medicine, San Raffaele Scientific Institute, Milan, Italy
| | - Vincenzo Ardita
- Department of Vascular Surgery, Vita-Salute University School of Medicine, San Raffaele Scientific Institute, Milan, Italy
| | - Daniele Mascia
- Department of Vascular Surgery, Vita-Salute University School of Medicine, San Raffaele Scientific Institute, Milan, Italy
| | - Luca Bertoglio
- Department of Vascular Surgery, Vita-Salute University School of Medicine, San Raffaele Scientific Institute, Milan, Italy
| | - Enrico Rinaldi
- Department of Vascular Surgery, Vita-Salute University School of Medicine, San Raffaele Scientific Institute, Milan, Italy
| | - Germano Melissano
- Department of Vascular Surgery, Vita-Salute University School of Medicine, San Raffaele Scientific Institute, Milan, Italy
| | - Roberto Chiesa
- Department of Vascular Surgery, Vita-Salute University School of Medicine, San Raffaele Scientific Institute, Milan, Italy
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D'Oria M, Ziani B, Damiano Pipitone M, Manganotti P, Mucelli RP, Gorgatti F, Riccitelli F, Zamolo F, Fisicaro M, Lepidi S. Prognostic interaction between age and sex on outcomes following carotid endarterectomy. VASA 2021; 50:453-461. [PMID: 34102866 DOI: 10.1024/0301-1526/a000957] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
Background: The aim of this study was to assess the prognostic interaction between age and sex on peri-operative and follow-up outcomes following elective carotid endarterectomy (CEA) for asymptomatic and symptomatic carotid stenosis. Patients and methods: A retrospective review of all patients admitted to a single vascular unit who underwent elective CEA between January, 2015 and December, 2019 was performed. The primary endpoints of the study were overall survival (from index operation) and cumulative stroke rate at thirty days. Results: A total of 383 consecutive patients were included in this study; of these 254 (66.4%) were males. At baseline, males were younger (mean age 73.4±11 vs. 76.3±10 years, p=.01) and with lower proportion of octogenarians (20.4% vs. 28.7%, p=.05). The rate of stroke in symptomatic and asymptomatic patients (males vs. females) were as follows: a) whole cohort 1.9% vs. 2% (p=1.00) and 2.7% vs. 1.3% (p=.66), respectively; b) ≥80 years old 3.7% vs. 0% (p=1.00) and 4% vs. 5.9% (p=1.00), respectively; c) <80 years old 1.2% vs. 3.3% (p=.47) and 2.5% vs. 0% (p=.55), respectively. The 3-year survival estimates were significantly lower for males (84% vs. 92%, p=.03). After stratification by age groups, males maintained inferior survival rates in the strata aged <80 years (85% vs. 97%, p=.005), while no differences were seen in the strata aged ≥80 years (82% vs. 79%, p=.92). Using multivariate Cox proportional hazards, age (HR: 2.1, 95% CI: 1.29-3.3, p=.002) and male gender (HR: 2.5, 95% CI: 1.16-5.5, p=.02) were associated with increased hazards of all-cause mortality. Conclusions: In this study of elective CEA for asymptomatic and symptomatic carotid stenosis, similar peri-operative neurologic outcomes were found in both males and females irrespective of age. Despite being usually older, females have superior long-term survival rates.
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Affiliation(s)
- Mario D'Oria
- Division of Vascular and Endovascular Surgery, Cardiovascular Department, Cattinara University Hospital ASUGI, Trieste, Italy
| | - Barbara Ziani
- Division of Vascular and Endovascular Surgery, Cardiovascular Department, Cattinara University Hospital ASUGI, Trieste, Italy
| | | | - Paolo Manganotti
- Clinical Unit of Neurology, Department of Medicine Surgery and Health Sciences, Cattinara University Hospital ASUGI, Trieste, Italy
| | - Roberta Pozzi Mucelli
- Radiology Unit, Department of Medicine Surgery and Health Sciences, Cattinara University Hospital ASUGI, Trieste, Italy
| | - Filippo Gorgatti
- Division of Vascular and Endovascular Surgery, Cardiovascular Department, Cattinara University Hospital ASUGI, Trieste, Italy
| | - Francesco Riccitelli
- Division of Vascular and Endovascular Surgery, Cardiovascular Department, Cattinara University Hospital ASUGI, Trieste, Italy
| | - Francesca Zamolo
- Division of Vascular and Endovascular Surgery, Cardiovascular Department, Cattinara University Hospital ASUGI, Trieste, Italy
| | - Maurizio Fisicaro
- Cardiovascular Health Services Centre, Cardiovascular Department, Maggiore Hospital ASUGI, Trieste, Italy
| | - Sandro Lepidi
- Division of Vascular and Endovascular Surgery, Cardiovascular Department, Cattinara University Hospital ASUGI, Trieste, Italy
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Skrypnik D, Vinogradov R, Falco C, Baryshev A, Porhanov V. Early-Term Complications after Carotid Endarterectomy and Their Risk Factors: Eight-Year Employment of Local Treatment Protocol of a Russian High-Volume Center. Eur Surg Res 2020; 61:101-112. [PMID: 33333536 DOI: 10.1159/000512457] [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: 04/21/2020] [Accepted: 10/14/2020] [Indexed: 11/19/2022]
