1
|
Gao X, Guo J, Pan D, Gu Y. Treatment Strategies for Asymptomatic Carotid Stenosis: A Systematic Review and Bayesian Network Meta-Analysis. Oper Neurosurg (Hagerstown) 2024:01787389-990000000-01241. [PMID: 38967441 DOI: 10.1227/ons.0000000000001251] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2024] [Accepted: 04/23/2024] [Indexed: 07/06/2024] Open
Abstract
BACKGROUND AND OBJECTIVES To compare the safety and efficacy of carotid endarterectomy (CEA), carotid stenting (CAS), and optimal medical therapy (OMT) in patients with asymptomatic carotid stenosis. METHODS Relevant randomized controlled trials were researched with PubMed, Web of Science, and the Cochrane Library databases. Fixed-effects model and random-effects model were used to estimate the relative risks and the hazard ratios (HRs). The results of the probabilistic analysis were reported as surfaces under the cumulative ranking curve. RESULTS Eight randomized controlled trials were included. Data from 10 348 patients (CEA: n = 4758; CAS: n = 3919; OMT: n = 1673) were evaluated. Compared with the previous OMT, CEA, CAS, and the current OMT (c-OMT) were all effective in reducing the risk of stroke (CEA: HR, 0.52; CI, 0.40-0.66; CAS: HR, 0.58; CI, 0.42-0.81; c-OMT: HR, 0.40; CI, 0.15-0.94); CEA and CAS reduced the risk of ipsilateral stroke (CEA: HR, 0.41; CI, 0.28-0.59; CAS: HR, 0.51; CI, 0.31-0.84), and the risk of fatal or disabling stroke (CEA: HR, 0.59; CI, 0.43-0.81; CAS: HR, 0.57; CI, 0.34-0.95). Regarding reducing the risk of stroke, only CEA was statistically significant in patients with any degree of stenosis compared with the previous medical treatment (<80%: HR, 0.48; CI, 0.33%-0.70%; 80%-99%: HR, 0.53; CI, 0.38-0.73). CONCLUSION In the treatment of asymptomatic carotid stenosis, the perioperative outcomes of CAS were similar to that of CEA; CEA, CAS, and c-OMT shared similar long-term outcomes; and CEA and CAS may be more effective in patients with high levels of asymptomatic stenosis.
Collapse
Affiliation(s)
- Xinyi Gao
- Department of Vascular Surgery, Xuanwu Hospital, Capital Medical University, Beijing, China
| | | | | | | |
Collapse
|
2
|
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
| |
Collapse
|
3
|
Pelz DM, Fox AJ, Spence JD, Lownie SP. Carotid Stenosis and Stroke: Historical Perspectives Leading to Current Challenges. Can J Neurol Sci 2024:1-6. [PMID: 38465386 DOI: 10.1017/cjn.2024.40] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/12/2024]
Abstract
The carotid artery is unique; it is the only vessel to bifurcate into a bulb larger than itself. The history of its anatomic description, understanding of its pathophysiology and evolution of its imaging are relevant to current controversies regarding measurement of stenosis, surgical/endovascular therapies and medical management of carotid stenosis in stroke prevention. Treatment decisions on millions of symptomatic and asymptomatic patients are routinely based on information from clinical trials from over 30 years ago. This article briefly summarizes the highlights of past research in key areas and discuss how they led to current challenges of diagnosis and treatment.
Collapse
Affiliation(s)
- David M Pelz
- Department of Medical Imaging, Schulich School of Medicine and Dentistry, Western University, London, ON, Canada
| | | | - J David Spence
- Neurology and Clinical Pharmacology, Schulich School of Medicine and Dentistry, Western University, London, ON, Canada
- Stroke Prevention and Atherosclerosis Research Centre, Robarts Research Institute, London, ON, Canada
| | - Stephen P Lownie
- Division of Neurosurgery, Department of Surgery, Dalhousie University, Halifax, NS, Canada
- Schulich School of Medicine and Dentistry, Western University, Halifax, NS, Canada
| |
Collapse
|
4
|
Benson JC, Saba L, Bathla G, Brinjikji W, Nardi V, Lanzino G. MR Imaging of Carotid Artery Atherosclerosis: Updated Evidence on High-Risk Plaque Features and Emerging Trends. AJNR Am J Neuroradiol 2023; 44:880-888. [PMID: 37385681 PMCID: PMC10411837 DOI: 10.3174/ajnr.a7921] [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: 03/29/2023] [Accepted: 05/14/2023] [Indexed: 07/01/2023]
Abstract
MR imaging is well-established as the criterion standard for carotid artery atherosclerosis imaging. The capability of MR imaging to differentiate numerous plaque components has been demonstrated, including those features that are associated with a high risk of sudden changes, thrombosis, or embolization. The field of carotid plaque MR imaging is constantly evolving, with continued insight into the imaging appearance and implications of various vulnerable plaque characteristics. This article will review the most up-to-date knowledge of these high-risk plaque features on MR imaging and will delve into 2 major emerging topics: the role of vulnerable plaques in cryptogenic strokes and the potential use of MR imaging to modify carotid endarterectomy treatment guidelines.
Collapse
Affiliation(s)
- J C Benson
- From the Departments of Radiology (J.C.B., G.B., W.B.)
| | - L Saba
- Department of Medical Sciences (L.S.), University of Cagliari, Cagliari, Italy
| | - G Bathla
- From the Departments of Radiology (J.C.B., G.B., W.B.)
| | - W Brinjikji
- From the Departments of Radiology (J.C.B., G.B., W.B.)
| | - V Nardi
- Cardiovascular Medicine (V.N.)
| | - G Lanzino
- Neurosurgery (G.L.), Mayo Clinic, Rochester, Minnesota
| |
Collapse
|
5
|
Gasior SA, O'Donnell JPM, Davey M, Clarke J, Jalali A, Ryan É, Aherne TM, Walsh SR. Optimal Management of Asymptomatic Carotid Artery Stenosis: A Systematic Review and Network Meta-Analysis. Eur J Vasc Endovasc Surg 2023; 65:690-699. [PMID: 36682406 DOI: 10.1016/j.ejvs.2023.01.020] [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: 05/14/2022] [Revised: 12/02/2022] [Accepted: 01/11/2023] [Indexed: 01/21/2023]
Abstract
OBJECTIVE Management of asymptomatic carotid artery stenosis (ACAS), including carotid endarterectomy (CEA), carotid artery stenting (CAS), and best medical treatment (BMT), remains inconsistent in current practice. Early studies reported a benefit of CEA vs. BMT; however, the current risk-benefit profile of invasive therapy lacks consensus. By evaluating the effects of modern BMT vs. invasive intervention on patient outcomes, this study aimed to influence the future management of ACAS. METHODS A systematic review and series of network meta-analyses were performed assessing peri-operative (within 30 days) and long term (30 days - 5 years) stroke and mortality risk between ACAS interventions. Total stroke, major, minor, ipsilateral, and contralateral stroke subtypes were assessed independently. Traditional (pre-2000) and modern (post-2000) BMT were compared to assess clinical improvements in medical therapy over the previous two decades. Risks of myocardial infarction (MI) and cranial nerve injury (CNI) were also assessed. RESULTS Seventeen reports of 14 310 patients with > 50% ACAS were included. CEA reduced the odds of a peri-operative stroke event occurring vs. CAS (odds ratio [OR] 1.6, 95% confidence interval [CI] 1.1 - 2.2 [0 - 20 fewer/1 000]). CEA and CAS reduced the long term odds of minor strokes (OR 0.35, 95% CI 0.21 - 0.59 [20 fewer/1 000]) and ipsilateral strokes (OR 0.27, 95% CI 0.19 - 0.39 [30 fewer/1 000]) vs. all BMT. CEA reduced the odds of major strokes and combined stroke and mortality vs. traditional BMT; however, no difference was found between CEA and modern BMT. CAS reduced the odds of peri-operative MI (OR 0.49, 95% CI 0. 26 - 0.91) and CNI (OR 0.07, 95% CI 0.01 - 0.42) vs. CEA. CONCLUSION Modern BMT demonstrates similar reductions in major stroke, combined stroke, and mortality to CEA. The overall risk reductions are low and data were unavailable to assess subgroups which may benefit from intervention. However, BMT carries the potential to reduce the requirement for surgical intervention in patients with ACAS.
Collapse
Affiliation(s)
- Sara A Gasior
- Department of Vascular Surgery, University Hospital Galway, Galway, Ireland.
| | - John P M O'Donnell
- Department of Vascular Surgery, University Hospital Galway, Galway, Ireland; Lambe Institute for Translational Discipline of Surgery, National University of Ireland, Galway, Ireland
| | - Matthew Davey
- Lambe Institute for Translational Discipline of Surgery, National University of Ireland, Galway, Ireland; Department of Surgery, Royal College of Surgeons in Ireland, Dublin, Ireland
| | - James Clarke
- Lambe Institute for Translational Discipline of Surgery, National University of Ireland, Galway, Ireland
| | | | - Éanna Ryan
- Lambe Institute for Translational Discipline of Surgery, National University of Ireland, Galway, Ireland
| | - Thomas M Aherne
- Department of Surgery, Royal College of Surgeons in Ireland, Dublin, Ireland
| | - Stewart R Walsh
- Department of Vascular Surgery, University Hospital Galway, Galway, Ireland; Lambe Institute for Translational Discipline of Surgery, National University of Ireland, Galway, Ireland
| |
Collapse
|
6
|
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: 184] [Impact Index Per Article: 184.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2022] [Accepted: 04/20/2022] [Indexed: 01/17/2023]
|
7
|
Monocyte Phenotypes and Physical Activity in Patients with Carotid Atherosclerosis. Antioxidants (Basel) 2022; 11:antiox11081529. [PMID: 36009247 PMCID: PMC9404804 DOI: 10.3390/antiox11081529] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2022] [Revised: 08/01/2022] [Accepted: 08/03/2022] [Indexed: 11/22/2022] Open
Abstract
Atherosclerosis is associated with low-grade inflammation involving circulating monocytes. It has been shown that the levels of intermediate pro-inflammatory monocytes are associated with cardiovascular mortality and risk of ischemic stroke. It also has been shown that physical activity (PA) decreases inflammation markers, incidence of strokes, and mortality. In this cross-sectional study, we tested the effect of PA on circulating monocytes phenotype rate. A total of 29 patients with a carotid stenosis > 50% were recruited. Levels of physical activity (MET.min/week) were measured by the GPAQ questionnaire, arterial samples of blood were collected to analyze monocyte phenotype (classical, intermediate and non-classical) assessed by flow cytometry, and venous blood samples were used to dose antioxidant activity and oxidative damage. Antioxidant capacity was reduced and oxidative damage increased in patients. There was a significant decrease in the percentage of classical and intermediate monocytes in moderately active patients as compared with non-active and highly active patients. Inversely, the rate of non-classical monocytes increased in moderately active patients. Intense PA appears to blunt the beneficial effects of moderate PA. Our study also suggests that PA could be beneficial in such patients by reducing the rate of intermediate monocytes known to predict the risk of ischemic stroke and by increasing the non-classical monocytes involved in lesions’ healing. Nevertheless, a longitudinal study would be necessary to confirm this hypothesis.
Collapse
|
8
|
Cheng SF, van Velzen TJ, Gregson J, Richards T, Jäger HR, Simister R, Kooi ME, de Borst GJ, Pizzini FB, Nederkoorn PJ, Brown MM, Bonati LH. The 2nd European Carotid Surgery Trial (ECST-2): rationale and protocol for a randomised clinical trial comparing immediate revascularisation versus optimised medical therapy alone in patients with symptomatic and asymptomatic carotid stenosis at low to intermediate risk of stroke. Trials 2022; 23:606. [PMID: 35897114 PMCID: PMC9328625 DOI: 10.1186/s13063-022-06429-z] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2022] [Accepted: 05/26/2022] [Indexed: 11/24/2022] Open
Abstract
Background Carotid endarterectomy is currently recommended for patients with recently symptomatic carotid stenosis ≥50%, based on randomised trials conducted 30 years ago. Several factors such as carotid plaque ulceration, age and associated comorbidities might influence the risk-benefit ratio of carotid revascularisation. A model developed in previous trials that calculates the future risk of stroke based on these features can be used to stratify patients into low, intermediate or high risk. Since the original trials, medical treatment has improved significantly. Our hypothesis is that patients with carotid stenosis ≥50% associated with a low to intermediate risk of stroke will not benefit from additional carotid revascularisation when treated with optimised medical therapy. We also hypothesise that prediction of future risk of stroke in individual patients with carotid stenosis can be improved using the results of magnetic resonance imaging (MRI) of the carotid plaque. Methods Patients are randomised between immediate revascularisation plus OMT versus OMT alone. Suitable patients are those with asymptomatic or symptomatic carotid stenosis ≥50% with an estimated 5-year risk of stroke of <20%, as calculated using the Carotid Artery Risk score. MRI of the brain at baseline and during follow-up will be used as a blinded measure to assess the incidence of silent infarction and haemorrhage, while carotid plaque MRI at baseline will be used to investigate the hypotheses that plaque characteristics determine future stroke risk and help identify a subgroup of patients that will benefit from revascularisation. An initial analysis will be conducted after recruitment of 320 patients with baseline MRI and a minimum of 2 years of follow-up, to provide data to inform the design and sample size for a continuation or re-launch of the study. The primary outcome measure of this initial analysis is the combined 2-year rate of any clinically manifest stroke, new cerebral infarct on MRI, myocardial infarction or periprocedural death. Discussion ECST-2 will provide new data on the efficacy of modern optimal medical therapy alone versus added carotid revascularisation in patients with carotid stenosis at low to intermediate risk of future stroke selected by individualised risk assessment. We anticipate that the results of baseline brain and carotid plaque MRI will provide data to improve the prediction of the risk of stroke and the effect of treatment in patients with carotid stenosis. Trial registration ISRCTN registry ISRCTN97744893. Registered on 05 July 2012
Collapse
Affiliation(s)
- Suk Fun Cheng
- Stroke Research Centre, Department of Brain Repair and Rehabilitation, UCL Queen Square Institute of Neurology, University College London, London, UK
| | - Twan J van Velzen
- Department of Neurology, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - John Gregson
- Department of Medical Statistics, London School of Hygiene and Tropical Medicine, London, UK
| | - Toby Richards
- Faculty of Health and Medical Sciences, Surgery, University of Western Australia, Perth, Australia
| | - Hans Rolf Jäger
- Neuroradiological Academic Unit, Department of Brain Repair and Rehabilitation, UCL Queen Square Institute of Neurology, University College London, London, UK.,Lysholm Department of Neuroradiology, National Hospital for Neurology and Neurosurgery, University College London Hospitals NHS Foundation Trust, London, UK
| | - Robert Simister
- Stroke Research Centre, Department of Brain Repair and Rehabilitation, UCL Queen Square Institute of Neurology, University College London, London, UK.,Comprehensive Stroke Service, University College London Hospitals NHS Foundation Trust, London, UK
| | - M Eline Kooi
- Department of Radiology and Nuclear Medicine, CARIM School for Cardiovascular Diseases, Maastricht University, Maastricht, The Netherlands
| | - Gert J de Borst
- Department of Vascular Surgery, University Medical Center, Utrecht, The Netherlands
| | - Francesca B Pizzini
- Radiology, Department of Diagnostic and Public Health, University of Verona, Verona, Italy
| | - Paul J Nederkoorn
- Department of Neurology, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Martin M Brown
- Stroke Research Centre, Department of Brain Repair and Rehabilitation, UCL Queen Square Institute of Neurology, University College London, London, UK.
