1
|
Kuehnl A, Kallmayer M, Bohmann B, Lohe V, Moser R, Naher S, Kirchhoff F, Eckstein HH, Knappich C. Association between hospital ownership and patient selection, management, and outcomes after carotid endarterectomy or carotid artery stenting : - Secondary data analysis of the Bavarian statutory quality assurance database. BMC Surg 2024; 24:158. [PMID: 38760789 PMCID: PMC11100040 DOI: 10.1186/s12893-024-02448-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2024] [Accepted: 05/08/2024] [Indexed: 05/19/2024] Open
Abstract
BACKGROUND This study analyses the association between hospital ownership and patient selection, treatment, and outcome of carotid endarterectomy (CEA) or carotid artery stenting (CAS). METHODS The analysis is based on the Bavarian subset of the nationwide German statutory quality assurance database. All patients receiving CEA or CAS for carotid artery stenosis between 2014 and 2018 were included. Hospitals were subdivided into four groups: university hospitals, public hospitals, hospitals owned by charitable organizations, and private hospitals. The primary outcome was any stroke or death until discharge from hospital. Research was funded by Germany's Federal Joint Committee Innovation Fund (01VSF19016 ISAR-IQ). RESULTS In total, 22,446 patients were included. The majority of patients were treated in public hospitals (62%), followed by private hospitals (17%), university hospitals (16%), and hospitals under charitable ownership (6%). Two thirds of patients were male (68%), and the median age was 72 years. CAS was most often applied in university hospitals (25%) and most rarely used in private hospitals (9%). Compared to university hospitals, patients in private hospitals were more likely asymptomatic (65% vs. 49%). In asymptomatic patients, the risk of stroke or death was 1.3% in university hospitals, 1.5% in public hospitals, 1.0% in hospitals of charitable owners, and 1.2% in private hospitals. In symptomatic patients, these figures were 3.0%, 2.5%, 3.4%, and 1.2% respectively. Univariate analysis revealed no statistically significant differences between hospital groups. In the multivariable analysis, compared to university hospitals, the odds ratio of stroke or death in asymptomatic patients treated by CEA was significantly lower in charitable hospitals (OR 0.19 [95%-CI 0.07-0.56, p = 0.002]) and private hospitals (OR 0.47 [95%-CI 0.23-0.98, p = 0.043]). In symptomatic patients (elective treatment, CEA), patients treated in private or public hospitals showed a significantly lower odds ratio compared to university hospitals (0.36 [95%-CI 0.17-0.72, p = 0.004] and 0.65 [95%-CI 0.42-1.00, p = 0.048], respectively). CONCLUSIONS Hospital ownership was related to patient selection and treatment, but not generally to outcomes. The lower risk of stroke or death in the subgroup of electively treated patients in private hospitals might be due to the right timing, the choice of treatment modality or actually to better structural and process quality.
Collapse
Affiliation(s)
- Andreas Kuehnl
- Department for Vascular and Endovascular Surgery, Klinikum rechts der Isar, Technical University of Munich, Ismaninger Str. 22, 81675, Munich, Germany.
| | - Michael Kallmayer
- Department for Vascular and Endovascular Surgery, Klinikum rechts der Isar, Technical University of Munich, Ismaninger Str. 22, 81675, Munich, Germany
| | - Bianca Bohmann
- Department for Vascular and Endovascular Surgery, Klinikum rechts der Isar, Technical University of Munich, Ismaninger Str. 22, 81675, Munich, Germany
| | - Vanessa Lohe
- Department for Vascular and Endovascular Surgery, Klinikum rechts der Isar, Technical University of Munich, Ismaninger Str. 22, 81675, Munich, Germany
| | - Rebecca Moser
- Landesarbeitsgemeinschaft zur datengestützten, einrichtungsübergreifenden Qualitätssicherung in Bayern, Munich, Germany
| | - Shamsun Naher
- Department for Vascular and Endovascular Surgery, Klinikum rechts der Isar, Technical University of Munich, Ismaninger Str. 22, 81675, Munich, Germany
| | - Felix Kirchhoff
- Department for Vascular and Endovascular Surgery, Klinikum rechts der Isar, Technical University of Munich, Ismaninger Str. 22, 81675, Munich, Germany
| | - Hans-Henning Eckstein
- Department for Vascular and Endovascular Surgery, Klinikum rechts der Isar, Technical University of Munich, Ismaninger Str. 22, 81675, Munich, Germany
| | - Christoph Knappich
- Department for Vascular and Endovascular Surgery, Klinikum rechts der Isar, Technical University of Munich, Ismaninger Str. 22, 81675, Munich, Germany
| |
Collapse
|
2
|
Erben Y, Li Y, Da Rocha-Franco JA, Tawk RG, Barrett KM, Freeman WD, Lin M, Huang JF, Miller D, Farres H, Brott TG, Meschia JF, Hakaim AG. Asymptomatic Females Are at Higher Risk for Perioperative TIA/Stroke and Males Are at Higher Risk for Long-Term Mortality after Carotid Artery Stenting: A Vascular Quality Initiative Analysis. Int J Angiol 2024; 33:36-45. [PMID: 38352638 PMCID: PMC10861297 DOI: 10.1055/s-0040-1712506] [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: 10/23/2022] Open
Abstract
The study aims to review the sex differences with respect to transient ischemic attack (TIA)/stroke and death in the perioperative period and on long-term follow-up among asymptomatic patients treated with carotid stenting (CAS) in the vascular quality initiative (VQI). All cases reported to VQI of asymptomatic CAS (ACAS) patients were reviewed. The primary end point was risk of TIA/stroke and death in the in-hospital perioperative period and in the long-term follow-up. The secondary end point was to evaluate predictors of in-hospital perioperative TIA/stroke and mortality on long-term follow-up after CAS. There were 22,079 CAS procedures captured from January 2005 to April 2019. There were 5,785 (62.7%) patients in the ACAS group. The rate of in-hospital TIA/stroke was higher in female patients (2.7 vs. 1.87%, p = 0.005) and the rate of death was not significant (0.03 vs. 0.07%, p = 0.66). On multivariable logistic regression analysis, prior/current smoking history (odds ratio = 0.58 [95% confidence interval or CI = 0.39-0.87]; p = 0.008) is a predictor of in-hospital TIA/stroke in females. The long-term all-cause mortality is significantly higher in male patients (26.9 vs. 15.7%, p < 0.001). On multivariable Cox-regression analysis, prior/current smoking history (hazard ratio or HR = 1.17 [95% CI = 1.01-1.34]; p = 0.03), coronary artery disease or CAD (HR = 1.15 [95% CI = 1.03-1.28]; p = 0.009), chronic obstructive pulmonary disease or COPD (HR = 1.73 [95% CI = 1.55-1.93]; p < 0.001), threat to life American Society of Anesthesiologists (ASA) class (HR = 2.3 [95% CI = 1.43-3.70]; p = 0.0006), moribund ASA class (HR = 5.66 [95% CI = 2.24-14.29]; p = 0.0003), and low hemoglobin levels (HR = 0.84 [95% CI = 0.82-0.86]; p < 0.001) are the predictors of long-term mortality. In asymptomatic carotid disease patients, women had higher rates of in-hospital perioperative TIA/stroke and a predictor of TIA/stroke is a prior/current history of smoking. Meanwhile, long-term all-cause mortality is higher for male patients compared with their female counterparts. Predictors of long-term mortality are prior/current smoking history, CAD, COPD, higher ASA classification of physical status, and low hemoglobin level. These data should be considered prior to offering CAS to asymptomatic female and male patients and careful risks versus benefits discussion should be offered to each individual patient.
