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Lewis AJ, Maningat A, Salzler GG, Ryer EJ. Avoiding Complications with Transcarotid Artery Revascularization. Ann Vasc Surg 2024:S0890-5096(24)00588-0. [PMID: 39343373 DOI: 10.1016/j.avsg.2024.07.127] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2024] [Revised: 07/12/2024] [Accepted: 07/23/2024] [Indexed: 10/01/2024]
Abstract
Transcarotid artery revascularization (TCAR) for carotid artery stenting offers an innovative method for treating carotid artery occlusive disease. This technique utilizes the ENROUTE Transcarotid Neuroprotection System (Silk Road Medical, Sunnyvale, CA) to temporarily reverse flow in the carotid artery prior to crossing or treating the carotid lesion, reducing the perioperative risk of stroke. Herein we summarize the available literature regarding potential complications that may be encountered when performing TCAR. We also report our group's real-world outcomes of 273 patients undergoing TCAR with median (interquartile range) follow up of 17.4 (4.4 - 38.7) months, including safety and restenosis data.
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Affiliation(s)
- Anthony J Lewis
- Department of Vascular and Endovascular Surgery, Geisinger Medical Center, Danville, PA.
| | - Alexandra Maningat
- Department of Vascular and Endovascular Surgery, Geisinger Medical Center, Danville, PA
| | - Gregory G Salzler
- Department of Vascular and Endovascular Surgery, Geisinger Medical Center, Danville, PA
| | - Evan J Ryer
- Department of Vascular and Endovascular Surgery, Geisinger Medical Center, Danville, PA
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2
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Willie-Permor D, Rahgozar S, Zarrintan S, Alsaigh T, Gaffey AC, Malas MB. Patients with Prior Exposure to a Combination of Statins & Angiotensin-Converting Enzyme Inhibitors (ACE-Is)/Angiotensin Receptor Blockers (ARBs) Have Better Outcomes after Carotid Revascularization than Patients with Prior Exposure to Statins Alone: A MultiCenter Analysis. Ann Vasc Surg 2024; 100:165-171. [PMID: 37852362 DOI: 10.1016/j.avsg.2023.08.036] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2023] [Revised: 08/23/2023] [Accepted: 08/24/2023] [Indexed: 10/20/2023]
Abstract
BACKGROUND Statin use has been studied and confirmed to have a beneficial impact on perioperative carotid endarterectomy (CEA) and carotid artery stenting (CAS) outcomes. The benefits of Angiotensin-converting enzyme inhibitors (ACE-I) in hypertension, ischemic heart disease, heart failure, diabetes mellitus, and renal disease are well-known; however, the impact of continuing or withholding ACE-Is/angiotensin receptor blockers (ARBs) on CEA and CAS outcomes is not addressed well in the literature. This study aimed to evaluate the impact of preoperative statin use combined with ACE-Is/ARBs in patients undergoing CEA or CAS on mortality and morbidity using a multi-institutional database. METHODS Using the data of all patients who underwent carotid artery revascularization, including CEA, transcarotid artery revascularization, and transfemoral carotid artery stenting from 2016 to 2021 in the Vascular Quality Initiative data, we determined as our primary outcome 30-day mortality/stroke after carotid revascularization based on periop exposure to statins alone, or the combination of statins and ACE-Is/ARBs. Secondary outcomes were postop myocardial infarction and postop congestive heart failure. Poisson regression with robust variance was used to determine postop outcomes comparing the combination of statin and ACE-Is/ARBs group with statins alone group. RESULTS A total of 131,285 patients were included in the study, with 59,860 (46%) patients receiving statin only, and 71,425 (54%) receiving both statin and ACE-Is/ARBs preoperatively. Both patient groups differed significantly in preop clinical and demographic characteristics. After adjusting for potential confounders, the statins plus ACE-I/ARB group had a 12% lower risk of postop mortality/stroke (Incident Rate Ratio comparing Statin/ACE group to Statins Only group [IRR] 0.88, 95% confidence interval 0.81-0.95, P = 0.001), 18% lower risk of postop congestive heart failure (IRR 0.82, 95% CI 0.68-0.98, P = 0.029), and similar risk of postop myocardial infarction (IRR 1.05 95% confidence interval 0.91-1.20, P = 0.54) compared to the statin-only group. CONCLUSION Statins combined with ACE-Is/ARBs perioperatively offer better protection compared to statins alone in patients undergoing carotid revascularization surgery. We recommend the continuation of ACE-Is/ARBs use in patients undergoing carotid revascularization, especially if they have concurrent hypertension. Further prospective studies are needed to evaluate the benefit of adding ACE-Is/ARBs.
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Affiliation(s)
- Daniel Willie-Permor
- Department of Surgery, Center for Learning and Excellence in Vascular & Endovascular Research(CLEVER), University of California San Diego (UCSD), La Jolla, CA
| | - Shima Rahgozar
- Department of Surgery, Center for Learning and Excellence in Vascular & Endovascular Research(CLEVER), University of California San Diego (UCSD), La Jolla, CA
| | - Sina Zarrintan
- Department of Surgery, Center for Learning and Excellence in Vascular & Endovascular Research(CLEVER), University of California San Diego (UCSD), La Jolla, CA
| | - Tom Alsaigh
- Department of Surgery, Center for Learning and Excellence in Vascular & Endovascular Research(CLEVER), University of California San Diego (UCSD), La Jolla, CA
| | - Ann C Gaffey
- Department of Surgery, Center for Learning and Excellence in Vascular & Endovascular Research(CLEVER), University of California San Diego (UCSD), La Jolla, CA
| | - Mahmoud B Malas
- Department of Surgery, Center for Learning and Excellence in Vascular & Endovascular Research(CLEVER), University of California San Diego (UCSD), La Jolla, CA.