| | - Leo H Bonati
- Department of Neurology, University Hospital Basel, Basel, Switzerland.,Department of Clinical Research, University of Basel, Basel, Switzerland.,Research Department, Reha Rheinfelden, Rheinfelden, Switzerland
| |
Collapse
|
9
|
Park SJ, Chan WY, Ng M, Chung YC, Chong TT, Bhakoo K, Chan JMS. Development of Molecular Magnetic Resonance Imaging Tools for Longitudinal Tracking of Carotid Atherosclerotic Disease Using Fast Imaging with Steady-State Precession. Transl Stroke Res 2022; 14:357-363. [PMID: 35856131 PMCID: PMC10159972 DOI: 10.1007/s12975-022-01067-8] [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: 03/17/2022] [Revised: 05/31/2022] [Accepted: 07/13/2022] [Indexed: 11/25/2022]
Abstract
Identification of patients with high-risk asymptomatic carotid plaques remains a challenging but essential step in stroke prevention. Current selection criteria for intervention in carotid disease are still determined by symptomatology and degree of luminal stenosis. This strategy has been less effective in identifying the high-risk asymptomatic individual patients. Inflammation is the key factor that drives plaque instability causing clinical sequelae. Currently, there is no imaging tool in routine clinical practice to assess the inflammatory status within atherosclerotic plaques. Herein we describe the development of a novel molecular magnetic resonance imaging (MRI) strategy to interrogate plaque inflammation, and hence its vulnerability in vivo, using dual-targeted iron particle-based probes and fast imaging with steady-state precession (FISP) sequence, adding further prognostic information to luminal stenosis alone. A periarterial cuff was used to generate high-risk plaques at specific timepoints and location of the carotid artery in an apolipoprotein-E-deficient mouse model. Using this platform, we demonstrated that in vivo dual-targeted iron particles with enhanced FISP can (i) target and characterise high-risk vulnerable plaques and (ii) quantitatively report and track the inflammatory activity within carotid plaques longitudinally. This molecular imaging tool may permit (i) accurate monitoring of the risk of carotid plaques and (ii) timely identification of high-risk asymptomatic patients for prophylactic carotid intervention, achieving early stroke prevention.
Collapse
Affiliation(s)
- Sung-Jin Park
- Translational Cardiovascular Imaging Group, Institute of Bioengineering and Bioimaging (IBB), Agency for Science, Technology and Research (A*STAR), Singapore, Singapore
| | - Wan Ying Chan
- Division of Oncologic Imaging, National Cancer Centre, Singapore, Singapore
| | - Michael Ng
- Translational Cardiovascular Imaging Group, Institute of Bioengineering and Bioimaging (IBB), Agency for Science, Technology and Research (A*STAR), Singapore, Singapore
| | | | - Tze Tec Chong
- Department of Vascular Surgery, Singapore General Hospital, SingHealth, Singapore, Singapore
| | - Kishore Bhakoo
- Institute of Bioengineering and Bioimaging (IBB), Agency for Science, Technology and Research (A*STAR), Singapore, Singapore
| | - Joyce M S Chan
- Translational Cardiovascular Imaging Group, Institute of Bioengineering and Bioimaging (IBB), Agency for Science, Technology and Research (A*STAR), Singapore, Singapore.
- Department of Vascular Surgery, Singapore General Hospital, SingHealth, Singapore, Singapore.
- Lee Kong Chian School of Medicine, Nanyang Technological University, Singapore, Singapore.
| |
Collapse
|
10
|
Abbott AL. Extra-Cranial Carotid Artery Stenosis: An Objective Analysis of the Available Evidence. Front Neurol 2022; 13:739999. [PMID: 35800089 PMCID: PMC9253595 DOI: 10.3389/fneur.2022.739999] [Citation(s) in RCA: 13] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2021] [Accepted: 01/24/2022] [Indexed: 12/26/2022] Open
Abstract
Background and Purpose Carotid stenosis is arterial disease narrowing of the origin of the internal carotid artery (main brain artery). Knowing how to best manage this is imperative because it is common in older people and an important cause of stroke. Inappropriately high expectations have grown regarding the value of carotid artery procedures, such as surgery (endarterectomy) and stenting, for lowering the stroke risk associated with carotid stenosis. Meanwhile, the improving and predominant value of medical intervention (lifestyle coaching and medication) continues to be underappreciated. Methods and Results This article aims to be an objective presentation and discussion of the scientific literature critical for decision making when the primary goal is to optimize patient outcome. This compilation follows from many years of author scrutiny to separate fact from fiction. Common sense conclusions are drawn from factual statements backed by original citations. Detailed research methodology is given in cited papers. This article has been written in plain language given the importance of the general public understanding this topic. Issues covered include key terminology and the economic impact of carotid stenosis. There is a summary of the evidence-base regarding the efficacy and safety of procedural and medical (non-invasive) interventions for both asymptomatic and symptomatic patients. Conclusions are drawn with respect to current best management and research priorities. Several "furphies" (misconceptions) are exposed that are commonly used to make carotid stenting and endarterectomy outcomes appear similar. Ongoing randomized trials are mentioned and why they are unlikely to identify a routine practice indication for carotid artery procedures. There is a discussion of relevant worldwide guidelines regarding carotid artery procedures, including how they should be improved. There is an outline of systematic changes that are resulting in better application of the evidence-base. Conclusion The cornerstone of stroke prevention is medical intervention given it is non-invasive and protects against all arterial disease complications in all at risk. The "big" question is, does a carotid artery procedure add patient benefit in the modern era and, if so, for whom?
Collapse
Affiliation(s)
- Anne L. Abbott
- Department of Neuroscience, Central Clinical School, Monash University, Melbourne, VIC, Australia
- Neurology Private Practice, Knox Private Hospital, Wantirna, VIC, Australia
| |
Collapse
|
11
|
Mura M, Rivoire E, Dehina-Khenniche L, Weiss-Gayet M, Chazaud B, Faes C, Connes P, Long A, Rytz CL, Mury P, Delrieu L, Gouraud E, Bordet M, Schiava ND, Lermusiaux P, Arsicot M, Millon A, Pialoux V. Effectiveness of an individualized home-based physical activity program in surgery-free non-endarterectomized asymptomatic stroke patients: a study protocol for the PACAPh interventional randomized trial. Trials 2022; 23:145. [PMID: 35164816 PMCID: PMC8842739 DOI: 10.1186/s13063-022-06061-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2021] [Accepted: 01/27/2022] [Indexed: 02/06/2023] Open
Abstract
Background Carotid atherosclerotic plaques remain silent until their rupture, which may lead to detrimental ischemic events such as strokes. This is due, in part, to intraplaque hemorrhages (IPH) and the resulting inflammatory processes, which may promote carotid plaque vulnerability. Currently, the benefits of carotid endarterectomy remain unclear for asymptomatic patients. Interestingly, the completion of physical activity (PA) may have beneficial effects; however, the paucity of current data warrants robust longitudinal interventions. We therefore aim to study the effects of a 6-month longitudinal personalized home-based PA program on IPH, biological, and inflammatory markers in asymptomatic stroke patients. Methods Eighty patients (≥ 18 years old) will be recruited for the Physical Activity and Carotid Atherosclerotic Plaque Hemorrhage (PACAPh) clinical trial from the Hospices Civils de Lyon. Patients will be eligible if they present with carotid stenosis ≥ 50% and are asymptomatic from any ischemic events for at least 6 months. Recruited patients will be randomized into either a PA or a control group, and assessed at baseline and after 6 months. At both time points, all patients will be assessed using magnetic resonance imaging to assess IPH, blood sampling to measure inflammatory markers and monocytic phenotyping, PA and sedentary behavior questionnaires, 6-min walking test, and maximal isometric quadricep contraction test. The randomized PA intervention will consist of reaching a daily walking step goal individually tailored to each patient. Steps will be collected using a wirelessly connected wristband. The number of steps completed by individuals in the PA group will be re-evaluated bimonthly to encourage walking habits. Discussion The PACAPh study is the first of its kind representing a feasible, easily accessible therapeutic strategy for asymptomatic stroke patients. We hypothesize that the personalized home-based PA program will reduce IPH and modulate inflammatory and biological parameters in patients presenting with carotid plaques. If the results of the PACAPh study prove to be beneficial on such health parameters, the implementation of such kind of intervention in the daily treatment of these patients would be an advantageous and cost-effective practice to adopt globally. Trial registration This study has been approved by the National Ethics Committee (IDRCB:2019-A01543-54/SI:19.06.21.40640). ClinicalTrials.gov NCT04053166
Collapse
|
12
|
Impact of the first COVID-19 pandemic peak and lockdown on the interventional management of carotid artery stenosis in France. J Vasc Surg 2021; 75:1670-1678.e2. [PMID: 34921965 PMCID: PMC8684845 DOI: 10.1016/j.jvs.2021.11.064] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2021] [Accepted: 11/12/2021] [Indexed: 02/07/2023]
Abstract
OBJECTIVE The aim of this study was to evaluate the impact of the COVID-19 pandemic on the trends of carotid revascularization (endarterectomy (CEA), transfemoral stenting (TFCAS)) for symptomatic and asymptomatic carotid stenosis before, during and after the end of the first lockdown in 2020 in France. METHODS Nationwide data were provided by the French National Hospital Discharge database (Programme de Médicalisation des Systèmes d'Information). We retrospectively analyzed patients admitted for CEA or TFCAS in all French public and private hospitals during a nine-month period (January-September) in 2017, 2018, 2019 and 2020. Procedures were identified using the French Common Classification of Medical Procedures. Stenoses were considered symptomatic in the presence of stroke and/or transient ischemic attack codes (according to the International Classification of Diseases-Tenth Revision) during the stay, and asymptomatic in the absence of these codes. Hospitalization rates in 2020 were compared with the rates in the same period in the three previous years. RESULTS Between January and September 2020, 12 546 patients were hospitalized for carotid artery surgery (CEA and TFCAS) in France. Compared with the three previous years, there was a decline in hospitalization rates for asymptomatic (-68.9%) and symptomatic (-12.6%) CEA procedures in April, starting at the pandemic peak concomitant with the first national lockdown. This decrease was significant for asymptomatic CEA (p<0.001). After the lockdown, while CEA for asymptomatic stenosis returned to usual activity, CEA for symptomatic stenosis presented a significant rebound, up 18.52% in August compared with previous years. Lockdown also had consequences on TFCAS procedures, with fewer interventions for both asymptomatic (-60.53%) and symptomatic stenosis (-16.67%) in April. CONCLUSIONS This study demonstrates a severe drop for all interventions during the first peak of the COVID-19 pandemic in France. However, the trends in the post-lockdown period were different for the various procedures. These data can be used to anticipate future decisions and organization for cardiovascular care.
Collapse
|
13
|
Knappich C, Lang T, Tsantilas P, Schmid S, Kallmayer M, Haller B, Eckstein HH. Intraoperative completion studies in carotid endarterectomy: systematic review and meta-analysis of techniques and outcomes. ANNALS OF TRANSLATIONAL MEDICINE 2021; 9:1201. [PMID: 34430642 PMCID: PMC8350645 DOI: 10.21037/atm-20-2931] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/28/2020] [Accepted: 10/16/2020] [Indexed: 11/18/2022]
Abstract
Background Declining perioperative stroke and death rates over the past 3 decades have been paralleled by an increasing use of intraoperative completion studies (ICS) following carotid endarterectomy (CEA). Techniques applied include angiography, intraoperative duplex ultrasound (IDUS), flowmetry, and angioscopy. This systematic review and meta-analysis is aiming on providing an overview of techniques and corresponding outcomes. Methods A PubMed based systematic literature review comprising the years 1980 through 2020 was performed using predefined keywords to identify articles on different ICS techniques. Pooled analyses and meta-analyses estimating risk ratios (RR) and 95% confidence intervals (CI) were performed to compare outcomes of different ICS modes to nonapplication of any ICS. I2 values were assessed to quantify study heterogeneities. Results Identification of 34 studies including patients undergoing CEA with angiography (n=53,218), IDUS (n=20,030), flowmetry (n=16,812), and angioscopy (n=2,291). Corresponding rates of perioperative stroke were 1.5%, 1.8%, 3.6%, and 1.5%, perioperative stroke or death occurred in 1.7%, 1.9%, 2.2%, and 2.0%. Intraoperative surgical revision rates were 6.2%, 5.9%, and 7.9% after CEA with angiography, IDUS, and angioscopy, respectively. Compared to nonapplication of any ICS, the pooled analysis revealed angiography to be significantly associated with lower rates of stroke (RR 0.47; 95% CI, 0.36–0.62; P<0.0001) and stroke or death (RR 0.76; 95% CI, 0.70–0.83; P<0.0001). IDUS was significantly associated with lower rates of stroke (RR 0.56; 95% CI, 0.43–0.73; P<0.0001) and stroke or death (RR 0.83; 95% CI, 0.74–0.93; P=0.0018), whereas angioscopy showed a significant association with a lower stroke rate (RR 0.48; 95% CI, 0.033–0.68; P=0.0001), but no effect on the combined stroke or death rate. Angioscopy was associated with a higher intraoperative revision rate compared to angiography (RR 1.29; 95% CI, 1.07–1.54; P=0.006). The meta-analyses confirmed lower perioperative stroke or death rates for angiography (RR 0.83; 95% CI, 0.76–0.91) and IDUS (RR 0.86; 95% CI, 0.76–0.98) compared to non-application of any ICS, whereas flowmetry showed no significant association. Conclusions This study represents the first systematic literature review and meta-analysis on usage of ICSs in CEA. Data strongly indicate a significant beneficial effect of angiography, IDUS, and angioscopy on perioperative CEA outcomes. Any carotid surgeon should consider implementation of ICSs in his routine armamentarium.
