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Abstract
Carotid artery stenting (CAS) has been recommended as an alternative treatment to carotid endarterectomy for patients with significant carotid stenosis. Only a few studies have analyzed clinical/anatomical and technical variables that affect perioperative outcomes of CAS. Following a comprehensive Medline search, it was reported that clinical factors, including age of >80 years, chronic renal failure, diabetes mellitus, symptomatic indications, and procedures performed within 2 weeks of transient ischemic attack symptoms, are associated with high perioperative stroke and death rates. They also highlighted that angiographic variables, e.g., ulcerated and calcified plaques, left carotid intervention, >90% stenosis, >10-mm target lesion length, ostial involvement, type III aortic arch, and >60°-angulated internal carotid and common carotid arteries, are predictors of increased stroke rates. Technical factors associated with increased perioperative risk of stroke include percutaneous transluminal angioplasty (PTA) without embolic protection devices, PTA before stent placement, and the use of multiple stents. This review describes the most widely quoted data in defining various predictors of perioperative stroke and death after CAS. (This is a review article based on the invited lecture of the 45th Annual Meeting of Japanese Society for Vascular Surgery.)
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Affiliation(s)
- Ali F AbuRahma
- Department of Surgery, West Virginia University, Charleston, West Virginia, USA
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Shams T, Zaidat O, Yavagal D, Xavier A, Jovin T, Janardhan V. Society of Vascular and Interventional Neurology (SVIN) Stroke Interventional Laboratory Consensus (SILC) Criteria: A 7M Management Approach to Developing a Stroke Interventional Laboratory in the Era of Stroke Thrombectomy for Large Vessel Occlusions. INTERVENTIONAL NEUROLOGY 2016; 5:1-28. [PMID: 27610118 PMCID: PMC4934489 DOI: 10.1159/000443617] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
Brain attack care is rapidly evolving with cutting-edge stroke interventions similar to the growth of heart attack care with cardiac interventions in the last two decades. As the field of stroke intervention is growing exponentially globally, there is clearly an unmet need to standardize stroke interventional laboratories for safe, effective, and timely stroke care. Towards this goal, the Society of Vascular and Interventional Neurology (SVIN) Writing Committee has developed the Stroke Interventional Laboratory Consensus (SILC) criteria using a 7M management approach for the development and standardization of each stroke interventional laboratory within stroke centers. The SILC criteria include: (1) manpower: personnel including roles of medical and administrative directors, attending physicians, fellows, physician extenders, and all the key stakeholders in the stroke chain of survival; (2) machines: resources needed in terms of physical facilities, and angiography equipment; (3) materials: medical device inventory, medications, and angiography supplies; (4) methods: standardized protocols for stroke workflow optimization; (5) metrics (volume): existing credentialing criteria for facilities and stroke interventionalists; (6) metrics (quality): benchmarks for quality assurance; (7) metrics (safety): radiation and procedural safety practices.
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Affiliation(s)
- Tanzila Shams
- Texas Stroke Institute, HCA North Texas Division, Dallas-Fort Worth, Tex., USA
| | - Osama Zaidat
- Mercy Neuroscience and Stroke Center, Toledo, Ohio, USA
| | - Dileep Yavagal
- Jackson Memorial Hospital, University of Miami Health System, Miami, Fla., USA
| | - Andrew Xavier
- Detroit Medical Center, Wayne State University, Detroit, Mich., USA
| | - Tudor Jovin
- UPMC Stroke Institute, University of Pittsburgh Medical Center, Pittsburg, Pa., USA
| | - Vallabh Janardhan
- Texas Stroke Institute, HCA North Texas Division, Dallas-Fort Worth, Tex., USA
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Fennell VS, Martirosyan NL, Palejwala SK, Lemole GM, Dumont TM. Morbidity and mortality of patients with endovascularly treated intracerebral aneurysms: does physician specialty matter? J Neurosurg 2015; 124:13-7. [PMID: 26274987 DOI: 10.3171/2014.11.jns141030] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECT Endovascular treatment of cerebrovascular pathology, particularly aneurysms, is becoming more prevalent. There is a wide variety in clinical background and training of physicians who treat cerebrovascular pathology through endovascular means. The impact of clinical training background on patient outcomes is not well documented. METHODS The authors conducted a retrospective analysis of a large national database, the University HealthSystem Consortium, that was queried in the years 2009-2013. Cases of both unruptured cerebral aneurysms and subarachnoid hemorrhage treated by endovascular obliteration were studied. Outcome measures of morbidity and mortality were evaluated according to the specialty of the treating physician. RESULTS Elective embolization of an unruptured aneurysm was the procedure code and primary diagnosis, respectively, for 12,400 cases. Patients with at least 1 