1
|
Abdou H, Treffalls RN, Stonko DP, Kundi R, Morrison JJ. Endovascular stenting techniques for blunt carotid injury. Vascular 2024; 32:1055-1062. [PMID: 37499267 DOI: 10.1177/17085381231193062] [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: 07/29/2023]
Abstract
OBJECTIVES While methods of endovascular carotid artery stenting have improved over time, concerns surrounding the safety and efficacy of stenting for blunt carotid injury (BCI) remain. This study aims to present our approach to carotid artery stenting (CAS) by incorporating new technologies such as flow-diverting stents and circuits. METHODS There is no robust evidence to support routine carotid artery stenting; however, there are several therapeutic options and approaches for treating BCI that currently require an individualized approach. Endovascular stenting and specific stent selection are largely dictated by the disease process the surgeon intends to treat. We will discuss patient selection, medical management, and the most common revascularization techniques, including transfemoral stenting, trans-carotid arterial revascularization using flow reversal, and stent-assisting coiling. RESULTS It must be stressed that endovascular intervention is not an alternative to or preclusive of antithrombotic or anticoagulant therapy. In the setting of BCI, transfemoral CAS is most appropriate in patients who are symptomatic, have a rapidly progressing or large lesion, and do not have a soft thrombus present due to risk of embolism. Unlike transfemoral CAS, TCAR offers an elegant solution for embolic protection when patients have a soft thrombus present. In the case of a large pseudoaneurysm, we perform stent-assisted coiling. CONCLUSIONS We practice selective endovascular intervention, stenting lesions that are flow-limiting or have large or rapidly expanding pseudoaneurysms, and only in patients for whom anticoagulation and antiplatelet agents are not contraindicated. As technology and investigation progress, the concerns regarding the safety and the role of endovascular intervention in the treatment of BCI will be more clearly defined.
Collapse
Affiliation(s)
- Hossam Abdou
- R Adams Cowley Shock Trauma Center, University of Maryland Medical System, Baltimore, MD, USA
| | - Rebecca N Treffalls
- R Adams Cowley Shock Trauma Center, University of Maryland Medical System, Baltimore, MD, USA
| | - David P Stonko
- R Adams Cowley Shock Trauma Center, University of Maryland Medical System, Baltimore, MD, USA
- Johns Hopkins Hospital Department of Surgery, Baltimore, MD, USA
| | - Rishi Kundi
- R Adams Cowley Shock Trauma Center, University of Maryland Medical System, Baltimore, MD, USA
| | - Jonathan J Morrison
- Department of Vascular and Endovascular Surgery, Mayo Clinic, Rochester, MN, USA
| |
Collapse
|
2
|
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.
Collapse
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.
| |
Collapse
|
3
|
Jabbour G, Yadavalli SD, Straus S, Sanders AP, Rastogi V, Eldrup-Jorgensen J, Powell RJ, Davis RB, Schermerhorn ML. Learning curve of transfemoral carotid artery stenting in the Vascular Quality Initiative registry. J Vasc Surg 2024; 80:138-150.e8. [PMID: 38428653 DOI: 10.1016/j.jvs.2024.02.026] [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: 12/10/2023] [Revised: 02/05/2024] [Accepted: 02/07/2024] [Indexed: 03/03/2024]
Abstract
OBJECTIVE With the recent expansion of the Centers for Medicare and Medicaid Services coverage, transfemoral carotid artery stenting (tfCAS) is expected to play a larger role in the management of carotid disease. Existing research on the tfCAS learning curve, primarily conducted over a decade ago, may not adequately describe the current effect of physician experience on outcomes. Because approximately 30% of perioperative strokes/deaths post-CAS occur after discharge, appropriate thresholds for in-hospital event rates have been suggested to be <4% for symptomatic and <2% for asymptomatic patients. This study evaluates the tfCAS learning curve using Vascular Quality Initiative (VQI) data. METHODS We identified VQI patients who underwent tfCAS between 2005 and 2023. Each physician's procedures were chronologically grouped into 12 categories, from procedure counts 1-25 to 351+. The primary outcome was in-hospital stroke/death rate; secondary outcomes were in-hospital stroke/death/myocardial infarction (MI), 30-day mortality, in-hospital stroke/transient ischemic attack (stroke/TIA), and access site complications. The relationship between outcomes and procedure counts was analyzed using the Cochran-Armitage test and a generalized linear model with restricted cubic splines. Our results were then validated using a generalized estimating equations model to account for the variability between physicians. RESULTS We analyzed 43,147 procedures by 2476 physicians. In symptomatic patients, there was a decrease in rates of in-hospital stroke/death (procedure counts 1-25 to 351+: 5.2%-1.7%), in-hospital stroke/death/MI (5.8%-1.7%), 30-day mortality (4.6%-2.8%), in-hospital stroke/TIA (5.0%-1.1%), and access site complications (4.1%-1.1%) as physician experience increased (all P values < .05). The in-hospital stroke/death rate remained above 4% until 235 procedures. Similarly, in asymptomatic patients, there was a decrease in rates of in-hospital stroke/death (2.1%-1.6%), in-hospital stroke/death/MI (2.6%-1.6%), 30-day mortality (1.7%-0.4%), and in-hospital stroke/TIA (2.8%-1.6%) with increasing physician experience (all P values <.05). The in-hospital stroke/death rate remained above 2% until 13 procedures. CONCLUSIONS In-hospital stroke/death and 30-day mortality rates after tfCAS decreased with increasing physician experience, showing a lengthy learning curve consistent with previous reports. Given that physicians' early cases may not be included in the VQI, the learning curve was likely underestimated. Nevertheless, a substantially high rate of in-hospital stroke/death was found in physicians' first 25 procedures. With the recent Centers for Medicare and Medicaid Services coverage expansion for tfCAS, a significant number of physicians would enter the early stage of the learning curve, potentially leading to increased postoperative complications.
Collapse
Affiliation(s)
- Gabriel Jabbour
- Division of Vascular and Endovascular Surgery, Department of Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA
| | - Sai Divya Yadavalli
- Division of Vascular and Endovascular Surgery, Department of Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA
| | - Sabrina Straus
- Division of Vascular and Endovascular Surgery, Department of Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA
| | - Andrew P Sanders
- Division of Vascular and Endovascular Surgery, Department of Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA
| | - Vinamr Rastogi
- Department of Vascular Surgery, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Jens Eldrup-Jorgensen
- Division of Vascular Surgery, Maine Medical Center, Tufts University School of Medicine, Portland, ME
| | - Richard J Powell
- Department of Vascular Surgery, Dartmouth-Hitchcock Medical Center, Lebanon, NH
| | - Roger B Davis
- Division of General Medicine, Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA
| | - Marc L Schermerhorn
- Division of Vascular and Endovascular Surgery, Department of Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA.
| |
Collapse
|
4
|
Spiliopoulos S, Blanc R, Gandini R, Müller-Hülsbeck S, Reith W, Moschovaki-Zeiger O. CIRSE Standards of Practice on Carotid Artery Stenting. Cardiovasc Intervent Radiol 2024; 47:705-716. [PMID: 38683353 PMCID: PMC11164804 DOI: 10.1007/s00270-024-03707-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/07/2023] [Accepted: 03/06/2024] [Indexed: 05/01/2024]
Abstract
BACKGROUND Carotid artery stenting has been used effectively to treat internal carotid artery stenosis since 1989 (Mathias et al. in World J Surg. 25(3):328-34, 2001), with refined and expanded techniques and tools presently delivering outstanding results in percutaneous endoluminal treatment of carotid artery stenosis. PURPOSE This CIRSE Standards of Practice document is directed at interventional radiologists and details the guidelines for carotid artery stenting, as well as the different implementation techniques. In addition to updating all previously published material on the different clinical indications, it will provide all technical details reflective of European practice for carotid artery stenting. CIRSE Standards of Practice documents do not aim to implement a standard of clinical patient care, but rather to provide a realistic strategy and best practices for the execution of this procedure. METHODS The writing group, which was established by the CIRSE Standards of Practice Committee, consisted of five clinicians with internationally recognised expertise in carotid artery stenting procedures. The writing group reviewed existing literature on carotid artery stenting procedures, performing a pragmatic evidence search using PubMed to select relevant publications in the English language from 2006 to 2022. RESULTS Carotid artery stenting has an established role in the management of internal carotid artery stenosis; this Standards of Practice document provides up-to-date recommendations for its safe performance.
Collapse
Affiliation(s)
- Stavros Spiliopoulos
- Interventional Radiology Unit, 2nd Department of Radiology, National and Kapodistrian University of Athens, "Attikon" University General Hospital, Athens, Greece.
| | - Raphaël Blanc
- Department of Interventional Neuroradiology, Foundation Rothschild Hospital, Paris, France
| | - Roberto Gandini
- Diagnostic and Interventional Radiology/Neuroradiology, University of Rome "Tor Vergata", Rome, Italy
| | - Stefan Müller-Hülsbeck
- Diagnostic and Interventional Radiology/Neuroradiology, DIAKO Hospital, Flensburg, Germany
| | - Wolfgang Reith
- Department of Neuroradiology, Saarland University, Homberg, Germany
| | - Ornella Moschovaki-Zeiger
- Interventional Radiology Unit, 2nd Department of Radiology, National and Kapodistrian University of Athens, "Attikon" University General Hospital, Athens, Greece
| |
Collapse
|
5
|
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.
Collapse
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.
| |
Collapse
|
6
|
AbuRahma A. An analysis of the recommendations of the 2022 Society for Vascular Surgery clinical practice guidelines for patients with asymptomatic carotid stenosis. J Vasc Surg 2024; 79:1235-1239. [PMID: 38157995 DOI: 10.1016/j.jvs.2023.12.041] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2023] [Revised: 12/20/2023] [Accepted: 12/22/2023] [Indexed: 01/03/2024]
Abstract
OBJECTIVE Patients with asymptomatic carotid artery stenosis currently account for the majority of carotid interventions performed in the United States; therefore, the following article will review the 2022 Society for Vascular Surgery (SVS) clinical practice guidelines perspective in treating patient with asymptomatic carotid stenosis. METHODS A systemic review and meta-analysis were conducted by the evidence practice center of the Mayo Clinic using a specified population, intervention, comparison, outcome (PICO) framework. RESULTS Based on published randomized trials and related supporting evidence, the following were noted: the SVS recommends that patients with asymptomatic ≥70% stenosis can be considered for carotid endarterectomy (CEA), transcarotid artery revascularization (TCAR), or transfemoral carotid artery stenting (TFCAS) for the reduction of long-term risk of stroke, provided the patient has a life expectancy of 3 to 5 years with risk of perioperative stroke and death not exceeding 3%. The type of carotid intervention should be based on the presence or absence of high-risk criteria for each specified intervention. Data from CREST, ACT, and the Vascular Quality Initiative suggest that certain properly selected asymptomatic patients can be treated with carotid stenting with equivalent outcome to CEA in the hands of experienced interventionalists. The institutions and operator performing carotid stenting must exhibit expertise sufficient to meet the established American Heart Association guidelines for treatment of patient with asymptomatic carotid stenosis (ie, combined stroke/death rate of less than 3%). CONCLUSIONS SVS recommends that low surgical risk patients with asymptomatic carotid stenosis of ≥70% to be treated with CEA with best medical therapy over medical therapy alone for the long-term prevention of stroke/death (GRADE 1B). Carotid intervention should also be based on the presence or absence of high-risk criteria for each specified intervention (ie, CEA, TCAR, and TFCAS).
Collapse
Affiliation(s)
- Ali AbuRahma
- Department of Surgery, Charleston Area Medical Center/West Virginia University, Charleston, WV.
| |
Collapse
|
7
|
Forman J, Ricotta JJ, Ricotta JJ. "TCAR or nothing": the only options for some complex carotid stenosis. J Vasc Surg Cases Innov Tech 2024; 10:101404. [PMID: 38357654 PMCID: PMC10864852 DOI: 10.1016/j.jvscit.2023.101404] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2023] [Accepted: 11/16/2023] [Indexed: 02/16/2024] Open
Abstract
Transcervical carotid artery revascularization has emerged as an alternative to carotid endarterectomy and transfemoral carotid artery stenting. We present four cases for which we believe transcervical carotid artery revascularization was the only option to treat the lesions. Each case presented with specific technical challenges that were overcome by intraoperative planning that allowed for safe deployment of the Enroute stent (Silk Road Medical) with resolution of each patient's stenosis.
Collapse
Affiliation(s)
- Jake Forman
- Department of Vascular Surgery, Florida Atlantic University Charles E. Schmidt School of Medicine, Boca Raton, FL
| | - John J. Ricotta
- Department of Vascular Surgery, Florida Atlantic University Charles E. Schmidt School of Medicine, Boca Raton, FL
| | - Joseph J. Ricotta
- Department of Vascular Surgery, Florida Atlantic University Charles E. Schmidt School of Medicine, Boca Raton, FL
| |
Collapse
|
8
|
Zhu J, Rao A, Berger K, Gopal M, Vrudhula A, Han D, Vouyouka A, Ting W, Finlay D, Kim SY, Tadros R, Marin M, Faries P. Determinants of Mortality and Mid-Term Outcomes After Transcarotid Artery Revascularization and Transfemoral Carotid Artery Stenting. J Endovasc Ther 2024:15266028241235791. [PMID: 38449352 DOI: 10.1177/15266028241235791] [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: 03/08/2024]
Abstract
OBJECTIVES The potential benefit of transcarotid artery revascularization (TCAR) over transfemoral carotid artery stenting (tfCAS) has been studied in the perioperative period with lower rates of stroke and death; however, data on mid-term outcomes are limited. We aimed to evaluate 3-year outcomes after TCAR and tfCAS and determine the primary predictors of 30-day and 1-year mortality following TCAR. METHODS Data from the Vascular Quality Initiative for patients undergoing TCAR or tfCAS from January 2016 to December 2022 were analyzed. 1:1 propensity score matching using the nearest-neighbor method was used to adjust baseline demographics and clinical characteristics. Kaplan-Meier survival analysis and Cox Proportional Hazard Regression were used to evaluate long-term outcomes. Iterative stepwise multiple logistic regression analysis and Cox Proportional Hazard Regression were used to identify predictors of 30-day and 1-year mortality, respectively, based upon preoperative, intraoperative, and postoperative factors. RESULTS A total of 70 237 patients were included in analysis (TCAR=58.7%, tfCAS=41.3%). Transcarotid artery revascularization patients were older and had higher rates of comorbid conditions and high-risk medical and anatomic features than tfCAS patients. Propensity score matching yielded 22 322 pairs with no major differences between groups except that TCAR patients were older (71.6 years vs 70.8 years). At 3 years, TCAR was associated with a 24% reduction in hazard of death compared with tfCAS (hazard ratio [HR]=0.76, 95% confidence interval [CI]=0.71-0.82, p<0.001), for both symptomatic and asymptomatic patients. This survival advantage was established in the first 6 months (HR=0.59, 95% CI=0.53-0.62, p<0.001), with no difference in mortality risk from 6 months to 36 months (HR=0.95, 95% CI=0.86-1.05, p=0.31). Transcarotid artery revascularization was also associated with decreased hazard for 3-year stroke (HR=0.81, 95% CI=0.66-0.99, p=0.04) and stroke or death (HR=0.81, 95% CI=0.76-0.87, p<0.001) compared with tfCAS. The top predictors for 30-day and 1-year mortality were postoperative complications. The primary independent predictor was the occurrence of postoperative stroke. CONCLUSIONS Transcarotid artery revascularization had a sustained mid-term survival advantage associated over tfCAS, with the benefit being established primarily within the first 6 months. Notably, our findings highlight the importance of postoperative stroke as the primary independent predictor for 30-day and 1-year mortal. CLINICAL IMPACT The ongoing debate over the superiority of TCAR compared to tfCAS and CEA has been limited by a lack of comparative studies examining the impact of pre-operative symptoms on outcomes. Furthermore, data are scarce on mid-term outcomes for TCAR beyond the perioperative period. As a result, it remains uncertain whether the initial benefits of stroke and death reduction observed with TCAR over tfCAS persist beyond one year. Our study addresses these gaps in the literature, offering evidence to enable clinicians to assess the efficacy of TCAR for up to three years. Additionally, our study seeks to identify risk factors for postoperative mortality following TCAR, facilitating optimal patient stratification.
