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Zhang X, Fan Z, Zhao P, Ye X, Deng X, Guidoin R, Liu M. Elucidating the hemodynamic impact of residual stenosis post-carotid artery stenting: A numerical study. Med Phys 2024. [PMID: 39255333 DOI: 10.1002/mp.17386] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2024] [Revised: 07/24/2024] [Accepted: 08/23/2024] [Indexed: 09/12/2024] Open
Abstract
BACKGROUND Residual stenosis (RS) and hemodynamics demonstrate a significant correlation with postoperative in-stent restenosis/thrombosis following carotid artery stenting (CAS). PURPOSE This study endeavors to elucidate the potential associations between RS and adverse postoperative hemodynamic factors. METHODS This study utilized 46 patient-specific carotid artery models post-stenting, which were categorized into two groups based on the presence of RS: the normal group (N, n = 23) and the RS group (RS, n = 23). A comparative analysis was conducted to evaluate the discrepancies in geometry and adverse hemodynamic parameters, alongside investigating the potential correlation between hemodynamic and geometric parameters. RESULTS The results reveal that a higher reflux flow volume is discernible in the RS group during low-velocity phases of the cardiac cycle, concomitant with an augmented extent of areas exposed to oscillatory shear stress and extended particle residence time. Moreover, the adverse hemodynamic parameters exhibit a positive correlation with the degree of stent expansion, stent length in the common carotid artery (CCA), and the distal slope of the RS. CONCLUSION The distal slope and tortuosity of RS significantly influence the development of adverse hemodynamic conditions post-stenting, exacerbating the hemodynamic environment near the stenosis. Interestingly, while an extended stent length in the internal carotid artery (ICA) region improves hemodynamics by reducing flow disturbance, a longer stent in the CCA significantly worsens these conditions. Hence, it is prudent to analyze the characteristics of the local lesion regions to optimize the strategy for stent implantation.
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Affiliation(s)
- Xianghao Zhang
- School of Mechanical Engineering, Jiangsu University of Technology, Changzhou, Jiangsu, China
- Key Laboratory for Biomechanics and Mechanobiology of Ministry of Education, School of Biological Science and Medical Engineering, Beihang University, Beijing, China
| | - Zhenmin Fan
- School of Mechanical Engineering, Jiangsu University of Technology, Changzhou, Jiangsu, China
| | - Pengfei Zhao
- Department of Radiology, Beijing Friendship Hospital, Capital Medical University, Beijing, China
| | - Xia Ye
- School of Mechanical Engineering, Jiangsu University of Technology, Changzhou, Jiangsu, China
| | - Xiaoyan Deng
- Key Laboratory for Biomechanics and Mechanobiology of Ministry of Education, School of Biological Science and Medical Engineering, Beihang University, Beijing, China
| | - Robert Guidoin
- Department of Surgery, Universit´e Laval and Division of Regenerative Medicine, CHU de Qu´ebec Research Centre, Québec City, Quebec, Canada
| | - Mingyuan Liu
- Department of Vascular Surgery, Beijing Friendship Hospital, Beijing Center for Vascular Surgery, Capital Medical University, Beijing, China
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Leung JH, Karmakar R, Mukundan A, Lin WS, Anwar F, Wang HC. Technological Frontiers in Brain Cancer: A Systematic Review and Meta-Analysis of Hyperspectral Imaging in Computer-Aided Diagnosis Systems. Diagnostics (Basel) 2024; 14:1888. [PMID: 39272675 PMCID: PMC11394276 DOI: 10.3390/diagnostics14171888] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2024] [Revised: 08/19/2024] [Accepted: 08/23/2024] [Indexed: 09/15/2024] Open
Abstract
Brain cancer is a substantial factor in the mortality associated with cancer, presenting difficulties in the timely identification of the disease. The precision of diagnoses is significantly dependent on the proficiency of radiologists and neurologists. Although there is potential for early detection with computer-aided diagnosis (CAD) algorithms, the majority of current research is hindered by its modest sample sizes. This meta-analysis aims to comprehensively assess the diagnostic test accuracy (DTA) of computer-aided design (CAD) models specifically designed for the detection of brain cancer utilizing hyperspectral (HSI) technology. We employ Quadas-2 criteria to choose seven papers and classify the proposed methodologies according to the artificial intelligence method, cancer type, and publication year. In order to evaluate heterogeneity and diagnostic performance, we utilize Deeks' funnel plot, the forest plot, and accuracy charts. The results of our research suggest that there is no notable variation among the investigations. The CAD techniques that have been examined exhibit a notable level of precision in the automated detection of brain cancer. However, the absence of external validation hinders their potential implementation in real-time clinical settings. This highlights the necessity for additional studies in order to authenticate the CAD models for wider clinical applicability.
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Affiliation(s)
- Joseph-Hang Leung
- Department of Radiology, Ditmanson Medical Foundation Chia-yi Christian Hospital, Chia Yi 60002, Taiwan
| | - Riya Karmakar
- Department of Mechanical Engineering, National Chung Cheng University, 168, University Rd., Min Hsiung, Chia Yi 62102, Taiwan
| | - Arvind Mukundan
- Department of Mechanical Engineering, National Chung Cheng University, 168, University Rd., Min Hsiung, Chia Yi 62102, Taiwan
| | - Wen-Shou Lin
- Neurology Division, Department of Internal Medicine, Kaohsiung Armed Forces General Hospital, 2, Zhongzheng 1st. Rd., Lingya District, Kaohsiung City 80284, Taiwan
| | - Fathima Anwar
- Faculty of Allied Health Sciences, The University of Lahore, 1-Km Defense Road, Lahore 54590, Punjab, Pakistan
| | - Hsiang-Chen Wang
- Department of Mechanical Engineering, National Chung Cheng University, 168, University Rd., Min Hsiung, Chia Yi 62102, Taiwan
- Department of Medical Research, Dalin Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, No. 2, Minsheng Road, Dalin, Chia Yi 62247, Taiwan
- Department of Technology Development, Hitspectra Intelligent Technology Co., Ltd., 8F.11-1, No. 25, Chenggong 2nd Rd., Qianzhen Dist., Kaohsiung City 80661, Taiwan
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Park S, Kim BJ, Choi HY, Chang DI, Woo HG, Heo SH. Risk factors of in-stent restenosis after carotid angioplasty and stenting: long-term follow-up study. Front Neurol 2024; 15:1411045. [PMID: 39175764 PMCID: PMC11340531 DOI: 10.3389/fneur.2024.1411045] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2024] [Accepted: 07/17/2024] [Indexed: 08/24/2024] Open
Abstract
Background After carotid artery angioplasty with stenting (CAS), it is unclear which risk factors are related to long-term outcomes, including in-stent restenosis (ISR). This study aimed to assess the factors associated with restenosis after CAS with a median follow-up of 35.7 months. Materials and methods Patients who underwent CAS from January 2013 to December 2018 were included if they had symptomatic or asymptomatic carotid artery stenosis. The carotid Doppler ultrasonography (CDU) was followed up after the procedure. We defined at least 50% restenosis using the criteria that the internal carotid artery (ICA) peak systolic velocity (PSV) was greater than 224 cm/s or the ICA to common carotid artery PSV ratio was higher than 3.4. The risk factors for ISR were also assessed. Results Of the 189 patients, 122 had symptomatic carotid artery stenosis, and 67 had asymptomatic carotid artery stenosis. Patients were evaluated by CDU for a median of 35.7 months (interquartile range 19.5 to 70.0). Kaplan-Meier analysis showed that the longest time to ISR was 39 months, and ISR-free was better in the asymptomatic CAS group. In all groups, ISR was independently associated with current smoker [adjusted odds ratio (aOR), 3.425; 95% confidence interval (CI), 1.086 to 10.801] and elevated ICA PSV at baseline (aOR, 1.004; 95% CI, 1.001 to 1.007). Conclusion Independent risk factors for ISR in the CAS group included current smoking and elevated ICA PSV at baseline. In the symptomatic CAS group, alcohol was independently associated with the ISR. ISR did not occur after 39 months from the CAS procedure in our study patients. Future studies with extended follow-up are necessary to fully understand the long-term outcomes of CAS.
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Affiliation(s)
- Sangil Park
- Department of Neurology, Uijeongbu Eulji Medical Center, Eulji University School of Medicine, Uijeongbu, Republic of Korea
- Department of Neurology, Kyung Hee University Hospital, Kyung Hee University College of Medicine, Seoul, Republic of Korea
| | - Bum Joon Kim
- Department of Neurology, Asan Medical Center, College of Medicine, University of Ulsan, Seoul, Republic of Korea
| | - Hye-Yeon Choi
- Department of Neurology, Kyung Hee University Hospital at Gangdong, Kyung Hee University College of Medicine, Seoul, Republic of Korea
- Department of Neurology, Gangnam Severance Hospital, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Dae-Il Chang
- Department of Neurology, Kyung Hee University Hospital, Kyung Hee University College of Medicine, Seoul, Republic of Korea
| | - Ho Geol Woo
- Department of Neurology, Kyung Hee University Hospital, Kyung Hee University College of Medicine, Seoul, Republic of Korea
| | - Sung Hyuk Heo
- Department of Neurology, Kyung Hee University Hospital, Kyung Hee University College of Medicine, Seoul, Republic of Korea
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Zhu J, Jhang J, Yu H, Mushlin AI, Kamel H, Alemayehu N, Giardina JC, Gupta A, Pandya A. Cost-Effectiveness of Screening Asymptomatic Carotid Stenosis by Atherosclerotic Cardiovascular Risk. MEDRXIV : THE PREPRINT SERVER FOR HEALTH SCIENCES 2024:2023.11.28.23299146. [PMID: 38798437 PMCID: PMC11118553 DOI: 10.1101/2023.11.28.23299146] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/29/2024]
Abstract
Importance Extracranial internal carotid artery stenosis (50-99% arterial narrowing) is an important risk factor for ischemic stroke. Yet, the benefits and harms of targeted screening for asymptomatic carotid artery stenosis (ACAS) have not been assessed in population-based studies. Objective To estimate the cost-effectiveness of one-time, targeted ACAS screening stratified by atherosclerotic cardiovascular disease (ASCVD) risk using the American Heart Association's Pooled Cohort Equations. Design Setting and Participants We developed a lifetime microsimulation model of ACAS and stroke for a hypothetical cohort representative of US adults aged 50-80 years without stroke history. We used the Cardiovascular Health Study to estimate the probability and severity of ACAS based on individual characteristics (e.g., age, sex, smoking status, blood pressure, and cholesterol). Stroke risks were functions of these characteristics and ACAS severity. In the model, individuals testing positive for >70% stenosis with Duplex ultrasound and a confirmatory diagnostic test undergo revascularization, which may reduce the risk of stroke but also introduces complication risks. Diagnostic performance parameters, revascularization benefits and risks, utility weights, and costs were estimated from published sources. Cost-effectiveness was assessed from the health care sector perspective using a $100,000/quality-adjusted life year (QALY) threshold. Main Outcomes and Measures Estimated stroke events prevented, lifetime costs, QALYs, and incremental cost-effectiveness ratios (ICERs) associated with ACAS screening. Costs (2023 USD) and QALYs were discounted at 3% annually. Results We found that screening individuals with a 10-year ASCVD risk >30% was the most cost-effective strategy, with an ICER of $89,000/QALY. This strategy would make approximately 11.9% of the population eligible for screening, averting an estimated 24,084 strokes. Results were sensitive to variations in the efficacy and complication risk of revascularization. In probabilistic sensitivity analysis, screening those in lower ASCVD risk groups (0-20%) only had a 0.6% chance of being cost-effective. Conclusion and Relevance A one-time screening may only be cost-effective for adults at a relatively high ASCVD risk. Our findings provide a framework that can be adapted as future clinical trial data continue to improve our understanding of the role of revascularization and intensive medical therapy in contemporary stroke prevention secondary to carotid disease.
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Giannopoulos S, Sagris M, Giannopoulos S, Tzoumas A, Kokkinidis DG, Texakalidis P, Koutsias G, Volteas P, Jing L, Malgor RD. Embolic protection devices for carotid artery stenting: A network meta-analysis. Vascular 2024; 32:447-457. [PMID: 36394946 DOI: 10.1177/17085381221140616] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/17/2024]
Abstract
OBJECTIVES Carotid artery stenting (CAS) is an alternative treatment option for patients at high risk for carotid endarterectomy (CEA) but has been correlated with increased risk for distal embolization and periprocedural stroke despite the use of adjunctive embolic protection devices (EPD). This study compared four types of EPDs and their intra and periprocedural related complications. METHODS A systematic review of the literature was conducted in PubMed/Medline to identify studies that investigated the outcomes of CAS with adjuvant use of EPDs, including Proximal Balloon (PB), Distal Filter (DF), and Distal Balloon (DB) strategy. Continuous flow reversal performed via transcarotid approach by a commercially available device as an embolic protection strategy was intentionally excluded based on its distinct procedural characteristics and lack of availability outside of the United States. This network meta-analysis was performed according to the PRISMA (Preferred Reporting Items for Systematic reviews and Meta-Analyses) guidelines. RESULTS Overall, 45 studies, consisting of 7600 participants satisfied the predetermined search criteria and were included in this network meta-analysis. Overall, 13 studies provided data regarding the number of patients with new ischemic lesions detected in the DW-MRI. DF (OR: 3.15; 95% CI: 1.54-6.44; p = 0.002) and DB (OR: 2.28; 95% CI: 1.58-3.29; p < 0.001) were associated with higher odds of new ischemic lesions compared to PB on DW-MRI imaging. No statistical difference was identified between DB versus DF groups (OR: 1.48; 95% CI: 0.73-2.59; p = 0.317). 36 and 27 studies reported on periprocedural stroke and transient ischemic attack (TIA) rates, respectively, showing similar odds of neurologic adverse events between all three groups. CONCLUSIONS PB deployment during CAS is superior to DF and DB in preventing distal embolization phenomena. However, no statistically significant difference in TIA and stroke rate was found among any of the analyzed EPD groups. Further research is warranted to investigate the association of embolic phenomena on imaging after CAS with clinically significant neurologic deficits.
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Affiliation(s)
- Stefanos Giannopoulos
- Division of Vascular and Endovascular Surgery, Department of Surgery, Stony Brook University Hospital, Stony Brook, NY, USA
| | | | - Spyridon Giannopoulos
- First Department of Surgery, National and Kapodistrian University of Athens, Laikon General Hospital, Athens, Greece
| | - Andreas Tzoumas
- Department of Medicine, University of Cincinnati Health, Cincinnati, OH, USA
| | - Damianos G Kokkinidis
- Section of Cardiovascular Medicine, Yale University/Yale New Haven Hospital, New Haven, CT, USA
| | - Pavlos Texakalidis
- Department of Neurosurgery, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - George Koutsias
- Aristotle University of Thessaloniki, Division of Vascular Surgery, 2(nd) Department of Surgery, Thessaloniki, Greece
| | - Panagiotis Volteas
- Division of Vascular and Endovascular Surgery, Department of Surgery, Stony Brook University Hospital, Stony Brook, NY, USA
| | - Li Jing
- Division of Vascular and Endovascular Surgery, Department of Surgery, Stony Brook University Hospital, Stony Brook, NY, USA
| | - Rafael D Malgor
- Division of Vascular Surgery and Endovascular Therapy, University of Colorado, Anschutz Medical Center, Aurora, CO, USA
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Zhang Y, Yu M, Tong C, Zhao Y, Han J. CA-UNet Segmentation Makes a Good Ischemic Stroke Risk Prediction. Interdiscip Sci 2024; 16:58-72. [PMID: 37626263 DOI: 10.1007/s12539-023-00583-x] [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: 04/10/2023] [Revised: 07/13/2023] [Accepted: 07/19/2023] [Indexed: 08/27/2023]
Abstract
Stroke is still the World's second major factor of death, as well as the third major factor of death and disability. Ischemic stroke is a type of stroke, in which early detection and treatment are the keys to preventing ischemic strokes. However, due to the limitation of privacy protection and labeling difficulties, there are only a few studies on the intelligent automatic diagnosis of stroke or ischemic stroke, and the results are unsatisfactory. Therefore, we collect some data and propose a 3D carotid Computed Tomography Angiography (CTA) image segmentation model called CA-UNet for fully automated extraction of carotid arteries. We explore the number of down-sampling times applicable to carotid segmentation and design a multi-scale loss function to resolve the loss of detailed features during the process of down-sampling. Moreover, based on CA-Unet, we propose an ischemic stroke risk prediction model to predict the risk in patients using their 3D CTA images, electronic medical records, and medical history. We have validated the efficacy of our segmentation model and prediction model through comparison tests. Our method can provide reliable diagnoses and results that benefit patients and medical professionals.
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Affiliation(s)
- Yuqi Zhang
- School of Computer Science and Engineering, Beihang University, Beijing, China
- State Key Laboratory of Virtual Reality Technology and Systems, Beihang University, Beijing, China
| | - Mengbo Yu
- School of Computer Science and Engineering, Beihang University, Beijing, China
- State Key Laboratory of Virtual Reality Technology and Systems, Beihang University, Beijing, China
| | - Chao Tong
- School of Computer Science and Engineering, Beihang University, Beijing, China.
- State Key Laboratory of Virtual Reality Technology and Systems, Beihang University, Beijing, China.
| | - Yanqing Zhao
- Department of Interventional Radiology and Vascular Surgery, Peking University Third Hospital, Beijing, China
| | - Jintao Han
- Department of Interventional Radiology and Vascular Surgery, Peking University Third Hospital, Beijing, China
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Ismail A, Ravipati S, Gonzalez-Hernandez D, Mahmood H, Imran A, Munoz EJ, Naeem S, Abdin ZU, Siddiqui HF. Carotid Artery Stenosis: A Look Into the Diagnostic and Management Strategies, and Related Complications. Cureus 2023; 15:e38794. [PMID: 37303351 PMCID: PMC10250083 DOI: 10.7759/cureus.38794] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/09/2023] [Indexed: 06/13/2023] Open
Abstract
Carotid stenosis (CS) is a buildup of atherosclerotic plaque within the artery leading to a wide range of symptoms, from mild symptoms, including blurred vision and confusion, to much more life-threatening presentations, including paralysis due to stroke. The presentation is insidious, with symptoms exhibiting predominantly at severe stenosis; hence the emphasis is placed on the importance of early diagnosis, treatment, and lifestyle modifications. CS is seen undergoing almost the same pathogenesis of any atherosclerotic plaque formation, from endothelial damage of the artery lumen to the formation of a fibrous cap with a foam cell, lipid-filled core. The findings of our review article were consistent with the recent literature, depicting that comorbid hypertension, diabetes, and chronic kidney disease (CKD), and lifestyle aspects, including smoking and diet, played the most salient role in plaque development. Among several imaging modalities, duplex ultrasound (DUS) imaging is the widely preferred method in clinical practice. Carotid endarterectomy (CEA) and carotid stenting are the primarily advocated procedures for symptomatic severe stenosis, with similar long-term outcomes. Although, earlier clinical trials showed promising results in mitigating the risk of stroke among asymptomatic severe CS with surgical intervention. However, recent advancements have shifted the focus to medical management alone due to comparable results among the asymptomatic population. Both surgical and medical regimens are beneficial in treating patients, but it is still an ongoing debate as to which is predominantly superior. The currently advancing trials and research will help elucidate definitive guidelines. However, the massive impact of lifestyle modifications advocates some degree of individualized multidisciplinary management strategies.
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Affiliation(s)
- Aqsa Ismail
- Department of Medicine, United Medical and Dental College, Karachi, PAK
| | - Shivani Ravipati
- Department of Medicine, Dr. Pinnamaneni Siddhartha Institute of Medical Sciences and Research Foundation, Vijayawada, IND
| | | | - Hashim Mahmood
- Department of Medicine, University College of Medicine and Dentistry, University of Lahore, Lahore, PAK
| | - Alizay Imran
- Department of Surgery, Windsor University School of Medicine, Chicago, USA
| | - Eduardo J Munoz
- Department of General Medicine, Montemorelos University, Montemorelos, MEX
| | - Saad Naeem
- Department of Internal Medicine, Faisalabad Medical University, Faisalabad, PAK
- Department of Internal Medicine, Punjab Social Security Hospital, Faisalabad, PAK
| | - Zain U Abdin
- Department of Medicine, District Head Quarters Hospital, Faisalabad, PAK
| | - Humza F Siddiqui
- Department of Medicine, Jinnah Sindh Medical University, Karachi, PAK
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Willman M, Lucke-Wold B. Commentary on a case report and literature review of acute carotid stent thrombosis. World J Clin Cases 2023; 11:1666-1668. [PMID: 36926393 PMCID: PMC10011977 DOI: 10.12998/wjcc.v11.i7.1666] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/04/2022] [Revised: 01/04/2023] [Accepted: 02/15/2023] [Indexed: 03/02/2023] Open
Abstract
In this commentary on the article entitled “Acute carotid stent thrombosis: A case report and literature review”, the key points of the article are discussed. Acute carotid stent thrombosis (ACST) in the setting of carotid artery stenting (CAS) represents a rare but potentially catastrophic event. There is a wide range of treatment options available, including carotid endarterectomy, which is generally recommended for cases of refractory ACST. While there is no standard treatment regimen, dual antiplatelet therapy is typically recommended both before and after CAS to reduce risk of ACST.