Collapse
Affiliation(s)
- Young Erben
- Division of Vascular and Endovascular Surgery, Mayo Clinic, Jacksonville, Florida
| | - Yupeng Li
- Department of Political Science and Economics, Rowan University, Glassboro, New Jersey
| | | | - Rabih G. Tawk
- Department of Neurologic Surgery, Mayo Clinic, Jacksonville, Florida
| | | | - William D. Freeman
- Department of Neurologic Surgery, Mayo Clinic, Jacksonville, Florida
- Department of Neurology, Mayo Clinic, Jacksonville, Florida
| | - Michelle Lin
- Department of Neurology, Mayo Clinic, Jacksonville, Florida
| | | | - David Miller
- Department of Radiology, Mayo Clinic, Jacksonville, Florida
| | - Houssam Farres
- Division of Vascular and Endovascular Surgery, Mayo Clinic, Jacksonville, Florida
| | | | | | - Albert G. Hakaim
- Division of Vascular and Endovascular Surgery, Mayo Clinic, Jacksonville, Florida
| |
Collapse
|
3
|
Etkin Y, Iyeke L, Yu G, Ahmed I, Matera P, Aminov J, Kokkosis A, Hastings L, Garg K, Rockman C. Sex disparities in outcomes after carotid artery interventions: A systematic review. Semin Vasc Surg 2023; 36:476-486. [PMID: 38030321 DOI: 10.1053/j.semvascsurg.2023.09.004] [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: 07/28/2023] [Revised: 09/13/2023] [Accepted: 09/28/2023] [Indexed: 12/01/2023]
Abstract
This systematic review aimed to identify sex-specific outcomes in men and women after carotid endarterectomy (CEA) and carotid artery stenting (CAS), including transfemoral and transcarotid. A search of literature published from January 2000 through December 2022 was conducted using key terms attributed to carotid interventions on PubMed. Studies comparing outcome metrics post intervention (ie, myocardial infarction [MI], cerebral vascular accident [CVA] or stroke, and long-term mortality) among male and female patients were reviewed. Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines were followed. Overall, all studies reported low rates of perioperative complications. Among the studies that did not stratify outcomes by the preoperative symptom status, there were no significant sex differences in rates of perioperative strokes or MIs. Two studies, however, noted a higher rate of 30-day mortality in male patients undergoing CEA than in female patients. Analysis of asymptomatic patients undergoing CEA revealed no difference in perioperative MIs (female: 0% to 1.8% v male: 0.4% to 4.3%), similar rates of CVAs (female: 0.8% to 5% v male: 0.8% to 4.9%), and no significant differences in the long-term mortality outcomes. Alternatively, symptomatic patients undergoing CEA reported a higher rate of CVAs in female patients vs. male patients (7.7% v 6.2%) and showed a higher rate of death in female patients (1% v 0.7%). Among studies that did not stratify outcome by symptomatology, there was no difference in the 30-day outcomes between sexes for patients undergoing CAS. Asymptomatic patients undergoing CAS demonstrated similar incident rates across perioperative MIs (female: 0% to 5.9% v male: 0.28% to 3.3%), CVAs (female: 0.5% to 4.1% v male: 0.4% to 6.2%), and long-term mortality outcomes (female: 0% to 1.75% v male: 0.2% to 1.5%). Symptomatic patients undergoing CAS similarly reported higher incidences of perioperative MIs (female: 0.3% to 7.1% v male: 0% to 5.5%), CVAs (female: 0% to 9.9% v male: 0% to 7.6%), and long-term mortality outcomes (female: 0.6% to 7.1% v male: 0.5% to 8.2%). Sex-specific differences in outcomes after major vascular procedures are well recognized. Our review suggests that symptomatic female patients have a higher incidence of neurologic and cardiac events after carotid interventions, but that asymptomatic patients do not.
Collapse
Affiliation(s)
- Yana Etkin
- Division of Vascular and Endovascular Surgery, Zucker School of Medicine at Hofstra/Northwell, 1999 Marcus Avenue, Suite 106, Lake Success, NY, 11042.
| | - Lisa Iyeke
- Division of Vascular and Endovascular Surgery, Zucker School of Medicine at Hofstra/Northwell, 1999 Marcus Avenue, Suite 106, Lake Success, NY, 11042
| | - Grace Yu
- Division of Vascular and Endovascular Surgery, Zucker School of Medicine at Hofstra/Northwell, 1999 Marcus Avenue, Suite 106, Lake Success, NY, 11042
| | | | | | - Jonathan Aminov
- Division of Vascular and Endovascular Surgery, Stony Brook University Medical Center, Stony Brook, NY
| | - Angela Kokkosis
- Division of Vascular and Endovascular Surgery, Stony Brook University Medical Center, Stony Brook, NY
| | - Laurel Hastings
- Division of Vascular Surgery, Einstein Medical Center, Philadelphia, PA
| | - Karan Garg
- Division of Vascular Surgery, New York University Langone Medical Center, New York, NY
| | - Caron Rockman
- Division of Vascular Surgery, New York University Langone Medical Center, New York, NY
| |
Collapse
|
4
|
Kirchhoff F, Eckstein HH. Locoregional Anaesthesia and Intra-Operative Angiography in Carotid Endarterectomy: 16 Year Results of a Consecutive Single Centre Series. Eur J Vasc Endovasc Surg 2023; 65:223-232. [PMID: 36229016 DOI: 10.1016/j.ejvs.2022.10.002] [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: 01/18/2022] [Revised: 08/11/2022] [Accepted: 10/02/2022] [Indexed: 11/30/2022]
Abstract
OBJECTIVE The benefit of local (LA) over general (GA) anaesthesia and the rationale of intra-operative imaging strategies during carotid endarterectomy (CEA) is debated. This study analysed the associations between patient characteristics, LA, and intra-operative imaging strategies and the in hospital stroke and death rates in elective CEA over a 16 year period. METHODS All consecutive patients treated by elective CEA between January 2004 and December 2019 (n = 1 872; median age 71 years, 70% male, 37% symptomatic) were included. All patients were assessed neurologically before and within 48 hours after CEA. The primary outcome event was the combined rate of any in hospital stroke or death. Secondary outcome events were the combined rates of any in hospital major stroke (modified Rankin scale [mRS] 3 - 5) or death, stroke, minor stroke (mRS 0 - 2), major stroke, and death alone. To detect changes over time, four quartiles (2004 - 2007, 2008 - 2011, 2012 - 2015, and 2016 - 2019) of this cohort were analysed. Statistical analysis comprised trend tests, and uni- and multivariable logistic regression. RESULTS Median patient age increased from 68 to 73 years (p < .001). Over time, LA (from 28% to 91%) and intra-operative imaging (angiography 2.8 - 98.1%, duplex ultrasound 0 - 78.2%) was applied more frequently. Surgical techniques did not change. The in hospital stroke or death and major stroke or death rates decreased from 3.7% to 1.5% (p = .041) and from 2.8% to 0.9% (p = .014), respectively, corresponding to a relative risk of decline of 7% and 12% annually. Multivariable analysis revealed that LA (odds ratio [OR] 0.25, 95% confidence interval [CI] 0.1 - 0.62) and intra-operative angiography (OR 0.09, 95% CI 0.10 - 0.81) were associated with lower in hospital major stroke and death rates. CONCLUSION These data demonstrate a decline in the combined rates of any in hospital major stroke or death after non-emergency CEA over time. Locoregional anaesthesia and intra-operative quality control were associated with these improvements and might be worthwhile in elective CEA.
