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Pagliariccio G, Di Sario I, Capoccia L, D'Elia M, Bafile G, Leopardi M, Fiore F, Palmieri A, Antico L, Antico A. Carotid Near-Occlusion: Surgical or Conservative Management? Retrospective Multicenter Study. Ann Vasc Surg 2024; 102:133-139. [PMID: 38408393 DOI: 10.1016/j.avsg.2023.11.047] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2023] [Revised: 11/14/2023] [Accepted: 11/26/2023] [Indexed: 02/28/2024]
Abstract
BACKGROUND Carotid near-occlusion (CNO) represents an anatomical-functional condition characterized by severe (more than 90%) internal carotid artery stenosis which can lead to a distal lumen diameter greater or less than 2 mm. CNO can be divided into a less severe subgroup (without lumen full collapse: diameter >2 mm) and a more severe subgroup (with lumen full collapse: diameter <2 mm). The decision for revascularization is still highly debated in Literature. The aim of the present multicenter retrospective study is to analyze the incidence of perioperative (30 days) and follow-up complications in 2 groups of patients with or without distal internal carotid lumen full collapse. METHODS Between January 2011 and March 2023, in 5 Vascular Surgery Units, 67 patients (49 male, 73% and 18 females, 27%) with CNO underwent carotid endarterectomy: 28 (41.7%) with lumen diameter <2 mm and 39 (58.3%) with diameter >2 mm. 19 patients were symptomatic and 48 asymptomatic. The outcomes considered for comparative analysis were: perioperative neurological and cardiac complications, carotid restenosis or occlusion at follow-up. Both groups were homogeneous in terms of risk factors, morphological features and pharmacological treatments. RESULTS In the group with lumen <2 mm, 3 perioperative major events (10.7%) occurred (1 ischemic stroke, 1 hemorrhagic stroke, 1 myocardial infarction) and 2 (7.1%) at follow-up (average 11 ± 14.5 months; 1 asymptomatic carotid occlusion, 1 hemodynamic restenosis treated with stenting). No event was recorded in the group with lumen >2 mm. CONCLUSIONS According to our results CNO patients show different complication risk according to the presence or not of distal lumen collapse. The later seems to play a significant role in perioperative and follow-up complication rate. These results therefore support a surgical treatment only in patients with CNO without lumen full collapse.
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Affiliation(s)
| | | | - Laura Capoccia
- Vascular Surgery Department, Avezzano Hospital, Avezzano, Italy
| | - Marcello D'Elia
- Vascular Surgery Department, Avezzano Hospital, Avezzano, Italy
| | - Gennaro Bafile
- Vascular Surgery Department, L'Aquila Hospital, L'Aquila, Italy
| | - Marco Leopardi
- Vascular Surgery Department, L'Aquila Hospital, L'Aquila, Italy
| | - Franco Fiore
- Vascular Surgery Department, Chieti Hospital, Chieti, Italy
| | | | - Lorenzo Antico
- Vascular Surgery Department, Pescara Hospital, Pescara, Italy
| | - Antonio Antico
- Vascular Surgery Department, Pescara Hospital, Pescara, Italy
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Ito Y, Ishikawa E, Sato M, Marushima A, Hayakawa M, Maruo K, Takigawa T, Kato N, Tsuruta W, Uemura K, Matsumaru Y. Comparison of the Clinical Outcome of Carotid Artery Stenting Between Institutions With a Treatment Strategy Based on Risk Factors and Those With First-Line Treatment. J Endovasc Ther 2023; 30:746-755. [PMID: 35678727 DOI: 10.1177/15266028221102654] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
PURPOSE Carotid endarterectomy (CEA) and carotid artery stenting (CAS) are recommended based on certain risk factors. The volume of an institution's treatment experience may be associated with good clinical outcomes. There is a dilemma between the treatment strategy based on risk factors and the experience volume. Therefore, we investigated the clinical outcomes of CAS performed at institutions that selected the treatment strategy based on risk factors and those that performed CAS at the first-line treatment. MATERIALS AND METHODS Patients who underwent CAS at 5 institutions were included in this retrospective case-control study. We defined CEA/CAS institutions as those that selected the treatment option based on risk factors, and CAS-first institutions as those that performed CAS as the first-line treatment. We investigated cases of ischemic stroke, hemorrhagic stroke, myocardial infarction, and deaths within 30 days of the intervention between the CEA/CAS- and CAS-first institution groups. One-to-one propensity score matching was performed to compare rates of ischemic and hemorrhagic strokes within 30 days of the intervention. RESULTS A total of 239 and 302 patients underwent CAS at the CEA/CAS institutions and CAS-first institutions, respectively; ischemic stroke occurred in 12 (5.0%) and 7 patients (2.3%), respectively (p=0.09). No differences in major ischemic strokes (0.8% vs 1.3%; p=0.59), hemorrhagic strokes (0.4% vs 0.3%; p=0.87), or deaths (0.0% vs 0.7%; p=0.21) were observed. Myocardial infarction did not occur in either group. Propensity score analysis showed that ischemic stroke (odds ratio: 1.845, 95% confidence interval: 0.601-5.668, p=0.28) and hemorrhagic stroke (odds ratio: 1.000, 95% confidence interval: 0.0061-16.418, p=1.00) were not significantly associated with either institution group. CONCLUSIONS The CAS-specific treatment strategies for CAS can achieve the same level of outcomes as the treatment strategy based on risk factors. The CAS performed based on risk factors in CEA/CAS institutions and the treatment of more than 30 patients/year/institution in CAS-first institutions were associated with good clinical outcomes.
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Affiliation(s)
- Yoshiro Ito
- Department of Neurosurgery, Faculty of Medicine, University of Tsukuba, Tsukuba, Japan
| | - Eiichi Ishikawa
- Department of Neurosurgery, Faculty of Medicine, University of Tsukuba, Tsukuba, Japan
| | - Masayuki Sato
- Department of Neurosurgery, Faculty of Medicine, University of Tsukuba, Tsukuba, Japan
| | - Aiki Marushima
- Department of Neurosurgery, Faculty of Medicine, University of Tsukuba, Tsukuba, Japan
| | - Mikito Hayakawa
- Division of Stroke Prevention and Treatment, Faculty of Medicine, University of Tsukuba, Tsukuba, Japan
| | - Kazushi Maruo
- Department of Biostatistics, Faculty of Medicine, University of Tsukuba, Tsukuba, Japan
| | - Tomoji Takigawa
- Department of Neurosurgery, Saitama Medical Center, Dokkyo Medical University, Koshigaya, Japan
| | - Noriyuki Kato
- Department of Neurosurgery, Mito Medical Center, Mito, Japan
| | - Wataro Tsuruta
- Department of Endovascular Neurosurgery, Toranomon Hospital, Tokyo, Japan
| | - Kazuya Uemura
- Department of Neurosurgery, Tsukuba Medical Center Hospital, Tsukuba, Japan
| | - Yuji Matsumaru
- Department of Neurosurgery, Faculty of Medicine, University of Tsukuba, Tsukuba, Japan
- Division of Stroke Prevention and Treatment, Faculty of Medicine, University of Tsukuba, Tsukuba, Japan
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Kabeil M, Wohlauer MV, D'Oria M, Khetarpaul V, Gillette R, Moore E, Colborn K, Cuff RF, O'Banion LA, Koleilat I, Aziz F, Mouawad NJ. Carotid Artery Operation Delay During the Covid-19 Pandemic: Results of a Multicenter International Study. Ann Vasc Surg 2023; 96:44-56. [PMID: 37355018 DOI: 10.1016/j.avsg.2023.05.041] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2023] [Revised: 04/09/2023] [Accepted: 05/14/2023] [Indexed: 06/26/2023]
Abstract
BACKGROUND To measure the impact of the COVID-19 pandemic on the management of patients with carotid artery stenosis. METHODS We prospectively collected data from 25 centers (19 centers in the United States and 6 centers internationally) on postponed carotid artery operations between March 2020 and January 2022. We describe the characteristics of these patients and their planned operations, along with outcomes including mortality and neurological deterioration during the period of operative delay due to the COVID-19 pandemic. RESULTS A total of 1,220 vascular operations were postponed during the pandemic, of them 96 patients presented with significant carotid stenosis (median stenosis of 71%; interquartile range; 70-80) and 80% of them were planned for carotid endarterectomy. Most patients were asymptomatic (69%), and 31% of patients were symptomatic (16% of patients had a stroke, 15% of patients had a transient ischemic attack, and 1% of patients experienced amaurosis fugax). The median length of surgical delay was 71 days (interquartile range: 45.5, 115.5). At the data entry time, 62% of patients had their carotid operations postponed and successfully completed. Most postponements (72%) were due to institutional policies aimed at resource conservation. During the delay, no patient decompensated or required an urgent operation. A total of 5 patients (5%) with carotid stenosis died while awaiting operations due to COVID-19. CONCLUSIONS Our study of a cohort of patients with carotid artery stenosis who underwent a median delay of 71 days during the COVID-19 pandemic showed a disparate operation delay between US regions and internationally, most postponements were due to hospital policy, and none of the patients deteriorated or required an emergency surgery during the delay.
