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Abdelkarim A, Hamouda M, Malas MB. What Is the Best Technique for Treating Carotid Disease? Adv Surg 2024; 58:161-189. [PMID: 39089775 DOI: 10.1016/j.yasu.2024.04.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/04/2024]
Abstract
This is a comprehensive review of carotid artery revascularization techniques: Carotid Endarterectomy (CEA), Transfemoral Carotid Artery Stenting (TFCAS), and Transcarotid Artery Revascularization (TCAR). CEA is the gold standard and is particularly effective in elderly and high-risk patients. TFCAS, introduced as a less invasive alternative, poses increased periprocedural stroke risks. TCAR, which combines minimally invasive benefits with CEA's neuroprotection principles, emerges as a safer option for high-risk patients, showing comparable results to CEA and better outcomes than TFCAS. The decision-making process for carotid revascularization is complex and influenced by the patient's medical comorbidities and anatomic factors.
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Affiliation(s)
- Ahmed Abdelkarim
- Department of Surgery, Division of Vascular and Endovascular Surgery, UC San Diego, San Diego, CA, USA; Center for Learning and Excellence in Vascular & Endovascular Research (CLEVER), UC San Diego, San Diego, CA, USA; Altman Center for Clinical and Translational Research, 9452 Medical Center Drive - LL2W 502A, La Jolla, CA 92037, USA
| | - Mohammed Hamouda
- Department of Surgery, Division of Vascular and Endovascular Surgery, UC San Diego, San Diego, CA, USA; Center for Learning and Excellence in Vascular & Endovascular Research (CLEVER), UC San Diego, San Diego, CA, USA; Altman Center for Clinical and Translational Research, 9452 Medical Center Drive - LL2W 502A, La Jolla, CA 92037, USA
| | - Mahmoud B Malas
- Department of Surgery, Division of Vascular and Endovascular Surgery, UC San Diego, San Diego, CA, USA; Center for Learning and Excellence in Vascular & Endovascular Research (CLEVER), UC San Diego, San Diego, CA, USA; Altman Center for Clinical and Translational Research, 9452 Medical Center Drive - LL2W 502A, La Jolla, CA 92037, USA.
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Omura Y, Imamura H, Tani S, Adachi H, Sakaguchi M, Todo K, Yamagami H, Goto M, Ohara N, Fukumitsu R, Sunohara T, Matsumoto S, Fukui N, Fukuda T, Akiyama T, Ohta T, Sakai C, Sakai N. Treatment Results of Carotid Artery Stenting with an Open-Cell Stent: Analysis of 734 Consecutive Cases at a Single Center. World Neurosurg 2024; 187:e453-e459. [PMID: 38663734 DOI: 10.1016/j.wneu.2024.04.108] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2024] [Revised: 04/16/2024] [Accepted: 04/17/2024] [Indexed: 05/27/2024]
Abstract
OBJECTIVE In carotid artery stenting (CAS) for internal carotid artery stenosis, the stent is often selected according to the plaque properties and arterial tortuosity. In our institute, an open-cell stent is used as the first-line stent regardless of the characteristics of the lesion. This study was performed to examine the outcome of CAS with an open-cell stent as the real-world results. METHODS In total, 811 CAS procedures using open-cell stents were performed for internal carotid artery stenosis from April 2002 to December 2019. Of these patients, we excluded those with hyperacute conditions for which CAS was performed within 3 days of onset, those in whom acute mechanical thrombectomy was performed simultaneously with CAS, and those with stenosis due to arterial dissection. Thus, 734 patients were retrospectively analyzed. Perioperative and long-term outcomes and risk factors for perioperative infarction were investigated. RESULTS The periprocedural stroke rate and mortality rate were 3.7% (27/734) and 0.4% (3/734), respectively. Low-echoic plaque was a significant risk factor for periprocedural stroke in both univariate (P < 0.03) and multivariate (odds ratio, 2.69; 95% confidence interval, 1.14-6.66; P = 0.02) analyses. Cerebral infarction and high grade restenosis were observed in 15 (2.0%) and 17 (2.3%) patients during a median 50-month follow-up. CONCLUSIONS CAS with open-cell stents showed good results in terms of both the postoperative stroke incidence and long-term severe restenosis rate. However, low-echoic plaque was a risk factor for perioperative stroke incidence, which should be considered when deciding on the indication for CAS with an open-cell stent.
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Affiliation(s)
- Yoshihiro Omura
- Department of Neurosurgery, Kobe City Medical Center General Hospital, Kobe, Hyogo, Japan; Department of Neurosurgery, Tokyo Women's Medical University Hospital, Shinjuku, Tokyo, Japan.
| | - Hirotoshi Imamura
- Department of Neurosurgery, Kobe City Medical Center General Hospital, Kobe, Hyogo, Japan
| | - Shoichi Tani
- Department of Neurosurgery, Kobe City Medical Center General Hospital, Kobe, Hyogo, Japan
| | - Hidemitsu Adachi
- Department of Neurosurgery, Kobe City Medical Center General Hospital, Kobe, Hyogo, Japan
| | - Manabu Sakaguchi
- Department of Neurology, Kobe City Medical Center General Hospital, Kobe, Hyogo, Japan
| | - Kenichi Todo
- Department of Neurology, Kobe City Medical Center General Hospital, Kobe, Hyogo, Japan
| | - Hiroshi Yamagami
- Department of Neurology, Kobe City Medical Center General Hospital, Kobe, Hyogo, Japan
| | - Masanori Goto
- Department of Neurosurgery, Kobe City Medical Center General Hospital, Kobe, Hyogo, Japan
| | - Nobuyuki Ohara
- Department of Neurology, Kobe City Medical Center General Hospital, Kobe, Hyogo, Japan
| | - Ryu Fukumitsu
- Department of Neurosurgery, Kobe City Medical Center General Hospital, Kobe, Hyogo, Japan
| | - Tadashi Sunohara
- Department of Neurosurgery, Kobe City Medical Center General Hospital, Kobe, Hyogo, Japan
| | - Shirabe Matsumoto
- Department of Neurosurgery, Kobe City Medical Center General Hospital, Kobe, Hyogo, Japan
| | - Nobuyuki Fukui
- Department of Neurosurgery, Kobe City Medical Center General Hospital, Kobe, Hyogo, Japan
| | - Tatsumaru Fukuda
- Department of Neurosurgery, Kobe City Medical Center General Hospital, Kobe, Hyogo, Japan
| | - Tomoaki Akiyama
- Department of Neurosurgery, Kobe City Medical Center General Hospital, Kobe, Hyogo, Japan
| | - Tsuyoshi Ohta
- Department of Neurosurgery, Kobe City Medical Center General Hospital, Kobe, Hyogo, Japan
| | - Chiaki Sakai
- Department of Neurosurgery, Kobe City Medical Center General Hospital, Kobe, Hyogo, Japan
| | - Nobuyuki Sakai
- Department of Neurosurgery, Kobe City Medical Center General Hospital, Kobe, Hyogo, Japan
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Langhoff R, Schwindt A, Vajda Z, Gjoreski A, Faurie B, Kedev S, Müller-Hülsbeck S. Navigating complexity with low-crossing profile dual-layer micromesh carotid stent: implications for contemporary carotid artery stenting outcomes (ROADSAVER study insights). THE JOURNAL OF CARDIOVASCULAR SURGERY 2024; 65:205-212. [PMID: 39007554 DOI: 10.23736/s0021-9509.24.13068-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 07/16/2024]
Abstract
BACKGROUND The safety and efficacy of carotid artery stenting (CAS) can be affected by certain technical and anatomical factors. However, it is not known whether the use of a dual-layer micromesh stent (DLMS) with a low-crossing profile could reduce the risks associated with complex vascular anatomies during CAS. METHODS This study involved 1965 asymptomatic or symptomatic carotid artery stenosis patients who received the Roadsaver DLMS during CAS, as part of a prospective, multicenter observational ROADSAVER study, conducted from January 2018 to February 2021. The primary outcome was the 30-day rate of major adverse events (MAE; i.e. any death or stroke) after CAS. Procedural details and outcomes were compared between patients with complex anatomical features and those without. RESULTS One or more complex anatomical characteristics were identified in 1639 (83.4%) patents. Patients with complex anatomies were older and had a higher prevalence of arterial hypertension, cardiovascular disease, and prior stroke. Between patients with or without complex anatomical features, no significant differences were found either in procedural techniques, or in 30-day MAE (age-adjusted odds ratio (95% CI) for complexities vs. no complexities: 0.76 (0.35, 1.66); p=0.4905) and any stroke (age-adjusted odds ratio (95% CI) for complexities vs. no complexities: 0.89 (0.37, 2.17); p=0.8032) incidence. Furthermore, neither the presence of specific types of anatomic complexity nor their number (per patient) markedly influenced the 30-day MAE and any stroke incidence. CONCLUSIONS In this real-world cohort of patients undergoing CAS with the Roadsaver DLMS, no significant difference in the occurrence of 30-day MAE and any stroke was observed between patients with or without high-risk anatomical features.
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Affiliation(s)
- Ralf Langhoff
- Department of Angiology, Brandenburg Medical School Theodor Fontane, Campus Clinic Brandenburg, Brandenburg an der Havel and Sankt Gertrauden Hospital, Berlin, Germany -
| | - Arne Schwindt
- Department of Vascular Surgery, St. Franziskus-Hospital, Münster, Germany
| | - Zsolt Vajda
- Neurovascular Unit, Moritz Kaposi Teaching Hospital, Kaposvár, Hungary
- Department of Radiology, Fejér County Szent György University Teaching Hospital, Székesfehérvár, Hungary
| | - Aleksander Gjoreski
- Department for Diagnostic and Interventional Radiology, Clinical Hospital "Acibadem Sistina", Skopje, Republic of North Macedonia
| | | | - Sasko Kedev
- Department of Cardiology, Faculty of Medicine, University Clinic of Cardiology, University of St. Cyril and Methodius, Skopje, Republic of North Macedonia
| | - Stefan Müller-Hülsbeck
- Department of Diagnostic and Interventional Radiology and Neuroradiology, DIAKO Hospital gGmbH, Flensburg, Germany
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Denorme F, Frösen J, Jouppila A, Lindgren A, Resendiz-Nieves JC, Manninen H, De Meyer SF, Lassila R. Pretreatment with a dual antiplatelet and anticoagulant (APAC) reduces ischemia-reperfusion injury in a mouse model of temporary middle cerebral artery occlusion-implications for neurovascular procedures. Acta Neurochir (Wien) 2024; 166:137. [PMID: 38485848 PMCID: PMC10940479 DOI: 10.1007/s00701-024-06017-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2023] [Accepted: 02/14/2024] [Indexed: 03/18/2024]
Abstract
BACKGROUND Several neurovascular procedures require temporary occlusion of cerebral arteries, leading to ischemia of unpredictable length, occasionally causing brain infarction. Experimental models of cerebral ischemia-reperfusion injury have established that platelet adhesion and coagulation play detrimental roles in reperfusion injury following transient cerebral ischemia. Therefore, in a model of cerebral ischemia-reperfusion injury (IRI), we investigated the therapeutic potential of a dual antiplatelet and anticoagulant (APAC) heparin proteoglycan mimetic which is able to bind to vascular injury sites. METHODS Brain ischemia was induced in mice by transient occlusion of the right middle cerebral artery for 60 min. APAC, unfractionated heparin (UFH) (both at heparin equivalent doses of 0.5 mg/kg), or vehicle was intravenously administered 10 min before or 60 min after the start of ischemia. At 24 h later, mice were scored for their neurological and motor behavior, and brain damage was quantified. RESULTS Both APAC and UFH administered before the onset of ischemia reduced brain injury. APAC and UFH pretreated mice had better neurological and motor functions (p < 0.05 and p < 0.01, respectively) and had significantly reduced cerebral infarct sizes (p < 0.01 and p < 0.001, respectively) at 24 h after transient occlusion compared with vehicle-treated mice. Importantly, no macroscopic bleeding complications were observed in either APAC- or UFH-treated animals. However, when APAC or UFH was administered 60 min after the start of ischemia, the therapeutic effect was lost, but without hemorrhaging either. CONCLUSIONS Pretreatment with APAC or UFH was safe and effective in reducing brain injury in a model of cerebral ischemia induced by transient middle cerebral artery occlusion. Further studies on the use of APAC to limit ischemic injury during temporary occlusion in neurovascular procedures are indicated.
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Affiliation(s)
- Frederik Denorme
- Laboratory for Thrombosis Research, KU Leuven Campus Kulak Kortrijk, Kortrijk, Belgium
| | - Juhana Frösen
- Hemorrhagic Brain Pathology Research Group, Dept. of Neurosurgery, Kuopio University Hospital, Kuopio, Finland
- Department of Neurosurgery, Tampere University Hospital, Tampere, Finland
| | - Annukka Jouppila
- Helsinki University Central Hospital Clinical Research Institute, Helsinki, Finland
| | - Antti Lindgren
- Department of Clinical Radiology, Kuopio University Hospital, Kuopio, Finland
- Institute of Clinical Medicine, School of Medicine, Faculty of Health Sciences, University of Eastern Finland, Kuopio, Finland
| | - Julio C Resendiz-Nieves
- Department of Neurosurgery, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Hannu Manninen
- Department of Radiology, Kuopio University Hospital, Kuopio, Finland
| | - Simon F De Meyer
- Laboratory for Thrombosis Research, KU Leuven Campus Kulak Kortrijk, Kortrijk, Belgium
| | - Riitta Lassila
- Coagulation Disorders Unit, Departments of Hematology and Cancer Center, Helsinki University Hospital, Helsinki, Finland.
- Faculty of Medicine, Research Program in Systems Oncology, University of Helsinki, Helsinki, Finland.
- Aplagon Oy, Helsinki, Finland.
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Nishimoto T, Oka F, Okazaki K, Sadahiro H, Oku T, Ishihara H. Safety of Tailored Transfemoral Carotid Artery Stenting for Symptomatic Elderly Patients: A Single Center Observational Study. World Neurosurg 2024; 181:e1038-e1046. [PMID: 37967746 DOI: 10.1016/j.wneu.2023.11.031] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2023] [Revised: 11/07/2023] [Accepted: 11/08/2023] [Indexed: 11/17/2023]
Abstract
OBJECTIVE Transfemoral carotid artery stenting (TFCAS) in symptomatic elderly patients (≥70 years old) may have a high periprocedural stroke rate. This study was performed to examine whether tailored TFCAS for symptomatic elderly patients is as safe as that for symptomatic nonelderly patients. METHODS The subjects were 185 patients with symptomatic internal carotid artery stenosis. Tailored TFCAS including postoperative management was performed based on preoperative examinations of vascular anatomy, plaque imaging, platelet aggregation activity, and cerebral hemodynamic impairment. The major 30-day perioperative stroke rates were examined. RESULTS The patients included 51 (27.6%) <70 (group Y) and 134 (72.4%) ≥70 (group E) years old. Group E included significantly more cases with an elongated aortic arch, tortuous target lesion, and longer plaques (all P < 0.05). Among all cases, 181 (97.8%) procedures were performed as per preoperative planning. Group E had more frequent use of a proximal embolic protection device and a closed-cell or dual-layer micromesh stent (all P < 0.05). Seven patients (3.8%) had major stroke. Rates of major ischemic stroke (2.0% vs. 3.0%, P = 1.00) and intracranial hemorrhage (2.0% vs. 0.8%, P = 0.48) were low and did not differ significantly between groups Y and E. CONCLUSIONS Symptomatic elderly patients have several unfavorable factors. However, tailored TFCAS for each patient based on preoperative examinations in symptomatic elderly patients may be as safe as that in symptomatic nonelderly patients.
