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Lee KB, Tanenbaum MT, Wang A, Tsai S, Modrall JG, Timaran CH, Kirkwood ML, Ramanan B. Impact of head and neck radiation on long-term outcomes after carotid revascularization. J Vasc Surg 2024:S0741-5214(24)00928-5. [PMID: 38570175 DOI: 10.1016/j.jvs.2024.03.441] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2024] [Revised: 03/21/2024] [Accepted: 03/25/2024] [Indexed: 04/05/2024]
Abstract
OBJECTIVE Radiation-induced carotid artery stenosis (RICS) is a well-described phenomenon seen after head and neck cancer radiation. Previously published literature suggests that, compared with atherosclerotic disease, RICS may result in worse long-term outcomes and early restenosis. This study aims to evaluate the effect of radiation on long-term outcomes after various carotid revascularization techniques using a multi-center registry database. METHODS Patients in the Society for Vascular Surgery (SVS) Vascular Quality Initiative (VQI) registry for carotid artery intervention (carotid endarterectomy [CEA]; transfemoral carotid artery stenting [CAS]; transcarotid artery revascularization [TCAR]), who are 65 years or older were included in the study. VQI Vascular Implant Surveillance and Interventional Outcomes Network (VISION) Medicare-linked database was used to obtain long-term procedure-specific outcomes. Primary endpoints were 3-year death, stroke, and reintervention. We performed propensity matching between patients with prior radiation and those without. Kaplan-Meier analysis and a multivariate logistic regression model were used to analyze the outcome variables. RESULTS A total of 56,472 patients had undergone carotid revascularization (CEA, n = 48,307; TCAR, n = 4593; CAS, n = 3572), 1244 patients with prior radiation and 54,925 patients without prior radiation. The prior radiation group was more likely to be male (71.9% vs 60.3%; P < .01), to receive a stent (47.5% vs 13.5%; P < .01), and to be on P2Y12 inhibitor (55.2% vs 38.3%; P < .01). Propensity matching was performed on 1223 patients (CEA, n = 655; TCAR, n = 292; CAS, n = 287). There were no significant differences in 30-day outcomes for death, stroke, or major adverse cardiovascular events for all three procedures. The prior radiation group had higher rates of cranial nerve injury (3.7% vs 1.8%; P = .04) and 90-day readmission (23.5% vs 18.3%; P = .01) after CEA. For long-term outcomes, prior radiation significantly increased mortality risk for CEA and CAS (hazard ratio [HR], 1.77; 95% confidence interval [CI], 1.38-2.27 and HR, 1.56; 95% CI, 1.02-2.36, respectively). The 3-year risk of stroke for CEA in radiated patients was also significantly higher (HR, 1.47; 95% CI, 1.03-2.09) compared with non-radiated patients. Prior radiation did not significantly affect death and stroke in patients undergoing TCAR. Prior radiation also did not impact the rates of short and long-term reintervention after CEA, CAS, or TCAR. CONCLUSIONS Prior head and neck radiation significantly increases the risk for mortality and stroke for CEA and the risk for mortality after CAS. Long-term outcomes for TCAR are not significantly affected by prior radiation. TCAR may be the preferred treatment modality for patients with radiation-induced carotid stenosis.
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Affiliation(s)
- K Benjamin Lee
- Division of Vascular Diseases and Surgery, Department of Surgery, The Ohio State University Wexner Medical Center, Columbus, OH
| | - Mira T Tanenbaum
- Division of Vascular and Endovascular Surgery, Department of Surgery, University of Texas Southwestern Medical Center, Dallas, TX
| | - Angela Wang
- Division of Vascular and Endovascular Surgery, Department of Surgery, University of Texas Southwestern Medical Center, Dallas, TX
| | - Shirling Tsai
- Division of Vascular and Endovascular Surgery, Department of Surgery, University of Texas Southwestern Medical Center, Dallas, TX; Division of Vascular and Endovascular Surgery, Department of Surgery, Dallas VA Medical Center, Dallas, TX
| | - J Gregory Modrall
- Division of Vascular and Endovascular Surgery, Department of Surgery, University of Texas Southwestern Medical Center, Dallas, TX; Division of Vascular and Endovascular Surgery, Department of Surgery, Dallas VA Medical Center, Dallas, TX
| | - Carlos H Timaran
- Division of Vascular and Endovascular Surgery, Department of Surgery, University of Texas Southwestern Medical Center, Dallas, TX
| | - Melissa L Kirkwood
- Division of Vascular and Endovascular Surgery, Department of Surgery, University of Texas Southwestern Medical Center, Dallas, TX
| | - Bala Ramanan
- Division of Vascular and Endovascular Surgery, Department of Surgery, University of Texas Southwestern Medical Center, Dallas, TX; Division of Vascular and Endovascular Surgery, Department of Surgery, Dallas VA Medical Center, Dallas, TX.
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Zhu J, Rao A, Berger K, Gopal M, Vrudhula A, Han D, Vouyouka A, Ting W, Finlay D, Kim SY, Tadros R, Marin M, Faries P. Determinants of Mortality and Mid-Term Outcomes After Transcarotid Artery Revascularization and Transfemoral Carotid Artery Stenting. J Endovasc Ther 2024:15266028241235791. [PMID: 38449352 DOI: 10.1177/15266028241235791] [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: 03/08/2024]
Abstract
OBJECTIVES The potential benefit of transcarotid artery revascularization (TCAR) over transfemoral carotid artery stenting (tfCAS) has been studied in the perioperative period with lower rates of stroke and death; however, data on mid-term outcomes are limited. We aimed to evaluate 3-year outcomes after TCAR and tfCAS and determine the primary predictors of 30-day and 1-year mortality following TCAR. METHODS Data from the Vascular Quality Initiative for patients undergoing TCAR or tfCAS from January 2016 to December 2022 were analyzed. 1:1 propensity score matching using the nearest-neighbor method was used to adjust baseline demographics and clinical characteristics. Kaplan-Meier survival analysis and Cox Proportional Hazard Regression were used to evaluate long-term outcomes. Iterative stepwise multiple logistic regression analysis and Cox Proportional Hazard Regression were used to identify predictors of 30-day and 1-year mortality, respectively, based upon preoperative, intraoperative, and postoperative factors. RESULTS A total of 70 237 patients were included in analysis (TCAR=58.7%, tfCAS=41.3%). Transcarotid artery revascularization patients were older and had higher rates of comorbid conditions and high-risk medical and anatomic features than tfCAS patients. Propensity score matching yielded 22 322 pairs with no major differences between groups except that TCAR patients were older (71.6 years vs 70.8 years). At 3 years, TCAR was associated with a 24% reduction in hazard of death compared with tfCAS (hazard ratio [HR]=0.76, 95% confidence interval [CI]=0.71-0.82, p<0.001), for both symptomatic and asymptomatic patients. This survival advantage was established in the first 6 months (HR=0.59, 95% CI=0.53-0.62, p<0.001), with no difference in mortality risk from 6 months to 36 months (HR=0.95, 95% CI=0.86-1.05, p=0.31). Transcarotid artery revascularization was also associated with decreased hazard for 3-year stroke (HR=0.81, 95% CI=0.66-0.99, p=0.04) and stroke or death (HR=0.81, 95% CI=0.76-0.87, p<0.001) compared with tfCAS. The top predictors for 30-day and 1-year mortality were postoperative complications. The primary independent predictor was the occurrence of postoperative stroke. CONCLUSIONS Transcarotid artery revascularization had a sustained mid-term survival advantage associated over tfCAS, with the benefit being established primarily within the first 6 months. Notably, our findings highlight the importance of postoperative stroke as the primary independent predictor for 30-day and 1-year mortal. CLINICAL IMPACT The ongoing debate over the superiority of TCAR compared to tfCAS and CEA has been limited by a lack of comparative studies examining the impact of pre-operative symptoms on outcomes. Furthermore, data are scarce on mid-term outcomes for TCAR beyond the perioperative period. As a result, it remains uncertain whether the initial benefits of stroke and death reduction observed with TCAR over tfCAS persist beyond one year. Our study addresses these gaps in the literature, offering evidence to enable clinicians to assess the efficacy of TCAR for up to three years. Additionally, our study seeks to identify risk factors for postoperative mortality following TCAR, facilitating optimal patient stratification.
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Affiliation(s)
- Jerry Zhu
- Division of Vascular Surgery, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Ajit Rao
- Division of Vascular Surgery, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Kelsey Berger
- Division of Vascular Surgery, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Malika Gopal
- Division of Vascular Surgery, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Amey Vrudhula
- Division of Vascular Surgery, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Daniel Han
- Division of Vascular Surgery, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Ageliki Vouyouka
- Division of Vascular Surgery, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Windsor Ting
- Division of Vascular Surgery, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - David Finlay
- Division of Vascular Surgery, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Sung Yup Kim
- Division of Vascular Surgery, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Rami Tadros
- Division of Vascular Surgery, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Michael Marin
- Division of Vascular Surgery, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Peter Faries
- Division of Vascular Surgery, Icahn School of Medicine at Mount Sinai, New York, NY, USA
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Kotsugi M, Nakagawa I, Sasaki H, Okamoto A, Nakase K, Maeoka R, Yokoyama S, Yamada S, Nakase H. Thin Calcification Predicts Lipid Component in Carotid Plaque-Relationship Between Lipid Distribution and Thin Calcification. World Neurosurg 2024; 183:e715-e721. [PMID: 38191057 DOI: 10.1016/j.wneu.2024.01.011] [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: 07/29/2023] [Accepted: 01/02/2024] [Indexed: 01/10/2024]
Abstract
BACKGROUND Accurately evaluating plaque characteristics is essential because lesions with lipid-rich plaque put patients at risk of thromboembolic complications from carotid artery stenting. Near-infrared spectroscopy (NIRS) is a diagnostic imaging modality that identifies lipid components from the near-infrared absorption pattern but does not reveal the distribution of calcification. The purpose of this study was to investigate the calcification characteristics of unstable carotid plaques, focusing on relationships between the calcification characteristics revealed by computed tomography angiography and the lipid core distribution derived from NIRS. METHODS Participants in this retrospective analysis comprised 35 patients (29 men, 6 women; mean age, 76.0 years; range, 52-89 years) who underwent carotid artery stenting in our institute between January 2021 and December 2022. We evaluated the thickness and length of carotid calcifications at the minimal lumen level from preoperative computed tomography angiography and analyzed the relationship with maximum lipid core burden index (max-LCBI) from NIRS. RESULTS Strong negative linear correlations were observed between the thickness of calcification and max-LCBI at Area (any segment in a target lesion) (r = -0.795, P < 0.001), max-LCBI at minimal lumen area (r = -0.795, P < 0.001) and lipid core burden index (LCBI) at lesion (rate of LCBI in entire plaque lesion) (r = -0.788, P < 0.001), respectively. Significant negative linear correlations were observed between distribution of calcification length and max-LCBI at area (r = -0.429, P = 0.01), max-LCBI at minimal lumen area (r = -0.373, P = 0.027), and LCBI at lesion (r = -0.443, P = 0.008). CONCLUSIONS Thin and ubiquitous carotid calcification was associated with LCBI values derived from NIRS indicative of carotid lipid plaque distribution, implying the possibility of predicting lesion instability.
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Affiliation(s)
- Masashi Kotsugi
- Departments of Neurosurgery, Nara Medical University, Nara, Japan
| | - Ichiro Nakagawa
- Departments of Neurosurgery, Nara Medical University, Nara, Japan.
| | - Hiromitsu Sasaki
- Departments of Neurosurgery, Nara Medical University, Nara, Japan
| | - Ai Okamoto
- Departments of Neurosurgery, Nara Medical University, Nara, Japan
| | - Kenta Nakase
- Departments of Neurosurgery, Nara Medical University, Nara, Japan
| | - Ryosuke Maeoka
- Departments of Neurosurgery, Nara Medical University, Nara, Japan
| | - Shohei Yokoyama
- Departments of Neurosurgery, Nara Medical University, Nara, Japan
| | - Shuichi Yamada
- Departments of Neurosurgery, Nara Medical University, Nara, Japan
| | - Hiroyuki Nakase
- Departments of Neurosurgery, Nara Medical University, Nara, Japan
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Paraskevas KI, Brown MM, Lal BK, Myrcha P, Lyden SP, Schneider PA, Poredos P, Mikhailidis DP, Secemsky EA, Musialek P, Mansilha A, Parikh SA, Silvestrini M, Lavie CJ, Dardik A, Blecha M, Liapis CD, Zeebregts CJ, Nederkoorn PJ, Poredos P, Gurevich V, Jawien A, Lanza G, Gray WA, Gupta A, Svetlikov AV, Fernandes E Fernandes J, Nicolaides AN, White CJ, Meschia JF, Cronenwett JL, Schermerhorn ML, AbuRahma AF. Recent advances and controversial issues in the optimal management of asymptomatic carotid stenosis. J Vasc Surg 2024; 79:695-703. [PMID: 37939746 DOI: 10.1016/j.jvs.2023.11.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2023] [Revised: 10/29/2023] [Accepted: 11/03/2023] [Indexed: 11/10/2023]
Abstract
OBJECTIVE The optimal management of patients with asymptomatic carotid stenosis (AsxCS) is enduringly controversial. We updated our 2021 Expert Review and Position Statement, focusing on recent advances in the diagnosis and management of patients with AsxCS. METHODS A systematic review of the literature was performed up to August 1, 2023, using PubMed/PubMed Central, EMBASE and Scopus. The following keywords were used in various combinations: "asymptomatic carotid stenosis," "carotid endarterectomy" (CEA), "carotid artery stenting" (CAS), and "transcarotid artery revascularization" (TCAR). Areas covered included (i) improvements in best medical treatment (BMT) for patients with AsxCS and declining stroke risk, (ii) technological advances in surgical/endovascular skills/techniques and outcomes, (iii) risk factors, clinical/imaging characteristics and risk prediction models for the identification of high-risk AsxCS patient subgroups, and (iv) the association between cognitive dysfunction and AsxCS. RESULTS BMT is essential for all patients with AsxCS, regardless of whether they will eventually be offered CEA, CAS, or TCAR. Specific patient subgroups at high risk for stroke despite BMT should be considered for a carotid revascularization procedure. These patients include those with severe (≥80%) AsxCS, transcranial Doppler-detected microemboli, plaque echolucency on Duplex ultrasound examination, silent infarcts on brain computed tomography or magnetic resonance angiography scans, decreased cerebrovascular reserve, increased size of juxtaluminal hypoechoic area, AsxCS progression, carotid plaque ulceration, and intraplaque hemorrhage. Treatment of patients with AsxCS should be individualized, taking into consideration individual patient preferences and needs, clinical and imaging characteristics, and cultural, ethnic, and social factors. Solid evidence supporting or refuting an association between AsxCS and cognitive dysfunction is lacking. CONCLUSIONS The optimal management of patients with AsxCS should include BMT for all individuals and a prophylactic carotid revascularization procedure (CEA, CAS, or TCAR) for some asymptomatic patient subgroups, additionally taking into consideration individual patient needs and preference, clinical and imaging characteristics, social and cultural factors, and the available stroke risk prediction models. Future studies should investigate the association between AsxCS with cognitive function and the role of carotid revascularization procedures in the progression or reversal of cognitive dysfunction.
