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Patel RJ, Dodo-Williams TS, Sendek G, Elsayed N, Malas MB. Non-White Patients Have a Higher Risk of Stroke Following Transcarotid Artery Revascularization. J Surg Res 2024; 300:71-78. [PMID: 38796903 DOI: 10.1016/j.jss.2024.04.062] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2023] [Revised: 01/28/2024] [Accepted: 04/14/2024] [Indexed: 05/29/2024]
Abstract
INTRODUCTION Carotid artery revascularization has traditionally been performed by either a carotid endarterectomy or carotid artery stent. Large data analysis has suggested there are differences in perioperative outcomes with regards to race, with non-White patients (NWP) having worse outcomes of stroke, restenosis and return to the operating room (RTOR). The introduction of transcarotid artery revascularization (TCAR) has started to shift the paradigm of carotid disease treatment. However, to date, there have been no studies assessing the difference in postoperative outcomes after TCAR between racial groups. METHODS All patients from 2016 to 2021 in the Vascular Quality Initiative who underwent TCAR were included in our analysis. Patients were split into two groups based on race: individuals who identified as White and a second group that comprised all other races. Demographic and clinical variables were compared using Student's t-Test and chi-square test of independence. Logistic regression analysis was performed to determine the impact of race on perioperative outcomes of stroke, myocardial infarction (MI), death, restenosis, RTOR, and transient ischemic attack (TIA). RESULTS The cohort consisted of 22,609 patients: 20,424 (90.3%) White patients and 2185 (9.7%) NWP. After adjusting for sex, diabetes, hypertension, coronary artery disease, history of prior stroke or TIA, symptomatic status, and high-risk criteria at time of TCAR, there was a significant difference in postoperative stroke, with 63% increased risk in NWP (odds ratio = 1.63, 95% confidence interval: 1.11-2.40, P = 0.014). However, we found no significant difference in the odds of MI, death, postoperative TIA, restenosis, or RTOR when comparing NWP to White patients. CONCLUSIONS This study demonstrates that NWP have increased risk of stroke but similar outcomes of death, MI, RTOR and restenosis following TCAR. Future studies are needed to elucidate and address the underlying causes of racial disparity in carotid revascularization.
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Affiliation(s)
- Rohini J Patel
- Center for Learning and Excellence in Vascular & Endovascular Research (CLEVER), Division of Vascular and Endovascular Surgery, Department of Surgery, University of California San Diego, San Diego, California
| | - Taiwo S Dodo-Williams
- Center for Learning and Excellence in Vascular & Endovascular Research (CLEVER), Division of Vascular and Endovascular Surgery, Department of Surgery, University of California San Diego, San Diego, California
| | - Gabriela Sendek
- Center for Learning and Excellence in Vascular & Endovascular Research (CLEVER), Division of Vascular and Endovascular Surgery, Department of Surgery, University of California San Diego, San Diego, California
| | - Nadin Elsayed
- Center for Learning and Excellence in Vascular & Endovascular Research (CLEVER), Division of Vascular and Endovascular Surgery, Department of Surgery, University of California San Diego, San Diego, California
| | - Mahmoud B Malas
- Center for Learning and Excellence in Vascular & Endovascular Research (CLEVER), Division of Vascular and Endovascular Surgery, Department of Surgery, University of California San Diego, San Diego, California.
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Zohourian T, Hines G. The Evolution of Current Management for Carotid Artery Bifurcation Disease. Cardiol Rev 2024; 32:257-262. [PMID: 36729106 DOI: 10.1097/crd.0000000000000497] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
Options for treatment of symptomatic carotid bifurcation disease include carotid endarterectomy (CEA) and carotid artery stenting (CAS). While over the years CEA has established itself as the gold standard for carotid artery revascularization, results from recent trials have shown CAS to be safe and effective in selected patients. This review details the evolution of carotid artery bifurcation disease by highlighting key clinical trials.
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Affiliation(s)
- Tirajeh Zohourian
- From the Department of Surgery, New York University Langone Long Island Hospital, Mineola, NY
- Department of Surgery, New York University Long Island School of Medicine, Mineola, NY
| | - George Hines
- From the Department of Surgery, New York University Langone Long Island Hospital, Mineola, NY
- Department of Surgery, New York University Long Island School of Medicine, Mineola, NY
- New York University Langone Vascular Surgery Associates-Mineola, Mineola, NY
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Jeon S, Park H, Kwak HS, Hwang SB. Findings of Angiography and Carotid Vessel Wall Imaging Associated with Post-Procedural Clinical Events after Carotid Artery Stenting. Neurointervention 2024; 19:14-23. [PMID: 38225678 PMCID: PMC10910175 DOI: 10.5469/neuroint.2023.00486] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2023] [Revised: 12/30/2023] [Accepted: 01/02/2024] [Indexed: 01/17/2024] Open
Abstract
PURPOSE Vessel wall imaging (VWI) for carotid plaque is better for detecting unstable carotid plaque such as intraplaque hemorrhage (IPH), lipid-rich necrotic core (LRNC), and thin/ruptured fibrous cap. However, the role of VWI before carotid artery stenting (CAS) is unclear. Thus, this study aimed to determine the findings of symptomatic carotid stenosis before CAS on angiography and carotid VWI and to evaluate the imaging findings associated with post-procedural clinical events after CAS. MATERIALS AND METHODS This retrospective study included 173 consecutive patients who underwent carotid VWI, CAS, and post-procedural diffusion-weighted imaging (DWI) after CAS. Findings of unstable plaque on carotid VWI and unstable findings on angiography were analyzed. We also analyzed the incidence of post-procedural clinical events, any stroke, myocardial infarction (MI), and death within 30 days of CAS. RESULTS Of 173 patients, 101 (58.4%) had initial ischemic symptoms and positive findings on DWI. Symptomatic patients were significantly higher in patients with IPH than in patients without IPH (62.4% vs. 45.8%, P=0.031). Degree of stenosis, thrombus of the stenotic lesion, flow delay of internal carotid artery, and flow arrest by filter thrombus had significantly higher prevalence in the symptomatic group. Twenty patients (11.6%) had post-procedural clinical events such as any stroke, clinical symptoms, and/or MI. Hyperlipidemia and intraluminal thrombus on angiography were identified as significant factors influencing post-procedural events after CAS. CONCLUSION An intraluminal thrombus on angiography was identified as a significant factor influencing post-procedural clinical events after CAS.
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Affiliation(s)
- Sujin Jeon
- Jeonbuk National University Medical School, Jeonju, Korea
| | - Heejae Park
- Jeonbuk National University Medical School, Jeonju, Korea
| | - Hyo Sung Kwak
- Department of Radiology, Research Institute of Clinical Medicine of Jeonbuk National University-Biomedical Research Institute of Jeonbuk National University Hospital, Jeonju, Korea
| | - Seung Bae Hwang
- Department of Radiology, Research Institute of Clinical Medicine of Jeonbuk National University-Biomedical Research Institute of Jeonbuk National University Hospital, Jeonju, Korea
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Succar B, Chou YH, Hsu CH, Rapcsak S, Trouard T, Zhou W. Cognitive effects of carotid revascularization in octogenarians. Surgery 2023; 174:1078-1082. [PMID: 37550167 PMCID: PMC10528540 DOI: 10.1016/j.surg.2023.07.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2023] [Revised: 06/01/2023] [Accepted: 07/08/2023] [Indexed: 08/09/2023]
Abstract
BACKGROUND Cognitive impairment is the epitome of cerebrovascular diseases, causing a significant economic burden on our health care system. Growing evidence has indicated the benefits of carotid interventions in patients with severe carotid atherosclerosis. However, the neurocognitive outcome of carotid revascularization in octogenarians is not clearly understood. We aim to evaluate postintervention cognitive changes in seniors older than 80 years. METHODS We prospectively recruited 170 patients undergoing carotid interventions. Neurocognitive testing was performed preoperatively and at 1, 6, and 12 months postoperatively. Episodic memory was assessed with Rey's Auditory Verbal Learning Test. Other executive functions and language measures were also evaluated at individual time points. Raw test scores were converted to z-scores or scaled scores adjusted for age and education. The sample was divided into 2 groups based on age: octogenarian (≥80 years) and nonoctogenarian (<80 years old). Postoperative cognitive scores were compared to baseline within each subcohort. RESULTS A total of 23 subjects (13%) were octogenarians, and 147 (87%) were younger than 80 years. Younger patients demonstrated significant cognitive improvements up to 12 months postop compared to the baseline. However, octogenarians exhibited a lack of improvement in verbal memory, measures of executive function, and language at all 3 postintervention time points. CONCLUSION Carotid interventions improve cognitive functions in younger patients with carotid occlusive atherosclerosis. However, no cognitive benefits were seen in male seniors older than 80 years. Further investigations are warranted to better understand the postinterventional cognitive changes in octogenarians.
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Affiliation(s)
- Bahaa Succar
- Department of Surgery, Division of Vascular Surgery, The University of Arizona, Tucson, AZ
| | - Ying-Hui Chou
- Department of Psychiatry, The University of Arizona, Tucson, AZ
| | - Chiu-Hsieh Hsu
- Mel and Enid Zuckerman College of Public Health, The University of Arizona, Tucson, AZ
| | - Steven Rapcsak
- Department of Psychiatry, The University of Arizona, Tucson, AZ
| | - Theodore Trouard
- Department of Biomedical Imaging, The University of Arizona, Tucson, AZ
| | - Wei Zhou
- Department of Surgery, Division of Vascular Surgery, The University of Arizona, Tucson, AZ.
