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Etkin Y, Iyeke L, Yu G, Ahmed I, Matera P, Aminov J, Kokkosis A, Hastings L, Garg K, Rockman C. Sex disparities in outcomes after carotid artery interventions: A systematic review. Semin Vasc Surg 2023; 36:476-486. [PMID: 38030321 DOI: 10.1053/j.semvascsurg.2023.09.004] [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: 07/28/2023] [Revised: 09/13/2023] [Accepted: 09/28/2023] [Indexed: 12/01/2023]
Abstract
This systematic review aimed to identify sex-specific outcomes in men and women after carotid endarterectomy (CEA) and carotid artery stenting (CAS), including transfemoral and transcarotid. A search of literature published from January 2000 through December 2022 was conducted using key terms attributed to carotid interventions on PubMed. Studies comparing outcome metrics post intervention (ie, myocardial infarction [MI], cerebral vascular accident [CVA] or stroke, and long-term mortality) among male and female patients were reviewed. Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines were followed. Overall, all studies reported low rates of perioperative complications. Among the studies that did not stratify outcomes by the preoperative symptom status, there were no significant sex differences in rates of perioperative strokes or MIs. Two studies, however, noted a higher rate of 30-day mortality in male patients undergoing CEA than in female patients. Analysis of asymptomatic patients undergoing CEA revealed no difference in perioperative MIs (female: 0% to 1.8% v male: 0.4% to 4.3%), similar rates of CVAs (female: 0.8% to 5% v male: 0.8% to 4.9%), and no significant differences in the long-term mortality outcomes. Alternatively, symptomatic patients undergoing CEA reported a higher rate of CVAs in female patients vs. male patients (7.7% v 6.2%) and showed a higher rate of death in female patients (1% v 0.7%). Among studies that did not stratify outcome by symptomatology, there was no difference in the 30-day outcomes between sexes for patients undergoing CAS. Asymptomatic patients undergoing CAS demonstrated similar incident rates across perioperative MIs (female: 0% to 5.9% v male: 0.28% to 3.3%), CVAs (female: 0.5% to 4.1% v male: 0.4% to 6.2%), and long-term mortality outcomes (female: 0% to 1.75% v male: 0.2% to 1.5%). Symptomatic patients undergoing CAS similarly reported higher incidences of perioperative MIs (female: 0.3% to 7.1% v male: 0% to 5.5%), CVAs (female: 0% to 9.9% v male: 0% to 7.6%), and long-term mortality outcomes (female: 0.6% to 7.1% v male: 0.5% to 8.2%). Sex-specific differences in outcomes after major vascular procedures are well recognized. Our review suggests that symptomatic female patients have a higher incidence of neurologic and cardiac events after carotid interventions, but that asymptomatic patients do not.
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Affiliation(s)
- Yana Etkin
- Division of Vascular and Endovascular Surgery, Zucker School of Medicine at Hofstra/Northwell, 1999 Marcus Avenue, Suite 106, Lake Success, NY, 11042.
| | - Lisa Iyeke
- Division of Vascular and Endovascular Surgery, Zucker School of Medicine at Hofstra/Northwell, 1999 Marcus Avenue, Suite 106, Lake Success, NY, 11042
| | - Grace Yu
- Division of Vascular and Endovascular Surgery, Zucker School of Medicine at Hofstra/Northwell, 1999 Marcus Avenue, Suite 106, Lake Success, NY, 11042
| | | | | | - Jonathan Aminov
- Division of Vascular and Endovascular Surgery, Stony Brook University Medical Center, Stony Brook, NY
| | - Angela Kokkosis
- Division of Vascular and Endovascular Surgery, Stony Brook University Medical Center, Stony Brook, NY
| | - Laurel Hastings
- Division of Vascular Surgery, Einstein Medical Center, Philadelphia, PA
| | - Karan Garg
- Division of Vascular Surgery, New York University Langone Medical Center, New York, NY
| | - Caron Rockman
- Division of Vascular Surgery, New York University Langone Medical Center, New York, NY
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Kremer C, Lorenzano S, Bejot Y, Lal A, Epple C, Gdovinova Z, Mono ML, Karapanayiotides T, Jovanovic D, Dawson J, Caso V. Sex differences in outcome after carotid revascularization in symptomatic and asymptomatic carotid artery stenosis. J Vasc Surg 2023; 78:817-827.e10. [PMID: 37055001 DOI: 10.1016/j.jvs.2023.03.502] [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: 11/22/2022] [Revised: 03/11/2023] [Accepted: 03/19/2023] [Indexed: 04/15/2023]
Abstract
OBJECTIVE Sex differences regarding the safety and efficacy of carotid revascularization in carotid artery stenosis have been addressed in several studies with conflicting results. Moreover, women are underrepresented in clinical trials, leading to limited conclusions regarding the safety and efficacy of acute stroke treatments. METHODS A systematic review and meta-analysis was performed by literature search including four databases from January 1985 to December 2021. Sex differences in the efficacy and safety of revascularization procedures, including carotid endarterectomy (CEA) and carotid artery stenting (CAS), for symptomatic and asymptomatic carotid artery stenoses were analyzed. RESULTS Regarding CEA in symptomatic carotid artery stenosis, the stroke risk in men (3.6%) and women (3.9%) based on 99,495 patients (30 studies) did not differ (P = .16). There was also no difference in the stroke risk by different time frames up to 10 years. Compared with men, women treated with CEA had a significantly higher stroke or death rate at 4 months (2 studies, 2565 patients; 7.2% vs 5.0%; odds ratio [OR], 1.49; 95% confidence interval [CI], 1.04-2.12; I2 = 0%; P = .03), and a significantly higher rate of restenosis (1 study, 615; 17.2% vs 6.7%; OR, 2.81; 95% CI, 1.66-4.75; P = .0001). For CAS in symptomatic artery stenosis, data showed a non-significant tendency toward higher peri-procedural stroke in women, whereas for asymptomatic carotid artery stenosis, data based on 332,344 patients showed that women (compared with men) after CEA had similar rates of stroke, stroke or death, and the composite outcome stroke/death/myocardial infarction. The rate of restenosis at 1 year was significantly higher in women compared with men (1 study, 372 patients; 10.8% vs 3.2%; OR, 3.71; 95% CI, 1.49-9.2; P = .005). Furthermore, CAS in asymptomatic patients was associated with low risk of a postprocedural stroke in both sexes, but a significantly higher risk of in-hospital myocardial infarction in women than men (8445 patients, 1.2% vs 0.6%; OR, 2.01; 95% CI, 1.23-3.28; I2 = 0%; P = .005). CONCLUSIONS A few sex-differences in short-term outcomes after carotid revascularization for symptomatic and asymptomatic carotid artery stenosis were found, although there were no significant differences in the overall stroke. This indicates a need for larger multicenter prospective studies to evaluate these sex-specific differences. More women, including those aged over 80 years, need to be enrolled in randomized controlled trials, to better understand if sex differences exist and to tailor carotid revascularization accordingly.
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Affiliation(s)
- Christine Kremer
- Neurology Department, Skåne University Hospital, Department Clinical Sciences Lund University, Malmö, Sweden.
| | - Svetlana Lorenzano
- Department of Human Neurosciences, Sapienza University of Rome, Rome, Italy
| | - Yannick Bejot
- Dijon Stroke Registry, EA7460, Pathophysiology and Epidemiology of Cerebro-Cardiovascular diseases (PEC2), University Hospital of Dijon, University of Burgundy, UBFC, Dijon, France
| | - Avtar Lal
- European Stroke Organisation (ESO), Basel, Switzerland
| | - Corina Epple
- Neurology Department, Klinikum Hanau, Hanau, Germany
| | - Zuzana Gdovinova
- Neurology Department, Faculty of Medicine P.J. Safarik University Košice, Košice, Slovakia
| | - Marie-Luise Mono
- Department of Neurology, Municipal Hospital Waid und Triemli, Zürich, Switzerland; University Hospital and University of Bern, Bern, Switzerland
| | - Theodore Karapanayiotides
- Second Department of Neurology, School of Medicine, Faculty of Health Sciences, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Dejana Jovanovic
- Department of Emergency Neurology, Neurology Clinic, Clinical Center of Serbia, Medical Faculty, University of Belgrade, Belgrade, Serbia
| | - Jesse Dawson
- Institute of Cardiovascular and Medical Sciences, College of Medical, Veterinary, and Life Sciences, University of Glasgow, Glasgow, Scotland
| | - Valeria Caso
- Stroke Unit, Santa Maria della Misericordia Hospital, University of Perugia, Perugia, Italy
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Nantakool S, Chuatrakoon B, Orrapin S, Leung R, Howard DPJ, Rerkasem A, Derraik JGB, Rerkasem K. Influences of age and gender on operative risks following carotid endarterectomy: A systematic review and meta-analysis. PLoS One 2023; 18:e0285540. [PMID: 37163559 PMCID: PMC10171679 DOI: 10.1371/journal.pone.0285540] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2022] [Accepted: 04/25/2023] [Indexed: 05/12/2023] Open
Abstract
OBJECTIVES This review aims to undertake a comprehensive review of the literature and investigate associations of age and gender on 30 days post carotid endarterectomy (CEA) and up to 5 years post CEA stroke, death, and combined stroke and death. DESIGN A systematic review and meta-analysis. METHODS Three main electronic databases including the Cochrane Library, MEDLINE, and Embase were searched from their inception to July 2022. Studies examining operative risks (i.e., stroke, death, and combined stroke and death following CEA) linked to age or gender were included. Two independent reviewers were responsible for study selection, quality assessment, and data extraction. Odds ratio (OR) and 95% confidence interval (CI) of all outcomes were calculated. RESULTS 44609 studies were retrieved from the search. There were 127 eligible studies (80 studies of age, 72 studies of gender, 25 studies of age and gender) for pooling in the meta-analysis. With regards to stroke and death risks within 30 days post CEA; patients aged ≥75 had higher death (OR 1.38; 95% CI 1.10-1.75) than patients aged <75. Patients aged ≥80 had higher stroke risk (OR 1.17; 95% CI 1.07-1.27) and death risk (OR 1.85; 95% CI 1.48-2.30) particular in asymptomatic patients (OR 2.4; 95% CI 1.56-3.81). Pooled effect estimates by gender, at 30 days post CEA, showed that female was associated with increased risk of stroke (OR 1.28; 95% CI 1.16-1.40), with more risk in asymptomatic female patients (OR 1.51; 95% CI 1.14-1.99). CONCLUSIONS This meta-analysis highlights that older people is associated with increased stroke risk, particularly asymptomatic octogenarians who had higher likelihood of death within 30 days post CEA. In addition, female especially those with asymptomatic carotid stenosis had greater likelihood of stroke within 30 days post CEA surgery.
