Diabetes is not a predictor of outcome for carotid revascularization with stenting as it may be for carotid endarterectomy

New Ischemic Cerebral Lesions in Postprocedural Magnetic Resonance Imaging in Carotid Artery Stenting Versus Carotid Endarterectomy: A Systematic Review and Meta-Analysis

BACKGROUND

Recent randomized controlled trials (RCTs) have demonstrated similar outcomes in terms of ischemic stroke incidence after carotid endarterectomy (CEA) or carotid artery stenting (CAS) in asymptomatic carotid disease, while CEA seems to be the first option for symptomatic carotid disease. The aim of this meta-analysis is to assess the incidence of silent cerebral microembolization detected by magnetic resonance imaging (MRI) following these procedures.

METHODS

A systematic search was conducted using PubMed, Scopus, and Cochrane databases, including comparative studies involving symptomatic or asymptomatic patients undergoing either CEA or CAS and reporting on new cerebral ischemic lesions in postoperative MRI. The primary outcome was the newly detected cerebral ischemic lesions. Pooled effect estimates for all outcomes were calculated using the random-effects model. Prespecified random effects metaregression and subgroup analysis were conducted to examine the impact of moderator variables on the presence of new cerebral ischemic lesions.

RESULTS

25 studies reporting on a total of 1827 CEA and 1500 CAS interventions fulfilled the eligibility criteria. The incidence of new cerebral ischemic lesions was significantly lower after CEA compared to CAS, regardless of the time of MRI assessment (first 24 hours; OR: 0.33, 95% CI: 0.17-0.64, P < 0.001), (the first 72 hours, OR: 0.25, 95% CI 0.18-0.36, P < 0.001), (generally within a week after the operation; OR: 0.24, 95% CI: 0.17-0.34, P < 0.001). Also, the rate of stroke (OR: 0.38, 95% CI: 0.23-0.63, P < 0.001) and the presence of contralateral new cerebral ischemic lesions (OR: 0.16, 95% CI 0.08-0.32, P < 0.001) were less frequent after CEA. Subgroup analysis based on the study design and the use of embolic protection device during CAS showed consistently lower rates of new lesions after CEA.

CONCLUSIONS

CEA demonstrates significant lower rates of new silent cerebral microembolization, as detected by MRI in postoperative period compared with CAS.

Diabetes mellitus and adverse outcomes after carotid endarterectomy: A systematic review and meta-analysis

BACKGROUND

There is still uncertainty regarding whether diabetes mellitus (DM) can adversely affect patients undergoing carotid endarterectomy (CEA) for carotid stenosis. The aim of the study was to assess the adverse impact of DM on patients with carotid stenosis treated by CEA.

METHODS

Eligible studies published between 1 January 2000 and 30 March 2023 were selected from the PubMed, EMBASE, Web of Science, CENTRAL, and ClinicalTrials databases. The short-term and long-term outcomes of major adverse events (MAEs), death, stroke, the composite outcomes of death/stroke, and myocardial infarction (MI) were collected to calculate the pooled effect sizes (ESs), 95% confidence intervals (CIs), and prevalence of adverse outcomes. Subgroup analysis by asymptomatic/symptomatic carotid stenosis and insulin/noninsulin-dependent DM was performed.

RESULTS

A total of 19 studies (n = 122,003) were included. Regarding the short-term outcomes, DM was associated with increased risks of MAEs (ES = 1.52, 95% CI: [1.15-2.01], prevalence = 5.1%), death/stroke (ES = 1.61, 95% CI: [1.13-2.28], prevalence = 2.3%), stroke (ES = 1.55, 95% CI: [1.16-1.55], prevalence = 3.5%), death (ES = 1.70, 95% CI: [1.25-2.31], prevalence =1.2%), and MI (ES = 1.52, 95% CI: [1.15-2.01], prevalence = 1.4%). DM was associated with increased risks of long-term MAEs (ES = 1.24, 95% CI: [1.04-1.49], prevalence = 12.2%). In the subgroup analysis, DM was associated with an increased risk of short-term MAEs, death/stroke, stroke, and MI in asymptomatic patients undergoing CEA and with only short-term MAEs in the symptomatic patients. Both insulin- and noninsulin-dependent DM patients had an increased risk of short-term and long-term MAEs, and insulin-dependent DM was also associated with the short-term risk of death/stroke, death, and MI.