Collapse
Affiliation(s)
- Christoph Knappich
- Department for Vascular and Endovascular Surgery, Klinikum rechts der Isar, Technical University of Munich, Munich, Germany
| | - Thomas Lang
- Department for Vascular and Endovascular Surgery, Klinikum rechts der Isar, Technical University of Munich, Munich, Germany
| | - Pavlos Tsantilas
- Department for Vascular and Endovascular Surgery, Klinikum rechts der Isar, Technical University of Munich, Munich, Germany
| | - Sofie Schmid
- Department for Vascular and Endovascular Surgery, Klinikum rechts der Isar, Technical University of Munich, Munich, Germany
| | - Michael Kallmayer
- Department for Vascular and Endovascular Surgery, Klinikum rechts der Isar, Technical University of Munich, Munich, Germany
| | - Bernhard Haller
- Institute of Medical Informatics, Statistics and Epidemiology, Klinikum rechts der Isar, Technical University of Munich, Munich, Germany
| | - Hans-Henning Eckstein
- Department for Vascular and Endovascular Surgery, Klinikum rechts der Isar, Technical University of Munich, Munich, Germany
| |
Collapse
|
14
|
Saba L, Brinjikji W, Spence JD, Wintermark M, Castillo M, Borst GJD, Yang Q, Yuan C, Buckler A, Edjlali M, Saam T, Saloner D, Lal BK, Capodanno D, Sun J, Balu N, Naylor R, Lugt AVD, Wasserman BA, Kooi ME, Wardlaw J, Gillard J, Lanzino G, Hedin U, Mikulis D, Gupta A, DeMarco JK, Hess C, Goethem JV, Hatsukami T, Rothwell P, Brown MM, Moody AR. Roadmap Consensus on Carotid Artery Plaque Imaging and Impact on Therapy Strategies and Guidelines: An International, Multispecialty, Expert Review and Position Statement. AJNR Am J Neuroradiol 2021; 42:1566-1575. [PMID: 34326105 DOI: 10.3174/ajnr.a7223] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2020] [Accepted: 01/26/2021] [Indexed: 12/19/2022]
Abstract
Current guidelines for primary and secondary prevention of stroke in patients with carotid atherosclerosis are based on the quantification of the degree of stenosis and symptom status. Recent publications have demonstrated that plaque morphology and composition, independent of the degree of stenosis, are important in the risk stratification of carotid atherosclerotic disease. This finding raises the question as to whether current guidelines are adequate or if they should be updated with new evidence, including imaging for plaque phenotyping, risk stratification, and clinical decision-making in addition to the degree of stenosis. To further this discussion, this roadmap consensus article defines the limits of luminal imaging and highlights the current evidence supporting the role of plaque imaging. Furthermore, we identify gaps in current knowledge and suggest steps to generate high-quality evidence, to add relevant information to guidelines currently based on the quantification of stenosis.
Collapse
Affiliation(s)
- L Saba
- From the Department of Radiology (L.S.), University of Cagliari, Cagliari, Italy
| | | | - J D Spence
- Stroke Prevention and Atherosclerosis Research Centre (J.D.S.), Robarts Research Institute, Western University, London, Ontario, Canada
| | - M Wintermark
- Department of Neuroradiology (M.W.), Stanford University and Healthcare System, Stanford, California
| | - M Castillo
- Department of Radiology (M.C.), University of North Carolina, Chapel Hill, North Carolina
| | - G J D Borst
- Department of Vascular Surgery (G.J.D.B.), University Medical Center Utrecht, Utrecht, the Netherlands
| | - Q Yang
- Department of Radiology (Q.Y.), Xuanwu Hospital, Capital Medical University, Beijing, China
| | - C Yuan
- Departments of Radiology (C.Y., J.S., N.B.)
| | - A Buckler
- Elucid Bioimaging (A.B.), Boston, Massachusetts
| | - M Edjlali
- Department of Neuroradiology (M.E.), Université Paris-Descartes-Sorbonne-Paris-Cité, IMABRAIN-INSERM-UMR1266, DHU-Neurovasc, Centre Hospitalier Sainte-Anne, Paris, France
| | - T Saam
- Department of Radiology (T.S.), University Hospital, Ludwig Maximilian University of Munich, Munich, Germany.,Radiologisches Zentrum (T.S.), Rosenheim, Germany
| | - D Saloner
- Departments of Radiology and Biomedical Imaging (D.S., C.H.), University of California San Francisco, San Francisco, California
| | - B K Lal
- Department of Vascular Surgery (B.K.L.), University of Maryland School of Medicine, Baltimore, Maryland
| | - D Capodanno
- Division of Cardiology (D.C.), A.O.U. Policlinico "G. Rodolico-San Marco," University of Catania, Italy
| | - J Sun
- Departments of Radiology (C.Y., J.S., N.B.)
| | - N Balu
- Departments of Radiology (C.Y., J.S., N.B.)
| | - R Naylor
- The Leicester Vascular Institute (R.N.), Glenfield Hospital, Leicester, UK
| | - A V D Lugt
- Department of Radiology and Nuclear Medicine (A.v.d.L.), Erasmus MC, University Medical Center Rotterdam, Rotterdam, the Netherlands
| | - B A Wasserman
- The Russell H. Morgan Department of Radiology and Radiological Science (B.A.W.), Johns Hopkins Hospital, Baltimore, Maryland
| | - M E Kooi
- Department of Radiology and Nuclear Medicine (M.E.K.), CARIM School for Cardiovascular Diseases, Maastricht University Medical Center, Maastricht, the Netherlands
| | - J Wardlaw
- Centre for Clinical Brain Sciences (J.W.), United Kingdom Dementia Research Institute and Edinburgh Imaging, University of Edinburgh, Edinburgh, UK
| | - J Gillard
- Christ's College (J.G.), Cambridge, UK
| | - G Lanzino
- Neurosurgery (G.L.) Mayo Clinic, Rochester, Minnesota
| | - U Hedin
- Department of Molecular Medicine and Surgery (U.H.), Karolinska Institutet, Stockholm, Sweden.,Department of Vascular Surgery (U.H.), Karolinska University Hospital and Karolinska Institute, Stockholm, Sweden
| | - D Mikulis
- Joint Department of Medical Imaging and the Functional Neuroimaging Laboratory (D.M.), University Health Network, Toronto, Ontario, Canada
| | - A Gupta
- Department of Radiology (A.G.), Weill Cornell Medical College, New York, New York
| | - J K DeMarco
- Walter Reed National Military Medical Center and Uniformed Services University of the Health Sciences (J.K.D.), Bethesda, Maryland
| | - C Hess
- Departments of Radiology and Biomedical Imaging (D.S., C.H.), University of California San Francisco, San Francisco, California
| | - J V Goethem
- Faculty of Biomedical Sciences (J.V.G.), University of Antwerp, Antwerp, Belgium
| | - T Hatsukami
- Surgery (T.H.), University of Washington, Seattle, Washington
| | - P Rothwell
- Centre for Prevention of Stroke and Dementia (P.R.), Nuffield Department of Clinical Neurosciences, John Radcliffe Hospital, University of Oxford, UK
| | - M M Brown
- Stroke Research Centre (M.M.B.), Department of Brain Repair and Rehabilitation, University College of London Queen Square Institute of Neurology, University College London, UK
| | - A R Moody
- Department of Medical Imaging (A.R.M.), University of Toronto, Toronto, Ontario, Canada
| |
Collapse
|
15
|
Paraskevas KI, Mikhailidis DP, Baradaran H, Davies AH, Eckstein HH, Faggioli G, Fernandes E Fernandes J, Gupta A, Jezovnik MK, Kakkos SK, Katsiki N, Kooi ME, Lanza G, Liapis CD, Loftus IM, Millon A, Nicolaides AN, Poredos P, Pini R, Ricco JB, Rundek T, Saba L, Spinelli F, Stilo F, Sultan S, Zeebregts CJ, Chaturvedi S. Management of patients with asymptomatic carotid stenosis may need to be individualized: a multidisciplinary call for action. Republication of J Stroke 2021;23:202-212. INT ANGIOL 2021; 40:487-496. [PMID: 34313413 DOI: 10.23736/s0392-9590.21.04751-9] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
The optimal management of patients with asymptomatic carotid stenosis (ACS) is the subject of extensive debate. According to the 2017 European Society for Vascular Surgery guidelines, carotid endarterectomy should (Class IIa; Level of Evidence: B) or carotid artery stenting may be considered (Class IIb; Level of Evidence: B) in the presence of one or more clinical/imaging characteristics that may be associated with an increased risk of late ipsilateral stroke (e.g. silent embolic infarcts on brain computed tomography/magnetic resonance imaging, progression in the severity of ACS, a history of contralateral transient ischemic attack/stroke, microemboli detection on transcranial Doppler, etc.), provided documented perioperative stroke/death rates are <3% and the patient's life expectancy is >5 years. Besides these clinical/imaging characteristics, there are additional individual, ethnic/racial or social factors that should probably be evaluated in the decision process regarding the optimal management of these patients, such as individual patient needs/patient choice, patient compliance with best medical treatment, patient sex, culture, race/ethnicity, age and comorbidities, as well as improvements in imaging/operative techniques/outcomes. The present multispecialty position paper will present the rationale why the management of patients with ACS may need to be individualized.
Collapse
Affiliation(s)
| | - Dimitri P Mikhailidis
- Department of Clinical Biochemistry, Royal Free Hospital Campus, University College London Medical School, University College London (UCL), London, UK
| | - Hediyeh Baradaran
- Department of Radiology, University of Utah, Salt Lake City, UT, USA
| | - Alun H Davies
- Section of Vascular Surgery, Imperial College & Imperial Healthcare NHS Trust, London, UK
| | - Hans-Henning Eckstein
- Department of Vascular and Endovascular Surgery, Klinikum rechts der Isar, Technical University of Munich, Munich, Germany
| | - Gianluca Faggioli
- Vascular Surgery, University of Bologna Alma Mater Studiorum, Policlinico S. Orsola Malpighi, Bologna, Italy
| | | | - Ajay Gupta
- Department of Radiology, Weill Cornell Medicine, New York, NY, USA
| | - Mateja K Jezovnik
- Department of Advanced Cardiopulmonary Therapies and Transplantation, The University of Texas Health Science Centre at Houston, Houston, TX, USA
| | - Stavros K Kakkos
- Department of Vascular Surgery, University of Patras Medical School, Patras, Greece
| | - Niki Katsiki
- First Department of Internal Medicine, AHEPA University Hospital, Thessaloniki, Greece
| | - M Eline Kooi
- CARIM School for Cardiovascular Diseases, Maastricht University, Maastricht, The Netherlands.,Department of Radiology and Nuclear Medicine, Maastricht University Medical Center, Maastricht, The Netherlands
| | - Gaetano Lanza
- Vascular Surgery Department, IRCSS MultiMedica Hospital, Castellanza, Varese, Italy
| | | | - Ian M Loftus
- St. George's Vascular Institute, St. George's University London, London, UK
| | - Antoine Millon
- Department of Vascular and Endovascular Surgery, Louis Pradel Hospital, Hospices Civils de Lyon, Lyon, France
| | - Andrew N Nicolaides
- Department of Surgery, University of Nicosia Medical School, Nicosia, Cyprus
| | - Pavel Poredos
- Department of Vascular Disease, University Medical Centre Ljubljana, Ljubljana, Slovenia
| | - Rodolfo Pini
- Vascular Surgery, University of Bologna Alma Mater Studiorum, Policlinico S. Orsola Malpighi, Bologna, Italy
| | - Jean-Baptiste Ricco
- Department of Clinical Research, University of Poitiers, CHU de Poitiers, Poitiers, France
| | - Tatjana Rundek
- Department of Neurology, Miller School of Medicine, University of Miami, Miami, FL, USA
| | - Luca Saba
- Department of Radiology, Azienda Ospedaliera Universitaria di Cagliari, Cagliari, Italy
| | - Francesco Spinelli
- Vascular Surgery Division, Campus Bio-Medico University of Rome, Rome, Italy
| | - Francesco Stilo
- Vascular Surgery Division, Campus Bio-Medico University of Rome, Rome, Italy
| | - Sherif Sultan
- Western Vascular Institute, Department of Vascular and Endovascular Surgery, University Hospital Galway, National University of Ireland, Galway, Ireland
| | - Clark J Zeebregts
- Division of Vascular Surgery, Department of Surgery, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Seemant Chaturvedi
- Department of Neurology & Stroke Program, University of Maryland School of Medicine, Baltimore, MD, USA
| |
Collapse
|
16
|
Chang RW, Tucker LY, Rothenberg KA, Lancaster EM, Avins AL, Kuang HC, Faruqi RM, Nguyen-Huynh MN. Establishing a carotid artery stenosis disease cohort for comparative effectiveness research using natural language processing. J Vasc Surg 2021; 74:1937-1947.e3. [PMID: 34182027 DOI: 10.1016/j.jvs.2021.05.054] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2020] [Accepted: 05/19/2021] [Indexed: 11/24/2022]
Abstract
OBJECTIVE Investigation of asymptomatic carotid stenosis treatment is hindered by the lack of a contemporary population-based disease cohort. We describe the use of natural language processing (NLP) to identify stenosis in patients undergoing carotid imaging. METHODS Adult patients with carotid imaging between 2008 and 2012 in a large integrated health care system were identified and followed through 2017. An NLP process was developed to characterize carotid stenosis according to the Society of Radiologists in Ultrasound (for ultrasounds) and North American Symptomatic Carotid Endarterectomy Trial (NASCET) (for axial imaging) guidelines. The resulting algorithm assessed text descriptors to categorize normal/non-hemodynamically significant stenosis, moderate or severe stenosis as well as occlusion in both carotid ultrasound (US) and axial imaging (computed tomography and magnetic resonance angiography [CTA/MRA]). For US reports, internal carotid artery systolic and diastolic velocities and velocity ratios were assessed and matched for laterality to supplement accuracy. To validate the NLP algorithm, positive predictive value (PPV or precision) and sensitivity (recall) were calculated from simple random samples from the population of all imaging studies. Lastly, all non-normal studies were manually reviewed for confirmation for prevalence estimates and disease cohort assembly. RESULTS A total of 95,896 qualifying index studies (76,276 US and 19,620 CTA/MRA) were identified among 94,822 patients including 1059 patients who underwent multiple studies on the same day. For studies of normal/non-hemodynamically significant stenosis arteries, the NLP algorithm showed excellent performance with a PPV of 99% for US and 96.5% for CTA/MRA. PPV/sensitivity to identify a non-normal artery with correct laterality in the CTA/MRA and US samples were 76.9% (95% confidence interval [CI], 74.1%-79.5%)/93.1% (95% CI, 91.1%-94.8%) and 74.7% (95% CI, 69.3%-79.5%)/94% (95% CI, 90.2%-96.7%), respectively. Regarding cohort assembly, 15,522 patients were identified with diseased carotid artery, including 2674 exhibiting equal bilateral disease. This resulted in a laterality-specific cohort with 12,828 moderate, 5283 severe, and 1895 occluded arteries and 326 diseased arteries with unknown stenosis. During follow-up, 30.1% of these patients underwent 61,107 additional studies. CONCLUSIONS Use of NLP to detect carotid stenosis or occlusion can result in accurate exclusion of normal/non-hemodynamically significant stenosis disease states with more moderate precision with lesion identification, which can substantially reduce the need for manual review. The resulting cohort allows for efficient research and holds promise for similar reporting in other vascular diseases.