Abstract
BACKGROUND More than 20,000 carotid endarterectomies are performed annually in the Russian Federation. Until now, no studies based on the national carotid data set have been published. The objectives of this study were to evaluate early outcomes after carotid endarterectomy and to identify potential risk factors for major adverse cardiovascular events. MATERIALS AND METHODS The retrospective analysis was based on data recorded in a single-center registry, including all carotid endarterectomies performed between 2010 and 2017. A univariate analysis was used to identify the risk factors for perioperative mortality, and predictors of stroke were determined using a multivariate logistic regression model. RESULTS Data from 1,832 patients with a mean age of 64.1 ± 7.6 years were analyzed. The combined in-hospital mortality was 0.65% (12/1,832). The rate of stroke was 0.7% (13/1,832), and the rate of myocardial infarction was 1.1% (20/1,832). The 30-day stroke-free survival was 99%. A history of stroke (p = 0.02) and chronic obstructive pulmonary disease (COPD; p = 0.0001) were found to be predictive of a lethal stroke. Previous myocardial infarction (p = 0.0001), an advanced stage of congestive heart failure (p = 0.0001), and angina pectoris (p = 0.01) were associated with cardiac-related mortality. Moreover, diabetes mellitus (p = 0.03), COPD (p = 0.0001), and carotid calcinosis (p = 0.006) increased the risk of poor survival due to myocardial infarction. The mean duration of clamping was found to be an independent predictor of any perioperative stroke (OR = 1.109; 95% CI 1.052-1.129; p < 0.0001). CONCLUSIONS The present retrospective analysis of the local carotid surgery register showed appropriate outcomes after CEA regarding the cumulative incidence of MACE, which is comparable to previously published international register data. A previous history of stroke, myocardial infarction, COPD, a prolonged clamping time during CEA, and diabetes mellitus were found to be factors of high-risk for cardiovascular mortality. A prolonged clamping was identified as an independent predictor of any stroke.
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Affiliation(s)
- Denis Skrypnik
- Kuban State Medical University, Krasnodar, Russian Federation,
| | - Roman Vinogradov
- Kuban State Medical University, Krasnodar, Russian Federation.,Professor S.V. Ochapovsky Regional Clinical Hospital No. 1, Krasnodar, Russian Federation
| | - Coral Falco
- Faculty of Education, Culture, and Sport, Western Norway University of Applied Sciences, Bergen, Norway
| | - Alexander Baryshev
- Kuban State Medical University, Krasnodar, Russian Federation.,Professor S.V. Ochapovsky Regional Clinical Hospital No. 1, Krasnodar, Russian Federation
| | - Vladimir Porhanov
- Kuban State Medical University, Krasnodar, Russian Federation.,Professor S.V. Ochapovsky Regional Clinical Hospital No. 1, Krasnodar, Russian Federation
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Sultan S, Acharya Y, Barrett N, Hynes N. A pilot protocol and review of triple neuroprotection with targeted hypothermia, controlled induced hypertension, and barbiturate infusion during emergency carotid endarterectomy for acute stroke after failed tPA or beyond 24-hour window of opportunity. ANNALS OF TRANSLATIONAL MEDICINE 2020; 8:1275. [PMID: 33178807 PMCID: PMC7607101 DOI: 10.21037/atm-2020-cass-14] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
An alternative to tissue plasminogen activator (tPA) failure has been a daunting challenge in ischemic stroke management. As tPA is time-dependent, delays can occur in definitive treatment while passively waiting to observe a clinical response to intravenous thrombolysis. Until today, uncertainty exists in the management strategy of wake-up stroke patients or those presenting beyond the therapeutic tPA window. Clinical dilemmas in these situations can prolong the transitional period of inertia, resulting in an adverse neurological outcome. We propose and review an innovative approach called triple neuro-protection (TNP), which encompasses three technical domains-targeted hypothermia, systemic induced hypertension, and barbiturates infusion, to protect the brain during carotid endarterectomy after failed tPA and/or beyond the 24-hour therapeutic mechanical thrombectomy window. This proposal assimilates discussion on the clinical evidence of the individual domains of TNP with our own clinical experience with TNP. Our first TNP was successfully employed in a 55-year-old man in 2015 while performing emergency carotid endarterectomy after he was referred to us 72 hours post tPA failure. The patient had a successful clinical outcome despite being in therapeutic inertia with 90–99% ipsilateral carotid stenosis and contralateral occlusion on presentation. In the last five years, we have safely used TNP in 25 selected cases with favourable clinical outcomes.
