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Mazzolai L, Teixido-Tura G, Lanzi S, Boc V, Bossone E, Brodmann M, Bura-Rivière A, De Backer J, Deglise S, Della Corte A, Heiss C, Kałużna-Oleksy M, Kurpas D, McEniery CM, Mirault T, Pasquet AA, Pitcher A, Schaubroeck HAI, Schlager O, Sirnes PA, Sprynger MG, Stabile E, Steinbach F, Thielmann M, van Kimmenade RRJ, Venermo M, Rodriguez-Palomares JF. 2024 ESC Guidelines for the management of peripheral arterial and aortic diseases. Eur Heart J 2024; 45:3538-3700. [PMID: 39210722 DOI: 10.1093/eurheartj/ehae179] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 09/04/2024] Open
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2
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Tătaru DA, Olinic M, Homorodean C, Ober MC, Spînu M, Lazăr FL, Onea L, Olinic DM. Correlation between Ultrasound Peak Systolic Velocity and Angiography for Grading Internal Carotid Artery Stenosis. J Clin Med 2024; 13:517. [PMID: 38256651 PMCID: PMC10816984 DOI: 10.3390/jcm13020517] [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: 11/21/2023] [Revised: 01/08/2024] [Accepted: 01/11/2024] [Indexed: 01/24/2024] Open
Abstract
(1) Background: The success of carotid revascularization depends on the accurate grading of carotid stenoses. Therefore, it is important for every vascular center to establish its protocols for the same. In this study, we aimed to determine the peak systolic velocity (PSV) thresholds that can predict moderate and severe internal carotid artery (ICA) stenoses. (2) Methods: To achieve this, we enrolled patients who underwent both duplex ultrasound (DUS) and invasive carotid artery digital subtraction angiography (DSA). The degree of ICA stenosis was assessed using the North American Symptomatic Carotid Endarterectomy Trial (NASCET) and the European Carotid Surgery Trial (ECST) protocols. The PSV thresholds were determined using receiver operating characteristic (ROC) curves. (3) Results: Our study included 47 stenoses, and we found that the PSV cut-off for predicting ≥70% NASCET ICA stenoses was 200 cm/s (sensitivity 90.32%, specificity 93.75%). However, PSV did not correlate significantly with ≥50% NASCET ICA stenoses. On the other hand, the optimal PSV threshold for predicting ≥80% ECST ICA stenoses was 180 cm/s (sensitivity 100%, specificity 81.82%). (4) Conclusions: Based on our findings, we concluded that PSV is a good and simple marker for the identification of severe stenoses. We found that PSV values correlate significantly with severe NASCET and ECST stenoses, with 200 cm/s and 180 cm/s PSV thresholds. However, PSV was not reliable with moderate NASCET stenoses. In such cases, complementary imaging should be used.
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Affiliation(s)
- Dan-Alexandru Tătaru
- Medical Clinic No. 1, University of Medicine and Pharmacy “Iuliu Hatieganu”, 400006 Cluj-Napoca, Romania; (D.-A.T.); (C.H.); (M.S.); (F.-L.L.); (L.O.); (D.-M.O.)
- Interventional Cardiology Department, Cluj County Emergency Hospital, 400006 Cluj-Napoca, Romania;
| | - Maria Olinic
- Medical Clinic No. 1, University of Medicine and Pharmacy “Iuliu Hatieganu”, 400006 Cluj-Napoca, Romania; (D.-A.T.); (C.H.); (M.S.); (F.-L.L.); (L.O.); (D.-M.O.)
- Interventional Cardiology Department, Cluj County Emergency Hospital, 400006 Cluj-Napoca, Romania;
| | - Călin Homorodean
- Medical Clinic No. 1, University of Medicine and Pharmacy “Iuliu Hatieganu”, 400006 Cluj-Napoca, Romania; (D.-A.T.); (C.H.); (M.S.); (F.-L.L.); (L.O.); (D.-M.O.)
- Interventional Cardiology Department, Cluj County Emergency Hospital, 400006 Cluj-Napoca, Romania;
| | - Mihai-Claudiu Ober
- Interventional Cardiology Department, Cluj County Emergency Hospital, 400006 Cluj-Napoca, Romania;
| | - Mihail Spînu
- Medical Clinic No. 1, University of Medicine and Pharmacy “Iuliu Hatieganu”, 400006 Cluj-Napoca, Romania; (D.-A.T.); (C.H.); (M.S.); (F.-L.L.); (L.O.); (D.-M.O.)
- Interventional Cardiology Department, Cluj County Emergency Hospital, 400006 Cluj-Napoca, Romania;
| | - Florin-Leontin Lazăr
- Medical Clinic No. 1, University of Medicine and Pharmacy “Iuliu Hatieganu”, 400006 Cluj-Napoca, Romania; (D.-A.T.); (C.H.); (M.S.); (F.-L.L.); (L.O.); (D.-M.O.)
| | - Laurențiu Onea
- Medical Clinic No. 1, University of Medicine and Pharmacy “Iuliu Hatieganu”, 400006 Cluj-Napoca, Romania; (D.-A.T.); (C.H.); (M.S.); (F.-L.L.); (L.O.); (D.-M.O.)
| | - Dan-Mircea Olinic
- Medical Clinic No. 1, University of Medicine and Pharmacy “Iuliu Hatieganu”, 400006 Cluj-Napoca, Romania; (D.-A.T.); (C.H.); (M.S.); (F.-L.L.); (L.O.); (D.-M.O.)
- Interventional Cardiology Department, Cluj County Emergency Hospital, 400006 Cluj-Napoca, Romania;
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3
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Sýkora J, Zeleňák K, Vorčák M, Števík M, Sýkorová M, Sivák J, Rovňák M, Zapletalová J, Mužík J, Šinák I, Kurča E, Meyer L, Fiehler J. Comparison of Restenosis Risk in Single-Layer versus Dual-Layer Carotid Stents: A Duplex Ultrasound Evaluation. Cardiovasc Intervent Radiol 2022; 45:1257-1266. [PMID: 35798859 DOI: 10.1007/s00270-022-03200-4] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/12/2022] [Accepted: 06/04/2022] [Indexed: 01/22/2023]
Abstract
PURPOSE The aim of this study was to report intermediate-term results of duplex ultrasound follow-up of carotid artery stenting performed with the dual-layer stent as compared to concurrent patients treated with other commercially available single-layer carotid stents. MATERIALS AND METHODS A single centre, retrospective, nonrandomized study including 162 non-consecutive patients with 199 implanted carotid stents treated over a 7-year period was conducted. Patients with at least one ultrasound examination after treatment were included. Procedural and follow-up data for patients treated with the dual-layer stent implantation (83 stents) vs first-generation carotid stents implantations (116 stents) were compared. RESULTS The median follow-up time was 24.0 months (IQR 10-32 months) for dual-layer stents and 27.5 months (IQR 10.3-59 months) for single-layer stents. The rate of severe restenosis was significantly higher in the dual-layer stent group than in the single-layer group (13.3% [11/83] vs 3.4% [4/116], p = 0.01). Seven reinterventions were performed in 5 patients with dual-layer stents. The rate of reintervention was significantly higher compared to no reinterventions in single-layer stents (6% [5/83] vs 0% [0/116], p = 0.012). Patients with restenosis had significantly higher presence of dyslipidaemia (100% [12/12] vs 63.3% [95/150], p = 0.009). CONCLUSIONS In this real-world cohort of patients undergoing carotid artery stenting, the patients treated with low-profile dual-layer micromesh stent showed higher rates of restenosis and reinterventions compared to first-generation single-layer stents.
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Affiliation(s)
- Ján Sýkora
- Clinic of Radiology, Comenius University's Jessenius Faculty of Medicine and University Hospital, Kollárova 2, 036 59, Martin, Slovakia.,Department of Radiology, Faculty of Medicine and Dentistry, Palacky University Olomouc, I. P. Pavlova 185/6, 77520, Olomouc, Czech Republic
| | - Kamil Zeleňák
- Clinic of Radiology, Comenius University's Jessenius Faculty of Medicine and University Hospital, Kollárova 2, 036 59, Martin, Slovakia.
| | - Martin Vorčák
- Clinic of Radiology, Comenius University's Jessenius Faculty of Medicine and University Hospital, Kollárova 2, 036 59, Martin, Slovakia
| | - Martin Števík
- Clinic of Radiology, Comenius University's Jessenius Faculty of Medicine and University Hospital, Kollárova 2, 036 59, Martin, Slovakia
| | - Martina Sýkorová
- Vaša Ambulancia, s. r. o., Prieložtek 1, 036 01, Martin, Slovakia
| | - Jozef Sivák
- Department of Radiology, Faculty of Medicine and Dentistry, Palacky University Olomouc, I. P. Pavlova 185/6, 77520, Olomouc, Czech Republic.,Middle-Slovak Institute of Cardiovascular Diseases, Cesta k nemocnici 1, 974 01, Banská Bystrica, Slovakia
| | - Marek Rovňák
- Orthopedic Clinic, Comenius University's Jessenius Faculty of Medicine and University Hospital, Kollárova 2, 036 59, Martin, Slovakia
| | - Jana Zapletalová
- Department of Medical Biophysics, Faculty of Medicine and Dentistry, Palacký University Olomouc, Hněvotínská 976/3, 775 15, Olomouc, Czech Republic
| | - Juraj Mužík
- Department of Geotechnics, Faculty of Civil Engineering, University of Žilina, Univerzitná, 8215/1, 010 26, Žilina, Slovakia
| | - Igor Šinák
- Department of Vascular Surgery, University Hospital, Kollárova 2, 036 59, Martin, Slovakia
| | - Egon Kurča
- Clinic of Neurology, University Hospital, Kollárova 2, 036 59, Martin, Slovakia
| | - Lukas Meyer
- Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, 20251, Hamburg, Germany
| | - Jens Fiehler
- Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, 20251, Hamburg, Germany
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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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Cui CL, Zarrintan S, Marmor RA, Nichols J, Cajas-Monson L, Malas M. Performance of Carotid Revascularization Procedures as Modified by Sex. Ann Vasc Surg 2021; 81:171-182. [PMID: 34752853 DOI: 10.1016/j.avsg.2021.08.051] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2021] [Revised: 08/27/2021] [Accepted: 08/31/2021] [Indexed: 11/25/2022]
Abstract
BACKGROUND Current recommendations on carotid revascularization postulate that women have both increased perioperative risks, such as stroke and death, as well as reduced benefit from intervention. These recommendations do not include data on transcarotid artery revascularization (TCAR). This study strives to compare safety and benefits of TCAR, TFCAS (Transfemoral Carotid Artery Stenting), and CEA (Carotid Endarterectomy) with regard to patient sex. METHODS We performed retrospective analysis of the Society for Vascular Surgery (SVS) Vascular Quality Initiative (VQI) CEA and stenting registries, as well as TCAR Surveillance Project data. We compared outcomes after TCAR, TFCAS, and CEA based on sex. The primary outcome was the rate of in-hospital stroke or death. Secondary outcomes included in-hospital stroke, death, transient ischemic attack (TIA), myocardial infarction (MI), stroke/death/MI, stroke/TIA, and recurrent ipsilateral stroke and/or death at 1-year of follow-up. RESULTS A total of 75,538 patients were included, of which 28,960 (38.3%) were female and 46,578 (61.7%) were male. TFCAS females had more than 2 times higher odds of stroke/death (OR:2.85, 95%CI: 2.21-3.67, P < 0.001) and stroke/death/MI (OR:2.23, 95%CI:1.75-2.83, P < 0.001) when compared to CEA females. Odds of TIA were also higher in both TFCAS females (OR:2.01, 95%CI:1.19-3.42, P = 0.010) and TCAR females (OR:1.91, 95%CI:1.09-3.35, P = .023) when compared to CEA females. However, only TFCAS females experienced increased odds of stroke/TIA (OR:1.96, 95%CI:1.45-2.65, P < 0.001) when compared to CEA females. TFCAS males had almost twice the odds of stroke/death (OR:1.74, 95%CI:1.39-2.16, P < 0.001) and 44% higher odds of stroke/death/MI (OR:1.44, 95%CI:1.19-1.75, P < 0.001), and more than 3-times increased odds of death (OR:3.45, 95%CI:2.53-4.71, P < 0.001) when compared to CEA males. Odds of in-hospital stroke were comparable between TFCAS and CEA after adjusting for covariates. TCAR males have half the odds of MI when compared to CEA males (OR:0.52, 95%CI:0.34-0.80, P = 0.003). At 1-year TCAR had comparable risk of stroke/death while TFCAS had increased risk of stroke/death when compared to CEA among both males and females. CONCLUSION TCAR performed similarly to CEA in both sexes regardless of symptomatic status. Stroke/death and stroke/death/MI rates were similar in symptomatic and asymptomatic males and females treated by CEA or TCAR. The 1-year outcomes of TCAR were also comparable to CEA in both sexes. It seems that TCAR may be a safe alternative to CEA particularly in women when surgical risk prohibits CEA and while TFCAS is associated with substantial adverse outcomes.
