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Abdelkarim A, Hamouda M, Malas MB. What Is the Best Technique for Treating Carotid Disease? Adv Surg 2024; 58:161-189. [PMID: 39089775 DOI: 10.1016/j.yasu.2024.04.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/04/2024]
Abstract
This is a comprehensive review of carotid artery revascularization techniques: Carotid Endarterectomy (CEA), Transfemoral Carotid Artery Stenting (TFCAS), and Transcarotid Artery Revascularization (TCAR). CEA is the gold standard and is particularly effective in elderly and high-risk patients. TFCAS, introduced as a less invasive alternative, poses increased periprocedural stroke risks. TCAR, which combines minimally invasive benefits with CEA's neuroprotection principles, emerges as a safer option for high-risk patients, showing comparable results to CEA and better outcomes than TFCAS. The decision-making process for carotid revascularization is complex and influenced by the patient's medical comorbidities and anatomic factors.
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Affiliation(s)
- Ahmed Abdelkarim
- Department of Surgery, Division of Vascular and Endovascular Surgery, UC San Diego, San Diego, CA, USA; Center for Learning and Excellence in Vascular & Endovascular Research (CLEVER), UC San Diego, San Diego, CA, USA; Altman Center for Clinical and Translational Research, 9452 Medical Center Drive - LL2W 502A, La Jolla, CA 92037, USA
| | - Mohammed Hamouda
- Department of Surgery, Division of Vascular and Endovascular Surgery, UC San Diego, San Diego, CA, USA; Center for Learning and Excellence in Vascular & Endovascular Research (CLEVER), UC San Diego, San Diego, CA, USA; Altman Center for Clinical and Translational Research, 9452 Medical Center Drive - LL2W 502A, La Jolla, CA 92037, USA
| | - Mahmoud B Malas
- Department of Surgery, Division of Vascular and Endovascular Surgery, UC San Diego, San Diego, CA, USA; Center for Learning and Excellence in Vascular & Endovascular Research (CLEVER), UC San Diego, San Diego, CA, USA; Altman Center for Clinical and Translational Research, 9452 Medical Center Drive - LL2W 502A, La Jolla, CA 92037, USA.
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Elizaga N, Ghosh R, Saldana-Ruiz N, Schermerhorn M, Soden P, Dansey K, Zettervall SL. Carotid endarterectomy and transcarotid artery revascularization can be performed with acceptable morbidity and mortality in patients with chronic kidney disease. J Vasc Surg 2024; 80:431-440. [PMID: 38649102 DOI: 10.1016/j.jvs.2024.04.045] [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: 12/19/2023] [Revised: 04/07/2024] [Accepted: 04/12/2024] [Indexed: 04/25/2024]
Abstract
OBJECTIVE Patients with chronic kidney disease (CKD) are considered a high-risk population, and the optimal approach to the treatment of carotid disease remains unclear. Thus, we compared outcomes following carotid revascularization for patients with CKD by operative approach of carotid endarterectomy (CEA), transfemoral carotid artery stenting (TFCAS), and transcarotid arterial revascularization (TCAR). METHODS The Vascular Quality Initiative was analyzed for patients undergoing carotid revascularizations (CEA, TFCAS, and TCAR) from 2016 to 2021. Patients with normal renal function (estimated glomular filtration rate >90 mL/min/1.72 m2) were excluded. Asymptomatic and symptomatic carotid stenosis were assessed separately. Preoperative demographics, operative details, and outcomes of 30-day mortality, stroke, myocardial infarction (MI), and composite variable of stroke/death were compared. Multivariable analysis adjusted for differences in groups, including CKD stage. RESULTS A total of 90,343 patients with CKD underwent revascularization (CEA, n = 66,870; TCAR, n = 13,459; and TFCAS, n = 10,014; asymptomatic, 63%; symptomatic, 37%). Composite 30-day mortality/stroke rates were: asymptomatic: CEA, 1.4%; TCAR, 1.2%; TFCAS, 1.8%; and symptomatic: CEA, 2.7%; TCAR, 2.3%; TFCAS, 3.7%. In adjusted analysis, TCAR had lower 30-day mortality compared with CEA (asymptomatic: adjusted odds ratio [aOR], 0.4; 95% confidence interval [CI], 0.3-0.7; symptomatic: aOR, 0.5; 95% CI, 0.3-0.7), and no difference in stroke, MI, or the composite outcome of stroke/death in both symptom cohorts. TCAR had lower risk of other cardiac complications compared with CEA in asymptomatic patients (aOR, 0.7; 95% CI, 0.6-0.9) and had similar risk in symptomatic patients. Compared with TFCAS, TCAR patients had lower 30-day mortality (asymptomatic: aOR, 0.5; 95% CI, 0.2-0.95; symptomatic: aOR, 0.3; 95% CI, 0.2-0.4), stroke (symptomatic: aOR, 0.7; 95% CI, 0.5-0.97), and stroke/death (asymptomatic: aOR, 0.7; 95% CI, 0.5-0.97; symptomatic: aOR, 0.6; 95% CI, 0.4-0.7), but no differences in MI or other cardiac complications. Patients treated with TFCAS had higher 30-day mortality (aOR, 1.8; 95% CI, 1.2-2.5) and stroke risk (aOR, 1.3; 95% CI, 1.02-1.7) in symptomatic patients compared with CEA. There were no differences in MI or other cardiac complications. CONCLUSIONS Among patients with CKD, TCAR and CEA showed rates of stroke/death less than 2% for asymptomatic patients and less than 3% for symptomatic patients. Given the increased risk of major morbidity and mortality, TFCAS should not be performed in patients with CKD who are otherwise anatomic candidates for TCAR or CEA.
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Affiliation(s)
- Norma Elizaga
- Division of Vascular Surgery, University of Washington, Seattle, WA
| | - Rahul Ghosh
- Texas A&M University School of Medicine, College Station, TX
| | | | - Marc Schermerhorn
- Department of Vascular and Endovascular Surgery, Beth Israel Deaconess Medical Center, Boston, MA
| | - Peter Soden
- Division of Vascular Surgery, Brown University, Providence, RI
| | - Kirsten Dansey
- Division of Vascular Surgery, University of Washington, Seattle, WA
| | - Sara L Zettervall
- Division of Vascular Surgery, University of Washington, Seattle, WA.
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Patel RJ, Dodo-Williams TS, Sendek G, Elsayed N, Malas MB. Non-White Patients Have a Higher Risk of Stroke Following Transcarotid Artery Revascularization. J Surg Res 2024; 300:71-78. [PMID: 38796903 DOI: 10.1016/j.jss.2024.04.062] [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: 03/13/2023] [Revised: 01/28/2024] [Accepted: 04/14/2024] [Indexed: 05/29/2024]
Abstract
INTRODUCTION Carotid artery revascularization has traditionally been performed by either a carotid endarterectomy or carotid artery stent. Large data analysis has suggested there are differences in perioperative outcomes with regards to race, with non-White patients (NWP) having worse outcomes of stroke, restenosis and return to the operating room (RTOR). The introduction of transcarotid artery revascularization (TCAR) has started to shift the paradigm of carotid disease treatment. However, to date, there have been no studies assessing the difference in postoperative outcomes after TCAR between racial groups. METHODS All patients from 2016 to 2021 in the Vascular Quality Initiative who underwent TCAR were included in our analysis. Patients were split into two groups based on race: individuals who identified as White and a second group that comprised all other races. Demographic and clinical variables were compared using Student's t-Test and chi-square test of independence. Logistic regression analysis was performed to determine the impact of race on perioperative outcomes of stroke, myocardial infarction (MI), death, restenosis, RTOR, and transient ischemic attack (TIA). RESULTS The cohort consisted of 22,609 patients: 20,424 (90.3%) White patients and 2185 (9.7%) NWP. After adjusting for sex, diabetes, hypertension, coronary artery disease, history of prior stroke or TIA, symptomatic status, and high-risk criteria at time of TCAR, there was a significant difference in postoperative stroke, with 63% increased risk in NWP (odds ratio = 1.63, 95% confidence interval: 1.11-2.40, P = 0.014). However, we found no significant difference in the odds of MI, death, postoperative TIA, restenosis, or RTOR when comparing NWP to White patients. CONCLUSIONS This study demonstrates that NWP have increased risk of stroke but similar outcomes of death, MI, RTOR and restenosis following TCAR. Future studies are needed to elucidate and address the underlying causes of racial disparity in carotid revascularization.
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Affiliation(s)
- Rohini J Patel
- Center for Learning and Excellence in Vascular & Endovascular Research (CLEVER), Division of Vascular and Endovascular Surgery, Department of Surgery, University of California San Diego, San Diego, California
| | - Taiwo S Dodo-Williams
- Center for Learning and Excellence in Vascular & Endovascular Research (CLEVER), Division of Vascular and Endovascular Surgery, Department of Surgery, University of California San Diego, San Diego, California
| | - Gabriela Sendek
- Center for Learning and Excellence in Vascular & Endovascular Research (CLEVER), Division of Vascular and Endovascular Surgery, Department of Surgery, University of California San Diego, San Diego, California
| | - Nadin Elsayed
- Center for Learning and Excellence in Vascular & Endovascular Research (CLEVER), Division of Vascular and Endovascular Surgery, Department of Surgery, University of California San Diego, San Diego, California
| | - Mahmoud B Malas
- Center for Learning and Excellence in Vascular & Endovascular Research (CLEVER), Division of Vascular and Endovascular Surgery, Department of Surgery, University of California San Diego, San Diego, California.
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El-Hajj VG, Ghaith AK, Gharios M, El Naamani K, Atallah E, Glener S, Habashy KJ, Hoang H, Sizdahkhani S, Mouchtouris N, Kaul A, Elmi-Terander A, Tjoumakaris S, Gooch MR, Rosenwasser RH, Jabbour P. General Versus Nongeneral Anesthesia for Carotid Endarterectomy: A Prospective Multicenter Registry-Based Study on 25 000 Patients. Neurosurgery 2024; 95:365-371. [PMID: 38391204 DOI: 10.1227/neu.0000000000002887] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2023] [Accepted: 01/05/2024] [Indexed: 02/24/2024] Open
Abstract
BACKGROUND AND OBJECTIVES Carotid endarterectomy (CEA) is a well-established treatment option for carotid stenosis. The choice between general anesthesia (GA) and nongeneral anesthesia (non-GA) during CEA remains a subject of debate, with concerns regarding perioperative complications, particularly myocardial infarctions. This study aimed to evaluate the outcomes associated with GA vs non-GA CEA using a large, nationwide database. METHODS The National Surgical Quality Improvement Project database was queried for patients undergoing CEA between 2013 and 2020. Primary outcome measures including surgical outcomes and 30-day postoperative complications were compared between the 2 anesthesia methods, after 2:1 propensity score matching. RESULTS After propensity score matching, a total of 25 356 patients (16 904 in the GA and 8452 in the non-GA group) were included. Non-GA compared with GA CEA was associated with significantly shorter operative times (101.9, 95% CI: 100.5-103.3 vs 115.8 95% CI: 114.4-117.2 minutes, P < .001), reduced length of hospital stays (2.3, 95% CI: 2.15-2.4 vs 2.5, 95% CI: 2.4-2.6 days, P < .001), and lower rates of 30-day postoperative complications, including myocardial infarctions (0.8% vs 1.2%, P = .003), unplanned intubations (0.8% vs 1.1%, P = .016), pneumonia (0.5% vs 1%, P < .001), and urinary tract infections (0.4% vs 0.7%, P = .003). These outcomes were notably more pronounced in the younger (≤70 years) and high morbidity (American Society of Anesthesiologists 3-5) cohorts. CONCLUSION In this nationwide registry-based study, non-GA CEA was associated with better short-term outcomes in terms of perioperative complications, compared with GA CEA. The findings suggest that non-GA CEA may be a safer alternative, especially in younger patients and those with more comorbidities.
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Affiliation(s)
| | - Abdul Karim Ghaith
- Department of Neurological Surgery, Mayo Clinic, Rochester , Minnesota , USA
| | - Maria Gharios
- Department of Clinical Neuroscience, Karolinska Institutet, Stockholm , Sweden
| | - Kareem El Naamani
- Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia , Pennsylvania , USA
| | - Elias Atallah
- Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia , Pennsylvania , USA
| | - Steven Glener
- Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia , Pennsylvania , USA
| | - Karl John Habashy
- Feinberg School of Medicine, Northwestern University, Chicago , Illinois , USA
| | - Harry Hoang
- Department of Neurological Surgery, Mayo Clinic, Rochester , Minnesota , USA
| | - Saman Sizdahkhani
- Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia , Pennsylvania , USA
| | - Nikolaos Mouchtouris
- Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia , Pennsylvania , USA
| | - Anand Kaul
- Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia , Pennsylvania , USA
| | | | - Stavropoula Tjoumakaris
- Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia , Pennsylvania , USA
| | - M Reid Gooch
- Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia , Pennsylvania , USA
| | - Robert H Rosenwasser
- Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia , Pennsylvania , USA
| | - Pascal Jabbour
- Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia , Pennsylvania , USA
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Ciaramella MA, Liang P, Hamdan AD, Wyers MC, Schermerhorn ML, Stangenberg L. Bailout Distal Internal Carotid Artery Stenting after Carotid Endarterectomy: Indications, Technique, and Outcomes. Ann Vasc Surg 2024; 105:218-226. [PMID: 38599489 DOI: 10.1016/j.avsg.2024.02.025] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2023] [Revised: 02/11/2024] [Accepted: 02/20/2024] [Indexed: 04/12/2024]
Abstract
BACKGROUND Distal internal carotid artery (ICA) stenting may be employed as a bailout maneuver when an inadequate end point or clamp injury is encountered at the time of carotid endarterectomy (CEA) in a surgically inaccessible region of the distal ICA. We sought to characterize the indications, technique, and outcomes for this infrequently encountered clinical scenario. METHODS We performed a retrospective review of all patients who underwent distal ICA stenting at the time of CEA at our institution between September 2008 and July 2022. Procedural details and postoperative follow-up were reviewed for each patient. RESULTS Six patients were identified during the study period. All were male with an age range of 63 to 82 years. Five underwent carotid revascularization for asymptomatic carotid artery stenosis, and one patient was treated for amaurosis fugax. Three patients were on dual antiplatelet therapy preoperatively, whereas 2 were on aspirin monotherapy, and one was on aspirin and low-dose rivaroxaban. Five patients underwent CEA with patch angioplasty, and one underwent eversion CEA. The indication for stenting was distal ICA dissection due to clamp or shunt injury in 2 patients and an inadequate distal ICA end point in 4 patients. In all cases, access for stenting was obtained under direct visualization within the common carotid artery, and a standard carotid stent was deployed with its proximal aspect landing within the endarterectomized site. Embolic protection was typically achieved via proximal common carotid artery and external carotid artery clamping for flow arrest with aspiration of debris before restoration of antegrade flow. There was 100% technical success. Postoperatively, 2 patients were found to have a cranial nerve injury, likely occurring due to the need for high ICA exposure. Median length of stay was 2 days (range 1-7 days) with no instances of perioperative stroke or myocardial infarction. All patients were discharged on dual antiplatelet therapy with no further occurrence of stroke, carotid restenosis, or reintervention through a median follow-up of 17 months. CONCLUSIONS Distal ICA stenting is a useful adjunct in the setting of CEA complicated by inadequate end point or vessel dissection in a surgically inaccessible region of the ICA and can minimize the need for high-risk extensive distal dissection of the ICA in this situation.
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Affiliation(s)
- Michael A Ciaramella
- Department of Surgery, Division of Vascular and Endovascular Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA
| | - Patric Liang
- Department of Surgery, Division of Vascular and Endovascular Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA
| | - Allen D Hamdan
- Department of Surgery, Division of Vascular and Endovascular Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA
| | - Mark C Wyers
- Department of Surgery, Division of Vascular and Endovascular Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA
| | - Marc L Schermerhorn
- Department of Surgery, Division of Vascular and Endovascular Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA
| | - Lars Stangenberg
- Department of Surgery, Division of Vascular and Endovascular Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA.