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Affiliation(s)
- Matthew Willman
- College of Medicine, University of Florida, Gainesville, FL 32610, United States
| | - Brandon Lucke-Wold
- Department of Neurosurgery, University of Florida, Gainesville, Florida 32608, United States
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Wang J, Lu J, Qi P, Li C, Yang X, Chen K, Wang D. Association between kinking of the cervical carotid or vertebral artery and ischemic stroke/TIA. Front Neurol 2022; 13:1008328. [PMID: 36176562 PMCID: PMC9513150 DOI: 10.3389/fneur.2022.1008328] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2022] [Accepted: 08/19/2022] [Indexed: 11/18/2022] Open
Abstract
Introduction Kinking of the cervical carotid or vertebral artery is a common structural abnormality in patients with cerebrovascular disease. However, there is no consensus about the relationship between kinking and ischemic stroke/TIA. We aim to determine the effect of arterial kinking on ischemic stroke/TIA. Methods A retrospective study was performed on patients who underwent cerebral angiography with DSA between January 2014 and December 2018. Demographic information and comorbidities were recorded. Each anatomical circulation system was defined as an observation unit. Kinking and stenosis of each circulation unit were recorded. Ischemia stroke or TIA within 6 months and its location were assessed as an outcome. Logistic regression with a generalized estimating equation approach was used for the analysis. Results A total of 1,062 patients (mean age 57.9 ± 14.5 years, 740 males and 322 females) were included in the study. Of the patients, 369 (35%) had kinking and 771 (73%) had ischemic stroke/TIA. There were 110 left anterior, 90 right anterior, and 308 posterior circulation units, among which 343 had mild, 160 had moderate, and 243 had severe kinking. Multivariate regression analysis showed that ischemic stroke/TIA was associated with severe kinking (OR 1.39, 95% CI 1.03-1.88, P = 0.03). Posterior circulation was more vulnerable to acute ischemia than left anterior and right anterior circulation (OR 3.58, 95% CI 2.81-4.56, P < 0.0001). Conclusion Severe kinking of the cervical carotid or vertebral artery may be associated with a higher risk of ischemic stroke/TIA, especially when the kinking is located in the posterior circulation.
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Affiliation(s)
- Junjie Wang
- Department of Neurosurgery, Beijing Hospital, National Center of Gerontology, Beijing, China
- Institute of Geriatric Medicine, Chinese Academy of Medical Sciences, Beijing, China
| | - Jun Lu
- Department of Neurosurgery, Beijing Hospital, National Center of Gerontology, Beijing, China
- Institute of Geriatric Medicine, Chinese Academy of Medical Sciences, Beijing, China
| | - Peng Qi
- Department of Neurosurgery, Beijing Hospital, National Center of Gerontology, Beijing, China
- Institute of Geriatric Medicine, Chinese Academy of Medical Sciences, Beijing, China
| | - Chunwei Li
- Department of Neurosurgery, Beijing Hospital, National Center of Gerontology, Beijing, China
- Institute of Geriatric Medicine, Chinese Academy of Medical Sciences, Beijing, China
| | - Ximeng Yang
- Department of Neurosurgery, Beijing Hospital, National Center of Gerontology, Beijing, China
- Institute of Geriatric Medicine, Chinese Academy of Medical Sciences, Beijing, China
| | - Kunpeng Chen
- Department of Neurosurgery, Beijing Hospital, National Center of Gerontology, Beijing, China
- Institute of Geriatric Medicine, Chinese Academy of Medical Sciences, Beijing, China
| | - Daming Wang
- Department of Neurosurgery, Beijing Hospital, National Center of Gerontology, Beijing, China
- Institute of Geriatric Medicine, Chinese Academy of Medical Sciences, Beijing, China
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Sun T, He Y, Wang F, Mao B, Han M, Zhao P, Wu W, Wang Y, Li X, Wang D. Hybrid surgery versus endovascular intervention for patients with chronic internal carotid artery occlusion: A single-center retrospective study. Front Surg 2022; 9:976318. [PMID: 36117814 PMCID: PMC9478368 DOI: 10.3389/fsurg.2022.976318] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2022] [Accepted: 08/11/2022] [Indexed: 11/13/2022] Open
Abstract
Objective Chronic internal carotid artery occlusion (CICAO) can cause transient ischemic attack (TIA) and ischemic stroke. Carotid artery stenting (CAS) with embolic protection devices and hybrid surgery combining carotid endarterectomy and endovascular treatment are effective methods for carotid revascularization. The objective of this study was to evaluate and compare the effect and safety of the two surgical procedures. Methods This was a single-center retrospective study. In this study, 44 patients who underwent hybrid surgery and 35 who underwent endovascular intervention (EI) at our center were enrolled consecutively between May 2016 and March 2022. All patients were classified into four groups (A-D), as described by Hasan et al. We recorded and analyzed clinical data, angiographic characteristics, technical success rate, perioperative complications, and follow-up data. Results There was no significant difference in baseline characteristics between hybrid surgery group and EI group, except for plasma high density lipoproteins (HDL) levels (median [interquartile range]: hybrid surgery, 0.99 [0.88–1.18] vs. EI, 0.85 [0.78–0.98] mmol/L, P = 0.001). The technical success rate of hybrid surgery was higher than that of EI (37/44 [84.1%] vs. 18/35 [51.4%], P = 0.002; type A: 15/16 [93.8%] vs. 10/11 [90.9%], P = 1.000; type B: 9/10 [90.0%] vs. 5/7 [71.4%], P = 0.537; type C: 12/15 [80.0%] vs. 3/12 [25.0%], P = 0.004; type D: 1/3 [33.3%] vs. 0/5 [0%], P = 0.375). No significant difference was observed in the incidence of perioperative complications between the two procedures (hybrid surgery: 7/44 [15.9%] vs. EI: 6/35 [17.1%], P = 0.883). In addition, there were no significant differences in the rates of stroke and restenosis during follow-up. Conclusions For patients with symptomatic CICAO, hybrid surgery may have an advantage over EI in successfully recanalizing occluded segments. There was no significant difference in safety and restenosis between hybrid surgery and EI.
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Affiliation(s)
- Tao Sun
- Department of Neurosurgery, Qilu Hospital of Shandong University, Cheeloo College of Medicine and Institute of Brain and Brain-Inspired Science, Shandong University, Jinan, China
- Jinan Microecological Biomedicine Shandong Laboratory and Shandong Key Laboratory of Brain Function Remodeling, Jinan, China
| | - Yiming He
- Department of Neurosurgery, Qilu Hospital of Shandong University, Cheeloo College of Medicine and Institute of Brain and Brain-Inspired Science, Shandong University, Jinan, China
- Jinan Microecological Biomedicine Shandong Laboratory and Shandong Key Laboratory of Brain Function Remodeling, Jinan, China
| | - Fei Wang
- Department of Neurosurgery, Qilu Hospital of Shandong University, Cheeloo College of Medicine and Institute of Brain and Brain-Inspired Science, Shandong University, Jinan, China
- Jinan Microecological Biomedicine Shandong Laboratory and Shandong Key Laboratory of Brain Function Remodeling, Jinan, China
| | - Bo Mao
- Department of Neurosurgery, Qilu Hospital of Shandong University, Cheeloo College of Medicine and Institute of Brain and Brain-Inspired Science, Shandong University, Jinan, China
- Jinan Microecological Biomedicine Shandong Laboratory and Shandong Key Laboratory of Brain Function Remodeling, Jinan, China
| | - Mengtao Han
- Department of Neurosurgery, Qilu Hospital of Shandong University, Cheeloo College of Medicine and Institute of Brain and Brain-Inspired Science, Shandong University, Jinan, China
- Jinan Microecological Biomedicine Shandong Laboratory and Shandong Key Laboratory of Brain Function Remodeling, Jinan, China
| | - Peng Zhao
- Department of Neurosurgery, Qilu Hospital of Shandong University, Cheeloo College of Medicine and Institute of Brain and Brain-Inspired Science, Shandong University, Jinan, China
- Jinan Microecological Biomedicine Shandong Laboratory and Shandong Key Laboratory of Brain Function Remodeling, Jinan, China
| | - Wei Wu
- Department of Neurology, Qilu Hospital of Shandong University, Cheeloo College of Medicine, Shandong University, Jinan, China
| | - Yunyan Wang
- Department of Neurosurgery, Qilu Hospital of Shandong University, Cheeloo College of Medicine and Institute of Brain and Brain-Inspired Science, Shandong University, Jinan, China
- Jinan Microecological Biomedicine Shandong Laboratory and Shandong Key Laboratory of Brain Function Remodeling, Jinan, China
| | - Xingang Li
- Department of Neurosurgery, Qilu Hospital of Shandong University, Cheeloo College of Medicine and Institute of Brain and Brain-Inspired Science, Shandong University, Jinan, China
- Jinan Microecological Biomedicine Shandong Laboratory and Shandong Key Laboratory of Brain Function Remodeling, Jinan, China
| | - Donghai Wang
- Department of Neurosurgery, Qilu Hospital of Shandong University, Cheeloo College of Medicine and Institute of Brain and Brain-Inspired Science, Shandong University, Jinan, China
- Jinan Microecological Biomedicine Shandong Laboratory and Shandong Key Laboratory of Brain Function Remodeling, Jinan, China
- Department of Neurosurgery, Qilu Hospital of Shandong University Dezhou Hospital (Dezhou, China), Cheeloo Hospital of Shandong University, Jinan, China
- Correspondence: Donghai Wang
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11
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Achim A, Lackó D, Hüttl A, Csobay-Novák C, Csavajda Á, Sótonyi P, Merkely B, Nemes B, Ruzsa Z. Impact of Diabetes Mellitus on Early Clinical Outcome and Stent Restenosis after Carotid Artery Stenting. J Diabetes Res 2022; 2022:4196195. [PMID: 35860343 PMCID: PMC9293551 DOI: 10.1155/2022/4196195] [Citation(s) in RCA: 16] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/24/2021] [Revised: 01/28/2022] [Accepted: 06/09/2022] [Indexed: 12/31/2022] Open
Abstract
Background Diabetes mellitus is closely related to both the severity of carotid disease and its outcome after revascularization. Carotid artery stenting (CAS) has emerged as a viable alternative to surgical endarterectomy but little is known about the impact of diabetes after CAS. Methods A consecutive cohort of 1940 patients undergoing CAS in two institutions was divided into two groups, diabetics and nondiabetics, and major cerebrovascular events (MACCEs) were analyzed at 30 days post-CAS and at 1 year follow-up. Results There were 730 patients with diabetes, with significantly higher BMI, hypertension, chronic dialysis, and dyslipidemia frequency (p < 0.05). There was no significant difference between the two groups in terms of early and late MACCEs (composite of transient ischemic attack, major stroke, myocardial infarction, and death), with an early rate of 3.5% nondiabetics vs. 5.3%, p = 0.08 and 2.4 nondiabetics vs. 2.3% diabetics, p = 0.1 at 12 months. Overall stroke/death rate in the asymptomatic patients was 2.4%, and the restenosis rate was higher in the diabetes population (2.3% vs. 1%, p = 0.04). Conclusion The presence of diabetes was associated with an acceptable increased periprocedural risk for CAS, but no further additional risk emerged during longer term follow-up. Diabetes may precipitate the rate of early in-stent restenosis.
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Affiliation(s)
- Alexandru Achim
- Department of Internal Medicine, Division of Invasive Cardiology, University of Szeged, Szeged, Hungary
- Department of Invasive Cardiology, Medicala 1 Clinic, University of Medicine and Pharmacy “Iuliu Hatieganu”, Cluj-Napoca, Romania
| | - Dávid Lackó
- Semmelweis University, Cardiac and Vascular Center, Budapest, Hungary
| | - Artúr Hüttl
- Semmelweis University, Cardiac and Vascular Center, Budapest, Hungary
| | | | - Ádám Csavajda
- Bács-Kiskun County Hospital, Teaching Hospital of the Szent-Györgyi Albert Medical University, Kecskemét, Hungary
| | - Péter Sótonyi
- Semmelweis University, Cardiac and Vascular Center, Budapest, Hungary
| | - Béla Merkely
- Semmelweis University, Cardiac and Vascular Center, Budapest, Hungary
| | - Balázs Nemes
- Semmelweis University, Cardiac and Vascular Center, Budapest, Hungary
| | - Zoltán Ruzsa
- Department of Invasive Cardiology, Medicala 1 Clinic, University of Medicine and Pharmacy “Iuliu Hatieganu”, Cluj-Napoca, Romania
- Semmelweis University, Cardiac and Vascular Center, Budapest, Hungary
- Bács-Kiskun County Hospital, Teaching Hospital of the Szent-Györgyi Albert Medical University, Kecskemét, Hungary
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12
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Liao YJ, Hsiao TH, Lin CH, Hsu CS, Chang YL, Chen YW, Hsu CY, Chen YM, Wu MF. Clopidogrel Use and CYP2C19 Genotypes in Patients Undergoing Vascular Intervention Procedure: A Hospital-Based Study. Pharmgenomics Pers Med 2022; 15:81-89. [PMID: 35140503 PMCID: PMC8819696 DOI: 10.2147/pgpm.s335860] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2021] [Accepted: 01/05/2022] [Indexed: 02/03/2023] Open
Abstract
Purpose Clopidogrel is widely used in coronary artery, peripheral arterial, and cerebrovascular disease. We aimed to study the association of the CYP2C19 phenotype with cardiovascular outcomes and interventional procedures in a hospital-based population. Patients and Methods This cross-sectional, retrospective study enrolled patients with prior exposure to clopidogrel at the Taichung Veterans General Hospital (TCVGH) using data extracted from the Taiwan Precision Medicine Initiative (TPMI). Data on the CYP2C19 phenotype, drug-prescription profile, comorbidities, vascular intervention procedures, and hospitalization due to acute myocardial infarction (AMI) or stroke of clopidogrel users were analyzed. Results From the 32,728 patients in the TCVGH-TPMI cohort, we selected 2687 clopidogrel users. A total of 400 (14.9%) clopidogrel poor metabolizers (PMs), 1235 (46.0%) intermediate metabolizers (IMs), and 1052 (39.2%) extensive metabolizers (EMs) were identified. The predominant loss-of-function allele is *2. In 2687 patients with clopidogrel exposure, the CYP2C19 PM phenotype was unassociated with hospitalization due to AMI or stroke after adjusting for comorbidities and carotid angiographies. Among the 1554 clopidogrel users who underwent cardiovascular intervention, 193 (12.4%) received two or more types of interventional procedures. Compared with non-PMs, patients with the PM phenotype had a higher risk of multiple carotid interventions (OR: 3.13, 95% CI: 1.19–8.22). Conclusion In this hospital-wide cohort, 8.2% were clopidogrel users, of which 14.9% were CYP2C19 PMs. The result of this study does not support universal genotyping of CYP2C19 in all clopidogrel users to identify risks for stroke and AMI. CYP2C19 PMs are more likely to undergo multiple carotid interventions than non-PMs. Prospective studies to investigate the association of the CYP2C19 genotype and carotid interventions and outcomes are needed to validate our results.
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Affiliation(s)
- Yi-Ju Liao
- Department of Pharmacy, Taichung Veterans General Hospital, Taichung, Taiwan
| | - Tzu-Hung Hsiao
- Department of Medical Research, Taichung Veterans General Hospital, Taichung, Taiwan
- Department of Public Health, Fu Jen Catholic University, New Taipei City, Taiwan
- Institute of Genomics and Bioinformatics, National Chung Hsing University, Taichung, Taiwan
| | - Ching-Heng Lin
- Department of Medical Research, Taichung Veterans General Hospital, Taichung, Taiwan
- Department of Public Health, Fu Jen Catholic University, New Taipei City, Taiwan
- Institute of Public Health and Community Medicine Research Center, National Yang Ming Chiao Tung University, Taipei, Taiwan
- Department of Industrial Engineering and Enterprise Information, Tunghai University, Taichung, Taiwan
| | - Chun-Sheng Hsu
- Department of Physical Medicine and Rehabilitation, Taichung Veterans General Hospital, Taichung, Taiwan
- Department of Public Health and Institute of Public Health, Chung Shan Medical University, Taichung, Taiwan
- School of Medicine, National Defense Medical Center, Taipei, Taiwan
- Department of Post-Baccalaureate Medicine, College of Medicine, National Chung Hsing University, Taichung, Taiwan
| | - Yen-Lin Chang
- Department of Pharmacy, Taichung Veterans General Hospital, Taichung, Taiwan
- Department of Public Health and Institute of Public Health, Chung Shan Medical University, Taichung, Taiwan
| | - Yu-Wei Chen
- Cardiovascular Center, Taichung Veterans General Hospital, Taichung, Taiwan
| | - Chiann-Yi Hsu
- Department of Medical Research, Taichung Veterans General Hospital, Taichung, Taiwan
- Biostatistics Task Force of Taichung Veterans General Hospital, Taichung, Taiwan
| | - Yi-Ming Chen
- Department of Medical Research, Taichung Veterans General Hospital, Taichung, Taiwan
- Department of Post-Baccalaureate Medicine, College of Medicine, National Chung Hsing University, Taichung, Taiwan
- Division of Allergy, Immunology and Rheumatology, Department of Internal Medicine, Taichung Veterans General Hospital, Taichung, Taiwan
- Rong Hsing Research Center for Translational Medicine & Ph.D. Program in Translational Medicine, National Chung Hsing University, Taichung, Taiwan
- School of Medicine, College of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan
- Correspondence: Yi-Ming Chen, Division of Allergy, Immunology and Rheumatology, Department of Internal Medicine, Taichung Veterans General Hospital, 1650, Section 4, Taiwan Boulevard, Xitun Dist., Taichung, 407, Taiwan, Tel +886-4-2359-2525 ext. 4400, Fax +886-4-2359-2705, Email
| | - Ming-Fen Wu
- Department of Pharmacy, Taichung Veterans General Hospital, Taichung, Taiwan
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13
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Engelter ST, Traenka C, Grond-Ginsbach C, Brandt T, Hakimi M, Worrall BB, Debette S, Pezzini A, Leys D, Tatlisumak T, Nolte CH, Lyrer P. Cervical Artery Dissection and Sports. Front Neurol 2021; 12:663830. [PMID: 34135851 PMCID: PMC8200565 DOI: 10.3389/fneur.2021.663830] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2021] [Accepted: 04/29/2021] [Indexed: 12/29/2022] Open
Abstract
Cervical artery dissection (CeAD) occurring in the context of sports is a matter of concern for CeAD patients. They seek advice on the role of sports in CeAD and on the safety of resuming sports after CeAD. The scarcity of studies and guidelines addressing these issues poses a challenge. We aimed at summarizing the current knowledge about CeAD and sports in order to provide an informed, comprehensive opinion for counseling CeAD patients. We took into account pathophysiological considerations, observations of cases reports, series, and registries, and conclusions by analogy from aortic dissection or inherited connective tissue syndromes. In summary, practicing active sports as the cause of CeAD seems uncommon. It seems recommendable to refrain from any kind of sports activities for at least 1 month, which can be extended in case of an unfavorable clinical or neurovascular course. We recommend starting with sport activities at low intensity—preferably with types of endurance sports—and to gradually increase the pace in an individually tailored manner, taking into circumstances of the occurrences of the CeAD in the individual patient (particularly in relation to sports), the meaning of sports activities for the individual well-being, the presence or absence of comorbidities and of neurological sequela, neurovascular findings, and whether there are signs of an underlying connective tissue alteration. Major limitations and several forms of bias are acknowledged. Still, in the absence of any better data, the summarized observations and considerations might help clinicians in advising and counseling patients with CeAD in clinical practice.
