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Abdelkarim A, Hamouda M, Malas MB. What Is the Best Technique for Treating Carotid Disease? Adv Surg 2024; 58:161-189. [PMID: 39089775 DOI: 10.1016/j.yasu.2024.04.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/04/2024]
Abstract
This is a comprehensive review of carotid artery revascularization techniques: Carotid Endarterectomy (CEA), Transfemoral Carotid Artery Stenting (TFCAS), and Transcarotid Artery Revascularization (TCAR). CEA is the gold standard and is particularly effective in elderly and high-risk patients. TFCAS, introduced as a less invasive alternative, poses increased periprocedural stroke risks. TCAR, which combines minimally invasive benefits with CEA's neuroprotection principles, emerges as a safer option for high-risk patients, showing comparable results to CEA and better outcomes than TFCAS. The decision-making process for carotid revascularization is complex and influenced by the patient's medical comorbidities and anatomic factors.
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Affiliation(s)
- Ahmed Abdelkarim
- Department of Surgery, Division of Vascular and Endovascular Surgery, UC San Diego, San Diego, CA, USA; Center for Learning and Excellence in Vascular & Endovascular Research (CLEVER), UC San Diego, San Diego, CA, USA; Altman Center for Clinical and Translational Research, 9452 Medical Center Drive - LL2W 502A, La Jolla, CA 92037, USA
| | - Mohammed Hamouda
- Department of Surgery, Division of Vascular and Endovascular Surgery, UC San Diego, San Diego, CA, USA; Center for Learning and Excellence in Vascular & Endovascular Research (CLEVER), UC San Diego, San Diego, CA, USA; Altman Center for Clinical and Translational Research, 9452 Medical Center Drive - LL2W 502A, La Jolla, CA 92037, USA
| | - Mahmoud B Malas
- Department of Surgery, Division of Vascular and Endovascular Surgery, UC San Diego, San Diego, CA, USA; Center for Learning and Excellence in Vascular & Endovascular Research (CLEVER), UC San Diego, San Diego, CA, USA; Altman Center for Clinical and Translational Research, 9452 Medical Center Drive - LL2W 502A, La Jolla, CA 92037, USA.
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2
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Musialek P, Rosenfield K, Siddiqui AH, Grunwald IQ. Carotid Stenosis and Stroke: Medicines, Stents, Surgery-"Wait-and-See" or Protect? Thromb Haemost 2024. [PMID: 36170885 DOI: 10.1055/a-1952-1159] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/14/2022]
Affiliation(s)
- Piotr Musialek
- Department of Cardiac and Vascular Diseases, Jagiellonian University, Krakow, Poland
- John Paul II Hospital Stroke Thrombectomy-Capable Centre, Krakow, Poland
| | - Kenneth Rosenfield
- Division of Cardiology, Vascular Medicine and Intervention Section, Massachusetts General Hospital, Boston, United States
| | - Adnan H Siddiqui
- Departments of Neurosurgery and Radiology, School of Medicine and Biomedical Sciences, University at Buffalo, State University of New York, Buffalo, New York, United States
- Jacobs Institute, Buffalo, New York, United States
- Department of Neurosurgery, Gates Vascular Institute Kaleida Health, Buffalo, New York, United States
| | - Iris Q Grunwald
- Department of Radiology, Ninewells Hospital, Chair of Neuroradiology, University of Dundee, Dundee, Scotland, United Kingdom
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3
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Columbo JA, Stone DH. Appropriateness of care: Asymptomatic carotid stenosis including transcarotid artery revascularization. Semin Vasc Surg 2024; 37:179-187. [PMID: 39151997 PMCID: PMC11330557 DOI: 10.1053/j.semvascsurg.2024.03.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2024] [Revised: 03/14/2024] [Accepted: 03/27/2024] [Indexed: 08/19/2024]
Abstract
Carotid artery stenosis is one of the most common diagnoses treated by vascular specialists in the United States. The optimal management of carotid stenosis remains controversial, however, with notable variation surrounding diagnostic imaging modalities, longitudinal surveillance, medical therapies, and procedural interventions. Data from high-quality randomized controlled trials and observational studies form the foundation for current management paradigms and societal guidelines that inform clinical practice. Presently, a diagnosis of carotid disease is most often established with duplex ultrasound and supplemental cross-sectional imaging using computed tomography or magnetic resonance angiography as needed to provide additional anatomic information. All patients with documented occlusive disease should receive goal-directed medical therapy with antiplatelet agents and a lipid-reduction strategy, most commonly with a statin. Those with severe carotid stenosis and an acceptable life expectancy may be considered for carotid artery revascularization. The proceduralist should optimally consider a shared decision-making approach in which the tradeoffs of revascularization can be carefully considered with the patient to optimize informed therapeutic decision making. In current practice, three distinct procedure options exist to treat carotid artery stenosis, including carotid endarterectomy, transfemoral carotid artery stenting, and transcarotid artery revascularization. It should be noted that each procedure, although often used interchangeably in most clinical settings, carry technical nuances and outcome disparities. In this review, each of these topics are explored and various approaches are outlined surrounding the appropriate use of treatments for patients with asymptomatic carotid artery stenosis.
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Affiliation(s)
- Jesse A Columbo
- Geisel School of Medicine at Dartmouth, Hanover, NH; Section of Vascular Surgery, 3V, Dartmouth-Hitchcock Medical Center, 1 Medical Center Drive, Lebanon, NH 03766; Veterans Affairs Medical Center, White River Junction, VT.
| | - David H Stone
- Geisel School of Medicine at Dartmouth, Hanover, NH; Section of Vascular Surgery, 3V, Dartmouth-Hitchcock Medical Center, 1 Medical Center Drive, Lebanon, NH 03766; Veterans Affairs Medical Center, White River Junction, VT
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4
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Ristow AVB, Massière B, Meirelles GV, Casella IB, Morales MM, Moreira RCR, Procópio RJ, Oliveira TF, de Araujo WJB, Joviliano EE, de Oliveira JCP. Brazilian Angiology and Vascular Surgery Society Guidelines for the treatment of extracranial cerebrovascular disease. J Vasc Bras 2024; 23:e20230094. [PMID: 39099701 PMCID: PMC11296686 DOI: 10.1590/1677-5449.202300942] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2023] [Accepted: 10/16/2023] [Indexed: 08/06/2024] Open
Abstract
Extracranial cerebrovascular disease has been the subject of intense research throughout the world, and is of paramount importance for vascular surgeons. This guideline, written by the Brazilian Society of Angiology and Vascular Surgery (SBACV), supersedes the 2015 guideline. Non-atherosclerotic carotid artery diseases were not included in this document. The purpose of this guideline is to bring together the most robust evidence in this area in order to help specialists in the treatment decision-making process. The AGREE II methodology and the European Society of Cardiology system were used for recommendations and levels of evidence. The recommendations were graded from I to III, and levels of evidence were classified as A, B, or C. This guideline is divided into 11 chapters dealing with the various aspects of extracranial cerebrovascular disease: diagnosis, treatments and complications, based on up-to-date knowledge and the recommendations proposed by SBACV.
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Affiliation(s)
- Arno von Buettner Ristow
- Pontifícia Universidade Católica do Rio de Janeiro – PUC-RIO, Disciplina de Cirurgia Vascular e Endovascular, Rio de Janeiro, RJ, Brasil.
- Sociedade Brasileira de Angiologia e de Cirurgia Vascular – SBACV-RJ, Rio de Janeiro, RJ, Brasil.
| | - Bernardo Massière
- Pontifícia Universidade Católica do Rio de Janeiro – PUC-RIO, Disciplina de Cirurgia Vascular e Endovascular, Rio de Janeiro, RJ, Brasil.
- Sociedade Brasileira de Angiologia e de Cirurgia Vascular – SBACV-RJ, Rio de Janeiro, RJ, Brasil.
| | - Guilherme Vieira Meirelles
- Sociedade Brasileira de Angiologia e de Cirurgia Vascular – SBACV-SP, São Paulo, SP, Brasil.
- Universidade Estadual de Campinas – UNICAMP, Hospital das Clínicas, Disciplina de Cirurgia do Trauma, Campinas, SP, Brasil.
| | - Ivan Benaduce Casella
- Sociedade Brasileira de Angiologia e de Cirurgia Vascular – SBACV-SP, São Paulo, SP, Brasil.
- Universidade de São Paulo – USP, Faculdade de Medicina, São Paulo, SP, Brasil.
| | - Marcia Maria Morales
- Sociedade Brasileira de Angiologia e de Cirurgia Vascular – SBACV-SP, São Paulo, SP, Brasil.
- Associação Portuguesa de Beneficência de São José do Rio Preto, Serviço de Cirurgia Vascular, São José do Rio Preto, SP, Brasil.
| | - Ricardo Cesar Rocha Moreira
- Sociedade Brasileira de Angiologia e de Cirurgia Vascular – SBACV-PR, Curitiba, PR, Brasil.
- Pontifícia Universidade Católica do Paraná – PUC-PR, Hospital Cajurú, Serviço de Cirurgia Vascular, Curitiba, PR, Brasil.
| | - Ricardo Jayme Procópio
- Universidade Federal de Minas Gerais – UFMG, Hospital das Clínicas, Setor de Cirurgia Endovascular, Belo Horizonte, MG, Brasil.
- Universidade Federal de Minas Gerais – UFMG, Faculdade de Medicina, Belo Horizonte, MG, Brasil.
- Sociedade Brasileira de Angiologia e de Cirurgia Vascular – SBACV-MG, Belo Horizonte, MG, Brasil.
| | - Tércio Ferreira Oliveira
- Sociedade Brasileira de Angiologia e de Cirurgia Vascular – SBACV-SE, Aracajú, SE, Brasil.
- Universidade de São Paulo – USP, Faculdade de Medicina de Ribeirão Preto – FMRP, Ribeirão Preto, SP, Brasil.
| | - Walter Jr. Boim de Araujo
- Sociedade Brasileira de Angiologia e de Cirurgia Vascular – SBACV-PR, Curitiba, PR, Brasil.
- Universidade Federal do Paraná – UFPR, Hospital das Clínicas – HC, Curitiba, PR, Brasil.
| | - Edwaldo Edner Joviliano
- Sociedade Brasileira de Angiologia e de Cirurgia Vascular – SBACV-SP, São Paulo, SP, Brasil.
- Universidade de São Paulo – USP, Faculdade de Medicina de Ribeirão Preto – FMRP, Ribeirão Preto, SP, Brasil.
| | - Júlio Cesar Peclat de Oliveira
- Sociedade Brasileira de Angiologia e de Cirurgia Vascular – SBACV-SP, São Paulo, SP, Brasil.
- Universidade Federal do Estado do Rio de Janeiro – UNIRIO, Departamento de Cirurgia, Rio de Janeiro, RJ, Brasil.