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Affiliation(s)
- Mahmood Kabeil
- Division of Vascular Surgery, University of Colorado Anschutz Medical Campus, Aurora, CO
| | - Max V Wohlauer
- Division of Vascular Surgery, University of Colorado Anschutz Medical Campus, Aurora, CO.
| | - Mario D'Oria
- Division of Vascular and Endovascular Surgery, Cardiovascular Department, University Hospital of Trieste ASUGI, Trieste, Italy
| | - Vipul Khetarpaul
- Department of Surgery, Section of Vascular Surgery, Washington University School of Medicine, St. Louis, MO
| | - Riley Gillette
- Department of Surgery, University of Colorado Anschutz Medical Campus, Aurora, CO
| | - Ethan Moore
- Division of Vascular Surgery, University of Colorado Anschutz Medical Campus, Aurora, CO
| | - Kathryn Colborn
- Department of Surgery, University of Colorado Anschutz Medical Campus, Aurora, CO
| | | | - Leigh Ann O'Banion
- Department of Surgery, University of California San Francisco (UCSF) Fresno, Fresno, CA
| | - Issam Koleilat
- Department of Surgery, RWJBH Community Medical Center, Toms River, NJ
| | - Faisal Aziz
- Division of Vascular Surgery, Department of Surgery, Penn State University, State College, PA
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4
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Zhang J, Chen J, Xu X, Sun M, Chen S, Liu P, Ye Z. Carotid Endarterectomy for the Treatment of Carotid Near-Occlusion With Recurrent Symptoms. Front Neurol 2022; 13:765795. [PMID: 35493837 PMCID: PMC9046581 DOI: 10.3389/fneur.2022.765795] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2021] [Accepted: 02/22/2022] [Indexed: 11/22/2022] Open
Abstract
Objective Report our preliminary experience of carotid endarterectomy (CEA) for the treatment of carotid near-occlusion (CNO) with recurrent symptoms. Materials and Methods Retrospectively analyze the demographics, treatment detail, and outcomes data of 122 patients with CNO from 2014 to 2020. According to whether distal full collapse exists, patients were classified into the full collapse group and the non-full collapse group. The incidence of death, myocardial infarction, stroke, and other variables were compared between the two groups. Results A total of 122 patients with CNO and recurrent symptoms were enrolled. The demographics were comparable between the two groups. Thirty-day incidence of primary endpoints was 1.85% in the full collapse group and 4.41% in the non-full collapse group. Twelve-month incidence of primary endpoints was 7.41% in the full collapse group and 4.41% in the non-full collapse group. One re-stenosis occurred in the non-full collapse group 8 months after CEA. Conclusion For patients with CNO with recurrent symptoms, CEA is not worse than the results described in historical control groups, despite whether distal full collapse exists. The shunt is important to avoid intraoperative hypoperfusion and postoperative hyperperfusion. The long-term results should be further evaluated.
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Affiliation(s)
- Jianbin Zhang
- Department of Cardiovascular Surgery, China-Japan Friendship Hospital, Beijing, China
| | - Jie Chen
- Department of Cardiovascular Surgery, China-Japan Friendship Hospital, Beijing, China
| | - Xiaojie Xu
- Department of Endocrinology, Beijing Jishuitan Hospital, The Fourth Clinical Medical College of Peking University, Beijing, China
| | - Mingsheng Sun
- Department of Vascular Surgery, Beijing Chao-Yang Hospital, Capital Medical University, Beijing, China
| | - Shu Chen
- Department of Interventional Radiology, Affiliated People's Hospital of Inner Mongolia Medical University, Hohhot, China
| | - Peng Liu
- Department of Cardiovascular Surgery, China-Japan Friendship Hospital, Beijing, China
| | - Zhidong Ye
- Department of Cardiovascular Surgery, China-Japan Friendship Hospital, Beijing, China
- *Correspondence: Zhidong Ye
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5
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Saba L, Brinjikji W, Spence JD, Wintermark M, Castillo M, Borst GJD, Yang Q, Yuan C, Buckler A, Edjlali M, Saam T, Saloner D, Lal BK, Capodanno D, Sun J, Balu N, Naylor R, Lugt AVD, Wasserman BA, Kooi ME, Wardlaw J, Gillard J, Lanzino G, Hedin U, Mikulis D, Gupta A, DeMarco JK, Hess C, Goethem JV, Hatsukami T, Rothwell P, Brown MM, Moody AR. Roadmap Consensus on Carotid Artery Plaque Imaging and Impact on Therapy Strategies and Guidelines: An International, Multispecialty, Expert Review and Position Statement. AJNR Am J Neuroradiol 2021; 42:1566-1575. [PMID: 34326105 DOI: 10.3174/ajnr.a7223] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2020] [Accepted: 01/26/2021] [Indexed: 12/19/2022]
Abstract
Current guidelines for primary and secondary prevention of stroke in patients with carotid atherosclerosis are based on the quantification of the degree of stenosis and symptom status. Recent publications have demonstrated that plaque morphology and composition, independent of the degree of stenosis, are important in the risk stratification of carotid atherosclerotic disease. This finding raises the question as to whether current guidelines are adequate or if they should be updated with new evidence, including imaging for plaque phenotyping, risk stratification, and clinical decision-making in addition to the degree of stenosis. To further this discussion, this roadmap consensus article defines the limits of luminal imaging and highlights the current evidence supporting the role of plaque imaging. Furthermore, we identify gaps in current knowledge and suggest steps to generate high-quality evidence, to add relevant information to guidelines currently based on the quantification of stenosis.
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Affiliation(s)
- L Saba
- From the Department of Radiology (L.S.), University of Cagliari, Cagliari, Italy
| | | | - J D Spence
- Stroke Prevention and Atherosclerosis Research Centre (J.D.S.), Robarts Research Institute, Western University, London, Ontario, Canada
| | - M Wintermark
- Department of Neuroradiology (M.W.), Stanford University and Healthcare System, Stanford, California
| | - M Castillo
- Department of Radiology (M.C.), University of North Carolina, Chapel Hill, North Carolina
| | - G J D Borst
- Department of Vascular Surgery (G.J.D.B.), University Medical Center Utrecht, Utrecht, the Netherlands
| | - Q Yang
- Department of Radiology (Q.Y.), Xuanwu Hospital, Capital Medical University, Beijing, China
| | - C Yuan
- Departments of Radiology (C.Y., J.S., N.B.)
| | - A Buckler
- Elucid Bioimaging (A.B.), Boston, Massachusetts
| | - M Edjlali
- Department of Neuroradiology (M.E.), Université Paris-Descartes-Sorbonne-Paris-Cité, IMABRAIN-INSERM-UMR1266, DHU-Neurovasc, Centre Hospitalier Sainte-Anne, Paris, France
| | - T Saam
- Department of Radiology (T.S.), University Hospital, Ludwig Maximilian University of Munich, Munich, Germany.,Radiologisches Zentrum (T.S.), Rosenheim, Germany
| | - D Saloner
- Departments of Radiology and Biomedical Imaging (D.S., C.H.), University of California San Francisco, San Francisco, California
| | - B K Lal
- Department of Vascular Surgery (B.K.L.), University of Maryland School of Medicine, Baltimore, Maryland
| | - D Capodanno
- Division of Cardiology (D.C.), A.O.U. Policlinico "G. Rodolico-San Marco," University of Catania, Italy
| | - J Sun
- Departments of Radiology (C.Y., J.S., N.B.)
| | - N Balu
- Departments of Radiology (C.Y., J.S., N.B.)