complication were reported in 799 cases (6.4%). Deaths were reported in 193 cases (1.6%). Complications and deaths were varied by specialty; the highest incidence of complications (11.1%) and deaths (3.0%) were reported by neurologists. The fewest complications were reported by neurosurgeons (5.4%; 1.4% deaths), with a higher incidence of complications reported in cases performed by neurologists (p < 0.0001 for both complications and deaths) and to a lesser degree interventional radiologists (p = 0.0093 for complications). Subarachnoid hemorrhage was the primary diagnosis and procedure for 8197 cases. At least 1 complication was reported in 2385 cases (29%) and deaths in 983 cases (12%). The number of complications and deaths varied among specialties. The highest incidence of complications (34%) and deaths (13.5%) in subarachnoid hemorrhage was in cases performed by neurologists. The fewest complications were in cases by neurosurgeons (27%), with a higher incidence of complications in cases performed by neurologists (34%, p < 0.0001), and a trend of increased complications with interventional radiologists (30%, p < 0.0676). The lowest incidence of mortality was in cases performed by neurosurgeons (11.5%), with a significantly higher incidence of mortality in cases performed by neurologists (13.5%, p = 0.0372). Mortality rates did not reach statistical significance with respect to interventional radiologists (12.1%, p = 0.4884). CONCLUSIONS Physicians of varied training types and backgrounds use endovascular treatment of ruptured and unruptured intracerebral aneurysms. In this study there was a statistically significant finding that neurosurgically trained physicians may demonstrate improved outcomes with respect to endovascular treatment of unruptured aneurysms in this cohort. This finding warrants further investigation.
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Affiliation(s)
- Vernard S Fennell
- Division of Neurosurgery, Department of Surgery, University of Arizona Medical Center, University of Arizona College of Medicine, Tucson, Arizona
| | - Nikolay L Martirosyan
- Division of Neurosurgery, Department of Surgery, University of Arizona Medical Center, University of Arizona College of Medicine, Tucson, Arizona
| | - Sheri K Palejwala
- Division of Neurosurgery, Department of Surgery, University of Arizona Medical Center, University of Arizona College of Medicine, Tucson, Arizona
| | - G Michael Lemole
- Division of Neurosurgery, Department of Surgery, University of Arizona Medical Center, University of Arizona College of Medicine, Tucson, Arizona
| | - Travis M Dumont
- Division of Neurosurgery, Department of Surgery, University of Arizona Medical Center, University of Arizona College of Medicine, Tucson, Arizona
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Qureshi AI. Interpretation and implications of the prematurely terminated Stenting and Aggressive Medical Management for Preventing Recurrent Stroke in the Intracranial Stenosis (SAMMPRIS) trial. Neurosurgery 2012; 70:E264-8. [PMID: 21964627 DOI: 10.1227/neu.0b013e318239f318] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
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Qureshi AI, Al-Senani FM, Husain S, Janjua NA, Lanzino G, Lavados PM, Nguyen T, Raymond J, Shah QA, Suarez JI, Suri MFK, Tolun R. Intracranial Angioplasty and Stent Placement After Stenting and Aggressive Medical Management for Preventing Recurrent Stroke in Intracranial Stenosis (SAMMPRIS) Trial: Present State and Future Considerations⋆. J Neuroimaging 2012; 22:1-13. [DOI: 10.1111/j.1552-6569.2011.00685.x] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
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Leifer D, Bravata DM, Connors J(B, Hinchey JA, Jauch EC, Johnston SC, Latchaw R, Likosky W, Ogilvy C, Qureshi AI, Summers D, Sung GY, Williams LS, Zorowitz R. Metrics for Measuring Quality of Care in Comprehensive Stroke Centers: Detailed Follow-Up to Brain Attack Coalition Comprehensive Stroke Center Recommendations. Stroke 2011; 42:849-77. [DOI: 10.1161/str.0b013e318208eb99] [Citation(s) in RCA: 129] [Impact Index Per Article: 9.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
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Khatri R, Memon MZ, Zacharatos H, Taqui AM, Qureshi MH, Vazquez G, Suri MFK, Rodriguez GJ, Tummala RP, Ezzeddine MA, Qureshi AI. Impact of Percutaneous Transluminal Angioplasty for Treatment of Cerebral Vasospasm on Subarachnoid Hemorrhage Patient Outcomes. Neurocrit Care 2011; 15:28-33. [DOI: 10.1007/s12028-010-9499-y] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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Qureshi AI, Tariq N, Hassan AE, Vazquez G, Hussein HM, Suri MFK, Georgiadis AL, Tummala RP, Taylor RA. Predictors and Timing of Neurological Complications Following Intracranial Angioplasty and/or Stent Placement. Neurosurgery 2011; 68:53-60; discussion 60-1. [DOI: 10.1227/neu.0b013e3181fc5f0a] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
Abstract
BACKGROUND:
Transient or permanent neurological complications can occur in the periprocedural period following intracranial angioplasty and/or stent placement. Which patients are at risk and the time period for maximum vulnerability among those who undergo intracranial angioplasty and/or stent placement have not been formally studied.