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3
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Roy JM, Rumalla K, Skandalakis GP, Kazim SF, Schmidt MH, Bowers CA. Failure to rescue as a patient safety indicator for neurosurgical patients: are we there yet? A systematic review. Neurosurg Rev 2023; 46:227. [PMID: 37672166 DOI: 10.1007/s10143-023-02137-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2023] [Revised: 08/25/2023] [Accepted: 09/01/2023] [Indexed: 09/07/2023]
Abstract
Failure to rescue (FTR) is a standardized patient safety indicator (PSI-04) developed by the Agency for Healthcare Research and Quality (AHRQ) to assess the ability of a healthcare team to prevent mortality following a major complication. However, FTR rates vary and are impacted by non-modifiable individual patient characteristics such as baseline frailty. This raises concerns regarding the validity of FTR as an objective quality metric, as not all patients have the same baseline frailty level, or physiological reserve, to recover from major complications. Literature from other surgical specialties has identified flaws in FTR and called for risk-adjusted metrics. Currently, knowledge of factors influencing FTR and its subsequent implementation in neurosurgical patients are limited. The present review assesses trends in FTR utilization to assess how FTR performs as an objective neurosurgery quality metric. This review then proposes how FTR may be best modified to optimize use in neurosurgical patients. A PubMed search was performed to identify articles published until August 9, 2023. Studies that reported FTR as an outcome in patients undergoing neurosurgical procedures were included. A qualitative assessment was performed using the Newcastle Ottawa Scale (NOS). The initial search revealed 1232 citations. After a title and abstract screen, followed by a full text screen, 12 studies met criteria for inclusion. These articles measured FTR across a total of 764,349 patients undergoing neurosurgical procedures. Five studies analyzed FTR with regard to hospital characteristics, and three studies utilized patient characteristics to predict FTR. All studies were considered high quality based on the NOS. Modifications in criteria to measure FTR are necessary since FTR depends on patient characteristics like frailty. This would allow for the incorporation of risk-adjusted FTR metrics that would aid in clinical decision making in neurosurgical patients.
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Affiliation(s)
- Joanna M Roy
- Topiwala National Medical College, Mumbai, India
- Bowers Neurosurgical Frailty and Outcomes Data Science Lab, Albuquerque, NM, 87131, USA
| | - Kavelin Rumalla
- Department of Neurosurgery, University of New Mexico Hospital (UNMH), 1 University New Mexico, MSC10 5615, Albuquerque, NM, 87131, USA
| | - Georgios P Skandalakis
- Department of Neurosurgery, University of New Mexico Hospital (UNMH), 1 University New Mexico, MSC10 5615, Albuquerque, NM, 87131, USA
| | - Syed Faraz Kazim
- Department of Neurosurgery, University of New Mexico Hospital (UNMH), 1 University New Mexico, MSC10 5615, Albuquerque, NM, 87131, USA
| | - Meic H Schmidt
- Bowers Neurosurgical Frailty and Outcomes Data Science Lab, Albuquerque, NM, 87131, USA
- Department of Neurosurgery, University of New Mexico Hospital (UNMH), 1 University New Mexico, MSC10 5615, Albuquerque, NM, 87131, USA
| | - Christian A Bowers
- Bowers Neurosurgical Frailty and Outcomes Data Science Lab, Albuquerque, NM, 87131, USA.
- Department of Neurosurgery, University of New Mexico Hospital (UNMH), 1 University New Mexico, MSC10 5615, Albuquerque, NM, 87131, USA.
- Department of Neurosurgery, University of New Mexico Health Sciences Center, 1 University New Mexico, MSC10 5615, Albuquerque, NM, 81731, USA.
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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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Anjorin AC, Marcaccio CL, Rastogi V, Patel PB, Garg PK, Soden PA, McCallum JC, Schermerhorn ML. Statin therapy is associated with improved perioperative outcomes and long-term mortality following carotid revascularization in the Vascular Quality Initiative. J Vasc Surg 2023; 77:158-169.e8. [PMID: 36029973 PMCID: PMC9789183 DOI: 10.1016/j.jvs.2022.08.019] [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: 07/07/2022] [Revised: 08/14/2022] [Accepted: 08/17/2022] [Indexed: 02/03/2023]
Abstract
OBJECTIVE Statin therapy is the standard of care for patients with carotid artery stenosis given its proven cardiovascular benefits. However, the impact of statin therapy on outcomes in patients undergoing carotid revascularization in the Vascular Quality Initiative has not yet been evaluated. Therefore, our aim was to investigate the association of statin therapy with outcomes following carotid endarterectomy (CEA), transfemoral carotid artery stenting (tfCAS), and transcarotid artery revascularization (TCAR). METHODS We identified all patients who underwent CEA, tfCAS, or TCAR in the Vascular Quality Initiative registry from January 2016 to September 2021. To compare outcomes, we stratified patients by procedure type and created 1:1 propensity score-matched cohorts of patients who received no preoperative statin therapy (within 36 hours of procedure) versus those who received preoperative statin therapy. Propensity scores incorporated demographic characteristics, comorbidities, carotid symptom status, preoperative medications, and physician and hospital procedural experience. The primary outcome was a composite end point of in-hospital stroke and/or death. As a secondary analysis, we performed repeat propensity score-matching by postoperative statin use (prescribed at discharge) and assessed 5-year mortality. Relative risks (RR) and hazard ratios (HR) were calculated using log binomial regression and Cox regression, respectively. RESULTS Among 97,835 CEA, 20,303 tfCAS, and 22,371 TCAR patients, 15%, 17%, and 10% of patients did not receive preoperative statin therapy, respectively. Compared with statin use, no statin use was associated with a higher risk of in-hospital stroke or death among 13,434 matched CEA patients (no statin, 1.7% vs statin, 1.4%; RR, 1.2; 95% confidence interval [CI], 1.02-1.5) and among 2707 matched tfCAS patients (4.8% vs 2.8%; RR, 1.7; 95% CI, 1.3-2.3). However, there was no difference for this outcome by statin use among 2089 matched TCAR patients (1.8% vs 1.6%; RR, 1.1; 95% CI, 0.7-1.8). At 5 years, no statin therapy at discharge was associated with higher 5-year mortality after CEA (15% vs 10%; HR, 1.8; 95% CI, 1.6-2) and tfCAS (18% vs 14%; HR, 1.5; 95% CI, 1.2-1.8), but there was no difference after TCAR (14% vs 11%; HR, 1.3; 95% CI, 0.9-1.8). CONCLUSIONS Compared with statin use, no statin use was associated with a higher risk of in-hospital stroke or death and 5-year mortality among CEA and tfCAS patients. Although there was no significant difference in outcomes among TCAR patients, this may in part be due to lower statistical power in this cohort. Overall, statin therapy is essential in the short- and long-term management of patients undergoing carotid revascularization. Our findings not only support current Society for Vascular Surgery recommendations for statin therapy in patients undergoing carotid revascularization, but they also highlight an important opportunity for quality improvement.