Collapse
Affiliation(s)
- Robert W Chang
- Department of Vascular Surgery, The Permanente Medical Group, South San Francisco, Calif; Division of Research, Kaiser Permanente, Oakland, Calif.
| | | | - Kara A Rothenberg
- Department of Surgery, University of California San Francisco - East Bay, Oakland, Calif
| | | | - Andrew L Avins
- Division of Research, Kaiser Permanente, Oakland, Calif; Departments of Medicine and Epidemiology and Biostatistics, University of California, San Francisco, Calif
| | - Hui C Kuang
- Department of Vascular Surgery, The Permanente Medical Group, San Francisco, Calif
| | - Rishad M Faruqi
- Department of Vascular Surgery, The Permanente Medical Group, Santa Clara, Calif
| | - Mai N Nguyen-Huynh
- Division of Research, Kaiser Permanente, Oakland, Calif; Department of Neurology, The Permanente Medical Group, Walnut Creek, Calif
| |
Collapse
|
17
|
Kamtchum-Tatuene J, Noubiap JJ, Wilman AH, Saqqur M, Shuaib A, Jickling GC. Prevalence of High-risk Plaques and Risk of Stroke in Patients With Asymptomatic Carotid Stenosis: A Meta-analysis. JAMA Neurol 2021; 77:1524-1535. [PMID: 32744595 DOI: 10.1001/jamaneurol.2020.2658] [Citation(s) in RCA: 75] [Impact Index Per Article: 25.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/16/2023]
Abstract
Importance There is an ongoing debate regarding the management of asymptomatic carotid stenosis. Previous studies have reported imaging features of high-risk plaques that could help to optimize the risk-benefit ratio of revascularization. However, such studies have not provided an accurate estimate of the prevalence of high-risk plaques and the associated annual incidence of ipsilateral ischemic cerebrovascular events to inform the design of clinical trials using a risk-oriented selection of patients before randomization. Objective To assess the relevance and feasibility of risk-oriented selection of patients for revascularization. Data Sources A systematic search of PubMed and Ovid Embase from database inception to July 31, 2019, was performed. Study Selection Prospective observational studies that reported prevalence of high-risk plaques and incidence of ipsilateral ischemic cerebrovascular events were included. Data Extraction and Synthesis Aggregated data were pooled using random-effects meta-analysis. Data were analyzed from December 16, 2019, to January 15, 2020. Main Outcomes and Measures Prevalence of high-risk plaques and annual incidence of ipsilateral ischemic events. Results Overall, 64 studies enrolling 20 751 participants aged 29 to 95 years (mean age range, 55.0-76.5 years; proportion of men, 45%-87%) were included in the meta-analysis. Among all participants, the pooled prevalence of high-risk plaques was 26.5% (95% CI, 22.9%-30.3%). The most prevalent high-risk plaque features were neovascularization (43.4%; 95% CI, 31.4%-55.8%) in 785 participants, echolucency (42.3%; 95% CI, 32.2%-52.8%) in 12 364 participants, and lipid-rich necrotic core (36.3%; 95% CI, 27.7%-45.2%) in 3728 participants. The overall incidence of ipsilateral ischemic cerebrovascular events was 3.2 events per 100 person-years (22 cohorts with 10 381 participants; mean follow-up period, 2.8 years; range, 0.7-6.5 years). The incidence of ipsilateral ischemic cerebrovascular events was higher in patients with high-risk plaques (4.3 events per 100 person-years; 95% CI, 2.5-6.5 events per 100 person-years) than in those without high-risk plaques (1.2 events per 100 person-years; 95% CI, 0.6-1.8 events per 100 person-years), with an odds ratio of 3.0 (95% CI, 2.1-4.3; I2 = 48.8%). In studies focusing on severe stenosis (9 cohorts with 2128 participants; mean follow-up period, 2.8 years; range, 1.4-6.5 years), the incidence of ipsilateral ischemic cerebrovascular events was 3.7 events per 100 person-years (95% CI, 1.9-6.0 events per 100 person-years). The incidence of ipsilateral ischemic cerebrovascular events was also higher in patients with high-risk plaques (7.3 events per 100 person-years; 95% CI, 2.0-15.0 events per 100 person-years) than in those without high-risk plaques (1.7 events per 100 person-years; 95% CI, 0.6-3.3 events per 100 person-years), with an odds ratio of 3.2 (95% CI, 1.7-5.9; I2 = 39.6%). Conclusions and Relevance High-risk plaques are common in patients with asymptomatic carotid stenosis, and the associated risk of an ipsilateral ischemic cerebrovascular event is higher than the currently accepted estimates. Extension of routine assessment of asymptomatic carotid stenosis beyond the grade of stenosis may help improve risk stratification and optimize therapy.
Collapse
Affiliation(s)
- Joseph Kamtchum-Tatuene
- Neuroscience and Mental Health Institute, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Alberta, Canada
| | - Jean Jacques Noubiap
- Centre for Heart Rhythm Disorders, South Australian Health and Medical Research Institute, Royal Adelaide Hospital, The University of Adelaide, Adelaide, South Australia, Australia
| | - Alan H Wilman
- Department of Biomedical Engineering, University of Alberta, Edmonton, Alberta, Canada
| | - Maher Saqqur
- Division of Neurology, Department of Medicine, University of Alberta, Edmonton, Alberta, Canada
| | - Ashfaq Shuaib
- Division of Neurology, Department of Medicine, University of Alberta, Edmonton, Alberta, Canada
| | - Glen C Jickling
- Division of Neurology, Department of Medicine, University of Alberta, Edmonton, Alberta, Canada
| |
Collapse
|
18
|
Paraskevas KI, Mikhailidis DP, Baradaran H, Davies AH, Eckstein HH, Faggioli G, Fernandes JFE, Gupta A, Jezovnik MK, Kakkos SK, Katsiki N, Kooi ME, Lanza G, Liapis CD, Loftus IM, Millon A, Nicolaides AN, Poredos P, Pini R, Ricco JB, Rundek T, Saba L, Spinelli F, Stilo F, Sultan S, Zeebregts CJ, Chaturvedi S. Management of Patients with Asymptomatic Carotid Stenosis May Need to Be Individualized: A Multidisciplinary Call for Action. J Stroke 2021; 23:202-212. [PMID: 34102755 PMCID: PMC8189852 DOI: 10.5853/jos.2020.04273] [Citation(s) in RCA: 20] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2020] [Accepted: 04/12/2021] [Indexed: 12/15/2022] Open
Abstract
The optimal management of patients with asymptomatic carotid stenosis (ACS) is the subject of extensive debate. According to the 2017 European Society for Vascular Surgery guidelines, carotid endarterectomy should (Class IIa; Level of Evidence: B) or carotid artery stenting may be considered (Class IIb; Level of Evidence: B) in the presence of one or more clinical/imaging characteristics that may be associated with an increased risk of late ipsilateral stroke (e.g., silent embolic infarcts on brain computed tomography/magnetic resonance imaging, progression in the severity of ACS, a history of contralateral transient ischemic attack/stroke, microemboli detection on transcranial Doppler, etc.), provided documented perioperative stroke/death rates are <3% and the patient’s life expectancy is >5 years. Besides these clinical/imaging characteristics, there are additional individual, ethnic/racial or social factors that should probably be evaluated in the decision process regarding the optimal management of these patients, such as individual patient needs/patient choice, patient compliance with best medical treatment, patient sex, culture, race/ethnicity, age and comorbidities, as well as improvements in imaging/operative techniques/outcomes. The present multispecialty position paper will present the rationale why the management of patients with ACS may need to be individualized.
Collapse
Affiliation(s)
| | - Dimitri P Mikhailidis
- Department of Clinical Biochemistry, Royal Free Hospital Campus, University College London Medical School, University College London (UCL), London, UK
| | - Hediyeh Baradaran
- Department of Radiology, University of Utah, Salt Lake City, UT, USA
| | - Alun H Davies
- Section of Vascular Surgery, Imperial College & Imperial Healthcare NHS Trust, London, UK
| | - Hans-Henning Eckstein
- Department of Vascular and Endovascular Surgery, Klinikum rechts der Isar, Technical University of Munich, Munich, Germany
| | - Gianluca Faggioli
- Vascular Surgery, University of Bologna "Alma Mater Studiorum", Policlinico S. Orsola Malpighi, Bologna, Italy
| | | | - Ajay Gupta
- Department of Radiology, Weill Cornell Medicine, New York, NY, USA
| | - Mateja K Jezovnik
- Department of Advanced Cardiopulmonary Therapies and Transplantation, The University of Texas Health Science Centre at Houston, Houston, TX, USA
| | - Stavros K Kakkos
- Department of Vascular Surgery, University of Patras Medical School, Patras, Greece
| | - Niki Katsiki
- First Department of Internal Medicine, AHEPA University Hospital, Thessaloniki, Greece
| | - M Eline Kooi
- CARIM School for Cardiovascular Diseases, Maastricht University, Maastricht, The Netherlands.,Department of Radiology and Nuclear Medicine, Maastricht University Medical Center, Maastricht, The Netherlands
| | - Gaetano Lanza
- Vascular Surgery Department, IRCSS MultiMedica Hospital, Castellanza, Italy
| | | | - Ian M Loftus
- St. George's Vascular Institute, St. George's University London, London, UK
| | - Antoine Millon
- Department of Vascular and Endovascular Surgery, Louis Pradel Hospital, Hospices Civils de Lyon, France
| | - Andrew N Nicolaides
- Department of Surgery, University of Nicosia Medical School, Nicosia, Cyprus
| | - Pavel Poredos
- Department of Vascular Disease, University Medical Centre Ljubljana, Slovenia
| | - Rodolfo Pini
- Vascular Surgery, University of Bologna "Alma Mater Studiorum", Policlinico S. Orsola Malpighi, Bologna, Italy
| | - Jean-Baptiste Ricco
- Department of Clinical Research, University of Poitiers, CHU de Poitiers, Poitiers, France
| | - Tatjana Rundek
- Department of Neurology, Miller School of Medicine, University of Miami, Miami, FL, USA
| | - Luca Saba
- Department of Radiology, Azienda Ospedaliera Universitaria Di Cagliari, Cagliari, Italy
| | - Francesco Spinelli
- Vascular Surgery Division, Campus Bio-Medico University of Rome, Rome, Italy
| | - Francesco Stilo
- Vascular Surgery Division, Campus Bio-Medico University of Rome, Rome, Italy
| | - Sherif Sultan
- Western Vascular Institute, Department of Vascular and Endovascular Surgery, University Hospital Galway, National University of Ireland, Galway, Ireland
| | - Clark J Zeebregts
- Division of Vascular Surgery, Department of Surgery, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Seemant Chaturvedi
- Department of Neurology & Stroke Program, University of Maryland School of Medicine, Baltimore, MD, USA
| |
Collapse
|
19
|
Azarpazhooh MR, Bogiatzi C, Spence JD. Stroke Prevention: Little-Known and Neglected Aspects. Cerebrovasc Dis 2021; 50:622-635. [PMID: 34044404 DOI: 10.1159/000515829] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2021] [Accepted: 03/10/2021] [Indexed: 11/19/2022] Open
Abstract
Combining available therapies has the potential to reduce the risk of stroke by 80% or more. A comprehensive review of all aspects of stroke prevention would be very lengthy; in this narrative review, we focus on some aspects of stroke prevention that are little-known and/or neglected. These include the following: (1) implementation of a Mediterranean diet; (2) B vitamins to lower homocysteine; (3) coordinated approaches to smoking cessation; (4) intensive lipid-lowering therapy; (5) lipid lowering in the elderly; (6) physiologically individualized therapy for hypertension based on renin/aldosterone phenotyping; (7) avoiding excessive blood pressure reduction in patients with stiff arteries; (8) treatment of insulin resistance with pioglitazone in stroke patients with prediabetes and diabetes; (9) impaired activation of clopidogrel in patients with variants of CYP2C19; (10) aspirin pseudoresistance due to enteric coating; (11) rationale for anticoagulation in patients with embolic stroke of unknown source; (12) pharmacologic properties of direct-acting oral anticoagulants that should be considered when choosing among them; (13) the identification of which patients with asymptomatic carotid stenosis are at a high enough risk to benefit from carotid endarterectomy or stenting; and (14) the importance of age in choosing between endarterectomy and stenting. Stroke prevention could be improved by better recognition of these issues and by implementation of the principles derived from them.
Collapse
Affiliation(s)
- M Reza Azarpazhooh
- Division of Neurology and Department of Epidemiology & Biostatistics, Western University, London, Ontario, Canada
| | - Chrysi Bogiatzi
- Department of Neurology, McMaster University, Hamilton, Ontario, Canada
| | - J David Spence
- Stroke Prevention & Atherosclerosis Research Center, Robarts Research Institute, Western University, London, Ontario, Canada
| |
Collapse
|
20
|
Knappich C, Tsantilas P, Salvermoser M, Schmid S, Kallmayer M, Trenner M, Eckstein HH, Kuehnl A. Editor's Choice - Distribution of Care and Hospital Incidence of Carotid Endarterectomy and Carotid Artery Stenting: A Secondary Analysis of German Hospital Episode Data. Eur J Vasc Endovasc Surg 2021; 62:167-176. [PMID: 33966984 DOI: 10.1016/j.ejvs.2021.03.021] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2020] [Revised: 03/10/2021] [Accepted: 03/21/2021] [Indexed: 10/21/2022]
Abstract
OBJECTIVE This is a description of the German healthcare landscape regarding carotid artery disease, assessment of hospital incidence time courses for carotid endarterectomy (CEA) and carotid artery stenting (CAS), and simulation of potential effects of minimum hospital caseload requirements for CEA and CAS. METHODS The study is a secondary data analysis of diagnosis related group statistics data (2005-2016), provided by the German Federal Statistical Office. Cases encoded by German operation procedure codes for CEA or CAS and by International Classification of Diseases (ICD-10) codes for carotid artery disease were included. Hospitals were categorised into quartiles according to annual caseloads. Linear distances to the closest hospital fulfilling hypothetical caseload requirements were calculated. RESULTS A total of 132 411 and 33 709 patients treated with CEA and CAS from 2012 to 2016 were included. CEA patients had lower rates of myocardial infarction (1.4% vs. 1.8%) and death (1.2% vs. 4.0%), and CAS patients were more often treated after emergency admission (38.1% vs. 27.1%). Age standardised annual hospital incidences were 67.2 per 100 000 inhabitants for CEA and 16.3 per 100 000 inhabitants for CAS. The incidence for CEA declined from 2005 to 2016, with CAS rising again until 2016 after having declined from 2010 to 2013. Regarding distance from home to hospital, centres offering CEA are distributed more homogeneously across Germany, compared with those performing CAS. Hypothetical introduction of minimum annual caseloads (> 20 for CEA; > 10 for CAS) imply that 75% of the population would reach their hospital after travelling 45 km for CEA and 70 km for CAS. CONCLUSION Differences in spatial distribution mean that statutory minimum annual caseloads would have a greater impact on CAS accessibility than CEA in Germany. Presumably because of a decline in carotid artery disease and a transition towards individualised therapy for asymptomatic patients, hospital incidence for CEA has been declining.
Collapse
Affiliation(s)
- Christoph Knappich
- Department for Vascular and Endovascular Surgery, Klinikum rechts der Isar, Technical University of Munich, Munich, Germany
| | - Pavlos Tsantilas
- Department for Vascular and Endovascular Surgery, Klinikum rechts der Isar, Technical University of Munich, Munich, Germany
| | - Michael Salvermoser
- Department for Vascular and Endovascular Surgery, Klinikum rechts der Isar, Technical University of Munich, Munich, Germany
| | - Sofie Schmid
- Department for Vascular and Endovascular Surgery, Klinikum rechts der Isar, Technical University of Munich, Munich, Germany
| | - Michael Kallmayer
- Department for Vascular and Endovascular Surgery, Klinikum rechts der Isar, Technical University of Munich, Munich, Germany
| | - Matthias Trenner
- Department for Vascular and Endovascular Surgery, Klinikum rechts der Isar, Technical University of Munich, Munich, Germany
| | - Hans-Henning Eckstein
- Department for Vascular and Endovascular Surgery, Klinikum rechts der Isar, Technical University of Munich, Munich, Germany
| | - Andreas Kuehnl
- Department for Vascular and Endovascular Surgery, Klinikum rechts der Isar, Technical University of Munich, Munich, Germany.
| |
Collapse
|
21
|
Abstract
Asymptomatic carotid stenosis (ACS) due to atherosclerosis is a risk factor for ipsilateral ischemic cerebrovascular events and cognitive impairment. The prognosis of ACS has improved over the past 4 decades due largely to improvements in medical management. Most patients with ACS can be managed without revascularization, but some patients with vulnerable plaque should be considered for revascularization. Regardless of the decision to refer for revascularization, all patients with ACS should receive intensive medical management. This includes lifestyle modification (Mediterranean diet, exercise, and smoking cessation) and pharmacological therapy (antiplatelets, lipid-lowering agents, blood pressure reduction, and glycemic control). Patients with ACS often have atherosclerosis in other critical locations, and thus optimal medical therapy is likely to reduce events outside the carotid arteries. The nature of optimal medical therapy is described.