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Paraskevas KI, Conrad MF, Schneider PA, Cambria RP. Best Medical Treatment Alone Is Adequate for the Management of All Patients With Asymptomatic Carotid Stenosis, or "Alice in Wonderland". Angiology 2024; 75:295-296. [PMID: 37165801 DOI: 10.1177/00033197231174724] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/12/2023]
Affiliation(s)
| | - Mark F Conrad
- Division of Vascular and Endovascular Surgery, St Elizabeth's Medical Center, Boston, MA, USA
| | - Peter A Schneider
- Division of Vascular and Endovascular Surgery, University of California, San Francisco, CA, USA
| | - Richard P Cambria
- Division of Vascular and Endovascular Surgery, St Elizabeth's Medical Center, Boston, MA, USA
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6
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Paraskevas KI, Musialek P, Mikhailidis DP, Lip GYH. The Fundamental Role of Medical Treatment in the Prevention of Carotid Related Strokes: Insights from a Multispecialty Consensus Document. Curr Vasc Pharmacol 2024; 22:5-7. [PMID: 37909660 DOI: 10.2174/0115701611282696231101072656] [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: 09/21/2023] [Accepted: 10/03/2023] [Indexed: 11/03/2023]
Affiliation(s)
| | - Piotr Musialek
- Department of Cardiac and Vascular Diseases, Jagiellonian University, Medical College, Krakow, Poland
- John Paul II Hospital, Krakow, Poland
| | - Dimitri P Mikhailidis
- Department of Surgical Biotechnology, Division of Surgery and Interventional Science, University College London Medical School, University College London (UCL) and Department of Clinical Biochemistry, Royal Free Hospital Campus, UCL, London, UK
| | - Gregory Y H Lip
- Liverpool Centre for Cardiovascular Science at University of Liverpool, Liverpool John Moores University and Liverpool Heart & Chest Hospital, Liverpool, UK
- Danish Center for Health Services Research, Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
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7
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Zarrintan S, Malas MB. What Is the Role of Transcarotid Artery Revascularization? Adv Surg 2023; 57:115-140. [PMID: 37536848 DOI: 10.1016/j.yasu.2023.04.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/05/2023]
Abstract
Carotid endarterectomy (CEA) is the gold-standard method of carotid revascularization in symptomatic patients with ≥50% and in asymptomatic patients with ≥70% stenosis. Transfemoral carotid artery stenting (TFCAS) has been associated with higher perioperative stroke rates compared to CEA in several studies. On the other hand, transcarotid artery revascularization (TCAR) has outperformed TFCAS in patients who are considered high risk for surgery. There is increasing data that supports TCAR as a safe and efficient technique with outcomes similar to those of CEA, but additional level-one studies are necessary to evaluate the long-term outcomes of TCAR in high- and standard-risk patients.
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Affiliation(s)
- Sina Zarrintan
- Department of Surgery, Division of Vascular and Endovascular Surgery, UC San Diego, San Diego, CA, USA; Center for Learning and Excellence in Vascular & Endovascular Research (CLEVER), UC San Diego, San Diego, CA, USA; Altman Center for Clinical and Translational Research, 9452 Medical Center Drive - LL2W 502A, La Jolla, CA 92037, USA
| | - Mahmoud B Malas
- Department of Surgery, Division of Vascular and Endovascular Surgery, UC San Diego, San Diego, CA, USA; Center for Learning and Excellence in Vascular & Endovascular Research (CLEVER), UC San Diego, San Diego, CA, USA; Altman Center for Clinical and Translational Research, 9452 Medical Center Drive - LL2W 502A, La Jolla, CA 92037, USA.
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8
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Rockman CB, Garg K. Contemporary Treatment of the Asymptomatic Carotid Patient. Surg Clin North Am 2023; 103:629-644. [PMID: 37455029 DOI: 10.1016/j.suc.2023.04.016] [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: 07/18/2023]
Abstract
Stroke is a persistent leading cause of morbidity and mortality, and carotid artery atherosclerosis remains a treatable cause of future stroke. Although most patients with asymptomatic carotid artery disease may be at a relatively low risk for future stroke, most completed strokes are unheralded; thus, the identification and appropriate treatment of patients with asymptomatic carotid artery disease remains a critical part of overall stroke prevention. Select patients with asymptomatic carotid artery stenosis with an increased risk of future stroke based on the degree of stenosis and other imaging or patient-related characteristics are appropriate to consider for carotid artery intervention.
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Affiliation(s)
- Caron B Rockman
- Florence and Joseph Ritorto Professor of Surgery, Division of Vascular Surgery, NYU Langone Medical Center, NYU Grossman School of Medicine, 530 1st Avenue, 11th Floor, New York, NY 10016, USA.
| | - Karan Garg
- Division of Vascular Surgery, NYU Langone Medical Center, 530 1st Avenue, 11th Floor, New York, NY 10016, USA
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9
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Gasior SA, O'Donnell JPM, Davey M, Clarke J, Jalali A, Ryan É, Aherne TM, Walsh SR. Optimal Management of Asymptomatic Carotid Artery Stenosis: A Systematic Review and Network Meta-Analysis. Eur J Vasc Endovasc Surg 2023; 65:690-699. [PMID: 36682406 DOI: 10.1016/j.ejvs.2023.01.020] [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: 05/14/2022] [Revised: 12/02/2022] [Accepted: 01/11/2023] [Indexed: 01/21/2023]
Abstract
OBJECTIVE Management of asymptomatic carotid artery stenosis (ACAS), including carotid endarterectomy (CEA), carotid artery stenting (CAS), and best medical treatment (BMT), remains inconsistent in current practice. Early studies reported a benefit of CEA vs. BMT; however, the current risk-benefit profile of invasive therapy lacks consensus. By evaluating the effects of modern BMT vs. invasive intervention on patient outcomes, this study aimed to influence the future management of ACAS. METHODS A systematic review and series of network meta-analyses were performed assessing peri-operative (within 30 days) and long term (30 days - 5 years) stroke and mortality risk between ACAS interventions. Total stroke, major, minor, ipsilateral, and contralateral stroke subtypes were assessed independently. Traditional (pre-2000) and modern (post-2000) BMT were compared to assess clinical improvements in medical therapy over the previous two decades. Risks of myocardial infarction (MI) and cranial nerve injury (CNI) were also assessed. RESULTS Seventeen reports of 14 310 patients with > 50% ACAS were included. CEA reduced the odds of a peri-operative stroke event occurring vs. CAS (odds ratio [OR] 1.6, 95% confidence interval [CI] 1.1 - 2.2 [0 - 20 fewer/1 000]). CEA and CAS reduced the long term odds of minor strokes (OR 0.35, 95% CI 0.21 - 0.59 [20 fewer/1 000]) and ipsilateral strokes (OR 0.27, 95% CI 0.19 - 0.39 [30 fewer/1 000]) vs. all BMT. CEA reduced the odds of major strokes and combined stroke and mortality vs. traditional BMT; however, no difference was found between CEA and modern BMT. CAS reduced the odds of peri-operative MI (OR 0.49, 95% CI 0. 26 - 0.91) and CNI (OR 0.07, 95% CI 0.01 - 0.42) vs. CEA. CONCLUSION Modern BMT demonstrates similar reductions in major stroke, combined stroke, and mortality to CEA. The overall risk reductions are low and data were unavailable to assess subgroups which may benefit from intervention. However, BMT carries the potential to reduce the requirement for surgical intervention in patients with ACAS.
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Affiliation(s)
- Sara A Gasior
- Department of Vascular Surgery, University Hospital Galway, Galway, Ireland.
| | - John P M O'Donnell
- Department of Vascular Surgery, University Hospital Galway, Galway, Ireland; Lambe Institute for Translational Discipline of Surgery, National University of Ireland, Galway, Ireland
| | - Matthew Davey
- Lambe Institute for Translational Discipline of Surgery, National University of Ireland, Galway, Ireland; Department of Surgery, Royal College of Surgeons in Ireland, Dublin, Ireland
| | - James Clarke
- Lambe Institute for Translational Discipline of Surgery, National University of Ireland, Galway, Ireland
| | | | - Éanna Ryan
- Lambe Institute for Translational Discipline of Surgery, National University of Ireland, Galway, Ireland
| | - Thomas M Aherne
- Department of Surgery, Royal College of Surgeons in Ireland, Dublin, Ireland
| | - Stewart R Walsh
- Department of Vascular Surgery, University Hospital Galway, Galway, Ireland; Lambe Institute for Translational Discipline of Surgery, National University of Ireland, Galway, Ireland
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10
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Weiner S, Benton MH, Guraziu B, Yange Y, He J, Chen YT, Marston WA, McGinigle KL. High Stroke Rate in Patients With Medically Managed Asymptomatic Carotid Stenosis at an Academic Center in the Southeastern United States. Ann Vasc Surg 2022; 85:418-423. [PMID: 35472498 DOI: 10.1016/j.avsg.2022.04.029] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2021] [Revised: 02/25/2022] [Accepted: 04/17/2022] [Indexed: 01/05/2023]
Abstract
BACKGROUND Although the publication of randomized clinical trials defining the benefit of carotid endarterectomy (CEA) for asymptomatic carotid stenosis, medical management of carotid stenosis has changed significantly. With antiplatelet agents and statins, some question whether these trials are still relevant, suggesting that asymptomatic patients with >70% internal carotid artery (ICA) stenosis may do better with medial management alone, lessening the need for CEA and carotid stenting. The Vascular Quality Initiative (VQI) registry has shown that there are wide practice variations regarding the degree of stenosis that prompts surgical intervention but there are few reports of outcomes in patients who do not undergo intervention. We sought to determine the clinical outcomes of the >70% carotid stenosis patients who are treated with medical management alone at our institution. METHODS We identified all patients with ICA stenosis >70% based on hemodynamic consensus criteria (peak systolic velocity >230 cm/s) in our peripheral vascular laboratory from January 2013 through December 2016. With a retrospective chart review, demographics, comorbid conditions, medications, radiographic studies, clinical follow-up, interventions, and outcomes at 2 years were included. Descriptive statistics were used to define these variables. RESULTS One hundred and seventy three patients were identified with medically managed asymptomatic >70% ICA stenosis based on hemodynamic criteria on duplex ultrasound. The mean age was 67.5 years, 49% were male, 64% were White, 14% were Black, 13% race was undisclosed, 89% were prescribed antiplatelet therapy, 85% were prescribed a statin, and 60% had hypertension controlled to <140/90. Twenty patients (11.5%) experienced a cerebrovascular event during the 2-year study period. There were eight patients with transient ischemic attack, 10 with ipsilateral strokes, and 2 with strokes in unrelated territories. CONCLUSIONS Despite good adherence to current recommendations for medical therapy, patients at our institution are developing symptomatic carotid disease at a rate similar to that reported in historical clinical trials. These data supports the concept that advances in medical management have not resulted in reduced stroke rates in asymptomatic patients with high-grade carotid stenosis at a large academic institution located in the southeastern United States. CEA and stenting provide a significant risk reduction and should be considered more often in this patient population.
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Affiliation(s)
- Sarah Weiner
- Department of Surgery, School of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, NC
| | - Mary Hunter Benton
- Department of Surgery, School of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, NC
| | - Benjana Guraziu
- Department of Biostatistics, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, NC
| | - Yue Yange
- Department of Biostatistics, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, NC
| | - Jie He
- Department of Biostatistics, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, NC
| | - Yi Tang Chen
- Department of Biostatistics, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, NC
| | - William A Marston
- Department of Surgery, School of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, NC
| | - Katharine L McGinigle
- Department of Surgery, School of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, NC.
