Differential outcomes of carotid stenting and endarterectomy performed exclusively by vascular surgeons in the Carotid Revascularization Endarterectomy versus Stenting Trial (CREST)

Long-term outcomes of carotid stenting in a single neurovascular center: up to 12-year retrospective analysis with a focus on the influence of comorbidities

BACKGROUND

The aim of this study was to evaluate long-term outcomes in patients who underwent carotid artery stenting (CAS) for symptomatic or asymptomatic high-grade stenosis.

METHODS

A total of 1158 patients (asymptomatic, n = 636; symptomatic, n = 522) underwent CAS at our center between 2009 and 2020. A total of 560 patients or contacts (asymptomatic, n = 316; symptomatic, n = 244) were interviewed by telephone to evaluate long-term outcomes with a mean follow-up of 5 years. Mortality from all causes, myocardial infarction, and stroke, as well as comorbidities influencing their occurrence, including overall survival and stroke-free survival, were examined.

RESULTS

The overall survival rate for all-cause mortality was 91.6% at 1 year, 77.1% at 5 years, and 55.7% at 10 years. A total of 39 (6.9%) patients had an ischemic stroke during long-term follow-up. The stroke-free survival rates at 1 year, 5 years, and 10 years were 97.9%, 92.7%, and 86.6%, respectively. Stroke-free survival and overall survival did not differ significantly between the symptomatic and asymptomatic groups (overall survival, p = 0.304; stroke-free survival, p = 0.336). Regular physical activity reduced the risk of stroke and death and was associated with better long-term clinical outcomes. Age at treatment and diabetes mellitus were statistically significantly associated with death during follow-up.

CONCLUSION

Long-term follow-up data confirmed the effectiveness and durability of CAS as a therapy option for both symptomatic and asymptomatic patients. In patient selection for CAS, special consideration should be paid to patient age, ability to engage in physical activity, and diabetes mellitus.

Hemodynamic instability in the immediate postoperative setting after transcarotid artery revascularization

OBJECTIVE

Transcarotid artery revascularization (TCAR) is a relatively recent development in the management of carotid artery occlusive disease, the utilization of which is becoming more prevalent. This study aims to evaluate the timing, prevalence, and types of hemodynamic instability after TCAR.

METHODS

We performed a retrospective review of all TCAR procedures performed at two tertiary care academic medical centers within a single hospital system from 2017 through 2019. Demographics, comorbidities, preoperative patient factors, procedural details, and postoperative data were collected. Patients were assessed over 24 hours postoperatively for stroke, death, myocardial infarction (MI), and hemodynamic instability at 3, 6, 9, 12, and 24 hour intervals. Hemodynamic instability was defined as any vital sign abnormality which required pharmacological intervention with antihypertensive, vasopressor, and/or anti-arrhythmic agents. The incidence and timing of postoperative complications and hemodynamic instability were recorded.

RESULTS

During the study period, 76 patients 80 TCAR procedures. Out of 80 procedures, 64 (80.0%) were receiving home antihypertensive medication and 28 (35.0%) were symptomatic lesions preoperatively. Intraoperatively, one patient (1.3%) received atropine, 26 (32.5%) received glycopyrrolate, 76 (95%) underwent predilatation, and 16 (20.0%) underwent postdilatation. Postoperatively, a total of 22 cases (27.5%) required medication for acute control of blood pressure or heart rate, which reached a peak of 19 patients (23.8%) within the first 3 hours, and tapered to nine patients (11.3%) by the 24 hour mark. A total of three patients (3.75%) required initiation of pharmacological management after the three-hour mark. Six patients (7.5%) underwent stroke code workup, 4 (5.0%) of whom were confirmed to have stroke on CT. Average time to neurologic event was 3.9 hours. No patients experienced MI or death. Median ICU and hospital days for unstable patients were two and three, respectively, compared to one and one for stable patients.

CONCLUSIONS

Hemodynamic instability is common after TCAR and reliably presents at or before postoperative hour 3. Hypo- followed by hyper-tension were the most common manifestations of hemodynamic instability. Regardless, unstable patients and stroke patients were more likely to require longer periods of time in the ICU and in the hospital overall. This may have implications for postoperative ICU resource management when deciding to transfer patients out of a monitored setting. Further study is required to establish relationships between pre- and intra-operative risk factors and outcomes such as hemodynamic instability and/or stroke. At present, one should proceed with careful evaluation of preoperative medications, strict management of postoperative hemodynamics, and clear communication among team members should all be employed to optimize outcomes.