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Sterpetti AV, Gabriele R, Dimarzo L. Asymptomatic Carotid Stenosis. Ann Vasc Surg 2024; 104:255-257. [PMID: 38599482 DOI: 10.1016/j.avsg.2024.02.019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2024] [Accepted: 02/28/2024] [Indexed: 04/12/2024]
Affiliation(s)
| | | | - Luca Dimarzo
- Department of Vascular Surgery, Sapienza University; Rome, Italy
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Paraskevas KI, Malas MB, Schermerhorn ML. Transcarotid Artery Revascularization Versus Carotid Endarterectomy. Angiology 2024:33197241261453. [PMID: 38864386 DOI: 10.1177/00033197241261453] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/13/2024]
Affiliation(s)
| | - Mahmoud B Malas
- Center for Learning and Excellence in Vascular and Endovascular Research (CLEVER), Department of Surgery, Division of Vascular Surgery, University of California San Diego, San Diego, CA, USA
| | - Marc L Schermerhorn
- Department of Surgery, Division of Vascular and Endovascular Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
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Paraskevas KI, AbuRahma AF. A comparison of the 2022 Society for Vascular Surgery and the 2023 European Society for Vascular Surgery guidelines for the management of patients with asymptomatic and symptomatic carotid stenosis. J Vasc Surg 2024; 79:1272-1275. [PMID: 38310980 DOI: 10.1016/j.jvs.2024.01.210] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2023] [Revised: 01/20/2024] [Accepted: 01/28/2024] [Indexed: 02/06/2024]
Affiliation(s)
| | - Ali F AbuRahma
- Department of Surgery, Charleston Area Medical Center/West Virginia University, Charleston, WV
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Yuksel A, Velioglu Y, Korkmaz UTK, Deser SB, Topal D, Badem S, Taner T, Ucaroglu ER, Kahraman N, Demir D. Systemic immune-inflammation index for predicting poor outcome after carotid endarterectomy: A novel hematological marker. Vascular 2024; 32:565-572. [PMID: 36441077 DOI: 10.1177/17085381221141476] [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: 02/17/2024]
Abstract
OBJECTIVE To investigate the predictive role of systemic immune-inflammation index (SII) on postoperative poor outcome in patients undergoing carotid endarterectomy (CEA). METHODS A total of 347 patients undergoing elective isolated CEA between March 2010 and April 2022 were included in this multicenter retrospective observational cohort and risk-prediction study and were divided into two groups as poor outcome group (n = 23) and favorable outcome group (n = 324). Poor outcome was defined as the presence of at least one of the complications within 30 days of surgery including stroke, myocardial infarction, and death. The patients' baseline clinical characteristics, comorbidities, and hematological indices were derived from the complete blood count (CBC) analysis, and perioperative data, outcomes, and complications were screened, recorded, and then compared between the groups. Multivariate logistic regression and receiver-operating characteristic (ROC) curve analyses were conducted following univariate analyses to detect the independent predictors of poor outcome as well as the cutoff values with sensitivity and specificity rates. RESULTS A total of 23 patients out of 347 (6.6%) manifested poor outcome; and stroke, myocardial infarction, and death occurred in 13, 3, and 7 cases, respectively. There were no significant differences between the groups in terms of basic clinical characteristics, comorbidities, and perioperative data, except for lengths of intensive care unit and hospital stays. Although the median values of PLT, PLR, NLR, and SII of the poor outcome group were found to be significantly higher than the favorable outcome group in univariate analysis, only SII was detected to be a significant and independent predictor of poor outcome in multivariate logistic regression analysis (OR = 1.0008; 95% CI: 1.0004-1.0012; p = 0.002). ROC curve analysis revealed that SII of 1356 × 103/mm3 constituted the cutoff value for predicting poor outcome with 78.3% sensitivity and 64.5% specificity (AUC = 0.746; 95% CI: 0.64-0.851). CONCLUSIONS Our study revealed for the first time in the literature that SII significantly predicted poor outcome after CEA.
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Affiliation(s)
- Ahmet Yuksel
- Department of Cardiovascular Surgery, Bursa City Hospital, Bursa, Turkey
| | - Yusuf Velioglu
- Department of Cardiovascular Surgery, Bursa City Hospital, Bursa, Turkey
| | - Ufuk Turan Kursat Korkmaz
- Department of Cardiovascular Surgery, Bolu Abant Izzet Baysal University, Faculty of Medicine, Bolu, Turkey
| | - Serkan Burc Deser
- Department of Cardiovascular Surgery, Istanbul University-Cerrahpasa, Institute of Cardiology, Istanbul, Turkey
| | - Dursun Topal
- Department of Cardiology, Bursa City Hospital, Bursa, Turkey
| | - Serdar Badem
- Department of Cardiovascular Surgery, Bursa City Hospital, Bursa, Turkey
| | - Temmuz Taner
- Department of Cardiovascular Surgery, Bursa City Hospital, Bursa, Turkey
| | - Erhan Renan Ucaroglu
- Department of Cardiovascular Surgery, Bolu Abant Izzet Baysal University, Faculty of Medicine, Bolu, Turkey
| | - Nail Kahraman
- Department of Cardiovascular Surgery, Bursa City Hospital, Bursa, Turkey
| | - Deniz Demir
- Department of Cardiovascular Surgery, Bursa City Hospital, Bursa, Turkey
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Sterpetti AV, Gabriele R, Borrelli V, Campagnol M, Iannone I, Costi U, Sapienza P, Dimarzo L. Clinical outcomes for patients with cardiovascular diseases before, during, and after the COVID19 pandemic. A pooled analysis of 600.000 patients. Curr Probl Cardiol 2024; 49:102540. [PMID: 38521287 DOI: 10.1016/j.cpcardiol.2024.102540] [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: 03/20/2024] [Accepted: 03/20/2024] [Indexed: 03/25/2024]
Abstract
BACKGROUND The unexpected virulence of the COVID19 pandemic brought to significant changes of generally accepted therapeutic approaches. The consequences of these changes were difficult to define during the pandemic period. METHODS We analyzed the National Registries including 97% of hospital admissions in Italy, regarding data describing number of operations for aortic valve implantation or repair, carotid and coronary revascularization, AAA repair, and lower limb arterial reconstruction performed in the period 2015 to 2019 and in the pandemic years 2020, 2021, and 2022. Primary outcomes were number and type of surgical procedures, 30-days operative mortality. RESULTS During the three years of the pandemic there was a statistically significant increase of the number of all-causes deaths in comparison with the mean of the previous five years (2015-2019). In Italy there was a total increase of all causes-deaths of 251.911 (+105900 in 2020; +66929 in 2021; and +79082 in 2022), and 73% of the excess of deaths was related with COVID19 infection and 27% occurred in COVID 19 negative patients. During the first year of the pandemic, worse clinical outcomes for hospitalized patients with CVD were registered. The medical system responded adequately and in the following two pandemic years clinical outcomes for hospitalized patients were similar with those of the pre-pandemic period. CONCLUSIONS The unexpected virulence of COVID19 pandemic determined worse clinical outcomes for patients with CVD during the first year. The adopted preventive measures allowed in the following two pandemic years improved clinical outcomes, similar with those of the pre-pandemic period.
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Affiliation(s)
| | | | | | | | | | | | | | - Luca Dimarzo
- Department of vascular endovascular surgery, Sapienza university Rome, Italy
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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).
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Affiliation(s)
- Ali AbuRahma
- Department of Surgery, Charleston Area Medical Center/West Virginia University, Charleston, WV.
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12
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Simioni A, Neves PF, Kabeil M, Jacobs D, Matsumura J, Yi J. Surveillance and risk factors for early restenosis following transcarotid artery revascularization. J Vasc Surg 2024; 79:1110-1118. [PMID: 38160989 DOI: 10.1016/j.jvs.2023.12.044] [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: 12/24/2023] [Indexed: 01/03/2024]
Abstract
OBJECTIVE Restenosis after transcarotid artery revascularization (TCAR) is a known complication. When identified in the early postoperative period, it may be related to technique. We evaluated our TCAR experience to identify potentially modifiable factors impacting restenosis. METHODS This is a single-institution, retrospective review of patients undergoing TCAR from November 2017 to July 2022. Restenosis was defined as >50% stenosis on duplex ultrasound (DUS) examination or computed tomographic angiography (CTA). Continuous variables were compared using Kruskal-Wallis's test. Categorical variables were compared using the Fisher's exact test. RESULTS Of 61 interventions, 11 (18%) developed restenosis within the median follow-up of 345 days (interquartile range, 103-623 days). Among these patients, 82% (9/11) had >50% stenosis, and 18% (2/11) had >80% stenosis. Both patients with high-grade restenosis were symptomatic and underwent revascularization. Diagnosis of post-TCAR restenosis was via DUS examination in 45% (5/11), CTA in 18% (2/11), or both CTA/DUS examination in 36% (4/11). Restenosis occurred within 1 month in 54% (6/11) and 6 months in 72% (8/11) of patients. However, three of the six patients with restenosis within 1 month had discordant findings on CTA vs DUS imaging. Patient comorbidities, degree of preoperative stenosis, medical management, balloon size, stent size, lesion characteristics, and predilatation angioplasty did not differ. Patients with restenosis were younger (P = .02), had prior ipsilateral endarterectomy (odds ratio [OR], 6.5; P = .02), had history of neck radiation (OR, 18.3; P = .01), and lower rate of postdilatation angioplasty (OR, 0.11; P = .04), without an increased risk of neurological events. CONCLUSIONS Although post-TCAR restenosis occurred in 18% of patients, only 3% of patients had critical restenosis and required reintervention. Patient factors associated with restenosis were younger age, prior endarterectomy, and history of neck radiation. Although early restenosis may be mitigated by improved technique, the only technical factor associated with restenosis was less use of postdilatation angioplasty. Balancing neurological risk, this factor may have increased application in appropriate patients. Diagnosis of restenosis was inconsistent between imaging modalities; current surveillance paradigms and diagnostic thresholds may warrant reconsideration.
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Affiliation(s)
- Andrea Simioni
- Department of Surgery, University of Colorado School of Medicine, Aurora, CO
| | - Pedro Furtado Neves
- Division of Vascular Surgery, University of Colorado School of Medicine, Aurora, CO
| | - Mahmood Kabeil
- Division of Vascular Surgery, University of Colorado School of Medicine, Aurora, CO
| | - Donald Jacobs
- Division of Vascular Surgery, University of Colorado School of Medicine, Aurora, CO
| | - Jon Matsumura
- Division of Vascular Surgery, University of Colorado School of Medicine, Aurora, CO
| | - Jeniann Yi
- Department of Surgery, University of Colorado School of Medicine, Aurora, CO; Division of Vascular Surgery, University of Colorado School of Medicine, Aurora, CO.
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13
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Zohourian T, Hines G. The Evolution of Current Management for Carotid Artery Bifurcation Disease. Cardiol Rev 2024; 32:257-262. [PMID: 36729106 DOI: 10.1097/crd.0000000000000497] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
Options for treatment of symptomatic carotid bifurcation disease include carotid endarterectomy (CEA) and carotid artery stenting (CAS). While over the years CEA has established itself as the gold standard for carotid artery revascularization, results from recent trials have shown CAS to be safe and effective in selected patients. This review details the evolution of carotid artery bifurcation disease by highlighting key clinical trials.
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Affiliation(s)
- Tirajeh Zohourian
- From the Department of Surgery, New York University Langone Long Island Hospital, Mineola, NY
- Department of Surgery, New York University Long Island School of Medicine, Mineola, NY
| | - George Hines
- From the Department of Surgery, New York University Langone Long Island Hospital, Mineola, NY
- Department of Surgery, New York University Long Island School of Medicine, Mineola, NY
- New York University Langone Vascular Surgery Associates-Mineola, Mineola, NY
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14
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Brandes F, Meidert AS, Kirchner B, Yu M, Gebhardt S, Steinlein OK, Dolch ME, Rantner B, Tsilimparis N, Schelling G, Pfaffl MW, Reithmair M. Identification of microRNA biomarkers simultaneously expressed in circulating extracellular vesicles and atherosclerotic plaques. Front Cardiovasc Med 2024; 11:1307832. [PMID: 38725837 PMCID: PMC11079260 DOI: 10.3389/fcvm.2024.1307832] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2023] [Accepted: 04/08/2024] [Indexed: 05/12/2024] Open
Abstract
Background Atherosclerosis is a widespread disorder of the cardiovascular system. The early detection of plaques by circulating biomarkers is highly clinically relevant to prevent the occurrence of major complications such as stroke or heart attacks. It is known that extracellular vesicles (EVs) are important in intercellular communication in atherosclerotic disorders and carry many components of their cells of origin, including microRNAs (miRNAs). In this study, we test the assumption that miRNAs present in material acquired from plaques in patients undergoing surgery for atherosclerotic carotid artery stenosis are also expressed in circulating EVs obtained from the identical patients. This would allow the adoption of a liquid biopsy approach for the detection of plaques. Methods We studied 22 surgical patients with atherosclerotic carotid arterial stenosis and 28 healthy controls. EVs were isolated from serum by precipitation. miRNA expression profiles of serum-derived EVs were obtained by small RNA sequencing and in plaque material simultaneously acquired from patients. A comparative analysis was performed to identify circulating atherosclerosis-associated miRNAs that are also detectable in plaques. Results Seven miRNAs were found to be differentially regulated in patient serum compared with the serum of healthy controls. Of these, miR-193b-5p, miR-193a-5p, and miR-125a-3p were significantly upregulated in patients compared with that in healthy controls and present in both, circulating EVs and plaque material. An overrepresentation analysis of experimentally validated mRNA targets revealed an increased regulation of inflammation and vascular growth factors, key players in atherosclerosis and plaque formation. Conclusion Our findings suggest that circulating EVs reflect plaque development in patients with symptomatic carotid artery stenosis, which can serve as biomarker candidates for detecting the presence of atherosclerotic plaques.
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Affiliation(s)
- Florian Brandes
- Department of Anesthesiology, LMU University Hospital, LMU Munich, Munich, Germany
| | - Agnes S. Meidert
- Department of Anesthesiology, LMU University Hospital, LMU Munich, Munich, Germany
| | - Benedikt Kirchner
- Division of Animal Physiology and Immunology, School of Life Sciences Weihenstephan, Technical University of Munich, Freising, Germany
| | - Mia Yu
- Division of Animal Physiology and Immunology, School of Life Sciences Weihenstephan, Technical University of Munich, Freising, Germany
| | - Sonja Gebhardt
- Department of Anaesthesiology, InnKlinikum Altötting, Altötting, Germany
| | - Ortrud K. Steinlein
- Institute of Human Genetics, LMU University Hospital, LMU Munich, Munich, Germany
| | - Michael E. Dolch
- Department of Anaesthesiology, InnKlinikum Altötting, Altötting, Germany
| | - Barbara Rantner
- Department of Vascular Surgery, LMU University Hospital, LMU Munich, Munich, Germany
| | - Nikolaos Tsilimparis
- Department of Vascular Surgery, LMU University Hospital, LMU Munich, Munich, Germany
| | - Gustav Schelling
- Department of Anesthesiology, LMU University Hospital, LMU Munich, Munich, Germany
| | - Michael W. Pfaffl
- Division of Animal Physiology and Immunology, School of Life Sciences Weihenstephan, Technical University of Munich, Freising, Germany
| | - Marlene Reithmair
- Institute of Human Genetics, LMU University Hospital, LMU Munich, Munich, Germany
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15
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Cambiaghi T, Mills A, Leonard S, Husman R, Zaidi ST, Koh EY, Keyhani K, Wang SK. Effect of Perioperative Stroke on Survival After Carotid Intervention. Vasc Endovascular Surg 2024; 58:280-286. [PMID: 37852227 PMCID: PMC10880410 DOI: 10.1177/15385744231207015] [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: 10/20/2023]
Abstract
OBJECTIVES Perioperative stroke is the most dreaded complication of carotid artery interventions and can severely affect patients' quality of life. This study evaluated the impact of this event on mortality for patients undergoing interventional treatment of carotid artery stenosis with three different modalities. METHODS Patients undergoing carotid revascularization at participating Memorial Hermann Health System facilities were captured from 2003-2022. These patients were treated with either carotid endarterectomy (CEA), transfemoral carotid stenting (TF-CAS), or transcarotid artery revascularization (TCAR). Perioperative outcomes, including stroke and mortality, as well as follow-up survival data at 6-month intervals, were analyzed and stratified per treatment modality. RESULTS Of the 1681 carotid revascularization patients identified, 992 underwent CEA (59.0%), 524 underwent TCAR (31.2%), and 165 underwent TF-CAS (9.8%). The incidence of stroke was 2.1% (CEA 2.1%, TCAR 1.7%, and TF-CAS 3.6%; P = .326). The perioperative (30-day) death rate was 2.1% (n = 36). The perioperative death rate was higher in patients who suffered from an intraoperative stroke than in those who did not (8.3% vs 1.9%, P = .007). Perioperative death was also different between CEA, TCAR, and TF-CAS for patients who had an intraoperative stroke (.0% vs 33.3% vs .0%, P = .05). TCAR patients were likely to be older (P < .001), have a higher body mass index (P < .001), and have diabetes mellitus (P < .001). Patients who suffered from an intraoperative stroke were more likely to have a symptomatic carotid lesion (58.3% vs 28.8%, P < .001). The TCAR group had a significantly lower survival at 6 months and 12 months when compared to the other two groups (64.9% vs 100% P = .007). CONCLUSION Perioperative stroke during carotid interventions significantly impacts early patient survival with otherwise no apparent change in mid-term outcomes at 5 years. This difference appears to be even more significant in patients undergoing TCAR, possibly due to their baseline higher-risk profile and lower functional reserve.