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Affiliation(s)
- Stefan T Engelter
- Department of Neurology and Stroke Center, University Hospital Basel and University of Basel, Basel, Switzerland.,Neurology and Neurorehabilitation, University Department of Geriatric Medicine FELIX PLATTER, University of Basel, Basel, Switzerland
| | - Christopher Traenka
- Department of Neurology and Stroke Center, University Hospital Basel and University of Basel, Basel, Switzerland.,Neurology and Neurorehabilitation, University Department of Geriatric Medicine FELIX PLATTER, University of Basel, Basel, Switzerland
| | - Caspar Grond-Ginsbach
- Neurology and Neurorehabilitation, University Department of Geriatric Medicine FELIX PLATTER, University of Basel, Basel, Switzerland.,Department of Vascular and Endovascular Surgery, Heidelberg University Hospital, Heidelberg, Germany
| | - Tobias Brandt
- Schweizerische Unfallversicherungsanstalt (SUVA), Swiss National Accident Insurance Institution, Lucerne, Switzerland
| | - Maani Hakimi
- Department of Vascular Surgery, Luzerner Kantonsspital, Lucerne, Switzerland
| | - Bradford B Worrall
- Departments of Neurology and Public Health Sciences, University of Virginia Health System, Charlottesville, VA, United States
| | - Stephanie Debette
- Department of Neurology, Bordeaux University Hospital, Bordeaux, France.,Inserm U1219, Bordeaux, France
| | - Alessandro Pezzini
- Department of Clinical and Experimental Sciences, Neurology Clinic, University of Brescia, Brescia, Italy
| | - Didier Leys
- Univ-Lille, Inserm U1171, Centre Hospitalier Universitaire (CHU) Lille, Lille, France
| | - Turgut Tatlisumak
- Department of Neurology, Sahlgrenska University Hospital and Department of Clinical Neuroscience, Institute for Neuroscience and Physiology, Sahlgrenska Academy at University of Gothenburg, Gothenburg, Sweden
| | - Christian H Nolte
- Department of Neurology, and Center for Stroke Research Berlin Charité-Universitätsmedizin Berlin, Berlin, Germany
| | - Philippe Lyrer
- Department of Neurology and Stroke Center, University Hospital Basel and University of Basel, Basel, Switzerland
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14
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Chen YC, Tsai SJ. Bilateral cerebral infarction in diabetic ketoacidosis and bilateral internal carotid artery occlusion: A case report and review of literature. World J Clin Cases 2021; 9:3787-3795. [PMID: 34046484 PMCID: PMC8130090 DOI: 10.12998/wjcc.v9.i15.3787] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/30/2021] [Revised: 03/02/2021] [Accepted: 03/29/2021] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Diabetic ketoacidosis (DKA) is a serious complication of type 1 diabetes mellitus (T1DM). Very rarely does DKA lead to cerebral edema, and it is even rarer for it to result in cerebral infarction. Bilateral internal carotid artery occlusion (BICAO) is also rare and can cause fatal stroke. Moreover, case reports about acute cerebral infarction throughout both internal carotid arteries with simultaneous BICAO are very scarce. In this study, we present a patient with BICAO, T1DM, hypertension, and hyperlipidemia, who had a catastrophic bilateral cerebral infarction after a DKA episode. We briefly introduce BICAO and the mechanisms by which DKA results in cerebral infarction. CASE SUMMARY A 41-year-old woman presented with ischemic stroke that took place 3 mo prior over the left corona radiata, bilateral frontal lobe, and parietal lobe with right hemiplegia and Broca's aphasia. She had a history of hypertension for 5 years, hyperlipidemia for 4 years, hyperthyroidism for 3 years, and T1DM for 31 years. The first brain magnetic resonance imaging not only revealed the aforementioned ischemic lesions but also bilateral internal carotid artery occlusion. She was admitted to our ward for rehabilitation due to prior stroke sequalae. DKA took place on hospital day 2. On hospital day 6, she had a new massive infarction over the bilateral anterior cerebral artery and middle cerebral artery territory. After weeks of aggressive treatment, she remained in a coma and on mechanical ventilation due to respiratory failure. After discussion with her family, compassionate extubation was performed on hospital day 29 and she died. CONCLUSION DKA can lead to cerebral infarction due to several mechanisms. In people with existing BICAO and several stroke risk factors such as hypertension, T1DM, hyperlipidemia, DKA has the potential to cause more serious ischemic strokes.
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Affiliation(s)
- Yi-Chung Chen
- Department of Physical Medicine and Rehabilitation, Chung Shan Medical University Hospital, Taichung 40201, Taiwan
| | - Su-Ju Tsai
- Department of Physical Medicine and Rehabilitation, Chung Shan Medical University Hospital, Taichung 40201, Taiwan
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15
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Boyd S, Tse W, Lavingia K, Amendola M. Frailty Measurement and Implications for Cerebrovascular Disease Management in a Veteran Based Population. Ann Vasc Surg 2021; 76:134-141. [PMID: 34004323 DOI: 10.1016/j.avsg.2021.04.026] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2021] [Revised: 04/07/2021] [Accepted: 04/28/2021] [Indexed: 10/21/2022]
Abstract
BACKGROUND Rapid and objective preoperative assessment of patients undergoing carotid endarterectomy (CEA) remains difficult and variable. The Risk Analysis Index (RAI) is a validated medical record-based assessment of frailty that has been used to predict clinical outcomes for patients undergoing surgical procedures including CEA. We applied RAI to a veteran population following CEA for asymptomatic cerebrovascular disease and examined the factors related to post-operative morbidity and mortality. METHODS After obtaining IRB approval, Veteran Affairs Surgical Quality Improvement Program data was queried for CEA procedures from 2002 to 2015 for ICD-9 codes indicating asymptomatic patients. RAI was then calculated based on Veteran Affairs Surgical Quality Improvement Program variable medical record extraction. Three groupings of patients were undertaken including non-frail (RAI < 30), frail (RAI 30-34) and very frail (RAI ≥ 35). Chi squared and ANOVA were used to assess cohort differences. Binary logistic regression was used to evaluate predictors of post-operative stroke, myocardial infarction (MI), any complication, and death. RESULTS Between 2002 and 2015, 37,873 asymptomatic patients underwent CEA. Over 98% (37,266) of the patients were male with an average age of 68.3 ± 8.55 years. The cohorts contained 82.8% (n = 31,362), 12.4% (n = 4,678), and 4.8% (n = 1,833) for the non-frail, frail and very frail groups respectively. Frailty was associated with increased rates of post-operative stroke, MI, any complication, death, and longer hospital length of stay (P< 0.001). Operative time did not significantly differ between the groups. Increasing frailty was associated with having one or more complications (OR 1.69, 95% CI 1.50-1.90 for frail and OR 2.79, 95% CI 2.41-3.24 for very frail, (P< 0.001), post-operative stroke in frail (OR 1.33 95% CI 1.06-1.67) and very frail (OR 1.57 1 95% CI 1.14-2.16) patients, and MI in both frail (OR 1.68, CI 1.17-2.43) and very frail (OR 3.73, CI 2.52-5.51) patients. Frailty was also significantly associated with death with in very frail patients (OR 4.14, 95% CI 3.00-5.71, P< 0.001). CONCLUSION Increasing frailty as determined by RAI was associated with worse post-operative outcomes in asymptomatic patients undergoing CEA. Higher RAI score cohorts were associated with higher rates of postoperative stroke, MI, complications, and death. We recommend the use of this frailty index as a screening tool to guide risk discussions with asymptomatic patients undergoing CEA.
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Affiliation(s)
- Sally Boyd
- Department of Surgery, Virginia Commonwealth University Health Systems, Richmond, VA; Department of Surgery, Central Virginia VA Health System, Richmond, VA.
| | - Wayne Tse
- Department of Surgery, Virginia Commonwealth University Health Systems, Richmond, VA; Department of Surgery, Central Virginia VA Health System, Richmond, VA
| | - Kedar Lavingia
- Department of Surgery, Central Virginia VA Health System, Richmond, VA; Department of Surgery, Virginia Commonwealth University School of Medicine, Richmond, VA.
| | - Michael Amendola
- Department of Surgery, Central Virginia VA Health System, Richmond, VA; Department of Surgery, Virginia Commonwealth University School of Medicine, Richmond, VA
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16
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Jang SH, Kwon DH, Han MK, Park H, Sohn SI, Choi H, Hong JH. Impact of statin pretreatment on the complications of carotid stenting in asymptomatic patients: observational study. BMC Neurol 2021; 21:75. [PMID: 33588788 PMCID: PMC7883458 DOI: 10.1186/s12883-021-02104-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2020] [Accepted: 02/02/2021] [Indexed: 11/10/2022] Open
Abstract
Background Carotid stenosis is a known risk factor for ischemic stroke, and carotid artery stenting is an effective preventive procedure. However, the stroke risk reduction for asymptomatic patients is small. Therefore, it is important to reduce the risk of complications, particularly in asymptomatic carotid stenosis. Statins are known to reduce the overall risk of periprocedural complications, although there is a lack of data focusing on asymptomatic patients. We aimed to investigate whether different doses of statin pretreatment can reduce periprocedural complications of carotid artery stenting (CAS) in patients with asymptomatic carotid artery stenosis. Methods Between July 2003 and June 2013, 276 consecutive patients received CAS for asymptomatic carotid stenosis. Periprocedural complications included the outcome of stroke, myocardial infarction, or death within 30 days of CAS. Statin pretreatment was categorized as no-statin (n = 87, 31.5%), standard-dose (< 40 mg, n = 139, 50.4%), and high-dose statin (≥40 mg, n = 50, 18.1%) according to the atorvastatin equivalent dose. The Cochran-Armitage (CA) trend test was performed to investigate the association of periprocedural complications with statin dose. Results The overall periprocedural complication rate was 3.3%. There was no significant difference in the risk of periprocedural complications between the three groups (no statin: n = 3 [3.4%]; standard-dose: n = 4 [2.9%]; high-dose n = 2 [4.0%] p = 0.923). The CA trend test did not demonstrate a trend in the proportion of periprocedural complications across increasing statin equivalent doses (p = 0.919). Conclusions Statin pretreatment before CAS showed neither absolute nor dose-dependent effects against periprocedural complications in asymptomatic patients undergoing CAS. Supplementary Information The online version contains supplementary material available at 10.1186/s12883-021-02104-z.
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Affiliation(s)
- Seong Hwa Jang
- Department of Neurology, Keimyung University Dongsan Hospital, Keimyung University School of Medicine, 1095 Dalgubeol-daero, Dalseo-gu, Daegu, 42601, South Korea
| | - Doo Hyuk Kwon
- Department of Neurology, Keimyung University Dongsan Hospital, Keimyung University School of Medicine, 1095 Dalgubeol-daero, Dalseo-gu, Daegu, 42601, South Korea
| | - Moon-Ku Han
- Department of Neurology, Seoul National University Bundang Hospital, Seoul National University School of Medicine, Seongnam, South Korea
| | - Hyungjong Park
- Department of Neurology, Keimyung University Dongsan Hospital, Keimyung University School of Medicine, 1095 Dalgubeol-daero, Dalseo-gu, Daegu, 42601, South Korea
| | - Sung-Il Sohn
- Department of Neurology, Keimyung University Dongsan Hospital, Keimyung University School of Medicine, 1095 Dalgubeol-daero, Dalseo-gu, Daegu, 42601, South Korea
| | - Huimahn Choi
- Department of Neurology and Neurosurgery, McGovern Medical School, University of Texas Health Science Center at Houston, Houston, TX, USA
| | - Jeong-Ho Hong
- Department of Neurology, Keimyung University Dongsan Hospital, Keimyung University School of Medicine, 1095 Dalgubeol-daero, Dalseo-gu, Daegu, 42601, South Korea.
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17
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Khattab M, Howard B, Al-Rifai S, Torgerson T, Vassar M. Adherence to the RIGHT statement in Society of Interventional Radiology guidelines. J Osteopath Med 2021; 121:11-24. [DOI: 10.1515/jom-2020-0024] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
Abstract
Context
The Reporting Items for Practice Guidelines in Health Care (RIGHT) Statement was developed by a multidisciplinary team of experts to improve reporting quality and transparency in clinical practice guideline development.
Objective
To assess the quality of reporting in clinical practice guidelines put forth by the Society of Interventional Radiology (SIR) and their adherence to the RIGHT statement checklist.
Methods
In March 2018, using the 22 criteria listed in the RIGHT statement, two researchers independently documented adherence to each item for all eligible guidelines listed by the SIR by reading through each guideline and using the RIGHT statement elaboration and explanation document as a guide to determine if each item was appropriately addressed as listed in the checklist. To qualify for inclusion in this study, each guideline must have met the strict definition for a clinical practice guideline as set forth by the National Institute of Health and the Institute of Medicine, meaning they were informed by a systematic review of evidence and intended to direct patient care and physician decisions. Guidelines were excluded if they were identified as consensus statements, position statements, reporting standards, and training standards or guidelines. After exclusion criteria were applied, the two researchers scored each of the remaining clinical practice guidelines (CPGs) using a prespecified abstraction Google form that reflected the RIGHT statement checklist (22 criteria; 35 items inclusive of subset questions). Each item on the abstraction form consisted of a “yes/no” option; each item on the RIGHT checklist was recorded as “yes” if it was included in the guideline and “no” if it was not. Each checklist item was weighed equally. Partial adherence to checklist items was recorded as “no.” Data were extracted into Microsoft Excel (Microsoft Corporation) for statistical analysis.
Results
The initial search results yielded 129 CPGs in the following areas: 13 of the guidelines were in the field of interventional oncology; 16 in neurovascular disorders; five in nonvascular interventions; four in pediatrics; 25 in peripheral, arterial, and aortic disease; one in cardiac; one in portal and mesenteric vascular disease; 37 in practice development and safety; three in spine and musculoskeletal disorders; 14 in venous disease; five in renal failure/hemodialysis; and five in women’s health. Of the 46 guidelines deemed eligible for evaluation by the RIGHT checklist, 12 of the checklist items showed less than 25% adherence and 13 showed more than 75% adherence. Of 35 individual RIGHT statement checklist items, adherence was found for a mean (SD) of 22.9 items (16.3). The median number of items with adherence was 21 (interquartile range, 7.5–38).
Conclusion
The quality of reporting in interventional radiology guidelines is lacking in several key areas, including whether patient preferences were considered, whether costs and resources were considered, the strength of the recommendations, and the certainty of the body of evidence. Poor adherence to the RIGHT statement checklist in these guidelines reveals many areas for improvement in guideline reporting.
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Affiliation(s)
- Mostafa Khattab
- Oklahoma State University Center for Health Sciences , Tulsa , OK , USA
| | - Benjamin Howard
- Oklahoma State University Center for Health Sciences , Tulsa , OK , USA
| | - Shafiq Al-Rifai
- Oklahoma State University Center for Health Sciences , Tulsa , OK , USA
| | - Trevor Torgerson
- Oklahoma State University Center for Health Sciences , Tulsa , OK , USA
| | - Matt Vassar
- Oklahoma State University Center for Health Sciences , Tulsa , OK , USA
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18
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Wang C, Zhao P, Sun T, Han M, Wang Y, Wu W, Li X, Wang D. Hybrid Recanalization for the Treatment of Carotid/Vertebral In-stent Restenosis or Occlusion: Pilot Surgery Experiences From One Single Center. Front Neurol 2020; 11:604672. [PMID: 33329364 PMCID: PMC7732432 DOI: 10.3389/fneur.2020.604672] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2020] [Accepted: 10/30/2020] [Indexed: 11/13/2022] Open
Abstract
Background : The hybrid recanalization of internal carotid artery (ICA) and vertebral artery (VA) in-stent restenosis or occlusion using a combination of endarterectomy and endovascular intervention has achieved technical success. We present our surgical experiences to further evaluate the safety and efficacy of the hybrid technique for the treatment of in-stent restenosis and occlusion. Methods : A cohort of 12 refractory patients with in-stent restenosis or occlusion who underwent hybrid recanalization, a combination of endarterectomy and endovascular intervention, were retrospectively analyzed. Medical records, including presenting symptoms, comorbidities, contralateral ICA/VA findings, use of antiplatelet drugs, postoperative complications, and angiographic outcomes, were collected. Results : Among 415 consecutive patients with ICA, common carotid artery, and V1 segment lesions, 12 refractory patients (2.89%) with 13 cases were enrolled in our study (1 female and 11 male). All patients underwent successful hybrid recanalization. There were no cases of postoperative stroke or death. Only two patients sustained hoarseness, but it resolved within 2 weeks after surgery. Three patients were treated with dual antiplatelet (aspirin and clopidogrel), seven with single antiplatelet (aspirin), one with single antiplatelet (clopidogrel), and one with single antiplatelet (ticagrelor). All patients were followed up in the outpatient department according to the protocol, with a mean follow-up period of 13 months (range, 6-24 months). No death or recurrent symptoms occurred during the regular follow-up period. Conclusion : The hybrid technique maybe a safe and feasible treatment option to recanalize in-stent restenosis or occlusion with acceptable complications.
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Affiliation(s)
- Chao Wang
- School of Clinical Medicine, Shandong University, Jinan, China.,Dezhou City People's Hospital, Dezhou, China.,Department of Neurosurgery, Binzhou Medical University Hospital, Binzhou, China.,Department of Neurosurgery, Qilu Hospital of Shandong University and Institute of Brain and Brain-Inspired Science, Shandong University, Jinan, China
| | - Peng Zhao
- Department of Neurosurgery, Qilu Hospital of Shandong University and Institute of Brain and Brain-Inspired Science, Shandong University, Jinan, China
| | - Tao Sun
- School of Clinical Medicine, Shandong University, Jinan, China.,Department of Neurosurgery, Qilu Hospital of Shandong University and Institute of Brain and Brain-Inspired Science, Shandong University, Jinan, China
| | - Mengtao Han
- School of Clinical Medicine, Shandong University, Jinan, China.,Department of Neurosurgery, Qilu Hospital of Shandong University and Institute of Brain and Brain-Inspired Science, Shandong University, Jinan, China
| | - Yunyan Wang
- Department of Neurosurgery, Qilu Hospital of Shandong University and Institute of Brain and Brain-Inspired Science, Shandong University, Jinan, China
| | - Wei Wu
- Department of Neurology, Qilu Hospital of Shandong University and Institute of Brain and Brain-Inspired Science, Shandong University, Jinan, China
| | - Xingang Li
- School of Clinical Medicine, Shandong University, Jinan, China.,Department of Neurosurgery, Qilu Hospital of Shandong University and Institute of Brain and Brain-Inspired Science, Shandong University, Jinan, China
| | - Donghai Wang
- School of Clinical Medicine, Shandong University, Jinan, China.,Department of Neurosurgery, Qilu Hospital of Shandong University and Institute of Brain and Brain-Inspired Science, Shandong University, Jinan, China
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19
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Huang K, Cheng CL, Yang YHK. Not all aspirin products have equivalent antiplatelet efficacy-Aspirin formulated with magnesium stearate is less effective in preventing ischemic stroke. Pharmacoepidemiol Drug Saf 2020; 29:1570-1578. [PMID: 32954579 DOI: 10.1002/pds.5134] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2020] [Revised: 08/27/2020] [Accepted: 09/08/2020] [Indexed: 11/09/2022]
Abstract
PURPOSE Magnesium stearate (MgSt) is a widely used excipient in pharmaceutical formulations but should be avoided in aspirin preparations as it hydrolyzes aspirin. We hypothesized that preparations of aspirin-containing MgSt (MgSt-ASA) are less effective in preventing thrombosis in clinical settings. The risk of composite cardiovascular events in patients treated with MgSt-ASA preparations for preventing secondary stroke was evaluated. METHODS This retrospective cohort study used Taiwan's claims data from 1997 to 2013. Patients who were discharged after ischemic stroke (IS) and administered with only MgSt-ASA or non-MgSt-ASA preparations were enrolled. Composite events including all-cause mortality, IS hospitalization, and myocardial infarction-related hospitalization in the follow-up period under therapy with MgSt-ASA or non-MgSt-ASA preparations were considered primary outcomes. Hazard ratios (HRs) were adjusted with the baseline comorbidities and medications using the Cox model. RESULTS A total of 19 500 patients with IS (60% males, average age 67 years) were identified, which included 2064 patients receiving MgSt-ASA treatment initially and 17 436 patients receiving non-MgSt-ASA preparation initially. The crude incidence of composite events was 11.65 per 100 person-years, whereas it was 11.45 and 13.90 per 100 person-years for patients receiving non-MgSt-ASA and MgSt-ASA treatments, respectively. The risk of composite events was higher in patients receiving MgSt-ASA preparations than in those receiving non-MgSt-ASA formulations, with the adjusted HR being 1.23 at 95% confidence interval of 1.02 to 1.47. CONCLUSIONS MgSt-ASA preparation use was associated with a higher risk of composite events than non-MgSt-ASA preparations. Review of aspirin formulations under regulatory intervention is warranted.