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Affiliation(s)
- Takuma Nishimoto
- Department of Neurosurgery, Yamaguchi University School of Medicine, Ube, Yamaguchi, Japan.
| | - Fumiaki Oka
- Department of Neurosurgery, Yamaguchi University School of Medicine, Ube, Yamaguchi, Japan
| | - Koki Okazaki
- Department of Neurosurgery, Yamaguchi University School of Medicine, Ube, Yamaguchi, Japan
| | - Hirokazu Sadahiro
- Department of Neurosurgery, Yamaguchi University School of Medicine, Ube, Yamaguchi, Japan
| | - Takayuki Oku
- Department of Neurosurgery, Yamaguchi University School of Medicine, Ube, Yamaguchi, Japan
| | - Hideyuki Ishihara
- Department of Neurosurgery, Yamaguchi University School of Medicine, Ube, Yamaguchi, Japan
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Ozaki S, Akimoto T, Iida Y, Miyake S, Suzuki R, Shimohigoshi W, Hori S, Suenaga J, Shimizu N, Nakai Y, Sakata K, Yamamoto T. Complications and outcomes of carotid artery stenting in high-risk cases. J Stroke Cerebrovasc Dis 2023; 32:107329. [PMID: 37657401 DOI: 10.1016/j.jstrokecerebrovasdis.2023.107329] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2023] [Revised: 05/21/2023] [Accepted: 08/24/2023] [Indexed: 09/03/2023] Open
Abstract
OBJECTIVES Carotid artery stenting is sometimes adapted for some at-risk cases; however, appropriate treatment timing with stroke onset is controversial. This study aims to identify factors that have an impact on complications and outcomes, especially in patients at high risk. MATERIALS AND METHODS We examined the characteristics of 152 consecutive patients treated by carotid artery stenting between January 2018 and March 2022 and retrospectively analyzed the risk factors for complications and poor outcomes (modified-Rankin-Scale deterioration), such as patient background, carotid artery stenting risks (access route tortuosity, severe calcification, vulnerable plaque, estimated glomerular filtration rate <30 mL/min/1.73 m2, etc.), characteristics of the stenosis, details of treatment, and treatment timing. RESULTS The average North American Symptomatic Carotid Endarterectomy Trial criteria score was 68.3% and the lesion length was 20.5±9.7mm. Among patients, 107 (70.4%) had a carotid artery stenting risk. In high-risk carotid artery stenting cases, symptomatic complications occurred in 32 (30.0%), and the 90-day modified Rankin scale score deteriorated in 15 cases (14.0%). Multivariate analysis showed that cases with triple antithrombotic therapy (p=0.003), stenting within 7 days (p=0.0032), and after 28+ days (p=0.0035) of stroke onset were independently associated factors for complications. CONCLUSIONS This study showed that among risk factors, triple antithrombotic therapy in particular was a risk factor for perioperative complications. Carotid artery stenting for patients with stroke after 28 days of onset affects the prognosis. Therefore, although further study is warranted, waiting more than one month for treatment in patients requiring carotid artery stenting is a potential risk.
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Affiliation(s)
- So Ozaki
- Department of Neurosurgery, Yokohama City University Medical Center, 4-57 Urafune, Minami, Yokohama 2320024, Japan
| | - Taisuke Akimoto
- Department of Neurosurgery, Yokohama City University Medical Center, 4-57 Urafune, Minami, Yokohama 2320024, Japan; Department of Neurosurgery, Yokohama City University Graduate School of Medicine, 3-9 Fukuura, Kanazawa, Yokohama 2360004, Japan.
| | - Yu Iida
- Department of Neurosurgery, Yokohama City University Graduate School of Medicine, 3-9 Fukuura, Kanazawa, Yokohama 2360004, Japan
| | - Shigeta Miyake
- Department of Neurosurgery, Yokohama Brain and Spine Center, 1-2-1, Takigashira, Isogo, Yokohama, Kanagawa 2350012, Japan
| | - Ryosuke Suzuki
- Department of Neurosurgery, Yokohama City University Graduate School of Medicine, 3-9 Fukuura, Kanazawa, Yokohama 2360004, Japan
| | - Wataru Shimohigoshi
- Department of Neurosurgery, Yokohama City University Medical Center, 4-57 Urafune, Minami, Yokohama 2320024, Japan
| | - Satoshi Hori
- Department of Neurosurgery, Yokohama City University Medical Center, 4-57 Urafune, Minami, Yokohama 2320024, Japan; Department of Neurosurgery, Yokohama City University Graduate School of Medicine, 3-9 Fukuura, Kanazawa, Yokohama 2360004, Japan
| | - Jun Suenaga
- Department of Neurosurgery, Yokohama City University Graduate School of Medicine, 3-9 Fukuura, Kanazawa, Yokohama 2360004, Japan
| | - Nobuyuki Shimizu
- Department of Neurosurgery, Yokohama City University Graduate School of Medicine, 3-9 Fukuura, Kanazawa, Yokohama 2360004, Japan
| | - Yasunobu Nakai
- Department of Neurosurgery, Yokohama City University Graduate School of Medicine, 3-9 Fukuura, Kanazawa, Yokohama 2360004, Japan; Department of Neurosurgery, Yokohama Brain and Spine Center, 1-2-1, Takigashira, Isogo, Yokohama, Kanagawa 2350012, Japan
| | - Katsumi Sakata
- Department of Neurosurgery, Yokohama City University Medical Center, 4-57 Urafune, Minami, Yokohama 2320024, Japan
| | - Tetsuya Yamamoto
- Department of Neurosurgery, Yokohama City University Graduate School of Medicine, 3-9 Fukuura, Kanazawa, Yokohama 2360004, Japan
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Yang L, Du H, Zhang D, Qiao Z, Su X, Han S, Gao BL, Cao Q. Complications and long-term in-stent restenosis of endovascular treatment of severe symptomatic intracranial atherosclerotic stenosis and relevant risk factors. Medicine (Baltimore) 2023; 102:e34697. [PMID: 37747021 PMCID: PMC10519467 DOI: 10.1097/md.0000000000034697] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/08/2023] [Revised: 06/07/2023] [Accepted: 07/20/2023] [Indexed: 09/26/2023] Open
Abstract
To investigate the complications and in-stent restenosis of endovascular treatment of severe symptomatic intracranial atherosclerotic stenosis and relevant risk factors. Three hundred and fifty-four consecutive patients with intracranial atherosclerotic stenosis (70%-99%) were retrospectively enrolled. The clinical data, treatment outcomes, complications and in-stent restenosis at follow-up were analyzed. The endovascular treatment was composed of balloon dilatation only in 21 (5.93%) patients, and deployment of self-expandable stents in 232 (65.54%), balloon-expandable stents in 75 (21.19%), and both balloon- and self-expandable stents in 26 (7.34%), with a total of 359 stents being successfully deployed at the stenotic location. After treatment, the residual stenosis ranged 9.2%±1.5% (range 7%-19%), which was significantly (P < .05) smaller than that before treatment. Periprocedural complications occurred in 43 patients with a complication rate of 12.15% including arterial dissection in 4 (1.13%) patients, new cerebral infarction in 21 (5.93%), cerebral hemorrhage in 12 (3.3%), and subarachnoid hemorrhage in 6 (1.69%). Hyperlipidemia [odds ratio (OR) 10.35, 95% confidence interval (CI) 4.42-24.28, and P < .0001] and location at the middle cerebral artery (MCA) (OR 4.15, 95% CI 1.92-8.97, and P < .001) were significant (P < .05) risk factors for periprocedural complications, whereas hyperlipidemia (OR 11.28, 95% CI 4.65-30.60, and P < .0001), location at the MCA (or 5.26, 95% CI 2.03-15.08, and P < .001), and angulation (OR 1.02, 95% CI 1.00-1.04, and P = .02) were significant (P < .05) independent risk factors for periprocedural complications. Follow-up was performed in 287 (81.07%) patients at 6 to 36 (28 ± 6.7) months. In-stent restenosis was present in 36 (12.54%), and female sex (OR 2.53, and 95% CI 1.27-5.06) and periprocedural complications (OR 9.18, and 95% CI 3.52-23.96) were significant (P < .05) risk factors for in-stent restenosis, with periprocedural complication (OR 9.61, and 95% CI 3.48-27.23) as the only significant (P < .0001) independent risk factor for in-stent restenosis. A certain rate of periprocedural complications and in-stent stenosis may occur in endovascular treatment of severe intracranial stenosis, and the relevant risk factors may include hyperlipidemia, MCA location, angulation at the stenosis and female sex.
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Affiliation(s)
- Lei Yang
- Department of Neurosurgery, Shijiazhuang People’s Hospital, Shijiazhuang, Hebei, China
| | - Hong Du
- Department of Neurosurgery, Shijiazhuang People’s Hospital, Shijiazhuang, Hebei, China
| | - Dongliang Zhang
- Department of Neurosurgery, Shijiazhuang People’s Hospital, Shijiazhuang, Hebei, China
| | - Zongrong Qiao
- Department of Neurosurgery, Shijiazhuang People’s Hospital, Shijiazhuang, Hebei, China
| | - Xianhui Su
- Department of Neurosurgery, Shijiazhuang People’s Hospital, Shijiazhuang, Hebei, China
| | - Siqin Han
- Department of Neurosurgery, Shijiazhuang People’s Hospital, Shijiazhuang, Hebei, China
| | - Bu-Lang Gao
- Department of Neurosurgery, Shijiazhuang People’s Hospital, Shijiazhuang, Hebei, China
| | - Qinying Cao
- Department of Neurosurgery, Shijiazhuang People’s Hospital, Shijiazhuang, Hebei, China
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Gorgulu S, Sahin M, Norgaz NT, Pala S, Sarı M, Yalcin AA, Sipahi I. Carotid artery stenting without embolic protection: A randomized multicenter trial (the CASWEP trial). Interv Neuroradiol 2023; 29:419-425. [PMID: 35469509 PMCID: PMC10399495 DOI: 10.1177/15910199221094388] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2022] [Accepted: 03/24/2022] [Indexed: 12/24/2022] Open
Abstract
BACKGROUND Carotid artery stenting (CAS) with a carotid protection device (CPD) has become the standard practice in patients with severe carotid stenosis and high surgical risk. However, the clinical efficacy and safety of CPDs are still controversial issues. We aimed to compare the clinical outcomes of the CAS without CPD with CAS combined with CPD. METHODS This is a multicenter randomized prospective study registered with http://clinicaltrials.gov (NCT02781181). After the exclusion, 279 patients were enrolled (139 patients in the CAS with CPD group and 140 patients in the CAS without CPD group). The primary outcome was a combination of peri-procedural in-hospital transient ischemic attack (TIA), ipsilateral stroke, or death. The secondary outcome was new ischemic brain lesions on post-procedural diffusion-weighted magnetic resonance imaging (DW-MRI). RESULTS Two patients died in CAS without CPD group, one patient died in CAS with CPD group. TIA was only seen in patients who underwent CAS under protection (n = 5). The combined primary outcome of TIA, ipsilateral stroke, and death rate was not different between groups (5.7% vs. 2.8%; p = 0.254). New defects were noted on the post-procedural DW-MRI in 28% of patients in the CPD group and 27% of patients in the no CPD group (p = 0.881). CONCLUSIONS This study suggests that CAS without CPD is not associated with higher rates of peri-procedural TIA, stroke, and death or new ischemic brain lesions on post-procedural DW-MRI compared to CAS with CPD in selected symptomatic and asymptomatic patients with significant carotid artery stenosis provided that there is no visible thrombus.
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Affiliation(s)
- Sevket Gorgulu
- Department of Cardiology, Acibadem University Medical Faculty, Istanbul, Turkey
| | - Muslum Sahin
- Department of Cardiology, Istinye University Medical Faculty, Istanbul, Turkey
| | | | - Selçuk Pala
- Department of Cardiology, University of Health Sciences, Kartal Kosuyolu High Speciality Educational and Research Hospital, Istanbul, Turkey
| | - Munevver Sarı
- Department of Cardiology, University of Health Sciences, Kartal Kosuyolu High Speciality Educational and Research Hospital, Istanbul, Turkey
| | - Ahmet Arif Yalcin
- Department of Cardiology, University of Health Sciences, Mehmet Akif Ersoy Chest and Cardiovascular Surgery Training and Research Hospital, Istanbul, Turkey
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Banks CA, Pearce BJ. Interventions in Carotid Artery Surgery: An Overview of Current Management and Future Implications. Surg Clin North Am 2023; 103:645-671. [PMID: 37455030 DOI: 10.1016/j.suc.2023.05.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/18/2023]
Abstract
Atherosclerotic carotid artery disease has been well studied over the last half-century by multiple randomized controlled trials attempting to elucidate the appropriate modality of therapy for this disease process. Surgical techniques have evolved from carotid artery endarterectomy and transfemoral carotid artery stenting to the development of hybrid techniques in transcarotid artery revascularization. In this article, the authors provide a review of the available literature regarding operative and medical management of carotid artery disease.
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Affiliation(s)
- Charles Adam Banks
- Division of Vascular Surgery and Endovascular Therapy, University of Alabama at Birmingham, 1808 7th Avenue South, Boshell Diabetes Building 652, Birmingham, AL 35294, USA
| | - Benjamin J Pearce
- Division of Vascular Surgery and Endovascular Therapy, University of Alabama at Birmingham, 1808 7th Avenue South, Boshell Diabetes Building 652, Birmingham, AL 35294, USA.
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Calo P, Oberhuber A, Görtz H. Patient Selection Criteria and Procedural Standardization for Carotid Artery Stenting-A Single Center Experience. J Clin Med 2023; 12:jcm12103534. [PMID: 37240640 DOI: 10.3390/jcm12103534] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2023] [Revised: 04/26/2023] [Accepted: 05/16/2023] [Indexed: 05/28/2023] Open
Abstract
The gold standard for the treatment of carotid artery stenosis is the carotid endarterectomy (CEA). According to current guidelines, carotid artery stenting (CAS) is an alternative. Randomized control trials (RCTs) show significantly higher rates of peri-interventional strokes after CAS compared to CEA. However, these trials were usually characterized by a great heterogeneity in the CAS procedure. In this retrospective analysis from 2012 to 2020, 202 symptomatic and asymptomatic patients were treated with CAS. Patients were carefully pre-selected according to anatomical and clinical criteria. In all cases, the same steps and material were used. All interventions were performed by five experienced vascular surgeons. Primary endpoints of this study were perioperative death and stroke. Asymptomatic carotid stenosis was present in 77% of the patients and symptomatic in 23%. The mean age was 66 years. The average degree of stenosis was 81%. The CAS technical success rate was 100%. Periprocedural complications occurred in 1.5% of cases, including one major stroke (0.5%) and two minor strokes (1%). The results of this study indicate that through a strict patient selection based on anatomical and clinical criteria, CAS can be performed with very low complication rates. Furthermore, standardization of the materials and the procedure itself is crucial.