Collapse
Affiliation(s)
- Jerry Zhu
- Division of Vascular Surgery, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Ajit Rao
- Division of Vascular Surgery, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Kelsey Berger
- Division of Vascular Surgery, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Malika Gopal
- Division of Vascular Surgery, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Amey Vrudhula
- Division of Vascular Surgery, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Daniel Han
- Division of Vascular Surgery, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Ageliki Vouyouka
- Division of Vascular Surgery, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Windsor Ting
- Division of Vascular Surgery, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - David Finlay
- Division of Vascular Surgery, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Sung Yup Kim
- Division of Vascular Surgery, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Rami Tadros
- Division of Vascular Surgery, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Michael Marin
- Division of Vascular Surgery, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Peter Faries
- Division of Vascular Surgery, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| |
Collapse
|
9
|
Cui CL, Reardon ES, Loanzon RS, Williams ZF, Cox MW, Southerland KW. Feasibility and Intermediate Results of Transcarotid Revascularization with a Prosthetic Conduit. Ann Vasc Surg 2024; 103:74-80. [PMID: 38395342 DOI: 10.1016/j.avsg.2023.12.075] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2023] [Revised: 12/11/2023] [Accepted: 12/13/2023] [Indexed: 02/25/2024]
Abstract
BACKGROUND Transcarotid artery revascularization (TCAR) is a hybrid technique with excellent initial outcomes. The technical success and safety of TCAR is heavily dependent on an anatomically suitable common carotid artery (CCA). Many patients do not meet anatomic criteria and therefore are not eligible for this therapy. We sought to extend the eligibility of TCAR to patients with unfavorable CCA anatomy via the adoption of a prosthetic arterial conduit. METHODS A single-center retrospective study of patients with critical carotid artery stenosis who underwent TCAR via a prosthetic conduit between June 2019 and October 2021 was performed. All patients in the study were considered high-risk for carotid endarterectomy based on anatomic features, such as restenosis post-carotid endarterectomy and neck radiation. Unfavorable CCA anatomy was defined as a clavicle to carotid bifurcation distance <5 cm, a CCA diameter <6 mm, and/or significant atherosclerotic disease at the intended arterial access site. The primary outcome of interest was technical success. Secondary outcomes included perioperative complications, intermediate and long-term patency, intermediate and long-term stroke and/or mortality and in-hospital length of stay. Follow-up ranged from 1 to 29 months. RESULTS Eight patients underwent 10 TCAR procedures via a prosthetic conduit. A total of 2 procedures (20%) were performed on female patients and 8 procedures (75%) were performed on male patients. The mean age was 65 years old (standard deviation 11 years). Technical success was 100%. The 30-day ipsilateral stroke rate was 0%. The 30-day patency was 90%. There was no re-exploration for hemorrhage and 30 day mortality was 0%. CONCLUSIONS TCAR is an excellent option for carotid artery revascularization. Unfavorable CCA anatomy has limited its applicability. TCAR via a prosthetic conduit has the potential to expand eligibility for this promising therapy.
Collapse
Affiliation(s)
- Christina L Cui
- Division of Vascular and Endovascular Surgery, Department of Surgery, Duke University Health, Durham, NC
| | - Emily S Reardon
- Sentara Healthcare, Sentara Vascular Specialists, Hampton, VA
| | - Roberto S Loanzon
- Division of Vascular and Endovascular Surgery, Department of Surgery, Duke University Health, Durham, NC
| | - Zachary F Williams
- Division of Vascular and Endovascular Surgery, Department of Surgery, Duke University Health, Durham, NC
| | - Mitchell W Cox
- Division of Vascular and Endovascular Surgery, Department of Surgery, University of Texas Medical Branch, Webster, TX
| | - Kevin W Southerland
- Division of Vascular and Endovascular Surgery, Department of Surgery, Duke University Health, Durham, NC.
| |
Collapse
|
10
|
Stonko DP, Mohammed S, Skojec D, Rutkowski J, Call D, Verdi KG, Tsai LL, Black JH, Perler BA, Abularrage CJ, Lum YW, Salameh MJ, Hicks CW. Automatic 1-year follow-up appointment creation and reminders can improve long-term follow-up after carotid revascularization. Am J Surg 2024; 227:57-62. [PMID: 37827870 PMCID: PMC10797636 DOI: 10.1016/j.amjsurg.2023.09.032] [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: 06/13/2023] [Revised: 09/17/2023] [Accepted: 09/25/2023] [Indexed: 10/14/2023]
Abstract
BACKGROUND Long-term follow-up (LTFU) following carotid revascularization is important for post-surgical care, stroke risk optimization and post-market surveillance of new technologies. METHODS We instituted a quality improvement project to improve LTFU rates for carotid revascularizations (primary outcome) by scheduling perioperative and one-year follow-up appointments at time of surgery discharge. A temporal trends analysis (Q1 2019 through Q1 2022), multivariable regression, and interrupted time series (ITS) were performed to compare pre-post intervention LTFU rates. RESULTS 269 consecutive patients were included (151 pre-intervention, 118 post-intervention; mean 71 ± 12 years-old, 39% female, 77% White). The overall LTFU rate improved (64.9%-78.8%; P = 0.013) after the intervention. After controlling for patient factors, procedures performed after the intervention were associated with increased odds of being seen for 1-year follow-up (OR: 2.2 95%CI: 1.2-4.0). Quarterly ITS analysis corroborated this relationship (P = 0.01). CONCLUSIONS Time-of-surgery appointment creation and automated patient reminders can improve LTFU rates following carotid revascularizations.
Collapse
Affiliation(s)
- David P Stonko
- Division of Vascular Surgery and Endovascular Therapy, Department of Surgery, The Johns Hopkins Hospital, Baltimore, MD, USA; Department of Surgery, The Johns Hopkins Hospital, Baltimore, MD, USA.
| | - Shira Mohammed
- Division of Vascular Surgery and Endovascular Therapy, Department of Surgery, The Johns Hopkins Hospital, Baltimore, MD, USA.
| | - Diane Skojec
- Division of Vascular Surgery and Endovascular Therapy, Department of Surgery, The Johns Hopkins Hospital, Baltimore, MD, USA.
| | - Joanna Rutkowski
- Division of Vascular Surgery and Endovascular Therapy, Department of Surgery, The Johns Hopkins Hospital, Baltimore, MD, USA.
| | - Diana Call
- Division of Vascular Surgery and Endovascular Therapy, Department of Surgery, The Johns Hopkins Hospital, Baltimore, MD, USA.
| | - Katherine G Verdi
- Department of Surgery, The Johns Hopkins Hospital, Baltimore, MD, USA.
| | - Lillian L Tsai
- Department of Surgery, The Johns Hopkins Hospital, Baltimore, MD, USA.
| | - James H Black
- Division of Vascular Surgery and Endovascular Therapy, Department of Surgery, The Johns Hopkins Hospital, Baltimore, MD, USA.
| | - Bruce A Perler
- Division of Vascular Surgery and Endovascular Therapy, Department of Surgery, The Johns Hopkins Hospital, Baltimore, MD, USA.
| | - Christopher J Abularrage
- Division of Vascular Surgery and Endovascular Therapy, Department of Surgery, The Johns Hopkins Hospital, Baltimore, MD, USA.
| | - Ying Wei Lum
- Division of Vascular Surgery and Endovascular Therapy, Department of Surgery, The Johns Hopkins Hospital, Baltimore, MD, USA.
| | - Maya J Salameh
- Johns Hopkins Center for Vascular Medicine, Division of Cardiology, The Johns Hopkins Hospital, Baltimore, MD, USA; Cardiovascular Specialist of Frederick, Frederick, MD, USA.
| | - Caitlin W Hicks
- Division of Vascular Surgery and Endovascular Therapy, Department of Surgery, The Johns Hopkins Hospital, Baltimore, MD, USA.
| |
Collapse
|
11
|
Smith JA, Chung JM, Schneider PA, Kwolek CJ, Arko FR, Henao S, Titus J, DiMuzio P, Roddy S, Farber MA, Kashyap VS. Female and male patients have similar outcomes after transcarotid artery revascularization in prospective trials. J Vasc Surg 2024; 79:81-87.e1. [PMID: 37716579 DOI: 10.1016/j.jvs.2023.09.007] [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: 08/14/2023] [Revised: 09/08/2023] [Accepted: 09/10/2023] [Indexed: 09/18/2023]
Abstract
OBJECTIVE Sex disparities in outcomes after carotid revascularization have long been a concern, with several studies demonstrating increased postoperative death and stroke for female patients after either carotid endarterectomy or transfemoral stenting. Adverse events after transfemoral stenting are higher in female patients, particularly in symptomatic cases. Our objective was to investigate outcomes after transcarotid artery revascularization (TCAR) stratified by patient sex hypothesizing that the results would be similar between males and females. METHODS We analyzed prospectively collected data from the Safety and Efficacy Study for Reverse Flow Used During Carotid Artery Stenting Procedure (ROADSTER)1 (pivotal), ROADSTER2 (US Food and Drug Administration indicated postmarket), and ROADSTER Extended Access TCAR trials. All patients had verified carotid stenosis meeting criteria for intervention (≥80% for asymptomatic patients and ≥50% in patient with symptomatic disease), and were included based on anatomical or clinical high-risk criteria for carotid stenting. Neurological assessments (National Institutes of Health Stroke Scale, Modified Rankin Scale) were obtained before and within 24 hours from procedure end by an independent neurologist or National Institutes of Health Stroke Scale-certified nurse. Patients were stratified by sex (male vs female). Baseline demographics were compared using χ2 and Fisher's exact tests where appropriate; primary outcomes were combination stroke/death (S/D) and S/D/myocardial infarction (S/D/M) at 30 days, and secondary outcomes were the individual components of S/D/M. Univariate logistic regression was conducted. RESULTS We included 910 patients for analysis (306 female [33.6%], 604 male [66.4%]). Female patients were more often <65 years old (20.6% vs 15%) or ≥80 years old (22.6% vs 20.2%) compared with males, and were more often of Black/African American ethnicity (7.5% vs 4.3%). There were no differences by sex in term of comorbidities, current or prior smoking status, prior stroke, symptomatic status, or prevalence of anatomical and/or clinical high-risk criteria. General anesthetic use, stent brands used, and procedure times did not differ by sex, although flow reversal times were longer in female patients (10.9 minutes male vs 12.4 minutes female; P = .01), as was more contrast used in procedures for female patients (43 mL male vs 48.9 mL female; P = .049). The 30-day S/D and S/D/M rates were similar between male and female patients (S/D, 2.7% male vs 1.6% female [P = .34]; S/D/M, 3.6% male vs 2.6% female [P = .41]), which did not differ when stratified by symptom status. Secondary outcomes did not differ by sex, including stroke rates at 30 days (2.2% male vs 1.6% female; P = .80), nor were differences seen with stratification by symptom status. Univariate analysis demonstrated that history of a prior ipsilateral stroke was associated with increased odds of S/D (odds ratio [OR], 4.19; P = .001) and S/D/M (OR, 2.78; P = .01), as was symptomatic presentation with increased odds for S/D (OR, 2.78; P = .02). CONCLUSIONS Prospective TCAR trial data demonstrate exceptionally low rates of S/D/MI, which do not differ by patient sex.
Collapse
Affiliation(s)
- Justin A Smith
- Division of Vascular Surgery and Endovascular Therapy, Department of Surgery, Case Western Reserve University School of Medicine, University Hospitals Cleveland Medical Center, Cleveland, OH
| | - Jane M Chung
- Division of Vascular Surgery and Endovascular Therapy, Department of Surgery, Case Western Reserve University School of Medicine, University Hospitals Cleveland Medical Center, Cleveland, OH
| | - Peter A Schneider
- Division of Vascular and Endovascular Surgery, University of California San Francisco, San Francisco, CA
| | - Christopher J Kwolek
- Division of Vascular and Endovascular Surgery of the General Surgical Services, Massachusetts General Hospital, Boston, MA
| | - Frank R Arko
- Sanger Hearth & Vascular Institute, Atrium Health Carolinas Medical Center, Charlotte, NC
| | | | | | - Paul DiMuzio
- Division of Vascular and Endovascular Surgery, Thomas Jefferson University Hospital, Philadelphia, PA
| | - Sean Roddy
- Division of Vascular Surgery, Albany Medical College, Albany, NY
| | - Mark A Farber
- Divison of Vascular Surgery, University of North Carolina School of Medicine, Chapel Hill, NC
| | - Vikram S Kashyap
- Frederik Meijer Heart and Vascular Institute, Corewell Health, Grand Rapids, MI.
| |
Collapse
|
12
|
Jabbour G, Yadavalli SD, Strauss S, Sanders AP, Rastogi V, Eldrup-Jorgensen J, Powell RJ, Davis RB, Schermerhorn ML. Impact of Physician Experience on Stroke or Death Rates in Transfemoral Carotid Artery Stenting: Insights from the Vascular Quality Initiative. MEDRXIV : THE PREPRINT SERVER FOR HEALTH SCIENCES 2023:2023.11.16.23298660. [PMID: 38014117 PMCID: PMC10680887 DOI: 10.1101/2023.11.16.23298660] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/29/2023]
Abstract
Objective With the recent expansion of the Centers for Medicare and Medicaid Services (CMS) coverage, transfemoral carotid artery stenting (tfCAS) is expected to play a larger role in the management of carotid disease. Existing research on the tfCAS learning curve, primarily conducted over a decade ago, may not adequately describe the current effect of physician experience on outcomes. This study evaluates the tfCAS learning curve using VQI data. Methods We analyzed tfCAS patient data from 2005-2023. Each physician's procedures were chronologically grouped into 12 categories, from procedure counts 1-25 to 351+. Primary outcome was in-hospital stroke/death rate; secondary outcomes were in-hospital stroke/death/MI, 30-day mortality, and in-hospital stroke/TIA. The relationship between outcomes and procedure counts was analyzed using Cochran Armitage test and a generalized linear model with restricted cubic splines, validated using generalized estimating equations. Results We analyzed 43,147 procedures by 2,476 physicians. In symptomatic patients, there was a decrease in rates of in-hospital stroke/death (procedure counts 1-25 to 351+: 5.2% to 1.7%), in-hospital stroke/death/MI (5.8% to 1.7%), 30-day mortality (4.6% to 2.8%), in-hospital stroke/TIA (5.0% to 1.1%) (all p-values<0.05). The in-hospital stroke/death rate remained above 4% until 235 procedures. Similarly, in asymptomatic patients, there was a decrease in rates of in-hospital stroke/death (2.1% to 1.6%), in-hospital stroke/death/MI (2.6% to 1.6%), 30-day mortality (1.7% to 0.4%), and in-hospital stroke/TIA (2.8% to 1.6%) with increasing physician experience (all p-values<0.05). The in-hospital stroke/death rate remained above 2% until 13 procedures. Conclusions In-hospital stroke/death and 30-day mortality rates post-tfCAS decreased with increasing physician experience, showing a lengthy learning curve consistent with previous reports. Given that physicians' early cases may not be included in the VQI, the learning curve was likely underestimated. With the recent CMS coverage expansion for tfCAS, a significant number of physicians would enter the early stage of the learning curve, potentially leading to increased post-operative complications.