Collapse
Affiliation(s)
- Daniel G Hackam
- Division of Clinical Pharmacology, Department of Medicine, Department of Clinical Neurological Sciences, and Department of Epidemiology and Biostatistics, Western University, London, Ontario, Canada
| |
Collapse
|
22
|
Spence JD. Treatment of asymptomatic carotid stenosis. Lancet Neurol 2021; 20:163-165. [PMID: 33609465 DOI: 10.1016/s1474-4422(21)00006-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2020] [Accepted: 01/05/2021] [Indexed: 01/15/2023]
Affiliation(s)
- J David Spence
- Stroke Prevention & Atherosclerosis Research Centre, Robarts Research Institute, Western University, London, ON N6G 2V4, Canada.
| |
Collapse
|
23
|
Mura M, Della Schiava N, Long A, Chirico EN, Pialoux V, Millon A. Carotid intraplaque haemorrhage: pathogenesis, histological classification, imaging methods and clinical value. ANNALS OF TRANSLATIONAL MEDICINE 2020; 8:1273. [PMID: 33178805 PMCID: PMC7607119 DOI: 10.21037/atm-20-1974] [Citation(s) in RCA: 23] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
Vulnerable carotid atherosclerotic plaques are characterised by several risk factors, such as inflammation, neovascularization and intraplaque haemorrhage (IPH). Vulnerable plaques can lead to ischemic events such as stroke. Many studies reported a relationship between IPH, plaque rupture, and ischemic stroke. Histology is the gold standard to evaluate IPH, but it required carotid endarterectomy (CEA) surgery to collect the tissue sample. In this context, several imaging methods can be used as a non-invasive way to evaluate plaque vulnerability and detect IPH. Most imaging studies showed that IPH is associated with plaque vulnerability and stroke, with magnetic resonance imaging (MRI) being the most sensitive and specific to detect IPH as a predictor of ischemic events. These conclusions are however still debated because of the limited number of patients included in these studies; further studies are required to better assess risks associated with different IPH stages. Moreover, IPH is implicated in plaque vulnerability with other risk factors which need to be considered to predict ischemic risk. In addition, MRI sequences standardization is required to compare results from different studies and agree on biomarkers that need to be considered to predict plaque rupture. In these circumstances, IPH detection by MRI could be an efficient clinical method to predict stroke. The goal of this review article is to first describe the pathophysiological process responsible for IPH, its histological detection in carotid plaques and its correlation with plaque rupture. The second part will discuss the benefits and limitations of imaging the carotid plaque, and finally the clinical interest of imaging IPH to predict plaque rupture, focusing on MRI-IPH.
Collapse
Affiliation(s)
- Mathilde Mura
- Univ Lyon, University Claude Bernard Lyon 1, Interuniversity Laboratory of Human Movement Biology EA7424, Lyon, France
| | - Nellie Della Schiava
- Department of Vascular and Endovascular Surgery, Groupement Hospitalier Est, Louis Pradel Hospital, Hospices Civils de Lyon, Lyon, France.,Institut National des Sciences Appliquées Lyon, Laboratoire de Génie Electrique et Ferroélectricité EA 682, Villeurbanne, France
| | - Anne Long
- Univ Lyon, University Claude Bernard Lyon 1, Interuniversity Laboratory of Human Movement Biology EA7424, Lyon, France.,Departement of Internal Medicine and Vascular Medicine, Groupement Hospitalier Edouard Herriot, Hospices Civils de Lyon, Lyon, France
| | - Erica N Chirico
- Department of Biomedical Sciences, Cooper Medical School of Rowan University, Camden, NJ, USA
| | - Vincent Pialoux
- Univ Lyon, University Claude Bernard Lyon 1, Interuniversity Laboratory of Human Movement Biology EA7424, Lyon, France.,Institut Universitaire de France, Paris, France
| | - Antoine Millon
- Department of Vascular and Endovascular Surgery, Groupement Hospitalier Est, Louis Pradel Hospital, Hospices Civils de Lyon, Lyon, France.,Univ Lyon, University Claude Bernard Lyon 1, CarMeN Laboratory, INSERM U1060, Bron, France
| |
Collapse
|
24
|
Abbott AL, Brunser AM, Giannoukas A, Harbaugh RE, Kleinig T, Lattanzi S, Poppert H, Rundek T, Shahidi S, Silvestrini M, Topakian R. Rectifying the misconceptions about current best management of asymptomatic carotid stenosis is not about revising history. J Vasc Surg 2020; 72:765-767. [PMID: 32259621 DOI: 10.1016/j.jvs.2020.03.020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2020] [Accepted: 03/13/2020] [Indexed: 10/24/2022]
Affiliation(s)
- Anne L Abbott
- Department of Neuroscience, Central Clinical School, Monash University, Melbourne, Victoria, Australia
| | - Alejandro M Brunser
- Department of Neurology, Clínica Alemana de Santiago, Facultad de Medicina Clínica Alemana-Universidad del Desarrollo, Santiago, Chile
| | - Athanasios Giannoukas
- University Hospital of Larissa, Faculty of Medicine, School of Health Sciences, University of Thessaly, Larissa, Greece
| | | | - Timothy Kleinig
- Neurology Department, Royal Adelaide Hospital, Department of Medicine, University of Adelaide, Adelaide, South Australia, Australia
| | - Simona Lattanzi
- Department of Experimental and Clinical Medicine, Marche Polytechnic University, Ancona, Italy
| | - Holger Poppert
- Neurology Department, Helios Dr Horst-Schmidt-Kliniken, Wiesbaden, Germany
| | - Tatjana Rundek
- Department of Neurology, University of Miami Miller School of Medicine, Miami, Fla
| | - Saeid Shahidi
- Department of Vascular and Endovascular Surgery, Acute Regional Hospital Slagelse, Copenhagen & South Denmark University, Copenhagen, Denmark
| | | | - Raffi Topakian
- Department of Neurology, Academic Teaching Hospital Wels-Grieskirchen, Wels, Austria
| |
Collapse
|
25
|
Golemati S, Patelaki E, Gastounioti A, Andreadis I, Liapis CD, Nikita KS. Motion synchronisation patterns of the carotid atheromatous plaque from B-mode ultrasound. Sci Rep 2020; 10:11221. [PMID: 32641773 PMCID: PMC7343786 DOI: 10.1038/s41598-020-65340-2] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2018] [Accepted: 04/21/2020] [Indexed: 01/18/2023] Open
Abstract
Asynchronous movement of the carotid atheromatous plaque from B-mode ultrasound has been previously reported, and associated with higher risk of stroke, but not quantitatively estimated. Based on the hypothesis that asynchronous plaque motion is associated with vulnerable plaque, in this study, synchronisation patterns of different tissue areas were estimated using cross-correlations of displacement waveforms. In 135 plaques (77 subjects), plaque radial deformation was synchronised by approximately 50% with the arterial diameter, and the mean phase shift was 0.4 s. Within the plaque, the mean phase shifts between the displacements of the top and bottom surfaces were 0.2 s and 0.3 s, in the radial and longitudinal directions, respectively, and the synchronisation about 80% in both directions. Classification of phase-shift-based features using Random Forests yielded Area-Under-the-Curve scores of 0.81, 0.79, 0.89 and 0.90 for echogenicity, symptomaticity, stenosis degree and plaque risk, respectively. Statistical analysis showed that echolucent, high-stenosis and high-risk plaques exhibited higher phase shifts between the radial displacements of their top and bottom surfaces. These findings are useful in the study of plaque kinematics.
Collapse
Affiliation(s)
- Spyretta Golemati
- Biomedical Simulations and Imaging Lab., School of Electrical and Computer Engineering, National Technical University of Athens, Athens, Greece. .,Medical School, National and Kapodistrian University of Athens, Athens, Greece.
| | - Eleni Patelaki
- Biomedical Simulations and Imaging Lab., School of Electrical and Computer Engineering, National Technical University of Athens, Athens, Greece.,Institute of Communication and Computer Systems, Athens, Greece
| | | | - Ioannis Andreadis
- Biomedical Simulations and Imaging Lab., School of Electrical and Computer Engineering, National Technical University of Athens, Athens, Greece.,Institute of Communication and Computer Systems, Athens, Greece
| | - Christos D Liapis
- Attikon University General Hospital, Medical School, National and Kapodistrian University of Athens, Athens, Greece
| | - Konstantina S Nikita
- Biomedical Simulations and Imaging Lab., School of Electrical and Computer Engineering, National Technical University of Athens, Athens, Greece.,Institute of Communication and Computer Systems, Athens, Greece
| |
Collapse
|
26
|
Abbott AL, Brunser AM, Giannoukas A, Harbaugh RE, Kleinig T, Lattanzi S, Poppert H, Rundek T, Shahidi S, Silvestrini M, Topakian R. Reply. J Vasc Surg 2020; 72:384-385. [PMID: 32259618 DOI: 10.1016/j.jvs.2020.03.019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2020] [Accepted: 03/14/2020] [Indexed: 11/20/2022]
Affiliation(s)
- Anne L Abbott
- Department of Neuroscience, Central Clinical School, Monash University, Melbourne, Victoria, Australia
| | - Alejandro M Brunser
- Department of Neurology, Clínica Alemana de Santiago, Facultad de Medicina Clínica Alemana-Universidad del Desarrollo, Santiago, Chile
| | - Athanasios Giannoukas
- University Hospital of Larissa, Faculty of Medicine, School of Health Sciences, University of Thessaly, Larissa, Greece
| | | | - Timothy Kleinig
- Neurology Department, Royal Adelaide Hospital, Adelaide, South Australia, Australia; Department of Medicine, University of Adelaide, Adelaide, South Australia, Australia
| | - Simona Lattanzi
- Department of Experimental and Clinical Medicine, Marche Polytechnic University, Ancona, Italy
| | - Holger Poppert
- Neurology Department, Helios Dr Horst-Schmidt-Kliniken, Wiesbaden, Germany
| | - Tatjana Rundek
- Department of Neurology, University of Miami Miller School of Medicine, Miami, Fla
| | - Saeid Shahidi
- Department of Vascular and Endovascular Surgery, Acute Regional Hospital Slagelse, Copenhagen & South Denmark University, Copenhagen, Denmark
| | | | - Raffi Topakian
- Department of Neurology, Academic Teaching Hospital Wels-Grieskirchen, Wels, Austria
| |
Collapse
|
27
|
Alkhalil M. A promising tool to tackle the risk of cerebral vascular disease, the emergence of novel carotid wall imaging. Brain Circ 2020; 6:81-86. [PMID: 33033777 PMCID: PMC7511918 DOI: 10.4103/bc.bc_65_19] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2019] [Revised: 02/24/2020] [Accepted: 03/25/2020] [Indexed: 11/24/2022] Open
Abstract
Stroke is a heterogeneous vascular disease. Carotid artery atherosclerosis is associated with almost one-quarter of ischemic strokes. Moreover, a large percentage of preventable strokes are currently attributed to carotid atherosclerosis. Over the past three decades, the management of carotid artery disease has evolved. The benefits of carotid revascularization alongside medical therapy have early been recognized. Nonetheless, the debate regarding the optimal strategy is still ongoing, particularly in patients with asymptomatic carotid artery disease. One of the challenges is the use of luminal stenosis to quantify the severity of the carotid artery disease and to guide decision-making regarding invasive revascularization. Characterizing carotid atherosclerotic plaque is a promising tool to identify vulnerable plaque. Certain features such as large lipid core have already been linked to acute vascular events, not only at the plaque level but also to predict systemic cardiovascular events. Recently, a quantitative T2 mapping magnetic resonance imaging technique was developed and validated against histology. The ability to accurately quantify plaque lipid content using this technique opens several new opportunities. In this review articles, we will discuss the current challenges in the management of carotid artery disease and the future roles of T2 mapping to aid therapeutic options. These roles may include how to determine the mode of invasive carotid revascularization in symptomatic patients. Moreover, there may be a rational to use T2 mapping as a risk stratification tool in asymptomatic patients with carotid artery stenosis. It may also provide an opportunity to stage atherosclerosis and identify patients with coronary atherosclerosis who may benefit maximally from intensive lipid interventions.
Collapse
Affiliation(s)
- Mohammad Alkhalil
- Department of Cardiology, Royal Victoria Hospital, Belfast, UK
- Department of Cardiology, Toronto General Hospital, Toronto, Canada
| |
Collapse
|
28
|
Goudot G, Khider L, Pedreira O, Poree J, Julia P, Alsac JM, Amemiya K, Bruneval P, Messas E, Pernot M, Mirault T. Innovative Multiparametric Characterization of Carotid Plaque Vulnerability by Ultrasound. Front Physiol 2020; 11:157. [PMID: 32194437 PMCID: PMC7064056 DOI: 10.3389/fphys.2020.00157] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2019] [Accepted: 02/12/2020] [Indexed: 01/22/2023] Open
Abstract
Objective The degree of stenosis of a carotid plaque is a well-established risk factor for ischemic stroke. Nevertheless, the risk of ipsilateral stroke in asymptomatic carotid stenosis remains low and new imaging markers are needed to better target which patients would benefit most from endarterectomy or intensive medical therapy. Ultrafast ultrasound imaging offers parameters helping at characterizing the carotid plaque by shear wave elastography and Ultrafast Doppler (UFD). We aimed at using these techniques to characterize 3 different ultrasound biomarkers: plaque stiffness heterogeneity, wall shear stress (WSS) and intraplaque micro-flows and to correlate these biomarkers with findings on computed tomography angiography (CTA) and the pathological examination. Methods We present the case of a multimodal evaluation of a carotid plaque using ultrasound. Elastography has been coupled to the WSS assessment and the detection of intraplaque micro-flows by UFD. The data have been compared to CTA and to the pathology examination of the tissue after carotid endarterectomy. Results Elastography allowed at identifying stiff areas corresponding to calcifications, as well as a soft area corresponding to an intraplaque hemorrhage. The flow evaluation with UFD showed an increase of the WSS along the plaque and identified the presence of a plaque rupture, confirmed by the pathologist. Conclusion Ultrafast ultrasound imaging is an innovative, easily accessible technique that provides imaging modalities on top of the conventional B-mode. Ultrafast ultrasound biomarkers such as plaque stiffness heterogeneity, WSS and intraplaque micro-flows could help to define the vulnerability of the carotid plaque in order to stratify patients that could benefit most from endarterectomy or intensive medical therapy.
