Carotid Revascularization in Older Adults: A Systematic Review and Meta-Analysis

A Comparison of Outcomes Between Transfemoral Versus Transradial Access for Carotid Stenting

BACKGROUND

The transradial (TR) approach has emerged as an alternative to the transfemoral (TF) approach in carotid artery stenting (CAS) because of its perceived benefits in access site complications and overall patient experience.

OBJECTIVE

To assess outcomes of TF vs TR approach for CAS.

METHODS

This is a retrospective single-center review of patients receiving CAS through the TR or TF route between 2017 and 2022. All patients with symptomatic and asymptomatic carotid disease who underwent attempted CAS were included in our study.

RESULTS

A total of 342 patients were included in this study: 232 underwent CAS through TF approach vs 110 through the TR route. On univariate analysis, the rate of overall complications was more than double for the TF vs TR cohort; however, this did not achieve statistical significance (6.5% vs 2.7%, odds ratio [OR] = 0.59 P = .36). The rate of cross-over from TR to TF was significantly higher on univariate analysis (14.6 % vs 2.6%, OR = 4.77, P = .005) and on inverse probability treatment weighting analysis (OR = 6.11, P < .001). The rate of in-stent stenosis (TR: 3.6% vs TF: 2.2%, OR = 1.71, P = .43) and strokes at follow-up (TF: 2.2% vs TR: 1.8%, OR = 0.84, P = .84) was not significantly different. Finally, median length of stay was comparable between both cohorts.

CONCLUSION

The TR approach is safe, feasible, and provides similar rates of complications and high rates of successful stent deployment compared with the TF route. Neurointerventionalists adopting the radial first approach should carefully assess the preprocedural computed tomography angiography to identify patients amenable to TR approach for carotid stenting.

Safety of Carotid Endarterectomy for Symptomatic Stenosis by Age: Meta-Analysis With Individual Patient Data

BACKGROUND

There is uncertainty whether elderly patients with symptomatic carotid stenosis have higher rates of adverse events following carotid endarterectomy. In trials, recurrent stroke risk on medical therapy alone increased with age, whereas operative stroke risk was not related. Few octogenarians were included in trials and there has been no systematic analysis of all study types. We aimed to evaluate the safety of carotid endarterectomy in symptomatic elderly patients, particularly in octogenarians.

METHODS

We did a systematic review and meta-analysis of studies (from January 1, 1980 through March 1, 2022) reporting post carotid endarterectomy risk of stroke, myocardial infarction, and death in patients with symptomatic carotid stenosis. We included observational studies and interventional arms of randomized trials if the outcome rates (or the raw data to calculate these) were provided. Individual patient data from 4 prospective cohorts enabled multivariate analysis.

RESULTS

Of 47 studies (107 587 patients), risk of perioperative stroke was 2.04% (1.94-2.14) in octogenarians (390 strokes/19 101 patients) and 1.85% (1.75-1.95) in nonoctogenarians (1395/75 537); P=0.046. Perioperative death was 1.09% (0.94-1.25) in octogenarians (203/18 702) and 0.53% (0.48-0.59) in nonoctogenarians (392/73 327); P<0.001. Per 5-year age increment, a linear increase in perioperative stroke, myocardial infarction, and death were observed; P=0.04 to 0.002. However, during the last 3 decades, perioperative stroke±death has declined significantly in octogenarians (7.78% [5.58-10.55] before year 2000 to 2.80% [2.56-3.04] after 2010); P<0.001. In Individual patient data multivariate-analysis (5111 patients), age ≥85 years was independently associated with perioperative stroke (P<0.001) and death (P=0.005). Yet, survival was similar for octogenarians versus nonoctogenarians at 1-year (95.0% [93.2-96.5] versus 97.5% [96.4-98.6]; P=0.08), as was 5-year stroke risk (11.93% [9.98-14.16]) versus 12.78% [11.65-13.61]; P=0.24).

CONCLUSIONS

We found a modest increase in perioperative risk with age in symptomatic patients undergoing carotid endarterectomy. As stroke risk increases with age when on medical therapy alone, our findings support selective urgent intervention in symptomatic elderly patients.