Collapse
Affiliation(s)
- Felix Kirchhoff
- Department for Vascular and Endovascular Surgery, Klinikum rechts der Isar, Technical University of Munich, Munich, Germany
| | - Hans-Henning Eckstein
- Department for Vascular and Endovascular Surgery, Klinikum rechts der Isar, Technical University of Munich, Munich, Germany.
| |
Collapse
|
5
|
Leung YYR, Bera K, Urriza Rodriguez D, Dardik A, Mas JL, Simonte G, Rerkasem K, Howard DP. Safety of Carotid Endarterectomy for Symptomatic Stenosis by Age: Meta-Analysis With Individual Patient Data. Stroke 2023; 54:457-467. [PMID: 36647921 PMCID: PMC9855737 DOI: 10.1161/strokeaha.122.040819] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2022] [Accepted: 12/06/2022] [Indexed: 01/18/2023]
Abstract
BACKGROUND There is uncertainty whether elderly patients with symptomatic carotid stenosis have higher rates of adverse events following carotid endarterectomy. In trials, recurrent stroke risk on medical therapy alone increased with age, whereas operative stroke risk was not related. Few octogenarians were included in trials and there has been no systematic analysis of all study types. We aimed to evaluate the safety of carotid endarterectomy in symptomatic elderly patients, particularly in octogenarians. METHODS We did a systematic review and meta-analysis of studies (from January 1, 1980 through March 1, 2022) reporting post carotid endarterectomy risk of stroke, myocardial infarction, and death in patients with symptomatic carotid stenosis. We included observational studies and interventional arms of randomized trials if the outcome rates (or the raw data to calculate these) were provided. Individual patient data from 4 prospective cohorts enabled multivariate analysis. RESULTS Of 47 studies (107 587 patients), risk of perioperative stroke was 2.04% (1.94-2.14) in octogenarians (390 strokes/19 101 patients) and 1.85% (1.75-1.95) in nonoctogenarians (1395/75 537); P=0.046. Perioperative death was 1.09% (0.94-1.25) in octogenarians (203/18 702) and 0.53% (0.48-0.59) in nonoctogenarians (392/73 327); P<0.001. Per 5-year age increment, a linear increase in perioperative stroke, myocardial infarction, and death were observed; P=0.04 to 0.002. However, during the last 3 decades, perioperative stroke±death has declined significantly in octogenarians (7.78% [5.58-10.55] before year 2000 to 2.80% [2.56-3.04] after 2010); P<0.001. In Individual patient data multivariate-analysis (5111 patients), age ≥85 years was independently associated with perioperative stroke (P<0.001) and death (P=0.005). Yet, survival was similar for octogenarians versus nonoctogenarians at 1-year (95.0% [93.2-96.5] versus 97.5% [96.4-98.6]; P=0.08), as was 5-year stroke risk (11.93% [9.98-14.16]) versus 12.78% [11.65-13.61]; P=0.24). CONCLUSIONS We found a modest increase in perioperative risk with age in symptomatic patients undergoing carotid endarterectomy. As stroke risk increases with age when on medical therapy alone, our findings support selective urgent intervention in symptomatic elderly patients.
Collapse
Affiliation(s)
- Ya Yuan Rachel Leung
- Wolfson Centre for Prevention of Stroke and Dementia, Nuffield Department of Clinical Neurosciences, University of Oxford, UK (Y.Y.R.L., D.P.J.H.)
| | - Kasia Bera
- Department of Vascular Surgery, Oxford University Hospitals NHS Trust, UK (K.B., D.U.R., D.P.J.H.)
| | - Daniel Urriza Rodriguez
- Department of Vascular Surgery, Oxford University Hospitals NHS Trust, UK (K.B., D.U.R., D.P.J.H.)
| | - Alan Dardik
- Yale Department of Surgery, Departments of Surgery and Cellular and Molecular Physiology, Yale School of Medicine, New Haven, CT (A.D.)
- Department of Surgery, VA Connecticut Healthcare System, West Haven (A.D.)
| | - Jean-Louis Mas
- Department of Neurology, GHU Paris, Hôpital Sainte-Anne, Université Paris-Cité, Inserm, France (J.-L.M.)
| | - Gioele Simonte
- Vascular and Endovascular Surgery Unit, Santa Maria della Misericordia, University of Perugia, Italy (G.S.)
| | - Kittipan Rerkasem
- Environmental - Occupational Health Sciences and Non-Communicable Diseases Research Group, Research Institute for Health Sciences, Chiang Mai University, Thailand (K.R.)
- Clinical Surgical Research Center, Department of Surgery, Faculty of Medicine, Chiang Mai University, Thailand (K.R.)
| | - Dominic P.J. Howard
- Wolfson Centre for Prevention of Stroke and Dementia, Nuffield Department of Clinical Neurosciences, University of Oxford, UK (Y.Y.R.L., D.P.J.H.)
- Department of Vascular Surgery, Oxford University Hospitals NHS Trust, UK (K.B., D.U.R., D.P.J.H.)
| |
Collapse
|
6
|
Abbott AL. Extra-Cranial Carotid Artery Stenosis: An Objective Analysis of the Available Evidence. Front Neurol 2022; 13:739999. [PMID: 35800089 PMCID: PMC9253595 DOI: 10.3389/fneur.2022.739999] [Citation(s) in RCA: 15] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2021] [Accepted: 01/24/2022] [Indexed: 12/26/2022] Open
Abstract
Background and Purpose Carotid stenosis is arterial disease narrowing of the origin of the internal carotid artery (main brain artery). Knowing how to best manage this is imperative because it is common in older people and an important cause of stroke. Inappropriately high expectations have grown regarding the value of carotid artery procedures, such as surgery (endarterectomy) and stenting, for lowering the stroke risk associated with carotid stenosis. Meanwhile, the improving and predominant value of medical intervention (lifestyle coaching and medication) continues to be underappreciated. Methods and Results This article aims to be an objective presentation and discussion of the scientific literature critical for decision making when the primary goal is to optimize patient outcome. This compilation follows from many years of author scrutiny to separate fact from fiction. Common sense conclusions are drawn from factual statements backed by original citations. Detailed research methodology is given in cited papers. This article has been written in plain language given the importance of the general public understanding this topic. Issues covered include key terminology and the economic impact of carotid stenosis. There is a summary of the evidence-base regarding the efficacy and safety of procedural and medical (non-invasive) interventions for both asymptomatic and symptomatic patients. Conclusions are drawn with respect to current best management and research priorities. Several "furphies" (misconceptions) are exposed that are commonly used to make carotid stenting and endarterectomy outcomes appear similar. Ongoing randomized trials are mentioned and why they are unlikely to identify a routine practice indication for carotid artery procedures. There is a discussion of relevant worldwide guidelines regarding carotid artery procedures, including how they should be improved. There is an outline of systematic changes that are resulting in better application of the evidence-base. Conclusion The cornerstone of stroke prevention is medical intervention given it is non-invasive and protects against all arterial disease complications in all at risk. The "big" question is, does a carotid artery procedure add patient benefit in the modern era and, if so, for whom?