Collapse
Affiliation(s)
- Guillaume Goudot
- Physics for Medicine Paris, INSERM U1273, ESPCI Paris, CNRS FRE 2031, PSL Research University, Paris, France.,Vascular Department, Hôpital Européen Georges Pompidou, APHP, Paris, France
| | - Lina Khider
- Physics for Medicine Paris, INSERM U1273, ESPCI Paris, CNRS FRE 2031, PSL Research University, Paris, France.,Vascular Department, Hôpital Européen Georges Pompidou, APHP, Paris, France
| | - Olivier Pedreira
- Physics for Medicine Paris, INSERM U1273, ESPCI Paris, CNRS FRE 2031, PSL Research University, Paris, France
| | - Jonathan Poree
- Physics for Medicine Paris, INSERM U1273, ESPCI Paris, CNRS FRE 2031, PSL Research University, Paris, France
| | - Pierre Julia
- Vascular Department, Hôpital Européen Georges Pompidou, APHP, Paris, France
| | - Jean-Marc Alsac
- Vascular Department, Hôpital Européen Georges Pompidou, APHP, Paris, France
| | | | | | - Emmanuel Messas
- Vascular Department, Hôpital Européen Georges Pompidou, APHP, Paris, France.,INSERM U970 PARCC, Paris University, Paris, France
| | - Mathieu Pernot
- Physics for Medicine Paris, INSERM U1273, ESPCI Paris, CNRS FRE 2031, PSL Research University, Paris, France
| | - Tristan Mirault
- Physics for Medicine Paris, INSERM U1273, ESPCI Paris, CNRS FRE 2031, PSL Research University, Paris, France.,Vascular Department, Hôpital Européen Georges Pompidou, APHP, Paris, France.,INSERM U970 PARCC, Paris University, Paris, France
| |
Collapse
|
29
|
Paraskevas KI, Eckstein HH, Mikhailidis DP, Veith FJ, Spence JD. Rationale for screening selected patients for asymptomatic carotid artery stenosis. Curr Med Res Opin 2020; 36:361-365. [PMID: 31910676 DOI: 10.1080/03007995.2020.1713075] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
Stroke is a leading cause of death and disability worldwide. Approximately 15% of all first-ever strokes occur due to atheroembolism from a previously undetected/untreated asymptomatic carotid stenosis (ACS). Despite that, international guidelines do not recommend screening for ACS. The rationale for not recommending screening include: (a) the harm associated with screening, (b) the questionable clinical benefit associated with surgery, (c) the lack of proven reduction in the risk of stroke, (d) the large number of false positive/false negative tests, and (e) the cost-effectiveness of such screening programs. A critical analysis of each of these arguments is presented. Patients with ACS have a very high risk of all-cause and cardiac mortality. Detection of ACS should not be viewed as an indication for surgery, but rather as an opportunity to implement best medical treatment (BMT) and lifestyle changes to prevent not only strokes, but also cardiac events. The implementation of screening programs for abdominal aortic aneurysms (AAAs) has led to a considerable reduction in the number of ruptured AAAs and AAA-related deaths. Similarly, screening high-risk individuals for ACS would enable timely identification of patients with ACS and implementation of BMT and lifestyle measures to prevent future strokes and cardiac events.
Collapse
Affiliation(s)
- Kosmas I Paraskevas
- Department of Vascular Surgery, "Attikon" University Hospital, Athens, Greece
| | - Hans-Henning Eckstein
- Department for Vascular and Endovascular Surgery, Klinikum rechts der Isar, Technical University of Munich, Munich, Germany
| | - Dimitri P Mikhailidis
- Department of Clinical Biochemistry, Royal Free Hospital Campus, University College London, London, UK
| | - Frank J Veith
- Departments of Vascular Surgery, Langone Medical Center, New York University, New York, NY, USA
- The Cleveland Clinic, Cleveland, OH, USA
| | - J David Spence
- Stroke Prevention & Atherosclerosis Research Centre, Robarts Research Institute, Western University, London, Canada
| |
Collapse
|
30
|
Bogiatzi C, Azarpazhooh MR, Spence JD. Choosing the right therapy for a patient with asymptomatic carotid stenosis. Expert Rev Cardiovasc Ther 2020; 18:53-63. [PMID: 32043917 DOI: 10.1080/14779072.2020.1729127] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
Introduction: Most patients with asymptomatic carotid stenosis (ACS) now have a lower risk with intensive medical therapy than with stenting (CAS) or endarterectomy (CEA); the annual risk of stroke or death with intensive medical therapy is ~ 0.5%, vs. a periprocedural risk with CAS of ~ 2.5-4.1% with CAS, and ~ 1.4-1.8% with CEA. The excess risk of CAS is greater in older patients.Areas covered: Discussed are the need for intensive medical therapy, the nature of intensive medical therapy, approaches to identifying the few patients with ACS who could benefit from CEA or CAS, and which patients would be better suited to CEA vs. CAS.Expert opinion: All patients with ACS are at high risk of cardiovascular events, soshould receive intensive medical therapy including lifestyle modification, intensive lipid-lowering, B vitamins to lower homocysteine (using methylcobalamin rather than cyanocobalamin), and appropriate antithrombotic therapy. High-risk patients who could benefit from intervention can be identified by clinical and imaging features including transcranial Doppler embolus detection, ulceration, intraplaque hemorrhage, reduced cerebrovascular reserve, plaque echolucency, silent infarction on brain imaging, and progression of stenosis. Most patients whose risk of stroke warrants intervention would be better treated with CEA than with CAS.
Collapse
Affiliation(s)
- Chrysi Bogiatzi
- Department of Neurology, McMaster University, Hamilton, Ontario, Canada
| | - M Reza Azarpazhooh
- Department of Clinical Neurological Sciences (Neurology), Western University, London, Ontario, Canada
| | - J David Spence
- Departments of Clinical Neurological Sciences (Neurology) and Internal Medicine (Clinical Pharmacology), Robarts Research Institute, London, Ontario, Canada
| |
Collapse
|
31
|
Huang Y, Liu Q, Xu J, Zhu W, Jiang J, Tang L, Chen M. Contrast-enhanced ultrasound perfusion patterns and serum lipid signatures of vulnerable carotid artery plaque in predicting stroke: A cohort study of carotid stenosis in Chinese patients. Clin Hemorheol Microcirc 2020; 75:349-359. [PMID: 32039838 DOI: 10.3233/ch-190804] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
BACKGROUND Early identification of vulnerable plaques at risk of rupture could help prevent cerebral ischemic stroke in patients with carotid artery disease. OBJECTIVE To investigate the correlation between contrast-enhanced ultrasound (CEUS) perfusion patterns and serum lipid signatures of carotid artery plaques with the degree of carotid stenosis. METHODS A total of 80 patients with carotid artery plaques who underwent CEUS were included. All patients underwent CEUS, computed tomography angiography or digital subtraction angiography, and serum lipid testing. RESULTS The contrast agent enhancement levels and the CEUS perfusion patterns in the plaques were associated with the degree of carotid stenosis (P < 0.05). Serum free fatty acid (FFA) was associated with the contrast agent enhancement levels (P < 0.05), but did not correlate with the degree of stenosis (P > 0.05). There was no significant difference in total cholesterol, high-density lipoprotein cholesterol, low-density lipoprotein cholesterol, and triglycerides with respect to contrast agent enhancement levels (P > 0.05) or the degree of stenosis (P > 0.05). CONCLUSION A high level of CEUS perfusion and increased serum FFA levels are indicative of vulnerable carotid plaques, which may be useful for the prediction of stroke in patients with carotid artery disease.
Collapse
Affiliation(s)
- Yunqian Huang
- Department of Ultrasound, Tongren Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Qi Liu
- Department of Ultrasound, Tongren Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Junmei Xu
- Department of Ultrasound, Tongren Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Wenqian Zhu
- Department of Ultrasound, Tongren Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Jianwei Jiang
- Department of Ultrasound, Tongren Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Lei Tang
- Department of Ultrasound, Tongren Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Man Chen
- Department of Ultrasound, Tongren Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| |
Collapse
|
32
|
Alkhalil M, Choudhury RP. Intraplaque Hemorrhage as a Marker of Stroke Risk. JACC Cardiovasc Imaging 2020; 13:407-409. [DOI: 10.1016/j.jcmg.2019.05.004] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/18/2019] [Revised: 05/02/2019] [Accepted: 05/02/2019] [Indexed: 10/26/2022]
|
33
|
Rafailidis V, Chryssogonidis I, Grisan E, Xerras C, Cheimariotis GA, Tegos T, Rafailidis D, Sidhu PS, Charitanti-Kouridou A. Does Quantification of Carotid Plaque Surface Irregularities Better Detect Symptomatic Plaques Compared to the Subjective Classification? JOURNAL OF ULTRASOUND IN MEDICINE : OFFICIAL JOURNAL OF THE AMERICAN INSTITUTE OF ULTRASOUND IN MEDICINE 2019; 38:3163-3171. [PMID: 31066924 DOI: 10.1002/jum.15017] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/22/2019] [Revised: 03/22/2019] [Accepted: 04/17/2019] [Indexed: 06/09/2023]
Abstract
OBJECTIVES To evaluate the interobserver agreement of color Doppler ultrasound (CDUS) and contrast-enhanced ultrasound (CEUS) for quantification of carotid plaque surface irregularities and to correlate objective and subjective measures with stroke occurrence. METHODS This work was an observational study involving 54 patients with 62 internal carotid artery or carotid bulb plaques (31 symptomatic) undergoing CDUS and CEUS between February 2016 and February 2018, with retrospective interpretation of prospectively acquired data. Plaques were included if causing moderate (50%-69%) or severe (70%-99%) stenosis based on velocity criteria, and their surface was classified as smooth, irregular, or ulcerated based on CEUS. The surface irregularities were quantified in the form of a surface irregularity index by 2 observers, based on CDUS and CEUS. The surface irregularity index was evaluated for interobserver agreement with CDUS and CEUS and correlated with the occurrence of stroke, as was the subjective characterization of the plaque surface. RESULTS Color Doppler ultrasound and CEUS showed good interobserver agreement (intraclass correlation coefficients, 0.979 and 0.952, respectively). Plaques were characterized as smooth in 30.6% of cases, irregular in 50%, and ulcerated in 19.4%. The subjective classification of the plaque surface did not correlate with stroke occurrence (P > .05, χ2 ). Surface irregularity index values were significantly higher for symptomatic plaques with both CDUS and CEUS (P < .05). CONCLUSIONS Color Doppler ultrasound and CEUS can quantify carotid plaque surface irregularities with good interobserver agreement. The resulting quantitative measure was significantly higher in symptomatic plaques, whereas the subjective characterization of plaque surface failed to differ between symptomatic and asymptomatic plaques.
Collapse
Affiliation(s)
- Vasileios Rafailidis
- Department of Radiology, AHEPA University General Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Ioannis Chryssogonidis
- Department of Radiology, AHEPA University General Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Enrico Grisan
- Department of Information Engineering, University of Padova, Padova, Italy
- School of Imaging Sciences and Biomedical Engineering, King's College London, London, England
| | - Chrysostomos Xerras
- First Neurological Department, AHEPA University General Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Grigorios-Aris Cheimariotis
- Laboratory of Computing, Medical Informatics, and Biomedical Imaging Technologies, School of Medicine, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Thomas Tegos
- First Neurological Department, AHEPA University General Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Dimitrios Rafailidis
- Department of Radiology, G. Gennimatas General Hospital of Thessaloniki, Thessaloniki, Greece
| | - Paul S Sidhu
- Department of Radiology, King's College Hospital, London, England
| | - Afroditi Charitanti-Kouridou
- Department of Radiology, AHEPA University General Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece
| |
Collapse
|
34
|
Spence JD. Asymptomatic Carotid Stenosis: High Risk With Suboptimal Treatment: Re: Five Year Outcomes in Men Screened for Carotid Artery Stenosis at 65 Years of Age: A Population Based Cohort Study. Eur J Vasc Endovasc Surg 2019; 59:151. [PMID: 31506221 DOI: 10.1016/j.ejvs.2019.07.035] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2019] [Accepted: 07/03/2019] [Indexed: 10/26/2022]
Affiliation(s)
- J David Spence
- Stroke Prevention & Atherosclerosis Research Centre, Robarts Research Institute, Western University, 1400 Western Road, London, N6G 2V4 ON Canada.
| |
Collapse
|
35
|
Johal AS, Loftus IM, Boyle JR, Naylor AR, Waton S, Heikkila K, Cromwell DA. Changing Patterns of Carotid Endarterectomy Between 2011 and 2017 in England. Stroke 2019; 50:2461-2468. [DOI: 10.1161/strokeaha.119.025231] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background and Purpose—
Carotid endarterectomy (CEA) reduces the risk of stroke in recently symptomatic patients and less so in asymptomatic patients. Recent evidence suggests that the number of CEAs may be declining. The aim of this study was to investigate annual patterns of CEA in asymptomatic and symptomatic patients in England from 2011 to 2017.
Methods—
Data from the National Vascular Registry were used to describe (1) the number of CEA procedures in England and its 9 geographic regions from 2011 to 2017, (2) the characteristics of patients undergoing CEA, and (3) whether rates of CEA correlated with the number of vascular arterial units within each region. Annual stroke incidence for each region was derived from official population figures and the number of index stroke admissions per year.
Results—
The overall number of CEAs performed in England fell from 4992 in 2011 to 3482 in 2017, a 30% decline. Among symptomatic patients, there was a 25% decline, the number of CEAs falling from 4270 to 3217. In asymptomatic patients, there were 722 CEAs performed in 2011 and 265 in 2017, a 63% decline. CEAs per 100 000 adults within all regions declined over time but the size of change varied across the regions (range, 1.7–5.5 per 100 000). The regional numbers of CEAs per year were associated with changes in the regional stroke incidence, the proportion of CEAs performed in asymptomatic patients, and the number of hospitals performing CEA.
Conclusions—
This population-based study revealed a 63% decline in CEAs among asymptomatic patients between 2011 and 2017, possibly because of changing attitudes in the role of CEA. Reasons for the 25% decline in CEAs among symptomatic patients are unclear as UK guidelines on CEA have not changed for these patients. Whether the proportion of symptomatic patients with 50% to 99% ipsilateral stenosis has changed requires investigation.
Collapse
Affiliation(s)
- Amundeep S. Johal
- From the Clinical Effectiveness Unit, The Royal College of Surgeons of England, London, United Kingdom (A.S.J., S.W., K.H., D.A.C.)
| | - Ian M. Loftus
- St George’s University Hospitals NHS Foundation Trust, London, United Kingdom (I.M.L.)
| | - Jonathan R. Boyle
- Division of Vascular and Endovascular Surgery, Addenbrooke’s Hospital, Cambridge University Hospital Trust, United Kingdom (J.R.B.)
| | - A. Ross Naylor
- The Leicester Vascular Institute, Glenfield Hospital, United Kingdom (A.R.N.)
| | - Sam Waton
- From the Clinical Effectiveness Unit, The Royal College of Surgeons of England, London, United Kingdom (A.S.J., S.W., K.H., D.A.C.)
| | - Katriina Heikkila
- From the Clinical Effectiveness Unit, The Royal College of Surgeons of England, London, United Kingdom (A.S.J., S.W., K.H., D.A.C.)
- Department of Health Services Research and Policy, London School of Hygiene and Tropical Medicine (K.H., D.A.C.)
| | - David A. Cromwell
- From the Clinical Effectiveness Unit, The Royal College of Surgeons of England, London, United Kingdom (A.S.J., S.W., K.H., D.A.C.)