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Affiliation(s)
- Paolo Calo
- Department of Vascular Surgery, Bonifatius Hospital Lingen, 49808 Lingen, Germany
| | - Alexander Oberhuber
- Department of Vascular and Endovascular Surgery, University Hospital Muenster, 48149 Muenster, Germany
| | - Hartmut Görtz
- Department of Vascular Surgery, Bonifatius Hospital Lingen, 49808 Lingen, Germany
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11
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MRI Outcomes Achieved by Simple Flow Blockage Technique in Symptomatic Carotid Artery Stenosis Stenting. J Pers Med 2022; 12:jpm12101564. [PMID: 36294703 PMCID: PMC9604835 DOI: 10.3390/jpm12101564] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2022] [Revised: 09/14/2022] [Accepted: 09/16/2022] [Indexed: 11/30/2022] Open
Abstract
In this study, we aimed to determine the frequency and clinical impact of new ischemic lesions detected with diffusion-weighted-imaging-MRI (DWI-MRI) as well as the clinical outcomes after carotid artery stenting (CAS) using the simple flow blockage technique (SFB). This is a retrospective study with data extraction from a monocentric prospective clinical registry (from 2017 to 2019) of consecutive patients admitted for symptomatic cervical ICA stenosis or web. Herein, patients benefited from DWI-MRI before and within 48 h of CAS for symptomatic ICA stenosis or web. The primary endpoint was the frequency of new DWI-MRI ischemic lesions and the secondary (composite) endpoint was the rate of mortality, symptomatic stroke or acute coronary syndrome within 30 days of the procedure. All of the 82 CAS procedures were successfully performed. Among the 33 patients (40.2%) with new DWI-MRI ischemic lesions, 30 patients were asymptomatic (90.9%). Irregular carotid plaque surface with (n = 13, 44.8%) or without ulceration (n = 12, 60.0%) was associated with higher rates of new DWI-MRI lesions by comparison to patients with a regular plaque (n = 7, 25%) (p = 0.048) using the univariate analysis. Less than half of this CAS cohort using the SFB technique had new ischemic lesions detected with DWI-MRI. Among these patients, more than 90% were asymptomatic. Irregularity of the plaque seems to increase the risk of peri-procedural DWI-MRI lesions.
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12
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Abbott AL. Extra-Cranial Carotid Artery Stenosis: An Objective Analysis of the Available Evidence. Front Neurol 2022; 13:739999. [PMID: 35800089 PMCID: PMC9253595 DOI: 10.3389/fneur.2022.739999] [Citation(s) in RCA: 15] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2021] [Accepted: 01/24/2022] [Indexed: 12/26/2022] Open
Abstract
Background and Purpose Carotid stenosis is arterial disease narrowing of the origin of the internal carotid artery (main brain artery). Knowing how to best manage this is imperative because it is common in older people and an important cause of stroke. Inappropriately high expectations have grown regarding the value of carotid artery procedures, such as surgery (endarterectomy) and stenting, for lowering the stroke risk associated with carotid stenosis. Meanwhile, the improving and predominant value of medical intervention (lifestyle coaching and medication) continues to be underappreciated. Methods and Results This article aims to be an objective presentation and discussion of the scientific literature critical for decision making when the primary goal is to optimize patient outcome. This compilation follows from many years of author scrutiny to separate fact from fiction. Common sense conclusions are drawn from factual statements backed by original citations. Detailed research methodology is given in cited papers. This article has been written in plain language given the importance of the general public understanding this topic. Issues covered include key terminology and the economic impact of carotid stenosis. There is a summary of the evidence-base regarding the efficacy and safety of procedural and medical (non-invasive) interventions for both asymptomatic and symptomatic patients. Conclusions are drawn with respect to current best management and research priorities. Several "furphies" (misconceptions) are exposed that are commonly used to make carotid stenting and endarterectomy outcomes appear similar. Ongoing randomized trials are mentioned and why they are unlikely to identify a routine practice indication for carotid artery procedures. There is a discussion of relevant worldwide guidelines regarding carotid artery procedures, including how they should be improved. There is an outline of systematic changes that are resulting in better application of the evidence-base. Conclusion The cornerstone of stroke prevention is medical intervention given it is non-invasive and protects against all arterial disease complications in all at risk. The "big" question is, does a carotid artery procedure add patient benefit in the modern era and, if so, for whom?
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Affiliation(s)
- Anne L. Abbott
- Department of Neuroscience, Central Clinical School, Monash University, Melbourne, VIC, Australia
- Neurology Private Practice, Knox Private Hospital, Wantirna, VIC, Australia
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13
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Mokin M, Levy EI. Endovascular Therapy of Extracranial and Intracranial Occlusive Disease. Stroke 2022. [DOI: 10.1016/b978-0-323-69424-7.00066-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
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14
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Miyake S, Suzuki R, Akimoto T, Iida Y, Shimohigoshi W, Nakai Y, Manaka H, Shimizu N, Yamamoto T. Renal Dysfunction is the Strongest Prognostic Factor After Carotid Artery Stenting According to Real-World Data. J Stroke Cerebrovasc Dis 2021; 31:106269. [PMID: 34963079 DOI: 10.1016/j.jstrokecerebrovasdis.2021.106269] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2021] [Revised: 11/17/2021] [Accepted: 12/04/2021] [Indexed: 11/30/2022] Open
Abstract
PURPOSE Through the progression of devices, the adaptation of carotid artery stenting (CAS) has been expanded according to the non-inferiority of CAS for carotid endarterectomy reported by several randomized control trials. To maintain favorable outcomes, identifying prognostic factors is essential for optimizing treatment indications and periprocedural management. This study focused on the prognostic factors of CAS using real-world data. METHODS This retrospective multicenter cohort study aimed to identify the prognostic factors after CAS using real-world data from the stroke registry of Yokohama (STrOke Registry of Yokohama; STORY) from January 1, 2018 to May 31, 2021. Patient characteristics, procedural factors, complications, and prognoses were collected using medical records. RESULTS Data from 107 patients were enrolled in this study after excluding those with insufficient data (2 cases). The mean participant age was 74.9±8.2 years, and 66 patients (61.7%) were symptomatic. Symptomatic lesions were a significant prognostic factor in the overall analysis (p=0.003). A multivariate analysis showed that the estimated glomerular filtration rate (eGFR) (odds ratio: 1.11, p=0.003) and staged CAS (odds ratio: 38.9, p=0.04) were independent prognostic factors. The odds ratio and relative risk of mRS deterioration when eGFR was under 49 mL/min/1.73 m2 compared with when eGFR was above 49 mL/min/1.73 m2 were 5.2 and 3.74, respectively. CONCLUSIONS In this real-world multicenter study, we established independent prognostic factors for CAS using high totality data. For patients with symptomatic lesions and low eGFR (≤49 mL/min/1.73 m2), indication for treatment should be considered strictly.
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Affiliation(s)
- Shigeta Miyake
- Department of Neurosurgery, Yokohama Brain and Spine Center, 1-2-1, Takigashira, Isogo, Yokohama, Kanagawa, 2350012, Japan
| | - Ryosuke Suzuki
- Department of Neurosurgery, Yokohama City University Graduate School of Medicine, 3-9 Fukuura, Kanazawa, Yokohama, 2360004, Japan
| | - Taisuke Akimoto
- Department of Neurosurgery, Yokohama City University Medical Center, 4-57 Urafune, Minami, Yokohama, 2320024, Japan.
| | - Yu Iida
- Department of Neurosurgery, Yokohama City University Graduate School of Medicine, 3-9 Fukuura, Kanazawa, Yokohama, 2360004, Japan
| | - Wataru Shimohigoshi
- Department of Neurosurgery, Yokohama City University Medical Center, 4-57 Urafune, Minami, Yokohama, 2320024, Japan
| | - Yasunobu Nakai
- Department of Neurosurgery, Yokohama Brain and Spine Center, 1-2-1, Takigashira, Isogo, Yokohama, Kanagawa, 2350012, Japan
| | - Hiroshi Manaka
- Department of Neurosurgery, Yokohama City University Medical Center, 4-57 Urafune, Minami, Yokohama, 2320024, Japan
| | - Nobuyuki Shimizu
- Department of Neurosurgery, Yokohama City University Graduate School of Medicine, 3-9 Fukuura, Kanazawa, Yokohama, 2360004, Japan
| | - Tetsuya Yamamoto
- Department of Neurosurgery, Yokohama City University Graduate School of Medicine, 3-9 Fukuura, Kanazawa, Yokohama, 2360004, Japan
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15
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Moacdieh MP, Khan MA, Layman P, Elsayed N, Malas MB. Innovation in the open and endovascular treatment of carotid artery stenosis. Semin Vasc Surg 2021; 34:163-171. [PMID: 34911622 DOI: 10.1053/j.semvascsurg.2021.10.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2021] [Revised: 10/17/2021] [Accepted: 10/18/2021] [Indexed: 11/11/2022]
Affiliation(s)
- Munir P Moacdieh
- Division of Vascular and Endovascular Surgery, University of California San Diego, La Jolla, CA 92093
| | - Maryam A Khan
- Division of Vascular and Endovascular Surgery, University of California San Diego, La Jolla, CA 92093
| | - Peter Layman
- Division of Vascular and Endovascular Surgery, University of California San Diego, La Jolla, CA 92093
| | - Nadin Elsayed
- Division of Vascular and Endovascular Surgery, University of California San Diego, La Jolla, CA 92093
| | - Mahmoud B Malas
- Division of Vascular and Endovascular Surgery, University of California San Diego, La Jolla, CA 92093.
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16
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El-Sudany AH, Georgy SS, Zaki AS, Bedros RY, El-Bassiouny A. Non-protected carotid artery stenting for symptomatic carotid stenosis in low resource settings. THE EGYPTIAN JOURNAL OF NEUROLOGY, PSYCHIATRY AND NEUROSURGERY 2021. [DOI: 10.1186/s41983-021-00330-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Abstract
Abstract
Background
The use of a distal cerebral protection device during extracranial carotid artery stenting is still a matter of debate. The aim of this work was to evaluate the safety of performing carotid artery stenting procedure without the use of cerebral protection device in patients with symptomatic carotid stenosis. A retrospective study was performed during the period from September 2015 till March 2020 including 91 patients with symptomatic carotid artery stenosis. All patients were treated with a single stent type (Wall stent® - Boston scientific) without the use of cerebral protection device. Pre- and post-procedural clinical assessment with the national institute of health stroke scale (NIHSS). Post procedure brain diffusion-weighted magnetic resonance imaging (DW-MRI) if clinically indicated within 24 h was used to determine periprocedural cerebral embolization.
Results
A low complication rate was found as only one case (1%) showed mild deterioration in NIHSS and new acute cerebral emboli were detected with brain DW-MRI.
Conclusion
Carotid artery stenting can be performed safely without the use of cerebral protection device.
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17
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Matsumura JS, Hanlon BM, Rosenfield K, Voeks JH, Howard G, Roubin GS, Brott TG. Treatment of carotid stenosis in asymptomatic, non-octogenarian, standard risk patients with stenting versus endarterectomy trials. J Vasc Surg 2021; 75:1276-1283.e1. [PMID: 34695552 DOI: 10.1016/j.jvs.2021.10.020] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2021] [Accepted: 10/08/2021] [Indexed: 10/20/2022]
Abstract
OBJECTIVE Asymptomatic carotid stenosis is the most frequent indication for carotid endarterectomy (CEA) in the United States. Published trials and guidelines support CEA indications in selected patients with longer projected survival and when periprocedural complications are low. Transfemoral carotid artery stenting with embolic protection (CAS) is a newer treatment option. The objective of this study was to compare outcomes in asymptomatic, nonoctogenarian patients treated with CAS vs CEA. METHODS Patient-level data was analyzed from 2544 subjects with ≥70% asymptomatic carotid stenosis who were randomized to CAS or CEA in addition to standard medical therapy. One trial enrolled 1091 (548 CAS, 543 CEA) and another enrolled 1453 (1089 CAS, 364 CEA) asymptomatic patients less than 80 years old (upper age eligibility). Independent neurologic assessment and routine cardiac enzyme screening were performed. The prespecified, primary composite endpoint was any stroke, myocardial infarction, or death during the periprocedural period or ipsilateral stroke within 4 years after randomization. RESULTS There was no significant difference in the primary endpoint between CAS and CEA (5.3% vs 5.1%; hazard ratio, 1.02; 95% confidence interval, 0.7-1.5; P = .91). Periprocedural rates for the components are (CAS vs CEA): any stroke (2.7% vs 1.5%; P = .07), myocardial infarction (0.6% vs 1.7%; P = .01), death (0.1% vs 0.2%; P = .62), and any stroke or death (2.7% vs 1.6%; P = .07). After this period, the rates of ipsilateral stroke were similar (2.3% vs 2.2%; P = .97). CONCLUSIONS In a pooled analysis of two large randomized trials of CAS and CEA in asymptomatic, nonoctogenarian patients, CAS achieves comparable short- and long-term results to CEA.
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Affiliation(s)
- Jon S Matsumura
- Department of Surgery, University of Wisconsin School of Medicine and Public Health, Madison, Wisc.
| | - Bret M Hanlon
- Department of Surgery, University of Wisconsin School of Medicine and Public Health, Madison, Wisc
| | | | - Jenifer H Voeks
- Department of Neurology, Medical University of South Carolina, Charleston, SC
| | - George Howard
- Department of Biostatistics, University of Alabama at Birmingham, Birmingham, Ala
| | - Gary S Roubin
- Cardiovascular Associates of the Southeast, Birmingham, Ala
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18
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Voss S, Campanella C, Burri M, Trenkwalder T, Sideris K, Erlebach M, Ruge H, Krane M, Vitanova K, Lange R. Anatomical reasons for failure of dual-filter cerebral embolic protection application in TAVR: A CT-based analysis. J Card Surg 2021; 36:4537-4545. [PMID: 34580919 DOI: 10.1111/jocs.16025] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2021] [Accepted: 09/06/2021] [Indexed: 12/01/2022]
Abstract
BACKGROUND The dual-filter Sentinel™ Cerebral Protection System (Sentinel-CPS) is increasingly used during transcatheter aortic valve replacement (TAVR). However, complex vascular anatomy may challenge Sentinel-CPS deployment. AIM OF THE STUDY We sought to investigate the impact of anatomic features of the aortic arch and the supra-aortic arteries on technical device failure of Sentinel-CPS application. METHODS Analysis of the multislice computed tomography pre-TAVR aortograms of all patients undergoing TAVR with Sentinel-CPS between 2016 and 2020 (n = 92) was performed. We investigated the impact of aortic arch anatomy, configuration, and the angles of the supra-aortic arteries, including the determination of vascular tortuosity index on device failure of Sentinel-CPS application. RESULTS The Sentinel-CPS was applied successfully in 83 patients (90.2%). Device failure in nine patients (9.8%) was due to the infeasibility to perform correct deployment of both filters (n = 7) and to obtain peripheral radial access (n = 2). Patients with a failure of Sentinel-CPS application had a higher right subclavian tortuosity index (217 [92-324] vs. 150 [42-252], p = .046), a higher brachiocephalic tortuosity index (27 [5-51] vs. 10 [0-102], p = 0.033) and a larger angulation of the brachiocephalic artery (59° [22-80] vs. 39° [7-104], p = .014) compared with patients with successful application. A brachiocephalic angle more than 59° was predictive for device failure. No differences in aortic arch anatomy or common carotid artery tortuosity were detected between the groups. CONCLUSIONS Brachiocephalic tortuosity was found to be associated with failure of Sentinel-CPS application. Filter-based usage should be avoided in TAVR patients with a brachiocephalic angle more than 59°.