Collapse
Affiliation(s)
- Anne L. Abbott
- Department of Neuroscience, Central Clinical School, Monash University, Melbourne, VIC, Australia
- Neurology Private Practice, Knox Private Hospital, Wantirna, VIC, Australia
| |
Collapse
|
7
|
Ho-Yan Lee M, Li PY, Li B, Shakespeare A, Samarasinghe Y, Feridooni T, Cuen-Ojeda C, Alshabanah L, Kishibe T, Al-Omran M. A systematic review and meta-analysis of sex- and gender-based differences in presentation severity and outcomes in adults undergoing major vascular surgery. J Vasc Surg 2022; 76:581-594.e25. [DOI: 10.1016/j.jvs.2022.02.030] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2021] [Accepted: 02/24/2022] [Indexed: 11/25/2022]
|
8
|
Gao J, Chen Z, Kou L, Zhang H, Yang Y. The Efficacy of Transcarotid Artery Revascularization With Flow Reversal System Compared to Carotid Endarterectomy: A Systematic Review and Meta-Analysis. Front Cardiovasc Med 2021; 8:695295. [PMID: 34869622 PMCID: PMC8640218 DOI: 10.3389/fcvm.2021.695295] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2021] [Accepted: 10/18/2021] [Indexed: 01/10/2023] Open
Abstract
Background: Carotid artery stenosis has long been a critical cause of stroke and death, and it can seriously affect the life quality. Transcarotid artery revascularization (TCAR) and carotid endarterectomy (CEA) are both feasible therapies for this disease. This systematic review and meta-analysis aim to evaluate if the efficacy of the two approaches is comparable. Methods: Clinical studies up to March 2021 were searched through PubMed, Embase, and Scopus from a computer. The screening process was designed according to the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) statement. Newcastle-Ottawa Scale (NOS) was used for methodological quality assessment of works of literature meeting the inclusion criteria, and Review Manager 5.4 was used for data synthesis. The I2 statistic was performed to measure the heterogeneity, and M-H/I-V fixed or random model was utilized depending on the I2 value. The evidence evaluation was accomplished based on grades of recommendation, assessment, development, and evaluation (GRADE) online tool. Results: A total of 14,200 subjects (six comparative studies) were finally included in this pooled study. There is no statistical discrepancy between the two treatments on reducing stroke/death/myocardial infarction (odds ratio [OR] 0.85, 95% CI 0.67–1.07), stroke (OR 1.03, 95% CI 0.77–1.37), or death (OR 1.14, 95% CI 0.67–1.94). Besides, TCAR is associated with a lower incidence of myocardial infarction (P = 0.004), cranial nerve injury (P < 0.00001), and shorter procedure time (P < 0.00001) than CEA among the overall cohort. Conclusions: TCAR is a rapidly developing treatment that reaches a comparable prognosis to CEA and significantly reduces the risk of myocardial infarction under the well-matched condition, which is a dependable choice for patients with carotid stenosis.
Collapse
Affiliation(s)
- Jianfeng Gao
- Department of Vascular, Beijing Anzhen Hospital, Capital Medical University, Beijing, China
| | - Zhong Chen
- Department of Vascular, Beijing Anzhen Hospital, Capital Medical University, Beijing, China
| | - Lei Kou
- Department of Vascular, Beijing Anzhen Hospital, Capital Medical University, Beijing, China
| | - Hanfang Zhang
- Department of Vascular, Beijing Anzhen Hospital, Capital Medical University, Beijing, China
| | - Yaoguo Yang
- Department of Vascular, Beijing Anzhen Hospital, Capital Medical University, Beijing, China
| |
Collapse
|
9
|
Halliday A, Bulbulia R, Bonati LH, Chester J, Cradduck-Bamford A, Peto R, Pan H. Second asymptomatic carotid surgery trial (ACST-2): a randomised comparison of carotid artery stenting versus carotid endarterectomy. Lancet 2021; 398:1065-1073. [PMID: 34469763 PMCID: PMC8473558 DOI: 10.1016/s0140-6736(21)01910-3] [Citation(s) in RCA: 121] [Impact Index Per Article: 40.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/22/2021] [Revised: 08/09/2021] [Accepted: 08/11/2021] [Indexed: 01/16/2023]
Abstract
BACKGROUND Among asymptomatic patients with severe carotid artery stenosis but no recent stroke or transient cerebral ischaemia, either carotid artery stenting (CAS) or carotid endarterectomy (CEA) can restore patency and reduce long-term stroke risks. However, from recent national registry data, each option causes about 1% procedural risk of disabling stroke or death. Comparison of their long-term protective effects requires large-scale randomised evidence. METHODS ACST-2 is an international multicentre randomised trial of CAS versus CEA among asymptomatic patients with severe stenosis thought to require intervention, interpreted with all other relevant trials. Patients were eligible if they had severe unilateral or bilateral carotid artery stenosis and both doctor and patient agreed that a carotid procedure should be undertaken, but they were substantially uncertain which one to choose. Patients were randomly allocated to CAS or CEA and followed up at 1 month and then annually, for a mean 5 years. Procedural events were those within 30 days of the intervention. Intention-to-treat analyses are provided. Analyses including procedural hazards use tabular methods. Analyses and meta-analyses of non-procedural strokes use Kaplan-Meier and log-rank methods. The trial is registered with the ISRCTN registry, ISRCTN21144362. FINDINGS Between Jan 15, 2008, and Dec 31, 2020, 3625 patients in 130 centres were randomly allocated, 1811 to CAS and 1814 to CEA, with good compliance, good medical therapy and a mean 5 years of follow-up. Overall, 1% had disabling stroke or death procedurally (15 allocated to CAS and 18 to CEA) and 2% had non-disabling procedural stroke (48 allocated to CAS and 29 to CEA). Kaplan-Meier estimates of 5-year non-procedural stroke were 2·5% in each group for fatal or disabling stroke, and 5·3% with CAS versus 4·5% with CEA for any stroke (rate ratio [RR] 1·16, 95% CI 0·86-1·57; p=0·33). Combining RRs for any non-procedural stroke in all CAS versus CEA trials, the RR was similar in symptomatic and asymptomatic patients (overall RR 1·11, 95% CI 0·91-1·32; p=0·21). INTERPRETATION Serious complications are similarly uncommon after competent CAS and CEA, and the long-term effects of these two carotid artery procedures on fatal or disabling stroke are comparable. FUNDING UK Medical Research Council and Health Technology Assessment Programme.