Collapse
Affiliation(s)
- Gabriel Jabbour
- Department of Surgery, Division of Vascular and Endovascular Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
| | - Sai Divya Yadavalli
- Department of Surgery, Division of Vascular and Endovascular Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
| | - Sabrina Strauss
- Department of Surgery, Division of Vascular and Endovascular Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
| | - Andrew P. Sanders
- Department of Surgery, Division of Vascular and Endovascular Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
| | - Vinamr Rastogi
- Department of Vascular Surgery, Erasmus University Medical Center, Rotterdam, the Netherlands
| | - Jens Eldrup-Jorgensen
- Maine Medical Center, Division of Vascular Surgery, Tufts University School of Medicine, Portland, Me
| | - Richard J. Powell
- Department of Vascular Surgery, Dartmouth-Hitchcock Medical Center, Lebanon, NH
| | - Roger B. Davis
- Department of Medicine, Division of General Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
| | - Marc L. Schermerhorn
- Department of Surgery, Division of Vascular and Endovascular Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
| |
Collapse
|
13
|
Zarrintan S, Elsayed N, Patel RJ, Clary B, Goodney PP, Malas MB. Propensity-Score Matched Analysis of Three Years Survival of Trans Carotid Artery Revascularization Versus Carotid Endarterectomy in the Vascular Quality Initiative Medicare-Linked Database. Ann Surg 2023; 278:559-567. [PMID: 37436847 DOI: 10.1097/sla.0000000000006009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/14/2023]
Abstract
OBJECTIVE Carotid endarterectomy (CEA) remains the gold standard procedure for carotid revascularization. Transfemoral carotid artery stenting (TFCAS) was introduced as a minimally invasive alternative procedure in patients who are at high risk for surgery. However, TFCAS was associated with an increased risk of stroke and death compared to CEA. BACKGROUND Transcarotid artery revascularization (TCAR) has outperformed TFCAS in several prior studies and has shown similar perioperative and 1-year outcomes compared with CEA. We aimed to compare the 1-year and 3-year outcomes of TCAR versus CEA in the Vascular Quality Initiative (VQI)-Medicare-Linked [Vascular Implant Surveillance and Interventional Outcomes Network (VISION)] database. METHODS The VISION database was queried for all patients undergoing CEA and TCAR between September 2016 to December 2019. The primary outcome was 1-year and 3-year survival. One-to-one propensity-score matching (PSM) without replacement was used to produce 2 well-matched cohorts. Kaplan-Meier estimates, and Cox regression was used for analyses. Exploratory analyses compared stroke rates using claims-based algorithms for comparison. RESULTS A total of 43,714 patients underwent CEA and 8089 patients underwent TCAR during the study period. Patients in the TCAR cohort were older and were more likely to have severe comorbidities. PSM produced two well-matched cohorts of 7351 pairs of TCAR and CEA. In the matched cohorts, there were no differences in 1-year death [hazard ratio (HR)=1.13; 95% CI, 0.99-1.30; P =0.065]. At 3-years, TCAR was associated with slight increased risk of death (HR=1.16; 95% CI, 1.04-1.30; P =0.008). When stratifying by initial symptomatic presentation, the increased 3-year death associated with TCAR persisted only in symptomatic patients (HR=1.33; 95% CI, 1.08-1.63; P =0.008). Exploratory analyses of postoperative stroke rates using administrative sources suggested that validated measures of claims-based stroke ascertainment are necessary. CONCLUSIONS In this large multi-institutional PSM analysis with robust Medicare-linked follow-up for survival analysis, the rate of death at 1 year was similar in TCAR and CEA regardless of symptomatic status. The slight increase in the risk of 3-year death in symptomatic patients undergoing TCAR is likely confounded by more severe comorbidities despite matching. A randomized controlled trial comparing TCAR to CEA is necessary to further determine the role of TCAR in standard-risk patients requiring carotid revascularization.
Collapse
Affiliation(s)
- Sina Zarrintan
- Department of Surgery, UC San Diego, San Diego, CA
- Center for Learning and Excellence in Vascular and Endovascular Research (CLEVER), UC San Diego, San Diego, CA
| | - Nadin Elsayed
- Department of Surgery, UC San Diego, San Diego, CA
- Center for Learning and Excellence in Vascular and Endovascular Research (CLEVER), UC San Diego, San Diego, CA
| | - Rohini J Patel
- Department of Surgery, UC San Diego, San Diego, CA
- Center for Learning and Excellence in Vascular and Endovascular Research (CLEVER), UC San Diego, San Diego, CA
| | - Bryan Clary
- Department of Surgery, UC San Diego, San Diego, CA
| | - Philip P Goodney
- Dartmouth Institute for Health Policy and Clinical Practice, Geisel School of Medicine at Dartmouth, Lebanon, NH
- Section of Vascular Surgery, Department of Surgery, Dartmouth-Hitchcock Medical Center, Lebanon, NH
| | - Mahmoud B Malas
- Department of Surgery, UC San Diego, San Diego, CA
- Center for Learning and Excellence in Vascular and Endovascular Research (CLEVER), UC San Diego, San Diego, CA
| |
Collapse
|
14
|
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.
Collapse
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.
| |
Collapse
|
15
|
Tong Y, Rhee RY, Sebastian A, Meghpara MK, Pu Q, Almadani M. Intraoperative fusion imaging during transcarotid artery revascularization. J Vasc Surg Cases Innov Tech 2023; 9:101228. [PMID: 37662569 PMCID: PMC10474460 DOI: 10.1016/j.jvscit.2023.101228] [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: 12/15/2022] [Accepted: 05/11/2023] [Indexed: 09/05/2023] Open
Abstract
Background Transcarotid artery revascularization (TCAR) with reverse-flow neuroprotection has emerged as an alternative to transfemoral carotid artery stenting and carotid endarterectomy. However, it requires fluoroscopic guidance, exposing the patient and surgeon to radiation. Although fusion-guided endovascular aneurysm repair has been demonstrated to significantly decrease this radiation risk, not much is known about similar outcomes for TCAR. The purpose of this study is to evaluate the outcomes at a single institution using fusion-guided imaging during TCAR compared with regional TCAR cases in the Vascular Quality Initiative (VQI) registry without fusion imaging. Methods A retrospective analysis was conducted of data collected from all patients undergoing TCAR with fusion-guided imaging (TCAR-F) at our hospital and patients undergoing TCAR alone within the VQI database. The primary outcomes included the total operative time, dose area product, fluoroscopy time, contrast usage, and flow-reversal time. The demographics and preoperative risk factors were also assessed in both groups. Continuous outcomes were compared using the Welch t test. Categorical outcomes were compared using the Fisher exact test. Results A total of 30 TCAR-F cases (January 2019 to May 2022) at our institution were compared against the regional VQI dataset (n = 2535). The TCAR-F cases had a lower dose area product (5.67 vs 93.1 Gy cm2; P < .0001), shorter fluoroscopy time (8.07 vs 16.4 minutes; P < .0001), and less contrast usage (13.49 vs 76.7 mL; P < .0001) compared with the regional averages of the same. The TCAR-F cases had a longer total operative time (117.3 vs 80.9 minutes; P < .0001) and flow-reversal time (14.4 vs 11.7 minutes; P = .025) compared with the regional cases. Conclusions The results from this pilot study comparing TCAR-F patients at a single institution with VQI regional TCAR patients suggest that TCAR-F cases use less radiation and contrast compared with TCAR without fusion imaging. Fusion-guided imaging might provide radiation protection to both patients and surgeons and decrease contrast usage for the patient.
Collapse
Affiliation(s)
- Yi Tong
- Division of Vascular Surgery, Maimonides Medical Center, Brooklyn, NY
| | - Robert Y. Rhee
- Division of Vascular Surgery, Maimonides Medical Center, Brooklyn, NY
| | | | | | - Qinghua Pu
- Division of Vascular Surgery, Maimonides Medical Center, Brooklyn, NY
| | - Mahmoud Almadani
- Division of Vascular Surgery, Maimonides Medical Center, Brooklyn, NY
| |
Collapse
|
16
|
Suh D, Ma Y, Newton DH, Amendola MF, Lavingia KS. Carotid artery dissections from transcarotid artery revascularization as reported by the Food and Drug Administration. Vascular 2023:17085381231194410. [PMID: 37553285 DOI: 10.1177/17085381231194410] [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: 08/10/2023]
Abstract
OBJECTIVES Transcarotid artery revascularization (TCAR) is a hybrid procedure that allows reversal of blood flow away from the brain while placing a stent through direct surgical access of the common carotid artery. It has been shown to have a lower risk of perioperative stroke compared with any prospective trial of transfemoral carotid artery stenting. However, intraoperative injuries related to the procedure and its management are not well characterized. One of the intraoperative complications seen in TCAR is iatrogenic carotid artery dissection (CD). We aim to add qualitative insight in further characterizing CDs and its management in this emerging technology. METHODS The Food and Drug Administration (FDA) maintains the Manufacturer and User Facility Device Experience (MAUDE) database for surveillance of all medical devices approved for use. This database was queried for all cases associated with Silk Road Medical's ENROUTE Transcarotid Neuroprotection System from September 2016 to October 2020. Case narratives related to CD were individually analyzed to determine time of injury (intraoperative, recovery, and post-discharge follow-up). CD reporting was further analyzed for the associated procedural event at the time of injury, number of access attempts to CD repair, and type of CD repair. Reports associated with CD repair were further categorized into endovascular repair and open surgical repair. RESULTS Of the 115 unique adverse events in the database, there were 58 CDs. Most were identified intraoperatively (n = 55), while three were incidentally found postoperatively. Overall, sheath placement was the most common procedural event attributed to CD (N = 34). There was adequate narrative information about CD repair in 54 patients. Intraoperative repair was performed in 52 cases and two were repaired after post-discharge follow-up imaging was performed.Among CDs that did not require additional access to engage the true lumen, the proportion of endovascular repair (62.5%) was significantly higher (p = .044) compared to the proportion of open surgical repair (37.5%). However, the proportion of open surgical repair (75%) was significantly higher than the proportion of endovascular repair (25%) in CDs with persistent failure to engage the true lumen despite ≥2 access attempts (p = .039). CONCLUSION CD is the most common injury related to TCAR as reported on MAUDE. The most commonly reported procedural event associated with CD was sheath placement. The rate of intraoperative endovascular and open surgical CD repair was associated with whether the access to the true lumen of the carotid artery required additional access attempts or not. This should add qualitative insight among the vascular surgery community regarding intraoperative management of CDs from a TCAR procedure.
Collapse
Affiliation(s)
- Dongjin Suh
- Department of Surgery, University of Iowa Hospitals and Clinics, Iowa, IA, USA
| | - Yuchi Ma
- Virginia Commonwealth University School of Medicine, Richmond, VA, USA
| | - Daniel H Newton
- Virginia Commonwealth University School of Medicine, Richmond, VA, USA
- Virginia Commonwealth University Health System, Richmond, VA
| | - Michael F Amendola
- Virginia Commonwealth University School of Medicine, Richmond, VA, USA
- Central Virginia VA Health Care System, Richmond, VA, USA
| | - Kedar S Lavingia
- Virginia Commonwealth University School of Medicine, Richmond, VA, USA
- Central Virginia VA Health Care System, Richmond, VA, USA
| |
Collapse
|
17
|
Banks CA, Pearce BJ. Interventions in Carotid Artery Surgery: An Overview of Current Management and Future Implications. Surg Clin North Am 2023; 103:645-671. [PMID: 37455030 DOI: 10.1016/j.suc.2023.05.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/18/2023]
Abstract
Atherosclerotic carotid artery disease has been well studied over the last half-century by multiple randomized controlled trials attempting to elucidate the appropriate modality of therapy for this disease process. Surgical techniques have evolved from carotid artery endarterectomy and transfemoral carotid artery stenting to the development of hybrid techniques in transcarotid artery revascularization. In this article, the authors provide a review of the available literature regarding operative and medical management of carotid artery disease.
Collapse
Affiliation(s)
- Charles Adam Banks
- Division of Vascular Surgery and Endovascular Therapy, University of Alabama at Birmingham, 1808 7th Avenue South, Boshell Diabetes Building 652, Birmingham, AL 35294, USA
| | - Benjamin J Pearce
- Division of Vascular Surgery and Endovascular Therapy, University of Alabama at Birmingham, 1808 7th Avenue South, Boshell Diabetes Building 652, Birmingham, AL 35294, USA.
| |
Collapse
|
18
|
Meschia JF, Lal B, Roubin G, Turan TN, Howard VJ, Benson RT, Carman K, Howard G, Brott TG. Adapting to Evolving Technologies and Treatment Guidelines in a Procedural Trial: A Qualitative Review of the CREST-2 Experience. Neurology 2023; 100:1060-1066. [PMID: 36746636 PMCID: PMC10259285 DOI: 10.1212/wnl.0000000000207075] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2022] [Accepted: 01/04/2023] [Indexed: 02/08/2023] Open
Abstract
Multiple challenges confront procedural trials, including slow enrollment, lack of equipoise among patients and physicians, and failure to achieve adequate masking. Nonetheless, randomized clinical trials provide the best evidence of efficacy. The evolution of technology, techniques, and standards of care during the conduct of procedural trials challenges external validity. In this study, we review how a multicenter trial of revascularization of asymptomatic carotid arteries for stroke prevention has managed changes in treating carotid stenosis and medical management of atherothrombotic disease. TRIAL REGISTRATION INFORMATION: ClinicalTrials.gov number: NCT02089217.