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Affiliation(s)
- Stephanie Voss
- Department of Cardiovascular Surgery, German Heart Centre Munich, Technical University Munich, Munich, Germany.,Department of Cardiovascular Surgery, Insure (Institute of Translational Cardiac Surgery), German Heart Centre Munich, Technical University Munich, Munich, Germany
| | - Caterina Campanella
- Department of Cardiovascular Surgery, German Heart Centre Munich, Technical University Munich, Munich, Germany.,Department of Cardiovascular Surgery, Insure (Institute of Translational Cardiac Surgery), German Heart Centre Munich, Technical University Munich, Munich, Germany
| | - Melchior Burri
- Department of Cardiovascular Surgery, German Heart Centre Munich, Technical University Munich, Munich, Germany.,Department of Cardiovascular Surgery, Insure (Institute of Translational Cardiac Surgery), German Heart Centre Munich, Technical University Munich, Munich, Germany
| | - Teresa Trenkwalder
- Klinik für Herz- und Kreislauferkrankungen, German Heart Centre Munich, Technical University Munich, Munich, Germany.,DZHK (German Centre for Cardiovascular Research) - Partner Site Munich Heart Alliance, Munich, Germany
| | - Konstantinos Sideris
- Department of Cardiovascular Surgery, German Heart Centre Munich, Technical University Munich, Munich, Germany.,Department of Cardiovascular Surgery, Insure (Institute of Translational Cardiac Surgery), German Heart Centre Munich, Technical University Munich, Munich, Germany
| | - Magdalena Erlebach
- Department of Cardiovascular Surgery, German Heart Centre Munich, Technical University Munich, Munich, Germany.,Department of Cardiovascular Surgery, Insure (Institute of Translational Cardiac Surgery), German Heart Centre Munich, Technical University Munich, Munich, Germany
| | - Hendrik Ruge
- Department of Cardiovascular Surgery, German Heart Centre Munich, Technical University Munich, Munich, Germany.,Department of Cardiovascular Surgery, Insure (Institute of Translational Cardiac Surgery), German Heart Centre Munich, Technical University Munich, Munich, Germany
| | - Markus Krane
- Division of Cardiac Surgery, Department of Surgery, Yale University School of Medicine, New Haven, CT, USA
| | - Keti Vitanova
- Department of Cardiovascular Surgery, German Heart Centre Munich, Technical University Munich, Munich, Germany.,Department of Cardiovascular Surgery, Insure (Institute of Translational Cardiac Surgery), German Heart Centre Munich, Technical University Munich, Munich, Germany
| | - Rüdiger Lange
- Department of Cardiovascular Surgery, German Heart Centre Munich, Technical University Munich, Munich, Germany.,Department of Cardiovascular Surgery, Insure (Institute of Translational Cardiac Surgery), German Heart Centre Munich, Technical University Munich, Munich, Germany.,DZHK (German Centre for Cardiovascular Research) - Partner Site Munich Heart Alliance, Munich, Germany
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19
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Coelho A, Peixoto J, Canedo A, Kappelle LJ, Mansilha A, de Borst GJ. Procedural Stroke after Carotid Revascularization - Critical Analysis of the Literature and Standards of Reporting. J Vasc Surg 2021; 75:363-371.e2. [PMID: 34182024 DOI: 10.1016/j.jvs.2021.05.055] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2020] [Accepted: 05/17/2021] [Indexed: 11/17/2022]
Abstract
OBJECTIVE Mechanisms of procedural stroke after carotid endarterectomy (CEA) or stenting (CAS) are surprisingly underresearched. However, understanding the underlying mechanism could: (1) assist in balancing the choice for revascularization versus conservative therapy; (2) assist in choosing either open or endo techniques; and (3) assist in taking appropriate periprocedural measures to further reduce procedural stroke rate. The purpose of this study was to overview mechanisms of procedural stroke after carotid revascularization and establish reporting standards to facilitate more granular investigation and individual patient data meta-analysis in the future. METHODS A systematic review was conducted according to the Preferred Reporting Items for Systematic reviews and Meta-analysis (PRISMA) statement. RESULTS The limited evidence in literature was heterogeneous and of low quality and hence no formal data meta-analysis could be performed. Procedural stroke was classified as haemorrhagic or ischemic; the latter was subclassified as haemodynamic, embolic (carotid- or cardio-embolic) or carotid occlusion-derived, using a combination of clinical inference and imaging data. Most events occurred in the first 24h after the procedure and were related to hypoperfusion (pooled incidence 10.2% (95% c.i. 3.0-17.5) versus 13.9% (95% c.i. 0.0-60.9) post-CEA vs CAS events, respectively) or atheroembolism (28.9% (95% c.i. 10.9-47.0) versus 34.3 (95% c.i. 0.0-91.5)) After the first 24 hours, haemorrhagic stroke (11.6 (95% c.i. 5.7-17.4) versus 9.0 (95% c.i. 1.3-16.7)) or thrombotic occlusion (18.4 (95% c.i. 0.9-35.8) versus 14.8 (95% c.i. 0.0-30.5)) became more likely. CONCLUSIONS Although procedural stroke incidence and aetiology may have changed over the last decades due to technical improvements and improvement in perioperative monitoring and quality control, the lack of literature data limits further statements. To simplify and enhance future reporting, procedural stroke analysis and classification should be documented pre-emptively in research settings. We propose a standardized form enclosing reporting standards for procedural stroke with a systematic approach to inference of the most likely aetiology, for prospective use in registries and RCTs on carotid revascularization.
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Affiliation(s)
- Andreia Coelho
- Angiology and Vascular Surgery Department, Centro Hospitalar e Universitário do Porto, Porto, Portugal; Fisiology and Cardiothoracic Surgery Department, Faculdade Medicina da Universidade do Porto, Porto, Portugal
| | - João Peixoto
- Fisiology and Cardiothoracic Surgery Department, Faculdade Medicina da Universidade do Porto, Porto, Portugal; Angiology and Vascular Surgery Department, Centro Hospitalar Vila Nova de Gaia, Espinho, Portugal
| | - Alexandra Canedo
- Fisiology and Cardiothoracic Surgery Department, Faculdade Medicina da Universidade do Porto, Porto, Portugal; Angiology and Vascular Surgery Department, Centro Hospitalar Vila Nova de Gaia, Espinho, Portugal
| | - L Jaap Kappelle
- Neurology Department, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Armando Mansilha
- Fisiology and Cardiothoracic Surgery Department, Faculdade Medicina da Universidade do Porto, Porto, Portugal
| | - Gert J de Borst
- Vascular Surgery Department, University Medical Center Utrecht, Utrecht, The Netherlands.
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20
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Assessing the Suitability of the Carotid Bifurcation for Stenting: Anatomic and Morphologic Considerations. J Vasc Surg 2021; 74:2087-2095. [PMID: 34175382 DOI: 10.1016/j.jvs.2021.05.048] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2020] [Accepted: 05/04/2021] [Indexed: 11/21/2022]
Abstract
OBJECTIVE Over the years where stents have been used to treat carotid lesions, a great deal has been learned about which anatomical characteristics lead to adverse outcomes. This review summarizes the anatomic and morphologic characteristics of the carotid vasculature that can help guide patient selection and clinical decision-making. METHODS Each of the carotid artery anatomy and lesion characteristics that are relevant to carotid stenting are described in detail. These are accompanied with evidence-based outcomes and results. RESULTS Data on the prevalence of carotid artery lesions that are unsuitable for stenting are summarized and the implications of these data for practice are discussed, especially as they pertain to transcarotid artery revascularization. CONCLUSIONS CAS can be viable option for carotid revascularization, but the lesion must be acceptable and safe for stent placement. There should be thorough assessment to rule out the presence of severe tortuosity, long-segment disease, severe calcification (circumferential or exophytic), mobile-plaque, swollen ICA sign, and carotid diameters outside the acceptable range. In carefully chosen lesions with the absence of the unfavorable characteristics described-TCAR may offer improved periprocedural success, and CAS may attain better long-term durability.
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21
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AbuRahma AF, Avgerinos ED, Chang RW, Darling RC, Duncan AA, Forbes TL, Malas MB, Perler BA, Powell RJ, Rockman CB, Zhou W. The Society for Vascular Surgery implementation document for management of extracranial cerebrovascular disease. J Vasc Surg 2021; 75:26S-98S. [PMID: 34153349 DOI: 10.1016/j.jvs.2021.04.074] [Citation(s) in RCA: 64] [Impact Index Per Article: 21.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2021] [Accepted: 04/28/2021] [Indexed: 12/24/2022]
Affiliation(s)
- Ali F AbuRahma
- Department of Surgery, West Virginia University-Charleston Division, Charleston, WV.
| | - Efthymios D Avgerinos
- Division of Vascular Surgery, University of Pittsburgh School of Medicine, UPMC Hearrt & Vascular Institute, Pittsburgh, Pa
| | - Robert W Chang
- Vascular Surgery, Permanente Medical Group, San Francisco, Calif
| | | | - Audra A Duncan
- Division of Vascular & Endovascular Surgery, University of Western Ontario, London, Ontario, Canada
| | - Thomas L Forbes
- Division of Vascular & Endovascular Surgery, University of Western Ontario, London, Ontario, Canada
| | - Mahmoud B Malas
- Vascular & Endovascular Surgery, University of California San Diego, La Jolla, Calif
| | - Bruce Alan Perler
- Division of Vascular Surgery & Endovascular Therapy, Johns Hopkins, Baltimore, Md
| | | | - Caron B Rockman
- Division of Vascular Surgery, New York University Langone, New York, NY
| | - Wei Zhou
- Division of Vascular Surgery, University of Arizona, Tucson, Ariz
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22
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Güner A, Çelik Ö, Topel Ç, Arif Yalçın A, Kalçık M, Uzun F, Altunova M, Örten M, Akman C, Güner EG, Ertürk M. The effect of complex vascular anatomy on silent new ischemic cerebral lesions in carotid artery stenting procedures (from the COMPLEX-CAS Trial). Vascular 2021; 30:292-300. [PMID: 33896290 DOI: 10.1177/17085381211010016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
BACKGROUND Carotid artery stenting is a minimally invasive, durable alternative treatment option, which is an alternative to the reference method, carotid endarterectomy, for patients with carotid artery stenosis; however, silent new ischemic cerebral lesions (SNICLs) after carotid artery stenting remain as a matter of concern. Hence, we aimed to assess the effect of complex vascular anatomy on silent new ischemic cerebral lesions in carotid artery stenting procedures. METHODS We prospectively evaluated 122 patients (mean age: 69.5 ± 7.1 years, male:83) who underwent carotid artery stenting for carotid artery revascularization. The patients having symptomatic transient ischemic attack or stroke after carotid artery stenting were excluded. The presence of a new hyperintense lesions on diffusion-weighted imaging without any neurological findings was considered as the SNICL. Patients were classified into two groups as DWI-positive and DWI-negative patients. RESULTS Among the study population, 32 patients (26.2%) had SNICLs. The DWI-positive group had a significantly higher common carotid artery (CCA)-internal carotid artery (ICA) angle, older age, more frequent history of stroke, a higher proportion of type III aortic arch, and longer fluoroscopy time than the DWI-negative group. High CCA-ICA angle was identified as one of the independent predictors of SNICL (OR (odds ratio) = 1.103 95%CI (confidence interval): (1.023-1.596); p = 0.034), and CCA-ICA angle higher than 34.5 degrees predicted SNICL with a sensitivity of 62.5% and a specificity of 62.2% (area under the curve: 0.680; 95% CI: 0.570 to 0.789; p = 0.003). CONCLUSIONS The higher CCA-ICA angle may predict pre-procedure SNICL risk in carotid artery stenting and may have clinical value in the management of patients with carotid artery stenosis.
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Affiliation(s)
- Ahmet Güner
- Department of Cardiology, Mehmet Akif Ersoy Thoracic and Cardiovascular Surgery Training and Research Hospital, Istanbul, Turkey
| | - Ömer Çelik
- Department of Cardiology, Mehmet Akif Ersoy Thoracic and Cardiovascular Surgery Training and Research Hospital, Istanbul, Turkey
| | - Çağdaş Topel
- Department of Radiology, Mehmet Akif Ersoy Thoracic and Cardiovascular Surgery Training and Research Hospital, Istanbul, Turkey
| | - Ahmet Arif Yalçın
- Department of Cardiology, Mehmet Akif Ersoy Thoracic and Cardiovascular Surgery Training and Research Hospital, Istanbul, Turkey
| | - Macit Kalçık
- Department of Cardiology, Faculty of Medicine, Hitit University, Çorum, Turkey
| | - Fatih Uzun
- Department of Cardiology, Mehmet Akif Ersoy Thoracic and Cardiovascular Surgery Training and Research Hospital, Istanbul, Turkey
| | - Mehmet Altunova
- Department of Cardiology, Mehmet Akif Ersoy Thoracic and Cardiovascular Surgery Training and Research Hospital, Istanbul, Turkey
| | - Murat Örten
- Department of Neurology, Mehmet Akif Ersoy Thoracic and Cardiovascular Surgery Training and Research Hospital, Istanbul, Turkey
| | - Cemalettin Akman
- Department of Cardiology, Mehmet Akif Ersoy Thoracic and Cardiovascular Surgery Training and Research Hospital, Istanbul, Turkey
| | - Ezgi Gültekin Güner
- Department of Cardiology, Mehmet Akif Ersoy Thoracic and Cardiovascular Surgery Training and Research Hospital, Istanbul, Turkey
| | - Mehmet Ertürk
- Department of Cardiology, Mehmet Akif Ersoy Thoracic and Cardiovascular Surgery Training and Research Hospital, Istanbul, Turkey
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Xin W, Yang S, Li Q, Yang X. Endarterectomy versus stenting for the prevention of periprocedural stroke or death in patients with symptomatic or asymptomatic carotid stenosis: a meta-analysis of 10 randomized trials. ANNALS OF TRANSLATIONAL MEDICINE 2021; 9:256. [PMID: 33708883 PMCID: PMC7940891 DOI: 10.21037/atm-20-4620] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Background The incidence of stroke or death in carotid endarterectomy (CEA) versus carotid artery stenting (CAS) cannot be estimated accurately. We aimed to compare periprocedural stroke or death in patients with symptomatic or asymptomatic carotid artery stenosis (CS) treated with CEA versus CAS. Methods Ten randomized trials (with ≥100 randomized patients per trial) compared the relative effectiveness of CAS and CEA for the prevention of stroke or death. Results In the symptomatic group during the periprocedural period, the results showed that the risk of death or any stroke [risk ratio (RR): 0.627; 95% CI: 0.497-0.792; P<0.001] and the risk of any stroke (RR: 0.654; 95% CI: 0.522-0.820; P<0.001) were significantly greater with CAS than with CEA. The difference in the risk of periprocedural stroke was mostly attributed to nondisabling stroke (RR: 0.407; 95% CI: 0.264-0.627; P<0.001), which was driven especially by ipsilateral ischemic stroke (RR: 0.649; 95% CI: 0.494-0.851; P=0.002) and bradycardia or hypotension (RR: 0.105; 95% CI: 0.051-0.217; P<0.001). However, we found that the CEA group had a higher rate of myocardial infarction than the CAS group (RR: 2.496; P=0.025). Meanwhile, ipsilateral stenosis >70% increased the incidence of periprocedural death or stroke for post-CEA patients (RR: 2.166, 95% CI: 1.112 to 4.220, P=0.023), but no risk factors were identified for post-CAS. Regarding the asymptomatic group, the results demonstrated that patients randomized to CEA had a significantly reduced risk of periprocedural stroke (RR: 0.518; 95% CI: 0.281-0.954; P=0.035), which seems to be driven by periprocedural minor stroke (RR: 0.482; 95% CI: 0.231-0.982; P=0.046). Conclusions Among patients with symptomatic CS, CEA was associated with reduced rates of periprocedural stroke and periprocedural nondisabling stroke. Among patients with asymptomatic CS, the rates of minor stroke and stroke in general were higher with stenting than with CEA. Based on the current data, CEA is more beneficial than CAS for 30-day stroke prevention.