The role of post-dilatation in carotid MicroNet-covered stent implantation, evaluated using 3D cone-beam CT angiography

BACKGROUND

This study aims to assess the role and safety of post-dilatation in protected carotid artery stenting (PCAS) using the new MicroNet-covered 2nd-generation stent assessed by cone beam CT scans.

METHODS

From March 2020 to March 2022, patients were enrolled in the study according to CT angiography results based on the following criteria: Evidence of 70% to 99% carotid stenosis in asymptomatic patients and 50% to 99% in symptomatic patients, per the NASCET index. Using a FilterWire EZ™ (Boston Scientific, Natick, MA, USA) embolic protection system (EPS), MicroNet-covered stent PCAS was performed by two interventional radiologists with at least 8 years of experience in endovascular intervention. Each patient underwent post-dilatation following stent placement. Finally, a third radiologist (not participating in the interventional procedures) evaluated the cone beam CT scans and calculated residual stenosis. Major and minor complications were recorded in the 30 days following the procedure.

RESULTS

A total of 192 patients (121 male, mean age 73±10 years) were included in the study, and all patients received post-dilatation following stent implantation. Technical successes were achieved in all procedures. Adverse events noted in this study were limited to periprocedural transient ischemic attacks that occurred in three out of 192 patients (1.6%) and showed a swift complete recovery. The post-dilatation balloon diameters used in the study were: 5.0 mm (30.3%), 5.5 mm (39.3%) and 6 mm (30.3%). Optimized postdilatation resulted in a significant increase in the final luminal area. Similar improvements were observed in all subtypes of plaque.

CONCLUSIONS

Post-dilatation in protected CAS is safe and induces a significant improvement in the cross-sectional area regardless of the stenotic plaque.

Carotid artery interventions - endarterectomy versus stenting

Current management of patients with carotid artery stenosis is based on well-established guidelines, including surgical procedures - carotid endarterectomy (CEA) and endovascular carotid artery stenting (CAS) - and optimal medical treatment alone. Outcomes in the postprocedural period after CAS and CEA are similar, suggesting strong clinical durability for both treatments. Recent advances, which include the emergence of novel endovascular treatment tools and techniques, combined with more recent randomised trial data shed new light on optimal patient selection and treatment in contemporary practice. Improved, modern technologies including enhanced embolic protection devices and dual-layered micromesh stents yield better outcomes and should result in further improvements in CAS. In centres of excellence, nowadays, the majority of patients with severe carotid artery stenosis can be successfully treated with either CEA or CAS.

A Systematic Review Supporting the Society for Vascular Surgery Guidelines on the Management of Carotid Artery Disease

BACKGROUND

To support the development of guidelines on the management of carotid disease, a writing committee from the Society for Vascular Surgery has commissioned this systematic review.

METHODS

We searched multiple data bases for studies addressing 5 questions: medical management vs. carotid revascularization (CEA) in asymptomatic patients, CEA vs. CAS in symptomatic low surgical risk patients, the optimal timing of revascularization after acute stroke, screening high risk patients for carotid disease, and the optimal sequence of interventions in patients with combined coronary and carotid disease. Studies were selected and appraised by pairs of independent reviewers. Meta-analyses were performed when feasible.

RESULTS

Medical management compared to carotid interventions in asymptomatic patients was associated with better early outcome during the first 30 days. However, CEA was associated with significantly lower long-term rate of stroke/death at 5 years. In symptomatic low risk surgical patients, CEA was associated with lower risk of stroke, but a significant increase in MI compared to CAS during the first 30 days. When the long-term outcome of transfemoral CAS vs. CEA in symptomatic patients were examined using pre-planned pooled analysis of individual patient data from four randomized trials, the risk of death or stroke within 120 days of the index procedure was 5.5% for CEA and 8.7% for CAS, which lends support that over the long-term, CEA has superior outcome than transfemoral CAS. When managing acute stroke, the comparison of CEA during the first 48 hours to that between day 2 and day14 did not reveal a statistically significant difference on outcomes during the first 30 days. Registry data show good results with CEA performed in the first week, but not within the first 48 hours. A single risk factor, aside from PAD, was associated with low carotid screening yield. Multiple risk factors greatly increase the yield of screening. Evidence on the timing of interventions in patients with combined carotid and coronary disease was sparse and imprecise. Patients without carotid symptoms, who had the carotid intervention first, compared to a combined carotid intervention and CABG, had better outcomes.

CONCLUSIONS

This updated evidence summary will support the SVS clinical practice guidelines for commonly raised clinical scenarios. CEA was superior to medical therapy in long-term prevention of stroke/death over medical therapy. CEA was also superior to transfemoral CAS in minimizing long-term stroke/death for symptomatic low risk surgical patients. CEA should optimally be performed between 2-14 days from the onset of acute stroke. Having multiple risk factors increases the value of carotid screening.