CONCLUSIONS

In patients with carotid stenosis treated by CEA, DM is associated with short-term and long-term MAEs. DM may have a greater impact on adverse outcomes in asymptomatic patients after CEA. Insulin-dependent DM may have a more significant impact on post-CEA adverse outcomes than noninsulin-dependent DM. Whether DM management could reduce the risk of adverse outcomes after CEA requires further investigation.

Clinical Outcomes of Second- versus First-Generation Carotid Stents: A Systematic Review and Meta-Analysis

Background: Single-cohort studies suggest that second-generation stents (SGS; “mesh stents”) may improve carotid artery stenting (CAS) outcomes by limiting peri- and postprocedural cerebral embolism. SGS differ in the stent frame construction, mesh material, and design, as well as in mesh-to-frame position (inside/outside). Objectives: To compare clinical outcomes of SGS in relation to first-generation stents (FGSs; single-layer) in CAS. Methods: We performed a systematic review and meta-analysis of clinical studies with FGSs and SGS (PRISMA methodology, 3302 records). Endpoints were 30-day death, stroke, myocardial infarction (DSM), and 12-month ipsilateral stroke (IS) and restenosis (ISR). A random-effect model was applied. Results: Data of 68,422 patients from 112 eligible studies (68.2% men, 44.9% symptomatic) were meta-analyzed. Thirty-day DSM was 1.30% vs. 4.11% (p < 0.01, data for SGS vs. FGS). Among SGS, both Casper/Roadsaver and CGuard reduced 30-day DSM (by 2.78 and 3.03 absolute percent, p = 0.02 and p < 0.001), whereas the Gore stent was neutral. SGSs significantly improved outcomes compared with closed-cell FGS (30-day stroke 0.6% vs. 2.32%, p = 0.014; DSM 1.3% vs. 3.15%, p < 0.01). At 12 months, in relation to FGS, Casper/Roadsaver reduced IS (−3.25%, p < 0.05) but increased ISR (+3.19%, p = 0.04), CGuard showed a reduction in both IS and ISR (−3.13%, −3.63%; p = 0.01, p < 0.01), whereas the Gore stent was neutral. Conclusions: Pooled SGS use was associated with improved short- and long-term clinical results of CAS. Individual SGS types, however, differed significantly in their outcomes, indicating a lack of a “mesh stent” class effect. Findings from this meta-analysis may provide clinically relevant information in anticipation of large-scale randomized trials.

Impact of Diabetes Mellitus on Early Clinical Outcome and Stent Restenosis after Carotid Artery Stenting

BACKGROUND

Diabetes mellitus is closely related to both the severity of carotid disease and its outcome after revascularization. Carotid artery stenting (CAS) has emerged as a viable alternative to surgical endarterectomy but little is known about the impact of diabetes after CAS.

METHODS

A consecutive cohort of 1940 patients undergoing CAS in two institutions was divided into two groups, diabetics and nondiabetics, and major cerebrovascular events (MACCEs) were analyzed at 30 days post-CAS and at 1 year follow-up.

RESULTS

There were 730 patients with diabetes, with significantly higher BMI, hypertension, chronic dialysis, and dyslipidemia frequency (p < 0.05). There was no significant difference between the two groups in terms of early and late MACCEs (composite of transient ischemic attack, major stroke, myocardial infarction, and death), with an early rate of 3.5% nondiabetics vs. 5.3%, p = 0.08 and 2.4 nondiabetics vs. 2.3% diabetics, p = 0.1 at 12 months. Overall stroke/death rate in the asymptomatic patients was 2.4%, and the restenosis rate was higher in the diabetes population (2.3% vs. 1%, p = 0.04).

CONCLUSION

The presence of diabetes was associated with an acceptable increased periprocedural risk for CAS, but no further additional risk emerged during longer term follow-up. Diabetes may precipitate the rate of early in-stent restenosis.

