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Fries F. [Stent angioplasty for internal carotid artery stenosis]. RADIOLOGIE (HEIDELBERG, GERMANY) 2024; 64:694-698. [PMID: 38700713 DOI: 10.1007/s00117-024-01306-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 04/17/2024] [Indexed: 08/28/2024]
Abstract
BACKGROUND Stent angioplasty of carotid stenosis has become established as a safe and efficient treatment method alongside carotid endarterectomy due to developments in stent design and refinement of interventional techniques. Today, the protocol for stent angioplasty is largely standardized. OBJECTIVE The aim of this article is to provide sound insight into the development and current practice of stent angioplasty. Particular attention is paid to technical implementation and periprocedural management.
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Affiliation(s)
- Frederik Fries
- Klinik für Diagnostische und Interventionelle Neuroradiologie, Universitätsklinikum des Saarlandes, Kirrberger Straße, 66421, Homburg/Saar, Deutschland.
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Durmuş G, Karataş MB, Gökalp M, Eren S, Cebeci AC, Nural A, Hatipoğlu E, Osken A, Karaca M, Zengin A. Increased Serum CRP-Albumin Ratio is Independently Associated With In-Stent Restenosis After Carotid Artery Stenting. Angiology 2024:33197241273331. [PMID: 39155812 DOI: 10.1177/00033197241273331] [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: 08/20/2024]
Abstract
Atherosclerotic stenosis of the carotid artery contributes significantly to ischemic strokes. This study investigates the correlation between the C-reactive protein (CRP) to albumin ratio (CAR) and in-stent restenosis (ISR) in patients (n = 529) undergoing carotid artery stenting. Patients were categorized based on ISR occurrence. Cox regression analyses were performed to identify independent predictors of ISR. The ISR rate was 10.3%. Laboratory analysis revealed higher levels of uric acid, CRP, and CAR in the ISR group. Cox regression identified CAR as an independent predictor of ISR (Hazard ratio (HR): 1.13, 95% CI: 1.03-1.24, P = .01), along with diabetes and smoking. A CAR cut-off of 0.28 predicted ISR with 93% sensitivity and 89% specificity (Area under the curve (AUC): 0.945, 95% CI: 0.923-0.963, P < .001). This study establishes a significant association between CAR and ISR in carotid artery stenting patients. The inflammatory response, indicated by CAR, emerges as a crucial factor in ISR development. The study contributes valuable insights into predicting and preventing ISR, emphasizing the potential of CAR as a prognostic biomarker. This easily accessible and cost-effective biomarker could enhance ISR prediction and guide preventive strategies for high-risk patients.
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Affiliation(s)
- Gündüz Durmuş
- Department of Cardiology, Istanbul Dr Siyami Ersek Thoracic and Cardiovascular Surgery Training and Research Hospital, Cardiology, Istanbul, Turkey
| | - Mehmet Baran Karataş
- Department of Cardiology, Istanbul Dr Siyami Ersek Thoracic and Cardiovascular Surgery Training and Research Hospital, Cardiology, Istanbul, Turkey
| | - Murat Gökalp
- Department of Cardiology, Istanbul Dr Siyami Ersek Thoracic and Cardiovascular Surgery Training and Research Hospital, Cardiology, Istanbul, Turkey
| | - Semih Eren
- Department of Cardiology, Istanbul Dr Siyami Ersek Thoracic and Cardiovascular Surgery Training and Research Hospital, Cardiology, Istanbul, Turkey
| | - Ahmet Ceyhun Cebeci
- Department of Cardiology, Istanbul Dr Siyami Ersek Thoracic and Cardiovascular Surgery Training and Research Hospital, Cardiology, Istanbul, Turkey
| | - Ali Nural
- Department of Cardiology, Istanbul Dr Siyami Ersek Thoracic and Cardiovascular Surgery Training and Research Hospital, Cardiology, Istanbul, Turkey
| | - Elif Hatipoğlu
- Department of Cardiology, Istanbul Dr Siyami Ersek Thoracic and Cardiovascular Surgery Training and Research Hospital, Cardiology, Istanbul, Turkey
| | - Altuğ Osken
- Department of Cardiology, Istanbul Dr Siyami Ersek Thoracic and Cardiovascular Surgery Training and Research Hospital, Cardiology, Istanbul, Turkey
| | - Mehmet Karaca
- Department of Cardiology, Memorial Atasehir Hospital, Istanbul, Turkey
| | - Ahmet Zengin
- Department of Cardiology, Istanbul Dr Siyami Ersek Thoracic and Cardiovascular Surgery Training and Research Hospital, Cardiology, Istanbul, Turkey
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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.