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Affiliation(s)
| | - Martin M Brown
- Stroke Research Centre, Department of Brain Repair and Rehabilitation, UCL Queen Square Institute of Neurology, University College London, London, UK
| | - Brajesh K Lal
- Department of Vascular Surgery, University of Maryland School of Medicine, Baltimore, MD; Department of Vascular Surgery, Baltimore VA Medical Center, Baltimore, MD; Department of Neurology, Mayo Clinic, Rochester, MN
| | - Piotr Myrcha
- Department of General and Vascular Surgery, Faculty of Medicine, Medical University of Warsaw, Warsaw, Poland
| | - Sean P Lyden
- Department of Vascular Surgery, The Cleveland Clinic, Cleveland, OH
| | - Peter A Schneider
- Division of Vascular and Endovascular Surgery, University of California, San Francisco, CA
| | - Pavel Poredos
- Department of Vascular Diseases, University Medical Centre Ljubljana, Ljubljana, Slovenia
| | - Dimitri P Mikhailidis
- Department of Clinical Biochemistry, Royal Free Hospital Campus, University College London Medical School, University College London (UCL), London, UK
| | - Eric A Secemsky
- Smith Center for Outcomes Research in Cardiology, Division of Cardiology, Department of Medicine, Beth Israel Deaconess Medical Center, Boston, MA
| | - Piotr Musialek
- Jagiellonian University Department of Cardiac and Vascular Diseases, John Paul II Hospital, Krakow, Poland
| | - Armando Mansilha
- Faculty of Medicine of the University of Porto, Porto, Portugal; Department of Angiology and Vascular Surgery, Hospital de S. Joao, Porto, Portugal
| | - Sahil A Parikh
- Division of Cardiology, Department of Medicine, New York-Presbyterian Hospital/Columbia University Irving Medical Center, New York, NY; Center for Interventional Cardiovascular Care and Division of Cardiology, Department of Medicine, Columbia University Irving Medical Center, New York, NY
| | - Mauro Silvestrini
- Neurological Clinic, Department of Experimental and Clinical Medicine, Marche Polytechnic University, Ancona, Italy
| | - Carl J Lavie
- John Ochsner Heart and Vascular Institute, Ochsner Clinical School, The University of Queensland School of Medicine, New Orleans, LA
| | - Alan Dardik
- Department of Surgery, Yale School of Medicine, New Haven, CT
| | - Matthew Blecha
- Division of Vascular Surgery and Endovascular Therapy, Loyola University Chicago, Stritch School of Medicine, Loyola University Health System, Chicago, IL
| | - Christos D Liapis
- Department of Vascular & Endovascular Surgery, Athens Medical Center, Athens, Greece
| | - Clark J Zeebregts
- Department of Surgery, Division of Vascular Surgery, University Medical Center Groningen, University of Groningen, Amsterdam, the Netherlands
| | - Paul J Nederkoorn
- Department of Neurology, Amsterdam UMC, University of Amsterdam, Amsterdam, the Netherlands
| | - Peter Poredos
- Department of Anaesthesiology and Surgical Intensive Care, University Medical Centre Ljubljana, Ljubljana, Slovenia
| | - Victor Gurevich
- Center of Atherosclerosis, Lab of Microangiopathic Mechanisms of Atherogenesis, Saint-Petersburg State University, North-Western State Medical University n.a. I.I. Mechnikov, Saint Petersburg, Russia
| | - Arkadiusz Jawien
- Department of Vascular Surgery and Angiology, Collegium Medicum in Bydgoszcz, Nicolaus Copernicus University in Torun, Torun, Poland
| | - Gaetano Lanza
- Department of Surgery, IRCCS Multimedica Hospital, Castellanza, Italy
| | | | - Ajay Gupta
- Department of Radiology, Weill Cornell Medicine, New York, NY
| | - Alexei V Svetlikov
- Division of Vascular & Endovascular Surgery, North-Western Scientific Clinical Center of Federal Medical Biological Agency, Department of Hospital Surgery, Saint-Petersburg State University, Saint Petersburg, Russia
| | | | - Andrew N Nicolaides
- Vascular Screening and Diagnostic Center, Nicosia, Cyprus; University of Nicosia Medical School, Nicosia, Cyprus; Department of Vascular Surgery, Imperial College, London, UK
| | - Christopher J White
- Department of Cardiology, Ochsner Clinical School, University of Queensland and Ochsner Health System, New Orleans, LA
| | | | - Jack L Cronenwett
- Section of Vascular Surgery, Dartmouth-Hitchcock Medical Center, Lebanon, NH
| | - Marc L Schermerhorn
- Department of Surgery, Division of Vascular and Endovascular Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA
| | - Ali F AbuRahma
- Department of Surgery, Division of Vascular and Endovascular Surgery, Charleston Area Medical Center/West Virginia University Health Sciences Center, Charleston, WV
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Zhou Y, Ma Y, Qian D, Zhou Z, Li B, Chai E. The Atherogenic Index of Plasma Predicts Carotid in-Stent Restenosis: Development and Validation of a Nomogram. Int J Gen Med 2024; 17:263-274. [PMID: 38292824 PMCID: PMC10824612 DOI: 10.2147/ijgm.s447008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2023] [Accepted: 01/16/2024] [Indexed: 02/01/2024] Open
Abstract
Purpose To explore the predictive value of atherogenic index of plasma(AIP) for carotid in-stent restenosis(ISR). Methods Patients who underwent carotid artery stenting (CAS) in hospital from January 2016 to January 2021 were retrospectively enrolled. They were randomly divided into training and validation sets. Based on the results of carotid digital subtraction angiography (DSA) during the follow-up period, the patients were divided into ISR group and non-ISR group. The differences of AIP and lipid levels between the two groups were compared. The independent risk factors of ISR and the predictive value of AIP for ISR were analyzed. A nomogram was developed based on the independent risk factors, and the receiver operating characteristic (ROC) curve, the calibration curve and the decision curve analysis were conducted to assess the predictive ability and clinical practicability of the nomogram in both the training set and validation sets. Results A total of 361 patients were enrolled, including 98 in the ISR group and 263 in the non-ISR group. In the training set, AIP was significantly higher in the ISR group than in the non-ISR group (P < 0.05) and was independently associated with ISR (OR= 10.912, 95% CI: 2.520-47.248). When AIP was 0.10, it had the highest predictive value for ISR, with a sensitivity of 72. 1% and a specificity of 75.0%. Additionally, hypertension, residual stenosis, symptomatic stenosis and Hcy were also independent risk factors for ISR. The nomogram showed good discrimination performance and clinical practicability in both the training set (AUC = 0.827) and the validation set (AUC = 0.880). Conclusion AIP was an independent risk factor for ISR and was closely related to ISR. The nomogram developed by AIP and other variables had good predictive ability and clinical practicability for ISR.
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Affiliation(s)
- Yu Zhou
- First Clinical Medical College, Lanzhou University, Lanzhou, People’s Republic of China
- Cerebrovascular Disease Center, Gansu Provincial Hospital, Lanzhou, People’s Republic of China
- Key Laboratory of Cerebrovascular Diseases, Lanzhou, People’s Republic of China
| | - Yong Ma
- Cerebrovascular Disease Center, Gansu Provincial Hospital, Lanzhou, People’s Republic of China
- Key Laboratory of Cerebrovascular Diseases, Lanzhou, People’s Republic of China
- Clinical Medicine College, Ningxia Medical University, Yinchuan, People’s Republic of China
| | - Dongliang Qian
- Cerebrovascular Disease Center, Gansu Provincial Hospital, Lanzhou, People’s Republic of China
- Key Laboratory of Cerebrovascular Diseases, Lanzhou, People’s Republic of China
| | - Zhou Zhou
- First Teaching Hospital of Tianjin University of Traditional Chinese Medicine, Tianjin, People’s Republic of China
- National Clinical Research Center for Chinese Medicine Acupuncture and Moxibustion, Tianjin, People’s Republic of China
| | - Bin Li
- Cerebrovascular Disease Center, Gansu Provincial Hospital, Lanzhou, People’s Republic of China
- Key Laboratory of Cerebrovascular Diseases, Lanzhou, People’s Republic of China
| | - Erqing Chai
- First Clinical Medical College, Lanzhou University, Lanzhou, People’s Republic of China
- Cerebrovascular Disease Center, Gansu Provincial Hospital, Lanzhou, People’s Republic of China
- Key Laboratory of Cerebrovascular Diseases, Lanzhou, People’s Republic of China
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Nardi P, Altieri C, Pisano C, Oddi FM, Ranucci A, Fresilli M, Salvati AC, Buioni D, Scognamiglio M, Ajello V, Bassano C, Ascoli Marchetti A, Ippoliti A, Ruvolo G. Early-Staged Carotid Artery Stenting Prior to Coronary Artery Bypass Grafting: Analysis of the Early and Mid-Term Results in Comparison with a Consecutive Cohort of Isolated Coronary Artery Surgery Patients. J Clin Med 2024; 13:480. [PMID: 38256614 PMCID: PMC10816890 DOI: 10.3390/jcm13020480] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2023] [Revised: 01/09/2024] [Accepted: 01/13/2024] [Indexed: 01/24/2024] Open
Abstract
AIM The aim of the present study was to analyze retrospectively the results of patients who underwent early-staged, i.e., within 24-48 h, carotid artery stenting (e-s CAS) before coronary artery bypass grafting (CABG). METHODS Between December 2014 and December 2022, 1046 consecutive patients underwent CABG; 31 of these patients (3%) were subjected to e-s CAS prior to CABG (e-s CAS + CABG group). Preoperative and intraoperative variables and early and mid-term results of the e-s CAS + CABG group were compared with those of patients who underwent isolated CABG (CABG group). RESULTS As compared with the CABG group, the e-s CAS + CABG group showed a worse clinical risk profile due to higher Euroscore-2 values and incidence of obstructive pulmonary disease and bilateral carotid artery and peripheral artery diseases (p < 0.05, for all comparisons). The combined end point of operative mortality, periprocedural myocardial infarction, and stroke was 3.2% (0%/0%/3.2%) in the e-s CAS + CABG group vs. 5.9% (2.2%/2.8%/0.9%) in the CABG group (p > 0.5, for all measurements). At 5 years, actuarial survival was 74% ± 16% in the e-s CAS + CABG group vs. 93% ± 4.0% in the CABG group, freedom from cardiac death was 100% vs. 98% ± 1.0% (p = 0.6), and freedom from MACCEs was 85% ± 15% vs. 97% ± 2.5% (p > 0.1, for all comparisons). Independent predictors of all-causes death were advanced age at the operation (p < 0.0001), a lower value for left ventricular ejection fraction (p = 0.05), and a high Euroscore-2 (p = 0.04). CONCLUSIONS CABG preceded by e-s CAS appears to be associated with satisfactory early outcomes while limiting the risk of myocardial infarction to a very short time interval between the two procedures. Freedom from late all-causes death, cardiac death, and MACCEs were comparable and equally satisfactory, underscoring the positive protective effects of CAS and CABG on the carotid and coronary territories over time.
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Affiliation(s)
- Paolo Nardi
- Cardiac Surgery Division, Tor Vergata University Hospital, 00133 Rome, Italy; (C.P.); (A.C.S.); (D.B.); (M.S.); (C.B.); (G.R.)
| | - Claudia Altieri
- Unit of Cardiology of the Cardiac Surgery Division, Tor Vergata University Hospital, 00133 Rome, Italy;
| | - Calogera Pisano
- Cardiac Surgery Division, Tor Vergata University Hospital, 00133 Rome, Italy; (C.P.); (A.C.S.); (D.B.); (M.S.); (C.B.); (G.R.)
| | - Fabio Massimo Oddi
- Unit of Vascular Surgery, Tor Vergata University Hospital, 00133 Rome, Italy; (F.M.O.); (A.R.); (M.F.); (A.A.M.); (A.I.)
| | - Alessandro Ranucci
- Unit of Vascular Surgery, Tor Vergata University Hospital, 00133 Rome, Italy; (F.M.O.); (A.R.); (M.F.); (A.A.M.); (A.I.)
| | - Mauro Fresilli
- Unit of Vascular Surgery, Tor Vergata University Hospital, 00133 Rome, Italy; (F.M.O.); (A.R.); (M.F.); (A.A.M.); (A.I.)
| | - Alessandro Cristian Salvati
- Cardiac Surgery Division, Tor Vergata University Hospital, 00133 Rome, Italy; (C.P.); (A.C.S.); (D.B.); (M.S.); (C.B.); (G.R.)
| | - Dario Buioni
- Cardiac Surgery Division, Tor Vergata University Hospital, 00133 Rome, Italy; (C.P.); (A.C.S.); (D.B.); (M.S.); (C.B.); (G.R.)
| | - Mattia Scognamiglio
- Cardiac Surgery Division, Tor Vergata University Hospital, 00133 Rome, Italy; (C.P.); (A.C.S.); (D.B.); (M.S.); (C.B.); (G.R.)
| | - Valentina Ajello
- Unit of Cardio-Thoracic Anesthesia, Tor Vergata University Hospital, 00133 Rome, Italy;
| | - Carlo Bassano
- Cardiac Surgery Division, Tor Vergata University Hospital, 00133 Rome, Italy; (C.P.); (A.C.S.); (D.B.); (M.S.); (C.B.); (G.R.)
| | - Andrea Ascoli Marchetti
- Unit of Vascular Surgery, Tor Vergata University Hospital, 00133 Rome, Italy; (F.M.O.); (A.R.); (M.F.); (A.A.M.); (A.I.)
| | - Arnaldo Ippoliti
- Unit of Vascular Surgery, Tor Vergata University Hospital, 00133 Rome, Italy; (F.M.O.); (A.R.); (M.F.); (A.A.M.); (A.I.)
| | - Giovanni Ruvolo
- Cardiac Surgery Division, Tor Vergata University Hospital, 00133 Rome, Italy; (C.P.); (A.C.S.); (D.B.); (M.S.); (C.B.); (G.R.)
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Li W, Wu C, Deng R, Li L, Wu Q, Zhang L, Yan T, Chen S. Comparison of Perioperative Safety of Carotid Artery Stenting and Endarterectomy in the Treatment of Carotid Artery Stenosis: A Meta-Analysis of Randomized Controlled Trials. World Neurosurg 2024; 181:e356-e375. [PMID: 37863425 DOI: 10.1016/j.wneu.2023.10.054] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2023] [Revised: 10/09/2023] [Accepted: 10/10/2023] [Indexed: 10/22/2023]
Abstract
BACKGROUND Current management guidelines for the treatment of carotid stenosis are controversial. We performed this meta-analysis to evaluate the perioperative safety of carotid artery stenting (CAS) and endarterectomy. METHODS We systematically searched EMBASE, PubMed, Web of Science, and the Cochrane Library from inception to November 10, 2022, for randomized controlled trials that compared CAS with carotid endarterectomy (CEA) among patients with carotid stenosis. The analyzed outcomes mainly included stroke, death, myocardial infarction (MI), cranial nerve palsy, the cumulative incidence of mortality, stroke, or MI and the cumulative incidence of death or stroke in the perioperative periods. The risk ratio (RR) and 95% confidence interval (95% CI) were calculated and pooled. Subgroup analyses were based on whether patients were symptomatic or asymptomatic. We assessed the certainty of evidence using the Grading of Recommendations Assessment, Development and Evaluation framework. RESULTS Seventeen randomized controlled trials with 12,277 participants (6514 and 5763 in the CAS and CEA groups, respectively) were included. Pooled analysis demonstrated that compared with CEA, CAS was associated with decreased risks of perioperative MI (RR = 0.47, 95% CI = 0.29∼0.77) and perioperative cranial nerve palsy (RR = 0.02, 95% CI = 0.01∼0.06) but higher risks of perioperative stroke (RR = 1.48, 95% CI = 1.18∼1.87) and cumulative incidence of death or stroke (RR = 1.52, 95% CI = 1.20∼1.93). CONCLUSIONS The perioperative safety was equivalent between CAS and CEA. However, CEA may be preferred when considering both procedural safety and long-term efficacy in preventing recurrent stroke.
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Affiliation(s)
- Wenkui Li
- Department of Neurology, Chongqing University Three Gorges Hospital, Chongqing, China; School of Medicine, Chongqing University, Chongqing, China
| | - Chuyue Wu
- Department of Neurology, Chongqing University Three Gorges Hospital, Chongqing, China; School of Medicine, Chongqing University, Chongqing, China; Chongqing Municipality Clinical Research Center for Geriatric Diseases, Chongqing University Three Gorges Hospital, Chongqing, China
| | - Rong Deng
- Department of Neurology, Chongqing University Three Gorges Hospital, Chongqing, China; School of Medicine, Chongqing University, Chongqing, China
| | - Li Li
- Department of Neurology, Chongqing University Three Gorges Hospital, Chongqing, China; School of Medicine, Chongqing University, Chongqing, China
| | - Qingyuan Wu
- Department of Neurology, Chongqing University Three Gorges Hospital, Chongqing, China; School of Medicine, Chongqing University, Chongqing, China; Chongqing Municipality Clinical Research Center for Geriatric Diseases, Chongqing University Three Gorges Hospital, Chongqing, China
| | - Lina Zhang
- Department of Neurology, Chongqing University Three Gorges Hospital, Chongqing, China; School of Medicine, Chongqing University, Chongqing, China; Chongqing Municipality Clinical Research Center for Geriatric Diseases, Chongqing University Three Gorges Hospital, Chongqing, China
| | - Tao Yan
- Department of Clinical Laboratory, Tianjin Medical University General Hospital, Tianjin, China
| | - Shengli Chen
- Department of Neurology, Chongqing University Three Gorges Hospital, Chongqing, China.
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Nakagawa I, Kotsugi M, Yokoyama S, Maeoka R, Furuta T, Tanaka H, Takeshima Y, Matsuda R, Yamada S, Nakase H. Dual-layered stents reduce cerebral embolism compared with first-generation stents during carotid stenting of high lipid core plaque lesions. J Neurointerv Surg 2023; 16:67-72. [PMID: 36944492 DOI: 10.1136/jnis-2023-020106] [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: 01/18/2023] [Accepted: 03/13/2023] [Indexed: 03/23/2023]
Abstract
BACKGROUND Periprocedural lipid core plaque (LCP) has been detected in carotid arteries assessed by catheter-based near-infrared spectroscopy (NIRS). High LCP is associated with cerebral embolism after carotid artery stenting (CAS) using a first-generation stent. We aimed to evaluate whether dual-layered stents reduce embolic infarcts in patients with high LCP and change of lipid signal as assessed by NIRS during CAS. METHODS Participants comprised 210 consecutive patients undergoing CAS. The study was divided into two distinct periods, with first-generation closed-cell stents used in the earlier period and dual-layered stents used in the later period. NIRS was performed at baseline, after stent implantation, and after balloon post-dilatation to analyze maximal lipid core burden index at minimal luminal area (max-LCBIMLA). RESULTS The ipsilateral cerebral embolism rate was significantly lower with dual-layered stents (9%) than with first-generation stents (33%, p<0.001), particularly with highly lipidic lesions (12% vs 60%, p<0.001). On multivariate logistic regression analysis, high LCP and first-generation stent usage were factors related to ipsilateral cerebral embolism (both p<0.001; OR 8.28 (95% CI 3.49 to 19.64) and OR 8.07 (95% CI 2.33 to 27.93), respectively). Max-LCBIMLA decreased significantly after stenting in both groups (both p<0.01) and max-LCBIMLA after balloon post-dilatation was significantly lower with dual-layered stents (22.4±65.6) than with first-generation stents (124.2±208.2; p=0.006). CONCLUSIONS Dual-layered stents reduce embolic infarcts in patients with highly lipidic plaque lesions as assessed by NIRS who undergo CAS. Dual-layered stents significantly reduced NIRS-derived lipid signals after stenting.