- Department of Health Services Research and Policy, London School of Hygiene and Tropical Medicine (K.H., D.A.C.)
| |
Collapse
|
36
|
Kazantsev AN, Tarasov RS, Burkov NN, Shabayev AR, Mironov AV, Lider RY, Grachev KI, Yakhnis EY, Sargsyan MT, Soldatov EO. [Predictors of long-term complications after carotid endarterectomy]. Khirurgiia (Mosk) 2019:20-25. [PMID: 31317937 DOI: 10.17116/hirurgia201906120] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
AIM To analyze the predictors of complications within 3 years after carotid endarterectomy (CEE). MATERIAL AND METHODS The study included 1035 patients after CEE for the period 2011-2016. Long-term follow-up period was 42.4±18.6 months (≈ 3.5 years). The endpoints were such unfavorable cardiovascular events as death, myocardial infarction, stroke/transient ischemic attack, redo revascularization. Statistical analysis was carried out by using of Statistica for Windows 8.0 software package (StatSoft Inc., USA). Stepwise logistic regression was applied to identify risk factors of adverse outcomes and death in long-term postoperative period. RESULTS Comprehensive analysis of numerous factors (anamnestic, instrumental-diagnostic, surgical) allowed us to identify predictors of long-term unfavorable outcomes in patients with occlusive-stenotic lesions of carotid arteries. Risk factors of long-term complications were SYNTAX score ≥33 (high risk), unstable plaque in the contralateral ICA, occlusion of contralateral ICA, LVEF <39%, ICA cross-clamping >40 min, previous CABG. CONCLUSION These data are extremely important and can be used to create prognostic models. The last ones are necessary to determine optimal treatment strategy in patients with occlusive-stenotic lesions of supra-aortic vessels.
Collapse
Affiliation(s)
- A N Kazantsev
- Research Institute for Complex Issues of Cardiovascular Diseases, Kemerovo, Russia
| | - R S Tarasov
- Research Institute for Complex Issues of Cardiovascular Diseases, Kemerovo, Russia
| | - N N Burkov
- Research Institute for Complex Issues of Cardiovascular Diseases, Kemerovo, Russia
| | - A R Shabayev
- Research Institute for Complex Issues of Cardiovascular Diseases, Kemerovo, Russia
| | - A V Mironov
- Research Institute for Complex Issues of Cardiovascular Diseases, Kemerovo, Russia
| | - R Yu Lider
- Kemerovo State Medical University of Ministry of Health of Russia, Kemerovo, Russia
| | - K I Grachev
- Kemerovo State Medical University of Ministry of Health of Russia, Kemerovo, Russia
| | - E Ya Yakhnis
- Kemerovo State Medical University of Ministry of Health of Russia, Kemerovo, Russia
| | - M T Sargsyan
- Kemerovo State Medical University of Ministry of Health of Russia, Kemerovo, Russia
| | - E O Soldatov
- Kemerovo State Medical University of Ministry of Health of Russia, Kemerovo, Russia
| |
Collapse
|
37
|
Wang Q, Tang D, Wang L, Canton G, Wu Z, Hatsukami TS, Billiar KL, Yuan C. Combining morphological and biomechanical factors for optimal carotid plaque progression prediction: An MRI-based follow-up study using 3D thin-layer models. Int J Cardiol 2019; 293:266-271. [PMID: 31301863 DOI: 10.1016/j.ijcard.2019.07.005] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/24/2019] [Revised: 05/24/2019] [Accepted: 07/02/2019] [Indexed: 11/24/2022]
Abstract
Plaque progression prediction is of fundamental significance to cardiovascular research and disease diagnosis, prevention, and treatment. Magnetic resonance image (MRI) data of carotid atherosclerotic plaques were acquired from 20 patients with consent obtained. 3D thin-layer models were constructed to calculate plaque stress and strain. Data for ten morphological and biomechanical risk factors were extracted for analysis. Wall thickness increase (WTI), plaque burden increase (PBI) and plaque area increase (PAI) were chosen as three measures for plaque progression. Generalized linear mixed models (GLMM) with 5-fold cross-validation strategy were used to calculate prediction accuracy and identify optimal predictor. The optimal predictor for PBI was the combination of lumen area (LA), plaque area (PA), lipid percent (LP), wall thickness (WT), maximum plaque wall stress (MPWS) and maximum plaque wall strain (MPWSn) with prediction accuracy = 1.4146 (area under the receiver operating characteristic curve (AUC) value is 0.7158), while PA, plaque burden (PB), WT, LP, minimum cap thickness, MPWS and MPWSn was the best for WTI (accuracy = 1.3140, AUC = 0.6552), and a combination of PA, PB, WT, MPWS, MPWSn and average plaque wall strain (APWSn) was the best for PAI with prediction accuracy = 1.3025 (AUC = 0.6657). The combinational predictors improved prediction accuracy by 9.95%, 4.01% and 1.96% over the best single predictors for PAI, PBI and WTI (AUC values improved by 9.78%, 9.45%, and 2.14%), respectively. This suggests that combining both morphological and biomechanical risk factors could lead to better patient screening strategies.
Collapse
Affiliation(s)
- Qingyu Wang
- School of Biological Science and Medical Engineering, Southeast University, Nanjing 210096, China
| | - Dalin Tang
- School of Biological Science and Medical Engineering, Southeast University, Nanjing 210096, China; Mathematical Sciences Department, Worcester Polytechnic Institute, Worcester, MA 01609, USA.
| | - Liang Wang
- School of Biological Science and Medical Engineering, Southeast University, Nanjing 210096, China.
| | - Gador Canton
- Department of Mechanical Engineering, University of Washington, Seattle, WA 98195, USA.
| | - Zheyang Wu
- Mathematical Sciences Department, Worcester Polytechnic Institute, Worcester, MA 01609, USA.
| | - Thomas S Hatsukami
- Division of Vascular Surgery, University of Washington, Seattle, WA 98195, USA.
| | - Kristen L Billiar
- Biomedical Engineering Department, Worcester Polytechnic Institute, Worcester, MA 01609, USA.
| | - Chun Yuan
- Department of Radiology, University of Washington, Seattle, WA 98195, USA.
| |
Collapse
|
38
|
Eilenberg W, Stojkovic S, Kaider A, Piechota-Polanczyk A, Nanobachvili J, Domenig CM, Wojta J, Huk I, Demyanets S, Neumayer C. Neutrophil Gelatinase Associated Lipocalin (NGAL) for Identification of Unstable Plaques in Patients with Asymptomatic Carotid Stenosis. Eur J Vasc Endovasc Surg 2019; 57:768-777. [PMID: 31164272 DOI: 10.1016/j.ejvs.2018.12.029] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2018] [Accepted: 12/26/2018] [Indexed: 12/13/2022]
Abstract
OBJECTIVE Neutrophil gelatinase associated lipocalin (NGAL) and matrix metalloproteinase (MMP)-9/NGAL complex were investigated in asymptomatic patients with carotid artery stenosis including gender specific differences aiming at vulnerable plaques prone to embolisation. METHODS Serum NGAL and MMP-9/NGAL levels were analysed in 83 patients with asymptomatic carotid artery stenosis. Pre-operative ultrasound and post-endarterectomy histology of carotid atherosclerotic lesions were evaluated. RESULTS Patients with vulnerable plaques, as determined by ultrasound (plaques with decreased echogenicity) and histological analysis (type VI according to the classification of the American Heart Association), displayed the highest levels of NGAL and MMP-9/NGAL complex (p = .0003 and p = .0078, respectively). Grade VI plaques were primarily detected in patients with "soft" plaques (12 type VI plaques in 25 patients), but also in patients with mixed (four of 19) and calcified (three of 39) plaques according to ultrasound. Higher grade carotid artery stenosis (≥90%) was not associated with elevated NGAL levels. The receiver operating characteristic curve analysis detecting grade VI lesions yields an area under the curve (AUC) = 0.85, with respect to soft plaque on ultrasound the AUC = 0.86. There were no gender specific differences in levels of NGAL 80.9 (37.7) ng/mL in women vs. 76.7 (36.3) ng/mL in men, p = .607) nor of MMP-9/NGAL 33.0 (18.2-55.5) ng/mL in women vs. 36.7 (20.2-54.0) ng/mL in men, p = .969. Likewise, there were no gender associated differences in vulnerable plaque characteristics: either for grade VI plaques (17.9% vs. 27.3%, p = .582) or for the presence of soft plaques as evaluated by ultrasound (35.9% vs. 25%, p = .503). CONCLUSION Circulating NGAL and MMP-9/NGAL are significantly increased in asymptomatic patients with vulnerable carotid atherosclerotic plaques independent of gender. Accordingly, serum NGAL may be proposed as a valuable biomarker for the detection of unstable carotid plaques in asymptomatic patients, who can then be selected for early carotid endarterectomy or stenting.
Collapse
Affiliation(s)
- Wolf Eilenberg
- Department of Surgery, Division of Vascular Surgery, Medical University of Vienna, Austria
| | - Stefan Stojkovic
- Department of Internal Medicine II, Division of Cardiology, Medical University of Vienna, Austria
| | - Alexandra Kaider
- Centre for Medical Statistics, Informatics, and Intelligent Systems, Medical University of Vienna, Austria
| | - Aleksandra Piechota-Polanczyk
- Department of Medical Biotechnology, Faculty of Biochemistry, Biophysics and Biotechnology, Jagiellonian University, Krakow, Poland
| | - Josif Nanobachvili
- Department of Surgery, Division of Vascular Surgery, Medical University of Vienna, Austria
| | - Christoph M Domenig
- Department of Surgery, Division of Vascular Surgery, Medical University of Vienna, Austria
| | - Johann Wojta
- Department of Internal Medicine II, Division of Cardiology, Medical University of Vienna, Austria; Core Facilities, Medical University of Vienna, Vienna, Austria
| | - Ihor Huk
- Department of Surgery, Division of Vascular Surgery, Medical University of Vienna, Austria
| | - Svitlana Demyanets
- Department of Laboratory Medicine, Medical University of Vienna, Austria
| | - Christoph Neumayer
- Department of Surgery, Division of Vascular Surgery, Medical University of Vienna, Austria.
| |
Collapse
|
39
|
Cheng SF, Brown MM, Simister RJ, Richards T. Contemporary prevalence of carotid stenosis in patients presenting with ischaemic stroke. Br J Surg 2019; 106:872-878. [PMID: 30938840 DOI: 10.1002/bjs.11136] [Citation(s) in RCA: 28] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2018] [Revised: 11/02/2018] [Accepted: 01/21/2019] [Indexed: 11/08/2022]
Abstract
BACKGROUND Carotid stenosis is a common cause of ischaemic stroke and transient ischaemic attack (TIA). Despite rising recognition and centralization of stroke services there has been a decline in interventions for carotid stenosis in recent years. The aim of this study was to determine the current prevalence and management of carotid stenosis in the UK. METHODS This was a 1-year prospective observational study of consecutive patients presenting with ischaemic stroke, TIA or ischaemic retinal artery occlusion to a central London hyperacute stroke unit. Patients with significant carotid stenosis, defined as atherosclerotic narrowing of 50 per cent or greater, underwent multidisciplinary team (MDT) discussion to determine the cause of stroke/TIA and classify carotid stenosis as symptomatic or incidental. RESULTS In total, 2707 patients were seen; half had an ischaemic event and the majority had carotid imaging (1252 of 1444). Carotid stenosis of at least 50 per cent was seen in 238 (prevalence 19·0 (95 per cent c.i. 16·6 to 21·4) per cent). Patients with significant carotid stenosis were more likely to have hypertension, hypercholesterolaemia, diabetes and ischaemic heart disease. Carotid stenosis was deemed symptomatic in 99 patients (7·9 (6·3 to 9·5) per cent); of these, 17 had carotid occlusion, 17 were unfit for surgery and 58 patients were referred for carotid intervention. Among 139 patients with asymptomatic stenosis, 75 had carotid stenosis ipsilateral to the stroke but, after MDT discussion, the cause was deemed to be atrial fibrillation (32), small-vessel disease (15), another determined cause (5), or not determined owing to atypical imaging or clinical presentation. CONCLUSION Carotid stenosis is common, affecting one in five patients presenting with stroke or TIA. Careful MDT discussion may avoid unnecessary intervention and should be the standard of care.
Collapse
Affiliation(s)
- S F Cheng
- Division of Surgery and Interventional Science, University College London, London, UK
| | - M M Brown
- Stroke Research Centre, Department of Brain Repair and Rehabilitation, Institute of Neurology, University College London, London, UK
| | - R J Simister
- University College London Hospitals NHS Foundation Trust, London, UK
| | - T Richards
- Division of Surgery and Interventional Science, University College London, London, UK
| |
Collapse
|
40
|
Naylor R. When two worlds collide. ANZ J Surg 2019; 89:279-280. [PMID: 30942547 DOI: 10.1111/ans.14965] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2018] [Revised: 09/17/2018] [Accepted: 10/16/2018] [Indexed: 11/30/2022]
Affiliation(s)
- Ross Naylor
- Leicester Vascular Institute, Glenfield Hospital, Leicester, UK
| |
Collapse
|
41
|
Liu Z, Bai Z, Huang C, Huang M, Huang L, Xu D, Zhang H, Yuan C, Luo J. Interoperator Reproducibility of Carotid Elastography for Identification of Vulnerable Atherosclerotic Plaques. IEEE TRANSACTIONS ON ULTRASONICS, FERROELECTRICS, AND FREQUENCY CONTROL 2019; 66:505-516. [PMID: 30575532 DOI: 10.1109/tuffc.2018.2888479] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/09/2023]
Abstract
Ultrasound-based carotid elastography has been developed to evaluate the vulnerability of carotid atherosclerotic plaques. The aim of this study was to investigate the in vivo interoperator reproducibility of carotid elastography for the identification of vulnerable plaques, with high-resolution magnetic resonance imaging (MRI) as reference. Ultrasound radio-frequency data of 45 carotid arteries (including 53 plaques) from 32 volunteers were acquired separately by two experienced operators in the longitudinal view and then were used to estimate the interframe axial strain rate (ASR) with a two-step optical flow method. The maximum 99th percentile of absolute ASR of all plaques in a carotid artery was used as the elastographic index. MRI scanning was also performed on each volunteer to identify the vulnerable plaque. The results showed no systematic bias in the Bland-Altman plot and an intraclass correlation coefficient of 0.66 between the two operators. In addition, no statistical significance was found between the receiver operating characteristic (ROC) curves from the two operators ( ), and their areas under the ROC curves were 0.83 and 0.77, respectively. Using the mean measurements of the two operators as the classification criterion, a sensitivity of 71.4%, a specificity of 87.1%, and an accuracy of 82.2% were obtained with a cutoff value of 1.37 [Formula: see text]. This study validates the interoperator reproducibility of ultrasound-based carotid elastography for identifying vulnerable carotid plaques.