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Sastry RA, Pertsch NJ, Sagaityte E, Poggi JA, Toms SA, Weil RJ. Early Outcomes After Carotid Endarterectomy and Carotid Artery Stenting: A Propensity-Matched Cohort Analysis. Neurosurgery 2021; 89:653-663. [PMID: 34320217 DOI: 10.1093/neuros/nyab250] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2020] [Accepted: 06/17/2021] [Indexed: 01/22/2023] Open
Abstract
BACKGROUND Carotid endarterectomy (CEA) and carotid artery stenting (CAS) represent options to treat many patients with carotid stenosis. Although randomized trial data are plentiful, estimated rates of morbidity and mortality for both CEA and CAS have varied substantially. OBJECTIVE To evaluate rates of adverse outcomes after CAS and CEA in a large national database. METHODS We analyzed 84 191 adult patients undergoing elective, nonemergent CAS (n = 81 361) or CEA (n = 2830), from 2011 to 2018, in the American College of Surgeons' National Surgical Quality Improvement Program database. Odds of adverse outcomes (30-d rates of stroke, myocardial infarction (MI), cardiac arrest, prolonged length of stay (LOS), readmission, reoperation, and mortality) were evaluated in propensity-matched (n = 2821) cohorts through logistic regression. RESULTS In the propensity-matched cohorts, CAS had increased odds of periprocedural stroke (odds ratio [OR] 1.97, 95% CI 1.32-2.95) and decreased odds of cardiac arrest (OR 0.33, 95% CI 0.13-0.84) and 30-d reoperation (OR 0.59, 95% CI 0.44-0.80) compared to CEA. Relative odds of MI, prolonged LOS, discharge to destination other than home, 30-d readmission, or 30-d mortality were statistically similar. In the unmatched patient population, rates of adverse outcomes with CEA were constant over time; however, for CAS, rates of stroke increased over time. In both the matched and unmatched patient cohorts, patients 70 yr and older had lower rates of post-procedural stroke with CEA, but not with CAS, compared to younger patients. CONCLUSION In a propensity-matched analysis of a large, prospectively collected, national, surgical database, CAS was associated with increased odds of periprocedural stroke, which increased over time. Rates of MI and death were not significantly different between the 2 procedures.
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Affiliation(s)
- Rahul A Sastry
- Department of Neurosurgery, Warren Alpert School of Medicine, Brown University, Providence, Rhode Island, USA
| | - Nathan J Pertsch
- Department of Neurosurgery, Warren Alpert School of Medicine, Brown University, Providence, Rhode Island, USA
| | - Emilija Sagaityte
- Department of Neurosurgery, Warren Alpert School of Medicine, Brown University, Providence, Rhode Island, USA
| | - Jonathan A Poggi
- Department of Neurosurgery, Warren Alpert School of Medicine, Brown University, Providence, Rhode Island, USA
| | - Steven A Toms
- Department of Neurosurgery, Warren Alpert School of Medicine, Brown University, Providence, Rhode Island, USA.,Department of Neurosurgery, Rhode Island Hospital, Lifespan Health System, Providence, Rhode Island, USA
| | - Robert J Weil
- Department of Neurosurgery, Rhode Island Hospital, Lifespan Health System, Providence, Rhode Island, USA
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Tran B. Assessment and management of peripheral arterial disease: what every cardiologist should know. HEART (BRITISH CARDIAC SOCIETY) 2021; 107:1835-1843. [PMID: 33985986 PMCID: PMC8562307 DOI: 10.1136/heartjnl-2019-316164] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Affiliation(s)
- Bao Tran
- Cardiology, St Mary's Medical Center, San Francisco, California, USA
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8
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Ösken A, Akdeniz E, Keskin M, Öz A, Ipek G, Zehir R, Barutça H, Çam N, Şahin S. Estimated Glomerular Filtration Rate as a Predictor of Restenosis After Carotid Stenting Using First-Generation Stents. Angiology 2021; 72:762-769. [PMID: 33966501 DOI: 10.1177/00033197211014684] [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] [Indexed: 12/12/2022]
Abstract
This study evaluated the impact of the baseline estimated glomerular filtration rate (eGFR) on clinical and angiographic outcomes and long-term in-stent restenosis (ISR) rates in patients undergoing elective carotid artery stenting (CAS) procedures. Consecutive patients who underwent CAS were retrospectively enrolled (n = 456). At the end of 3 years of follow-up, patients who had died or were lost follow-up were excluded from the study and a final analysis was performed using data from the remaining 405 patients. The study population (n = 405) was divided into 3 tertiles based on the tertile values of the eGFR level (T1, T2, and T3); then, clinical and procedural characteristics and 3-year ISR rates were compared between the groups. An ISR of 50% was detected in 49 (12%) surviving patients. The 3-year ISR was higher among patients with the lowest eGFR values (T1) by 3.7 times (95% CI: 2.01-11.38) than that among patients with the highest eGFR values (T3). These significant relationships persisted following adjustment for confounders. A lower baseline eGFR level was significantly associated with an increased ISR rate. Decreased renal function may be a predictor of ISR after CAS using first-generation stents.
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Affiliation(s)
- Altuğ Ösken
- Department of Cardiology, 111319Dr Siyami Ersek Thoracic and Cardiovascular Surgery Center, Training and Research Hospital, Istanbul, Turkey
| | - Evliya Akdeniz
- Department of Cardiology, 111319Dr Siyami Ersek Thoracic and Cardiovascular Surgery Center, Training and Research Hospital, Istanbul, Turkey.,Department of Cardiology, Başkent University Faculty of Medicine, Istanbul, Turkey
| | - Muhammed Keskin
- Department of Cardiology, 111319Dr Siyami Ersek Thoracic and Cardiovascular Surgery Center, Training and Research Hospital, Istanbul, Turkey.,Department of Cardiology, Abdulhamid Han Training and Research Hospital, Istanbul, Turkey
| | - Ahmet Öz
- Department of Cardiology, 111319Dr Siyami Ersek Thoracic and Cardiovascular Surgery Center, Training and Research Hospital, Istanbul, Turkey.,Department of Cardiology, Istanbul Training and Research Hospital, Istanbul, Turkey
| | - Göktürk Ipek
- Department of Cardiology, 111319Dr Siyami Ersek Thoracic and Cardiovascular Surgery Center, Training and Research Hospital, Istanbul, Turkey
| | - Regayip Zehir
- Department of Cardiology, 111319Dr Siyami Ersek Thoracic and Cardiovascular Surgery Center, Training and Research Hospital, Istanbul, Turkey.,Department of Cardiology, Kartal Koşuyolu Training and Research Hospital, Istanbul, Turkey
| | - Hakan Barutça
- Department of Radiology, 111319Dr Siyami Ersek Thoracic and Cardiovascular Surgery Center, Training and Research Hospital, Istanbul, Turkey
| | - Neşe Çam
- Department of Cardiology, 111319Dr Siyami Ersek Thoracic and Cardiovascular Surgery Center, Training and Research Hospital, Istanbul, Turkey
| | - Sinan Şahin
- Department of Radiology, 111319Dr Siyami Ersek Thoracic and Cardiovascular Surgery Center, Training and Research Hospital, Istanbul, Turkey
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Mendoza JFW, Latorraca CDOC, Oliveira RDÁ, Pachito DV, Martimbianco ALC, Pacheco RL, Riera R. Methodological quality and redundancy of systematic reviews that compare endarterectomy versus stenting for carotid stenosis. BMJ Evid Based Med 2021; 26:14-18. [PMID: 31266765 DOI: 10.1136/bmjebm-2018-111151] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 06/10/2019] [Indexed: 12/14/2022]
Abstract
A review of systematic reviews (SRs) and a critical appraisal study was conducted at Escola Paulista de Medicina, Universidade Federal de São Paulo (Unifesp). The objectives of this review are (1) to identify all published SRs comparing the effectiveness and safety of carotid endarterectomy (CEA) versus carotid artery stenting (CAS) for carotid artery stenosis, (2) to assess their methodological quality and (3) to compare the primary studies contained in each SR. We included 17 SRs published between 2005 and 2017. None of the SRs fulfilled all items of AMSTAR-2. The overall confidence in the results was graded as critically low for 16 SRs (94%) and low for 1 SR (6%). Five items were judged inadequate in all SRs: reference to a published protocol, explanation to the selection of study design, comprehensive search of the literature, methods for statistical combination of findings and consideration of the risk of bias on the results of meta-analysis. In total, 15 randomised clinical trials (RCTs) were included at least in one SR. The number of included RCTs in each SR was inconsistent (4 to 15) and was not related to the year of publication of the SR. Our study found redundant and low methodological quality SR comparing CAS versus CEA for carotid stenosis.
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Affiliation(s)
- Juan Fulgencio Welko Mendoza
- Discipline of Evidence-Based Medicine, Universidade Federal de São Paulo (Unifesp), São Paulo, São Paulo, Brazil
| | | | - Ricardo de Ávila Oliveira
- Discipline of Evidence-Based Medicine, Universidade Federal de São Paulo (Unifesp), São Paulo, São Paulo, Brazil
- Department of Surgery, Universidade Federal de Uberlândia, Uberlândia, Minas Gerais, Brazil
| | - Daniela Vianna Pachito
- Center of Health Technology Assessment, Hospital Sírio-Libanês, São Paulo, São Paulo, Brazil
| | - Ana Luiza Cabrera Martimbianco
- Postgraduate of Health and Environment, Universidade Metropolitana de Santos, Santos, São Paulo, Brazil
- Medical Research Center, Centro Universitário São Camilo, São Paulo, São Paulo, Brazil
| | - Rafael Leite Pacheco
- Discipline of Evidence-Based Medicine, Universidade Federal de São Paulo (Unifesp), São Paulo, São Paulo, Brazil
- Medical Research Center, Centro Universitário São Camilo, São Paulo, São Paulo, Brazil
| | - Rachel Riera
- Discipline of Evidence-Based Medicine, Universidade Federal de São Paulo (Unifesp), São Paulo, São Paulo, Brazil
- Center of Health Technology Assessment, Hospital Sírio-Libanês, São Paulo, São Paulo, Brazil
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10
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Schubert T, Rivera-Rivera L, Roldan-Alzate A, Consigny D, Leitner L, Strother C, Aagaard-Kienitz B. Achievable aspiration flow rates with large balloon guide catheters during carotid artery stenting. CVIR Endovasc 2020; 3:65. [PMID: 32910271 PMCID: PMC7483693 DOI: 10.1186/s42155-020-00134-1] [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: 03/29/2020] [Accepted: 06/23/2020] [Indexed: 11/24/2022] Open
Abstract
Background Emergency carotid artery stenting (CAS) is a frequent endovascular procedure, especially in combination with intracranial thrombectomy. Balloon guide catheters are frequently used in these procedures. Our aim was to determine if mechanical aspiration through the working lumen of a balloon occlusion catheter during the steps of a carotid stenting procedure achieve flow rates that may lead to internal carotid artery (ICA) flow reversal which consecutively may prevent distal embolism. Methods Aspiration experiments were conducted using a commercially available aspiration pump. Aspiration flow rates/min with 6 different types of carotid stents inserted into a balloon guide catheter were measured. Measurements were repeated three times with increasing pressure in the phantom. To determine if the achieved aspiration flow rates were similar to physiologic values, flow rates in the ICA and external carotid artery (ECA) in 10 healthy volunteers were measured using 4D-flow MRI. Results Aspiration flow rates ranged from 25 to 82 mL/min depending on the stent model. The pressure in the phantom had a significant influence on the aspiration volume. Mean blood flow volumes in volunteers were 210 mL/min in the ICA and 101 mL/min in the ECA. Conclusions Based on the results of this study, flow reversal in the ICA during common carotid artery occlusion is most likely achieved with the smallest diameter stent sheath and the stent model with the shortest outer stent sheath maximum diameter. This implies that embolic protection during emergency CAS through aspiration is most effective with these models.