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Affiliation(s)
- Aderike C Anjorin
- Division of Vascular and Endovascular Surgery, Department of Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA
| | - Christina L Marcaccio
- Division of Vascular and Endovascular Surgery, Department of Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA
| | - Vinamr Rastogi
- Division of Vascular and Endovascular Surgery, Department of Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA
| | - Priya B Patel
- Division of Vascular and Endovascular Surgery, Department of Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA
| | - Parveen K Garg
- Division of Cardiology, University of Southern California Keck School of Medicine, Los Angeles, CA
| | - Peter A Soden
- Division of Vascular Surgery, Department of Surgery, Alpert Medical School of Brown University, Rhode Island Hospital, Providence, RI
| | - John C McCallum
- Division of Vascular and Endovascular Surgery, Los Angeles County Harbor-UCLA Medical Center, Torrance, CA
| | - Marc L Schermerhorn
- Division of Vascular and Endovascular Surgery, Department of Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA.
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6
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Elsayed N, Unkart J, Abdelgawwad M, Naazie I, Lawrence PF, Malas MB. Role of Renin-Angiotensin-Aldosterone System Inhibition in Patients Undergoing Carotid Revascularization. J Am Heart Assoc 2022; 11:e025034. [PMID: 36000412 PMCID: PMC9496413 DOI: 10.1161/jaha.121.025034] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background Previous data suggest that using renin‐angiotensin‐aldosterone system inhibitors (RAASIs) improves survival in patients with cardiovascular diseases. We sought to investigate the association of different patterns of use of RAASIs on perioperative and 1‐year outcomes following carotid revascularization. Methods and Results We investigated patients undergoing carotid revascularization, either with carotid endarterectomy or transfemoral carotid artery stenting, in the VQI (Vascular Quality Initiative) VISION (Vascular Implant Surveillance and Interventional Outcomes Network) data set between 2003 and 2018. We divided our cohort into 3 groups: (1) no history of RAASI intake, (2) preoperative intake only, and (3) continuous pre‐ and postoperative intake. The final cohort included 73 174 patients; 44.4% had no intake, 50% had continuous intake, and 5.6% had only preoperative intake. Compared with continuous intake, preoperative and no intake were associated with higher odds of postoperative stroke (odds ratio [OR], 1.7 [95% CI, 1.5–1.9]; P<0.001; OR, 1.1 [95% CI, 1.03–1.2]; P=0.010); death (OR, 4.8 [95% CI, 3.8–6.1]; P<0.001; OR, 1.9 [95% CI, 1.6–2.2]; P<0.001); and stroke/death (OR, 2.05 [95% CI, 1.8–2.3]; P<0.001; OR, 1.2 [95% CI, 1.1–1.3]; P<0.001), respectively. At 1 year, preoperative and no intake were associated with higher odds of stroke (hazard ratio [HR], 1.4 [95% CI, 1.3–1.6]; P<0.001; HR, 1.15, [95% CI, 1.08–1.2]; P<0.001); death (HR, 1.7 [95% CI, 1.5–1.9]; P<0.001; HR, 1.3 [95% CI, 1.2–1.4]; P<0.001); and stroke/death (HR, 1.5 [95% CI, 1.4–1.7]; P<0.001; HR, 1.2 [95% CI, 1.17–1.3]; P<0.001), respectively. Conclusions Compared with subjects discontinuing or never starting RAASIs, use of RAASIs before and after carotid revascularization was associated with a short‐term stroke and mortality benefit. Future clinical trials examining prescribing patterns of RAASIs should aim to clarify the timing and potential to maximize the protective effects of RAASIs in high‐risk vascular patients.
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Affiliation(s)
- Nadin Elsayed
- Division of Vascular and Endovascular Surgery University of California San Diego La Jolla CA
| | - Jonathan Unkart
- Department of Surgery State University New York Downstate University Health Sciences University Brooklyn NY
| | - Mohammad Abdelgawwad
- Division of Vascular and Endovascular Surgery University of California San Diego La Jolla CA
| | - Isaac Naazie
- Division of Vascular and Endovascular Surgery University of California San Diego La Jolla CA
| | - Peter F Lawrence
- Division of Vascular and Endovascular Surgery, Department of Surgery David Geffen School of Medicine at UCLA Los Angeles CA
| | - Mahmoud B Malas
- Division of Vascular and Endovascular Surgery University of California San Diego La Jolla CA
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Cui C, Dong S, Liu Q, Bao J, Gao L, Li Y, He L. Low-dose statins improve prognosis of patients with ischaemic stroke undergoing intra-arterial thrombectomy: A prospective cohort study. J Clin Neurosci 2022; 103:124-130. [PMID: 35868229 DOI: 10.1016/j.jocn.2022.07.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/25/2021] [Revised: 06/23/2022] [Accepted: 07/05/2022] [Indexed: 02/05/2023]
Abstract
BACKGROUND High-dose statins are recommended as preventive drugs in guidelines for patients with ischaemic stroke undergoing thrombectomy. Not only in clinical practice but also based on large-scale studies, low-dose statins have been widely used and demonstrated to be efficient in Asian populations. However, it remains unknown whether a low-dose statin is related to the prognosis of patients with thrombectomy. Can low-dose statins reduce the risk of bleeding at the same time? METHODS We prospectively collected data from patients with acute ischaemic stroke undergoing intra-arterial thrombectomy. Efficacy outcomes were National Institutes of Health Stroke Scale (NIHSS) score improvement at 7 days after admission and a favourable functional outcome (FFO) at 90 days. Safety outcomes were rates of in-hospital haemorrhage events and death within 2 years. RESULTS We included 256 patients in this study. Compared with the control group, the low-dose statin group had a higher NIHSS improvement rate at 7 days, a higher FFO rate at 90 days and a lower death rate within 2 years. The low-dose statin group had a lower percentage of gastrointestinal haemorrhage. Statin use was significantly related to an improved NIHSS score (p = 0.028, OR = 1.773) at 7 days and FFO (P < 0.001, OR = 2.962) at 90 days and to lower death rates (P = 0.025, or = 0.554) within 2 years. CONCLUSION In Asian acute ischaemic stroke patients with intra-arterial thrombectomy, low-dose statin use was significantly related to NIHSS improvement at 7 days, FFO at 90 days and decreased death rates within 2 years.