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Affiliation(s)
- Kelly Huang
- Institute of Clinical Pharmacy and Pharmaceutical Sciences, College of Medicine, National Cheng Kung University, Tainan, Taiwan, ROC
| | - Ching-Lan Cheng
- Institute of Clinical Pharmacy and Pharmaceutical Sciences, College of Medicine, National Cheng Kung University, Tainan, Taiwan, ROC.,School of Pharmacy, College of Medicine, National Cheng Kung University, Tainan, Taiwan, ROC
| | - Yea-Huei Kao Yang
- Institute of Clinical Pharmacy and Pharmaceutical Sciences, College of Medicine, National Cheng Kung University, Tainan, Taiwan, ROC.,School of Pharmacy, College of Medicine, National Cheng Kung University, Tainan, Taiwan, ROC
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20
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Han W, Hwang G, Oh SH, Lee JJ, Kim MK, Chung BS, Rhim JK, Sheen SH, Kim T. Impact of Time Interval between Index Event and Stenting on Periprocedural Risk in Patients with Symptomatic Carotid Stenosis. J Korean Neurosurg Soc 2020; 63:598-606. [PMID: 32883055 PMCID: PMC7477147 DOI: 10.3340/jkns.2020.0113] [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: 04/13/2020] [Accepted: 06/22/2020] [Indexed: 11/27/2022] Open
Abstract
OBJECTIVE The purpose of this study was to evaluate the impact of time interval between index event and stenting on the periprocedural risk of stenting for symptomatic carotid stenosis and to determine the optimal timing of stenting. METHODS This retrospective study included 491 (322 symptomatic [65.6%] and 169 asymptomatic [34.4%]) patients undergoing carotid stenting. The symptomatic patients were categorized into Day 0-3, 4-7, 8-10, 11-14, 15-21, and >21 groups according to the time interval between index event and stenting. Periprocedural (≤30 days) risk for clinical (any neurological deterioration) and radiological (new infarction on postprocedural diffusion-weighted imaging) events of stenting in each time interval versus asymptomatic stenosis was calculated with logistic regression analysis adjusted for confounders, and provided as odds ratio (OR) and 95% confidence interval (CI). RESULTS Overall clinical event rate (4.3%) of stenting for symptomatic carotid stenosis was higher than that for asymptomatic stenosis (1.2%; OR, 3.979 [95% CI, 1.093-14.489]; p=0.036). Stenting in Day 0-3 (13.2%; OR, 10.997 [95% CI, 2.333-51.826]; p=0.002) and Day 4-7 (8.3%; OR, 6.775 [95% CI, 1.382-33.227]; p=0.018) was associated with high risk for clinical events. However, the clinical event rates in stenting after 7 days from index event (Day 8-10, 1.8%; Day 11-14, 2.5%; Day 15-21, 0%; Day >21, 2.9%) were not different from that in stenting for asymptomatic stenosis. Overall radiological event rate (55.6%) in symptomatic stenosis was also higher than that in asymptomatic stenosis (35.5%; OR, 2.274 [95% CI, 1.553-3.352]; p<0.001). The high risk for radiological events was maintained in all time intervals (Day 0-3 : 55.3%; OR, 2.224 [95% CI, 1.103-4.627]; p=0.026; Day 4-7 : 58.3%; OR, 2.543 [95% CI, 1.329-4.949]; p=0.005; Day 8-10 : 53.6%; OR, 2.096 [95% CI, 1.138-3.889]; p=0.018; Day 11-14 : 57.5%; OR, 2.458 [95% CI, 1.225-5.021]; p=0.012; Day 15-21 : 55.6%; OR, 2.271 [95% CI, 1.099-4.764]; p=0.028; Day >21 : 54.8%; OR, 2.203 [95% CI, 1.342-3.641]; p=0.002). CONCLUSION This study showed that as stenting was delayed, the periprocedural risk for clinical events decreased. The clinical event risk was high only in stenting within 7 days and comparable with that for asymptomatic stenosis in stenting after 7 days from index event, although the radiological event risk was not affected by stenting timing. Therefore, our results suggest that delayed stenting after 7 days from symptom onset is a safe strategy for symptomatic stenosis.
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Affiliation(s)
- Wonsuck Han
- Department of Neurosurgery, Bundang Jesaeng General Hospital, Seongnam, Korea
| | - Gyojun Hwang
- Department of Neurosurgery, Bundang Jesaeng General Hospital, Seongnam, Korea
| | - Sung Han Oh
- Department of Neurosurgery, Bundang Jesaeng General Hospital, Seongnam, Korea
| | - Jong Joo Lee
- Department of Neurosurgery, Bundang Jesaeng General Hospital, Seongnam, Korea
| | - Mi Kyung Kim
- Department of Neurosurgery, Bundang Jesaeng General Hospital, Seongnam, Korea
| | - Bong Sub Chung
- Department of Neurosurgery, Anyang Sam Hospital, Anyang, Korea
| | - Jong Kook Rhim
- Department of Neurosurgery, Jeju National University Hospital, Jeju, Korea
| | - Seung Hun Sheen
- Department of Neurosurgery, Bundang CHA Medical Center, CHA University, Seongnam, Korea
| | - Taehyung Kim
- Department of Neurosurgery, Pyeongtaek St. Mary's Hospital, Pyeongtaek, Korea
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21
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Yaghi S, Liberman AL, Henninger N, Grory BM, Nouh A, Scher E, Giles J, Liu A, Nagy M, Kaushal A, Azher I, Fakhri H, Espaillat KB, Asad SD, Pasupuleti H, Martin H, Tan J, Veerasamy M, Esenwa C, Cheng N, Moncrieffe K, Moeini-Naghani I, Siddu M, Trivedi T, Ishida K, Frontera J, Lord A, Furie K, Keyrouz S, de Havenon A, Mistry E, Leon Guerrero CR, Khan M. Factors associated with therapeutic anticoagulation status in patients with ischemic stroke and atrial fibrillation. J Stroke Cerebrovasc Dis 2020; 29:104888. [PMID: 32414583 DOI: 10.1016/j.jstrokecerebrovasdis.2020.104888] [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: 03/02/2020] [Revised: 04/09/2020] [Accepted: 04/12/2020] [Indexed: 12/14/2022] Open
Abstract
BACKGROUND AND PURPOSE Understanding factors associated with ischemic stroke despite therapeutic anticoagulation is an important goal to improve stroke prevention strategies in patients with atrial fibrillation (AF). We aim to determine factors associated with therapeutic or supratherapeutic anticoagulation status at the time of ischemic stroke in patients with AF. METHODS The Initiation of Anticoagulation after Cardioembolic stroke (IAC) study is a multicenter study pooling data from stroke registries of eight comprehensive stroke centers across the United States. Consecutive patients hospitalized with acute ischemic stroke in the setting of AF were included in the IAC cohort. For this study, we only included patients who reported taking warfarin at the time of the ischemic stroke. Patients not on anticoagulation and patients who reported use of a direct oral anticoagulant were excluded. Analyses were stratified based on therapeutic (INR ≥2) versus subtherapeutic (INR <2) anticoagulation status. We used binary logistic regression models to determine factors independently associated with anticoagulation status after adjustment for pertinent confounders. In particular, we sought to determine whether atherosclerosis with 50% or more luminal narrowing in an artery supplying the infarct (a marker for a competing atherosclerotic mechanism) and small stroke size (≤ 10 mL; implying a competing small vessel disease mechanism) related to anticoagulant status. RESULTS Of the 2084 patients enrolled in the IAC study, 382 patients met the inclusion criteria. The mean age was 77.4 ± 10.9 years and 52.4% (200/382) were women. A total of 222 (58.1%) subjects presented with subtherapeutic INR. In adjusted models, small stroke size (OR 1.74 95% CI 1.10-2.76, p = 0.019) and atherosclerosis with 50% or more narrowing in an artery supplying the infarct (OR 1.96 95% CI 1.06-3.63, p = 0.031) were independently associated with INR ≥2 at the time of their index stroke. CONCLUSION Small stroke size (≤ 10 ml) and ipsilateral atherosclerosis with 50% or more narrowing may indicate a competing stroke mechanism. There may be important opportunities to improve stroke prevention strategies for patients with AF by targeting additional ischemic stroke mechanisms to improve patient outcomes.
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Affiliation(s)
- Shadi Yaghi
- Department of Neurology, New York Langone Health, 150 55th St Suite 3667, Brooklyn, NY, 11220, USA.
| | - Ava L Liberman
- Department of Neurology, Montefiore Medical Center, New York, NY, USA
| | - Nils Henninger
- Department of Neurology, University of Massachusetts, Worcester, MA, USA; Department of Psychiatry, University of Massachusetts, Worcester, MA, USA
| | - Brian Mac Grory
- Department of Neurology, Brown University, Providence, RI, USA
| | - Amre Nouh
- Department of Neurology, Hartford Hospital, Hartford, CT, USA
| | - Erica Scher
- Department of Neurology, New York Langone Health, 150 55th St Suite 3667, Brooklyn, NY, 11220, USA
| | - James Giles
- Department of Neurology, Washington University, Saint Louis, MO, USA
| | - Angela Liu
- Department of Neurology, Washington University, Saint Louis, MO, USA
| | - Muhammad Nagy
- Department of Neurology, University of Massachusetts, Worcester, MA, USA
| | | | - Idrees Azher
- Department of Neurology, Brown University, Providence, RI, USA
| | - Hiba Fakhri
- Department of Neurology, Vanderbilt University, Nashville, TN, USA
| | | | | | | | - Heather Martin
- Department of Neurology, Spectrum Health, Grand Rapids, MI, USA
| | - Jose Tan
- Department of Neurology, Spectrum Health, Grand Rapids, MI, USA
| | | | - Charles Esenwa
- Department of Neurology, Montefiore Medical Center, New York, NY, USA
| | - Natalie Cheng
- Department of Neurology, Montefiore Medical Center, New York, NY, USA
| | | | | | - Mithilesh Siddu
- Department of Neurology, George Washington University, Washington, DC, USA
| | - Tushar Trivedi
- Department of Neurology, New York Langone Health, 150 55th St Suite 3667, Brooklyn, NY, 11220, USA
| | - Koto Ishida
- Department of Neurology, New York Langone Health, 150 55th St Suite 3667, Brooklyn, NY, 11220, USA
| | - Jennifer Frontera
- Department of Neurology, New York Langone Health, 150 55th St Suite 3667, Brooklyn, NY, 11220, USA
| | - Aaron Lord
- Department of Neurology, New York Langone Health, 150 55th St Suite 3667, Brooklyn, NY, 11220, USA
| | - Karen Furie
- Department of Neurology, Brown University, Providence, RI, USA
| | - Salah Keyrouz
- Department of Neurology, Washington University, Saint Louis, MO, USA
| | - Adam de Havenon
- Department of Neurology, University of Utah, Salt Lake City, UT, USA
| | - Eva Mistry
- Department of Neurology, Vanderbilt University, Nashville, TN, USA
| | | | - Muhib Khan
- Department of Neurology, Spectrum Health, Grand Rapids, MI, USA
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22
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Yin J, Yu C, Liu H, Du M, Sun F, Yu C, Wei L, Wang C, Wang X. A model to predict unstable carotid plaques in population with high risk of stroke. BMC Cardiovasc Disord 2020; 20:164. [PMID: 32264828 PMCID: PMC7137419 DOI: 10.1186/s12872-020-01450-z] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2019] [Accepted: 03/26/2020] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Several models have been developed to predict asymptomatic carotid stenosis (ACS), however these models did not pay much attention to people with lower level of stenosis (<50% or carotid plaques, especially instable carotid plaques) who might benefit from early interventions. Here, we developed a new model to predict unstable carotid plaques through systematic screening in population with high risk of stroke. METHODS Community residents who participated the China National Stroke Screening and Prevention Project (CNSSPP) were screened for their stroke risks. A total of 2841 individuals with high risk of stroke were enrolled in this study, 266 (9.4%) of them were found unstable carotid plaques. A total of 19 risk factors were included in this study. Subjects were randomly distributed into Derivation Set group or Validation Set group. According to their carotid ultrasonography records, subjects in derivation set group were further categorized into unstable plaque group or stable plaque group. RESULTS 174 cases and 1720 cases from Derivation Set group were categorized into unstable plaque group and stable plaque group respectively. The independent risk factors for carotid unstable plaque were: male (OR 1.966, 95%CI 1.406-2.749), older age (50-59, OR 6.012, 95%CI 1.410-25.629; 60-69, OR 13.915, 95%CI 3.381-57.267;≥70, OR 31.267, 95%CI 7.472-130.83), married(OR 1.780, 95%CI 1.186-2.672), LDL-C(OR 2.015, 95%CI 1.443-2.814), and HDL-C(OR 2.130, 95%CI 1.360-3.338). A predictive scoring system was generated, ranging from 0 to 10. The cut-off value of this predictive scoring system is 6.5. The AUC value for derivation and validation set group were 0.738 and 0.737 respectively. CONCLUSIONS For those individuals with high risk of stroke, we developed a new model which could identify those who have a higher chance to have unstable carotid plaques. When an individual's predictive model score exceeds 6.5, the probability of having carotid unstable plaques is high, and carotid ultrasonography should be conducted accordingly. This model could be helpful in the primary prevention of stroke.
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Affiliation(s)
- Junxiong Yin
- Department of Neurology, Brain Hospital Affiliated to Nanjing Medical University, 264# Guangzhou road, Nanjing, 210012, Jiangsu, China
| | - Chuanyong Yu
- Department of Neurology, Brain Hospital Affiliated to Nanjing Medical University, 264# Guangzhou road, Nanjing, 210012, Jiangsu, China
| | - Hongxing Liu
- Department of Neurology, Brain Hospital Affiliated to Nanjing Medical University, 264# Guangzhou road, Nanjing, 210012, Jiangsu, China
| | - Mingyang Du
- Department of Neurology, Brain Hospital Affiliated to Nanjing Medical University, 264# Guangzhou road, Nanjing, 210012, Jiangsu, China
| | - Feng Sun
- Department of Neurology, Brain Hospital Affiliated to Nanjing Medical University, 264# Guangzhou road, Nanjing, 210012, Jiangsu, China
| | - Cheng Yu
- Department of Computer Science and Technology, Nanjing University, Nanjing, 210012, Jiangsu, China
| | - Lixia Wei
- Department of Computer Science and Technology, Nanjing University, Nanjing, 210012, Jiangsu, China
| | - Chongjun Wang
- Department of Computer Science and Technology, Nanjing University, Nanjing, 210012, Jiangsu, China
| | - Xiaoshan Wang
- Department of Neurology, Brain Hospital Affiliated to Nanjing Medical University, 264# Guangzhou road, Nanjing, 210012, Jiangsu, China.
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23
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The structural properties of carotid arteries in carotid artery diseases - a retrospective computed tomography angiography study. Pol J Radiol 2020; 85:e82-e89. [PMID: 32467741 PMCID: PMC7247020 DOI: 10.5114/pjr.2020.93367] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2019] [Accepted: 01/20/2020] [Indexed: 11/17/2022] Open
Abstract
Purpose Aim of the study was to find answers to the following questions: What haemodynamic changes may occur in patients with stenotic, aneurysmal, dissection of the carotid artery and its branches? How do these changes differ in patients with normal and carotid disease? Material and methods In order to achieve this aim, the cranio-cervical CT angiography images of patients who were referred to our clinic for any reason and received the diagnosis of carotid stenosis, carotid dissection, and extra or intracranial aneurysm were reviewed retrospectively. Results Significant differences were detected in the carotid arteries of normal patients and those with aneurysm and dissection. When normal and aneurismal patients were compared, right and left ICA diameters (p = 0.000, p = 0.002, respectively), total ICA diameters (p = 0.000), carotid left Ø diameters (p = 0.026), right and left total Ø diameters (p = 0.024), and Murray’s and our cosine values of Ø angles (p = 0.001 and p = 0.022, respectively) were found to be different. Also, in a comparison made between normal patients and patients with dissection, right CCA (p = 0.000), ICA (p = 0.001), ECA (p = 0.004) diameters, total CCA (p = 0.001), ICA (p = 0.009), and ECA (p = 0.003) diameters were also found to be different. Conclusions This study showed that the presence of aneurysm plays an important role in the remodelling of the carotid arteries. Also, it is understood that Murray’s laws are still valid for the detection of structural deterioration in carotid artery diseases. Hence, it is believed that these data can be used in artificial intelligence studies.
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24
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Oshita J, Sakamoto S, Okazaki T, Ishii D, Kurisu K. Safety of simultaneous bilateral carotid artery stenting for bilateral carotid artery stenosis. Interv Neuroradiol 2020; 26:19-25. [PMID: 31423862 PMCID: PMC6997998 DOI: 10.1177/1591019919869478] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2019] [Accepted: 07/17/2019] [Indexed: 11/15/2022] Open
Abstract
BACKGROUND Bilateral carotid artery stenting (BCAS) is often performed in two stages (staged BCAS) but it is also an option to be performed in one stage (simultaneous BCAS). To confirm the safety of simultaneous BCAS, we retrospectively analyzed perioperative and postoperative course of simultaneous BCAS compared with staged BCAS. MATERIALS AND METHODS Patients with symptomatic stenosis of ≥50% or asymptomatic stenosis of ≥80% of bilateral carotid arteries underwent BCAS. Procedure time, symptomatic ischemic complications, presence/absence of high-intensity spots on postoperative diffusion-weighted image, duration of postoperative hospital stays and 30 days outcome of patients performed with simultaneous BCAS (group A, 8 patients with 16 stenotic lesions (8 procedures)) were compared with those of staged BCAS (group B, 4 patients with 8 stenotic lesions (8 procedures)). RESULTS In groups A and B, procedure time was 146.0 ± 53.8 and 103.5 ± 39.4 min; intraoperative hypotension was observed in 62.5% and 50.0%; postoperative hypotension occurred in 37.5% and 50.0%; diffusion-weighted image showed high-intensity spots in 37.5% and 12.5%; and duration of postoperative hospital stays was 5.1 ± 1.8 and 5.3 ± 2.3 days. No patients suffered symptomatic ischemic complications. In simultaneous BCAS, there was a tendency that procedure time was longer and high-intensity spots on postoperative diffusion-weighted image was more frequent, but there was no increase in symptomatic ischemic complications and duration of hospital stays compared to staged BCAS. CONCLUSIONS Safety of simultaneous BCAS may not be inferior to staged BCAS. In terms of duration of hospital stays, simultaneous BCAS can be superior to staged BCAS for patients with bilateral carotid artery stenosis.
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Affiliation(s)
- Jumpei Oshita
- Department of Neurosurgery, Graduate School of
Biomedical and Health Sciences, Hiroshima University, Hiroshima, Japan
| | - Shigeyuki Sakamoto
- Department of Neurosurgery, Graduate School of
Biomedical and Health Sciences, Hiroshima University, Hiroshima, Japan
| | - Takahito Okazaki
- Department of Neurosurgery, Graduate School of
Biomedical and Health Sciences, Hiroshima University, Hiroshima, Japan
| | - Daizo Ishii
- Department of Neurosurgery, Graduate School of
Biomedical and Health Sciences, Hiroshima University, Hiroshima, Japan
| | - Kaoru Kurisu
- Department of Neurosurgery, Graduate School of
Biomedical and Health Sciences, Hiroshima University, Hiroshima, Japan
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25
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Does contralateral carotid artery occlusion affect the clinical and long-term outcomes of carotid artery stenting? ACTA ACUST UNITED AC 2020; 5:e13-e19. [PMID: 33585720 PMCID: PMC7863550 DOI: 10.5114/amsad.2020.92723] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2019] [Accepted: 01/02/2020] [Indexed: 11/17/2022]
Abstract
Introduction Carotid artery stenting (CAS) has been used with increasing frequency in recent years as an alternative to surgery. Contralateral carotid occlusion (CCO) is present in approximately 2.3% to 25% of cases of revascularised carotid atherosclerotic stenosis. We aimed to compare the outcomes of 30-day, 6-month and 1-year stroke, transient ischaemic attack (TIA), death and myocardial infarction (MI) in patients with and without CCO who underwent CAS in our clinic. Material and methods The study was conducted with 288 consecutive patients who underwent CAS between September 2010 and June 2018. Patients with carotid stenting were divided into two groups: with (48 patients) and without CCO (240 patients). Results Total mortality (2.08% vs. 2.08% p = 1), stroke (2.08% vs. 0.83%, p = 0.43), TIA (0% vs. 0.83%, p = 0.52), MI (0% vs. 0%), and composite outcome (4.17% vs. 3.33%, p = 0.77) at 30 days were not significantly different between CCO and non-CCO groups. Also there was no statistically significant difference between the two groups in terms of the 6-month and 1-year outcomes (p > 0.05). Conclusions There was no difference between 30-day, 6-month and 1-year non-fatal MI, TIA, ischaemic stroke and mortality in the comparison of patients with and without CCO who underwent CAS. The outcomes were similar in terms of age and symptoms, and these data should be supported by prospective multicenter studies.