| | - R Naylor
- The Leicester Vascular Institute (R.N.), Glenfield Hospital, Leicester, UK
| | - A V D Lugt
- Department of Radiology and Nuclear Medicine (A.v.d.L.), Erasmus MC, University Medical Center Rotterdam, Rotterdam, the Netherlands
| | - B A Wasserman
- The Russell H. Morgan Department of Radiology and Radiological Science (B.A.W.), Johns Hopkins Hospital, Baltimore, Maryland
| | - M E Kooi
- Department of Radiology and Nuclear Medicine (M.E.K.), CARIM School for Cardiovascular Diseases, Maastricht University Medical Center, Maastricht, the Netherlands
| | - J Wardlaw
- Centre for Clinical Brain Sciences (J.W.), United Kingdom Dementia Research Institute and Edinburgh Imaging, University of Edinburgh, Edinburgh, UK
| | - J Gillard
- Christ's College (J.G.), Cambridge, UK
| | - G Lanzino
- Neurosurgery (G.L.) Mayo Clinic, Rochester, Minnesota
| | - U Hedin
- Department of Molecular Medicine and Surgery (U.H.), Karolinska Institutet, Stockholm, Sweden.,Department of Vascular Surgery (U.H.), Karolinska University Hospital and Karolinska Institute, Stockholm, Sweden
| | - D Mikulis
- Joint Department of Medical Imaging and the Functional Neuroimaging Laboratory (D.M.), University Health Network, Toronto, Ontario, Canada
| | - A Gupta
- Department of Radiology (A.G.), Weill Cornell Medical College, New York, New York
| | - J K DeMarco
- Walter Reed National Military Medical Center and Uniformed Services University of the Health Sciences (J.K.D.), Bethesda, Maryland
| | - C Hess
- Departments of Radiology and Biomedical Imaging (D.S., C.H.), University of California San Francisco, San Francisco, California
| | - J V Goethem
- Faculty of Biomedical Sciences (J.V.G.), University of Antwerp, Antwerp, Belgium
| | - T Hatsukami
- Surgery (T.H.), University of Washington, Seattle, Washington
| | - P Rothwell
- Centre for Prevention of Stroke and Dementia (P.R.), Nuffield Department of Clinical Neurosciences, John Radcliffe Hospital, University of Oxford, UK
| | - M M Brown
- Stroke Research Centre (M.M.B.), Department of Brain Repair and Rehabilitation, University College of London Queen Square Institute of Neurology, University College London, UK
| | - A R Moody
- Department of Medical Imaging (A.R.M.), University of Toronto, Toronto, Ontario, Canada
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6
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Saba L, Agarwal N, Cau R, Gerosa C, Sanfilippo R, Porcu M, Montisci R, Cerrone G, Qi Y, Balestrieri A, Lucatelli P, Politi C, Faa G, Suri JS. Review of imaging biomarkers for the vulnerable carotid plaque. JVS Vasc Sci 2021; 2:149-158. [PMID: 34617065 PMCID: PMC8489200 DOI: 10.1016/j.jvssci.2021.03.001] [Citation(s) in RCA: 24] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2020] [Accepted: 03/23/2021] [Indexed: 12/26/2022] Open
Abstract
Identification of carotid artery atherosclerosis is conventionally based on measurements of luminal stenosis. However, histopathologic studies demonstrate considerable differences between plaques with identical degrees of stenosis and indicate that certain plaque features are associated with increased risk for ischemic events. As a result of the rapid technological evolution in medical imaging, several important steps have been taken in the field of carotid plaque imaging allowing us to visualize the carotid atherosclerotic plaque and its composition in great detail. For computed tomography, magnetic resonance imaging, positron emission tomography, and ultrasound scan, evidence has accumulated on novel imaging-based markers that confer information on carotid plaque vulnerability, such as intraplaque hemorrhage and lipid-rich necrotic cores. In terms of the imaging-based identification of individuals at high risk of stroke, routine assessments of such imaging markers are the way forward for improving current clinical practice. The current review highlights the main characteristics of the vulnerable plaque indicating their role in the etiology of ischemic stroke as identified by intensive plaque imaging.
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Affiliation(s)
- Luca Saba
- Department of Radiology, University of Cagliari, Cagliari, Italy
| | - Nivedita Agarwal
- Section of Radiology, Santa Maria del Carmine Hospital, Rovereto, Italy
| | - Riccardo Cau
- Department of Radiology, University of Cagliari, Cagliari, Italy
| | - Clara Gerosa
- Department of Pathology, Azienda Ospedaliero Universitaria, Cagliari, Italy
| | - Roberto Sanfilippo
- Department of Vascular Surgery, Azienda Ospedaliero Universitaria, Cagliari, Italy
| | - Michele Porcu
- Department of Radiology, University of Cagliari, Cagliari, Italy
| | - Roberto Montisci
- Department of Vascular Surgery, Azienda Ospedaliero Universitaria, Cagliari, Italy
| | - Giulia Cerrone
- Department of Pathology, Azienda Ospedaliero Universitaria, Cagliari, Italy
| | - Yang Qi
- Xuanwu Hospital, Capital Medical University, Beijing, China
| | | | - Pierleone Lucatelli
- Vascular and Interventional Unit, Department of Radiological Sciences, Policlinico Umberto I, “Sapienza” University of Rome, Rome, Italy
| | - Carola Politi
- Department of Radiology, University of Cagliari, Cagliari, Italy
| | - Gavino Faa
- Department of Pathology, Azienda Ospedaliero Universitaria, Cagliari, Italy
| | - Jasjit S. Suri
- Stroke Diagnosis and Monitoring Division, AtheroPoint™, Roseville, Calif
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7
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Benson RA, Nandhra S. Outcomes of Vascular and Endovascular Interventions Performed During the Coronavirus Disease 2019 (COVID-19) Pandemic. Ann Surg 2021; 273:630-635. [PMID: 33378307 PMCID: PMC7959857 DOI: 10.1097/sla.0000000000004722] [Citation(s) in RCA: 36] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
OBJECTIVE The aim of the COVER Study is to identify global outcomes and decision making for vascular procedures during the pandemic. BACKGROUND DATA During its initial peak, there were many reports of delays to vital surgery and the release of several guidelines advising later thresholds for vascular surgical intervention for key conditions. METHODS An international multi-center observational study of outcomes after open and endovascular interventions. RESULTS In an analysis of 1103 vascular intervention (57 centers in 19 countries), 71.6% were elective or scheduled procedures. Mean age was 67 ± 14 years (75.6% male). Suspected or confirmed COVID-19 infection was documented in 4.0%. Overall, in-hospital mortality was 11.0% [aortic interventions mortality 15.2% (23/151), amputations 12.1% (28/232), carotid interventions 10.7% (11/103), lower limb revascularisations 9.8% (51/521)]. Chronic obstructive pulmonary disease [odds ratio (OR) 2.02, 95% confidence interval (CI) 1.30-3.15] and active lower respiratory tract infection due to any cause (OR 24.94, 95% CI 12.57-241.70) ware associated with mortality, whereas elective or scheduled cases were lower risk (OR 0.4, 95% CI 0.22-0.73 and 0.60, 95% CI 0.45-0.98, respectively. After adjustment, antiplatelet (OR 0.503, 95% CI: 0.273-0.928) and oral anticoagulation (OR 0.411, 95% CI: 0.205-0.824) were linked to reduced risk of in-hospital mortality. CONCLUSIONS Mortality after vascular interventions during this period was unexpectedly high. Suspected or confirmed COVID-19 cases were uncommon. Therefore an alternative cause, for example, recommendations for delayed surgery, should be considered. The vascular community must anticipate longer term implications for survival.