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Jeon SY, Lee JM. Protected carotid artery stenting in patients with severe stenosis. Medicine (Baltimore) 2022; 101:e30106. [PMID: 35984161 PMCID: PMC9388035 DOI: 10.1097/md.0000000000030106] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/05/2023] Open
Abstract
Intraplaque hemorrhage (IPH) and ulcers are the major findings of unstable plaques. In addition, initial symptoms are associated with postprocedural complications after carotid artery stenting (CAS). The aim of this study was to determine the safety of CAS using an embolic protection device in symptomatic patients with severe carotid artery stenosis and unstable plaques such as IPH and ulcers. This retrospective study included 140 consecutive patients with severe carotid stenosis. These patients underwent preprocedural carotid vessel wall imaging to evaluate the plaque status. We analyzed the incidence of initial clinical symptoms, such as headache, nausea, and vomiting, after CAS. The primary outcomes analyzed were the incidence of stroke, myocardial infarction, and death within 30 days of CAS. Sixty-seven patients (47.9%) had IPH, and 53 (38.9%) had ulcers on carotid wall imaging/angiography. Sixty-three patients (45.0%) had acute neurological symptoms with positive diffusion-weighted image findings. Intraluminal thrombi on initial angiography and flow arrest during CAS were significantly higher in patients with IPH and symptomatic patients. Symptoms were significantly higher in patients with IPH than in those without (63.5% vs 35.1%, P < .001). There were no significant differences in clinical symptoms after stenting or in primary outcomes, regardless of IPH, ulcer, or initial symptoms. IPH and plaque ulceration are risk factors in symptomatic carotid stenosis. However, IPH and plaque ulceration were not a significant risk factors for cerebral embolism during protected carotid artery stent placement in patients with carotid stenosis. Protected CAS might be feasible and safe despite the presence of unstable plaques.
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Affiliation(s)
- Seo-Young Jeon
- Jeonbuk National University Hospital & Medical School, Jeon-Ju, Republic of Korea
| | - Jong-Myong Lee
- Department of Neurosurgery, Jeonbuk National University Hospital & Medical School, Jeon-Ju, Republic of Korea
- *Correspondence: Jong-Myong Lee, Department of Neurosurgery, Jeonbuk National University Hospital & Medical School, 664-14, Deokjin-Gu, Jeonju, Jeonbuk 54907, Republic of Korea (e-mail: )
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The clinical application of a scoring protocol to select endarterectomy or stenting for carotid artery stenosis. Sci Rep 2022; 12:4687. [PMID: 35304584 PMCID: PMC8933476 DOI: 10.1038/s41598-022-08807-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2021] [Accepted: 03/08/2022] [Indexed: 12/14/2022] Open
Abstract
Previously we described the protocol-based decision for choosing the proper surgical treatment option for carotid stenosis. The objective of this study is to describe our experiences of using this scoring protocol in the selection of endarterectomy or stenting for carotid stenosis. Between October 2014 and March 2018, the scoring protocol was applied to a total of 105 consecutive patients. Eighty (76.2%) patients had symptomatic stenosis ≥ 50%, and 25 (23.8%) patients had asymptomatic stenosis ≥ 80%. We also speculated about how effectively the protocol worked in the real clinical setting. Stenting was performed in 73 patients and endarterectomy in 32 patients. Overall, 98 (93.3%) patients were treated according to the protocol, while the protocol was violated in seven (6.7%) patients. Sixty-one (58.1%) patients received treatments that were decided by the protocol. There were 37 (35.2%) patients who had the same score for both treatment options. Among these patients, 28 patients underwent stenting and nine patients underwent endarterectomy. In the stenting cases, 90.4% of the patients followed the protocol and violations occurred in 9.6%. In the endarterectomy cases, all of the patients followed the protocol. Overall, one patient had a procedure-related complication without morbidity. During the 12-month follow-ups, there were no restenoses or major strokes. Minor strokes were diagnosed in three (2.8%) patients. In patients with carotid artery stenosis, stenting and endarterectomy should be considered simultaneously together, not against each other. Our scoring protocol can be used to weigh these options and applied in clinical practice.
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Poorthuis MH, Herings RA, Dansey K, Damen JA, Greving JP, Schermerhorn ML, de Borst GJ. External Validation of Risk Prediction Models to Improve Selection of Patients for Carotid Endarterectomy. Stroke 2022; 53:87-99. [PMID: 34634926 PMCID: PMC8712365 DOI: 10.1161/strokeaha.120.032527] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
BACKGROUND AND PURPOSE The net benefit of carotid endarterectomy (CEA) is determined partly by the risk of procedural stroke or death. Current guidelines recommend CEA if 30-day risks are <6% for symptomatic stenosis and <3% for asymptomatic stenosis. We aimed to identify prediction models for procedural stroke or death after CEA and to externally validate these models in a large registry of patients from the United States. METHODS We conducted a systematic search in MEDLINE and EMBASE for prediction models of procedural outcomes after CEA. We validated these models with data from patients who underwent CEA in the American College of Surgeons National Surgical Quality Improvement Program (2011-2017). We assessed discrimination using C statistics and calibration graphically. We determined the number of patients with predicted risks that exceeded recommended thresholds of procedural risks to perform CEA. RESULTS After screening 788 reports, 15 studies describing 17 prediction models were included. Nine were developed in populations including both asymptomatic and symptomatic patients, 2 in symptomatic and 5 in asymptomatic populations. In the external validation cohort of 26 293 patients who underwent CEA, 702 (2.7%) developed a stroke or died within 30-days. C statistics varied between 0.52 and 0.64 using all patients, between 0.51 and 0.59 using symptomatic patients, and between 0.49 to 0.58 using asymptomatic patients. The Ontario Carotid Endarterectomy Registry model that included symptomatic status, diabetes, heart failure, and contralateral occlusion as predictors, had C statistic of 0.64 and the best concordance between predicted and observed risks. This model identified 4.5% of symptomatic and 2.1% of asymptomatic patients with procedural risks that exceeded recommended thresholds. CONCLUSIONS Of the 17 externally validated prediction models, the Ontario Carotid Endarterectomy Registry risk model had most reliable predictions of procedural stroke or death after CEA and can inform patients about procedural hazards and help focus CEA toward patients who would benefit most from it.
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Affiliation(s)
| | - Reinier A.R. Herings
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
| | - Kirsten Dansey
- Division of Vascular and Endovascular Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, US
| | - Johanna A.A. Damen
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
| | - Jacoba P. Greving
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
| | - Marc L. Schermerhorn
- Division of Vascular and Endovascular Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, US
| | - Gert J. de Borst
- Department of Vascular Surgery, University Medical Center Utrecht, Utrecht, The Netherlands
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Assessing the Suitability of the Carotid Bifurcation for Stenting: Anatomic and Morphologic Considerations. J Vasc Surg 2021; 74:2087-2095. [PMID: 34175382 DOI: 10.1016/j.jvs.2021.05.048] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2020] [Accepted: 05/04/2021] [Indexed: 11/21/2022]
Abstract
OBJECTIVE Over the years where stents have been used to treat carotid lesions, a great deal has been learned about which anatomical characteristics lead to adverse outcomes. This review summarizes the anatomic and morphologic characteristics of the carotid vasculature that can help guide patient selection and clinical decision-making. METHODS Each of the carotid artery anatomy and lesion characteristics that are relevant to carotid stenting are described in detail. These are accompanied with evidence-based outcomes and results. RESULTS Data on the prevalence of carotid artery lesions that are unsuitable for stenting are summarized and the implications of these data for practice are discussed, especially as they pertain to transcarotid artery revascularization. CONCLUSIONS CAS can be viable option for carotid revascularization, but the lesion must be acceptable and safe for stent placement. There should be thorough assessment to rule out the presence of severe tortuosity, long-segment disease, severe calcification (circumferential or exophytic), mobile-plaque, swollen ICA sign, and carotid diameters outside the acceptable range. In carefully chosen lesions with the absence of the unfavorable characteristics described-TCAR may offer improved periprocedural success, and CAS may attain better long-term durability.
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Mid-term and late results of endovascular treatment for symptomatic carotid artery stenosis under proximal protection. Wideochir Inne Tech Maloinwazyjne 2021; 16:175-182. [PMID: 33786132 PMCID: PMC7991930 DOI: 10.5114/wiitm.2020.94519] [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: 03/01/2020] [Accepted: 03/29/2020] [Indexed: 11/17/2022] Open
Abstract
Introduction Although filters are still preferred during carotid stenting, proximal protection systems (PPS) are increasingly used during these procedures. PPS seem to be safer than distal systems, especially in symptomatic patients, but evidence supporting their use is limited. Aim This was a post hoc survey with 30-day mid-term and long-term follow up, which was aimed at assessment of the safety and efficacy of stenting of the internal carotid artery under PPS in symptomatic patients. Material and methods We analysed the results of stenting in 120 symptomatic patients presenting with at least 60% stenosis. Patients were aged 67.9 ±9.8 years, and 12 patients were older than 80 years. An occlusion of contralateral artery was found in 5 patients and bilateral stenosis in 26 patients. The primary endpoint of this study was the proportion of patients who had new neurological events, including transient ischemic attack and minor or major stroke in 30-day follow-up. The secondary endpoint was a composite of technical and clinical success. During long-term follow-up we assessed new neurological events and stenoses of implanted stents. Results The incidence of new neurological events during 30-day follow-up was 0.8%. The rate of technical success defined by secondary endpoint was 100%. Mean internal carotid artery stenosis before and after stent implantation was 93.8 ±9% and 8.4 ±6.3%, respectively (p < 0.001). Procedural success was achieved in all cases. During long-term follow-up there were two (1.7%) asymptomatic in-stent stenoses and no (0%) new neurological events. Conclusions Endovascular management of symptomatic carotid stenosis under PPS is safe, feasible, and appears to be a good alternative to surgical endarterectomy.
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Lanza G, Giannandrea D, Lanza J, Ricci S, Gensini GF. Personalized-medicine on carotid endarterectomy and stenting. ANNALS OF TRANSLATIONAL MEDICINE 2020; 8:1274. [PMID: 33178806 PMCID: PMC7607117 DOI: 10.21037/atm-20-1126] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
Evidence based medicine (EBM) is the core of current clinical guidelines and is considered as the gold standard of clinical practice. Despite this, a number of limitations and criticisms are moved to EBM. The major one is that this method privileges randomized controlled trials (RCTs), in which the selection of patients is often based on rigid inclusion criteria. The lack of “pragmatism” of some RCTs sometimes makes it difficult to apply guidelines that derive from them to patients observed in clinical practice, who are often affected by comorbidities and disabilities. The new paradigm to overcome this limitation is personalized medicine (PM), which aims to take into account the particular characteristics displayed by the individual. In order to tailor the best treatment for the patient, PM uses EBM but emphasizes the person's specific information from the assessment of the clinic, lifestyle and risk/benefit scores. This narrative review tries to find the best evidence by analysing subgroups and risk scores of patients from meta-analysis and RCTs in order to try to apply PM and to provide good practice points (GPP) on grey aspects and open questions not fully covered by current guidelines on carotid endarterectomy (CEA) and stenting for stroke prevention.