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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
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Ristow AVB, Massière B, Meirelles GV, Casella IB, Morales MM, Moreira RCR, Procópio RJ, Oliveira TF, de Araujo WJB, Joviliano EE, de Oliveira JCP. Brazilian Angiology and Vascular Surgery Society Guidelines for the treatment of extracranial cerebrovascular disease. J Vasc Bras 2024; 23:e20230094. [PMID: 39099701 PMCID: PMC11296686 DOI: 10.1590/1677-5449.202300942] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2023] [Accepted: 10/16/2023] [Indexed: 08/06/2024] Open
Abstract
Extracranial cerebrovascular disease has been the subject of intense research throughout the world, and is of paramount importance for vascular surgeons. This guideline, written by the Brazilian Society of Angiology and Vascular Surgery (SBACV), supersedes the 2015 guideline. Non-atherosclerotic carotid artery diseases were not included in this document. The purpose of this guideline is to bring together the most robust evidence in this area in order to help specialists in the treatment decision-making process. The AGREE II methodology and the European Society of Cardiology system were used for recommendations and levels of evidence. The recommendations were graded from I to III, and levels of evidence were classified as A, B, or C. This guideline is divided into 11 chapters dealing with the various aspects of extracranial cerebrovascular disease: diagnosis, treatments and complications, based on up-to-date knowledge and the recommendations proposed by SBACV.
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Affiliation(s)
- Arno von Buettner Ristow
- Pontifícia Universidade Católica do Rio de Janeiro – PUC-RIO, Disciplina de Cirurgia Vascular e Endovascular, Rio de Janeiro, RJ, Brasil.
- Sociedade Brasileira de Angiologia e de Cirurgia Vascular – SBACV-RJ, Rio de Janeiro, RJ, Brasil.
| | - Bernardo Massière
- Pontifícia Universidade Católica do Rio de Janeiro – PUC-RIO, Disciplina de Cirurgia Vascular e Endovascular, Rio de Janeiro, RJ, Brasil.
- Sociedade Brasileira de Angiologia e de Cirurgia Vascular – SBACV-RJ, Rio de Janeiro, RJ, Brasil.
| | - Guilherme Vieira Meirelles
- Sociedade Brasileira de Angiologia e de Cirurgia Vascular – SBACV-SP, São Paulo, SP, Brasil.
- Universidade Estadual de Campinas – UNICAMP, Hospital das Clínicas, Disciplina de Cirurgia do Trauma, Campinas, SP, Brasil.
| | - Ivan Benaduce Casella
- Sociedade Brasileira de Angiologia e de Cirurgia Vascular – SBACV-SP, São Paulo, SP, Brasil.
- Universidade de São Paulo – USP, Faculdade de Medicina, São Paulo, SP, Brasil.
| | - Marcia Maria Morales
- Sociedade Brasileira de Angiologia e de Cirurgia Vascular – SBACV-SP, São Paulo, SP, Brasil.
- Associação Portuguesa de Beneficência de São José do Rio Preto, Serviço de Cirurgia Vascular, São José do Rio Preto, SP, Brasil.
| | - Ricardo Cesar Rocha Moreira
- Sociedade Brasileira de Angiologia e de Cirurgia Vascular – SBACV-PR, Curitiba, PR, Brasil.
- Pontifícia Universidade Católica do Paraná – PUC-PR, Hospital Cajurú, Serviço de Cirurgia Vascular, Curitiba, PR, Brasil.
| | - Ricardo Jayme Procópio
- Universidade Federal de Minas Gerais – UFMG, Hospital das Clínicas, Setor de Cirurgia Endovascular, Belo Horizonte, MG, Brasil.
- Universidade Federal de Minas Gerais – UFMG, Faculdade de Medicina, Belo Horizonte, MG, Brasil.
- Sociedade Brasileira de Angiologia e de Cirurgia Vascular – SBACV-MG, Belo Horizonte, MG, Brasil.
| | - Tércio Ferreira Oliveira
- Sociedade Brasileira de Angiologia e de Cirurgia Vascular – SBACV-SE, Aracajú, SE, Brasil.
- Universidade de São Paulo – USP, Faculdade de Medicina de Ribeirão Preto – FMRP, Ribeirão Preto, SP, Brasil.
| | - Walter Jr. Boim de Araujo
- Sociedade Brasileira de Angiologia e de Cirurgia Vascular – SBACV-PR, Curitiba, PR, Brasil.
