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Korshunov DA, Kulbak VA, Chupin AV. [Advisability of carotid endarterectomy in asymptomatic patients]. Khirurgiia (Mosk) 2024:45-53. [PMID: 38477243 DOI: 10.17116/hirurgia202403145] [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: 03/14/2024]
Abstract
OBJECTIVE To determine the optimal treatment strategy for patients with asymptomatic carotid stenosis. MATERIAL AND METHODS The authors reviewed clinical guidelines for the management of patients with asymptomatic carotid stenosis 60-99%, as well as medical studies and meta-analyses comparing carotid endarterectomy and optimal drug therapy in asymptomatic patients between 1993 and 2023. RESULTS The choice of treatment strategy for patients with asymptomatic carotid artery stenosis is still a controversial issue. There were several large randomized clinical trials comparing carotid endarterectomy with optimal medical therapy in asymptomatic patients at the end of the 20th century. However, drug therapy has undergone significant changes calling into question the relevance of previous results. This review highlights the evolution of management of patients with asymptomatic carotid stenosis and also presents modern approaches to the treatment of these patients. CONCLUSION Patients younger 75 years old gain an advantage from carotid endarterectomy with small perioperative risk compared to optimal drug therapy and yearly risk of cerebral embolism. Patients with asymptomatic carotid stenosis 80-99% are candidates for carotid endarterectomy due to higher risk of acute cerebrovascular accident at least until more data are available. The choice of the best tactics for a particular patient should be made individually depending on own experience and patient's adherence to therapy and lifestyle correction. The results of the ACTRIS (2025) and CREST-2 (2026) studies are expected to clarify this issue.
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Affiliation(s)
- D A Korshunov
- Vishnevsky National Medical Research Center for Surgery, Moscow, Russia
| | - V A Kulbak
- Lomonosov Moscow State University, Moscow, Russia
| | - A V Chupin
- Russian Medical Academy of Continuing Professional Education, Moscow, Russia
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Saati AA, Nielsen C, Bishop GJ. Vascular Imaging for the Primary Care Provider: Venous and Arterial Disease. Med Clin North Am 2023; 107:925-943. [PMID: 37541717 DOI: 10.1016/j.mcna.2023.05.004] [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: 08/06/2023]
Abstract
The vascular laboratory provides important contributions to the diagnosis, workup, and treatment of known or suspected vascular disease. Knowing what tests to order (and when to order them) allows for the best utilization of these resources. This article will focus on the appropriate use of the vascular lab for the primary care clinician regarding a variety of vascular presentations, including swollen leg, suspected peripheral artery disease, vasospastic disease, carotid artery stenosis, and abdominal aortic aneurysms. Patients with known vascular disease often require serial surveillance imaging to document the stability or progression of disease, and consensus guidelines regarding these strategies will be reviewed.
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Affiliation(s)
- Ammar A Saati
- Section of Vascular Medicine, Cleveland Clinic, 9500 Euclid Avenue, J 3-5, Cleveland, OH 44195, USA
| | - Craig Nielsen
- Internal Medicine and Geriatrics, Department of Internal Medicine, Cleveland Clinic, 9500 Euclid Avenue, G10, Cleveland, OH 44195, USA
| | - Gerald Jay Bishop
- Section of Vascular Medicine, Cleveland Clinic, J 3-5, Cleveland, OH, USA.