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Affiliation(s)
- Gaetano Lanza
- Vascular Surgery Department, IRCCS MultiMedica Hospital, Castellanza, Italy
| | - David Giannandrea
- Neurology Department-Stroke Unit, Gubbio/Gualdo Tadino and Città di Castello Hospitals, USL Umbria 1, Perugia, Italy.,Association "Naso Sano", Umbria Regional Registry of No-Profit Organization, Corciano, Italy
| | - Jessica Lanza
- ASST Fatebenefratelli Sacco, Angioma Center, Vittore Buzzi Hospital, Milan, Italy
| | - Stefano Ricci
- Neurology Department-Stroke Unit, Gubbio/Gualdo Tadino and Città di Castello Hospitals, USL Umbria 1, Perugia, Italy
| | - Gian Franco Gensini
- Permanent Technical Committee for Guidelines, Tuscany Regional Health Service, Florence, Italy
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Xu X, Feng Y, Bai X, Ma Y, Wang Y, Chen Y, Yang B, Ling F, Zhang X, Jiao L. Risk factors for silent new ischemic cerebral lesions following carotid artery stenting. Neuroradiology 2020; 62:1177-1184. [DOI: 10.1007/s00234-020-02447-3] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2019] [Accepted: 04/22/2020] [Indexed: 10/24/2022]
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Abstract
Objective Carotid artery stenting (CAS) in patients undergoing maintenance hemodialysis is characterized by high complication rates. These patients are excluded from clinical trials of CAS. The purpose of our retrospective study was to investigate the long-term clinical outcomes of CAS in patients undergoing maintenance hemodialysis. Methods CAS was performed under local anesthesia. The technical success rate, periprocedural complications, 30-day major vascular event rate (stroke, myocardial infarction, and/or death), 3-month morbidity and mortality rates, and 5-year survival probability were investigated. Patients Nineteen patients undergoing maintenance hemodialysis were identified. Results The mean age of the patients was 69 years. Periprocedural complications occurred in two patients (confusion following CAS in one and transient hemiparesis in the other). Complete neurological recovery was achieved in both patients. No major cardiovascular events occurred within 30 days after CAS. Asymptomatic intracranial hemorrhage only occurred in one patient, and seven patients died during the follow-up period at a mean of 3.5 years after the procedure (range, 6 months to 8 years). No permanent neurologic deficit remained in the patient with intracranial hemorrhage. The causes of death were cardiovascular disease (n = 4), cancer (n = 2), and pneumonia (n = 1). No patients died of stroke. The 5-year survival probability in patients undergoing maintenance hemodialysis was 57%. Conclusion CAS in maintenance hemodialysis patients may be feasible and effective for the prevention of stroke with proper case selection, appropriate technique and strict perioperative management. The most common causes of death during the follow-up of maintenance hemodialysis patients were diseases other than stroke.
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Affiliation(s)
| | - Takahisa Mori
- Department of Stroke Treatment, Shonan Kamakura General Hospital Stroke Center, Japan
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Lanza G, Lanza J, Ricci S, Pini R, Faggioli G, Gensini GF. Personalized medicine: new enhancement to guidelines on carotid endarterectomy and stenting. ITALIAN JOURNAL OF VASCULAR AND ENDOVASCULAR SURGERY 2019. [DOI: 10.23736/s1824-4777.19.01422-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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Wynants L, Kent DM, Timmerman D, Lundquist CM, Van Calster B. Untapped potential of multicenter studies: a review of cardiovascular risk prediction models revealed inappropriate analyses and wide variation in reporting. Diagn Progn Res 2019; 3:6. [PMID: 31093576 PMCID: PMC6460661 DOI: 10.1186/s41512-019-0046-9] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/13/2018] [Accepted: 01/03/2019] [Indexed: 12/17/2022] Open
Abstract
BACKGROUND Clinical prediction models are often constructed using multicenter databases. Such a data structure poses additional challenges for statistical analysis (clustered data) but offers opportunities for model generalizability to a broad range of centers. The purpose of this study was to describe properties, analysis, and reporting of multicenter studies in the Tufts PACE Clinical Prediction Model Registry and to illustrate consequences of common design and analyses choices. METHODS Fifty randomly selected studies that are included in the Tufts registry as multicenter and published after 2000 underwent full-text screening. Simulated examples illustrate some key concepts relevant to multicenter prediction research. RESULTS Multicenter studies differed widely in the number of participating centers (range 2 to 5473). Thirty-nine of 50 studies ignored the multicenter nature of data in the statistical analysis. In the others, clustering was resolved by developing the model on only one center, using mixed effects or stratified regression, or by using center-level characteristics as predictors. Twenty-three of 50 studies did not describe the clinical settings or type of centers from which data was obtained. Four of 50 studies discussed neither generalizability nor external validity of the developed model. CONCLUSIONS Regression methods and validation strategies tailored to multicenter studies are underutilized. Reporting on generalizability and potential external validity of the model lacks transparency. Hence, multicenter prediction research has untapped potential. REGISTRATION This review was not registered.
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Affiliation(s)
- L. Wynants
- Department of Development and Regeneration, KU Leuven, Herestraat 49, box 7003, 3000 Leuven, Belgium
- Department of Epidemiology, CAPHRI Care and Public Health Research Institute, Maastricht University, PO Box 9600, 6200 MD Maastricht, The Netherlands
| | - D. M. Kent
- Predictive Analytics and Comparative Effectiveness (PACE) Center, Institute for Clinical Research and Health Policy Studies, Tufts Medical Center, 800 Washington St, Box 63, Boston, MA 02111 USA
| | - D. Timmerman
- Department of Development and Regeneration, KU Leuven, Herestraat 49, box 7003, 3000 Leuven, Belgium
- Department of Obstetrics and Gynecology, University Hospitals Leuven, Herestraat 49, 3000 Leuven, Belgium
| | - C. M. Lundquist
- Predictive Analytics and Comparative Effectiveness (PACE) Center, Institute for Clinical Research and Health Policy Studies, Tufts Medical Center, 800 Washington St, Box 63, Boston, MA 02111 USA
| | - B. Van Calster
- Department of Development and Regeneration, KU Leuven, Herestraat 49, box 7003, 3000 Leuven, Belgium
- Department of Biomedical Data Sciences, Leiden University Medical Center, PO Box 9600, Leiden, 2300RC The Netherlands
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Habib N, Mahmoodi BK, Suttorp MJ, Kelder JC, Tromp SC, Sonker U, Van der Heyden J. Long-term results of carotid stenting and risk factors in patients with severe carotid artery stenosis undergoing subsequent cardiac surgery. Catheter Cardiovasc Interv 2019; 93:E134-E139. [PMID: 30411845 DOI: 10.1002/ccd.27947] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/21/2018] [Revised: 09/06/2018] [Accepted: 10/08/2018] [Indexed: 11/12/2022]
Abstract
AIMS To identify risk factors for composite outcome of mortality, stroke or myocardial infarction in patients with severe carotid stenosis undergoing staged carotid artery stenting (CAS) with subsequent cardiac surgery. METHODS AND RESULTS In this prospective observational study, we enrolled 643 consecutive patients with both symptomatic (i.e., with history of stroke) and asymptomatic severe carotid artery disease, who required cardiac surgery. Generally, cardiac surgery was planned 30 days after the CAS procedure. The composite outcome consisted of death, stroke and myocardial infarction. The composite outcome rate was 26.3% at 5 years and 47% at 8 years after CAS. Age ≥ 80 years (hazard ratio [HR] = 1.89; 95%CI, 1.18-3.03; P = 0.008), history of stroke (HR = 1.66, 1.16-2.37; P = 0.006), chronic obstructive pulmonary disease (HR = 1.86; 1.07-3.24; P = 0.03) and kidney disease (HR = 1.83, 1.11-3.04; P = 0.02) were independent risk factors for the composite outcome during long-term follow-up. CONCLUSIONS In this study with staged CAS followed by cardiac surgery, we confirm previously reported event-free survival rates and identify several risk factors for the composite outcome. Future studies are needed to confirm the importance of the identified risk factors and to assess their predictive ability.