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Affiliation(s)
- Sothida Nantakool
- Research Institute for Health Sciences, Environmental-Occupational Health Sciences and Non Communicable Diseases Research Group (EOHS and NCD Research Group), Chiang Mai University, Chiang Mai, Thailand
| | - Busaba Chuatrakoon
- Faculty of Associated Medical Sciences, Department of Physical Therapy, Chiang Mai University, Chiang Mai, Thailand
| | - Saritphat Orrapin
- Faculty of Medicine, Department of Surgery, Division of Vascular Surgery, Thammasat University (Rangsit Campus), Pathum Thani, Thailand
| | - Rachel Leung
- Nuffield Department of Clinical Neurosciences, Centre for Prevention of Stroke and Dementia, University of Oxford, Oxford, United Kingdom
| | - Dominic P J Howard
- Nuffield Department of Clinical Neurosciences, Centre for Prevention of Stroke and Dementia, University of Oxford, Oxford, United Kingdom
| | - Amaraporn Rerkasem
- Research Institute for Health Sciences, Environmental-Occupational Health Sciences and Non Communicable Diseases Research Group (EOHS and NCD Research Group), Chiang Mai University, Chiang Mai, Thailand
| | - José G B Derraik
- Research Institute for Health Sciences, Environmental-Occupational Health Sciences and Non Communicable Diseases Research Group (EOHS and NCD Research Group), Chiang Mai University, Chiang Mai, Thailand
- Liggins Institute, University of Auckland, Auckland, New Zealand
- Department of Women's and Children's Health, Uppsala University, Uppsala, Sweden
- Faculty of Medical and Health Sciences, Department of Paediatrics, Child and Youth Health, University of Auckland, Auckland, New Zealand
| | - Kittipan Rerkasem
- Research Institute for Health Sciences, Environmental-Occupational Health Sciences and Non Communicable Diseases Research Group (EOHS and NCD Research Group), Chiang Mai University, Chiang Mai, Thailand
- Faculty of Medicine, Department of Surgery, Chiang Mai University, Chiang Mai, Thailand
- Faculty of Medicine, Clinical Surgical Research Center, Chiang Mai University, Chiang Mai, Thailand
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Allen AJ, Russell D, Lombardi ME, Duchesneau ED, Agala CB, McGinigle KL, Marston WA, Farber MA, Parodi FE, Wood J, Pascarella L. Gender Disparities in Aortoiliac Revascularization in Patients with Aortoiliac Occlusive Disease. Ann Vasc Surg 2022; 86:199-209. [PMID: 35605762 PMCID: PMC10681021 DOI: 10.1016/j.avsg.2022.05.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2022] [Revised: 05/02/2022] [Accepted: 05/06/2022] [Indexed: 11/28/2022]
Abstract
BACKGROUND Gender disparities have been previously reported in aortic aneurysm and critical limb ischemia outcomes; however, limited info is known about disparities in aortoiliac occlusive disease. We sought to characterize potential disparities in this specific population. MATERIAL AND METHODS Patients who underwent aortobifemoral bypass and aortic thromboendarterectomy (Current Procedural Terminology codes 35646 and 35331) between 2012 and 2019 were identified in the National Surgical Quality Improvement Program database. A binomial regression model was used to estimate gender differences in 30-day morbidity and mortality. Inverse probability weighting was used to standardize demographic and surgical characteristics. RESULTS We identified 1,869 patients, of which 39.8% were female and the median age was 61 years. Age, body composition, and other baseline characteristics were overall similar between genders; however, racial data were missing for 26.1% of patients. Females had a higher prevalence of preexisting chronic obstructive pulmonary disease (20.9% vs. 14.7%, prevalence difference 6.1%, P < 0.01), diabetes mellitus (25.4% vs. 19.4%, prevalence difference 6.0%, P < 0.01), and high-risk anatomical features (39.4% vs. 33.7%, prevalence difference 5.8%, P = 0.01). Preprocedural medications included a statin in only 68.2% of patients and antiplatelet agent in 76.7% of patients. Females also had a higher incidence of bleeding events when compared to males (25.2% vs. 17.5%, standardized risk difference 7.2%, P < 0.01), but were less likely to have a prolonged hospitalization greater than 10 days (18.2% vs. 20.9%, standardized risk difference -5.0%, P = 0.01). The 30-day mortality rate was not significantly different between genders (4.7% vs. 3.6%, standardized risk difference 1.2%, P = 0.25). CONCLUSIONS Female patients treated with aortobifemoral bypass or aortic thromboendarterectomy are more likely to have preexisting chronic obstructive pulmonary disease, diabetes mellitus, and high-risk anatomical features. Regardless of a patient's gender, there is poor adherence to preoperative medical optimization with both statins and antiplatelet agents. Female patients are more likely to have postoperative bleeding complications while males are more likely to have a prolonged hospital stay greater than 10 days. Future work could attempt to further delineate disparities using databases with longer follow-up data and seek to create protocols for reducing these observed disparities.
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Affiliation(s)
- Austin J Allen
- University of North Carolina at Chapel Hill School of Medicine, Chapel Hill, NC
| | - Devin Russell
- Department of Surgery, Eastern Virginia Medical School, Norfolk, VA
| | - Megan E Lombardi
- Department of Surgery, University of North Carolina School of Medicine, Chapel Hill, NC
| | - Emilie D Duchesneau
- Department of Epidemiology, University of North Carolina at Chapel Hill, Chapel Hill, NC
| | - Chris B Agala
- University of North Carolina at Chapel Hill School of Medicine, Chapel Hill, NC
| | - Katharine L McGinigle
- Department of Vascular Surgery, University of North Carolina School of Medicine, Chapel Hill, NC
| | - William A Marston
- Department of Vascular Surgery, University of North Carolina School of Medicine, Chapel Hill, NC
| | - Mark A Farber
- Department of Vascular Surgery, University of North Carolina School of Medicine, Chapel Hill, NC
| | - Federico E Parodi
- Department of Vascular Surgery, University of North Carolina School of Medicine, Chapel Hill, NC
| | - Jacob Wood
- Department of Vascular Surgery, University of North Carolina School of Medicine, Chapel Hill, NC
| | - Luigi Pascarella
- Department of Vascular Surgery, University of North Carolina School of Medicine, Chapel Hill, NC.
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Husman R, Tanaka A, George M, Cambiaghi T, Leonard SD, Motaganahalli RL, Fajardo A, Wang SK. An Analysis of Sex-Based Outcomes Following Transcarotid Artery Revascularization. Vasc Endovascular Surg 2022; 57:48-52. [PMID: 36167464 DOI: 10.1177/15385744221130861] [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: 11/17/2022]
Abstract
OBJECTIVE Several studies suggest that females have higher perioperative adverse events and decreased benefit from carotid artery revascularization with transfemoral carotid artery stenting and carotid endarterectomy (CEA) compared to males. However, there are limited data of sex-based outcomes for transcarotid artery revascularization (TCAR). METHODS A retrospective review of prospectively maintained system-wide TCAR databases was performed between December 2015-January 2022. Patients who underwent TCAR were stratified based on sex. Relevant demographics, medical conditions, anatomical characteristics, intra- and postoperative courses, and adverse events were captured. RESULTS 729 patients underwent TCAR, 486 (66.6%) male and 243 (33.3%) female. Males were more likely to be diagnosed with coronary artery disease (56.9% vs 47.7%, P<.01) and were active smokers (30.4% vs 21.4%, P < .01). Age, symptomatic status, BMI, hypertension, hyperlipidemia, diabetes mellitus, arrhythmia, chronic obstructive pulmonary disease, history of myocardial infarction, heart failure with reduced ejection fraction <30%, end-stage renal disease and Charlson Comorbidity Index were similar. In the perioperative period, there was no significant difference in reintervention rates (1.6% vs 1.2%, P = .75), cranial nerve palsy (.6% vs .4%, P > .99), ipsilateral stroke (1.9% vs 3.3%, P = .29), stent thrombosis (.4% vs .8%, P > .99), myocardial infarction (0% vs 0%, P > .99) and death (1.2% vs 1.2%, P > .99). In follow-up, no significant difference was found in reintervention, ipsilateral stroke, contralateral stroke, myocardial infarction, in-stent restenosis >50%, stent thrombosis, and death. CONCLUSIONS Males and females did not have a statistically significant difference in outcomes when comparing ipsilateral stroke, in-stent thrombosis, conversion to CEA, and death after TCAR. However, our cohort comprised predominantly male patients and may conceal statistical significance as the females in our cohort did have a higher tendency toward developing complications. Future studies with a larger female cohort should be conducted to determine whether there is a true disparity of outcomes between the males and females undergoing TCAR.