Collapse
Affiliation(s)
- Alison Halliday
- Nuffield Department of Population Health, University of Oxford, Oxford, UK; Nuffield Department of Surgery, University of Oxford, Oxford, UK.
| | - Richard Bulbulia
- Nuffield Department of Population Health, University of Oxford, Oxford, UK; Medical Research Council Population Health Research Unit, Nuffield Department of Population Health, University of Oxford, Oxford, UK
| | - Leo H Bonati
- Department of Neurology, University Hospital, Basel, Switzerland
| | - Johanna Chester
- Nuffield Department of Population Health, University of Oxford, Oxford, UK
| | | | - Richard Peto
- Nuffield Department of Population Health, University of Oxford, Oxford, UK
| | - Hongchao Pan
- Nuffield Department of Population Health, University of Oxford, Oxford, UK; Medical Research Council Population Health Research Unit, Nuffield Department of Population Health, University of Oxford, Oxford, UK
| |
Collapse
|
10
|
Paraskevas KI, Mikhailidis DP, Baradaran H, Davies AH, Eckstein HH, Faggioli G, Fernandes E Fernandes J, Gupta A, Jezovnik MK, Kakkos SK, Katsiki N, Kooi ME, Lanza G, Liapis CD, Loftus IM, Millon A, Nicolaides AN, Poredos P, Pini R, Ricco JB, Rundek T, Saba L, Spinelli F, Stilo F, Sultan S, Zeebregts CJ, Chaturvedi S. Management of patients with asymptomatic carotid stenosis may need to be individualized: a multidisciplinary call for action. Republication of J Stroke 2021;23:202-212. INT ANGIOL 2021; 40:487-496. [PMID: 34313413 DOI: 10.23736/s0392-9590.21.04751-9] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
The optimal management of patients with asymptomatic carotid stenosis (ACS) is the subject of extensive debate. According to the 2017 European Society for Vascular Surgery guidelines, carotid endarterectomy should (Class IIa; Level of Evidence: B) or carotid artery stenting may be considered (Class IIb; Level of Evidence: B) in the presence of one or more clinical/imaging characteristics that may be associated with an increased risk of late ipsilateral stroke (e.g. silent embolic infarcts on brain computed tomography/magnetic resonance imaging, progression in the severity of ACS, a history of contralateral transient ischemic attack/stroke, microemboli detection on transcranial Doppler, etc.), provided documented perioperative stroke/death rates are <3% and the patient's life expectancy is >5 years. Besides these clinical/imaging characteristics, there are additional individual, ethnic/racial or social factors that should probably be evaluated in the decision process regarding the optimal management of these patients, such as individual patient needs/patient choice, patient compliance with best medical treatment, patient sex, culture, race/ethnicity, age and comorbidities, as well as improvements in imaging/operative techniques/outcomes. The present multispecialty position paper will present the rationale why the management of patients with ACS may need to be individualized.
Collapse
Affiliation(s)
| | - Dimitri P Mikhailidis
- Department of Clinical Biochemistry, Royal Free Hospital Campus, University College London Medical School, University College London (UCL), London, UK
| | - Hediyeh Baradaran
- Department of Radiology, University of Utah, Salt Lake City, UT, USA
| | - Alun H Davies
- Section of Vascular Surgery, Imperial College & Imperial Healthcare NHS Trust, London, UK
| | - Hans-Henning Eckstein
- Department of Vascular and Endovascular Surgery, Klinikum rechts der Isar, Technical University of Munich, Munich, Germany
| | - Gianluca Faggioli
- Vascular Surgery, University of Bologna Alma Mater Studiorum, Policlinico S. Orsola Malpighi, Bologna, Italy
| | | | - Ajay Gupta
- Department of Radiology, Weill Cornell Medicine, New York, NY, USA
| | - Mateja K Jezovnik
- Department of Advanced Cardiopulmonary Therapies and Transplantation, The University of Texas Health Science Centre at Houston, Houston, TX, USA
| | - Stavros K Kakkos
- Department of Vascular Surgery, University of Patras Medical School, Patras, Greece
| | - Niki Katsiki
- First Department of Internal Medicine, AHEPA University Hospital, Thessaloniki, Greece
| | - M Eline Kooi
- CARIM School for Cardiovascular Diseases, Maastricht University, Maastricht, The Netherlands.,Department of Radiology and Nuclear Medicine, Maastricht University Medical Center, Maastricht, The Netherlands
| | - Gaetano Lanza
- Vascular Surgery Department, IRCSS MultiMedica Hospital, Castellanza, Varese, Italy
| | | | - Ian M Loftus
- St. George's Vascular Institute, St. George's University London, London, UK
| | - Antoine Millon
- Department of Vascular and Endovascular Surgery, Louis Pradel Hospital, Hospices Civils de Lyon, Lyon, France
| | - Andrew N Nicolaides
- Department of Surgery, University of Nicosia Medical School, Nicosia, Cyprus
| | - Pavel Poredos
- Department of Vascular Disease, University Medical Centre Ljubljana, Ljubljana, Slovenia
| | - Rodolfo Pini
- Vascular Surgery, University of Bologna Alma Mater Studiorum, Policlinico S. Orsola Malpighi, Bologna, Italy
| | - Jean-Baptiste Ricco
- Department of Clinical Research, University of Poitiers, CHU de Poitiers, Poitiers, France
| | - Tatjana Rundek
- Department of Neurology, Miller School of Medicine, University of Miami, Miami, FL, USA
| | - Luca Saba
- Department of Radiology, Azienda Ospedaliera Universitaria di Cagliari, Cagliari, Italy
| | - Francesco Spinelli
- Vascular Surgery Division, Campus Bio-Medico University of Rome, Rome, Italy
| | - Francesco Stilo
- Vascular Surgery Division, Campus Bio-Medico University of Rome, Rome, Italy
| | - Sherif Sultan
- Western Vascular Institute, Department of Vascular and Endovascular Surgery, University Hospital Galway, National University of Ireland, Galway, Ireland
| | - Clark J Zeebregts
- Division of Vascular Surgery, Department of Surgery, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Seemant Chaturvedi
- Department of Neurology & Stroke Program, University of Maryland School of Medicine, Baltimore, MD, USA
| |
Collapse
|
11
|
Paraskevas KI, Mikhailidis DP, Baradaran H, Davies AH, Eckstein HH, Faggioli G, Fernandes JFE, Gupta A, Jezovnik MK, Kakkos SK, Katsiki N, Kooi ME, Lanza G, Liapis CD, Loftus IM, Millon A, Nicolaides AN, Poredos P, Pini R, Ricco JB, Rundek T, Saba L, Spinelli F, Stilo F, Sultan S, Zeebregts CJ, Chaturvedi S. Management of Patients with Asymptomatic Carotid Stenosis May Need to Be Individualized: A Multidisciplinary Call for Action. J Stroke 2021; 23:202-212. [PMID: 34102755 PMCID: PMC8189852 DOI: 10.5853/jos.2020.04273] [Citation(s) in RCA: 20] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2020] [Accepted: 04/12/2021] [Indexed: 12/15/2022] Open
Abstract
The optimal management of patients with asymptomatic carotid stenosis (ACS) is the subject of extensive debate. According to the 2017 European Society for Vascular Surgery guidelines, carotid endarterectomy should (Class IIa; Level of Evidence: B) or carotid artery stenting may be considered (Class IIb; Level of Evidence: B) in the presence of one or more clinical/imaging characteristics that may be associated with an increased risk of late ipsilateral stroke (e.g., silent embolic infarcts on brain computed tomography/magnetic resonance imaging, progression in the severity of ACS, a history of contralateral transient ischemic attack/stroke, microemboli detection on transcranial Doppler, etc.), provided documented perioperative stroke/death rates are <3% and the patient’s life expectancy is >5 years. Besides these clinical/imaging characteristics, there are additional individual, ethnic/racial or social factors that should probably be evaluated in the decision process regarding the optimal management of these patients, such as individual patient needs/patient choice, patient compliance with best medical treatment, patient sex, culture, race/ethnicity, age and comorbidities, as well as improvements in imaging/operative techniques/outcomes. The present multispecialty position paper will present the rationale why the management of patients with ACS may need to be individualized.