Collapse
|
42
|
Oksala NK, Lindström I, Khan N, Pihlajaniemi VJ, Lyytikäinen LP, Pienimäki JP, Hernesniemi J. Pre-Operative Masseter Area is an Independent Predictor of Long-Term Survival after Carotid Endarterectomy. Eur J Vasc Endovasc Surg 2019; 57:331-338. [DOI: 10.1016/j.ejvs.2018.11.011] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2018] [Accepted: 11/18/2018] [Indexed: 01/09/2023]
|
43
|
Carotid artery plaque echomorphology and its association with histopathologic characteristics. J Vasc Surg 2018; 68:1772-1780. [DOI: 10.1016/j.jvs.2018.01.068] [Citation(s) in RCA: 27] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2017] [Accepted: 01/27/2018] [Indexed: 12/27/2022]
|
44
|
Mulatti GC, Puech-Leão P, De Luccia N, da Silva ES. Characterization and Natural History of Patients with Internal Carotid Occlusion: A Comparative Study. Ann Vasc Surg 2018; 53:44-52. [PMID: 30053548 DOI: 10.1016/j.avsg.2018.04.039] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2018] [Revised: 03/24/2018] [Accepted: 04/26/2018] [Indexed: 11/26/2022]
Abstract
BACKGROUND To characterize patients with internal carotid occlusion (ICO) with respect to demographic data, associated diseases, medical management, and risk factors and to compare these patients with those with nonsignificant stenosis (NSS; less than 50% stenosis). Secondary end points were new neurologic events, progression of contralateral degree of stenosis, cardiovascular symptoms, and death during follow-up. METHODS Retrospective analysis was performed using data collected from clinical records and added to a prospective database. Missing data were obtained during phone interviews or requested medical appointments. RESULTS From 2005 to 2013, 213 patients with ICO and 172 with NSS were studied (medium follow-up 37.81 months). Among the patients with ICO, a greater proportion were men, had a history of smoking, and presented with peripheral arterial disease and a lower creatinine clearance compared with those with NSS (P < 0.05). At the time of diagnosis, 76.1% of the patients with ICO were symptomatic compared with 35.5% of those with NSS (P = 0.000001). The patients in the ICO group exhibited significant progression of contralateral stenosis compared with those in the control group with progression on any side (15.0% vs. 2.3%, P = 0.00011). In addition, 18 patients in the ICO group (8.5%) exhibited new neurological symptoms compared with 13 (7.6%) in the NSS group (P = 0.41). When the ICO and NSS groups were combined, 10.8% of the initially symptomatic patients presented with new symptoms compared with 4.3% of those who were initially asymptomatic (P = 0.0218). The number of deaths was significantly higher among the patients in the ICO group (14.1% vs. 6.4%, P = 0.0150). CONCLUSIONS Patients presenting with ICO have more risk factors and higher mortality by any cause. Initially, symptomatic patients will likely present with more neurological symptoms during follow-up, independent of carotid morphology, ICO, or NSS. Efforts must be made to identify those at risk before occlusion and to prevent secondary events and death.
Collapse
Affiliation(s)
- Grace Carvajal Mulatti
- Vascular and Endovascular Division, Surgery Department, University of São Paulo Medical School, Sao Paulo, Sao Paulo, Brazil.
| | - Pedro Puech-Leão
- Vascular and Endovascular Division, Surgery Department, University of São Paulo Medical School, Sao Paulo, Sao Paulo, Brazil
| | - Nelson De Luccia
- Vascular and Endovascular Division, Surgery Department, University of São Paulo Medical School, Sao Paulo, Sao Paulo, Brazil
| | - Erasmo S da Silva
- Vascular and Endovascular Division, Surgery Department, University of São Paulo Medical School, Sao Paulo, Sao Paulo, Brazil
| |
Collapse
|
45
|
Naylor AR. Hype springs eternal. J Vasc Surg 2018; 68:657. [PMID: 30037682 DOI: 10.1016/j.jvs.2018.03.431] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2018] [Accepted: 03/27/2018] [Indexed: 11/29/2022]
Affiliation(s)
- A Ross Naylor
- Vascular Surgery Group, Division of Cardiovascular Sciences, Leicester Royal Infirmary, Leicester, United Kingdom
| |
Collapse
|
46
|
Jones DW, Brott TG, Schermerhorn ML. Trials and Frontiers in Carotid Endarterectomy and Stenting. Stroke 2018; 49:1776-1783. [PMID: 29866753 DOI: 10.1161/strokeaha.117.019496] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2017] [Revised: 04/19/2018] [Accepted: 04/30/2018] [Indexed: 11/16/2022]
Affiliation(s)
- Douglas W Jones
- From the Division of Vascular and Endovascular Surgery, Boston Medical Center, Boston University School of Medicine, MA (D.W.J.)
| | - Thomas G Brott
- Department of Neurology, Mayo Clinic, Jacksonville, FL (T.G.B.)
| | - Marc L Schermerhorn
- Division of Vascular and Endovascular Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA (M.L.S.).
| |
Collapse
|
47
|
Tsivgoulis G, Safouris A, Kim DE, Alexandrov AV. Recent Advances in Primary and Secondary Prevention of Atherosclerotic Stroke. J Stroke 2018; 20:145-166. [PMID: 29886715 PMCID: PMC6007302 DOI: 10.5853/jos.2018.00773] [Citation(s) in RCA: 26] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2018] [Revised: 05/13/2018] [Accepted: 05/23/2018] [Indexed: 01/09/2023] Open
Abstract
Atherosclerosis is a major cause of ischemic stroke that can be effectively prevented with appropriate lifestyle modifications and control of cardiovascular risk factors. Medical advances in recent years along with aggressive cardiovascular risk factor modifications have resulted in decreased recurrence rates of atherosclerotic stroke. Non-statin lipid-lowering molecules have recently shown clinical benefit and are recommended for very high-risk patients to reduce their risk of stroke. Aggressive hypertension treatment is crucial to reduce atherosclerotic stroke risk. Advances in antithrombotic treatments include combinations of antiplatelets and new antiplatelet agents in the acute phase post-stroke, which carries a high risk of recurrence. Intensive medical treatment has also limited the indications for carotid interventions, especially for asymptomatic disease. Intracranial atherosclerotic disease may provoke stroke through various mechanisms; it is increasingly recognized as a cause of ischemic stroke with advanced imaging and is best managed with lifestyle modifications and medical therapy. The diagnostic search for the vulnerable culprit atherosclerotic plaque is an area of intense research, from the level of the intracranial arteries to that of the aortic arch. Ultrasonography and novel magnetic resonance imaging techniques (high-resolution vessel-wall imaging) may assist in the identification of vulnerable atherosclerotic plaques as the underlying cause in cryptogenic or misdiagnosed non-atherosclerotic ischemic stroke. Vertebrobasilar atherosclerotic disease is less common than carotid artery disease; thus, high-quality data on effective prevention strategies are scarcer. However, aggressive medical treatment is also the gold standard to reduce cerebrovascular disease located in posterior circulation.
Collapse
Affiliation(s)
- Georgios Tsivgoulis
- Second Department of Neurology, “Attikon” University Hospital, National and Kapodistrian University of Athens School of Medicine, Athens, Greece
- Department of Neurology, The University of Tennessee Health Science Center, Memphis, TN, USA
| | - Apostolos Safouris
- Second Department of Neurology, “Attikon” University Hospital, National and Kapodistrian University of Athens School of Medicine, Athens, Greece
- Stroke Unit, Metropolitan Hospital, Pireus, Greece
| | - Dong-Eog Kim
- Department of Neurology, Dongguk University Ilsan Hospital, Dongguk University College of Medicine, Goyang, Korea
| | - Andrei V. Alexandrov
- Department of Neurology, The University of Tennessee Health Science Center, Memphis, TN, USA
| |
Collapse
|
48
|
Chan JMS, Monaco C, Wylezinska-Arridge M, Tremoleda JL, Cole JE, Goddard M, Cheung MSH, Bhakoo KK, Gibbs RGJ. Imaging vulnerable plaques by targeting inflammation in atherosclerosis using fluorescent-labeled dual-ligand microparticles of iron oxide and magnetic resonance imaging. J Vasc Surg 2018; 67:1571-1583.e3. [PMID: 28648478 DOI: 10.1016/j.jvs.2017.04.046] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2017] [Accepted: 04/01/2017] [Indexed: 11/17/2022]
Abstract
OBJECTIVE Identification of patients with high-risk asymptomatic carotid plaques remains an elusive but essential step in stroke prevention. Inflammation is a key process in plaque destabilization and a prelude to clinical sequelae. There are currently no clinical imaging tools to assess the inflammatory activity within plaques. This study characterized inflammation in atherosclerosis using dual-targeted microparticles of iron oxide (DT-MPIO) as a magnetic resonance imaging (MRI) probe. METHODS DT-MPIO were used to detect and characterize inflammatory markers, vascular cell adhesion molecule 1 (VCAM-1). and P-selectin on (1) tumor necrosis factor-α-treated cells by immunocytochemistry and (2) aortic root plaques of apolipoprotein-E deficient mice by in vivo MRI. Furthermore, apolipoprotein E-deficient mice with focal carotid plaques of different phenotypes were developed by means of periarterial cuff placement to allow in vivo molecular MRI using these probes. The association between biomarkers and the magnetic resonance signal in different contrast groups was assessed longitudinally in these models. RESULTS Immunocytochemistry confirmed specificity and efficacy of DT-MPIO to VCAM-1 and P-selectin. Using this in vivo molecular MRI strategy, we demonstrated (1) the DT-MPIO-induced magnetic resonance signal tracked with VCAM-1 (r = 0.69; P = .014), P-selectin (r = 0.65; P = .022), and macrophage content (r = 0.59; P = .045) within aortic root plaques and (2) high-risk inflamed plaques were distinguished from noninflamed plaques in the murine carotid artery within a practical clinical imaging time frame. CONCLUSIONS These molecular MRI probes constitute a novel imaging tool for in vivo characterization of plaque vulnerability and inflammatory activity in atherosclerosis. Further development and translation into the clinical arena will facilitate more accurate risk stratification in carotid atherosclerotic disease in the future.
Collapse
Affiliation(s)
- Joyce M S Chan
- Department of Surgery, Prince of Wales Hospital, The Chinese University of Hong Kong, Hong Kong, United Kingdom; Regional Vascular Unit, St Mary's Hospital, Imperial College Healthcare National Health Service Trust, Imperial College London, London, United Kingdom; The Laboratory of Molecular Imaging, Singapore Bioimaging Consortium, Agency for Science, Technology and Research (ASTAR), Singapore.
| | - Claudia Monaco
- Kennedy Institute of Rheumatology, Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, United Kingdom
| | - Marzena Wylezinska-Arridge
- Neuroradiological Academic Unit, University of College London Institute of Neurology, University College London, London, United Kingdom
| | - Jordi L Tremoleda
- Medical Research Council-Clinical Sciences Centre, Imperial College London, and Centre for Trauma Sciences, Queen Mary University of London, London, United Kingdom
| | - Jennifer E Cole
- Kennedy Institute of Rheumatology, Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, United Kingdom
| | - Michael Goddard
- Kennedy Institute of Rheumatology, Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, United Kingdom
| | - Maggie S H Cheung
- Department of Surgery, Prince of Wales Hospital, The Chinese University of Hong Kong, Hong Kong, United Kingdom
| | - Kishore K Bhakoo
- The Laboratory of Molecular Imaging, Singapore Bioimaging Consortium, Agency for Science, Technology and Research (ASTAR), Singapore
| | - Richard G J Gibbs
- Regional Vascular Unit, St Mary's Hospital, Imperial College Healthcare National Health Service Trust, Imperial College London, London, United Kingdom
| |
Collapse
|
49
|
Naylor AR, Ricco JB, de Borst GJ, Debus S, de Haro J, Halliday A, Hamilton G, Kakisis J, Kakkos S, Lepidi S, Markus HS, McCabe DJ, Roy J, Sillesen H, van den Berg JC, Vermassen F, Kolh P, Chakfe N, Hinchliffe RJ, Koncar I, Lindholt JS, Vega de Ceniga M, Verzini F, Archie J, Bellmunt S, Chaudhuri A, Koelemay M, Lindahl AK, Padberg F, Venermo M. Editor's Choice - Management of Atherosclerotic Carotid and Vertebral Artery Disease: 2017 Clinical Practice Guidelines of the European Society for Vascular Surgery (ESVS). Eur J Vasc Endovasc Surg 2018; 55:3-81. [PMID: 28851594 DOI: 10.1016/j.ejvs.2017.06.021] [Citation(s) in RCA: 794] [Impact Index Per Article: 132.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
|
50
|
Eckstein HH, Tsantilas P, Kühnl A, Haller B, Breitkreuz T, Zimmermann A, Kallmayer M. Surgical and Endovascular Treatment of Extracranial Carotid Stenosis. DEUTSCHES ARZTEBLATT INTERNATIONAL 2017; 114:729-736. [PMID: 29143732 PMCID: PMC5696565 DOI: 10.3238/arztebl.2017.0729] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/16/2017] [Revised: 03/16/2017] [Accepted: 07/19/2017] [Indexed: 11/27/2022]
Abstract
BACKGROUND Carotid endarterectomy (CEA) and carotid artery stenting (CAS) can be used to prevent stroke due to arteriosclerotic lesions of the carotid artery. In Germany, legally mandated quality assurance (QA) enables the evaluation of outcome quality after CEA and CAS performed under routine conditions. METHODS We analyzed data on all elective CEA and CAS procedures performed over the periods 2009-2014 and 2012-2014, respectively. The endpoints of the study were the combined in-hospital stroke and death rate, stroke rate and mortality separately, local complications, and other complications. We analyzed the raw data with descriptive statistics and carried out a risk-adjusted analysis of the association of clinically unalterable variables with the risk of stroke and death. All analyses were performed separately for CEA and CAS. RESULTS Data were analyzed from 142 074 CEA procedures (67.8% of them in men) and 13 086 CAS procedures (69.7% in men). The median age was 72 years (CEA) and 71 years (CAS). The periprocedural rate of stroke and death after CEA was 1.4% for asymptomatic and 2.5% for symptomatic stenoses; the corresponding rates for CAS were 1.7% and 3.7%. Variables associated with increased risk included older age, higher ASA class (ASA = American Society of Anesthesiologists), symptomatic vs. asymptomatic stenosis, 50-69% stenosis, and contralateral carotid occlusion (for CEA only). CONCLUSION These data reveal a low periprocedural rate of stroke or death for both CEA and CAS. This study does however not permit any conclusions as to the superiority or inferiority of CEA and CAS.
Collapse
Affiliation(s)
- Hans-Henning Eckstein
- Department of Vascular and Endovascular Surgery/Vascular Center, Klinikum rechts der Isar der Technischen Universität München
| | - Pavlos Tsantilas
- Department of Vascular and Endovascular Surgery/Vascular Center, Klinikum rechts der Isar der Technischen Universität München
| | - Andreas Kühnl
- Department of Vascular and Endovascular Surgery/Vascular Center, Klinikum rechts der Isar der Technischen Universität München
| | - Bernhard Haller
- Institut für Medizinische Statistik und Epidemiologie, Klinikum rechts der Isar, Technische Universität München
| | - Thorben Breitkreuz
- AQUA—Institute for Applied Quality Improvement and Research in Health Care GmbH, Göttingen
| | - Alexander Zimmermann
- Department of Vascular and Endovascular Surgery/Vascular Center, Klinikum rechts der Isar der Technischen Universität München
| | - Michael Kallmayer
- Department of Vascular and Endovascular Surgery/Vascular Center, Klinikum rechts der Isar der Technischen Universität München
| |
Collapse
|