Improving Quality of Carotid Interventions: Identifying Hospital-Level Structural Factors that can Improve Outcomes

BACKGROUND

"Structural factors" relating to organization of hospitals may affect procedural outcomes. This study's aim was to clarify associations between structural factors and outcomes after carotid endarterectomy (CEA) and carotid endarterectomy stenting (CAS).

METHODS

A systematic review of studies published in English since 2005 was conducted. Structural factors assessed were as follows: population size served by the vascular department; number of hospital beds; availability of dedicated vascular beds; established clinical pathways; surgical intensive care unit (SICU) size; and specialty of surgeon/interventionalist. Primary outcomes were as follows: mortality; stroke; cardiac complications; length of hospital stay (LOS); and cost.

RESULTS

There were 11 studies (n = 95,100 patients) included in this systematic review. For CEA, reduced mortality (P < 0.0001) and stroke rates (P = 0.001) were associated with vascular departments serving >75,000 people. Larger hospitals were associated with lower mortality, stroke rate, and cardiac events, compared with smaller hospitals (less than 130 beds). Provision of vascular beds after CEA was associated with lower mortality (P = 0.0008) and fewer cardiac events (P = 0.03). Adherence to established clinical pathways was associated with reduced stroke and cardiac event rates while reducing CEA costs. Large SICUs (≥7 beds) and dedicated intensivists were associated with decreased mortality after CEA while a large SICU was associated with reduced stroke rate (P = 0.001). Vascular surgeons performing CEA were associated with lower stroke rates and shorter LOS (P = 0.0001) than other specialists. CAS outcomes were not influenced by specialty but costless when performed by vascular surgeons (P < 0.0001).

CONCLUSIONS

Structural factors affect CEA outcomes, but data on CAS were limited. These findings may inform reconfiguration of vascular services, reducing risks and costs associated with carotid interventions.

A systematic review and meta-analysis of complication rates after carotid procedures performed by different specialties

OBJECTIVE

Different competencies and skills are required and obtained during medical specialization. However, whether these have an impact on procedural outcomes of carotid endarterectomy (CEA) or carotid artery stenting (CAS) is unclear. We assessed the reported association between operator specialization and procedural outcomes after CEA or CAS to determine whether CEA and CAS should be performed by specific specialties.

METHODS

We systematically searched PubMed and Embase up to August 21, 2017, for randomized clinical trials and observational studies that compared two or more specialties performing CEA or CAS for symptomatic and asymptomatic carotid artery stenosis. The composite primary outcome was procedural stroke or death (ie, occurring within 30 days of the procedure or before discharge). Risk estimates were pooled with a generic inverse variance random effects model.

RESULTS

A total of 35 studies (26 providing data on CEA, 8 providing data on CAS, and 1 providing data on both CEA and CAS) were included, describing 256,033 CEA and 38,605 CAS procedures. For CEA, decreased risk of procedural stroke or death for operations performed by vascular surgeons was found with pooled unadjusted relative risk (RR) of 0.63 (95% confidence interval [CI], 0.46-0.86; seven studies) compared with neurosurgeons and RR of 0.81 (95% CI, 0.66-0.99; six studies) compared with general surgeons. An increased risk of procedural stroke or death for operations performed by neurosurgeons compared with cardiothoracic surgeons was found with a pooled unadjusted RR of 1.22 (95% CI, 1.02-1.46). No studies adjusted for potential confounding, and no significant unadjusted associations were found in other comparisons of operator specialty for the primary outcome. For CAS, no differences in procedural stroke or death were found by operator specialty.

CONCLUSIONS

Studies were at high risk of bias mainly because of potential confounding by patient selection for CEA and CAS. Current evidence is insufficient to restrict CEA or CAS to specific specialties.

Management of Asymptomatic Carotid Artery Stenosis

PURPOSE OF REVIEW

The goal of this paper is to provide the reader with a review of the evidence supporting the surgical and medical management of patients with asymptomatic internal carotid artery (ICA) stenosis.

RECENT FINDINGS

Based on the results of earlier clinical trials, surgical intervention with carotid endarterectomy (CEA) has long been the preferred method of management for patients with asymptomatic severe carotid stenosis. Carotid artery stenting (CAS) is another less invasive surgical option that has similar outcomes over the long-term. However, more recent improvements in medical management have reduced the risk of stroke in this population to comparable rates seen with CEA. As a result, medical management alone is advocated as well for patients with asymptomatic carotid stenosis. In addition to stenosis severity, there are a number of features of plaque morphology associated with vulnerable plaque that predict future stroke risk. Rates of stroke in patients with asymptomatic severe carotid stenosis with modern surgical techniques, CEA and CAS, are similar to modern medical therapy alone. Both surgery and medical therapy are good treatment options but it is not known which treatment is superior. The Carotid Revascularization and Medical Management for Asymptomatic Carotid Stenosis Trial (CREST-2), an NIH-sponsored, multicenter, randomized trial that aims to answer this important management decision.