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Affiliation(s)
- Regina Husman
- 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
| | - Mitchell 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, TX, USA
| | - Tommaso Cambiaghi
- 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
| | - Samuel D Leonard
- 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
| | - Raghu L Motaganahalli
- Division of Vascular Surgery, Department of Surgery, 12250Indiana University School of Medicine, Indianapolis, IN, USA
| | - Andres Fajardo
- Division of Vascular Surgery, Department of Surgery, 12250Indiana University School of Medicine, Indianapolis, IN, 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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Li B, Eisenberg N, Howe KL, Forbes TL, Roche-Nagle G. The impact of sex on outcomes following carotid endarterectomy. Ann Vasc Surg 2022; 88:210-217. [PMID: 36029946 DOI: 10.1016/j.avsg.2022.08.003] [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: 06/30/2022] [Revised: 07/29/2022] [Accepted: 08/04/2022] [Indexed: 11/01/2022]
Abstract
BACKGROUND Previous studies have demonstrated significant sex differences in vascular surgery outcomes. We assessed stroke or death rates following carotid endarterectomy (CEA) in women vs. men. METHODS The Vascular Quality Initiative (VQI) was used to identify all patients who underwent CEA between 2010-2019. Demographic, clinical, and procedural characteristics were recorded and differences between women vs. men were assessed using independent t-test and chi-square test. The primary outcomes were 30-day and 1-year stroke or death. Associations between sex and outcomes were assessed using univariate/multivariate logistic regression and Cox proportional hazards analysis. RESULTS 52,137 women and 79,974 men underwent CEA in VQI sites during the study period. Women were younger (70.3 vs. 70.5 years, p < 0.001) and more likely to have hypertension (89.2% vs. 88.9%, p < 0.05) and diabetes (36.2% vs. 35.8%, p < 0.001), but less likely to be diagnosed with coronary artery disease (23.2% vs. 31.0%, p < 0.001). A greater proportion of men were receiving cardiovascular risk reduction medications and had symptomatic carotid stenosis (28.5% vs. 26.7%, p < 0.001). Women had shorter procedure times (113 vs. 122 minutes, p < 0.001) and were less likely to receive electroencephalography neuromonitoring (27.9% vs. 28.8%, p < 0.001), drain (35.9% vs. 37.3%, p < 0.001), and protamine (67.4% vs. 68.0%, p < 0.01). Stroke or death at 30 days (1.9% vs. 1.8%, p = 0.60) and 1 year (HR 0.98 [95% CI 0.94 - 1.01], p = 0.20) were similar between groups, which persisted in asymptomatic patients (HR 0.97 [95% CI 0.93 - 1.01], p = 0.17) and symptomatic patients (HR 0.99 [95% CI 0.93 - 1.05], p = 0.71). The similarities in 1-year stroke or death rates existed in both the US (HR 0.96 [95% CI 0.92 - 1.01], p = 0.09) and Canada (HR 1.21 [95% CI 0.47 - 3.11], p = 0.70). CONCLUSIONS Despite sex differences in clinical and procedural characteristics, women and men have similar 30-day and 1-year outcomes following carotid endarterectomy.
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Affiliation(s)
- Ben Li
- Division of Vascular Surgery, Peter Munk Cardiac Centre, University Health Network, University of Toronto, Toronto, Ontario, Canada
| | - Naomi Eisenberg
- Division of Vascular Surgery, Peter Munk Cardiac Centre, University Health Network, University of Toronto, Toronto, Ontario, Canada
| | - Kathryn L Howe
- Division of Vascular Surgery, Peter Munk Cardiac Centre, University Health Network, University of Toronto, Toronto, Ontario, Canada
| | - Thomas L Forbes
- Division of Vascular Surgery, Peter Munk Cardiac Centre, University Health Network, University of Toronto, Toronto, Ontario, Canada
| | - Graham Roche-Nagle
- Division of Vascular Surgery, Peter Munk Cardiac Centre, University Health Network, University of Toronto, Toronto, Ontario, Canada.
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Ho-Yan Lee M, Li PY, Li B, Shakespeare A, Samarasinghe Y, Feridooni T, Cuen-Ojeda C, Alshabanah L, Kishibe T, Al-Omran M. A systematic review and meta-analysis of sex- and gender-based differences in presentation severity and outcomes in adults undergoing major vascular surgery. J Vasc Surg 2022; 76:581-594.e25. [DOI: 10.1016/j.jvs.2022.02.030] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2021] [Accepted: 02/24/2022] [Indexed: 11/25/2022]
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Dudanov IP, Ordinec SV, Zelenin VV, Kudrijavcev OI, Vryganov FA. [Carotid endarterectomy with stent removal in a patient with early bilateral restenosis of the internal carotid arteries in the acute period of recurrent ischemic stroke]. Zh Nevrol Psikhiatr Im S S Korsakova 2021; 121:88-92. [PMID: 34932292 DOI: 10.17116/jnevro202112111188] [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: 11/18/2022]
Abstract
We present a rare clinical observation of a patient with an early reoperation performed up to 2 weeks after a recurrent stroke. Carotid endarterectomy with removal of previously installed stents for critical stenoses of the internal carotid arteries after the first stroke was performed. Early bilateral restenosis up to 80-90% of the lumen in the stents of both internal carotid arteries was observed 6 months after stenting. Open interventions were performed in the acute period of recurrent ischemic stroke in two stages with a favorable outcome. No data on the increase of neurological symptoms were obtained for 2 years of observation. Treatment and application of early rehabilitation methods, improved the patient's general condition, strength in the left extremities increased up to 4.5 points, left-sided hemihypesthesia decreased, speech disorders regressed. The patient walks and serves himself independently.
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Affiliation(s)
- I P Dudanov
- Petrozavodsk State University, Petrozavodsk, Russia.,Mariinsky Hospital, Regional Cardiovascular Center, St. Petersburg, Russia
| | - S V Ordinec
- Mariinsky Hospital, Regional Cardiovascular Center, St. Petersburg, Russia
| | - V V Zelenin
- Mariinsky Hospital, Regional Cardiovascular Center, St. Petersburg, Russia
| | - O I Kudrijavcev
- Mariinsky Hospital, Regional Cardiovascular Center, St. Petersburg, Russia
| | - F A Vryganov
- Petrozavodsk State University, Petrozavodsk, Russia
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Cui CL, Zarrintan S, Marmor RA, Nichols J, Cajas-Monson L, Malas M. Performance of Carotid Revascularization Procedures as Modified by Sex. Ann Vasc Surg 2021; 81:171-182. [PMID: 34752853 DOI: 10.1016/j.avsg.2021.08.051] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2021] [Revised: 08/27/2021] [Accepted: 08/31/2021] [Indexed: 11/25/2022]
Abstract
BACKGROUND Current recommendations on carotid revascularization postulate that women have both increased perioperative risks, such as stroke and death, as well as reduced benefit from intervention. These recommendations do not include data on transcarotid artery revascularization (TCAR). This study strives to compare safety and benefits of TCAR, TFCAS (Transfemoral Carotid Artery Stenting), and CEA (Carotid Endarterectomy) with regard to patient sex. METHODS We performed retrospective analysis of the Society for Vascular Surgery (SVS) Vascular Quality Initiative (VQI) CEA and stenting registries, as well as TCAR Surveillance Project data. We compared outcomes after TCAR, TFCAS, and CEA based on sex. The primary outcome was the rate of in-hospital stroke or death. Secondary outcomes included in-hospital stroke, death, transient ischemic attack (TIA), myocardial infarction (MI), stroke/death/MI, stroke/TIA, and recurrent ipsilateral stroke and/or death at 1-year of follow-up. RESULTS A total of 75,538 patients were included, of which 28,960 (38.3%) were female and 46,578 (61.7%) were male. TFCAS females had more than 2 times higher odds of stroke/death (OR:2.85, 95%CI: 2.21-3.67, P < 0.001) and stroke/death/MI (OR:2.23, 95%CI:1.75-2.83, P < 0.001) when compared to CEA females. Odds of TIA were also higher in both TFCAS females (OR:2.01, 95%CI:1.19-3.42, P = 0.010) and TCAR females (OR:1.91, 95%CI:1.09-3.35, P = .023) when compared to CEA females. However, only TFCAS females experienced increased odds of stroke/TIA (OR:1.96, 95%CI:1.45-2.65, P < 0.001) when compared to CEA females. TFCAS males had almost twice the odds of stroke/death (OR:1.74, 95%CI:1.39-2.16, P < 0.001) and 44% higher odds of stroke/death/MI (OR:1.44, 95%CI:1.19-1.75, P < 0.001), and more than 3-times increased odds of death (OR:3.45, 95%CI:2.53-4.71, P < 0.001) when compared to CEA males. Odds of in-hospital stroke were comparable between TFCAS and CEA after adjusting for covariates. TCAR males have half the odds of MI when compared to CEA males (OR:0.52, 95%CI:0.34-0.80, P = 0.003). At 1-year TCAR had comparable risk of stroke/death while TFCAS had increased risk of stroke/death when compared to CEA among both males and females. CONCLUSION TCAR performed similarly to CEA in both sexes regardless of symptomatic status. Stroke/death and stroke/death/MI rates were similar in symptomatic and asymptomatic males and females treated by CEA or TCAR. The 1-year outcomes of TCAR were also comparable to CEA in both sexes. It seems that TCAR may be a safe alternative to CEA particularly in women when surgical risk prohibits CEA and while TFCAS is associated with substantial adverse outcomes.
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Goicoechea S, Walsh M, Soult M, Halandras PM, Bechara C, Aulivola B, Crisostomo P. Female Gender Increases Risk of Stroke and Readmission after CEA and CAS. J Vasc Surg 2021; 75:1935-1944. [PMID: 34740804 DOI: 10.1016/j.jvs.2021.10.034] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2020] [Accepted: 10/21/2021] [Indexed: 11/15/2022]
Abstract
OBJECTIVES Carotid endarterectomy (CEA) has historically demonstrated a higher rate of perioperative adverse events for female patients. However, recent evidence suggests similar outcomes for CEA between genders. In contrast, fewer studies have examined gender in carotid artery stenting (CAS). Using contemporary data from the American College of Surgeons (ACS) National Surgical Quality Improvement Program (NSQIP) database, we aim to determine if gender impacts differences in postoperative complications in patients who undergo CEA or CAS. METHODS The ACS NSQIP database was queried from 2005-2017 using Current Procedural Terminology (CPT) and International Classification of Diseases (ICD) codes for retrospective review. Patients with carotid intervention (CEA or CAS) were stratified into asymptomatic vs symptomatic cohorts to determine the effect of gender on 30-day postoperative outcomes. Symptomatic patients were defined as those with perioperative transient cerebral ischemic attack or stenosis of carotid artery with cerebral infarction. Descriptive statistics were calculated. Risk-adjusted odds of 30-day postoperative outcomes were calculated using multivariate regression analysis with fixed effects for age, race, and comorbidities. RESULTS There were 106,568 patients with CEA or CAS (104,412 CEA and 2,156 CAS). Average age was 70.9 years old and female patients accounted for 39.9% of the population. For asymptomatic patients that underwent CEA or CAS, female gender was associated with significantly higher rates of CVA/stroke (13%, p=0.005), readmission (10%, p=0.004), bleeding complication (32%, p=0.001), and UTI (54%, p=0.001) as well as less infection (26%, p=0.001). In the symptomatic cohort, female gender was associated with significantly higher rates of CVA/stroke (32%, p=0.034), bleeding complication (203%, p=0.001), and UTI (70%, p=0.011), while female gender was associated with a lower rate of pneumonia (39%, p=0.039). Subset analysis found that, compared to male patients, female patients <75yo have an increased rate of CVA/stroke (21%, p=0.001) and readmission (15%, p<0.001), while female patients ≥75yo did not. In asymptomatic and symptomatic patients that underwent CEA, female gender was associated with significantly higher rates of CVA/stroke (13%, p=0.006 and 31%, p=0.044, respectively), but this finding was present not in patients undergoing CAS. CONCLUSION In patients undergoing carotid intervention, female gender was associated with significantly increased rates of postoperative CVA/stroke in the asymptomatic and symptomatic cohorts as well as readmission in the asymptomatic cohort. Female gender was associated with higher rates of CVA/stroke following CEA, but not CAS. We recommend that randomized control trials ensure adequate representation of female patients to better understand gender-based disparities in carotid intervention.