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Affiliation(s)
- Tilman Schubert
- Department of Radiology, University of Wisconsin-Madison, Madison, WI, USA. .,Department of Neuroradiology, Zurich University Hospital, Zurich, Switzerland.
| | | | - Alejandro Roldan-Alzate
- Department of Radiology, University of Wisconsin-Madison, Madison, WI, USA.,Department of Mechanical Engineering, University of Wisconsin-Madison, Madison, WI, USA.,Department of Biomedical Engineering, University of Wisconsin-Madison, Madison, WI, USA
| | - Daniel Consigny
- Department of Radiology, University of Wisconsin-Madison, Madison, WI, USA
| | - Lorenz Leitner
- Department of Neuro-Urology, Balgrist University Hospital, Zurich, Switzerland
| | - Charles Strother
- Department of Radiology, University of Wisconsin-Madison, Madison, WI, USA
| | - Beverly Aagaard-Kienitz
- Department of Radiology, University of Wisconsin-Madison, Madison, WI, USA.,Department of Neurological Surgery, University of Wisconsin-Madison, Madison, WI, USA
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Velz J, Esposito G, Wegener S, Kulcsar Z, Luft A, Regli L. [Diagnostic and Therapeutic Management of Carotid Artery Disease]. PRAXIS 2020; 109:705-723. [PMID: 32635848 DOI: 10.1024/1661-8157/a003475] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/11/2023]
Abstract
Diagnostic and Therapeutic Management of Carotid Artery Disease Abstract. A quarter of all ischemic strokes is caused by atherosclerotic obliterations of the extra- and intracranial brain-supplying vessels. The prevalence of atherosclerotic extracranial carotid stenosis rises up to 6-15 % from the age of 65. The risk of stroke in symptomatic carotid stenosis, i.e. after stroke or transient ischemic attack (TIA), is very high at 25 % within 14 days. Conservative therapy is the cornerstone of treatment by controlling the risk factors, treatment with platelet aggregation inhibitors and antihypertensive and lipid-lowering medication. Carotid endarterectomy (CEA) is the first line treatment for symptomatic patients with a >50 % and asymptomatic patients with a >60 % carotid stenosis. In order to ensure the best possible treatment of patients with asymptomatic and symptomatic carotid stenosis, interdisciplinary cooperation in diagnostics, therapy and aftercare in a neuromedical centre of maximum care is necessary.
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Affiliation(s)
- Julia Velz
- Klinik für Neurochirurgie, Klinisches Neurozentrum, Universitätsspital Zürich
- Universität Zürich
| | - Giuseppe Esposito
- Klinik für Neurochirurgie, Klinisches Neurozentrum, Universitätsspital Zürich
- Universität Zürich
| | - Susanne Wegener
- Universität Zürich
- Klinik für Neurologie, Klinisches Neurozentrum, Universitätsspital Zürich
| | - Zsolt Kulcsar
- Universität Zürich
- Klinik für Neuroradiologie, Klinisches Neurozentrum, Universitätsspital Zürich
| | - Andreas Luft
- Universität Zürich
- Klinik für Neurologie, Klinisches Neurozentrum, Universitätsspital Zürich
- Cereneo Zentrum für Neurologie und Rehabilitation, Vitznau
| | - Luca Regli
- Klinik für Neurochirurgie, Klinisches Neurozentrum, Universitätsspital Zürich
- Universität Zürich
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Aboyans V, Ricco JB, Bartelink MLEL, Björck M, Brodmann M, Cohnert T, Collet JP, Czerny M, De Carlo M, Debus S, Espinola-Klein C, Kahan T, Kownator S, Mazzolai L, Naylor AR, Roffi M, Röther J, Sprynger M, Tendera M, Tepe G, Venermo M, Vlachopoulos C, Desormais I. 2017 ESC Guidelines on the Diagnosis and Treatment of Peripheral Arterial Diseases, in collaboration with the European Society for Vascular Surgery (ESVS): Document covering atherosclerotic disease of extracranial carotid and vertebral, mesenteric, renal, upper and lower extremity arteriesEndorsed by: the European Stroke Organization (ESO)The Task Force for the Diagnosis and Treatment of Peripheral Arterial Diseases of the European Society of Cardiology (ESC) and of the European Society for Vascular Surgery (ESVS). Eur Heart J 2019; 39:763-816. [PMID: 28886620 DOI: 10.1093/eurheartj/ehx095] [Citation(s) in RCA: 2015] [Impact Index Per Article: 403.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
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13
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Koh LB, Zuo K, Kumar GP, Ding X, Leo HL, Cui F, Charles CJ, Yang YY, Yim EKF, Ho P. Optimization of a Novel Preferential Covered Stent through Bench Experiments and in Vitro Platelet Activation Studies. ACS Biomater Sci Eng 2019; 5:6216-6230. [PMID: 33405529 DOI: 10.1021/acsbiomaterials.9b00763] [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: 11/30/2022]
Abstract
Bare metal stenting (BMS) does not adequately address the atheroembolic characteristic of carotid artery stenosis. While simple covered stents (CS) may prevent dislodged fragments of the atherosclerotic plaque from entering the blood stream, they also block blood flow into the major branches of the artery alongside the lesion, which is not desirable. Preferential covered stents (PCS) behave as a covered stent in a tubular part of a vessel but maintain side-branch flow over the bifurcation region by means of slits in the membrane. Stent design, membrane material, and slits configuration are the three main components contributing to stent performance. Optimization of PCS designs was conducted and tested. METHODS A newly designed BMS was developed and compared to a commercially available peripheral stent. Two materials (expanded poly(tetrafluoroethylene)) and silicone polyurethane co-polymers (Elast-eon E2A) were used as stent coverings with slits applied using various cutting methods to form the PCS. These PCS samples were tested for physical resilience, flexibility, ability to preserve side-branch flow, slit edge roughness, and platelet activation. RESULTS Fabrication of E2A-coated stents required pretreatment of the stent with poly(ethylene glycol) to achieve firm attachment. The newly designed BMS with nine crowns design and larger cell size showed higher flexibility than commercially available stents. A combination of a larger stent cell size, E2A membrane coating, and three slits per stent cell unit configuration resulted in preserved side-branch flow similar to physiological conditions in the flow experiment. Slit edge roughness changed with different cutting methods and laser machine cutting parameters. In vitro studies showed platelet activation was minimal with lower slit edge roughness samples. CONCLUSION An optimized PCS prototype was developed consisting of a newly designed stent, E2A membrane, and a three-slit pattern created by specific femtosecond laser cutting.
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Affiliation(s)
| | | | | | | | | | | | | | | | - Evelyn K F Yim
- Department of Chemical Engineering, University of Waterloo, Ontario, Canada
| | - Pei Ho
- Department of Cardiac, Thoracic & Vascular Surgery, National University Health System, Singapore
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Texakalidis P, Chaitidis N, Giannopoulos S, Giannopoulos S, Machinis T, Jabbour P, Rivet D, Reavey-Cantwell J, Rangel-Castilla L. Carotid Revascularization in Older Adults: A Systematic Review and Meta-Analysis. World Neurosurg 2019; 126:656-663.e1. [DOI: 10.1016/j.wneu.2019.02.030] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2018] [Revised: 02/04/2019] [Accepted: 02/06/2019] [Indexed: 11/24/2022]
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Beloiartsev DF. [Some comments on the 2017 European Guidelines on treatment of atherosclerotic lesions of brachiocephalic arteries]. ANGIOLOGII︠A︡ I SOSUDISTAI︠A︡ KHIRURGII︠A︡ = ANGIOLOGY AND VASCULAR SURGERY 2019; 25:109-114. [PMID: 30994616 DOI: 10.33529/angio2019115] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
Analysed herein are the indications for primary interventions in patients with atherosclerotic lesions of internal carotid arteries according to the recommendations laid down in the 2017 Guidelines of the European Society for Vascular Surgery.
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Affiliation(s)
- D F Beloiartsev
- Vascular Surgery Department, National Medical Research Centre of Surgery named after A.V. Vishnevsky under the RF Ministry of Public Health, Moscow, Russia
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16
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Texakalidis P, Giannopoulos S, Kokkinidis DG, Karasavvidis T, Rangel-Castilla L, Reavey-Cantwell J. Carotid Artery Endarterectomy Versus Carotid Artery Stenting for Patients with Contralateral Carotid Occlusion: A Systematic Review and Meta-Analysis. World Neurosurg 2018; 120:563-571.e3. [PMID: 30189300 DOI: 10.1016/j.wneu.2018.08.183] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2018] [Revised: 08/22/2018] [Accepted: 08/23/2018] [Indexed: 11/24/2022]
Abstract
BACKGROUND Results from studies investigating the effect of contralateral carotid occlusion (CCO) in patients with carotid artery stenosis undergoing carotid artery endarterectomy (CEA) or carotid artery stenting (CAS) are variable in the literature. We sought to determine whether CEA or CAS is the optimal revascularization approach for patients with CCO. METHODS This meta-analysis was performed according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. A random effects model meta-analysis was conducted, and the I2 statistic was used to assess for heterogeneity. Subgroup and sensitivity analyses were performed as needed. RESULTS Five retrospective observational cohort studies comprising 6346 patients were included. Patients in the CEA group had a significantly lower risk of 30-day periprocedural mortality (odds ratio, 0.46; 95% confidence interval, 0.30-0.71; I2 = 0%). However, no significant differences were identified in terms of stroke, myocardial infarction (MI), and major adverse cardiovascular events (MACEs) between the 2 groups. Subgroup analyses of symptomatic and asymptomatic patients did not yield significant differences for stroke, MI, and death. CONCLUSIONS Patients with CCO can safely undergo both CAS and CEA with similar risks of stroke, MI, and MACE. However, patients treated with CEA have a lower risk of 30-day periprocedural mortality. Future studies can help further clarify the ideal approach for these patients.
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Affiliation(s)
- Pavlos Texakalidis
- Department of Neurologic Surgery, Emory University School of Medicine, Atlanta, Georgia, USA.
| | | | - Damianos G Kokkinidis
- Department of Medicine, Jacobi Medical Center, Albert Einstein College of Medicine, Bronx, New York, USA
| | | | | | - John Reavey-Cantwell
- Department of Neurologic Surgery, Virginia Commonwealth University Hospital, Richmond, Virginia, USA
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Texakalidis P, Giannopoulos S, Jonnalagadda AK, Chitale RV, Jabbour P, Armstrong EJ, Schwartz GG, Kokkinidis DG. Preoperative Use of Statins in Carotid Artery Stenting: A Systematic Review and Meta-analysis. J Endovasc Ther 2018; 25:624-631. [PMID: 30101624 DOI: 10.1177/1526602818794030] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
PURPOSE To determine through meta-analysis whether administration of statins before carotid artery stenting (CAS) is associated with fewer periprocedural adverse events. METHODS All randomized and observational English-language studies of periprocedural statin administration prior to CAS that reported the outcomes of interest (stroke, transient ischemic attack, myocardial infarction, and death at 30 days) were included in a random-effects meta-analysis. The I2 statistic was used to assess heterogeneity. Meta-regression analysis was performed to determine whether an association of statin treatment with risk of outcome events was influenced by other trial-level baseline characteristics of statin-treated and untreated patients. RESULTS Eleven studies comprising 4088 patients were included. Patients who received statins prior to CAS had a significantly lower risk of stroke (OR 0.39, 95% CI 0.27 to 0.58, p<0.01; I2=0%) and death (OR 0.30, 95% CI 0.10 to 0.96, p=0.042; I2=0%). Statin use was not associated with a reduced risk of transient ischemic attack or myocardial infarction. In meta-regression analysis, other trial-level baseline characteristics had no significant influence on the association of statin treatment with death or stroke. CONCLUSION Statin therapy prior to CAS is associated with decreased risk of perioperative stroke and death without any effect on the rates of transient ischemic attack or myocardial infarction.