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11
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Chang RW, Tucker LY, Rothenberg KA, Lancaster E, Faruqi RM, Kuang HC, Flint AC, Avins AL, Nguyen-Huynh MN. Incidence of Ischemic Stroke in Patients With Asymptomatic Severe Carotid Stenosis Without Surgical Intervention. JAMA 2022; 327:1974-1982. [PMID: 35608581 PMCID: PMC9131743 DOI: 10.1001/jama.2022.4835] [Citation(s) in RCA: 33] [Impact Index Per Article: 16.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
IMPORTANCE Optimal management of patients with asymptomatic severe carotid stenosis is uncertain, due to advances in medical care and a lack of contemporary data comparing medical and surgical treatment. OBJECTIVE To estimate stroke outcomes among patients with medically treated asymptomatic severe carotid stenosis who did not undergo surgical intervention. DESIGN, SETTING, AND PARTICIPANTS Retrospective cohort study that included 3737 adult participants with asymptomatic severe (70%-99%) carotid stenosis diagnosed between 2008 and 2012 and no prior intervention or ipsilateral neurologic event in the prior 6 months. Participants received follow-up through 2019, and all were members of an integrated US regional health system serving 4.5 million members. EXPOSURES Imaging diagnosis of asymptomatic carotid stenosis of 70% to 99%. MAIN OUTCOMES AND MEASURES Occurrence of ipsilateral carotid-related acute ischemic stroke. Censoring occurred with death, disenrollment, or ipsilateral intervention. RESULTS Among 94 822 patients with qualifying imaging studies, 4230 arteries in 3737 (mean age, 73.8 [SD 9.5 years]; 57.4% male) patients met selection criteria including 2539 arteries in 2314 patients who never received intervention. The mean follow-up in this cohort was 4.1 years (SD 3.6 years). Prior to any intervention, there were 133 ipsilateral strokes with a mean annual stroke rate of 0.9% (95% confidence interval [CI], 0.7%-1.2%). The Kaplan-Meier estimate of ipsilateral stroke by 5 years was 4.7% (95% CI, 3.9%-5.7%). CONCLUSIONS AND RELEVANCE In a community-based cohort of patients with asymptomatic severe carotid stenosis who did not undergo surgical intervention, the estimated rate of ipsilateral carotid-related acute ischemic stroke was 4.7% over 5 years. These findings may inform decision-making regarding surgical and medical treatment for patients with asymptomatic severe carotid artery stenosis.
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Affiliation(s)
- Robert W. Chang
- Department of Vascular Surgery, The Permanente Medical Group, South San Francisco, California
- Division of Research, Kaiser Permanente Northern California, Oakland
| | - Lue-Yen Tucker
- Division of Research, Kaiser Permanente Northern California, Oakland
| | - Kara A. Rothenberg
- Department of Surgery, University of California San Francisco - East Bay, Oakland
| | | | - Rishad M. Faruqi
- Department of Vascular Surgery, The Permanente Medical Group, Santa Clara, California
| | - Hui C. Kuang
- Department of Vascular Surgery, The Permanente Medical Group, San Francisco, California
| | - Alexander C. Flint
- Division of Research, Kaiser Permanente Northern California, Oakland
- Department of Neurology, The Permanente Medical Group, Redwood City, California
| | - Andrew L. Avins
- Division of Research, Kaiser Permanente Northern California, Oakland
- Department of Medicine, University of California San Francisco
- Department of Epidemiology and Biostatistics, University of California San Francisco
| | - Mai N. Nguyen-Huynh
- Division of Research, Kaiser Permanente Northern California, Oakland
- Department of Neurology, The Permanente Medical Group, Walnut Creek, California
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12
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Chang RW, Tucker LY, Rothenberg KA, Lancaster EM, Avins AL, Kuang HC, Faruqi RM, Nguyen-Huynh MN. Establishing a carotid artery stenosis disease cohort for comparative effectiveness research using natural language processing. J Vasc Surg 2021; 74:1937-1947.e3. [PMID: 34182027 DOI: 10.1016/j.jvs.2021.05.054] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2020] [Accepted: 05/19/2021] [Indexed: 11/24/2022]
Abstract
OBJECTIVE Investigation of asymptomatic carotid stenosis treatment is hindered by the lack of a contemporary population-based disease cohort. We describe the use of natural language processing (NLP) to identify stenosis in patients undergoing carotid imaging. METHODS Adult patients with carotid imaging between 2008 and 2012 in a large integrated health care system were identified and followed through 2017. An NLP process was developed to characterize carotid stenosis according to the Society of Radiologists in Ultrasound (for ultrasounds) and North American Symptomatic Carotid Endarterectomy Trial (NASCET) (for axial imaging) guidelines. The resulting algorithm assessed text descriptors to categorize normal/non-hemodynamically significant stenosis, moderate or severe stenosis as well as occlusion in both carotid ultrasound (US) and axial imaging (computed tomography and magnetic resonance angiography [CTA/MRA]). For US reports, internal carotid artery systolic and diastolic velocities and velocity ratios were assessed and matched for laterality to supplement accuracy. To validate the NLP algorithm, positive predictive value (PPV or precision) and sensitivity (recall) were calculated from simple random samples from the population of all imaging studies. Lastly, all non-normal studies were manually reviewed for confirmation for prevalence estimates and disease cohort assembly. RESULTS A total of 95,896 qualifying index studies (76,276 US and 19,620 CTA/MRA) were identified among 94,822 patients including 1059 patients who underwent multiple studies on the same day. For studies of normal/non-hemodynamically significant stenosis arteries, the NLP algorithm showed excellent performance with a PPV of 99% for US and 96.5% for CTA/MRA. PPV/sensitivity to identify a non-normal artery with correct laterality in the CTA/MRA and US samples were 76.9% (95% confidence interval [CI], 74.1%-79.5%)/93.1% (95% CI, 91.1%-94.8%) and 74.7% (95% CI, 69.3%-79.5%)/94% (95% CI, 90.2%-96.7%), respectively. Regarding cohort assembly, 15,522 patients were identified with diseased carotid artery, including 2674 exhibiting equal bilateral disease. This resulted in a laterality-specific cohort with 12,828 moderate, 5283 severe, and 1895 occluded arteries and 326 diseased arteries with unknown stenosis. During follow-up, 30.1% of these patients underwent 61,107 additional studies. CONCLUSIONS Use of NLP to detect carotid stenosis or occlusion can result in accurate exclusion of normal/non-hemodynamically significant stenosis disease states with more moderate precision with lesion identification, which can substantially reduce the need for manual review. The resulting cohort allows for efficient research and holds promise for similar reporting in other vascular diseases.
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Affiliation(s)
- Robert W Chang
- Department of Vascular Surgery, The Permanente Medical Group, South San Francisco, Calif; Division of Research, Kaiser Permanente, Oakland, Calif.
| | | | - Kara A Rothenberg
- Department of Surgery, University of California San Francisco - East Bay, Oakland, Calif
| | | | - Andrew L Avins
- Division of Research, Kaiser Permanente, Oakland, Calif; Departments of Medicine and Epidemiology and Biostatistics, University of California, San Francisco, Calif
| | - Hui C Kuang
- Department of Vascular Surgery, The Permanente Medical Group, San Francisco, Calif
| | - Rishad M Faruqi
- Department of Vascular Surgery, The Permanente Medical Group, Santa Clara, Calif
| | - Mai N Nguyen-Huynh
- Division of Research, Kaiser Permanente, Oakland, Calif; Department of Neurology, The Permanente Medical Group, Walnut Creek, Calif
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Dominguez D, Levin SR, Cheng TW, Farber A, Jones DW, Eberhard RT, Kalish JA, Eslami MH, Siracuse JJ. Selective Nonoperative and Delayed Management of Severe Asymptomatic Carotid Artery Stenosis. Ann Vasc Surg 2020; 72:159-165. [PMID: 33346124 DOI: 10.1016/j.avsg.2020.10.045] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2019] [Revised: 10/18/2020] [Accepted: 10/28/2020] [Indexed: 11/16/2022]
Abstract
OBJECTIVES Although intervention is generally the standard of care for severe (80-99%) asymptomatic carotid stenosis, conservative management may be appropriate for a subset of patients. Our goal was to assess reasons for and outcomes of nonoperative/delayed operative management of asymptomatic severe carotid stenosis. METHODS Institutional vascular laboratory data from 2010 to 2018 was queried for all patients who underwent a carotid duplex ultrasonography. Patients with severe asymptomatic carotid stenosis (80-99%) were included. Such stenosis was defined by an end diastolic velocity >140 cm/sec on duplex ultrasound in patients without transient ischemic attacks (TIA)/strokes ≤6 months prior to imaging. Nonoperative/delayed operative management was defined as not undergone carotid endarterectomy (CEA) or carotid artery stent (CAS) ≤6 months after imaging. Reasons for nonoperative management or delayed intervention as well as subsequent TIA/stroke and survival were determined. Kaplan-Meier analysis was performed to evaluate survival. RESULTS Among 211 patients with severe carotid stenosis, 35 (16.6%) were managed nonoperatively or with delayed operation. Mean age in this subset was 72.6 ± 11.4 years and the majority were female (57.1%), had a smoking history (74.3%), and were on statins (91.4%) at the time of index duplex ultrasound. Reasons for no/delayed intervention were classified as severe medical comorbidities (37.1%), advanced age (17.1%), no referral for intervention (14.3%), patient refusal (14.3%), other severe concomitant cerebrovascular disease (11.4%), and active/advanced cancer (5.7%). Over a median follow-up of 35.2 months, no patients experienced TIAs/strokes attributable to carotid stenosis. One patient had a multifocal bilateral stroke after a cardiac arrest and prolonged resuscitation. A subset of patients underwent delayed CEA (8.6%) or CAS (2.9%). Four-year survival after initial imaging was 79%. CONCLUSIONS Reasons for nonoperative and delayed operative management in our cohort of asymptomatic carotid stenosis were commonly due to comorbidities and advanced age. However, a subset of patients was never referred to vascular surgeons/interventionalists. Adverse neurologic events due to carotid stenosis were not observed during follow-up and patients had relatively high long-term survival.
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Affiliation(s)
- Dylan Dominguez
- Division of Vascular and Endovascular Surgery, Boston Medical Center, Boston University School of Medicine, Boston, MA
| | - Scott R Levin
- Division of Vascular and Endovascular Surgery, Boston Medical Center, Boston University School of Medicine, Boston, MA
| | - Thomas W Cheng
- Division of Vascular and Endovascular Surgery, Boston Medical Center, Boston University School of Medicine, Boston, MA
| | - Alik Farber
- Division of Vascular and Endovascular Surgery, Boston Medical Center, Boston University School of Medicine, Boston, MA
| | - Douglas W Jones
- Division of Vascular and Endovascular Surgery, Boston Medical Center, Boston University School of Medicine, Boston, MA
| | - Robert T Eberhard
- Division of Cardiovascular Medicine, Boston Medical Center, Boston University School of Medicine, Boston, MA
| | - Jeffrey A Kalish
- Division of Vascular and Endovascular Surgery, Boston Medical Center, Boston University School of Medicine, Boston, MA
| | - Mohammad H Eslami
- Division of Vascular and Endovascular Surgery, University of Pittsburgh, School of Medicine, Pittsburgh, PA
| | - Jeffrey J Siracuse
- Division of Vascular and Endovascular Surgery, Boston Medical Center, Boston University School of Medicine, Boston, MA.
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Fernandes E Fernandes J, Mendes Pedro L, Gonçalves I. The conundrum of asymptomatic carotid stenosis-determinants of decision and evidence. ANNALS OF TRANSLATIONAL MEDICINE 2020; 8:1279. [PMID: 33178811 PMCID: PMC7607137 DOI: 10.21037/atm-2020-cass-12] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Abstract
Management of asymptomatic carotid disease continues to challenge medical practice and present evidence is often conflicting. Stroke is a significant burden in Public Health and 11% to 15% appear as first neurologic event associated with asymptomatic carotid stenosis. Randomized trials provided support for Guidelines and Recommendations to intervene on asymptomatic stenosis, but at a known cost of a high number of unnecessary operations. Conflicting evidence from natural history studies and the widespread use of proper medical management including risk factors control, lowering-lipid drugs and strict control of arterial hypertension have reduced the incidence of strokes associated to asymptomatic carotid disease challenging established practice. Need to identify vulnerable lesions prone to develop thromboembolic brain events and also vulnerable patients at a higher risk of stroke is necessary and essential to further improve effectiveness of our interventions. After review of published literature on natural history of asymptomatic carotid stenosis, diagnostic methods to identify plaque vulnerability and present-day results of both endarterectomy and stenting, a strategy for management of asymptomatic carotid stenosis is suggested aiming to reduce unnecessary interventions and effectively contribute to stroke prevention.
