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Chang RW, Pimentel N, Tucker LY, Rothenberg KA, Avins AL, Flint AC, Faruqi RM, Nguyen-Huynh MN, Neugebauer R. A comparative effectiveness study of carotid intervention for long-term stroke prevention in patients with severe asymptomatic stenosis from a large integrated health system. J Vasc Surg 2023; 78:1239-1247.e4. [PMID: 37406943 PMCID: PMC11020993 DOI: 10.1016/j.jvs.2023.06.024] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2023] [Revised: 06/23/2023] [Accepted: 06/26/2023] [Indexed: 07/07/2023]
Abstract
OBJECTIVE The results of current prospective trials comparing the effectiveness of carotid endarterectomy (CEA) vs standard medical therapy for long-term stroke prevention in patients with asymptomatic carotid stenosis (ACS) will not be available for several years. In this study, we compared the observed effectiveness of CEA and standard medical therapy vs standard medical therapy alone to prevent ipsilateral stroke in a contemporary cohort of patients with ACS. METHODS This cohort study was conducted in a large integrated health system in adult subjects with 70% to 99% ACS (no neurologic symptom within 6 months) with no prior ipsilateral carotid artery intervention. Causal inference methods were used to emulate a conceptual randomized trial using data from January 1, 2008, through December 31, 2017, for comparing the event-free survival over 96 months between two treatment strategies: (1) CEA within 12 months from cohort entry vs (2) no CEA (standard medical therapy alone). To account for both baseline and time-dependent confounding, inverse probability weighting estimation was used to derive adjusted hazard ratios, and cumulative risk differences were assessed based on two logistic marginal structural models for counterfactual hazards. Propensity scores were data-adaptively estimated using super learning. The primary outcome was ipsilateral anterior ischemic stroke. RESULTS The cohort included 3824 eligible patients with ACS (mean age: 73.7 years, 57.9% male, 12.3% active smokers), of whom 1467 underwent CEA in the first year, whereas 2297 never underwent CEA. The median follow-up was 68 months. A total of 1760 participants (46%) died, 445 (12%) were lost to follow-up, and 158 (4%) experienced ipsilateral stroke. The cumulative risk differences for each year of follow-up showed a protective effect of CEA starting in year 2 (risk difference = 1.1%, 95% confidence interval: 0.5%-1.6%) and persisting to year 8 (2.6%, 95% confidence interval: 0.3%-4.8%) compared with patients not receiving CEA. CONCLUSIONS In this contemporary cohort study of patients with ACS using rigorous analytic methodology, CEA appears to have a small but statistically significant effect on stroke prevention out to 8 years. Further study is needed to appropriately select the subset of patients most likely to benefit from intervention.
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Affiliation(s)
- Robert W Chang
- Department of Vascular Surgery, the Permanente Medical Group, South San Francisco, CA; Division of Research, Kaiser Permanente Northern California, Oakland, CA.
| | - Noel Pimentel
- Division of Research, Kaiser Permanente Northern California, Oakland, CA
| | - Lue-Yen Tucker
- Division of Research, Kaiser Permanente Northern California, Oakland, CA
| | - Kara A Rothenberg
- Department of Surgery, University of California San Francisco-East Bay, Oakland, CA
| | - Andrew L Avins
- Division of Research, Kaiser Permanente Northern California, Oakland, CA; Departments of Medicine and Epidemiology & Biostatistics, University of California San Francisco, San Francisco, CA
| | - Alexander C Flint
- Department of Neurology, The Permanente Medical Group, Redwood City, CA
| | - Rishad M Faruqi
- Department of Vascular Surgery, The Permanente Medical Group, Santa Clara, CA
| | - Mai N Nguyen-Huynh
- Division of Research, Kaiser Permanente Northern California, Oakland, CA; Department of Neurology, The Permanente Medical Group, Walnut Creek, CA
| | - Romain Neugebauer
- Division of Research, Kaiser Permanente Northern California, Oakland, CA; Department of Health System Science, Kaiser Permanente Bernard J. Tyson School of Medicine, Pasadena, CA
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Lareyre F, Nasr B, Chaudhuri A, Di Lorenzo G, Carlier M, Raffort J. Comprehensive Review of Natural Language Processing (NLP) in Vascular Surgery. EJVES Vasc Forum 2023; 60:57-63. [PMID: 37822918 PMCID: PMC10562666 DOI: 10.1016/j.ejvsvf.2023.09.002] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2023] [Revised: 07/13/2023] [Accepted: 09/08/2023] [Indexed: 10/13/2023] Open
Abstract
Objective The use of Natural Language Processing (NLP) has attracted increased interest in healthcare with various potential applications including identification and extraction of health information, development of chatbots and virtual assistants. The aim of this comprehensive literature review was to provide an overview of NLP applications in vascular surgery, identify current limitations, and discuss future perspectives in the field. Data sources The MEDLINE database was searched on April 2023. Review methods The database was searched using a combination of keywords to identify studies reporting the use of NLP and chatbots in three main vascular diseases. Keywords used included Natural Language Processing, chatbot, chatGPT, aortic disease, carotid, peripheral artery disease, vascular, and vascular surgery. Results Given the heterogeneity of study design, techniques, and aims, a comprehensive literature review was performed to provide an overview of NLP applications in vascular surgery. By enabling identification and extraction of information on patients with vascular diseases, such technology could help to analyse data from healthcare information systems to provide feedback on current practice and help in optimising patient care. In addition, chatbots and NLP driven techniques have the potential to be used as virtual assistants for both health professionals and patients. Conclusion While Artificial Intelligence and NLP technology could be used to enhance care for patients with vascular diseases, many challenges remain including the need to define guidelines and clear consensus on how to evaluate and validate these innovations before their implementation into clinical practice.