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Affiliation(s)
- Tommaso Cambiaghi
- Division of Vascular Surgery, Department of Cardiothoracic and Vascular Surgery, McGovern Medical School at UTHealth Houston, Houston, TX, USA
| | - Alexander Mills
- Division of Vascular Surgery, Department of Cardiothoracic and Vascular Surgery, McGovern Medical School at UTHealth Houston, Houston, TX, USA
| | - Samuel Leonard
- Division of Vascular Surgery, Department of Cardiothoracic and Vascular Surgery, McGovern Medical School at UTHealth Houston, Houston, TX, USA
| | - Regina Husman
- Division of Vascular Surgery, Department of Cardiothoracic and Vascular Surgery, McGovern Medical School at UTHealth Houston, Houston, TX, USA
| | - Syed T. Zaidi
- Division of Vascular Surgery, Department of Cardiothoracic and Vascular Surgery, McGovern Medical School at UTHealth Houston, Houston, TX, USA
| | - Ezra Y. Koh
- Division of Vascular Surgery, Department of Cardiothoracic and Vascular Surgery, McGovern Medical School at UTHealth Houston, Houston, TX, USA
| | - Kourosh Keyhani
- Division of Vascular Surgery, Department of Cardiothoracic and Vascular Surgery, McGovern Medical School at UTHealth Houston, Houston, TX, USA
| | - S. Keisin Wang
- Division of Vascular Surgery, Department of Cardiothoracic and Vascular Surgery, McGovern Medical School at UTHealth Houston, Houston, TX, USA
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16
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Sterpetti AV, Di Marzo L, Sapienza P, Gabriele R, Borrelli V. Reduced carotid revascularization and screening for asymptomatc patients during the COVID-19 pandemic in Italy. J Vasc Surg 2024; 79:988-990. [PMID: 38519224 DOI: 10.1016/j.jvs.2023.12.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2023] [Revised: 12/06/2023] [Accepted: 12/06/2023] [Indexed: 03/24/2024]
Affiliation(s)
| | - Luca Di Marzo
- Department of Surgery, Sapienza University, Rome, Italy
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17
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Kolde G, Penton A, Li R, Weise L, Potluri V, Conrad MF, Blecha M. Carotid Endarterectomy With Simultaneous Proximal Common Carotid Endovascular Intervention is Beneficial for Symptomatic Stenosis and Likely Confers No Advantage for Asymptomatic Lesions. Vasc Endovascular Surg 2024; 58:263-279. [PMID: 37846944 DOI: 10.1177/15385744231207014] [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] [Indexed: 10/18/2023]
Abstract
INTRODUCTION Carotid bifurcation stenosis may co-exist simultaneously with more proximal common carotid artery (CCA) atherosclerotic plaquing, primarily at the vessel origin in the aortic arch. This scenario is relatively infrequent and its' management does not have quality randomized data to support medical vs surgical treatment. It is logical to treat any high grade common carotid lesions proximal to a carotid bifurcation endarterectomy (CEA) site both to prevent perioperative emboli or thrombosis as well as future embolization. Prior long-term investigations of the combined treatment paradigm have been low volume analysis. Further, prior studies focus on perioperative outcomes with respect to stroke prevention. The only prior VQI study investigating mid-term outcomes following simultaneous CEA with proximal CCA endovascular therapy provided data on less than 10 patients beyond 1.5 years. The long-term follow-up (LFTU) component initiative within VQI has been emphasized in recent years, now allowing for much more robust LTFU analysis. METHODS Four cohorts were created for perioperative outcome analysis and Kaplan Meier freedom from event analysis: CEA in isolation for asymptomatic disease; CEA in isolation for symptomatic patients; CEA with proximal CCA endovascular intervention for asymptomatic; and, CEA with proximal CCA intervention for symptomatic patients. Binary logistic multivariable regression was performed for perioperative neurological event and 90-day mortality risk determination and Cox multivariable regression analysis was performed for long term freedom from cumulative ischemic neurological event and long-term mortality analysis. Symptomatology and type of surgery (CEA with or without CCA intervention) were individual variables in the multivariable analysis. Neurological ischemic event in this study encompassed transient ischemic attack (TIA) and stroke combined. RESULTS We noted a statistically significant (P < .001) escalation in rates of perioperative neurological event, myocardial infarction (MI), carotid re-exploration, 90 day mortality and combined neurological event and 90 day mortality moving from: A) asymptomatic CEA in isolation to B) symptomatic CEA in isolation to C) asymptomatic CEA combined with proximal CCA intervention to D) symptomatic CEA in combination with proximal CCA intervention. The positivity rate for the combined outcome of perioperative ischemic neurological event and 90 day mortality was 2.2% amongst asymptomatic CEA in isolation, 4.1% amongst symptomatic CEA in isolation, 4.4% amongst asymptomatic CEA in combination with proximal CCA intervention; and 8.8% in patients with symptomatic lesions undergoing combined CEA with proximal CCA intervention. On multivariable analysis patients undergoing CEA with proximal CCA endovascular intervention experienced greater risk for perioperative neurological ischemic event (aOR 2.03, 1.43-2.90, P < .001), combined perioperative neurological ischemic event and 90 day mortality (aOR 2.13, 1.62-2.80, P < .001), long term mortality (HR 1.62, 1.12-2.29, P < .001), and cumulative neurological ischemic event in long term follow up (HR 1.62, 1.12-2.29, P = .007). Amongst 4395 cumulative ischemic neurological events in all study patients, 34% were TIA. CONCLUSIONS Carotid bifurcation endarterectomy in combination with proximal endovascular common carotid artery intervention caries an over two fold higher perioperative risk of neurologic ischemic event and 90 day mortality relative to CEA in isolation for asymptomatic and symptomatic cohorts respectively. After surgery, freedom from cerebral ischemia and mortality for patients undergoing dual intervention is closely aligned with patients undergoing CEA in isolation. Despite high adverse perioperative event rates for the combined CEA and CCA treatment, there is likely long term stroke reduction and mortality benefit to this approach in symptomatic patients based on the event free rates seen herein after initial hospital discharge. The benefit of treating asymptomatic tandem ICA and CCA lesions remains vague but the 4.4% perioperative neurologic event and death rate suggests that these patients would be better managed with medical therapy.
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Affiliation(s)
- Grant Kolde
- Loyola University Chicago Stritch School of Medicine, Maywood, IL, USA
- Loyola University Medical Center, Maywood, IL, USA
| | - Ashley Penton
- Loyola University Chicago Stritch School of Medicine, Maywood, IL, USA
- Loyola University Medical Center, Maywood, IL, USA
| | - Ruojia Li
- Loyola University Chicago Stritch School of Medicine, Maywood, IL, USA
- Loyola University Medical Center, Maywood, IL, USA
| | - Lorela Weise
- Loyola University Chicago Stritch School of Medicine, Maywood, IL, USA
- Loyola University Medical Center, Maywood, IL, USA
| | - Vamsi Potluri
- Loyola University Chicago Stritch School of Medicine, Maywood, IL, USA
- Loyola University Medical Center, Maywood, IL, USA
| | | | - Matthew Blecha
- Loyola University Chicago Stritch School of Medicine, Maywood, IL, USA
- Loyola University Medical Center, Maywood, IL, USA
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18
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Paraskevas KI, Zeebregts CJ, AbuRahma AF, Perler BA. Implications of the Centers for Medicare and Medicaid Services (CMS) decision to expand indications for carotid artery stenting. J Vasc Surg 2024:S0741-5214(24)00425-7. [PMID: 38462061 DOI: 10.1016/j.jvs.2024.03.008] [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: 01/18/2024] [Revised: 02/24/2024] [Accepted: 03/03/2024] [Indexed: 03/12/2024]
Abstract
OBJECTIVE On October 11, 2023, the Centers for Medicare and Medicaid Services (CMS) expanded the indications for carotid artery stenting (CAS) to include patients with ≥50% symptomatic or ≥70% asymptomatic carotid stenosis. The aim of this article was to investigate the implications of this decision. METHODS The reasons behind the increased coverage for CAS are analyzed and discussed, as well as the various Societies supporting or opposing the expansion of indications for CAS. RESULTS The benefits associated with expanding CAS indications include providing an additional therapeutic option to patients and enabling individualization of treatment according to patient-specific characteristics. The drawbacks of expanding CAS indications include a possible bias in decision-making and an increase in inappropriate CAS procedures. CONCLUSIONS The purpose of the CMS recommendation to expand indications for CAS is to improve the available therapeutic options for patients. Hopefully this decision will not be misinterpreted and will be used to improve patient options and patient outcomes.
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Affiliation(s)
| | - Clark J Zeebregts
- Department of Surgery (Division of Vascular Surgery), University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Ali F AbuRahma
- Department of Surgery, Charleston Area Medical Center/West Virginia University, Charleston, WV
| | - Bruce A Perler
- Department of Surgery, The Johns Hopkins Hospital, Baltimore, MD
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19
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Norman AV, Smolkin ME, Farivar BS, Tracci MC, Weaver ML, Kern JA, Ratcliffe SJ, Clouse WD. Current Transthoracic Supra-Aortic Trunk Surgical Reconstruction Has Similar 30-Day Cardiovascular Outcomes Compared to Extra-Anatomic Revascularization but With Higher Morbidity Burden. Ann Vasc Surg 2024; 100:155-164. [PMID: 37852366 DOI: 10.1016/j.avsg.2023.08.032] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2023] [Revised: 08/16/2023] [Accepted: 08/17/2023] [Indexed: 10/20/2023]
Abstract
BACKGROUND Operative risk for supra-aortic trunk (SAT) surgical revascularization for occlusive disease, particularly transthoracic reconstruction (TR), remains ill-defined. This study sought to describe and compare 30-day outcomes of TR and extra-anatomic (ER) SAT surgical reconstruction for an occlusive indication across the United States over a contemporary 15-year period. METHODS Using the National Surgical Quality Improvement Program, TR and ER performed during 2005-2019 were identified. Procedures performed for nonocclusive indications and those concomitant with coronary or valve operations were excluded. Rates of stroke, death, myocardial infarction (MI) and these as composite outcome (S/D/M) were compared. Logistic regression with stabilized inverse probability weighting (IPW) was used to compare groups via average treatment effect (ATE) while adjusting for covariate imbalances. RESULTS Over the 15-year period, 166 TR and 1,900 ER patients were identified. The majority of ERs were carotid-subclavian bypass (n = 1,344; 70.7%) followed by carotid-carotid bypass (n = 261; 13.7%) and subclavian/carotid transpositions (n = 123; 6.5%). TR consisted of aorto-SAT bypass (n = 120; 72.3%) and endarterectomy (n = 46; 27.7%). The median age was 64 years for TR and 65 years in ER (P = 0.039). Those undergoing TR were more often women (69.0% vs. 56.9%; P = 0.001) and less likely to have undergone previous cardiac surgery (9.2% vs. 20.8%; P = 0.006). TR were also less frequently hypertensive (68.1% vs. 75.4%; P = 0.038) and had statistically lower preoperative creatinine levels (0.86 vs 0.91; P = 0.002). Unadjusted rates of MI (0.6% vs. 1.3%; P = 0.72) and stroke (3.6% vs. 1.9%; P = 0.15) were similar between groups with mortality (3.6% vs. 1.5%; P = 0.05) and S/D/M (6.6% vs. 3.9%; P = 0.10) trending higher with TR. IPWs could be calculated for 1,754 patients (148 TR; 1,606 ER). The estimated probability of S/D/M was 3.8% in the ER group and 6.2% in TR; no difference was seen in ATE (2.4%; 95% confidence interval [CI]: -1.5 to 6.2; P = 0.23). No differences were seen in individual component ATEs (stroke: 3.0% vs. 1.7%; ATE = 1.3%; 95% CI: -3.9 to 1.3; P = 0.32; mortality: 3.8% vs. 1.4%; ATE = 2.4%; 95% CI: -5.6 to 0.7; P = 0.13). Secondary outcomes showed TR patients were more likely to have non-home discharge (18.7% vs. 6.6%; ATE = 12.1%; 95% CI: 5.0-19.2; P < 0.001) and longer lengths of stay (6.1 vs. 4.0; ATE = 2.2 days; 95% CI: 0.9-3.4; P < 0.001). Moreover, TR patients were more likely to require transfusion (22.7% vs. 5.0%; ATE = 17.7%; 95% CI: 10.2-25.2; P < 0.001) and develop sepsis (2.7% vs. 0.2%; ATE = 2.5%; 95% CI: 0.1-5.0; P = 0.04). CONCLUSIONS Transthoracic and extra-anatomic surgical reconstruction of the SATs for occlusive disease have similar operative cardiovascular risk. However, morbidity tends to be higher with TR due to higher transfusion requirements, sepsis risk, and need for facility stay. These results suggest ER as a first-line approach in those with proper disease anatomy is reasonable with lower morbidity, while TR remains justified in appropriate patients.
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Affiliation(s)
- Anthony V Norman
- Division of Vascular and Endovascular Surgery, Department of Surgery, University of Virginia, Charlottesville, VA
| | - Mark E Smolkin
- Division of Biostatistics, Department of Public Health Sciences, Old Med School, University of Virginia, Charlottesville, VA
| | - Behzad S Farivar
- Division of Vascular and Endovascular Surgery, Department of Surgery, University of Virginia, Charlottesville, VA
| | - Margaret C Tracci
- Division of Vascular and Endovascular Surgery, Department of Surgery, University of Virginia, Charlottesville, VA
| | - M Libby Weaver
- Division of Vascular and Endovascular Surgery, Department of Surgery, University of Virginia, Charlottesville, VA
| | - John A Kern
- Division of Vascular and Endovascular Surgery, Department of Surgery, University of Virginia, Charlottesville, VA
| | - Sarah J Ratcliffe
- Division of Biostatistics, Department of Public Health Sciences, Old Med School, University of Virginia, Charlottesville, VA
| | - W Darrin Clouse
- Division of Vascular and Endovascular Surgery, Department of Surgery, University of Virginia, Charlottesville, VA.
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20
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Paraskevas KI, Conrad MF, Schneider PA, Cambria RP. Best Medical Treatment Alone Is Adequate for the Management of All Patients With Asymptomatic Carotid Stenosis, or "Alice in Wonderland". Angiology 2024; 75:295-296. [PMID: 37165801 DOI: 10.1177/00033197231174724] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/12/2023]
Affiliation(s)
| | - Mark F Conrad
- Division of Vascular and Endovascular Surgery, St Elizabeth's Medical Center, Boston, MA, USA
| | - Peter A Schneider
- Division of Vascular and Endovascular Surgery, University of California, San Francisco, CA, USA
| | - Richard P Cambria
- Division of Vascular and Endovascular Surgery, St Elizabeth's Medical Center, Boston, MA, USA
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21
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Paraskevas KI, Brown MM, Lal BK, Myrcha P, Lyden SP, Schneider PA, Poredos P, Mikhailidis DP, Secemsky EA, Musialek P, Mansilha A, Parikh SA, Silvestrini M, Lavie CJ, Dardik A, Blecha M, Liapis CD, Zeebregts CJ, Nederkoorn PJ, Poredos P, Gurevich V, Jawien A, Lanza G, Gray WA, Gupta A, Svetlikov AV, Fernandes E Fernandes J, Nicolaides AN, White CJ, Meschia JF, Cronenwett JL, Schermerhorn ML, AbuRahma AF. Recent advances and controversial issues in the optimal management of asymptomatic carotid stenosis. J Vasc Surg 2024; 79:695-703. [PMID: 37939746 DOI: 10.1016/j.jvs.2023.11.004] [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: 09/21/2023] [Revised: 10/29/2023] [Accepted: 11/03/2023] [Indexed: 11/10/2023]
Abstract
OBJECTIVE The optimal management of patients with asymptomatic carotid stenosis (AsxCS) is enduringly controversial. We updated our 2021 Expert Review and Position Statement, focusing on recent advances in the diagnosis and management of patients with AsxCS. METHODS A systematic review of the literature was performed up to August 1, 2023, using PubMed/PubMed Central, EMBASE and Scopus. The following keywords were used in various combinations: "asymptomatic carotid stenosis," "carotid endarterectomy" (CEA), "carotid artery stenting" (CAS), and "transcarotid artery revascularization" (TCAR). Areas covered included (i) improvements in best medical treatment (BMT) for patients with AsxCS and declining stroke risk, (ii) technological advances in surgical/endovascular skills/techniques and outcomes, (iii) risk factors, clinical/imaging characteristics and risk prediction models for the identification of high-risk AsxCS patient subgroups, and (iv) the association between cognitive dysfunction and AsxCS. RESULTS BMT is essential for all patients with AsxCS, regardless of whether they will eventually be offered CEA, CAS, or TCAR. Specific patient subgroups at high risk for stroke despite BMT should be considered for a carotid revascularization procedure. These patients include those with severe (≥80%) AsxCS, transcranial Doppler-detected microemboli, plaque echolucency on Duplex ultrasound examination, silent infarcts on brain computed tomography or magnetic resonance angiography scans, decreased cerebrovascular reserve, increased size of juxtaluminal hypoechoic area, AsxCS progression, carotid plaque ulceration, and intraplaque hemorrhage. Treatment of patients with AsxCS should be individualized, taking into consideration individual patient preferences and needs, clinical and imaging characteristics, and cultural, ethnic, and social factors. Solid evidence supporting or refuting an association between AsxCS and cognitive dysfunction is lacking. CONCLUSIONS The optimal management of patients with AsxCS should include BMT for all individuals and a prophylactic carotid revascularization procedure (CEA, CAS, or TCAR) for some asymptomatic patient subgroups, additionally taking into consideration individual patient needs and preference, clinical and imaging characteristics, social and cultural factors, and the available stroke risk prediction models. Future studies should investigate the association between AsxCS with cognitive function and the role of carotid revascularization procedures in the progression or reversal of cognitive dysfunction.