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26
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Knappich C, Kuehnl A, Haller B, Salvermoser M, Algra A, Becquemin JP, Bonati LH, Bulbulia R, Calvet D, Fraedrich G, Gregson J, Halliday A, Hendrikse J, Howard G, Jansen O, Malas MB, Ringleb PA, Brown MM, Mas JL, Brott TG, Morris DR, Lewis SC, Eckstein HH. Associations of Perioperative Variables With the 30-Day Risk of Stroke or Death in Carotid Endarterectomy for Symptomatic Carotid Stenosis. Stroke 2019; 50:3439-3448. [PMID: 31735137 DOI: 10.1161/strokeaha.119.026320] [Citation(s) in RCA: 22] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
Background and Purpose- This analysis was performed to assess the association between perioperative and clinical variables and the 30-day risk of stroke or death after carotid endarterectomy for symptomatic carotid stenosis. Methods- Individual patient-level data from the 5 largest randomized controlled carotid trials were pooled in the Carotid Stenosis Trialists' Collaboration database. A total of 4181 patients who received carotid endarterectomy for symptomatic stenosis per protocol were included. Determinants of outcome included carotid endarterectomy technique, type of anesthesia, intraoperative neurophysiological monitoring, shunting, antiplatelet medication, and clinical variables. Stroke or death within 30 days after carotid endarterectomy was the primary outcome. Adjusted risk ratios (aRRs) were estimated in multilevel multivariable analyses using a Poisson regression model. Results- Mean age was 69.5±9.2 years (70.7% men). The 30-day stroke or death rate was 4.3%. In the multivariable regression analysis, local anesthesia was associated with a lower primary outcome rate (versus general anesthesia; aRR, 0.70 [95% CI, 0.50-0.99]). Shunting (aRR, 1.43 [95% CI, 1.05-1.95]), a contralateral high-grade carotid stenosis or occlusion (aRR, 1.58 [95% CI, 1.02-2.47]), and a more severe neurological deficit (mRS, 3-5 versus 0-2: aRR, 2.51 [95% CI, 1.30-4.83]) were associated with higher primary outcome rates. None of the other characteristics were significantly associated with the perioperative stroke or death risk. Conclusions- The current results indicate lower perioperative stroke or death rates in patients operated upon under local anesthesia, whereas a more severe neurological deficit and a contralateral high-grade carotid stenosis or occlusion were identified as potential risk factors. Despite a possible selection bias and patients not having been randomized, these findings might be useful to guide surgeons and anesthetists when treating patients with symptomatic carotid disease.
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Affiliation(s)
- Christoph Knappich
- From the Department for Vascular and Endovascular Surgery (C.K., A.K., M.S., H.-H.E.), Klinikum rechts der Isar, Technical University of Munich, Germany
| | - Andreas Kuehnl
- From the Department for Vascular and Endovascular Surgery (C.K., A.K., M.S., H.-H.E.), Klinikum rechts der Isar, Technical University of Munich, Germany
| | - Bernhard Haller
- Institute of Medical Informatics, Statistics and Epidemiology (B.H.), Klinikum rechts der Isar, Technical University of Munich, Germany
| | - Michael Salvermoser
- From the Department for Vascular and Endovascular Surgery (C.K., A.K., M.S., H.-H.E.), Klinikum rechts der Isar, Technical University of Munich, Germany
| | - Ale Algra
- Department of Neurology and Neurosurgery, Brain Center Rudolf Magnus and Julius Centre for Health Sciences and Primary Care (A.A.), University Medical Center Utrecht, the Netherlands
| | - Jean-Pierre Becquemin
- Vascular Institute Paris East, Private Hospital Paul D'Egine, Ramsay Group, Champigny sur Marne, France (J.-P.B.)
| | - Leo H Bonati
- Department of Neurology and Stroke Center (L.H.B.), University Hospital Basel, Switzerland
- Department of Clinical Research (L.H.B.), University Hospital Basel, Switzerland
- Department of Brain Repair and Rehabilitation, Stroke Research Centre, UCL Queen Square Institute of Neurology, University College London, United Kingdom (L.H.B., M.M.B.)
| | - Richard Bulbulia
- Clinical Trial Service Unit and Epidemiological Studies Unit (R.B., D.R.M.), Nuffield Department of Population Health, University of Oxford, United Kingdom
- Medical Research Council Population Health Research Unit (R.B.), Nuffield Department of Population Health, University of Oxford, United Kingdom
| | | | - Gustav Fraedrich
- Department of Vascular Surgery, Medical University of Innsbruck, Austria (G.F.)
| | - John Gregson
- Department of Medical Statistics, London School of Hygiene and Tropical Medicine, United Kingdom (J.G.)
| | - Alison Halliday
- Nuffield Department of Surgical Sciences, John Radcliffe Hospital, Oxford, United Kingdom (A.H.)
| | - Jeroen Hendrikse
- Department of Radiology (J.H.), University Medical Center Utrecht, the Netherlands
| | - George Howard
- Department of Biostatistics, UAB School of Public Health, Birmingham, AL (G.H.)
| | - Olav Jansen
- Department of Radiology and Neuroradiology, UKSH Campus Kiel, Germany (O.J.)
| | - Mahmoud B Malas
- Department of Surgery, Division of Vascular and Endovascular Surgery, University of California San Diego, Health System (M.B.M.)
| | - Peter A Ringleb
- Department of Neurology, University of Heidelberg Medical School, Germany (P.A.R.)
| | - Martin M Brown
- Department of Brain Repair and Rehabilitation, Stroke Research Centre, UCL Queen Square Institute of Neurology, University College London, United Kingdom (L.H.B., M.M.B.)
| | | | - Thomas G Brott
- Department of Neurology, Mayo Clinic, Jacksonville, FL (T.G.B.)
| | - Dylan R Morris
- Clinical Trial Service Unit and Epidemiological Studies Unit (R.B., D.R.M.), Nuffield Department of Population Health, University of Oxford, United Kingdom
| | - Steff C Lewis
- Edinburgh Clinical Trials Unit, Usher Institute of Population Health Sciences and Informatics, University of Edinburgh, United Kingdom (S.C.L.)
| | - Hans-Henning Eckstein
- From the Department for Vascular and Endovascular Surgery (C.K., A.K., M.S., H.-H.E.), Klinikum rechts der Isar, Technical University of Munich, Germany
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27
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Dasenbrock HH, Smith TR, Gormley WB, Castlen JP, Patel NJ, Frerichs KU, Aziz-Sultan MA, Du R. Predictive Score of Adverse Events After Carotid Endarterectomy: The NSQIP Registry Carotid Endarterectomy Scale. J Am Heart Assoc 2019; 8:e013412. [PMID: 31662028 PMCID: PMC6898838 DOI: 10.1161/jaha.119.013412] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
Abstract
Background The goal of this study was to create a comprehensive, integer‐weighted predictive scale of adverse events after carotid endarterectomy (CEA), which may augment risk stratification and patient counseling. Methods and Results The targeted carotid files from the prospective NSQIP (National Surgical Quality Improvement Program) registry (2011–2013) comprised the derivation population. Multivariable logistic regression evaluated predictors of a 30‐day adverse event (stroke, myocardial infarction, or death), the effect estimates of which were used to build a weighted predictive scale that was validated using the 2014 to 2015 NSQIP registry release. A total of 10 766 and 8002 patients were included in the derivation and the validation populations, in whom 4.0% and 3.7% developed an adverse event, respectively. The NSQIP registry CEA scale included 14 variables; the highest points were allocated for insulin‐dependent diabetes mellitus, high‐risk cardiac physiological characteristics, admission source other than home, an emergent operation, American Society of Anesthesiologists’ classification IV to V, modified Rankin Scale score ≥2, and presentation with a stroke. NSQIP registry CEA score was predictive of an adverse event (concordance=0.67), stroke or death (concordance=0.69), mortality (concordance=0.76), an extended hospitalization (concordance=0.73), and a nonroutine discharge (concordance=0.83) in the validation population, as well as among symptomatic and asymptomatic subgroups (P<0.001). In the validation population, patients with an NSQIP registry CEA scale score >8 and 17 had 30‐day stroke or death rates >3% and 6%, the recommended thresholds for asymptomatic and symptomatic patients, respectively. Conclusions The NSQIP registry CEA scale predicts adverse outcomes after CEA and can risk stratify patients with both symptomatic and asymptomatic carotid stenosis using different thresholds for each population.
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Affiliation(s)
| | - Timothy R Smith
- Department of Neurosurgery Brigham and Women's Hospital Harvard Medical School Boston MA
| | - William B Gormley
- Department of Neurosurgery Brigham and Women's Hospital Harvard Medical School Boston MA
| | - Joseph P Castlen
- Department of Neurosurgery Brigham and Women's Hospital Harvard Medical School Boston MA
| | - Nirav J Patel
- Department of Neurosurgery Brigham and Women's Hospital Harvard Medical School Boston MA
| | - Kai U Frerichs
- Department of Neurosurgery Brigham and Women's Hospital Harvard Medical School Boston MA
| | - M Ali Aziz-Sultan
- Department of Neurosurgery Brigham and Women's Hospital Harvard Medical School Boston MA
| | - Rose Du
- Department of Neurosurgery Brigham and Women's Hospital Harvard Medical School Boston MA
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Vellimana AK, Washington CW, Yarbrough CK, Pilgram TK, Hoh BL, Derdeyn CP, Zipfel GJ. Thrombolysis is an Independent Risk Factor for Poor Outcome After Carotid Revascularization. Neurosurgery 2019; 83:922-930. [PMID: 29136204 DOI: 10.1093/neuros/nyx551] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2015] [Accepted: 10/02/2017] [Indexed: 12/14/2022] Open
Abstract
BACKGROUND Thrombolysis is the standard of care for acute ischemic stroke patients presenting in the appropriate time window. Studies suggest that the risk of recurrent ischemia is lower if carotid revascularization is performed early after the index event. The safety of early carotid revascularization in this patient population is unclear. OBJECTIVE To evaluate the safety of carotid revascularization in patients who received thrombolysis for acute ischemic stroke. METHODS The Nationwide Inpatient Sample database was queried for patients admitted through the emergency room with a primary diagnosis of carotid stenosis and/or occlusion. Each patient was reviewed for administration of thrombolysis, carotid endarterectomy, (CEA) or carotid angioplasty and stenting (CAS). Primary endpoints were intracerebral hemorrhage (ICH), postprocedural stroke (PPS), poor outcome, and in-hospital mortality. Potential risk factors were examined using univariate and multivariate analyses. RESULTS A total of 310 257 patients were analyzed. Patients who received tissue plasminogen activator (tPA) and underwent either CEA or CAS had a significantly higher risk of developing an ICH or PPS than patients who underwent either CEA or CAS without tPA administration. The increased risk of ICH or PPS in tPA-treated patients who underwent carotid revascularization diminished with time, and became similar to patients who underwent carotid revascularization without tPA administration by 7 d after thrombolysis. Patients who received tPA and underwent CEA or CAS also had higher odds of poor outcome and in-hospital mortality. CONCLUSION Thrombolysis is a strong risk factor for ICH, PPS, poor outcome, and in-hospital mortality in patients with carotid stenosis/occlusion who undergo carotid revascularization. The increased risk of ICH or PPS due to tPA declines with time after thrombolysis. Delaying carotid revascularization in these patients may therefore be appropriate. This delay, however, will expose these patients to the risk of recurrent stroke. Future studies are needed to determine the relative risks of these 2 adverse events.
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Affiliation(s)
- Ananth K Vellimana
- Department of Neurological Surgery, Washington University School of Medi-cine, St. Louis, Missouri
| | - Chad W Washington
- Department of Neurological Surgery, Washington University School of Medi-cine, St. Louis, Missouri
| | - Chester K Yarbrough
- Department of Neurological Surgery, Washington University School of Medi-cine, St. Louis, Missouri
| | - Thomas K Pilgram
- Mallinckrodt Institute of Radiology, Washington University School of Medicine, St. Louis, Missouri
| | - Brian L Hoh
- Department of Neurosurgery, University of Florida, Gainesville, Florida
| | - Colin P Derdeyn
- Department of Neurological Surgery, Washington University School of Medi-cine, St. Louis, Missouri.,Mallinckrodt Institute of Radiology, Washington University School of Medicine, St. Louis, Missouri
| | - Gregory J Zipfel
- Department of Neurological Surgery, Washington University School of Medi-cine, St. Louis, Missouri
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29
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Wang Q, Tang D, Wang L, Canton G, Wu Z, Hatsukami TS, Billiar KL, Yuan C. Combining morphological and biomechanical factors for optimal carotid plaque progression prediction: An MRI-based follow-up study using 3D thin-layer models. Int J Cardiol 2019; 293:266-271. [PMID: 31301863 DOI: 10.1016/j.ijcard.2019.07.005] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/24/2019] [Revised: 05/24/2019] [Accepted: 07/02/2019] [Indexed: 11/24/2022]
Abstract
Plaque progression prediction is of fundamental significance to cardiovascular research and disease diagnosis, prevention, and treatment. Magnetic resonance image (MRI) data of carotid atherosclerotic plaques were acquired from 20 patients with consent obtained. 3D thin-layer models were constructed to calculate plaque stress and strain. Data for ten morphological and biomechanical risk factors were extracted for analysis. Wall thickness increase (WTI), plaque burden increase (PBI) and plaque area increase (PAI) were chosen as three measures for plaque progression. Generalized linear mixed models (GLMM) with 5-fold cross-validation strategy were used to calculate prediction accuracy and identify optimal predictor. The optimal predictor for PBI was the combination of lumen area (LA), plaque area (PA), lipid percent (LP), wall thickness (WT), maximum plaque wall stress (MPWS) and maximum plaque wall strain (MPWSn) with prediction accuracy = 1.4146 (area under the receiver operating characteristic curve (AUC) value is 0.7158), while PA, plaque burden (PB), WT, LP, minimum cap thickness, MPWS and MPWSn was the best for WTI (accuracy = 1.3140, AUC = 0.6552), and a combination of PA, PB, WT, MPWS, MPWSn and average plaque wall strain (APWSn) was the best for PAI with prediction accuracy = 1.3025 (AUC = 0.6657). The combinational predictors improved prediction accuracy by 9.95%, 4.01% and 1.96% over the best single predictors for PAI, PBI and WTI (AUC values improved by 9.78%, 9.45%, and 2.14%), respectively. This suggests that combining both morphological and biomechanical risk factors could lead to better patient screening strategies.
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Affiliation(s)
- Qingyu Wang
- School of Biological Science and Medical Engineering, Southeast University, Nanjing 210096, China
| | - Dalin Tang
- School of Biological Science and Medical Engineering, Southeast University, Nanjing 210096, China; Mathematical Sciences Department, Worcester Polytechnic Institute, Worcester, MA 01609, USA.
| | - Liang Wang
- School of Biological Science and Medical Engineering, Southeast University, Nanjing 210096, China.
| | - Gador Canton
- Department of Mechanical Engineering, University of Washington, Seattle, WA 98195, USA.
| | - Zheyang Wu
- Mathematical Sciences Department, Worcester Polytechnic Institute, Worcester, MA 01609, USA.
| | - Thomas S Hatsukami
- Division of Vascular Surgery, University of Washington, Seattle, WA 98195, USA.
| | - Kristen L Billiar
- Biomedical Engineering Department, Worcester Polytechnic Institute, Worcester, MA 01609, USA.
| | - Chun Yuan
- Department of Radiology, University of Washington, Seattle, WA 98195, USA.
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30
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Casana R, Malloggi C, Tolva VS, Odero A, Bulbulia R, Halliday A, Silani V, Parati G. Three-year outcomes after carotid artery revascularization: Gender-related differences. Vascular 2019; 27:459-467. [PMID: 30860445 DOI: 10.1177/1708538119836312] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Objectives Carotid artery stenosis is thought to cause up to 10% of ischemic strokes. Historically, carotid artery endarterectomy has shown a higher risk of perioperative adverse events for women. More recent trials reported conflicting results regarding the benefit of carotid artery endarterectomy and carotid artery stenting for men and women. The aim of the present retrospective study was to investigate the influence of gender on the short- (30 days) and long-term (3 years) outcomes of carotid artery endarterectomy and carotid artery stenting in a single centre. Methods From 2010 to 2017, 912 consecutive symptomatic and asymptomatic patients who underwent carotid artery endarterectomy (389, 42.7%) or carotid artery stenting (523, 57.3%) in a single institution had been evaluated to determine the influence of sex (540 men, 59.2%, vs. 372 women, 40.8%) on the outcomes after both revascularization procedures during three years of follow-up. The primary endpoint was the incidence of death, stroke, myocardial infarction, and restenosis in the short-term follow-up. The secondary endpoint was the incidence of death, stroke, myocardial infarction, and restenosis in the long-term follow-up. Results Mean clinical follow-up was 21.1 (16.1) months. Women had internal and common carotid artery diameters significantly smaller with respect to men. For peri-procedural outcomes, women undergoing carotid artery stenting had a higher risk of moderate (50–70%) restenosis (6 women, 2.9%, vs. 3 men, 1.0%). For long-term outcomes, women undergoing carotid artery endarterectomy had a higher rate of moderate restenosis (16 women, 16.3%, vs. 11 men, 7.6%). No significant differences in long-term outcomes were observed between men and women undergoing carotid artery stenting, even after stratification for baseline risk factors. Conclusions Contrary to previous reports, from this single-centre study, long-term risk of events seems to be higher in women who underwent carotid artery endarterectomy than in those who underwent carotid artery stenting, while fewer differences were observed in men.
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Affiliation(s)
- Renato Casana
- Istituto Auxologico Italiano, IRCCS, Centro Chirurgia Vascolare, Auxologico Capitanio, Milano, Italy.,Istituto Auxologico Italiano, IRCCS, Laboratorio Sperimentale di Ricerche di Chirurgia Vascolare, Milano, Italy
| | - Chiara Malloggi
- Istituto Auxologico Italiano, IRCCS, Laboratorio Sperimentale di Ricerche di Chirurgia Vascolare, Milano, Italy
| | | | - Andrea Odero
- Istituto Auxologico Italiano, IRCCS, Centro Chirurgia Vascolare, Auxologico Capitanio, Milano, Italy
| | - Richard Bulbulia
- Clinical Trial Service Unit, Nuffield Department of Population Health, University of Oxford, Oxford, UK.,MRC Population Health Research Unit, Nuffield Department of Population Health, University of Oxford, Oxford, UK
| | - Alison Halliday
- Nuffield Department of Surgical Sciences, University of Oxford, Oxford, UK
| | - Vincenzo Silani
- Istituto Auxologico Italiano, IRCCS, Dipartimento di Neurologia e Stroke Unit e Laboratorio di Ricerche di Neuroscienze, Ospedale San Luca, Milano, Italy.,Dipartimento di Fisiopatologia Medico-Chirurgica e dei Trapianti, Centro 'Dino Ferrari', Università degli Studi di Milano, Milano, Italy
| | - Gianfranco Parati
- Istituto Auxologico Italiano, IRCCS, Dipartimento di Scienze Cardiovascolari, Neurologiche, Metaboliche, Ospedale San Luca, Milano, Italy.,Dipartimento di Medicina e Chirurgia, Università di Milano-Bicocca, Milano, Italy
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31
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Roussopoulou A, Tsivgoulis G, Krogias C, Lazaris A, Moulakakis K, Georgiadis GS, Mikulik R, Kakisis JD, Zompola C, Faissner S, Chondrogianni M, Liantinioti C, Hummel T, Safouris A, Matsota P, Voumvourakis K, Lazarides M, Geroulakos G, Vasdekis SN. Safety of urgent endarterectomy in acute non-disabling stroke patients with symptomatic carotid artery stenosis: an international multicenter study. Eur J Neurol 2018; 26:673-679. [PMID: 30472766 DOI: 10.1111/ene.13876] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2018] [Accepted: 11/19/2018] [Indexed: 11/28/2022]
Abstract
BACKGROUND AND PURPOSE International recommendations advocate that carotid endarterectomy (CEA) should be performed within 2 weeks from the index event in symptomatic carotid artery stenosis (sCAS) patients. However, there are controversial data regarding the safety of CEA performed during the first 2 days of ictus. The aim of this international, multicenter study was to prospectively evaluate the safety of urgent (0-2 days) in comparison to early (3-14 days) CEA in patients with sCAS. METHODS Consecutive patients with non-disabling (modified Rankin Scale scores ≤2) acute ischaemic stroke or transient ischaemic attack due to sCAS (≥70%) underwent urgent or early CEA at five tertiary-care stroke centers during a 6-year period. The primary outcome events included stroke, myocardial infarction or death during the 30-day follow-up period. RESULTS A total of 311 patients with sCAS underwent urgent (n = 63) or early (n = 248) CEA. The two groups did not differ in baseline characteristics with the exception of crescendo transient ischaemic attacks (21% in urgent vs. 7% in early CEA; P = 0.001). The 30-day rates of stroke did not differ (P = 0.333) between patients with urgent (7.9%; 95% confidence interval 3.1%-17.7%) and early (4.4%; 95% confidence interval 2.4%-7.9%) CEA. The mortality and myocardial infarction rates were similar between the two groups. The median length of hospitalization was shorter in urgent CEA [6 days (interquartile range 4-6) vs. 10 days (interquartile range 7-14); P < 0.001]. CONCLUSIONS Our findings highlight that urgent CEA performed within 2 days from the index event is related to a non-significant increase in the risk of peri-procedural stroke. The safety of urgent CEA requires further evaluation in larger datasets.