Editor's Choice - Overview of Primary and Secondary Analyses From 20 Randomised Controlled Trials Comparing Carotid Artery Stenting With Carotid Endarterectomy

OBJECTIVES

The aim of this review was to carry out primary and secondary analyses of 20 randomised controlled trials (RCTs) comparing carotid endarterectomy (CEA) with carotid artery stenting (CAS).

METHODS

A systematic review and meta-analysis of data from 20 RCTs (126 publications) was carried out.

RESULTS

Compared with CEA, the 30 day death/stroke rate was significantly higher after CAS in seven RCTs involving 3467 asymptomatic patients (odds ratio [OR] 1.64, 95% confidence interval [CI] 1.02-2.64) and in 10 RCTs involving 5797 symptomatic patients (OR 1.71, 95% CI 1.38-2.11). Excluding procedural risks, late ipsilateral stroke was about 4% at 9 years for both CEA and CAS, i.e., CAS was durable. Reducing procedural death/stroke after CAS may be achieved through better case selection, e.g., performing CEA in (i) symptomatic patients aged > 70 years; (ii) interventions within 14 days of symptom onset; and (iii) situations where stroke risk after CAS is predicted to be higher (segmental/remote plaques, plaque length > 13 mm, heavy burden of white matter lesions [WMLs], where two or more stents might be needed). New WMLs were significantly more common after CAS (52% vs. 17%) and were associated with higher rates of late stroke/transient ischaemic attack (23% vs. 9%), but there was no evidence that new WMLs predisposed towards late cognitive impairment. Restenoses were more common after CAS (10%) but did not increase late ipsilateral stroke. Restenoses (70%-99%) after CEA were associated with a small but significant increase in late ipsilateral stroke (OR 3.87, 95% CI 1.96-7.67; p < .001).

CONCLUSIONS

CAS confers higher rates of 30 day death/stroke than CEA. After 30 days, ipsilateral stroke is virtually identical for CEA and CAS. Key issues to be resolved include the following: (i) Will newer stent technologies and improved cerebral protection allow CAS to be performed < 14 days after symptom onset with risks similar to CEA? (ii) What is the optimal volume of CAS procedures to maintain competency? (iii) How to deliver better risk factor control and best medical treatment? (iv) Is there a role for CEA/CAS in preventing/reversing cognitive impairment?

Asymptomatic Carotid Stenosis: Intervention or Best Medical Therapy?

PURPOSE OF REVIEW

Provide a current overview regarding the optimal strategy for managing patients with asymptomatic carotid artery stenosis.

RECENT FINDINGS

Carotid endarterectomy (CEA) and carotid artery stenting (CAS) reduce long-term stroke risk in asymptomatic patients. However, CAS is associated with a higher risk of peri-procedural stroke. Improvements in best medical therapy (BMT) have renewed uncertainty regarding the extent to which results from older randomised controlled trials (RCTs) comparing outcomes following carotid intervention can be generalised to modern medical practise. 'Average surgical risk' patients with an asymptomatic carotid artery stenosis of 60-99% and increased risk of late stroke should be considered for either CEA or CAS. In patients deemed 'high risk' for surgery, CAS is indicated. Use of an anti-platelet, anti-hypertensive and statin, with strict glycaemic control, is recommended. Results from ongoing large, multicentre RCTs comparing CEA, CAS and BMT will provide clarity regarding the optimal management of patients with asymptomatic carotid artery stenosis.

Predictors of Perioperative Stroke/Death after Carotid Artery Stenting: A Review Article

Carotid artery stenting (CAS) has been recommended as an alternative treatment to carotid endarterectomy for patients with significant carotid stenosis. Only a few studies have analyzed clinical/anatomical and technical variables that affect perioperative outcomes of CAS. Following a comprehensive Medline search, it was reported that clinical factors, including age of >80 years, chronic renal failure, diabetes mellitus, symptomatic indications, and procedures performed within 2 weeks of transient ischemic attack symptoms, are associated with high perioperative stroke and death rates. They also highlighted that angiographic variables, e.g., ulcerated and calcified plaques, left carotid intervention, >90% stenosis, >10-mm target lesion length, ostial involvement, type III aortic arch, and >60°-angulated internal carotid and common carotid arteries, are predictors of increased stroke rates. Technical factors associated with increased perioperative risk of stroke include percutaneous transluminal angioplasty (PTA) without embolic protection devices, PTA before stent placement, and the use of multiple stents. This review describes the most widely quoted data in defining various predictors of perioperative stroke and death after CAS. (This is a review article based on the invited lecture of the 45th Annual Meeting of Japanese Society for Vascular Surgery.)