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Affiliation(s)
- Chaohua Cui
- Department of Rehabilitation, Liuzhou Municipal Liutie Central Hospital, Liunan Distract, Liuzhou, Guangxi, China
| | - Shuju Dong
- Department of Neurology, West China Hospital, Sichuan University, Chengdu, China
| | - Qian Liu
- Department of Neurology, West China Hospital, Sichuan University, Chengdu, China
| | - Jiajia Bao
- Department of Neurology, West China Hospital, Sichuan University, Chengdu, China
| | - Lijie Gao
- Department of Neurology, West China Hospital, Sichuan University, Chengdu, China
| | - Yanbo Li
- Department of Neurology, West China Hospital, Sichuan University, Chengdu, China
| | - Li He
- Department of Neurology, West China Hospital, Sichuan University, Chengdu, China.
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AbuRahma AF, Avgerinos ED, Chang RW, Darling RC, Duncan AA, Forbes TL, Malas MB, Perler BA, Powell RJ, Rockman CB, Zhou W. The Society for Vascular Surgery implementation document for management of extracranial cerebrovascular disease. J Vasc Surg 2021; 75:26S-98S. [PMID: 34153349 DOI: 10.1016/j.jvs.2021.04.074] [Citation(s) in RCA: 64] [Impact Index Per Article: 21.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2021] [Accepted: 04/28/2021] [Indexed: 12/24/2022]
Affiliation(s)
- Ali F AbuRahma
- Department of Surgery, West Virginia University-Charleston Division, Charleston, WV.
| | - Efthymios D Avgerinos
- Division of Vascular Surgery, University of Pittsburgh School of Medicine, UPMC Hearrt & Vascular Institute, Pittsburgh, Pa
| | - Robert W Chang
- Vascular Surgery, Permanente Medical Group, San Francisco, Calif
| | | | - Audra A Duncan
- Division of Vascular & Endovascular Surgery, University of Western Ontario, London, Ontario, Canada
| | - Thomas L Forbes
- Division of Vascular & Endovascular Surgery, University of Western Ontario, London, Ontario, Canada
| | - Mahmoud B Malas
- Vascular & Endovascular Surgery, University of California San Diego, La Jolla, Calif
| | - Bruce Alan Perler
- Division of Vascular Surgery & Endovascular Therapy, Johns Hopkins, Baltimore, Md
| | | | - Caron B Rockman
- Division of Vascular Surgery, New York University Langone, New York, NY
| | - Wei Zhou
- Division of Vascular Surgery, University of Arizona, Tucson, Ariz
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9
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Comparison of open- and closed-cell stent design outcomes after carotid artery stenting in the Vascular Quality Initiative. J Vasc Surg 2020; 73:1639-1648. [PMID: 33080326 DOI: 10.1016/j.jvs.2020.08.155] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2020] [Accepted: 08/31/2020] [Indexed: 11/23/2022]
Abstract
BACKGROUND The association between stent design and outcomes after carotid artery stenting (CAS) has remained controversial. The available data are conflicting regarding the superiority of any specific stent design. The present study investigated the association between cell design and outcomes after carotid artery stenting (CAS) in a real world setting. METHODS Patients who had undergone CAS with distal embolic protection in the Society for Vascular Surgery Vascular Quality Initiative (VQI) database from 2016 to 2018 were included in the present study. Patients undergoing CAS for trauma or dissection or more than two treated lesions were excluded. We also excluded lesions for which more than two carotid stents had been used and lesions confined to the common or external carotid artery. Univariable and multivariable logistic regression analyses were used to compare the outcomes after CAS between the open- and closed-cell stent designs. RESULTS Of the 2671 CAS procedures included in the present analysis, 1384 (51.8%) had used closed-cell stents and 1287 (48.2%) had used open-cell stents. On univariable analysis, no significant differences were noted between the closed- and open-cell stents in in-hospital mortality (1.8% vs 1.4%; P = .40), stroke (1.8% vs 2.4%; P = .28), and stroke/death (3.3% vs 3.5%; P = .81). After adjusting for potential confounders (ie, age, symptomatic status, previous major amputation, statin and antiplatelet use, American Society of Anesthesiologists class, elective procedures, approach, and post-stent dilatation), no difference was noted in in-hospital stroke/death between the two stent designs (odds ratio [OR], 1.08; 95% confidence interval [CI], 0.68-1.74; P = .74). However, the interaction between stent design (open vs closed) and lesion location (bifurcation vs internal carotid artery [ICA]) was statistically significant (P = .02). Closed-cell stents were associated with five times the odds of in-hospital stroke/death when used in carotid artery bifurcation (OR, 5.5; 95% CI, 1.3-22.2; P = .02). However, when the stent was limited to the ICA, no differences were noted (OR, 0.87; 95% CI, 0.51-1.45; P = .62). One-year follow-up data were available for 19% of patients. No differences in ipsilateral stroke or death at 1 year were noted between the open- and closed-cell stents, except when the lesion was located in the carotid bifurcation (hazard ratio, 6.7; 95% CI, 1.4-31.4; P = .02). CONCLUSIONS Closed-cell stents were associated with an increased odds of in-hospital stroke/death for carotid bifurcation lesions, which might be related to the relatively lower conformability of closed-cell stents in the tortuous and diameter-mismatched bifurcation anatomy vs the relatively linear uniform diameter of the ICA. Improved follow-up and in-depth analysis of lesion-specific characteristics that might influence the outcomes of these two designs are needed to validate these results.