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Affiliation(s)
- Steven Goicoechea
- Department of Surgery, Loyola University Medical Center, Maywood, IL
| | - Martin Walsh
- Department of Surgery, Loyola University Medical Center, Maywood, IL
| | - Michael Soult
- Department of Surgery, Division of Vascular Surgery and Endovascular Therapy, Loyola University Medical Center, Maywood, IL
| | - Pegge M Halandras
- Department of Surgery, Division of Vascular Surgery and Endovascular Therapy, Loyola University Medical Center, Maywood, IL
| | - Carlos Bechara
- Department of Surgery, Division of Vascular Surgery and Endovascular Therapy, Loyola University Medical Center, Maywood, IL
| | - Bernadette Aulivola
- Department of Surgery, Division of Vascular Surgery and Endovascular Therapy, Loyola University Medical Center, Maywood, IL
| | - Paul Crisostomo
- Department of Surgery, Division of Vascular Surgery and Endovascular Therapy, Loyola University Medical Center, Maywood, IL.
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Valle CED, Miyamotto M, Timi JRR. Experimental comparative assay of tensile resistance of greater saphenous vein from ankle and groin. J Vasc Bras 2021; 20:e20190117. [PMID: 34249114 PMCID: PMC8244984 DOI: 10.1590/1677-5449.190117] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2019] [Accepted: 10/31/2019] [Indexed: 11/26/2022] Open
Abstract
Background The great saphenous vein is used as patch material in several types of arterial reconstruction, including trauma and carotid and femoral endarterectomy. There have been reports of saphenous patch blowout, particularly of patches constructed with veins harvested from the ankle. There is a need for objective measurement of the resistance of saphenous vein tissues. Objectives To measure the tensile strength of the great saphenous vein harvested at the ankle and groin and analyze the correlation between diameter and tissue strength. Methods Venous samples were harvested during elective saphenous stripping in patients with symptomatic varicose veins. Only segments without reflux were included. Ten limbs from eight patients were studied, providing 20 samples in total. Venous segments were opened along their longitudinal axis and fitted to electronic traction assay equipment to obtain values for material maximum tension in kilograms-force per square centimeter (kgf/cm2; the maximum force resisted by the segment, divided by its cross-sectional area). Results The average maximum tension in the ankle saphenous vein group ranged from 74.02 to 190.10 kgf/cm2 and from 13.53 to 69.45 kgf/cm2 in the groin saphenous vein group (p < 0.0001). The Pearson coefficient for the correlation between vein diameter and maximum tension was -0.852 (moderate to strong inverse correlation). Conclusions Ankle saphenous vein tissue from female patients operated for varicose veins has significantly higher resistance than saphenous vein tissue from the groin and there is an inverse relation between vein diameter and resistance of tissue from the same population.
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Affiliation(s)
- Carlos Eduardo Del Valle
- Universidade Federal do Paraná - UFPR, Hospital de Clínicas, Unidade de Cardiologia e Pneumologia, Curitiba, PR, Brasil
| | - Marcio Miyamotto
- Pontifícia Universidade Católica do Paraná - PUC-PR, Curitiba, PR, Brasil.,Hospital Universitário Cajuru - HUC, Serviço de Cirurgia Vascular e Endovascular, Curitiba, PR, Brasil.,Instituto VESSEL de Aperfeiçoamento Endovascular, Curitiba, PR, Brasil.,Hospital Nossa Senhora das Graças - HNSG, Serviço de Cirurgia Vascular e Endovascular Elias Abrão, Curitiba, PR, Brasil
| | - Jorge Rufino Ribas Timi
- Universidade Federal do Paraná - UFPR, Hospital de Clínicas, Unidade de Cardiologia e Pneumologia, Curitiba, PR, Brasil.,Núcleo Integrado de Cirurgia Endovascular do Paraná - NICEP, Curitiba, PR, Brasil
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12
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Sex-related disparities in intervention rates and type of intervention in patients with aortic and peripheral arterial diseases in the National Inpatient Sample Database. J Vasc Surg 2021; 73:2081-2089.e7. [PMID: 33301865 PMCID: PMC9945691 DOI: 10.1016/j.jvs.2020.11.034] [Citation(s) in RCA: 29] [Impact Index Per Article: 9.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2020] [Accepted: 11/25/2020] [Indexed: 02/07/2023]
Abstract
OBJECTIVE The first annual Women's Vascular Summit highlighted sex- and gender-related knowledge gaps in vascular disease diagnosis and treatment. This finding suggests an opportunity for further research to improve care and outcomes in people who identify as women, specifically. The purpose of this study was to a large national dataset to identify all operations performed for abdominal aortic aneurysm (AAA), carotid artery stenosis (CAS), and peripheral arterial disease (PAD) in the United States, and to provide data on sex-related disparities in treatment. METHODS All hospitalizations of adult patients (≥18 years old) diagnosed with AAA, CAS, or PAD who underwent vascular surgery from 2000 to 2016 were identified in the Healthcare Cost and Utilization Project National Inpatient Sample. Sex-stratified U.S. Census data and sex-specific population disease prevalence estimates from the National Institute of Health and Agency for Healthcare Research and Quality were used to calculate the number of U.S. adults with AAA, CAS, and PAD. Sex-stratified rates of surgery and incidence rate ratios were estimated using Poisson regression. Among those undergoing surgery, multivariable logistic regression was used to assess differences in endovascular vs open approach. RESULTS Over 16 years, there were 1,021,684 hospitalizations for vascular surgery: 13% AAA (21% female, 79% male), 40% CAS (42% female, 58% male), and 47% PAD (42% female, 58% male). Females were older than males at time of surgery (median age, 71.3 years vs 69.7 years) and less likely to have private insurance (18% vs 23%); minimal differences were seen across race/ethnicity, comorbidities, and hospital characteristics. After accounting for disease prevalence, females were still 25% less likely to undergo surgery for AAA and 30% less likely to undergo surgery for PAD compared with males with the same disease. These results were consistent over time. After adjustment, females, compared with males, were less likely to receive an endovascular procedure compared with open for AAA or CAS, and more likely to receive one for PAD. CONCLUSIONS From 2000 to 2016 in the United States, females were less likely to undergo intervention for AAA and PAD than males. This finding is particularly significant for PAD, because the prevalence is the same for both sexes, indicating that females are likely undertreated for PAD. Additionally, females were less likely to undergo endovascular surgery for AAA and more likely to undergo endovascular surgery for PAD than males. These findings suggest that improvement in AAA and PAD identification and management in females may improve outcomes.
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Ansuategui M, Ibarra G, Romero C, Comanges A, Gonzalez-Fajardo JA. Carotid artery stenting has similar outcomes in men and women. J Vasc Bras 2021; 20:e20200169. [PMID: 34104132 PMCID: PMC8166161 DOI: 10.1590/1677-5449.200169] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
Background The aim of carotid interventions is to prevent cerebrovascular events. Endovascular treatment (carotid-artery-stenting/CAS) has become established as an alternative to open surgery in some cases. Historically, female sex has been considered as a perioperative risk factor, however, there are few studies regarding this hypothesis when it comes to CAS. Objectives To analyze the CAS results in our center adjusted by sex. Methods A retrospective cohort study was designed, including patients with carotid atheromatosis operated at a single center from January 2016 to June 2019. Our objective was to compare cardiovascular risk, including myocardial infarction, stroke, and mortality, by sex. Follow-up rates of stent patency, restenosis, stroke, myocardial infarction, and death were reported. Results 71 interventions were performed in 50 men (70.42%) and 21 women (29.57%). Mean age was 70.50 ± 10.72 years for men and 73.62 ± 11.78 years for women. Cardiovascular risk factors did not differ significantly between sexes. Mean follow-up was 11.28 ± 11.28 months. There were no significant differences in neurological events during follow-up. No adverse cardiological events were detected at any time. Regarding the mortality rate, during medium-term follow up there were 2 neurological related deaths with no significant differences between sexes (p=0.8432). Neither sex had higher rated of restenosis during long term follow-up (5.63% vs. 1.41%, p = 0.9693) or reoperation (1.41% vs. 1.41%, p = 0.4971). All procedures remained patent (<50% restenosis). Conclusions Despite the limitations of our study, CAS is a therapeutic option that is as effective and safe in women as in men. No sex differences were observed.