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Affiliation(s)
- A Roussopoulou
- Second Department of Neurology, School of Medicine, 'Attikon' Hospital, University of Athens, Athens, Greece
| | - G Tsivgoulis
- Second Department of Neurology, School of Medicine, 'Attikon' Hospital, University of Athens, Athens, Greece
| | - C Krogias
- Department of Neurology, St Josef-Hospital, Ruhr University, Bochum, Germany
| | - A Lazaris
- Department of Vascular Surgery, School of Medicine, 'Attikon' Hospital, University of Athens, Athens, Greece
| | - K Moulakakis
- Department of Vascular Surgery, School of Medicine, 'Attikon' Hospital, University of Athens, Athens, Greece
| | - G S Georgiadis
- Department of Vascular Surgery, School of Medicine, Democritus University of Thrace, Alexandroupolis, Greece
| | - R Mikulik
- Department of Neurology, St Anne's University Hospital in Brno and Masaryk University, Brno, Czech Republic
| | - J D Kakisis
- Department of Vascular Surgery, School of Medicine, 'Attikon' Hospital, University of Athens, Athens, Greece
| | - C Zompola
- Second Department of Neurology, School of Medicine, 'Attikon' Hospital, University of Athens, Athens, Greece
| | - S Faissner
- Department of Neurology, St Josef-Hospital, Ruhr University, Bochum, Germany
| | - M Chondrogianni
- Second Department of Neurology, School of Medicine, 'Attikon' Hospital, University of Athens, Athens, Greece
| | - C Liantinioti
- Second Department of Neurology, School of Medicine, 'Attikon' Hospital, University of Athens, Athens, Greece
| | - T Hummel
- Department of Vascular Surgery, St Josef-Hospital, Ruhr University, Bochum, Germany
| | - A Safouris
- Second Department of Neurology, School of Medicine, 'Attikon' Hospital, University of Athens, Athens, Greece.,Acute Stroke Unit, Metropolitan Hospital, Piraeus, Greece
| | - P Matsota
- Second Department of Anaesthesiology, School of Medicine, 'Attikon' Hospital, University of Athens, Athens, Greece
| | - K Voumvourakis
- Second Department of Neurology, School of Medicine, 'Attikon' Hospital, University of Athens, Athens, Greece
| | - M Lazarides
- Department of Vascular Surgery, School of Medicine, Democritus University of Thrace, Alexandroupolis, Greece
| | - G Geroulakos
- Department of Vascular Surgery, School of Medicine, 'Attikon' Hospital, University of Athens, Athens, Greece
| | - S N Vasdekis
- Department of Vascular Surgery, School of Medicine, 'Attikon' Hospital, University of Athens, Athens, Greece
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Gruber P, Hlavica M, Berberat J, Victor Ineichen B, Diepers M, Nedeltchev K, Kahles T, Remonda L. Acute administration of tirofiban versus aspirin in emergent carotid artery stenting. Interv Neuroradiol 2018; 25:219-224. [PMID: 30394839 DOI: 10.1177/1591019918808777] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
BACKGROUND Carotid artery stenting requires antiplatelet therapy for prevention of in-stent thrombosis. Patients suffering from acute ischemic stroke undergoing intravenous thrombolysis and emergent carotid artery stenting (eCAS) are at high risk for intracranial bleeding. We assessed efficacy and safety of acute administration of intravenous tirofiban versus aspirin in these patients. METHODS A retrospective, single center, cohort study was carried out of 32 patients who underwent eCAS (18 received tirofiban, 14 received aspirin) at our comprehensive stroke center (2008-2016). RESULTS Of our 32 consecutive eCAS patients, favorable clinical outcomes (modified Rankin scale ≤ 2) were achieved in eight (47%) tirofiban patients and six (46%) aspirin patients ( p = 0.96). Overall rates were similar for symptomatic intracranial bleeding (tirofiban 22%, aspirin 29%, p = 0.68) and mortality (tirofiban 18%, aspirin 23%, p = 0.71). CONCLUSIONS Tirofiban and aspirin demonstrated similar efficacy and safety in thrombolyzed stroke patients who underwent eCAS in our cohort. Intravenous tirofiban with its short half-life might represent an alternative to aspirin in select patients.
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Affiliation(s)
- Philipp Gruber
- 1 Department of Neuroradiology, Cantonal Hospital Aarau, Aarau, Switzerland.,2 Department of Neurology, Cantonal Hospital Aarau, Aarau, Switzerland
| | - Martin Hlavica
- 1 Department of Neuroradiology, Cantonal Hospital Aarau, Aarau, Switzerland
| | - Jatta Berberat
- 1 Department of Neuroradiology, Cantonal Hospital Aarau, Aarau, Switzerland
| | - Benjamin Victor Ineichen
- 3 Brain Research Institute, University of Zurich, Zurich, Switzerland.,4 Department of Health Sciences and Technology, ETH Zurich, Zurich, Switzerland
| | - Michael Diepers
- 1 Department of Neuroradiology, Cantonal Hospital Aarau, Aarau, Switzerland
| | | | - Timo Kahles
- 2 Department of Neurology, Cantonal Hospital Aarau, Aarau, Switzerland
| | - Luca Remonda
- 5 Department of Neuroradiology, Cantonal Hospital Aarau, Aarau, University of Bern, Switzerland
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Casana R, Malloggi C, Odero A, Tolva V, Bulbulia R, Halliday A, Silani V. Is diabetes a marker of higher risk after carotid revascularization? Experience from a single centre. Diab Vasc Dis Res 2018; 15:314-321. [PMID: 29676604 DOI: 10.1177/1479164118769530] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
PURPOSE This single centre study investigates the influence of diabetes mellitus on outcomes following carotid artery endarterectomy or stenting. METHODS In total, 752 carotid revascularizations (58.2% carotid artery stenting and 41.8% carotid endarterectomy) were performed in 221 (29.4%) patients with diabetes and 532 (70.6%) patients without diabetes. The study outcomes were death, disabling and non-disabling stroke, transient ischaemic attack and restenosis within 36 months after the procedure. RESULTS Patients with diabetes had higher periprocedural risk of any stroke or death (3.6% diabetes vs 0.6% no diabetes; p < 0.05), transient ischaemic attack (1.8% diabetes vs 0.2% no diabetes; p > 0.05) and restenosis (2.7% diabetes vs 0.6% no diabetes; p < 0.05). During long-term follow-up, there were no significant differences in Kaplan-Meier estimates of freedom from death, any stroke and transient ischaemic attack, between people with and without diabetes for each carotid artery stenting and carotid endarterectomy subgroup. Patients with diabetes showed higher rates of restenosis during follow-up than patients without diabetes (36-months estimate risk of restenosis: 21.2% diabetes vs 12.5% no diabetes; p < 0.05). CONCLUSION The presence of diabetes was associated with increased periprocedural risk, but no further additional risk emerged during longer term follow-up. Restenosis rates were higher among patients with diabetes.
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Affiliation(s)
- Renato Casana
- 1 Department of Surgery, IRCCS Istituto Auxologico Italiano, Milan, Italy
- 2 Vascular Surgery Research Experimental Laboratory, IRCCS Istituto Auxologico Italiano, Milan, Italy
| | - Chiara Malloggi
- 2 Vascular Surgery Research Experimental Laboratory, IRCCS Istituto Auxologico Italiano, Milan, Italy
| | - Andrea Odero
- 1 Department of Surgery, IRCCS Istituto Auxologico Italiano, Milan, Italy
| | - Valerio Tolva
- 3 Department of Vascular Surgery, Policlinico Di Monza Hospital, Monza, Italy
| | - Richard Bulbulia
- 4 Clinical Trial Service Unit, Nuffield Department of Population Health, University of Oxford, Oxford, UK
| | - Alison Halliday
- 5 Nuffield Department of Surgical Sciences, University of Oxford, Oxford, UK
| | - Vincenzo Silani
- 6 Department of Neurology-Stroke Unit and Laboratory of Neuroscience, IRCCS Istituto Auxologico Italiano, 'Dino Ferrari' Centre, Department of Pathophysiology and Transplantation, Università degli Studi di Milano, Milan, Italy
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Mortimer R, Nachiappan S, Howlett DC. Carotid artery stenosis screening: where are we now? Br J Radiol 2018; 91:20170380. [PMID: 29770736 DOI: 10.1259/bjr.20170380] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Abstract
Stroke poses a significant burden on healthcare and is the second largest cause of death globally. Both medical and surgical interventions to reduce the risk of stroke in asymptomatic patients have been shown to be effective but identifying the target at risk population is more problematic. Screening for carotid artery stenosis offers one pathway for this, as there is some correlation between risk of stroke and extent of stenosis. Identification of patients who are at risk of cardiovascular disease as well as stroke, allows initiation of effective medical treatment of modifiable risk factors to address this risk. In addition, carotid intima-media thickness is a way of assessing systemic atherosclerosis and may be valuable in risk stratification of patients for cardiovascular disease. Given the low prevalence of stenosis in the general population and the risks associated with undergoing surgical intervention, population wide screening is not recommended. This recommendation has not changed over the last 15 years, since the last major studies evaluating management and outcomes were published. However, both medical and surgical/endovascular treatments have advanced over that time. Further studies are underway to compare current treatments for the appropriate management of both symptomatic and asymptomatic patients with stenosis. Two of these trials, ECST-2 and CREST-2, are expected to be completed in the next 2-4 years and the results may initiate changes in the recommendations. The use of carotid intima-media thickness alongside traditional risk scores is controversial and more research is required in this area.
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Affiliation(s)
- Rebecca Mortimer
- 1 Emergency Department, East Sussex Healthcare Trust , Eastbourne , UK
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35
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Wilcox T, Newman JD, Maldonado TS, Rockman C, Berger JS. Peripheral vascular disease risk in diabetic individuals without coronary heart disease. Atherosclerosis 2018; 275:419-425. [PMID: 29801688 DOI: 10.1016/j.atherosclerosis.2018.04.026] [Citation(s) in RCA: 25] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/14/2017] [Revised: 04/05/2018] [Accepted: 04/24/2018] [Indexed: 01/05/2023]
Abstract
BACKGROUND AND AIMS Diabetes mellitus is a coronary heart disease (CHD) risk-equivalent for the outcome of peripheral vascular disease. The impact of diabetes with comorbid risk factors on the outcome of peripheral vascular disease remains unexplored. METHODS We performed a cross-sectional analysis of participants in Lifeline Vascular Screening Inc. age 40-90 who were screened for peripheral vascular disease, defined as lower extremity peripheral artery disease (PAD, ABI <0.9) and/or carotid artery stenosis (CAS, internal CAS ≥50%). CHD was defined as prior myocardial infarction or revascularization. Risk factors included hypertension, hyperlipidemia, smoking, obesity, sedentary lifestyle and family history of cardiovascular disease. RESULTS Among 3,517,804 participants, PAD and CAS was identified in 4.4% and 3.7%, respectively. Diabetes was identified in 376,528 participants, 324,680 (86%) of whom did not have CHD. Among diabetic participants without CHD, prevalence of PAD increased with 1-2 (4.3%), 3-4 (7.3%), and ≥5 (12.0%) comorbid risk factors (p trend < 0.0001). The pattern was similar for CAS (3.7%, 6.2%, 8.8%, p trend < 0.0001). Compared to participants without diabetes, those with diabetes and 1-2, 3-4 and ≥5 risk factors had increasing odds of PAD and CAS after adjustment for age, sex and race/ethnicity (1.0, 95% CI 0.98-1.06; 1.8, 95% CI 1.8-1.89; 3.5, 95% CI 3.43-3.64, respectively, p trend < 0.0001). By comparison, in nondiabetic participants, CHD increased odds of PAD and CAS by 2-fold (2.06, 95% CI 2.02-2.1; 2.19, 95% CI 2.15-2.23 respectively). CONCLUSIONS Diabetes, particularly with comorbid risk factors, confers increased odds of PAD and CAS, even in the absence of CHD. Counseling regarding screening and prevention for peripheral vascular disease among individuals with diabetes and multiple risk factors may be useful.
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Affiliation(s)
- Tanya Wilcox
- New York University School of Medicine, Department of Medicine, 227 E. 30th Street, TRB rm. 853, New York, NY 10016, USA.
| | - Jonathan D Newman
- New York University School of Medicine, Department of Medicine, Division of Cardiology, 227E. 30th Street, TRB rm. 853, New York, NY 10016, USA.
| | - Thomas S Maldonado
- New York University School of Medicine, Department of Vascular Surgery, 530 1st Ave, New York, NY, 10016, USA
| | - Caron Rockman
- New York University School of Medicine, Department of Vascular Surgery, 530 1st Ave, New York, NY, 10016, USA
| | - Jeffrey S Berger
- New York University School of Medicine, Department of Medicine, Division of Cardiology, 227E. 30th Street, TRB rm. 853, New York, NY 10016, USA
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Mehta T, Desai N, Mehta K, Parikh R, Male S, Hussain M, Ollenschleger M, Spiegel G, Grande A, Ezzeddine M, Jagadeesan B, Tummala R, McCullough L. Outcomes of early carotid stenting and angioplasty in large-vessel anterior circulation strokes treated with mechanical thrombectomy and intravenous thrombolytics. Interv Neuroradiol 2018; 24:392-397. [PMID: 29697301 DOI: 10.1177/1591019918768574] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
Introduction Proximal cervical internal carotid artery stenosis greater than 50% merits revascularization to mitigate the risk of stroke recurrence among large-vessel anterior circulation strokes undergoing mechanical thrombectomy. Carotid artery stenting necessitates the use of antiplatelets, and there is a theoretical increased risk of hemorrhagic transformation given that such patients may already have received intravenous thrombolytics and have a significant infarct burden. We investigate the outcomes of large-vessel anterior circulation stroke patients treated with intravenous thrombolytics receiving same-day carotid stenting or selective angioplasty compared to no carotid intervention. Materials and methods The study cohort was obtained from the National (Nationwide) Inpatient Sample database between 2006 and 2014, using International Statistical Classification of Diseases, ninth revision discharge diagnosis and procedure codes. A total of 11,825 patients with large-vessel anterior circulation stroke treated with intravenous thrombolytic and mechanical thrombectomy on the same day were identified. The study population was subdivided into three subgroups: no carotid intervention, same-day carotid angioplasty without carotid stenting, and same-day carotid stenting. Outcomes were assessed with respect to mortality, significant disability at discharge, hemorrhagic transformation, and requirement of percutaneous endoscopic gastronomy tube placement, prolonged mechanical ventilation, or craniotomy. Results This study found no statistically significant difference in patient outcomes in those treated with concurrent carotid stenting compared to no carotid intervention in terms of morbidity or mortality. Conclusions If indicated, it is reasonable to consider concurrent carotid stenting and/or angioplasty for large-vessel anterior circulation stroke patients treated with mechanical thrombectomy who also receive intravenous thrombolytics.
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Affiliation(s)
- T Mehta
- 1 Department of Neurology, University of Minnesota, Minneapolis, MN, USA
| | - N Desai
- 2 Department of Neurology, Hartford Hospital, Hartford, CT, USA
| | - K Mehta
- 3 Department of Hematology-Oncology, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - R Parikh
- 4 Department of Public Health, University of Minnesota, Minneapolis, MN, USA
| | - S Male
- 1 Department of Neurology, University of Minnesota, Minneapolis, MN, USA
| | - M Hussain
- 5 Department of Interventional Neuroradiology, Hartford Hospital, Hartford, CT, USA
| | - M Ollenschleger
- 5 Department of Interventional Neuroradiology, Hartford Hospital, Hartford, CT, USA
| | - G Spiegel
- 6 Department of Neuroradiology, University of Texas Health Sciences Center, Houston, TX, USA
| | - A Grande
- 7 Department of Neurosurgery, University of Minnesota, Minneapolis, MN, USA
| | - M Ezzeddine
- 1 Department of Neurology, University of Minnesota, Minneapolis, MN, USA
| | - B Jagadeesan
- 8 Department of Radiology, University of Minnesota, Minneapolis, MN, USA
| | - R Tummala
- 7 Department of Neurosurgery, University of Minnesota, Minneapolis, MN, USA
| | - L McCullough
- 9 Department of Neurology, University of Texas Health Sciences Center, Houston, TX, USA
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Dai Z, Gao J, Li S, Li R, Chen Z, Liang M, Liu X, Xu G. Mean Platelet Volume as a Predictor for Restenosis After Carotid Angioplasty and Stenting. Stroke 2018; 49:872-876. [PMID: 29559579 DOI: 10.1161/strokeaha.117.019748] [Citation(s) in RCA: 27] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2017] [Revised: 01/18/2018] [Accepted: 02/16/2018] [Indexed: 01/08/2023]
Affiliation(s)
- Zhengze Dai
- From the Department of Neurology, Jinling Clinical College of Nanjing Medical University, China (Z.D., Z.C., X.L., G.X.); Department of Neurology, Nanjing Pukou Hospital, China (Z.D.); Department of Neurology, Jinling Hospital, Medical School of Nanjing University, China (J.G., R.L., X.L., G.X.); Department of Neurology, Jinling Hospital, Southern Medical University, Nanjing, China (S.L.); Department of Neurology, Jiangsu Province Hospital of Traditional Chinese Medicine, Nanjing, China (Z.C.); and
| | - Jie Gao
- From the Department of Neurology, Jinling Clinical College of Nanjing Medical University, China (Z.D., Z.C., X.L., G.X.); Department of Neurology, Nanjing Pukou Hospital, China (Z.D.); Department of Neurology, Jinling Hospital, Medical School of Nanjing University, China (J.G., R.L., X.L., G.X.); Department of Neurology, Jinling Hospital, Southern Medical University, Nanjing, China (S.L.); Department of Neurology, Jiangsu Province Hospital of Traditional Chinese Medicine, Nanjing, China (Z.C.); and
| | - Shun Li
- From the Department of Neurology, Jinling Clinical College of Nanjing Medical University, China (Z.D., Z.C., X.L., G.X.); Department of Neurology, Nanjing Pukou Hospital, China (Z.D.); Department of Neurology, Jinling Hospital, Medical School of Nanjing University, China (J.G., R.L., X.L., G.X.); Department of Neurology, Jinling Hospital, Southern Medical University, Nanjing, China (S.L.); Department of Neurology, Jiangsu Province Hospital of Traditional Chinese Medicine, Nanjing, China (Z.C.); and
| | - Rongrong Li
- From the Department of Neurology, Jinling Clinical College of Nanjing Medical University, China (Z.D., Z.C., X.L., G.X.); Department of Neurology, Nanjing Pukou Hospital, China (Z.D.); Department of Neurology, Jinling Hospital, Medical School of Nanjing University, China (J.G., R.L., X.L., G.X.); Department of Neurology, Jinling Hospital, Southern Medical University, Nanjing, China (S.L.); Department of Neurology, Jiangsu Province Hospital of Traditional Chinese Medicine, Nanjing, China (Z.C.); and
| | - Zhaoyao Chen
- From the Department of Neurology, Jinling Clinical College of Nanjing Medical University, China (Z.D., Z.C., X.L., G.X.); Department of Neurology, Nanjing Pukou Hospital, China (Z.D.); Department of Neurology, Jinling Hospital, Medical School of Nanjing University, China (J.G., R.L., X.L., G.X.); Department of Neurology, Jinling Hospital, Southern Medical University, Nanjing, China (S.L.); Department of Neurology, Jiangsu Province Hospital of Traditional Chinese Medicine, Nanjing, China (Z.C.); and
| | - Meng Liang
- From the Department of Neurology, Jinling Clinical College of Nanjing Medical University, China (Z.D., Z.C., X.L., G.X.); Department of Neurology, Nanjing Pukou Hospital, China (Z.D.); Department of Neurology, Jinling Hospital, Medical School of Nanjing University, China (J.G., R.L., X.L., G.X.); Department of Neurology, Jinling Hospital, Southern Medical University, Nanjing, China (S.L.); Department of Neurology, Jiangsu Province Hospital of Traditional Chinese Medicine, Nanjing, China (Z.C.); and
| | - Xinfeng Liu
- From the Department of Neurology, Jinling Clinical College of Nanjing Medical University, China (Z.D., Z.C., X.L., G.X.); Department of Neurology, Nanjing Pukou Hospital, China (Z.D.); Department of Neurology, Jinling Hospital, Medical School of Nanjing University, China (J.G., R.L., X.L., G.X.); Department of Neurology, Jinling Hospital, Southern Medical University, Nanjing, China (S.L.); Department of Neurology, Jiangsu Province Hospital of Traditional Chinese Medicine, Nanjing, China (Z.C.); and
| | - Gelin Xu
- From the Department of Neurology, Jinling Clinical College of Nanjing Medical University, China (Z.D., Z.C., X.L., G.X.); Department of Neurology, Nanjing Pukou Hospital, China (Z.D.); Department of Neurology, Jinling Hospital, Medical School of Nanjing University, China (J.G., R.L., X.L., G.X.); Department of Neurology, Jinling Hospital, Southern Medical University, Nanjing, China (S.L.); Department of Neurology, Jiangsu Province Hospital of Traditional Chinese Medicine, Nanjing, China (Z.C.); and
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Oldenburg WA, Almerey T, Selim M, Farres H, Hakaim AG. Durability of Carotid Endarterectomy with Bovine Pericardial Patch. Ann Vasc Surg 2018; 50:218-224. [PMID: 29481939 DOI: 10.1016/j.avsg.2017.11.062] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2017] [Revised: 10/10/2017] [Accepted: 11/19/2017] [Indexed: 10/18/2022]
Abstract
BACKGROUND Multiple studies have shown that patch angioplasty after carotid endarterectomy (CEA) reduces the risk of stroke and restenosis when compared with primary closure. Biological, synthetic, or vein patches have been traditionally used in CEA. This article reports the early and long-term outcomes of bovine pericardium (BP) for patch angioplasty in CEA. METHODS A retrospective, consecutive analysis of 874 patients who underwent CEA during the past 17 years at Mayo Clinic, Florida, was performed. BP patch (BPP) was used in 680 patients. Other CEA techniques were used in 194 patients (standard without patch, 78; standard with Dacron, 74; standard with vein patch, 16; and other techniques: bypasses, 26). We defined group 1 as those who underwent BPP angioplasty and group 2 as those who underwent all other techniques. Early and late clinical outcomes and patch-related complications (restenosis, infection, and hematoma) were recorded and analyzed. RESULTS Median follow-up for the entire series was 39.6 months. There were no statistically significant differences in 30-day mortality and morbidity between the 2 groups, except that BP group has less 30-day stroke (0.1%, 1 of 680) versus other techniques (1.5%, 3 of 194, P = 0.03). Thirty-day postoperative mortality rate was 0.1% (1 of 680) in BPP group and 1.0% (2 of 194) in other technique group (P = 0.13). No statistically significant difference was noted in 30-day postoperative major complications (transient ischemic attack [TIA], wound infection, hematoma requiring surgical evacuation, and nerve injury) between the 2 groups. Ten-year freedom from stroke/TIA were 97.8% in the BP group compared with 98.5% in the other group (P = 0.86). Ten-year freedom from restenosis was also similar between groups (89.0% BP vs. 90.4% others, P = 0.69). Ten-year survival rate was 38.4% in BP group and 45.0% in other technique group, and this was statistically significant on univariate analysis only. CONCLUSIONS CEA with BP angioplasty has excellent early and late outcomes with minor morbidity and mortality.