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Affiliation(s)
- Ichiro Nakagawa
- Department of Neurosurgery, Nara Medical University, Kashihara, Japan
| | - Masashi Kotsugi
- Department of Neurosurgery, Nara Medical University, Kashihara, Japan
| | - Shohei Yokoyama
- Department of Neurosurgery, Nara Medical University, Kashihara, Japan
| | - Ryosuke Maeoka
- Department of Neurosurgery, Nara Medical University, Kashihara, Japan
| | - Takanori Furuta
- Department of Neurosurgery, Nara Medical University, Kashihara, Japan
| | - Haku Tanaka
- Department of Neurosurgery, Nara Medical University, Kashihara, Japan
| | | | - Ryosuke Matsuda
- Department of Neurosurgery, Nara Medical University, Kashihara, Japan
| | - Shuichi Yamada
- Department of Neurosurgery, Nara Medical University, Kashihara, Japan
| | - Hiroyuki Nakase
- Department of Neurosurgery, Nara Medical University, Kashihara, Japan
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Kazantsev AN, Korotkikh A, Dzhanelidze M, Kharchilava E, Zarkua N, Alekseeva E, Staroverova V, Koplik V, Leader R, Zakeryaev A, Bagdavadze G, Zakharova K, Semyin I, Kostenkov A, Chernykh K, Shmatov D, Lebedev O, Artyukhov S, Mukhtorov O, Wang S, Komarov R, Roshkovskaya L, Khetagurov M, Unguryan V, Chernyavin M, Palagin P, Sirotkin A, Belov Y. Prospective multicenter online testing of the carotid endarterectomy risk stratification calculator carotidscore.ru. Indian J Thorac Cardiovasc Surg 2023; 39:608-614. [PMID: 37885939 PMCID: PMC10597897 DOI: 10.1007/s12055-023-01538-z] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2023] [Revised: 05/08/2023] [Accepted: 05/11/2023] [Indexed: 10/28/2023] Open
Abstract
Aim To evaluate the incidence of complications, including fatal outcomes, ischemic strokes, and transient ischemic attacks, associated with carotid endarterectomy (CEA) in patients categorized as low-, medium-, and high-risk based on their CarotidSCORE (carotidscore.ru). Material and Methods This prospective, multicenter study was conducted from January 1, 2022, to December 20, 2022, and enrolled 5,496 patients with stenosis of the internal carotid artery (ICA), who were categorized into four groups according to their risk level. Group 1 (n=1,759) included patients at low risk; Group 2 (n=2,483) included those at medium risk; Group 3 (n=429) included those at high risk, who underwent carotid angioplasty with stenting (CAS) due to the high risk of complications associated with carotid endarterectomy (CEA); and Group 4 (n=825) did not use CarotidSCORE (carotidscore.ru). Patients in Groups 1, 2, and 4 underwent CEA. Results During the postoperative hospital stay, the highest number of complications, including fatal outcomes (p=0.0007), ischemic strokes (p<0.0001), and the combined endpoints (p<0.0001) were observed in Group 4. No complications were reported in Group 1. Conclusion The use of CarotidSCORE (carotidscore.ru) allows for the identification of high-risk patients, enabling clinicians to opt for CAS instead of CEA and reduce the incidence of complications.
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Affiliation(s)
| | - Alexander Korotkikh
- Clinic of Cardiac Surgery of the Amur State Medical Academy of the Ministry of Health of Russia, Blagoveshchensk, Russian Federation
| | - Merab Dzhanelidze
- Western Regional Center for Modern Medical Technologies, Kutaisi, Georgia
| | - Elguja Kharchilava
- North-Western State Medical University. Named After I.I. Mechnikov, St. Petersburg, Russian Federation
| | - Nonna Zarkua
- North-Western State Medical University. Named After I.I. Mechnikov, St. Petersburg, Russian Federation
| | - Elena Alekseeva
- Novgorod State University Named After Yaroslav the Wise, Veliky Novgorod, Russia
| | - Valeria Staroverova
- Novgorod State University Named After Yaroslav the Wise, Veliky Novgorod, Russia
| | - Victoria Koplik
- Novgorod State University Named After Yaroslav the Wise, Veliky Novgorod, Russia
| | - Roman Leader
- Kemerovo State Medical University, Kemerovo, Russian Federation
| | - Aslan Zakeryaev
- Regional Clinical Hospital No. 1 Named After. Prof. S.V. Ochapovsky, Krasnodar, Russian Federation
| | - Goderzi Bagdavadze
- Kostroma Regional Clinical Hospital Named After Korolev E.I., Kostroma, Russian Federation
| | | | - Igor Semyin
- Arkhangelsk Regional Clinical Hospital, Arkhangelsk, Russian Federation
| | - Anton Kostenkov
- Arkhangelsk Regional Clinical Hospital, Arkhangelsk, Russian Federation
| | | | - Dmitry Shmatov
- St. Petersburg State University, St. Petersburg, Russian Federation
| | - Oleg Lebedev
- Kostroma Regional Clinical Hospital Named After Korolev E.I., Kostroma, Russian Federation
- Yaroslavl State Medical University, St. Petersburg, Yaroslavl, Russia
| | - Sergey Artyukhov
- North-Western State Medical University. Named After I.I. Mechnikov, St. Petersburg, Russian Federation
- City Alexander Hospital, St. Petersburg, Russian Federation
| | - Otabek Mukhtorov
- Kostroma Regional Clinical Hospital Named After Korolev E.I., Kostroma, Russian Federation
| | - Shuowen Wang
- First Moscow State Medical University Named After Sechenov, Moscow, Russian Federation
| | - Roman Komarov
- First Moscow State Medical University Named After Sechenov, Moscow, Russian Federation
| | | | - Mikhail Khetagurov
- Kostroma Regional Clinical Hospital Named After Korolev E.I., Kostroma, Russian Federation
| | | | - Maxim Chernyavin
- Clinical Hospital of the Administration of the President of the Russian Federation, Moscow, Russian Federation
| | - Petr Palagin
- Kostroma Regional Clinical Hospital Named After Korolev E.I., Kostroma, Russian Federation
| | - Alexey Sirotkin
- Kostroma Regional Clinical Hospital Named After Korolev E.I., Kostroma, Russian Federation
| | - Yuri Belov
- First Moscow State Medical University Named After Sechenov, Moscow, Russian Federation
- Federal State Budgetary Scientific Institution “Russian Scientific Center for Surgery Named After Academician B.V. Petrovsky”, Moscow, Russian Federation
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Banks CA, Pearce BJ. Interventions in Carotid Artery Surgery: An Overview of Current Management and Future Implications. Surg Clin North Am 2023; 103:645-671. [PMID: 37455030 DOI: 10.1016/j.suc.2023.05.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/18/2023]
Abstract
Atherosclerotic carotid artery disease has been well studied over the last half-century by multiple randomized controlled trials attempting to elucidate the appropriate modality of therapy for this disease process. Surgical techniques have evolved from carotid artery endarterectomy and transfemoral carotid artery stenting to the development of hybrid techniques in transcarotid artery revascularization. In this article, the authors provide a review of the available literature regarding operative and medical management of carotid artery disease.
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Affiliation(s)
- Charles Adam Banks
- Division of Vascular Surgery and Endovascular Therapy, University of Alabama at Birmingham, 1808 7th Avenue South, Boshell Diabetes Building 652, Birmingham, AL 35294, USA
| | - Benjamin J Pearce
- Division of Vascular Surgery and Endovascular Therapy, University of Alabama at Birmingham, 1808 7th Avenue South, Boshell Diabetes Building 652, Birmingham, AL 35294, USA.
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11
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Morikawa S, Okumura K, Inoue N, Ogane T, Takayama Y, Murohara T. Systemic immune-inflammation index as a predictor of prognosis after carotid artery stenting compared with C-reactive protein. PLoS One 2023; 18:e0288564. [PMID: 37440549 DOI: 10.1371/journal.pone.0288564] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2023] [Accepted: 06/29/2023] [Indexed: 07/15/2023] Open
Abstract
BACKGROUND Immune-inflammatory processes are highly associated with the progression of atherosclerosis. The systemic immune-inflammation index (SII) is a potential predictor for clinical outcomes in patients with stroke and ischemic heart disease. Therefore, this study aimed to investigate whether SII can accurately predict the short- and long-term prognoses in patients who underwent carotid artery stenting (CAS) compared to that with C-reactive protein (CRP). METHODS This study was a single-center retrospective investigation. Overall, 129 patients who underwent CAS were categorized into tertiles based on their SII levels. We primarily investigated the long-term major adverse cardiac and cerebrovascular events (MACCE) and secondarily the in-hospital and long-term stroke incidence, as well as all-cause death. RESULTS The in-hospital stroke rate tended to increase with a rise in SII (P = 0.13). Over the 5-year follow-up period, the Kaplan-Meier overall incidence of MACCE was 9.3%, 16.3%, and 39.5% in the lowest to highest tertiles, respectively (log-rank trend test, P<0.001). The rates of stroke and MACCE during the long-term follow-up were significantly higher with increasing SII. Cox regression analysis showed that the highest tertile of SII (>647) was a predictor of the incidence of long-term stroke (hazard ratio (HR), 21.3; 95% confidence interval (CI), 2.41-188; P = 0.006) and MACCE (HR, 3.98; 95% CI, 1.80-8.81; P<0.001). However, after adjusting for both SII and CRP, only SII remained a significant independent predictor, whereas CRP became less relevant. The receiver operating characteristic curve analysis of long-term MACCE showed that the area under the curve (AUC) for SII (AUC, 0.72; 95% CI, 0.60-0.84; P<0.001) was greater than that of CRP (AUC, 0.64; 95% CI, 0.51-0.77; P = 0.040). CONCLUSION SII was shown to be an independent predictor of long-term prognosis in patients who underwent CAS and was suggested to be superior to CRP as an inflammatory prognosis predictor.
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Affiliation(s)
- Shuji Morikawa
- Department of Cardiology, Chutoen General Medical Center, Kakegawa, Shizuoka, Japan
- Department of Cardiology, Nagoya University Graduate School of Medicine, Showa-ku, Nagoya, Japan
| | - Kenji Okumura
- Department of Cardiology, Tohno Kosei Hospital, Mizunami, Japan
| | - Naoya Inoue
- Department of Cardiology, Chutoen General Medical Center, Kakegawa, Shizuoka, Japan
- Department of Cardiology, Nagoya University Graduate School of Medicine, Showa-ku, Nagoya, Japan
| | - Takashi Ogane
- Department of Cardiology, Chutoen General Medical Center, Kakegawa, Shizuoka, Japan
| | - Yohei Takayama
- Department of Cardiology, Chutoen General Medical Center, Kakegawa, Shizuoka, Japan
| | - Toyoaki Murohara
- Department of Cardiology, Nagoya University Graduate School of Medicine, Showa-ku, Nagoya, Japan
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12
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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.
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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
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Shahat M, Cieri E, Rocha-Neves J, Sa K. Carotid stenting: Does stent design matter? Vascular 2023:17085381231160957. [PMID: 36867405 DOI: 10.1177/17085381231160957] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/04/2023]
Abstract
BACKGROUND Carotid artery stenting (CAS) is considered an important tool in carotid revascularization. Carotid artery stenting is usually performed by using self-expandable stent with different designs. The stent design influences many physical characteristics. Also, it may affect the complication rate with special relevance to perioperative stroke, hemodynamic instability, and late restenosis. METHODS This study comprised all consecutive patients who underwent carotid artery stenting for atherosclerotic carotid stenosis from March 2014 to May 2021. Both symptomatic patient and asymptomatic patients were included. Patients with a symptomatic carotid stenosis of ≥50% or asymptomatic carotid stenosis of ≥60% were selected for carotid artery stenting . Patients with fibromuscular dysplasia and acute or unstable plaque were not included. Variables of clinical relevance were tested in multivariable analysis using binary logistic regression model. RESULTS A total of 728 patients were enrolled. The majority of this cohort was asymptomatic (578/728, 79.4%), while 150/728 (20.6%) were symptomatic. The mean degree of carotid stenosis was 77.82 ± 4.73%, with a mean plaque length of 1.76 ± 0.55 cm. A total of 277 (38%) patients were treated with Xact® Carotid Stent System. Successful carotid artery stenting was achieved in 698 (96%) of patients. Of these patients, stroke rate in symptomatic patients was nine (5.8%), while in asymptomatic patients was 20 (3.4%). In a multivariable analysis, the open-cell carotid stent was not associated with a differential risk for combined acute and sub-acute neurologic complications as compared with closed-cell stents. Patients treated with open cell stents had a significantly lower rate of procedural hypotension (P 0.0188) at bivariate analysis. CONCLUSION Carotid artery stenting is considered a safe alternative to CEA that can be used in selected average surgical risk patient. Different stent designs can affect the rate of major adverse events in carotid artery stenting patients, but further studies are necessary with avoiding different bias to study the effect of different stent designs.
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Affiliation(s)
- Mohamed Shahat
- Department of Vascular and Endovascular Surgery, 68866Assiut University Hospital, Assiut University, Assiut, Egypt
| | - Enrico Cieri
- 9309Vascular and endovascular surgery unit university of Perugia, ospedale S.Maria della Misericordia, Perugia, Italy
| | - Joao Rocha-Neves
- Department of Biomedicine - Unit of Anatomy, 68797Faculdade de Medicina da Universidade do Porto, Portugal
| | - Khairy Sa
- Department of Vascular and Endovascular Surgery, 68866Assiut University Hospital, Assiut University, Assiut, Egypt
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14
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Baek JH. Carotid Artery Stenting for Asymptomatic Carotid Stenosis: What We Need to Know for Treatment Decision. Neurointervention 2023; 18:9-22. [PMID: 36809873 PMCID: PMC9986346 DOI: 10.5469/neuroint.2023.00031] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2023] [Accepted: 02/05/2023] [Indexed: 02/24/2023] Open
Abstract
A clinical decision on the treatment of asymptomatic carotid stenosis is challenging, unlike symptomatic carotid stenosis. Carotid artery stenting (CAS) has been recommended as an alternative to carotid endarterectomy (CEA) based on the finding that the efficacy and safety of CAS were comparable to CEA in randomized trials. However, in some countries, CAS is often performed more frequently than CEA for asymptomatic carotid stenosis. Moreover, it has been recently reported that CAS is not superior to the best medical treatment in asymptomatic carotid stenosis. Due to these recent changes, the role of CAS in asymptomatic carotid stenosis should be revisited. When determining the treatment for asymptomatic carotid stenosis, one should consider several clinical factors including stenosis degree, patient life expectancy, stroke risk by medical treatment, availability of a vascular surgeon, high risk for CEA or CAS, and insurance coverage. This review aimed to present and pragmatically organize the information that is necessary for a clinical decision on CAS in asymptomatic carotid stenosis. In conclusion, although the traditional benefit of CAS is being revisited recently, it seems too early to conclude that CAS is no longer beneficial under intense and systemic medical treatment. Instead, a treatment strategy with CAS should evolve to select eligible or medically high-risk patients more precisely.