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Affiliation(s)
- Najibullah Habib
- Department of Cardiology, Sint Antonius Hospital, Nieuwegein, The Netherlands
| | | | - Maarten J Suttorp
- Department of Cardiology, Sint Antonius Hospital, Nieuwegein, The Netherlands
| | - Johannes C Kelder
- Department of Cardiology, Sint Antonius Hospital, Nieuwegein, The Netherlands
| | - Selma C Tromp
- Department of Clinical Neurophysiology, Sint Antonius Hospital, Nieuwegein, The Netherlands
| | - Uday Sonker
- Department of Cardiothoracic and Cardiovascular Surgery, Sint Antonius Hospital, Nieuwegein, The Netherlands
| | - Jan Van der Heyden
- Department of Cardiology, Sint Antonius Hospital, Nieuwegein, The Netherlands
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Assaad M, Berry A, Zughaib M. Transcervical Carotid Artery Stenting Without Flow Reversal: A Report of Two Cases. AMERICAN JOURNAL OF CASE REPORTS 2019; 20:15-20. [PMID: 30606999 PMCID: PMC6330995 DOI: 10.12659/ajcr.912769] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
Case series Patients: Male, 78 • Male, 69 Final Diagnosis: Severe carotid artery stenosis Symptoms: Asymptomatic Medication: — Clinical Procedure: Carotid artery stenting Specialty: Cardiology
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Affiliation(s)
- Mahmoud Assaad
- Department of Cardiology, Providence and Providence Park Hospitals, Southfield, MI, USA
| | - Abeer Berry
- Department of Cardiology, Providence and Providence Park Hospitals, Southfield, MI, USA
| | - Marcel Zughaib
- Department of Cardiology, Providence and Providence Park Hospitals, Southfield, MI, USA
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Gao BL, Xu GQ, Wang ZL, Li TX, Wang YF, Liang XD, Yang BW. Transradial Stenting for Carotid Stenosis in Patients with Bovine Type and Type III Aortic Arch: Experience in 28 Patients. World Neurosurg 2018; 111:e661-e667. [DOI: 10.1016/j.wneu.2017.12.138] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2017] [Revised: 12/20/2017] [Accepted: 12/21/2017] [Indexed: 11/15/2022]
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Bennett KM, Hoch JR, Scarborough JE. Predictors of 30-day postoperative major adverse clinical events after carotid artery stenting: An analysis of the procedure-targeted American College of Surgeons National Surgical Quality Improvement Program. J Vasc Surg 2017; 66:1093-1099. [DOI: 10.1016/j.jvs.2017.04.039] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2017] [Accepted: 04/10/2017] [Indexed: 10/19/2022]
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Müller MD, Ahlhelm FJ, von Hessling A, Doig D, Nederkoorn PJ, Macdonald S, Lyrer PA, van der Lugt A, Hendrikse J, Stippich C, van der Worp HB, Richards T, Brown MM, Engelter ST, Bonati LH. Vascular Anatomy Predicts the Risk of Cerebral Ischemia in Patients Randomized to Carotid Stenting Versus Endarterectomy. Stroke 2017; 48:1285-1292. [PMID: 28400487 DOI: 10.1161/strokeaha.116.014612] [Citation(s) in RCA: 45] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2016] [Revised: 02/23/2017] [Accepted: 02/27/2017] [Indexed: 11/16/2022]
Abstract
BACKGROUND AND PURPOSE Complex vascular anatomy might increase the risk of procedural stroke during carotid artery stenting (CAS). Randomized controlled trial evidence that vascular anatomy should inform the choice between CAS and carotid endarterectomy (CEA) has been lacking. METHODS One-hundred eighty-four patients with symptomatic internal carotid artery stenosis who were randomly assigned to CAS or CEA in the ICSS (International Carotid Stenting Study) underwent magnetic resonance (n=126) or computed tomographic angiography (n=58) at baseline and brain magnetic resonance imaging before and after treatment. We investigated the association between aortic arch configuration, angles of supra-aortic arteries, degree, length of stenosis, and plaque ulceration with the presence of ≥1 new ischemic brain lesion on diffusion-weighted magnetic resonance imaging (DWI+) after treatment. RESULTS Forty-nine of 97 patients in the CAS group (51%) and 14 of 87 in the CEA group (16%) were DWI+ (odds ratio [OR], 6.0; 95% confidence interval [CI], 2.9-12.4; P<0.001). In the CAS group, aortic arch configuration type 2/3 (OR, 2.8; 95% CI, 1.1-7.1; P=0.027) and the degree of the largest internal carotid artery angle (≥60° versus <60°; OR, 4.1; 95% CI, 1.7-10.1; P=0.002) were both associated with DWI+, also after correction for age. No predictors for DWI+ were identified in the CEA group. The DWI+ risk in CAS increased further over CEA if the largest internal carotid artery angle was ≥60° (OR, 11.8; 95% CI, 4.1-34.1) than if it was <60° (OR, 3.4; 95% CI, 1.2-9.8; interaction P=0.035). CONCLUSIONS Complex configuration of the aortic arch and internal carotid artery tortuosity increase the risk of cerebral ischemia during CAS, but not during CEA. Vascular anatomy should be taken into account when selecting patients for stenting. CLINICAL TRIAL REGISTRATION URL: http://www.isrctn.com/ISRCTN25337470. Unique identifier: ISRCTN25337470.
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Affiliation(s)
- Mandy D Müller
- From the Department of Neurology and Stroke Center (M.D.M., P.A.L., S.T.E., L.H.B.) and Division of Diagnostic and Interventional Neuroradiology (F.J.A., A.v.H., C.S.), University Hospital Basel, Switzerland; Stroke Research Centre, Department of Brain Repair and Rehabilitation, UCL Institute of Neurology (D.D., M.M.B., L.H.B.) and Division of Surgery and Interventional Science (T.R.), University College London, United Kingdom; Department of Neurology, Academic Medical Center Amsterdam, the Netherlands (P.J.N.); Department of Radiology, Freeman Hospital, Newcastle-upon-Tyne, United Kingdom (S.M.); Department of Radiology, Erasmus MC, University Medical Center Rotterdam, the Netherlands (A.v.d.L.); Department of Radiology (J.H.) and Department of Neurology and Neurosurgery, Brain Center Rudolf Magnus (H.B.v.d.W.), University Medical Center Utrecht, the Netherlands; and Neurorehabilitation Unit, University of Basel and University Center for Medicine of Aging, Felix Platter Hospital, Switzerland (S.T.E.)
| | - Frank J Ahlhelm
- From the Department of Neurology and Stroke Center (M.D.M., P.A.L., S.T.E., L.H.B.) and Division of Diagnostic and Interventional Neuroradiology (F.J.A., A.v.H., C.S.), University Hospital Basel, Switzerland; Stroke Research Centre, Department of Brain Repair and Rehabilitation, UCL Institute of Neurology (D.D., M.M.B., L.H.B.) and Division of Surgery and Interventional Science (T.R.), University College London, United Kingdom; Department of Neurology, Academic Medical Center Amsterdam, the Netherlands (P.J.N.); Department of Radiology, Freeman Hospital, Newcastle-upon-Tyne, United Kingdom (S.M.); Department of Radiology, Erasmus MC, University Medical Center Rotterdam, the Netherlands (A.v.d.L.); Department of Radiology (J.H.) and Department of Neurology and Neurosurgery, Brain Center Rudolf Magnus (H.B.v.d.W.), University Medical Center Utrecht, the Netherlands; and Neurorehabilitation Unit, University of Basel and University Center for Medicine of Aging, Felix Platter Hospital, Switzerland (S.T.E.)
| | - Alexander von Hessling
- From the Department of Neurology and Stroke Center (M.D.M., P.A.L., S.T.E., L.H.B.) and Division of Diagnostic and Interventional Neuroradiology (F.J.A., A.v.H., C.S.), University Hospital Basel, Switzerland; Stroke Research Centre, Department of Brain Repair and Rehabilitation, UCL Institute of Neurology (D.D., M.M.B., L.H.B.) and Division of Surgery and Interventional Science (T.R.), University College London, United Kingdom; Department of Neurology, Academic Medical Center Amsterdam, the Netherlands (P.J.N.); Department of Radiology, Freeman Hospital, Newcastle-upon-Tyne, United Kingdom (S.M.); Department of Radiology, Erasmus MC, University Medical Center Rotterdam, the Netherlands (A.v.d.L.); Department of Radiology (J.H.) and Department of Neurology and Neurosurgery, Brain Center Rudolf Magnus (H.B.v.d.W.), University Medical Center Utrecht, the Netherlands; and Neurorehabilitation Unit, University of Basel and University Center for Medicine of Aging, Felix Platter Hospital, Switzerland (S.T.E.)
| | - David Doig
- From the Department of Neurology and Stroke Center (M.D.M., P.A.L., S.T.E., L.H.B.) and Division of Diagnostic and Interventional Neuroradiology (F.J.A., A.v.H., C.S.), University Hospital Basel, Switzerland; Stroke Research Centre, Department of Brain Repair and Rehabilitation, UCL Institute of Neurology (D.D., M.M.B., L.H.B.) and Division of Surgery and Interventional Science (T.R.), University College London, United Kingdom; Department of Neurology, Academic Medical Center Amsterdam, the Netherlands (P.J.N.); Department of Radiology, Freeman Hospital, Newcastle-upon-Tyne, United Kingdom (S.M.); Department of Radiology, Erasmus MC, University Medical Center Rotterdam, the Netherlands (A.v.d.L.); Department of Radiology (J.H.) and Department of Neurology and Neurosurgery, Brain Center Rudolf Magnus (H.B.v.d.W.), University Medical Center Utrecht, the Netherlands; and Neurorehabilitation Unit, University of Basel and University Center for Medicine of Aging, Felix Platter Hospital, Switzerland (S.T.E.)
| | - Paul J Nederkoorn
- From the Department of Neurology and Stroke Center (M.D.M., P.A.L., S.T.E., L.H.B.) and Division of Diagnostic and Interventional Neuroradiology (F.J.A., A.v.H., C.S.), University Hospital Basel, Switzerland; Stroke Research Centre, Department of Brain Repair and Rehabilitation, UCL Institute of Neurology (D.D., M.M.B., L.H.B.) and Division of Surgery and Interventional Science (T.R.), University College London, United Kingdom; Department of Neurology, Academic Medical Center Amsterdam, the Netherlands (P.J.N.); Department of Radiology, Freeman Hospital, Newcastle-upon-Tyne, United Kingdom (S.M.); Department of Radiology, Erasmus MC, University Medical Center Rotterdam, the Netherlands (A.v.d.L.); Department of Radiology (J.H.) and Department of Neurology and Neurosurgery, Brain Center Rudolf Magnus (H.B.v.d.W.), University Medical Center Utrecht, the Netherlands; and Neurorehabilitation Unit, University of Basel and University Center for Medicine of Aging, Felix Platter Hospital, Switzerland (S.T.E.)
| | - Sumaira Macdonald
- From the Department of Neurology and Stroke Center (M.D.M., P.A.L., S.T.E., L.H.B.) and Division of Diagnostic and Interventional Neuroradiology (F.J.A., A.v.H., C.S.), University Hospital Basel, Switzerland; Stroke Research Centre, Department of Brain Repair and Rehabilitation, UCL Institute of Neurology (D.D., M.M.B., L.H.B.) and Division of Surgery and Interventional Science (T.R.), University College London, United Kingdom; Department of Neurology, Academic Medical Center Amsterdam, the Netherlands (P.J.N.); Department of Radiology, Freeman Hospital, Newcastle-upon-Tyne, United Kingdom (S.M.); Department of Radiology, Erasmus MC, University Medical Center Rotterdam, the Netherlands (A.v.d.L.); Department of Radiology (J.H.) and Department of Neurology and Neurosurgery, Brain Center Rudolf Magnus (H.B.v.d.W.), University Medical Center Utrecht, the Netherlands; and Neurorehabilitation Unit, University of Basel and University Center for Medicine of Aging, Felix Platter Hospital, Switzerland (S.T.E.)