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Affiliation(s)
- Wenqiang Xin
- Department of Neurosurgery, Tianjin Medical University General Hospital, Tianjin, China
| | - Shixue Yang
- Department of Neurosurgery, Tianjin Medical University General Hospital, Tianjin, China
| | - Qifeng Li
- Department of Neurosurgery, Tianjin Medical University General Hospital, Tianjin, China
| | - Xinyu Yang
- Department of Neurosurgery, Tianjin Medical University General Hospital, Tianjin, China
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Çelik Ö, Güner A, Kalçık M, Güler A, Demir AR, Demir Y, Uygur B, Şahin AA, Topel Ç, Ertürk M. The predictive value of CHADS2 score for subclinical cerebral ischemia after carotid artery stenting (from the PREVENT-CAS trial). Catheter Cardiovasc Interv 2021; 97:301-309. [PMID: 33085162 DOI: 10.1002/ccd.29344] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/18/2020] [Revised: 09/10/2020] [Accepted: 10/08/2020] [Indexed: 11/09/2022]
Abstract
BACKGROUND Carotid artery stenting (CAS) is being increasingly used as an alternative revascularization procedure to carotid endarterectomy; however, subclinical ischemic cerebral lesions after CAS remain as a matter of concern. Hence, we aimed to assess the clinical utility of the CHADS2 score in predicting subclinical ischemic events after CAS. METHODS We prospectively evaluated 107 patients (mean age: 70.4 ± 6.6 years, male:77) who underwent CAS for carotid artery revascularization. The patients having symptomatic transient ischemic attack or stroke after CAS were excluded. The presence of new hyperintense lesion on diffusion-weighted imaging (DWI) without any neurological findings was considered as silent ischemia. Patients were classified into two groups as DWI-positive and DWI-negative patients. RESULTS Among study population, 28 patients (26.2%) had subclinical embolism. The DWI-positive group had a significantly higher CHADS2 scores, older age, more frequent history of stroke, higher proportion of type III aortic arch, and longer fluoroscopy time than the DWI-negative group. Increased CHADS2 score was identified as one of the independent predictors of silent embolism (OR = 5.584; 95%CI: 1.516-20.566; p = .010), and CHADS2 score higher than 2.5 predicted subclinical cerebral ischemia with a sensitivity of 72% and a specificity of 71% (AUC: 0.793; 95% CI: 0.696 - 0.890; p < .001). CONCLUSIONS CHADS2 score was able to predict the risk of periprocedural subclinical ischemic events in CAS and might be of clinical value in the management of patients with carotid artery stenosis.
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Affiliation(s)
- Ömer Çelik
- Department of Cardiology, University of Health Sciences Turkey, Mehmet Akif Ersoy Thoracic and Cardiovascular Surgery Training and Research Hospital, Istanbul, Turkey
| | - Ahmet Güner
- Department of Cardiology, University of Health Sciences Turkey, Mehmet Akif Ersoy Thoracic and Cardiovascular Surgery Training and Research Hospital, Istanbul, Turkey
| | - Macit Kalçık
- Department of Cardiology, Faculty of Medicine, Hitit University, Çorum, Turkey
| | - Arda Güler
- Department of Cardiology, University of Health Sciences Turkey, Mehmet Akif Ersoy Thoracic and Cardiovascular Surgery Training and Research Hospital, Istanbul, Turkey
| | - Ali Rıza Demir
- Department of Cardiology, University of Health Sciences Turkey, Mehmet Akif Ersoy Thoracic and Cardiovascular Surgery Training and Research Hospital, Istanbul, Turkey
| | - Yusuf Demir
- Department of Cardiology, University of Health Sciences Turkey, Mehmet Akif Ersoy Thoracic and Cardiovascular Surgery Training and Research Hospital, Istanbul, Turkey
| | - Begum Uygur
- Department of Cardiology, University of Health Sciences Turkey, Mehmet Akif Ersoy Thoracic and Cardiovascular Surgery Training and Research Hospital, Istanbul, Turkey
| | - Ahmet Anıl Şahin
- Department of Cardiology, University of Health Sciences Turkey, Mehmet Akif Ersoy Thoracic and Cardiovascular Surgery Training and Research Hospital, Istanbul, Turkey
| | - Çağdaş Topel
- Department of Radiology, Mehmet Akif Ersoy Thoracic and Cardiovascular Surgery Training and Research Hospital, Istanbul, Turkey
| | - Mehmet Ertürk
- Department of Cardiology, University of Health Sciences Turkey, Mehmet Akif Ersoy Thoracic and Cardiovascular Surgery Training and Research Hospital, Istanbul, Turkey
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Clinical situations requiring radial or brachial access during carotid artery stenting. ADVANCES IN INTERVENTIONAL CARDIOLOGY 2020; 16:410-417. [PMID: 33598013 PMCID: PMC7863832 DOI: 10.5114/aic.2020.101765] [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: 04/30/2020] [Accepted: 06/29/2020] [Indexed: 11/17/2022] Open
Abstract
Introduction Radial or brachial access may be preferred in the case of severe peripheral artery disease (PAD) or difficult aortic arch anatomy during carotid artery stenting (CAS). Aim To evaluate the clinical conditions indicating potential benefit from non-femoral access as well as feasibility and safety of transradial/transbrachial access (TRA/TBA) as an alternative approach for CAS. Material and methods Since 2013, 67 patients (mean age: 70 years old, 44 men, 42% symptomatic) were selected for CAS with the TRA/TBA approach. The composite endpoint was stroke/death/myocardial infarction within 30 days of the procedure and compared to the propensity score matched transfemoral approach (TFA) group. Clinical (including neurological) examination and Doppler ultrasonography were performed before the procedure, at discharge and at 30 days. Results CAS with TRA/TBA was successful in 63/67 patients. Transfemoral access was not feasible due to PAD in 35 (52.2%) patients, bovine arch in 10 (14.9%), obesity (BMI > 35 kg/m2) in 9 (13.4%), severe degenerative disease of the spine in 7 (10.5%), arch type III in 5 (7.5%) and excessive subclavian stent protrusion in 1 (1.5%) patient. Mean NASCET carotid artery stenosis was reduced from 81% to 9% (p < 0.001). The composite endpoint occurred in 3 (4.8%) cases and it was not statistically significantly different from the matched TFA group (6.3%; p = 0.697). No access site complications requiring surgical intervention or blood transfusion developed. Conclusions Transradial and transbrachial CAS may be an effective and safe procedure, and it may constitute a viable alternative to the femoral approach in patients with severe PAD, difficult aortic arch anatomy or obesity.
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Scullen T, Mathkour M, Carr C, Wang A, Amenta PS, Nerva JD, Dumont AS. Anatomical Considerations for Endovascular Intervention for Extracranial Carotid Disease: A Review of the Literature and Recommended Guidelines. J Clin Med 2020; 9:E3460. [PMID: 33121192 PMCID: PMC7693974 DOI: 10.3390/jcm9113460] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2020] [Revised: 09/15/2020] [Accepted: 10/16/2020] [Indexed: 12/17/2022] Open
Abstract
Patient selection for endovascular intervention in extracranial carotid disease is centered on vascular anatomy. We review anatomical considerations for non-traumatic disease and offer guidelines in patient selection and management. We conducted a systematic literature review without meta-analysis for studies involving anatomical considerations in extracranial carotid intervention for non-traumatic disease. Anatomical considerations discussed included aortic arch variants, degree of vessel stenosis, angulation, tortuosity, and anomalous origins, and atheromatous plaque morphology, composition, and location. Available literature suggests that anatomical risks of morbidity are largely secondary to increased procedural times and difficulties in intervention system delivery. We recommend the prioritization of endovascular techniques on an individual basis in cases where accessible systems and surgeon familiarity provide an acceptable likelihood of rapid access and device deployment.
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Affiliation(s)
- Tyler Scullen
- Department of Neurological Surgery, Tulane Medical Center, New Orleans, LA 70130, USA; (T.S.); (M.M.); (C.C.); (A.W.); (P.S.A.); (J.D.N.)
- Department of Neurological Surgery, Ochsner Medical Center, Jefferson, LA 70121, USA
| | - Mansour Mathkour
- Department of Neurological Surgery, Tulane Medical Center, New Orleans, LA 70130, USA; (T.S.); (M.M.); (C.C.); (A.W.); (P.S.A.); (J.D.N.)
- Department of Neurological Surgery, Ochsner Medical Center, Jefferson, LA 70121, USA
| | - Christopher Carr
- Department of Neurological Surgery, Tulane Medical Center, New Orleans, LA 70130, USA; (T.S.); (M.M.); (C.C.); (A.W.); (P.S.A.); (J.D.N.)
- Department of Neurological Surgery, Ochsner Medical Center, Jefferson, LA 70121, USA
| | - Arthur Wang
- Department of Neurological Surgery, Tulane Medical Center, New Orleans, LA 70130, USA; (T.S.); (M.M.); (C.C.); (A.W.); (P.S.A.); (J.D.N.)
- Department of Neurological Surgery, Ochsner Medical Center, Jefferson, LA 70121, USA
| | - Peter S. Amenta
- Department of Neurological Surgery, Tulane Medical Center, New Orleans, LA 70130, USA; (T.S.); (M.M.); (C.C.); (A.W.); (P.S.A.); (J.D.N.)
- Department of Neurological Surgery, Ochsner Medical Center, Jefferson, LA 70121, USA
| | - John D. Nerva
- Department of Neurological Surgery, Tulane Medical Center, New Orleans, LA 70130, USA; (T.S.); (M.M.); (C.C.); (A.W.); (P.S.A.); (J.D.N.)
- Department of Neurological Surgery, Ochsner Medical Center, Jefferson, LA 70121, USA
| | - Aaron S. Dumont
- Department of Neurological Surgery, Tulane Medical Center, New Orleans, LA 70130, USA; (T.S.); (M.M.); (C.C.); (A.W.); (P.S.A.); (J.D.N.)
- Department of Neurological Surgery, Ochsner Medical Center, Jefferson, LA 70121, USA
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Guner A, Kalçık M, Çelik Ö, Ertürk M. Complex vascular anatomy is a predictor of silent cerebral ischemia after carotid artery stenting. Neuroradiology 2020; 62:1551. [PMID: 33040202 DOI: 10.1007/s00234-020-02578-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2020] [Accepted: 10/04/2020] [Indexed: 11/28/2022]
Affiliation(s)
- Ahmet Guner
- Department of Cardiology, Mehmet Akif Ersoy Thoracic and Cardiovascular Surgery Training and Research Hospital, University of Health Sciences, Kucukcekmece, 34303, Istanbul, Turkey.
| | - Macit Kalçık
- Department of Cardiology, Faculty of Medicine, Hitit University, Çorum, Turkey
| | - Ömer Çelik
- Department of Cardiology, Mehmet Akif Ersoy Thoracic and Cardiovascular Surgery Training and Research Hospital, University of Health Sciences, Kucukcekmece, 34303, Istanbul, Turkey
| | - Mehmet Ertürk
- Department of Cardiology, Mehmet Akif Ersoy Thoracic and Cardiovascular Surgery Training and Research Hospital, University of Health Sciences, Kucukcekmece, 34303, Istanbul, Turkey
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Osipova O, Popova I, Starodubtsev V, Bugurov S, Karpenko A. Is it possible to prevent cerebral embolization by improving the design and technology of carotid stent implantation? Expert Rev Cardiovasc Ther 2020; 18:891-904. [PMID: 33021842 DOI: 10.1080/14779072.2020.1833718] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
INTRODUCTION The prevention of atherosclerotic plaque fragmentation during carotid artery stenting is a fundamental problem in decreasing the risk of disability of patients. The goal of this review is to clarify whether the stent design can have a decisive impact on the rate of intraoperative and postoperative complications. AREAS COVERED Different designs of the carotid stents are briefed and the advantages and disadvantages of different stent designs are discussed as well as the results of their clinical use. Various solutions are presented to reduce cerebral embolism during carotid artery stenting. EXPERT OPINION There is no conclusive evidence for the benefits of closed cell and hybrid stents. The stent design cannot completely resolve the problem of cerebral embolism. Most of the events of cerebral microembolism occur at the stages of stent delivery rather than protrusion of an atherosclerotic plaque in the long-term follow-up. Most likely, minimization of the risks for periprocedural and postprocedural strokes requires not only the new solutions in stent design as well as the corresponding delivery systems and brain embolic protection systems, but also the new strategies of preprocedural drug stabilization of the atherosclerotic plaque in the carotid artery. Abbreviations: CAS, carotid artery stenting; CE, carotid endarterectomy; DW-MRI, diffusion-weighted magnetic resonance imaging; ECA, external carotid artery; ICA, internal carotid artery; IVUS, intravascular ultrasound examination; OCT, optical coherence tomography.
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Affiliation(s)
- Olesia Osipova
- Center for Vascular and Hybrid Surgery, Meshalkin National Medical Research Center, Ministry of Health of the Russian Federation , Novosibirsk, Russian Federation
| | - Irina Popova
- Center for Vascular and Hybrid Surgery, Meshalkin National Medical Research Center, Ministry of Health of the Russian Federation , Novosibirsk, Russian Federation
| | - Vladimir Starodubtsev
- Center for Vascular and Hybrid Surgery, Meshalkin National Medical Research Center, Ministry of Health of the Russian Federation , Novosibirsk, Russian Federation
| | - Savr Bugurov
- Center for Vascular and Hybrid Surgery, Meshalkin National Medical Research Center, Ministry of Health of the Russian Federation , Novosibirsk, Russian Federation
| | - Andrey Karpenko
- Center for Vascular and Hybrid Surgery, Meshalkin National Medical Research Center, Ministry of Health of the Russian Federation , Novosibirsk, Russian Federation
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Risk Factors of Cerebellar Microembolic Infarctions After Carotid Artery Stenting. World Neurosurg 2020; 142:e290-e296. [DOI: 10.1016/j.wneu.2020.06.207] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2020] [Revised: 06/24/2020] [Accepted: 06/25/2020] [Indexed: 12/28/2022]
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Liu S, Tang R, Xie W, Chai S, Zhang Q, Luo Y, Guo Y, Chai C, Huang L, Zheng M, Zhu J, Chang B, Yang Q, Jin S, Fan Z, Xia S. Plaque characteristics and hemodynamics contribute to neurological impairment in patients with ischemic stroke and transient ischemic attack. Eur Radiol 2020; 31:2062-2072. [PMID: 32997174 DOI: 10.1007/s00330-020-07327-1] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2020] [Revised: 07/31/2020] [Accepted: 09/18/2020] [Indexed: 11/27/2022]
Abstract
OBJECTIVES We aimed to investigate differential characteristics of plaque in the middle cerebral artery (MCA) and hemodynamics in patients with ischemic stroke and transient ischemic attack (TIA), and to develop a predictive model for the presence of ischemic stroke and neurological impairment. METHODS Sixty-seven patients with acute ischemic events in MCA territory who underwent high-resolution vessel wall imaging between September 2016 and August 2018 were reviewed retrospectively. Patients were assigned to either the stroke group or TIA group, according to diffusion-weighted imaging and neurological examination. Plaque characteristics and anterograde score (AnS) were calculated. Tmax > 6.0-s volume was acquired by RApid Processing of perfusIon and Diffusion software. Multivariate logistic regression analysis and multiple linear regression analysis were performed to establish a predictive model for irreversible infarction occurrence and clinical severity. RESULTS Forty-five patients were assigned to the stroke group, and 22 were assigned to the TIA group. Plaque length, intraplaque hemorrhage (IPH), enhancement, AnS, and Tmax > 6.0-s volumes were significantly different between the two groups (p < 0.05). IPH and AnS were independent predictors for patients with stroke (p = 0.020 and 0.034, respectively). Tmax > 6.0-s volume, IPH, hypertension, and AnS were associated with high National Institutes of Health Stroke Scale (NIHSS) scores (all p < 0.05, R = 0.725, and adjusted R2 = 0.494). CONCLUSIONS IPH and AnS are useful in predicting stroke occurrence. Tmax > 6.0-s volume, IPH, hypertension, and AnS are associated with neurological impairment of the patients. KEY POINTS • Ischemic stroke and TIA patients have different plaque characteristics and hemodynamics. • Intraplaque hemorrhage and anterograde score have high diagnostic efficiency for ischemic stroke. • The combination of Tmax > 6.0-s volume, intraplaque hemorrhage, hypertension, and anterograde score can predict the National Institutes of Health Stroke Scale scores of patients.