Endarterectomy achieves lower stroke and death rates compared with stenting in patients with asymptomatic carotid stenosis

BACKGROUND

It is currently unclear if carotid artery stenting (CAS) is as safe as carotid endarterectomy (CEA) for patients with significant asymptomatic stenosis. The aim of our study was to perform a systematic review and meta-analysis of trials comparing CAS with CEA.

METHODS

On March 17, 2017, a search for randomized controlled trials was performed in MEDLINE and Scopus databases with no time limits. We performed meta-analyses with Peto odds ratios (ORs) and 95% confidence intervals (CIs). Quality of evidence was assessed with the Grading of Recommendations Assessment, Development, and Evaluation method. The primary safety and efficacy outcome measures were stroke or death rate at 30 days and ipsilateral stroke at 1 year (including ipsilateral stroke and death rate at 30 days), respectively. Perioperative stroke, ipsilateral stroke, myocardial infarction (MI), and cranial nerve injury (CNI) were all secondary outcome measures.

RESULTS

The systematic review of the literature identified nine randomized controlled trials reporting on 3709 patients allocated into CEA (n = 1479) or CAS (n = 2230). Stroke or death rate at 30 days was significantly higher for CAS (64/2176 [2.94%]) compared with CEA (27/1431 [1.89%]; OR, 1.57; 95% CI, 1.01-2.44; P = .044), with low level of heterogeneity beyond chance (I² = 0%). Also, stroke rate at 30 days was significantly higher for CAS (63/2176 [2.90%]) than for CEA (26/1431 [1.82%]; OR, 1.63; 95% CI, 1.04-2.54; P = .032; I² = 0%). MI at 30 days was nonsignificantly lower for CAS (12/1815 [0.66%]) compared with CEA (16/1070 [1.50%]; OR, 0.53; 95% CI, 0.24-1.14; P = .105; I² = 0%); however, CNI at 30 days was significantly lower for CAS (2/1794 [0.11%]) than for CEA (33/1061 [3.21%]; OR, 0.13; 95% CI, 0.07-0.26; P < .00001; I² = 0%). Regarding the long-term outcome of stroke or death rate at 30 days plus ipsilateral stroke during follow-up, this was significantly higher for CAS (79/2173 [3.64%]) than for CEA (35/1430 [2.45%]; OR, 1.51; 95% CI, 1.02-2.24; P = .04; I² = 0%). Quality of evidence for all stroke outcomes was graded moderate.

CONCLUSIONS

Among patients with asymptomatic stenosis undergoing carotid intervention, there is moderate-quality evidence to suggest that CEA had significantly lower 30-day stroke and also stroke or death rates compared with CAS at the cost of higher CNI and nonsignificantly higher MI rates. The long-term efficacy of CEA in ipsilateral stroke prevention, taking into account perioperative stroke and death, was preserved during follow-up. There is an urgent need for high-quality research before a firm recommendation is made that CAS is inferior or not to CEA.

Clinical Outcome of Carotid Artery Stenting According to Provider Specialty and Volume

BACKGROUND

Several studies have demonstrated better outcomes for carotid endarterectomy with high-volume hospitals and providers. However, only a few studies have reported on the impact of operator specialty/volume on the perioperative outcome of carotid artery stenting (CAS). This study will analyze the correlation of CAS outcomes and provider specialty and volume.

METHODS

Prospectively collected data of CAS procedures done at our institution during a 10-year period were analyzed. Major adverse events (MAEs; 30-day stroke, myocardial infarction, and death) were compared according to provider specialty (vascular surgeons [VSs], interventional cardiologists [ICs], interventional radiologists [IRs], interventional vascular medicine [IVM]), and volume (≥5 CAS/year vs. <5 CAS/year).

RESULTS

Four hundred fourteen CAS procedures (44% for symptomatic indications) were analyzed. Demographics/clinical characteristics were somewhat similar between specialties. MAE rates were not significantly different between various specialties: 3.1% for IC, 6.3% for VS, 7.1% for IR, 6.7% for IVM (P = 0.3121; 6.3% for VS and 3.8% for others combined, P = 0.2469). When physicians with <5 CAS/year were excluded: the MAE rates were 3.1% for IC, 4.7% for VS, and 6.7% for IVM (P = 0.5633). When VS alone were compared with others, and physicians with <5 CAS/year were excluded, the MAE rates were 4.7% for VS vs. 3.6% for non-VS (P = 0.5958). The MAE rates for low-volume providers, regardless of their specialty, were 9.5% vs. 4% for high-volume providers (P = 0.1002). Logistic regression analysis showed that the odds ratio of MAE was 0.4 (0.15-1.1, P = 0.0674) for high-volume providers, while the odds ratio for VS was 1.3 (0.45-3.954, P = 0.5969).