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Katsiki N, Mikhailidis DP. Diabetes and carotid artery disease: a narrative review. ANNALS OF TRANSLATIONAL MEDICINE 2020; 8:1280. [PMID: 33178812 PMCID: PMC7607073 DOI: 10.21037/atm.2019.12.153] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
Diabetes mellitus (DM) has been linked to an increased prevalence and severity of carotid artery disease, as well as polyvascular disease. Carotid disease is also associated with obesity and abnormal peri-organ and intra-organ fat (APIFat) deposition (i.e., excess fat accumulation in several organs such as the liver, heart and vessels). In turn, DM is associated with APIFat. The coexistence of these comorbidities confers a greater risk of vascular events. Clinicians should also consider that carotid bruits may predict cardiovascular risk. DM has been related to a greater risk of adverse outcomes after carotid endarterectomy or stenting. Whether modifying risk factors (e.g., glycaemia and dyslipidaemia) in DM patients can improve the outcomes of these procedures needs to be established. Furthermore, DM is a risk factor for contrast-induced acute kidney injury (CI-AKI). The latter should be recorded in DM patients undergoing carotid stenting since it can influence both short- and long-term outcomes. From a pathophysiological perspective, functional changes in the carotid artery may precede morphological ones. Furthermore, carotid plaque characteristics are increasingly being studied in terms of vascular risk stratification and monitoring short-term changes attributed to treatment. The present narrative review discusses the recent (2019) literature on the associations between DM and carotid artery disease. Physicians and vascular surgeons looking after patients with carotid disease and DM should consider these links that may influence outcomes. Further research in this field is also needed to optimise the treatment of such patients.
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Affiliation(s)
- Niki Katsiki
- Diabetes Center, Division of Endocrinology and Metabolism, First Department of Internal Medicine, AHEPA University Hospital, Medical School Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Dimitri P Mikhailidis
- Department of Clinical Biochemistry, Royal Free Hospital Campus, University College London Medical School, University College London (UCL), London, UK.,Mohammed Bin Rashid University of Medicine and Health Sciences, Dubai, United Arab Emirates
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Ziapour B, Schermerhorn ML, Iafrati MD, Suarez LB, TourSavadkohi S, Salehi P. A systematic review and meta-analysis of predilation and postdilation in transfemoral carotid artery stenting. J Vasc Surg 2020; 72:346-355.e1. [DOI: 10.1016/j.jvs.2019.11.044] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2019] [Accepted: 11/23/2019] [Indexed: 12/28/2022]
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Nejim B, Mathlouthi A, Weaver L, Faateh M, Arhuidese I, Malas MB. Safety of carotid artery revascularization procedures in patients with atrial fibrillation. J Vasc Surg 2020; 72:2069-2078.e4. [PMID: 32471737 DOI: 10.1016/j.jvs.2020.01.074] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2019] [Accepted: 01/21/2020] [Indexed: 10/24/2022]
Abstract
BACKGROUND Atrial fibrillation (Afib) is a major contributor to cerebrovascular events. Coexisting carotid artery disease is not uncommon in Afib patients, yet they have been excluded from major randomized clinical trials. Therefore, the aim of this study was to evaluate the safety of carotid endarterectomy (CEA) and carotid artery stenting (CAS) in Afib patients. METHODS The Premier Healthcare Database was queried (2009-2015). Patients who underwent CEA or CAS were captured by International Classification of Diseases, Ninth Revision, Clinical Modification codes. Multivariable logistic modeling was implemented to examine the outcomes: in-hospital stroke, intracerebral hemorrhage (ICH), mortality, and stroke/death. RESULTS There were 86,778 patients included. The majority were asymptomatic (n = 82,128 [94.6%]). Afib was reported in 6743 patients (7.8%). In terms of absolute outcomes in both asymptomatic and symptomatic patients, Afib patients (vs non-Afib patients) had higher mortality and stroke/death (asymptomatic: mortality, 0.4% vs 0.2%; stroke/death, 1.7% vs 1.2%; symptomatic: mortality, 6.9% vs 2.1%; stroke/death, 10.6% vs 4.5%; all P < .05). Adjusted analysis yielded higher odds of ICH (adjusted odds ratio [aOR], 1.29; 95% confidence interval [CI], 1.00-1.67), mortality (aOR, 1.59; 95% CI, 1.11-2.26), and stroke/death (aOR, 1.30; 95% CI, 1.08-1.58) in Afib patients. Although univariable analysis found Afib to be a statistically significant predictor of ischemic stroke, similar results could not be elucidated in the multivariable analysis (aOR, 1.17; 95% CI, 0.93-1.47). In Afib patients, important predictors of stroke/death included CAS (aOR, 1.80; 95% CI, 1.21-2.68) and symptomatic presentation (aOR, 5.00; 95% CI, 3.20-7.83). Other important predictors were type of preoperative medication use, age, and hospital size. CONCLUSIONS Afib was associated with worse postoperative outcomes in patients with carotid artery disease. Symptomatic status in Afib patients is associated with a stroke/death risk that is higher than in recommended guidelines for CEA and particularly for CAS. Overall, CEA was associated with lower periprocedural ICH, mortality, and stroke/death in Afib patients compared with CAS.
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Affiliation(s)
- Besma Nejim
- Division of Vascular and Endovascular Surgery, Penn State Hershey Medical Center, Hershey, Pa
| | - Asma Mathlouthi
- Division of Vascular and Endovascular Surgery, University of California San Diego, La Jolla, Calif
| | - Libby Weaver
- Department of Surgery, Johns Hopkins Medical Institutes, Baltimore, Md
| | - Muhammad Faateh
- Department of Surgery, Johns Hopkins Medical Institutes, Baltimore, Md
| | - Isibor Arhuidese
- Division of Vascular and Endovascular Surgery, University of South Florida, Tampa, Fla
| | - Mahmoud B Malas
- Division of Vascular and Endovascular Surgery, University of California San Diego, La Jolla, Calif.