Guideline on carotid surgery for stroke prevention: updates from the Italian Society of Vascular and Endovascular Surgery. A trend towards personalized medicine

BACKGROUND

This guideline (GL) on carotid surgery as updating of "Stroke: Italian guidelines for Prevention and Treatment" of the ISO-SPREAD Italian Stroke Organization-Group, has recently been published in the National Guideline System and shared with the Italian Society of Vascular and Endovascular Surgery (SICVE) and other Scientific Societies and Patient's Association.

METHODS

GRADE-SIGN version, AGREE quality of reporting checklist. Clinical questions formulated according to the PICO model. Recommendations developed based on clinical questions by a multidisciplinary experts' panel and patients' representatives. Systematic reviews performed for each PICO question. Considered judgements filled by assessing the evidence level, direction, and strength of the recommendations.

RESULTS

The panel provided indications and recommendations for appropriate, comprehensive, and individualized management of patients with carotid stenosis. Diagnostic and therapeutic processes of the best medical therapy, carotid endarterectomy (CEA), carotid stenting (CAS) according to the evidences and the judged opinions were included. Symptomatic carotid stenosis in elective and emergency, asymptomatic carotid stenosis, association with ischemic heart disease, preoperative diagnostics, types of anesthesia, monitoring in case of CEA, CEA techniques, comparison between CEA and CAS, post-surgical carotid restenosis, and medical therapy are the main topics, even with analysis of uncertainty areas for risk-benefit assessments in the individual patient (personalized medicine [PM]).

CONCLUSIONS

This GL updates on the main recommendations for the most appropriate diagnostic and medical-surgical management of patients with atherosclerotic carotid artery stenosis to prevent ischemic stroke. This GL also provides useful elements for the application of PM in good clinical practice.

Patient-Tailored Stenting versus Endarterectomy for the Treatment of Asymptomatic Carotid Artery Stenosis

Carotid artery stenosis is a major cause of acute ischemic strokes in adults. Given the consequences and sequelae of an acute ischemic stroke, intervention while patients are still asymptomatic is a key opportunity for stroke prevention. Although carotid endarterectomy has been the gold standard of treatment for carotid stenosis for many years, recent advances in carotid stenting technology, practitioner experience, and dual antiplatelet therapy have expanded the use for treatments other than endarterectomy. Review of the current literature has demonstrated that endarterectomy and carotid artery stenting produce overall similar results for the treatment of asymptomatic carotid stenosis, but certain factors may help guide physicians and patients in choosing one treatment over the other. Age 70 years and older, renal disease, poor medication compliance, and unstable plaque features all portend better outcomes from endarterectomy, whereas age under 70 years, high cervical location of disease, cardiac disease, and reliable medication compliance favor stenting. The decision to pursue endarterectomy versus stenting is therefore complex, and although large studies have demonstrated similar outcomes, the approach to treatment of asymptomatic carotid stenosis must be optimized for each individual patient to achieve the best possible outcome.

[Carotid endarterectomy and carotid artery stenting in advanced age patients]

The manuscript is devoted to world experience of carotid endarterectomy and carotid artery stenting in advanced age patients. Some authors report the advantages of endovascular surgery in elderly patients while the others prefer carotid endarterectomy. Senile patients (75-80 years old) with asymptomatic internal carotid artery stenosis is one of the most difficult group for the management. This is due to a more complex assessment of perioperative surgical risk, high incidence of complicated atherosclerotic plaques in carotid arteries and dubious benefits of surgery considering short life expectancy and severe comorbidities. Accumulation of experience in the management of advanced age patients should be valuable for either optimizing or individualizing surgical strategy.

Impact of early diagnosis of carotid artery stenosis by carotid ultrasound: A protocol of systematic review and meta-analysis

BACKGROUND

The purpose of this study is to explore the impact of carotid ultrasound (CU) for early diagnosis of carotid artery stenosis (CAS).

METHODS

Literatures will be sought from the following electronic databases: MEDLINE, EMBASE, Cochrane Library, PSYCINFO, Web of Science, Allied and Complementary Medicine Database, and China National Knowledge Infrastructure. The search will cover from the start of indexing to the present without any limitations of language and publication status. All study quality will be assessed by Quality Assessment of Diagnostic Accuracy Studies tool, and data will be analyzed by RevMan V.5.3 software and Stata V.12.0 software.