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Affiliation(s)
| | | | - Anil K Jonnalagadda
- 3 Division of Cardiology, Medstar Washington Hospital Center, Washington, DC, USA
| | - Rohan V Chitale
- 4 Department of Neurosurgery, Vanderbilt University Hospital, Nashville, TN, USA
| | - Pascal Jabbour
- 5 Department of Neurosurgery, Thomas Jefferson University, Philadelphia, PA, USA
| | - Ehrin J Armstrong
- 6 Division of Cardiology, Denver VA Medical Center, University of Colorado, Denver, CO, USA
| | - Gregory G Schwartz
- 6 Division of Cardiology, Denver VA Medical Center, University of Colorado, Denver, CO, USA
| | - Damianos G Kokkinidis
- 7 Department of Medicine, Jacobi Medical Center, Albert Einstein College of Medicine, Bronx, NY, USA
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18
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Outcome of Carotid Artery Endarterectomy in Statin Users versus Statin-Naïve Patients: A Systematic Review and Meta-Analysis. World Neurosurg 2018; 116:444-450.e1. [DOI: 10.1016/j.wneu.2018.05.160] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2018] [Revised: 05/21/2018] [Accepted: 05/23/2018] [Indexed: 11/22/2022]
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Texakalidis P, Giannopoulos S, Kokkinidis DG, Lanzino G. Effect of Open- vs Closed-Cell Stent Design on Periprocedural Outcomes and Restenosis After Carotid Artery Stenting: A Systematic Review and Comprehensive Meta-analysis. J Endovasc Ther 2018; 25:523-533. [DOI: 10.1177/1526602818783505] [Citation(s) in RCA: 26] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/30/2023]
Abstract
Purpose:To compare periprocedural complications and in-stent restenosis rates associated with open- vs closed-cell stent designs used in carotid artery stenting (CAS). Methods: A systematic search was conducted to identify all randomized and observational studies published in English up to October 31, 2017, that compared open- vs closed-cell stent designs in CAS. Identified studies were included if they reported the following outcomes: stroke, transient ischemic attack (TIA), myocardial infarction (MI), hemodynamic depression, new ischemic lesions detected on imaging, and death within 30 days, as well as the incidence of in-stent restenosis. A random-effects model meta-analysis was employed. Model results are reported as the odds ratio (OR) and 95% confidence interval (CI). The I2 statistic was used to assess heterogeneity. Results: Thirty-three studies (2 randomized trials) comprising 20, 291 patients (mean age 71.3±3.0 years; 74.6% men) were included. Patients in the open-cell stent group had a statistically significant lower risk of restenosis ⩾40% (OR 0.42, 95% CI 0.19 to 0.92; I2=0%) and ⩾70% (OR 0.23, 95% CI 0.10 to 0.52; I2=0%) at a mean follow-up of 24 months. No statistically significant differences were identified for periprocedural stroke, TIA, new ischemic lesions, MI, hemodynamic depression, or death within 30 days after CAS. Sensitivity analysis of the 2 randomized controlled trials only did not point to any significant differences either. Conclusion: Use of open-cell stent design in CAS is associated with a decreased risk for restenosis when compared to the closed-cell stent, without significant differences in periprocedural outcomes.
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Affiliation(s)
- Pavlos Texakalidis
- Department of Neurologic Surgery, Mayo Clinic, Rochester, MN, USA
- Aristotle University of Thessaloniki, Greece
| | | | - Damianos G. Kokkinidis
- Department of Medicine, Jacobi Medical Center, Albert Einstein College of Medicine, Bronx, NY, USA
| | - Giuseppe Lanzino
- Department of Neurologic Surgery, Mayo Clinic, Rochester, MN, USA
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Dhillon AS, Li S, Lewinger JP, Shavelle DM, Matthews RV, Clavijo LC, Weaver FA, Garg P. Comparison of devices used in carotid artery stenting: A vascular quality initiative analysis of commonly used carotid stents and embolic protection devices. Catheter Cardiovasc Interv 2018; 92:743-749. [DOI: 10.1002/ccd.27646] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/22/2017] [Revised: 03/10/2018] [Accepted: 04/02/2018] [Indexed: 11/12/2022]
Affiliation(s)
- Ashwat S. Dhillon
- Division of Cardiovascular Medicine; University of Southern California Keck School of Medicine; Los Angeles California
| | - Sisi Li
- Department of Biostatistics; University of Southern California; Los Angeles California
| | - Juan Pablo Lewinger
- Department of Biostatistics; University of Southern California; Los Angeles California
| | - David M. Shavelle
- Division of Cardiovascular Medicine; University of Southern California Keck School of Medicine; Los Angeles California
| | - Ray V. Matthews
- Division of Cardiovascular Medicine; University of Southern California Keck School of Medicine; Los Angeles California
| | - Leonardo C. Clavijo
- Division of Cardiovascular Medicine; University of Southern California Keck School of Medicine; Los Angeles California
| | - Fred A. Weaver
- Division of Vascular Surgery; University of Southern California Keck School of Medicine; Los Angeles California
| | - Parveen Garg
- Division of Cardiovascular Medicine; University of Southern California Keck School of Medicine; Los Angeles California
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21
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Carotid Artery Endarterectomy versus Carotid Artery Stenting for Restenosis After Carotid Artery Endarterectomy: A Systematic Review and Meta-Analysis. World Neurosurg 2018; 115:421-429.e1. [DOI: 10.1016/j.wneu.2018.02.196] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2017] [Revised: 02/25/2018] [Accepted: 02/28/2018] [Indexed: 11/24/2022]
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Tsivgoulis G, Safouris A, Kim DE, Alexandrov AV. Recent Advances in Primary and Secondary Prevention of Atherosclerotic Stroke. J Stroke 2018; 20:145-166. [PMID: 29886715 PMCID: PMC6007302 DOI: 10.5853/jos.2018.00773] [Citation(s) in RCA: 26] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2018] [Revised: 05/13/2018] [Accepted: 05/23/2018] [Indexed: 01/09/2023] Open
Abstract
Atherosclerosis is a major cause of ischemic stroke that can be effectively prevented with appropriate lifestyle modifications and control of cardiovascular risk factors. Medical advances in recent years along with aggressive cardiovascular risk factor modifications have resulted in decreased recurrence rates of atherosclerotic stroke. Non-statin lipid-lowering molecules have recently shown clinical benefit and are recommended for very high-risk patients to reduce their risk of stroke. Aggressive hypertension treatment is crucial to reduce atherosclerotic stroke risk. Advances in antithrombotic treatments include combinations of antiplatelets and new antiplatelet agents in the acute phase post-stroke, which carries a high risk of recurrence. Intensive medical treatment has also limited the indications for carotid interventions, especially for asymptomatic disease. Intracranial atherosclerotic disease may provoke stroke through various mechanisms; it is increasingly recognized as a cause of ischemic stroke with advanced imaging and is best managed with lifestyle modifications and medical therapy. The diagnostic search for the vulnerable culprit atherosclerotic plaque is an area of intense research, from the level of the intracranial arteries to that of the aortic arch. Ultrasonography and novel magnetic resonance imaging techniques (high-resolution vessel-wall imaging) may assist in the identification of vulnerable atherosclerotic plaques as the underlying cause in cryptogenic or misdiagnosed non-atherosclerotic ischemic stroke. Vertebrobasilar atherosclerotic disease is less common than carotid artery disease; thus, high-quality data on effective prevention strategies are scarcer. However, aggressive medical treatment is also the gold standard to reduce cerebrovascular disease located in posterior circulation.
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Affiliation(s)
- Georgios Tsivgoulis
- Second Department of Neurology, “Attikon” University Hospital, National and Kapodistrian University of Athens School of Medicine, Athens, Greece
- Department of Neurology, The University of Tennessee Health Science Center, Memphis, TN, USA
| | - Apostolos Safouris
- Second Department of Neurology, “Attikon” University Hospital, National and Kapodistrian University of Athens School of Medicine, Athens, Greece
- Stroke Unit, Metropolitan Hospital, Pireus, Greece
| | - Dong-Eog Kim
- Department of Neurology, Dongguk University Ilsan Hospital, Dongguk University College of Medicine, Goyang, Korea
| | - Andrei V. Alexandrov
- Department of Neurology, The University of Tennessee Health Science Center, Memphis, TN, USA
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Balucani C, Arnedo V, Weedon J, Leys D, Mas JL, Brown M, Grotta JC, Gonzales NR, Hacke W, Brott T, Levine SR. Transatlantic Differences in Management of Carotid Stenosis: BRIDGing the Gap in StrokE Management (BRIDGE) Project. Neurohospitalist 2018; 8:113-123. [PMID: 29977441 DOI: 10.1177/1941874417747772] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Background and Purpose Management of carotid stenosis remains controversial despite several trials evaluating carotid endarterectomy (CEA) and carotid angioplasty/stenting (CAS). We compared attitudes in the management of carotid stenosis between selected experts within Europe and North America. Methods A 3-phase Delphi survey was e-mailed to select stroke experts from Europe (n = 390) and North America (n = 289). Those completing the initial survey were shown all responses after each survey round. Consensus was defined as ≥80% agreement. Results For phases 1, 2, and 3, response rates were 32%, 62%, and 73%, respectively. Overall, 100 (15%) of 679 participated in all 3 phases, 19% Europeans versus 9% North Americans (P = .0007). The European group reached consensus in 6 of 15 statements; The North American group reached consensus in 4 of 15. Ninety percentage of Europeans versus 70% of North Americans (P = .017) stated CEA is superior to CAS for symptomatic carotid stenosis. This difference was not significant in the final model (adjusted odds ratio: 3.72 [95% confidence interval: 0.95-14.5]). Sixty-nine percentage of North Americans agreed there is a stronger indication for CAS over CEA in patients younger than 65 years for symptomatic carotid stenosis, whereas 55% of Europeans (P = .023) disagreed. For asymptomatic carotid stenosis, when asked how likely they would recommend CAS, 62% North Americans said "sometimes" versus 60% of Europeans said "never" (P = .06). Conclusion The majority of North American and European respondents did not consider the 2 procedures equivalent and seemed to indicate that CEA was preferred for the management of carotid stenosis. These findings need to be further explored to help establish evidence-based guidelines.