The impact of diabetes mellitus on carotid artery stenting: a meta-analysis

Diabetes is considered to be one of the important factors affecting the prognosis of patients undergoing carotid endarterectomy (CEA), but its effect on carotid stenting (CAS) has not been determined. We performed this analysis to evaluate the impact of diabetes mellitus (DM) on carotid stenting. Studies were searched in the MEDLINE, EMBASE, and Cochrane Library databases for all available studies comparing the outcomes of diabetic and nondiabetic patients who underwent CAS. A meta-analysis was performed using the Mantel-Haenszel model to calculate odds ratios (ORs) with RevMan 5.3 software. Five studies with high quality were ultimately included. A total of 3364 patients underwent CAS, including 1042 diabetic patients and 2322 nondiabetic patients. Meta-analysis showed that there was no statistically significant difference in the risk of perioperative stroke(OR,1.20;95%CI,0.74-1.97;P = 0.46;I² = 24%), transient ischemic attack(TIA)(OR,1.46;95%CI,0.80-2.66;P=0.22;I²=37%), myocardial infarction(MI)(OR,1.12;95%CI,0.47-2.67;P=0.80;I²=0%), mortality (OR,1.77;95%CI,0.91-3.42;P = 0.09;I²=0%), and composite of stroke or death (OR,1.26;95%CI,0.87-1.81;P = 0.22;I²=35%) between diabetic and nondiabetic patients receiving CAS. Sensitivity analysis showed that the meta-analysis results of all outcome events were stable. Compared with nondiabetic patients, diabetes did not increase the risk of the following: perioperative stroke, TIA, MI, mortality, and composite of stroke or death in patients receiving CAS. This study may be used to guide carotid artery stenosis patients with diabetes to choose the optimal treatment option. However, due to the limited number of studies and the different technical levels of institutions, the results should be interpreted caution.

Stroke in the patient with diabetes (part 1) - Epidemiology, etiology, therapy and prognosis

There is a higher incidence of stroke in both the type 2 diabetic and the non-diabetic insulin resistant patient which is accompanied by higher morbidity and mortality. The increase in the frequency of stroke is due to an increase in cerebral infarction, mainly lacunar infarcts, with the incidence of cerebral hemorrhage being less frequent. The major risk factors for stroke in the type 2 diabetic patient are age, hypertension, the number of features of the Metabolic Syndrome, the presence of diabetic nephropathy in both the type 1 and type 2 patient, the presence of peripheral and coronary artery disease and especially the presence of atrial fibrillation. Hyperglycemia is associated with a poor outcome from stroke but is not causative.

Neurologic complications in patients with carotid artery stenting

Objective

Carotid artery stenting is helpful in patients with carotid artery stenosis and is a common method of treatment. However, data on the neurological consequences that might arise from, especially Asian patients after CAS is not enough. The purpose of this study was to investigate the outcome and prognostic factors affecting CAS patients.

Methods

From January 2013 to June 2018 it was enrolled 97 patients who underwent CAS with severe carotid artery stenosis in a single institution. We retrospectively reviewed neurologic complications such as restenosis, ipsilateral or contralateral stroke, and hyperperfusion during the 6-month follow-up period.

Results

There were no complication occured during the procedure in all 97 patients. Neurologic complications occurred in 30 patients (30.9%) after the procedure, and ipsilateral stroke 6 (6.2%), contralateral stroke 9 (9.4%), restenosis 2 (2.1%) and hyperperfusion 13 respectively. One of them had died (1.0%), of which the rest were discharged after symptoms improve. On univariate analysis, DM and pre-op NIHSS score was associated with the risk of CAS complication, exclusively. On the binary logistic regression for risk factors, DM (OR 0.144, 95% CI [0.029-0.718]), history of radiotheraphy (OR 36.103, 95% CI [1.009-1291.789]) and preoperative NIHSS (OR 1.266, 95% CI [1.059-1.513]) showed independent risk factors associated with post procedural neurological complications, statistically.

Conclusion

Carotid artery stenting is a relatively safe and reliable long-term outcome for patients with carotid artery stenosis. However, careful observation should be taken after procedure immediately for any possible complications.

Comparison of outcomes after carotid endarterectomy between type 2 diabetic and non-diabetic patients with significant carotid stenosis

BACKGROUND

We aimed to compare early and late outcomes after carotid endarterectomy (CEA) between Korean type 2 diabetic and non-diabetic patients and to investigate the impact of diabetes on the overall incidence of cardiovascular events after CEA.

METHODS

We retrospectively analyzed 675 CEAs, which were performed on 613 patients with significant carotid stenosis between January 2007 and December 2014. The CEAs were divided into a type 2 diabetes mellitus (DM) group (n = 265, 39.3%) and a non-DM group (n = 410, 60.7%). The study outcomes included the incidence of major adverse events (MAEs), defined as fatal or nonfatal stroke or myocardial infarction or all-cause mortality, during the perioperative period and within 4 years after CEA.