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Affiliation(s)
| | - Martin M Brown
- Stroke Research Centre, Department of Brain Repair and Rehabilitation, UCL Queen Square Institute of Neurology, University College London, London, UK
| | - Brajesh K Lal
- Department of Vascular Surgery, University of Maryland School of Medicine, Baltimore, MD; Department of Vascular Surgery, Baltimore VA Medical Center, Baltimore, MD; Department of Neurology, Mayo Clinic, Rochester, MN
| | - Piotr Myrcha
- Department of General and Vascular Surgery, Faculty of Medicine, Medical University of Warsaw, Warsaw, Poland
| | - Sean P Lyden
- Department of Vascular Surgery, The Cleveland Clinic, Cleveland, OH
| | - Peter A Schneider
- Division of Vascular and Endovascular Surgery, University of California, San Francisco, CA
| | - Pavel Poredos
- Department of Vascular Diseases, University Medical Centre Ljubljana, Ljubljana, Slovenia
| | - Dimitri P Mikhailidis
- Department of Clinical Biochemistry, Royal Free Hospital Campus, University College London Medical School, University College London (UCL), London, UK
| | - Eric A Secemsky
- Smith Center for Outcomes Research in Cardiology, Division of Cardiology, Department of Medicine, Beth Israel Deaconess Medical Center, Boston, MA
| | - Piotr Musialek
- Jagiellonian University Department of Cardiac and Vascular Diseases, John Paul II Hospital, Krakow, Poland
| | - Armando Mansilha
- Faculty of Medicine of the University of Porto, Porto, Portugal; Department of Angiology and Vascular Surgery, Hospital de S. Joao, Porto, Portugal
| | - Sahil A Parikh
- Division of Cardiology, Department of Medicine, New York-Presbyterian Hospital/Columbia University Irving Medical Center, New York, NY; Center for Interventional Cardiovascular Care and Division of Cardiology, Department of Medicine, Columbia University Irving Medical Center, New York, NY
| | - Mauro Silvestrini
- Neurological Clinic, Department of Experimental and Clinical Medicine, Marche Polytechnic University, Ancona, Italy
| | - Carl J Lavie
- John Ochsner Heart and Vascular Institute, Ochsner Clinical School, The University of Queensland School of Medicine, New Orleans, LA
| | - Alan Dardik
- Department of Surgery, Yale School of Medicine, New Haven, CT
| | - Matthew Blecha
- Division of Vascular Surgery and Endovascular Therapy, Loyola University Chicago, Stritch School of Medicine, Loyola University Health System, Chicago, IL
| | - Christos D Liapis
- Department of Vascular & Endovascular Surgery, Athens Medical Center, Athens, Greece
| | - Clark J Zeebregts
- Department of Surgery, Division of Vascular Surgery, University Medical Center Groningen, University of Groningen, Amsterdam, the Netherlands
| | - Paul J Nederkoorn
- Department of Neurology, Amsterdam UMC, University of Amsterdam, Amsterdam, the Netherlands
| | - Peter Poredos
- Department of Anaesthesiology and Surgical Intensive Care, University Medical Centre Ljubljana, Ljubljana, Slovenia
| | - Victor Gurevich
- Center of Atherosclerosis, Lab of Microangiopathic Mechanisms of Atherogenesis, Saint-Petersburg State University, North-Western State Medical University n.a. I.I. Mechnikov, Saint Petersburg, Russia
| | - Arkadiusz Jawien
- Department of Vascular Surgery and Angiology, Collegium Medicum in Bydgoszcz, Nicolaus Copernicus University in Torun, Torun, Poland
| | - Gaetano Lanza
- Department of Surgery, IRCCS Multimedica Hospital, Castellanza, Italy
| | | | - Ajay Gupta
- Department of Radiology, Weill Cornell Medicine, New York, NY
| | - Alexei V Svetlikov
- Division of Vascular & Endovascular Surgery, North-Western Scientific Clinical Center of Federal Medical Biological Agency, Department of Hospital Surgery, Saint-Petersburg State University, Saint Petersburg, Russia
| | | | - Andrew N Nicolaides
- Vascular Screening and Diagnostic Center, Nicosia, Cyprus; University of Nicosia Medical School, Nicosia, Cyprus; Department of Vascular Surgery, Imperial College, London, UK
| | - Christopher J White
- Department of Cardiology, Ochsner Clinical School, University of Queensland and Ochsner Health System, New Orleans, LA
| | | | - Jack L Cronenwett
- Section of Vascular Surgery, Dartmouth-Hitchcock Medical Center, Lebanon, NH
| | - Marc L Schermerhorn
- Department of Surgery, Division of Vascular and Endovascular Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA
| | - Ali F AbuRahma
- Department of Surgery, Division of Vascular and Endovascular Surgery, Charleston Area Medical Center/West Virginia University Health Sciences Center, Charleston, WV
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22
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Solomon Y, Conroy PD, Rastogi V, Yadavalli SD, Schneider PA, Wang GJ, Malas MB, de Borst GJ, Schermerhorn ML. Outcomes following carotid revascularization for stroke stratified by Modified Rankin Scale and time of intervention. J Vasc Surg 2024; 79:287-296.e1. [PMID: 38179993 DOI: 10.1016/j.jvs.2023.10.041] [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: 03/08/2023] [Revised: 10/12/2023] [Accepted: 10/13/2023] [Indexed: 01/06/2024]
Abstract
OBJECTIVES The relationship between baseline Modified Rankin Scale (mRS) in patients with prior stroke and optimal timing of carotid revascularization is unclear. Therefore, we evaluated the timing of transfemoral carotid artery stenting (tfCAS), transcarotid artery revascularization (TCAR), and carotid endarterectomy (CEA) after prior stroke, stratified by preoperative mRS. METHODS We identified patients with recent stroke who underwent tfCAS, TCAR, or CEA between 2012 and 2021. Patients were stratified by preoperative mRS (0-1, 2, 3-4, or 5) and days from symptom onset to intervention (time to intervention; ≤2 days, 3-14 days, 15-90 days, and 91-180 days). First, we performed univariate analyses comparing in-hospital outcomes between separate mRS or time-to-intervention cohorts for all carotid intervention methods. Afterward, multivariable logistic regression was used to adjust for demographics and comorbidities across groups, and outcomes between the various intervention methods were compared. Primary outcome was the in-hospital stroke/death rate. RESULTS We identified 4260 patients who underwent tfCAS, 3130 patients who underwent TCAR, and 20,012 patients who underwent CEA. Patients were most likely to have minimal disability (mRS, 0-1 [61%]) and least likely to have severe disability (mRS, 5 [1.5%]). Patients most often underwent revascularization in 3 to 14 days (45%). Across all intervention methods, increasing preoperative mRS was associated with higher procedural in-hospital stroke/death (all P < .03), whereas increasing time to intervention was associated with lower stroke/death rates (all P < .01). After adjustment for demographics and comorbidities, undergoing tfCAS was associated with higher stroke/death compared with undergoing CEA (adjusted odds ratio, 1.6; 95% confidence interval, 1.3-1.9; P < .01) or undergoing TCAR (adjusted odds ratio, 1.3; 95% confidence interval, 1.0-1.8; P = .03). CONCLUSIONS In patients with preoperative stroke, optimal timing for carotid revascularization varies with stroke severity. Increasing preoperative mRS was associated with higher procedural in-hospital stroke/death rates, whereas increasing time to-intervention was associated with lower stroke/death rates. Overall, patients undergoing CEA were associated with lower in-hospital stroke/deaths. To determine benefit for delayed intervention, these results should be weighed against the risk of recurrent stroke during the interval before intervention.
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Affiliation(s)
- Yoel Solomon
- Department of Surgery, Division of Vascular and Endovascular Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA; Department of Vascular Surgery, University Medical Center, Utrecht, the Netherlands
| | - Patrick D Conroy
- Department of Surgery, Division of Vascular and Endovascular Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA
| | - Vinamr Rastogi
- Department of Surgery, Division of Vascular and Endovascular Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA
| | - Sai Divya Yadavalli
- Department of Surgery, Division of Vascular and Endovascular Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA
| | - Peter A Schneider
- Division of Vascular and Endovascular Surgery, University of California San Francisco, San Francisco, CA
| | - Grace J Wang
- Division of Vascular Surgery and Endovascular Therapy, Department of Surgery, Hospital of the University of Pennsylvania, Philadelphia, PA
| | - Mahmoud B Malas
- Division of Vascular and Endovascular Surgery, Department of Surgery, University of California San Diego Health System, San Diego, CA
| | - Gert J de Borst
- Department of Vascular Surgery, University Medical Center, Utrecht, the Netherlands
| | - Marc L Schermerhorn
- Department of Surgery, Division of Vascular and Endovascular Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA.
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23
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Pini R, Faggioli G, Rocchi C, Fronterrè S, Lodato M, Vacirca A, Gallitto E, Gargiulo M. The mid-term results of the Carotid Asymptomatic Stenosis (CARAS) observational study. J Stroke Cerebrovasc Dis 2024; 33:107508. [PMID: 38176228 DOI: 10.1016/j.jstrokecerebrovasdis.2023.107508] [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: 08/18/2023] [Revised: 10/26/2023] [Accepted: 11/20/2023] [Indexed: 01/06/2024] Open
Abstract
INTRODUCTION Carotid endarterectomy (CEA) in patients with asymptomatic carotid stenosis (ACAS) remains a subject of debate. Current recommendations are based on randomized trials conducted over 20 years ago and improvements in medical therapies may have reduced the risk of cerebral ischemic events (CIE). This study presents a mid-term analysis of results from an ongoing prospective observational study of ACAS patients to assess their CIE risk in a real-world setting. METHODS This is a prospective observational cohort study of patients with ACAS >60 % (NASCET criteria) identified in a single duplex ultrasonography (DUS) vascular laboratory (trial registered: NCT04825080). Patients were not considered for CEA due to their short life expectancy (<3 year) or absence of signs of plaque vulnerability (ulceration, ipoechogenic core). Patient enrollment started in January 2019 and ended in March 2020 with a targeted sample size of 300 patients.A 5-year follow-up was scheduled. Clinical characteristics, risk factors, and medical therapies were documented, and, when necessary, the best medical therapy (BMT), involving antiplatelet agents, blood pressure control, and statins, was recommended during clinical visits. The primary endpoint was to asses CIEs (including strokes, transient ischemic attacks, amaurosis-fugax) ipsilateral to ACAS along with plaque progression rate and patients survival. Follow-up involved annual clinical visit and carotid DUS examination, complemented by telephone interviews at six-month intervals. RESULTS The study included 307 patients, with an average age of 80 ± 7 years, of whom 55 % were male. Contralateral stenosis exceeding 60 % was present in 61 (20 %) patients. Seventy-seven percent of patients were on BMT. At a mean follow-up of 41±9 months, 7 ispilateral strokes and 9 TIAs occurred, resulting in 14 CIEs (2 patients experienced both TIA and stroke). According to Kaplan-Meier analysis, the 4-year CIE rate was 6±2 %, with an annual CIE rate of 1.5 %. Fifty-eight (19 %) patients had a stenosis progression which was associated with a higher 4-year estimated CIE rate compared to patients with stable plaque (10.3 % vs 3.2 %, P=.01). Similarly, a contralateral carotid stenosis >60 % was associated with a higher 4-year estimated CIE rate: 11.7 % vs 2.9 %, P=.002. These factors were independently associated with high risk for CIE at the multivariate COX analysis: Hazard Ratio (HR): 3.2; 95 % Confidence Interval: 1.1-9.2 and HR: 3.6; 95 % CI: 1.2-10.5. CONCLUSION The mid-term results of this prospective study suggest that the incidence of CIE in ACAS patients should not be underestimated, with plaque progression and contralateral stenosis serving as primary predictors of CIEs.
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Affiliation(s)
- Rodolfo Pini
- Vascular Surgery, University of Bologna "Alma Mater Studiorum", Policlinico S. Orsola Malpighi, IRCCS, Istituto di Ricovero e Cura a Carattere Scientifico, Bologna 40138, Italy.
| | - Gianluca Faggioli
- Vascular Surgery, University of Bologna "Alma Mater Studiorum", Policlinico S. Orsola Malpighi, IRCCS, Istituto di Ricovero e Cura a Carattere Scientifico, Bologna 40138, Italy
| | - Cristina Rocchi
- Vascular Surgery, University of Bologna "Alma Mater Studiorum", Policlinico S. Orsola Malpighi, IRCCS, Istituto di Ricovero e Cura a Carattere Scientifico, Bologna 40138, Italy
| | - Sara Fronterrè
- Vascular Surgery, University of Bologna "Alma Mater Studiorum", Policlinico S. Orsola Malpighi, IRCCS, Istituto di Ricovero e Cura a Carattere Scientifico, Bologna 40138, Italy
| | - Marcello Lodato
- Vascular Surgery, University of Bologna "Alma Mater Studiorum", Policlinico S. Orsola Malpighi, IRCCS, Istituto di Ricovero e Cura a Carattere Scientifico, Bologna 40138, Italy
| | - Andrea Vacirca
- Vascular Surgery, University of Bologna "Alma Mater Studiorum", Policlinico S. Orsola Malpighi, IRCCS, Istituto di Ricovero e Cura a Carattere Scientifico, Bologna 40138, Italy
| | - Enrico Gallitto
- Vascular Surgery, University of Bologna "Alma Mater Studiorum", Policlinico S. Orsola Malpighi, IRCCS, Istituto di Ricovero e Cura a Carattere Scientifico, Bologna 40138, Italy
| | - Mauro Gargiulo
- Vascular Surgery, University of Bologna "Alma Mater Studiorum", Policlinico S. Orsola Malpighi, IRCCS, Istituto di Ricovero e Cura a Carattere Scientifico, Bologna 40138, Italy
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24
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Paraskevas KI, Mikhailidis DP, Ringleb PA, Brown MM, Dardik A, Poredos P, Gray WA, Nicolaides AN, Lal BK, Mansilha A, Antignani PL, de Borst GJ, Cambria RP, Loftus IM, Lavie CJ, Blinc A, Lyden SP, Matsumura JS, Jezovnik MK, Bacharach JM, Meschia JF, Clair DG, Zeebregts CJ, Lanza G, Capoccia L, Spinelli F, Liapis CD, Jawien A, Parikh SA, Svetlikov A, Menyhei G, Davies AH, Musialek P, Roubin G, Stilo F, Sultan S, Proczka RM, Faggioli G, Geroulakos G, Fernandes E Fernandes J, Ricco JB, Saba L, Secemsky EA, Pini R, Myrcha P, Rundek T, Martinelli O, Kakkos SK, Sachar R, Goudot G, Schlachetzki F, Lavenson GS, Ricci S, Topakian R, Millon A, Di Lazzaro V, Silvestrini M, Chaturvedi S, Eckstein HH, Gloviczki P, White CJ. An international, multispecialty, expert-based Delphi Consensus document on controversial issues in the management of patients with asymptomatic and symptomatic carotid stenosis. J Vasc Surg 2024; 79:420-435.e1. [PMID: 37944771 DOI: 10.1016/j.jvs.2023.09.031] [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: 08/22/2023] [Revised: 09/25/2023] [Accepted: 09/25/2023] [Indexed: 11/12/2023]
Abstract
OBJECTIVE Despite the publication of various national/international guidelines, several questions concerning the management of patients with asymptomatic (AsxCS) and symptomatic (SxCS) carotid stenosis remain unanswered. The aim of this international, multi-specialty, expert-based Delphi Consensus document was to address these issues to help clinicians make decisions when guidelines are unclear. METHODS Fourteen controversial topics were identified. A three-round Delphi Consensus process was performed including 61 experts. The aim of Round 1 was to investigate the differing views and opinions regarding these unresolved topics. In Round 2, clarifications were asked from each participant. In Round 3, the questionnaire was resent to all participants for their final vote. Consensus was reached when ≥75% of experts agreed on a specific response. RESULTS Most experts agreed that: (1) the current periprocedural/in-hospital stroke/death thresholds for performing a carotid intervention should be lowered from 6% to 4% in patients with SxCS and from 3% to 2% in patients with AsxCS; (2) the time threshold for a patient being considered "recently symptomatic" should be reduced from the current definition of "6 months" to 3 months or less; (3) 80% to 99% AsxCS carries a higher risk of stroke compared with 60% to 79% AsxCS; (4) factors beyond the grade of stenosis and symptoms should be added to the indications for revascularization in AsxCS patients (eg, plaque features of vulnerability and silent infarctions on brain computed tomography scans); and (5) shunting should be used selectively, rather than always or never. Consensus could not be reached on the remaining topics due to conflicting, inadequate, or controversial evidence. CONCLUSIONS The present international, multi-specialty expert-based Delphi Consensus document attempted to provide responses to several unanswered/unresolved issues. However, consensus could not be achieved on some topics, highlighting areas requiring future research.