Collapse
Affiliation(s)
| | - Dimitri P Mikhailidis
- Department of Clinical Biochemistry, Royal Free Hospital Campus, University College London Medical School, University College London (UCL), London, UK
| | - Hediyeh Baradaran
- Department of Radiology, University of Utah, Salt Lake City, UT, USA
| | - Alun H Davies
- Section of Vascular Surgery, Imperial College & Imperial Healthcare NHS Trust, London, UK
| | - Hans-Henning Eckstein
- Department of Vascular and Endovascular Surgery, Klinikum rechts der Isar, Technical University of Munich, Munich, Germany
| | - Gianluca Faggioli
- Vascular Surgery, University of Bologna "Alma Mater Studiorum", Policlinico S. Orsola Malpighi, Bologna, Italy
| | | | - Ajay Gupta
- Department of Radiology, Weill Cornell Medicine, New York, NY, USA
| | - Mateja K Jezovnik
- Department of Advanced Cardiopulmonary Therapies and Transplantation, The University of Texas Health Science Centre at Houston, Houston, TX, USA
| | - Stavros K Kakkos
- Department of Vascular Surgery, University of Patras Medical School, Patras, Greece
| | - Niki Katsiki
- First Department of Internal Medicine, AHEPA University Hospital, Thessaloniki, Greece
| | - M Eline Kooi
- CARIM School for Cardiovascular Diseases, Maastricht University, Maastricht, The Netherlands.,Department of Radiology and Nuclear Medicine, Maastricht University Medical Center, Maastricht, The Netherlands
| | - Gaetano Lanza
- Vascular Surgery Department, IRCSS MultiMedica Hospital, Castellanza, Italy
| | | | - Ian M Loftus
- St. George's Vascular Institute, St. George's University London, London, UK
| | - Antoine Millon
- Department of Vascular and Endovascular Surgery, Louis Pradel Hospital, Hospices Civils de Lyon, France
| | - Andrew N Nicolaides
- Department of Surgery, University of Nicosia Medical School, Nicosia, Cyprus
| | - Pavel Poredos
- Department of Vascular Disease, University Medical Centre Ljubljana, Slovenia
| | - Rodolfo Pini
- Vascular Surgery, University of Bologna "Alma Mater Studiorum", Policlinico S. Orsola Malpighi, Bologna, Italy
| | - Jean-Baptiste Ricco
- Department of Clinical Research, University of Poitiers, CHU de Poitiers, Poitiers, France
| | - Tatjana Rundek
- Department of Neurology, Miller School of Medicine, University of Miami, Miami, FL, USA
| | - Luca Saba
- Department of Radiology, Azienda Ospedaliera Universitaria Di Cagliari, Cagliari, Italy
| | - Francesco Spinelli
- Vascular Surgery Division, Campus Bio-Medico University of Rome, Rome, Italy
| | - Francesco Stilo
- Vascular Surgery Division, Campus Bio-Medico University of Rome, Rome, Italy
| | - Sherif Sultan
- Western Vascular Institute, Department of Vascular and Endovascular Surgery, University Hospital Galway, National University of Ireland, Galway, Ireland
| | - Clark J Zeebregts
- Division of Vascular Surgery, Department of Surgery, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Seemant Chaturvedi
- Department of Neurology & Stroke Program, University of Maryland School of Medicine, Baltimore, MD, USA
| |
Collapse
|
12
|
Paraskevas KI, Cambria RP. Carotid Revascularization Procedural Volume and Perioperative Outcomes. Angiology 2021; 72:703-705. [PMID: 33827274 DOI: 10.1177/00033197211005605] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
| | - Richard P Cambria
- Division of Vascular and Endovascular Surgery, 1951St. Elizabeth's Medical Center, Brighton, MA, USA
| |
Collapse
|
13
|
Abstract
BACKGROUND Stroke is the third leading cause of death and the most common cause of long-term disability. Severe narrowing (stenosis) of the carotid artery is an important cause of stroke. Surgical treatment (carotid endarterectomy) may reduce the risk of stroke, but carries a risk of operative complications. This is an update of a Cochrane Review, originally published in 1999, and most recently updated in 2017. OBJECTIVES To determine the balance of benefit versus risk of endarterectomy plus best medical management compared with best medical management alone, in people with a recent symptomatic carotid stenosis (i.e. transient ischaemic attack (TIA) or non-disabling stroke). SEARCH METHODS We searched the Cochrane Stroke Group Trials Register, CENTRAL, MEDLINE Ovid, Embase Ovid, Web of Science Core Collection, ClinicalTrials.gov, and the WHO International Clinical Trials Registry Platform (ICTRP) portal to October 2019. We also reviewed the reference lists of all relevant studies and abstract books from research proceedings. SELECTION CRITERIA We included randomised controlled trials (RCTs) comparing carotid artery surgery plus best medical treatment with best medical treatment alone. DATA COLLECTION AND ANALYSIS: Two review authors independently selected studies, assessed risk of bias, and extracted the data. We assessed the results and the quality of the evidence of the primary and secondary outcomes by the GRADE method, which classifies the quality of evidence as high, moderate, low, or very low. MAIN RESULTS We included three trials involving 6343 participants. The trials differed in the methods of measuring carotid stenosis and in the definition of stroke. Using the primary electronic data files, we pooled and analysed individual patient data on 6092 participants (35,000 patient-years of follow-up), after reassessing the carotid angiograms and outcomes from all three trials, and redefining outcome events where necessary, to achieve comparability. Surgery increased the five-year risk of any stroke or operative death in participants with less than 30% stenosis (risk ratio (RR) 1.25, 95% confidence interval (CI) 0.99 to 1.56; 2 studies, 1746 participants; high-quality evidence). Surgery decreased the five-year risk of any stroke or operative death in participants with 30% to 49% stenosis (RR 0.97, 95% CI 0.79 to 1.19; 2 studies, 1429 participants; high-quality evidence), was of benefit in participants with 50% to 69% stenosis (RR 0.77, 95% CI 0.63 to 0.94; 3 studies, 1549 participants; moderate-quality evidence), and was highly beneficial in participants with 70% to 99% stenosis without near-occlusion (RR 0.53, 95% CI 0.42 to 0.67; 3 studies, 1095 participants; moderate-quality evidence). However, surgery decreased the five-year risk of any stroke or operative death in participants with near-occlusions (RR 0.95, 95% CI 0.59 to 1.53; 2 studies, 271 participants; moderate-quality evidence). AUTHORS' CONCLUSIONS Carotid endarterectomy reduced the risk of recurrent stroke for people with significant stenosis. Endarterectomy might be of some benefit for participants with 50% to 69% symptomatic stenosis (moderate-quality evidence) and highly beneficial for those with 70% to 99% stenosis (moderate-quality evidence).