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Affiliation(s)
- Ruth A Benson
- Institute of Cancer and Genomics, University of Birmingham, Birmingham, United Kingdom and Newcastle upon Tyne, United Kingdom
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8
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Giurgius M, Horn M, Thomas SD, Shishehbor MH, Barry Beiles C, Mwipatayi BP, Varcoe RL. The Relationship Between Carotid Revascularization Procedural Volume and Perioperative Outcomes in Australia and New Zealand. Angiology 2021; 72:715-723. [PMID: 33535812 DOI: 10.1177/0003319721991717] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Carotid endarterectomy (CEA) and carotid artery stenting (CAS) prevent stroke in selected patients. However, each intervention carries a risk of perioperative complications including stroke or death (S/D). We aimed to determine the relationship between operator volume, hospital volume, and the perioperative risk of S/D in carotid revascularization in Australia and New Zealand. Retrospective analysis was performed on prospectively collected data extracted from the Australasian Vascular Audit between 2010 and 2017. Annual caseload volume was analyzed in quintiles (Q) using multivariate regression to assess its impact on perioperative S/D. Carotid endarterectomy procedures (n = 16 765) demonstrated higher S/D rates for lower-volume operators (2.21% for Q1-Q3 [1-17 annual cases] vs 1.76% for Q4-Q5 [18-61 annual cases]; odds ratio [OR]: 1.28; 95% CI: 1.001-1.64; P = .049). Carotid artery stenting procedures (n = 1350) also demonstrated higher S/D rates for lower-volume operators (2.63% for Q1-Q3 [1-11 annual cases] vs 0.37% for Q4-Q5 [12-31 annual cases]; OR: 6.11; 95% CI: 1.27-29.33; P = .024). No significant hospital volume-outcome effect was observed for either procedure. An inverse relationship was demonstrated between operator volume and perioperative S/D rates following CEA and CAS. Consideration of minimum operator thresholds, restructuring of services and networked referral pathways of care in Australia and New Zealand, would likely result in improved patient outcomes.
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Affiliation(s)
- Mary Giurgius
- Department of Surgery, Prince of Wales Hospital, Sydney, Australia.,Faculty of Medicine, University of New South Wales, Sydney, Australia
| | - Marco Horn
- Department of Surgery, Prince of Wales Hospital, Sydney, Australia
| | - Shannon D Thomas
- Department of Surgery, Prince of Wales Hospital, Sydney, Australia.,Faculty of Medicine, University of New South Wales, Sydney, Australia.,The Vascular Institute, Prince of Wales Hospital, Sydney, Australia
| | - Mehdi H Shishehbor
- Harrington Heart & Vascular Institute and Case Western Reserve University School of Medicine, University Hospitals, Cleveland, OH, USA
| | - C Barry Beiles
- Australasian Vascular Audit, Australian and New Zealand Society for Vascular Surgery, Melbourne, Australia
| | - B Patrice Mwipatayi
- Department of Vascular Surgery, University of Western Australia, School of Surgery and Royal Perth Hospital, Perth, Australia
| | - Ramon L Varcoe
- Department of Surgery, Prince of Wales Hospital, Sydney, Australia.,Faculty of Medicine, University of New South Wales, Sydney, Australia.,The Vascular Institute, Prince of Wales Hospital, Sydney, Australia
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9
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Kordzadeh A, Abbassi OA, Prionidis I, Shawish E. The Role of Carotid Stump Pressure in Carotid Endarterectomy: A Systematic Review and Meta-Analysis. Ann Vasc Dis 2020; 13:28-37. [PMID: 32273919 PMCID: PMC7140166 DOI: 10.3400/avd.ra.19-00100] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
This review evaluates the carotid stump pressure (CSP)’s role as a single parameter at any given pressure as an indicator for selective shunting, or vice versa, in carotid endarterectomy (CEA). A systematic review of literature in MEDLINE and the Cochrane Library from 1969 to 2019 was conducted. The primary end point was set at 0 to 30-day mortality, ischemic stroke (IS), transient ischemic attack (TIA), and a secondary point at recognition of an optimal CSP pressure. The data was subjected to meta-analytics. The odds ratio (OR) was reported at 95% confidence interval (CI). This study has been registered with PROSPERO: CRD42019119851. The pooled analysis on the primary endpoint of IS demonstrated higher incidence of stroke in shunted CEAs solely based on CSP measurement alone (OR, 0.14, 95%CI: 0.08–0.24, I2=48%, p<0.001). Sub group analysis demonstrated similar patterns at 25 mmHg (OR, 0.06, 95%CI: 0.01–0.5, p<0.01), 30 mmHg (OR, 0.07, 95%CI: 0.01–0.63, p=0.02) and 40 mmHg (OR, 0.23, 95%CI: 0.09–0.57, p<0.01). This effect on end points of mortality and TIA demonstrated no benefit in either direction. CSP, as a single criterion, is not a reliable parameter in reduction of TIA, mortality, and IS at any given pressure range.
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Affiliation(s)
- Ali Kordzadeh
- Mid Essex Hospitals Services NHS Trust, Department of Vascular, Endovascular and Renal Access Surgery, Broomfield Hospital
| | - Omar Ahmed Abbassi
- Mid Essex Hospitals Services NHS Trust, Department of Vascular, Endovascular and Renal Access Surgery, Broomfield Hospital
| | - Ioannis Prionidis
- Mid Essex Hospitals Services NHS Trust, Department of Vascular, Endovascular and Renal Access Surgery, Broomfield Hospital
| | - Emad Shawish
- Department of Vascular Surgery, Royal Shrewsbury and Telford Hospitals NHS Trust
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10
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Santangelo G, Mix D, Ghazi A, Stoner M, Vates GE, Stone JJ. Development of a Whole-Task Simulator for Carotid Endarterectomy. Oper Neurosurg (Hagerstown) 2019; 14:697-704. [PMID: 29029228 DOI: 10.1093/ons/opx209] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2017] [Accepted: 09/03/2017] [Indexed: 02/04/2023] Open
Abstract
BACKGROUND Surgical education relies on operative exposure with live patients. Carotid endarterectomy (CEA) demands an experienced surgeon with a very low complication rate. The high-risk nature of this procedure and the decline in number of CEAs performed annually has created a gap in residency training. OBJECTIVE To develop a high-fidelity whole-task simulation for CEA that demonstrates content, construct, and face validity. METHODS Anatomically accurate models of the human neck were created using multilayered poly-vinyl alcohol hydrogels. Graded polymerization of the hydrogel was achieved by inducing crosslinks during freeze/thaw cycles, stiffening the simulated tissues to achieve realistic tactile properties. Venous bleeding was simulated using pressure bags and a ventricular assistive device created pulsatile flow in the carotid. Ten surgeons performed the simulation under operating room conditions, and metrics were compared among experience levels to determine construct validity. Participants completed surveys about realism and usefulness to evaluate face validity. RESULTS A significant difference was found in operative measures between attending and resident physicians. The mean operative time for the expert group was 63.6 min vs 138.8 for the resident group (P = .002). There was a difference in mean internal carotid artery clamp time of 43.4 vs 83.2 min (P = .04). There were only 2 hypoglossal nerve injuries, both in the resident group (P = .009). CONCLUSION The whole-task CEA simulator is a realistic, inexpensive model that offers comprehensive training and allows residents to master skills prior to operating on live patients. Overall, the model demonstrated face and construct validity among neurosurgery and vascular surgeons.
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Affiliation(s)
| | - Doran Mix
- Division of Vascular Surgery, Strong Memorial Hospital, University of Rochester, Rochester New York
| | - Ahmed Ghazi
- Department of Urology, Strong Memorial Hospital, University of Rochester, Rochester, New York
| | - Michael Stoner
- Division of Vascular Surgery, Strong Memorial Hospital, University of Rochester, Rochester New York
| | - G Edward Vates
- Department of Neurosurgery, Strong Memorial Hospital, University of Rochester, Rochester, New York
| | - Jonathan J Stone
- Department of Neurosurgery, Strong Memorial Hospital, University of Rochester, Rochester, New York
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11
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Long-term Outcomes of Carotid Endarterectomy Versus Stenting in a Multicenter Population-based Canadian Study. Ann Surg 2019; 268:364-373. [PMID: 28498234 DOI: 10.1097/sla.0000000000002301] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
OBJECTIVE To compare the long-term outcomes of patients treated with carotid endarterectomy and carotid-artery stenting. BACKGROUND Evidence for the long-term safety and efficacy of carotid-artery stenting compared with endarterectomy is accumulating from randomized trials. However, comparative data on the long-term outcomes of carotid revascularization strategies in real world practice are lacking. METHODS We conducted a population-based, multicenter, observational cohort study using validated linked databases from Ontario, Canada. We identified all individuals treated with carotid endarterectomy and stenting (2002-2014), and followed them up to 2015. We compared long-term (up to 13 years) and 30-day outcomes of each strategy using multilevel multivariable Cox proportional-hazards models, and conducted confirmatory analyses using propensity-score matching methods. RESULTS In all, 15,525 patients received carotid-artery revascularization. Rate of the primary composite outcome of 30-day death, stroke, or myocardial infarction plus any stroke during 13-year follow-up was higher with stenting (16.3%) compared with endarterectomy (9.7%) [adjusted hazard ratio (HR) 1.57, 95% confidence interval (CI) 1.43-1.73, P < 0.001). The increased risk with stenting was observed regardless of age, sex, intervention year, carotid-artery symptoms, or diabetes. The primary outcome was driven by higher rates of 30-day stroke (adjusted HR 1.59, 95% CI 1.29-1.95), 30-day death (adjusted HR 2.62, 95% CI 2.20-3.13), and long-term stroke >30 days after the procedure (adjusted HR 1.47, 95% CI 1.36-1.59) with stenting; 30-day myocardial infarction was lower with stenting (adjusted HR 0.70, 95% CI 0.57-0.86). These results were confirmed with 1:2 propensity-score matching (HR for primary composite outcome with stenting 1.55, 95% CI 1.31-1.83, P < 0.001). CONCLUSIONS Compared with carotid endarterectomy, stenting was associated with an early and sustained approximately 55% increased hazard for major adverse events over long-term follow-up. Although nonrandomized, these results raise potential concerns about the interchangeability of carotid endarterectomy and stenting in the context of actual clinical practice.