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Affiliation(s)
- José Fernandes E Fernandes
- Department of Surgery and Vascular Surgery, Faculty of Medicine University of Lisbon, Lisbon, Portugal.,Santa Maria University Hospital, Lisbon Academic Medical Center, Lisbon, Portugal.,Senior Consultant Vascular Surgeon, Cardiovascular Institute/Hospital da Luz Torres de Lisboa, Lisbon, Portugal
| | - Luis Mendes Pedro
- Senior Consultant Vascular Surgeon, Cardiovascular Institute/Hospital da Luz Torres de Lisboa, Lisbon, Portugal.,Department of Vascular Surgery, Faculty of Medicine University of Lisbon, Lisbon, Portugal.,Vascular Surgery Department, Santa Maria University Hospital, Lisbon Academic Medical Center, Lisbon, Portugal
| | - Isabel Gonçalves
- Cardiology Department, Skåne University Hospital and Clinical Sciences Malmö, Lund University, Sweden
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15
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Chan C, Fort D, Velasco-Gonzalez C, Hawken TN, Leithead CC, Brinster CJ, Sternbergh WC, Bazan HA. Rapid progression of carotid stenosis was rare in a large integrated healthcare system during an eight-year period. J Vasc Surg 2020; 73:1623-1629. [PMID: 33080325 DOI: 10.1016/j.jvs.2020.09.032] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2020] [Accepted: 09/10/2020] [Indexed: 11/19/2022]
Abstract
OBJECTIVE Few studies have evaluated the rapid progression of carotid stenosis on a large scale. We created a custom software algorithm to analyze an electronic medical record database to examine the natural progression of carotid stenosis, identify a subset of patients with rapid progression, and evaluate the specific patient risk factors associated with this rapid progression. METHODS Patients in a large integrated healthcare system who had undergone two or more carotid ultrasound scans from August 2010 to August 2018 were identified. We did not distinguish between those with an established carotid stenosis diagnosis and those with a screening ultrasound scan. We used our novel algorithm to extract data from their carotid ultrasound reports. The degrees of carotid stenosis were categorized as follows: level 1, 0% to 39%; level 2, 40% to 59%; level 3, 60% to 79%; level 4, 80% to 99%; and level 5, complete occlusion. The primary endpoint was rapid vs slow progression of carotid stenosis, with rapid progression defined as an increase of two or more levels within any 18-month period of the study, regardless of the date of the initial ultrasound scan. The association of the demographic and clinical characteristics with rapid progression was assessed by univariable and multivariable logistic regression. RESULTS From a cohort of 4.4 million patients, we identified 4982 patients with two or more carotid ultrasound scans and a median follow-up period of 13.1 months (range, 0.1-93.7 months). Of the 4982 patients, 879 (17.6%) had shown progression of carotid stenosis. Only 116 patients (2.3%) had had progression to level 4 (80%-99% stenosis) from any starting level during a median of 11.5 months. A total of 180 patients (3.6%) were identified as experiencing rapid progression during a median follow-up of 9.9 months. The final multivariable analysis showed that younger age (P < .01), white race (P = .02), lower body mass index (P = .01), a diagnosis of peripheral arterial disease (P = .03), and a diagnosis of transient ischemic attack (P < .01) were associated with rapid progression. CONCLUSIONS Using a novel algorithm to extract data from >4 million patient records, we found that rapid progression of carotid stenosis appears to be rare. Although 17.6% of patients showed any degree of progression, only 3.6% had experienced rapid progression. Among those with any disease progression, 20.5% had experienced rapid progression. Although the overall incidence of rapid progression was low, patients with any progression might warrant close follow-up, especially if they have the associated risk factors for rapid progression. The custom software algorithm might be a powerful tool for creating and evaluating large datasets.
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Affiliation(s)
- Carney Chan
- Section of Vascular/Endovascular Surgery, Department of Surgery, Ochsner Clinic Foundation, New Orleans, La
| | - Daniel Fort
- Department of Applied Health, Ochsner Clinic Foundation, New Orleans, La
| | | | - Thomas N Hawken
- Section of Vascular/Endovascular Surgery, Department of Surgery, Ochsner Clinic Foundation, New Orleans, La
| | - Charles C Leithead
- Section of Vascular/Endovascular Surgery, Department of Surgery, Ochsner Clinic Foundation, New Orleans, La; University of Queensland Faculty of Medicine, Ochsner Clinical School, New Orleans, La
| | - Clayton J Brinster
- Section of Vascular/Endovascular Surgery, Department of Surgery, Ochsner Clinic Foundation, New Orleans, La
| | - Waldemar C Sternbergh
- Section of Vascular/Endovascular Surgery, Department of Surgery, Ochsner Clinic Foundation, New Orleans, La; University of Queensland Faculty of Medicine, Ochsner Clinical School, New Orleans, La
| | - Hernan A Bazan
- Section of Vascular/Endovascular Surgery, Department of Surgery, Ochsner Clinic Foundation, New Orleans, La; University of Queensland Faculty of Medicine, Ochsner Clinical School, New Orleans, La.
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Sorber R, Clemens MS, Wang P, Makary MA, Hicks CW. Contemporary Trends in Physician Utilization Rates of CEA and CAS for Asymptomatic Carotid Stenosis among Medicare Beneficiaries. Ann Vasc Surg 2020; 71:132-144. [PMID: 32890650 DOI: 10.1016/j.avsg.2020.08.118] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2019] [Revised: 06/10/2020] [Accepted: 08/09/2020] [Indexed: 01/14/2023]
Abstract
BACKGROUND Carotid revascularization for asymptomatic carotid artery stenosis (ACAS) has become increasingly controversial in the past few decades as the best medical therapy has improved. The aim of this study was to assess and define contemporary trends in the rate of carotid revascularization procedures for ACAS in the United States and to characterize outlier physicians performing a higher rate of asymptomatic revascularization compared to their peers. METHODS We used 100% Medicare fee-for-service claims to identify all patients who were newly diagnosed with ACAS between 01/2011-06/2018. Patients with symptomatic carotid artery stenosis, those with prior carotid revascularization, and surgeons who performed ≤10 CEAs during the study period were excluded. We used a hierarchical multivariable logistic regression model to evaluate patient and physician characteristics associated with undergoing a carotid endarterectomy or carotid artery stent procedure within 3 months after the initial diagnosis of ACAS. We also assessed temporal trends in carotid revascularization rates over time using the Cochran-Armitage Trend Test. RESULTS Overall, 795,512 patients (median age 73.9 years, 50.9% male, 87.6% white) had a first-time diagnosis of ACAS during the study period, of which 23,481 (3.0%) underwent carotid revascularization within 3 months. There was a significant decline in overall carotid artery revascularization rates over time (2011: 3.2% vs. 2018: 2.1%; P < 0.001). The median and mean physician-specific carotid revascularization rates were 2.0% (IQR 0.0%-6.3%) and 4.7% ± 7.1%, respectively. Three-hundred and fifty physicians (5.2%) had carotid revascularization rates ≥19%, which was more than 2 standard deviations above the mean. After adjusting for patient-level characteristics, physician-level variables associated with carotid revascularization for newly diagnosed ACAS included male sex (adjusted OR 1.59, 95% CI 1.35-1.89), more years in practice (≥31 vs. <10 years, aOR 1.64, 95% CI 1.32-2.04), rural practice location (aOR 1.34, 95% CI 1.18-1.52), Southern region practice location (versus Northeast, aOR 1.54, 95% CI 1.39-1.69), and lower volume of ACAS patients (lower versus upper tertile, aOR 2.62, 95% CI 2.39-2.89). Cardiothoracic surgeons had a 1.52-fold higher odds of carotid revascularization compared to vascular surgeons (95% CI 1.36-1.68), whereas cardiologists and radiologists had lower intervention rates (both, P < 0.05). CONCLUSIONS The current early revascularization rate for newly diagnosed ACAS is <5% among proceduralists in the United States, and has been decreasing steadily since 2014. There are particular physician-level characteristics that are associated with higher rates of carotid revascularization that cannot be fully contextualized without high-level contemporary outcomes data to guide decision making in ACAS.
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Affiliation(s)
- Rebecca Sorber
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD
| | | | - Peiqi Wang
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Martin A Makary
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD; Department of Health Policy & Management, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD
| | - Caitlin W Hicks
- Division of Vascular Surgery and Endovascular Therapy, Johns Hopkins University School of Medicine, Baltimore, MD.
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17
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Natural History of Non-operative Management in Asymptomatic Patients with 70%-80% Internal Carotid Artery Stenosis by Duplex Criteria. Eur J Vasc Endovasc Surg 2020; 60:339-346. [PMID: 32660806 DOI: 10.1016/j.ejvs.2020.05.039] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2019] [Revised: 05/04/2020] [Accepted: 05/27/2020] [Indexed: 11/20/2022]
Abstract
OBJECTIVE Treatment of asymptomatic internal carotid artery (ICA) stenosis, particularly for moderate to severe (70%-80%) disease, is controversial. The goal was to assess the clinical course of patients with moderate to severe carotid stenosis. METHODS A single institution retrospective analysis of patients with asymptomatic ICA stenosis identified on duplex ultrasound as moderate to severe (70%-80%) from 2003 to 2018 were analysed. Duplex criteria for 70%-80% stenosis was a systolic velocity of ≥325 cm/s or an ICA:common carotid artery ratio of ≥4, and an end diastolic velocity of <140 cm/s. Asymptomatic status was defined as no stroke/transient ischaemic attack (TIA) within six months of index duplex. Primary outcomes were progression of stenosis to >80%, ipsilateral stroke/TIA without documented progression, and death. RESULTS In total, 206 carotid arteries were identified in 182 patients meeting the inclusion criteria. Mean patient age was 71.5 years, 57.7% were male, and 67% were white. There were 19 stenoses removed from analysis except for survival analysis as they initially underwent carotid endarterectomy or carotid artery stent based on surgeon/patient preference. Documented progression occurred in 24.1% of stenoses. There were 5.3% of stenoses associated with an ipsilateral stroke/TIA without documented progression, which occurred at a mean of 26.4 months. Kaplan-Meier analysis demonstrated a 60.3% five year freedom from stenosis progression, 92.5% five year freedom from stroke/TIA without documented progression, and 83.7% five year survival. Risk factors associated with stroke/TIA without documented progression at five years were atrial fibrillation (hazard ratio [HR] 14.87, 95% confidence interval [CI] 2.72-81.16; p = .002) and clopidogrel use at index duplex (HR 6.19, 95% CI 1.33-28.83; p = .020). Risk factors associated with death at five years were end stage renal disease (HR 9.67, 95% CI 2.05-45.6; p = .004), atrial fibrillation (HR 7.55, 95% CI 2.48-23; p < .001), prior head/neck radiation (HR 6.37, 95% CI 1.39-29.31; p = .017), non-obese patients (HR 5.49, 95% CI 1.52-20; p = .009), and non-aspirin use at index duplex (HR 3.05, 95% CI 1.12-8.33; p = .030). CONCLUSION Patients with asymptomatic moderate to severe carotid stenosis had a low rate of stroke/TIA without documented progression. However, there was a high rate of stenosis progression reinforcing the need to follow these patients closely.