Collapse
Affiliation(s)
- Amaraporn Rerkasem
- Research Institute for Health Sciences, Chiang Mai University, Chiang Mai, Thailand
| | - Saritphat Orrapin
- Division of Vascular Surgery, Department of Surgery, Faculty of Medicine, Thammasat University (Rangsit Campus), Pathum thani, Thailand
| | - Dominic Pj Howard
- Centre for Prevention of Stroke and Dementia, Nuffield Department of Clinical Neurosciences, University of Oxford, Oxford, UK
| | - Kittipan Rerkasem
- Research Institute for Health Sciences, Chiang Mai University, Chiang Mai, Thailand
- Division of Vascular and Endovascular Surgery, Department of Surgery, Faculty of Medicine, Chiang Mai University, Chiang Mai, Thailand
| |
Collapse
|
14
|
Feng Y, Bai X, Wang T, Wang Y, Chen Y, Li M, Hua Y, Ling F, Ma Y, Jiao L. Thirty-day outcomes of carotid endarterectomy in the elderly: A 17-year single-center study. J Clin Neurosci 2020; 78:86-90. [PMID: 32622649 DOI: 10.1016/j.jocn.2020.06.007] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2020] [Accepted: 06/06/2020] [Indexed: 12/25/2022]
Abstract
INTRODUCTION Carotid endarterectomy (CEA) has been supported as a durable procedure for treating patients with carotid artery stenosis by many randomized controlled trials (RCTs). The aim of this study was to evaluate the 30-day outcomes and risk factors for CEA in elderly patients with a retrospective single-center study. METHODS Our study sample consisted of patients from 2001 to 2017 CEA-targeted Xuanwu Hospital, Capital Medical University data set. The primary outcome was 30-day postoperative incidence of major adverse clinical events (MACEs; death, myocardial infarction (MI) and ipsilateral stroke). Univariable and multivariable analyses were performed to identify high-risk patients and procedural characteristics associated with MACEs. RESULTS A total of 348 elderly patients undergoing CEA for carotid artery stenosis were identified and analyzed. The incidence of postoperative MACEs was 4.6% (16 cases, included 1 death, 14 S, and 1 MI respectively) for elderly patients. Univariate analysis indicated symptomatic lesion (81.3% vs 55.7%, p = 0.044), diabetes mellitus (56.3% vs 26.8%, p = 0.011) and DBP (85.56 ± 11.26 mmHg vs 76.53 ± 9.51 mmHg, p < 0.001) were statistically significant with MACEs. On multivariable analysis, independent predictors of MACEs included diabetes mellitus (DM) (OR = 2.882; 95% CI = 1.005-8.266; P = 0.049) and higher diastolic blood pressure (DBP) (OR = 1.079; 95% CI = 1.025-1.136; P = 0.004). Symptomatic lesion was not an independent risk factor (OR = 2.805; 95% CI = 0.759-10.361; P = 0.122). CONCLUSIONS According to our single-center experience, CEA could be safely performed in elderly patients. Risk factors identified for MACEs in this special group patients were DM and higher DBP.
Collapse
Affiliation(s)
- Yao Feng
- Interventional Radiology Diagnosis and Treatment Center, Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Xuesong Bai
- Interventional Radiology Diagnosis and Treatment Center, Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Tao Wang
- Interventional Radiology Diagnosis and Treatment Center, Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Yabing Wang
- Interventional Radiology Diagnosis and Treatment Center, Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Yanfei Chen
- Interventional Radiology Diagnosis and Treatment Center, Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Meng Li
- Interventional Radiology Diagnosis and Treatment Center, Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Yang Hua
- Department of Vascular Ultrasonography, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Feng Ling
- Interventional Radiology Diagnosis and Treatment Center, Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Yan Ma
- Interventional Radiology Diagnosis and Treatment Center, Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Liqun Jiao
- Interventional Radiology Diagnosis and Treatment Center, Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, Beijing, China.
| |
Collapse
|
15
|
Higher Long-Term Mortality with Carotid Artery Stenting in Asymptomatic Male Compared with Female Patients in the Southeastern Vascular Study Group. Ann Vasc Surg 2020; 66:390-399. [DOI: 10.1016/j.avsg.2020.01.090] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2019] [Revised: 01/13/2020] [Accepted: 01/14/2020] [Indexed: 12/26/2022]
|
16
|
Lee MS, Choi BG, Hollowed J, Han SK, Baek MJ, gi Ryu Y, Choi SY, Byun JK, Mashaly A, Park Y, Jang WY, Kim W, Choi JY, Park EJ, Na JO, Choi CU, Kim EJ, Park CG, Seo HS, Rha SW. Assessment of Sex Differences in 5-Year Clinical Outcomes Following Endovascular Revascularization for Peripheral Artery Disease. CARDIOVASCULAR REVASCULARIZATION MEDICINE 2020; 21:110-115. [DOI: 10.1016/j.carrev.2019.03.018] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2018] [Revised: 02/24/2019] [Accepted: 03/22/2019] [Indexed: 11/28/2022]
|
17
|
Tsantilas P, Knappich C, Schmid S, Kallmayer M, Breitkreuz T, Zimmermann A, Eckstein HH, Kuehnl A. Last neurologic event is associated with risk of in-hospital stroke or death after carotid endarterectomy or carotid artery stenting: Secondary data analysis of the German statutory quality assurance database. J Vasc Surg 2019; 70:1488-1498. [DOI: 10.1016/j.jvs.2019.02.038] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2018] [Accepted: 02/16/2019] [Indexed: 10/26/2022]
|
18
|
Trenner M, Eckstein HH, Kallmayer MA, Reutersberg B, Kühnl A. Secondary analysis of statutorily collected routine data. GEFASSCHIRURGIE 2019. [DOI: 10.1007/s00772-019-0524-y] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
|
19
|
Age but not sex is associated with higher risk of in-hospital stroke or death after carotid artery stenting in symptomatic and asymptomatic carotid stenosis. J Vasc Surg 2019; 69:1090-1101.e3. [DOI: 10.1016/j.jvs.2018.03.439] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2017] [Accepted: 03/30/2018] [Indexed: 11/20/2022]
|
20
|
Regional frequency variation of revascularization procedures for carotid stenosis in Germany: Secondary data analysis of DRG data from 2012 to 2014. GEFASSCHIRURGIE 2018; 23:56-65. [PMID: 30147245 PMCID: PMC6096714 DOI: 10.1007/s00772-018-0415-7] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
Abstract
Background For Germany, regional variation of procedure rates of carotid endarterectomy (CEA) and carotid artery stenting (CAS) performed for carotid stenosis have so far not been analyzed at a national level. The aim of this study was to assess small area estimates of procedure rates among German regions, and to identify regional characteristics, which are associated with the regional frequency of procedures. Methods German diagnosis-related groups (DRG) statistics (2012-2014) were analyzed. Inclusion and exclusion criteria for procedural codes were set according to German quality assurance measures in combination with the diagnosis of carotid stenosis (I65.2). Rates of CEA and CAS were indirectly standardized for sex and age. Results In total, 88,182 procedures were performed (73,042 CEA; 15,367 CAS). The overall procedure rate varied between 13.2 per 100,000 (Augsburg) and 89.2 per 100,000 (Wilhelmshaven). Spatial analysis revealed that regional distribution was significantly clustered. Conclusion The rates of CEA, and especially of CAS showed high regional variation. The spatial distribution was significantly clustered. In addition to the regional prevalence of diabetes mellitus, smoking and obesity, socioeconomic factors, such as income and debts were correlated with the overall frequency of CEA and CAS. No significant association was found between indicators of health infrastructure (e. g. density of hospital beds, vascular surgeons and angiologists) and the overall procedure rate.