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Knappich C, Tsantilas P, Salvermoser M, Schmid S, Kallmayer M, Trenner M, Eckstein HH, Kuehnl A. Editor's Choice - Distribution of Care and Hospital Incidence of Carotid Endarterectomy and Carotid Artery Stenting: A Secondary Analysis of German Hospital Episode Data. Eur J Vasc Endovasc Surg 2021; 62:167-176. [PMID: 33966984 DOI: 10.1016/j.ejvs.2021.03.021] [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: 08/12/2020] [Revised: 03/10/2021] [Accepted: 03/21/2021] [Indexed: 10/21/2022]
Abstract
OBJECTIVE This is a description of the German healthcare landscape regarding carotid artery disease, assessment of hospital incidence time courses for carotid endarterectomy (CEA) and carotid artery stenting (CAS), and simulation of potential effects of minimum hospital caseload requirements for CEA and CAS. METHODS The study is a secondary data analysis of diagnosis related group statistics data (2005-2016), provided by the German Federal Statistical Office. Cases encoded by German operation procedure codes for CEA or CAS and by International Classification of Diseases (ICD-10) codes for carotid artery disease were included. Hospitals were categorised into quartiles according to annual caseloads. Linear distances to the closest hospital fulfilling hypothetical caseload requirements were calculated. RESULTS A total of 132 411 and 33 709 patients treated with CEA and CAS from 2012 to 2016 were included. CEA patients had lower rates of myocardial infarction (1.4% vs. 1.8%) and death (1.2% vs. 4.0%), and CAS patients were more often treated after emergency admission (38.1% vs. 27.1%). Age standardised annual hospital incidences were 67.2 per 100 000 inhabitants for CEA and 16.3 per 100 000 inhabitants for CAS. The incidence for CEA declined from 2005 to 2016, with CAS rising again until 2016 after having declined from 2010 to 2013. Regarding distance from home to hospital, centres offering CEA are distributed more homogeneously across Germany, compared with those performing CAS. Hypothetical introduction of minimum annual caseloads (> 20 for CEA; > 10 for CAS) imply that 75% of the population would reach their hospital after travelling 45 km for CEA and 70 km for CAS. CONCLUSION Differences in spatial distribution mean that statutory minimum annual caseloads would have a greater impact on CAS accessibility than CEA in Germany. Presumably because of a decline in carotid artery disease and a transition towards individualised therapy for asymptomatic patients, hospital incidence for CEA has been declining.
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Affiliation(s)
- Christoph Knappich
- Department for Vascular and Endovascular Surgery, Klinikum rechts der Isar, Technical University of Munich, Munich, Germany
| | - Pavlos Tsantilas
- Department for Vascular and Endovascular Surgery, Klinikum rechts der Isar, Technical University of Munich, Munich, Germany
| | - Michael Salvermoser
- Department for Vascular and Endovascular Surgery, Klinikum rechts der Isar, Technical University of Munich, Munich, Germany
| | - Sofie Schmid
- Department for Vascular and Endovascular Surgery, Klinikum rechts der Isar, Technical University of Munich, Munich, Germany
| | - Michael Kallmayer
- Department for Vascular and Endovascular Surgery, Klinikum rechts der Isar, Technical University of Munich, Munich, Germany
| | - Matthias Trenner
- Department for Vascular and Endovascular Surgery, Klinikum rechts der Isar, Technical University of Munich, Munich, Germany
| | - Hans-Henning Eckstein
- Department for Vascular and Endovascular Surgery, Klinikum rechts der Isar, Technical University of Munich, Munich, Germany
| | - Andreas Kuehnl
- Department for Vascular and Endovascular Surgery, Klinikum rechts der Isar, Technical University of Munich, Munich, Germany.
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Lanza G, Giannandrea D, Lanza J, Ricci S, Gensini GF. Personalized-medicine on carotid endarterectomy and stenting. ANNALS OF TRANSLATIONAL MEDICINE 2020; 8:1274. [PMID: 33178806 PMCID: PMC7607117 DOI: 10.21037/atm-20-1126] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
Evidence based medicine (EBM) is the core of current clinical guidelines and is considered as the gold standard of clinical practice. Despite this, a number of limitations and criticisms are moved to EBM. The major one is that this method privileges randomized controlled trials (RCTs), in which the selection of patients is often based on rigid inclusion criteria. The lack of “pragmatism” of some RCTs sometimes makes it difficult to apply guidelines that derive from them to patients observed in clinical practice, who are often affected by comorbidities and disabilities. The new paradigm to overcome this limitation is personalized medicine (PM), which aims to take into account the particular characteristics displayed by the individual. In order to tailor the best treatment for the patient, PM uses EBM but emphasizes the person's specific information from the assessment of the clinic, lifestyle and risk/benefit scores. This narrative review tries to find the best evidence by analysing subgroups and risk scores of patients from meta-analysis and RCTs in order to try to apply PM and to provide good practice points (GPP) on grey aspects and open questions not fully covered by current guidelines on carotid endarterectomy (CEA) and stenting for stroke prevention.
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Affiliation(s)
- Gaetano Lanza
- Vascular Surgery Department, IRCCS MultiMedica Hospital, Castellanza, Italy
| | - David Giannandrea
- Neurology Department-Stroke Unit, Gubbio/Gualdo Tadino and Città di Castello Hospitals, USL Umbria 1, Perugia, Italy.,Association "Naso Sano", Umbria Regional Registry of No-Profit Organization, Corciano, Italy
| | - Jessica Lanza
- ASST Fatebenefratelli Sacco, Angioma Center, Vittore Buzzi Hospital, Milan, Italy
| | - Stefano Ricci
- Neurology Department-Stroke Unit, Gubbio/Gualdo Tadino and Città di Castello Hospitals, USL Umbria 1, Perugia, Italy
| | - Gian Franco Gensini
- Permanent Technical Committee for Guidelines, Tuscany Regional Health Service, Florence, Italy
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Carotid Artery Stenting in Asymptomatic Carotid Artery Stenosis: JACC Review Topic of the Week. J Am Coll Cardiol 2020; 75:648-656. [PMID: 32057380 DOI: 10.1016/j.jacc.2019.11.054] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/08/2019] [Accepted: 11/19/2019] [Indexed: 01/22/2023]
Abstract
The advance of therapies to reduce the stroke impact of asymptomatic carotid artery stenosis has proved difficult over the last decade. Disagreement concerning the underlying randomized control trials has limited entry into the care arena of endovascular therapies. Recently, advances in percutaneous therapies for carotid artery disease have been reported and provide a substantial database supporting the further incorporation of endovascular-based therapies in patients who need revascularization and meet selection criteria. With a second randomized control trial now published, it is time for a re-evaluation of endovascular therapy as a component of carotid artery care. This review describes the advances in the field in the last 5 years, clarifying the current position of these therapies in the care of the patient with asymptomatic carotid artery disease.
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Dansey KD, Pothof AB, Zettervall SL, Swerdlow NJ, Liang P, Schneider JR, Nolan BW, Schermerhorn ML. Clinical impact of sex on carotid revascularization. J Vasc Surg 2020; 71:1587-1594.e2. [PMID: 32014286 DOI: 10.1016/j.jvs.2019.07.088] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2019] [Accepted: 07/02/2019] [Indexed: 12/21/2022]
Abstract
BACKGROUND The impact of sex in the management of carotid disease is unclear in the current literature. Therefore, we evaluated the effect of sex on perioperative outcomes following carotid endarterectomy (CEA) and carotid artery stenting (CAS). METHODS We included patients who underwent CEA or CAS between 2012 and 2017 in the Vascular Quality Initiative database. Our primary outcome was perioperative stroke/death. Secondary outcomes were in-hospital stroke, 30-day mortality, and in-hospital MI. We compared perioperative outcomes between female and male patients, stratified by treatment modality and symptom status, and used multivariable regression to account for differences in baseline characteristics. RESULTS A total of 83,436 patients underwent either a CEA (71,383) or CAS (12,053). Asymptomatic and symptomatic CEA females were less likely to be on a preoperative antiplatelet agent, when compared to males. Females overall, were less likely to be on a preoperative statin and more likely to have chronic obstructive pulmonary disease. Within the CAS cohort, females were more likely to have a previous ipsilateral CEA. There were no differences between males and females in major adverse events following CEA for asymptomatic disease. Following CEA for symptomatic disease, there was no difference in stroke/death rate or in-hospital stroke. However, females experienced a higher 30-mortality after adjustment (univariate: 1.0% vs 0.7%, P = .04; adjusted: odds ratio [OR], 1.4:1.02-1.94). Following CAS for asymptomatic disease, females experienced a higher rate of perioperative stroke/death (2.9% vs 1.9% P = .02; OR, 1.5: 1.05-2.03) and in-hospital stroke (2.1% vs 1.2% P = .01; OR, 1.8: 1.20-2.60). There were no differences in outcomes for symptomatic females vs males undergoing CAS. CONCLUSIONS Females with carotid disease less frequently receive optimal medical treatment with antiplatelet agents and statins. This is an important target area for quality improvement issue in both females and males. Furthermore, among symptomatic CEA patients the female sex is associated with higher mortality and among asymptomatic CAS patients, females experience higher rates of stroke/death. These findings suggest that careful patient selection is necessary in the treatment of female patients. Quality improvement projects should be created to further investigate and eliminate the disparities of optimal medical management between the sexes.
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Affiliation(s)
- Kirsten D Dansey
- Division of Vascular and Endovascular Surgery, Beth Israel Deaconess Medical Center, Boston, Mass
| | - Alexander B Pothof
- Department of Vascular Surgery, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Sara L Zettervall
- Division of Vascular and Endovascular Surgery, Beth Israel Deaconess Medical Center, Boston, Mass
| | - Nicholas J Swerdlow
- Division of Vascular and Endovascular Surgery, Beth Israel Deaconess Medical Center, Boston, Mass
| | - Patric Liang
- Division of Vascular and Endovascular Surgery, Beth Israel Deaconess Medical Center, Boston, Mass
| | | | - Brian W Nolan
- Division of Vascular and Endovascular Surgery, Maine Medical Center, Portland, Me
| | - Marc L Schermerhorn
- Division of Vascular and Endovascular Surgery, Beth Israel Deaconess Medical Center, Boston, Mass.