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12
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Hoffer EP. America's Health Care System is Broken: What Went Wrong and How We Can Fix It. Part 3: Hospitals and Doctors. Am J Med 2019; 132:907-911. [PMID: 30928345 DOI: 10.1016/j.amjmed.2019.03.010] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/04/2019] [Accepted: 03/04/2019] [Indexed: 02/01/2023]
Abstract
Thirty-two percent of US health care spending goes to hospital care, and 20% goes to physicians' charges. The cost of hospital care in the United States is 2-3 times greater than in most similar countries. A large part of the high cost is due to a very large administrative overhead. Both higher quality and lower cost would be achieved if complex procedures were done in fewer centers. Hospitals with a geographic or prestige monopoly receive higher payments than warranted. As physicians are increasingly employed by hospitals rather than independent, costs go up with no added benefit to patients. The United States has too many specialists and too few primary care physicians. Practice guidelines are slanted to favor expensive treatments, often with little solid evidence behind the recommendations.
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Affiliation(s)
- Edward P Hoffer
- Laboratory of Computer Science, Massachusetts General Hospital, Boston; Harvard Medical School, Boston, MA.
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13
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Tan LP, Ye YB, Zhu Y, Gu ZL, Chen QG, Long MY. International normalized ratio on admission predicts the 90-day mortality of critically ill patients undergoing endarterectomy. Exp Ther Med 2018; 17:323-331. [PMID: 30651798 PMCID: PMC6307363 DOI: 10.3892/etm.2018.6935] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2018] [Accepted: 10/03/2018] [Indexed: 02/07/2023] Open
Abstract
The association of the international normalized ratio (INR) with the long-term clinical outcome of patients who undergo endarterectomy has not yet been studied. The present study therefore primarily aimed to evaluate the association of INR on admission with the 90-day mortality of critically ill patients who underwent endarterectomy during hospitalization. The Medical Information Mart for Intensive Care III database was queried for patients undergoing endarterectomy. The 90-day mortality of patients was selected as a primary endpoint. Receiver-operating characteristic (ROC) curves were plotted to present the accuracy of predictions. Kaplan-Meier curves and multivariate Cox regression analysis were performed to analyse associations. Propensity score matching (PSM) was also conducted to reduce confounding bias. A total of 230 patients were included, with 36 90-day non-survivors. Patients with a high INR (≥1.5) on admission exhibited a higher 90-day mortality than those with a low INR (<1.5; 29.09 vs. 11.43%; P=0.003). The ROC area under the curve value was 0.687 [95% confidence interval (CI), 0.571–0.780]. Kaplan-Meier plots identified divergence in survival between patients with different INR levels (log-rank test, P=0.0013). The results of the multivariate Cox regression analysis indicated that a high INR level was significantly associated with 90-day mortality (hazard ratio, 2.19; 95% CI, 1.08–4.45; P=0.0305). Analysis of the PSM cohort presented similar results. In conclusion, the INR levels of critically ill patients who undergo endarterectomy may be used to stratify their risk of 90-day mortality.
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Affiliation(s)
- Lang-Ping Tan
- Department of Vascular Surgery, Sun Yat-Sen Memorial Hospital of Sun Yat-Sen University, Guangzhou, Guangdong 510000, P.R. China
| | - Yi-Biao Ye
- Department of Hepatobiliary Surgery, Sun Yat-Sen Memorial Hospital of Sun Yat-Sen University, Guangzhou, Guangdong 510000, P.R. China
| | - Yue Zhu
- Department of Vascular Surgery, Sun Yat-Sen Memorial Hospital of Sun Yat-Sen University, Guangzhou, Guangdong 510000, P.R. China
| | - Zhi-Long Gu
- Intensive Care Unit, First Affiliated Hospital of Jinzhou Medical University, Jinzhou, Liaoning 121001, P.R. China
| | - Qin-Gui Chen
- Medical Intensive Care Unit, First Affiliated Hospital of Sun Yat-Sen University, Guangzhou, Guangdong 510080, P.R. China
| | - Miao-Yun Long
- Department of Vascular Surgery, Sun Yat-Sen Memorial Hospital of Sun Yat-Sen University, Guangzhou, Guangdong 510000, P.R. China
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14
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Meershoek AJA, Vonken EPA, Nederkoorn PJ, Kappelle LJ, de Borst GJ. Carotid endarterectomy in patients with recurrent symptoms associated with an ipsilateral carotid artery near occlusion with full collapse. J Neurol 2018; 265:1900-1905. [PMID: 29916130 PMCID: PMC6060778 DOI: 10.1007/s00415-018-8939-z] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2018] [Revised: 06/12/2018] [Accepted: 06/12/2018] [Indexed: 11/28/2022]
Abstract
OBJECTIVE Near occlusion (NO) of the internal carotid artery (ICA) with full collapse (NOFC) is a rare condition, with a prevalence of around 1%. Guidelines on carotid stenosis recommend a conservative treatment in patients with a single-event ipsilateral to a NOFC, but the optimal treatment for patients with recurrent symptoms associated with NOFC remains uncertain. We describe a consecutive series of patients with recurrent symptoms associated with NOFC (RSNOFC) who underwent carotid endarterectomy (CEA). METHODS From 2008 to 2017, 17 consecutive patients with RSNOFC were treated according to our standardized multidisciplinary work-up and protocol and included for this single-center cohort study. NO was defined according to the angiographic North American Symptomatic Carotid Endarterectomy Trial criteria. Only patients with NOFC were included in this study. RESULTS Standard longitudinal CEA was performed in 15 patients, whereas in 2 patients the ICA was ligated with concomitant endarterectomy of the ECA. Within 30 postoperative days, one patient died from a hemorrhagic infarction. During follow-up (median 23 months) one patient died of unknown cause 90 days after CEA. No TIA, stroke, myocardial infarction or re-stenosis occurred in the remaining patients. CONCLUSION In patients with RSNOFC, CEA may be considered a potential treatment option. Although procedural risks in this small subgroup may be higher as compared to patients with low-to-moderate risk anatomy, this risk may outbalance the natural course.
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Affiliation(s)
- A J A Meershoek
- Department of Vascular Surgery, Room G04.129, University Medical Centre Utrecht, Utrecht University, PO Box 85500, 3508 GA, Utrecht, The Netherlands
| | - E P A Vonken
- Department of Radiology, University Medical Centre Utrecht, Utrecht University, Utrecht, The Netherlands
| | - P J Nederkoorn
- Department of Neurology, Academic Medical Centre Amsterdam, Amsterdam, The Netherlands
| | - L J Kappelle
- Department of Neurology, University Medical Centre Utrecht, Utrecht University, Utrecht, The Netherlands
| | - G J de Borst
- Department of Vascular Surgery, Room G04.129, University Medical Centre Utrecht, Utrecht University, PO Box 85500, 3508 GA, Utrecht, The Netherlands.