Collapse
|
21
|
Knappich C, Kuehnl A, Tsantilas P, Schmid S, Breitkreuz T, Kallmayer M, Zimmermann A, Eckstein HH. Patient characteristics and in-hospital outcomes of emergency carotid endarterectomy and carotid stenting after stroke in evolution. J Vasc Surg 2018; 68:436-444.e6. [DOI: 10.1016/j.jvs.2017.10.085] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2017] [Accepted: 10/26/2017] [Indexed: 11/30/2022]
|
22
|
Ding L, Peng B. Efficacy and safety of dual antiplatelet therapy in the elderly for stroke prevention: a systematic review and meta‐analysis. Eur J Neurol 2018; 25:1276-1284. [PMID: 29855121 DOI: 10.1111/ene.13695] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2017] [Accepted: 05/23/2018] [Indexed: 11/30/2022]
Affiliation(s)
- L. Ding
- Department of Neurology Peking Union Medical College Hospital Chinese Academy of Medical Sciences Peking Union Medical College Beijing China
| | - B. Peng
- Department of Neurology Peking Union Medical College Hospital Chinese Academy of Medical Sciences Peking Union Medical College Beijing China
| |
Collapse
|
23
|
Kuehnl A, Salvermoser M, Knipfer E, Zimmermann A, Schmid V, Eckstein H. Regionale Häufigkeit von revaskularisierenden Prozeduren bei Karotisstenose in Deutschland. GEFASSCHIRURGIE 2018. [DOI: 10.1007/s00772-018-0385-9] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
|
24
|
Tsantilas P, Kuehnl A, Kallmayer M, Knappich C, Schmid S, Breitkreuz T, Zimmermann A, Eckstein HH. Risk of Stroke or Death Is Associated With the Timing of Carotid Artery Stenting for Symptomatic Carotid Stenosis: A Secondary Data Analysis of the German Statutory Quality Assurance Database. J Am Heart Assoc 2018; 7:e007983. [PMID: 29588311 PMCID: PMC5907586 DOI: 10.1161/jaha.117.007983] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/15/2017] [Accepted: 02/06/2018] [Indexed: 01/22/2023]
Abstract
BACKGROUND Subgroup analyses from randomized trials indicate that the time interval between the neurologic index event and carotid artery stenting is associated with periprocedural stroke and death rates in patients with symptomatic carotid stenosis. The aim of this article is to analyze whether this observation holds true under routine conditions in Germany. METHODS AND RESULTS Secondary data analysis was done on 4717 elective carotid artery stenting procedures that were performed for symptomatic carotid stenosis. The patient cohort was divided into 4 groups according to the time interval between the index event and intervention (group I 0-2, II 3-7, III 8-14, and IV 15-180 days). Primary outcome was any in-hospital stroke or death. For risk-adjusted analyses, a multilevel multivariable regression model was used. The in-hospital stroke or death rate was 3.7% in total and 6.0%, 4.4%, 2.4%, and 3.0% in groups I, II, III, and IV, respectively. Adjusted analysis showed a decreased risk for any stroke or death in group III, a decreased risk for any major stroke or death in groups III and IV, and a decreased risk for any death in groups II and III compared to the reference group I. CONCLUSIONS A short time interval between the neurologic index event and carotid artery stenting of up to 7 days is associated with an increased risk for stroke or death under routine conditions in Germany. Although results cannot prove causal relationships, carotid artery stenting may be accompanied by an increased risk of stroke or death during the early period after the index event.
Collapse
Affiliation(s)
- Pavlos Tsantilas
- Department of Vascular and Endovascular Surgery, Klinikum rechts der Isar, Technical University Munich, Germany
| | - Andreas Kuehnl
- Department of Vascular and Endovascular Surgery, Klinikum rechts der Isar, Technical University Munich, Germany
| | - Michael Kallmayer
- Department of Vascular and Endovascular Surgery, Klinikum rechts der Isar, Technical University Munich, Germany
| | - Christoph Knappich
- Department of Vascular and Endovascular Surgery, Klinikum rechts der Isar, Technical University Munich, Germany
| | - Sofie Schmid
- Department of Vascular and Endovascular Surgery, Klinikum rechts der Isar, Technical University Munich, Germany
| | - Thorben Breitkreuz
- aQua-Institute for Applied Quality Improvement and Research in Health GmbH, Göttingen, Germany
| | - Alexander Zimmermann
- Department of Vascular and Endovascular Surgery, Klinikum rechts der Isar, Technical University Munich, Germany
| | - Hans-Henning Eckstein
- Department of Vascular and Endovascular Surgery, Klinikum rechts der Isar, Technical University Munich, Germany
| |
Collapse
|
25
|
Eckstein HH, Tsantilas P, Kühnl A, Haller B, Breitkreuz T, Zimmermann A, Kallmayer M. Surgical and Endovascular Treatment of Extracranial Carotid Stenosis. DEUTSCHES ARZTEBLATT INTERNATIONAL 2017; 114:729-736. [PMID: 29143732 PMCID: PMC5696565 DOI: 10.3238/arztebl.2017.0729] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/16/2017] [Revised: 03/16/2017] [Accepted: 07/19/2017] [Indexed: 11/27/2022]
Abstract
BACKGROUND Carotid endarterectomy (CEA) and carotid artery stenting (CAS) can be used to prevent stroke due to arteriosclerotic lesions of the carotid artery. In Germany, legally mandated quality assurance (QA) enables the evaluation of outcome quality after CEA and CAS performed under routine conditions. METHODS We analyzed data on all elective CEA and CAS procedures performed over the periods 2009-2014 and 2012-2014, respectively. The endpoints of the study were the combined in-hospital stroke and death rate, stroke rate and mortality separately, local complications, and other complications. We analyzed the raw data with descriptive statistics and carried out a risk-adjusted analysis of the association of clinically unalterable variables with the risk of stroke and death. All analyses were performed separately for CEA and CAS. RESULTS Data were analyzed from 142 074 CEA procedures (67.8% of them in men) and 13 086 CAS procedures (69.7% in men). The median age was 72 years (CEA) and 71 years (CAS). The periprocedural rate of stroke and death after CEA was 1.4% for asymptomatic and 2.5% for symptomatic stenoses; the corresponding rates for CAS were 1.7% and 3.7%. Variables associated with increased risk included older age, higher ASA class (ASA = American Society of Anesthesiologists), symptomatic vs. asymptomatic stenosis, 50-69% stenosis, and contralateral carotid occlusion (for CEA only). CONCLUSION These data reveal a low periprocedural rate of stroke or death for both CEA and CAS. This study does however not permit any conclusions as to the superiority or inferiority of CEA and CAS.
Collapse
Affiliation(s)
- Hans-Henning Eckstein
- Department of Vascular and Endovascular Surgery/Vascular Center, Klinikum rechts der Isar der Technischen Universität München
| | - Pavlos Tsantilas
- Department of Vascular and Endovascular Surgery/Vascular Center, Klinikum rechts der Isar der Technischen Universität München
| | - Andreas Kühnl
- Department of Vascular and Endovascular Surgery/Vascular Center, Klinikum rechts der Isar der Technischen Universität München
| | - Bernhard Haller
- Institut für Medizinische Statistik und Epidemiologie, Klinikum rechts der Isar, Technische Universität München
| | - Thorben Breitkreuz
- AQUA—Institute for Applied Quality Improvement and Research in Health Care GmbH, Göttingen
| | - Alexander Zimmermann
- Department of Vascular and Endovascular Surgery/Vascular Center, Klinikum rechts der Isar der Technischen Universität München
| | - Michael Kallmayer
- Department of Vascular and Endovascular Surgery/Vascular Center, Klinikum rechts der Isar der Technischen Universität München
| |
Collapse
|