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Affiliation(s)
- Sherif Sultan
- Western Vascular Institute, Department of Vascular and Endovascular Surgery, University Hospital Galway, National University of Ireland, Galway, Ireland.,Department of Vascular & Endovascular Surgery, Galway Clinic, Royal College of Surgeons of Ireland/National University of Ireland Affiliated Teaching Hospitals, Doughiska, Galway, Ireland
| | - Yogesh Acharya
- Western Vascular Institute, Department of Vascular and Endovascular Surgery, University Hospital Galway, National University of Ireland, Galway, Ireland
| | - Nora Barrett
- Western Vascular Institute, Department of Vascular and Endovascular Surgery, University Hospital Galway, National University of Ireland, Galway, Ireland
| | - Niamh Hynes
- Department of Vascular & Endovascular Surgery, Galway Clinic, Royal College of Surgeons of Ireland/National University of Ireland Affiliated Teaching Hospitals, Doughiska, Galway, Ireland
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Veraldi GF, Scorsone L, Mastrorilli D, Bruno S, Macrì M, Criscenti P, Onorati F, Faggian G, Bovo C, Mezzetto L. Carotid Endarterectomy with Modified Eversion Technique: Results of a Single Center. Ann Vasc Surg 2020; 72:627-636. [PMID: 33197539 DOI: 10.1016/j.avsg.2020.09.047] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2020] [Revised: 09/14/2020] [Accepted: 09/21/2020] [Indexed: 11/30/2022]
Abstract
BACKGROUND Carotid endarterectomy (CEA) has a wide range of approaches based on personal expertise and preference. We evaluated our outcome with CEA with modified eversion technique (meCEA) under local anesthesia and whether the surgeon's experience could influence it. METHODS at our Institution, 837 patients underwent CEA across 8 years. Although the surgical technique was standardized, 2 groups were considered further: meCEA performed by a single Senior Operator (Group A) and meCEA performed by 4 young Consultants (Group B). RESULTS A selective shunting policy was needed in 5.1%, together with general anesthesia. Overall operative time was 63.9 ± 15.1 minutes (61.4 ± 12.5 and 66 ± 16.9 minutes in Group A and Group B respectively; P < 0.001) and cross-clamp time 19.3 ± 2.9 minutes (19.0 ± 3.2 vs. 19.5 ± 2.8, P = 0.009). At 30 days, 0.7% TIA and 0.8% strokes were recorded. No differences (p = N.S.) between the 2 study groups in terms of postoperative neurological complications, with postoperative ipsilateral strokes always < 1%. At a median imaging follow-up of 22.5 months, the overall percentage of restenosis was 3.7%, with no difference between the 2 groups (P = 0.954). Twenty-two patients (2.6%) underwent reintervention for significant restenosis, and none of them had an ipsilateral stroke or TIA. Freedom from reintervention for restenosis at 24 months was 97.9% in Group A and 95.9% in Group B, with no between-group difference (P = 0.14). At the median survival follow-up of 37 months, the overall survival rate at 24 months was 97.9%in Group A, and 97.9% in Group B, with no between-group difference (P = 0.070). CONCLUSIONS In our experience, CEA with a modified technique is safe and achieves comparable outcomes to those of other established techniques. The reported short cross-clamp time, also in less experienced hands, is an additional strength.
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Affiliation(s)
- Gian Franco Veraldi
- Department of Vascular Surgery, University Hospital and Trust of Verona, University of Verona - School of Medicine, Verona, Italy
| | - Lorenzo Scorsone
- Department of Vascular Surgery, University Hospital and Trust of Verona, University of Verona - School of Medicine, Verona, Italy.
| | - Davide Mastrorilli
- Department of Vascular Surgery, University Hospital and Trust of Verona, University of Verona - School of Medicine, Verona, Italy
| | - Salvatore Bruno
- Department of Vascular Surgery, University Hospital and Trust of Verona, University of Verona - School of Medicine, Verona, Italy
| | - Marco Macrì
- Department of Vascular Surgery, University Hospital and Trust of Verona, University of Verona - School of Medicine, Verona, Italy
| | - Paolo Criscenti
- Department of Vascular Surgery, University Hospital and Trust of Verona, University of Verona - School of Medicine, Verona, Italy
| | - Francesco Onorati
- Department of Cardiac Surgery, University Hospital and Trust of Verona, University of Verona - School of Medicine, Verona, Italy
| | - Giuseppe Faggian
- Department of Cardiac Surgery, University Hospital and Trust of Verona, University of Verona - School of Medicine, Verona, Italy
| | - Chiara Bovo
- Medical Direction, University Hospital and Trust of Verona, University of Verona - School of Medicine, Verona, Italy
| | - Luca Mezzetto
- Department of Vascular Surgery, University Hospital and Trust of Verona, University of Verona - School of Medicine, Verona, Italy
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Single-Center Vascular Hub Experience after 7 weeks of COVID-19 Pandemic in Lombardy (Italy). Ann Vasc Surg 2020; 69:90-99. [PMID: 32763457 PMCID: PMC7403135 DOI: 10.1016/j.avsg.2020.07.022] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2020] [Revised: 07/22/2020] [Accepted: 07/27/2020] [Indexed: 11/23/2022]