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Columbo JA, Zwolak RM, Arous EJ, Goodney PP, Lilly MP, Welch HG. Variation in Ultrasound Diagnostic Thresholds for Carotid Stenosis in the United States. Circulation 2020; 141:946-953. [PMID: 31941366 DOI: 10.1161/circulationaha.119.043963] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Individuals with carotid stenosis enter surveillance or are considered for surgery on the basis of disease severity assessed by ultrasound. However, there is variation in the ultrasound diagnostic thresholds used to determine disease severity. Our objective was to describe this variation and its potential impact on patients. METHODS To describe the variation in carotid ultrasound diagnostic thresholds, we examined testing protocols from 338 accredited vascular testing centers in the United States. To determine the potential impact of this variation, we applied the range of thresholds to carotid ultrasound parameters from 2 groups: a population-based sample ≥65 years of age in the Cardiovascular Health Study (n=4791), and a cohort of patients who underwent surgery for asymptomatic carotid stenosis in the Vascular Quality Initiative registry (n=28 483). RESULTS Internal carotid artery peak systolic velocity was used by all centers to assess disease severity, with 60 distinct thresholds in use. The peak systolic velocity threshold for moderate (≥50%) stenosis ranged from 110 to 245 cm/s (median, 125; 5th and 95th percentile, 125 and 150), and the threshold for severe (≥70%) stenosis ranged from 175 to 340 cm/s (median, 230; 5th and 95th percentile, 230 and 275). In the population-based sample, the 5th percentile threshold would assign a diagnosis of moderate carotid stenosis to twice as many individuals as the 95th percentile threshold (7.9% versus 3.9%; relative risk, 2.01 [CI, 1.70-2.38]). In the surgical cohort, 1 in 10 (9.8%) patients had peak systolic velocity values that warranted the diagnosis of severe carotid stenosis at centers in the 5th percentile, but not in the 95th. CONCLUSIONS The diagnostic threshold for carotid stenosis varies considerably. Whether or not a person is said to have moderate stenosis and enters surveillance, and whether or not they have severe stenosis and are candidates for surgery, can depend on which center performs their ultrasound.
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Affiliation(s)
- Jesse A Columbo
- Section of Vascular Surgery, Geisel School of Medicine at Dartmouth, Hanover, NH (J.A.C., P.P.G.)
| | - Robert M Zwolak
- Department of Surgery, VA Medical Center, Manchester, NH (R.M.Z.)
| | - Edward J Arous
- Division of Vascular and Endovascular Surgery, University of Massachusetts Medical School, Worcester (E.J.A.)
| | - Philip P Goodney
- Section of Vascular Surgery, Geisel School of Medicine at Dartmouth, Hanover, NH (J.A.C., P.P.G.)
| | - Michael P Lilly
- Division of Vascular Surgery, University of Maryland School of Medicine, Baltimore (M.P.L.)
| | - H Gilbert Welch
- Center for Surgery and Public Health, Department of Surgery, Brigham & Women's Hospital, Boston, MA (H.G.W.)
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Cambria RP, Conrad MF. Asymptomatic carotid stenosis: Revisionist history is usually wrong. J Vasc Surg 2020; 71:2-4. [DOI: 10.1016/j.jvs.2019.05.029] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2019] [Accepted: 05/31/2019] [Indexed: 11/29/2022]
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20
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Abbott AL, Brunser AM, Giannoukas A, Harbaugh RE, Kleinig T, Lattanzi S, Poppert H, Rundek T, Shahidi S, Silvestrini M, Topakian R. Misconceptions regarding the adequacy of best medical intervention alone for asymptomatic carotid stenosis. J Vasc Surg 2020; 71:257-269. [PMID: 31564585 DOI: 10.1016/j.jvs.2019.04.490] [Citation(s) in RCA: 46] [Impact Index Per Article: 11.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2018] [Accepted: 04/11/2019] [Indexed: 10/25/2022]
Abstract
BACKGROUND Medical intervention (risk factor identification, lifestyle coaching, and medication) for stroke prevention has improved significantly. It is likely that no more than 5.5% of persons with advanced asymptomatic carotid stenosis (ACS) will now benefit from a carotid procedure during their lifetime. However, some question the adequacy of medical intervention alone for such persons and propose using markers of high stroke risk to intervene with carotid endarterectomy (CEA) and/or carotid angioplasty/stenting (CAS). Our aim was to examine the scientific validity and implications of this proposal. METHODS We reviewed the evidence for using medical intervention alone or with additional CEA or CAS in persons with ACS. We also reviewed the evidence regarding the validity of using commonly cited makers of high stroke risk to select such persons for CEA or CAS, including markers proposed by the European Society for Vascular Surgery in 2017. RESULTS Randomized trials of medical intervention alone versus additional CEA showed a definite statistically significant CEA stroke prevention benefit for ACS only for selected average surgical risk men aged less than 75 to 80 years with 60% or greater stenosis using the North American Symptomatic Carotid Endarterectomy Trial criteria. However, the most recent measurements of stroke rate with ACS using medical intervention alone are overall lower than for those who had CEA or CAS in randomized trials. Randomized trials of CEA versus CAS in persons with ACS were underpowered. However, the trend was for higher stroke and death rates with CAS. There are no randomized trial results related to comparing current optimal medical intervention with CEA or CAS. Commonly cited markers of high stroke risk in relation to ACS lack specificity, have not been assessed in conjunction with current optimal medical intervention, and have not been shown in randomized trials to identify those who benefit from a carotid procedure in addition to current optimal medical intervention. CONCLUSIONS Medical intervention has an established role in the current routine management of persons with ACS. Stroke risk stratification studies using current optimal medical intervention alone are the highest research priority for identifying persons likely to benefit from adding a carotid procedure.
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Affiliation(s)
- Anne L Abbott
- Department of Neuroscience, Central Clinical School, Monash University, Melbourne, Victoria, Australia.
| | - Alejandro M Brunser
- Department of Neurology, Clínica Alemana de Santiago, Facultad de Medicina Clínica Alemana, Universidad del Desarrollo, Santiago, Chile
| | - Athanasios Giannoukas
- University Hospital of Larissa, Faculty of Medicine, School of Health Sciences, University of Thessaly, Larissa, Greece
| | - Robert E Harbaugh
- Department of Neurosurgery, Penn State University, State College, Pa
| | - Timothy Kleinig
- Neurology Department, Royal Adelaide Hospital, Department of Medicine, University of Adelaide, Adelaide, South Australia, Australia
| | - Simona Lattanzi
- Department of Experimental and Clinical Medicine, Marche Polytechnic University, Ancona, Italy
| | - Holger Poppert
- Neurology Department, Helios Dr Horst-Schmidt-Kliniken, Wiesbaden, Germany
| | - Tatjana Rundek
- Department of Neurology, University of Miami Miller School of Medicine, Miami, Fla
| | - Saeid Shahidi
- Department of Vascular and Endovascular Surgery, Acute Regional Hospital Slagelse, Copenhagen & South Denmark University, Copenhagen, Denmark
| | | | - Raffi Topakian
- Department of Neurology, Academic Teaching Hospital Wels-Grieskirchen, Wels, Austria
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Eslami MH, Saadeddin Z, Farber A, Fish L, Avgerinos ED, Makaroun MS. External validation of the Vascular Study Group of New England carotid endarterectomy risk predictive model using an independent U.S. national surgical database. J Vasc Surg 2019; 71:1954-1963. [PMID: 31676184 DOI: 10.1016/j.jvs.2019.04.495] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2018] [Accepted: 04/11/2019] [Indexed: 11/15/2022]
Abstract
OBJECTIVE Previously, we described a Vascular Study Group of New England (VSGNE) risk predictive model to predict composite adverse outcomes (postoperative death, stroke, myocardial infarction, or discharge to extended care facilities) after carotid endarterectomy (CEA). The goal of this study was to externally validate this model using an independent database. METHODS The American College of Surgeons National Surgical Quality Improvement Program (NSQIP) CEA-targeted database (2010-2014) was used to externally validate the risk predictor model of adverse outcomes after CEA previously created using the VSGNE carotid database. Emergent cases and those in which CEA was combined with another operation were excluded. Cases in which a discharge destination cannot be determined were also excluded. To assess the predictive power of our VSGNE prediction score within this sample, a receiver operating characteristic curve was constructed. Risk scores for each NSQIP patient were also computed using beta weights from the VSGNE CEA model. To further assess the construct validity of our VSGNE prediction score, the observed proportion of adverse outcomes was examined at each level of our prediction scale and within five roughly equally sized risk groups formed on the basis of our VSGNE prediction scores. RESULTS In this database, 10,889 cases met our inclusion criteria and were used in this analysis. The overall rate of adverse outcomes in this cohort was 8.5%. External validation of the VSGNE model on this sample showed moderately good predictive ability (area under the curve = 0.745). Patients in progressively higher risk groups, based on their VSGNE model scores, exhibited progressively higher rates of observed adverse outcomes, as predicted. CONCLUSIONS The VSGNE CEA risk predictive model was externally validated on an NSQIP CEA-targeted sample and showed a fairly accurate global predictive ability for adverse outcomes after CEA. Although this model has a good population concordance, the lack of cut point indicates that individual risk prediction requires more evaluation. Further studies should be geared toward identification of variables that make this risk predictive model more robust.
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Affiliation(s)
- Mohammad H Eslami
- Division of Vascular Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pa.
| | - Zein Saadeddin
- Division of Vascular Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pa
| | - Alik Farber
- Division of Vascular and Endovascular Surgery, Boston University School of Medicine, Boston, Mass
| | - Larry Fish
- Division of Vascular Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pa
| | - Efthymios D Avgerinos
- Division of Vascular Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pa
| | - Michel S Makaroun
- Division of Vascular Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pa
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Musiałek P, Roubin GS. Commentary: Double-Layer Carotid Stents: From the Clinical Need, through a Stent-in-Stent Strategy, to Effective Plaque Isolation… the Journey Toward Safe Carotid Revascularization Using the Endovascular Route. J Endovasc Ther 2019; 26:572-577. [DOI: 10.1177/1526602819861546] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Piotr Musiałek
- Jagiellonian University Department of Cardiac & Vascular Diseases, John Paul II Hospital, Krakow, Poland
| | - Gary S. Roubin
- Cardiovascular Associates of the Southeast, Birmingham, AL, USA
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Naylor AR. Hype springs eternal. J Vasc Surg 2018; 68:657. [PMID: 30037682 DOI: 10.1016/j.jvs.2018.03.431] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2018] [Accepted: 03/27/2018] [Indexed: 11/29/2022]
Affiliation(s)
- A Ross Naylor
- Vascular Surgery Group, Division of Cardiovascular Sciences, Leicester Royal Infirmary, Leicester, United Kingdom
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Klarin D, Cambria RP, Ergul EA, Silverman SB, Patel VI, LaMuraglia GM, Conrad MF, Clouse WD. Risk factor profile and anatomic features of previously asymptomatic patients presenting with carotid-related stroke. J Vasc Surg 2018; 68:1390-1395. [PMID: 29804741 DOI: 10.1016/j.jvs.2018.01.064] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2017] [Accepted: 01/31/2018] [Indexed: 11/19/2022]
Abstract
OBJECTIVE Although carotid atherosclerotic-mediated stroke remains a major cause of morbidity and mortality, some have suggested intervention in carotid stenosis should be limited to symptomatic patients given the advances in medical therapy. The present study was conducted to assess the atherosclerotic risk factor profiles, anatomic features, and clinical outcomes of previously asymptomatic patients admitted with stroke of carotid etiology. METHODS We reviewed the data from 3382 patients admitted to a tertiary referral center with an ischemic stroke during 2005 to 2015. We focused on patients admitted with a radiographically confirmed infarct ipsilateral to a documented carotid artery stenosis ≥50%, with the admitting neurology team adjudicating the stroke etiology as carotid related. Patients were excluded if they had had a previous transient ischemic attack, previous infarct ipsilateral to any carotid lesion, or previous carotid revascularization, intracranial hemorrhage, or malignancy. Patient demographic data, medical treatments before stroke, stroke admission carotid imaging, and stroke treatments and outcomes were assessed. RESULTS A total of 219 carotid stroke patients (7% of all strokes) were identified, of whom 61% were white and 66% were men, with a mean age of 68 ± 12 years. Hypertension (79%) and smoking (33% current; 29% former) were predominant risk factors. On admission, 50% were receiving antiplatelet therapy (aspirin, n = 92 [41%]; clopidogrel, n = 9 [4%]; dual therapy, n = 11 [5%]) and 55% were receiving lipid-lowering agents (statin, n = 115 [53%]; other, n = 6 [2%]); 77 patients (35%) were receiving both antiplatelet and lipid-lowering therapy. Of the 219 patients, 156 (71%) presented with a moderate or severe stroke (National Institutes of Health stroke scale ≥5 at admission), 54 (25%) received lytic therapy, 96 (43%) presented with an occluded ipsilateral internal carotid artery, and 117 (53%) ultimately underwent carotid revascularization at a median of 4 days. Individuals receiving both antiplatelet and lipid-lowering therapy were significantly less likely to experience a moderate or severe stroke (44% vs 78%; P = .006). CONCLUSIONS Internal carotid artery occlusion is the culprit lesion in 43% of carotid-related strokes in those without previous symptoms. Previously asymptomatic patients not receiving combined antiplatelet and lipid-lowering medical therapy presenting with carotid-related stroke are significantly more likely to experience a severe, debilitating stroke. However, those receiving appropriate risk-reduction medical therapy are still at risk of carotid-mediated stroke. These results suggest medical therapy alone is unlikely to be sufficient stroke prevention for patients with significant carotid stenosis.