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Hussain MA, Mamdani M, Tu JV, Saposnik G, Salata K, Bhatt DL, Verma S, Al-Omran M. Association between operator specialty and outcomes after carotid artery revascularization. J Vasc Surg 2018; 67:478-489.e6. [DOI: 10.1016/j.jvs.2017.05.123] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2017] [Accepted: 05/18/2017] [Indexed: 01/18/2023]
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16
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Meltzer AJ, Agrusa C, Connolly PH, Schneider DB, Sedrakyan A. Impact of Provider Characteristics on Outcomes of Carotid Endarterectomy for Asymptomatic Carotid Stenosis in New York State. Ann Vasc Surg 2017; 45:56-61. [DOI: 10.1016/j.avsg.2017.05.015] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2016] [Revised: 04/21/2017] [Accepted: 05/10/2017] [Indexed: 10/19/2022]
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17
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Lichtman JH, Jones MR, Leifheit EC, Sheffet AJ, Howard G, Lal BK, Howard VJ, Wang Y, Curtis J, Brott TG. Carotid Endarterectomy and Carotid Artery Stenting in the US Medicare Population, 1999-2014. JAMA 2017; 318:1035-1046. [PMID: 28975306 PMCID: PMC5818799 DOI: 10.1001/jama.2017.12882] [Citation(s) in RCA: 105] [Impact Index Per Article: 15.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
IMPORTANCE Carotid endarterectomy and carotid artery stenting are the leading approaches to revascularization for carotid stenosis, yet contemporary data on trends in rates and outcomes are limited. OBJECTIVE To describe US national trends in performance and outcomes of carotid endarterectomy and stenting among Medicare beneficiaries from 1999 to 2014. DESIGN, SETTING, AND PARTICIPANTS Serial cross-sectional analysis of Medicare fee-for-service beneficiaries aged 65 years or older from 1999 to 2014 using the Medicare Inpatient and Denominator files. Spatial mixed models adjusted for age, sex, and race were fit to calculate county-specific risk-standardized revascularization rates. Mixed models were fit to assess trends in outcomes after adjustment for demographics, comorbidities, and symptomatic status. EXPOSURES Carotid endarterectomy and carotid artery stenting. MAIN OUTCOMES AND MEASURES Revascularization rates per 100 000 beneficiary-years of fee-for-service enrollment, in-hospital mortality, 30-day stroke or death, 30-day stroke, myocardial infarction, or death, 30-day all-cause mortality, and 1-year stroke. RESULTS During the study, 937 111 unique patients underwent carotid endarterectomy (mean age, 75.8 years; 43% women) and 231 077 underwent carotid artery stenting (mean age, 75.4 years; 49% women). There were 81 306 patients who underwent endarterectomy in 1999 and 36 325 in 2014; national rates per 100 000 beneficiary-years decreased from 298 in 1999-2000 to 128 in 2013-2014 (P < .001). The number of patients who underwent stenting ranged from 10 416 in 1999 to 22 865 in 2006 (an increase per 100 000 beneficiary-years from 40 in 1999-2000 to 75 in 2005-2006; P < .001); by 2014, there were 10 208 patients who underwent stenting and the rate decreased to 38 per 100 000 beneficiary-years (P < .001). Outcomes improved over time despite increases in vascular risk factors (eg, hypertension prevalence increased from 67% to 81% among patients who underwent endarterectomy and from 61% to 70% among patients who underwent stenting) and the proportion of symptomatic patients (all P < .001). There were adjusted annual decreases in 30-day ischemic stroke or death of 2.90% (95% CI, 2.63% to 3.18%) among patients who underwent endarterectomy and 1.13% (95% CI, 0.71% to 1.54%) among patients who underwent stenting; an absolute decrease from 1999 to 2014 was observed for endarterectomy (1.4%; 95% CI, 1.2% to 1.5%) but not stenting (-0.1%; 95% CI, -0.5% to 0.4%). Rates for 1-year ischemic stroke decreased after endarterectomy (absolute decrease, 3.5% [95% CI, 3.2% to 3.7%]; adjusted annual decrease, 2.17% [95% CI, 2.00% to 2.34%]) and stenting (absolute decrease, 1.6% [95% CI, 1.2% to 2.1%]; adjusted annual decrease, 1.86% [95% CI, 1.45%-2.26%]). Additional improvements were noted for in-hospital mortality, 30-day stroke, myocardial infarction, or death, and 30-day all-cause mortality as well as within demographic subgroups. CONCLUSIONS AND RELEVANCE Among fee-for-service Medicare beneficiaries, the performance of carotid endarterectomy declined from 1999 to 2014, whereas the performance of carotid artery stenting increased until 2006 and then declined from 2007 to 2014. Outcomes improved despite increases in vascular risk factors.
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Affiliation(s)
- Judith H. Lichtman
- Department of Chronic Disease Epidemiology, Yale School of Public Health, New Haven, Connecticut
- Center for Neuroepidemiology and Clinical Neurological Research, Yale School of Medicine, New Haven, Connecticut
| | - Michael R. Jones
- Cardiology Division, Baptist Health Lexington, Lexington, Kentucky
| | - Erica C. Leifheit
- Department of Chronic Disease Epidemiology, Yale School of Public Health, New Haven, Connecticut
| | - Alice J. Sheffet
- Department of Surgery, Rutgers New Jersey Medical School, Newark
| | - George Howard
- Department of Biostatistics, School of Public Health, University of Alabama, Birmingham
| | - Brajesh K. Lal
- Department of Vascular Surgery, School of Medicine, University of Maryland, Baltimore
| | - Virginia J. Howard
- Department of Epidemiology, School of Public Health, University of Alabama, Birmingham
| | - Yun Wang
- Department of Biostatistics, Harvard T. H. Chan School of Public Health, Boston, Massachusetts
- Center for Outcomes Research and Evaluation, Yale-New Haven Hospital, Yale University, New Haven, Connecticut
| | - Jeptha Curtis
- Center for Outcomes Research and Evaluation, Yale-New Haven Hospital, Yale University, New Haven, Connecticut
- Section of Cardiovascular Medicine, Department of Internal Medicine, Yale School of Medicine, New Haven, Connecticut
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Mao J, Goodney P, Cronenwett J, Sedrakyan A. Association of Very Low-Volume Practice With Vascular Surgery Outcomes in New York. JAMA Surg 2017; 152:759-766. [PMID: 28514469 DOI: 10.1001/jamasurg.2017.1100] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/17/2023]
Abstract
Importance Little research has focused on very low-volume surgery, especially in the context of decreasing vascular surgery volume with the adoption of endovascular procedures. Objective To investigate the existence and outcomes of open abdominal aortic aneurysm repair (OAR) and carotid endarterectomy (CEA) performed by very low-volume surgeons in New York. Design, Settings, and Participants This cohort study examined inpatient data of patients undergoing elective OAR or CEA from 2000 to 2014 from all New York hospitals. Exposures Surgeons who performed 1 or less designated procedure per year on average were considered very low volume, as opposed to higher-volume surgeons. Main Outcomes and Measures Temporal trends of the existence of very low-volume practice were evaluated. Hierarchical logistic regression was used to compare in-hospital outcomes and health care resource use between patients treated by very low-volume surgeons and higher-volume surgeons for both OAR and CEA, adjusting for patient, surgeon, and hospital characteristics. Results There were 8781 OAR procedures and 68 896 CEA procedures included in the study. The mean (SD) patient age was 71.7 (8.4) years for OAR and 71.5 (9.1) years for CEA. A total of 614 surgeons performed OAR and 1071 performed CEA in New York during the study period. Of these, 318 (51.8%) and 512 (47.8%), respectively, were very low-volume surgeons. Very low-volume surgeons were less likely to be vascular surgeons. The number and proportion of very low-volume surgeons decreased over years. Compared with patients treated by higher-volume surgeons, those treated by very low-volume surgeons were more likely to have higher in-hospital mortality (odds ratio [OR], 2.09; 95% CI, 1.41-3.08) following OAR and higher risks of postoperative myocardial infarction (OR, 1.83; 95% CI, 1.03-3.26) and stroke (OR, 1.78; 95% CI, 1.21-2.62) following CEA. Patients treated by very low-volume surgeons also had greater health care resource use following both surgeries, including prolonged length of stay (OR, 1.37; 95% CI, 1.11-1.70) following OAR as well as higher charges (OR, 1.28; 95% CI, 1.01-1.62) and increased 30-day readmission (OR, 1.30; 95% CI 1.04-1.62) following CEA. Conclusions and Relevance The OAR and CEA procedures performed by very low-volume surgeons resulted in worse postoperative outcomes and greater lengths of stay. Although the percentage of very low-volume surgeons declined from 2000 to 2014, it remains concerning, given ready access to higher-volume surgeons. Future research is needed to understand the existence of this practice pattern in other surgical fields. Efforts to eliminate this practice pattern are warranted to ensure high-quality care for all patients.