CONCLUSIONS

Perioperative MAE rates for CAS were similar between various providers, regardless of specialties, particularly for vascular surgeons with similar volume to nonvascular surgeons. Low-volume providers had higher MAE rates.

The urgent need for contemporary clinical trials in patients with asymptomatic carotid stenosis

Asymptomatic extracranial internal carotid artery atherosclerotic stenosis increases with age and is more common in men. Studies performed more than 2 decades ago showed that carotid endarterectomy reduced the rate of stroke in carefully selected patients with asymptomatic carotid stenosis compared with medical therapy in the long term. Those trials were completed more than 20 years ago and with advances in the treatment of atherosclerotic disease, the question has been raised to as to whether endarterectomy is still of value for patients with asymptomatic narrowing. Perioperative risk of carotid revascularization procedures has also declined. Due to improvements in both medical and surgical treatments for carotid artery stenosis, it is timely to reevaluate the efficacy of carotid intervention relative to medical treatment for patients with asymptomatic stenosis.

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.

Carotid Stenting Versus Carotid Endarterectomy: What Did the Carotid Revascularization Endarterectomy Versus Stenting Trial Show and Where Do We Go From Here?

Although rapidly expanding in its use, carotid artery stenting remains a relatively new procedure. Its growth is due, at least in part, to the perceived advantages of a less invasive technique. However, the clinical effectiveness and specific role for stenting in the treatment of carotid occlusive disease are still under evaluation. The primary aim of the randomized clinical trial, Carotid Revascularization Endarterectomy versus Stenting Trial (CREST), was to contrast the relative efficacy of carotid stenting versus carotid endarterectomy in preventing stroke, myocardial infarction, or death during a 30-day periprocedural period or ipsilateral stroke over the follow-up period in patients with symptomatic and asymptomatic extracranial carotid stenosis. The secondary goals were to describe the differential efficacy of the 2 procedures in men and women, contrast periprocedural (30-day) morbidity and postprocedural morbidity and mortality, estimate and contrast the restenosis rates of the 2 procedures, evaluate differences in measures of health-related quality of life and cost-effectiveness, and identify subgroups of participants at differential risk of stenting or surgery. This report summarizes the results obtained from CREST with respect to its primary and secondary aims.

Decreased ¹³N-labeled ammonia uptake in the ipsilateral and contralateral hemispheres following carotid endarterectomy

Carotid artery plaques are a leading cause of ischemic stroke, and carotid endarterectomy (CEA) is one of the major treatment approaches for this disease. Changes in cerebral metabolism following CEA remain unclear. The present study aimed to evaluate the effect of cerebral ammonia metabolism following CEA using ¹³N-labeled ammonia positron emission tomography (PET) in humans. A total of 20 patients were enrolled in the present study, with a mean age of 59.5 years, comprising 16 males and four females. Of these patients, eight underwent right CEA and 12 underwent left CEA. The rate of carotid artery stenosis was between 50–69% in six of the patients, between 70–99% in 11 of the patients and was at 100% (thrombosis) in three of the patients, measured by computerised tomography digital subtraction angiography prior to CEA. ¹³N-labeled ammonia (137 MBq) PET scanning was performed prior and subsequent to CEA surgery for each patient. The first ammonia PET scan was performed 1 day prior to CEA, while the second PET scan was performed 1–4 weeks following CEA. Following injection of ¹³N-labeled ammonia, static PET was acquired for 10 min. The region of interest (ROI), covering the major cerebral hemisphere, was selected and ammonia uptake in the ROI was determined in the ipsilateral and contralateral hemispheres. No hyperperfusion syndrome was observed in the patients subsequent to CEA. No significant change in cerebral hemisphere ammonia uptake was observed between the ipsilateral and contralateral hemispheres prior to (ratio =0.98; P>0.01) or following (ratio =1.09; P>0.01) CEA. Ammonia uptake in the ipsilateral and contralateral hemispheres was significantly reduced to 23.2 and 23.5%, respectively, following CEA. Using ¹³N-labeled ammonia PET to evaluate cerebral ammonia metabolism following CEA in patients with severe carotid artery stenosis, the present study demonstrated that uptake of ammonia in the ipsilateral and contralateral hemispheres was significantly reduced.