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Ratcliffe F, Rothwell PM. The case for statin use to reduce perioperative adverse cardiovascular and cerebrovascular events. Br J Anaesth 2020; 124:525-534. [PMID: 32111371 DOI: 10.1016/j.bja.2020.01.010] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2019] [Revised: 01/12/2020] [Accepted: 01/24/2020] [Indexed: 12/11/2022] Open
Abstract
Ischaemic heart disease and stroke are the leading causes of death worldwide at 119 per 100,000 and 85 per 100,000 population. For the USA, heart disease is leading cause of death at 165 per 100,000 population. In developed countries, strokes and acute myocardial infarction in the general population have fallen from smoking reduction, lifestyle modifications and therapeutic interventions including statins. In a population-based stroke study in the UK involving primary care practices, of in-hospital strokes 90% were ischaemic, and 37% occurred within 1 week of an operation. Approximately 50% of the patients were not on a statin. In the UK, there is a national screening initiative for the prevention of atherosclerotic cardiovascular disease (ASCVD) offered to people aged 40-74 yr old. The QRISK3 tool calculates the risk of developing heart disease or stroke over 10 yr, from which recommendations are made on interventions for the prevention of ASCVD up to age 84 yr, with similar screening and assessment tools in Europe and the US. If the QRISK3 score tool for calculating cardiovascular risk is considered sufficiently robust for population screening in primary care, should anaesthetists not use the same screening for secondary care? We present a case for statin use over the perioperative period, to reduce early vascular adverse events based on statins' early pleiotropic actions, using the primary care QRISK tool for screening of ASCVD risk.
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Affiliation(s)
- Fiona Ratcliffe
- Nuffield Department of Anaesthetics, Oxford University Hospitals NHS Foundation Trust, Oxford, UK.
| | - Peter M Rothwell
- Nuffield Department of Clinical Neurosciences, University of Oxford, Oxford, UK
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Dakour-Aridi H, Faateh M, Kuo PL, Zarkowsky DS, Beck A, Malas MB. The Vascular Quality Initiative 30-day stroke/death risk score calculator after transfemoral carotid artery stenting. J Vasc Surg 2020; 71:526-534. [DOI: 10.1016/j.jvs.2019.05.051] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2019] [Accepted: 05/18/2019] [Indexed: 10/26/2022]
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15
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Qiao L, Wang S, Jia Q, Bian J, Fan Y, Xu X. Clinical efficacy and safety of statin treatment after carotid artery stenting. ARTIFICIAL CELLS NANOMEDICINE AND BIOTECHNOLOGY 2019; 47:3110-3115. [PMID: 31352800 DOI: 10.1080/21691401.2019.1645149] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/24/2023]
Abstract
Objective: The randomized controlled trail was carried out to investigate the influence of statin pre-treatment on clinical efficacy of carotid artery stenting (CAS). Methods: 160 eligible patients were randomly divided into statin group (n = 82) and control group (n = 78). The patients in statin group received 40 mg atorvastatin daily 7 days before operation. Major endpoints included transient ischemic attack (TIA), stroke, death, myocardial infarction (MI), and other cardiac adverse events within 30 days after CAS. Results: Preoperative baseline information was similar between the statin and control groups (p > 0.05 for all). Within 48 h after operation, the occurrence rate of CIN (3.66% vs 8.97%, p = .019) and new infarction (4.88% vs. 14.10%, p = .045) were significantly lower in statin group than in control group. 30 days after CAS, the incidences of TIA (12.20% vs. 26.92%, p = .018), ischemic stroke (6.10% vs. 16.67%, p = .034), and other cardiac complications (7.32% vs. 19.23%, p = .026) were also significantly lower in statin group, than in the control group. Multiple analysis demonstrated that statin use exerted protective effect against ischemic stroke (OR = 0.038, 95% CI = 0.003-0.543, p = .016) and other cardiac complications (OR = 0.208, 95%CI = 0.063-0.694, p = .011). Conclusion: Pre-treatment with statin is an effective and safe strategy to prevent from perioperative complications and to improve postoperative outcomes in patients undergoing CAS.
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Affiliation(s)
- Lingya Qiao
- a Department of Neurology, Tianjin Huanhu Hospital , Tianjin , China
| | - Shibo Wang
- b Department of Neurosurgery, Tianjin Huanhu Hospital , Tianjin , China
| | - Qiang Jia
- b Department of Neurosurgery, Tianjin Huanhu Hospital , Tianjin , China
| | - Ji Bian
- a Department of Neurology, Tianjin Huanhu Hospital , Tianjin , China
| | - Yimu Fan
- b Department of Neurosurgery, Tianjin Huanhu Hospital , Tianjin , China
| | - Xiaolin Xu
- a Department of Neurology, Tianjin Huanhu Hospital , Tianjin , China
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Association between statin use and perioperative mortality after aortobifemoral bypass in patients with aortoiliac occlusive disease. J Vasc Surg 2019; 70:509-515. [PMID: 30837182 DOI: 10.1016/j.jvs.2018.10.120] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2018] [Accepted: 10/23/2018] [Indexed: 11/21/2022]
Abstract
OBJECTIVE The benefit of statins in reducing perioperative cardiovascular events in patients undergoing suprainguinal bypass is still controversial. The purpose of this study was to evaluate the association between statin use and perioperative mortality in patients undergoing aortobifemoral bypass (ABFB) for aortoiliac occlusive disease. METHODS We retrospectively analyzed all patients who had ABFB in the American College of Surgeons National Surgical Quality Improvement Program data set from 2011 to 2016. Univariable (t-test, χ2 test, or Fisher exact test) and multivariable logistic regression analyses were used to compare patients' characteristics and the primary outcome (30-day mortality) between statin users and nonstatin users. Propensity score matching between statin users and nonusers was also performed on the basis of variables that were different between the two groups. RESULTS A total of 4445 patients underwent ABFB. Of those, 3032 (68.2%) were taking statins. Compared with nonstatin users, statins users were older (median [interquartile range], 67 years [59-74 years] vs 63 years [56-72 years]; P < .01) and more likely to be diabetic (31% vs 16%) and hypertensive (84% vs 63%) and to have a history of chronic obstructive pulmonary disease (20% vs 17%; all P < .05). Statin users had lower rates of 30-day mortality (3.4% vs 4.7%; P = .03) and renal complications (2.5% vs 3.7%; P = .04) compared with nonstatin users. After adjustment for patients' demographics (age, sex, race), comorbidities (diabetes, hypertension, congestive heart failure, chronic obstructive pulmonary disease, chronic kidney disease, dialysis, bleeding disorder), smoking, clinical presentation (claudication vs critical limb ischemia), and elective surgery status, statin use was associated with 32% reduction in 30-day mortality (odds ratio, 0.68; 95% confidence interval, 0.47-0.96; P = .03). Propensity score matching showed similar results (odds ratio, 0.63; 95% confidence interval, 0.41-0.95; P = .03). CONCLUSIONS This is the largest study to date demonstrating an association between preoperative statin use and lower 30-day mortality after ABFB for aortoiliac occlusive disease. This study highlights an area of potential quality improvement as one-third of the patients undergoing this procedure are not receiving statins.