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Affiliation(s)
- Clotilde Balucani
- The Department of Neurology and Stroke Center, Downstate Medical Center, The State University of New York, SUNY, Brooklyn, New York, NY, USA
| | - Vanessa Arnedo
- The Department of Neurology and Stroke Center, Downstate Medical Center, The State University of New York, SUNY, Brooklyn, New York, NY, USA
| | - Jeremy Weedon
- The Department of Public Health, SUNY Downstate Medical Center, Brooklyn, New York, NY, USA
| | - Didier Leys
- The Department of Neurology, Lille University Hospital, Lille, France
| | - Jean-Louis Mas
- Neurology Department and Stroke Unit, INSERM UMR S 894, Sainte-Anne Hospital, Paris Descartes University, Paris, France
| | - Martin Brown
- The Stroke Research Group, UCL Institute of Neurology, London, UK
| | - James C Grotta
- Stroke Research, Memorial Hermann Hospital, Houston, TX, USA
| | - Nicole R Gonzales
- The Department of Neurology, UTHealth Medical School, Houston, TX, USA
| | - Werner Hacke
- The Department of Neurology, Heidelberg, Germany
| | - Thomas Brott
- The Department of Neurology, The Mayo Clinic, Jacksonville, FL, USA
| | - Steven R Levine
- The Department of Neurology and Stroke Center, Downstate Medical Center, The State University of New York, SUNY, Brooklyn, New York, NY, USA
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Naylor AR, Ricco JB, de Borst GJ, Debus S, de Haro J, Halliday A, Hamilton G, Kakisis J, Kakkos S, Lepidi S, Markus HS, McCabe DJ, Roy J, Sillesen H, van den Berg JC, Vermassen F, Kolh P, Chakfe N, Hinchliffe RJ, Koncar I, Lindholt JS, Vega de Ceniga M, Verzini F, Archie J, Bellmunt S, Chaudhuri A, Koelemay M, Lindahl AK, Padberg F, Venermo M. Editor's Choice - Management of Atherosclerotic Carotid and Vertebral Artery Disease: 2017 Clinical Practice Guidelines of the European Society for Vascular Surgery (ESVS). Eur J Vasc Endovasc Surg 2018; 55:3-81. [PMID: 28851594 DOI: 10.1016/j.ejvs.2017.06.021] [Citation(s) in RCA: 803] [Impact Index Per Article: 133.8] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
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Qian C, Yang X. An integrated method for atherosclerotic carotid plaque segmentation in ultrasound image. COMPUTER METHODS AND PROGRAMS IN BIOMEDICINE 2018; 153:19-32. [PMID: 29157451 DOI: 10.1016/j.cmpb.2017.10.002] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/10/2017] [Revised: 09/16/2017] [Accepted: 10/02/2017] [Indexed: 06/07/2023]
Abstract
BACKGROUND AND OBJECTIVE Carotid artery atherosclerosis is an important cause of stroke. Ultrasound imaging has been widely used in the diagnosis of atherosclerosis. Therefore, segmenting atherosclerotic carotid plaque in ultrasound image is an important task. Accurate plaque segmentation is helpful for the measurement of carotid plaque burden. In this paper, we propose and evaluate a novel learning-based integrated framework for plaque segmentation. METHODS In our study, four different classification algorithms, along with the auto-context iterative algorithm, were employed to effectively integrate features from ultrasound images and later also the iteratively estimated and refined probability maps together for pixel-wise classification. The four classification algorithms were support vector machine with linear kernel, support vector machine with radial basis function kernel, AdaBoost and random forest. The plaque segmentation was implemented in the generated probability map. The performance of the four different learning-based plaque segmentation methods was tested on 29 B-mode ultrasound images. The evaluation indices for our proposed methods were consisted of sensitivity, specificity, Dice similarity coefficient, overlap index, error of area, absolute error of area, point-to-point distance, and Hausdorff point-to-point distance, along with the area under the ROC curve. RESULTS The segmentation method integrated the random forest and an auto-context model obtained the best results (sensitivity 80.4 ± 8.4%, specificity 96.5 ± 2.0%, Dice similarity coefficient 81.0 ± 4.1%, overlap index 68.3 ± 5.8%, error of area -1.02 ± 18.3%, absolute error of area 14.7 ± 10.9%, point-to-point distance 0.34 ± 0.10 mm, Hausdorff point-to-point distance 1.75 ± 1.02 mm, and area under the ROC curve 0.897), which were almost the best, compared with that from the existed methods. CONCLUSIONS Our proposed learning-based integrated framework investigated in this study could be useful for atherosclerotic carotid plaque segmentation, which will be helpful for the measurement of carotid plaque burden.
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Affiliation(s)
- Chunjun Qian
- School of Science, Nanjing University of Science and Technology, Jiangsu, China.
| | - Xiaoping Yang
- School of Science, Nanjing University of Science and Technology, Jiangsu, China; Department of Mathematics, Nanjing University, Jiangsu, China
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Mazzaccaro D, Stegher S, Muzzarelli L, Malacrida G, Nano G. The Carotid Wallstent for the endovascular treatment of carotid artery stenosis. INTERDISCIPLINARY NEUROSURGERY 2017. [DOI: 10.1016/j.inat.2017.08.002] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022] Open
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Long-Term Outcome After Carotid Endarterectomy in Patients with Ischemic Heart Disease. World Neurosurg 2017; 110:e806-e814. [PMID: 29180080 DOI: 10.1016/j.wneu.2017.11.092] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2017] [Revised: 11/16/2017] [Accepted: 11/18/2017] [Indexed: 12/17/2022]
Abstract
BACKGROUND The long-term outcome after carotid endarterectomy (CEA) is determined by many confounding factors. Ischemic heart disease (IHD) is linked to atherosclerotic stroke, and it is an important cause of death during the perioperative and follow-up periods after CEA. We aimed to investigate mortality and long-term major adverse cardiovascular events (MACEs) in patients with IHD compared with patients who do not have IHD. METHODS We consecutively enrolled 229 patients who underwent CEA procedures from 2000 to 2011. Of these patients, 45 had known or probable IHD defined by history or medical record of myocardial infarction, stable/unstable angina, previous coronary revascularization such as percutaneous coronary intervention or coronary artery bypass graft, or positive stress test. Long-term outcome was identified by using death certificates from the Korean National Statistical Office and telephone interviews by June 2013. We investigated predictors of early (≤30 days) and long-term mortality and MACEs (stroke, myocardial infarction, and death). RESULTS Mean follow-up period was 49 months. Cox proportional analysis adjusted for potent predictors revealed symptomatic stenosis (hazard ratio, 1.72; 95% confidence interval, 1.02-2.88; P = 0.042) and presence of IHD (hazard ratio, 1.93; 95% confidence interval, 1.09-3.42; P = 0.025) as significant predictors of long-term MACEs. Kaplan-Meier analysis showed a significantly lower rate of survival (P = 0.030) and MACE-free survival (P = 0.003) in the IHD group. CONCLUSIONS In this study, a poor long-term outcome was observed in patients with IHD and symptomatic stenosis but not in patients with conventional high-risk factors for surgery. Therefore, appropriate evaluation and treatment of IHD before and after CEA might be helpful for better outcome.
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Editor's Choice - Comparison of Early Outcomes and Restenosis Rate Between Carotid Endarterectomy and Carotid Artery Stenting Using Propensity Score Matching Analysis. Eur J Vasc Endovasc Surg 2017; 54:573-578. [PMID: 28893482 DOI: 10.1016/j.ejvs.2017.08.006] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2017] [Accepted: 08/06/2017] [Indexed: 11/18/2022]
Abstract
OBJECTIVE/BACKGROUND Despite randomised evidence, the debate continues about the preferred treatment strategy for carotid stenosis in routine clinical practice. The aim of this study was to compare early outcomes and restenosis rates after carotid endarterectomy (CEA) and carotid stenting (CAS) in unselected patients using propensity score matching (PSM). METHODS The 30 day incidence of major adverse clinical events (MACE; defined as stroke, transient ischaemic attack, myocardial infarction, or death) and procedure related complications, as well as restenosis rates during follow-up were compared between unselected patients undergoing CEA or CAS between January 2002 and December 2015 at a single institution. PSM was used to balance the following factors between the CEA and CAS cohorts: age, sex, hypertension, diabetes, dyslipidaemia, smoking, atrial fibrillation, previous percutaneous coronary intervention or coronary artery bypass grafting, valvular heart disease, contralateral carotid occlusion, degree of carotid stenosis, and symptomatic status. Statistical comparisons of outcomes were based on logistic regression analysis and log rank test. RESULTS Of 1184 patients (654 CEA and 530 CAS), 452 PSM pairs of CEA and CAS patients were created. The CAS group showed a relatively higher 30 day incidence of MACE (7.5% vs. 2.4%; odds ratio [OR] 3.261, 95% confidence interval [CI] 1.634-6.509; p = .001) but a lower incidence of procedure related complications (1.5% vs. 5.3%; OR 0.199, 95% CI 0.075-0.528; p = .001). During a mean follow-up of 49.1 months (range 1-180 months), restenosis rates were higher after CAS than after CEA (1.5% vs. 1.0% at 12 months and 5.4% vs. 1.2% at 24 months, respectively; p = .008). CONCLUSION This PSM based observation reconfirmed previous trial results in both asymptomatic and symptomatic patients with carotid artery stenosis in routine clinical practice: CEA showed lower 30 day MACE and mid-term restenosis rates than CAS.
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Cho SM, Deshpande A, Pasupuleti V, Hernandez AV, Uchino K. Radiographic and symptomatic brain ischemia in CEA and CAS: A systematic review and meta-analysis. Neurology 2017; 89:1977-1984. [PMID: 29021357 DOI: 10.1212/wnl.0000000000004626] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2017] [Accepted: 08/21/2017] [Indexed: 01/17/2023] Open
Abstract
OBJECTIVE In a systematic review, we compared ratio of new periprocedural radiographic brain ischemia (RBI) to the number of strokes and TIAs among patients undergoing carotid endarterectomy (CEA) and carotid artery stenting (CAS). METHODS We searched 5 databases for entries related to brain ischemia in CEA or CAS from inception through September 2015. We included articles with CEA or CAS and systematic performance of preprocedural and postprocedural brain MRI and reporting of RBI and stroke incidence. We calculated a symptomatic risk ratio of number of strokes and TIAs to RBI. Random effects models were used. RESULTS Fifty-nine studies (5,431 participants) met the inclusion criteria. There were 22 cohorts in CEA, 34 in CAS with distal protection, 8 in CAS with proximal protection, 9 in CAS without protection, and 9 in CAS with unspecified devices. Overall, 30.7% (95% confidence interval [CI] 26.6%-34.7%) had RBI, while 3.2% (95% CI 2.6%-3.8%) had clinical strokes or TIAs, with a stroke and TIA to RBI weighted ratio of 0.18 (95% CI 0.15-0.22). CEA had lower incidence of RBI compared to CAS (13.0% vs 37.4%) and also lower number of strokes and TIAs (1.8% vs 4.1%). The stroke and TIA to RBI ratio did not differ across 5 different types of carotid interventions (p = 0.58). CONCLUSIONS One in 5 persons with periprocedural radiographic brain ischemia during CEA and CAS had strokes and TIAs. The stable ratio of stroke and TIA to radiographic ischemia suggests that MRI ischemia could serve as a surrogate measure of periprocedural risk.
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Affiliation(s)
- Sung-Min Cho
- From the Cerebrovascular Center, Neurological Institute (S.-M.C., K.U.), and Medicine Institute (A.D.), Cleveland Clinic, Cleveland, OH; Case Western Reserve University (V.P.), Cleveland, OH; School of Medicine (A.V.H.), Universidad Peruana de Ciencias Aplicadas (UPC), Lima, Peru; and University of Connecticut/Hartford Hospital Evidence-Based Practice Center (A.V.H.)
| | - Abhishek Deshpande
- From the Cerebrovascular Center, Neurological Institute (S.-M.C., K.U.), and Medicine Institute (A.D.), Cleveland Clinic, Cleveland, OH; Case Western Reserve University (V.P.), Cleveland, OH; School of Medicine (A.V.H.), Universidad Peruana de Ciencias Aplicadas (UPC), Lima, Peru; and University of Connecticut/Hartford Hospital Evidence-Based Practice Center (A.V.H.)
| | - Vinay Pasupuleti
- From the Cerebrovascular Center, Neurological Institute (S.-M.C., K.U.), and Medicine Institute (A.D.), Cleveland Clinic, Cleveland, OH; Case Western Reserve University (V.P.), Cleveland, OH; School of Medicine (A.V.H.), Universidad Peruana de Ciencias Aplicadas (UPC), Lima, Peru; and University of Connecticut/Hartford Hospital Evidence-Based Practice Center (A.V.H.)
| | - Adrian V Hernandez
- From the Cerebrovascular Center, Neurological Institute (S.-M.C., K.U.), and Medicine Institute (A.D.), Cleveland Clinic, Cleveland, OH; Case Western Reserve University (V.P.), Cleveland, OH; School of Medicine (A.V.H.), Universidad Peruana de Ciencias Aplicadas (UPC), Lima, Peru; and University of Connecticut/Hartford Hospital Evidence-Based Practice Center (A.V.H.)
| | - Ken Uchino
- From the Cerebrovascular Center, Neurological Institute (S.-M.C., K.U.), and Medicine Institute (A.D.), Cleveland Clinic, Cleveland, OH; Case Western Reserve University (V.P.), Cleveland, OH; School of Medicine (A.V.H.), Universidad Peruana de Ciencias Aplicadas (UPC), Lima, Peru; and University of Connecticut/Hartford Hospital Evidence-Based Practice Center (A.V.H.).