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Affiliation(s)
- Jang-Hyun Baek
- Department of Neurology, Kangbuk Samsung Hospital, Sungkyunkwan University School of Medicine, Seoul, Korea
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15
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Miyake S, Takahashi K, Nakai Y, Amano Y, Yamamoto R, Amari K, Hara H, Johkura K. Visual suppression of vestibulo-ocular reflex in patients treated with carotid artery revascularization: A potential biomarker for cerebral perfusion. J Neurol Sci 2023; 445:120534. [PMID: 36587563 DOI: 10.1016/j.jns.2022.120534] [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: 10/20/2022] [Revised: 12/20/2022] [Accepted: 12/23/2022] [Indexed: 12/27/2022]
Abstract
BACKGROUND Carotid endarterectomy (CEA) and carotid artery stenting (CAS) are common treatments for ischemic stroke prevention in patients with carotid artery stenosis. However, the beneficial effects of CEA/CAS for cerebral hypoperfusion due to carotid artery stenosis have yet to be fully established. As dizziness is a common symptom in patients with carotid artery stenosis, we aimed to evaluate the effects of CEA/CAS on cerebral function in patients with carotid artery stenosis, using equilibrium function tests. METHODS This prospective observational cohort study included 50 patients who had carotid artery stenosis and were scheduled to undergo CEA or CAS. Before CEA/CAS, we quantitatively evaluated the vestibulo-ocular reflex (VOR) and vestibular evoked myogenic potential (VEMP), as indicators of brainstem/inner ear functions related to balance, and visual suppression of VOR, as an indicator of cerebral control over the brainstem reflex related to balance. These were then compared with supratentorial cerebral blood flow (CBF). Changes in VOR, VEMP, visual suppression of VOR, CBF, and dizziness after CEA/CAS were also evaluated. RESULTS The visual suppression rates of VOR correlated with supratentorial CBFs before CEA/CAS (correlation coefficient = 0.47, p = 0.003). The visual suppression rates of VOR (p < 0.001) and supratentorial CBFs (p = 0.003) were improved by CEA/CAS, while VOR and VEMP did not change. Symptoms of dizziness improved after CEA/CAS. CONCLUSIONS Our results suggest that visual suppression of the VOR may be a novel and practical marker for the beneficial effects of CEA/CAS on supratentorial cerebral function.
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Affiliation(s)
- Shigeta Miyake
- Department of Neurosurgery, Yokohama Brain and Spine Center, Yokohama, Japan
| | - Koji Takahashi
- Department of Clinical Laboratory, Yokohama Brain and Spine Center, Yokohama, Japan
| | - Yasunobu Nakai
- Department of Neurosurgery, Yokohama Brain and Spine Center, Yokohama, Japan
| | - Yu Amano
- Department of Neurology, Yokohama Brain and Spine Center, Yokohama, Japan
| | - Ryoo Yamamoto
- Department of Neurology, Yokohama Brain and Spine Center, Yokohama, Japan
| | - Kazumitsu Amari
- Department of Neurosurgery, Yokohama Brain and Spine Center, Yokohama, Japan
| | - Hiroya Hara
- Department of Clinical Laboratory, Yokohama Brain and Spine Center, Yokohama, Japan
| | - Ken Johkura
- Department of Neurology, Yokohama Brain and Spine Center, Yokohama, Japan.
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Zivkovic I, Krasic S, Milacic P, Milicic M, Vukovic P, Tabakovic Z, Sagic D, Ilijevski N, Petrovic I, Peric M, Bojic M, Micovic S. Same-Day Carotid Artery Stenting and Coronary Artery Bypass Surgery. Tex Heart Inst J 2023; 50:490544. [PMID: 36735614 PMCID: PMC9969787 DOI: 10.14503/thij-21-7781] [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: 02/04/2023]
Abstract
BACKGROUND The optimal treatment strategy for patients with severe carotid artery disease undergoing coronary artery bypass grafting is still problematic. The important question is whether it is necessary to treat significant carotid disease in patients who have undergone coronary artery bypass grafting. This study analyzed short- and midterm results after same-day carotid artery stenting and coronary artery bypass grafting. METHODS From 2013 to 2020, a total of 69 patients were enrolled in the study. Same-day carotid artery stenting and coronary artery bypass grafting were performed in all patients. The study's primary end points were the evaluation rate of stroke, myocardial infarction, and death within short- and midterm periods after the procedures. RESULTS The 30-day mortality was 0%. The occurrences of perioperative adverse events, namely stroke, myocardial infarction, and transient ischemic attack, were 1 (1.4%), 1 (1.4%), and 4 (5.8%), respectively. Mean (IQR) follow-up time was 28 (IQR, 17-43) months. Six (8.8%) patients died during this period. Fatal stroke was registered in 2 cases, and 1 patient experienced a disabling stroke with a fatal outcome. The other 3 patients died because of chronic renal disease, a traffic accident, and for an unknown reason, respectively. Midterm survival in the group was 91.2%. CONCLUSION The study showed that same-day carotid artery stenting and coronary artery bypass grafting for concomitant carotid and coronary disease treatment could be a promising and feasible therapeutic strategy.
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Affiliation(s)
- Igor Zivkovic
- Department of Cardiac Surgery, Dedinje Cardiovascular Institute, Belgrade, Serbia
| | - Stasa Krasic
- Cardiology Department, Mother and Child Health Institute of Serbia, Belgrade, Serbia
| | - Petar Milacic
- Department of Cardiac Surgery, Dedinje Cardiovascular Institute, Belgrade, Serbia
,School of Medicine, University of Belgrade, Belgrade, Serbia
| | - Miroslav Milicic
- Department of Cardiac Surgery, Dedinje Cardiovascular Institute, Belgrade, Serbia
,School of Medicine, University of Belgrade, Belgrade, Serbia
| | - Petar Vukovic
- Department of Cardiac Surgery, Dedinje Cardiovascular Institute, Belgrade, Serbia
,School of Medicine, University of Belgrade, Belgrade, Serbia
| | - Zoran Tabakovic
- Department of Cardiac Surgery, Dedinje Cardiovascular Institute, Belgrade, Serbia
| | - Dragan Sagic
- School of Medicine, University of Belgrade, Belgrade, Serbia
,Department of Interventional Radiology, Dedinje Cardiovascular Institute, Belgrade, Serbia
| | - Nenad Ilijevski
- School of Medicine, University of Belgrade, Belgrade, Serbia
,Department of Vascular Surgery, Dedinje Cardiovascular Institute, Belgrade, Serbia
| | - Ivana Petrovic
- Department of Cardiac Surgery, Dedinje Cardiovascular Institute, Belgrade, Serbia
| | - Miodrag Peric
- Department of Cardiac Surgery, Dedinje Cardiovascular Institute, Belgrade, Serbia
,School of Medicine, University of Belgrade, Belgrade, Serbia
| | - Milovan Bojic
- Department of Cardiac Surgery, Dedinje Cardiovascular Institute, Belgrade, Serbia
| | - Slobodan Micovic
- Department of Cardiac Surgery, Dedinje Cardiovascular Institute, Belgrade, Serbia
,School of Medicine, University of Belgrade, Belgrade, Serbia
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17
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Vasavada AM, Singh P, Firdaus A, Meenashi Sundaram D, Patel M, Singh G, Palanisamy L, Ansari SA, Thummala S, Pandya H. Carotid Endarterectomy Versus Stenting for the Treatment of Patients With Carotid Artery Stenosis: An Updated Systematic Review and Meta-Analysis. Cureus 2023; 15:e35070. [PMID: 36942176 PMCID: PMC10024598 DOI: 10.7759/cureus.35070] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/16/2023] [Indexed: 02/18/2023] Open
Abstract
Carotid endarterectomy (CEA) is a surgical procedure that treats the narrowed carotid arteries, which may be narrowed by atherosclerosis. Stenting is the insertion of a wire mesh scaffold into the narrowed portion of the carotid artery to keep it open by preventing blood from clotting. Using the study done over 10 years back as a point of reference, this study will seek an update on an assessment comparing CEA and stenting in studies carried out between 2015 and to date. The PICOS (population, intervention, control, outcome, and study designs) criteria were used to construct a set of inclusion and exclusion guidelines. This meta-analysis and systematic review used two forms of investigative analysis; both quantitative and qualitative assessments. From the studies, stroke (95% CI: 0.51-0.71, P < 0.001), myocardial infarction (95% CI: 1.49-3.42, P = 0.001), and stroke or death analysis (95% CI: 0.53-0.77, P < 0.001) were noted to be significant. From the analysis, CEA was observed as having better treatment results in terms of stroke events and stroke or death incidences when compared to stenting. Carotid stenting was observed as having lower cases of myocardial infarctions when compared to endarterectomy.
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Affiliation(s)
- Advait M Vasavada
- Internal Medicine, Shri M. P. Shah Government Medical College, Jamnagar, IND
| | - Priyansha Singh
- Internal Medicine, Smt. Nathiba Hargovandas Lakhmichand (NHL) Municipal Medical College, Ahmedabad, IND
| | - Arshia Firdaus
- Surgery, Deccan College of Medical Sciences, Hyderabad, IND
| | - Dakshin Meenashi Sundaram
- Internal Medicine, Employees' State Insurance Corporation (ESIC) Medical College & Post Graduate Institute of Medical Sciences and Research (PGIMSR), Chennai, IND
| | - Malvik Patel
- Surgery, Government Medical College, Vadodara, IND
| | - Ganeev Singh
- Surgery, Sri Guru Ram Das Institute of Medical Sciences & Research, Amritsar, IND
| | - Logesh Palanisamy
- Internal Medicine, Government Mohan Kumaramangalam Medical College, Salem, IND
| | | | - Sumaina Thummala
- Internal Medicine, Karpaga Vinayaga Institute of Medical Sciences and Research Center, Maduranthakam, IND
| | - Harsh Pandya
- General Surgery, Shardaben General Hospital, Ahmedabad, IND
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18
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Naylor R, Rantner B, Ancetti S, de Borst GJ, De Carlo M, Halliday A, Kakkos SK, Markus HS, McCabe DJH, Sillesen H, van den Berg JC, Vega de Ceniga M, Venermo MA, Vermassen FEG, Esvs Guidelines Committee, Antoniou GA, Bastos Goncalves F, Bjorck M, Chakfe N, Coscas R, Dias NV, Dick F, Hinchliffe RJ, Kolh P, Koncar IB, Lindholt JS, Mees BME, Resch TA, Trimarchi S, Tulamo R, Twine CP, Wanhainen A, Document Reviewers, Bellmunt-Montoya S, Bulbulia R, Darling RC, Eckstein HH, Giannoukas A, Koelemay MJW, Lindström D, Schermerhorn M, Stone DH. Editor's Choice - European Society for Vascular Surgery (ESVS) 2023 Clinical Practice Guidelines on the Management of Atherosclerotic Carotid and Vertebral Artery Disease. Eur J Vasc Endovasc Surg 2023; 65:7-111. [PMID: 35598721 DOI: 10.1016/j.ejvs.2022.04.011] [Citation(s) in RCA: 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]
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19
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Petkoska D, Zafirovska B, Vasilev I, Novotni G, Bertrand OF, Kedev S. Radial and ulnar approach for carotid artery stenting with Roadsaver™ double layer micromesh stent: Early and long-term follow-up. Catheter Cardiovasc Interv 2023; 101:154-163. [PMID: 36478513 DOI: 10.1002/ccd.30514] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/19/2022] [Revised: 11/15/2022] [Accepted: 11/24/2022] [Indexed: 12/13/2022]
Abstract
AIMS We aimed to evaluate the feasibility and safety of carotid artery stenting (CAS) with a newly designed double-layer micromesh stent using wrist approach in patients with significant carotid disease. MATERIALS AND METHODS Between January 2016 and December 2021, 105 patients undergoing CAS with Roadsaver™ stent were enrolled in a single center prospective study. Follow-up assessments included neurological exams, duplex ultrasound (DUS), and 12-lead ECG. The primary endpoint was the 30-day composite rate of stroke, death, and myocardial infarction. Secondary endpoints included procedure success, access site complications, device success, target lesion revascularization, and in-stent restenosis evaluated with DUS. Long-term outcomes up to 72 months of follow-up were assessed in all eligible patients. RESULTS The study population was predominantly male (69.5%) with a median age of 68 ± 8 years. Patients were symptomatic in 80% of the cases, and 35% fulfilled the high-risk criteria for surgical endarterectomy. The right internal carotid artery was the target artery in 56 (53.4%), and the left in 49 (46.6%) of the cases. All procedures were successfully completed from the right wrist, with right radial access in 94 (89.5%) cases and ulnar artery access with previous radial artery occlusion in 11 (10.5%) cases. All patients were treated successfully with the study device. The primary endpoint was met with a 30-day major adverse event rate of 0.9% (1/105). Up to 72 months of follow-up (median 30 ± 20 months) there were no strokes, neurological deaths, or target lesion revascularization of the treated lesion. Doppler ultrasound examination revealed nonsignificant in-stent restenosis in two asymptomatic patients. There was no hand ischemia detected in any patient. CONCLUSION Results from this study demonstrate the radial and ulnar access for CAS with double layer micromesh Roadsaver™ stent is safe and feasible and associated with favorable early and long-term follow-up.
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Affiliation(s)
| | | | - Ivan Vasilev
- University Clinic of Cardiology, Skopje, North Macedonia
| | | | - Olivier F Bertrand
- Interventional Cardiology, Quebec Heart-Lung Institute, Quebec City, Quebec, Canada
| | - Sasko Kedev
- University Clinic of Cardiology, Skopje, North Macedonia
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20
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Wang J, Bai X, Wang T, Dmytriw AA, Patel AB, Jiao L. Carotid Stenting Versus Endarterectomy for Asymptomatic Carotid Artery Stenosis: A Systematic Review and Meta-Analysis. Stroke 2022; 53:3047-3054. [PMID: 35730457 DOI: 10.1161/strokeaha.122.038994] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND To compare safety and efficacy between carotid artery stenting (CAS) and carotid endarterectomy (CEA) in treating asymptomatic carotid artery stenosis based on results from randomized controlled trials. METHODS Randomized controlled trials comparing CAS and CEA in treating asymptomatic carotid artery stenosis were searched from databases of the EMBASE, PubMed, MEDLINE, and Cochrane libraries. Two independent reviewers identified eligible studies, extracted relevant data, and used the Cochrane risk of bias tool to assess quality. Mantel-Haenszel method random-effects models were used to estimate odds ratio (OR) regarding perioperative risks between CAS and CEA. Kaplan-Meier curve data were extracted and analyzed through Exp[(O-E)/Var] fixed-effect models to calculate the Peto odds ratio (OR) regarding long-term outcomes. RESULTS Sixteen articles from 7 randomized controlled trials were included, reporting relevant outcomes for 7230 asymptomatic carotid artery stenosis patients (CAS: n=3920; CEA: n=3198). Compared with the CEA group, CAS group had no difference in perioperative composite end point events including stroke, death, and myocardial infarction (MI; OR, 1.13 [95% CI, 0.87-1.47]; P=0.37, I2=0%). Compared with CEA, CAS had a higher risk of any stroke during the perioperative period (OR, 1.62 [95% CI, 1.16-2.24]; P=0.004, I2=0%) and an increased risk of nondisabling stroke (OR, 1.81 [95% CI, 1.23-2.65]; P=0.003, I2=0%), but there was no significant difference in disabling stroke and death between groups (OR, 0.91 [95% CI, 0.50-1.65]; P=0.76, I2=0%). For long-term outcomes, no difference regarding the composite outcome of any stroke, death, and myocardial infarction existed between CEA and CAS (Peto OR, 1.18 [95% CI, 0.94-1.48]; P=0.14, I2=0%). Individual-level patient data would be important to verify the long-term outcome results. CONCLUSIONS When treating asymptomatic carotid artery stenosis, CAS has comparable perioperative and long-term composite outcomes compared with CEA. However, CAS may have a higher risk of any stroke and nondisabling stroke in the perioperative period.
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Affiliation(s)
- Jie Wang
- China International Neuroscience Institute (China-INI), Peoples Republic of China (J.W., X.B., T.W., L.J.).,Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, Beijing, Peoples Republic of China (J.W., X.B., T.W., L.J.)
| | - Xuesong Bai
- China International Neuroscience Institute (China-INI), Peoples Republic of China (J.W., X.B., T.W., L.J.).,Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, Beijing, Peoples Republic of China (J.W., X.B., T.W., L.J.)
| | - Tao Wang
- China International Neuroscience Institute (China-INI), Peoples Republic of China (J.W., X.B., T.W., L.J.).,Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, Beijing, Peoples Republic of China (J.W., X.B., T.W., L.J.)
| | - Adam A Dmytriw
- Neuroendovascular Program, Massachusetts General Hospital, Harvard Medical School, Boston (A.A.D.)
| | | | - Liqun Jiao
- China International Neuroscience Institute (China-INI), Peoples Republic of China (J.W., X.B., T.W., L.J.).,Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, Beijing, Peoples Republic of China (J.W., X.B., T.W., L.J.).,Department of Interventional Neuroradiology, Xuanwu Hospital, Capital Medical University, Peoples Republic of China (L.J.)