| | - Philippe A Lyrer
- From the Department of Neurology and Stroke Center (M.D.M., P.A.L., S.T.E., L.H.B.) and Division of Diagnostic and Interventional Neuroradiology (F.J.A., A.v.H., C.S.), University Hospital Basel, Switzerland; Stroke Research Centre, Department of Brain Repair and Rehabilitation, UCL Institute of Neurology (D.D., M.M.B., L.H.B.) and Division of Surgery and Interventional Science (T.R.), University College London, United Kingdom; Department of Neurology, Academic Medical Center Amsterdam, the Netherlands (P.J.N.); Department of Radiology, Freeman Hospital, Newcastle-upon-Tyne, United Kingdom (S.M.); Department of Radiology, Erasmus MC, University Medical Center Rotterdam, the Netherlands (A.v.d.L.); Department of Radiology (J.H.) and Department of Neurology and Neurosurgery, Brain Center Rudolf Magnus (H.B.v.d.W.), University Medical Center Utrecht, the Netherlands; and Neurorehabilitation Unit, University of Basel and University Center for Medicine of Aging, Felix Platter Hospital, Switzerland (S.T.E.)
| | - Aad van der Lugt
- From the Department of Neurology and Stroke Center (M.D.M., P.A.L., S.T.E., L.H.B.) and Division of Diagnostic and Interventional Neuroradiology (F.J.A., A.v.H., C.S.), University Hospital Basel, Switzerland; Stroke Research Centre, Department of Brain Repair and Rehabilitation, UCL Institute of Neurology (D.D., M.M.B., L.H.B.) and Division of Surgery and Interventional Science (T.R.), University College London, United Kingdom; Department of Neurology, Academic Medical Center Amsterdam, the Netherlands (P.J.N.); Department of Radiology, Freeman Hospital, Newcastle-upon-Tyne, United Kingdom (S.M.); Department of Radiology, Erasmus MC, University Medical Center Rotterdam, the Netherlands (A.v.d.L.); Department of Radiology (J.H.) and Department of Neurology and Neurosurgery, Brain Center Rudolf Magnus (H.B.v.d.W.), University Medical Center Utrecht, the Netherlands; and Neurorehabilitation Unit, University of Basel and University Center for Medicine of Aging, Felix Platter Hospital, Switzerland (S.T.E.)
| | - Jeroen Hendrikse
- From the Department of Neurology and Stroke Center (M.D.M., P.A.L., S.T.E., L.H.B.) and Division of Diagnostic and Interventional Neuroradiology (F.J.A., A.v.H., C.S.), University Hospital Basel, Switzerland; Stroke Research Centre, Department of Brain Repair and Rehabilitation, UCL Institute of Neurology (D.D., M.M.B., L.H.B.) and Division of Surgery and Interventional Science (T.R.), University College London, United Kingdom; Department of Neurology, Academic Medical Center Amsterdam, the Netherlands (P.J.N.); Department of Radiology, Freeman Hospital, Newcastle-upon-Tyne, United Kingdom (S.M.); Department of Radiology, Erasmus MC, University Medical Center Rotterdam, the Netherlands (A.v.d.L.); Department of Radiology (J.H.) and Department of Neurology and Neurosurgery, Brain Center Rudolf Magnus (H.B.v.d.W.), University Medical Center Utrecht, the Netherlands; and Neurorehabilitation Unit, University of Basel and University Center for Medicine of Aging, Felix Platter Hospital, Switzerland (S.T.E.)
| | - Christoph Stippich
- From the Department of Neurology and Stroke Center (M.D.M., P.A.L., S.T.E., L.H.B.) and Division of Diagnostic and Interventional Neuroradiology (F.J.A., A.v.H., C.S.), University Hospital Basel, Switzerland; Stroke Research Centre, Department of Brain Repair and Rehabilitation, UCL Institute of Neurology (D.D., M.M.B., L.H.B.) and Division of Surgery and Interventional Science (T.R.), University College London, United Kingdom; Department of Neurology, Academic Medical Center Amsterdam, the Netherlands (P.J.N.); Department of Radiology, Freeman Hospital, Newcastle-upon-Tyne, United Kingdom (S.M.); Department of Radiology, Erasmus MC, University Medical Center Rotterdam, the Netherlands (A.v.d.L.); Department of Radiology (J.H.) and Department of Neurology and Neurosurgery, Brain Center Rudolf Magnus (H.B.v.d.W.), University Medical Center Utrecht, the Netherlands; and Neurorehabilitation Unit, University of Basel and University Center for Medicine of Aging, Felix Platter Hospital, Switzerland (S.T.E.)
| | - H Bart van der Worp
- From the Department of Neurology and Stroke Center (M.D.M., P.A.L., S.T.E., L.H.B.) and Division of Diagnostic and Interventional Neuroradiology (F.J.A., A.v.H., C.S.), University Hospital Basel, Switzerland; Stroke Research Centre, Department of Brain Repair and Rehabilitation, UCL Institute of Neurology (D.D., M.M.B., L.H.B.) and Division of Surgery and Interventional Science (T.R.), University College London, United Kingdom; Department of Neurology, Academic Medical Center Amsterdam, the Netherlands (P.J.N.); Department of Radiology, Freeman Hospital, Newcastle-upon-Tyne, United Kingdom (S.M.); Department of Radiology, Erasmus MC, University Medical Center Rotterdam, the Netherlands (A.v.d.L.); Department of Radiology (J.H.) and Department of Neurology and Neurosurgery, Brain Center Rudolf Magnus (H.B.v.d.W.), University Medical Center Utrecht, the Netherlands; and Neurorehabilitation Unit, University of Basel and University Center for Medicine of Aging, Felix Platter Hospital, Switzerland (S.T.E.)
| | - Toby Richards
- From the Department of Neurology and Stroke Center (M.D.M., P.A.L., S.T.E., L.H.B.) and Division of Diagnostic and Interventional Neuroradiology (F.J.A., A.v.H., C.S.), University Hospital Basel, Switzerland; Stroke Research Centre, Department of Brain Repair and Rehabilitation, UCL Institute of Neurology (D.D., M.M.B., L.H.B.) and Division of Surgery and Interventional Science (T.R.), University College London, United Kingdom; Department of Neurology, Academic Medical Center Amsterdam, the Netherlands (P.J.N.); Department of Radiology, Freeman Hospital, Newcastle-upon-Tyne, United Kingdom (S.M.); Department of Radiology, Erasmus MC, University Medical Center Rotterdam, the Netherlands (A.v.d.L.); Department of Radiology (J.H.) and Department of Neurology and Neurosurgery, Brain Center Rudolf Magnus (H.B.v.d.W.), University Medical Center Utrecht, the Netherlands; and Neurorehabilitation Unit, University of Basel and University Center for Medicine of Aging, Felix Platter Hospital, Switzerland (S.T.E.)
| | - Martin M Brown
- From the Department of Neurology and Stroke Center (M.D.M., P.A.L., S.T.E., L.H.B.) and Division of Diagnostic and Interventional Neuroradiology (F.J.A., A.v.H., C.S.), University Hospital Basel, Switzerland; Stroke Research Centre, Department of Brain Repair and Rehabilitation, UCL Institute of Neurology (D.D., M.M.B., L.H.B.) and Division of Surgery and Interventional Science (T.R.), University College London, United Kingdom; Department of Neurology, Academic Medical Center Amsterdam, the Netherlands (P.J.N.); Department of Radiology, Freeman Hospital, Newcastle-upon-Tyne, United Kingdom (S.M.); Department of Radiology, Erasmus MC, University Medical Center Rotterdam, the Netherlands (A.v.d.L.); Department of Radiology (J.H.) and Department of Neurology and Neurosurgery, Brain Center Rudolf Magnus (H.B.v.d.W.), University Medical Center Utrecht, the Netherlands; and Neurorehabilitation Unit, University of Basel and University Center for Medicine of Aging, Felix Platter Hospital, Switzerland (S.T.E.)
| | - Stefan T Engelter
- From the Department of Neurology and Stroke Center (M.D.M., P.A.L., S.T.E., L.H.B.) and Division of Diagnostic and Interventional Neuroradiology (F.J.A., A.v.H., C.S.), University Hospital Basel, Switzerland; Stroke Research Centre, Department of Brain Repair and Rehabilitation, UCL Institute of Neurology (D.D., M.M.B., L.H.B.) and Division of Surgery and Interventional Science (T.R.), University College London, United Kingdom; Department of Neurology, Academic Medical Center Amsterdam, the Netherlands (P.J.N.); Department of Radiology, Freeman Hospital, Newcastle-upon-Tyne, United Kingdom (S.M.); Department of Radiology, Erasmus MC, University Medical Center Rotterdam, the Netherlands (A.v.d.L.); Department of Radiology (J.H.) and Department of Neurology and Neurosurgery, Brain Center Rudolf Magnus (H.B.v.d.W.), University Medical Center Utrecht, the Netherlands; and Neurorehabilitation Unit, University of Basel and University Center for Medicine of Aging, Felix Platter Hospital, Switzerland (S.T.E.)
| | - Leo H Bonati
- From the Department of Neurology and Stroke Center (M.D.M., P.A.L., S.T.E., L.H.B.) and Division of Diagnostic and Interventional Neuroradiology (F.J.A., A.v.H., C.S.), University Hospital Basel, Switzerland; Stroke Research Centre, Department of Brain Repair and Rehabilitation, UCL Institute of Neurology (D.D., M.M.B., L.H.B.) and Division of Surgery and Interventional Science (T.R.), University College London, United Kingdom; Department of Neurology, Academic Medical Center Amsterdam, the Netherlands (P.J.N.); Department of Radiology, Freeman Hospital, Newcastle-upon-Tyne, United Kingdom (S.M.); Department of Radiology, Erasmus MC, University Medical Center Rotterdam, the Netherlands (A.v.d.L.); Department of Radiology (J.H.) and Department of Neurology and Neurosurgery, Brain Center Rudolf Magnus (H.B.v.d.W.), University Medical Center Utrecht, the Netherlands; and Neurorehabilitation Unit, University of Basel and University Center for Medicine of Aging, Felix Platter Hospital, Switzerland (S.T.E.).