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Affiliation(s)
- Jialin Mao
- Department of Healthcare Policy and Research, Weill Cornell Medical College, New York, New York
| | - Philip Goodney
- Section of Vascular Surgery, Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire
| | - Jack Cronenwett
- Section of Vascular Surgery, Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire
| | - Art Sedrakyan
- Department of Healthcare Policy and Research, Weill Cornell Medical College, New York, New York
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Olafson EM, DeGrote JR, Drofa A, Kouznetsov E, Manchak M, Leedahl ND, Leedahl DD. A Case Series of 18 Patients Receiving Ticagrelor After Carotid Stenting. J Pharm Pract 2017; 31:519-521. [DOI: 10.1177/0897190017729524] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
Purpose: Dual antiplatelet therapy (DAPT) with aspirin and a P2Y12 receptor antagonist is often used to prevent thrombotic complications after endovascular stent placement. Most of the published experience surrounding DAPT after carotid stenting is with clopidogrel. Ticagrelor may be a promising alternative, especially in patients who may be considered nonresponders to clopidogrel. However, clinical outcomes utilizing DAPT with ticagrelor in a cohort with carotid stenting is lacking. In this case series, we describe our experience with systematic prescribing of ticagrelor after carotid stent placement in 18 patients. Methods: A retrospective review of 18 patients prescribed ticagrelor who underwent carotid stenting between November 2015 and January 2017 was performed. All eligible patients were included in the review. The primary end point of interest was any ischemic stroke or death within 30 days following the procedure. Intracranial hemorrhage was a secondary end point. Results and Conclusions: No patients experienced the primary end point of ischemic stroke or death within 30 days. No intracranial hemorrhages were observed. The use of ticagrelor after carotid stenting may be a reasonable alternative to clopidogrel after carotid stent placement. Randomized trials to support our findings are needed.
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Affiliation(s)
| | | | - Alexander Drofa
- Department of Surgery, University of North Dakota, Grand Forks, ND, USA
- Department of Neurosurgery, Sanford Brain and Spine Institute, Fargo, ND, USA
| | - Evgueni Kouznetsov
- Department of Neurosurgery, Sanford Brain and Spine Institute, Fargo, ND, USA
| | - Michael Manchak
- Department of Neurosurgery, Sanford Brain and Spine Institute, Fargo, ND, USA
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20
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AbuRahma AF, Campbell JE, Hariri N, AbuRahma J, Dean LS, Bates MC, Nanjundappa A, Stone PA, O'vil A. Clinical Outcome of Carotid Artery Stenting According to Provider Specialty and Volume. Ann Vasc Surg 2017; 44:361-367. [PMID: 28495538 DOI: 10.1016/j.avsg.2017.04.028] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2017] [Revised: 03/28/2017] [Accepted: 04/30/2017] [Indexed: 10/19/2022]
Abstract
BACKGROUND Several studies have demonstrated better outcomes for carotid endarterectomy with high-volume hospitals and providers. However, only a few studies have reported on the impact of operator specialty/volume on the perioperative outcome of carotid artery stenting (CAS). This study will analyze the correlation of CAS outcomes and provider specialty and volume. METHODS Prospectively collected data of CAS procedures done at our institution during a 10-year period were analyzed. Major adverse events (MAEs; 30-day stroke, myocardial infarction, and death) were compared according to provider specialty (vascular surgeons [VSs], interventional cardiologists [ICs], interventional radiologists [IRs], interventional vascular medicine [IVM]), and volume (≥5 CAS/year vs. <5 CAS/year). RESULTS Four hundred fourteen CAS procedures (44% for symptomatic indications) were analyzed. Demographics/clinical characteristics were somewhat similar between specialties. MAE rates were not significantly different between various specialties: 3.1% for IC, 6.3% for VS, 7.1% for IR, 6.7% for IVM (P = 0.3121; 6.3% for VS and 3.8% for others combined, P = 0.2469). When physicians with <5 CAS/year were excluded: the MAE rates were 3.1% for IC, 4.7% for VS, and 6.7% for IVM (P = 0.5633). When VS alone were compared with others, and physicians with <5 CAS/year were excluded, the MAE rates were 4.7% for VS vs. 3.6% for non-VS (P = 0.5958). The MAE rates for low-volume providers, regardless of their specialty, were 9.5% vs. 4% for high-volume providers (P = 0.1002). Logistic regression analysis showed that the odds ratio of MAE was 0.4 (0.15-1.1, P = 0.0674) for high-volume providers, while the odds ratio for VS was 1.3 (0.45-3.954, P = 0.5969). CONCLUSIONS Perioperative MAE rates for CAS were similar between various providers, regardless of specialties, particularly for vascular surgeons with similar volume to nonvascular surgeons. Low-volume providers had higher MAE rates.
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Affiliation(s)
- Ali F AbuRahma
- Charleston Area Medical Center Vascular Center of Excellence, Charleston, WV; Department of Surgery, West Virginia University, Charleston, WV.
| | - John E Campbell
- Department of Surgery, West Virginia University, Charleston, WV
| | - Nizar Hariri
- Department of Surgery, West Virginia University, Charleston, WV
| | - Joseph AbuRahma
- Department of Surgery, West Virginia University, Charleston, WV
| | - L Scott Dean
- CAMC Health Education and Research Institute, Charleston, WV
| | - Mark C Bates
- Charleston Area Medical Center Vascular Center of Excellence, Charleston, WV; Department of Surgery, West Virginia University, Charleston, WV
| | | | - Patrick A Stone
- Department of Surgery, West Virginia University, Charleston, WV
| | - Ace O'vil
- Department of Surgery, West Virginia University, Charleston, WV
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Lieber BA, Henry JK, Agarwal N, Day JD, Morris TW, Stephens ML, Abla AA. Impact of Surgical Specialty on Outcomes Following Carotid Endarterectomy. Neurosurgery 2016; 80:217-225. [DOI: 10.1093/neuros/nyw027] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2015] [Accepted: 10/22/2016] [Indexed: 11/13/2022] Open
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Hussain MA, Mamdani M, Tu JV, Saposnik G, Khoushhal Z, Aljabri B, Verma S, Al-Omran M. Impact of Clinical Trial Results on the Temporal Trends of Carotid Endarterectomy and Stenting From 2002 to 2014. Stroke 2016; 47:2923-2930. [PMID: 27834754 PMCID: PMC5120767 DOI: 10.1161/strokeaha.116.014856] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2016] [Revised: 09/07/2016] [Accepted: 10/04/2016] [Indexed: 01/25/2023]
Abstract
Supplemental Digital Content is available in the text. Background and Purpose— Randomized trials provide conflicting data for the efficacy of carotid-artery stenting compared with endarterectomy. The purpose of this study was to examine the impact of conflicting clinical trial publications on the utilization rates of carotid revascularization procedures. Methods— We conducted a population-level time-series analysis of all individuals who underwent carotid endarterectomy and stenting in Ontario, Canada (2002–2014). The primary analysis examined temporal changes in the rates of carotid revascularization procedures after publications of major randomized trials. Secondary analyses examined changes in overall and age, sex, carotid-artery symptom, and operator specialty–specific procedure rates. Results— A total of 16 772 patients were studied (14 394 endarterectomy [86%]; 2378 stenting [14%]). The overall rate of carotid revascularization decreased from 6.0 procedures per 100 000 individuals ≥40 years old in April 2002 to 4.3 procedures in the first quarter of 2014 (29% decrease; P<0.001). The rate of endarterectomy decreased by 36% (P<0.001), whereas the rate of carotid-artery stenting increased by 72% (P=0.006). We observed a marked increase (P=0.01) in stenting after publication of the SAPPHIRE trial (Stenting and Angioplasty With Protection in Patients at High Risk for Endarterectomy) in 2004, whereas stenting remained relatively unchanged after subsequent randomized trials published in 2006 (P=0.11) and 2010 (P=0.34). In contrast, endarterectomy decreased after trials published in 2006 (P=0.04) and 2010 (P=0.005). Conclusions— Although the overall rates of carotid revascularization and endarterectomy have fallen since 2002, the rate of carotid-artery stenting has risen since the publication of stenting-favorable SAPPHIRE trial. Subsequent conflicting randomized trials were associated with a decreasing rate of carotid endarterectomy.