Abstract
BACKGROUND The aim of this study was to report the experience of one of the major "hubs" for vascular surgery in Lombardy, Italy, during the first 7 weeks after total lockdown due to COVID-19 pandemic. METHODS Data from all patients treated at our Department since the decision of the regional healthcare authorities of Lombardy to centralize surgical specialties creating a hub/spoke system (March 9, 2020) were prospectively collected and compared with a retrospectively collected cohort from the same period of year 2019. Primary study end point was defined as primary clinical success. Secondary end points were defined as in-hospital mortality and/or any in hospital major adverse event or lower limb amputation. RESULTS One hundred sixteen patients were treated (81 men, 70%; median age: 71 years, IQR 65-81). Thirty-two patients (28%) were addressed from spoke hospitals directly referring to our hub, 19 (16%) from hospitals belonging to other hub/spoke nets, 48 (41%) came directly from our emergency department, and 17 (15%) were already hospitalized for COVID-19 pneumonia. Acute limb ischemia was the most observed disease, occurring in 31 (26.7%), 12 (38.7%) of whom were found positive for COVID-19 pneumonia on admission, whereas 3 (9.7%) became positive during hospitalization. Chronic limb ischemia was the indication to treatment in 24 (20.7%) patients. Six (5.2%) patients underwent primary amputation for irreversible ischemia. Aortic emergencies included 21 cases (18.1%), including 13 (61.9%) symptomatic abdominal aortic or iliac aneurysms, 4 (19.0%) thoracoabdominal aortic aneurysms, 2 (9.5%) cases of acute type B aortic dissection (one post-traumatic). Seventeen (14.7%) patients were admitted for symptomatic carotid stenosis (no COVID-19 patients); all of them underwent carotid endarterectomy. Seventeen (14.7%) cases were treated for other vascular emergencies. Overall, at a median follow-up of 23 ± 13 days, primary clinical success was 87.1% and secondary clinical success was 95.9%. We recorded 3 in-hospital deaths for an overall mortality rate of 2.6%. Compared with the 2019 cohort, "COVID era" patients were older (72 vs. 63 years, P = 0.002), more frequently transferred from other hospitals (44% vs. 21%, P = 0.014) and more frequently with decompensated chronic limb threatening ischemia (21% vs. 3%, P = 0.015); surgical outcomes were similar between the 2 cohorts. CONCLUSIONS Since its appearance, SARS-CoV-2 has been testing all national healthcare systems which founds themselves facing an unprecedented emergency. Late referral in the pandemic period could seriously worsen limb prognosis; this aspect should be known and addressed by health care providers. Vascular surgical outcomes in pre-COVID and COVID era were comparable in our experience.
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Rocha-Neves JP, Pereira-Macedo J, Moreira AL, Oliveira-Pinto JP, Afonso G, Mourão J, Andrade JP, Vaz RP, Mansilha A. Efficacy of near-infrared spectroscopy cerebral oximetry on detection of critical cerebral perfusion during carotid endarterectomy under regional anesthesia. VASA 2020; 49:367-374. [DOI: 10.1024/0301-1526/a000879] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
Summary: Background: Patients undergoing carotid endarterectomy (CEA) may suffer from cerebral hypoperfusion during the carotid cross-clamping. Near-infrared spectroscopy cerebral oximetry (NIRS) is a non-invasive method of regional cerebral oxygen saturation measurement reflecting changes in cerebral blood flow during CEA. The main goal of the study was to evaluate the accuracy of the NIRS in detecting cerebral hypoperfusion during CEA under regional anesthesia (RA) and compare it with awake neurological testing. Patients and methods: A prospective observational study of 28 patients that underwent CEA in RA and manifested neurologic deficits, and 28 consecutive controls from a tertiary and referral center, was performed. All patients were monitored with NIRS cerebral oximetry and awake testing as the control technique. Subsequently, operating characteristic curve and Cohen’s kappa coefficient were determined to evaluate the reliability of the monitoring test. Results: NIRS presented a sensitivity of 27.3% and a specificity of 89.3% in comparison to awake testing. Receiver operating characteristic (ROC) curve analysis demonstrated that a decrease of at least 20% in cerebral oxygen saturation is the best threshold to infer cerebral hypoperfusion. However, the respective area under the curve (AUROC) was 0.606 (95% CI: 0.456–0.756, P = 0.178) with a calculated Cohen’s kappa of 0.179, P = 0.093. Regarding 30-days outcomes, only awake testing has shown significant associations with stroke and postoperative complications ( P = 0.043 and P = 0.05), which were higher in patients with post-clamping neurologic deficits. Conclusions: NIRS demonstrated a reduced discriminative capacity for critical cerebral hypoperfusion, and does not seem to add substantial clinical benefits to the awake test.