RESULTS

Patients in the DM and non-DM groups did not differ significantly in the incidence of MAEs or any of the individual MAE manifestations during the perioperative period. However, within 4 years after CEA, the difference in the MAE incidence was significantly greater in the DM group (P = 0.040). Analysis of the individual MAE manifestations indicated a significantly higher risk of stroke in the DM group (P = 0.006). Multivariate analysis indicated that diabetes was not associated with MAEs or individual MAE manifestations during the perioperative period, whereas within 4 years after CEA, diabetes was an independent risk factor for MAEs overall (hazard ratio [HR], 1.62; 95% confidence interval [CI] 1.06-2.48; P = 0.026) and stroke (HR, 2.55; 95% CI 1.20-5.41; P = 0.015) in particular.

CONCLUSIONS

Diabetic patients were not at greater risk of perioperative MAEs after CEA; however, the risk of late MAE occurrence was significantly greater in these patients. Within 4 years after CEA, DM was an independent risk factor for the occurrence of MAEs overall and stroke in particular.

Risk of insulin-dependent diabetes mellitus in patients undergoing carotid endarterectomy

OBJECTIVE

There is conflicting evidence regarding the association of diabetes mellitus (DM) and insulin use with outcomes after carotid endarterectomy (CEA). Therefore, we sought to evaluate the risk of insulin-dependent DM (IDDM) and noninsulin-dependent DM (NIDDM) on 30-day outcomes after CEA.

METHODS

We identified patients undergoing CEA from the Targeted Vascular module of the National Surgical Quality Improvement Program (2011-2015) and stratified patients on the basis of their preprocedural symptom status. We compared 30-day outcomes between nondiabetics and patients with NIDDM or IDDM, with 30-day stroke/death as the primary end point.

RESULTS

Of 16,739 CEA patients, 9784 (58%) were asymptomatic, of whom 6720 (69%) had no diagnosis of DM, 1109 (11%) had IDDM, and 1955 (20%) had NIDDM. Of the 6955 symptomatic patients, 4982 (72%) had no diagnosis of DM, 810 (12%) had IDDM, and 1163 (17%) had NIDDM. Among asymptomatic patients, patients with IDDM experienced higher rates of 30-day stroke/death compared with those without DM (3.4% vs 1.5%; P < .001), whereas those with NIDDM experienced rates similar to those of patients without DM (2.1% vs 1.5%; P = .1). Moreover, asymptomatic patients with IDDM and an anatomic high-risk criterion experienced a 30-day stroke/death rate of 6.6%. After adjustment, IDDM was associated with 30-day stroke/death in asymptomatic patients compared with patients without DM (odds ratio, 2.3; 95% confidence interval, 1.5-3.4; P < .001), but NIDDM was not (odds ratio, 1.4; 95% confidence interval, 1.0-2.1; P = .1). In comparison, among symptomatic patients, those with IDDM and NIDDM experienced similar rates of 30-day stroke/death as patients without DM (4.9% vs 3.6% and 4.0% vs 3.6%; both P > .1). After adjustment, neither IDDM nor NIDDM was associated with 30-day stroke/death in symptomatic patients compared with symptomatic patients without DM.

CONCLUSIONS

Rates of 30-day stroke/death after CEA in asymptomatic patients with IDDM exceed international vascular societies' guideline thresholds for acceptable outcomes in asymptomatic patients, especially those with anatomic high-risk criteria. Thus, asymptomatic patients with IDDM may not benefit from CEA, although more data are needed about the natural history of carotid disease in this population.

Impact of diabetes mellitus on early outcome of carotid endarterectomy

BACKGROUND

Diabetes mellitus increases the risk of ischaemic stroke in the general population but its impact on early outcome after the carotid endarterectomy (CEA) is controversial with conflicting results.

PATIENTS AND METHODS

This prospective study includes 902 consecutive CEAs. Patients were divided into non-diabetic and diabetic groups and subsequently analysed. Early outcomes in terms of 30-day stroke and death rates were then analysed and compared.