Collapse
Affiliation(s)
- James F Meschia
- From the Mayo Clinic (J.F.M., K.C., T.G.B.), Jacksonville, FL; University of Maryland School of Medicine (B.L.), Baltimore; CREST-2 Executive Committee (G.R.), Jackson, WY; Medical University of South Carolina (T.N.T.), Charleston; University of Alabama at Birmingham (V.J.H., G.H.); and National Institute of Neurological Disorders and Stroke (R.T.B.), Bethesda, MD.
| | - Brajesh Lal
- From the Mayo Clinic (J.F.M., K.C., T.G.B.), Jacksonville, FL; University of Maryland School of Medicine (B.L.), Baltimore; CREST-2 Executive Committee (G.R.), Jackson, WY; Medical University of South Carolina (T.N.T.), Charleston; University of Alabama at Birmingham (V.J.H., G.H.); and National Institute of Neurological Disorders and Stroke (R.T.B.), Bethesda, MD
| | - Gary Roubin
- From the Mayo Clinic (J.F.M., K.C., T.G.B.), Jacksonville, FL; University of Maryland School of Medicine (B.L.), Baltimore; CREST-2 Executive Committee (G.R.), Jackson, WY; Medical University of South Carolina (T.N.T.), Charleston; University of Alabama at Birmingham (V.J.H., G.H.); and National Institute of Neurological Disorders and Stroke (R.T.B.), Bethesda, MD
| | - Tanya N Turan
- From the Mayo Clinic (J.F.M., K.C., T.G.B.), Jacksonville, FL; University of Maryland School of Medicine (B.L.), Baltimore; CREST-2 Executive Committee (G.R.), Jackson, WY; Medical University of South Carolina (T.N.T.), Charleston; University of Alabama at Birmingham (V.J.H., G.H.); and National Institute of Neurological Disorders and Stroke (R.T.B.), Bethesda, MD
| | - Virginia J Howard
- From the Mayo Clinic (J.F.M., K.C., T.G.B.), Jacksonville, FL; University of Maryland School of Medicine (B.L.), Baltimore; CREST-2 Executive Committee (G.R.), Jackson, WY; Medical University of South Carolina (T.N.T.), Charleston; University of Alabama at Birmingham (V.J.H., G.H.); and National Institute of Neurological Disorders and Stroke (R.T.B.), Bethesda, MD
| | - Richard T Benson
- From the Mayo Clinic (J.F.M., K.C., T.G.B.), Jacksonville, FL; University of Maryland School of Medicine (B.L.), Baltimore; CREST-2 Executive Committee (G.R.), Jackson, WY; Medical University of South Carolina (T.N.T.), Charleston; University of Alabama at Birmingham (V.J.H., G.H.); and National Institute of Neurological Disorders and Stroke (R.T.B.), Bethesda, MD
| | - Kaley Carman
- From the Mayo Clinic (J.F.M., K.C., T.G.B.), Jacksonville, FL; University of Maryland School of Medicine (B.L.), Baltimore; CREST-2 Executive Committee (G.R.), Jackson, WY; Medical University of South Carolina (T.N.T.), Charleston; University of Alabama at Birmingham (V.J.H., G.H.); and National Institute of Neurological Disorders and Stroke (R.T.B.), Bethesda, MD
| | - George Howard
- From the Mayo Clinic (J.F.M., K.C., T.G.B.), Jacksonville, FL; University of Maryland School of Medicine (B.L.), Baltimore; CREST-2 Executive Committee (G.R.), Jackson, WY; Medical University of South Carolina (T.N.T.), Charleston; University of Alabama at Birmingham (V.J.H., G.H.); and National Institute of Neurological Disorders and Stroke (R.T.B.), Bethesda, MD
| | - Thomas G Brott
- From the Mayo Clinic (J.F.M., K.C., T.G.B.), Jacksonville, FL; University of Maryland School of Medicine (B.L.), Baltimore; CREST-2 Executive Committee (G.R.), Jackson, WY; Medical University of South Carolina (T.N.T.), Charleston; University of Alabama at Birmingham (V.J.H., G.H.); and National Institute of Neurological Disorders and Stroke (R.T.B.), Bethesda, MD
| |
Collapse
|
19
|
Low M, Gray B, Dicks A, Ochiobi O, Blas J, Gandhi S, Carsten C. Comparison of Complications and Cost for Transfemoral Versus Transcarotid Stenting of Carotid Artery Stenosis. Ann Vasc Surg 2022. [DOI: 10.1016/j.avsg.2022.08.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
|
20
|
Stonko DP, Goldsborough E, Kibrik P, Zhang G, Holscher CM, Hicks CW. Use of Transcarotid Artery Revascularization, Transfemoral Carotid Artery Stenting, and Carotid Endarterectomy in the US From 2015 to 2019. JAMA Netw Open 2022; 5:e2231944. [PMID: 36112371 PMCID: PMC9482062 DOI: 10.1001/jamanetworkopen.2022.31944] [Citation(s) in RCA: 17] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/26/2022] Open
Abstract
IMPORTANCE A transcarotid artery revascularization (TCAR) device was approved by the US Food and Drug Administration in 2015 for carotid revascularization in patients at high risk for stroke, cranial nerve injury, or major cardiac event. It is unclear how the introduction of TCAR has changed the use of carotid endarterectomy (CEA) and transfemoral carotid artery stenting (TFCAS). OBJECTIVE To quantify the temporal changes in the operative approach to carotid revascularization (CEA vs TFCAS vs TCAR), and to identify patient and disease characteristics commonly associated with each approach. DESIGN, SETTING, AND PARTICIPANTS This retrospective cohort study obtained data from the Vascular Quality Initiative database from January 1, 2015, to December 31, 2019. Patients with carotid artery stenosis who underwent CEA, TFCAS, or TCAR were included. Data were analyzed from January to April 2022. EXPOSURES Month and year of surgery as well as patient risk status. MAIN OUTCOMES AND MEASURES Number and proportion of carotid revascularization procedures by operative approach. RESULTS A total of 108 676 patients (mean [SD] age 56.6 [12.5] years; 66 684 men [61.4%]) were included in the analysis. The most common operative approach overall was CEA (n = 81 508 [75.0%]), followed by TFCAS (n = 15 578 [14.3%]) and TCAR (n = 11 590 [10.7%]). The number of procedures increased over the study period (16 754 in 2015 vs 27 269 in 2019; P < .001). In 2015, CEA was used in 84.9% of all cases, followed by TFCAS (14.4%) and TCAR (0.8%). In 2019, CEA was used in 64.8% of cases, followed by TCAR (21.9%) and TFCAS (13.3%). The proportional use of CEA decreased by 5.0% (95% CI, -7.4% to -2.6%) per year, and TCAR use increased by 5.3% (95% CI, 2.3%-8.3%) per year. Among patients at high risk, the change was greater: CEA use decreased by 7.8% (95% CI, -11.9% to -3.8%) per year, TFCAS decreased by 4.8% (95% CI, -9.5% to -0.14%) per year, and TCAR increased by 12.6% (95% CI, 7.1%-18.1%) per year. Multinomial logistic regression showed that patient risk status was the most important characteristic associated with TCAR compared with CEA (relative risk ratio, 36.10; 95% CI, 29.24-44.66; P < .001) and TFCAS (relative risk ratio, 14.10; 95% CI, 11.86-16.66; P < .001). Linear regression revealed no association between year of surgery and in-hospital myocardial infarction, stroke, or mortality. CONCLUSIONS AND RELEVANCE Results of this study indicate that TCAR has become the dominant carotid revascularization approach, surpassing TFCAS and CEA in patients at high risk for stroke, cranial nerve injury, or cardiovascular events. Patient high-risk status was the main characteristic associated with a stenting approach, highlighting the perceived importance of carotid stenting therapies in this patient population.
Collapse
Affiliation(s)
- David P. Stonko
- Department of Surgery, The Johns Hopkins Hospital, Baltimore, Maryland
- R. Adams Cowley Shock Trauma Center, University of Maryland, Baltimore
| | - Earl Goldsborough
- Division of Vascular Surgery and Endovascular Therapy, Department of Surgery, The Johns Hopkins Hospital, Baltimore, Maryland
| | - Pavel Kibrik
- Vascular Institute of New York, Brooklyn, New York
| | - George Zhang
- Department of Surgery, Brigham and Women’s Hospital, Boston, Massachusetts
| | - Courtenay M. Holscher
- Division of Vascular Surgery and Endovascular Therapy, Department of Surgery, The Johns Hopkins Hospital, Baltimore, Maryland
| | - Caitlin W. Hicks
- Division of Vascular Surgery and Endovascular Therapy, Department of Surgery, The Johns Hopkins Hospital, Baltimore, Maryland
| |
Collapse
|
21
|
Mazurek A, Malinowski K, Rosenfield K, Capoccia L, Speziale F, de Donato G, Setacci C, Wissgott C, Sirignano P, Tekieli L, Karpenko A, Kuczmik W, Stabile E, Metzger DC, Amor M, Siddiqui AH, Micari A, Pieniążek P, Cremonesi A, Schofer J, Schmidt A, Musialek P. Clinical Outcomes of Second- versus First-Generation Carotid Stents: A Systematic Review and Meta-Analysis. J Clin Med 2022; 11:4819. [PMID: 36013058 PMCID: PMC9409706 DOI: 10.3390/jcm11164819] [Citation(s) in RCA: 31] [Impact Index Per Article: 15.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2022] [Revised: 07/20/2022] [Accepted: 07/29/2022] [Indexed: 01/10/2023] Open
Abstract
Background: Single-cohort studies suggest that second-generation stents (SGS; “mesh stents”) may improve carotid artery stenting (CAS) outcomes by limiting peri- and postprocedural cerebral embolism. SGS differ in the stent frame construction, mesh material, and design, as well as in mesh-to-frame position (inside/outside). Objectives: To compare clinical outcomes of SGS in relation to first-generation stents (FGSs; single-layer) in CAS. Methods: We performed a systematic review and meta-analysis of clinical studies with FGSs and SGS (PRISMA methodology, 3302 records). Endpoints were 30-day death, stroke, myocardial infarction (DSM), and 12-month ipsilateral stroke (IS) and restenosis (ISR). A random-effect model was applied. Results: Data of 68,422 patients from 112 eligible studies (68.2% men, 44.9% symptomatic) were meta-analyzed. Thirty-day DSM was 1.30% vs. 4.11% (p < 0.01, data for SGS vs. FGS). Among SGS, both Casper/Roadsaver and CGuard reduced 30-day DSM (by 2.78 and 3.03 absolute percent, p = 0.02 and p < 0.001), whereas the Gore stent was neutral. SGSs significantly improved outcomes compared with closed-cell FGS (30-day stroke 0.6% vs. 2.32%, p = 0.014; DSM 1.3% vs. 3.15%, p < 0.01). At 12 months, in relation to FGS, Casper/Roadsaver reduced IS (−3.25%, p < 0.05) but increased ISR (+3.19%, p = 0.04), CGuard showed a reduction in both IS and ISR (−3.13%, −3.63%; p = 0.01, p < 0.01), whereas the Gore stent was neutral. Conclusions: Pooled SGS use was associated with improved short- and long-term clinical results of CAS. Individual SGS types, however, differed significantly in their outcomes, indicating a lack of a “mesh stent” class effect. Findings from this meta-analysis may provide clinically relevant information in anticipation of large-scale randomized trials.
Collapse
Affiliation(s)
- Adam Mazurek
- Department of Cardiac and Vascular Diseases, John Paul II Hospital, Jagiellonian University, 31-202 Krakow, Poland
| | - Krzysztof Malinowski
- Department of Bioinformatics and Telemedicine, Faculty of Medicine, Jagiellonian University Medical College, 31-008 Krakow, Poland
| | - Kenneth Rosenfield
- Vascular Surgery, Surgery Department, Massachusetts General Hospital, Boston, MA 02114, USA
| | - Laura Capoccia
- Vascular and Endovascular Surgery Unit, Department of Surgery, Sapienza University of Rome, 00185 Rome, Italy
| | - Francesco Speziale
- Vascular and Endovascular Surgery Unit, Department of Surgery, Sapienza University of Rome, 00185 Rome, Italy
| | | | - Carlo Setacci
- Department of Vascular Surgery, University of Siena, 53100 Siena, Italy
| | - Christian Wissgott
- Institut für Diagnostische und Interventionelle Radiologie/Neuroradiologie, Imland Klinik Rendsburg, 24768 Rendsburg, Germany
| | - Pasqualino Sirignano
- Vascular and Endovascular Surgery Unit, Department of Surgery, Sapienza University of Rome, 00185 Rome, Italy
| | - Lukasz Tekieli
- Department of Interventional Cardiology, John Paul II Hospital, Jagiellonian University, 31-202 Krakow, Poland
| | - Andrey Karpenko
- Centre of Vascular and Hybrid Surgery, E.N. Meshalkin National Medical Research Center, 630055 Novosibirsk, Russia
| | - Waclaw Kuczmik
- Department of General, Vascular Surgery, Angiology and Phlebology, Medical University of Silesia, 40-055 Katowice, Poland
| | | | | | - Max Amor
- Department of Interventional Cardiology, U.C.C.I. Polyclinique d’Essey, 54270 Nancy, France
| | - Adnan H. Siddiqui
- Department of Neurosurgery, SUNY University at Buffalo, Buffalo, NY 14203, USA
| | - Antonio Micari
- Department of Biomedical and Dental Sciences and Morphological and Functional Imaging, University of Messina, 98122 Messina, Italy
| | - Piotr Pieniążek
- Department of Cardiac and Vascular Diseases, John Paul II Hospital, Jagiellonian University, 31-202 Krakow, Poland
- Department of Interventional Cardiology, John Paul II Hospital, Jagiellonian University, 31-202 Krakow, Poland
| | - Alberto Cremonesi
- Cardiovascular Department, Humanitas Gavazzeni Hospital, 24125 Bergamo, Italy
| | - Joachim Schofer
- MVZ-Department Structural Heart Disease, Asklepios Clinic St. Georg, 20099 Hamburg, Germany
| | - Andrej Schmidt
- Department of Angiology, University Hospital Leipzig, 04103 Leipzig, Germany
| | - Piotr Musialek
- Department of Cardiac and Vascular Diseases, John Paul II Hospital, Jagiellonian University, 31-202 Krakow, Poland
| |
Collapse
|
22
|
Predicting Transcarotid Artery Revascularization adverse outcomes by Imaging Characteristics. Ann Vasc Surg 2022; 87:388-401. [PMID: 35714841 DOI: 10.1016/j.avsg.2022.05.013] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2022] [Revised: 04/29/2022] [Accepted: 05/08/2022] [Indexed: 11/20/2022]
Abstract
OBJECTIVES Approximately 20-30% of ischemic strokes are caused by internal carotid artery stenosis. Stroke is the leading cause of disability and the second leading cause of death in the United States. Second generation Trans Carotid Arterial Revascularization (TCAR) stenting, using the ENROUTE flow reversal technology to prevent embolic stroke during the stenting process, has demonstrated stroke and death outcomes equivalent to CEA with reduced cranial nerve injury. However, at present, it is not known whether imaging characteristics obtained pre-operatively can predict outcomes of TCAR procedures. METHODS This retrospective cohort study included patients who underwent TCAR with flow reversal at 3 hospitals within a single hospital network who had CT angiography, MRI angiography or pre-operative diagnostic angiogram to determine whether carotid and lesion characteristics could predict patients who experienced Major Adverse Critical Events (MACE) versus those who did not. MACE was defined as myocardial infarction at 30 days, restenosis/persistent stenosis (peak systolic velocity within the stent >230cm/sec by post-operative ultrasound), stroke within any time of follow up or death within 1 year of TCAR. Student's t-tests and chi-squared tests were used to compare imaging characteristics, such as presence of pinpoint stenosis, calcification within the common carotid artery (CCA) at the take-off from the aorta, and plaque length in millimeters. Binomial logistic regression was used to examine the likelihood that imaging characteristics were associated with MACE. RESULTS Of 220 patients who underwent TCAR in our network, 7 were excluded because flow reversal was not used or appropriate imaging had not been performed prior to TCAR. Of the 213 patients that were included in analysis, the median length of follow up was 10.8 months (IQR: 3.4-33.1 months). Twelve percent (26/213) experienced a MACE, and a model based on imaging characteristics was statistically significant in predicting MACE with 68% accuracy (P=0.005). The presence of pinpoint stenosis was highly predictive of MACE (HR: 3.34, CI: 1.2 to 9.3, P=0.021). A shorter clavicle to carotid bifurcation distance was associated with an increased likelihood of experiencing a MACE (P=0.009), but it was weakly predictive (HR 1.03, CI: 1.01 to 1.05). CONCLUSIONS Pre-operative imaging characteristics, such as pinpoint stenosis and clavicle to carotid bifurcation distance, can be used to predict adverse outcomes in TCAR placement.