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Lackey AR, Durham F, Voeks JH, Lal BK. Clinical consideration of biologic sex on the choice of revascularization technique: does (should) sex affect the choice of carotid artery stenting versus carotid endarterectomy? ITALIAN JOURNAL OF VASCULAR AND ENDOVASCULAR SURGERY 2020. [DOI: 10.23736/s1824-4777.19.01435-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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19
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Hicks CW, Daya NR, Black JH, Matsushita K, Selvin E. Race and sex-based disparities associated with carotid endarterectomy in the Atherosclerosis Risk in Communities (ARIC) study. Atherosclerosis 2020; 292:10-16. [PMID: 31731080 PMCID: PMC6928429 DOI: 10.1016/j.atherosclerosis.2019.10.019] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/23/2019] [Revised: 10/12/2019] [Accepted: 10/30/2019] [Indexed: 01/09/2023]
Abstract
BACKGROUND AND AIMS The indications for carotid endarterectomy (CEA) are well established. The aim of the current study was to investigate sex and race-based disparities in the incidence of CEA after adjusting for carotid artery stenosis risk factors. METHODS We conducted a prospective cohort analysis of 14,492 black and white participants in the Atherosclerosis Risk in Communities (ARIC) study without prevalent stroke at baseline (1987-1989). We used Kaplan-Meier curves and Cox proportional hazards models adjusting for sociodemographic, cardiovascular, and disease severity risk factors to quantify the associations of sex and race with incident CEA. RESULTS CEA was performed in 330 of 14,492 ARIC participants during a median of 27 years of follow-up [incidence rate 1.00 (95% CI 0.90-1.12) per 1000 persons-years]. The crude incidence of CEA varied significantly by sex [female vs. male: HR 0.60 (95% CI 0.48-0.74)] and race [black vs. white: HR 0.65 (95% CI 0.49-0.86)]. Adjustment for sociodemographic and cardiovascular risk factors, carotid intima-media thickness, and symptomatic status attenuated the association of sex with CEA [females vs. males HR 0.96 (0.76-1.22)], but black participants had a lower risk of incident CEA after adjustment [HR 0.68 (95% CI 0.49-0.95)]. CONCLUSIONS We found significant variation in the incidence of CEA procedures based on race that was independent of traditional risk factors and carotid IMT. Whether this disparity is a reflection of differences in disease presentation or access to care deserves investigation.
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Affiliation(s)
- Caitlin W Hicks
- Division of Vascular Surgery and Endovascular Therapy, Johns Hopkins University School of Medicine, Baltimore, MD, USA.
| | - Natalie R Daya
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - James H Black
- Division of Vascular Surgery and Endovascular Therapy, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Kunihiro Matsushita
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Elizabeth Selvin
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
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Jeong MJ, Kwon SU, Kim MJ, Han Y, Kwon TW, Cho YP. Effects of patient age on outcomes after carotid endarterectomy: A retrospective, single-center study in Korea. Medicine (Baltimore) 2019; 98:e16781. [PMID: 31393403 PMCID: PMC6708719 DOI: 10.1097/md.0000000000016781] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
In this single-center, retrospective study, we aimed to compare early and late outcomes after carotid endarterectomy (CEA) between younger and elderly patients and to investigate the impact of patient age on the overall incidence of cardiovascular events after CEA.A total of 613 patients with 675 CEAs between January 2007 and December 2014 were stratified by patient age into 2 groups: younger (≤60 years, n = 103 CEAs, 15.3%) and elderly (>60 years, n = 572 CEAs, 84.7%) groups. The study outcomes were defined as the occurrence of major adverse events (MAEs), including fatal or nonfatal stroke or myocardial infarction (MI), or any-cause mortality, and overall cardiovascular events (meaning the composite incidence of stroke or MI) during the perioperative period and within 4 years after CEA.Although there were no significant differences in the incidence of 30-day MAEs and any of the individual MAE manifestations between the 2 groups, the differences in the MAE incidence (P = .006) and any-cause mortality (P = .023) within 4 years after CEA were significantly greater in patients in the elderly group. For overall incidence of cardiovascular events, no significant difference was noted between the 2 groups (P = .096). On multivariate analysis, older age (>60 years) did not affect the incidence of perioperative MAEs and individual MAE manifestations; however, older age was significantly associated with an increased risk of 4-year MAEs (hazard ratio [HR], 3.68, 95% confidence interval [CI], 1.35-10.0; P = .011) and any-cause mortality (HR, 3.26, 95% CI, 1.02-10.5; P = .047). With regard to the 4-year overall incidence of cardiovascular events, older age was not an independent predictor of increased risk of these cardiovascular events.Our study indicates that the risks of perioperative MAEs and the 4-year overall incidence of cardiovascular events do not significantly differ between younger and elderly Korean patients undergoing CEA, although there was a higher risk of 4-year any-cause mortality in the elderly patients. Older age does not appear to be an independent risk factor for perioperative MAEs and overall cardiovascular events within 4 years after CEA.
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Affiliation(s)
| | | | - Min-Ju Kim
- Departments of Clinical Epidemiology and Biostatistics, University of Ulsan College of Medicine and Asan Medical Center, Seoul, Republic of Korea
| | - Youngjin Han
- Department of Surgery, Division of Vascular Surgery
| | - Tae-Won Kwon
- Department of Surgery, Division of Vascular Surgery
| | - Yong-Pil Cho
- Department of Surgery, Division of Vascular Surgery
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Age but not sex is associated with higher risk of in-hospital stroke or death after carotid artery stenting in symptomatic and asymptomatic carotid stenosis. J Vasc Surg 2019; 69:1090-1101.e3. [DOI: 10.1016/j.jvs.2018.03.439] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2017] [Accepted: 03/30/2018] [Indexed: 11/20/2022]
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22
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Nevidomskyte D, Tang GL, Shin SH, Hatsukami TS, Khor S, Flum DR, Meissner MH, Shalhub S. Comparison of outcomes in women and men following carotid interventions in the Washington state's Vascular Interventional Surgical Care and Outcomes Assessment Program. J Vasc Surg 2019; 69:1121-1128. [DOI: 10.1016/j.jvs.2018.08.152] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2017] [Accepted: 08/08/2018] [Indexed: 12/01/2022]
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23
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Casana R, Malloggi C, Tolva VS, Odero A, Bulbulia R, Halliday A, Silani V, Parati G. Three-year outcomes after carotid artery revascularization: Gender-related differences. Vascular 2019; 27:459-467. [PMID: 30860445 DOI: 10.1177/1708538119836312] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Objectives Carotid artery stenosis is thought to cause up to 10% of ischemic strokes. Historically, carotid artery endarterectomy has shown a higher risk of perioperative adverse events for women. More recent trials reported conflicting results regarding the benefit of carotid artery endarterectomy and carotid artery stenting for men and women. The aim of the present retrospective study was to investigate the influence of gender on the short- (30 days) and long-term (3 years) outcomes of carotid artery endarterectomy and carotid artery stenting in a single centre. Methods From 2010 to 2017, 912 consecutive symptomatic and asymptomatic patients who underwent carotid artery endarterectomy (389, 42.7%) or carotid artery stenting (523, 57.3%) in a single institution had been evaluated to determine the influence of sex (540 men, 59.2%, vs. 372 women, 40.8%) on the outcomes after both revascularization procedures during three years of follow-up. The primary endpoint was the incidence of death, stroke, myocardial infarction, and restenosis in the short-term follow-up. The secondary endpoint was the incidence of death, stroke, myocardial infarction, and restenosis in the long-term follow-up. Results Mean clinical follow-up was 21.1 (16.1) months. Women had internal and common carotid artery diameters significantly smaller with respect to men. For peri-procedural outcomes, women undergoing carotid artery stenting had a higher risk of moderate (50–70%) restenosis (6 women, 2.9%, vs. 3 men, 1.0%). For long-term outcomes, women undergoing carotid artery endarterectomy had a higher rate of moderate restenosis (16 women, 16.3%, vs. 11 men, 7.6%). No significant differences in long-term outcomes were observed between men and women undergoing carotid artery stenting, even after stratification for baseline risk factors. Conclusions Contrary to previous reports, from this single-centre study, long-term risk of events seems to be higher in women who underwent carotid artery endarterectomy than in those who underwent carotid artery stenting, while fewer differences were observed in men.
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Affiliation(s)
- Renato Casana
- Istituto Auxologico Italiano, IRCCS, Centro Chirurgia Vascolare, Auxologico Capitanio, Milano, Italy.,Istituto Auxologico Italiano, IRCCS, Laboratorio Sperimentale di Ricerche di Chirurgia Vascolare, Milano, Italy
| | - Chiara Malloggi
- Istituto Auxologico Italiano, IRCCS, Laboratorio Sperimentale di Ricerche di Chirurgia Vascolare, Milano, Italy
| | | | - Andrea Odero
- Istituto Auxologico Italiano, IRCCS, Centro Chirurgia Vascolare, Auxologico Capitanio, Milano, Italy
| | - Richard Bulbulia
- Clinical Trial Service Unit, Nuffield Department of Population Health, University of Oxford, Oxford, UK.,MRC Population Health Research Unit, Nuffield Department of Population Health, University of Oxford, Oxford, UK
| | - Alison Halliday
- Nuffield Department of Surgical Sciences, University of Oxford, Oxford, UK
| | - Vincenzo Silani
- Istituto Auxologico Italiano, IRCCS, Dipartimento di Neurologia e Stroke Unit e Laboratorio di Ricerche di Neuroscienze, Ospedale San Luca, Milano, Italy.,Dipartimento di Fisiopatologia Medico-Chirurgica e dei Trapianti, Centro 'Dino Ferrari', Università degli Studi di Milano, Milano, Italy
| | - Gianfranco Parati
- Istituto Auxologico Italiano, IRCCS, Dipartimento di Scienze Cardiovascolari, Neurologiche, Metaboliche, Ospedale San Luca, Milano, Italy.,Dipartimento di Medicina e Chirurgia, Università di Milano-Bicocca, Milano, Italy
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Huang Y, Gloviczki P, Duncan AA, Kalra M, Oderich GS, DeMartino RR, Harmsen WS, Bower TC. Outcomes after early and delayed carotid endarterectomy in patients with symptomatic carotid artery stenosis. J Vasc Surg 2018; 67:1110-1119.e1. [DOI: 10.1016/j.jvs.2017.09.021] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2017] [Accepted: 09/05/2017] [Indexed: 11/25/2022]
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25
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Diab HMH, Rasmussen LM, Duvnjak S, Diederichsen A, Jensen PS, Lindholt JS. Computed tomography scan based prediction of the vulnerable carotid plaque. BMC Med Imaging 2017; 17:61. [PMID: 29237404 PMCID: PMC5729460 DOI: 10.1186/s12880-017-0233-5] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2017] [Accepted: 11/24/2017] [Indexed: 12/20/2022] Open
Abstract
BACKGROUND Primary to validate a commercial semi-automated computed tomography angiography (CTA) -software for vulnerable plaque detection compared to histology of carotid endarterectomy (CEA) specimens and secondary validating calcifications scores by in vivo CTA with ex vivo non-contrast enhanced computed tomography (NCCT). METHODS From January 2014 to October 2016 53 patients were included retrospectively, using a cross-sectional design. All patients underwent both CTA and CEA. Sixteen patients had their CEA specimen NCCT scanned. The semi-automated CTA software analyzed carotid stenosis using different HU values defining plaque components. The predictive values of CTA based detection of vulnerable plaques were calculated. Quantification of calcifications on CTA using region of interest (ROI)-function and mathematical equations was done manually, and validated by NCCT of the CEA specimen. RESULTS The semi-automated CTA software had a sensitivity, specificity, positive predictive value (PPV) and negative predictive value (NPV) of 89.1% (95% CI, 73.6% - 96.4%), 31.3% (95% CI, 12.1% - 58.5%), 75% (95% CI, 59.3% - 86.2%) and 55.6% (95% CI, 22.6% - 84.6%). Strong correlation between in vivo CTA and ex vivo NCCT in quantification of calcification was observed, but CTA systematically underestimated calcificationsscore (CALS) with increasing calcification. CONCLUSION The CTA-software cannot be used in risk assessment of patients, due to poor specificity and NPV. The correlation between in vivo CTA and ex vivo NCCT was strong, proposing it to be used in both scientifically and clinical settings, but studies with larger sample sizes are needed.