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Affiliation(s)
- Song Liu
- Department of Radiology, Tianjin First Central Hospital, No.24 Fukang Road, Nankai District, Tianjin, 300192, China
| | - Ruowei Tang
- Department of Radiology, Tianjin First Central Hospital, No.24 Fukang Road, Nankai District, Tianjin, 300192, China
| | - Weiwei Xie
- Department of Radiology, Tianjin First Central Hospital, No.24 Fukang Road, Nankai District, Tianjin, 300192, China
| | - Shengting Chai
- Department of Radiology, Tianjin First Central Hospital, No.24 Fukang Road, Nankai District, Tianjin, 300192, China
| | - Qingqing Zhang
- Department of Radiology, Tianjin First Central Hospital, No.24 Fukang Road, Nankai District, Tianjin, 300192, China
| | - Yu Luo
- Department of Radiology, Translational Research Institute of Brain and Brain-Like Intelligence, Shanghai Fourth People's Hospital Affiliated to Tongji University School of Medicine, Shanghai, 200081, China
| | - Yu Guo
- Department of Radiology, Tianjin First Central Hospital, No.24 Fukang Road, Nankai District, Tianjin, 300192, China
| | - Chao Chai
- Department of Radiology, Tianjin First Central Hospital, No.24 Fukang Road, Nankai District, Tianjin, 300192, China
| | - Lixiang Huang
- Department of Radiology, Tianjin First Central Hospital, No.24 Fukang Road, Nankai District, Tianjin, 300192, China
| | - Meizhu Zheng
- Department of Radiology, Tianjin Third Central Hospital, Tianjin, 300170, China
| | - Jinxia Zhu
- MR Collaboration, Siemens Healthcare Ltd., Beijing, 100102, China
| | - Binge Chang
- Department of Neurosurgery, Tianjin First Central Hospital, Tianjin, 300192, China
| | - Qi Yang
- Department of Radiology, Beijing Xuanwu Hospital, Capital Medical University, Beijing, 100053, China
| | - Song Jin
- Department of Radiology, Tianjin Huanhu Hospital, Tianjin, 300350, China
| | - Zhaoyang Fan
- Biomedical Imaging Research Institute, Cedars-Sinai Medical Center, Los Angeles, CA, 90048, USA
| | - Shuang Xia
- Department of Radiology, Tianjin First Central Hospital, No.24 Fukang Road, Nankai District, Tianjin, 300192, China.
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Miszczuk M, Bauknecht HC, Kleine JF, Liebig T, Bohner G, Siebert E. Direct puncture of the carotid artery as a bailout vascular access technique for mechanical thrombectomy in acute ischemic stroke-the revival of an old technique in a modern setting. Neuroradiology 2020; 63:275-283. [PMID: 32803336 PMCID: PMC7846543 DOI: 10.1007/s00234-020-02520-x] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2020] [Accepted: 08/08/2020] [Indexed: 12/03/2022]
Abstract
Purpose To describe our single-center experience of mechanical thrombectomy (MTE) via a direct carotid puncture (DCP) with regard to indication, time metrics, procedural details, as well as safety and efficacy aspects. Methods DCP thrombectomy cases performed at our center were retrospectively identified from a prospectively maintained institutional MTE database. Various patient (age, sex, stroke cause, comorbidities), clinical (NIHSS, mRS), imaging (occlusion site, ASPECT score), procedural (indication for DCP, time from DCP to reperfusion, materials used, technical nuances), and outcome data (NIHSS, mRS) were tabulated. Results Among 715 anterior circulation MTEs, 12 DCP-MTEs were identified and analyzed. Nine were left-sided M1 occlusions, one right-sided M1 occlusion, and two right-sided M2 occlusions. DCP was successfully carried out in 91.7%; TICI 2b/3-recanalization was achieved in 83.3% via direct lesional aspiration and/or stent-retrieval techniques. Median time from DCP to reperfusion was 23 min. Indications included futile transfemoral catheterization attempts of the cervical target vessels as well as iliac occlusive disease. Neck hematoma occurred in 2 patients, none of which required further therapy. Conclusion MTE via DCP in these highly selected patients was reasonably safe, fast, and efficient. It thus represents a valuable technical extension of MTE, especially in patients with difficult access.
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Affiliation(s)
- Milena Miszczuk
- Institute of Neuroradiology, Charité-Universitary Medicine Berlin, Charitéplatz 1, 10117, Berlin, Germany.
| | - Hans Christian Bauknecht
- Institute of Neuroradiology, Charité-Universitary Medicine Berlin, Charitéplatz 1, 10117, Berlin, Germany
| | - Justus F Kleine
- Institute of Neuroradiology, Charité-Universitary Medicine Berlin, Charitéplatz 1, 10117, Berlin, Germany
| | - Thomas Liebig
- Institute of Neuroradiology, Ludwig Maximillian University Munich, Munich, Germany
| | - Georg Bohner
- Institute of Neuroradiology, Charité-Universitary Medicine Berlin, Charitéplatz 1, 10117, Berlin, Germany
| | - Eberhard Siebert
- Institute of Neuroradiology, Charité-Universitary Medicine Berlin, Charitéplatz 1, 10117, Berlin, Germany
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Öcal L, Küp A, Keskin M, Cerşit S, Çelik M, Eren H, Gürsoy MO, Öztürkeri B, Öztürk B, Turkmen MM. Prognostic significance of pre-procedural prognostic nutritional index in patients with carotid artery stenting. J Stroke Cerebrovasc Dis 2020; 29:104932. [PMID: 32689619 DOI: 10.1016/j.jstrokecerebrovasdis.2020.104932] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2020] [Revised: 04/30/2020] [Accepted: 05/03/2020] [Indexed: 01/07/2023] Open
Abstract
BACKGROUND Inflammation and malnutrition play a critical role in the outcomes of patients undergoing carotid artery stenting (CAS). Prognostic nutritional index (PNI) is commonly utilized to evaluate the peri-operative immune-nutritional status of patients undergoing colorectal cancer surgery and is independently associated with survival. We assessed the association between immune-nutritional status, indexed by PNI, and outcomes in CAS patients. METHODS A total of 615 patients hospitalized for CAS in a tertiary heart center were enrolled in the study. PNI was calculated using the following formula: 10× serum albumin value (g/dL) + 0.005 × total lymphocyte count in the peripheral blood (per mm3). In-hospital and 5-year outcomes (ipsilateral stroke, major stroke, transient ischemic attack, myocardial infarction, and mortality) were compared between the tertiles of PNI. RESULTS In-hospital outcomes were similar between the groups except the increased mortality in decreasing tertiles of PNI. During a mean follow-up duration of 51.1 months, the lower PNI tertile was related to unfavorable outcomes. After adjusting for multi-model Cox regression analysis, PNI persisted as an independent prognostic factor for mortality and major stroke. CONCLUSION PNI was independently associated with long-term mortality and major stroke in CAS patients. Malnutrition and inflammation, which can be assessed easily and quickly using PNI, have an important prognostic value in the patients undergoing CAS.
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Affiliation(s)
- Lütfi Öcal
- Kartal Koşuyolu Heart Training and Research Hospital, Cardiology, Health Sciences University, Istanbul, Turkey.
| | - Ayhan Küp
- Kartal Koşuyolu Heart Training and Research Hospital, Cardiology, Health Sciences University, Istanbul, Turkey.
| | - Muhammed Keskin
- Sultan Abdulhamid Han Training and Research Hospital, Cardiology, Health Sciences University, Istanbul, Turkey.
| | - Sinan Cerşit
- Kartal Koşuyolu Heart Training and Research Hospital, Cardiology, Health Sciences University, Istanbul, Turkey.
| | - Mehmet Çelik
- Kartal Koşuyolu Heart Training and Research Hospital, Cardiology, Health Sciences University, Istanbul, Turkey.
| | - Hayati Eren
- Cardiology, Elbistan State Hospital, Kahramanmaraş, Turkey.
| | - Mustafa Ozan Gürsoy
- Cardiology, Atatürk Training And Research Hospital, Katip Çelebi University, İzmir, Turkey.
| | - Burak Öztürkeri
- Ümraniye Training and Research Hospital, Cardiology, Health Sciences University, Istanbul, Turkey.
| | - Bayram Öztürk
- Cardiology, Sutcu Imam University, Kahramanmaraş, Turkey.
| | - Mehmet Muhsin Turkmen
- Kartal Koşuyolu Heart Training and Research Hospital, Cardiology, Health Sciences University, Istanbul, Turkey.
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Zhang Y, Wang W, Fang Q. Clinical study of stent forming for symptomatic internal carotid artery stenosis. Medicine (Baltimore) 2020; 99:e20637. [PMID: 32569194 PMCID: PMC7310902 DOI: 10.1097/md.0000000000020637] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/31/2019] [Revised: 05/01/2020] [Accepted: 05/06/2020] [Indexed: 11/26/2022] Open
Abstract
Stroke is one of the diseases that seriously threaten the survival and health of human beings. In Europe and the United States, stroke is the second leading cause of death after heart disease and tumors. Stroke is also one of the fatal diseases in Asian countries. On average, about 1.5 million new stroke patients are added each year in China, and the incidence of stroke is increasing year by year. About 80% of all stroke patients are ischemic stroke, and symptomatic internal carotid atherosclerotic stenosis is another important cause of ischemic stroke. Ipsilateral carotid stenosis ≥50% increases the incidence of transient cerebral ischemia and stroke in the carotid artery region by 10% to 15%, and is also closely related to the recurrence of acute and long-term stroke in patients. Therefore, the clinical application and efficacy of carotid stenting in patients with symptomatic internal carotid artery stenosis are analyzed and evaluated to provide a basis for the selection of clinical treatment options.The clinical data of patients with symptomatic carotid stenosis who underwent carotid stenting and the clinical data of conservative treatment of patients with symptomatic carotid stenosis were retrospectively analyzed, and the carotid stenosis rate, symptoms, and National Institute of Health stroke scale where compared before and after surgery. And activities of daily living score. Because the control group treatment method in this article is completely free for patients to choose, and belongs to a retrospective analysis, the results suggest that it can provide a high-quality treatment approach for the treatment of patients with symptomatic carotid stenosis, without causing any harm to the patient, So no ethical approval is needed, and no patient informed consent is required.In recent years, with the continuous advancement of science and technology and new stent materials, intravascular interventional technology has developed rapidly. In continuous clinical practice and research, the safety and effectiveness of stent technology have also been gradually improved. Arterial stenting has gradually become an important method for the treatment of atherosclerotic carotid stenosis. This technique can not only improve the symptoms and prognosis of patients with symptomatic internal carotid stenosis, but also prevent the occurrence of ischemic events. The promotion of this technology has the effect of reducing disability and mortality.The alternative therapy of drug therapy, namely arterial stent implantation, has become a new way to treat atherosclerotic stroke. This treatment technology can quickly relieve the abnormal hemodynamics of distal blood vessels caused by arterial stenosis, which is ischemic. Cerebrovascular disease provides new ideas for treatment. Carotid angioplasty and stenting for symptomatic internal carotid stenosis under a distal cerebral protection device is a safe and effective treatment.
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Affiliation(s)
- Yiqin Zhang
- The First Affiliated Hospital of Soochow University, Suzhou, Jiangsu
- Chongming Branch, Xinhua Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai
| | - Wen’an Wang
- Chongming Branch, Xinhua Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai
| | - Qi Fang
- The First Affiliated Hospital of Soochow University, Suzhou, Jiangsu, China
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Nana PN, Brotis AG, Spanos KT, Kouvelos GN, Matsagkas MI, Giannoukas AD. A systematic review and meta-analysis of carotid artery stenting using the transcervical approach. INT ANGIOL 2020; 39:372-380. [PMID: 32536113 DOI: 10.23736/s0392-9590.20.04434-x] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
Abstract
INTRODUCTION Carotid artery stenting (CAS) via a transcarotid revascularization (TCAR) approach has emerged as an alternative when carotid endarterectomy or conventional CAS is contraindicated. The present study was conducted to assess the feasibility and safety of TCAR in patients with carotid artery stenosis. EVIDENCE ACQUISITION A systematic review of the literature was performed, according to PRISMA guidelines (Preferred Reporting Items for Systematic reviews and Meta-Analyses), using PubMed, EMBASE and CENTRAL databases. The primary outcomes included technical success, perioperative neurological event, myocardial ischemic events, death and their composite. Operational duration, flow reversal time and any local procedure related complication (carotid dissection and cranial nerve injury) were also recorded. EVIDENCE SYNTHESIS Twenty-three studies were included, reporting on 3130 patients, undergoing TCAR. Thirty-five per cent of them were symptomatic. Technical success was 98% (95% CI: 0.97-0.99; P=0.11, I<sup>2</sup>=32%). Early (30-day) new neurological event rate was estimated at 2% (95% CI: 0.01-0.02; P=1.0, I<sup>2</sup>=0%, respectively) while early death rate was 1% (95% CI: 0.00-0.01; P=1.0, I<sup>2</sup>=0%). Myocardial ischemic (MI) event rate was 1% (95% CI, 0.00-0.01, P=0.97, I<sup>2</sup>=6.6%). The composite outcome of neurological event/MI/death at 30-day follow-up was 2% (95% CI: 0.01-0.02, P=0.79, I<sup>2</sup>=14%). Carotid dissection rate during the intervention was 2% (95% CI: 0.01-0.03, P=0.58, I<sup>2</sup>=2.9%) while the post-operatively detected cranial nerve injury rate was 1% (95% CI, 0.00-0.01, P=1.0, I<sup>2</sup>=0%). Regarding the technical aspects of the procedures, operational and flow reversal time were at 73.8 min and 13.7 min, respectively (95% CI: 68.2-79.3, P=0.18, I<sup>2</sup>=37.6% and 95% CI: 11.3-16.1, P=0.48, I<sup>2</sup>=0%, respectively). CONCLUSIONS TCAR is feasible with high technical success rate. The procedure presents low incidence of local complications, neurological events, myocardial complications and mortality during the early postoperative period and should be considered an acceptable alternative for patients treated for carotid artery stenosis.