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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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Shin JJ, Hachinski V, Azarpazhooh MR, Shariatzadeh A, Spence JD. Measurement of carotid plaque burden: A tool for predicting and preventing dementia? CEREBRAL CIRCULATION - COGNITION AND BEHAVIOR 2021; 2:100004. [PMID: 36324719 PMCID: PMC9616284 DOI: 10.1016/j.cccb.2021.100004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/19/2020] [Revised: 01/25/2021] [Accepted: 01/26/2021] [Indexed: 11/29/2022]
Abstract
Strokes markedly increase the risk of dementia from Alzheimer disease, and preventing strokes reduces the risk of dementia. Delaying dementia by 5 years nearly halves the incidence of dementia, because old patients often die before dementia is expressed. Carotid plaque burden is a strong predictor of the risk of stroke, and measurement of plaque burden has also been used to treat atherosclerosis. In high-risk patients with asymptomatic carotid stenosis, doing so was associated with a >80% reduction of the 2-year risk of stroke and myocardial infarction compared to usual therapy. We found that high plaque burden was significantly associated with impairment of cognitive function. We suggest that measurement of carotid plaque burden may be a powerful tool not only for predicting risk of dementia, but also for preventing dementia.
Introduction Carotid plaque burden is a strong predictor of stroke risk, and preventing stroke reduces the risk of dementia. Treating carotid plaque burden markedly reduces the risk of stroke. Methods Among patients age 65–80 years attending a stroke prevention clinic, we identified those with a carotid plaque burden in the top 20% of Total Plaque Area (High TPA) and the bottom 20% (Low TPA) and performed cognitive tests: The Montreal Cognitive Assessment test (MoCA), the WAIS-III Digit Symbol-Coding Test (DSST) and Trail-Making Test (TMT) part A and B. Results There were 31 patients recruited; 11 Low TPA (5 men) and 20 High TPA (17 men), p = 0.04. TPA was 35 ± 25 mm2 in the Low TPA vs.392 ± 169 mm2 in the High TPA group (0.0001). Patients with a high plaque burden had significantly worse performance on all the cognitive tests, all p< 0.05 Discussion A high carotid plaque burden identifies patients at risk of cognitive impairment. Because carotid plaque burden is treatable, and treating it markedly reduces the risk of stroke, we suggest that measurement of plaque burden is a useful tool for both prediction of cognitive impairment, and prevention of dementia.
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Affiliation(s)
- John J. Shin
- Medical Student, Faculty of Medicine, University of Ottawa, Canada
| | - Vladimir Hachinski
- Department of Clinical Neurological Sciences, Western University, London, ON, Canada
| | - M. Reza Azarpazhooh
- Department of Clinical Neurological Sciences, Western University, London, ON, Canada
- Stroke Prevention & Atherosclerosis Research Centre, Robarts Research Institute, Western University, 1400 Western Road, London, ON, Canada
| | - Aidin Shariatzadeh
- Stroke Prevention & Atherosclerosis Research Centre, Robarts Research Institute, Western University, 1400 Western Road, London, ON, Canada
| | - J. David Spence
- Department of Clinical Neurological Sciences, Western University, London, ON, Canada
- Stroke Prevention & Atherosclerosis Research Centre, Robarts Research Institute, Western University, 1400 Western Road, London, ON, Canada
- Corresponding author at: Stroke Prevention & Atherosclerosis Research Centre, Robarts Research Institute, Western University, 1400 Western Road, London, ON, Canada.