RESULTS

There were 606 non-diabetic patients. Among 296 diabetic patients, 83 were insulin-dependent. The cumulative TIA/stroke rate was statistically higher in the diabetic group (2.6 vs. 5.7 %, P = 0.02). Stroke was more frequent in the diabetic group (2.0 vs. 4.4 %, P = 0.04) comparedto TIA (0.7 vs. 1.4 %, P = 0.45). Mortality was statistically more frequent in diabetic patients (0.2 vs. 1.7 %, P = 0.01). The 30-day stroke/death rate (2.6 vs. 5.7 %, P = 0.02) was also statistically higher in the diabetic group. Factors that were identified to increase risk of death and stroke in multivariate analysis were: use of insulin for blood glucose control (OR = 2.47, 95 % CI 1.61-4.68, P = 0.01), higher low-density lipoprotein cholesterol value (OR = 1.52, 95 % CI 1.15-2.22, P < 0.01), presence of coronary disease (OR = 2.04, 95 % CI 1.40-3.31, P = 0.03), peripheral artery disease (OR = 2.14, 95 % CI 1.34-3.65, P = 0.02), complicated plaque (OR = 1.77, 95 % CI 1.11-3.68, P = 0.03), contralateral carotid artery occlusion (OR = 2.37, 95 % CI 1.25-4.74, P = 0.02), shunt use (OR = 3.46, 95 % CI 1.18-7.10, P < 0.01), and among diabetic patients higher HbA1c levels (OR = 1.28, 95 % CI 1.05-1.66, P = 0.03). Clamp toleration was associated with lower risk of death and stroke rates (OR = 0.43, 95 % CI 0.23-0.76, P < 0.01).

CONCLUSIONS

In our study, perioperative neurological complications and mortality were statistically higher in diabetic patients compared to non-diabetic patients during CEA. Further research will have to show whether other treatment modalities of carotid artery stenosis and better glycaemia and dyslipidaemia controlling in diabetics can reduce this risk.

Is diabetes a marker of higher risk after carotid revascularization? Experience from a single centre

PURPOSE

This single centre study investigates the influence of diabetes mellitus on outcomes following carotid artery endarterectomy or stenting.

METHODS

In total, 752 carotid revascularizations (58.2% carotid artery stenting and 41.8% carotid endarterectomy) were performed in 221 (29.4%) patients with diabetes and 532 (70.6%) patients without diabetes. The study outcomes were death, disabling and non-disabling stroke, transient ischaemic attack and restenosis within 36 months after the procedure.

RESULTS

Patients with diabetes had higher periprocedural risk of any stroke or death (3.6% diabetes vs 0.6% no diabetes; p < 0.05), transient ischaemic attack (1.8% diabetes vs 0.2% no diabetes; p > 0.05) and restenosis (2.7% diabetes vs 0.6% no diabetes; p < 0.05). During long-term follow-up, there were no significant differences in Kaplan-Meier estimates of freedom from death, any stroke and transient ischaemic attack, between people with and without diabetes for each carotid artery stenting and carotid endarterectomy subgroup. Patients with diabetes showed higher rates of restenosis during follow-up than patients without diabetes (36-months estimate risk of restenosis: 21.2% diabetes vs 12.5% no diabetes; p < 0.05).

CONCLUSION

The presence of diabetes was associated with increased periprocedural risk, but no further additional risk emerged during longer term follow-up. Restenosis rates were higher among patients with diabetes.

Long-term Results of Tapered Stents in Endovascular Treatment of Carotid Stenosis

BACKGROUND

Recent technological developments allowed significant improvements in interventional approach to carotid artery stenosis. Tapered stents were specifically designed for extracranial carotid artery stenting (CAS) to deal with vessels mismatch with the objective of decreasing the risk of thrombosis. Nevertheless, whether the stent geometry may affect the outcomes of CAS is uncertain. This study aims to investigate the impact of stent configuration on perioperative and long-term results of this procedure.

METHODS

All CAS procedures performed between 2005 and 2012 at a single high-volume center were reviewed. Primary end points of the study were 30-day mortality and any ipsilateral neurological event. Secondary end points were any late (>30 days) neurological event and restenosis >50%.

RESULTS

About 1,368 procedures were performed in the period 2005-2012. 9.1% of the patients were symptomatic for recent focal neurological event. 883 patients were treated with a cylindrical stent while the others underwent a tapered design device implantation. Technical success was achieved in 96% of the procedures. No perioperative mortality was recorded; perioperative stroke occurred in 1.2% vs. 1.6% (P = not significant) in tapered and straight stent group respectively. Stent design did not predict perioperative ipsilateral neurological events neither at bivariate nor at multivariate analysis. At a mean follow-up of 30 months, late neurological events occurred in 26 cases (1.9%); conic stents resulted protective at Kaplan-Meier analysis (P = 0.027).