Collapse
|
23
|
Kashyap VS, So KL, Schneider PA, Rathore R, Pham T, Motaganahalli RL, Massop DW, Foteh MI, Eckstein HH, Jim J, Leal Lorenzo JI, Melton JG. One-Year Outcomes After Transcarotid Artery Revascularization (TCAR) in the ROADSTER 2 TRIAL. J Vasc Surg 2022; 76:466-473.e1. [DOI: 10.1016/j.jvs.2022.03.872] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2021] [Accepted: 03/27/2022] [Indexed: 10/18/2022]
|
24
|
Ilijevski N, Atanasijević I, Lozuk B, Gajin P, Matić P, Babić S, Sagić D, Unić-Stojanović D, Tanasković S. Direct Ischemic Postconditioning After Carotid Endarterectomy in the Prevention of Postoperative Cerebral Ischemic Complications—Observational Case–Control Study. J Cardiovasc Pharmacol Ther 2022; 27:10742484221137489. [DOI: 10.1177/10742484221137489] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Introduction: Ischemic postconditioning (IPCT) represents one of the several therapeutic strategies to attenuate ischemic reperfusion injury (IR) after carotid endarterectomy (CEA). We here present the first in-human study of IPCT in carotid surgery. Methods: The study represents an observational case-control study, with the data collected in our Institution carotid database. From December 2015 to December 2020, a total of 300 patients were included in our study; IPCT group consisted of 148 patients in whom ischemic postconditioning was performed while control group consisted of 152 patients in whom IPCT was not performed. Indications for IPCT technique were: severe unilateral internal carotid artery (ICA) stenosis (>90%), severe bilateral ICA stenosis (>80%), severe ICA stenosis (>80%) with contralateral ICA occlusion and ICA subocclusion. IPCT was performed by applying 6 cycles of 30 sec reperfusion (declamping of ICA)/30 sec ischemia (clamping of ICA) after finishing the procedure and initial declamping. Two groups of patients were compared in terms of occurrence of intrahospital and early postoperative stroke, TIA (transient ischemic attack) and neurologic morbidity. Results: Cumulative incidence of intrahospital postoperative stroke or TIA was significantly higher in the control group (5.3% vs 0.7%, P = .036). According to carotid plaque characteristics, patients in the IPCT group had significantly more frequent presence of heterogenous plaque, as well as ulcerated plaque, which was associated with the absence of postoperative stroke and significantly lower cumulative rate of TIA/stroke when compared to the control group (43.9% vs 8% and 47.3% vs 1.5%). During the follow-up period of 1 month after the surgery, there were no cases of stroke, TIA and deaths due to neurological causes in both groups of patients. Conclusion: Our results showed that IPCT significantly reduced the incidence of postoperative cerebral ischemic complications after CEA in high-risk patients for IR injury when compared to the control group.
Collapse
Affiliation(s)
- Nenad Ilijevski
- “Dedinje” Cardiovascular Institute, Belgrade, Serbia
- Faculty of Medicine, University of Belgrade, Belgrade, Serbia
| | | | - Branko Lozuk
- “Dedinje” Cardiovascular Institute, Belgrade, Serbia
- Faculty of Medicine, University of Banja Luka, Banja Luka, Bosnia and Herzegovina
| | - Predrag Gajin
- “Dedinje” Cardiovascular Institute, Belgrade, Serbia
- Faculty of Medicine, University of Belgrade, Belgrade, Serbia
| | - Predrag Matić
- “Dedinje” Cardiovascular Institute, Belgrade, Serbia
- Faculty of Medicine, University of Belgrade, Belgrade, Serbia
| | - Srđan Babić
- “Dedinje” Cardiovascular Institute, Belgrade, Serbia
- Faculty of Medicine, University of Belgrade, Belgrade, Serbia
| | - Dragan Sagić
- “Dedinje” Cardiovascular Institute, Belgrade, Serbia
- Faculty of Medicine, University of Belgrade, Belgrade, Serbia
| | - Dragana Unić-Stojanović
- “Dedinje” Cardiovascular Institute, Belgrade, Serbia
- Faculty of Medicine, University of Belgrade, Belgrade, Serbia
| | - Slobodan Tanasković
- “Dedinje” Cardiovascular Institute, Belgrade, Serbia
- Faculty of Medicine, University of Belgrade, Belgrade, Serbia
| |
Collapse
|
25
|
Moacdieh MP, Khan MA, Layman P, Elsayed N, Malas MB. Innovation in the open and endovascular treatment of carotid artery stenosis. Semin Vasc Surg 2021; 34:163-171. [PMID: 34911622 DOI: 10.1053/j.semvascsurg.2021.10.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2021] [Revised: 10/17/2021] [Accepted: 10/18/2021] [Indexed: 11/11/2022]
Affiliation(s)
- Munir P Moacdieh
- Division of Vascular and Endovascular Surgery, University of California San Diego, La Jolla, CA 92093
| | - Maryam A Khan
- Division of Vascular and Endovascular Surgery, University of California San Diego, La Jolla, CA 92093
| | - Peter Layman
- Division of Vascular and Endovascular Surgery, University of California San Diego, La Jolla, CA 92093
| | - Nadin Elsayed
- Division of Vascular and Endovascular Surgery, University of California San Diego, La Jolla, CA 92093
| | - Mahmoud B Malas
- Division of Vascular and Endovascular Surgery, University of California San Diego, La Jolla, CA 92093.
| |
Collapse
|
26
|
Ghamraoui AK, Chang H, Maldonado TS, Ricotta JJ. Clopidogrel Versus Ticagrelor for Antiplatelet Therapy in Transcarotid Artery Revascularization (TCAR) in the Society for Vascular Surgery Vascular Quality Initiative. J Vasc Surg 2021; 75:1652-1660. [PMID: 34920001 DOI: 10.1016/j.jvs.2021.11.060] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2021] [Accepted: 11/11/2021] [Indexed: 01/24/2023]
Abstract
OBJECTIVE Transcarotid artery revascularization (TCAR) with dynamic flow reversal is a hybrid technique for operative management of carotid artery stenosis. Dual antiplatelet therapy is recommended for patients undergoing TCAR; however, nonresponders to these medications may be predisposed to perioperative thromboembolic complications. Prevalent in up to 44-66% of patients taking clopidogrel, high on-treatment platelet reactivity (HTPR) may thus be responsible for a portion of adverse cerebrovascular events in TCAR. A previous single-institution study has demonstrated the use of ticagrelor as a viable alternative to clopidogrel for antiplatelet therapy in patients undergoing TCAR; however, large-scale comparisons between clopidogrel and ticagrelor are needed to confirm the safety of ticagrelor outside of highly selected patients and providers. METHODS Data from patients enrolled in the Society for Vascular Surgery Vascular Quality Initiative undergoing TCAR with a perioperative antiplatelet therapy regimen including either clopidogrel or ticagrelor from January 2015 to March 2021 were analyzed and compared. Multivariable logistic regression and propensity score matching were used to evaluate the primary 30-day outcomes of stroke, major bleeding event, and combined stroke/myocardial infarction (MI)/death rate while adjusting for baseline characteristics of the patients. RESULTS A total of 11973 patients underwent TCAR with a dual antiplatelet therapy regimen that included clopidogrel versus 426 patients with ticagrelor. Compared to clopidogrel, patients on ticagrelor were significantly more likely to have coronary artery disease (51% vs 66% [P = <.001]), particularly unstable angina or MI within 6 months (3% vs 9% [P = <.001]), and more likely to have insulin-dependent diabetes mellitus (14% vs 19% [P = <.001]). The unadjusted 30-day rates of stroke, major bleeding, and combined stroke/MI/death were not statistically significant among both groups (1.3% vs 0.5% [P = .14], 2.4% vs 1.4% [P = .18], and 1.9% vs 1.6% [P = .71], respectively). After multivariable adjustment and propensity matching, these remained statistically insignificant. CONCLUSIONS Despite a substantially higher medical risk in patients undergoing TCAR with ticagrelor, 30-day rates of stroke, major bleeding events, and combined stroke/MI/death were similar between patients on ticagrelor and clopidogrel as part of adjunctive antiplatelet therapy. Randomized prospective trials, and studies with larger sample sizes and longer follow-up will be needed to better examine the outcome differences in TCAR between these two medications.
Collapse
Affiliation(s)
- Ahmed K Ghamraoui
- Charles E. Schmidt College of Medicine, Florida Atlantic University, Boca Raton, FL, USA
| | - Heepeel Chang
- Westchester Medical Center, New York Medical College, Valhalla, NY, USA
| | - Thomas S Maldonado
- The Schwartz Buckely Professor of Surgery, NYU Langone Health, New York, NY, USA; Director of the Venous Thromboembolic Center and Aortic Center, NYU Langone Medical Center, New York, NY, USA
| | - Joseph J Ricotta
- National Director of Vascular Surgery and Endovascular Therapy, Tenet Healthcare Corporation, Delray Medical Center, Delray Beach, FL, USA; Professor of Surgery and Program Director, Vascular Surgery Fellowship, Charles E. Schmidt College of Medicine, Florida Atlantic University, Boca Raton, FL, USA
| |
Collapse
|
27
|
Salem MM, Kvint S, Choudhri OA, Burkhardt JK. Endovascular Transcarotid Artery Revascularization Using the Walrus Balloon Guide Catheter: Preliminary Experience. World Neurosurg 2021; 156:e175-e182. [PMID: 34534717 DOI: 10.1016/j.wneu.2021.09.026] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2021] [Revised: 09/04/2021] [Accepted: 09/06/2021] [Indexed: 02/08/2023]
Abstract
BACKGROUND The Walrus Balloon Guided System Catheter is a new generation of balloon guide catheter (BGC) designed to bypass some technical limitations of conventional BGC devices. Their utility in cervical carotid disease treatment has not been reported. We report our preliminary experience in cervical carotid treatment using the Walrus BGC to perform a modified endovascular transcarotid artery revascularization technique. METHODS Patients with cervical carotid disease undergoing endovascular treatment using the Walrus BGC at our institution were identified. The pertinent baseline demographics and procedural outcomes were collected and analyzed. RESULTS Twelve patients were included (median age, 70; 58.3% females). All patients had an imaging-confirmed cervical carotid disease that indicated intervention: 6 with high-grade cervical arteriosclerotic carotid stenosis, 2 with intraluminal thrombi, 1 with traumatic carotid dissection, and 3 patients with cervical carotid tandem occlusion along with acute ischemic stroke secondary to large vessel occlusion that required mechanical thrombectomy. Carotid artery stenting was performed in all cases, except 2 of the 3 mechanical thrombectomy cases (angioplasty only). All patients had at least periprocedural follow-up of 30 days, with no stroke, myocardial infarction, or death encountered. CONCLUSIONS We describe a modified endovascular transcarotid artery revascularization technique. We used a standard femoral access to navigate the Walrus catheter in the common carotid artery, followed by balloon inflation for proximal flow arrest or flow reversal (when connected to the aspiration pump) to deploy the carotid stent across the stenosis, while avoiding distal external carotid artery balloon occlusion. Successful treatment was achieved in all cases, with no periprocedural complications encountered.
Collapse
Affiliation(s)
- Mohamed M Salem
- Department of Neurosurgery, Hospital of the University of Pennsylvania, Penn Medicine, Philadelphia, Pennsylvania, USA
| | - Svetlana Kvint
- Department of Neurosurgery, Hospital of the University of Pennsylvania, Penn Medicine, Philadelphia, Pennsylvania, USA
| | - Omar A Choudhri
- Department of Neurosurgery, Hospital of the University of Pennsylvania, Penn Medicine, Philadelphia, Pennsylvania, USA
| | - Jan-Karl Burkhardt
- Department of Neurosurgery, Hospital of the University of Pennsylvania, Penn Medicine, Philadelphia, Pennsylvania, USA.
| |
Collapse
|
28
|
|
29
|
Cui CL, Zarrintan S, Marmor RA, Nichols J, Cajas-Monson L, Malas M. Performance of Carotid Revascularization Procedures as Modified by Sex. Ann Vasc Surg 2021; 81:171-182. [PMID: 34752853 DOI: 10.1016/j.avsg.2021.08.051] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2021] [Revised: 08/27/2021] [Accepted: 08/31/2021] [Indexed: 11/25/2022]
Abstract
BACKGROUND Current recommendations on carotid revascularization postulate that women have both increased perioperative risks, such as stroke and death, as well as reduced benefit from intervention. These recommendations do not include data on transcarotid artery revascularization (TCAR). This study strives to compare safety and benefits of TCAR, TFCAS (Transfemoral Carotid Artery Stenting), and CEA (Carotid Endarterectomy) with regard to patient sex. METHODS We performed retrospective analysis of the Society for Vascular Surgery (SVS) Vascular Quality Initiative (VQI) CEA and stenting registries, as well as TCAR Surveillance Project data. We compared outcomes after TCAR, TFCAS, and CEA based on sex. The primary outcome was the rate of in-hospital stroke or death. Secondary outcomes included in-hospital stroke, death, transient ischemic attack (TIA), myocardial infarction (MI), stroke/death/MI, stroke/TIA, and recurrent ipsilateral stroke and/or death at 1-year of follow-up. RESULTS A total of 75,538 patients were included, of which 28,960 (38.3%) were female and 46,578 (61.7%) were male. TFCAS females had more than 2 times higher odds of stroke/death (OR:2.85, 95%CI: 2.21-3.67, P < 0.001) and stroke/death/MI (OR:2.23, 95%CI:1.75-2.83, P < 0.001) when compared to CEA females. Odds of TIA were also higher in both TFCAS females (OR:2.01, 95%CI:1.19-3.42, P = 0.010) and TCAR females (OR:1.91, 95%CI:1.09-3.35, P = .023) when compared to CEA females. However, only TFCAS females experienced increased odds of stroke/TIA (OR:1.96, 95%CI:1.45-2.65, P < 0.001) when compared to CEA females. TFCAS males had almost twice the odds of stroke/death (OR:1.74, 95%CI:1.39-2.16, P < 0.001) and 44% higher odds of stroke/death/MI (OR:1.44, 95%CI:1.19-1.75, P < 0.001), and more than 3-times increased odds of death (OR:3.45, 95%CI:2.53-4.71, P < 0.001) when compared to CEA males. Odds of in-hospital stroke were comparable between TFCAS and CEA after adjusting for covariates. TCAR males have half the odds of MI when compared to CEA males (OR:0.52, 95%CI:0.34-0.80, P = 0.003). At 1-year TCAR had comparable risk of stroke/death while TFCAS had increased risk of stroke/death when compared to CEA among both males and females. CONCLUSION TCAR performed similarly to CEA in both sexes regardless of symptomatic status. Stroke/death and stroke/death/MI rates were similar in symptomatic and asymptomatic males and females treated by CEA or TCAR. The 1-year outcomes of TCAR were also comparable to CEA in both sexes. It seems that TCAR may be a safe alternative to CEA particularly in women when surgical risk prohibits CEA and while TFCAS is associated with substantial adverse outcomes.