RESULTS

This study will investigate the impact of CU for early diagnosis of CAS through sensitivity, specificity, positive likelihood ratio, negative likelihood ratio, and diagnostic odds ratio.

CONCLUSION

The findings of this study may provide helpful evidence for the impact of CU for early diagnosis of CAS.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO CRD42019153904.

Thirty-Day Outcome of Carotid Artery Stenting in Elderly Patients: A Single-Center Experience

BACKGROUND

The safety of carotid artery stenting (CAS) in elderly patients is controversial. The aims of this study were to evaluate 30-day outcomes after CAS in elderly patients (≥70 years old) and to investigate risk factors for postoperative incidence of major adverse clinical events (MACE) to improve CAS safety based on clinical evidence in this specific subgroup of patients.

METHODS

The data set included patients who underwent CAS between 2001 and 2017 at Xuanwu Hospital, Capital Medical University. The primary outcome variable was 30-day postoperative incidence of the following MACE: death, myocardial infarction, and ipsilateral stroke. Univariate and multivariate analyses were performed to identify high-risk patients and procedural characteristics associated with MACE.

RESULTS

A total of 1029 elderly patients who underwent CAS for carotid artery stenosis were identified and analyzed. The incidence of postoperative MACE was 3.01% (n = 31 cases [5 deaths, 24 strokes, and 2 myocardial infarctions]). After multivariate analysis, independent predictors of MACE included a family history of stroke (odds ratio [OR] = 3.817; 95% confidence interval [CI], 1.227-11.876; P = 0.021), symptomatic status (OR = 2.650; 95% CI, 1.210-5.806; P = 0.015), and modified Rankin Scale score ≥3 (OR = 4.594; 95% CI, 1.708-12.352; P = 0.003). Hyperlipidemia was not an independent risk factor (OR = 1.597; 95% CI, 0.745-3.425; P = 0.229).

CONCLUSIONS

At our center, CAS was safely performed in elderly patients. A family history of stroke, symptomatic status, and modified Rankin Scale score ≥3 indicating a neurologic deficit increased the risk of 30-day postoperative MACE.

Synchronous versus Staged Carotid Endarterectomy and Coronary Artery Bypass Graft for Patients with Concomitant Severe Coronary and Carotid Artery Stenosis: A Systematic Review and Meta-analysis

BACKGROUND

Due to the systemic nature of atherosclerosis, arteries at different sites are commonly simultaneously affected. As a result, severe coronary artery disease (CAD) requiring coronary artery bypass grafting (CABG) frequently coexists with significant carotid stenosis that warrants revascularization. To compare simultaneous carotid endarterectomy (CEA) and CABG versus staged CEA and CABG for patients with concomitant CAD and carotid artery stenosis in terms of perioperative outcomes.

METHODS

This study was performed according to the Preferred Reporting Items for Systematic reviews and Meta-Analyses guidelines. A meta-analysis was conducted with the use of a random effects model. The I² statistic was used to assess for heterogeneity.

RESULTS

Eleven studies comprising 44,895 patients were included in this meta-analysis (21,710 in the synchronous group and 23,185 patients in the staged group). The synchronous CEA and CABG group had a statistically significant lower risk for myocardial infarction (MI) (odds ratio [OR] 0.15, 95% CI 0.04-0.61, I² = 0%) and higher risk for stroke (OR 1.51, 95% CI 1.34-1.71, I² = 0%) and death (OR 1.33, 95% CI 1.01-1.75, I² = 47.8%). Transient ischemic attacks (TIAs) (OR 1.27, 95% CI 1.00-1.61, I² = 0.0%), postoperative bleeding (OR 0.82, 95% CI 0.22-3.05, I² = 0.0%), and pulmonary complications (OR 1.52, 95% CI 0.24-9.60, I² = 67.5%) were similar between the 2 groups.

CONCLUSIONS

Patients in the simultaneous CEA and CABG group had a significantly higher risk of 30-day mortality and stroke and lower risk for MI as compared to staged CEA and CABG group. The rates of TIA, postoperative bleeding, and pulmonary complications were similar between the 2 groups. Future randomized trials or prospective cohorts are needed to validate our results.