CONCLUSIONS

The use of conic stents appears to be associated with similar perioperative results when compared with straight stents. Late outcomes suggest a lower risk of restenosis and late neurological events in patients with conical shape stents.

Association between proximal internal carotid artery steno-occlusive disease and diffuse wall thickening in its petrous segment: a magnetic resonance vessel wall imaging study

PURPOSE

Significant stenosis or occlusion in carotid arteries may lead to diffuse wall thickening (DWT) in the arterial wall of downstream. This study aimed to investigate the correlation between proximal internal carotid artery (ICA) steno-occlusive disease and DWT in ipsilateral petrous ICA.

METHODS

Symptomatic patients with atherosclerotic stenosis (>0%) in proximal ICA were recruited and underwent carotid MR vessel wall imaging. The 3D motion sensitized-driven equilibrium prepared rapid gradient-echo (3D-MERGE) was acquired for characterizing the wall thickness and longitudinal extent of the lesions in petrous ICA and the distance from proximal lesion to the petrous ICA. The stenosis degree in proximal ICA was measured on the time-of-flight (TOF) images.

RESULTS

In total, 166 carotid arteries from 125 patients (mean age 61.0 ± 10.5 years, 99 males) were eligible for final analysis and 64 showed DWT in petrous ICAs. The prevalence of severe DWT in petrous ICA was 1.4%, 5.3%, 5.9%, and 80.4% in ipsilateral proximal ICAs with stenosis category of 1%-49%, 50%-69%, 70%-99%, and total occlusion, respectively. Proximal ICA stenosis was significantly correlated with the wall thickness in petrous ICA (r = 0.767, P < 0.001). Logistic regression analysis showed that proximal ICA stenosis was independently associated with DWT in ipsilateral petrous ICA (odds ratio (OR) = 2.459, 95% confidence interval (CI) 1.896-3.189, P < 0.001].

CONCLUSION

Proximal ICA steno-occlusive disease is independently associated with DWT in ipsilateral petrous ICA.

Appropriate Patient Selection for Carotid Revascularization Procedures is Urgently Needed

The identification/selection of appropriate patient subgroups with asymptomatic carotid artery stenosis and the performance of prophylactic carotid endarterectomy (CEA)/carotid artery stenting (CAS) exclusively on these asymptomatic patient subgroups is currently one of the "hottest" topics in vascular surgery. It is now clear that offering CEA/CAS to asymptomatic carotid patients based only on the degree of carotid stenosis is unjustified and scientifically flawed. On the other hand, offering only best medical therapy to every asymptomatic patient, irrespective of certain high-risk criteria (such as the detection of microemboli by transcranial Doppler, intraplaque hemorrhage, silent embolic infarcts on brain computed tomography/magnetic resonance imaging, elevated biomarkers, family history), is equally wrong. The validation of specific measures to identify those asymptomatic patients at high risk for developing symptoms is crucial to achieve optimal use of carotid interventions and avoid wasting stroke prevention resources.

Diabetes Mellitus with Chronic Complications in Relation to Carotid Endarterectomy and Carotid Artery Stenting Outcomes

BACKGROUND

Carotid endarterectomy and carotid artery stenting are effective treatment procedures for carotid artery stenosis. Although diabetes mellitus is highly prevalent among patients undergoing these revascularization procedures, few studies have examined their impact on periprocedural outcomes.

OBJECTIVES

The study aimed to determine whether perioperative outcomes among patients undergoing carotid artery stenting and carotid endarterectomy varied depending on the presence of diabetes with or without chronic complications.

METHODS

We examined adults aged 45 and above hospitalized between 2007 and 2011 in U.S. hospitals who underwent carotid artery revascularization procedures. We used data from the Healthcare Cost and Utilization Project's Nationwide Inpatient Sample and evaluated the influence of diabetes with or without chronic complications on outcomes.

RESULTS

Among patients receiving carotid artery stenting, diabetic patients with chronic complications had significantly increased odds of acute kidney injury (odds ratio [OR]: 3.17, 95% confidence interval [CI]: 2.31-4.35) and longer hospital stay (β: 1.98, 95% CI: 1.58-2.38) compared with nondiabetic patients. Diabetic patients with chronic complications receiving carotid endarterectomy experienced increased odds of myocardial infarction (OR: 1.12, 95% CI: .90-1.40), stroke (OR: 1.29, 95% CI: .97-1.72), perioperative infection (OR: 2.45, 95% CI: 1.29-4.65), mortality (OR: 1.48, 95% CI: 1.01-2.16), and longer hospital stay (β (days): 2.05, 95% CI: 1.90-2.20) compared with nondiabetic patients. No significant increased odds of perioperative outcomes were observed among diabetic patients without chronic complications.