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Affiliation(s)
- João P. Rocha-Neves
- Department of Biomedicine, Unity of Anatomy, Faculdade de Medicina, Universidade do Porto, Porto, Portugal
- Department of Angiology and Vascular Surgery, Centro Hospitalar Universitário de São João, Porto, Portugal
- Department of Surgery and Physiology, Faculdade de Medicina da Universidade do Porto, Porto, Portugal
| | | | - André L. Moreira
- Department of Surgery and Physiology, Faculdade de Medicina da Universidade do Porto, Porto, Portugal
- Department of Anesthesiology, Centro Hospitalar Universitário de São João, Porto, Portugal
- Cardiovascular R&D Unit, Faculdade de Medicina, Universidade do Porto, Porto, Portugal
| | - José P. Oliveira-Pinto
- Department of Angiology and Vascular Surgery, Centro Hospitalar Universitário de São João, Porto, Portugal
- Department of Surgery and Physiology, Faculdade de Medicina da Universidade do Porto, Porto, Portugal
- Cardiovascular R&D Unit, Faculdade de Medicina, Universidade do Porto, Porto, Portugal
| | - Graça Afonso
- Departamento de Anestesiologia, Faculdade de Medicina, Universidade do Porto, Porto, Portugal
| | - Joana Mourão
- Departamento de Anestesiologia, Faculdade de Medicina, Universidade do Porto, Porto, Portugal
- Serviço de Anestesiologia, Centro Hospitalar São João, Porto, Portugal
| | - José P. Andrade
- Department of Biomedicine, Unity of Anatomy, Faculdade de Medicina, Universidade do Porto, Porto, Portugal
- Center for Health Technology and Services Research (CINTESIS), Porto, Portugal
| | - Ricardo P. Vaz
- Department of Biomedicine, Unity of Anatomy, Faculdade de Medicina, Universidade do Porto, Porto, Portugal
- Center for Health Technology and Services Research (CINTESIS), Porto, Portugal
| | - Armando Mansilha
- Department of Angiology and Vascular Surgery, Centro Hospitalar Universitário de São João, Porto, Portugal
- Department of Surgery and Physiology, Faculdade de Medicina da Universidade do Porto, Porto, Portugal
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Kahlberg A, Ardita V, Spertino A, Mascia D, Bertoglio L, Baccellieri D, Lembo R, Melissano G, Chiesa R. Propensity-Matched Comparison for Carotid Artery Stenting in Primary Stenosis Versus after Carotid Endarterectomy Restenosis. Ann Vasc Surg 2020; 70:332-340. [PMID: 32634561 DOI: 10.1016/j.avsg.2020.06.063] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2020] [Revised: 06/24/2020] [Accepted: 06/28/2020] [Indexed: 10/23/2022]
Abstract
BACKGROUND Carotid artery stenting (CAS) has been proposed as the treatment of choice in case of restenosis (RES) after carotid endarterectomy (CEA). The aim of this study was to analyze periprocedural results of CAS for the treatment of post-CEA RES compared with those of CAS performed for primary carotid stenosis (PRS). METHODS Data from consecutive patients submitted to CAS at our institution from 2008 to 2016 were retrospectively reviewed. Patients with in-stent RES were excluded. Initially, preoperative risk factors, demographics, intraoperative variables, and perioperative outcomes were analyzed according to the indication groups (PRS and RES). Then, propensity score matching was performed obtaining 2 homogeneous groups of patients. Covariates included were age, gender, hypertension, hyperlipidemia, cardiac disease, chronic renal disease, symptomatic carotid plaque, and positive ipsilateral brain computed tomography scan. Intraoperative data and perioperative outcomes were then compared between the 2 matched groups. RESULTS Of 480 included patients, 300 (62.5%) underwent CAS for PRS, and 180 (37.5%) for RES. After propensity score analysis (158 patients/group), no significant difference was observed in terms of technical success, number, and type of stent used, except for need of intraoperative atropine administration that was higher in the PRS group (38.6% vs. 13.3%, respectively; P < 0.001). In the perioperative period, composite neurologic event was significantly higher in the PRS group (7.6% vs. 1.9%; P = 0.017). Moreover, need of ionotropic support was higher in the PRS group (8.9% vs. 1.9%; P = 0.0069). Myocardial infarction rate and 30-day mortality were similar in both groups (P = 0.317; P = 1, respectively). CONCLUSIONS In a large single-center experience, CAS for post-CEA RES was associated with a significantly lower risk of any neurologic event and hemodynamic instability in the perioperative period compared with CAS performed for primary carotid lesions. Our results confirm that post-CEA RES may represent an elective indication for CAS.