- Universidade Federal do Paraná – UFPR, Hospital das Clínicas – HC, Curitiba, PR, Brasil.
| | - Edwaldo Edner Joviliano
- Sociedade Brasileira de Angiologia e de Cirurgia Vascular – SBACV-SP, São Paulo, SP, Brasil.
- Universidade de São Paulo – USP, Faculdade de Medicina de Ribeirão Preto – FMRP, Ribeirão Preto, SP, Brasil.
| | - Júlio Cesar Peclat de Oliveira
- Sociedade Brasileira de Angiologia e de Cirurgia Vascular – SBACV-SP, São Paulo, SP, Brasil.
- Universidade Federal do Estado do Rio de Janeiro – UNIRIO, Departamento de Cirurgia, Rio de Janeiro, RJ, Brasil.
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Aridi HD, Leon B, Murphy MP, Malas M, Schermerhorn ML, Kashyap VS, Wang GJ, Eldrup-Jorgensen J, Gonzalez AA, Motaganahalli RL. Predictors of prolonged length of stay after elective carotid revascularization. J Vasc Surg 2024:S0741-5214(24)01201-1. [PMID: 38763455 DOI: 10.1016/j.jvs.2024.05.022] [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: 03/13/2024] [Revised: 05/12/2024] [Accepted: 05/14/2024] [Indexed: 05/21/2024]
Abstract
OBJECTIVE Postoperative day-one discharge is used as a quality-of-care indicator after carotid revascularization. This study identifies predictors of prolonged length of stay (pLOS), defined as a postprocedural LOS of >1 day, after elective carotid revascularization. METHODS Patients undergoing carotid endarterectomy (CEA), transcarotid artery revascularization (TCAR), and transfemoral carotid artery stenting (TFCAS) in the Vascular Quality Initiative between 2016 and 2022 were included in this analysis. Multivariable logistic regression analysis was used to identify predictors of pLOS, defined as a postprocedural LOS of >1 day, after each procedure. RESULTS A total of 118,625 elective cases were included. pLOS was observed in nearly 23.2% of patients undergoing carotid revascularization. Major adverse events, including neurological, cardiac, infectious, and bleeding complications, occurred in 5.2% of patients and were the most significant contributor to pLOS after the three procedures. Age, female sex, non-White race, insurance status, high comorbidity index, prior ipsilateral CEA, non-ambulatory status, symptomatic presentation, surgeries occurring on Friday, and postoperative hypo- or hypertension were significantly associated with pLOS across all three procedures. For CEA, additional predictors included contralateral carotid artery occlusion, preoperative use of dual antiplatelets and anticoagulation, low physician volume (<11 cases/year), and drain use. For TCAR, preoperative anticoagulation use, low physician case volume (<6 cases/year), no protamine use, and post-stent dilatation intraoperatively were associated with pLOS. One-year analysis showed a significant association between pLOS and increased mortality for all three procedures; CEA (hazard ratio [HR],1.64; 95% confidence interval [CI], 1.49-1.82), TCAR (HR,1.56; 95% CI, 1.35-1.80), and TFCAS (HR, 1.33; 95%CI, 1.08-1.64) (all P < .05). CONCLUSIONS A postoperative LOS of more than 1 day is not uncommon after carotid revascularization. Procedure-related complications are the most common drivers of pLOS. Identifying patients who are risk for pLOS highlights quality improvement strategies that can optimize short and 1-year outcomes of patients undergoing carotid revascularization.
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Affiliation(s)
- Hanaa D Aridi
- Division of Vascular Surgery, Indiana University School of Medicine, Indianapolis, IN
| | - Brandon Leon
- Division of Vascular Surgery, Indiana University School of Medicine, Indianapolis, IN
| | - Michael P Murphy
- Division of Vascular Surgery, Indiana University School of Medicine, Indianapolis, IN
| | - Mahmoud Malas
- Division of Vascular and Endovascular Surgery, University of California San Diego, La Jolla, CA
| | - Marc L Schermerhorn
- Division of Vascular and Endovascular Surgery, Beth Israel Deaconess Medical Center, Boston, MA
| | - Vikram S Kashyap
- Frederik Meijer Heart and Vascular Institute, Corewell Health, Grand Rapids, MI
| | - Grace J Wang
- Division of Vascular and Endovascular Surgery, Hospital of the University of Pennsylvania, Philadelphia, PA
| | | | - Andrew A Gonzalez
- Division of Vascular Surgery, Indiana University School of Medicine, Indianapolis, IN
| | - Raghu L Motaganahalli
- Division of Vascular Surgery, Indiana University School of Medicine, Indianapolis, IN.