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Affiliation(s)
- Hadi Mahmoud Haider Diab
- Department of Cardiothoracic and Vascular Surgery, Odense University Hospital, Sdr. Boulevard 29, 5000 Odense C, Denmark
| | - Lars Melholt Rasmussen
- Department of Clinical Biochemistry and Pharmacology, Odense University Hospital, Sdr. Boulevard 29, 5000 Odense C, Denmark
| | - Stevo Duvnjak
- Department of Radiology, Odense University Hospital, Sdr. Boulevard 29, 5000 Odense C, Denmark
| | - Axel Diederichsen
- Department of Cardiology, Odense University Hospital, Sdr. Boulevard 29, 5000 Odense C, Denmark
| | - Pia Søndergaard Jensen
- Department of Clinical Biochemistry and Pharmacology, Odense University Hospital, Sdr. Boulevard 29, 5000 Odense C, Denmark
| | - Jes Sanddal Lindholt
- Department of Cardiothoracic and Vascular Surgery, Odense University Hospital, Sdr. Boulevard 29, 5000 Odense C, Denmark
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Eckstein HH, Tsantilas P, Kühnl A, Haller B, Breitkreuz T, Zimmermann A, Kallmayer M. Surgical and Endovascular Treatment of Extracranial Carotid Stenosis. DEUTSCHES ARZTEBLATT INTERNATIONAL 2017; 114:729-736. [PMID: 29143732 PMCID: PMC5696565 DOI: 10.3238/arztebl.2017.0729] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/16/2017] [Revised: 03/16/2017] [Accepted: 07/19/2017] [Indexed: 11/27/2022]
Abstract
BACKGROUND Carotid endarterectomy (CEA) and carotid artery stenting (CAS) can be used to prevent stroke due to arteriosclerotic lesions of the carotid artery. In Germany, legally mandated quality assurance (QA) enables the evaluation of outcome quality after CEA and CAS performed under routine conditions. METHODS We analyzed data on all elective CEA and CAS procedures performed over the periods 2009-2014 and 2012-2014, respectively. The endpoints of the study were the combined in-hospital stroke and death rate, stroke rate and mortality separately, local complications, and other complications. We analyzed the raw data with descriptive statistics and carried out a risk-adjusted analysis of the association of clinically unalterable variables with the risk of stroke and death. All analyses were performed separately for CEA and CAS. RESULTS Data were analyzed from 142 074 CEA procedures (67.8% of them in men) and 13 086 CAS procedures (69.7% in men). The median age was 72 years (CEA) and 71 years (CAS). The periprocedural rate of stroke and death after CEA was 1.4% for asymptomatic and 2.5% for symptomatic stenoses; the corresponding rates for CAS were 1.7% and 3.7%. Variables associated with increased risk included older age, higher ASA class (ASA = American Society of Anesthesiologists), symptomatic vs. asymptomatic stenosis, 50-69% stenosis, and contralateral carotid occlusion (for CEA only). CONCLUSION These data reveal a low periprocedural rate of stroke or death for both CEA and CAS. This study does however not permit any conclusions as to the superiority or inferiority of CEA and CAS.
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Affiliation(s)
- Hans-Henning Eckstein
- Department of Vascular and Endovascular Surgery/Vascular Center, Klinikum rechts der Isar der Technischen Universität München
| | - Pavlos Tsantilas
- Department of Vascular and Endovascular Surgery/Vascular Center, Klinikum rechts der Isar der Technischen Universität München
| | - Andreas Kühnl
- Department of Vascular and Endovascular Surgery/Vascular Center, Klinikum rechts der Isar der Technischen Universität München
| | - Bernhard Haller
- Institut für Medizinische Statistik und Epidemiologie, Klinikum rechts der Isar, Technische Universität München
| | - Thorben Breitkreuz
- AQUA—Institute for Applied Quality Improvement and Research in Health Care GmbH, Göttingen
| | - Alexander Zimmermann
- Department of Vascular and Endovascular Surgery/Vascular Center, Klinikum rechts der Isar der Technischen Universität München
| | - Michael Kallmayer
- Department of Vascular and Endovascular Surgery/Vascular Center, Klinikum rechts der Isar der Technischen Universität München
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Bennett KM, Hoch JR, Scarborough JE. Predictors of 30-day postoperative major adverse clinical events after carotid artery stenting: An analysis of the procedure-targeted American College of Surgeons National Surgical Quality Improvement Program. J Vasc Surg 2017; 66:1093-1099. [DOI: 10.1016/j.jvs.2017.04.039] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2017] [Accepted: 04/10/2017] [Indexed: 10/19/2022]
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Carotid artery stenting is associated with a higher incidence of major adverse clinical events than carotid endarterectomy in female patients. J Vasc Surg 2017; 66:794-801. [DOI: 10.1016/j.jvs.2017.03.413] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2017] [Accepted: 03/01/2017] [Indexed: 11/23/2022]
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Wabnitz AM, Turan TN. Symptomatic Carotid Artery Stenosis: Surgery, Stenting, or Medical Therapy? CURRENT TREATMENT OPTIONS IN CARDIOVASCULAR MEDICINE 2017; 19:62. [PMID: 28677035 PMCID: PMC5496976 DOI: 10.1007/s11936-017-0564-0] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
Symptomatic carotid artery disease is a significant cause of ischemic stroke, and these patients are at high risk for recurrent vascular events. Patients with symptoms of stroke or transient ischemic attack attributable to a significantly stenotic vessel (70–99% luminal narrowing) should be treated with intensive medical therapy. Intensive medical therapy is a combination of pharmacologic and lifestyle interventions consistent with best-known practices as follows: initiation of antiplatelet agent or anticoagulation if medically indicated, high potency statin medication, blood pressure control with goal blood pressure of greater than 140/90, Mediterranean-style diet, exercise, and smoking cessation. Further, patients who have extracranial culprit lesions should be considered for revascularization with either carotid endarterectomy or carotid angioplasty and stenting depending on several factors including the patient’s anatomy, age, gender, and procedural risk. Based on current evidence, patients with symptomatic intracranial stenosis should be managed with intensive medical therapy, including the use of dual antiplatelet therapy with aspirin and clopidogrel for the first 90 days following the ischemic event. While the literature has shown a stronger benefit of revascularization of extracranial symptomatic disease among certain subgroups of patients with greater than 70% stenosis, there is less benefit from revascularization with endarterectomy in patients with moderate stenosis of 50–69% if the surgeon’s risk of perioperative stroke or death rate is greater than 6%.
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Affiliation(s)
- Ashley M Wabnitz
- Division of Neurology, Medical University of South Carolina, 19 Hagood Ave, Harborview Office Tower Suite 501, Charleston, SC, 29425-8050, USA.
| | - Tanya N Turan
- Division of Neurology, Medical University of South Carolina, 19 Hagood Ave, Harborview Office Tower Suite 501, Charleston, SC, 29425-8050, USA
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30
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Kassavin DS, Clair DG. An update on the role of proximal occlusion devices in carotid artery stenting. J Vasc Surg 2017; 65:271-275. [DOI: 10.1016/j.jvs.2016.09.048] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2016] [Accepted: 09/27/2016] [Indexed: 11/28/2022]
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31
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Paraskevas K, Kalmykov E, Naylor A. Stroke/Death Rates Following Carotid Artery Stenting and Carotid Endarterectomy in Contemporary Administrative Dataset Registries: A Systematic Review. Eur J Vasc Endovasc Surg 2016; 51:3-12. [DOI: 10.1016/j.ejvs.2015.07.032] [Citation(s) in RCA: 95] [Impact Index Per Article: 11.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2015] [Accepted: 07/14/2015] [Indexed: 11/29/2022]
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32
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La mujer y la enfermedad vascular: características específicas. ANGIOLOGIA 2016. [DOI: 10.1016/j.angio.2015.04.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
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Intermediate Outcomes of Femoropopliteal Stenting in Women: 3-Year Results of the DURABILITY II Trial. Ann Vasc Surg 2015; 30:110-7. [PMID: 26585648 DOI: 10.1016/j.avsg.2015.10.005] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2015] [Revised: 09/16/2015] [Accepted: 10/27/2015] [Indexed: 11/22/2022]
Abstract
BACKGROUND This study investigated the effects of gender on the 3-year outcomes of the StuDy for EvalUating EndovasculaR TreAtments of Lesions in the Superficial Femoral Artery and Proximal Popliteal By usIng the Protege EverfLex NitInol STent System II (DURABILITY II) trial. METHODS A total of 287 patients enrolled in the DURABILITY II trial (prospective and nonrandomized trial) were stratified by gender and evaluated for primary, primary assisted, and secondary patency at 3 years. Clinical scores including changes in ankle-brachial index (ABI) and walking impairment questionnaire (WIQ) scores were evaluated. RESULTS Overall 190 male and 97 female patients were included for analysis. The 3-year primary, assisted primary, and secondary patency rates for women versus men were 62.5% vs. 58.8%, 68.5% vs. 64.9%, and 72.1% vs. 67.2%, respectively (P < 0.05). Although ABIs at presentation were similar between women versus men (0.64 vs. 0.65, P < 0.05), women had lower ABI scores at 3 years compared with men (0.85 vs. 0.92, P = 0.03). Women versus men had inferior walking distance scores at presentation (13.6 vs. 25.7, P < 0.001), scores were equalized by 2 years (51.6 vs. 60.8, P < 0.05); however, 3-year follow-up demonstrated less durable results for women versus men (37.3 vs. 58.8, P < 0.05). In addition, women had worse WIQ scores for pain, walking speed, and stair climbing. However, the relative change in scores between men and women were comparable, with both groups seeing similar improvements from baseline for these parameters. CONCLUSIONS Women continue to see clinical improvement after intervention, achieving comparable ABIs and walking distance to men at 2 years. These benefits are diminished at 3-year follow-up with women achieving lower absolute ABI and WIQ parameters compared with men, but improved overall compared with scores at presentation.