Collapse
|
30
|
Sridharan ND, Chaer RA, Smith K, Eslami MH. Carotid Endarterectomy remains cost-effective for the surgical management of carotid stenosis. J Vasc Surg 2021; 75:1304-1310. [PMID: 34634417 DOI: 10.1016/j.jvs.2021.09.039] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2021] [Accepted: 09/21/2021] [Indexed: 10/20/2022]
Abstract
BACKGROUND Transcarotid arterial revascularization (TCAR) has gained popularity as an alternative to carotid endarterectomy (CEA) and transfemoral carotid artery stenting (TFCAS) potentially combining the benefits of a minimally invasive approach with a lower risk of procedural stroke compared to TFCAS. Emerging evidence shows TCAR to have excellent perioperative outcomes. However, the cost effectiveness of TCAR is not well understood. METHODS Incorporating data from Carotid Revascularization Endarterectomy vs. Stenting Trial (CREST), the Vascular Quality Initiative Surveillance Project, and local cost data, we compared the cost-effectiveness of these three treatment modalities (TFCAS, CEA, and TCAR) for both symptomatic and asymptomatic carotid stenosis using a Markov state-transition model to quantify lifetime costs in $US and effectiveness in quality-adjusted life-years (QALYs). We accounted for perioperative stroke and MI as well as long-term risks of stroke and restenosis. Based on CREST, we assumed a start age of 69 and a cost-effectiveness acceptability threshold of $100,000/QALY gained. Sensitivity analyses were performed. RESULTS In the base case scenario, TCAR cost $160,642/QALY gained compared to CEA, greater than the frequently cited $100,000/QALY gained threshold. TFCAS was more expensive and less effective than other strategies, largely due to a greater periprocedural stroke risk. In one-way sensitivity analysis, if TCAR stroke risk was <0.9% (base case risk 1.4%), than it was economically favorable compared to CEA at its current procedural cost. Alternatively, if TCAR procedural costs were reduced by approximately $2000 (base case $15,182), it would also become economically favorable. In a probabilistic sensitivity analysis, varying all parameters simultaneously over distributions, CEA was favored in 80% of model iterations at $100,000/QALY, with TCAR favored in 19%. CONCLUSIONS At current cost and outcomes, TCAR does not meet a traditional cost-effectiveness threshold to replace CEA as the primary treatment modality for carotid stenosis. TFCAS is the least cost-effective strategy for carotid revascularization. Given these observations, TCAR should be limited to select patients, specifically those at high physiologic and anatomic risk from CEA. However, TCAR can become cost-effective if its cost is reduced. Given the current outcomes and cost, CEA remains the most cost-effective treatment for carotid revascularization.
Collapse
|
31
|
Nakagawa I, Kotsugi M, Park H, Furuta T, Sato F, Myochin K, Nishimura F, Yamada S, Motoyama Y, Nakase H. Near-infrared spectroscopy carotid plaque characteristics and cerebral embolism in carotid artery stenting. EUROINTERVENTION 2021; 17:599-606. [PMID: 33283761 PMCID: PMC9725057 DOI: 10.4244/eij-d-20-01050] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
BACKGROUND Perioperative thromboembolism is the main consideration in carotid artery stenting (CAS). Precise evaluation of carotid plaque components is clinically important to reduce ischaemic complications since CAS mechanically pushes plaque outwards, which releases plaque debris into the bloodstream. AIMS This study aimed to determine whether high lipid core plaque (LCP) assessed by catheter-based near-infrared spectroscopy (NIRS) is associated with ipsilateral cerebral embolism by diffusion-weighted magnetic resonance imaging during CAS using a first-generation stent. METHODS Carotid stenosis magnetic resonance (MR) T1-weighted plaque signal intensity ratio (T1W-SIR) followed by NIRS assessment at the time of CAS (using the carotid artery Wallstent) was performed in 117 consecutive patients. RESULTS The maximum lipid core burden index (max-LCBI) at minimal luminal areas (MLA; max-LCBIMLA) and the max-LCBI for any 4 mm segment in a target lesion defined as max-LCBIarea were significantly higher for the post-procedural new ipsilateral diffusion-weighted magnetic resonance imaging (DWI)-positive than negative patients (p<0.001 for all). There was a significant linear correlation between max-LCBIarea and the number of new emboli (r=0.544, p<0.0001). We also found that the second quantile (Q2) of T1W-SIRMLA had a significantly higher max-LCBIMLA and a higher incidence of DWI positivity than Q1 and Q3 (p<0.001 for all). Furthermore, max-LCBIMLA appeared to distinguish between patients with and without postoperative new ipsilateral DWI positivity (AUC 0.91, 95% CI: 0.86-0.96; p<0.0001). CONCLUSIONS High LCP assessed by NIRS is associated with cerebral embolism by diffusion-weighted imaging in CAS using a first-generation stent.
Collapse
Affiliation(s)
- Ichiro Nakagawa
- Department of Neurosurgery, Nara Medical University, 840 Shijo-cho, Kashihara, Nara, 634-8522, Japan
| | - Masashi Kotsugi
- Department of Neurosurgery, Nara Medical University, Nara, Japan
| | - Hun Park
- Department of Neurosurgery, Nara Medical University, Nara, Japan
| | - Takanori Furuta
- Department of Neurosurgery, Nara Medical University, Nara, Japan
| | - Fumiya Sato
- Department of Neurosurgery, Nara Medical University, Nara, Japan
| | - Kaoru Myochin
- Department of Radiology, Nara Medical University, Nara, Japan
| | | | - Syuichi Yamada
- Department of Neurosurgery, Nara Medical University, Nara, Japan
| | - Yasushi Motoyama
- Department of Neurosurgery, Nara Medical University, Nara, Japan
| | - Hiroyuki Nakase
- Department of Neurosurgery, Nara Medical University, Nara, Japan
| |
Collapse
|
32
|
Malas MB, Elsayed N, Naazie I, Dakour-Aridi H, Yei KS, Schermerhorn ML. Propensity score-matched analysis of 1-year outcomes of transcarotid revascularization with dynamic flow reversal, carotid endarterectomy, and transfemoral carotid artery stenting. J Vasc Surg 2021; 75:213-222.e1. [PMID: 34500027 DOI: 10.1016/j.jvs.2021.07.242] [Citation(s) in RCA: 36] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2021] [Accepted: 07/30/2021] [Indexed: 11/16/2022]
Abstract
OBJECTIVE Initial studies showed no significant differences in perioperative stroke or death between transcarotid artery revascularization (TCAR) and carotid endarterectomy (CEA) and lower stroke/death rates after TCAR compared with transfemoral carotid artery stenting (TFCAS). This study focuses on the 1-year outcomes of ipsilateral stroke or death after TCAR, CEA, and TFCAS. METHODS All patients undergoing TCAR, TFCAS, and CEA between September 2016 and December 2019 were identified in the Vascular Quality Initiative (VQI) database. The latest follow-up was September 3, 2020. One-to-one propensity score-matched analysis was performed for patients with available 1-year follow-up data for TCAR vs CEA and for TCAR vs TFCAS. Kaplan-Meier survival and Cox proportional hazard regression analyses were used to evaluate 1-year ipsilateral stroke or death after the three procedures. RESULTS A total of 41,548 patients underwent CEA, 5725 patients underwent TCAR, and 6064 patients underwent TFCAS during the study period and had recorded 1-year outcomes. The cohorts were well-matched in terms of baseline demographics and comorbidities. Among 4180 TCAR vs CEA matched pairs of patients, there were no significant differences in 30-day stroke, death, and stroke/death. However, TCAR was associated with a lower risk of 30-day stroke/death/myocardial infarction (2.30% vs 3.25%; relative risk, 0.71; 95% confidence interval [CI], 0.55-0.91; P = .008), driven by a lower risk of myocardial infarction (0.55% vs 1.12%; hazard ratio [HR], 0.49; 95% CI, 0.30-0.81; P = .004). At 1 year, no significant difference was observed in the risk of ipsilateral stroke or death (6.49% vs 5.68%; HR, 1.14; 95% CI, 0.95-1.37; P = .157). Among 4036 matched pairs in the TCAR vs TFCAS group, TCAR was also associated with lower risk of perioperative stroke or death compared with TFCAS (1.83% vs 2.55%; HR, 0.72; 95% CI, 0.54-0.96; P = .027). At 1 year, the risks of ipsilateral stroke or death of TCAR and TFCAS were comparable (6.07% vs 7.07%; HR, 0.85; 95% CI, 0.71-1.01; P = .07). Symptomatic status did not modify the association in TCAR vs CEA. However, asymptomatic patients had favorable outcomes with TCAR vs TFCAS at 1 year (HR, 0.78; 95% CI, 0.62-0.98; P = .033). CONCLUSIONS In this propensity score-matched analysis, no significant differences in ipsilateral stroke/death-free survival were observed between TCAR and CEA or between TCAR and TFCAS. The advantages of TCAR compared with TFCAS seem to be mainly in the perioperative period, which makes it a suitable minimally invasive option for surgically high-risk patients with carotid artery stenosis. Larger studies, with longer follow-up and data on restenosis, are warranted to confirm the mid- and long-term benefits and durability of TCAR.
Collapse
Affiliation(s)
- Mahmoud B Malas
- Division of Vascular and Endovascular Surgery, Department of Surgery, University of California San Diego, La Jolla, Calif.
| | - Nadin Elsayed
- Division of Vascular and Endovascular Surgery, Department of Surgery, University of California San Diego, La Jolla, Calif
| | - Isaac Naazie
- Division of Vascular and Endovascular Surgery, Department of Surgery, University of California San Diego, La Jolla, Calif
| | - Hanaa Dakour-Aridi
- Division of Vascular and Endovascular Surgery, Department of Surgery, University of California San Diego, La Jolla, Calif
| | - Kevin S Yei
- Division of Vascular and Endovascular Surgery, Department of Surgery, University of California San Diego, La Jolla, Calif
| | - Marc L Schermerhorn
- Division of Vascular and Endovascular Surgery, Department of Surgery, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, Mass
| |
Collapse
|
33
|
Elsayed N, Ramakrishnan G, Naazie I, Sheth S, Malas MB. Outcomes of Carotid Revascularization in the Treatment of Restenosis After Prior Carotid Endarterectomy. Stroke 2021; 52:3199-3208. [PMID: 34281373 DOI: 10.1161/strokeaha.120.033667] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
BACKGROUND AND PURPOSE Restenosis after carotid endarterectomy (CEA) is associated with an increased risk of ipsilateral stroke. The optimal procedural modality for this indication has yet to be determined. Here, we evaluate the in-hospital outcomes of transcarotid artery revascularization (TCAR), redo-CEA, and transfemoral carotid artery stenting (TFCAS) in a large contemporary cohort of patients who underwent treatment for restenosis after CEA. METHODS We performed a retrospective analysis of all patients in the vascular quality initiative database who underwent TCAR, redo-CEA, or TFCAS after ipsilateral CEA between September 2016 and April 2020. Patients with prior ipsilateral CAS were excluded from this analysis. In-hospital outcomes following TCAR versus CEA and TCAR versus TFCAS were evaluated using multivariate logistic regression analysis. RESULTS A total of 4425 patients were available for this analysis. There were 963 (21.8%) redo-CEA, 1786 (40.4%) TFCAS, and 1676 (37.9%) TCAR. TCAR was associated with lower odds of in-hospital stroke/death (odds ratio [OR], 0.41 [95% CI, 0.24-0.70], P=0.021), stroke (OR, 0.46 [95% CI, 0.23-0.93], P=0.03), myocardial infarction (MI; OR, 0.32 [95% CI, 0.14-0.73], P=0.007), stroke/transient ischemic attack (OR, 0.42 [95% CI, 0.24-0.74], P=0.002), and stroke/death/MI (OR, 0.41 [95% CI, 0.24-0.70], P=0.001) when compared with redo-CEA. There was no significant difference in the odds of death between the 2 groups (OR, 0.99 [95% CI, 0.28-3.5], P=0.995). TCAR was also associated with lower odds of stroke/transient ischemic attack (OR, 0.37 [95% CI, 0.18-0.74], P=0.005) when compared with TFCAS. There was no significant difference in the odds of stroke, death, MI, stroke/death, or stroke/death/MI between TCAR and TFCAS. CONCLUSIONS TCAR was associated with significantly lower odds of in-hospital stroke, MI, stroke/transient ischemic attack, stroke/death, and stroke/death/MI when compared with redo-CEA and lower odds of in-hospital stroke/transient ischemic attack when compared with TFCAS. Additional long-term studies are warranted to establish the role of TCAR for the treatment of restenosis after CEA.
Collapse
Affiliation(s)
- Nadin Elsayed
- Division of Vascular and Endovascular Surgery, University of California San Diego, La Jolla (N.E., I.N., M.B.M.)
| | | | - Isaac Naazie
- Division of Vascular and Endovascular Surgery, University of California San Diego, La Jolla (N.E., I.N., M.B.M.)
| | - Sharvil Sheth
- Division of Vascular and Endovascular Surgery, St Luke's University Health Network, Bethlehem, PA (S.S.)
| | - Mahmoud B Malas
- Division of Vascular and Endovascular Surgery, University of California San Diego, La Jolla (N.E., I.N., M.B.M.)
| |
Collapse
|
34
|
Zhong S, Sun K, Zuo X, Chen A. Monitoring and Prognostic Analysis of Severe Cerebrovascular Diseases Based on Multi-Scale Dynamic Brain Imaging. Front Neurosci 2021; 15:684469. [PMID: 34276294 PMCID: PMC8277932 DOI: 10.3389/fnins.2021.684469] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2021] [Accepted: 04/26/2021] [Indexed: 12/18/2022] Open
Abstract
Severe cerebrovascular disease is an acute cerebrovascular event that causes severe neurological damage in patients, and is often accompanied by severe dysfunction of multiple systems such as breathing and circulation. Patients with severe cerebrovascular disease are in critical condition, have many complications, and are prone to deterioration of neurological function. Therefore, they need closer monitoring and treatment. The treatment strategy in the acute phase directly determines the prognosis of the patient. The case of this article selected 90 patients with severe cerebrovascular disease who were hospitalized in four wards of the Department of Neurology and the Department of Critical Care Medicine in a university hospital. The included cases were in accordance with the guidelines for the prevention and treatment of cerebrovascular diseases. Patients with cerebral infarction are given routine treatments such as improving cerebral circulation, protecting nutrient brain cells, dehydration, and anti-platelet; patients with cerebral hemorrhage are treated within the corresponding safe time window. We use Statistical Product and Service Solutions (SPSS) Statistics21 software to perform statistical analysis on the results. Based on the study of the feature extraction process of convolutional neural network, according to the hierarchical principle of convolutional neural network, a backbone neural network MF (Multi-Features)—Dense Net that can realize the fusion, and extraction of multi-scale features is designed. The network combines the characteristics of densely connected network and feature pyramid network structure, and combines strong feature extraction ability, high robustness and relatively small parameter amount. An end-to-end monitoring algorithm for severe cerebrovascular diseases based on MF-Dense Net is proposed. In the experiment, the algorithm showed high monitoring accuracy, and at the same time reached the speed of real-time monitoring on the experimental platform. An improved spatial pyramid pooling structure is designed to strengthen the network’s ability to merge and extract local features at the same level and at multiple scales, which can further improve the accuracy of algorithm monitoring by paying a small amount of additional computational cost. At the same time, a method is designed to strengthen the use of low-level features by improving the network structure, which improves the algorithm’s monitoring performance on small-scale severe cerebrovascular diseases. For patients with severe cerebrovascular disease in general, APACHEII1, APACHEII2, APACHEII3 and the trend of APACHEII score change are divided into high-risk group and low-risk group. The overall severe cerebrovascular disease, severe cerebral hemorrhage and severe cerebral infarction are analyzed, respectively. The differences are statistically significant.