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Yang K, Tan J, Deng Y, Jiang S, Tang J, Shi W, Yu B. Debris generated by laser and/or balloon cause cerebral infarction with different severity. Lasers Med Sci 2023; 39:15. [PMID: 38135785 DOI: 10.1007/s10103-023-03904-0] [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: 08/24/2023] [Accepted: 10/04/2023] [Indexed: 12/24/2023]
Abstract
The purpose of this study is to determine the effects that debris generated by laser and/or balloon on the brain. Debris generated by laser, balloon, and laser combined with balloon were collected and then injected into rats' left common carotid artery. Rats were divided into five groups: sham, saline, laser (L), balloon (B), and laser combined with balloon (LB). The cognition ability of rats was evaluated by Morris water maze. Cerebral blood flow (CBF) was examined by laser speckle. TTC staining and MRI scan were conducted to detect cerebral ischemic infarction. Intracranial arteries in rats were visualized by MRI angiography via contrast medium injected via tail vein. Immunohistologic staining for NeuN and Iba1 and hematoxylin-eosin staining were performed to assess brain infarction. White matter demyelination was assessed by Luxol fast blue staining. Long-term memory and CBF of rats in different groups exhibited no significant difference. No obstruction sign in intracranial artery tree was noticed in each group. Debris generated by different treatments all caused brain infarction. Infarction lesion caused by debris produced by balloon was much more severe than the one caused by debris generated by laser. While the LB group lay in between. The thickness of white matter decreased in the B group, but not in the L and LB groups. Rat brain has a tolerance for debris as cognition ability and cerebral blood flow are not significantly declined. The severity of cerebral infarction varies by debris generated by different treatments.
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Affiliation(s)
- Kai Yang
- Department of Vascular Surgery, Shanghai Pudong Hospital, Fudan University Pudong Medical Center, 2800 Gongwei Road, Pudong, 201399, Shanghai, China
- Department of Vascular Surgery, Huashan Hospital, Fudan University, 12 Urumqi Middle Road, Jingan, 200040, Shanghai, China
- Shanghai Key Laboratory of Vascular Lesions Regulation and Remodeling, Fudan University Pudong Medical Center, 2800 Gongwei Road, 201399, Shanghai, China
| | - Jinyun Tan
- Department of Vascular Surgery, Huashan Hospital, Fudan University, 12 Urumqi Middle Road, Jingan, 200040, Shanghai, China
- Shanghai Key Laboratory of Vascular Lesions Regulation and Remodeling, Fudan University Pudong Medical Center, 2800 Gongwei Road, 201399, Shanghai, China
- Zhangjiang Institute, Fudan University, 1688 Guoquan North Road, Yangpu, 201203, Shanghai, China
| | - Ying Deng
- Department of Vascular Surgery, Shanghai Pudong Hospital, Fudan University Pudong Medical Center, 2800 Gongwei Road, Pudong, 201399, Shanghai, China
- Shanghai Key Laboratory of Vascular Lesions Regulation and Remodeling, Fudan University Pudong Medical Center, 2800 Gongwei Road, 201399, Shanghai, China
| | - Shuai Jiang
- Department of Vascular Surgery, Shanghai Pudong Hospital, Fudan University Pudong Medical Center, 2800 Gongwei Road, Pudong, 201399, Shanghai, China
- Shanghai Key Laboratory of Vascular Lesions Regulation and Remodeling, Fudan University Pudong Medical Center, 2800 Gongwei Road, 201399, Shanghai, China
| | - Jingdong Tang
- Department of Vascular Surgery, Shanghai Pudong Hospital, Fudan University Pudong Medical Center, 2800 Gongwei Road, Pudong, 201399, Shanghai, China
- Shanghai Key Laboratory of Vascular Lesions Regulation and Remodeling, Fudan University Pudong Medical Center, 2800 Gongwei Road, 201399, Shanghai, China
| | - Weihao Shi
- Department of Vascular Surgery, Huashan Hospital, Fudan University, 12 Urumqi Middle Road, Jingan, 200040, Shanghai, China
- Shanghai Key Laboratory of Vascular Lesions Regulation and Remodeling, Fudan University Pudong Medical Center, 2800 Gongwei Road, 201399, Shanghai, China
| | - Bo Yu
- Department of Vascular Surgery, Shanghai Pudong Hospital, Fudan University Pudong Medical Center, 2800 Gongwei Road, Pudong, 201399, Shanghai, China.