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Doig D, Turner EL, Dobson J, Featherstone RL, de Borst GJ, Stansby G, Beard JD, Engelter ST, Richards T, Brown MM. Risk Factors For Stroke, Myocardial Infarction, or Death Following Carotid Endarterectomy: Results From the International Carotid Stenting Study. Eur J Vasc Endovasc Surg 2015; 50:688-94. [PMID: 26460291 PMCID: PMC4684145 DOI: 10.1016/j.ejvs.2015.08.006] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2014] [Accepted: 08/10/2015] [Indexed: 11/29/2022]
Abstract
OBJECTIVES Carotid endarterectomy (CEA) is standard treatment for symptomatic carotid artery stenosis but carries a risk of stroke, myocardial infarction (MI), or death. This study investigated risk factors for these procedural complications occurring within 30 days of endarterectomy in the International Carotid Stenting Study (ICSS). METHODS Patients with recently symptomatic carotid stenosis >50% were randomly allocated to endarterectomy or stenting. Analysis is reported of patients in ICSS assigned to endarterectomy and limited to those in whom CEA was initiated. The occurrence of stroke, MI, or death within 30 days of the procedure was reported by investigators and adjudicated. Demographic and technical risk factors for these complications were analysed sequentially in a binomial regression analysis and subsequently in a multivariable model. RESULTS Eight-hundred and twenty-one patients were included in the analysis. The risk of stroke, MI, or death within 30 days of CEA was 4.0%. The risk was higher in female patients (risk ratio [RR] 1.98, 95% CI 1.02-3.87, p = .05) and with increasing baseline diastolic blood pressure (dBP) (RR 1.30 per +10 mmHg, 95% CI 1.02-1.66, p = .04). Mean baseline dBP, obtained at the time of randomization in the trial, was 78 mmHg (SD 13 mmHg). In a multivariable model, only dBP remained a significant predictor. The risk was not related to the type of surgical reconstruction, anaesthetic technique, or perioperative medication regimen. Patients undergoing CEA stayed a median of 4 days before discharge, and 21.2% of events occurred on or after the day of discharge. CONCLUSIONS Increasing diastolic blood pressure was the only independent risk factor for stroke, MI, or death following CEA. Cautious attention to blood pressure control following symptoms attributable to carotid stenosis could reduce the risks associated with subsequent CEA.
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Affiliation(s)
- D Doig
- Institute of Neurology, University College London, UK
| | - E L Turner
- Department of Biostatistics and Bioinformatics and Duke Global Health Institute, Duke University, Durham, NC, USA
| | - J Dobson
- Department of Medical Statistics, London School of Hygiene and Tropical Medicine, UK
| | | | - G J de Borst
- Department of Vascular Surgery, University Medical Centre Utrecht, The Netherlands
| | - G Stansby
- Department of Vascular Surgery, Freeman Hospital, Newcastle upon Tyne, UK
| | - J D Beard
- Sheffield Vascular Institute, Northern General Hospital, Sheffield, UK
| | - S T Engelter
- Department of Neurology and Stroke Center, University Hospital Basel, Basel, Switzerland
| | - T Richards
- Division of Surgery and Interventional Science, University College London, UK
| | - M M Brown
- Institute of Neurology, University College London, UK.
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Saha SP, Saha S, Vyas KS. Carotid Endarterectomy: Current Concepts and Practice Patterns. Int J Angiol 2015; 24:223-35. [PMID: 26417192 PMCID: PMC4572020 DOI: 10.1055/s-0035-1558645] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022] Open
Abstract
Background Stroke is the number one cause of disability and third leading cause of death among adults in the United States. A major cause of stroke is carotid artery stenosis (CAS) caused by atherosclerotic plaques. Randomized trials have varying results regarding the equivalence and perioperative complication rates of stents versus carotid endarterectomy (CEA) in the management of CAS. Objectives We review the evidence for the current management of CAS and describe the current concepts and practice patterns of CEA. Methods A literature search was conducted using PubMed to identify relevant studies regarding CEA and stenting for the management of CAS. Results The introduction of CAS has led to a decrease in the percentage of CEA and an increase in the number of CAS procedures performed in the context of all revascularization procedures. However, the efficacy of stents in patients with symptomatic CAS remains unclear because of varying results among randomized trials, but the perioperative complication rates exceed those found after CEA. Conclusions Vascular surgeons are uniquely positioned to treat carotid artery disease through medical therapy, CEA, and stenting. Although data from randomized trials differ, it is important for surgeons to make clinical decisions based on the patient. We believe that CAS can be adopted with low complication rate in a selected subgroup of patients, but CEA should remain the standard of care. This current evidence should be incorporated into practice of the modern vascular surgeon.
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Affiliation(s)
- Sibu P. Saha
- Division of Cardiothoracic Surgery, Department of Surgery, University of Kentucky College of Medicine, Lexington, Kentucky
| | - Subhajit Saha
- MediCiti Institute of Medical Science, Hyderabad, India
| | - Krishna S. Vyas
- Division of Cardiothoracic Surgery, Department of Surgery, University of Kentucky College of Medicine, Lexington, Kentucky
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Luebke T, Brunkwall J. Meta- analysis and meta-regression analysis of the associations between sex and the operative outcomes of carotid endarterectomy. BMC Cardiovasc Disord 2015; 15:32. [PMID: 25956903 PMCID: PMC4432947 DOI: 10.1186/s12872-015-0029-x] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2015] [Accepted: 04/21/2015] [Indexed: 12/26/2022] Open
Abstract
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.
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Affiliation(s)
- Thomas Luebke
- Department of Vascular and Endovascular Surgery, University Hospital of Cologne, Kerpener Str. 62, 50937, Cologne, Germay.
| | - Jan Brunkwall
- Department of Vascular and Endovascular Surgery, University Hospital of Cologne, Kerpener Str. 62, 50937, Cologne, Germay.
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Abstract
Stroke is the leading cause of acquired disability and the third leading cause of death in women worldwide. Sex differences in risk factors, treatment response and quality of life after stroke complicate stroke management in women. Women have an increased lifetime incidence of stroke compared to men, largely due to a sharp increase in stroke risk in older postmenopausal women. Women also have an increased lifetime prevalence of stroke risk factors, including hypertension and atrial fibrillation in postmenopausal women, as well as abdominal obesity and metabolic syndrome in middle-aged women. Controversy continues over the risks of oral contraceptives, hormone therapy and surgical intervention for carotid stenosis in women. Pregnancy and the postpartum period represent a time of increased risk, presenting challenges to stroke management. Recognition of these issues is critical to improving acute care and functional recovery after stroke in women.
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Affiliation(s)
- Matthew D Howe
- Department of Neuroscience, The University of Connecticut Health Center, Farmington, CT 06030, USA
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Abstract
Despite a decline during the recent decades in stroke-related death, the incidence of stroke has remained unchanged or slightly increased, and extracranial carotid artery stenosis is implicated in 20%–30% of all strokes. Medical therapy and risk factor modification are first-line therapies for all patients with carotid occlusive disease. Evidence for the treatment of patients with symptomatic carotid stenosis greater than 70% with either carotid artery stenting (CAS) or carotid endarterectomy (CEA) is compelling, and several trials have demonstrated a benefit to carotid revascularization in the symptomatic patient population. Asymptomatic carotid stenosis is more controversial, with the largest trials only demonstrating a 1% per year risk stroke reduction with CEA. Although there are sufficient data to advocate for aggressive medical therapy as the primary mode of treatment for asymptomatic carotid stenosis, there are also data to suggest that certain patient populations will benefit from a stroke risk reduction with carotid revascularization. In the United States, consensus and practice guidelines dictate that CEA is reasonable in patients with high-grade asymptomatic stenosis, a reasonable life expectancy, and perioperative risk of less than 3%. Regarding CAS versus CEA, the best-available evidence demonstrates no difference between the two procedures in early perioperative stroke, myocardial infarction, or death, and no difference in 4-year ipsilateral stroke risk. However, because of the higher perioperative risks of stroke in patients undergoing CAS, particularly in symptomatic, female, or elderly patients, it is difficult to recommend CAS over CEA except in populations with prohibitive cardiac risk, previous carotid surgery, or prior neck radiation. Current treatment paradigms are based on identifying the magnitude of perioperative risk in patient subsets and on using predictive factors to stratify patients with high-risk asymptomatic stenosis.
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Affiliation(s)
- Marlene O'Brien
- Department of Surgery, Division of Vascular Surgery, University of Rochester School of Medicine and Dentistry, Rochester, NY, USA
| | - Ankur Chandra
- Department of Surgery, Division of Vascular Surgery, University of Rochester School of Medicine and Dentistry, Rochester, NY, USA
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