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Ledwoch J, Staubach S, Segerer M, Strohm H, Mudra H. Carotid artery stenting in clinical practice depending on patient age. Catheter Cardiovasc Interv 2017; 90:451-460. [PMID: 28557365 DOI: 10.1002/ccd.27127] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/18/2017] [Revised: 03/28/2017] [Accepted: 04/23/2017] [Indexed: 11/07/2022]
Abstract
BACKGROUND The age-dependent outcome of carotid artery stenting (CAS) outside of randomized controlled trials is largely unknown. Therefore, we assessed acute and long-term results of CAS in a single-center real-world registry. METHODS All symptomatic and asymptomatic patients who consecutively underwent CAS were enrolled into the present analysis. The population was divided into three groups dependent on patients' age (<65, 65-74, and ≥75 years). RESULTS Between 1999 and 2015, a total of 878 patients (24%, <65 years; 40%, 65-74 years; and 36%, ≥75 years) underwent CAS. The rate of the primary endpoint (30-day composite of death, stroke, and myocardial infarction [MACCE] plus long-term ipsilateral stroke) was higher in patients aged ≥75 years compared to the middle-age group (hazard ratio [HR] 2.30, confidence interval [CI] 1.22-4.36; P = 0.001). Similarly, the rate of the stroke endpoint (30-day any stroke plus long-term ipsilateral stroke) was higher in patients aged ≥75 years compared to patients aged 65-74 years (HR 2.03, CI 1.01-4.10; P = 0.04). There was no significant age-dependent difference of the primary endpoint and stroke endpoint in the subset of asymptomatic patients. Furthermore, age had no influence on the risk of stroke beyond the periprocedural period. CONCLUSIONS Patients aged ≥75 years had poorer outcomes after CAS compared to younger patients. Importantly, age did not influence the outcome in asymptomatic patients and the risk for stroke beyond the periprocedural period.
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Affiliation(s)
- Jakob Ledwoch
- Klinikum Neuperlach, Klinik für Kardiologie, Pneumologie und Internistische Intensivmedizin, Städtisches Klinikum München GmbH, Oskar-Maria-Graf-Ring 51, Munich, 81737, Germany
| | - Stephan Staubach
- Klinikum Neuperlach, Klinik für Kardiologie, Pneumologie und Internistische Intensivmedizin, Städtisches Klinikum München GmbH, Oskar-Maria-Graf-Ring 51, Munich, 81737, Germany
| | - Manuela Segerer
- Klinikum Neuperlach, Klinik für Kardiologie, Pneumologie und Internistische Intensivmedizin, Städtisches Klinikum München GmbH, Oskar-Maria-Graf-Ring 51, Munich, 81737, Germany
| | - Henning Strohm
- Klinikum Neuperlach, Klinik für Kardiologie, Pneumologie und Internistische Intensivmedizin, Städtisches Klinikum München GmbH, Oskar-Maria-Graf-Ring 51, Munich, 81737, Germany
| | - Harald Mudra
- Klinikum Neuperlach, Klinik für Kardiologie, Pneumologie und Internistische Intensivmedizin, Städtisches Klinikum München GmbH, Oskar-Maria-Graf-Ring 51, Munich, 81737, Germany
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de Vries EE, Baldew VGM, den Ruijter HM, de Borst GJ. Meta-analysis of the costs of carotid artery stenting and carotid endarterectomy. Br J Surg 2017; 104:1284-1292. [PMID: 28783225 DOI: 10.1002/bjs.10649] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2017] [Revised: 06/02/2017] [Accepted: 06/19/2017] [Indexed: 11/07/2022]
Abstract
BACKGROUND Carotid artery stenting (CAS) is currently associated with an increased risk of 30-day stroke compared with carotid endarterectomy (CEA), whereas both interventions seem equally durable beyond the periprocedural period. Although the clinical outcomes continue to be scrutinized, there are few data summarizing the costs of both techniques. METHODS A systematic search was conducted in MEDLINE, Embase and Cochrane databases in August 2016 identifying articles comparing the costs or cost-effectiveness of CAS and CEA in patients with carotid artery stenosis. Combined overall effect sizes were calculated using random-effects models. The in-hospital costs were specified to gain insight into the main heads of expenditure associated with both procedures. RESULTS The literature search identified 617 unique articles, of which five RCTs and 12 cohort studies were eligible for analysis. Costs of the index hospital admission were similar for CAS and CEA. Costs of the procedure itself were 51 per cent higher for CAS, mainly driven by the higher costs of devices and supplies, but were balanced by higher postprocedural costs of CEA. Long-term cost analysis revealed no difference in costs or quality of life after 1 year of follow-up. CONCLUSION Hospitalization and long-term costs of CAS and CEA appear similar. Economic considerations should not influence the choice of stenting or surgery in patients with carotid artery stenosis being considered for revascularization.
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Affiliation(s)
- E E de Vries
- Department of Vascular Surgery, University Medical Centre Utrecht, Utrecht, The Netherlands
| | - V G M Baldew
- Department of Vascular Surgery, University Medical Centre Utrecht, Utrecht, The Netherlands
| | - H M den Ruijter
- Experimental Cardiology Laboratory, University Medical Centre Utrecht, Utrecht, The Netherlands
| | - G J de Borst
- Department of Vascular Surgery, University Medical Centre Utrecht, Utrecht, The Netherlands
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Editor's Choice - 2017 ESC Guidelines on the Diagnosis and Treatment of Peripheral Arterial Diseases, in collaboration with the European Society for Vascular Surgery (ESVS). Eur J Vasc Endovasc Surg 2017; 55:305-368. [PMID: 28851596 DOI: 10.1016/j.ejvs.2017.07.018] [Citation(s) in RCA: 665] [Impact Index Per Article: 95.0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
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Galyfos G, Sianou A, Filis K. Cerebral hyperperfusion syndrome and intracranial hemorrhage after carotid endarterectomy or carotid stenting: A meta-analysis. J Neurol Sci 2017; 381:74-82. [PMID: 28991720 DOI: 10.1016/j.jns.2017.08.020] [Citation(s) in RCA: 38] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2017] [Revised: 08/03/2017] [Accepted: 08/15/2017] [Indexed: 11/18/2022]
Abstract
INTRODUCTION Cerebral hyperperfusion syndrome (CHS) and intracranial hemorrhage (ICH) after carotid revascularization have been associated with significant morbidity and mortality, although pooled data comparing these outcomes between open and endovascular treatment are lacking. Aim of this meta-analysis is to compare CHS and ICH risk between carotid endarterectomy (CEA) and carotid angioplasty with stenting (CAS). METHODS A systematic literature review was conducted conforming to established criteria, in order to identify eligible articles published prior to February 2017. Eligible studies compared CHS and/or ICH between patients undergoing CEA and CAS. Other outcomes evaluated in this review included stroke and death due to ICH. Outcome risks are presented as odds ratios (OR) and 95% confidence intervals (CI). RESULTS Overall, 6 studies (5 studies reporting on CHS and 4 studies reporting on ICH) included 236,537 procedures (218,144 CEA; 18,393 CAS) in total. CEA was associated with a higher risk for CHS compared to CAS (pooled OR=1.432 [95% CI=1.078-1901]; P=0.015), although this difference was generated mainly from older studies (prior to 2012). However, no difference was found regarding ICH risk between the two methods (pooled OR=0.544 [95% CI=0.111-2.658]; P=0.452). Regarding stroke incidence, no difference was found between the two methods as well, although this resulted mainly from studies with a higher volume of CAS procedures (pooled OR=0.964 [95% CI=0.741-1.252]; P=0.833). Finally, death rate was significantly higher among patients with ICH compared to patients without ICH (pooled OR=386.977 [95% CI=246.746-606.906]; P<0.0001). Pooled data were not adequate to calculate potential risk factors for CHS/ICH after CEA compared to CAS. CONCLUSIONS CEA seems to be associated with a higher risk for CHS compared to CAS, although this difference was generated mainly from older studies. However, there seems to be no difference regarding ICH risk between the two methods, with ICH being associated with a significantly higher risk for death.
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Affiliation(s)
- George Galyfos
- First Department of Propaedeutic Surgery, University of Athens Medical School, Hippocration Hospital, Athens, Greece.
| | - Argiri Sianou
- Department of Microbiology, University of Athens Medical School, Areteion Hospital, Athens, Greece
| | - Konstantinos Filis
- First Department of Propaedeutic Surgery, University of Athens Medical School, Hippocration Hospital, Athens, Greece
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Setacci C, Mele M, de Donato G, Mazzitelli G, Benevento D, Palasciano G, Setacci F. Device selection for carotid stenting: reviewing the evidence. Expert Rev Cardiovasc Ther 2017; 15:787-796. [PMID: 28777008 DOI: 10.1080/14779072.2017.1364627] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
INTRODUCTION Carotid artery stenting (CAS) has recently changed the status in the treatment of the extracranial carotid atheromasic disease. In recent years, evolution in both stents and protection devices as well as in carotid stenting techniques, has resulted in an important reduction in the rate of stroke in patients undergoing CAS procedures. Areas covered: The purpose of this article is reviewing the literature and summarizing the current evidence of the new available materials to underline the importance of the correct choice of the devices during the procedure. Expert commentary: Certainly a key issue in order to limit the periprocedural events to the lowest possible, is to select the appropriate device for the appropriate patient anatomy and clinical syndrome, the so called 'tailored approach'.
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Affiliation(s)
- Carlo Setacci
- a Department of Vascular and Endovascular Surgery , University of Siena , Siena , Italy
| | - Mariagnese Mele
- a Department of Vascular and Endovascular Surgery , University of Siena , Siena , Italy
| | - Gianmarco de Donato
- a Department of Vascular and Endovascular Surgery , University of Siena , Siena , Italy
| | - Giulia Mazzitelli
- a Department of Vascular and Endovascular Surgery , University of Siena , Siena , Italy
| | - Domenico Benevento
- a Department of Vascular and Endovascular Surgery , University of Siena , Siena , Italy
| | - Giancarlo Palasciano
- a Department of Vascular and Endovascular Surgery , University of Siena , Siena , Italy
| | - Francesco Setacci
- a Department of Vascular and Endovascular Surgery , University of Siena , Siena , Italy
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Dong S, Peng Z, Tao Y, Huo Y, Zhou H. Metabolic syndrome is associated with increased risk of short-term post-procedural complications after carotid artery stenting. Neurol Sci 2017; 38:1933-1939. [DOI: 10.1007/s10072-017-3085-4] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2017] [Accepted: 07/31/2017] [Indexed: 12/30/2022]
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Kakkos SK, Kakisis I, Tsolakis IA, Geroulakos G. Endarterectomy achieves lower stroke and death rates compared with stenting in patients with asymptomatic carotid stenosis. J Vasc Surg 2017; 66:607-617. [PMID: 28735954 DOI: 10.1016/j.jvs.2017.04.053] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2016] [Accepted: 04/10/2017] [Indexed: 11/28/2022]
Abstract
BACKGROUND It is currently unclear if carotid artery stenting (CAS) is as safe as carotid endarterectomy (CEA) for patients with significant asymptomatic stenosis. The aim of our study was to perform a systematic review and meta-analysis of trials comparing CAS with CEA. METHODS On March 17, 2017, a search for randomized controlled trials was performed in MEDLINE and Scopus databases with no time limits. We performed meta-analyses with Peto odds ratios (ORs) and 95% confidence intervals (CIs). Quality of evidence was assessed with the Grading of Recommendations Assessment, Development, and Evaluation method. The primary safety and efficacy outcome measures were stroke or death rate at 30 days and ipsilateral stroke at 1 year (including ipsilateral stroke and death rate at 30 days), respectively. Perioperative stroke, ipsilateral stroke, myocardial infarction (MI), and cranial nerve injury (CNI) were all secondary outcome measures. RESULTS The systematic review of the literature identified nine randomized controlled trials reporting on 3709 patients allocated into CEA (n = 1479) or CAS (n = 2230). Stroke or death rate at 30 days was significantly higher for CAS (64/2176 [2.94%]) compared with CEA (27/1431 [1.89%]; OR, 1.57; 95% CI, 1.01-2.44; P = .044), with low level of heterogeneity beyond chance (I2 = 0%). Also, stroke rate at 30 days was significantly higher for CAS (63/2176 [2.90%]) than for CEA (26/1431 [1.82%]; OR, 1.63; 95% CI, 1.04-2.54; P = .032; I2 = 0%). MI at 30 days was nonsignificantly lower for CAS (12/1815 [0.66%]) compared with CEA (16/1070 [1.50%]; OR, 0.53; 95% CI, 0.24-1.14; P = .105; I2 = 0%); however, CNI at 30 days was significantly lower for CAS (2/1794 [0.11%]) than for CEA (33/1061 [3.21%]; OR, 0.13; 95% CI, 0.07-0.26; P < .00001; I2 = 0%). Regarding the long-term outcome of stroke or death rate at 30 days plus ipsilateral stroke during follow-up, this was significantly higher for CAS (79/2173 [3.64%]) than for CEA (35/1430 [2.45%]; OR, 1.51; 95% CI, 1.02-2.24; P = .04; I2 = 0%). Quality of evidence for all stroke outcomes was graded moderate. CONCLUSIONS Among patients with asymptomatic stenosis undergoing carotid intervention, there is moderate-quality evidence to suggest that CEA had significantly lower 30-day stroke and also stroke or death rates compared with CAS at the cost of higher CNI and nonsignificantly higher MI rates. The long-term efficacy of CEA in ipsilateral stroke prevention, taking into account perioperative stroke and death, was preserved during follow-up. There is an urgent need for high-quality research before a firm recommendation is made that CAS is inferior or not to CEA.