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Affiliation(s)
- Petroula N Nana
- Department of Vascular Surgery, Faculty of Medicine, School of Health Sciences, University Hospital of Larissa, University of Thessaly, Larissa, Greece -
| | - Alexandros G Brotis
- Department of Neurosurgery, Faculty of Medicine, School of Health Sciences, University Hospital of Larissa, University of Thessaly, Larissa, Greece
| | - Konstantinos T Spanos
- Department of Vascular Surgery, Faculty of Medicine, School of Health Sciences, University Hospital of Larissa, University of Thessaly, Larissa, Greece
| | - George N Kouvelos
- Department of Vascular Surgery, Faculty of Medicine, School of Health Sciences, University Hospital of Larissa, University of Thessaly, Larissa, Greece
| | - Miltiadis I Matsagkas
- Department of Vascular Surgery, Faculty of Medicine, School of Health Sciences, University Hospital of Larissa, University of Thessaly, Larissa, Greece
| | - Athanasios D Giannoukas
- Department of Vascular Surgery, Faculty of Medicine, School of Health Sciences, University Hospital of Larissa, University of Thessaly, Larissa, Greece
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Conway AM, Nguyen Tran NT, Qato K, Ehidom C, Stoffels GJ, Giangola G, Carroccio A. Complexity of Aortic Arch Anatomy Affects the Outcomes of Transcarotid Artery Revascularization Versus Transfemoral Carotid Artery Stenting. Ann Vasc Surg 2020; 67:78-89. [PMID: 32339690 DOI: 10.1016/j.avsg.2020.04.016] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2020] [Revised: 04/09/2020] [Accepted: 04/17/2020] [Indexed: 11/26/2022]
Abstract
BACKGROUND Transcarotid artery revascularization (TCAR) has been shown to have half the rates of transient ischemic attack (TIA), stroke, and death compared with transfemoral carotid artery stenting (TFCAS). Successful outcomes of TFCAS require careful patient selection. The aim of this study was to determine the outcomes of TFCAS versus TCAR in both simple (type I) and complex (type II and III) aortic arches. METHODS A retrospective cohort study was performed comparing the outcomes of patients undergoing TFCAS versus TCAR with simple and complex aortic arches using the Vascular Quality Initiative registry from August 2011 to May 2019. The primary outcome was a composite of in-hospital TIA/stroke/death. RESULTS About 6,108 carotid artery interventions were analyzed, including 3,536 (57.9%) patients with type I, 2,013 (33.0%) with type II, and 559 (9.2%) with type III aortic arch. In 3,535 patients with a simple arch, 1,917 underwent TFCAS and 1,619 had TCAR. Mean age was 70.6 (±9.5) years, and 2,382 (67.4%) patients were males. The primary outcome of postoperative TIA/stroke/death was seen significantly less frequently in those undergoing TCAR compared with TFCAS in simple arches (odds ratio [OR], 0.63; 95% confidence interval [95% CI], 0.43-0.94; P = 0.0236). Although the individual outcome of death occurred less often in TCAR (P = 0.0025), there was no difference in the occurrence of in-hospital stroke (P = 0.8836) or TIA (P = 0.4608). On multivariable analysis, TCAR was associated with improved outcomes (P = 0.0062). A worse outcome was associated with increasing age (P < 0.001), a prior stroke (P < 0.0001), and increasing number of stents (P = 0.0483). In 2,572 patients with a complex arch, 1,416 underwent TFCAS and 1,156 had TCAR. Mean age was 73.0 (±9.1) years, and 1,655 (64.4%) were males. In complex arch anatomy, the primary outcome of in-hospital TIA/stroke/death was seen significantly less frequently in TCAR compared with TFCAS (OR, 0.49; 95% CI, 0.31-0.77; P = 0.0022). Again noted was a significant difference in death, with better outcomes in TCAR (P = 0.0133). Although the occurrence of in-hospital TIA was no different between the 2 approaches (P = 0.6158), there were significantly fewer strokes in those treated with TCAR (P = 0.0132). TCAR (P = 0.0146) was associated with improved outcomes. A worse outcome was seen with advancing age (P = 0.0003), prior strokes (P = 0.01), and a left-sided lesion (P = 0.0176). CONCLUSIONS TCAR has improved outcomes of TIA/stroke/death compared with TFCAS in both simple and complex aortic arch anatomy. In simple aortic arches, there is no difference in neurologic outcomes between both approaches. In complex arch anatomy, TCAR has fewer strokes.
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Affiliation(s)
- Allan M Conway
- Department of Surgery, Lenox Hill Hospital, Northwell Health, New York, NY.
| | - Nhan T Nguyen Tran
- Department of Surgery, Lenox Hill Hospital, Northwell Health, New York, NY
| | - Khalil Qato
- Department of Surgery, Lenox Hill Hospital, Northwell Health, New York, NY
| | - Clinton Ehidom
- Department of Surgery, Lenox Hill Hospital, Northwell Health, New York, NY
| | | | - Gary Giangola
- Department of Surgery, Lenox Hill Hospital, Northwell Health, New York, NY
| | - Alfio Carroccio
- Department of Surgery, Lenox Hill Hospital, Northwell Health, New York, NY
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Carotid Artery Stenting in Asymptomatic Carotid Artery Stenosis: JACC Review Topic of the Week. J Am Coll Cardiol 2020; 75:648-656. [PMID: 32057380 DOI: 10.1016/j.jacc.2019.11.054] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/08/2019] [Accepted: 11/19/2019] [Indexed: 01/22/2023]
Abstract
The advance of therapies to reduce the stroke impact of asymptomatic carotid artery stenosis has proved difficult over the last decade. Disagreement concerning the underlying randomized control trials has limited entry into the care arena of endovascular therapies. Recently, advances in percutaneous therapies for carotid artery disease have been reported and provide a substantial database supporting the further incorporation of endovascular-based therapies in patients who need revascularization and meet selection criteria. With a second randomized control trial now published, it is time for a re-evaluation of endovascular therapy as a component of carotid artery care. This review describes the advances in the field in the last 5 years, clarifying the current position of these therapies in the care of the patient with asymptomatic carotid artery disease.
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A Clinical Validation Study of Anatomical Risk Scoring for Procedural Stroke in Patients Treated by Carotid Artery Stenting in the International Carotid Stenting Study. Eur J Vasc Endovasc Surg 2019; 58:664-670. [DOI: 10.1016/j.ejvs.2019.04.035] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2018] [Revised: 02/20/2019] [Accepted: 04/24/2019] [Indexed: 11/22/2022]
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Long-term Outcomes of Carotid Endarterectomy Versus Stenting in a Multicenter Population-based Canadian Study. Ann Surg 2019; 268:364-373. [PMID: 28498234 DOI: 10.1097/sla.0000000000002301] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
OBJECTIVE To compare the long-term outcomes of patients treated with carotid endarterectomy and carotid-artery stenting. BACKGROUND Evidence for the long-term safety and efficacy of carotid-artery stenting compared with endarterectomy is accumulating from randomized trials. However, comparative data on the long-term outcomes of carotid revascularization strategies in real world practice are lacking. METHODS We conducted a population-based, multicenter, observational cohort study using validated linked databases from Ontario, Canada. We identified all individuals treated with carotid endarterectomy and stenting (2002-2014), and followed them up to 2015. We compared long-term (up to 13 years) and 30-day outcomes of each strategy using multilevel multivariable Cox proportional-hazards models, and conducted confirmatory analyses using propensity-score matching methods. RESULTS In all, 15,525 patients received carotid-artery revascularization. Rate of the primary composite outcome of 30-day death, stroke, or myocardial infarction plus any stroke during 13-year follow-up was higher with stenting (16.3%) compared with endarterectomy (9.7%) [adjusted hazard ratio (HR) 1.57, 95% confidence interval (CI) 1.43-1.73, P < 0.001). The increased risk with stenting was observed regardless of age, sex, intervention year, carotid-artery symptoms, or diabetes. The primary outcome was driven by higher rates of 30-day stroke (adjusted HR 1.59, 95% CI 1.29-1.95), 30-day death (adjusted HR 2.62, 95% CI 2.20-3.13), and long-term stroke >30 days after the procedure (adjusted HR 1.47, 95% CI 1.36-1.59) with stenting; 30-day myocardial infarction was lower with stenting (adjusted HR 0.70, 95% CI 0.57-0.86). These results were confirmed with 1:2 propensity-score matching (HR for primary composite outcome with stenting 1.55, 95% CI 1.31-1.83, P < 0.001). CONCLUSIONS Compared with carotid endarterectomy, stenting was associated with an early and sustained approximately 55% increased hazard for major adverse events over long-term follow-up. Although nonrandomized, these results raise potential concerns about the interchangeability of carotid endarterectomy and stenting in the context of actual clinical practice.
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Batchelder AJ, Saratzis A, Ross Naylor A. Editor's Choice - Overview of Primary and Secondary Analyses From 20 Randomised Controlled Trials Comparing Carotid Artery Stenting With Carotid Endarterectomy. Eur J Vasc Endovasc Surg 2019; 58:479-493. [PMID: 31492510 DOI: 10.1016/j.ejvs.2019.06.003] [Citation(s) in RCA: 46] [Impact Index Per Article: 9.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2018] [Revised: 05/30/2019] [Accepted: 06/05/2019] [Indexed: 12/19/2022]
Abstract
OBJECTIVES The aim of this review was to carry out primary and secondary analyses of 20 randomised controlled trials (RCTs) comparing carotid endarterectomy (CEA) with carotid artery stenting (CAS). METHODS A systematic review and meta-analysis of data from 20 RCTs (126 publications) was carried out. RESULTS Compared with CEA, the 30 day death/stroke rate was significantly higher after CAS in seven RCTs involving 3467 asymptomatic patients (odds ratio [OR] 1.64, 95% confidence interval [CI] 1.02-2.64) and in 10 RCTs involving 5797 symptomatic patients (OR 1.71, 95% CI 1.38-2.11). Excluding procedural risks, late ipsilateral stroke was about 4% at 9 years for both CEA and CAS, i.e., CAS was durable. Reducing procedural death/stroke after CAS may be achieved through better case selection, e.g., performing CEA in (i) symptomatic patients aged > 70 years; (ii) interventions within 14 days of symptom onset; and (iii) situations where stroke risk after CAS is predicted to be higher (segmental/remote plaques, plaque length > 13 mm, heavy burden of white matter lesions [WMLs], where two or more stents might be needed). New WMLs were significantly more common after CAS (52% vs. 17%) and were associated with higher rates of late stroke/transient ischaemic attack (23% vs. 9%), but there was no evidence that new WMLs predisposed towards late cognitive impairment. Restenoses were more common after CAS (10%) but did not increase late ipsilateral stroke. Restenoses (70%-99%) after CEA were associated with a small but significant increase in late ipsilateral stroke (OR 3.87, 95% CI 1.96-7.67; p < .001). CONCLUSIONS CAS confers higher rates of 30 day death/stroke than CEA. After 30 days, ipsilateral stroke is virtually identical for CEA and CAS. Key issues to be resolved include the following: (i) Will newer stent technologies and improved cerebral protection allow CAS to be performed < 14 days after symptom onset with risks similar to CEA? (ii) What is the optimal volume of CAS procedures to maintain competency? (iii) How to deliver better risk factor control and best medical treatment? (iv) Is there a role for CEA/CAS in preventing/reversing cognitive impairment?
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Affiliation(s)
| | | | - A Ross Naylor
- The Leicester Vascular Institute, Glenfield Hospital, Leicester, UK.
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Rots ML, Meershoek AJ, Bonati LH, den Ruijter HM, de Borst GJ. Editor's Choice – Predictors of New Ischaemic Brain Lesions on Diffusion Weighted Imaging After Carotid Stenting and Endarterectomy: A Systematic Review. Eur J Vasc Endovasc Surg 2019; 58:163-174. [DOI: 10.1016/j.ejvs.2019.04.016] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2018] [Revised: 04/09/2019] [Accepted: 04/14/2019] [Indexed: 12/16/2022]
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Rolls AE, Riga CV, Rahim SU, Willaert W, Van Herzeele I, Stoyanov DV, Hamady MS, Cheshire NJ, Bicknell CD. The use of video motion analysis to determine the impact of anatomic complexity on endovascular performance in carotid artery stenting. J Vasc Surg 2019; 69:1482-1489. [DOI: 10.1016/j.jvs.2018.07.063] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2018] [Accepted: 07/22/2018] [Indexed: 10/27/2022]
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Vascular Anatomy and Not Age is Responsible for Increased Risk of Complications in Symptomatic Elderly Patients Undergoing Carotid Artery Stenting. World Neurosurg 2019; 128:e513-e521. [PMID: 31048049 DOI: 10.1016/j.wneu.2019.04.187] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2019] [Revised: 04/22/2019] [Accepted: 04/23/2019] [Indexed: 11/22/2022]
Abstract
BACKGROUND Various studies have suggested that age ≥80 years is associated with a higher rate of complications after carotid artery stenting (CAS). The Buffalo Risk Assessment Scale (BRASS) predicts complications in symptomatic patients undergoing CAS. Application of the BRASS has shown the ability to improve patient selection. We used the BRASS system to evaluate whether the higher rate of complications associated with CAS in the elderly is related to vascular anatomy. METHODS A retrospective review of CAS was performed at our institution over 7 years. Demographic information, anatomic characteristics, BRASS categorization, and outcome measures were compared between elderly (≥80 years) and younger patients (<80 years). RESULTS The study included 447 patients: 335 patients (75%) <80 years and 112 patients (25%) ≥80 years. There were significantly more elderly patients in the high-risk BRASS category (P < 0.01), and more young patients in the low-risk BRASS category (P = 0.04). The complication rates in the 2 groups were similar. Older patients were more likely to harbor complex vascular anatomy: they had significantly higher rates of types II and III aortic arches (P = 0.01 and P < 0.01, respectively), higher percentage of tortuous carotid vessels (P < 0.01), and higher rates of hostile anatomy for deployment of distal embolic protection devices (P = 0.02). CONCLUSIONS Complex vascular anatomy, rather than age, is the key factor behind the higher CAS-associated complication rate in the elderly. Complications can be avoided through proper patient selection and stratifying patients based on anatomic characteristics, which can be achieved through the BRASS scoring system.
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Marrocco-Trischitta MM, Rylski B, Schofer F, Secchi F, Piffaretti G, de Beaufort H, Belvroy V, Bismuth J, Czerny M, Trimarchi S. Prevalence of type III arch configuration in patients with type B aortic dissection. Eur J Cardiothorac Surg 2019; 56:1075-1080. [DOI: 10.1093/ejcts/ezz137] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/17/2018] [Revised: 03/26/2019] [Accepted: 04/01/2019] [Indexed: 12/23/2022] Open
Abstract
Abstract
OBJECTIVES
Type III aortic arch configuration consistently presents anatomical and biomechanical characteristics which have been associated with an increased risk of type B aortic dissection (TBD). Our aim was to investigate the prevalence of type III arch in patients with TBD and type B intramural haematoma (IMH-B).
METHODS
A multicentre retrospective analysis was performed on patients with TBD and IMH-B observed between 2002 and 2017. The computed tomographic images were reviewed to identify the type of aortic arch. Exclusion criteria included previous arch surgery, presence of aortic dissection or aneurysm proximal to the left subclavian artery and bovine arches. An ad hoc systematic literature review was conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) guidelines to assess the prevalence of type III arch in non-TBD and non-aneurysmal patients.
RESULTS
Two hundred and sixty-one patients with TBD/IMH-B were found to be suitable for the study and were stratified according to aortic arch classification. The ad hoc literature search provided 10 relevant articles, from which a total of 7983 control cases were retrieved. TBD/IMH-B patients were significantly younger than controls [64.3, standard error: 0.74 (62.84–65.76) vs mean pooled age 70.5, standard error: 0.40 (69.71–71.28)]. Patients with TBD/IMH-B presented with a significantly higher prevalence of type III arch [41.0% (107/261) (35.2–47.1)] than controls [16% (1241/7983) (10–22)].
CONCLUSIONS
Our data indicate an association between type III arch configuration and the occurrence of TBD/IMH-B. These findings warrant further studies to disclose the potential role of type III arch configuration as an anatomical risk factor for TBD/IMH-B.