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Affiliation(s)
- Fabien Lareyre
- Department of Vascular Surgery, Hospital of Antibes Juan-les-Pins, France
- Université Côte d'Azur, Inserm, U1065, C3M, Nice, France
| | - Bahaa Nasr
- Department of Vascular and Endovascular Surgery, Brest University Hospital, Brest, France
- INSERM, UMR 1101, LaTIM, Brest, France
| | - Arindam Chaudhuri
- Bedfordshire - Milton Keynes Vascular Centre, Bedfordshire Hospitals, NHS Foundation Trust, Bedford, UK
| | - Gilles Di Lorenzo
- Department of Vascular Surgery, Hospital of Antibes Juan-les-Pins, France
| | - Mathieu Carlier
- Department of Urology, University Hospital of Nice, Nice, France
| | - Juliette Raffort
- Université Côte d'Azur, Inserm, U1065, C3M, Nice, France
- Institute 3IA Côte d’Azur, Université Côte d’Azur, France
- Clinical Chemistry Laboratory, University Hospital of Nice, France
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Gologorsky RC, Lancaster E, Tucker LY, Nguyen-Huynh MN, Rothenberg KA, Avins AL, Kuang HC, Chang RW. Natural History of Asymptomatic Moderate Carotid Artery Stenosis in a Large Community-Based Cohort. Stroke 2022; 53:2838-2846. [DOI: 10.1161/strokeaha.121.038426] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background:
Moderate carotid artery stenosis is a poorly defined risk factor for ischemic stroke. As such, practice recommendations are lacking. In this study, we describe the long-term risk of stroke in patients with moderate asymptomatic stenosis in an integrated health care system.
Methods:
All adult patients with asymptomatic moderate (50%–69%) internal carotid artery stenosis between 2008 and 2012 were identified, with follow-up through 2017. The primary outcome was acute ischemic stroke attributed to the ipsilateral carotid artery. Stroke rates were calculated using competing risk analysis. Secondary outcomes included disease progression, ipsilateral intervention, and long-term survival.
Results:
Overall, 11 614 arteries with moderate stenosis in 9803 patients were identified. Mean age was 74.2±9.9 years with 51.4% women. Mean follow-up was 5.1±2.9 years. There were 180 ipsilateral ischemic strokes (1.6%) identified (crude annual risk, 0.31% [95% CI, 0.21%–0.41%]), of which thirty-one (17.2%) underwent subsequent intervention. Controlling for death and intervention as competing risks, the cumulative incidence of stroke was 1.2% (95% CI, 1.0%–1.4%) at 5 years and 2.0% (95% CI, 1.7%–2.4%) at 10 years. Of identified strokes, 50 (27.8%) arteries had progressed to severe stenosis or occlusion. During follow-up, there were 17 029 carotid studies performed in 5951 patients, revealing stenosis progression in 1674 (14.4%) arteries, including 1614 (13.9%) progressing to severe stenosis and 60 (0.5%) to occlusion. The mean time to stenosis progression was 2.6±2.1 years. Carotid intervention occurred in 708 arteries (6.1%). Of these, 66.1% (468/708) had progressed to severe stenosis. The overall mortality rate was 44.5%, with 10.5% of patients lost to follow-up.
Conclusions:
In this community-based sample of patients with asymptomatic moderate internal carotid artery stenosis followed for an average of 5 years, the cumulative incidence of stroke is low out to 10 years. Future research is needed to optimize management strategies for this population.
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Affiliation(s)
- Rebecca C. Gologorsky
- Department of Surgery, University of California, San Francisco, East Bay, Oakland (R.C.G., K.A.R.)
| | | | - Lue-Yen Tucker
- Division of Research, Kaiser Permanente Northern California, Oakland (L.-Y.T., M.N.N.-H., A.L.A., R.W.C.)
| | - Mai N. Nguyen-Huynh
- Division of Research, Kaiser Permanente Northern California, Oakland (L.-Y.T., M.N.N.-H., A.L.A., R.W.C.)