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Affiliation(s)
- Stavros K Kakkos
- Department of Vascular Surgery, University of Patras Medical School, Patras, Greece; Department of Surgery and Cancer, Imperial College London, London, United Kingdom.
| | - Ioannis Kakisis
- National and Kapodistrian University of Athens, Athens, Greece
| | - Ioannis A Tsolakis
- Department of Vascular Surgery, University of Patras Medical School, Patras, Greece
| | - George Geroulakos
- Department of Surgery and Cancer, Imperial College London, London, United Kingdom; National and Kapodistrian University of Athens, Athens, Greece
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Kammler J, Blessberger H, Lambert T, Kellermair J, Grund M, Nahler A, Lichtenauer M, Schwarz S, Reiter C, Steinwender C, Kypta A. In-stent restenosis after interventional treatment of carotid artery stenoses: a long-term follow-up of a single center cohort. Clin Res Cardiol 2017; 106:493-500. [DOI: 10.1007/s00392-017-1078-1] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/08/2016] [Accepted: 01/10/2017] [Indexed: 11/28/2022]
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Školoudík D, Kuliha M, Hrbáč T, Jonszta T, Herzig R. Sonolysis in Prevention of Brain Infarction During Carotid Endarterectomy and Stenting (SONOBUSTER): a randomized, controlled trial. Eur Heart J 2016; 37:3096-3102. [DOI: 10.1093/eurheartj/ehv492] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 08/30/2023] Open
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Affiliation(s)
- Ali F AbuRahma
- Vascular Laboratory, Vascular Surgery Fellowship and Residency Programs, Vascular & Endovascular Surgery, Vascular Center of Excellence, 3110 MacCorkle Avenue, Southeast, Charleston, WV 25304, USA; Department of Surgery, West Virginia University, 3110 MacCorkle Avenue, Southeast, Charleston, WV 25304, USA.
| | - Albeir Y Mousa
- Department of Surgery, West Virginia University, 3110 MacCorkle Avenue, Southeast, Charleston, WV 25304, USA
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Kuliha M, Roubec M, Goldírová A, Hurtíková E, Jonszta T, Procházka V, Gumulec J, Herzig R, Školoudík D. Laboratory-Based Markers as Predictors of Brain Infarction During Carotid Stenting: a Prospective Study. J Atheroscler Thromb 2016; 23:839-47. [PMID: 26783048 PMCID: PMC7399266 DOI: 10.5551/jat.31799] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2015] [Accepted: 11/17/2015] [Indexed: 12/28/2022] Open
Abstract
AIM New ischemic lesions in the brain can be detected in approximately 50% of patients undergoing carotid artery stenting (CAS). We wished to discover the laboratory-based predictors of new infarctions in the brain after CAS. METHODS All consecutive patients with internal carotid artery stenosis of ≥70% with indication for CAS were enrolled in a prospective study for 16 months. All patients used dual antiplatelet therapy for ≥7 days before CAS. Neurologic examination and magnetic resonance imaging (MRI) of the brain were undertaken before and at 24 h after CAS. Samples of venous blood were collected at <24 h before CAS for the evaluation of hematology, reticulocytes, coagulation markers (PT, APTT, Fbg, Clauss), vWF antigen, PAI-1 activity, PAI-1 polymorphism 4G/5G, and the multiplate (aspirin and clopidogrel) resistance test. Blood samples for the assessment of anti-Xa activity were collected during CAS. Differences in the values of laboratory markers between patients with and without new ischemic lesions of the brain on control MRI were evaluated. RESULTS The cohort comprised 81 patients (53 males; mean age, 67.3±7.2 years). New ischemic infarctions in the brain on control MRI were found in 46 (56.8%) patients. Three of seven patients with resistance to aspirin or clopidogrel had a new ischemic infarction in the brain. No significant differences for particular markers were found between patients with and without an ischemic lesion in the brain. CONCLUSION A high risk of a new ischemic infarction in the brain was detected in patients undergoing CAS, but a laboratory-based predictor of such an infarction could not be identified.
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Affiliation(s)
- Martin Kuliha
- Department of Neurology, Comprehensive Stroke Center, University Hospital Ostrava, Czech Republic
- Department of Neurology and Center of Clinical Neuroscience, Charles University in Prague, 1st Faculty of Medicine and General University Hospital in Prague, Prague, Czech Republic
| | - Martin Roubec
- Department of Neurology, Comprehensive Stroke Center, University Hospital Ostrava, Czech Republic
| | - Andrea Goldírová
- Department of Neurology, Comprehensive Stroke Center, University Hospital Ostrava, Czech Republic
| | - Eva Hurtíková
- Department of Neurology, Comprehensive Stroke Center, University Hospital Ostrava, Czech Republic
| | - Tomáš Jonszta
- Department of Radiology, Comprehensive Stroke Center, University Hospital Ostrava, Czech Republic
| | - Václav Procházka
- Department of Radiology, Comprehensive Stroke Center, University Hospital Ostrava, Czech Republic
| | - Jaromír Gumulec
- Department of Hematology, Comprehensive Stroke Center, University Hospital Ostrava, Czech Republic
| | - Roman Herzig
- Department of Neurology, Comprehensive Stroke Center, Charles University Faculty of Medicine and University Hospital, Hradec Králové, Czech Republic
| | - David Školoudík
- Department of Neurology, Comprehensive Stroke Center, University Hospital Ostrava, Czech Republic
- Department of Neurology and Center of Clinical Neuroscience, Charles University in Prague, 1st Faculty of Medicine and General University Hospital in Prague, Prague, Czech Republic
- Department of Nursing, Faculty of Health Science, Palacký University Olomouc, Czech Republic
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Nanna MG, Gomes P, Njoh RF, Ward C, Attaran RR, Mena C. Carotid artery stenting versus carotid endarterectomy. Postgrad Med J 2016; 92:532-9. [DOI: 10.1136/postgradmedj-2015-133689] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2015] [Accepted: 05/24/2016] [Indexed: 02/04/2023]
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Sato K, Fujiyoshi K, Hoshi K, Noda C, Yamaoka-Tojo M, Ako J, Kumabe T. Low Stroke Rate of Carotid Stenosis Under the Guideline-Oriented Medical Treatment Compared With Surgical Treatment. Int Heart J 2016; 57:80-6. [DOI: 10.1536/ihj.15-196] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Affiliation(s)
- Kimitoshi Sato
- Department of Neurosurgery, Kitasato University School of Medicine
| | | | - Keika Hoshi
- Department of Hygiene, Kitasato University School of Medicine
| | - Chiharu Noda
- Department of Cardiovascular Medicine, Kitasato University School of Medicine
| | - Minako Yamaoka-Tojo
- Department of Rehabilitation, Kitasato University School of Allied Health Sciences
| | - Junya Ako
- Department of Cardiovascular Medicine, Kitasato University School of Medicine
| | - Toshihiro Kumabe
- Department of Neurosurgery, Kitasato University School of Medicine
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Galyfos G, Geropapas G, Sigala F, Aggeli K, Sianou A, Filis K. Meta-Analysis of Studies Evaluating the Effect of Cilostazol on Major Outcomes After Carotid Stenting. J Endovasc Ther 2015; 23:186-95. [PMID: 26620397 DOI: 10.1177/1526602815619409] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
PURPOSE To evaluate the effect of cilostazol on major outcomes after carotid artery stenting (CAS). METHODS A systematic literature review was conducted conforming to established criteria in order to identify articles published prior to May 2015 evaluating major post-CAS outcomes in patients treated with cilostazol vs patients not treated with cilostazol. Major outcomes included in-stent restenosis (ISR) within the observation period, the revascularization rate, major/minor bleeding, and the myocardial infarction/stroke/death rate (MI/stroke/death) at 30 days and within the observation period. Data were pooled for all studies containing adequate data for each outcome investigated; effect estimates are presented as the odds ratios (ORs) and 95 confidence intervals (CI). RESULTS Overall, 7 studies pertaining to 1297 patients were eligible. Heterogeneity was low among studies so a fixed-effect analysis was conducted. Six studies (n=1233) were compared for the ISR endpoint, showing a significantly lower ISR rate with cilostazol treatment after a mean follow-up of 20 months (OR 0.158, 95% CI 0.072 to 0.349, p<0.001). Five studies (n=649) were compared regarding 30-day MI/stroke/death (OR 0.724, 95% CI 0.293 to 1.789, p=0.484) and 3 studies (n=1076) were analyzed regarding MI/stroke/death within the entire follow-up period (OR 0.768, 95% CI 0.477 to 1.236, p=0.276); no significant difference was found between the groups. Data on bleeding rates and revascularization rates post ISR were inadequate to conduct further analysis. CONCLUSION Cilostazol seems to decrease total ISR rates in patients undergoing CAS without affecting MI/stroke/death events, both in the early and late settings.
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Affiliation(s)
- George Galyfos
- First Department of Propaedeutic Surgery, University of Athens Medical School, Hippocration Hospital, Athens, Greece Department of Vascular Surgery, KAT General Hospital, Athens, Greece
| | | | - Fragiska Sigala
- First Department of Propaedeutic Surgery, University of Athens Medical School, Hippocration Hospital, Athens, Greece
| | - Konstantina Aggeli
- First Department of Cardiology, University of Athens Medical School, Hippocration Hospital, Athens, Greece
| | - Argiri Sianou
- Department of Microbiology, University of Athens Medical School, Areteion Hospital, Athens, Greece
| | - Konstantinos Filis
- First Department of Propaedeutic Surgery, University of Athens Medical School, Hippocration Hospital, Athens, Greece
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Ouyang YA, Jiang Y, Yu M, Zhang Y, Huang H. Efficacy and safety of stenting for elderly patients with severe and symptomatic carotid artery stenosis: a critical meta-analysis of randomized controlled trials. Clin Interv Aging 2015; 10:1733-42. [PMID: 26604720 PMCID: PMC4631412 DOI: 10.2147/cia.s91721] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/05/2022] Open
Abstract
OBJECTIVE To investigate both short-term and long-term therapeutic efficacy and safety of carotid artery stenting (CAS) and carotid artery endarterectomy (CEA) for elderly patients with severe and symptomatic carotid artery stenosis. METHODS PubMed, EMBASE, Cochrane Library, Clinical Trials Register Centers, and Google Scholar were comprehensively searched. After identifying relevant randomized controlled trials, methodological quality was assessed by using Cochrane tools of bias assessment. Meta-analysis was performed by RevMan software, and subgroup analyses according to different follow-up periods were also conducted. RESULTS Sixteen articles of nine randomized controlled trials containing 6,984 patients were included. Compared with CEA, CAS was associated with high risks of stroke during periprocedural 30 days (risk ratio [RR]=1.47, 95% confidence interval [CI]: 1.15-1.88), 48 months (RR=1.37, 95% CI: 1.11-1.70), and >48 months (RR=1.76, 95% CI: 1.34-2.31). There was no significant difference in the aspects of death, disabling stroke, or death at any time between the groups. For other periprocedural complications, CAS decreased the risk of myocardial infarction (RR=0.44, 95% CI: 0.26-0.75), cranial nerve palsy (RR=0.09, 95% CI: 0.04-0.22) and hematoma (RR=0.31, 95% CI: 0.14-0.68) compared with CEA, while it increased the risk of bradycardia or hypotension (RR=8.45, 95% CI 2.91-24.58). CONCLUSION Compared with CEA, CAS reduced hematoma, periprocedural myocardial infarction, and cranial nerve palsy, while it was associated with higher risks of both short-term and long-term nondisabling stroke. And they seemed to be equivalent in other outcome measures. As regards to its minimal invasion, it should be applied only in specific patients.