- Shanghai Key Laboratory of Vascular Lesions Regulation and Remodeling, Fudan University Pudong Medical Center, 2800 Gongwei Road, 201399, Shanghai, China.
- Zhangjiang Institute, Fudan University, 1688 Guoquan North Road, Yangpu, 201203, Shanghai, China.
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Pelz DM, Lownie SP, Iftikhar UF, Munoz C, Lopez-Ojeda P, Azarpazhooh R. Safety Evaluation of Primary Carotid Stenting: Transcranial Doppler and MRI. Can J Neurol Sci 2023; 50:651-655. [PMID: 36245094 DOI: 10.1017/cjn.2022.304] [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: 11/08/2022]
Abstract
BACKGROUND AND PURPOSE Cerebral emboli are generated by every step of standard carotid angioplasty and stenting. Primary carotid stenting (PCS) is a technique in which the use of balloon angioplasty (BA) is minimized to decrease the embolic load. The primary aim of this study is to establish the number of emboli generated by each step of primary stenting and determine the relationship to new diffusion (DWI) lesions on subsequent magnetic resonance imaging (MRI). METHODS Eighty-five patients with severe, symptomatic carotid stenosis were prospectively recruited and underwent carotid stenting. Intraoperative transcranial Doppler was performed in 77 patients. The number and size of microemboli for each of seven procedural steps were recorded. Correlation was made with the number and location of new DWI lesions. RESULTS PCS was performed in 73 patients. BA was required in 12 patients. The mean number of microemboli was 114, and most microemboli were generated by stent deployment, followed by BA. Balloon techniques generated significantly more emboli than primary stenting (p = 0.017). There was a significant relationship between total microemboli and new DWI lesions (p = 0.009), and between new DWI lesions in multiple territories and the severity of pretreatment stenosis (p = 0.002). CONCLUSIONS During PCS, more emboli are generated by stent deployment than during any other stage of the procedure. When BA is necessary, more malignant emboli are generated but total emboli are unchanged and there is no difference in new diffusion lesions on MRI. PCS is safe and is not inferior to historical controls for the generation of new DWI lesions.
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Affiliation(s)
- David M Pelz
- Departments of Medical Imaging and Clinical Neurological Sciences, Schulich School of Medicine and Dentistry, Western University, London, ON, Canada
| | - Stephen P Lownie
- Departments of Medical Imaging and Clinical Neurological Sciences, Schulich School of Medicine and Dentistry, Western University, London, ON, Canada
- Division of Neurosurgery, Dalhousie University, Halifax, NS, Canada
| | - Urooj F Iftikhar
- Schulich School of Medicine and Dentistry, Western University, London, ON, Canada
| | - Claudio Munoz
- Robarts Research Institute, Schulich School of Medicine and Dentistry, Western University, London, ON, Canada
| | | | - Reza Azarpazhooh
- Department of Clinical Neurological Sciences, Schulich School of Medicine and Surgery, Western University, London, ON, Canada
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Ahmet Y, Murat Y. Evaluation of the association between silent ischemic lesions and stent design in carotid stenting applications. REVISTA DA ASSOCIACAO MEDICA BRASILEIRA (1992) 2023; 69:e20221437. [PMID: 37222323 DOI: 10.1590/1806-9282.20221437] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/10/2023] [Accepted: 02/23/2023] [Indexed: 05/25/2023]
Abstract
OBJECTIVE Minor ischemic events and silent ischemic lesions are more common in carotid stenting than in endarterectomy. These silent ischemic lesions are also associated with stroke risk and cognitive impairment, so it is important to understand the factors that increase the risk and develop strategies to reduce the risk. We aimed to evaluate the association between carotid stent design and silent ischemic lesion development. METHODS The files of the patients who underwent carotid stenting between January 2020 and April 2022 were scanned. Patients with diffusion MR images taken within the postoperative 24 h were included in the study, while those undergoing acute stent placement were excluded. The patients were divided into two groups: those with open-cell stents and those with closed-cell stents. RESULTS A total of 65 patients, including 39 patients undergoing open-cell stenting and 26 patients undergoing closed-cell stenting, were included in the study. There was no significant difference in demographic data and vascular risk factors between the groups. New ischemic lesions were detected in 29 (74.4%) patients in the open-cell stent group and 10 (38.4%) patients in the closed-cell stent group and were significantly higher in the open-cell group. There was no significant difference between the two groups in terms of major and minor ischemic events and stent restenosis at the 3-month follow-up. CONCLUSION The rate of new ischemic lesion development was found to be significantly higher in carotid stent procedures performed with an open-cell Protégé stent than in those performed with a closed-cell Wallstent stent.