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Lanza G, Setacci C, Ricci S, Castelli P, Cremonesi A, Lanza J, Novali C, Pratesi C, Santalucia P, Speziale F, Zaninelli A, Gensini GF. An update of the Italian Stroke Organization–Stroke Prevention Awareness Diffusion Group guidelines on carotid endarterectomy and stenting: A personalized medicine approach. Int J Stroke 2017; 12:560-567. [DOI: 10.1177/1747493017694395] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Although proof-based medicine has generated much valid evidence for the drawing up of guidelines and recommendations for best clinical practice in symptomatic and asymptomatic carotid stenosis, whether and when it is better to employ endarterectomy or stenting as the intervention of choice still remain matters of debate. Moreover, guidelines have been targeted up to now to the ‘representative’ patient, as resulting from the statistical analyses of the studies conducted on the safety and efficacy of both interventions as well as on medical therapy alone. The Italian Stroke Organization (ISO) and Stroke Prevention and Awareness Diffusion (SPREAD) group has thus decided to update its statements for an 8th edition. To this end, a multidisciplinary team of authors representing Italian scientific societies in the neurology, neuroradiology, vascular and endovascular surgery, interventional cardiology, and general medicine fields re-examined the literature available on stroke. Analyses and considerations on patient subgroups have allowed to model the risks/benefits of endarterectomy and stenting in the individual. Accordingly, the guideline's original methodology has been revised to follow the new SIGN (Scottish Intercollegiate Guideline Network) Grade-like approach, integrating it with new considerations on Precision, or Personalized Medicine. Therefore, this guideline offers recommendations on precision medicine for the single patient, and can be followed in addition to the more standard guidelines.
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Affiliation(s)
- Gaetano Lanza
- Department of Vascular Surgery, IRCCS MultiMedica Hospital, Castellanza, Italy
| | - Carlo Setacci
- Department of Surgery, University of Siena, Siena, Italy
| | - Stefano Ricci
- Department of Neurology, ASL 1, Città di Castello e Branca, Italy
| | - Patrizio Castelli
- Department of Surgical Sciences, University of Insubria, Varese, Italy
| | - Alberto Cremonesi
- Department of Medical and Surgical Cardiology, Cecilia Hospital, Cotignola, Italy
| | - Jessica Lanza
- Department of Vascular Surgery, University of Pavia, Pavia, Italy
| | - Claudio Novali
- Department of Vascular Surgery, S. Croce e Carle Hospital, Cuneo, Italy
| | - Carlo Pratesi
- Department of Vascular Surgery, University of Florence, Florence, Italy
| | - Paola Santalucia
- Scientific Direction and Emergency Medicine Department, Fondazione IRCCS Cà Granda Ospedale Maggiore Policlinico, Milan, Italy
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Garg PK, Koh WJH, Delaney JA, Halm EA, Hirsch CH, Longstreth WT, Mukamal KJ, Kucharska-Newton A, Polak JF, Curtis L. Risk Factors for Incident Carotid Artery Revascularization among Older Adults: The Cardiovascular Health Study. Cerebrovasc Dis Extra 2016; 6:129-139. [PMID: 27846618 PMCID: PMC5836156 DOI: 10.1159/000452426] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2016] [Accepted: 10/04/2016] [Indexed: 12/04/2022] Open
Abstract
Background Population-based risk factors for carotid artery revascularization are not known. We investigated the association between demographic and clinical characteristics and incident carotid artery revascularization in a cohort of older adults. Methods Among Cardiovascular Health Study participants, a population-based cohort of 5,888 adults aged 65 years or older enrolled in two waves (1989–1990 and 1992–1993), 5,107 participants without a prior history of carotid endarterectomy (CEA) or cerebrovascular disease had a carotid ultrasound at baseline and were included in these analyses. Cox proportional hazards multivariable analysis was used to determine independent risk factors for incident carotid artery revascularization. Results Over a mean follow-up of 13.5 years, 141 participants underwent carotid artery revascularization, 97% were CEA. Baseline degree of stenosis and incident ischemic cerebral events occurring during follow-up were the strongest predictors of incident revascularization. After adjustment for these, factors independently associated with an increased risk of incident revascularization were: hypertension (HR 1.53; 95% CI: 1.05–2.23), peripheral arterial disease (HR 2.57; 95% CI: 1.34–4.93), and low-density lipoprotein cholesterol (HR 1.23 per standard deviation [SD] increment [35.4 mg/dL]; 95% CI: 1.04–1.46). Factors independently associated with a lower risk of incident revascularization were: female gender (HR 0.51; 95% CI: 0.34–0.77) and older age (HR 0.69 per SD increment [5.5 years]; 95% CI: 0.56–0.86). Conclusions Even after accounting for carotid stenosis and incident cerebral ischemic events, carotid revascularization is related to age, gender, and cardiovascular risk factors. Further study of these demographic disparities and the role of risk factor control is warranted.
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Affiliation(s)
- Parveen K Garg
- Division of Cardiology, University of Southern California Keck School of Medicine, Los Angeles, CA, USA
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Abstract
Because stroke is the third leading disease that causes mortality in the world, the prevention of stroke from advanced carotid stenosis is an important issue. The carotid stent (CAS) is a less invasive to treat advanced carotid stenosis, but for high-risk patients it may cause some events after the procedure that reduces the benefit of stroke prevention. Because patients and their families have less information about risk of events after CAS and are easy concerned, this study calculates the individual probability of major adverse cardiovascular events including any stroke, myocardial infarction, or death after procedure.The analyzed dataset was composed of patients undergoing CAS from the longitudinal National Health Insurance claim database in Taiwan. The validation dataset was composed of patients undergoing CAS from the Tri-Service General Hospital. We excluded patients under 18 years of age. The prediction model was constructed with a multivariable Cox proportional hazard regression and performed with forward stepwise selection. The nomogram construction was based on the multivariable Cox model.The risk factors were determined as follows: age with a hazard ratio (HR) of 1.027 (95% confidence interval [CI]: 1.002-1.053) for every 1 year older, congestive heart failure with a HR of 2.196 (95% CI: 1.368-3.524), malignant disease with a HR of 1.724 (95% CI: 1.009-2.944), diabetes mellitus with a HR of 1.722 (95% CI: 1.109-2.674), and symptomatic status with a HR of 1.604 (95% CI: 1.027-2.507). The model showed good discrimination with a P < 0.001 (concordance index, 0.681; bootstrap corrected, 0.661) in the derivation data. The concordance index of external validation was 0.66 (P = 0.048), which indicates acceptable performance.We developed a nomogram with a visual scale method and prognostic information, and it is easy to use in clinical practice. The integer-base method may support communication between clinicians and patients before CAS to reduce the anxiety about making a treatment decision. However, insofar as older patients with multiple comorbidities are at high risk, the option of an alternative treatment strategy with medical therapy should be suggested. In the future, prospective tests should be performed to validate whether this model helps patients to prevent events.
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Affiliation(s)
- Chun-An Cheng
- Graduate Institute of Biomedical Informatics, Taipei Medical University
- Department of Neurology, Tri-Service General Hospital, National Defense Medical Center
| | - Wu-Chien Chien
- Department of Medical Research, Tri-Service General Hospital, National Defense Medical Center
- School of Public Health, National Defense Medical Center
| | - Chien-Yeh Hsu
- Department of Information Management, National Taipei University of Nursing and Health Sciences, Taipei, Taiwan, ROC
| | - Hui-Chen Lin
- Department of Neurology, Tri-Service General Hospital, National Defense Medical Center
| | - Hung-Wen Chiu
- Graduate Institute of Biomedical Informatics, Taipei Medical University
- Correspondence: Hung-Wen Chiu, Graduate Institute of Biomedical Informatics, Taipei Medical University, No. 250 Wu-Hsing Street, Taipei 110, Taiwan, ROC (e-mail: )
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Wayangankar S, Kapadia S, Bajzer C. Carotid Artery Stenting: 2016 and Beyond. CARDIOVASCULAR INNOVATIONS AND APPLICATIONS 2016. [DOI: 10.15212/cvia.2016.0015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
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Howard G, Roubin GS, Jansen O, Hendrikse J, Halliday A, Fraedrich G, Eckstein HH, Calvet D, Bulbulia R, Bonati LH, Becquemin JP, Algra A, Brown MM, Ringleb PA, Brott TG, Mas JL. Association between age and risk of stroke or death from carotid endarterectomy and carotid stenting: a meta-analysis of pooled patient data from four randomised trials. Lancet 2016; 387:1305-11. [PMID: 26880122 DOI: 10.1016/s0140-6736(15)01309-4] [Citation(s) in RCA: 132] [Impact Index Per Article: 16.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
BACKGROUND Age was reported to be an effect-modifier in four randomised controlled trials comparing carotid artery stenting (CAS) and carotid endarterectomy (CEA), with better CEA outcomes than CAS outcomes noted in the more elderly patients. We aimed to describe the association of age with treatment differences in symptomatic patients and provide age-specific estimates of the risk of stroke and death within narrow (5 year) age groups. METHODS In this meta-analysis, we analysed individual patient-level data from four randomised controlled trials within the Carotid Stenosis Trialists' Collaboration (CSTC) involving patients with symptomatic carotid stenosis. We included only trials that randomly assigned patients to CAS or CEA and only patients with symptomatic stenosis. We assessed rates of stroke or death in 5-year age groups in the periprocedural period (between randomisation and 120 days) and ipsilateral stroke during long-term follow-up for patients assigned to CAS or CEA. We also assessed differences between CAS and CEA. All analyses were done on an intention-to-treat basis. FINDINGS Collectively, 4754 patients were randomly assigned to either CEA or CAS treatment in the four studies. 433 events occurred over a median follow-up of 2·7 years. For patients assigned to CAS, the periprocedural hazard ratio (HR) for stroke and death in patients aged 65-69 years compared with patients younger than 60 years was 2·16 (95% CI 1·13-4·13), with HRs of roughly 4·0 for patients aged 70 years or older. We noted no evidence of an increased periprocedural risk by age group in the CEA group (p=0·34). These changes underpinned a CAS-versus CEA periprocedural HR of 1·61 (95% CI 0·90-2·88) for patients aged 65-69 years and an HR of 2·09 (1·32-3·32) for patients aged 70-74 years. Age was not associated with the postprocedural stroke risk either within treatment group (p≥0·09 for CAS and 0·83 for CEA), or between treatment groups (p=0·84). INTERPRETATION In these RCTs, CEA was clearly superior to CAS in patients aged 70-74 years and older. The difference in older patients was almost wholly attributable to increasing periprocedural stroke risk in patients treated with CAS. Age had little effect on CEA periprocedural risk or on postprocedural risk after either procedure. FUNDING None.