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Affiliation(s)
| | - Dimitri P Mikhailidis
- Division of Surgery and Interventional Science, Department of Surgical Biotechnology, University College London Medical School, University College London (UCL) and Department of Clinical Biochemistry, Royal Free Hospital Campus, UCL, London, United Kingdom
| | | | - Martin M Brown
- Department of Brain Repair and Rehabilitation, Stroke Research Centre, UCL Queen Square Institute of Neurology, University College London, London, United Kingdom
| | - Alan Dardik
- Department of Surgery, Yale School of Medicine, New Haven, CT
| | - Pavel Poredos
- Department of Vascular Diseases, University Medical Centre Ljubljana, Ljubljana, Slovenia
| | | | - Andrew N Nicolaides
- Vascular Screening and Diagnostic Center, Nicosia, Cyprus; University of Nicosia Medical School, Nicosia, Cyprus; Department of Vascular Surgery, Imperial College, London, United Kingdom
| | - Brajesh K Lal
- Department of Vascular Surgery, University of Maryland School of Medicine, Baltimore, MD; Department of Vascular Surgery, Baltimore VA Medical Center, Baltimore, MD; Department of Neurology, Mayo Clinic, Rochester, MN
| | - Armando Mansilha
- Faculty of Medicine of the University of Porto, Porto, Portugal; Department of Angiology and Vascular Surgery, Hospital de S. Joao, Porto, Portugal
| | | | - Gert J de Borst
- Department of Vascular Surgery, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Richard P Cambria
- Division of Vascular and Endovascular Surgery, St. Elizabeth's Medical Center, Boston, MA
| | - Ian M Loftus
- St George's Vascular Institute, St George's University London, London, United Kingdom
| | - Carl J Lavie
- John Ochsner Heart and Vascular Institute, Ochsner Clinical School, The University of Queensland School of Medicine, New Orleans, LA
| | - Ales Blinc
- Division of Internal Medicine, Department of Vascular Diseases, University Medical Centre Ljubljana, Ljubljana, Slovenia; Faculty of Medicine, University of Ljubljana, Ljubljana, Slovenia
| | - Sean P Lyden
- Department of Vascular Surgery, The Cleveland Clinic, Cleveland, OH
| | - Jon S Matsumura
- Department of Surgery, University of Wisconsin School of Medicine and Public Health, Madison, WI
| | - Mateja K Jezovnik
- Department of Advanced Cardiopulmonary Therapies and Transplantation, The University of Texas Health Science Centre at Houston, Houston, TX
| | - J Michael Bacharach
- Department of Vascular Medicine and Endovascular Intervention, North Central Heart Institute and the Avera Heart Hospital, Sioux Falls, SD
| | | | - Daniel G Clair
- Department of Vascular Surgery, Vanderbilt University Medical Center, Nashville, TN
| | - Clark J Zeebregts
- Department of Surgery (Division of Vascular Surgery), University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Gaetano Lanza
- Vascular Surgery Department, IRCSS Multimedica Hospital, Castellanza, Italy
| | - Laura Capoccia
- Vascular Surgery Division, Department of Surgery, SS. Filippo e Nicola Hospital, Avezzano, Italy
| | - Francesco Spinelli
- Vascular Surgery Division, Department of Medicine and Surgery, Campus Bio-Medico University of Rome, Rome, Italy
| | | | - Arkadiusz Jawien
- Department of Vascular Surgery and Angiology, Collegium Medicum, Nicolaus Copernicus University, Bydgoszcz, Poland
| | - Sahil A Parikh
- Division of Cardiology, Department of Medicine, New York-Presbyterian Hospital/ Columbia University Irving Medical Center, New York, NY; Center for Interventional Cardiovascular Care and Division of Cardiology, Department of Medicine, Columbia University Irving Medical Center, New York, NY
| | - Alexei Svetlikov
- Division of Vascular and Endovascular Surgery, North-Western Scientific Clinical Center of Federal Medical Biological Agency of Russia, St Petersburg, Russia
| | - Gabor Menyhei
- Department of Vascular Surgery, University of Pecs, Pecs, Hungary
| | - Alun H Davies
- Department of Surgery and Cancer, Section of Vascular Surgery, Imperial College London, Charing Cross Hospital, London, United Kingdom
| | - Piotr Musialek
- Jagiellonian University Department of Cardiac and Vascular Diseases, John Paul II Hospital, Krakow, Poland
| | - Gary Roubin
- Department of Cardiology, Cardiovascular Associates of the Southeast/ Brookwood, Baptist Medical Center, Birmingham, AL
| | - Francesco Stilo
- Vascular Surgery Division, Department of Medicine and Surgery, Campus Bio-Medico University of Rome, Rome, Italy
| | - Sherif Sultan
- Department of Vascular and Endovascular Surgery, Western Vascular Institute, University Hospital Galway, University of Galway, Galway, Ireland
| | - Robert M Proczka
- First Department of Vascular Surgery, Medicover Hospital, Warsaw, Poland, Lazarski University Faculty of Medicine, Warsaw, Poland
| | - Gianluca Faggioli
- Vascular Surgery, University of Bologna "Alma Mater Studiorum", Policlinico S. Orsola Malpighi, Bologna, Italy
| | - George Geroulakos
- Department of Vascular Surgery, "Attikon" University Hospital, National and Kapodistrian University of Athens, Athens, Greece
| | - Jose Fernandes E Fernandes
- Faculty of Medicine, Lisbon Academic Medical Center, University of Lisbon, Portugal, Hospital da Luz Torres de Lisboa, Lisbon, Portugal
| | - Jean-Baptiste Ricco
- Department of Vascular Surgery, University Hospital of Toulouse, Toulouse, France
| | - Luca Saba
- Department of Radiology, Azienda Ospedaliera Universitaria Di Cagliari, Cagliari, Italy
| | - Eric A Secemsky
- Division of Cardiology, Department of Medicine, Smith Center for Outcomes Research, Beth Israel Deaconess Medical Center, Boston, MA; Harvard Medical School, Boston, MA
| | - Rodolfo Pini
- Vascular Surgery, University of Bologna "Alma Mater Studiorum", Policlinico S. Orsola Malpighi, Bologna, Italy
| | - Piotr Myrcha
- Department of General and Vascular Surgery, Faculty of Medicine, Medical University of Warsaw, Warsaw, Poland
| | - Tatjana Rundek
- Department of Neurology, Miller School of Medicine, University of Miami, Miami, FL
| | - Ombretta Martinelli
- Faculty of Medicine, Sapienza University of Rome, Rome, Italy; Vascular Surgery Unit, "Umberto I." Hospital, Rome, Italy
| | - Stavros K Kakkos
- Department of Vascular Surgery, University of Patras Medical School, Patras, Greece
| | - Ravish Sachar
- North Carolina Heart and Vascular Hospital, UNC-REX Healthcare, University of North Carolina, Raleigh, NC
| | - Guillaume Goudot
- Vascular Medicine Department, Georges Pompidou European Hospital, APHP, Université Paris Cité, Paris, France
| | - Felix Schlachetzki
- Department of Neurology, University Hospital of Regensburg, Regensburg, Germany
| | | | - Stefano Ricci
- Neurology Department-Stroke Unit, Gubbio-Gualdo Tadino and Citta di Castello Hospitals, USL Umbria 1, Perugia, Italy
| | - Raffi Topakian
- Department of Neurology, Academic Teaching Hospital Wels-Grieskirchen, Wels, Austria
| | - Antoine Millon
- Department of Vascular and Endovascular Surgery, Louis Pradel Hospital, Hospices Civil de Lyon, Bron, France
| | - Vincenzo Di Lazzaro
- Department of Medicine and Surgery, Unit of Neurology, Neurophysiology, Neurobiology and Psychiatry, Universita Campus Bio-Medico di Roma, Roma, Italy; Fondazione Policlinico Universitario Campus Bio-Medico, Roma, Italy
| | - Mauro Silvestrini
- Department of Experimental and Clinical Medicine, Neurological Clinic, Marche Polytechnic University, Ancona, Italy
| | - Seemant Chaturvedi
- Department of Neurology, University of Maryland School of Medicine, Baltimore, MD
| | - Hans-Henning Eckstein
- Department for Vascular and Endovascular Surgery, Klinikum Rechts der Isar, Technical University of Munich, Munich, Germany
| | - Peter Gloviczki
- Division of Vascular and Endovascular Surgery, Mayo Clinic, Rochester, MN
| | - Christopher J White
- Department of Medicine and Cardiology, Ochsner Clinical School, University of Queensland, Brisbane, Australia; Department of Cardiology, The John Ochsner Heart and Vascular Institute, New Orleans, LA
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25
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Penton A, Driscoll M, Li R, DeJong M, Blecha M. Carotid Endarterectomy for Asymptomatic Stenosis Based on Duplex Ultrasound Alone Achieves Equivalent Perioperative and Long-Term Outcomes Relative to Advanced Imaging Based Endarterectomy. Ann Vasc Surg 2024; 98:44-57. [PMID: 37454891 DOI: 10.1016/j.avsg.2023.07.093] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2022] [Revised: 05/08/2023] [Accepted: 07/03/2023] [Indexed: 07/18/2023]
Abstract
BACKGROUND The purpose of this study is to compare both perioperative as well as long-term outcomes of patients undergoing carotid endarterectomy (CEA) for asymptomatic carotid bifurcation stenosis based on duplex ultrasound in isolation relative to a combination of duplex and more advanced imaging. METHODS All CEA in the VQI between January 2003 and May 2022 were queried. We identified 171,816 CEAs in the database. Exclusions were symptomatic carotid lesion (57,742), lack of imaging documentation (908), lack of advanced imaging status (1,816), simultaneous additional arterial intervention in the carotid, coronary, or peripheral arterial system (n = 4,118), and anatomic high-risk status for CEA (n = 4,071). Included patients were then placed into 1 of 2 cohorts: patients undergoing CEA based on duplex imaging alone (n = 33,437) and those undergoing CEA based on advanced imaging (CTA, MRA, or invasive angiography) with or without duplex (n = 69,715). We performed multivariable analysis for the following outcomes utilizing CEA based on duplex in isolation as 1 of the variables: perioperative neurological ischemic event utilizing binary logistic regression; combined 90-day mortality and neurological ischemic event utilizing binary logistic regression; neurological event in long-term follow-up with date of surgery serving as time zero; time dependent Cox regression analysis; mortality in long-term follow-up utilizing time-dependent Cox regression. RESULTS Carotid endarterectomy based on duplex alone and CEA based on advanced imaging had essentially equivalent rates of 90-day mortality (0.9% vs. 1.0%, P = 0.108); combined perioperative neurological event and 90-day mortality (2.0% vs. 2.2%, P = 0.042); and, return to the operating room (1.6% vs. 1.7%, P = 0.154). On multivariable analysis CEA based on advanced imaging was noted to have a slightly higher absolute rate of perioperative neurological event without achieving multivariable significance (1.3% vs. 1.2%, adjusted odds ratio 1.11 (0.98-1.25), P = 0.092. CEA based on advanced imaging had a higher rate of neurological event after index hospital admission relative to duplex in isolation (hazard ratio (HR) 1.44 (1.31-1.60), P < 0.001). However, the absolute percentage difference was just 0.5% (1.6% vs. 2.1%). CEA based on duplex alone was associated with a slightly increased risk of mortality in LTFU (HR 1.16 (1.11-1.21), P < 0.001). At 5 years the absolute risk of mortality was less than 1% different between the cohorts. CONCLUSIONS Performing CEA for asymptomatic bifurcation stenosis based on duplex ultrasound alone is a safe practice which achieves clinically equivalent perioperative and long-term freedom from cerebral ischemia and mortality relative to CEA based on advanced imaging. This has potential implications for health care cost saving as well as avoidance of radiation and iodinated contrast.
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Affiliation(s)
- Ashley Penton
- Loyola University Medical Center Department of Sugery, Maywood, IL
| | - Matthew Driscoll
- Loyola University Chicago Stritch School of Medicine, Maywood, IL
| | - Ruojia Li
- Division of Vascular Surgery and Endovascular Therapy, Maywood, IL
| | - Matthew DeJong
- Loyola University Medical Center Department of Sugery, Maywood, IL
| | - Matthew Blecha
- Division of Vascular Surgery and Endovascular Therapy, Maywood, IL.
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26
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Poorthuis MHF, Sherliker P, de Borst GJ, Clack R, Lewington S, Clarke R, Bulbulia R, Halliday A. Detection rates of asymptomatic carotid artery stenosis and atrial fibrillation by selective screening of patients without cardiovascular disease. Int J Cardiol 2023; 391:131262. [PMID: 37574023 DOI: 10.1016/j.ijcard.2023.131262] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/09/2023] [Revised: 08/02/2023] [Accepted: 08/10/2023] [Indexed: 08/15/2023]
Abstract
BACKGROUND Individuals with significant asymptomatic carotid artery stenosis (ACAS) and atrial fibrillation (AF) could benefit from specific interventions to prevent heart attack and stroke, but are often clinically 'silent'. We aimed to determine detection rate of ACAS and AF by screening, targeting a population at increased cardiovascular risk. METHODS Data on adults who attended voluntary and self-funded commercial screening clinics in the United States or the United Kingdom between 2008 and 2013 were used. The Atherosclerotic Cardiovascular Disease (ASCVD) risk equation was applied to each participants and detection rates of targeted screening for ≥50% ACAS and AF to those at highest risk of CVD was assessed. RESULTS Among 0.4 million individuals between 40 and 80 years, without CVD, 6191 (1.6%) had ACAS and 1026 (0.3%) had AF. Selective screening of participants with a predicted 10-year CVD risk of ≥20% identified 40% of ACAS cases, a prevalence of 3.7%, leading to a number needed to screen (NNS) of 27, as well as 39% of AF cases, a prevalence of 0.6%, with a NNS of 170. Selective screening of those with a predicted 10-year CVD risk of ≥15% identified 54% of ACAS cases, a prevalence of 3.3%, and an NNS of 31, as well as 51% of AF cases, a prevalence of 0.5%, with an NNS of 195. CONCLUSIONS Selective screening for ACAS and AF implemented in ASCVD risk assessment greatly reduces the NNS when compared with population-level screening with detection rates of ACAS and AF substantially greater in people at higher predicted CVD risk.
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Affiliation(s)
- Michiel H F Poorthuis
- Clinical Trial Service Unit and Epidemiological Studies Unit, Nuffield Department of Population Health, University of Oxford, Oxford, UK; MRC Population Health Research Unit, Nuffield Department of Population Health, University of Oxford, Oxford, UK; Department of Neurology and Neurosurgery, Brain Center, University Medical Center Utrecht, Utrecht University, the Netherlands
| | - Paul Sherliker
- Clinical Trial Service Unit and Epidemiological Studies Unit, Nuffield Department of Population Health, University of Oxford, Oxford, UK
| | - Gert J de Borst
- Department of Vascular Surgery, University Medical Center Utrecht, Utrecht University, the Netherlands
| | - Rachel Clack
- Clinical Trial Service Unit and Epidemiological Studies Unit, Nuffield Department of Population Health, University of Oxford, Oxford, UK
| | - Sarah Lewington
- Clinical Trial Service Unit and Epidemiological Studies Unit, Nuffield Department of Population Health, University of Oxford, Oxford, UK; MRC Population Health Research Unit, Nuffield Department of Population Health, University of Oxford, Oxford, UK
| | - Robert Clarke
- Clinical Trial Service Unit and Epidemiological Studies Unit, Nuffield Department of Population Health, University of Oxford, Oxford, UK
| | - Richard Bulbulia
- Clinical Trial Service Unit and Epidemiological Studies Unit, Nuffield Department of Population Health, University of Oxford, Oxford, UK; MRC Population Health Research Unit, Nuffield Department of Population Health, University of Oxford, Oxford, UK.
| | - Alison Halliday
- Clinical Trial Service Unit and Epidemiological Studies Unit, Nuffield Department of Population Health, University of Oxford, Oxford, UK; MRC Population Health Research Unit, Nuffield Department of Population Health, University of Oxford, Oxford, UK
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Moore JM, Garg K, Laskowski IA, Maldonado TS, Mateo RB, Babu S, Goyal A, Ventarola DJ, Chang H. Intraoperative Infusion of Dextran Confers No Additional Benefit after Carotid Endarterectomy but Is Associated with Increased Perioperative Major Adverse Cardiac Events. Ann Vasc Surg 2023; 97:8-17. [PMID: 37004920 DOI: 10.1016/j.avsg.2023.03.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2023] [Revised: 03/25/2023] [Accepted: 03/26/2023] [Indexed: 04/03/2023]
Abstract
BACKGROUND Intraoperative dextran infusion has been associated with reduction of an embolic risk in patients undergoing carotid endarterectomy (CEA). Nonetheless, dextran has been associated with adverse reactions, including anaphylaxis, hemorrhage, cardiac, and renal complications. Herein, we aimed to compare the perioperative outcomes of CEA stratified by the use of intraoperative dextran infusion using a large multiinstitutional dataset. METHODS Patients undergoing CEA between 2008 and 2022 from the Vascular Quality Initiative database were reviewed. Patients were categorized by use of intraoperative dextran infusion, and demographics, procedural data, and in-hospital outcomes were compared. Logistic regression analysis was utilized to adjust for differences in patients while assessing the association between postoperative outcomes and intraoperative infusion of dextran. RESULTS Of 140,893 patients undergoing CEA, 9,935 (7.1%) patients had intraoperative dextran infusion. Patients with intraoperative dextran infusion were older with lower rates of symptomatic stenosis (24.7% vs. 29.3%; P < 0.001) and preoperative use of antiplatelets, anticoagulants and statins. Additionally, they were more likely to have severe carotid stenosis (>80%; 49% vs. 45%; P < 0.001) and undergo CEA under general anesthesia (96.4% vs. 92.3%; P < 0.001), with a more frequent use of shunt (64.4% vs. 49.5%; P < 0.001). After adjustment, multivariable analysis showed that intraoperative dextran infusion was associated with higher odds of in-hospital major adverse cardiac events (MACE), including myocardial infarction [MI] (odds ratio [OR], 1.76, 95% confidence interval [CI]: 1.34-2.3, P < 0.001), congestive heart failure [CHF] (OR, 2.15, 95% CI: 1.67-2.77, P = 0.001), and hemodynamic instability requiring vasoactive agents (OR, 1.08, 95% CI: 1.03-1.13, P = 0.001). However, it was not associated with decreased odds of stroke (OR, 0.92, 95% CI: 0.74-1.16, P = 0.489) or death (OR, 0.88, 95% CI: 0.58-1.35, P = 0.554). These trends persisted even when stratified by symptomatic status and degree of stenosis. CONCLUSIONS Intraoperative infusion of dextran was associated with increased odds of MACE, including MI, CHF, and persistent hemodynamic instability, without decreasing the risk of stroke perioperatively. Given these results, judicious use of dextran in patients undergoing CEA is recommended. Furthermore, careful perioperative cardiac management is warranted in select patients receiving intraoperative dextran during CEA.
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Affiliation(s)
| | - Karan Garg
- Division of Vascular and Endovascular Surgery, Department of Surgery, NYU Langone Medical Center, New York, NY
| | - Igor A Laskowski
- Division of Vascular and Endovascular Surgery, Department of Surgery, Westchester Medical Center, New York Medical College, Valhalla, NY
| | - Thomas S Maldonado
- Division of Vascular and Endovascular Surgery, Department of Surgery, NYU Langone Medical Center, New York, NY
| | - Romeo B Mateo
- Division of Vascular and Endovascular Surgery, Department of Surgery, Westchester Medical Center, New York Medical College, Valhalla, NY
| | - Sateesh Babu
- Division of Vascular and Endovascular Surgery, Department of Surgery, Westchester Medical Center, New York Medical College, Valhalla, NY
| | - Arun Goyal
- Division of Vascular and Endovascular Surgery, Department of Surgery, Westchester Medical Center, New York Medical College, Valhalla, NY
| | - Daniel J Ventarola
- Division of Vascular and Endovascular Surgery, Department of Surgery, Westchester Medical Center, New York Medical College, Valhalla, NY
| | - Heepeel Chang
- New York Medical College, Valhalla, NY; Division of Vascular and Endovascular Surgery, Department of Surgery, Westchester Medical Center, New York Medical College, Valhalla, NY.