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21
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Cheng CC, Lin CS, Yin WH, Lin C, Liu IF, Lee YF, Liu WT, Fu HN, Huang CL, Tsao TP. The safety and efficacy of the Mo.Ma system device for carotid artery stenting: A single-center experience from Taiwan. Front Cardiovasc Med 2022; 9:926513. [PMID: 36186979 PMCID: PMC9522320 DOI: 10.3389/fcvm.2022.926513] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2022] [Accepted: 08/25/2022] [Indexed: 11/18/2022] Open
Abstract
Background Proximal protection devices, such as the Mo.Ma system provides better neurological outcomes than the distal filter system in the carotid artery stenting (CAS) procedure. This study first evaluated the safety and efficacy of the Mo.Ma system during CAS in a single tertiary referral hospital from Taiwan. The outcomes of distal vs. proximal embolic protection devices were also studied. Methods A total of 294 patients with carotid artery stenosis who underwent the CAS procedure were retrospectively included and divided into two groups: 152 patients in the distal filter system group and 142 patients in the Mo.Ma system. The outcomes of interest were compared between the two groups. The factors contributing to occlusion intolerance (OI) in the Mo.Ma system were evaluated. Results The procedure success rates were more than 98% in both groups. No major stroke occurred in this study. The minor stroke rates were 2.8% (4/142) and 4.6% (7/152) in the Mo.Ma system and filter system, respectively (p = 0.419). Patients with hypoalbuminemia significantly predicted the risk of stroke with an odds ratio of 0.08 [95% confidence interval (CI), 0.01–0.68, p = 0.020] per 1 g/day of serum albumin in the filter group. A total of 12 patients developed OI in the Mo.Ma system (12/142, 8%). Low occlusion pressure predicted the occurrence of OI in the Mo.Ma group with the hazard ratios of 0.88 (95% CI: 0.82–0.96) and 0.90 (95% CI: 0.84–0.98) per 1 mmHg of occlusion systolic pressure (OSP) and diastolic pressure (ODP), respectively. We further indicated that patients with an OSP of ≥60 mmHg or an ODP of ≥44 mmHg could tolerate the procedure of occlusion time up to 400 s, while patients with an OSP of <49 mmHg or an ODP of <34 mmHg should undergo the procedure of occlusion time less than 300 s to prevent the occurrence of OI. Conclusion We have demonstrated the safety and effectiveness of the Mo.Ma system during CAS in an Asia population. By reducing the occlusion time, our study indicated a lower risk of OI in the Mo.Ma system and proposed the optimal occlusion time according to occlusion pressure to prevent OI during the CAS procedure. Further large-scale and prospective studies are needed to verify our results.
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Affiliation(s)
- Cheng-Chung Cheng
- Division of Cardiology, Department of Internal Medicine, Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan
| | - Chin-Sheng Lin
- Division of Cardiology, Department of Internal Medicine, Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan
| | - Wei-Hsian Yin
- Division of Cardiology, Heart Center, Cheng Hsin General Hospital, Taipei, Taiwan
- Faculty of Medicine, School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan
| | - Chin Lin
- School of Public Health, National Defense Medical Center, Taipei, Taiwan
- School of Medicine, National Defense Medical Center, Taipei, Taiwan
| | - I-Fan Liu
- Division of Cardiology, Heart Center, Cheng Hsin General Hospital, Taipei, Taiwan
- Institute of Clinical Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan
| | - Yu-Feng Lee
- School of Medicine, National Defense Medical Center, Taipei, Taiwan
| | - Wei-Ting Liu
- Division of Cardiology, Department of Internal Medicine, Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan
| | - Hao-Neng Fu
- Division of Cardiology, Heart Center, Cheng Hsin General Hospital, Taipei, Taiwan
| | - Chien-Lung Huang
- Division of Cardiology, Heart Center, Cheng Hsin General Hospital, Taipei, Taiwan
- Faculty of Medicine, School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan
| | - Tien-Ping Tsao
- Division of Cardiology, Department of Internal Medicine, Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan
- Division of Cardiology, Heart Center, Cheng Hsin General Hospital, Taipei, Taiwan
- *Correspondence: Tien-Ping Tsao,
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22
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Kim HW, Regenhardt RW, D'Amato SA, Nahhas MI, Dmytriw AA, Hirsch JA, Silverman SB, Martinez-Gutierrez JC. Asymptomatic carotid artery stenosis: a summary of current state of evidence for revascularization and emerging high-risk features. J Neurointerv Surg 2022:jnis-2022-018732. [DOI: 10.1136/jnis-2022-018732] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2022] [Accepted: 08/23/2022] [Indexed: 11/03/2022]
Abstract
Carotid artery stenosis is a leading cause of ischemic stroke. While management of symptomatic carotid stenosis is well established, the optimal approach in asymptomatic carotid artery stenosis (aCAS) remains controversial. The rapid evolution of medical therapies within the time frame of existing landmark aCAS surgical revascularization trials has rendered their findings outdated. In this review, we sought to summarize the controversies in the management of aCAS by providing the most up-to-date medical and surgical evidence. Subsequently, we compile the evidence surrounding high-risk clinical and imaging features that might identify higher-risk lesions. With this, we aim to provide a practical framework for a precision medicine approach to the management of aCAS.
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23
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Low M, Gray B, Dicks A, Ochiobi O, Blas J, Gandhi S, Carsten C. Comparison of Complications and Cost for Transfemoral Versus Transcarotid Stenting of Carotid Artery Stenosis. Ann Vasc Surg 2022. [DOI: 10.1016/j.avsg.2022.08.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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24
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Reed LK, Nguyen AV, Soto JM, Robinson TM, Huang JH, Vance AZ. Safety of Contemporary Carotid Artery Stenting and Associated Risk Factors for Treatment of Carotid Artery Stenosis. World Neurosurg 2022; 165:e223-e234. [PMID: 35691520 DOI: 10.1016/j.wneu.2022.06.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2022] [Revised: 06/02/2022] [Accepted: 06/02/2022] [Indexed: 12/14/2022]
Abstract
BACKGROUND The prevalence of carotid artery atherosclerosis and stroke is increasing. Carotid artery stenting (CAS), which treats carotid artery stenosis and prevents strokes, has benefited from advances in techniques and technology. In this study, we aimed to identify significant risk factors for major complications following contemporary CAS. METHODS Utilizing the National Surgical Quality Improvement Program registry, we investigated individuals who underwent CAS between the years 2015-2018. Multivariable logistic regression was performed to identify risk factors associated with stroke, myocardial infarction (MI), and death within 30 days of CAS. RESULTS Of the 770 patients within the National Surgical Quality Improvement Program registry who met study criteria, 3.2% experienced strokes, 1.6% experienced MIs, and 2.2% died within 30 days of CAS. A total of 6.1% of patients experienced any of these major complications. Of the 395 asymptomatic patients, 3.5% suffered a stroke, 1.5% experienced an MI, and 1.0% died for a total of 5.6% patients suffering from any event. Of the 375 symptomatic patients, there were 2.9% strokes, 1.6% MIs, and 3.5% deaths with 6.7% suffering any event. Age, race, and hyponatremia were significantly associated with stroke, and hyponatremia was associated with MI. Age, anemia, hypoalbuminemia, international normalized ratio, and emergency case were associated with death. CONCLUSIONS These results suggest that preoperative risk stratification of CAS patients may not be straightforward as each adverse event has its own risk factors, precluding a generalized CAS risk stratification scoring system from being created. This paper can aid in patient selection for CAS by highlighting risk factors in modern CAS.
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Affiliation(s)
- Laura K Reed
- Department of Neurosurgery, Baylor Scott & White Health, Scott and White Medical Center, Temple, Texas, USA; Department of Surgery, Texas A&M University College of Medicine, Temple, Texas, USA.
| | - Anthony V Nguyen
- Department of Neurosurgery, Baylor Scott & White Health, Scott and White Medical Center, Temple, Texas, USA; Department of Surgery, Texas A&M University College of Medicine, Temple, Texas, USA
| | - Jose M Soto
- Department of Neurosurgery, Baylor Scott & White Health, Scott and White Medical Center, Temple, Texas, USA; Department of Surgery, Texas A&M University College of Medicine, Temple, Texas, USA
| | - T Matthew Robinson
- Department of Neurosurgery, Baylor Scott & White Health, Scott and White Medical Center, Temple, Texas, USA; Department of Surgery, Texas A&M University College of Medicine, Temple, Texas, USA; Methodist Neurological Institute, Houston Methodist Willowbrook Hospital, Houston, Texas, USA
| | - Jason H Huang
- Department of Neurosurgery, Baylor Scott & White Health, Scott and White Medical Center, Temple, Texas, USA; Department of Surgery, Texas A&M University College of Medicine, Temple, Texas, USA
| | - Awais Z Vance
- Department of Neurosurgery, Baylor Scott & White Health, Scott and White Medical Center, Temple, Texas, USA; Department of Surgery, Texas A&M University College of Medicine, Temple, Texas, USA
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25
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Stonko DP, Goldsborough E, Kibrik P, Zhang G, Holscher CM, Hicks CW. Use of Transcarotid Artery Revascularization, Transfemoral Carotid Artery Stenting, and Carotid Endarterectomy in the US From 2015 to 2019. JAMA Netw Open 2022; 5:e2231944. [PMID: 36112371 PMCID: PMC9482062 DOI: 10.1001/jamanetworkopen.2022.31944] [Citation(s) in RCA: 16] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/26/2022] Open
Abstract
IMPORTANCE A transcarotid artery revascularization (TCAR) device was approved by the US Food and Drug Administration in 2015 for carotid revascularization in patients at high risk for stroke, cranial nerve injury, or major cardiac event. It is unclear how the introduction of TCAR has changed the use of carotid endarterectomy (CEA) and transfemoral carotid artery stenting (TFCAS). OBJECTIVE To quantify the temporal changes in the operative approach to carotid revascularization (CEA vs TFCAS vs TCAR), and to identify patient and disease characteristics commonly associated with each approach. DESIGN, SETTING, AND PARTICIPANTS This retrospective cohort study obtained data from the Vascular Quality Initiative database from January 1, 2015, to December 31, 2019. Patients with carotid artery stenosis who underwent CEA, TFCAS, or TCAR were included. Data were analyzed from January to April 2022. EXPOSURES Month and year of surgery as well as patient risk status. MAIN OUTCOMES AND MEASURES Number and proportion of carotid revascularization procedures by operative approach. RESULTS A total of 108 676 patients (mean [SD] age 56.6 [12.5] years; 66 684 men [61.4%]) were included in the analysis. The most common operative approach overall was CEA (n = 81 508 [75.0%]), followed by TFCAS (n = 15 578 [14.3%]) and TCAR (n = 11 590 [10.7%]). The number of procedures increased over the study period (16 754 in 2015 vs 27 269 in 2019; P < .001). In 2015, CEA was used in 84.9% of all cases, followed by TFCAS (14.4%) and TCAR (0.8%). In 2019, CEA was used in 64.8% of cases, followed by TCAR (21.9%) and TFCAS (13.3%). The proportional use of CEA decreased by 5.0% (95% CI, -7.4% to -2.6%) per year, and TCAR use increased by 5.3% (95% CI, 2.3%-8.3%) per year. Among patients at high risk, the change was greater: CEA use decreased by 7.8% (95% CI, -11.9% to -3.8%) per year, TFCAS decreased by 4.8% (95% CI, -9.5% to -0.14%) per year, and TCAR increased by 12.6% (95% CI, 7.1%-18.1%) per year. Multinomial logistic regression showed that patient risk status was the most important characteristic associated with TCAR compared with CEA (relative risk ratio, 36.10; 95% CI, 29.24-44.66; P < .001) and TFCAS (relative risk ratio, 14.10; 95% CI, 11.86-16.66; P < .001). Linear regression revealed no association between year of surgery and in-hospital myocardial infarction, stroke, or mortality. CONCLUSIONS AND RELEVANCE Results of this study indicate that TCAR has become the dominant carotid revascularization approach, surpassing TFCAS and CEA in patients at high risk for stroke, cranial nerve injury, or cardiovascular events. Patient high-risk status was the main characteristic associated with a stenting approach, highlighting the perceived importance of carotid stenting therapies in this patient population.
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Affiliation(s)
- David P. Stonko
- Department of Surgery, The Johns Hopkins Hospital, Baltimore, Maryland
- R. Adams Cowley Shock Trauma Center, University of Maryland, Baltimore
| | - Earl Goldsborough
- Division of Vascular Surgery and Endovascular Therapy, Department of Surgery, The Johns Hopkins Hospital, Baltimore, Maryland
| | - Pavel Kibrik
- Vascular Institute of New York, Brooklyn, New York
| | - George Zhang
- Department of Surgery, Brigham and Women’s Hospital, Boston, Massachusetts
| | - Courtenay M. Holscher
- Division of Vascular Surgery and Endovascular Therapy, Department of Surgery, The Johns Hopkins Hospital, Baltimore, Maryland
| | - Caitlin W. Hicks
- Division of Vascular Surgery and Endovascular Therapy, Department of Surgery, The Johns Hopkins Hospital, Baltimore, Maryland
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26
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Tsai CH, Huang CC, Hsiao HM, Hung MY, Su GJ, Lin LH, Chen YH, Lin MS, Yeh CF, Hung CS, Kao HL. Detection of Carotid Artery Stenosis Based on Video Motion Analysis for Fast Screening. J Am Heart Assoc 2022; 11:e025702. [PMID: 35975739 PMCID: PMC9496434 DOI: 10.1161/jaha.122.025702] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
Background Carotid artery stenosis (CAS) is a common cause of ischemic stroke, and the early detection of CAS may improve patient outcomes. Carotid Doppler ultrasound is commonly used to diagnose CAS. However, it is costly and may not be practical for regular screening practice. This article presents a novel noninvasive and noncontact detection technique using video‐based motion analysis (VMA) to extract useful information from subtle pulses on the skin surface to screen for CAS. Methods and Results We prospectively enrolled 202 patients with prior carotid Doppler ultrasound data. A short 30‐second video clip of the neck was taken using a commercial mobile device and analyzed by VMA with mathematical quantification of the amplitude of skin motion changes in a blinded manner. The first 40 subjects were used to set up the VMA protocol and define cutoff values, and the following 162 subjects were used for validation. Overall, 54% of the 202 subjects had ultrasound‐confirmed CAS. Using receiver operating characteristic curve analysis, the area under the curve of VMA‐derived discrepancy values to differentiate patients with and without CAS was excellent (area under the curve, 0.914 [95% CI, 0.874–0.954]; P<0.01). The best cutoff value of VMA‐derived discrepancy values to screen for CAS was 5.1, with a sensitivity of 87% and a specificity of 87%. The diagnostic accuracy was consistently high in different subject subgroups. Conclusions A simple and accurate screening technique to quickly screen for CAS using a VMA system is feasible, with acceptable sensitivity and specificity.
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Affiliation(s)
- Cheng-Hsuan Tsai
- Graduate Institute of Clinical Medicine National Taiwan University College of Medicine Taipei Taiwan.,Division of Cardiology, Department of Internal Medicine and Cardiovascular Center National Taiwan University Hospital Taipei Taiwan
| | - Ching-Chang Huang
- Division of Cardiology, Department of Internal Medicine and Cardiovascular Center National Taiwan University Hospital Taipei Taiwan
| | - Hao-Ming Hsiao
- Department of Mechanical Engineering National Taiwan University Taipei Taiwan
| | - Ming-Ya Hung
- Department of Mechanical Engineering National Taiwan University Taipei Taiwan
| | - Guan-Jie Su
- Department of Mechanical Engineering National Taiwan University Taipei Taiwan
| | - Li-Han Lin
- Department of Mechanical Engineering National Taiwan University Taipei Taiwan
| | - Ying-Hsien Chen
- Division of Cardiology, Department of Internal Medicine and Cardiovascular Center National Taiwan University Hospital Taipei Taiwan
| | - Mao-Shin Lin
- Division of Cardiology, Department of Internal Medicine and Cardiovascular Center National Taiwan University Hospital Taipei Taiwan
| | - Chih-Fan Yeh
- Division of Cardiology, Department of Internal Medicine and Cardiovascular Center National Taiwan University Hospital Taipei Taiwan
| | - Chi-Sheng Hung
- Division of Cardiology, Department of Internal Medicine and Cardiovascular Center National Taiwan University Hospital Taipei Taiwan
| | - Hsien-Li Kao
- Division of Cardiology, Department of Internal Medicine and Cardiovascular Center National Taiwan University Hospital Taipei Taiwan
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Mazurek A, Malinowski K, Rosenfield K, Capoccia L, Speziale F, de Donato G, Setacci C, Wissgott C, Sirignano P, Tekieli L, Karpenko A, Kuczmik W, Stabile E, Metzger DC, Amor M, Siddiqui AH, Micari A, Pieniążek P, Cremonesi A, Schofer J, Schmidt A, Musialek P. Clinical Outcomes of Second- versus First-Generation Carotid Stents: A Systematic Review and Meta-Analysis. J Clin Med 2022; 11:jcm11164819. [PMID: 36013058 PMCID: PMC9409706 DOI: 10.3390/jcm11164819] [Citation(s) in RCA: 18] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2022] [Revised: 07/20/2022] [Accepted: 07/29/2022] [Indexed: 01/10/2023] Open
Abstract
Background: Single-cohort studies suggest that second-generation stents (SGS; “mesh stents”) may improve carotid artery stenting (CAS) outcomes by limiting peri- and postprocedural cerebral embolism. SGS differ in the stent frame construction, mesh material, and design, as well as in mesh-to-frame position (inside/outside). Objectives: To compare clinical outcomes of SGS in relation to first-generation stents (FGSs; single-layer) in CAS. Methods: We performed a systematic review and meta-analysis of clinical studies with FGSs and SGS (PRISMA methodology, 3302 records). Endpoints were 30-day death, stroke, myocardial infarction (DSM), and 12-month ipsilateral stroke (IS) and restenosis (ISR). A random-effect model was applied. Results: Data of 68,422 patients from 112 eligible studies (68.2% men, 44.9% symptomatic) were meta-analyzed. Thirty-day DSM was 1.30% vs. 4.11% (p < 0.01, data for SGS vs. FGS). Among SGS, both Casper/Roadsaver and CGuard reduced 30-day DSM (by 2.78 and 3.03 absolute percent, p = 0.02 and p < 0.001), whereas the Gore stent was neutral. SGSs significantly improved outcomes compared with closed-cell FGS (30-day stroke 0.6% vs. 2.32%, p = 0.014; DSM 1.3% vs. 3.15%, p < 0.01). At 12 months, in relation to FGS, Casper/Roadsaver reduced IS (−3.25%, p < 0.05) but increased ISR (+3.19%, p = 0.04), CGuard showed a reduction in both IS and ISR (−3.13%, −3.63%; p = 0.01, p < 0.01), whereas the Gore stent was neutral. Conclusions: Pooled SGS use was associated with improved short- and long-term clinical results of CAS. Individual SGS types, however, differed significantly in their outcomes, indicating a lack of a “mesh stent” class effect. Findings from this meta-analysis may provide clinically relevant information in anticipation of large-scale randomized trials.