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Affiliation(s)
- Derek Klarin
- Division of Vascular and Endovascular Surgery, Massachusetts General Hospital, Boston, Mass
| | - Richard P Cambria
- Division of Vascular and Endovascular Surgery, St. Elizabeth's Medical Center, Brighton, Mass
| | - Emel A Ergul
- Division of Vascular and Endovascular Surgery, Massachusetts General Hospital, Boston, Mass
| | - Scott B Silverman
- Department of Neurology, Massachusetts General Hospital, Boston, Mass
| | - Virendra I Patel
- Division of Vascular Surgery and Endovascular Interventions, Columbia University Medical Center, New York, NY
| | - Glenn M LaMuraglia
- Division of Vascular and Endovascular Surgery, Massachusetts General Hospital, Boston, Mass
| | - Mark F Conrad
- Division of Vascular and Endovascular Surgery, Massachusetts General Hospital, Boston, Mass
| | - W Darrin Clouse
- Division of Vascular and Endovascular Surgery, Massachusetts General Hospital, Boston, Mass.
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Högberg D, Mani K, Wanhainen A, Svensjö S. Clinical Effect and Cost-Effectiveness of Screening for Asymptomatic Carotid Stenosis: A Markov Model. Eur J Vasc Endovasc Surg 2018; 55:819-827. [PMID: 29636252 DOI: 10.1016/j.ejvs.2018.02.029] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2017] [Accepted: 02/24/2018] [Indexed: 11/30/2022]
Abstract
OBJECTIVE/BACKGROUND The cost-effectiveness of screening depends on the cost of screening, prevalence of asymptomatic carotid artery stenosis (ACAS), and the potential effect of medical intervention in reducing the risk of stroke. The aim of the study was to determine the threshold values for these parameters in order for screening for ACAS to be cost-effective. METHODS The clinical effect and cost-effectiveness of ultrasound screening for ACAS with subsequent initiation of preventive therapy versus not screening was assessed in a Markov model with a lifetime perspective. Key parameters, including stroke risk, all cause mortality, and costs, were based on contemporary published data, population statistics, and data from an ongoing screening program in Uppsala county (population 300,000), Sweden. Prevalence of ACAS (2%) and the rate of best medical treatment (BMT; 40%) were based on data from a male Swedish population recently screened for ACAS. The required stroke risk reduction from BMT, incremental cost-efficiency ratio (ICER), absolute risk reduction for stroke (ARR), and number needed to screen (NNS) were calculated. RESULTS Screening was cost-effective at an ICER of €5744 per incremental quality adjusted life year (QALY) gained. ARR was 135 per 100,000 screened, NNS was 741, and QALYs gained were 6700 per 100,000 invited. At a willingness to pay (WTP) threshold of €50,000 per QALY the minimum required stroke risk reduction from BMT was 22%. The assumed degree of stroke risk reduction was the most important determinant of cost-efficiency. CONCLUSION A moderate (22%) reduction in the risk of stroke was required for an ACAS screening strategy to be cost-effective at a WTP of €50,000/QALY. Targeting populations with a higher prevalence of ACAS could further improve cost-efficiency.
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Affiliation(s)
- Dominika Högberg
- Department of Surgical Sciences, Section of Vascular Surgery, Uppsala University Hospital, Uppsala, Sweden; Department Hybrid and Interventional Surgery, Sahlgrenska University Hospital, Gothenburg, Sweden.
| | - Kevin Mani
- Department of Surgical Sciences, Section of Vascular Surgery, Uppsala University Hospital, Uppsala, Sweden
| | - Anders Wanhainen
- Department of Surgical Sciences, Section of Vascular Surgery, Uppsala University Hospital, Uppsala, Sweden
| | - Sverker Svensjö
- Department of Surgical Sciences, Section of Vascular Surgery, Uppsala University Hospital, Uppsala, Sweden; Department of Surgery, Falun County Hospital, Falun, Sweden; Centre for Clinical Research, Falun, Sweden
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Paraskevas KI, Cambria RP. Best Medical Treatment for Patients with Carotid Stenosis: Evidence-Based Medicine or Wishful Thinking? Angiology 2018; 69:97-99. [DOI: 10.1177/0003319717709860] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/30/2023]
Affiliation(s)
- Kosmas I. Paraskevas
- Liverpool Vascular and Endovascular Services, Royal Liverpool University Hospital, Liverpool, UK
| | - Richard P. Cambria
- Division of Vascular and Endovascular Surgery, Thoracic Aortic Centre, Massachusetts General Hospital, Boston, MA, USA
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Langhoff R. Carotid stenosis - basing treatment on individual patients' needs. Optimal medical therapy alone or accompanied by stenting or endarterectomy. VASA 2017; 47:7-16. [PMID: 29064776 DOI: 10.1024/0301-1526/a000668] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
Though carotid artery stenosis is a known origin of stroke, risk assessment and treatment modality are not yet satisfactorily established. Guideline updates according to latest evidence are expected shortly. Current clinical weakness concerns in particular the identification of "at-risk" patients. Beside the symptomatic status and the degree of stenosis, further signs of unstable plaque on carotid and cerebral imaging should be considered. Moreover, medical and endovascular therapy are continuously improving. Randomized trials and meta-analyses have shown similar long-term results for protected carotid artery stenting and endarterectomy. However, endovascular revascularization was associated with an increased 30-day rate of minor strokes. Newly developed embolic protection devices could possibly compensate for this disadvantage. Furthermore, high-level optimal medical therapy alone is currently being evaluated comparatively. We assume that a comprehensive evaluation of plaque vulnerability, serious consideration of advanced embolic protection, and more space for optimal medical therapy alone according to latest evidence, will benefit patients with carotid stenosis.
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Affiliation(s)
- Ralf Langhoff
- 1 Department of Angiology, Sankt Gertrauden-Krankenhaus, Berlin, Germany
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Pini R, Faggioli G, Vacirca A, Cacioppa LM, Gallitto E, Gargiulo M, Stella A. The fate of asymptomatic severe carotid stenosis in the era of best medical therapy. Brain Inj 2017; 31:1711-1717. [DOI: 10.1080/02699052.2017.1346285] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Affiliation(s)
- Rodolfo Pini
- Vascular Surgery Unit, Policlinico S. Orsola-Malpighi, University of Bologna, Bologna, Italy
| | - Gianluca Faggioli
- Vascular Surgery Unit, Policlinico S. Orsola-Malpighi, University of Bologna, Bologna, Italy
| | - Andrea Vacirca
- Vascular Surgery Unit, Policlinico S. Orsola-Malpighi, University of Bologna, Bologna, Italy
| | - Laura Maria Cacioppa
- Vascular Surgery Unit, Policlinico S. Orsola-Malpighi, University of Bologna, Bologna, Italy
| | - Enrico Gallitto
- Vascular Surgery Unit, Policlinico S. Orsola-Malpighi, University of Bologna, Bologna, Italy
| | - Mauro Gargiulo
- Vascular Surgery Unit, Policlinico S. Orsola-Malpighi, University of Bologna, Bologna, Italy
| | - Andrea Stella
- Vascular Surgery Unit, Policlinico S. Orsola-Malpighi, University of Bologna, Bologna, Italy
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Columbo JA, Suckow BD, Griffin CL, Cronenwett JL, Goodney PP, Lukovits TG, Zwolak RM, Fillinger MF. Carotid endarterectomy should not be based on consensus statement duplex velocity criteria. J Vasc Surg 2017; 65:1029-1038.e1. [PMID: 28190714 DOI: 10.1016/j.jvs.2016.11.028] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2016] [Accepted: 11/08/2016] [Indexed: 10/20/2022]
Abstract
OBJECTIVE Randomized trials support carotid endarterectomy (CEA) in asymptomatic patients with ≥60% internal carotid artery (ICA) stenosis. The widely referenced Society for Radiologists in Ultrasound Consensus Statement on carotid duplex ultrasound (CDUS) imaging indicates that an ICA peak systolic velocity (PSV) ≥230 cm/s corresponds to a ≥70% ICA stenosis, leading to the potential conclusion that asymptomatic patients with an ICA PSV ≥230 cm/s would benefit from CEA. Our goal was to determine the natural history stroke risk of asymptomatic patients who might have undergone CEA based on consensus statement PSV of ≥230 cm/s but instead were treated medically based on more conservative CDUS imaging criteria. METHODS All patients who underwent CDUS imaging at our institution during 2009 were retrospectively reviewed. The year 2009 was chosen to ensure extended follow-up. Asymptomatic patients were included if their ICA PSV was ≥230 cm/s but less than what our laboratory considers a ≥80% stenosis by CDUS imaging (PSV ≥430 cm/s, end-diastolic velocity ≥151 cm/s, or ICA/common carotid artery PSV ratio ≥7.5). Study end points included freedom from transient ischemic attack (TIA), freedom from any stroke, freedom from carotid-etiology stroke, and freedom from revascularization. RESULTS Criteria for review were met by 327 patients. Mean follow-up was 4.3 years, with 85% of patients having >3-year follow-up. Four unheralded strokes occurred during follow-up at <1, 17, 25, and 30 months that were potentially attributable to the index carotid artery. Ipsilateral TIA occurred in 17 patients. An additional 12 strokes occurred that appeared unrelated to ipsilateral carotid disease, including hemorrhagic events, contralateral, and cerebellar strokes. Revascularization was undertaken in 59 patients, 1 for stroke, 12 for TIA, and 46 for asymptomatic disease. Actuarial freedom from carotid-etiology stroke was 99.7%, 98.4%, and 98.4% at 1, 3, and 5 years, respectively. Freedom from TIA was 98%, 96%, and 95%, freedom from any stroke was 99%, 96%, and 93%, and freedom from revascularization was 95%, 86%, and 81% at 1, 3, and 5 years, respectively. CONCLUSIONS Patients with intermediate asymptomatic carotid stenosis (ICA PSV 230-429 cm/s) do well with medical therapy when carefully monitored and intervened upon using conservative CDUS criteria. Furthermore, a substantial number of patients would undergo unnecessary CEA if consensus statement CDUS thresholds are used to recommend surgery. Current velocity threshold recommendations should be re-evaluated, with potentially important implications for upcoming clinical trials.