CONCLUSIONS

Uncomplicated diabetes did not appear to convey a higher odds of perioperative outcomes among patients undergoing revascularization. However, the presence of diabetes with chronic complications is an important risk factor in the carotid endarterectomy category.

Prognostic Factors for Neurologic Outcome in Patients with Carotid Artery Stenting

BACKGROUND

Carotid artery stenting (CAS) is a valid treatment for patients with carotid artery stenosis. The long-term outcome and prognostic factors in Asian population after CAS are not clear. This study aimed to identify the prognostic factors among Asian patients who have undergone CAS.

METHODS

We retrospectively analyzed 246 patients with CAS. Annual carotid duplex ultrasound was used to identify restenosis. Peri-procedural complications, restenosis, neurologic outcomes, and mortality were recorded. Cox regression analyses were used to identify prognostic factors.

RESULTS

The mean follow-up time was 49.2 months. Procedural success was achieved in 237 patients (98.3%), and protection devices were used in 208 patients (84.5%). Within 30 days of CAS, 13 (4.3% per procedure) peri-procedural complications occurred. During the follow-up period, 24 (9.7%) patients developed restenosis, and 37 (15.0%) developed ischemic strokes. In a multiple logistic regression analysis, head and neck radiotherapy [hazard ratio (HR) = 9.9, 95% confidence interval (CI), 3.38-29.1, p < .001], stent diameter (HR = 0.72, 95% CI, 0.58-0.89, p = .003), and predilatation (HR = 3.08 95% CI, 1.21-7.81, p = .018) were independent predictors for restenosis. In Cox regression analysis, hypercholesterolemia (HR = 0.25, 95% CI, 0.07-0.94, p = .04), head and neck radiotherapy (HR = 6.2, 95% CI, 1.8-21.3, p = .004), and restenosis (HR = 3.6, 95% CI, 1.1-11.18, p = .04) were predictors for recurrent ipsilateral ischemic stroke.

CONCLUSIONS

CAS provides reliable long-term results in Asian patients with carotid stenosis. Restenosis is associated with an increased rate of recurrent stroke and should be monitored carefully following CAS.

KEY WORDS

Carotid artery disease • Prognosis • Cerebrovascular disease.

Systematic Review and Meta-Analysis of Carotid Artery Stenting Versus Endarterectomy for Carotid Stenosis: A Chronological and Worldwide Study

There are disparities among the results of meta-analyses under different circumstances of carotid artery stenting (CAS) versus endarterectomy (CEA) for carotid stenosis. This study aimed to assess the efficacies of CAS and CEA for carotid stenosis at 5-year intervals and worldwide.Comparative studies simultaneously reporting CAS and CEA for carotid stenosis with at least 10 patients in each group were identified by searching PubMed and Embase in accordance with preferred reporting items for systematic reviews and meta-analyses guidelines, and by reviewing the reference lists of retrieved articles.The studies were stratified into different subgroups according to the publication year, location in which the study was mainly performed, and randomized and nonrandomized study designs.Thirty-five comparative studies encompassing 27,525 patients were identified. The risk ratios (RRs) of stroke/death when CAS was compared with CEA within 30 d of treatment were 1.51 (95% CI 1.32-1.74, P < 0.001) for overall, 1.50 (95% CI 1.14-1.98, P = 0.004) from 2011 to 2015, 1.61 (95% CI 1.35-1.91, P < 0.001) from 2006 to 2010, 1.59 (95% CI 1.27-1.99, P < 0.001) in North America, 1.50 (95% CI 1.24-1.81, P < 0.001) in Europe, 1.63 (95% CI 1.31-2.02, P < 0.001) for randomized, and 1.44 (95% CI 1.20-1.73, P < 0.001) for nonrandomized comparative studies. CEA decreased the risks of transient ischemic attack at 30 d (RR: 2.07, 95% CI 1.50-2.85, P < 0.001) and restenosis at 1-year (RR: 1.97, 95% CI 1.28-3.05, P = 0.002). Data from follow-up showed that the RRs of stroke/death were 0.74 (95% CI 0.55-0.99, P = 0.04) at 1 year, 1.24 (95% CI 1.04-1.46, P = 0.01) at 4 year, and 2.27 (95% CI 1.39-3.71, P = 0.001) at 10 year. This systematic review, compared with those of other meta-analyses, included all available comparative studies and analyzed them at 5-year intervals, in different continents, and under different study designs. Current evidence suggests that the efficacy of CEA is superior to CAS for freedom from stroke/death within 30 d, especially from 2006 to 2015, in North America and Europe. Meanwhile, the superiority was also observed for restenosis at 1-year, transient ischemic attack within 30 d, and stroke/death at 4- and 10-year follow-ups.