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Faateh M, Dakour-Aridi H, Kuo PL, Locham S, Rizwan M, Malas MB. Risk of emergent carotid endarterectomy varies by type of presenting symptoms. J Vasc Surg 2019; 70:130-137.e1. [PMID: 30777684 DOI: 10.1016/j.jvs.2018.10.064] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2018] [Accepted: 10/04/2018] [Indexed: 11/16/2022]
Abstract
BACKGROUND The timing of carotid revascularization in symptomatic patients is a matter of ongoing debate. Current evidence indicates that carotid endarterectomy (CEA) within 2 weeks of symptoms is superior to delayed treatment. However, there is little evidence on the outcomes of emergent CEA (eCEA). The purpose of this study was to compare outcomes of emergency eCEA vs nonemergent CEA (non-eCEA), stratified by type of presenting symptoms. METHODS We analyzed the Vascular Targeted-National Surgical Quality Improvement Program dataset from 2011 to 2016. Symptomatic patients were divided into two groups: eCEA and non-eCEA. Univariable and multivariable methods were used to compare patient characteristics and to evaluate stroke, death, myocardial infarction (MI), stroke/death, and stroke/death/MI within 30 days of surgery adjusting for all potential confounders. A further subgroup analysis was done to compare the outcomes of eCEA vs non-eCEA stratified by the type of presenting symptoms (amaurosis, transient ischemic attack [TIA], and stroke). RESULTS A total of 9271 patients were identified, of which 10.7% were eCEA vs 89.3% non-eCEA. Comparing eCEA vs non-eCEA, the two groups were similar in age (70.8 vs 70.5), female gender (36.3% vs 36.9%), diabetes (26.2% vs 28.9%), and smoking status (31.9% vs 28.7%; all P > .05). Patients undergoing eCEA were less likely to be hypertensive (76.2% vs 80.2%; P = .025), but more likely to belong to non-white race (51.5% vs 20.5%; P < .001). The eCEA patients were less likely to be on preprocedural medication vs non-eCEA (antiplatelets, 76.8% vs 89.2%; statins, 74.2% vs 79.9%; beta-blockers, 44.6% vs 50.4%; all P < .05). The 30-day outcomes comparing eCEA vs non-eCEA were: stroke, 6.2% vs 3.1%; death, 2% vs 1%; and stroke/death, 6.9% vs 3.7% (all P < .05). After risk adjustment, perioperative stroke (odds ratio [OR], 2.04; 95% confidence interval [CI], 1.36-3.0), stroke/death (OR, 1.66; 95% CI, 1.13-2.45), and stroke/death/MI (OR, 1.58; 95% CI, 1.18-2.23) were higher after eCEA (all P < .01). When stratified by the type of presenting symptom, eCEA vs non-eCEA stroke outcomes were similar in patients who presented with stroke or amaurosis fugax. However, in the subset of patients presenting with TIA, eCEA had much worse outcomes compared with non-eCEA (stroke, 8.3% vs 2.5%; stroke/death, 8.3% vs 3.2%) and had significantly higher odds of stroke (OR, 3.12; 95% CI, 1.71-5.68) and stroke/death (OR, 2.24; 95% CI, 1.25-4.03) in the adjusted analysis (all P < .05). CONCLUSIONS In patients presenting with stroke, eCEA does not seem to add significant risk compared with non-eCEA. However, patients presenting with TIA might be better served with non-emergent surgery as their risk of stroke is tripled when CEA is performed emergently.
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Affiliation(s)
- Muhammad Faateh
- Johns Hopkins Bayview Vascular and Endovascular Research Center, Baltimore, Md
| | - Hanaa Dakour-Aridi
- Johns Hopkins Bayview Vascular and Endovascular Research Center, Baltimore, Md
| | - Pei-Lun Kuo
- Johns Hopkins Bayview Vascular and Endovascular Research Center, Baltimore, Md
| | - Satinderjit Locham
- Johns Hopkins Bayview Vascular and Endovascular Research Center, Baltimore, Md
| | - Muhammad Rizwan
- Johns Hopkins Bayview Vascular and Endovascular Research Center, Baltimore, Md
| | - Mahmoud B Malas
- Johns Hopkins Bayview Vascular and Endovascular Research Center, Baltimore, Md.