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Affiliation(s)
| | - Tariq Almerey
- Division of Vascular Surgery, Mayo Clinic Florida, Jacksonville, FL
| | - Mahmoud Selim
- Division of Vascular Surgery, Mayo Clinic Florida, Jacksonville, FL
| | - Houssam Farres
- Division of Vascular Surgery, Mayo Clinic Florida, Jacksonville, FL
| | - Albert G Hakaim
- Division of Vascular Surgery, Mayo Clinic Florida, Jacksonville, FL
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Bennett GM, Bluth EI, Larson ML, Luo Q. Recommendations for Low-Grade Carotid Stenosis Follow-up Based on a Single-Institution Database. JOURNAL OF ULTRASOUND IN MEDICINE : OFFICIAL JOURNAL OF THE AMERICAN INSTITUTE OF ULTRASOUND IN MEDICINE 2018; 37:439-445. [PMID: 28877387 DOI: 10.1002/jum.14354] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/08/2017] [Accepted: 05/16/2017] [Indexed: 06/07/2023]
Abstract
OBJECTIVES The purpose of this study was to determine the incidences and rates of progression of varying degrees of carotid stenosis that do not require intervention according to the Asymptomatic Carotid Atherosclerosis Study, the European Carotid Surgery Trial, and the North American Symptomatic Carotid Endarterectomy Trial, and from this information, to provide evidence-based recommendations for follow-up imaging. METHODS A retrospective review was performed of all carotid ultrasound examinations performed at a single institution from January 1995 through April 2015. Examinations following endarterectomy or stenting were excluded. Stenoses were classified by a modification of the criteria of Bluth et al (Radiographics 1988; 8:487-506). A Kaplan-Meier survival analysis was performed for stenosis progression and to provide information for follow-up recommendations. RESULTS Most of the carotid arteries (91.6%) reviewed for this study showed 1% to 39% stenosis. However, only 6.8% of carotid arteries with 1% to 39% stenosis progressed compared to 38.9% of carotid arteries with 40% to 59% stenosis. A table of evidence-based follow-up recommendations is provided for patients with varying levels of stenosis. CONCLUSIONS We provide evidence-based follow-up recommendations for patients who have low degrees of carotid stenosis. Different degrees of carotid stenosis progress at different rates and therefore should be followed at different intervals. Additionally, the most patients in our database showed 1% to 39% stenosis and did not have any follow-up imaging, suggesting that carotid ultrasound may not be overused for low degrees of stenosis.
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Affiliation(s)
- Garrett M Bennett
- Department of Radiology, Ochsner Clinic Foundation, New Orleans, Louisiana, USA
| | - Edward I Bluth
- Department of Radiology, Ochsner Clinic Foundation, New Orleans, Louisiana, USA
- University of Queensland School of Medicine, Ochsner Clinical School, New Orleans, Louisiana, USA
| | - Michael L Larson
- Department of Radiology, Ochsner Clinic Foundation, New Orleans, Louisiana, USA
| | - Qingyang Luo
- Office of Biostatistical Support, Ochsner Clinic Foundation, New Orleans, Louisiana, USA
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40
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Tse GTW, Kilkenny MF, Bladin C, Grigg M, Dewey HM. Carotid endarterectomy: the change in practice over 11 years in a stroke centre. ANZ J Surg 2017; 89:314-319. [PMID: 29132196 DOI: 10.1111/ans.14241] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2017] [Revised: 07/26/2017] [Accepted: 08/24/2017] [Indexed: 12/01/2022]
Abstract
BACKGROUND Recent research evidence has impacted the practice of carotid endarterectomy (CEA). We aim to characterize changes in the practice and outcome of CEA over time in a single large-volume stroke centre. METHODS All patients who underwent CEA from 2004 to 2014 and carotid angioplasty and stenting (CAS) from 2003 to 2008 at an Australian metropolitan tertiary stroke centre hospital were included. Clinical data were analysed to identify time trends in choice of intervention, patient selection, preoperative imaging utilization, surgical timing and outcome. RESULTS There were 510 CEAs performed during 2004-2014 and 95 CASs during 2003-2008. The proportion of patients undergoing CEA compared to CAS increased from 60% to 90% from 2004 to 2008 (P < 0.001). CAS patients were more likely to have cardiac co-morbidities. From 2004 to 2014, the proportion of CEA patients aged ≥80 years increased (P = 0.001) and the proportion of asymptomatic patients decreased (P = 0.003) over time. Median time from symptom onset to surgery decreased from 52 days (Q1: 25, Q3: 74) in 2004 to 8 days (Q1: 5, Q3: 37) in 2014 (P < 0.001). Use of preoperative ultrasonography decreased whilst CT angiography and the number of imaging modalities applied to each patient increased over time (P < 0.001). Overall, 5.9% of CEAs were complicated by death, stroke or acute myocardial infarction with no significant change over time. CONCLUSION The trends in CEA practice at our centre align with international trends and guidelines. This study provides a representative indicator of Australian hospital practice, and illustrates how evidence from research is translated into clinical care.
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Affiliation(s)
- Gabrielle T W Tse
- Department of Neurosciences, Eastern Health, Melbourne, Victoria, Australia
| | - Monique F Kilkenny
- Stroke and Ageing Research, School of Clinical Sciences at Monash Health, Monash University, Melbourne, Victoria, Australia.,Florey Institute of Neuroscience and Mental Health, Melbourne, Victoria, Australia
| | - Chris Bladin
- Department of Neurosciences, Eastern Health, Melbourne, Victoria, Australia.,Eastern Health Clinical School, Faculty of Medicine, Nursing and Health Sciences, Monash University, Melbourne, Victoria, Australia
| | - Michael Grigg
- Eastern Health Clinical School, Faculty of Medicine, Nursing and Health Sciences, Monash University, Melbourne, Victoria, Australia.,Department of Vascular Surgery, Eastern Health, Melbourne, Victoria, Australia
| | - Helen M Dewey
- Department of Neurosciences, Eastern Health, Melbourne, Victoria, Australia.,Eastern Health Clinical School, Faculty of Medicine, Nursing and Health Sciences, Monash University, Melbourne, Victoria, Australia
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41
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Hamilton RD, Shield CE, Laughrun D. Progression of asymptomatic mild carotid artery stenosis: Implications for frequency of surveillance. Vasc Med 2017; 22:411-417. [PMID: 28825353 DOI: 10.1177/1358863x17722215] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
We looked retrospectively at the 3- to 5-year progression of mild, asymptomatic carotid artery stenosis (CAS). A random sample of 600 patients who had undergone at least two carotid artery duplex ultrasounds between 31 October 2006 and 1 November 2016 with a second duplex ⩾3 and ⩽5 years following the initial one were screened for inclusion. Internal carotid arteries (ICAs) were included if they had 20-49% stenosis on the initial duplex, with 440 carotid arteries meeting this criteria. Analyses were performed utilizing chi-squared and two-tailed t-tests. Twenty-four (5.45%) of the initial 440 carotid arteries progressed to moderate CAS. There was a statistically significant increase in the prevalence of hypertension (68% vs 47%, p=0.022) and diabetes mellitus (44% vs 22%, p=0.008) in patients with carotids that progressed to moderate CAS. There was a decrease in moderate-intensity statin use (32% vs 58%, p=0.005) and an increase in patients not on statins (36% vs 11%, p=0.001) in the group of carotids that progressed to moderate CAS. One carotid artery (0.2%) progressed from mild CAS to severe CAS. If supported by others, our data may lead to a change in the recommendations regarding appropriate follow-up of asymptomatic CAS.
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Affiliation(s)
- Russell D Hamilton
- 1 Department of Internal Medicine, Mercy Medical Center, Des Moines, IA, USA
| | - Cory E Shield
- 1 Department of Internal Medicine, Mercy Medical Center, Des Moines, IA, USA
| | - David Laughrun
- 2 Department of Cardiology, Iowa Heart Center, Des Moines, IA, USA
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42
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Rimmele DL, Larena-Avellaneda A, Alegiani AC, Rosenkranz M, Schmidt NO, Regelsberger J, Hummel FC, Magnus T, Debus ES, Fiehler J, Gerloff C, Thomalla G. Real-world experience of treatment decision-making in carotid stenosis in a neurovascular board. Neurology 2017; 89:399-407. [PMID: 28659428 DOI: 10.1212/wnl.0000000000004151] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2016] [Accepted: 03/28/2017] [Indexed: 11/15/2022] Open
Abstract
OBJECTIVE To describe our experience with consensus-based decision-making for treatment of internal carotid artery (ICA) stenosis by neurologists, interventional neuroradiologists, vascular surgeons, and neurosurgeons in a multidisciplinary neurovascular board and to study adherence to treatment recommendations in the context of uncertainty with respect to the best treatment option. METHODS We established a multidisciplinary neurovascular board meeting twice a week with structured documentation of consensus decisions. Over a time period of 53 months, 614 cases with ICA stenosis were discussed, with 285 (46%) symptomatic and 279 (45%) asymptomatic cases. RESULTS Recommendation for symptomatic ICA stenosis was revascularization in 76%, medical management alone in 8%, and further diagnostics in 16%. For asymptomatic ICA stenosis, recommendation was randomization in a clinical trial in 29%, revascularization in 27%, medical management alone in 23%, and further diagnostics in 22%. Treatment recommendations were followed in 94% of symptomatic ICA stenosis and 69% of asymptomatic ICA stenosis. Patients in whom carotid artery stenting was recommended for revascularization were younger and showed a higher rate of severe (≥70%) ICA stenosis. CONCLUSIONS Interdisciplinary board decisions are a helpful and transparent tool to assure adherence to guideline recommendations, and to provide consensus-based individualized treatment strategies in clinical practice in the absence of unequivocal evidence.
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Affiliation(s)
- David Leander Rimmele
- From Klinik und Poliklinik für Neurologie (D.L.R., A.C.A., T.M., C.G., G.T.) and Klinik und Poliklinik für Neurochirurgie (N.O.S., J.R.), Kopf- und Neurozentrum, and Klinik und Poliklinik für Neuroradiologische Diagnostik und Intervention, Diagnostikzentrum (J.F.), Universitätsklinikum Hamburg-Eppendorf; Klinik für Gefäβmedizin (A.L.-A., E.S.D.), Universitäres Herzzentrum Hamburg; Klinik für Neurologie und Neurologische Frührehabilitation (M.R.), Albertinen-Krankenhaus, Hamburg, Germany; Swiss Federal Institute of Technology (EPFL) (F.C.H.), Campus Biotech, Geneva; and Clinique Romande de Réadaptation (F.C.H.), Sion, Switzerland
| | - Axel Larena-Avellaneda
- From Klinik und Poliklinik für Neurologie (D.L.R., A.C.A., T.M., C.G., G.T.) and Klinik und Poliklinik für Neurochirurgie (N.O.S., J.R.), Kopf- und Neurozentrum, and Klinik und Poliklinik für Neuroradiologische Diagnostik und Intervention, Diagnostikzentrum (J.F.), Universitätsklinikum Hamburg-Eppendorf; Klinik für Gefäβmedizin (A.L.-A., E.S.D.), Universitäres Herzzentrum Hamburg; Klinik für Neurologie und Neurologische Frührehabilitation (M.R.), Albertinen-Krankenhaus, Hamburg, Germany; Swiss Federal Institute of Technology (EPFL) (F.C.H.), Campus Biotech, Geneva; and Clinique Romande de Réadaptation (F.C.H.), Sion, Switzerland
| | - Anna C Alegiani
- From Klinik und Poliklinik für Neurologie (D.L.R., A.C.A., T.M., C.G., G.T.) and Klinik und Poliklinik für Neurochirurgie (N.O.S., J.R.), Kopf- und Neurozentrum, and Klinik und Poliklinik für Neuroradiologische Diagnostik und Intervention, Diagnostikzentrum (J.F.), Universitätsklinikum Hamburg-Eppendorf; Klinik für Gefäβmedizin (A.L.-A., E.S.D.), Universitäres Herzzentrum Hamburg; Klinik für Neurologie und Neurologische Frührehabilitation (M.R.), Albertinen-Krankenhaus, Hamburg, Germany; Swiss Federal Institute of Technology (EPFL) (F.C.H.), Campus Biotech, Geneva; and Clinique Romande de Réadaptation (F.C.H.), Sion, Switzerland
| | - Michael Rosenkranz
- From Klinik und Poliklinik für Neurologie (D.L.R., A.C.A., T.M., C.G., G.T.) and Klinik und Poliklinik für Neurochirurgie (N.O.S., J.R.), Kopf- und Neurozentrum, and Klinik und Poliklinik für Neuroradiologische Diagnostik und Intervention, Diagnostikzentrum (J.F.), Universitätsklinikum Hamburg-Eppendorf; Klinik für Gefäβmedizin (A.L.-A., E.S.D.), Universitäres Herzzentrum Hamburg; Klinik für Neurologie und Neurologische Frührehabilitation (M.R.), Albertinen-Krankenhaus, Hamburg, Germany; Swiss Federal Institute of Technology (EPFL) (F.C.H.), Campus Biotech, Geneva; and Clinique Romande de Réadaptation (F.C.H.), Sion, Switzerland
| | - Nils Ole Schmidt
- From Klinik und Poliklinik für Neurologie (D.L.R., A.C.A., T.M., C.G., G.T.) and Klinik und Poliklinik für Neurochirurgie (N.O.S., J.R.), Kopf- und Neurozentrum, and Klinik und Poliklinik für Neuroradiologische Diagnostik und Intervention, Diagnostikzentrum (J.F.), Universitätsklinikum Hamburg-Eppendorf; Klinik für Gefäβmedizin (A.L.-A., E.S.D.), Universitäres Herzzentrum Hamburg; Klinik für Neurologie und Neurologische Frührehabilitation (M.R.), Albertinen-Krankenhaus, Hamburg, Germany; Swiss Federal Institute of Technology (EPFL) (F.C.H.), Campus Biotech, Geneva; and Clinique Romande de Réadaptation (F.C.H.), Sion, Switzerland
| | - Jan Regelsberger
- From Klinik und Poliklinik für Neurologie (D.L.R., A.C.A., T.M., C.G., G.T.) and Klinik und Poliklinik für Neurochirurgie (N.O.S., J.R.), Kopf- und Neurozentrum, and Klinik und Poliklinik für Neuroradiologische Diagnostik und Intervention, Diagnostikzentrum (J.F.), Universitätsklinikum Hamburg-Eppendorf; Klinik für Gefäβmedizin (A.L.-A., E.S.D.), Universitäres Herzzentrum Hamburg; Klinik für Neurologie und Neurologische Frührehabilitation (M.R.), Albertinen-Krankenhaus, Hamburg, Germany; Swiss Federal Institute of Technology (EPFL) (F.C.H.), Campus Biotech, Geneva; and Clinique Romande de Réadaptation (F.C.H.), Sion, Switzerland
| | - Friedhelm C Hummel
- From Klinik und Poliklinik für Neurologie (D.L.R., A.C.A., T.M., C.G., G.T.) and Klinik und Poliklinik für Neurochirurgie (N.O.S., J.R.), Kopf- und Neurozentrum, and Klinik und Poliklinik für Neuroradiologische Diagnostik und Intervention, Diagnostikzentrum (J.F.), Universitätsklinikum Hamburg-Eppendorf; Klinik für Gefäβmedizin (A.L.-A., E.S.D.), Universitäres Herzzentrum Hamburg; Klinik für Neurologie und Neurologische Frührehabilitation (M.R.), Albertinen-Krankenhaus, Hamburg, Germany; Swiss Federal Institute of Technology (EPFL) (F.C.H.), Campus Biotech, Geneva; and Clinique Romande de Réadaptation (F.C.H.), Sion, Switzerland
| | - Tim Magnus
- From Klinik und Poliklinik für Neurologie (D.L.R., A.C.A., T.M., C.G., G.T.) and Klinik und Poliklinik für Neurochirurgie (N.O.S., J.R.), Kopf- und Neurozentrum, and Klinik und Poliklinik für Neuroradiologische Diagnostik und Intervention, Diagnostikzentrum (J.F.), Universitätsklinikum Hamburg-Eppendorf; Klinik für Gefäβmedizin (A.L.-A., E.S.D.), Universitäres Herzzentrum Hamburg; Klinik für Neurologie und Neurologische Frührehabilitation (M.R.), Albertinen-Krankenhaus, Hamburg, Germany; Swiss Federal Institute of Technology (EPFL) (F.C.H.), Campus Biotech, Geneva; and Clinique Romande de Réadaptation (F.C.H.), Sion, Switzerland
| | - Eike Sebastian Debus
- From Klinik und Poliklinik für Neurologie (D.L.R., A.C.A., T.M., C.G., G.T.) and Klinik und Poliklinik für Neurochirurgie (N.O.S., J.R.), Kopf- und Neurozentrum, and Klinik und Poliklinik für Neuroradiologische Diagnostik und Intervention, Diagnostikzentrum (J.F.), Universitätsklinikum Hamburg-Eppendorf; Klinik für Gefäβmedizin (A.L.-A., E.S.D.), Universitäres Herzzentrum Hamburg; Klinik für Neurologie und Neurologische Frührehabilitation (M.R.), Albertinen-Krankenhaus, Hamburg, Germany; Swiss Federal Institute of Technology (EPFL) (F.C.H.), Campus Biotech, Geneva; and Clinique Romande de Réadaptation (F.C.H.), Sion, Switzerland
| | - Jens Fiehler
- From Klinik und Poliklinik für Neurologie (D.L.R., A.C.A., T.M., C.G., G.T.) and Klinik und Poliklinik für Neurochirurgie (N.O.S., J.R.), Kopf- und Neurozentrum, and Klinik und Poliklinik für Neuroradiologische Diagnostik und Intervention, Diagnostikzentrum (J.F.), Universitätsklinikum Hamburg-Eppendorf; Klinik für Gefäβmedizin (A.L.-A., E.S.D.), Universitäres Herzzentrum Hamburg; Klinik für Neurologie und Neurologische Frührehabilitation (M.R.), Albertinen-Krankenhaus, Hamburg, Germany; Swiss Federal Institute of Technology (EPFL) (F.C.H.), Campus Biotech, Geneva; and Clinique Romande de Réadaptation (F.C.H.), Sion, Switzerland
| | - Christian Gerloff
- From Klinik und Poliklinik für Neurologie (D.L.R., A.C.A., T.M., C.G., G.T.) and Klinik und Poliklinik für Neurochirurgie (N.O.S., J.R.), Kopf- und Neurozentrum, and Klinik und Poliklinik für Neuroradiologische Diagnostik und Intervention, Diagnostikzentrum (J.F.), Universitätsklinikum Hamburg-Eppendorf; Klinik für Gefäβmedizin (A.L.-A., E.S.D.), Universitäres Herzzentrum Hamburg; Klinik für Neurologie und Neurologische Frührehabilitation (M.R.), Albertinen-Krankenhaus, Hamburg, Germany; Swiss Federal Institute of Technology (EPFL) (F.C.H.), Campus Biotech, Geneva; and Clinique Romande de Réadaptation (F.C.H.), Sion, Switzerland
| | - Götz Thomalla
- From Klinik und Poliklinik für Neurologie (D.L.R., A.C.A., T.M., C.G., G.T.) and Klinik und Poliklinik für Neurochirurgie (N.O.S., J.R.), Kopf- und Neurozentrum, and Klinik und Poliklinik für Neuroradiologische Diagnostik und Intervention, Diagnostikzentrum (J.F.), Universitätsklinikum Hamburg-Eppendorf; Klinik für Gefäβmedizin (A.L.-A., E.S.D.), Universitäres Herzzentrum Hamburg; Klinik für Neurologie und Neurologische Frührehabilitation (M.R.), Albertinen-Krankenhaus, Hamburg, Germany; Swiss Federal Institute of Technology (EPFL) (F.C.H.), Campus Biotech, Geneva; and Clinique Romande de Réadaptation (F.C.H.), Sion, Switzerland.