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Affiliation(s)
- Jesse A Columbo
- Section of Vascular Surgery, Dartmouth-Hitchcock Medical Center, Lebanon, NH
| | - Bjoern D Suckow
- Section of Vascular Surgery, Dartmouth-Hitchcock Medical Center, Lebanon, NH
| | - Claire L Griffin
- Department of Vascular Surgery, University of Utah, Salt Lake City, Utah
| | - Jack L Cronenwett
- Section of Vascular Surgery, Dartmouth-Hitchcock Medical Center, Lebanon, NH
| | - Philip P Goodney
- Section of Vascular Surgery, Dartmouth-Hitchcock Medical Center, Lebanon, NH
| | - Timothy G Lukovits
- Department of Neurology, Dartmouth-Hitchcock Medical Center, Lebanon, NH
| | - Robert M Zwolak
- Section of Vascular Surgery, Dartmouth-Hitchcock Medical Center, Lebanon, NH
| | - Mark F Fillinger
- Section of Vascular Surgery, Dartmouth-Hitchcock Medical Center, Lebanon, NH.
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Columbo JA, McCallum JC, Goodney PP, Bower TC, Schermerhorn ML, Powell RJ, DeMartino RR. Multicenter Experience of Surgical Explantation of Carotid Stents for Recurrent Stenosis. Vasc Endovascular Surg 2016; 50:547-553. [PMID: 27881699 DOI: 10.1177/1538574416677668] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
OBJECTIVE A significant cohort of patients who have undergone carotid artery stenting (CAS) will have in-stent restenosis (ISR). The optimal management of symptomatic or severe ISR remains poorly defined. The purpose of this study was to describe the indications, treatment, and mid- to long-term outcomes of patients undergoing CAS explantation for ISR. METHODS All patients undergoing internal carotid artery stent explantation with carotid artery reconstruction at Mayo Clinic Rochester, Dartmouth-Hitchcock Medical Center, and Beth-Israel Deaconess Medical Center from 2003 to 2013 were retrospectively reviewed. Isolated common carotid artery stents were excluded. Demographics, comorbidities, indications for explantation, operative details, and perioperative and postoperative outcomes were reviewed. RESULTS Over the study interval, a total of 971 patients underwent carotid stenting across the 3 centers. Of these, 8 patients ultimately underwent CAS explantation with carotid artery reconstruction. Mean age was 69 years and 5 patients were male. Index stent placement was for symptomatic stenosis in 4 patients, asymptomatic restenosis after endarterectomy in 2 patients, asymptomatic high lesion in 1 patient, and asymptomatic critical stenosis in 1 patient. Indications for explantation were symptomatic ISR in 4 patients and asymptomatic severe ISR in 4 patients. Method of repair was stent explantation and patch angioplasty in 5 and en bloc carotid resection with bypass in 3 patients. There were no perioperative neurologic events or cranial nerve injuries. At a mean follow-up of 38.7 months, there were 2 late disabling ipsilateral strokes (14.4 months and 19.1 months). CONCLUSION A significant cohort of patients who have undergone CAS will have ISR. Although excellent perioperative results after surgical explantation can be obtained, this patient subgroup remains at risk for late neurologic events. Appropriate patient selection and diligent long-term follow-up are mandated to obtain optimal outcomes.
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Affiliation(s)
- Jesse A Columbo
- 1 Section of Vascular Surgery, Dartmouth-Hitchcock Medical Center, Lebanon, NH, USA
| | - John C McCallum
- 2 Division of General Surgery, Beth Israel Deaconess Medical Center, Boston, MA, USA
| | - Philip P Goodney
- 1 Section of Vascular Surgery, Dartmouth-Hitchcock Medical Center, Lebanon, NH, USA
| | - Thomas C Bower
- 3 Department of Vascular and Endovascular Surgery, Mayo Clinic, Rochester, MN, USA
| | - Marc L Schermerhorn
- 4 Division of Vascular and Endovascular Surgery, Beth Israel Deaconess Medical Center, Boston, MA, USA
| | - Richard J Powell
- 1 Section of Vascular Surgery, Dartmouth-Hitchcock Medical Center, Lebanon, NH, USA
| | - Randall R DeMartino
- 3 Department of Vascular and Endovascular Surgery, Mayo Clinic, Rochester, MN, USA
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Giannoukas A, Chabok M, Spanos K, Nicolaides A. Screening for Asymptomatic Carotid Plaques with Ultrasound. Eur J Vasc Endovasc Surg 2016; 52:309-12. [DOI: 10.1016/j.ejvs.2016.04.013] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2016] [Accepted: 04/16/2016] [Indexed: 10/21/2022]
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Kim JB, Spotnitz M, Lindsay ME, MacGillivray TE, Isselbacher EM, Sundt TM. Risk of Aortic Dissection in the Moderately Dilated Ascending Aorta. J Am Coll Cardiol 2016; 68:1209-1219. [DOI: 10.1016/j.jacc.2016.06.025] [Citation(s) in RCA: 62] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/02/2016] [Revised: 06/03/2016] [Accepted: 06/07/2016] [Indexed: 01/15/2023]
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The detrimental impact of silent cerebral infarcts on asymptomatic carotid endarterectomy outcome. J Vasc Surg 2016; 64:15-24. [DOI: 10.1016/j.jvs.2015.12.049] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2015] [Accepted: 12/20/2015] [Indexed: 11/21/2022]
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Park YJ, Kim DI, Kim GM, Kim DK, Kim YW. Natural History of Asymptomatic Moderate Carotid Artery Stenosis in the Era of Medical Therapy. World Neurosurg 2016; 91:247-53. [DOI: 10.1016/j.wneu.2016.04.037] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2016] [Revised: 04/12/2016] [Accepted: 04/12/2016] [Indexed: 10/21/2022]
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Liu X, Zhang H, Ren L, Xiong H, Gao Z, Xu P, Huang W, Wu W. Functional assessment of the stenotic carotid artery by CFD-based pressure gradient evaluation. Am J Physiol Heart Circ Physiol 2016; 311:H645-53. [PMID: 27371686 DOI: 10.1152/ajpheart.00888.2015] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/16/2015] [Accepted: 06/24/2016] [Indexed: 11/22/2022]
Abstract
The functional assessment of a hemodynamic significant stenosis base on blood pressure variation has been applied for evaluation of the myocardial ischemic event. This functional assessment shows great potential for improving the accuracy of the classification of the severity of carotid stenosis. To explore the value of grading the stenosis using a pressure gradient (PG)-we had reconstructed patient-specific carotid geometries based on MRI images-computational fluid dynamics were performed to analyze the PG in their stenotic arteries. Doppler ultrasound image data and the corresponding MRI image data of 19 patients with carotid stenosis were collected. Based on these, 31 stenotic carotid arterial geometries were reconstructed. A combinatorial boundary condition method was implemented for steady-state computer fluid dynamics simulations. Anatomic parameters, including tortuosity (T), the angle of bifurcation, and the cross-sectional area of the remaining lumen, were collected to investigate the effect on the pressure distribution. The PG is highly correlated with the severe stenosis (r = 0.902), whereas generally, the T and the angle of the bifurcation negatively correlate to the pressure drop of the internal carotid artery stenosis. The calculation required <10 min/case, which made it prepared for the fast diagnosis of the severe stenosis. According to the results, we had proposed a potential threshold value for distinguishing severe stenosis from mild-moderate stenosis (PG = 0.88). In conclusion, the PG could serve as the additional factor for improving the accuracy of grading the severity of the stenosis.
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Affiliation(s)
- Xin Liu
- Institute of Clinical Anatomy, Southern Medical University, Guangzhou, China
| | - Heye Zhang
- Institute of Biomedical and Health Engineering, Shenzhen Institutes of Advanced Technology, Chinese Academy of Sciences, Shenzhen, China
| | - Lijie Ren
- Neurology Department, Shenzhen Second People's Hospital, Shenzhen, Guangdon, China
| | - Huahua Xiong
- Department of Ultrasound, Shenzhen Second People's Hospital, Shenzhen, Guangdon, China; and
| | - Zhifan Gao
- Institute of Biomedical and Health Engineering, Shenzhen Institutes of Advanced Technology, Chinese Academy of Sciences, Shenzhen, China
| | - Pengcheng Xu
- Institute of Clinical Anatomy, Southern Medical University, Guangzhou, China
| | - Wenhua Huang
- Institute of Clinical Anatomy, Southern Medical University, Guangzhou, China
| | - Wanqing Wu
- Institute of Biomedical and Health Engineering, Shenzhen Institutes of Advanced Technology, Chinese Academy of Sciences, Shenzhen, China
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Oda M, Ito H, Miyachi T, Maruyama H, Izumi Y. Research of carotid stenosis in the elderly aged 80 and over in mountain towns. Nihon Ronen Igakkai Zasshi 2016; 53:168-70. [PMID: 27250225 DOI: 10.3143/geriatrics.53.168] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Affiliation(s)
- Masaya Oda
- Department of Neurology, Mifukai Vihara Hananosato Hospital
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Kim JB, Ejiofor JI, Yammine M, Ando M, Camuso JM, Youngster I, Nelson SB, Kim AY, Melnitchouk SI, Rawn JD, MacGillivray TE, Cohn LH, Byrne JG, Sundt TM. Surgical outcomes of infective endocarditis among intravenous drug users. J Thorac Cardiovasc Surg 2016; 152:832-841.e1. [PMID: 27068439 DOI: 10.1016/j.jtcvs.2016.02.072] [Citation(s) in RCA: 103] [Impact Index Per Article: 12.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/12/2015] [Revised: 01/24/2016] [Accepted: 02/14/2016] [Indexed: 11/28/2022]
Abstract
BACKGROUND With increasing prevalence of injected drug use in the United States, a growing number of intravenous drug users (IVDUs) are at risk for infective endocarditis (IE) that may require surgical intervention; however, few data exist about clinical outcomes of these individuals. METHODS We evaluated consecutive adult patients undergoing surgery for active IE between 2002 and 2014 pooled from 2 prospective institutional databases. Death and valve-related events, including reinfection or heart valve reoperation, thromboembolism, and anticoagulation-related hemorrhage were evaluated. RESULTS Of the 436 patients identified, 78 (17.9%) were current IVDUs. The proportion of IVDUs increased from 14.8% in 2002 to 2004 to 26.1% in 2012 to 2014. IVDUs were younger (aged 35.9 ± 9.9 years vs 59.3 ± 14.1 years) and had fewer cardiovascular risk factors than non-IVDUs. During follow-up (median, 29.4 months; quartile 1-3, 4.7-72.6 months), adverse events among all patients included death in 92, reinfection in 42, valve-reoperation in 35, thromboembolism in 17, and hemorrhage in 16. Operative mortality was lower among IVDUs (odds ratio, 0.25; 95% confidence interval [CI], 0.06-0.71), but overall mortality was not significantly different (hazard ratio [HR], 0.78; 95% CI, 0.44-1.37). When baseline profiles were adjusted by propensity score, IVDUs had higher risk of valve-related complications (HR, 3.82; 95% CI, 1.95-7.49; P < .001) principally attributable to higher rates of reinfection (HR, 6.20; 95% CI, 2.56-15.00; P < .001). CONCLUSIONS The proportion of IVDUs among surgically treated IE patients is increasing. Although IVDUs have lower operative risk, long-term outcomes are compromised by reinfection.
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Affiliation(s)
- Joon Bum Kim
- Division of Cardiac Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, Mass; Department of Thoracic and Cardiovascular Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, South Korea
| | - Julius I Ejiofor
- Division of Cardiac Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Mass
| | - Maroun Yammine
- Division of Cardiac Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Mass
| | - Masahiko Ando
- Division of Cardiac Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, Mass
| | - Janice M Camuso
- Division of Cardiac Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, Mass
| | - Ilan Youngster
- Division of Infectious Disease, Massachusetts General Hospital, Harvard Medical School, Boston, Mass
| | - Sandra B Nelson
- Division of Infectious Disease, Massachusetts General Hospital, Harvard Medical School, Boston, Mass
| | - Arthur Y Kim
- Division of Infectious Disease, Massachusetts General Hospital, Harvard Medical School, Boston, Mass
| | - Serguei I Melnitchouk
- Division of Cardiac Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, Mass
| | - James D Rawn
- Division of Cardiac Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Mass
| | - Thomas E MacGillivray
- Division of Cardiac Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, Mass
| | - Lawrence H Cohn
- Division of Cardiac Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Mass
| | - John G Byrne
- Division of Cardiac Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Mass
| | - Thoralf M Sundt
- Division of Cardiac Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, Mass.