Demographic and Technical Risk Factors of 30-Day Stroke, Myocardial Infarction, and/or Death in Standard- and High-Risk Patients Who Underwent Carotid Angioplasty and Stenting

BACKGROUND

Carotid angioplasty and stenting (CAS) is an accepted treatment to prevent stroke in patients with carotid artery stenosis. The purpose of this study is to identify risk factors for major complications after CAS.

MATERIALS AND METHODS

This is a prospective study that was conducted at Shiraz University of Medical Sciences in southern Iran from March 2011 to June 2014. Consecutive patients undergoing CAS were enrolled. Both standard- and high-risk patients for endarterectomy were enrolled. Demographic data, atherosclerotic risk factors, site of stenosis, degree of stenosis, and data regarding technical factors were recorded. Thirty-day stroke, myocardial infarction, and/or death were considered as the composite primary outcomes of the study.

RESULTS

A total of 251 patients were recruited (mean age: 71.1 ± 9.6 years; male: 65.3%). Of these, 178 (70.9%) were symptomatic, 73 (29.1%) were diabetic, 129 (51.4%) were hyperlipidemic, 165 (65.7%) were hypertensive, and 62 (24.7%) patients were smokers. CAS was performed for left internal carotid artery (ICA) in 113 (45.4%) patients. Fourteen (5.6%) patients had sequential bilateral stenting. Mean stenosis of operated ICA was 80.2 ± 13.8%. An embolic protection device was used in 203 (96.2%) patients. Pre- and postdilation were performed in 39 (18.5%) and 182 (86.3%) patients, respectively. Composite outcomes were observed in 3.6% of patients (3.2% stroke, 0% myocardial infarction, and 1.2% death). Left-sided lesions and the presence of diabetes mellitus were significantly associated with poor short-term outcome (p = 0.025 and p = 0.020, respectively).

CONCLUSION

There was a higher risk of short-term major complications in diabetic patients and for left carotid artery intervention.

Meta- analysis and meta-regression analysis of the associations between sex and the operative outcomes of carotid endarterectomy

Background

Subgroup analyses from randomized controlled trials (RCT) of carotid endarterectomy (CEA) for both symptomatic and asymptomatic carotid stenosis suggest less benefit in women compared to men, due partly to higher age-independent peri-operative risk. However, a meta-analysis of case series and databases focussing on CEA-related gender differences has never been investigated.

Methods

A systematic review of all available publications (including case series, databases and RCTs) reporting data on the association between sex and procedural risk of stroke and/or death following CEA from 1980 to 2015 was investigated. Pooled Peto odds ratios of the procedural risk of stroke and/or death were obtained by Mantel-Haenszel random-effects meta-analysis. The I² statistic was used as a measure of heterogeneity. Potential publication bias was assessed with the Egger test and represented graphically with Begg funnel plots of the natural log of the OR versus its standard error. Additional sensitivity analyses were undertaken to evaluate the potential effect of key assumptions and study-level factors on the overall results. Meta-regression models were formed to explore potential heterogeneity as a result of potential risk factors or confounders on outcomes. A tria sequential analysis (TSA) was performed with the aim to maintain an over- all 5 % risk of type I error, being the standard in most meta- analyses and systematic reviews.

Results

58 articles reported combined stroke and mortality rates within 30 days of treatment. In the unselected overall meta-analysis, the incidence of stroke and death in the male and female groups differed significantly (Peto OR, 1,162; 95 % CI, 1.067-1.266; P = .001), revealing a worse outcome for female patients. Moderate heterogeneity among the studies was identified (I² = 36 %), and the possibility of publication bias was low (P = .03). In sensitivity analyses the meta-analysis of case series with gender aspects as a secondary outcome showed a significantly increased risk for 30-day stroke and death in women compared to men (Peto OR, 1.390; 95 % CI, 1.148-1.684; P = .001), In contrast, meta-analysis of databases (Peto OR, 1.025; 95 % CI, 0.958-1.097; P = .474) and case series with gender related outcomes as a primary aim (Peto OR, 1.202; 95 % CI, 0.925-1.561; P = .168) demonstrated no increase in operative risk of stroke and death in women compared to men.

Conclusions

Metanalyses of case series and databases dealing with CEA reveal inconsistent results regarding gender differences related to CEA-procedure and should not be transferred into clinical practice.

Preoperative symptom type influences the 30-day perioperative outcomes of carotid endarterectomy and carotid stenting in the Society for Vascular Surgery Vascular Registry

OBJECTIVE

The objective of this study was to determine the effect of presenting symptom types on 30-day periprocedural outcomes of carotid endarterectomy (CEA) and carotid artery stenting (CAS) in contemporary vascular practice.