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Penton A, Kelly R, Le L, Blecha M. Temporal Trends and Contemporary Regional Variation in Management of Patients Undergoing Carotid Endarterectomy. Vasc Endovascular Surg 2023; 57:869-877. [PMID: 37303024 DOI: 10.1177/15385744231183750] [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: 06/13/2023]
Abstract
INTRODUCTION The purpose of this study is to investigate regional variation and temporal trends in seven quality metrics amongst CEA patients: discharge on antiplatelet after CEA; discharge on statin after CEA; protamine administration during CEA; patch placement at conventional CEA site; continued statin usage at the time of most recent follow-up; continued antiplatelet usage at the time of most recent follow-up; and smoking cessation at the time of long term follow up. METHODS There are 19 de-identified regions within the VQI database in the United States. Patients were placed into one of three temporal eras based on the time of their CEA: 2003-2008; 2009-2015; and 2016-2022. We first investigated temporal trends across the seven quality metrics for all regions combined on a national basis. The percentage of patients in each time era with the presence/absence of each metric was identified. Chi-squared testing was performed to confirm statistical significance of the differences across eras. Next, analysis was performed within each region and within each time metric. We separated out the 2016-2022 patients within each region to serve as the status of each metric application in the most modern era. We then compared the frequency of metric non-adherence in each region utilizing Chi-squared testing. RESULTS There was statistically significant improvement in achievement of all seven metrics between the initial 2003-2008 era and the modern 2016-2022 era. The most marked change in practice pattern was noted for lack of protamine usage at surgery (decreased from 48.7% to 25.9%), discharge home postoperatively without statin (decreased from 50.6% to 15.3%), and lack of statin usage confirmed at time of most recent long term follow up (decreased from 24% to 8.9%). Significant regional variation exists across all metrics (P < .01 for all). Lack of patch placement at the time of conventional endarterectomy ranges from 1.9% to 17.8% across regions in the modern era. Lack of protamine utilization ranges from 10.8% to 49.7%. Lack of antiplatelet and statin at the time of discharge varies from 5.5% to 8.2% and 4.8% to 14.4% respectively. Adherence to the various measures at the time of most recent follow up are more tightly aligned across regions with ranges of: 5.3% to 7.5% for lack of antiplatelet usage; 6.6% to 11.7% lack of statin utilization; and 13.3 to 15.4% for persistent smoking. CONCLUSIONS Prior studies and societal initiatives on CEA documenting the beneficial effects of patch angioplasty, protamine use at surgery, smoking cessation, antiplatelet utilization and statin compliance have positively impacted adherence to these measures over time. In the modern 2016-2022 era the widest regional variation is noted in patch placement, protamine utilization and discharge medications allowing individual geographic areas to identify areas for potential improvement via internal VQI administrative feedback.
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Affiliation(s)
- Ashley Penton
- Division of Vascular Surgery and Endovascular Therapy, Loyola University Health System, Loyola University Chicago Stritch School of Medicine, Maywood, IL, USA
| | - Robert Kelly
- Division of Vascular Surgery and Endovascular Therapy, Loyola University Health System, Loyola University Chicago Stritch School of Medicine, Maywood, IL, USA
| | - Linda Le
- Department of Cardiovascular Surgery, Methodist DeBakey Heart & Vascular Center, Houston Methodist Hospital, Houston, TX, USA
| | - Matthew Blecha
- Division of Vascular Surgery and Endovascular Therapy, Loyola University Health System, Loyola University Chicago Stritch School of Medicine, Maywood, IL, USA
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Succar B, Zhou W. Does Carotid Intervention Improve Cognitive Function? Adv Surg 2023; 57:267-277. [PMID: 37536858 DOI: 10.1016/j.yasu.2023.04.007] [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] [Indexed: 08/05/2023]
Abstract
Carotid artery disease has been linked to baseline cognitive impairment, even in asymptomatic patients. Therefore, there has been a persistent interest in investigating the impact of carotid revascularization on cognitive functions, but the results have been heterogeneous. Our recent prospective evaluation showed improved cognitive scores across multiple cognitive measures following carotid intervention. Herein, we summarize the studies published to date, identify the potential contributors to the inconsistency of post-interventional cognitive outcomes, and explore further opportunities in cognitive evaluations.
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Affiliation(s)
- Bahaa Succar
- Division of Vascular Surgery, Department of Surgery, University of Arizona, Tucson, AZ, USA
| | - Wei Zhou
- Division of Vascular Surgery, Department of Surgery, University of Arizona, Tucson, AZ, USA.
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Kedev S. Carotid artery interventions - endarterectomy versus stenting. ASIAINTERVENTION 2023; 9:172-179. [PMID: 37736202 PMCID: PMC10509610 DOI: 10.4244/aij-d-23-00009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/07/2023] [Accepted: 06/02/2023] [Indexed: 09/23/2023]
Abstract
Current management of patients with carotid artery stenosis is based on well-established guidelines, including surgical procedures - carotid endarterectomy (CEA) and endovascular carotid artery stenting (CAS) - and optimal medical treatment alone. Outcomes in the postprocedural period after CAS and CEA are similar, suggesting strong clinical durability for both treatments. Recent advances, which include the emergence of novel endovascular treatment tools and techniques, combined with more recent randomised trial data shed new light on optimal patient selection and treatment in contemporary practice. Improved, modern technologies including enhanced embolic protection devices and dual-layered micromesh stents yield better outcomes and should result in further improvements in CAS. In centres of excellence, nowadays, the majority of patients with severe carotid artery stenosis can be successfully treated with either CEA or CAS.
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Affiliation(s)
- Sasko Kedev
- University Clinic of Cardiology, Faculty of Medicine, Ss. Cyril and Methodius University, Skopje, Republic of North Macedonia
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Zarrintan S, Malas MB. What Is the Role of Transcarotid Artery Revascularization? Adv Surg 2023; 57:115-140. [PMID: 37536848 DOI: 10.1016/j.yasu.2023.04.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/05/2023]
Abstract
Carotid endarterectomy (CEA) is the gold-standard method of carotid revascularization in symptomatic patients with ≥50% and in asymptomatic patients with ≥70% stenosis. Transfemoral carotid artery stenting (TFCAS) has been associated with higher perioperative stroke rates compared to CEA in several studies. On the other hand, transcarotid artery revascularization (TCAR) has outperformed TFCAS in patients who are considered high risk for surgery. There is increasing data that supports TCAR as a safe and efficient technique with outcomes similar to those of CEA, but additional level-one studies are necessary to evaluate the long-term outcomes of TCAR in high- and standard-risk patients.
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Affiliation(s)
- Sina Zarrintan
- Department of Surgery, Division of Vascular and Endovascular Surgery, UC San Diego, San Diego, CA, USA; Center for Learning and Excellence in Vascular & Endovascular Research (CLEVER), UC San Diego, San Diego, CA, USA; Altman Center for Clinical and Translational Research, 9452 Medical Center Drive - LL2W 502A, La Jolla, CA 92037, USA
| | - Mahmoud B Malas
- Department of Surgery, Division of Vascular and Endovascular Surgery, UC San Diego, San Diego, CA, USA; Center for Learning and Excellence in Vascular & Endovascular Research (CLEVER), UC San Diego, San Diego, CA, USA; Altman Center for Clinical and Translational Research, 9452 Medical Center Drive - LL2W 502A, La Jolla, CA 92037, USA.
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Columbo JA, Stone DH, Martinez-Camblor P, Goodney PP, O’Malley AJ. Adoption and Diffusion of Transcarotid Artery Revascularization in Contemporary Practice. Circ Cardiovasc Interv 2023; 16:e012805. [PMID: 37725675 PMCID: PMC10516509 DOI: 10.1161/circinterventions.122.012805] [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: 02/02/2023] [Accepted: 07/14/2023] [Indexed: 09/21/2023]
Abstract
BACKGROUND In 2015, the FDA approved transcarotid artery revascularization (TCAR) as an alternative to carotid endarterectomy (CEA) and transfemoral carotid artery stenting (TF-CAS) for high-risk patients with carotid stenosis. This was granted in the absence of level 1 evidence to support TCAR. We aimed to document trends in TCAR utilization, its diffusion over time, and the clinical phenotypes of patients undergoing TCAR, CEA, and TF-CAS. METHODS We used the Vascular Quality Initiative to study patients who underwent TCAR. We calculated the number of TCARs performed and the percent of TCAR utilization versus CEA/TF-CAS. Using data from before TCAR was widespread, we calculated propensity scores for patients to receive CEA. We applied this model to patients undergoing carotid revascularization from 2016 to 2022 and grouped patients by the procedure they ultimately underwent, examining overlap in score distribution to measure patient similarity. We measured the trend of in-hospital stroke/death after TCAR. RESULTS We studied 31 447 patients who underwent TCAR from January 1, 2016 to March 31, 2022. The number of centers performing TCAR increased from 29 to 606. In 2021, TCAR represented 22.5% of carotid revascularizations at centers offering all 3 procedures. The percentage of patients that underwent TCAR who met approved high-risk criteria decreased from 88.5% to 80.9% (P<0.001). Those with a prior ipsilateral carotid procedure decreased from 20.6% in 2016 to 12.0% in 2021 (P<0.001). Patients undergoing TCAR after stroke increased from 19.7% to 30.7% (P<0.001). Propensity-score overlap was 55.4% for TCAR/CEA, and 58.6% for TCAR/TF-CAS, demonstrating that TCAR patients have a clinical phenotype mixed between those who undergo CEA and TF-CAS. The average in-hospital stroke/death risk after TCAR was 2.3% in 2016 and 1.7% in 2022 (P trend: 0.954). CONCLUSIONS TCAR now represents nearly 1-in-4 procedures at centers offering it. TCAR was increasingly performed among standard-risk patients and as a first-line procedural option after stroke. The absence of level 1 evidence underscores the importance of high-quality registry-based analyses to document TCAR's real-world outcomes and durability.
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Affiliation(s)
- Jesse A. Columbo
- Section of Vascular Surgery, Heart and Vascular Center, Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire
- Geisel School of Medicine at Dartmouth College, Hanover, New Hampshire
| | - David H. Stone
- Section of Vascular Surgery, Heart and Vascular Center, Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire
- Geisel School of Medicine at Dartmouth College, Hanover, New Hampshire
| | - Pablo Martinez-Camblor
- Department of Anesthesia, Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire
- Department of Biomedical Data Science, Dartmouth College, Hanover, New Hampshire
| | - Philip P. Goodney
- Section of Vascular Surgery, Heart and Vascular Center, Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire
- Geisel School of Medicine at Dartmouth College, Hanover, New Hampshire
| | - A. James O’Malley
- Geisel School of Medicine at Dartmouth College, Hanover, New Hampshire
- Department of Biomedical Data Science, Dartmouth College, Hanover, New Hampshire
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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.
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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.
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Marcaccio CL, AbuRahma AF, Eldrup-Jorgensen J, Brooke BS, Schermerhorn ML. Vascular Quality Initiative assessment of compliance with Society for Vascular Surgery clinical practice guidelines on the management of extracranial cerebrovascular disease. J Vasc Surg 2023; 78:111-121.e2. [PMID: 36948279 DOI: 10.1016/j.jvs.2023.03.026] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2023] [Revised: 02/28/2023] [Accepted: 03/07/2023] [Indexed: 03/24/2023]
Abstract
OBJECTIVES Compliance with Society for Vascular Surgery (SVS) clinical practice guidelines (CPGs) is associated with improved outcomes for the treatment of abdominal aortic aneurysm, but this has not been assessed for carotid artery disease. The Vascular Quality Initiative (VQI) registry was used to examine compliance with the SVS CPGs for the management of extracranial cerebrovascular disease and its impact on outcomes. METHODS The 2021 SVS extracranial cerebrovascular disease CPGs were reviewed for evaluation by VQI data. Compliance rates by the center and provider were calculated, and the impact of compliance on outcomes was assessed using logistic regression with inverse probability-weighted risk adjustment for each CPG recommendation, allowing for clustering by the center. Our primary outcome was a composite end point of in-hospital stroke/death. As a secondary analysis, compliance with the 2021 SVS carotid implementation document recommendations and associated outcomes were also assessed. RESULTS Of the 11 carotid CPG recommendations, 4 (36%) could be evaluated using VQI registry data. Median center-specific CPG compliance ranged from 38% to 95%, and median provider-specific compliance ranged from 36% to 100%. After adjustment, compliance with 2 of the recommendations was associated with lower rates of in-hospital stroke/death: first, the use of best medical therapy (antiplatelet and statin therapy) in low/standard surgical risk patients undergoing carotid endarterectomy for >70% asymptomatic stenosis (event rate in compliant vs noncompliant cases 0.59% vs 1.3%; adjusted odds ratio: 0.44, 95% confidence interval: 0.29-0.66); and second, carotid endarterectomy over transfemoral carotid artery stenting in low/standard surgical risk patients with >50% symptomatic stenosis (1.9% vs 3.4%; adjusted odds ratio: 0.55, 95% confidence interval: 0.43-0.71). Of the 132 implementation document recommendations, only 10 (7.6%) could be assessed using VQI data, with median center- and provider-specific compliance rates ranging from 67% to 100%. The impact of compliance on outcomes could only be assessed for 6 (4.5%) of these recommendations, and compliance with all 6 recommendations was associated with lower stroke/death. CONCLUSIONS Few SVS recommendations could be assessed in the VQI because of incongruity between the recommendations and the VQI data variables collected. Although guideline compliance was extremely variable among VQI centers and providers, compliance with most of these recommendations was associated with improved outcomes after carotid revascularization. This finding confirms the value of guideline compliance, which should be encouraged for centers and providers. Optimization of VQI data to promote evaluation of guideline compliance and distribution of these findings to VQI centers and providers will help facilitate quality improvement efforts in the care of vascular patients.
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Affiliation(s)
- Christina L Marcaccio
- Department of Surgery, Division of Vascular and Endovascular Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA
| | - Ali F AbuRahma
- Department of Surgery, West Virginia University-Charleston Division, Charleston, WV
| | - Jens Eldrup-Jorgensen
- Department of Surgery, Division of Vascular Surgery, Maine Medical Center, Portland, ME
| | - Benjamin S Brooke
- Department of Surgery, Division of Vascular Surgery, University of Utah, School of Medicine, Salt Lake City, UT
| | - Marc L Schermerhorn
- Department of Surgery, Division of Vascular and Endovascular Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA.
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Rockman C. "Traffic signals in New York are just rough guidelines" David Letterman. J Vasc Surg 2023; 78:122. [PMID: 37349007 DOI: 10.1016/j.jvs.2023.04.021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2023] [Accepted: 04/11/2023] [Indexed: 06/24/2023]
Affiliation(s)
- Caron Rockman
- Chief, Division of Vascular Surgery, NYU Langone Health, Florence and Joseph Ritorto Professor of Surgical Research, NYU Langone Health, New York, NY
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36
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Paraskevas KI. Mind the young patients undergoing carotid endarterectomy! J Vasc Surg 2023; 78:131. [PMID: 37349008 DOI: 10.1016/j.jvs.2023.02.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2023] [Accepted: 02/23/2023] [Indexed: 06/24/2023]
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Said S, Dardik A, Ochoa Chaar CI. What are the benefits and drawbacks of statins in carotid artery disease? A perspective review. Expert Rev Cardiovasc Ther 2023; 21:763-777. [PMID: 37994875 DOI: 10.1080/14779072.2023.2286011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/15/2023] [Accepted: 11/16/2023] [Indexed: 11/24/2023]
Abstract
INTRODUCTION The prevalence of carotid artery stenosis in the general population is approximately 3%, but approximately 20% among people with acute ischemic stroke. Statins are recommended by multiple international guidelines as the drug of choice for lipid control in people with asymptomatic or symptomatic carotid artery stenosis due to their lipid-lowering and other pleiotropic effects. AREAS COVERED This review discusses the guidelines for statin usage as a cornerstone in the prevention and management of atherosclerotic carotid artery disease and the impact of statins on stroke incidence and mortality. Statin side effects, alternative therapy, and genetic polymorphisms are reviewed. EXPERT OPINION Statin therapy is associated with a decreased incidence of stroke and mortality as well as improved outcomes for patients treated with carotid revascularization. Statins are a safe and effective class of medications, but the initiation of therapy warrants close monitoring to avoid rare and potentially serious side effects. Lack of clinical efficacy or the presence of side effects suggests a need for treatment with an alternative therapy such as PCSK9 inhibitors. Understanding the interplay between the mechanisms of statins and PCSK9 inhibition therapies will allow optimal benefits while minimizing risks. Future research into genetic polymorphisms may improve patient selection for personalized therapy.
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Affiliation(s)
- Shreef Said
- Division of Vascular Surgery and Endovascular Therapy, Department of Surgery, Yale School of Medicine, New Haven, CT, USA
| | - Alan Dardik
- Division of Vascular Surgery and Endovascular Therapy, Department of Surgery, Yale School of Medicine, New Haven, CT, USA
- Department of Cellular and Molecular Physiology, Yale School of Medicine, New Haven, CT, USA
- Department of Surgery, VA Connecticut Healthcare Systems, West Haven, CT, USA
| | - Cassius Iyad Ochoa Chaar
- Division of Vascular Surgery and Endovascular Therapy, Department of Surgery, Yale School of Medicine, New Haven, CT, USA
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Liu Y, Wang R, Zhang Y, Feng L, Huang W. Virtual reality psychological intervention helps reduce preoperative anxiety in patients undergoing carotid artery stenting: a single-blind randomized controlled trial. Front Psychol 2023; 14:1193608. [PMID: 37457093 PMCID: PMC10342209 DOI: 10.3389/fpsyg.2023.1193608] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2023] [Accepted: 06/14/2023] [Indexed: 07/18/2023] Open
Abstract
Objective This study aimed to explore the effectiveness and applicability of a psychological intervention using virtual reality (VR) to reduce preoperative anxiety in patients undergoing carotid artery stenting (CAS). Methods A total of 114 patients aged 18-86 years who were scheduled to undergo CAS were randomized to the VR and control groups. Patients in the VR group used a VR headset to view a 16-min psychological intervention video, while those in the control group used a tablet for viewing. The primary assessment instrument was the State Anxiety Inventory (S-AI), which was given 20 min before and after the intervention and 24 h after surgery. Secondary assessment tools were the Self-efficacy for Managing Chronic Disease (SEMCD-6) scale, which was completed before the intervention and 24 h after the operation, a smart bracelet to assess sleep quality, monitored in the evening before the operation, and the VR Suitability and Satisfaction Questionnaire, completed 24 h after the operation. Results The two groups were similar in terms of demographic information, preintervention STAI scores and preintervention SEMCD-6 scores (p > 0.05). S-AI scores were lower in both groups after the intervention and surgery, and the scores of the VR group were lower than those of the control group (p = 0.036, p = 0.014). SEMCD-6 scores post-surgery had improved in both groups, but the VR group had significantly higher scores than the control group (p = 0.005). Smart bracelet measurements showed no significant differences in postintervention sleep quality between the two groups (p = 0.540). For satisfaction, the VR group scored higher in all aspects except scheduling. A total of 47 (85.45%) patients reported having a comfortable experience, and only 5 (9.09%) experienced mild adverse effects. Conclusion The use of a virtual reality psychological intervention was beneficial to reduce the anxiety of patients before CAS and improved their self-efficacy. As virtual reality devices evolve and demonstrate better comfort and safety, more comprehensive and in-depth research of the use of VR to reduce patient anxiety should be performed in the future.Clinical trial registration:https://www.chictr.org.cn/showproj.aspx?proj=186412, identifier ChiCTR2200066219.