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Affiliation(s)
- Andrea Kahlberg
- Department of Vascular Surgery, San Raffaele Scientific Institute, Vita-Salute University School of Medicine, Milan, Italy
| | - Vincenzo Ardita
- Department of Vascular Surgery, San Raffaele Scientific Institute, Vita-Salute University School of Medicine, Milan, Italy.
| | - Andrea Spertino
- Department of Vascular Surgery, San Raffaele Scientific Institute, Vita-Salute University School of Medicine, Milan, Italy
| | - Daniele Mascia
- Department of Vascular Surgery, San Raffaele Scientific Institute, Vita-Salute University School of Medicine, Milan, Italy
| | - Luca Bertoglio
- Department of Vascular Surgery, San Raffaele Scientific Institute, Vita-Salute University School of Medicine, Milan, Italy
| | - Domenico Baccellieri
- Department of Vascular Surgery, San Raffaele Scientific Institute, Vita-Salute University School of Medicine, Milan, Italy
| | - Rosalba Lembo
- Department of Anesthesia and Intensive Care, San Raffaele Scientific Institute, Vita-Salute University School of Medicine, Milan, Italy
| | - Germano Melissano
- Department of Vascular Surgery, San Raffaele Scientific Institute, Vita-Salute University School of Medicine, Milan, Italy
| | - Roberto Chiesa
- Department of Vascular Surgery, San Raffaele Scientific Institute, Vita-Salute University School of Medicine, Milan, Italy
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Safety of Triple Neuroprotection with Targeted Hypothermia, Controlled Induced Hypertension, and Barbiturate Infusion during Emergency Carotid Endarterectomy for Acute Stroke after Missing the 24 Hours Window Opportunity. Ann Vasc Surg 2020; 69:163-173. [PMID: 32473308 DOI: 10.1016/j.avsg.2020.05.041] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2019] [Revised: 04/30/2020] [Accepted: 05/02/2020] [Indexed: 11/20/2022]
Abstract
BACKGROUND The aim of this study is to establish the initial safety of triple neuroprotection (TNP) in an acute stroke setting in patients presenting outside the window for systemic tissue plasminogen activator (tPA). METHODS Over 12,000 patients were referred to our vascular services with carotid artery disease, of whom 832 had carotid intervention with a stroke rate of 0.72%. Of these, 25 patients presented (3%), between March 2015 and 2019, with acute dense stroke. These patients had either failed tPA or passed the recommended timing for acute stroke intervention. Fifteen (60%) had hemi-neglect with evidence of acute infarct on magnetic resonance imaging of the brain and a Rankin score of 4 or 5. Ninety-six percent had an 80-99% stenosis on the symptomatic side. Mean ABCD3-I score was 11.35. All patients underwent emergency carotid endarterectomy (CEA) with therapeutically induced hypothermia (32-34°C), targeted hypertension (systolic blood pressure 180-200 mm Hg), and brain suppression with barbiturate. RESULTS There were no cases of myocardial infarction, death, cranial nerve injury, wound hematoma, or procedural bleeding. Mean hospital stay was 8.4 (±9.5) days. All cases had resolution of neurological symptoms, except 3 who had failed previous thrombolysis. Eighty percent had a postoperative Rankin score of 0 on discharge and 88% of patients were discharged home with 3 requiring rehabilitation. CONCLUSIONS Positive neurological outcomes and no serious adverse events were observed using TNP during emergency CEA in patients with acute brain injury. We recommend TNP for patients who are at an increased risk of stroke perioperatively, or who have already suffered from an acute stroke beyond the recommended window of 24 hr. Certainly, the positive outcomes are not likely reproducible outside of high-volume units and patients requiring this surgery should be transferred to experienced surgeons in appropriate tertiary referral centers.
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Rocha-Neves JM, Pereira-Macedo J, Dias-Neto MF, Andrade JP, Mansilha AA. Benefit of selective shunt use during carotid endarterectomy under regional anesthesia. Vascular 2020; 28:505-512. [DOI: 10.1177/1708538120922098] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Objectives Carotid cross-clamping during endarterectomy exposes the patient to intraoperative neurological deficits due to embolism or cerebral hypoperfusion. To prevent further cerebrovascular incidents, resorting to shunt is frequently recommended. However, since this method is also considered a stroke risk factor, the use is still controversial. This study aims to shed some light on the best approach regarding the use of shunt in symptomatic cerebral malperfusion after carotid artery cross-clamping. Methods From January 2012 to January 2018, 79 patients from a tertiary referral hospital who underwent carotid endarterectomy with regional anesthesia for carotid artery stenosis and manifested post-clamping neurologic deficits were prospectively gathered. Shunt use was left to the decision of the surgeon and performed in 31.6% (25) of the patients. Demographics, comorbidities, imaging tests, and clinical/intraoperative features were evaluated. For data assessment, univariate analysis was performed. Results Regarding 30-day stroke, 30-day postoperative complications (stroke, surgical hematoma, hyperperfusion syndrome), and cranial nerve injury, no significant differences were found ( P = 0.301, P = 0.460, and P = 0.301, respectively) between resource to shunt and non-shunt. Clamping and surgery times were significantly higher in the shunt group ( P < 0.001 and P = 0.0001, respectively). Conclusions Selective-shunting did not demonstrate superiority for patients who developed focal deficits regarding stroke or other postoperative complications. However, due to the limitations of this study, the benefit of shunting cannot be excluded. Further randomized trials are recommended for precise results on this matter with current sparse clinical evidence.