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Affiliation(s)
- Yabalak Ahmet
- Düzce Üniversitesi, Faculty of Medicine, Department of Neurology - Düzce, Turkey
| | - Yılmaz Murat
- Bolu Abant İzzet Baysal Üniversitesi, Faculty of Medicine, Department of Neurology - Bolu, Turkey
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9
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Naylor R, Rantner B, Ancetti S, de Borst GJ, De Carlo M, Halliday A, Kakkos SK, Markus HS, McCabe DJH, Sillesen H, van den Berg JC, Vega de Ceniga M, Venermo MA, Vermassen FEG, Esvs Guidelines Committee, Antoniou GA, Bastos Goncalves F, Bjorck M, Chakfe N, Coscas R, Dias NV, Dick F, Hinchliffe RJ, Kolh P, Koncar IB, Lindholt JS, Mees BME, Resch TA, Trimarchi S, Tulamo R, Twine CP, Wanhainen A, Document Reviewers, Bellmunt-Montoya S, Bulbulia R, Darling RC, Eckstein HH, Giannoukas A, Koelemay MJW, Lindström D, Schermerhorn M, Stone DH. Editor's Choice - European Society for Vascular Surgery (ESVS) 2023 Clinical Practice Guidelines on the Management of Atherosclerotic Carotid and Vertebral Artery Disease. Eur J Vasc Endovasc Surg 2023; 65:7-111. [PMID: 35598721 DOI: 10.1016/j.ejvs.2022.04.011] [Citation(s) in RCA: 218] [Impact Index Per Article: 218.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2022] [Accepted: 04/20/2022] [Indexed: 01/17/2023]
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10
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Teng L, Zhang Y, Fang J, Qu C, Li J, Shen C. Impact of residual stenosis on clinical outcomes when performing carotid artery stenting without postdilation. J Vasc Surg 2023; 77:182-190. [PMID: 35931400 DOI: 10.1016/j.jvs.2022.07.021] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2022] [Revised: 07/03/2022] [Accepted: 07/17/2022] [Indexed: 02/03/2023]
Abstract
OBJECTIVE Many centers consider postdilation if the final angiography after carotid artery stenting (CAS) shows residual stenosis of >30% to 40%. Postdilation has been demonstrated to potentially increase the risk of developing neurologic events. This study aimed to investigate the safety of CAS without postdilation regardless of the degree of residual stenosis. METHODS We retrospectively investigated 191 patients who underwent transfemoral CAS without postdilation intendedly. All cases underwent mild predilation and self-expanding stent implantation. We divided the patients into a residual stenosis of ≥40% group (n = 69 [36.1%]) and a residual stenosis of <40% group (n = 122 [63.9%]) according to their final angiography. We compared the procedural (within 30 days after CAS) and nonprocedural (afterward) adverse cardiovascular events and in-stent restenosis between the two groups. We also investigated the incidence of perioperative hemodynamic depression between the groups and the changes in residual stenosis over the follow-up time. RESULTS Patients in the residual stenosis of ≥40% group had a higher preoperative stenosis rate and a greater proportion of severely calcified lesions than those in the <40% group. There was one procedural cardiac death (0.5%), five strokes (2.6%), and four myocardial infarctions (2.1%). A total of 2.9% had stroke or death procedurally in the residual stenosis of ≥40% group and 3.2% in the residual stenosis of <40% group (P > .950). The median nonprocedural follow-up time was 22 months, with a total of six deaths and four strokes. The cumulative 2-year death or stroke rate was 6.2%, with 5.9% in the residual stenosis of ≥40% group versus 6.7% in the residual stenosis of <40% group (P = .507). There were two cases of in-stent restenosis in the residual stenosis of ≥40% group and three in the residual stenosis of <40% group (P = .927). The difference in the peak systolic velocity of the target lesion between groups at 3 months after CAS was no longer present, and residual stenosis stabilized at 10% to 20% at 6 months in both groups. The patients showed an association between increasing hemodynamic depression incidence and residual stenosis in a significantly graded response (P = .021). CONCLUSIONS Residual stenosis after carotid stenting without postdilation is not associated with a risk of postoperative adverse events. This study provides evidence for the feasibility of a no postdilation strategy for CAS.