Collapse
Affiliation(s)
- Suting Zhong
- Department of Emergency Medicine, Hanyang Hospital, Wuhan University of Science and Technology, Wuhan, China
| | - Kai Sun
- Department of Neurosurgery, Yantai Penglai Traditional Chinese Medicine Hospital, Yantai, China
| | - Xiaobing Zuo
- Department of Emergency Medicine, Hanyang Hospital, Wuhan University of Science and Technology, Wuhan, China
| | - Aihong Chen
- Department of Emergency Medicine, Hanyang Hospital, Wuhan University of Science and Technology, Wuhan, China
| |
Collapse
|
35
|
Cui C, Ramakrishnan G, Murphy J, Malas MB. Cost-Effectiveness of TransCarotid Artery Revascularization versus Carotid Endarterectomy. J Vasc Surg 2021; 74:1910-1918.e3. [PMID: 34182030 DOI: 10.1016/j.jvs.2021.05.051] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2020] [Accepted: 05/17/2021] [Indexed: 12/19/2022]
Abstract
OBJECTIVES Recent studies have demonstrated that TransCarotid Artery Stenting (TCAR) has comparable outcomes to the surgical gold standard, carotid endarterectomy (CEA). However, few studies have analyzed the cost of TCAR and no study has evaluated its cost-effectiveness. The purpose of this study is to conduct a cost-effectiveness analysis comparing TCAR to CEA for carotid artery stenosis. METHODS We built a Markov microsimulation using transition probabilities and utilities from existing literature for symptomatic patients undergoing TCAR or CEA. Costs were derived from literature then converted to 2019 dollars. The model included six health states with monthly cycle lengths: surgery, death, alive after surgery, alive after myocardial infarction, alive after stroke, and alive after stroke and death. Quality adjusted life years (QALYs), costs, and incremental cost-effectiveness ratio (ICER) were analyzed over a five-year period. One-way sensitivity and probabilistic sensitivity analyses were conducted to study the impact of parameter variability on cost effectiveness. RESULTS For symptomatic patients, CEA cost $7821 for 2.85 QALYs while TCAR cost $19154 for 2. 92 QALYs, leading to an ICER of $152,229 per QALY gained in the TCAR arm Sensitivity analysis demonstrated that our model was most sensitive to probability of restenosis, costs of TCAR and costs of CEA. Probabilistic sensitivity analysis demonstrated TCAR would be considered cost effective 49% of iterations. CONCLUSIONS This study found that while five-year costs for TCAR were greater than CEA, TCAR afforded greater QALYs than CEA. TCAR became cost-effective at six-years follow-up.
Collapse
Affiliation(s)
- Christina Cui
- School of Medicine, University of California San Diego, La Jolla, Calif
| | - Ganesh Ramakrishnan
- Division of Vascular and Endovascular Surgery, Department of Surgery, University of California San Diego, La Jolla, Calif
| | - James Murphy
- Department of Radiation Medicine and Applied Sciences, University of California San Diego, La Jolla, Calif
| | - Mahmoud B Malas
- Division of Vascular and Endovascular Surgery, Department of Surgery, University of California San Diego, La Jolla, Calif.
| |
Collapse
|
36
|
Bikk A, Sohrabi S, Navaran P, Farsar C. First-Bite Syndrome: A Rare Complication of Carotid Endarterectomy. Cureus 2021; 13:e15868. [PMID: 34327093 PMCID: PMC8301279 DOI: 10.7759/cureus.15868] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/21/2021] [Indexed: 11/25/2022] Open
Abstract
This report describes the rare complication of first-bite syndrome (FBS) after carotid endarterectomy (CEA). Although FBS is well known in otolaryngologic literature, it is rarely discussed in relation to vascular surgery. FBS is most commonly a postoperative pain syndrome that is thought to be the result of selective parotid gland sympathetic denervation. The resultant facial pain is centered around the parotid region and triggered by initiation of mastication. The pain is severe, but short in duration, and quite specific in pattern. We present a case of FBS after CEA with complex anatomy. The patient developed typical symptoms of ipsilateral parotid, mandibular pain during the postoperative course. Workup excluded other diagnoses. The symptoms were self-limiting but did not resolve completely. Vascular surgeons, who are universally aware of the presentation of Horner’s syndrome, should also be aware of this rare complication with similar pathophysiology.
Collapse
Affiliation(s)
- Andras Bikk
- Surgery, VA Central California Health Care System, Fresno, USA
| | - Sohrab Sohrabi
- Surgery, VA Central California Health Care System, Fresno, USA
| | | | - Cameron Farsar
- Medical Education, Idaho College of Osteopathic Medicine, Meridian, USA
| |
Collapse
|
37
|
SOCIETY FOR VASCULAR SURGERY CLINICAL PRACTICE GUIDELINES FOR MANAGEMENT OF EXTRACRANIAL CEREBROVASCULAR DISEASE. J Vasc Surg 2021; 75:4S-22S. [PMID: 34153348 DOI: 10.1016/j.jvs.2021.04.073] [Citation(s) in RCA: 214] [Impact Index Per Article: 71.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2021] [Accepted: 04/20/2021] [Indexed: 11/22/2022]
Abstract
Management of carotid bifurcation stenosis in stroke prevention has been the subject of extensive investigations, including multiple randomized controlled trials. The proper treatment of patients with carotid bifurcation disease is of major interest to vascular surgeons and other vascular specialists. In 2011, the Society for Vascular Surgery published guidelines for treatment of carotid artery disease. At the time, several randomized trials, comparing carotid endarterectomy (CEA) and carotid artery stenting (CAS), were published. Since that publication, several studies and a few systematic reviews comparing CEA and CAS have been published, and the role of medical management has been re-emphasized. The current publication updates and expands the 2011 guidelines with specific emphasis on five areas: is carotid endarterectomy recommended over maximal medical therapy in low risk patients; is carotid endarterectomy recommended over trans-femoral carotid artery stenting in low surgical risk patients with symptomatic carotid artery stenosis of >50%; timing of carotid Intervention in patients presenting with acute stroke; screening for carotid artery stenosis in asymptomatic patients; and optimal sequence for intervention in patients with combined carotid and coronary artery disease. A separate implementation document will address other important clinical issues in extracranial cerebrovascular disease. Recommendations are made using the GRADE (Grades of Recommendation Assessment, Development and Evaluation) approach, as has been done with other Society for Vascular Surgery guidelines. The committee recommends CEA as the first-line treatment for symptomatic low risk surgical patients with stenosis of 50% to 99% and asymptomatic patients with stenosis of 70% to 99%. The perioperative risk of stroke and death in asymptomatic patients must be <3% to ensure benefit for the patient. In patients with recent stable stroke (modified Rankin 0-2), carotid revascularization is considered appropriate in symptomatic patients with greater than 50% stenosis and is recommended and performed as soon as the patient is neurologically stable after 48 hours but definitely before 14 days of onset of symptoms. In the general population, screening for clinically asymptomatic carotid artery stenosis in patients without cerebrovascular symptoms or significant risk factors for carotid artery disease is not recommended. In selected asymptomatic patients who are at increased risk for carotid stenosis, we suggest screening for clinically asymptomatic carotid artery stenosis as long as the patients would potentially be fit for and willing to consider carotid intervention if significant stenosis is discovered. In patients with symptomatic carotid stenosis 50-99%, who require both CEA and CABG, we suggest CEA before or concomitant with CABG to potentially reduce the risk of stroke and stroke/death. The sequencing of the intervention depends on clinical presentation and institutional experience.
Collapse
|
38
|
Malgor RD, Mouawad NJ. Carotid artery calcific disease management strategies during transcarotid artery revascularization. J Vasc Bras 2021; 20:e20200152. [PMID: 34093688 PMCID: PMC8147888 DOI: 10.1590/1677-5449.210152] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/31/2023] Open
Affiliation(s)
- Rafael Demarchi Malgor
- University of Colorado, Division of Vascular Surgery and Endovascular Therapy, Aurora, CO, United States of America
| | - Nicolas J Mouawad
- McLaren Health System, Division of Vascular & Endovascular Surgery, Bay Region, Bay City, MI, United States of America.,Michigan State University, Division of Vascular Surgery, East Lansing, MI, United States of America
| |
Collapse
|
39
|
Zebolsky AL, Chou J, Key P, Knight P, Mahmood G, Jain K, Rummel M. Safety and efficacy of transcarotid artery revascularization in a community hospital. J Vasc Surg 2020; 74:203-208. [PMID: 33348008 DOI: 10.1016/j.jvs.2020.12.066] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2020] [Accepted: 12/05/2020] [Indexed: 11/24/2022]
Abstract
OBJECTIVE We evaluated the outcomes and complications of transcarotid artery revascularization (TCAR) outside of academic vascular surgery programs. METHODS An institutional review board-approved retrospective study was performed. Data from all cases of TCAR performed at a community hospital from May 2017 to February 2020 were collected and analyzed. Seven vascular surgeons performed the procedures after receiving appropriate training. The primary outcomes included technical success, the need for further revascularization, and major adverse events (death, cerebrovascular accident [CVA], myocardial infarction). The secondary outcomes included other adverse events and complications. The outcomes were assessed in the perioperative and 30-day follow-up periods. RESULTS During a 33-month period, TCAR was completed in 147 of 149 attempted cases (98.7%). No patients required further revascularization. The perioperative and 30-day major adverse event rates were 0.7% (n = 1) and 3.4% (n = 5), respectively. One case of a minor perioperative CVA occurred. At 30 days, one patient had died. The 30-day complications included CVA (n = 1) and myocardial infarction (n = 3). The combined perioperative and 30-day minor complication rates were 2.7% and 1.4%, respectively. CONCLUSIONS TCAR is a safe and effective method of carotid artery revascularization in a community hospital setting. This technology might help improve revascularization in patients without access to larger academic centers.
Collapse
Affiliation(s)
- Aaron L Zebolsky
- Western Michigan University Homer Stryker M.D. School of Medicine, Kalamazoo, Mich
| | - Jesse Chou
- Western Michigan University Homer Stryker M.D. School of Medicine, Kalamazoo, Mich
| | - Phillip Key
- Western Michigan University Homer Stryker M.D. School of Medicine, Kalamazoo, Mich
| | - Patrick Knight
- Western Michigan University Homer Stryker M.D. School of Medicine, Kalamazoo, Mich
| | - Gulrez Mahmood
- Western Michigan University Homer Stryker M.D. School of Medicine, Kalamazoo, Mich
| | - Krishna Jain
- Western Michigan University Homer Stryker M.D. School of Medicine, Kalamazoo, Mich.
| | - Mark Rummel
- Advanced Vascular Surgery at Kalamazoo, Kalamazoo, Mich
| |
Collapse
|
40
|
Goudreau BJ, Wang LJ, Latz CA, Conrad MF, Williams CA, Tracci MC, Kern JA, Clouse WD. Adding Supra-Aortic Trunk Surgical Reconstruction to Carotid Endarterectomy: Implications on Risk of Stroke and Death. J Am Coll Surg 2020; 232:629-635. [PMID: 33316428 DOI: 10.1016/j.jamcollsurg.2020.11.016] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2020] [Accepted: 11/30/2020] [Indexed: 11/17/2022]
Abstract
BACKGROUND Additive risks of combining supra-aortic trunk surgical reconstruction (SAT) with carotid endarterectomy (CEA) for associated carotid bifurcation and great vessel disease management are not well defined. This study sought to define risk of combining SAT with CEA. STUDY DESIGN Isolated CEA (ICEA) and CEA+SAT (from 2005 to 2015) were identified from NSQIP, excluding nonocclusive indications. CEA+SAT were compared with ICEA as well as a propensity-matched ICEA cohort. Primary outcomes included 30-day stroke, death, and composite (SD). Outcomes were then weighted by symptomatic status. Univariate and logistic regression analyses were performed. RESULTS Patients included 79,477 ICEA and 270 CEA+SAT. SAT reconstructions included 19 (7%) aorto-carotid bypasses, 21 (8%) carotid-subclavian transpositions, 85 (31%) carotid-carotid bypasses, and 145 (54%) carotid-subclavian bypasses. There was no difference in 30-day mortality (vs CEA+SAT 1.5% vs ICEA 0.7% p = 0.12). CEA+SAT had higher rates of stroke (3.7% vs 1.6%, p = 0.005) and stroke and death (SD) (4.8% vs 2.1%, p = 0.001). Predictors of SD included CEA+SAT (odds ratio [OR] 5.2, 95% CI 1.03-26.3, p = 0.046) and symptomatic status (OR 1.9, 95% CI 1.1-3.2, p = 0.02). After propensity matching, CEA+SAT continued to have higher rates of stroke (3.4% vs 0.4%, p = 0.01) and SD (4.5% vs 1.5%, p = 0.04), with similar mortality (1.5% vs 1.1%, p = 0.70). No differences were noted in primary endpoints in asymptomatic patients. In symptomatic patients, CEA+SAT carried significantly higher stroke (5.6% vs 2.1%, p = 0.04) and SD risk (7.0% vs 2.8%, p = 0.03). CONCLUSIONS CEA+SAT confers increased risk of stroke and SD over ICEA. Symptomatic status and concomitant procedure contribute to this risk. Management should be considered within the context of lesion characteristics, patient longevity, and individual operative risk profile.