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Affiliation(s)
- João M Rocha-Neves
- Department of Angiology and Vascular Surgery, Centro Hospitalar Universitário de São João, Porto, Portugal
- Department of Biomedicine – Unity of Anatomy, Faculdade de Medicina da Universidade do Porto, Porto, Portugal
- Department of Physiology and Surgery, Faculdade de Medicina da Universidade do Porto, Porto, Portugal
| | - Juliana Pereira-Macedo
- Department of Angiology and Vascular Surgery, Centro Hospitalar Universitário de São João, Porto, Portugal
| | - Marina F Dias-Neto
- Department of Angiology and Vascular Surgery, Centro Hospitalar Universitário de São João, Porto, Portugal
- Department of Physiology and Surgery, Faculdade de Medicina da Universidade do Porto, Porto, Portugal
| | - José Paulo Andrade
- Department of Biomedicine – Unity of Anatomy, Faculdade de Medicina da Universidade do Porto, Porto, Portugal
| | - Armando A Mansilha
- Department of Angiology and Vascular Surgery, Centro Hospitalar Universitário de São João, Porto, Portugal
- Department of Physiology and Surgery, Faculdade de Medicina da Universidade do Porto, Porto, Portugal
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Squizzato F, Antonello M, Taglialavoro J, Prosdocimi L, Grego F, Lupia M, Piazza M. Clinical Impact of Routine Cardiology Consultation Prior to Elective Carotid Endarterectomy in Neurologically Asymptomatic Patients. Eur J Vasc Endovasc Surg 2020; 59:536-544. [DOI: 10.1016/j.ejvs.2019.11.007] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2018] [Revised: 09/13/2019] [Accepted: 11/06/2019] [Indexed: 01/29/2023]
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Protack CD, Smith A, Moennich LA, Hardy D, Lyden SP, Farivar BS. Midterm outcomes of subclavian artery revascularization in the setting of thoracic endovascular aortic repair. J Vasc Surg 2020; 72:1222-1228. [PMID: 32093914 DOI: 10.1016/j.jvs.2019.11.049] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2019] [Accepted: 11/20/2019] [Indexed: 11/30/2022]
Abstract
OBJECTIVE The outcomes of subclavian artery revascularization (SAR) have been examined extensively in the setting of atherosclerotic occlusive disease but have been poorly characterized in the setting of thoracic endovascular aortic repair (TEVAR). As trials for branched thoracic endovascular stent grafts materialize, the outcomes of the subclavian artery branched prosthesis will need to be compared with TEVAR with SAR by carotid-subclavian bypass or subclavian transposition. METHODS A database of 1516 patients undergoing TEVAR from 2000 to 2015 was queried. Of those undergoing TEVAR, 19% (282 patients) also underwent SAR. Patient demographics, TEVAR indication, 30-day morbidity and mortality, and midterm patency and survival were analyzed. RESULTS During the study period, 282 patients underwent 288 SARs in the setting of TEVAR. A total of 269 (93%) carotid-subclavian bypasses and 19 (7%) subclavian artery transpositions were performed; 76% of the SARs occurred before TEVAR, 14% occurred concurrently with TEVAR, and 10% occurred after TEVAR. The most common indications for TEVAR was aortic aneurysm (56%), chronic aortic dissection with aneurysmal degeneration (23%), and aortic dissections (13%). The 30-day ipsilateral stroke rate was 3.5%. Eight patients (2.8%) underwent an unplanned return to the operating room (2.1% for hematoma evacuation and 0.7% for management of chyle leak). Six patients (2.1%) sustained a nerve injury. The mean follow-up was 4.2 years. All-cause 30-day mortality was 4.6%. The overall survival rates at 1 year, 5 years, and 10 years were 82%, 60%, and 42%, respectively. The median survival was 7.2 years. Four patients were found to have a failure in primary patency during follow-up. All four patients had undergone a carotid-subclavian bypass. The 1-, 2-, and 5-year primary patency rates were 99.5%, 98.9%, and 98.0%, respectively, for carotid-subclavian bypass and 100% for carotid-subclavian transposition. CONCLUSIONS During our 16-year study, we found SAR in the setting of TEVAR to be associated with low morbidity, durable long-term patency, and infrequent need for reintervention.
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Affiliation(s)
| | - Andrew Smith
- Department of Vascular Surgery, Cleveland Clinic, Cleveland, Ohio
| | | | - David Hardy
- Department of Vascular Surgery, Cleveland Clinic, Cleveland, Ohio
| | - Sean P Lyden
- Department of Vascular Surgery, Cleveland Clinic, Cleveland, Ohio
| | - Behzad S Farivar
- Department of Vascular Surgery, Cleveland Clinic, Cleveland, Ohio.