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Affiliation(s)
- Yi-An Ouyang
- Department of Neurosurgery, Second Xiang-Ya Hospital of Central South University, Changsha, People’s Republic of China
| | - Yugang Jiang
- Department of Neurosurgery, Second Xiang-Ya Hospital of Central South University, Changsha, People’s Republic of China
| | - Mengqiang Yu
- Department of Neurosurgery, Second Xiang-Ya Hospital of Central South University, Changsha, People’s Republic of China
| | - Yunze Zhang
- Department of Neurosurgery, Second Xiang-Ya Hospital of Central South University, Changsha, People’s Republic of China
| | - Hao Huang
- Department of Neurosurgery, Second Xiang-Ya Hospital of Central South University, Changsha, People’s Republic of China
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Lai ZC, Liu B, Chen Y, Ni L, Liu CW. Prediction of Cerebral Hyperperfusion Syndrome with Velocity Blood Pressure Index. Chin Med J (Engl) 2015; 128:1611-7. [PMID: 26063363 PMCID: PMC4733740 DOI: 10.4103/0366-6999.158317] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Abstract
Background: Cerebral hyperperfusion syndrome is an important complication of carotid endarterectomy (CEA). An >100% increase in middle cerebral artery velocity (MCAV) after CEA is used to predict the cerebral hyperperfusion syndrome (CHS) development, but the accuracy is limited. The increase in blood pressure (BP) after surgery is a risk factor of CHS, but no study uses it to predict CHS. This study was to create a more precise parameter for prediction of CHS by combined the increase of MCAV and BP after CEA. Methods: Systolic MCAV measured by transcranial Doppler and systematic BP were recorded preoperatively; 30 min postoperatively. The new parameter velocity BP index (VBI) was calculated from the postoperative increase ratios of MCAV and BP. The prediction powers of VBI and the increase ratio of MCAV (velocity ratio [VR]) were compared for predicting CHS occurrence. Results: Totally, 6/185 cases suffered CHS. The best-fit cut-off point of 2.0 for VBI was identified, which had 83.3% sensitivity, 98.3% specificity, 62.5% positive predictive value and 99.4% negative predictive value for CHS development. This result is significantly better than VR (33.3%, 97.2%, 28.6% and 97.8%). The area under the curve (AUC) of receiver operating characteristic: AUCVBI= 0.981, 95% confidence interval [CI] 0.949–0.995; AUCVR= 0.935, 95% CI 0.890–0.966, P = 0.02. Conclusions: The new parameter VBI can more accurately predict patients at risk of CHS after CEA. This observation needs to be validated by larger studies.
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Affiliation(s)
| | | | | | | | - Chang-Wei Liu
- Department of Vascular Surgery, Peking Union Medical College Hospital, Chinese Academy of Medical Science, Beijing 100730, China
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New cerebral lesions at magnetic resonance imaging after carotid artery stenting versus endarterectomy: an updated meta-analysis. PLoS One 2015; 10:e0129209. [PMID: 26017678 PMCID: PMC4446340 DOI: 10.1371/journal.pone.0129209] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2015] [Accepted: 05/07/2015] [Indexed: 11/20/2022] Open
Abstract
Background Carotid endarterectomy (CEA) or stenting (CAS) are associated with a relatively low rate of clinical events, but diffusion-weighted imaging (DWI) is increasingly being used to compare the incidence of new ischemic lesions. Therefore, we conducted an updated meta-analysis on the occurrence of post-procedural new DWI lesions after CAS versus CEA. Methods and Results MEDLINE, Cochrane, ISI Web of Science and SCOPUS databases were searched and 20 studies (2 randomized and 18 non-randomized) with a total of 2104 procedures (CAS = 989; CEA = 1115) were included. The incidence of new DWI cerebral lesions was significantly greater after CAS than CEA (40.3% vs 12.2%; 20 studies; 2104 patients; odds ratio [OR] 5.17; 95% confidence interval [CI], 3.31-8.06; p<0.00001). Also peri-procedural stroke (17 studies; 1833 patients; OR 2.01; 95% CI, 1.14-3.55; p=0.02) and stroke or TIA (17 studies; 1833 patients; OR 2.40; 95% CI, 1.42-4.08; p=0.001) were significantly increased after CAS. This latter clinical advantage in the CEA group over CAS was tempered when CEA procedures were performed with shunting in all instead of selective shunting or when CAS was performed with only closed cell stents instead of both closed and open cell stents, however, no significant differences between subgroups emerged. Conclusions CAS is associated with an increased incidence of post-procedural brain DWI lesions. This greater amount of ischemic burden may also reflect a higher rate of cerebral events after CAS. However, whether recent technical advances mainly for CAS could potentially reduce these ischemic events still remains to be evaluated.
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Sato K, Suzuki S, Yamada M, Oka H, Kurata A, Okamoto H, Fujii K, Kumabe T. Selecting an appropriate surgical treatment instead of carotid artery stenting alone according to the patient's risk factors contributes to reduced perioperative complications in patients with internal carotid stenosis: a single institutional retrospective analysis. Neurol Med Chir (Tokyo) 2015; 55:124-32. [PMID: 25746306 PMCID: PMC4533410 DOI: 10.2176/nmc.oa.2014-0049] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
This retrospective study was aimed to compare the perioperative complications for internal carotid artery stenosis (ICS) in a Japanese single institute between the use of carotid artery stenting (CAS) alone or the use of an appropriate individualized treatment method allowing either carotid endarterectomy (CEA) or CAS based on patient risk factors. Based on the policy at our hospital, only CAS was performed on patients (n = 33) between January 2005 and November 2009. From December 2009 to December 2012, either CEA or CAS (tailored treatment) was selected for patients (n = 61) based on individual patient risk factors. CEA was considered the first-line treatment in all cases. In high-risk CEA cases, CAS was performed instead (n = 11), whereas in low-risk CEA cases, CEA was performed (n = 19). Further, in moderate-risk CEA cases based on own criteria, CAS was considered first, whereas for high-risk CAS cases, CEA was performed (n = 17). For low-risk CAS cases, CAS was performed (n = 9). Perioperative clinical complications (any stroke, myocardial infarction, or death within 30 days) were compared between both periods. Significantly reduced perioperative complications were observed during the tailored period (4/61 sites, 6.6%) as compared with the CAS period (8/33 sites, 24.2%) [Fisher’s exact test p = 0.022; odds ratio, 4.56 (CAS/tailored); 95% confidence interval, 1.26–16.5]. Selecting an appropriate individualized treatment method according to patient risk factors, as opposed to adhering to a single treatment approach such as CAS, may contribute to improved overall outcomes in patients with ICS.
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Affiliation(s)
- Kimitoshi Sato
- Department of Neurosurgery, Kitasato University School of Medicine
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Affiliation(s)
- Marco Roffi
- Division of Cardiology, University Hospital, 1211 Geneva 14, Switzerland.
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49
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Abstract
In patients with carotid disease, the purpose of carotid artery revascularization is stroke prevention. For >50 years, carotid endarterectomy has been considered the standard treatment for severe asymptomatic and symptomatic carotid stenoses. Carotid artery stenting (CAS) has emerged in the last 15 years as minimally invasive alternative to surgery. However, the value of the endovascular approach in the management of carotid disease patients remains highly controversial. The aims of this review are to elucidate the current role of CAS, to describe the major technology advancements in the field, and to speculate about the future of this therapy.
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Affiliation(s)
- Alberto Cremonesi
- Interventional Cardiovascular Unit, GVM Care and Research, Maria Cecilia Hospital, Cotignola, Italy
| | - Fausto Castriota
- Interventional Cardiovascular Unit, GVM Care and Research, Maria Cecilia Hospital, Cotignola, Italy
| | - Gioel Gabrio Secco
- Maggiore Della Carità Hospital, University of Eastern Piedmont, Novara, Italy
| | | | - Marco Roffi
- Division of Cardiology, University Hospital, Geneva, Switzerland
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Kuliha M, Roubec M, Procházka V, Jonszta T, Hrbáč T, Havelka J, Goldírová A, Langová K, Herzig R, Školoudík D. Randomized clinical trial comparing neurological outcomes after carotid endarterectomy or stenting. Br J Surg 2014; 102:194-201. [DOI: 10.1002/bjs.9677] [Citation(s) in RCA: 37] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2014] [Revised: 07/02/2014] [Accepted: 09/19/2014] [Indexed: 11/10/2022]
Abstract
Abstract
Background
Silent infarction in the brain can be detected in around 34 per cent of patients after carotid endarterectomy (CEA) and 54 per cent after carotid angioplasty and stenting (CAS). This study compared the risk of new infarctions in the brain in patients undergoing CEA or CAS.
Methods
Consecutive patients with internal carotid artery (ICA) stenosis exceeding 70 per cent were screened for inclusion in this prospective study. Patients with indications for intervention, and eligible for both methods, were allocated randomly to CEA or CAS. Neurological examination, cognitive function tests and MRI of the brain were undertaken before and 24 h after intervention.
Results
Of 150 randomized patients, 73 (47 men; mean age 64·9(7·1) years) underwent CEA and 77 (58 men; 66·4(7·5) years) had CAS. New infarctions on MRI were found more frequently after CAS (49 versus 25 per cent; P = 0·002). Lesion volume was also significantly greater after CAS (P = 0·010). Multiple logistic regression analyses identified intervention in the right ICA as the only independent predictor of brain infarction (odds ratio 2·10, 95 per cent c.i. 1·03 to 4·25; P = 0·040). Stroke or transient ischaemic attack occurred in one patient after CEA and in two after CAS. No significant differences were found in cognitive test results between the groups.
Conclusion
These data confirm a higher risk of silent infarction in the brain on MRI after CAS in comparison with CEA, but without measurable change in cognitive function. Registration number: NCT01591005 (http://www.clinicaltrials.gov).
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Affiliation(s)
- M Kuliha
- Departments of Neurology, University Hospital Ostrava, Ostrava, Czech Republic
| | - M Roubec
- Departments of Neurology, University Hospital Ostrava, Ostrava, Czech Republic
| | - V Procházka
- Departments of Radiology, University Hospital Ostrava, Ostrava, Czech Republic
| | - T Jonszta
- Departments of Radiology, University Hospital Ostrava, Ostrava, Czech Republic
| | - T Hrbáč
- Departments of Neurosurgery, Comprehensive Stroke Centre, University Hospital Ostrava, Ostrava, Czech Republic
| | - J Havelka
- Departments of Radiology, University Hospital Ostrava, Ostrava, Czech Republic
| | - A Goldírová
- Departments of Neurology, University Hospital Ostrava, Ostrava, Czech Republic
- Department of Nursing, Faculty of Health Sciences, Palacký University, Olomouc, Czech Republic
| | - K Langová
- Department of Biophysics, Faculty of Medicine and Dentistry, Institute of Molecular and Translational Medicine, Palacký University, Olomouc, Czech Republic
| | - R Herzig
- Department of Neurosurgery, Comprehensive Stroke Centre, Military University Hospital, Prague, Czech Republic
| | - D Školoudík
- Departments of Neurology, University Hospital Ostrava, Ostrava, Czech Republic
- Department of Nursing, Faculty of Health Sciences, Palacký University, Olomouc, Czech Republic
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