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Affiliation(s)
- Yanhua Liu
- Department of Neurology, West China Hospital, West China School of Nursing, Sichuan University, Chengdu, China
| | - Rui Wang
- Department of Neurology, West China Hospital, West China School of Nursing, Sichuan University, Chengdu, China
| | - Yang Zhang
- Department of Neurology, West China Hospital, West China School of Nursing, Sichuan University, Chengdu, China
| | - Ling Feng
- Department of Neurology, West China Hospital, West China School of Nursing, Sichuan University, Chengdu, China
| | - Wenxia Huang
- General Practice Medical Center, West China Hospital, West China School of Nursing, Sichuan University, Chengdu, China
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Oh EC, Sridharan ND, Avgerinos ED. Cognitive function after carotid endarterectomy in asymptomatic patients. THE JOURNAL OF CARDIOVASCULAR SURGERY 2023; 64:317-321. [PMID: 36897209 PMCID: PMC10957150 DOI: 10.23736/s0021-9509.23.12632-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 03/11/2023]
Abstract
Asymptomatic carotid stenosis has been shown to be associated with progressive neurocognitive decline, but the effects of carotid endarterectomy (CEA) on this are not well defined. Due to the wide heterogeneity of studies and lack of standardization in cognitive function tests and study design, there is mounting scientific evidence to support the notion that CEA is effective in reversing or slowing neurocognitive decline; however, definitive conclusions are difficult to make. Further, while the association between ACS and cognitive decline has been well document, a direct etiological role has not been established. More research is required to elucidate the relationship between asymptomatic carotid stenosis and the benefit of carotid endarterectomy and its potential protective effects regarding cognitive decline. This article aims to review current evidence in preoperative and postoperative cognitive function in asymptomatic patients with carotid stenosis undergoing CEA.
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Affiliation(s)
- Edward C Oh
- Division of Vascular Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA, USA -
| | - Natalie D Sridharan
- Division of Vascular Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Efthymios D Avgerinos
- Clinic of Vascular and Endovascular Surgery, Athens Medical Group, Athens, Greece
- Department of Vascular Surgery, Attikon Hospital, University of Athens, Athens, Greece
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AbuRahma Z, Williams E, Lee A, AbuRahma A, Davis-Jordan M, Veith C, Dargy N, Dean S, Davis E. Long-term durability and clinical outcome of a prospective randomized trial comparing carotid endarterectomy with ACUSEAL polytetrafluoroethylene patching versus pericardial patching. J Vasc Surg 2023; 77:1694-1699.e2. [PMID: 36958535 DOI: 10.1016/j.jvs.2023.01.189] [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: 12/23/2022] [Revised: 01/27/2023] [Accepted: 01/27/2023] [Indexed: 03/25/2023]
Abstract
BACKGROUND Several studies have shown the superiority of carotid endarterectomy (CEA) with patch closure over primary closure. However, no definite study has shown any significant differences in clinical outcome between various types of patches. Because more vascular surgeons have used pericardial patching recently, this study will analyze the late clinical outcome (≥10 years) of our previously reported prospective randomized trial comparing CEA with ACUSEAL (polytetrafluoroethylene) vs pericardial patching. METHODS A total of 200 CEAs were randomized (1:1) to either Vascu-Guard pericardial patching or ACUSEAL patching. All patients had immediate duplex ultrasound imaging, which was repeated at 6 months and annually thereafter. Kaplan-Meier analysis was used to estimate rates of freedom from stroke, stroke-free survival, and rates of freedom from ≥50% and ≥80% restenosis. RESULTS Overall demographic and clinical characteristics were somewhat similar with a mean follow-up of 80 months (range: 0-149 months). The rates of freedom from stroke were 97, 97, 97, 96, 93 for ACUSEAL vs 99, 98, 97, 97, 92 for pericardial patching (P = .1112) at 1, 2, 3, 5, and 10 years, respectively. Similarly, the rates of freedom from stroke/death were 94, 93, 90, 76, 50 for ACUSEAL vs 99, 96, 91, 78, 47 for pericardial patching (P = .8591). The rates of freedom from ≥50% restenosis were 98, 98, 96, 89, 79 for ACUSEAL vs 87, 83, 83, 81, 71 for pericardial patching (P = .0489). The rates of freedom from ≥80% restenosis were 99, 99, 99, 96, 85 for ACUSEAL vs 96, 96, 96, 93, 93 for pericardial patching (P = .9407). The overall survival rates were 95, 94, 91, 77, 51 for ACUSEAL vs 100, 98, 93, 79, 50 for pericardial patching (P = .9123). Other patch complications (eg, rupture, aneurysmal dilation, infection, etc) were similar. CONCLUSIONS Both CEA with ACUSEAL (polytetrafluoroethylene) and pericardial patching are durable and have similar clinical outcomes at 10 years except that ACUSEAL patching has significantly better rates of freedom from ≥50% restenosis.
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Affiliation(s)
- Zachary AbuRahma
- Department of Surgery, West Virginia University, Charleston, WV.
| | | | - Andrew Lee
- Department of Surgery, West Virginia University, Charleston, WV
| | - Ali AbuRahma
- Department of Surgery, West Virginia University, Charleston, WV
| | | | - Christina Veith
- Department of Surgery, West Virginia University, Charleston, WV
| | - Noah Dargy
- Department of Surgery, West Virginia University, Charleston, WV
| | - Scott Dean
- Research Department for CAMC Hospital, CAMC Health Education and Research Institute, Charleston, WV
| | - Elaine Davis
- Research Department for CAMC Hospital, CAMC Health Education and Research Institute, Charleston, WV
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Haywood NS, Ratcliffe SJ, Zheng X, Mao J, Farivar BS, Tracci MC, Malas MB, Goodney PP, Clouse WD. Operative and long-term outcomes of combined and staged carotid endarterectomy and coronary bypass. J Vasc Surg 2023; 77:1424-1433.e1. [PMID: 36681256 PMCID: PMC10353412 DOI: 10.1016/j.jvs.2023.01.015] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2022] [Revised: 12/31/2022] [Accepted: 01/10/2023] [Indexed: 01/19/2023]
Abstract
OBJECTIVE Optimal temporal surgical management of significant carotid stenosis and coronary artery disease remains unknown. Carotid endarterectomy (CEA) and coronary artery bypass (CABG) are performed concurrently (CCAB) or in a staged (CEA-CABG or CABG-CEA) approach. Using the Vascular Quality Initiative-Vascular Implant Surveillance and Interventional Outcomes Coordinated Registry Network-Medicare-linked dataset, this study compared operative and long-term outcomes after CCAB and staged approaches. METHODS The Vascular Quality Initiative-Vascular Implant Surveillance and Interventional Outcomes Coordinated Registry Network dataset was used to identify CEAs from 2011 to 2018 with combined CABG or CABG within 45 days preceding or after CEA. Patients were stratified based on concurrent or staged approach. Primary outcomes were stroke, myocardial infarction (MI), all-cause mortality, stroke and death as composite (SD) and all as composite within 30 days from the last procedure as well as in the long term. Univariate analysis and risk-adjusted analysis using inverse propensity weighting were performed. Kaplan-Meier curves of stroke, MI, and death were created and compared. RESULTS There were 1058 patients included: 643 CCAB and 415 staged (309 CEA-CABG and 106 CABG-CEA). Compared with staged patients, those undergoing CCAB had a higher preoperative rate of congestive heart failure (24.8% vs 18.4%; P = .01) and decreased renal function (14.9% vs 8.5%; P < .01), as well as fewer prior neurological events (23.5% vs 31.4%; P < .01). Patients undergoing CCAB had similar weighted rate of 30-day stroke (4.6% vs 4.1%; P = .72), death (7.0% vs 5.0%; P = .32), and composite outcomes (stroke and death, 9.8% vs 8.5%; P = .56; stroke, death, and MI, 14.7% vs 17.4%; P = .31), but a lower weighted rate of MI (5.5% vs 11.5%; P < .01) vs the staged cohort. Long-term adjusted risks of stroke (hazard ratio [HR], 0.85; 95% confidence interval [CI], 0.54-1.36; P = .51) and mortality (HR, 1.02; 95% CI, 0.76-1.36; P=.91) were similar between groups, but higher risk of MI long-term was seen in those staged (HR, 1.49; 95% CI, 1.07-2.08; P = .02). CONCLUSIONS In patients undergoing CCAB or staged open revascularization for carotid stenosis and coronary artery disease, the staged approach had an increased risk of postoperative cardiac event, but the short- and long-term rates of stroke and mortality seem to be comparable. Adverse cardiovascular event risk is high between operations when staged and should be a consideration when selecting an approach. Although factors leading to staged sequencing performance need further clarity, CCAB seems to be safe and should be considered an equally reasonable option.
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Affiliation(s)
- Nathan S Haywood
- Department of Vascular and Endovascular Surgery, University of Virginia, Charlottesville, VA
| | - Sarah J Ratcliffe
- Department of Biostatistics, University of Virginia, Charlottesville, VA
| | - Xinyan Zheng
- Population Health Sciences, Weill Cornell Medicine, New York, NY
| | - Jialin Mao
- Population Health Sciences, Weill Cornell Medicine, New York, NY
| | - Behzad S Farivar
- Department of Vascular and Endovascular Surgery, University of Virginia, Charlottesville, VA
| | - Margaret C Tracci
- Department of Vascular and Endovascular Surgery, University of Virginia, Charlottesville, VA
| | - Mahmoud B Malas
- Department of Vascular and Endovascular Surgery, University of California San Diego, San Diego, CA
| | - Philip P Goodney
- Department of Vascular and Endovascular Surgery, Dartmouth-Hitchcock Medical Center, Lebanon, NH
| | - W Darrin Clouse
- Department of Vascular and Endovascular Surgery, University of Virginia, Charlottesville, VA.
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Marcaccio CL, Patel PB, Rastogi V, Stangenberg L, Liang P, Wyers MC, Jim J, Schneider PA, Schermerhorn ML. Efficacy and safety of single versus dual antiplatelet therapy in carotid artery stenting. J Vasc Surg 2023; 77:1434-1446.e11. [PMID: 36581013 PMCID: PMC10122699 DOI: 10.1016/j.jvs.2022.12.034] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2022] [Revised: 12/12/2022] [Accepted: 12/14/2022] [Indexed: 12/27/2022]
Abstract
OBJECTIVE Current guidelines recommend dual antiplatelet (AP) therapy (DAPT) before carotid artery stenting (CAS); however, the true clinical effect of single AP therapy vs DAPT is unknown. We examined the efficacy and safety of preoperative single AP therapy vs DAPT in patients who had undergone transfemoral CAS (tfCAS) or transcarotid artery revascularization (TCAR). METHODS We identified all patients who had undergone tfCAS or TCAR in the Vascular Quality Initiative database from 2016 to 2021. We stratified the patients by procedure and identified those who had received the following preoperative AP regimens: DAPT (acetylsalicylic acid [ASA] + P2Y12 inhibitor [P2Yi]), no AP therapy, ASA only, ASA + AP loading dose, P2Yi only, and P2Yi + AP loading dose. The AP loading dose was given within 4 hours of CAS. We generated propensity scores for each treatment regimen and assessed in-hospital outcomes using inverse probability weighted log binomial regression, with DAPT as the reference and adjusting for intraoperative protamine use. The primary efficacy outcome was a composite end point of stroke and death, and the primary safety outcome was access-related bleeding. RESULTS Of the 18,570 tfCAS patients, 70% had received DAPT, 5.6% no AP therapy, 10% ASA only, 8.0% ASA + AP loading dose, 4.6% P2Yi only, and 2.9% P2Yi + AP loading dose. The corresponding unadjusted rates of stroke/death were 2.2%, 6.8%, 4.1%, 5.1%, 2.4%, and 2.3%. After adjustment, compared with DAPT, the incidence of stroke/death was higher with no AP therapy (relative risk [RR], 2.3; 95% confidence interval [CI], 1.7-3.2), ASA only (RR, 1.6; 95% CI, 1.2-2.1), and ASA + AP loading dose (RR, 2.0; 95% CI, 1.5-2.7) but was similar with P2Yi only (RR, 0.99; 95% CI, 0.58-1.7) and P2Yi + AP loading dose (RR, 1.1; 95% CI, 0.49-2.5). Of the 25,459 TCAR patients, 81% had received DAPT, 2.0% no AP therapy, 5.5% ASA only, 3.5% ASA + AP loading dose, 4.9% P2Yi only, and 2.4% P2Yi + AP loading dose. The corresponding unadjusted rates of stroke/death were 1.5%, 3.3%, 3.3%, 2.9%, 1.2%, and 1.1%. After adjustment, compared with DAPT, the incidence of stroke/death was higher with no AP therapy (RR, 2.0; 95% CI, 1.2-3.3) and ASA only (RR, 2.2; 95% CI, 1.5-3.1), with a trend toward a higher incidence with ASA + AP loading dose (RR, 1.6; 95% CI, 0.99-2.6), and was similar with P2Yi only (RR, 0.98; 95% CI, 0.54-1.8) and P2Yi + AP loading dose (RR, 0.66; 95% CI, 0.27-1.6). No differences were found in the incidence of access-related bleeding between the treatment groups after tfCAS or TCAR. CONCLUSIONS Compared with DAPT, no AP therapy or ASA monotherapy was associated with higher rates of stroke/death after CAS and should be discouraged as unsafe practice. Meanwhile, P2Yi monotherapy was associated with similar rates of stroke/death. No differences were found in the incidence of bleeding complications, and adding an AP loading dose to ASA or P2Yi monotherapy within 4 hours of the procedure did not affect the outcomes. Overall, these findings support the current guidelines recommending DAPT before CAS but also suggest that P2Yi monotherapy might confer thromboembolic benefits similar to those with DAPT. However, an immediate preoperative AP loading dose might not provide additional thromboembolic benefits.
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Affiliation(s)
- Christina L Marcaccio
- Division of Vascular and Endovascular Surgery, Department of Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA
| | - Priya B Patel
- Division of Vascular and Endovascular Surgery, Department of Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA
| | - Vinamr Rastogi
- Division of Vascular and Endovascular Surgery, Department of Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA; Department of Vascular Surgery, Erasmus University Medical Centre, Rotterdam, The Netherlands
| | - Lars Stangenberg
- Division of Vascular and Endovascular Surgery, Department of Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA
| | - Patric Liang
- Division of Vascular and Endovascular Surgery, Department of Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA
| | - Mark C Wyers
- Division of Vascular and Endovascular Surgery, Department of Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA
| | - Jeffrey Jim
- Section of Vascular and Endovascular Surgery, Minneapolis Heart Institute, Abbott Northwestern Hospital, Minneapolis, MN
| | - Peter A Schneider
- Division of Vascular and Endovascular Surgery, University of California, San Francisco, San Francisco, CA
| | - Marc L Schermerhorn
- Division of Vascular and Endovascular Surgery, Department of Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA.
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Levin SR, Farber A, Kobzeva-Herzog A, King EG, Eslami MH, Garg K, Patel VI, Rockman CB, Rybin D, Siracuse JJ. Postoperative Disability and One-Year Outcomes for Patients Suffering a Stroke after Carotid Endarterectomy. J Vasc Surg 2023:S0741-5214(23)01012-1. [PMID: 37040850 DOI: 10.1016/j.jvs.2023.04.002] [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: 12/04/2022] [Revised: 03/30/2023] [Accepted: 04/01/2023] [Indexed: 04/13/2023]
Abstract
OBJECTIVES Although post-carotid endarterectomy (CEA) strokes are rare, they can be devastating. The degree of disability that patients develop after such events and its effects on long-term outcomes are unclear. Our goal was to assess the extent of postoperative disability in patients suffering strokes after CEA and evaluate its association with long-term outcomes. METHODS The Vascular Quality Initiative CEA registry (2016-2020) was queried for CEAs performed for asymptomatic or symptomatic indications in patients with preoperative modified Rankin Scale (mRS) scores of 0-1. The mRS grades stroke-related disability as 0 (none), 1 (not significant), 2-3 (moderate), 4-5 (severe), and 6 (dead). Patients suffering postoperative strokes with recorded mRS scores were included. Postoperative stroke-related disability based on mRS and its association with long-term outcomes were analyzed. RESULTS Among 149,285 patients undergoing CEA, there were 1,178 patients without preoperative disability who had postoperative strokes and reported mRS scores. Mean age was 71 ± 9.2 years and 59.6% of patients were male. Regarding ipsilateral cortical symptoms within six months preoperatively, 83.5% of patients were asymptomatic, 7.3% had transient ischemic attacks, and 9.2% had strokes. Postoperative stroke-related disability was classified as mRS 0 (11.6%), 1 (19.5%), 2-3 (29.4%), 4-5 (31.5%), and 6 (8%). One-year survival stratified by postoperative stroke-related disability was 91.4% for mRS 0, 95.6% for mRS 1, 92.1% for mRS 2-3, and 81.5% for mRS 4-5 (P<.001). Multivariable analysis demonstrated that while severe postoperative disability was associated with increased death at one year (HR 2.97, 95% CI 1.5-5.89, P=.002), moderate postoperative disability had no such association (HR .95, 95% CI .45-2, P=.88). One-year freedom from subsequent ipsilateral neurological events or death stratified by postoperative stroke-related disability was 87.8% for mRS 0, 93.3% for mRS 1, 88.5% for mRS 2-3, and 77.9% for mRS 4-5 (P<.001). Severe postoperative disability was independently associated with increased ipsilateral neurological events or death at one year (HR 2.34, 95% CI 1.25-4.38, P=.01). However, moderate postoperative disability exhibited no such association (HR .92, 95% CI .46-1.82, P=.8). CONCLUSIONS The majority of patients without preoperative disability who suffered strokes after CEA developed significant disability. Severe stroke-related disability was associated with higher one-year mortality and subsequent neurological events. These data can improve informed consent for CEA and guide prognostication after postoperative strokes.