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Affiliation(s)
- Massimiliano M Marrocco-Trischitta
- Division of Vascular Surgery II, IRCCS - Policlinico San Donato, San Donato Milanese, Italy
- Thoracic Aortic Research Center, IRCCS - Policlinico San Donato, San Donato Milanese, Italy
| | - Bartosz Rylski
- Department of Cardiovascular Surgery, Faculty of Medicine, Albert Ludwigs University, University Heart Center Freiburg, Freiburg, Germany
| | - Florian Schofer
- Department of Cardiovascular Surgery, Faculty of Medicine, Albert Ludwigs University, University Heart Center Freiburg, Freiburg, Germany
| | - Francesco Secchi
- Division of Radiology, IRCCS - Policlinico San Donato, San Donato Milanese, Italy
| | - Gabriele Piffaretti
- Vascular Surgery, Department of Medicine and Surgery, University of Insubria School of Medicine, ASST Settelaghi University Teaching Hospital, Varese, Italy
| | - Hector de Beaufort
- Thoracic Aortic Research Center, IRCCS - Policlinico San Donato, San Donato Milanese, Italy
| | - Viony Belvroy
- Houston Methodist DeBakey Heart & Vascular Center, Houston, TX, USA
| | - Jean Bismuth
- Houston Methodist DeBakey Heart & Vascular Center, Houston, TX, USA
| | - Martin Czerny
- Department of Cardiovascular Surgery, Faculty of Medicine, Albert Ludwigs University, University Heart Center Freiburg, Freiburg, Germany
| | - Santi Trimarchi
- Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico Milan, Milan, Italy
- Department of Clinical and Community Sciences, University of Milan, Milan, Italy
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Kawabata Y, Nakajima N, Miyake H, Fukuda S, Tsukahara T. Postoperative ischemic events in patients undergoing carotid artery stenting using algorithmic selection for embolic protection. Neuroradiol J 2019; 32:294-302. [PMID: 30971186 DOI: 10.1177/1971400919839644] [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: 11/16/2022] Open
Abstract
PURPOSE Carotid artery stenting (CAS) is a valuable alternative to carotid endarterectomy, especially in high-risk patients. However, the reported incidences of perioperative stroke and death remain higher than for carotid endarterectomy, even when using embolic protection devices (EPDs) during CAS. Our purpose was to evaluate 30-day major adverse events after CAS when selecting the most appropriate EPD. METHODS We reviewed the clinical outcomes of 61 patients with 64 lesions who underwent CAS with EPDs. Patients who underwent CAS associated with thrombectomy and who had a preoperative modified Rankin scale score >3 were excluded from the analysis. The EPD was selected based on symptoms, carotid wall magnetic resonance imaging and lesion length, and we analyzed combined 30-day complication rates (transient ischemic attack, minor stroke, major stroke or death). RESULTS Forty-nine patients were men and 12 were women. The median age was 72 years (range: 59-89 years) and 44 lesions were asymptomatic. A filter-type EPD was selected in 23 procedures, distal-balloon protection in 14 procedures and proximal-occlusive protection in 27 procedures. Two patients (3.1%) experienced a transient ischemic attack and one patient (1.6%) had a minor stroke within 30 days of the procedure. No patients experienced procedure-related morbidities (modified Rankin score >2) or death. CONCLUSIONS The perioperative stoke rate was low when we selected a proximal-occlusive-type EPD in high-risk patients with vulnerable carotid artery disease. Our algorithm for EPD selection was an effective tool in the perioperative management of carotid artery stenosis.
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Affiliation(s)
- Yasuhiro Kawabata
- 1 Department of Neurosurgery, Kyoto Katsura Hospital, Japan.,2 Department of Neurosurgery, National Hospital Organization Kyoto Medical Center, Japan
| | - Norio Nakajima
- 1 Department of Neurosurgery, Kyoto Katsura Hospital, Japan
| | | | - Shunichi Fukuda
- 2 Department of Neurosurgery, National Hospital Organization Kyoto Medical Center, Japan
| | - Tetsuya Tsukahara
- 2 Department of Neurosurgery, National Hospital Organization Kyoto Medical Center, Japan
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Ito H, Uchida M, Sase T, Kushiro Y, Wakui D, Onodera H, Takasuna H, Morishima H, Oshio K, Tanaka Y. Risk Factors of Contralateral Microembolic Infarctions Related to Carotid Artery Stenting. Neurol Med Chir (Tokyo) 2018; 58:311-319. [PMID: 29887547 PMCID: PMC6048354 DOI: 10.2176/nmc.oa.2018-0023] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
This study sought to analyze the incidence of contralateral microembolic infarctions (MIs) on diffusion-weighted imaging (DWI) following protected carotid artery stenting (CAS) and compared the difference of risk factors between ipsilateral and contralateral lesions. From April 2010 to March 2017, 147 CASs in 140 patients were performed. All the patients underwent DWI within 1 week before and 24 hrs after the procedures. CAS was successfully completed in 145 (98.6%) of the 147 procedures. Forty-nine (33.8%) patients with new MIs revealed on postprocedural DWI were enrolled. They were divided into ipsilateral and contralateral groups based on the side of the CAS and MIs. The ipsilateral group indicates patients with MIs exclusively on the side of CAS. The contralateral group includes patients with MIs on the opposite side of the CAS or both sides. Patients with MIs at vertebrobasilar territory were excluded. Patient characteristics, morphology of the carotid artery and aortic arch, and procedural data were retrospectively assessed and compared between the two groups. Twenty-two (15.2%) and 14 (9.7%) patients were assigned to the ipsilateral and contralateral groups, respectively. Advanced age, left-sided stenosis, severe aortic arch calcification (AAC) on chest X-ray and contralateral carotid occlusion significantly increased the occurrence of contralateral MIs. On multivariable logistic regression analysis, severe AAC was statistically more frequent in the contralateral group. In the present study, the incidences of contralateral MIs after CAS is relatively not low. Advanced aortic atherosclerosis is statistically predictive for contralateral MIs. AAC on chest X-ray is a useful finding for estimating aortic atherosclerosis in candidates for CAS.
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Affiliation(s)
- Hidemichi Ito
- Department of Neurosurgery, St. Marianna University School of Medicine
| | - Masashi Uchida
- Department of Neurosurgery, St. Marianna University School of Medicine
| | - Taigen Sase
- Department of Neurosurgery, St. Marianna University School of Medicine
| | - Yuichiro Kushiro
- Department of Neurosurgery, St. Marianna University School of Medicine
| | - Daisuke Wakui
- Department of Neurosurgery, St. Marianna University School of Medicine Yokohama City Seibu Hospital
| | - Hidetaka Onodera
- Department of Neurosurgery, St. Marianna University School of Medicine Yokohama City Seibu Hospital
| | - Hiroshi Takasuna
- Department of Neurosurgery, St. Marianna University School of Medicine
| | | | - Kotaro Oshio
- Department of Neurosurgery, St. Marianna University School of Medicine
| | - Yuichiro Tanaka
- Department of Neurosurgery, St. Marianna University School of Medicine
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46
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Jones DW, Brott TG, Schermerhorn ML. Trials and Frontiers in Carotid Endarterectomy and Stenting. Stroke 2018; 49:1776-1783. [PMID: 29866753 DOI: 10.1161/strokeaha.117.019496] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2017] [Revised: 04/19/2018] [Accepted: 04/30/2018] [Indexed: 11/16/2022]
Affiliation(s)
- Douglas W Jones
- From the Division of Vascular and Endovascular Surgery, Boston Medical Center, Boston University School of Medicine, MA (D.W.J.)
| | - Thomas G Brott
- Department of Neurology, Mayo Clinic, Jacksonville, FL (T.G.B.)
| | - Marc L Schermerhorn
- Division of Vascular and Endovascular Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA (M.L.S.).
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47
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Symptomatic carotid stenosis: is stenting as safe and effective as carotid endarterectomy? Curr Opin Neurol 2018; 30:22-27. [PMID: 28002121 DOI: 10.1097/wco.0000000000000409] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
PURPOSE OF REVIEW Reviewing current evidence on carotid artery stenting (CAS) compared with carotid endarterectomy (CEA) in the prevention of ipsilateral stroke in patients with a symptomatic carotid stenosis. RECENT FINDINGS Randomized clinical trials and registries have consistently shown that CAS is associated with a higher risk of procedural stroke or death and a lower risk of procedural myocardial infarction and local complications compared with CEA. Both procedures are equally effective to prevent late recurrent ipsilateral stroke and are associated with similar low risk of restenosis.Individual patient data analyses of the Carotid Stenosis Trialists' Collaboration recently showed that CAS is as safe and as effective in patients younger than 70. SUMMARY Although CEA remains the standard treatment in patients with recently symptomatic carotid stenosis, CAS is a safe and effective alternative option in patients younger than 70 and can be also considered when a contraindication to CEA exists.
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48
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Abstract
Carotid artery stenting (CAS) has been recommended as an alternative treatment to carotid endarterectomy for patients with significant carotid stenosis. Only a few studies have analyzed clinical/anatomical and technical variables that affect perioperative outcomes of CAS. Following a comprehensive Medline search, it was reported that clinical factors, including age of >80 years, chronic renal failure, diabetes mellitus, symptomatic indications, and procedures performed within 2 weeks of transient ischemic attack symptoms, are associated with high perioperative stroke and death rates. They also highlighted that angiographic variables, e.g., ulcerated and calcified plaques, left carotid intervention, >90% stenosis, >10-mm target lesion length, ostial involvement, type III aortic arch, and >60°-angulated internal carotid and common carotid arteries, are predictors of increased stroke rates. Technical factors associated with increased perioperative risk of stroke include percutaneous transluminal angioplasty (PTA) without embolic protection devices, PTA before stent placement, and the use of multiple stents. This review describes the most widely quoted data in defining various predictors of perioperative stroke and death after CAS. (This is a review article based on the invited lecture of the 45th Annual Meeting of Japanese Society for Vascular Surgery.)
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Affiliation(s)
- Ali F AbuRahma
- Department of Surgery, West Virginia University, Charleston, West Virginia, USA
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49
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Labeyrie MA, Ducroux C, Civelli V, Reiner P, Cognat E, Aymard A, Bisdorff A, Saint-Maurice JP, Houdart E. Endovascular management of extracranial occlusions at the hyperacute phase of stroke with tandem occlusions. J Neuroradiol 2017; 45:196-201. [PMID: 29132938 DOI: 10.1016/j.neurad.2017.10.003] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2017] [Accepted: 10/24/2017] [Indexed: 11/30/2022]
Abstract
BACKGROUND AND PURPOSE The management of cervical artery occlusions in hyperacute stroke with tandem cervical/intracranial occlusions has not yet become standardized, especially when the circle of Willis is effective. METHODS We retrospectively analyzed the safety and accuracy of current approaches to manage the cervical occlusion in consecutive patients with tandem occlusions addressed for intracranial mechanical thrombectomy (MT) in our department from January 2012 to May 2017. The different approaches that could be performed in a same patient during the same procedure or hospitalization were analyzed separately. RESULTS We reported 64 approaches to manage the cervical occlusion in 49 patients with tandem occlusion (14% of MT): medical treatment alone in 16/64 (25%), stenting/angioplasty in 16/64 (25%), occlusion with coils in 12/64 (19%), angioplasty alone in 9/64 (14%), stent-retriever in 8/64 (12%), and/or thromboaspiration in 3/64 (5%). Early ipsilateral embolic recurrence occurred after 9/64 (14%) of them. It was strongly associated with the presence of a cervical intraluminal thrombus (P=0.001) and was then lower after occlusion with coils and stent-retriever compared to medical treatment alone and thromboaspiration (P=0.002). Occlusion with coils had a lower rate of radiological intracranial hemorrhage at 48-hour compared to other approaches (P=0.009). The 3-month rates of favorable outcome (P=0.806) and mortality (P=0.878) were similar. One delayed stroke was imputable to an occlusion with coils, for a median (Q1-Q3) follow-up of 10 (3-20) months. CONCLUSIONS Cervical occlusion with coils and thrombectomy with stent-retrievers may be relevant to prevent early embolic recurrence in cervical occlusions with intraluminal thrombus. Stent-retrievers should be further assessed as a first-line approach, since delayed stroke may occur following occlusion with coils. Medical treatment alone may be sufficient when no cervical intraluminal thrombus is present, the Willis polygon is effective, and the cervical occlusion can be crossed easily to perform the intracranial thrombectomy.
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Affiliation(s)
- M-A Labeyrie
- Department of Interventional Neuroradiology, hôpital Lariboisière, 2, rue Ambroise-Paré, 75010 Paris, France; EA 7334 REMES (MAL, EH), université de Paris 7, 75013 Paris, France.
| | - C Ducroux
- Department of Interventional Neuroradiology, hôpital Lariboisière, 2, rue Ambroise-Paré, 75010 Paris, France
| | - V Civelli
- Department of Neurology, hôpital Lariboisière, 2, rue Ambroise-Paré, 75010 Paris, France
| | - P Reiner
- Department of Neurology, hôpital Lariboisière, 2, rue Ambroise-Paré, 75010 Paris, France
| | - E Cognat
- Department of Interventional Neuroradiology, hôpital Lariboisière, 2, rue Ambroise-Paré, 75010 Paris, France; EA 7334 REMES (MAL, EH), université de Paris 7, 75013 Paris, France
| | - A Aymard
- Department of Interventional Neuroradiology, hôpital Lariboisière, 2, rue Ambroise-Paré, 75010 Paris, France; EA 7334 REMES (MAL, EH), université de Paris 7, 75013 Paris, France
| | - A Bisdorff
- Department of Interventional Neuroradiology, hôpital Lariboisière, 2, rue Ambroise-Paré, 75010 Paris, France; EA 7334 REMES (MAL, EH), université de Paris 7, 75013 Paris, France
| | - J-P Saint-Maurice
- Department of Interventional Neuroradiology, hôpital Lariboisière, 2, rue Ambroise-Paré, 75010 Paris, France; EA 7334 REMES (MAL, EH), université de Paris 7, 75013 Paris, France
| | - E Houdart
- Department of Interventional Neuroradiology, hôpital Lariboisière, 2, rue Ambroise-Paré, 75010 Paris, France; EA 7334 REMES (MAL, EH), université de Paris 7, 75013 Paris, France
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50
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Kaymaz ZO, Nikoubashman O, Brockmann MA, Wiesmann M, Brockmann C. Influence of carotid tortuosity on internal carotid artery access time in the treatment of acute ischemic stroke. Interv Neuroradiol 2017; 23:583-588. [PMID: 28944705 DOI: 10.1177/1591019917729364] [Citation(s) in RCA: 41] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023] Open
Abstract
Purpose Carotid artery anatomy is thought to influence internal carotid artery access time (ICA-AT) in patients requiring mechanical thrombectomy for acute ischemic stroke. This study investigates the association between ICA-AT and carotid anatomy. Material and methods Computed tomography angiography (CTA) data of 76 consecutive patients presenting with acute ischemic stroke requiring mechanical thrombectomy for middle cerebral artery or carotid T occlusion were evaluated. The supraaortic extracranial vasculature was analyzed regarding take-off angles and curvature of the affected side. Digital subtraction angiography data were primarily analyzed regarding ICA-AT and secondarily regarding recanalization time and radiographic result. Results ICA-AT was significantly influenced by vessel tortuosity. Take-off angle of the left common carotid artery ( p = 0.001) and the brachiocephalic trunk ( p = 0.002) as well as the tortuosity of the common carotid artery ( p = 0.002) had highest impact on ICA-AT. For recanalization time, however, we found only the take-off angle of the left common carotid artery to be of significance ( p = 0.020). There was a tendency for ICA-AT to correlate with successful (mTICI ≥ 2 b) revascularization (average time of successful results was 24.3 minutes, of unsuccessful was 35.6 minutes; p = 0.065). Every evaluated segment with less carotid tortuosity showed a carotid AT below 25 minutes. Conclusion Supraaortic vessel tortuosity significantly influences ICA-AT in mechanical thrombectomy for an acute large vessel. There furthermore was a trend for lower successful recanalization rates with increasing ICA-AT.
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Affiliation(s)
- Z O Kaymaz
- 1 Department of Diagnostic and Interventional Neuroradiology, 39058 University Hospital of the RWTH Aachen , Aachen, Germany.,2 Department of Neuroradiology, 9182 University Medical Center Mainz, Mainz , Germany
| | - O Nikoubashman
- 1 Department of Diagnostic and Interventional Neuroradiology, 39058 University Hospital of the RWTH Aachen , Aachen, Germany
| | - M A Brockmann
- 2 Department of Neuroradiology, 9182 University Medical Center Mainz, Mainz , Germany
| | - M Wiesmann
- 1 Department of Diagnostic and Interventional Neuroradiology, 39058 University Hospital of the RWTH Aachen , Aachen, Germany
| | - C Brockmann
- 2 Department of Neuroradiology, 9182 University Medical Center Mainz, Mainz , Germany
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