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Rizwan M, Aridi HD, Dang T, Alshwaily W, Nejim B, Malas MB. Long-Term Outcomes of Carotid Endarterectomy and Carotid Artery Stenting When Performed by a Single Vascular Surgeon. Vasc Endovascular Surg 2019; 53:216-223. [PMID: 30614413 DOI: 10.1177/1538574418823379] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
OBJECTIVES: Carotid artery endarterectomy (CEA) and carotid artery stenting (CAS) are 2 effective treatment options for carotid revascularization and stroke prevention. The long-term outcomes of Carotid Revascularization Endarterectomy versus Stenting Trial (CREST) reported similar stroke and death rate between the 2 procedures. This study presents the short- and long-term outcomes of CEA and CAS of all risk patients performed by a single vascular surgeon in a real-world setting. METHODS: We retrospectively reviewed all patients who underwent CEA and CAS from September 2005 to June 2017 at our institute. Student t test, χ2, and Fisher exact tests were used to compare patient's characteristics. Multivariate logistic, cox regression models and survival analysis were used to compare postoperative and long-term outcomes between the 2 groups. RESULTS: Over 2000 patients were evaluated for carotid artery stenosis during the study period, and 313 revascularization procedures were performed (CEA: 47%, CAS: 53%). Patients' age (Mean [95% confidence interval, CI] 68.8 [67.2-70.4] vs 69.7 [68.2-71.3], P = .40) was similar between CEA and CAS. Patients who underwent CAS had significantly higher comorbidities (chronic obstructive pulmonary disease [COPD], chronic heart failure [CHF], hyperlipidemia, and prior ipsilateral intervention, all P < .05). No difference was found in 30-day complications after CEA versus CAS including stroke (2.0% vs 1.2%), myocardial infarction (MI; 0.7% vs 1.2%), death (0% vs 1.2%) as well as combined major adverse events (stroke/death/MI; 2.7% vs 3.0%; all P > .05). Overall 7-year survival, stroke-free survival and restenosis-free survival were similar between the 2 groups ( P > .5). Significant predictors of mortality were diabetes (hazard ratio, HR [95% CI]: 2.41 [1.15-5.08]), chronic kidney disease (HR [95% CI]: 4.89 [1.97-12.13]), and COPD (HR [95% CI]: 3.31 [1.43-7.71]; all P values <.05). Statin use was protective with 71% reduction in risk of mortality (HR [95% CI]: 0.29 [0.12-0.67], P = .004). CONCLUSION: Our experience showed comparable short- and long-term outcomes of CAS and CEA performed for carotid artery stenosis by vascular surgeon. There was no difference between single institutional long-term outcomes and CREST outcomes following CEA and CAS.
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Affiliation(s)
- Muhammad Rizwan
- 1 The Johns Hopkins Bayview Vascular and Endovascular Research Center, Baltimore, MD, USA
| | - Hanaa Dakour Aridi
- 1 The Johns Hopkins Bayview Vascular and Endovascular Research Center, Baltimore, MD, USA
| | - Tru Dang
- 1 The Johns Hopkins Bayview Vascular and Endovascular Research Center, Baltimore, MD, USA
| | - Widian Alshwaily
- 1 The Johns Hopkins Bayview Vascular and Endovascular Research Center, Baltimore, MD, USA
| | - Besma Nejim
- 1 The Johns Hopkins Bayview Vascular and Endovascular Research Center, Baltimore, MD, USA
| | - Mahmoud B Malas
- 1 The Johns Hopkins Bayview Vascular and Endovascular Research Center, Baltimore, MD, USA.,2 Health System, University of California San Diego, San Diego, CA, USA.,3 Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
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Colussi G, Zuttion F, Bais B, Dolso P, Valente M, Gigli GL, Gasparini D, Sponza M, Catena C, Sechi LA, Cavarape A. Pre-Procedural Statin Use Is Associated with Improved Long-Term Survival and Reduced Major Cardiovascular Events in Patients Undergoing Carotid Artery Stenting: A Retrospective Study. J Clin Med 2018; 7:E286. [PMID: 30227674 PMCID: PMC6162515 DOI: 10.3390/jcm7090286] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2018] [Revised: 09/09/2018] [Accepted: 09/12/2018] [Indexed: 11/28/2022] Open
Abstract
Carotid artery stenting (CAS) is a minimal invasive procedure used to resolve carotid occlusion that can be affected by peri-procedural complications. Statin use before CAS has shown to reduce peri-procedural risk and improve survival, though time-dependent cofactors that influence mortality has not been considered. The aim of this study was to evaluate long-term survival of patients who undergo CAS considering new occurred major adverse cardiovascular event (MACE) as time-dependent cofactor. In this study, 171 high cardiovascular risk patients (age 72 ± 8 years, 125 males) were enrolled after CAS procedure and were followed for a median of 8.4 years. Death occurred in 44% of patients with a mean time to death of 69 ± 39 months and MACE in 34% with a mean time of 35 ± 42 months. In patients who used or not statins at baseline, death occurred in 33% and 65%, respectively (p < 0.001). Survival analysis showed that statin use reduced risk of death (hazard ratio HR 0.36, 95% confidence interval CI 0.23⁻0.58, p < 0.0001). Including MACE as time-dependent variable did not change beneficial effects of statins. Additionally, statin use was associated with a protective effect on MACE (HR 0.48, 95% CI 0.27⁻0.85, p = 0.012); particularly, the prevalence of stroke was reduced by 59% (p = 0.018). In multivariate analysis, effects of statins were independent of demographic and anthropometric variables, prevalence of cardiovascular risk factors, renal function, antiplatelet use, and MACE occurrence. In conclusion, use of statins before CAS procedure is associated with increased long-term survival and reduced MACE occurrence. This evidence supports the hypothesis that statin use before CAS might be beneficial in high risk patients.
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Affiliation(s)
- GianLuca Colussi
- Division of Internal Medicine, Department of Medicine, University of Udine, 33100 Udine, Italy.
| | - Francesca Zuttion
- Division of Internal Medicine, Department of Medicine, University of Udine, 33100 Udine, Italy.
| | - Bruno Bais
- Division of Internal Medicine, Department of Medicine, University of Udine, 33100 Udine, Italy.
| | - Pierluigi Dolso
- Division of Neurology, Department of Medicine, University of Udine, 33100 Udine, Italy.
| | - Mariarosaria Valente
- Division of Neurology, Department of Medicine, University of Udine, 33100 Udine, Italy.
| | - Gian Luigi Gigli
- Division of Neurology, Department of Medicine, University of Udine, 33100 Udine, Italy.
| | - Daniele Gasparini
- Division of Interventional Radiology, Department of Radiology, Academic Hospital of Udine, 33100 Udine, Italy.
| | - Massimo Sponza
- Division of Interventional Radiology, Department of Radiology, Academic Hospital of Udine, 33100 Udine, Italy.
| | - Cristiana Catena
- Division of Internal Medicine, Department of Medicine, University of Udine, 33100 Udine, Italy.
| | - Leonardo A Sechi
- Division of Internal Medicine, Department of Medicine, University of Udine, 33100 Udine, Italy.
| | - Alessandro Cavarape
- Division of Internal Medicine, Department of Medicine, University of Udine, 33100 Udine, Italy.
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