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Affiliation(s)
- George Howard
- Department of Biostatistics, UAB School of Public Health, Birmingham, AL, USA.
| | - Gary S Roubin
- Cardiovascular Associates of the Southeast, Birmingham, AL, USA
| | - Olav Jansen
- Clinic for Radiology and Neuroradiology, UKSH Campus Kiel, Kiel, Germany
| | - Jeroen Hendrikse
- Department of Radiology, University Medical Center Utrecht, Utrecht, Netherlands
| | - Alison Halliday
- Nuffield Department of Surgical Sciences, John Radcliffe Hospital, Oxford, UK
| | - Gustav Fraedrich
- Department of Vascular Surgery, Medical University of Innsbruck, Innsbruck, Austria
| | - Hans-Henning Eckstein
- Department of Vascular and Endovascular Surgery, Vascular Center, Klinikum rechts der Isar der Technischen Universität München, Munich, Germany
| | - David Calvet
- Department of Neurology, Hôpital Sainte-Anne, Université Paris-Descartes, DHU Neurovasc Sorbonne Paris Cité, INSERM U894, Paris, France
| | - Richard Bulbulia
- Clinical Trial Service Unit and Epidemiological Studies Unit, Oxford University, Oxford, UK
| | - Leo H Bonati
- Department of Neurology and Stroke Center, University Hospital Basel, Basel, Switzerland; Department of Brain Repair and Rehabilitation, UCL Institute of Neurology, University College London, London, UK
| | - Jean-Pierre Becquemin
- Department of Vascular Surgery, University of Paris, XII, Hôpital Henri Mondor, Paris, France
| | - Ale Algra
- Department of Neurology and Neurosurgery, Brain Center Rudolf Magnus and Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, Netherlands
| | - Martin M Brown
- Department of Brain Repair and Rehabilitation, UCL Institute of Neurology, University College London, London, UK
| | - Peter A Ringleb
- Department of Neurology, University of Heidelberg Medical School, Heidelberg, Germany
| | - Thomas G Brott
- Department of Neurology, Mayo Clinic, Jacksonville, FL, USA
| | - Jean-Louis Mas
- Department of Neurology, Hôpital Sainte-Anne, Université Paris-Descartes, DHU Neurovasc Sorbonne Paris Cité, INSERM U894, Paris, France
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Jang EW, Chung J, Seo KD, Suh SH, Kim YB, Lee KY. A Protocol-Based Decision for Choosing a Proper Surgical Treatment Option for Carotid Artery Stenosis. J Cerebrovasc Endovasc Neurosurg 2015; 17:101-7. [PMID: 26157689 PMCID: PMC4495083 DOI: 10.7461/jcen.2015.17.2.101] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2014] [Revised: 10/27/2014] [Accepted: 04/29/2015] [Indexed: 11/23/2022] Open
Abstract
OBJECTIVE There are two established surgical treatment options for carotid artery stenosis. Carotid endarterectomy (CEA) has been accepted as a gold standard for surgical treatment while carotid artery stenting (CAS) has recently become an alternative option. Each treatment option has advantages and disadvantages for the treatment outcomes. We propose a protocol for selection of a proper surgical treatment option for carotid artery stenosis. MATERIALS AND METHODS A total of 192 published articles on management of carotid artery stenosis were reviewed. Preoperatively considerable factors which had been repeatedly noted in those articles for the risk/benefits of CEA or CAS were selected. According to those factors, a protocol with four categories was established. RESULTS CEA or CAS is indicated when the patient has a symptomatic stenosis ≥ 50%, or when the patient has an asymptomatic stenosis ≥ 80%. Each treatment option has absolute indications and favorable indications. Each absolute indication is scored with three points, and each favorable indication, one point. Based on the highest scores, a proper treatment option (CEA or CAS) is selected. CONCLUSION We have been treating patients according to this protocol and evaluating the outcomes of our protocol-based decision because this protocol might be helpful in assessment of risk/benefit for selection of a proper surgical treatment option in patients with carotid artery stenosis.
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Affiliation(s)
- E-Wook Jang
- Department of Neurosurgery, Cerebrovascular Center, Gangnam Severance Hospital, Seoul, Korea
| | - Joonho Chung
- Department of Neurosurgery, Cerebrovascular Center, Gangnam Severance Hospital, Seoul, Korea
- Severance Institute for Vascular and Metabolic Research, Yonsei University College of Medicine, Seoul, Korea
| | - Kwon-Duk Seo
- Department of Neurology, Cerebrovascular Center, Gangnam Severance Hospital, Seoul, Korea
| | - Sang Hyun Suh
- Department of Radiology, Cerebrovascular Center, Gangnam Severance Hospital, Seoul, Korea
- Severance Institute for Vascular and Metabolic Research, Yonsei University College of Medicine, Seoul, Korea
| | - Yong Bae Kim
- Department of Neurosurgery, Cerebrovascular Center, Gangnam Severance Hospital, Seoul, Korea
- Severance Institute for Vascular and Metabolic Research, Yonsei University College of Medicine, Seoul, Korea
| | - Kyung-Yul Lee
- Department of Neurology, Cerebrovascular Center, Gangnam Severance Hospital, Seoul, Korea
- Severance Institute for Vascular and Metabolic Research, Yonsei University College of Medicine, Seoul, Korea
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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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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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Lanza G, Ricci S, Setacci C, Castelli P, Novalil C, Pratesi C, Speziale F, Cremonesi A, Morlacchi E, Lanza J, Santalucia P, Zaninelli A, Gensini GF. An Update on Italian Stroke Organization Guidelines on Carotid Endarterectomy and Stenting. Int J Stroke 2014; 9 Suppl A100:14-9. [DOI: 10.1111/ijs.12226] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2013] [Accepted: 10/29/2013] [Indexed: 11/29/2022]
Abstract
One hundred and fifty-three authors, 45 Italian scientific societies, and two Italian patients' associations participated in drafting the Italian Stroke Organization document, which has become the national guideline for the prevention and treatment of stroke in Italy. For the surgical therapy section of the Italian Stroke Organization document, the main trials on carotid endoarterectomy and stenting were critically reviewed in order to formulate recommendations for these procedures. Recommendations are presented here for the referral of patients to either carotid endarterectomy or stenting on the basis of whether carotid stenosis is symptomatic or asymptomatic.
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Affiliation(s)
- Gaetano Lanza
- Department of Vascular Surgery, IRCCS MultiMedica Hospital, Castellanza, Italy
| | - Stefano Ricci
- Department of Neurology, ASL 1, Città di Castello e Branca, Italy
| | - Carlo Setacci
- Vascular Endovascular Surgery Unit, Department of Surgery, University of Siena, Siena, Italy
| | - Patrizio Castelli
- Vascular Endovascular Surgery Unit, Department of Surgical Sciences, University of Insubria, Varese, Italy
| | - Claudio Novalil
- Department of Vascular Surgery, S. Croce e Carle Hospital, Cuneo, Italy
| | - Carlo Pratesi
- Department of Vascular Surgery, University of Florence, Florence, Italy
| | - Francesco Speziale
- Vascular Surgery Department, Policlinico Umberto I, ‘La Sapienza’ University, Rome, Italy
| | - Alberto Cremonesi
- Department of Medical and Surgical Cardiology, Cecilia Hospital, Cotignola, Ravenna, Italy
| | - Ernesto Morlacchi
- Department of Vascular Surgery, IRCCS MultiMedica Hospital, Castellanza, Italy
| | - Jessica Lanza
- Vascular Endovascular Surgery Unit, Department of Surgical Sciences, University of Insubria, Varese, Italy
| | - Paola Santalucia
- Scientific Direction and Emergency Medicine Department, Fondazione IRCCS Cà Granda Ospedale Maggiore Policlinico, Milan, Italy
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29
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Hamann GF. [Prediction in cerebrovascular diseases]. DER NERVENARZT 2014; 85:1269-1279. [PMID: 25292162 DOI: 10.1007/s00115-014-4063-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/03/2023]
Abstract
Prediction of the outcome of cerebrovascular diseases or of the effects and complications of various forms of treatment are essential components of all stroke treatment regimens. This review focuses on the prediction of the stroke risk in primary prevention, the prediction of the risk of secondary stroke following a transient ischemic attack (TIA), the estimation of the outcome following manifest stroke and the treatment effects, the prediction of secondary cerebrovascular events and the prediction of vascular cognitive impairment following stroke. All predictive activities in cerebrovascular disease are hindered by the translation of predictive results from studies and patient populations to the individual patient. Future efforts in genetic analyses may be able to overcome this barrier and to enable individual prediction in the area of so-called personalized medicine. In all the various fields of prediction in cerebrovascular diseases, three major variables are always important: age of the patient, severity and subtype of the stroke. Increasing age, more severe stroke symptoms and the cardioembolic stroke subtype predict a poor outcome regarding both survival and permanent disability. This finding is somewhat banal and will therefore never replace the well experienced clinician judging the chances of a patient and taking into account the personal situation of this patient, e.g. for initiation of a rehabilitation program. Besides the individualized prediction, in times of restricted economic resources and increasing tendency to clarify questions of medical treatment in court, it seems unavoidable to use prediction in economic and medicolegal interaction with clinical medicine. This tendency will be accompanied by difficult ethical problems which neurologists must be aware of. Improved prediction should not be used to allocate or restrict resources or to restrict medically indicated treatment.