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Affiliation(s)
- Adam Mazurek
- Department of Cardiac and Vascular Diseases, John Paul II Hospital, Jagiellonian University, 31-202 Krakow, Poland
- Correspondence: (A.M.); (P.M.)
| | - Krzysztof Malinowski
- Department of Bioinformatics and Telemedicine, Faculty of Medicine, Jagiellonian University Medical College, 31-008 Krakow, Poland
| | - Kenneth Rosenfield
- Vascular Surgery, Surgery Department, Massachusetts General Hospital, Boston, MA 02114, USA
| | - Laura Capoccia
- Vascular and Endovascular Surgery Unit, Department of Surgery, Sapienza University of Rome, 00185 Rome, Italy
| | - Francesco Speziale
- Vascular and Endovascular Surgery Unit, Department of Surgery, Sapienza University of Rome, 00185 Rome, Italy
| | | | - Carlo Setacci
- Department of Vascular Surgery, University of Siena, 53100 Siena, Italy
| | - Christian Wissgott
- Institut für Diagnostische und Interventionelle Radiologie/Neuroradiologie, Imland Klinik Rendsburg, 24768 Rendsburg, Germany
| | - Pasqualino Sirignano
- Vascular and Endovascular Surgery Unit, Department of Surgery, Sapienza University of Rome, 00185 Rome, Italy
| | - Lukasz Tekieli
- Department of Interventional Cardiology, John Paul II Hospital, Jagiellonian University, 31-202 Krakow, Poland
| | - Andrey Karpenko
- Centre of Vascular and Hybrid Surgery, E.N. Meshalkin National Medical Research Center, 630055 Novosibirsk, Russia
| | - Waclaw Kuczmik
- Department of General, Vascular Surgery, Angiology and Phlebology, Medical University of Silesia, 40-055 Katowice, Poland
| | | | | | - Max Amor
- Department of Interventional Cardiology, U.C.C.I. Polyclinique d’Essey, 54270 Nancy, France
| | - Adnan H. Siddiqui
- Department of Neurosurgery, SUNY University at Buffalo, Buffalo, NY 14203, USA
| | - Antonio Micari
- Department of Biomedical and Dental Sciences and Morphological and Functional Imaging, University of Messina, 98122 Messina, Italy
| | - Piotr Pieniążek
- Department of Cardiac and Vascular Diseases, John Paul II Hospital, Jagiellonian University, 31-202 Krakow, Poland
- Department of Interventional Cardiology, John Paul II Hospital, Jagiellonian University, 31-202 Krakow, Poland
| | - Alberto Cremonesi
- Cardiovascular Department, Humanitas Gavazzeni Hospital, 24125 Bergamo, Italy
| | - Joachim Schofer
- MVZ-Department Structural Heart Disease, Asklepios Clinic St. Georg, 20099 Hamburg, Germany
| | - Andrej Schmidt
- Department of Angiology, University Hospital Leipzig, 04103 Leipzig, Germany
| | - Piotr Musialek
- Department of Cardiac and Vascular Diseases, John Paul II Hospital, Jagiellonian University, 31-202 Krakow, Poland
- Correspondence: (A.M.); (P.M.)
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Borhani-Haghighi A, Hooshmandi E, Zahediasl F, Molavi Vardanjani H, Rezaei M, Rahimi-Jaberi A, Ashjazadeh N, Petramfar P, Ostovan VR, Fadakar N, Poursadeghfard M, Izadi S, Nazeri M, Zafarmand SS, Bayat M, Salehi MS, Owjfard M, Sedighi B, Iranmanesh F, Shafiei K, Vakilian A, Moghadam Ahmadi A, Nemati R, Rezaeian Jahromi F, Jalalijahromi M, Kashani K, Razmeh S, Bahrehbar M, Basir M, Qureshi AI. Early and mid-term outcomes of carotid angioplasty and stent placement in 579 patients. J Neuroimaging 2022; 32:1161-1169. [PMID: 35969379 DOI: 10.1111/jon.13036] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2022] [Revised: 07/11/2022] [Accepted: 07/28/2022] [Indexed: 11/30/2022] Open
Abstract
BACKGROUND AND PURPOSE Carotid angioplasty and stenting (CAS) could be considered for preventing stroke in patients with carotid artery stenosis. This study aimed to determine the incidence and the risk factors of the early and mid-term complications associated with CAS. METHODS This is a retrospective cohort study conducted at Shiraz University of Medical Sciences from March 2011 to March 2019. Patients at high risk and standard risk for carotid endarterectomy were included. The primary composite outcome was defined as stroke, myocardial infarction (MI), and death in the first 30 days after CAS. All-cause mortality, vascular mortality, and stroke were investigated during mid-term follow-up. RESULTS A total of 579 patients (618 CAS) were recruited (mean age: 71.52 years). Overall, 394 (68.40%), 211 (36.63%), 179 (31.07%), and 96 (16.72%) patients had hypertension, dyslipidemia, diabetes mellitus, or were cigarette smokers, respectively. Primary composite outcomes were observed in 2.59% of patients (1.55% stroke, 0.69% MI, and 1.72% death). Atrial fibrillation was a predictor of primary composite outcome in multivariate logistic regression (p = .048). The presence of total occlusion in the contralateral carotid artery was significantly associated with the risk of stroke in univariate logistic regression (p = .041). The patients were followed for a period ranging from 1 to 83 months. The overall survival rate for all-cause mortality was 93.48% at 1 year, 77.24% at 5 years, and 52.92% at 8 years. All-cause mortality was significantly higher among patients with symptomatic carotid stenosis (p = .014). CONCLUSION CAS provides acceptable short-term and mid-term outcomes in a unique population of high- and standard-surgical-risk, symptomatic and asymptomatic, octogenarian, and nonoctogenarian patients.
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Affiliation(s)
| | - Etrat Hooshmandi
- Clinical Neurology Research Center, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Farzaneh Zahediasl
- Clinical Neurology Research Center, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Hossein Molavi Vardanjani
- Research Center for Traditional Medicine and History of Medicine, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Mahdiyeh Rezaei
- Clinical Neurology Research Center, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Abbas Rahimi-Jaberi
- Clinical Neurology Research Center, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Nahid Ashjazadeh
- Clinical Neurology Research Center, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Peyman Petramfar
- Clinical Neurology Research Center, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Vahid Reza Ostovan
- Clinical Neurology Research Center, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Nima Fadakar
- Clinical Neurology Research Center, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Maryam Poursadeghfard
- Clinical Neurology Research Center, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Sadegh Izadi
- Clinical Neurology Research Center, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Masoumeh Nazeri
- Clinical Neurology Research Center, Shiraz University of Medical Sciences, Shiraz, Iran
| | | | - Mahnaz Bayat
- Clinical Neurology Research Center, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Mohammad Saied Salehi
- Clinical Neurology Research Center, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Maryam Owjfard
- Clinical Neurology Research Center, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Behnaz Sedighi
- Neurology Research Center, Kerman University of Medical Science, Kerman, Iran
| | - Farhad Iranmanesh
- Neurology Research Center, Kerman University of Medical Science, Kerman, Iran
| | - Kaveh Shafiei
- Neurology Research Center, Kerman University of Medical Science, Kerman, Iran
| | - Alireza Vakilian
- Non-Communicable Diseases Research Center, Rafsanjan University of Medical Sciences, Rafsanjan, Iran
| | - Amir Moghadam Ahmadi
- Neuro-immunology Research Scholar, Thomas Jefferson University, Philadelphia, PA, USA
| | - Reza Nemati
- Department of Neurology, Bushehr Medical University Hospital, School of Medicine, Bushehr University of Medical Sciences, Bushehr, Iran
| | | | | | - Kaveh Kashani
- Department of Neurology, Fasa University of Medical Sciences, Fasa, Iran
| | - Saeed Razmeh
- Department of Neurology, Yasuj University of Medical Sciences, Yasuj, Iran
| | - Mansour Bahrehbar
- Department of Neurology, Yasuj University of Medical Sciences, Yasuj, Iran
| | - Marzieh Basir
- Clinical Neurology Research Center, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Adnan I Qureshi
- Zeenat Qureshi Stroke Institute and University of Missouri, Columbia, Missouri, USA
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Hagiwara Y, Takao N, Usuki N, Yoshie T, Takaishi S, Shimizu T, Ueda T, Hasegawa Y, Yamano Y. Carotid ultrasound using superb microvascular imaging to identify patients developing in-stent restenosis after CAS. J Stroke Cerebrovasc Dis 2022; 31:106627. [DOI: 10.1016/j.jstrokecerebrovasdis.2022.106627] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2022] [Revised: 06/23/2022] [Accepted: 06/26/2022] [Indexed: 10/17/2022] Open
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Hamada Y, Ikeda M, Shimotakahara S, Tahara S, Onobuchi N, Kanda Y, Takaguchi G, Matsuoka H. Plaque Protrusion in a Patient with Left Common Carotid Artery Stenting after Radiation Therapy: A Case Report. JOURNAL OF NEUROENDOVASCULAR THERAPY 2022; 16:503-509. [PMID: 37502203 PMCID: PMC10370822 DOI: 10.5797/jnet.cr.2022-0023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/10/2022] [Accepted: 05/25/2022] [Indexed: 07/29/2023]
Abstract
Objective We report a case of additional carotid artery stenting (CAS) for plaque protrusion occurring after initial CAS for radiation-induced common carotid artery (CCA) stenosis. Case Presentation A 69-year-old man with a history of radiotherapy for laryngeal cancer presented to our hospital with sudden-onset right hemiparesis. Since vulnerable plaque of the left CCA was considered the embolic source for ischemic stroke, CAS was performed for left CCA stenosis. No perioperative complications were observed and the patient was discharged with a modified Rankin Scale score of 0. However, 1 month after CAS, cerebral embolism recurred. As protruding plaque was found on CTA, additional endovascular treatment was performed with intravascular ultrasonography. He was discharged without complications and showed a good outcome at 3 months. Conclusion In CCA stenosis after radiotherapy, accelerated arteriosclerosis may cause drug-resistant cerebral embolism and plaque protrusion after CAS, making determination of the treatment strategy difficult. Appropriate treatment options need to be based on individual underlying diseases and plaque instability.
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Affiliation(s)
- Yuki Hamada
- Department of Strokology, Stroke Center, National Hospital Organization Kagoshima Medical Center, Kagoshima, Kagoshima, Japan
| | - Mei Ikeda
- Department of Strokology, Stroke Center, National Hospital Organization Kagoshima Medical Center, Kagoshima, Kagoshima, Japan
| | - Shinju Shimotakahara
- Department of Strokology, Stroke Center, National Hospital Organization Kagoshima Medical Center, Kagoshima, Kagoshima, Japan
| | - Sayaka Tahara
- Department of Strokology, Stroke Center, National Hospital Organization Kagoshima Medical Center, Kagoshima, Kagoshima, Japan
| | - Nao Onobuchi
- Department of Strokology, Stroke Center, National Hospital Organization Kagoshima Medical Center, Kagoshima, Kagoshima, Japan
| | - Yoshiki Kanda
- Department of Strokology, Stroke Center, National Hospital Organization Kagoshima Medical Center, Kagoshima, Kagoshima, Japan
| | - Go Takaguchi
- Department of Strokology, Stroke Center, National Hospital Organization Kagoshima Medical Center, Kagoshima, Kagoshima, Japan
| | - Hideki Matsuoka
- Department of Strokology, Stroke Center, National Hospital Organization Kagoshima Medical Center, Kagoshima, Kagoshima, Japan
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31
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Prakash V, Lau I, Faries PL. Carotid Artery Angioplasty and Stenting. Interv Cardiol 2022. [DOI: 10.1002/9781119697367.ch72] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
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32
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Rein LCDS, Siqueira DED, Guillaumon AT, Avelar WM, Cendes F. Near Infrared Spectroscopy For Cerebral Hemodynamic Monitoring During Carotid Endarterectomy Under General Anesthesia. Open Cardiovasc Med J 2022. [DOI: 10.2174/18741924-v16-e2203250] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
Background:
Near infrared spectroscopy (NIRS) is a noninvasive method for continuous monitoring of cerebral oxygenation.
Objective:
To describe the intraoperative behavior of NIRS variables used to evaluate hemodynamic response in patients with atherosclerotic disease undergoing carotid endarterectomy under general anesthesia.
Methods:
Fifteen volunteers with atherosclerotic carotid disease with indications for endarterectomy were evaluated. After selection of patients, carotid stenosis was confirmed by appropriate diagnostic methods. NIRS was used for intraoperative monitoring. The variables total hemoglobin (Hb), oxygenated hemoglobin (O2Hb), deoxygenated hemoglobin (HHb), and regional oxygen saturation (rSO2) were evaluated at three intraoperative time points: before, during, and after carotid clamping.
Results and Discussion:
Measurements recorded by NIRS showed that, during the first 5 min of clamp time, patients experienced a decline in O2Hb levels, an increase in HHb levels, and a marked decrease in rSO2. Hb remained constant throughout the procedure. At the post-clamping time point, HHb, O2Hb, and rSO2 returned to patterns similar to those observed before clamping.
Conclusion:
NIRS was able to reliably and accurately identify the three stages of carotid endarterectomy and may predict the risk of cerebral hypoxia during carotid clamping under general anesthesia.
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Din MTU, Mohamed MM, Shah SY, Arshad A, Ahmed A, Osman M. Meta-Analysis Comparing Carotid Artery Stenting With Endarterectomy for Asymptomatic Carotid Artery Stenosis. Am J Cardiol 2022; 171:178-179. [PMID: 35331472 DOI: 10.1016/j.amjcard.2022.02.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/06/2022] [Accepted: 02/15/2022] [Indexed: 11/01/2022]
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Takahashi Y, Higashida T, Uchida T, Watanabe S, Kanazawa R. Carotid endarterectomy with stent removal for recurring in-stent restenosis: A case report and literature review. Surg Neurol Int 2022; 13:192. [PMID: 35673638 PMCID: PMC9168307 DOI: 10.25259/sni_1222_2021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2021] [Accepted: 04/20/2022] [Indexed: 11/28/2022] Open
Abstract
Background: Percutaneous transcatheter angioplasty (PTA) and carotid artery stenting (CAS) are often performed repeatedly for in-stent restenosis (ISR) after CAS. Only a few reports describe the treatment for repeated ISR. Furthermore, only a few reports describe carotid endarterectomy (CEA) after CAS; thus, the evidence for this procedure is insufficient. Case Description: Herein, we describe a case in which CEA with stent removal was performed in a patient with repeated ISR after CAS. A 78-year-old man presented with dysarthria and slight left limb weakness. CAS was performed for the right internal carotid artery stenosis. ISR occurred again and PTA and stenting were performed. After the second CAS, ISR occurred again. CEA with stent removal was performed. After the CEA with stent removal, the patient experienced no restenosis or other complications. Conclusion: CEA with stent removal can be a good option for treating repeated ISR after CAS.
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Gologorsky R, Somani SS, Neifert SN, Valliani AA, Link KE, Chen VJ, Costa AB, Oermann EK. Population scale latent space cohort matching for the improved use and exploration of observational trial data. MATHEMATICAL BIOSCIENCES AND ENGINEERING : MBE 2022; 19:6795-6813. [PMID: 35730283 DOI: 10.3934/mbe.2022320] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/15/2023]
Abstract
A significant amount of clinical research is observational by nature and derived from medical records, clinical trials, and large-scale registries. While there is no substitute for randomized, controlled experimentation, such experiments or trials are often costly, time consuming, and even ethically or practically impossible to execute. Combining classical regression and structural equation modeling with matching techniques can leverage the value of observational data. Nevertheless, identifying variables of greatest interest in high-dimensional data is frequently challenging, even with application of classical dimensionality reduction and/or propensity scoring techniques. Here, we demonstrate that projecting high-dimensional medical data onto a lower-dimensional manifold using deep autoencoders and post-hoc generation of treatment/control cohorts based on proximity in the lower-dimensional space results in better matching of confounding variables compared to classical propensity score matching (PSM) in the original high-dimensional space (P<0.0001) and performs similarly to PSM models constructed by experts with prior knowledge of the underlying pathology when evaluated on predicting risk ratios from real-world clinical data. Thus, in cases when the underlying problem is poorly understood and the data is high-dimensional in nature, matching in the autoencoder latent space might be of particular benefit.