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Kharroubi A, Petit-Colau MD, Jouhannet C, Mameli A, Karsenti A, Gigou F, Tremblay B. Endarterectomy with "systematized" resection anastomosis of carotid bulb, about 240 cases. JOURNAL DE MÉDECINE VASCULAIRE 2020; 45:260-267. [PMID: 32862983 DOI: 10.1016/j.jdmv.2020.07.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/15/2019] [Accepted: 07/18/2020] [Indexed: 11/25/2022]
Abstract
OBJECTIVE Carotid endarterectomy has traditionally been the strategy for the surgical management of carotid stenosis. Alongside the usual techniques, this study presents another technique: endarterectomy with systematized resection-anastomosis. MATERIAL AND METHODS A retrospective study from January 2006 to December 2018, included all patients managed for carotid stenosis at Meaux hospital with the "endarterectomy with systematized resection-anastomosis" technique. The perioperative death and stroke rate were evaluated according to the judgment criterion "homolateral ischemic stroke and any stroke or perioperative death". Statistical analysis of the data was performed using SPSS software. RESULTS For 415 carotids operated, we identified 240 managed with this technique. The average age was 71.7±9.6 years, 70% men and 30% women. The main cardiovascular risk factor was hypertension (76.7%), 24.2% of patients had an ischemic heart disease history, 43.7% homolateral ischemic stroke and 29% transient ischemic attack. Bilateral lesions were diagnosed in 6.2% of patients and 7.5% had contralateral occlusion. Carotid stenosis was symptomatic in 52.9% of patients. The average stenosis rate observed was 82.9±8.1% on computed tomography angiogram and 83.7±7.7% on magnetic resonance angiogram. The shunt was used in 45.4% of procedures. The average length of stay was 5.9±2.3 days. All patients had satisfactory results in terms of patency and anatomical appearance on the 1st check. In the post-operative period during the first month, complications occurred in 12.5% of patients (1.6% acute coronary syndrome, 0.8% neurological event, 0.8% death, 0.4% infection, 12.1% hematoma, 1.6% recovery for bleeding). The overall perioperative death and stroke rate was 2.6%. Myocardial infarction and sepsis were the causes of death for the 2 patients in the peri operative period. The mean duration of follow-up was 21.2 months, without any restenosis or occurrence of neurological complications. One patient died beyond the 1st month of follow-up without established cause, and the overall mortality rate was 1.3%. CONCLUSION Thromboendarterectomy with "systematized" anastomosis resection represents an angioplasty method for carotid stenosis surgical management under visual control.
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Affiliation(s)
- A Kharroubi
- Department of vascular and thoracic surgery, GHEF (Grand Hôpital de l'Est Francilien), Meaux site, 6-8 St fiacre street, BP 218, 77104 Meaux Cedex, France; Ibn Zohr University, Faculty of Medicine and Pharmacy, department of Vascular surgery, quartier Tilila, 80000 Agadir, Morocco.
| | - M D Petit-Colau
- Department of vascular and thoracic surgery, GHEF (Grand Hôpital de l'Est Francilien), Meaux site, 6-8 St fiacre street, BP 218, 77104 Meaux Cedex, France
| | - C Jouhannet
- Department of vascular and thoracic surgery, GHEF (Grand Hôpital de l'Est Francilien), Meaux site, 6-8 St fiacre street, BP 218, 77104 Meaux Cedex, France
| | - A Mameli
- Department of vascular and thoracic surgery, GHEF (Grand Hôpital de l'Est Francilien), Meaux site, 6-8 St fiacre street, BP 218, 77104 Meaux Cedex, France
| | - A Karsenti
- Department of vascular and thoracic surgery, GHEF (Grand Hôpital de l'Est Francilien), Meaux site, 6-8 St fiacre street, BP 218, 77104 Meaux Cedex, France
| | - F Gigou
- Department of vascular and thoracic surgery, GHEF (Grand Hôpital de l'Est Francilien), Meaux site, 6-8 St fiacre street, BP 218, 77104 Meaux Cedex, France
| | - B Tremblay
- Department of vascular and thoracic surgery, GHEF (Grand Hôpital de l'Est Francilien), Meaux site, 6-8 St fiacre street, BP 218, 77104 Meaux Cedex, France
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Abstract
Interventional neuroradiology (INR) has evolved from a hybrid mixture of daring radiologists and iconoclastic neurosurgeons into a multidisciplinary specialty, which has become indispensable for cerebrovascular and neurological centers worldwide. This manuscript traces the origins of INR and describes its evolution to the present day. The focus will be on cerebrovascular disorders including aneurysms, stroke, brain arteriovenous malformations, dural arteriovenous fistulae, and atherosclerotic disease, both intra- and extracranial. Also discussed are cerebral vasospasm, venolymphatic malformations of the head and neck, tumor embolization, idiopathic intracranial hypertension, inferior petrosal venous sinus sampling for Cushing's disease, and spinal interventions. Pediatric INR has not been included and deserves a separate, dedicated review.
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