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Affiliation(s)
- Lequn Teng
- National Center for Cardiovascular Disease, Chinese Academy of Medical Sciences, Fuwai Hospital, Beijing, China
| | - Yongbao Zhang
- National Center for Cardiovascular Disease, Chinese Academy of Medical Sciences, Fuwai Hospital, Beijing, China
| | - Jie Fang
- National Center for Cardiovascular Disease, Chinese Academy of Medical Sciences, Fuwai Hospital, Beijing, China
| | - Chengjia Qu
- National Center for Cardiovascular Disease, Chinese Academy of Medical Sciences, Fuwai Hospital, Beijing, China
| | - Jialiang Li
- National Center for Cardiovascular Disease, Chinese Academy of Medical Sciences, Fuwai Hospital, Beijing, China
| | - Chenyang Shen
- National Center for Cardiovascular Disease, Chinese Academy of Medical Sciences, Fuwai Hospital, Beijing, China.
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Hajiyev K, Hellstern V, Cimpoca A, Wendl C, Bäzner H, Henkes H, von Gottberg P. Carotid Artery Stenting in Patients with Symptomatic and Asymptomatic Stenosis: In-Hospital Clinical Outcomes at a Single Neurovascular Center. J Clin Med 2022; 11:jcm11082086. [PMID: 35456179 PMCID: PMC9031352 DOI: 10.3390/jcm11082086] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2022] [Revised: 03/18/2022] [Accepted: 04/05/2022] [Indexed: 02/05/2023] Open
Abstract
Background: Carotid artery stenting (CAS) is a minimally invasive and proven percutaneous procedure that is widely used to treat patients with symptomatic and asymptomatic carotid artery stenosis. The purpose of this study was to characterize the in-hospital outcomes of symptomatic and asymptomatic patients undergoing CAS at a single neurovascular center. Methods: The study was conducted as a retrospective analysis of 1158 patients (asymptomatic, n = 636; symptomatic, n = 522; male, n = 816; median age, 71 years; NASCET method, 70–99% stenosis, n = 830) who underwent CAS between May 2009 and December 2020. In-hospital neurological outcomes, adverse reactions to iodinated contrast media, acute myocardial infarction, intraprocedural complications, and access-site issues were evaluated. The primary endpoints were disabling stroke (including disabling cerebral hyperperfusion syndrome [CHS]) and all in-hospital deaths. Results: A carotid stent could not be deployed in one patient due to calcified plaques (technical failure rate of 0.09%). Four patients (0.3%) experienced in-hospital, stroke-associated death, while five patients (0.4%) died from non-stroke-related causes. All stroke-associated deaths occurred in the symptomatic group and were due to CHS. The disabling stroke rate was 0.9% overall (n = 10; 0.5% versus 1.3% in asymptomatic versus symptomatic patients, respectively). Nineteen patients (1.6%) reached the in-hospital primary endpoint. More patients in the symptomatic group achieved this endpoint than in the asymptomatic group (2.5% versus 0.9%, respectively; p = 0.060). Conclusions: An evaluation was conducted on the in-hospital outcomes of 1158 patients at a single center who underwent CAS and was performed by trained physicians who were supervised by a senior neurovascular interventionist with over 20 years of experience, confirming the excellent safety profile of this procedure with a low rate of complications.
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Affiliation(s)
- Kamran Hajiyev
- Neuroradiologische Klinik, Klinikum Stuttgart, D-70174 Stuttgart, Germany; (V.H.); (A.C.); (H.H.); (P.v.G.)
- Correspondence:
| | - Victoria Hellstern
- Neuroradiologische Klinik, Klinikum Stuttgart, D-70174 Stuttgart, Germany; (V.H.); (A.C.); (H.H.); (P.v.G.)
| | - Alexandru Cimpoca
- Neuroradiologische Klinik, Klinikum Stuttgart, D-70174 Stuttgart, Germany; (V.H.); (A.C.); (H.H.); (P.v.G.)
| | - Christina Wendl
- Institut für Röntgendiagnostik, Zentrum für Neuroradiologie, Fakultät für Medizin, Universität Regensburg, D-93053 Regensburg, Germany;
| | - Hansjörg Bäzner
- Neurologische Klinik, Klinikum Stuttgart, D-70174 Stuttgart, Germany;
| | - Hans Henkes
- Neuroradiologische Klinik, Klinikum Stuttgart, D-70174 Stuttgart, Germany; (V.H.); (A.C.); (H.H.); (P.v.G.)
- Medizinische Fakultät, University Duisburg-Essen, D-47057 Duisburg, Germany
| | - Philipp von Gottberg
- Neuroradiologische Klinik, Klinikum Stuttgart, D-70174 Stuttgart, Germany; (V.H.); (A.C.); (H.H.); (P.v.G.)