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Affiliation(s)
- Rachel Gologorsky
- Department of Medicine, Icahn School of Medicine, New York, NY 10028, USA
| | - Sulaiman S Somani
- Department of Medicine, Stanford University School of Medicine, Stanford, CA 94305, USA
| | - Sean N Neifert
- Department of Neurosurgery, NYU Grossman School of Medicine, New York, NY 10016, USA
| | - Aly A Valliani
- Department of Medicine, Icahn School of Medicine, New York, NY 10028, USA
| | - Katherine E Link
- Department of Medicine, Icahn School of Medicine, New York, NY 10028, USA
| | - Viola J Chen
- Oncology Early development, Merck & Co., Inc, Kenilworth, NJ 07033, USA
| | | | - Eric K Oermann
- Department of Neurosurgery, NYU Grossman School of Medicine, New York, NY 10016, USA
- Department of Radiology, NYU Grossman School of Medicine, New York, NY 10016, USA
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36
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Zhang GQ, Bose S, Stonko DP, Abularrage CJ, Zarkowsky DS, Hicks CW. Transcarotid artery revascularization is associated with similar outcomes to carotid endarterectomy regardless of patient risk status. J Vasc Surg 2022; 76:474-481.e3. [PMID: 35367564 PMCID: PMC9329175 DOI: 10.1016/j.jvs.2022.03.860] [Citation(s) in RCA: 16] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2021] [Accepted: 03/14/2022] [Indexed: 10/18/2022]
Abstract
BACKGROUND Carotid artery stenting, including both transfemoral carotid artery stenting (TFCAS) and transcarotid artery revascularization (TCAR), reimbursement has been limited to high-risk patients by the Centers for Medicare & Medicaid Services (CMS) since 2005. We aimed to assess the association of CMS high-risk status with perioperative outcomes for carotid endarterectomy (CEA), TFCAS, and TCAR. METHODS We performed a retrospective review of all Vascular Quality Initiative (VQI) patients who underwent carotid revascularization between 2015 and 2020. Patients were stratified by whether they met CMS CAS criteria, and univariable and multivariable logistic regression analyses were performed to assess the association of procedure type (CEA, TFCAS, TCAR) with perioperative stroke. RESULTS Of 124,531 individuals who underwent carotid revascularization procedures, 91,687 (73.6%) underwent CEA, 17,247 (13.9%) underwent TFCAS, and 15,597 (12.5%) underwent TCAR. Among patients who met CMS CAS criteria (i.e., high-risk patients), the incidence of perioperative stroke was 2.7% for CEA, 3.4% for TFCAS, and 2.4% for TCAR (p<0.001). Among standard-risk patients, the incidence of perioperative stroke was 1.7% for CEA, 2.7% for TFCAS, and 1.8% for TCAR (p<0.001). After adjusting for baseline demographic and clinical characteristics, the odds of perioperative stroke were lower for TCAR vs. CEA in high-risk patients [adjusted odds ratio (aOR) 0.82 (95% CI 0.68, 0.99)] and similar in standard-risk patients [aOR 1.05 (95% CI 0.84, 1.31)]. In contrast, the adjusted odds of perioperative stroke were higher for TFCAS vs. CEA in high-risk patients [aOR 1.23 (95% CI 1.03, 1.46)] and standard-risk patients [aOR 1.60 (95% CI 1.37, 1.86)]. In both populations, TFCAS and TCAR patients had significantly lower odds of MI than CEA patients (both, p<0.001). CONCLUSIONS The perioperative risks associated with CEA, TFCAS, and TCAR in high-risk patients support the current Centers for Medicare & Medicaid Services (CMS) criteria, while the risks associated with each revascularization approach in standard-risk patients suggest that distinguishing TCAR from TFCAS may be warranted.
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Affiliation(s)
- George Q Zhang
- Department of Surgery, Brigham and Women's Hospital, Boston, MA
| | - Sanuja Bose
- Johns Hopkins Bloomberg School of Public Health, Baltimore, MD.
| | - David P Stonko
- Department of Surgery, The Johns Hopkins Hospital, Baltimore, MD
| | - Christopher J Abularrage
- Department of Surgery, The Johns Hopkins Hospital, Baltimore, MD; Division of Vascular Surgery and Endovascular Therapy, Department of Surgery, The Johns Hopkins Hospital, Baltimore, MD
| | - Devin S Zarkowsky
- Division of Vascular Surgery and Endovascular Therapy, Department of Surgery, University of Colorado Medicine, Denver, CO
| | - Caitlin W Hicks
- Department of Surgery, The Johns Hopkins Hospital, Baltimore, MD; Division of Vascular Surgery and Endovascular Therapy, Department of Surgery, The Johns Hopkins Hospital, Baltimore, MD.
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Varbella F, Cerrato E, Rolfo C, Quadri G, Franzè A, Ferrari F, Mariani F, Giacobbe F, Lo Savio L, Giay Pron P, Amarù S, Tomassini F. Characteristics and outcomes of elderly patients undergoing carotid stenting: Experience of a high-volume interventional cardiology center. Catheter Cardiovasc Interv 2022; 99:853-859. [PMID: 35235693 DOI: 10.1002/ccd.30002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/31/2021] [Revised: 09/28/2021] [Accepted: 10/17/2021] [Indexed: 12/24/2022]
Abstract
BACKGROUND Carotid artery stenting (CAS) is an attractive option in order to treat carotid artery stenosis. However, its safety in elderly patients is questioned. Aim of this single-center retrospective study was to assess data of elderly patients undergoing CAS, and to compare them with those of the younger (< 75 years). METHODS We collected data of 580 consecutive patients undergoing CAS between December 2007 and June 2020 and compared clinical and procedural characteristics as well as in-hospital major adverse events (MACCE) and long-term mortality between patients < 75 years and patients ≥ 75 years old. RESULTS There were 272 patients (46.9%) with age ≥ 75 years and 308 patients (53.1%) with age < 75 years. The median follow-up was 48 months (range 2-144). There was no significant difference about in-hospital MACCE between the two groups (4.7% in the older vs. 3.5% in the younger group, p = 0.9), but a higher rate of cerebral hemorrhage occurred in the older group (1.8% vs. = 0.3%, p = 0.07), even if not significant. Long-term mortality was significantly higher in the older group (27.9 vs. 20.1%, p = 0.027). Multivariate predictors of 12-months mortality were neurologic symptoms within 6 months (OR: 4.83; 95% CI: 2.04-11.42; p ≤ 0.001), smoking status (OR: 2.84; 95% CI: 1.17-6.86; p = 0.02) and age ≥ 75 years (OR: 2.78; 95% CI: 1.14-6.76; p = 0.024). CONCLUSIONS In elderly patients, CAS can be carried out efficaciously with acceptable procedural risks, if performed by expert operators and after a correct selection by a multidisciplinary team.
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Affiliation(s)
- Ferdinando Varbella
- Interventional Cardiology Unit, Infermi Hospital, Rivoli, Italy.,San Luigi Gonzaga Hospital, Orbassano, Italy.,Department of Cardiology, Infermi Hospital, Rivoli, Italy
| | - Enrico Cerrato
- Interventional Cardiology Unit, Infermi Hospital, Rivoli, Italy.,San Luigi Gonzaga Hospital, Orbassano, Italy.,Department of Cardiology, San Luigi Gonzaga Hospital, Orbassano, Italy
| | - Cristina Rolfo
- Interventional Cardiology Unit, Infermi Hospital, Rivoli, Italy.,San Luigi Gonzaga Hospital, Orbassano, Italy.,Department of Cardiology, Infermi Hospital, Rivoli, Italy
| | - Giorgio Quadri
- Interventional Cardiology Unit, Infermi Hospital, Rivoli, Italy.,San Luigi Gonzaga Hospital, Orbassano, Italy.,Department of Cardiology, Infermi Hospital, Rivoli, Italy
| | - Alfonso Franzè
- Interventional Cardiology Unit, Infermi Hospital, Rivoli, Italy.,San Luigi Gonzaga Hospital, Orbassano, Italy.,Department of Cardiology, Infermi Hospital, Rivoli, Italy
| | - Fabio Ferrari
- Interventional Cardiology Unit, Infermi Hospital, Rivoli, Italy.,San Luigi Gonzaga Hospital, Orbassano, Italy.,Department of Cardiology, San Luigi Gonzaga Hospital, Orbassano, Italy
| | - Fabio Mariani
- Interventional Cardiology Unit, Infermi Hospital, Rivoli, Italy.,San Luigi Gonzaga Hospital, Orbassano, Italy.,Department of Cardiology, San Luigi Gonzaga Hospital, Orbassano, Italy
| | - Federico Giacobbe
- Department of Cardiology, San Luigi Gonzaga Hospital, Orbassano, Italy
| | - Luca Lo Savio
- Department of Cardiology, Infermi Hospital, Rivoli, Italy
| | | | | | - Francesco Tomassini
- Interventional Cardiology Unit, Infermi Hospital, Rivoli, Italy.,San Luigi Gonzaga Hospital, Orbassano, Italy.,Department of Cardiology, Infermi Hospital, Rivoli, Italy
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Management of atherosclerotic extracranial carotid artery stenosis. Lancet Neurol 2022; 21:273-283. [DOI: 10.1016/s1474-4422(21)00359-8] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2020] [Revised: 09/30/2021] [Accepted: 10/08/2021] [Indexed: 02/05/2023]
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Hara T, Rai Y. Carotid Endarterectomy. Adv Tech Stand Neurosurg 2022; 44:187-207. [PMID: 35107680 DOI: 10.1007/978-3-030-87649-4_10] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
Stroke is the second leading cause of death worldwide. One of the main causes of stroke is carotid artery stenosis. Stenosis with atherosclerosis in the carotid artery can cause stroke by hemodynamic ischemia or artery to artery embolism. A most common surgical intervention for carotid artery stenosis is carotid endarterectomy (CEA). Many studies on CEA have been reported and suggested medical indications. For symptomatic carotid stenosis, generally, CEA may be indicated for patients with more than 50% stenosis and is especially beneficial in men, patients aged 75 years or older, and patients who underwent surgery within 2 weeks of their last symptoms. For asymptomatic carotid stenosis, CEA may be indicated for those with more than 60% stenosis, though each guideline has different suggestions in detail. In order to evaluate the indication for CEA in each case, it is important to assess risks for CEA carefully including anatomical factors and comorbidities, and to elaborate each strategy for each operation based on preoperative imaging studies including carotid ultrasonography, magnetic resonance imaging and angiography. In surgery there are many tips on operative position, procedure, shunt usage and monitoring to perform a safe and smooth operation. Now that carotid artery stenting has been rapidly developed, better understanding for CEA is required to treat carotid artery stenosis adequately. This chapter must be a good help to understand CEA well.
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Affiliation(s)
- Takayuki Hara
- Department of Neurosurgery, Toranomon Hospital, Minato-ku, Tokyo, Japan.
| | - Yurie Rai
- Department of Neurosurgery, Toranomon Hospital, Minato-ku, Tokyo, Japan
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40
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Miyachi S. Carotid Angioplasty and Stenting for Occlusive Diseases. Adv Tech Stand Neurosurg 2022; 44:209-223. [PMID: 35107681 DOI: 10.1007/978-3-030-87649-4_11] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Stenting for carotid artery stenosis (CAS) was once denied 15 years ago because it failed to prove the non-inferiority to carotid endarterectomy (CEA). However, it is now reevaluated and is thought better due to higher safety and efficacy thanks to the development of devices, strategies, and various protection methods. To achieve the safe CAS, protection methods and stents should be properly selected based on the vessel course and plaque components on the preoperative plaque images. Particularly multiple protection methods including proximal balloon protection and double-layer micromesh stents are useful for the cases with high-risk and fragile plaque. Perioperative anti-platelet management and the control of blood pressure are also important to avoid the ischemic complications and hyperperfusion. Properly protected and tailored CAS based on the risk management has dramatically improved the clinical results and contributed to extend the indication for more difficult lesions.
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Affiliation(s)
- Shigeru Miyachi
- Department of Neurological Surgery, Aichi Medical University, Nagakute, Japan.
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41
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Laukkavirta M, Blomgren K, Rautio R, Nikulainen V, Helmiö P. Compensated and non-compensated patient injury claims in internal carotid artery interventions in Finland, 2004-2017. Vascular 2022; 31:544-550. [PMID: 35089091 DOI: 10.1177/17085381211069294] [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: 11/16/2022]
Abstract
OBJECTIVES Analysis of patient injuries offers possibilities for improving quality in patient care. The aim of this study was to identify errors and adverse events leading to patient injuries in the treatment of internal carotid artery stenosis (ICAS). METHODS A retrospective analysis was performed on data from Finnish patient injury claims and patient insurance center decisions in the treatment of ICAS, 2004-2017. Contributing factors to injury were identified and evaluated. RESULTS During the 14-year study period, 42 patient injury claims involving ICAS treatment were closed in Finland. One claim involved carotid artery stenting, and the other operations were carotid artery endarterectomies. Nine of the claims were compensated (seven for operations and two for evaluations). Fully trained vascular surgeons had carried out all the operations and evaluations. Stroke was the most common complaint in the claims (n = 12). Six of the compensated patients were symptomatic prior to the interventions. Injuries were related to errors in decision-making and patient selection in two cases. Four patients received compensation for nerve injury and three for stroke. No deaths were compensated as patient injuries. Most negative claim decisions were related to the injury having been unavoidable. CONCLUSION Compensated patient injuries involving the treatment of ICAS are rare but often serious and mostly involve open surgery. Patient injury claims provide a valuable source of information for recognizing errors in care and offer possibilities to improve patient safety.
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Affiliation(s)
- Minna Laukkavirta
- Department of Vascular Surgery, 60674Kanta-Häme Central Hospital, University of Turku, Hämeenlinna, Finland
| | | | - Riitta Rautio
- Department of Radiology, 60652Turku University Hospital, Turku, Finland
| | - Veikko Nikulainen
- Department of Vascular Surgery, 60652Turku University Hospital, University of Turku, Turku, Finland
| | - Päivi Helmiö
- Department of Vascular Surgery, 60652Turku University Hospital, University of Turku, Turku, Finland
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42
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Diyora B, Chheda R, Dhall G, Gupta P, Dewani K, Mulla M, Gaud D. Carotid Endarterectomy and Carotid Artery Stenting for Symptomatic Carotid Stenosis: An Experience of a Hybrid Neurosurgeon in a Developing Nation. Neurol India 2022; 70:94-101. [DOI: 10.4103/0028-3886.336326] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
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43
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Vibha D, Sudheer P, Misra S. Asymptomatic carotid stenosis: Several guidelines with unclear answers. Ann Indian Acad Neurol 2022; 25:171-176. [PMID: 35693653 PMCID: PMC9175419 DOI: 10.4103/aian.aian_566_21] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2021] [Revised: 08/30/2021] [Accepted: 09/01/2021] [Indexed: 12/24/2022] Open
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44
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Bogniotti LAC, Teivelis MP, Cardozo FAM, Caramelli B, Wolosker N, Puech-Leão P, De Luccia N, Calderaro D. Hemodynamic depression after carotid surgery: Incidence, risk factors and outcomes. Clinics (Sao Paulo) 2022; 77:100090. [PMID: 36088886 PMCID: PMC9474302 DOI: 10.1016/j.clinsp.2022.100090] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/07/2022] [Accepted: 06/11/2022] [Indexed: 12/24/2022] Open
Abstract
INTRODUCTION Hemodynamic Depression (HD) characterized by hypotension and bradycardia is a complication of carotid surgery due to direct autonomic stimulation in the carotid sinus. The authors believe the incidence of HD is high and possibly related to major cardiac complications. METHODS Analysis of patient records during admissions for carotid surgery between January 2014 and December 2018 in two hospitals. HD was defined as bradycardia or hypotension in the first 24 postoperative hours. Bradycardia was defined as heart rate < 50bpm; hypotension as systolic blood pressure < 90 mmHg, continuous use of vasopressors, or a drop in SBP > 20% compared to preoperative values. Myocardial infarction, stroke, and cardiovascular death were defined as adverse events. RESULTS Overall, 237 carotid surgeries (178 endarterectomies, 59 angioplasties) were studied, and the global incidence of HD was 54.4% (hypotension in 50.2%, bradycardia in 11.0%, and hypotension and bradycardia in 6.8%). The independent predictors of HD were asymptomatic carotid stenosis (OR = 1.824; 95% CI 1.014-3.280; p = 0.045), endovascular surgery (OR = 3.319; 95% CI 1.675-6.576; p = 0.001) and intraoperative hypotension or bradycardia (OR = 2.144; 95% CI 1.222-3.762; p = 0.008). Hypotension requiring continuous vasopressor infusion was the only factor independently associated with adverse cardiovascular events (OR = 5.504; 95% CI 1.729-17.529; p = 0.004). DISCUSSION/CONCLUSION Incidence of Hemodynamic Depression after carotid surgery is high and independently associated with surgical technique, symptomatic repercussion of the carotid stenosis, and intraoperative hypotension or bradycardia. Hypotension requiring the continuous infusion of vasopressors was independently associated with the occurrence of MACE.