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Affiliation(s)
- G F Hamann
- Klinik für Neurologie und Neurologische Rehabilitation, Bezirkskrankenhaus Günzburg, Ludwig-Heilmeyer Str. 2, 89132, Günzburg, Deutschland,
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Morgan CE, Lee CJ, Chin JA, Eskandari MK, Morasch MD, Rodriguez HE, Helenowski IB, Kibbe MR. High-Risk Anatomic Variables and Plaque Characteristics in Carotid Artery Stenting. Vasc Endovascular Surg 2014; 48:452-9. [DOI: 10.1177/1538574414551577] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Objectives: To determine anatomic and plaque-related risk factors for patients undergoing carotid artery stenting. Methods: A retrospective review of patients from a prospectively maintained database undergoing carotid artery stenting at our institution between 2001 and 2010 was performed. Preoperative imaging studies (ie, ultrasound, computed tomography angiography, magnetic resonance angiography, and angiograms) were reviewed for specific anatomic criteria and plaque characteristics. Primary outcomes included 30-day stroke or transient ischemic attack (TIA). Secondary outcomes included 30-day death and myocardial infarction (MI). Statistical significance was assumed for P = .05. Results: Imaging was reviewed for 381 carotid arteries in 375 patients. There were 14 (3.7%) perioperative neurologic events, which included 8 TIA and 6 strokes. Thirty-day mortality and MI were 0.5% and 0.75%, respectively. Degree of internal carotid artery stenosis was associated with primary outcomes ( P = .03), and the presence of arch calcification trended toward an increase in primary outcomes ( P = .07). However, arch type, ostial involvement, tandem lesions, and plaque calcification did not correlate with primary outcomes. Differences were noted between the sexes, with females having more common carotid artery tortuosity than males (34% vs 27%, P = .04). Females also had a trend toward more plaque calcification and more severe arch calcification than males. These differences did not translate to differences in perioperative neurologic events. Conclusion: Our data suggest that degree of internal carotid artery stenosis and aortic arch calcification may be associated with increased perioperative neurologic risk during carotid stenting, but arch type is not.
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Affiliation(s)
- Courtney E. Morgan
- Department of Surgery, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Cheong J. Lee
- Department of Surgery, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Jason A. Chin
- Department of Surgery, Yale University School of Medicine, New Haven, CT, USA
| | - Mark K. Eskandari
- Department of Surgery, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Mark D. Morasch
- Department of Vascular Surgery, St Vincent Healthcare, Billings, MT, USA
| | - Heron E. Rodriguez
- Department of Surgery, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Irene B. Helenowski
- Department of Surgery, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
- Department of Preventative Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Melina R. Kibbe
- Department of Surgery, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
- Department of Vascular Surgery, Jesse Brown Veterans Affairs Medical Center, Chicago, IL, USA
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Lanza G, Setacci C, Cremonesi A, Ricci S, Inzitari D, de Donato G, Castelli P, Pratesi C, Peinetti F, Lanza J, Zaninelli A, Gensini GF. Carotid Artery Stenting: Second Consensus Document of the ICCS/ISO-SPREAD Joint Committee. Cerebrovasc Dis 2014; 38:77-93. [DOI: 10.1159/000365501] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2014] [Accepted: 06/25/2014] [Indexed: 11/19/2022] Open
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Wen T, He S, Attenello F, Cen SY, Kim-Tenser M, Adamczyk P, Amar AP, Sanossian N, Mack WJ. The impact of patient age and comorbidities on the occurrence of "never events" in cerebrovascular surgery: an analysis of the Nationwide Inpatient Sample. J Neurosurg 2014; 121:580-6. [PMID: 24972123 DOI: 10.3171/2014.4.jns131253] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECT As health care administrators focus on patient safety and cost-effectiveness, methodical assessment of quality outcome measures is critical. In 2008 the Centers for Medicare and Medicaid Services (CMS) published a series of "never events" that included 11 hospital-acquired conditions (HACs) for which related costs of treatment are not reimbursed. Cerebrovascular procedures (CVPs) are complex and are often performed in patients with significant medical comorbidities. METHODS This study examines the impact of patient age and medical comorbidities on the occurrence of CMS-defined HACs, as well as the effect of these factors on the length of stay (LOS) and hospitalization charges in patients undergoing common CVPs. RESULTS The HACs occurred at a frequency of 0.49% (1.33% in the intracranial procedures and 0.33% in the carotid procedures). Falls/trauma (n = 4610, 72.3% HACs, 357 HACs per 100,000 CVPs) and catheter-associated urinary tract infections (n = 714, 11.2% HACs, 55 HACs per 100,000 CVPs) were the most common events. Age and the presence of ≥ 2 comorbidities were strong independent predictors of HACs (p < 0.0001). The occurrence of HACs negatively impacts both LOS and hospital costs. Patients with at least 1 HAC were 10 times more likely to have prolonged LOS (≥ 90th percentile) (p < 0.0001), and 8 times more likely to have high inpatient costs (≥ 90th percentile) (p < 0.0001) when adjusting for patient and hospital factors. CONCLUSIONS Improved quality protocols focused on individual patient characteristics might help to decrease the frequency of HACs in this high-risk population. These data suggest that risk adjustment according to underlying patient factors may be warranted when considering reimbursement for costs related to HACs in the setting of CVPs.
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Jimenez-Gomez E, Cano Sánchez A, Oteros Fernández R, Valenzuela Alvarado S, Bravo-Rodriguez F, Delgado Acosta F. Unprotected carotid artery stenting in symptomatic elderly patients: a single-center experience. J Neurointerv Surg 2014; 7:341-5. [DOI: 10.1136/neurintsurg-2014-011131] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2014] [Accepted: 03/14/2014] [Indexed: 11/04/2022]
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35
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Wach MM, Dumont TM, Shakir HJ, Snyder KV, Hopkins LN, Levy EI, Siddiqui AH. Carotid artery stenting in nonagenarians: are there benefits in surgically treating this high risk population? J Neurointerv Surg 2014; 7:182-7. [DOI: 10.1136/neurintsurg-2013-011052] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
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37
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Montorsi P, Galli S, Ravagnani PM, Trabattoni D, Fabbiocchi F, Lualdi A, Ballerini G, Andreini D, Pontone G, Caputi L, Bartorelli AL. Carotid Artery Stenting in Patients With Left ICA Stenosis and Bovine Aortic Arch: A Single-Center Experience in 60 Consecutive Patients Treated Via the Right Radial or Brachial Approach. J Endovasc Ther 2014; 21:127-36. [DOI: 10.1583/13-4491mr.1] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
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Abstract
Symptomatic carotid artery stenosis is an important cause of stroke with significant morbidity and mortality. Revascularization with carotid endarterectomy reduces the recurrence of stroke and until recently was considered the gold standard of therapy. Carotid artery stenting has emerged as an alternative method of revascularization in both high-risk and standard-risk patients. This review appraises the role of surgery versus stenting for patients with symptomatic carotid stenosis.
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Affiliation(s)
- Jun Li
- Department of Medicine, Case Western Reserve University School of Medicine, 11100 Euclid Avenue, Cleveland, OH 44106, USA; Division of Cardiovascular Medicine, Harrington Heart and Vascular Institute, University Hospitals Case Medical Center, 11100 Euclid Avenue, Cleveland, OH 44106, USA
| | - Rahul Sakhuja
- Department of Medicine, Division of Cardiology, Wellmont CVA Heart Institute, 2050 Meadowview Pkwy, Kingsport, TN 37660, USA
| | - Sahil A Parikh
- Department of Medicine, Case Western Reserve University School of Medicine, 11100 Euclid Avenue, Cleveland, OH 44106, USA; Division of Cardiovascular Medicine, Harrington Heart and Vascular Institute, University Hospitals Case Medical Center, 11100 Euclid Avenue, Cleveland, OH 44106, USA.
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Wagdi P. Carotid Artery Stenting 2013: Thumbs up. Cardiol Res 2013; 4:8-14. [PMID: 28348697 PMCID: PMC5358182 DOI: 10.4021/cr253w] [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] [Accepted: 02/19/2013] [Indexed: 11/06/2022] Open
Abstract
It has been customary for interventional cardiologists involved in carotid artery stenting, to underline non-inferiority of the percutaneous technique versus surgical carotid endarterectomy. To that end, all cause morbidity and mortality figures of both methods are compared. Surgery has, in most large randomized studies, had an edge over stenting in terms of cerebrovascular adverse events. This may have partly been due to occasional indiscriminate indication for stenting in lesions and/or vessels with unfavourable characteristics (severe target vessel tortuosity and calcification, Type III aortic arch, and so on). On one hand, the author pleads for improvement of the excellent results of endarterectomy, by subjecting all patients planned for surgery to a thorough preoperative cardiological work up, including generous invasive investigation, thus reducing the incidence of perioperative myocardial infarction, heart failure and cardiac death. On the other hand, we are convinced that the results of carotid stenting should then be compared to best practice surgery. The rate of neurological adverse event rate after carotid endarterectomy at our institution lies under 0.7% at 30 days postoperatively. Specifically, the goal should be that carotid stenting underbids surgical endarterectomy, also and mainly, in terms of cerebral and cerebrovascular adverse events. Cardiac morbidity and mortality as well as laryngeal nerve palsy should no more be the main arguments for the percutaneous approach. This should easily be possible if patient selection for carotid revascularisation would be approached according to morphological criteria, in analogy with the “Syntax”-score used to optimise revascularisation strategies in coronary artery disease.
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Affiliation(s)
- Philipp Wagdi
- Interventional Cardiology, HerzZentrum Hirslanden, Witellikerstrasse 36, 8008 Zurich, Switzerland.
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