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12
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Balloon Dilation Strategy Does Not Affect Outcomes for Transcarotid Artery Revascularization (TCAR) in Prospective Trials. J Vasc Surg 2022; 76:202-208. [PMID: 35149162 DOI: 10.1016/j.jvs.2022.01.124] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2021] [Accepted: 01/21/2022] [Indexed: 11/21/2022]
Abstract
OBJECTIVES Strategies of balloon dilation during trans-femoral carotid artery stenting (TFCAS) include pre-stent dilation only (PRE), post-stent dilation only (POST), or both pre- and post- dilation (PRE+POST). Concerns over higher neurological risk have been raised with POST and PRE+POST during TFCAS. Whether these concerns are applicable to Transcarotid Artery Revascularization (TCAR) which utilizes proximal clamping and cerebral blood flow reversal during stent deployment and balloon angioplasty remains unknown. Our aim is to analyze outcomes of PRE, POST or PRE+POST balloon dilation strategies during TCAR. METHODS We analyzed the prospectively collected data from the ROADSTER1 (pivotal), ROADSTER2 (FDA indicated post-market), and Roadster Extended Access TCAR trials. All trial patients had high risk anatomic or clinical factors for carotid endarterectomy and were included unless they did not undergo stent deployment nor balloon dilation. For trial inclusion, asymptomatic patients had >80% carotid stenosis, and symptomatic patients had >50% stenosis. Primary outcome measures were stroke, death, and myocardial infarction (MI) at 30 days. Data were statistically analyzed with chi-square, ANOVA, and multivariable analysis as appropriate. RESULTS There were 851 patients (566 male) who underwent dilation by PRE (N=216), POST (N=249), or PRE+POST (N=386). Patients had carotid stenosis >70% (N=828, 97%), and 207 (24%) were symptomatic. Flow reversal times were longer in the PRE+POST group (PRE 10.2mins, POST 9.8mins, PRE+ POST 13.3mins, P<.001). The 30-day stroke rate for the whole cohort was 1.9%, mortality was 0.5%, and MI rate was 0.94%. Stroke rates for the PRE cohort (1.9%), POST cohort (2.0%), and PRE+POST cohort (1.8%, P=.98) were similar. Also, death rates at 30 days, and composite stroke/death/myocardial infarction rates were similar in the three cohorts. No significant differences in adverse outcomes were noted among the various dilation strategies for both symptomatic and asymptomatic patients. CONCLUSION Based on these prospective trial data, there is no difference in neurological complications due to balloon dilation strategy during TCAR. Balloon dilation technique best suited to the patient's specific lesion morphology should be utilized. Further studies are needed to evaluate the relationship of these dilation strategies to long term outcomes including stent patency, restenosis and reintervention.
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AbuRahma AF, Avgerinos ED, Chang RW, Darling RC, Duncan AA, Forbes TL, Malas MB, Perler BA, Powell RJ, Rockman CB, Zhou W. The Society for Vascular Surgery implementation document for management of extracranial cerebrovascular disease. J Vasc Surg 2021; 75:26S-98S. [PMID: 34153349 DOI: 10.1016/j.jvs.2021.04.074] [Citation(s) in RCA: 61] [Impact Index Per Article: 20.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2021] [Accepted: 04/28/2021] [Indexed: 12/24/2022]
Affiliation(s)
- Ali F AbuRahma
- Department of Surgery, West Virginia University-Charleston Division, Charleston, WV.
| | - Efthymios D Avgerinos
- Division of Vascular Surgery, University of Pittsburgh School of Medicine, UPMC Hearrt & Vascular Institute, Pittsburgh, Pa
| | - Robert W Chang
- Vascular Surgery, Permanente Medical Group, San Francisco, Calif
| | | | - Audra A Duncan
- Division of Vascular & Endovascular Surgery, University of Western Ontario, London, Ontario, Canada
| | - Thomas L Forbes
- Division of Vascular & Endovascular Surgery, University of Western Ontario, London, Ontario, Canada
| | - Mahmoud B Malas
- Vascular & Endovascular Surgery, University of California San Diego, La Jolla, Calif
| | - Bruce Alan Perler
- Division of Vascular Surgery & Endovascular Therapy, Johns Hopkins, Baltimore, Md
| | | | - Caron B Rockman
- Division of Vascular Surgery, New York University Langone, New York, NY
| | - Wei Zhou
- Division of Vascular Surgery, University of Arizona, Tucson, Ariz
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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.
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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.
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