METHODS

Retrospective review was undertaken of the Society for Vascular Surgery Vascular Registry database subjects who underwent CEA or CAS from 2004 to 2011. Patients were grouped by discrete 12-month preprocedural ipsilateral symptom type: stroke, transient ischemic attack (TIA), transient monocular blindness (TMB), or asymptomatic (ASX). Risk-adjusted odds ratios (ORs) were used to compare the likelihood of the 30-day outcomes of death, stroke, and myocardial infarction (MI) and the composite outcomes of death + stroke and death + stroke + MI.

RESULTS

Symptom type significantly influences risk-adjusted 30-day outcomes for carotid intervention. Presentation with stroke predicted the poorest outcomes (death + stroke + MI composite: OR, 1.3; 95% confidence interval [CI], 0.83-2.03 vs TIA; OR, 2.56; 95% CI, 1.18-5.57 vs TMB; OR, 2.12; 95% CI, 1.46-3.08 vs ASX), followed by TIA (death + stroke + MI composite: OR, 1.97; 95% CI, 0.91-4.25 vs TMB; OR, 1.63; 95% CI, 1.14-2.33 vs ASX). For both CAS and CEA patients, presentation with stroke or TIA predicted a higher risk of periprocedural stroke than in ASX patients. Presentation with stroke predicted higher 30-day risk of death with CAS but not with CEA. MI rates were not affected by presenting symptom type. The 30-day outcomes for the TMB and ASX patient groups were equivalent in both treatment arms.

CONCLUSIONS

Presenting symptom type significantly affects the 30-day outcomes of both CAS and CEA in contemporary vascular surgical practice. Presentation with stroke and TIA predicts higher rates of periprocedural complications, whereas TMB presentation predicts a periprocedural risk profile similar to that of ASX disease.

Effect of carotid artery stenting on ophthalmic artery flow patterns

OBJECTIVES

The purpose of this study was to assess the effect of carotid artery stenting on ophthalmic artery blood flow using transorbital color and spectral Doppler sonography and review the changes in relation to cerebral hemodynamics.

METHODS

Twenty-eight consecutive patients with severe internal carotid artery stenosis (≥ 70%) who were scheduled for carotid stenting were included. Ophthalmic artery Doppler sonography was performed bilaterally before and after stenting. The flow direction, peak systolic velocity (PSV), end-diastolic velocity (EDV), pulsatility index (PI), and resistive index in the ophthalmic artery were recorded.

RESULTS

Twenty male and 8 female patients with 10 right-sided and 18 left-sided stenoses were studied. The mean overall carotid stenosis ratio ± SD was 87.3% ± 9.9%. After stenting in the ophthalmic artery ipsilateral to the stenosis, significant increases in the PSV (-3.87 ± 48.81 to 46.70 ± 25.33 cm/s; P < .001), and EDV (-3.02 ± 16.31 to 11.24 ± 7.37 cm/s; P < .001) were detected, and the increase in the PI approached significance (1.40 ± 0.59 to 1.62 ± 0.52; P = .055). A change in the flow direction from retrograde to antegrade was noted in 11 patients (39%) after stenting, and in 1 patient with no detectable flow, reconstitution of flow was observed. Increases in the PSV and EDV (P= .03 for ΔEDV) were more pronounced in symptomatic patients than asymptomatic patients after stenting.

CONCLUSIONS

Substantially decreased ophthalmic artery velocity and retrograde flow are suggestive of high-grade carotid artery stenosis (≳90%). Stenting improves ophthalmic artery perfusion and positively changes cerebral hemodynamics in high-grade carotid artery stenosis, especially in symptomatic patients, which can be monitored with ophthalmic artery Doppler sonography.

Predictors of Restenosis After Carotid Endarterectomy

Introduction:

Carotid endarterectomy (CEA) is a well-established surgical technique in stroke prophylaxis. Long-term follow-up data on restenosis or recurrent neurological symptoms in Oriental patients are unclear.

Methods:

Patients’ notes from 1994 to 2011 were retrospectively reviewed and analyzed. A total of 301 cases of CEA were identified.

Results:

A lower restenosis rate was associated with the use of patch and never smokers in both univariate and multivariate analysis. Use of patch and never smokers were also found to be significantly associated with longer restenosis-free survival. Use of patch and postoperative use of statin were associated with better overall survival in both univariate and multivariate analysis.

Conclusion:

Use of patch and lack of smoking history are associated with less restenosis and longer restenosis-free survival. Use of patch and use of postoperative statin improves overall survival. Although restenosis after CEA is relatively common, reintervention was rarely necessary.