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Affiliation(s)
- Scott R Levin
- Division of Vascular and Endovascular Surgery, Boston Medical Center, Boston University Chobanian and Avedisian School of Medicine, Boston, MA
| | - Alik Farber
- Division of Vascular and Endovascular Surgery, Boston Medical Center, Boston University Chobanian and Avedisian School of Medicine, Boston, MA
| | - Anna Kobzeva-Herzog
- Division of Vascular and Endovascular Surgery, Boston Medical Center, Boston University Chobanian and Avedisian School of Medicine, Boston, MA
| | - Elizabeth G King
- Division of Vascular and Endovascular Surgery, Boston Medical Center, Boston University Chobanian and Avedisian School of Medicine, Boston, MA
| | - Mohammad H Eslami
- Division of Vascular and Endovascular Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA
| | - Karan Garg
- Division of Vascular and Endovascular Surgery, NYU Langone Health, New York, NY
| | - Virendra I Patel
- Section of Vascular Surgery and Endovascular Interventions, NYP-Columbia University Irving Medical Center, New York, NY
| | - Caron B Rockman
- Division of Vascular and Endovascular Surgery, NYU Langone Health, New York, NY
| | - Denis Rybin
- Department of Biostatistics, Boston University School of Public Health, Boston, MA
| | - Jeffrey J Siracuse
- Division of Vascular and Endovascular Surgery, Boston Medical Center, Boston University Chobanian and Avedisian School of Medicine, Boston, MA.
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Paraskevas KI, Dardik A, Gloviczki P. Management of Restenosis after Carotid Endarterectomy or Stenting. Angiology 2023; 74:305-307. [PMID: 36239036 DOI: 10.1177/00033197221133945] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Kosmas I Paraskevas
- Department of Vascular Surgery, 69087Central Clinic of Athens, Athens, Greece
| | - Alan Dardik
- Division of Vascular Surgery and Endovascular Therapy, 12228Yale University School of Medicine, New Haven, CT, USA
| | - Peter Gloviczki
- Division of Vascular and Endovascular Surgery, 4352Mayo Clinic, Rochester, MN, USA
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Wang SX, Marcaccio CL, Patel PB, Giles KA, Soden PA, Schermerhorn ML, Liang P. Distal embolic protection use during transfemoral carotid artery stenting is associated with improved in-hospital outcomes. J Vasc Surg 2023; 77:1710-1719.e6. [PMID: 36796592 DOI: 10.1016/j.jvs.2023.01.210] [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: 12/14/2022] [Revised: 01/29/2023] [Accepted: 01/30/2023] [Indexed: 02/16/2023]
Abstract
OBJECTIVE Despite current guidelines recommending the use of distal embolic protection during transfemoral carotid artery stenting (tfCAS) to prevent periprocedural stroke, there remains significant variation in the routine use of distal filters. We sought to assess in-hospital outcomes in patients undergoing tfCAS with and without embolic protection using a distal filter. METHODS We identified all patients undergoing tfCAS in the Vascular Quality Initiative from March 2005 to December 2021 and excluded those who received proximal embolic balloon protection. We created propensity score-matched cohorts of patients who underwent tfCAS with and without attempted placement of a distal filter. Subgroup analyses of patients with failed vs successful filter placement and failed vs no attempt at filter placement were performed. In-hospital outcomes were assessed using log binomial regression, adjusted for protamine use. Outcomes of interest were composite stroke/death, stroke, death, myocardial infarction (MI), transient ischemic attack (TIA), and hyperperfusion syndrome. RESULTS Among 29,853 patients who underwent tfCAS, 28,213 (95%) had a filter attempted for distal embolic protection and 1640 (5%) did not. After matching, 6859 patients were identified. No attempted filter was associated with significantly higher risk of in-hospital stroke/death (6.4% vs 3.8%; adjusted relative risk [aRR], 1.72; 95% confidence interval [CI], 1.32-2.23; P < .001), stroke (3.7% vs 2.5%; aRR, 1.49; 95% CI, 1.06-2.08; P = .022), and mortality (3.5% vs 1.7%; aRR, 2.07; 95% CI, 1.42-3.020; P < .001). In a secondary analysis of patients who had failed attempt at filter placement vs successful filter placement, failed filter placement was associated with worse outcomes (stroke/death: 5.8% vs 2.7%; aRR, 2.10; 95% CI, 1.38-3.21; P = .001 and stroke: 5.3% vs 1.8%; aRR, 2.87; 95% CI, 1.78-4.61; P < .001). However, there were no differences in outcomes in patients with failed vs no attempted filter placement (stroke/death: 5.4% vs 6.2%; aRR, 0.99; 95% CI, 0.61-1.63; P = .99; stroke: 4.7% vs 3.7%; aRR, 1.40; 95% CI, 0.79-2.48; P = .20; death: 0.9% vs 3.4%; aRR, 0.35; 95% CI, 0.12-1.01; P = .052). CONCLUSIONS tfCAS performed without attempted distal embolic protection was associated with a significantly higher risk of in-hospital stroke and death. Patients undergoing tfCAS after failed attempt at filter placement have equivalent stroke/death to patients in whom no filter was attempted, but more than a two-fold higher risk of stroke/death compared with those with successfully placed filters. These findings support current Society for Vascular Surgery guidelines recommending routine use of distal embolic protection during tfCAS. If a filter cannot be placed safely, an alternative approach to carotid revascularization should be considered.
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Affiliation(s)
- Sophie X Wang
- Department of Surgery, Division of Vascular and Endovascular Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA
| | - Christina L Marcaccio
- Department of Surgery, Division of Vascular and Endovascular Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA
| | - Priya B Patel
- Department of Surgery, Division of Vascular and Endovascular Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA
| | - Kristina A Giles
- Department of Surgery, Division of Vascular Surgery, Maine Medical Center, Portland, ME
| | - Peter A Soden
- Department of Surgery, Division of Vascular Surgery, Brown University, Providence, RI
| | - Marc L Schermerhorn
- Department of Surgery, Division of Vascular and Endovascular Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA
| | - Patric Liang
- Department of Surgery, Division of Vascular and Endovascular Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA.
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Blecha M, DeJong M, Nam J, Penton A. Modifiable risk factors for occurrence of ipsilateral ischemic events after carotid endarterectomy beyond perioperative period. J Vasc Surg 2023; 77:538-547.e2. [PMID: 36181995 DOI: 10.1016/j.jvs.2022.09.021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2022] [Revised: 09/07/2022] [Accepted: 09/19/2022] [Indexed: 01/25/2023]
Abstract
OBJECTIVE The purpose of this study was to quantify the effects of several modifiable variables on the occurrence of stroke after the initial perioperative period for patients who had undergone carotid endarterectomy (CEA). METHODS The primary outcome for the present study was the development of an ischemic stroke or transient ischemic attack (TIA) in the cerebral hemisphere ipsilateral to CEA after the initial hospitalization. All CEAs in the VQI between January 2003 and May 2022 were queried. We identified 171,816 CEAs in the database. The exclusion criteria for the study were the lack of follow-up data for >30 days, concomitant coronary artery bypass surgery, concomitant proximal or distal carotid intervention at CEA, other arterial interventions at CEA, and stroke or TIA during the initial hospital admission, leaving 126,290 patients for analysis. We used the χ2 test for statistical analysis of the outcome of ipsilateral ischemic stroke or TIA after the initial CEA hospital admission to determine the relevant variables. Age was evaluated as an ordinal variable using the Student t test. Variables with P ≤ .05 on univariable analysis were included in the multivariable Cox regression time-to-event analysis for the primary outcome. Kaplan-Meier curves were constructed of the most significant variables on Cox regression as a visual aid. RESULTS The following variables achieved significance on Cox regression for an association with development of ipsilateral hemispheric ischemic events after the index CEA hospital admission: lack of patch placement at CEA site (hazard ratio [HR], 18.24; P < .0001), lack of antiplatelet therapy at long-term follow-up (LTFU; HR, 9.75; P < .0001), lack of statin therapy at LTFU (HR, 3.18; P < .001), lack of statin therapy at hospital discharge (HR, 1.25; P = .015), anticoagulation at LTFU (HR, 1.53; P < .001), development of >70% recurrent stenosis (HR, 2.15; P < .001), and shunt use at surgery (HR, 1.20; P = .007). Patients with patch placement at surgery and patients with confirmed antiplatelet therapy at LTFU had had 99.8% and 99.6% freedom from an ischemic event ipsilateral to the side of the CEA at LTFU, respectively. This finding is in contrast to the 5.7% and 4.7% positivity for ischemic events for those without patch placement at surgery and those not receiving antiplatelet therapy at LTFU, respectively (P < .0001 for both). CONCLUSIONS Performance of patch angioplasty arterial closure was remarkably protective against ipsilateral cerebral ischemic events at LTFU after CEA. Discharging and maintaining patients with antiplatelet and statin medication after CEA significantly reduces the incidence of future ipsilateral ischemic events. Thus, a significant opportunity exists for enhanced outcomes with improved implementation of these measures.
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Affiliation(s)
- Matthew Blecha
- Division of Vascular Surgery and Endovascular Therapy, Loyola University Health System, Maywood, IL.
| | - Matthew DeJong
- Department of Surgery, Loyola University Medical Center, Maywood, IL
| | - Janice Nam
- Stritch School of Medicine, Loyola University Chicago, Maywood, IL
| | - Ashley Penton
- Department of Surgery, Loyola University Medical Center, Maywood, IL
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Elsayed N, Vasudevan RS, Zarrintan S, Barleben A, Kashyap VS, Malas MB. TransCarotid Artery Revascularization Can Be Safely Performed in Patients Undergoing Dialysis. Ann Vasc Surg 2023; 92:57-64. [PMID: 36690251 DOI: 10.1016/j.avsg.2023.01.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2022] [Revised: 12/27/2022] [Accepted: 01/05/2023] [Indexed: 01/21/2023]
Abstract
BACKGROUND TransCarotid Artery Revascularization (TCAR) has been effectively performed to prevent stroke in patients with carotid artery stenosis (CS). Prior studies established that TCAR can be safely performed in high-risk patients such as octogenarians, patients with prior carotid endarterectomy (CEA), contralateral occlusion, and heavily calcified lesions. Hemodialysis patients are at an increased risk of exhibiting cardiovascular complications. This study aims to investigate how dialysis may affect TCAR outcomes. METHODS The Vascular Quality Initiative (VQI) dataset was queried for patients undergoing TCAR from November 2016 to November 2021. Patients were divided into dialysis and nondialysis groups. The primary outcome was the composite endpoint of in-hospital stroke, death, or myocardial infarction (MI). Secondary outcomes were in-hospital stroke, stroke, or transient ischemic attack (TIA), death, prolonged length of stay (more than 1 day) (PLOS), MI, and stroke or death. Multivariable logistic regression analysis was used to assess in-hospital outcomes. Kaplan-Meier survival and log-rank test were used to assess 1-year survival. RESULTS A total of 22,619 patients underwent TCAR during the study period. Of these, 327 patients were undergoing dialysis. On univariable analysis, dialysis patients were associated with a higher risk of mortality compared to nondialysis patients (1.2% vs. 0.6%, P = 0.030). However, after adjusting for potential confounders, this difference did not persist (odd ratio [OR]: 1.99, 95% confidence interval [CI] (0.8-4.9), P = 0.136). Dialysis patients were more likely to experience PLOS (OR: 1.6, 95% CI (1.2-2), P < 0.001). There was no difference between dialysis and nondialysis patients in the risk of stroke or death, stroke, stroke or TIA, MI, and stroke or death, or MI on univariable and multivariable analyses. At 1 year, the overall survival for dialysis versus nondialysis patients was 81.5% vs. 95.5%, P < 0.001. CONCLUSIONS To our knowledge, this is the first study to date of dialysis patients who have undergone TCAR. We have shown that there was no difference in the risk of stroke, death, and MI between dialysis and nondialysis patients. Therefore, TCAR can be safely offered to patients undergoing dialysis. Future studies with larger number of patients are warranted to confirm these results.
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Affiliation(s)
- Nadin Elsayed
- Division of Vascular and Endovascular Surgery, University of California San Diego, La Jolla, CA
| | - Rajiv S Vasudevan
- Division of Vascular and Endovascular Surgery, University of California San Diego, La Jolla, CA
| | - Sina Zarrintan
- Division of Vascular and Endovascular Surgery, University of California San Diego, La Jolla, CA
| | - Andrew Barleben
- Division of Vascular and Endovascular Surgery, University of California San Diego, La Jolla, CA
| | - Vikram S Kashyap
- Frederik Meijer Heart and Vascular Institute, Spectrum Health, Grand Rapids, MI
| | - Mahmoud B Malas
- Division of Vascular and Endovascular Surgery, University of California San Diego, La Jolla, CA.
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Patel RJ, Marmor R, Dakour H, Elsayed N, Ramachandran M, Malas MB. Dual Antiplatelet Therapy Is Associated with Increased Risk of Bleeding and Decreased Risk of Stroke Following Carotid Endarterectomy. Ann Vasc Surg 2023; 88:191-198. [PMID: 35921978 PMCID: PMC10238168 DOI: 10.1016/j.avsg.2022.07.010] [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: 04/15/2022] [Revised: 06/22/2022] [Accepted: 07/07/2022] [Indexed: 11/27/2022]
Abstract
BACKGROUND Despite many patients undergoing carotid endarterectomy (CEA) being on dual antiplatelet therapy (DAPT) for cardiac or neurologic indications, the impact of such therapy on perioperative outcomes remains unclear. We aim to compare rates of postoperative bleeding, stroke and major adverse events (stroke, death or MI) among patients on Aspirin alone (ASAA) versus DAPT (Clopidogrel and Aspirin). METHODS Patients undergoing CEA for carotid artery stenosis between 2010 and 2021 in the Vascular Quality Initiative (VQI) were included. We excluded patients undergoing concomitant or re-do operations or patients with missing antiplatelet information. Propensity score matching was performed between the 2 groups ASAA and DAPT based on age, sex, race, presenting symptoms, major comorbidities [hypertension, diabetes and coronary artery disease (CAD)], degree of ipsilateral stenosis, presence of contralateral occlusion, as well as preoperative medications. Intergroup differences between the treatment groups and differences in perioperative outcomes were tested with the McNemar's test for categorical variables and paired t-test or Wilcoxon matched-pairs signed-rank test for continuous variables where appropriate. Relative risks with 95% confidence intervals were estimated as the ratio of the probability of the outcome event in the patients treated within each treatment group. RESULTS A total of 125,469 patients were included [ASAA n = 82,920 (66%) and DAPT n = 42,549 (34%)]. Patients on DAPT were more likely to be symptomatic, had higher rates of CAD, prior percutaneous coronary intervention or coronary artery bypass grafting, and higher rates of diabetes. After propensity score matching, the DAPT group had an increased rate of bleeding complications (RR: 1.6: 1.4-1.8, P < 0.001) as compared with those on ASAA despite being more likely to receive both drains and protamine. In addition, patients on DAPT had a slight decrease in the risk of in-hospital stroke as compared with patients on ASAA (RR: 0.80: 0.7-0.9, P = 0.001). CONCLUSIONS This large multi-institutional study demonstrates a modest decrease in the risk of in-hospital stroke for patients on DAPT undergoing CEA as compared with those on ASAA. This small benefit is at the expense of a significant increase in the risk of perioperative bleeding events incurred by those on DAPT at the time of CEA. This analysis suggests avoiding DAPT when possible, during CEA.
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Affiliation(s)
- Rohini J Patel
- Division of Vascular and Endovascular Surgery, University of California San Diego, San Diego, CA
| | - Rebecca Marmor
- Division of Vascular Surgery and Endovascular Therapy, The Johns Hopkins University, Baltimore, MD
| | - Hanaa Dakour
- Division of Vascular Surgery, Indiana University, Indianapolis, IN
| | - Nadin Elsayed
- Division of Vascular and Endovascular Surgery, University of California San Diego, San Diego, CA
| | - Mokhshan Ramachandran
- Division of Vascular and Endovascular Surgery, University of California San Diego, San Diego, CA
| | - Mahmoud B Malas
- Division of Vascular and Endovascular Surgery, University of California San Diego, San Diego, CA.
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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: 205] [Impact Index Per Article: 205.0] [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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50
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Zeebregts CJ, Paraskevas KI. The New 2023 European Society for Vascular Surgery (ESVS) Carotid Guidelines - The European Perspective. Eur J Vasc Endovasc Surg 2023; 65:3-4. [PMID: 35533843 DOI: 10.1016/j.ejvs.2022.04.033] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2022] [Accepted: 04/29/2022] [Indexed: 01/17/2023]
Affiliation(s)
- Clark J Zeebregts
- Department of Surgery, Division of Vascular Surgery, University Medical Centre Groningen, University of Groningen, Groningen, the Netherlands.
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