Collapse
Affiliation(s)
- Bernadette J Goudreau
- Divisions of Vascular and Endovascular Surgery, University of Virginia, Charlottesville, VA
| | | | | | | | - Carlin A Williams
- Divisions of Vascular and Endovascular Surgery, University of Virginia, Charlottesville, VA
| | - Margaret C Tracci
- Divisions of Vascular and Endovascular Surgery, University of Virginia, Charlottesville, VA
| | - John A Kern
- Divisions of Vascular and Endovascular Surgery, University of Virginia, Charlottesville, VA
| | - W Darrin Clouse
- Divisions of Vascular and Endovascular Surgery, University of Virginia, Charlottesville, VA.
| |
Collapse
|
41
|
Dakour-Aridi H, Cui CL, Barleben A, Schermerhorn ML, Eldrup-Jorgensen J, Malas MB. Poststent ballooning during transcarotid artery revascularization. J Vasc Surg 2020; 73:2041-2049.e1. [PMID: 33253868 DOI: 10.1016/j.jvs.2020.10.071] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2020] [Accepted: 10/18/2020] [Indexed: 11/24/2022]
Abstract
BACKGROUND Poststent ballooning/angioplasty (post-SB) have been shown to increase the risk of stroke risk after transfemoral carotid artery stenting. With the advancement of transcarotid artery revascularization (TCAR) with dynamic cerebral blood flow reversal, we aimed to study the impact of post-SB during TCAR. METHODS Patients undergoing TCAR in the Vascular Quality Initiative between September 2016 and May 2019 were included and were divided into three groups: those who received prestent deployment angioplasty only (pre-SB, reference group), those who received poststent deployment ballooning only (post-SB), and those who received both prestent and poststent deployment ballooning (prepost-SB). Patients who did not receive any angioplasty during their procedure (n = 367 [6.7%]) were excluded because these represent a different group of patients with less complex lesions than those requiring angioplasty. Primary outcome was in-hospital stroke or death. Analysis was performed using univariable and multivariable logistic regression models. RESULTS Of 5161 patients undergoing TCAR, 34.7% had pre-SB only, 25% had post-SB only, and 40.3% had both (prepost-SB). No differences in the rates of in-hospital and 30-day stroke, death, and stroke/death were observed among the three groups; in-hospital stroke/death in the pre-SB group was 1.4% (n = 25), post-SB 1.2% (n = 16), and prepost-SB 1.4% (n = 29; P = .92). However, patients undergoing post-SB and prepost-SB had higher rates of in-hospital transient ischemic attacks (TIA) (post-SB, 0.9%; prepost-SB, 1% vs pre-SB, 0.2%, P < .01) and postprocedural hypotension (16.6% and 16.8% vs 13.1%, respectively; P < .001). Post-SB also had longer operative times, as well as flow reversal and fluoroscopy times. On multivariable analysis, no association was seen between post-SB and the primary outcome of in-hospital stroke/death (post-SB odds ratio [OR], 0.88; 95% confidence interval [CI], 0.44-1.73; prepost-SB OR, 0.98; 95% CI, 0.57-1.70). Similarly, no significant differences were noted in terms of postprocedural hemodynamic instability and 30-day outcomes. However, post-SB and prepost-SB were associated with four times the odds of in-hospital TIA compared with pre-SB alone (post-SB OR, 4.24 [95% CI, 1.51-11.8]; prepost-SB OR, 4.76 [95% CI, 1.53-14.79]; P = .01). Symptomatic patients had higher rates of in-hospital stroke/death compared with their asymptomatic counterparts; however, there was no significant interaction between symptomatic status and ballooning in predicting the primary outcome. CONCLUSIONS Post-SB was used in 65.3% of TCAR patients. This maneuver seems to be safe without an increase in the odds of postoperative in-hospital stroke/death. However, the increased rates of TIA associated with post-SB requires further investigation.
Collapse
Affiliation(s)
- Hanaa Dakour-Aridi
- Division of Vascular and Endovascular Surgery, Department of Surgery, University of California San Diego, Calif
| | - Christina L Cui
- Division of Vascular and Endovascular Surgery, Department of Surgery, University of California San Diego, Calif
| | - Andrew Barleben
- Division of Vascular and Endovascular Surgery, Department of Surgery, University of California San Diego, Calif
| | - Marc L Schermerhorn
- Division of Vascular and Endovascular Surgery, Beth Israel Deaconess Medical Center, Boston, Mass
| | | | - Mahmoud B Malas
- Division of Vascular and Endovascular Surgery, Department of Surgery, University of California San Diego, Calif.
| |
Collapse
|
42
|
Beeman BR, Kuhn BA, Recht MH, Muck PE, Schneider PA. Duplex Ultrasound Surveillance after Transcarotid Artery Revascularization (TCAR) in Clinical Practice. Ann Vasc Surg 2020; 72:330-339. [PMID: 33245990 DOI: 10.1016/j.avsg.2020.09.065] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2020] [Revised: 09/25/2020] [Accepted: 09/27/2020] [Indexed: 11/25/2022]
Abstract
BACKGROUND To propose a protocol for the routine clinical use of duplex ultrasound (DUS) assessment after transcarotid artery revascularization (TCAR) procedures, with its specific point of vascular access, based on DUS data from routine clinical practice. METHODS DUS data were retrospectively collected at 2 centers from a total of 97 patients who underwent a TCAR procedure with at least 30-day and up to 12-month follow-up. Peak systolic velocity (PSV), end diastolic velocity (EDV), and the internal carotid artery (ICA)/common carotid artery (CCA) PSV ratio were collected at baseline (≤30 days after the procedure) and compared with subsequent measurements. RESULTS Baseline data were established within 30 days after the procedure. There were no access site stenoses, pseudoaneurysms, or dissections detected in follow-up. Average hemodynamics measurements at 12 months after the procedure (36% of patients reached this time point to date) were PSV 167 ± 153 cm/sec, EDV 51 ± 55 cm/sec, and ICA/CCA PSV 2.3 ± 1.9. Five patients (5.2%) exhibited velocities indicative of ≥80% in-stent restenosis (ISR) at 12 months after the procedure. Two patients (2.1%) underwent repeat intervention for ISR based on high velocities and before significant clinical consequence. The other 3 patients (3.1%) were asymptomatic and are being managed medically and monitored for neurological symptoms. One intraprocedural stroke (1.0% of total treated) was observed. CONCLUSIONS This protocol not only illustrates the utility of using the CCA for the arterial access sheath for carotid stenting, but also successfully identifies patients with clinically significant restenosis >80%-99%. A surveillance regimen of baseline at ≤30 days after the procedure, followed by assessment at 6 and 12 months, and yearly thereafter appears to be a safe and effective protocol, based on the data available to date. A PSV >340 cm/sec and ICA/CCA ratio >4.15 is consistent with an 80-99% restenosis after TCAR. Although a small number, this study serves as a starting point for those who perform TCAR to specifically look at the CCA access site to rule out these potential pitfalls which did occur in the early trials.
Collapse
Affiliation(s)
- Brian R Beeman
- Carle Heart and Vascular Institute, Carle Foundation Hospital, Urbana, IL.
| | - Brian A Kuhn
- TriHealth/Good Samaritan Hospital, Cincinnati, OH
| | | | | | | |
Collapse
|
43
|
Kumins NH, Kashyap VS. Learning curve and proficiency of transcarotid artery revascularization compared to transfemoral carotid artery stenting. Semin Vasc Surg 2020; 33:16-23. [PMID: 33218612 DOI: 10.1053/j.semvascsurg.2020.05.009] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
Both transfemoral carotid artery stenting (TF-CAS) and transcarotid artery revascularization (TCAR) are competing endovascular alternatives to carotid endarterectomy for the treatment of atherosclerotic carotid artery stenosis. TF-CAS is an endovascular procedure associated with a long learning curve and higher periprocedural stroke and death rates during an operator's early experience. Estimates suggest that more than 50 cases are required to achieve outcomes similar to carotid endarterectomy. TCAR is a novel hybrid procedure combining direct common carotid artery access and cerebral blood flow reversal with carotid stent placement. In distinction from TF-CAS, TCAR has a rather short learning curve. A multi-institutional analysis showed that operators achieved technical proficiency after approximately 10 to 15 cases. This was reinforced by a large Society for Vascular Surgery, Vascular Quality Initiative Transcarotid Artery Revascularization Surveillance Project analysis that demonstrated that expertise peaked after approximately 20 cases. Both studies found that TCAR was not associated with an increased rate of stroke or death during operator's early experience. These data suggest that TCAR is readily learned and patients are not at increased risk during a surgeon's early experience.
Collapse
Affiliation(s)
- Norman H Kumins
- Department of Surgery, Division of Vascular and Surgery and Endovascular Therapy, University Hospitals Cleveland Medical Center, 11100 Euclid Avenue, LKS 7060, Cleveland, OH 44106-7060
| | - Vikram S Kashyap
- Department of Surgery, Division of Vascular and Surgery and Endovascular Therapy, University Hospitals Cleveland Medical Center, 11100 Euclid Avenue, LKS 7060, Cleveland, OH 44106-7060.
| |
Collapse
|
44
|
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.
Collapse
|
45
|
Cui CL, Dakour-Aridi H, Eldrup-Jorgensen J, Schermerhorn ML, Siracuse JJ, Malas MB. Effects of timing on in-hospital and one-year outcomes after transcarotid artery revascularization. J Vasc Surg 2020; 73:1649-1657.e1. [PMID: 33038481 DOI: 10.1016/j.jvs.2020.08.148] [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: 05/17/2020] [Accepted: 08/27/2020] [Indexed: 11/28/2022]
Abstract
OBJECTIVE The current recommendations are to perform carotid endarterectomy within 2 weeks of symptoms for maximum long-term stroke prevention, although urgent carotid endarterectomy within 48 hours has been associated with increased perioperative stroke. With the development and rapid adoption of transcarotid artery revascularization (TCAR), we decided to study the effect of timing on the outcomes after TCAR. METHODS The Vascular Quality Initiative database was searched for symptomatic patients who had undergone TCAR from September 2016 to November 2019. These patients were stratified by the interval to TCAR after symptom onset: urgent, within 48 hours; early, 3 to 14 days; and late, >14 days. The primary outcome was the in-hospital rate of combined stroke and death (stroke/death), evaluated using logistic regression analysis. The secondary outcome was the 1-year rate of recurrent ipsilateral stroke and mortality, evaluated using Kaplan-Meier survival analysis. RESULTS A total of 2608 symptomatic patients who had undergone TCAR were included. The timing was urgent for 144 patients (5.52%), early for 928 patients (35.58%), and late for 1536 patients (58.90%). Patients undergoing urgent intervention had an increased risk of in-hospital stroke/death, which was driven primarily by an increased risk of stroke. No differences were seen for in-hospital death. On adjusted analysis, urgent intervention resulted in a threefold increased risk of stroke (odds ratio [OR], 2.8; 95% confidence interval [CI], 1.3-6.2; P = .01) and a threefold increased risk of stroke/death (OR, 2.9; 95% CI, 1.3-6.4; P = .01) compared with late intervention. Patients undergoing early intervention had comparable risks of stroke (OR, 1.3; 95% CI, 0.7-2.3; P = .40) and stroke/death (OR, 1.2; 95% CI, 0.7-2.1; P = .48) compared with late intervention. On subset analysis, the type of presenting symptoms was an effect modifier. Patients presenting with stroke and those presenting with transient ischemic attack or amaurosis fugax both had an increased risk of stroke/death when undergoing urgent compared with late TCAR (OR, 2.7; 95% CI, 1.1-6.6; P = .04; and OR, 4.1; 95% CI, 1.1-15.0; P = .03, respectively). However only patients presenting with transient ischemic attack or amaurosis fugax had experienced an increased risk of stroke with urgent compared with late TCAR (OR, 5.0; 95% CI, 1.4-17.5; P < .01). At 1 year of follow-up, no differences were seen in the incidence of recurrent ipsilateral stroke (urgent, 0.7%; early, 0.2%; late, 0.1%; P = .13) or postdischarge mortality (urgent, 0.7%; early, 1.6%; late, 1.8%; P = .71). CONCLUSIONS We found that TCAR had a reduced incidence of stroke when performed 48 hours after symptom onset. Urgent TCAR within 48 hours of the onset of stroke was associated with a threefold increased risk of in-hospital stroke/death, with no added benefit for ≤1 year after intervention. Further studies are needed on long-term outcomes of TCAR stratified by the timing of the procedure.
Collapse
Affiliation(s)
- Christina L Cui
- Division of Vascular and Endovascular Surgery, Department of Surgery, University of California, San Diego, La Jolla, Calif
| | - Hanaa Dakour-Aridi
- Division of Vascular and Endovascular Surgery, Department of Surgery, University of California, San Diego, La Jolla, Calif
| | - Jens Eldrup-Jorgensen
- Division of Vascular and Endovascular Therapy, Department of Surgery, Maine Medical Center, Portland, Me
| | - Marc L Schermerhorn
- Division of Vascular and Endovascular Surgery, Department of Surgery, Beth Israel Deaconess Medical Center, Boston, Mass
| | - Jeffrey J Siracuse
- Division of Vascular and Endovascular Surgery, Department of Surgery, Boston University, Boston Medical Center, Boston, Mass
| | - Mahmoud B Malas
- Division of Vascular and Endovascular Surgery, Department of Surgery, University of California, San Diego, La Jolla, Calif.
| |
Collapse
|
46
|
Ghamraoui AK, Ricotta JJ. Outcomes of Transcarotid Artery Revascularization (TCAR) in Octogenarians and Older. Ann Vasc Surg 2020; 68:151-158. [DOI: 10.1016/j.avsg.2020.05.034] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2020] [Revised: 04/30/2020] [Accepted: 05/02/2020] [Indexed: 11/27/2022]
|
47
|
Malas MB, Dakour-Aridi H, Kashyap VS, Eldrup-Jorgensen J, Wang GJ, Motaganahalli RL, Cronenwett JL, Schermerhorn ML. TransCarotid Revascularization with Dynamic Flow reversal versus Carotid Endarterectomy in the Vascular Quality Initiative Surveillance Project. Ann Surg 2020; 276:398-403. [DOI: 10.1097/sla.0000000000004496] [Citation(s) in RCA: 30] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
|
48
|
Dakour-Aridi H, Kashyap VS, Wang GJ, Eldrup-Jorgensen J, Schermerhorn ML, Malas MB. The impact of age on in-hospital outcomes after transcarotid artery revascularization, transfemoral carotid artery stenting, and carotid endarterectomy. J Vasc Surg 2020; 72:931-942.e2. [DOI: 10.1016/j.jvs.2019.11.037] [Citation(s) in RCA: 28] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2019] [Accepted: 11/11/2019] [Indexed: 11/16/2022]
|
49
|
Coelho A, Prassaparo T, Mansilha A, Kappelle J, Naylor R, de Borst GJ. Critical Appraisal on the Quality of Reporting on Safety and Efficacy of Transcarotid Artery Stenting With Flow Reversal. Stroke 2020; 51:2863-2871. [PMID: 32811389 DOI: 10.1161/strokeaha.120.030283] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Transcarotid revascularization is an alternative to transfemoral carotid artery stenting, designed to avoid aortic arch manipulation and concomitant periprocedural stroke. This article aims to perform a detailed analysis on the quality of the currently available evidence on safety and efficacy of transcarotid artery revascularization. Although current evidence is promising, independent randomized controlled studies comparing transcarotid artery revascularization with carotid endarterectomy in recently symptomatic patients are lacking and will be necessary to establish the true value of transcarotid artery revascularization in carotid artery revascularization.
Collapse
Affiliation(s)
- Andreia Coelho
- Department of Angiology and Vascular Surgery, Centro Hospitalar Vila Nova de Gaia/Espinho, Portugal (A.C.).,Faculdade Medicina da Universidade do Porto, Portugal (A.C., A.M.)
| | | | - Armando Mansilha
- Faculdade Medicina da Universidade do Porto, Portugal (A.C., A.M.)
| | - Jaap Kappelle
- Department of Neurology (J.K.), University Medical Center Utrecht, the Netherlands
| | - Ross Naylor
- Department of Vascular Surgery, Leicester, United Kingdom (R.N.)
| | - Gert J de Borst
- Department of Vascular Surgery (G.J.d.B.), University Medical Center Utrecht, the Netherlands
| |
Collapse
|
50
|
Klarin D, Patel VI, Zhang S, Xian Y, Kosinski A, Yerokun B, Badhwar V, Thourani VH, Sundt TM, Shahian D, Melnitchouk S. Concomitant carotid endarterectomy and cardiac surgery does not decrease postoperative stroke rates. J Vasc Surg 2020; 72:589-596.e3. [DOI: 10.1016/j.jvs.2019.10.072] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2019] [Accepted: 10/08/2019] [Indexed: 10/25/2022]
|