OBJECTIVE:
To assess the predictors and timing of neurological complications following intracranial angioplasty and/or stent placement in the periprocedural period in a consecutive series of patients.
METHODS:
We reviewed medical records and angiograms of consecutive patients treated with intracranial angioplasty and/or stent placement in 3 academic institutions. We evaluated the effect of demographic, clinical, intraprocedural, and angiographic risk factors on subsequent development of periprocedural neurological complications. Periprocedural neurological complications were defined as new or worsening transient or permanent neurological complications that occurred during or within 1 month of the procedure. We also recorded the timing and nature of neurological complications in the periprocedural period.
RESULTS:
A total of 92 patients were included in the study (mean age ± standard deviation: 59 ± 14 years; 59 were men). The overall rate of in-hospital neurological complications was 9.8% (9 of 92 patients). Eight out of 9 neurological complications occurred either during the procedure or within 6 hours thereafter. Presence of diabetes mellitus (P = .003) and use of balloon-expandable stent (P = .09) were associated with periprocedural neurological complications. The degree of pre- and post-procedure stenosis, morphological appearance, and length of lesion were unrelated to periprocedural complications.
CONCLUSION:
Patients with diabetes mellitus and those treated with balloon expandable stents are at high risk for periprocedural neurological complications. The first 6 hours following intracranial angioplasty and stent placement represent the period of highest risk.
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Affiliation(s)
- Adnan I. Qureshi
- Zeenat Qureshi Stroke Research Center, Departments of Neurology and Neurosurgery, University of Minnesota, Minneapolis, Minnesota
| | - Nauman. Tariq
- Zeenat Qureshi Stroke Research Center, Departments of Neurology and Neurosurgery, University of Minnesota, Minneapolis, Minnesota
| | - Ameer E. Hassan
- Zeenat Qureshi Stroke Research Center, Departments of Neurology and Neurosurgery, University of Minnesota, Minneapolis, Minnesota
| | - Gabriela. Vazquez
- Zeenat Qureshi Stroke Research Center, Departments of Neurology and Neurosurgery, University of Minnesota, Minneapolis, Minnesota
| | - Haitham M. Hussein
- Zeenat Qureshi Stroke Research Center, Departments of Neurology and Neurosurgery, University of Minnesota, Minneapolis, Minnesota
| | - M Fareed K. Suri
- Zeenat Qureshi Stroke Research Center, Departments of Neurology and Neurosurgery, University of Minnesota, Minneapolis, Minnesota
| | - Alexandros L. Georgiadis
- Zeenat Qureshi Stroke Research Center, Departments of Neurology and Neurosurgery, University of Minnesota, Minneapolis, Minnesota
| | - Ramachandra P. Tummala
- Zeenat Qureshi Stroke Research Center, Departments of Neurology and Neurosurgery, University of Minnesota, Minneapolis, Minnesota
| | - Robert A. Taylor
- Zeenat Qureshi Stroke Research Center, Departments of Neurology and Neurosurgery, University of Minnesota, Minneapolis, Minnesota
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Rasmussen PA. The evolution and role of endovascular therapy for the treatment of intracranial atherosclerotic disease. J Neuroimaging 2010; 19 Suppl 1:30S-4S. [PMID: 19807856 DOI: 10.1111/j.1552-6569.2009.00420.x] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
Abstract
Intracranial atherosclerotic disease (ICAD) is being seen as an increasingly important cause of transient ischemic attack and stroke. Attention on this disease entity has been focused as a result of two recent events: the publication of the WASID trial and the recent Food and Drug Administration approval of the Wingspan-Gateway stent system. This manuscript will review the evolution of the role of endovascular therapy in the management of ICAD. In addition, the available devices currently available for endovascular therapy will be reviewed with an eye toward peri-procedural and follow-up complication rates.
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Affiliation(s)
- Peter A Rasmussen
- Cerebrovascular Center, Neurological Institute, Cleveland Clinic, Cleveland, OH 44195, USA.
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