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Hong JH, Sohn SI, Kwak J, Yoo J, Chang HW, Kwon OK, Jung C, Chung I, Bae HJ, Lee JS, Han MK. Dose-Dependent Effect of Statin Pretreatment on Preventing the Periprocedural Complications of Carotid Artery Stenting. Stroke 2017. [PMID: 28626049 DOI: 10.1161/strokeaha.117.016680] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
BACKGROUND AND PURPOSE We investigated whether statin pretreatment can dose dependently reduce periprocedural complications in patients undergoing carotid artery stenting because of symptomatic carotid artery stenosis. METHODS We enrolled a consecutive series of 397 symptomatic carotid artery stenosis (≥50% stenosis on conventional angiography) treated with carotid artery stenting at 2 tertiary university hospitals over a decade. Definition of periprocedural complications included any stroke, myocardial infarction, and death within 1 month after or during the procedure. Statin pretreatment was divided into 3 categories according to the atorvastatin equivalent dose: none (n=158; 39.8%), standard dose (<40 mg of atorvastatin, n=155; 39.0%), and high dose (≥40 mg; n=84; 21.2%). A multivariable logistic regression analysis with the generalized estimating equation method was used to investigate independent factors in periprocedural complications. RESULTS The patients' mean age was 68.7 years (81.6% men). The periprocedural complication rates across the 3 categories of statin use were 12.0%, 4.5%, and 1.2%. After adjustment, a change in the atorvastatin dose category was associated with reduction in the odds of periprocedural complications for each change in dose category (standard-dose statin: odds ratio, 0.24; 95% confidence interval, 0.07-0.81; high-dose statin: odds ratio, 0.11; 95% confidence interval, 0.01-0.96; P for trend=0.01). Administration of antiplatelet drugs was also an independent factor in periprocedural complications (OR, 0.18; 95% CI, 0.05-0.69). CONCLUSIONS This study shows that statin pretreatment may reduce the incidence of periprocedural complications dose dependently in patients with symptomatic carotid artery stenting.
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Affiliation(s)
- Jeong-Ho Hong
- From the Department of Neurology (J.-H.H., S.-I.S., J.K., J.Y.); Department of Radiology (H.W.C.), Keimyung University School of Medicine, Dongsan Medical Center, Daegu, Korea; Department of Neurology (I.C., H.-J.B., M.-K.H.), Department of Neurosurgery (O.-K.K.), and Department of Radiology (C.J.), Seoul National University Bundang Hospital, Seongnam, Korea; and Clinical Trial Center, University of Ulsan College of Medicine and Asan Medical Center, Seoul, Korea (J.S.L.)
| | - Sung-Il Sohn
- From the Department of Neurology (J.-H.H., S.-I.S., J.K., J.Y.); Department of Radiology (H.W.C.), Keimyung University School of Medicine, Dongsan Medical Center, Daegu, Korea; Department of Neurology (I.C., H.-J.B., M.-K.H.), Department of Neurosurgery (O.-K.K.), and Department of Radiology (C.J.), Seoul National University Bundang Hospital, Seongnam, Korea; and Clinical Trial Center, University of Ulsan College of Medicine and Asan Medical Center, Seoul, Korea (J.S.L.)
| | - Jaehyuk Kwak
- From the Department of Neurology (J.-H.H., S.-I.S., J.K., J.Y.); Department of Radiology (H.W.C.), Keimyung University School of Medicine, Dongsan Medical Center, Daegu, Korea; Department of Neurology (I.C., H.-J.B., M.-K.H.), Department of Neurosurgery (O.-K.K.), and Department of Radiology (C.J.), Seoul National University Bundang Hospital, Seongnam, Korea; and Clinical Trial Center, University of Ulsan College of Medicine and Asan Medical Center, Seoul, Korea (J.S.L.)
| | - Joonsang Yoo
- From the Department of Neurology (J.-H.H., S.-I.S., J.K., J.Y.); Department of Radiology (H.W.C.), Keimyung University School of Medicine, Dongsan Medical Center, Daegu, Korea; Department of Neurology (I.C., H.-J.B., M.-K.H.), Department of Neurosurgery (O.-K.K.), and Department of Radiology (C.J.), Seoul National University Bundang Hospital, Seongnam, Korea; and Clinical Trial Center, University of Ulsan College of Medicine and Asan Medical Center, Seoul, Korea (J.S.L.)
| | - Hyuk Won Chang
- From the Department of Neurology (J.-H.H., S.-I.S., J.K., J.Y.); Department of Radiology (H.W.C.), Keimyung University School of Medicine, Dongsan Medical Center, Daegu, Korea; Department of Neurology (I.C., H.-J.B., M.-K.H.), Department of Neurosurgery (O.-K.K.), and Department of Radiology (C.J.), Seoul National University Bundang Hospital, Seongnam, Korea; and Clinical Trial Center, University of Ulsan College of Medicine and Asan Medical Center, Seoul, Korea (J.S.L.)
| | - O-Ki Kwon
- From the Department of Neurology (J.-H.H., S.-I.S., J.K., J.Y.); Department of Radiology (H.W.C.), Keimyung University School of Medicine, Dongsan Medical Center, Daegu, Korea; Department of Neurology (I.C., H.-J.B., M.-K.H.), Department of Neurosurgery (O.-K.K.), and Department of Radiology (C.J.), Seoul National University Bundang Hospital, Seongnam, Korea; and Clinical Trial Center, University of Ulsan College of Medicine and Asan Medical Center, Seoul, Korea (J.S.L.)
| | - Cheolkyu Jung
- From the Department of Neurology (J.-H.H., S.-I.S., J.K., J.Y.); Department of Radiology (H.W.C.), Keimyung University School of Medicine, Dongsan Medical Center, Daegu, Korea; Department of Neurology (I.C., H.-J.B., M.-K.H.), Department of Neurosurgery (O.-K.K.), and Department of Radiology (C.J.), Seoul National University Bundang Hospital, Seongnam, Korea; and Clinical Trial Center, University of Ulsan College of Medicine and Asan Medical Center, Seoul, Korea (J.S.L.)
| | - Inyoung Chung
- From the Department of Neurology (J.-H.H., S.-I.S., J.K., J.Y.); Department of Radiology (H.W.C.), Keimyung University School of Medicine, Dongsan Medical Center, Daegu, Korea; Department of Neurology (I.C., H.-J.B., M.-K.H.), Department of Neurosurgery (O.-K.K.), and Department of Radiology (C.J.), Seoul National University Bundang Hospital, Seongnam, Korea; and Clinical Trial Center, University of Ulsan College of Medicine and Asan Medical Center, Seoul, Korea (J.S.L.)
| | - Hee-Joon Bae
- From the Department of Neurology (J.-H.H., S.-I.S., J.K., J.Y.); Department of Radiology (H.W.C.), Keimyung University School of Medicine, Dongsan Medical Center, Daegu, Korea; Department of Neurology (I.C., H.-J.B., M.-K.H.), Department of Neurosurgery (O.-K.K.), and Department of Radiology (C.J.), Seoul National University Bundang Hospital, Seongnam, Korea; and Clinical Trial Center, University of Ulsan College of Medicine and Asan Medical Center, Seoul, Korea (J.S.L.)
| | - Ji Sung Lee
- From the Department of Neurology (J.-H.H., S.-I.S., J.K., J.Y.); Department of Radiology (H.W.C.), Keimyung University School of Medicine, Dongsan Medical Center, Daegu, Korea; Department of Neurology (I.C., H.-J.B., M.-K.H.), Department of Neurosurgery (O.-K.K.), and Department of Radiology (C.J.), Seoul National University Bundang Hospital, Seongnam, Korea; and Clinical Trial Center, University of Ulsan College of Medicine and Asan Medical Center, Seoul, Korea (J.S.L.)
| | - Moon-Ku Han
- From the Department of Neurology (J.-H.H., S.-I.S., J.K., J.Y.); Department of Radiology (H.W.C.), Keimyung University School of Medicine, Dongsan Medical Center, Daegu, Korea; Department of Neurology (I.C., H.-J.B., M.-K.H.), Department of Neurosurgery (O.-K.K.), and Department of Radiology (C.J.), Seoul National University Bundang Hospital, Seongnam, Korea; and Clinical Trial Center, University of Ulsan College of Medicine and Asan Medical Center, Seoul, Korea (J.S.L.).
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Abstract
As a common etiology for ischemic stroke, atherosclerotic carotid stenosis has been targeted by vascular surgery since 1950s. Compared with carotid endarterectomy, carotid angioplasty and stenting (CAS) is almost similarly efficacious and less invasive. These advantages make CAS an alternative in treating carotid stenosis. However, accumulative evidences suggested that the long-term benefit-risk ratio of CAS may be decreased or even neutralized by the complications related to in-stent restenosis (ISR). Therefore, investigating the mechanisms and identifying the influential factors of ISR are of vital importance for improving the long-term outcomes of CAS. As responses to intrinsic and extrinsic injuries, intimal hyperplasia and vascular smooth muscle cell proliferation have been regarded as the principle mechanisms for ISR development. Due to the lack of consensus-based definition and consistent follow-up protocol, the reported incidences of ISR after CAS varied widely among studies. These variations made the inter-study comparisons of ISR largely illogical. To eliminate restenosis after CAS, both surgery and endovascular procedures have been attempted with promising results. For preventing ISR, drug-eluting stents and antiplatelets have been proposed as potential solutions.
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Affiliation(s)
- Zhengze Dai
- Department of Neurology, Jinling Hospital, Nanjing Medical University, Nanjing, China
- Department of Neurology, Pukou Hospital, Nanjing, China
| | - Gelin Xu
- Department of Neurology, Jinling Hospital, Nanjing Medical University, Nanjing, China
- Department of Neurology, Jinling Hospital, Medical School of Nanjing University, Nanjing, China
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Schmid S, Tsantilas P, Knappich C, Kallmayer M, König T, Breitkreuz T, Zimmermann A, Kuehnl A, Eckstein HH. Risk of Inhospital Stroke or Death Is Associated With Age But Not Sex in Patients Treated With Carotid Endarterectomy for Asymptomatic or Symptomatic Stenosis in Routine Practice: Secondary Data Analysis of the Nationwide German Statutory Quality Assurance Database From 2009 to 2014. J Am Heart Assoc 2017; 6:JAHA.116.004764. [PMID: 28288976 PMCID: PMC5524011 DOI: 10.1161/jaha.116.004764] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/02/2022]
Abstract
Background Guideline recommendations on carotid endarterectomy are based predominantly on randomized, controlled trials, in which women or elderly patients are often under‐represented. This study analyzed the association of age and sex with the risk of in‐hospital stroke or death following carotid endarterectomy under routine conditions in Germany. Methods and Results Secondary data analysis using the Statutory German Quality Assurance Database on all carotid endarterectomy procedures (n=142 074) performed between 2009 and 2014. Primary outcome was any stroke or death until discharge; secondary outcomes were any in‐hospital stroke (alone), and death (alone). Descriptive statistics and multilevel multivariable regression analyses were applied. Patients were predominately male (68%), with mean age 71 years. Carotid stenosis was symptomatic in 40%. Primary outcome occurred in 1.8% of women and 1.9% of men. Multivariable regression analysis revealed that more‐advanced age was associated with a higher primary outcome rate (relative risk [RR] per 10‐year increase: 1.19; 95% CI, 1.14–1.24). Risk of death (alone) was associated with age (RR, 1.68; 95% CI, 1.54–1.84). Age was associated with the risk of stroke (alone; RR, 1.05; 95% CI, 1.00–1.11). Sex was not associated with primary outcome rate (1.01; 95% CI, 0.93–1.10), nor did it significantly modify the age effect. Conclusions This study shows that increasing age, but not sex, is associated with a higher risk of in‐hospital stroke or death following carotid endarterectomy under everyday conditions in Germany. Whereas the risk of death (alone) is significantly associated with age, the association between age and the risk of stroke (alone) can be considered of minor importance.
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Affiliation(s)
- Sofie Schmid
- Department of Vascular and Endovascular Surgery, Klinikum rechts der Isar Technical University of Munich, Germany
| | - Pavlos Tsantilas
- Department of Vascular and Endovascular Surgery, Klinikum rechts der Isar Technical University of Munich, Germany
| | - Christoph Knappich
- Department of Vascular and Endovascular Surgery, Klinikum rechts der Isar Technical University of Munich, Germany
| | - Michael Kallmayer
- Department of Vascular and Endovascular Surgery, Klinikum rechts der Isar Technical University of Munich, Germany
| | - Thomas König
- AQUA-Institut für angewandte Qualitätsförderung und Forschung im Gesundheitswesen GmbH, Göttingen, Germany
| | - Thorben Breitkreuz
- AQUA-Institut für angewandte Qualitätsförderung und Forschung im Gesundheitswesen GmbH, Göttingen, Germany
| | - Alexander Zimmermann
- Department of Vascular and Endovascular Surgery, Klinikum rechts der Isar Technical University of Munich, Germany
| | - Andreas Kuehnl
- Department of Vascular and Endovascular Surgery, Klinikum rechts der Isar Technical University of Munich, Germany
| | - Hans-Henning Eckstein
- Department of Vascular and Endovascular Surgery, Klinikum rechts der Isar Technical University of Munich, Germany
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Wang Y, Liu M, Pu C. 2014 Chinese guidelines for secondary prevention of ischemic stroke and transient ischemic attack. Int J Stroke 2017; 12:302-320. [PMID: 28381199 DOI: 10.1177/1747493017694391] [Citation(s) in RCA: 88] [Impact Index Per Article: 12.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
Ischemic stroke and transient ischemic attack (TIA) are the most common cerebrovascular disorder and leading cause of death in China. The Effective secondary prevention is the vital strategy for reducing stroke recurrence. The aim of this guideline is to provide the most updated evidence-based recommendation to clinical physicians from the prior version. Control of risk factors, intervention for vascular stenosis/occlusion, antithrombotic therapy for cardioembolism, and antiplatelet therapy for noncardioembolic stroke are all recommended, and the prevention of recurrent stroke in a variety of uncommon causes and subtype provided as well. We modified the level of evidence and recommendation according to part of results from domestic RCT in order to facility the clinical practice.
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Affiliation(s)
- Yongjun Wang
- 1 Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Ming Liu
- 2 Department of Neurology, West China Hospital, Sichuan University, Chengdu, China
| | - Chuanqiang Pu
- 3 Department of Neurology, The General Hospital of Chinese People's Liberation Army, Beijing, China
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Abstract
The incidence of vertigo in the population is 20% to 30% and one-fourth of the cases are related to central causes. The aim of this study was to evaluate computed tomography angiography (CTA) findings of the vertebrobasilar system in central vertigo without stroke.CTA and magnetic resonance images of patients with vertigo were retrospectively evaluated. One hundred twenty-nine patients suspected of having central vertigo according to history, physical examination, and otological and neurological tests without signs of infarction on diffusion-weighted magnetic resonance imaging were included in the study. The control group included 120 patients with similar vascular disease risk factors but without vertigo. Vertebral and basilar artery diameters, hypoplasias, exit-site variations of vertebral artery, vertebrobasilar tortuosity, and stenosis of ≥50% detected on CTA were recorded for all patients. Independent-samples t test was used in variables with normal distribution, and Mann-Whitney U test in non-normal distribution. The difference of categorical variable distribution according to groups was analyzed with χ and/or Fisher exact test.Vertebral artery hypoplasia and ≥50% stenosis were seen more often in the vertigo group (P = 0.000, <0.001). Overall 78 (60.5%) vertigo patients had ≥50% stenosis, 54 (69.2%) had stenosis at V1 segment, 9 (11.5%) at V2 segment, 2 (2.5%) at V3 segment, and 13 (16.6%) at V4 segment. Both vertigo and control groups had similar basilar artery hypoplasia and ≥50% stenosis rates (P = 0.800, >0.05).CTA may be helpful to clarify the association between abnormal CTA findings of vertebral arteries and central vertigo.This article reveals the opportunity to diagnose posterior circulation abnormalities causing central vertigo with a feasible method such as CTA.
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Internal Carotid Artery Stenosis Presenting with Limb Shaking TIA. Case Rep Neurol Med 2016; 2016:3656859. [PMID: 27840754 PMCID: PMC5093263 DOI: 10.1155/2016/3656859] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2016] [Accepted: 10/04/2016] [Indexed: 01/10/2023] Open
Abstract
Internal carotid artery (ICA) stenosis may lead to a wide range of clinical symptoms. We describe the case of a 66-year-old female who experienced a transient ischemic attack (TIA) with episodes of limb shaking caused by ICA stenosis. After epilepsy had been suspected and ruled out, studies of her left ICA showed extensive blockage as a result of atherosclerosis. Magnetic resonance angiography (MRA) revealed total occlusion of the left ICA and the patient was eventually medically managed due to the strong possibility of surgical complications. We reported this patient's clinical course to shed light on a rare manifestation of carotid stenosis that may be confused with other diagnoses if not closely scrutinized.
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Liu H, Chu J, Zhang L, Liu C, Yan Z, Zhou S. Early Carotid Artery Stenting for Cerebral Watershed Infarction Is Safe and Effective: A Retrospective Study. Eur Neurol 2016; 76:256-260. [DOI: 10.1159/000452149] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2016] [Accepted: 09/29/2016] [Indexed: 11/19/2022]
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