- Department of Surgery, The Permanente Medical Group, Inc, Walnut Creek, CA (M.N.N.-H.,)
| | - Kara A. Rothenberg
- Department of Surgery, University of California, San Francisco, East Bay, Oakland (R.C.G., K.A.R.)
| | - Andrew L. Avins
- Division of Research, Kaiser Permanente Northern California, Oakland (L.-Y.T., M.N.N.-H., A.L.A., R.W.C.)
- Departments of Medicine and Epidemiology and Biostatistics, University of California, San Francisco (A.L.A.)
| | - Hui C. Kuang
- Department of Surgery, The Permanente Medical Group, San Francisco, CA (H.C.K.)
| | - Robert W. Chang
- Division of Research, Kaiser Permanente Northern California, Oakland (L.-Y.T., M.N.N.-H., A.L.A., R.W.C.)
- Department of Surgery, The Permanente Medical Group, South San Francisco, CA (R.W.C.)
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Chang RW, Tucker LY, Rothenberg KA, Lancaster E, Faruqi RM, Kuang HC, Flint AC, Avins AL, Nguyen-Huynh MN. Incidence of Ischemic Stroke in Patients With Asymptomatic Severe Carotid Stenosis Without Surgical Intervention. JAMA 2022; 327:1974-1982. [PMID: 35608581 PMCID: PMC9131743 DOI: 10.1001/jama.2022.4835] [Citation(s) in RCA: 33] [Impact Index Per Article: 16.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
IMPORTANCE Optimal management of patients with asymptomatic severe carotid stenosis is uncertain, due to advances in medical care and a lack of contemporary data comparing medical and surgical treatment. OBJECTIVE To estimate stroke outcomes among patients with medically treated asymptomatic severe carotid stenosis who did not undergo surgical intervention. DESIGN, SETTING, AND PARTICIPANTS Retrospective cohort study that included 3737 adult participants with asymptomatic severe (70%-99%) carotid stenosis diagnosed between 2008 and 2012 and no prior intervention or ipsilateral neurologic event in the prior 6 months. Participants received follow-up through 2019, and all were members of an integrated US regional health system serving 4.5 million members. EXPOSURES Imaging diagnosis of asymptomatic carotid stenosis of 70% to 99%. MAIN OUTCOMES AND MEASURES Occurrence of ipsilateral carotid-related acute ischemic stroke. Censoring occurred with death, disenrollment, or ipsilateral intervention. RESULTS Among 94 822 patients with qualifying imaging studies, 4230 arteries in 3737 (mean age, 73.8 [SD 9.5 years]; 57.4% male) patients met selection criteria including 2539 arteries in 2314 patients who never received intervention. The mean follow-up in this cohort was 4.1 years (SD 3.6 years). Prior to any intervention, there were 133 ipsilateral strokes with a mean annual stroke rate of 0.9% (95% confidence interval [CI], 0.7%-1.2%). The Kaplan-Meier estimate of ipsilateral stroke by 5 years was 4.7% (95% CI, 3.9%-5.7%). CONCLUSIONS AND RELEVANCE In a community-based cohort of patients with asymptomatic severe carotid stenosis who did not undergo surgical intervention, the estimated rate of ipsilateral carotid-related acute ischemic stroke was 4.7% over 5 years. These findings may inform decision-making regarding surgical and medical treatment for patients with asymptomatic severe carotid artery stenosis.
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Affiliation(s)
- Robert W. Chang
- Department of Vascular Surgery, The Permanente Medical Group, South San Francisco, California
- Division of Research, Kaiser Permanente Northern California, Oakland
| | - Lue-Yen Tucker
- Division of Research, Kaiser Permanente Northern California, Oakland
| | - Kara A. Rothenberg
- Department of Surgery, University of California San Francisco - East Bay, Oakland
| | | | - Rishad M. Faruqi
- Department of Vascular Surgery, The Permanente Medical Group, Santa Clara, California
| | - Hui C. Kuang
- Department of Vascular Surgery, The Permanente Medical Group, San Francisco, California
| | - Alexander C. Flint
- Division of Research, Kaiser Permanente Northern California, Oakland
- Department of Neurology, The Permanente Medical Group, Redwood City, California
| | - Andrew L. Avins
- Division of Research, Kaiser Permanente Northern California, Oakland
- Department of Medicine, University of California San Francisco
- Department of Epidemiology and Biostatistics, University of California San Francisco
| | - Mai N. Nguyen-Huynh
- Division of Research, Kaiser Permanente Northern California, Oakland
- Department of Neurology, The Permanente Medical Group, Walnut Creek, California
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