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Song LP, Gu YQ, Yu HX, Ji XM, Wang CM, Zhang J. Long-term outcomes of axillary to carotid bypass for symptomatic patients with chronic common carotid artery occlusion. J Vasc Surg 2019; 72:597-602. [PMID: 31882308 DOI: 10.1016/j.jvs.2019.10.059] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2019] [Accepted: 10/06/2019] [Indexed: 11/28/2022]
Abstract
OBJECTIVE Relatively little is known about the natural history of atherosclerotic common carotid artery occlusion and optimal treatment of these patients is still unclear. The aim of this retrospective study was to evaluate the immediate- and long-term outcomes of axillary to carotid bypass with polytetrafluoroethylene graft for symptomatic patients with chronic common carotid artery occlusion. METHODS From March 2001 to December 2017, 58 symptomatic patients (41 men; mean age 64.7 years) with chronic common carotid artery occlusion underwent axillary to carotid bypass at one academic hospital. The clinical data of this patient cohort were retrospectively analyzed. The cumulative graft patency, overall survival, freedom from symptoms, and freedom from ipsilateral stroke were calculated with Kaplan-Meier method. RESULTS Thirty-three patients presented with transient ischemic attack and 25 patients presented with minor stroke. At 30 days after bypass, the overall perioperative complication rate was 3.4% (2/58). Mild injuries of brachial plexus occurred in one (1.7%) patient and myocardial infarction occurred in one (1.7%) patient. No perioperative stroke or death occurred. The median follow-up was 51 months (range, 12-203) for this series. The cumulative graft patency rates at 1, 3, 5, and 10 years were 100%, 100%, 94%, and 83%, respectively. The cumulative freedom from symptoms rates at 1, 3, 5, and 10 years were 100%, 100%, 94%, and 75%, respectively. The cumulative freedom from ipsilateral stroke rates at 1, 3, 5, and 10 years were 100%, 100%, 94%, and 82%, respectively. The overall survival rates at 1, 3, 5, and 10 years were 98%, 89%, 81%, and 67%, respectively. CONCLUSIONS Axillary to carotid bypass with polytetrafluoroethylene graft is safe and durable for symptomatic patients with chronic common carotid artery occlusion. The results of this study should be confirmed with a larger, randomized controlled trial in future.
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Affiliation(s)
- Li Po Song
- Department of Vascular Surgery, XuanWu Hospital, Capital Medical University, Beijing, China
| | - Yong Quan Gu
- Department of Vascular Surgery, XuanWu Hospital, Capital Medical University, Beijing, China.
| | - Heng Xi Yu
- Department of Vascular Surgery, XuanWu Hospital, Capital Medical University, Beijing, China
| | - Xun Ming Ji
- Department of Neurology, XuanWu Hospital, Capital Medical University, Beijing, China
| | - Chun Mei Wang
- Department of Neurology, XuanWu Hospital, Capital Medical University, Beijing, China
| | - Jian Zhang
- Department of Vascular Surgery, XuanWu Hospital, Capital Medical University, Beijing, China
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Song LP, Zhang WW, Gu YQ, Ji XM, Zhang J. Cognitive improvement after carotid artery stenting in patients with symptomatic internal carotid artery near-occlusion. J Neurol Sci 2019; 404:86-90. [PMID: 31352294 DOI: 10.1016/j.jns.2019.07.023] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2019] [Revised: 07/04/2019] [Accepted: 07/18/2019] [Indexed: 11/17/2022]
Abstract
BACKGROUND AND PURPOSE To investigate the influence of carotid artery stenting (CAS) with embolic protection device (EPD) on the cognitive function of patients with near-occlusion of the cervical internal carotid artery (ICA). METHODS From February 2014 to December 2017, a total of 79 symptomatic patients were recruited in this study. Of these patients, 31 patients refused to receive CAS therapy. They were divided into the CAS group (48 patients) and the medical treatment group (31 patients). Montreal cognitive assessment (MoCA) instrument was used for the evaluation of cognitive function. The analyzed endpoints included cumulative 12 month incidence of ipsilateral ischemic cerebrovascular events and MoCA scores at 1 month and 12 months after treatment. RESULTS Cumulative 12 months incidence of ipsilateral ischemic cerebrovascular events was lower in patients who underwent CAS than in patients on medical treatment (P < 0.05). In CAS group, the total MoCA score, scores of attention and delayed recall at months 1 and 12 increased when compared with those at baseline (P < 0.05). In medical treatment group, the total MoCA score and attention score at month 12 decreased when compared with those at baseline (P < 0.05). In CAS group, the total MoCA score, scores of line connection test, drawing clock, attention and delayed recall were improved at 1 and 12 months when compared with medical treatment at the same time points (P < 0.05). CONCLUSIONS CAS with EPD not only decreases the risk of ipsilateral TIA and stroke but also may improve the cognitive function of symptomatic patients with ICA near-occlusion.
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Affiliation(s)
- Li Po Song
- Department of Vascular Surgery, XuanWu Hospital, Capital Medical University, Beijing, China.
| | - Wei Wei Zhang
- Department of Neurology, AnZhen Hospital, Capital Medical University, Beijing, China
| | - Yong Quan Gu
- Department of Vascular Surgery, XuanWu Hospital, Capital Medical University, Beijing, China
| | - Xun Ming Ji
- Department of Neurology, XuanWu Hospital, Capital Medical University, Beijing, China
| | - Jian Zhang
- Department of Vascular Surgery, XuanWu Hospital, Capital Medical University, Beijing, China
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