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Mohebali J, Patel VI, Romero JM, Hannon KM, Jaff MR, Cambria RP, LaMuraglia GM. Acoustic shadowing impairs accurate characterization of stenosis in carotid ultrasound examinations. J Vasc Surg 2016; 62:1236-44. [PMID: 26506272 DOI: 10.1016/j.jvs.2015.06.137] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2015] [Accepted: 06/04/2015] [Indexed: 12/24/2022]
Abstract
OBJECTIVE Duplex ultrasonography (DUS) has been the mainstay for diagnosing carotid artery stenosis and is often the sole diagnostic modality used prior to intervention. Highly calcified plaque, however, results in an acoustic shadow (AcS) that obscures the vessel lumen and inhibits the sonographer's ability to obtain Doppler velocity measurements. It is unknown whether DUS can accurately determine the degree of carotid stenosis in these settings. METHODS From July 2012 to December 2013, all patients with AcS on DUS measuring ≥5 mm in the longitudinal axis were cross-referenced with multidetector computed tomographic angiography (MD-CTA) images of the neck to define the study population. After standardizing the MD-CTA windows, percent stenosis was determined by cross-sectional area reduction using two separate previously described methods based on North American Symptomatic Carotid Endarterectomy Trial (NASCET) and European Carotid Surgery Trial (ECST) criteria. DUS waveform parameters in the internal carotid artery near the AcS were then compared with these MD-CTA measurements to determine the accuracy of DUS in characterizing the severity of carotid stenosis. RESULTS During this period, 8517 DUS studies were performed at the Massachusetts General Hospital, 550 of which had AcS, for an incidence of 6.45%. There were 92 lesions with a concomitant MD-CTA; however, seven were excluded because of poor study quality, because ≥6 months had elapsed between DUS and MD-CTA, or because the patient had undergone carotid reconstruction between studies. Of the 85 remaining lesions, DUS characterized 17 as severe (peak systolic velocity [PSV] >250 cm/s), 31 as moderate (PSV = 151-250 cm/s), and 37 as mild (PSV ≤150 cm/s) stenoses using PSV criteria. PSV weakly correlated with CTA-NASCET (r = 0.361; P = .004) and CTA-ECST (r = 0.306; P = .004) percent stenosis. Using PSV >250 cm/s as the predictor of >70% stenosis, and a ≥70% cutoff by both CTA-ECST and CTA-NASCET methods as the reference measure, DUS sensitivity ranged from 22.7% to 32.5%, specificity from 89.4% to 91.1%, positive predictive value from 88.2% to 76.4%, and negative predictive value from 25% to 60.2%. A subgroup analysis of lesions identified as non-severe by DUS revealed that waveforms with lower deceleration were associated with severe stenosis on CTA. CONCLUSIONS In the presence of AcS, DUS alone is inadequate to accurately determine the degree of carotid stenosis with sensitivity, specificity, and negative predictive values far below that needed for clinical decision-making. MD-CTA may be necessary for improved characterization of plaque in these AcS lesions. Further studies are needed to determine DUS parameters that may identify patients who should undergo further evaluation with MD-CTA to characterize the true severity of the stenosis.
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Affiliation(s)
- Jahan Mohebali
- Department of Surgery, Massachusetts General Hospital and Harvard Medical School, Boston, Mass
| | - Virendra I Patel
- Department of Surgery, Massachusetts General Hospital and Harvard Medical School, Boston, Mass; Division of Vascular and Endovascular Surgery, Department of Surgery, Massachusetts General Hospital and Harvard Medical School, Boston, Mass
| | - Javier M Romero
- Department of Radiology, Massachusetts General Hospital and Harvard Medical School, Boston, Mass
| | - Kathleen M Hannon
- Section of Vascular Medicine, Division of Cardiovascular Medicine, Massachusetts General Hospital Vascular Center and Harvard Medical School, Boston, Mass
| | - Michael R Jaff
- Division of Vascular and Endovascular Surgery, Department of Surgery, Massachusetts General Hospital and Harvard Medical School, Boston, Mass; Section of Vascular Medicine, Division of Cardiovascular Medicine, Massachusetts General Hospital Vascular Center and Harvard Medical School, Boston, Mass
| | - Richard P Cambria
- Department of Surgery, Massachusetts General Hospital and Harvard Medical School, Boston, Mass; Division of Vascular and Endovascular Surgery, Department of Surgery, Massachusetts General Hospital and Harvard Medical School, Boston, Mass
| | - Glenn M LaMuraglia
- Department of Surgery, Massachusetts General Hospital and Harvard Medical School, Boston, Mass; Division of Vascular and Endovascular Surgery, Department of Surgery, Massachusetts General Hospital and Harvard Medical School, Boston, Mass.
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Eslami MH, Rybin D, Doros G, Farber A. An externally validated robust risk predictive model of adverse outcomes after carotid endarterectomy. J Vasc Surg 2016; 63:345-54. [DOI: 10.1016/j.jvs.2015.09.003] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2015] [Accepted: 09/14/2015] [Indexed: 01/12/2023]
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Kolos I, Troitskiy A, Balakhonova T, Shariya M, Skrypnik D, Tvorogova T, Deev A, Boytsov S. Modern medical treatment with or without carotid endarterectomy for severe asymptomatic carotid atherosclerosis. J Vasc Surg 2016; 62:914-22. [PMID: 26410046 DOI: 10.1016/j.jvs.2015.05.005] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2015] [Accepted: 05/05/2015] [Indexed: 10/23/2022]
Abstract
OBJECTIVE This study assessed the value of modern medical treatment (MMT) with and without carotid endarterectomy (CEA) in patients with asymptomatic severe carotid artery stenosis. METHODS We conducted a randomized trial involving 55 patients with 70% to 79% carotid stenosis at three Russian centers. Between 2009 and 2013, 31 patients were randomized to undergo CEA with MMT (CEA group) and 24 to receive MMT alone. The primary end point was nonfatal ipsilateral stroke or death from any cause during a follow-up period of 5.0 years. The secondary end point was any nonfatal stroke, carotid revascularization, or death from any cause during follow-up. RESULTS The trial was stopped after a median follow-up of 3.3 years (maximum, 5.0 years). There were two primary events in the CEA group and nine events in the MMT group. The 3.3-year cumulative primary event rates were 6.5% in the CEA group and 37.5% in the MMT group (hazard ratio for the MMT group, 5.06; 95% confidence interval, 1.53-16.79; P = .008). The 3.3-year cumulative secondary end point was 12.9% in the CEA group and 50.0% in the MMT group (hazard ratio for the MMT group, 4.23; 95% confidence interval, 1.55-11.53; P = .0048). CONCLUSIONS CEA as an initial management strategy could reduce the risk of death and major cerebrovascular events when added to MMT.
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Affiliation(s)
- Igor Kolos
- Department of Clinical Cardiology and Molecular Genetics, National Research Center for Preventive Medicine, Moscow, Russian Federation.
| | - Alexandr Troitskiy
- Department of Vascular Surgery, Federal Medical and Biological Agency, Moscow, Russian Federation
| | - Tatiana Balakhonova
- Department of Vascular Ultrasound, Russian Cardiology Research and Production Center, Moscow, Russian Federation
| | - Merab Shariya
- Department of Tomography, Russian Cardiology Research and Production Center, Moscow, Russian Federation
| | - Denis Skrypnik
- Department of Vascular Surgery, Regional Clinical Hospital No. 1, Krasnodar, Russian Federation
| | - Tatiana Tvorogova
- Neurology Department, National Research Center for Preventive Medicine, Moscow, Russian Federation
| | - Alexandr Deev
- Laboratory of Biostatistics, National Research Center for Preventive Medicine, Moscow, Russian Federation
| | - Sergey Boytsov
- Department of Clinical Cardiology and Molecular Genetics, National Research Center for Preventive Medicine, Moscow, Russian Federation
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Long-term Mortality in Patients with Asymptomatic Carotid Stenosis: Implications for Statin Therapy. Eur J Vasc Endovasc Surg 2015; 50:573-82. [DOI: 10.1016/j.ejvs.2015.06.115] [Citation(s) in RCA: 66] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2014] [Accepted: 06/17/2015] [Indexed: 11/24/2022]
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Eslami MH, Rybin DV, Doros G, Farber A. The Association of Publication of Center for Medicaid and Medicare Services Guidelines for Carotid Artery Angioplasty and Stenting (CAS) and CREST Results on the Utilization of CAS in Carotid Revascularization. Ann Vasc Surg 2015; 29:1606-13. [PMID: 26315795 DOI: 10.1016/j.avsg.2015.06.091] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2015] [Revised: 06/26/2015] [Accepted: 06/29/2015] [Indexed: 10/23/2022]
Abstract
BACKGROUND Since the 2004 approval of carotid artery angioplasty and stenting (CAS), there have been 2 seminal publications about CAS reimbursement (Center for Medicaid and Medicare Several guidelines [CMSG]; 2008) and clinical outcomes (Carotid Revascularization Endarterectomy versus Stent Trial [CREST]; 2010). We explored trends in CAS utilization after these publications nationally. METHODS The most recent datasets of the nationwide inpatient sample (NIS) was queried for patients undergoing carotid revascularization. Utilization proportions of CAS were calculated quarterly from 2005 to 2011 for NIS. Three-time intervals related to CMSG and CREST publication were selected 2005-2008, 2008-2010, and after 2010. Logistic regression with piecewise linear trend for time was used to estimate different trends in CAS utilization for overall samples and for neurologically asymptomatic and symptomatic cases. RESULTS The majority (95%) of the carotid revascularizations were performed on asymptomatic patients. Overall, CAS utilization constituted 12.5% of carotid revascularization procedures with a significant period increase of CAS; from 9.4% to 14%; P < 0.001. There was a small but significant decrease in the rate of CAS utilization after CMSG were published corresponding to a 2% decline in the odds ratio (OR) of CAS per quarter (OR, 0.98; 95% confidence interval, 0.97-0.99; P = 0.001). After CREST, CAS utilization continued to increase in both NIS but the rate of increase did not change significantly from the prepublication to the postpublication time interval. The odds of in-hospital mortality and postoperative stroke were independently and significantly higher for CAS patients in both overall and within the symptomatic cohorts. In all 3 periods of the study, and compared to carotid endarterectomy, the odds of mortality and postoperative stroke were significantly higher among patients who underwent CAS. CONCLUSIONS Although overall utilization of CAS increased since 2005, it was not uniformly associated by the publication of CMSG or CREST. Despite increased utilization, the odds of adverse outcomes were independently higher among CAS patients.
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Affiliation(s)
- Mohammad H Eslami
- Division of Vascular and Endovascular Surgery, Boston University School of Medicine, Boston, MA.
| | - Denis V Rybin
- Department of Biostatistics, Boston University School of Public Health, Boston, MA
| | - Gheorghe Doros
- Department of Biostatistics, Boston University School of Public Health, Boston, MA
| | - Alik Farber
- Division of Vascular and Endovascular Surgery, Boston University School of Medicine, Boston, MA
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Aboyans V, Brodmann M, De Carlo M, Clement D, Mazzolai L, van Bortel L, van Sambeek MRH, Vlachopoulos C. The year in cardiology 2014: peripheral circulation. Eur Heart J 2015; 36:591-7. [DOI: 10.1093/eurheartj/ehu515] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
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