Incidence and risk factors for medical complications and 30-day end points after carotid artery stenting

With the extensive use of carotid artery stenting (CAS) surgeries, scholars are paying more attention to the safety and efficiency of CAS. Our study aims to analyze the clinical efficiency, safety, and technical feasibility of CAS surgery in the treatment of carotid artery stenosis. A total of 379 cases of CAS were collected and retrospectively analyzed. The outcomes were summarized according to decrease in stenosis extent, incidence of early complications after procedure, 30-day end point events, and the follow-up data. Logistic regression was employed to analyze the correlations between risk factors and complications within 30 days and 30-day end points of stroke, myocardial infarctions (MIs), and mortality. The average extent of stenosis reduced from preoperative (81% ± 17%) to postoperative (26% ± 17%). In all, 53 patients had 72 medical complications, including 6 (1.58%) cerebral hemorrhage, 7 (1.85%) cerebral infarction, 5 (1.32%) transient ischemic attack (TIA), 5 (1.32%) heart failure, 10 (2.63%) symptomatic hypertension, 21 (5.54%) symptomatic hypotension, 10 (2.63%) symptomatic bradycardia, and 8 other complications; 15 patients had at least 2 complications. Advanced age, diabetes, and heart failure were associated with the high incidence of early complications (P < .05). Asymptomatic stenosis (odds ratio [OR] = 0.39, 95% confidence interval [CI]: 0.131-1.131, P = .0426) and diabetes (OR = 3.38, 95% CI: 1.340-8.574, P = .0099) were correlated with the incidence of 30-day end point events. Diabetes and symptomatic stenosis are independent risk factors for 30-day end point events of CAS. Advanced age, hypertension, and vascular unstable plaque will increase the risk of postoperative complications.

Characteristics of Ischemic Brain Lesions After Stenting or Endarterectomy for Symptomatic Carotid Artery Stenosis

Background and Purpose—

In a substudy of the International Carotid Stenting Study (ICSS), more patients had new ischemic brain lesions on diffusion-weighted magnetic resonance imaging (MRI) after stenting (CAS) than after endarterectomy (CEA). In the present analysis, we compared characteristics of diffusion-weighted MRI lesions.

Methods—

Number, individual and total volumes, and location of new diffusion-weighted MRI lesions were compared in patients with symptomatic carotid stenosis randomized to CAS (n=124) or CEA (n=107) in the ICSS-MRI substudy.

Results—

CAS patients had higher lesion numbers than CEA patients (1 lesion, 15% vs 8%; 2–5 lesions, 19% vs 5%; >5 lesions, 16% vs 4%). The overall risk ratio for the expected lesion count with CAS versus CEA was 8.8 (95% confidence interval, 4.4–17.5; P <0.0001) and significantly increased among patients with lower blood pressure at randomization, diabetes mellitus, stroke as the qualifying event, left-side stenosis, and if patients were treated at centers routinely using filter-type protection devices during CAS. Individual lesions were smaller in the CAS group than in the CEA group ( P <0.0001). Total lesion volume per patient did not differ significantly. Lesions in the CAS group were more likely to occur in cortical areas and subjacent white matter supplied by leptomeningeal arteries than lesions in the CEA group (odds ratio, 4.2; 95% confidence interval, 1.7–10.2; P =0.002).

Conclusions—

Compared with patients undergoing CEA, patients treated with CAS had higher numbers of periprocedural ischemic brain lesions, and lesions were smaller and more likely to occur in cortical areas and subjacent white matter. These findings may reflect differences in underlying mechanisms of cerebral ischemia.

Clinical Trial Registration—

URL: http://www.isrctn.org . Unique identifier: ISRCTN25337470.