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Affiliation(s)
- Lauro A C Bogniotti
- Anesthesiology Division, Hospital das Clínicas, Faculdade de Medicina, Universidade de São Paulo (HCFMUSP), São Paulo, SP, Brazil.
| | - Marcelo P Teivelis
- Vascular and Endovascular Surgery, Hospital Israelita Albert Einstein, São Paulo, SP, Brazil
| | - Francisco A M Cardozo
- Unidade de Medicina Interdisciplinar em Cardiologia, Instituto do Coração, Hospital das Clínicas, Faculdade de Medicina, Universidade de São Paulo (HCFMUSP), São Paulo, SP, Brazil
| | - Bruno Caramelli
- Unidade de Medicina Interdisciplinar em Cardiologia, Instituto do Coração, Hospital das Clínicas, Faculdade de Medicina, Universidade de São Paulo (HCFMUSP), São Paulo, SP, Brazil
| | - Nelson Wolosker
- Vascular and Endovascular Surgery, Hospital Israelita Albert Einstein, São Paulo, SP, Brazil; Vascular Surgery Division, Hospital das Clínicas, Faculdade de Medicina, Universidade de São Paulo (HCFMUSP), São Paulo, SP, Brazil
| | - Pedro Puech-Leão
- Vascular Surgery Division, Hospital das Clínicas, Faculdade de Medicina, Universidade de São Paulo (HCFMUSP), São Paulo, SP, Brazil
| | - Nelson De Luccia
- Vascular Surgery Division, Hospital das Clínicas, Faculdade de Medicina, Universidade de São Paulo (HCFMUSP), São Paulo, SP, Brazil
| | - Daniela Calderaro
- Unidade de Medicina Interdisciplinar em Cardiologia, Instituto do Coração, Hospital das Clínicas, Faculdade de Medicina, Universidade de São Paulo (HCFMUSP), São Paulo, SP, Brazil
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45
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Dudanov IP, Ordinec SV, Zelenin VV, Kudrijavcev OI, Vryganov FA. [Carotid endarterectomy with stent removal in a patient with early bilateral restenosis of the internal carotid arteries in the acute period of recurrent ischemic stroke]. Zh Nevrol Psikhiatr Im S S Korsakova 2021; 121:88-92. [PMID: 34932292 DOI: 10.17116/jnevro202112111188] [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: 11/18/2022]
Abstract
We present a rare clinical observation of a patient with an early reoperation performed up to 2 weeks after a recurrent stroke. Carotid endarterectomy with removal of previously installed stents for critical stenoses of the internal carotid arteries after the first stroke was performed. Early bilateral restenosis up to 80-90% of the lumen in the stents of both internal carotid arteries was observed 6 months after stenting. Open interventions were performed in the acute period of recurrent ischemic stroke in two stages with a favorable outcome. No data on the increase of neurological symptoms were obtained for 2 years of observation. Treatment and application of early rehabilitation methods, improved the patient's general condition, strength in the left extremities increased up to 4.5 points, left-sided hemihypesthesia decreased, speech disorders regressed. The patient walks and serves himself independently.
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Affiliation(s)
- I P Dudanov
- Petrozavodsk State University, Petrozavodsk, Russia.,Mariinsky Hospital, Regional Cardiovascular Center, St. Petersburg, Russia
| | - S V Ordinec
- Mariinsky Hospital, Regional Cardiovascular Center, St. Petersburg, Russia
| | - V V Zelenin
- Mariinsky Hospital, Regional Cardiovascular Center, St. Petersburg, Russia
| | - O I Kudrijavcev
- Mariinsky Hospital, Regional Cardiovascular Center, St. Petersburg, Russia
| | - F A Vryganov
- Petrozavodsk State University, Petrozavodsk, Russia
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46
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Moacdieh MP, Khan MA, Layman P, Elsayed N, Malas MB. Innovation in the open and endovascular treatment of carotid artery stenosis. Semin Vasc Surg 2021; 34:163-171. [PMID: 34911622 DOI: 10.1053/j.semvascsurg.2021.10.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2021] [Revised: 10/17/2021] [Accepted: 10/18/2021] [Indexed: 11/11/2022]
Affiliation(s)
- Munir P Moacdieh
- Division of Vascular and Endovascular Surgery, University of California San Diego, La Jolla, CA 92093
| | - Maryam A Khan
- Division of Vascular and Endovascular Surgery, University of California San Diego, La Jolla, CA 92093
| | - Peter Layman
- Division of Vascular and Endovascular Surgery, University of California San Diego, La Jolla, CA 92093
| | - Nadin Elsayed
- Division of Vascular and Endovascular Surgery, University of California San Diego, La Jolla, CA 92093
| | - Mahmoud B Malas
- Division of Vascular and Endovascular Surgery, University of California San Diego, La Jolla, CA 92093.
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47
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Nguyen J, Li A, Tam DY, Forbes TL. ANALYSIS OF SPIN IN VASCULAR SURGERY RANDOMIZED CONTROLLED TRIALS WITH NONSIGNIFICANT OUTCOMES. J Vasc Surg 2021; 75:1074-1080.e17. [PMID: 34923067 DOI: 10.1016/j.jvs.2021.09.051] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2021] [Accepted: 09/25/2021] [Indexed: 12/17/2022]
Abstract
OBJECTIVES Spin is the manipulation of language that distorts the interpretation of objective findings. The purpose of this study is to describe the characteristics of spin found in statistically nonsignificant randomized controlled trials (RCT) comparing carotid endarterectomy (CEA) to carotid artery stenting (CAS) for carotid stenosis (CS), and endovascular repair (EVAR) to open repair (OR) for abdominal aortic aneurysms (AAA). METHODS A search of MEDLINE, EMBASE, and the Cochrane Controlled Register of Trials was performed in June 2020 for studies published describing AAA or CS. All phase three RCTs with nonsignificant primary outcomes comparing OR to EVAR or CEA to CAS were included. Studies were appraised for the characteristics and severity of spin using a validated tool. Binary logistic regression was performed to assess the association of spin grade to (1) funding source (commercial vs non-commercial) and (2) the publishing journal's impact factor. RESULTS Thirty-one of 355 articles captured were included for analysis. Spin was identified in nine abstracts (9/18) and 13 main texts (13/18) of AAA articles and seven abstracts (7/13) and ten main texts (10/13) of CS articles. For both AAA and CS articles, spin was most commonly found in the manuscript discussion section, with the most commonly employed strategy being the interpretation of statistically nonsignificant primary results to show treatment equivalence or rule out adverse treatment effects. Increasing journal impact factor was associated with a statistically significant lower likelihood of spin in the study title or abstract conclusion (βOR = 0.96, 95% CI: 0.94 - 0.98, p < 0.01) while no significant association could be found with funding source (βOR = 1.33, 95% CI: 0.30-5.92, p = 0.71). CONCLUSIONS A large proportion of statistically nonsignificant RCTs contain interpretations that are inconsistent with their results. These findings should prompt authors and readers to appraise study findings independently and to limit the use of spin in study interpretations.
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Affiliation(s)
| | - Allen Li
- University of Ottawa, Faculty of Medicine
| | - Derrick Y Tam
- Division of Cardiac Surgery, University of Toronto; Department of Surgery, University of Toronto, Toronto, ON, Canada
| | - Thomas L Forbes
- Division of Vascular Surgery, Peter Munk Cardiac Centre, University Health Network; Department of Surgery, University of Toronto, Toronto, ON, Canada.
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48
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Demir M, Özbek M. Impact of nutritional assessment on long-term outcomes in patients with carotid artery stenting. Int J Clin Pract 2021; 75:e14637. [PMID: 34310821 DOI: 10.1111/ijcp.14637] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/02/2021] [Accepted: 07/21/2021] [Indexed: 12/15/2022] Open
Abstract
BACKGROUND AND AIMS Malnutrition is associated with poor clinical outcomes in many diseases. The Controlling Nutritional Status (CONUT) is an objective index used for evaluating nutritional status of hospitalised patients. The aim of this study was to investigate the relationship between malnutrition assessed by CONUT score and the prognosis in patients undergoing carotid artery stenting (CAS). METHODS AND RESULTS The study included 170 patients who underwent CAS because of symptomatic or asymptomatic severe carotid artery stenosis. Median follow-up period was 50 (interquartile range [IQR], 41-60) months. Patients were divided into two groups according to the CONUT score as normal CONUT (score <2) and mild-severe CONUT (score ≥2). Primary endpoint was accepted as MACE (major adverse cardiac events) including all-cause death and ischaemic stroke. The prevalence of MACE was significantly higher in the mild-severe CONUT score group (P = .001). Kaplan Meier analysis showed lower survival rates in the mild-severe CONUT score group (log rank = 9.36, P = .002; Figure 5). The Cox regression analysis showed that, the CONUT score was associated with increased risk of MACE for both unadjusted model and age- and gender- adjusted model, while in a full adjusted model the best predictor was age. CONCLUSION Higher CONUT scores were associated with adverse outcomes in patients with CAS. Malnutrition assessed by the CONUT score is preferable with regards to the detection of MACE in patients with CAS. Larger studies are warranted to investigate if our preliminary findings translate into clinical outcomes in patients with CAS.
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Affiliation(s)
- Muhammed Demir
- Department of Cardiology, Dicle University School of Medicine, Diyarbakir, Turkey
| | - Mehmet Özbek
- Department of Cardiology, Dicle University School of Medicine, Diyarbakir, Turkey
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49
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Nakagawa I, Kotsugi M, Park H, Furuta T, Sato F, Myochin K, Nishimura F, Yamada S, Motoyama Y, Nakase H. Near-infrared spectroscopy carotid plaque characteristics and cerebral embolism in carotid artery stenting. EUROINTERVENTION 2021; 17:599-606. [PMID: 33283761 PMCID: PMC9725057 DOI: 10.4244/eij-d-20-01050] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
BACKGROUND Perioperative thromboembolism is the main consideration in carotid artery stenting (CAS). Precise evaluation of carotid plaque components is clinically important to reduce ischaemic complications since CAS mechanically pushes plaque outwards, which releases plaque debris into the bloodstream. AIMS This study aimed to determine whether high lipid core plaque (LCP) assessed by catheter-based near-infrared spectroscopy (NIRS) is associated with ipsilateral cerebral embolism by diffusion-weighted magnetic resonance imaging during CAS using a first-generation stent. METHODS Carotid stenosis magnetic resonance (MR) T1-weighted plaque signal intensity ratio (T1W-SIR) followed by NIRS assessment at the time of CAS (using the carotid artery Wallstent) was performed in 117 consecutive patients. RESULTS The maximum lipid core burden index (max-LCBI) at minimal luminal areas (MLA; max-LCBIMLA) and the max-LCBI for any 4 mm segment in a target lesion defined as max-LCBIarea were significantly higher for the post-procedural new ipsilateral diffusion-weighted magnetic resonance imaging (DWI)-positive than negative patients (p<0.001 for all). There was a significant linear correlation between max-LCBIarea and the number of new emboli (r=0.544, p<0.0001). We also found that the second quantile (Q2) of T1W-SIRMLA had a significantly higher max-LCBIMLA and a higher incidence of DWI positivity than Q1 and Q3 (p<0.001 for all). Furthermore, max-LCBIMLA appeared to distinguish between patients with and without postoperative new ipsilateral DWI positivity (AUC 0.91, 95% CI: 0.86-0.96; p<0.0001). CONCLUSIONS High LCP assessed by NIRS is associated with cerebral embolism by diffusion-weighted imaging in CAS using a first-generation stent.
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Affiliation(s)
- Ichiro Nakagawa
- Department of Neurosurgery, Nara Medical University, 840 Shijo-cho, Kashihara, Nara, 634-8522, Japan
| | - Masashi Kotsugi
- Department of Neurosurgery, Nara Medical University, Nara, Japan
| | - Hun Park
- Department of Neurosurgery, Nara Medical University, Nara, Japan
| | - Takanori Furuta
- Department of Neurosurgery, Nara Medical University, Nara, Japan
| | - Fumiya Sato
- Department of Neurosurgery, Nara Medical University, Nara, Japan
| | - Kaoru Myochin
- Department of Radiology, Nara Medical University, Nara, Japan
| | | | - Syuichi Yamada
- Department of Neurosurgery, Nara Medical University, Nara, Japan
| | - Yasushi Motoyama
- Department of Neurosurgery, Nara Medical University, Nara, Japan
| | - Hiroyuki Nakase
- Department of Neurosurgery, Nara Medical University, Nara, Japan
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50
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Malas MB, Elsayed N, Naazie I, Dakour-Aridi H, Yei KS, Schermerhorn ML. Propensity score-matched analysis of 1-year outcomes of transcarotid revascularization with dynamic flow reversal, carotid endarterectomy, and transfemoral carotid artery stenting. J Vasc Surg 2021; 75:213-222.e1. [PMID: 34500027 DOI: 10.1016/j.jvs.2021.07.242] [Citation(s) in RCA: 34] [Impact Index Per Article: 11.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2021] [Accepted: 07/30/2021] [Indexed: 11/16/2022]
Abstract
OBJECTIVE Initial studies showed no significant differences in perioperative stroke or death between transcarotid artery revascularization (TCAR) and carotid endarterectomy (CEA) and lower stroke/death rates after TCAR compared with transfemoral carotid artery stenting (TFCAS). This study focuses on the 1-year outcomes of ipsilateral stroke or death after TCAR, CEA, and TFCAS. METHODS All patients undergoing TCAR, TFCAS, and CEA between September 2016 and December 2019 were identified in the Vascular Quality Initiative (VQI) database. The latest follow-up was September 3, 2020. One-to-one propensity score-matched analysis was performed for patients with available 1-year follow-up data for TCAR vs CEA and for TCAR vs TFCAS. Kaplan-Meier survival and Cox proportional hazard regression analyses were used to evaluate 1-year ipsilateral stroke or death after the three procedures. RESULTS A total of 41,548 patients underwent CEA, 5725 patients underwent TCAR, and 6064 patients underwent TFCAS during the study period and had recorded 1-year outcomes. The cohorts were well-matched in terms of baseline demographics and comorbidities. Among 4180 TCAR vs CEA matched pairs of patients, there were no significant differences in 30-day stroke, death, and stroke/death. However, TCAR was associated with a lower risk of 30-day stroke/death/myocardial infarction (2.30% vs 3.25%; relative risk, 0.71; 95% confidence interval [CI], 0.55-0.91; P = .008), driven by a lower risk of myocardial infarction (0.55% vs 1.12%; hazard ratio [HR], 0.49; 95% CI, 0.30-0.81; P = .004). At 1 year, no significant difference was observed in the risk of ipsilateral stroke or death (6.49% vs 5.68%; HR, 1.14; 95% CI, 0.95-1.37; P = .157). Among 4036 matched pairs in the TCAR vs TFCAS group, TCAR was also associated with lower risk of perioperative stroke or death compared with TFCAS (1.83% vs 2.55%; HR, 0.72; 95% CI, 0.54-0.96; P = .027). At 1 year, the risks of ipsilateral stroke or death of TCAR and TFCAS were comparable (6.07% vs 7.07%; HR, 0.85; 95% CI, 0.71-1.01; P = .07). Symptomatic status did not modify the association in TCAR vs CEA. However, asymptomatic patients had favorable outcomes with TCAR vs TFCAS at 1 year (HR, 0.78; 95% CI, 0.62-0.98; P = .033). CONCLUSIONS In this propensity score-matched analysis, no significant differences in ipsilateral stroke/death-free survival were observed between TCAR and CEA or between TCAR and TFCAS. The advantages of TCAR compared with TFCAS seem to be mainly in the perioperative period, which makes it a suitable minimally invasive option for surgically high-risk patients with carotid artery stenosis. Larger studies, with longer follow-up and data on restenosis, are warranted to confirm the mid- and long-term benefits and durability of TCAR.
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Affiliation(s)
- Mahmoud B Malas
- Division of Vascular and Endovascular Surgery, Department of Surgery, University of California San Diego, La Jolla, Calif.
| | - Nadin Elsayed
- Division of Vascular and Endovascular Surgery, Department of Surgery, University of California San Diego, La Jolla, Calif
| | - Isaac Naazie
- Division of Vascular and Endovascular Surgery, Department of Surgery, University of California San Diego, La Jolla, Calif
| | - Hanaa Dakour-Aridi
- Division of Vascular and Endovascular Surgery, Department of Surgery, University of California San Diego, La Jolla, Calif
| | - Kevin S Yei
- Division of Vascular and Endovascular Surgery, Department of Surgery, University of California San Diego, La Jolla, Calif
| | - Marc L Schermerhorn
- Division of Vascular and Endovascular Surgery, Department of Surgery, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, Mass
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