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Affiliation(s)
- Mohamad A Hussain
- From the Divisions of Vascular Surgery (M.A.H., Z.K., B.A., M.A.-O.), Neurology (G.S.), and Cardiac Surgery (S.V.) and Li Ka Shing Knowledge Institute, St Michael's Hospital (M.M., G.S., S.V., M.A.-O.), Toronto, Canada; Departments of Surgery (M.A.H., S.V., M.A.-O.) and Medicine (J.V.T., G.S.), University of Toronto, Toronto, Canada; Institute of Health Policy, Management, and Evaluation (M.M., J.V.T., G.S.) and Leslie Dan Faculty of Pharmacy (M.M.), University of Toronto, Canada; King Saud University-Li Ka Shing Collaborative Research Program (M.M., B.A., S.V., M.A.-O.); Department of Surgery, Taibah University, Madinah, Kingdom of Saudi Arabia (Z.K.); Department of Surgery, King Saud University, Riyadh, Kingdom of Saudi Arabia (B.A., M.A.-O.); Institute for Clinical Evaluative Sciences (M.M., J.V.T., G.S.), Toronto, Canada; and Division of Cardiology, Schulich Heart Centre, Sunnybrook Health Sciences Centre, Toronto, Canada (J.V.T.)
| | - Muhammad Mamdani
- From the Divisions of Vascular Surgery (M.A.H., Z.K., B.A., M.A.-O.), Neurology (G.S.), and Cardiac Surgery (S.V.) and Li Ka Shing Knowledge Institute, St Michael's Hospital (M.M., G.S., S.V., M.A.-O.), Toronto, Canada; Departments of Surgery (M.A.H., S.V., M.A.-O.) and Medicine (J.V.T., G.S.), University of Toronto, Toronto, Canada; Institute of Health Policy, Management, and Evaluation (M.M., J.V.T., G.S.) and Leslie Dan Faculty of Pharmacy (M.M.), University of Toronto, Canada; King Saud University-Li Ka Shing Collaborative Research Program (M.M., B.A., S.V., M.A.-O.); Department of Surgery, Taibah University, Madinah, Kingdom of Saudi Arabia (Z.K.); Department of Surgery, King Saud University, Riyadh, Kingdom of Saudi Arabia (B.A., M.A.-O.); Institute for Clinical Evaluative Sciences (M.M., J.V.T., G.S.), Toronto, Canada; and Division of Cardiology, Schulich Heart Centre, Sunnybrook Health Sciences Centre, Toronto, Canada (J.V.T.)
| | - Jack V Tu
- From the Divisions of Vascular Surgery (M.A.H., Z.K., B.A., M.A.-O.), Neurology (G.S.), and Cardiac Surgery (S.V.) and Li Ka Shing Knowledge Institute, St Michael's Hospital (M.M., G.S., S.V., M.A.-O.), Toronto, Canada; Departments of Surgery (M.A.H., S.V., M.A.-O.) and Medicine (J.V.T., G.S.), University of Toronto, Toronto, Canada; Institute of Health Policy, Management, and Evaluation (M.M., J.V.T., G.S.) and Leslie Dan Faculty of Pharmacy (M.M.), University of Toronto, Canada; King Saud University-Li Ka Shing Collaborative Research Program (M.M., B.A., S.V., M.A.-O.); Department of Surgery, Taibah University, Madinah, Kingdom of Saudi Arabia (Z.K.); Department of Surgery, King Saud University, Riyadh, Kingdom of Saudi Arabia (B.A., M.A.-O.); Institute for Clinical Evaluative Sciences (M.M., J.V.T., G.S.), Toronto, Canada; and Division of Cardiology, Schulich Heart Centre, Sunnybrook Health Sciences Centre, Toronto, Canada (J.V.T.)
| | - Gustavo Saposnik
- From the Divisions of Vascular Surgery (M.A.H., Z.K., B.A., M.A.-O.), Neurology (G.S.), and Cardiac Surgery (S.V.) and Li Ka Shing Knowledge Institute, St Michael's Hospital (M.M., G.S., S.V., M.A.-O.), Toronto, Canada; Departments of Surgery (M.A.H., S.V., M.A.-O.) and Medicine (J.V.T., G.S.), University of Toronto, Toronto, Canada; Institute of Health Policy, Management, and Evaluation (M.M., J.V.T., G.S.) and Leslie Dan Faculty of Pharmacy (M.M.), University of Toronto, Canada; King Saud University-Li Ka Shing Collaborative Research Program (M.M., B.A., S.V., M.A.-O.); Department of Surgery, Taibah University, Madinah, Kingdom of Saudi Arabia (Z.K.); Department of Surgery, King Saud University, Riyadh, Kingdom of Saudi Arabia (B.A., M.A.-O.); Institute for Clinical Evaluative Sciences (M.M., J.V.T., G.S.), Toronto, Canada; and Division of Cardiology, Schulich Heart Centre, Sunnybrook Health Sciences Centre, Toronto, Canada (J.V.T.)
| | - Zeyad Khoushhal
- From the Divisions of Vascular Surgery (M.A.H., Z.K., B.A., M.A.-O.), Neurology (G.S.), and Cardiac Surgery (S.V.) and Li Ka Shing Knowledge Institute, St Michael's Hospital (M.M., G.S., S.V., M.A.-O.), Toronto, Canada; Departments of Surgery (M.A.H., S.V., M.A.-O.) and Medicine (J.V.T., G.S.), University of Toronto, Toronto, Canada; Institute of Health Policy, Management, and Evaluation (M.M., J.V.T., G.S.) and Leslie Dan Faculty of Pharmacy (M.M.), University of Toronto, Canada; King Saud University-Li Ka Shing Collaborative Research Program (M.M., B.A., S.V., M.A.-O.); Department of Surgery, Taibah University, Madinah, Kingdom of Saudi Arabia (Z.K.); Department of Surgery, King Saud University, Riyadh, Kingdom of Saudi Arabia (B.A., M.A.-O.); Institute for Clinical Evaluative Sciences (M.M., J.V.T., G.S.), Toronto, Canada; and Division of Cardiology, Schulich Heart Centre, Sunnybrook Health Sciences Centre, Toronto, Canada (J.V.T.)
| | - Badr Aljabri
- From the Divisions of Vascular Surgery (M.A.H., Z.K., B.A., M.A.-O.), Neurology (G.S.), and Cardiac Surgery (S.V.) and Li Ka Shing Knowledge Institute, St Michael's Hospital (M.M., G.S., S.V., M.A.-O.), Toronto, Canada; Departments of Surgery (M.A.H., S.V., M.A.-O.) and Medicine (J.V.T., G.S.), University of Toronto, Toronto, Canada; Institute of Health Policy, Management, and Evaluation (M.M., J.V.T., G.S.) and Leslie Dan Faculty of Pharmacy (M.M.), University of Toronto, Canada; King Saud University-Li Ka Shing Collaborative Research Program (M.M., B.A., S.V., M.A.-O.); Department of Surgery, Taibah University, Madinah, Kingdom of Saudi Arabia (Z.K.); Department of Surgery, King Saud University, Riyadh, Kingdom of Saudi Arabia (B.A., M.A.-O.); Institute for Clinical Evaluative Sciences (M.M., J.V.T., G.S.), Toronto, Canada; and Division of Cardiology, Schulich Heart Centre, Sunnybrook Health Sciences Centre, Toronto, Canada (J.V.T.)
| | - Subdoh Verma
- From the Divisions of Vascular Surgery (M.A.H., Z.K., B.A., M.A.-O.), Neurology (G.S.), and Cardiac Surgery (S.V.) and Li Ka Shing Knowledge Institute, St Michael's Hospital (M.M., G.S., S.V., M.A.-O.), Toronto, Canada; Departments of Surgery (M.A.H., S.V., M.A.-O.) and Medicine (J.V.T., G.S.), University of Toronto, Toronto, Canada; Institute of Health Policy, Management, and Evaluation (M.M., J.V.T., G.S.) and Leslie Dan Faculty of Pharmacy (M.M.), University of Toronto, Canada; King Saud University-Li Ka Shing Collaborative Research Program (M.M., B.A., S.V., M.A.-O.); Department of Surgery, Taibah University, Madinah, Kingdom of Saudi Arabia (Z.K.); Department of Surgery, King Saud University, Riyadh, Kingdom of Saudi Arabia (B.A., M.A.-O.); Institute for Clinical Evaluative Sciences (M.M., J.V.T., G.S.), Toronto, Canada; and Division of Cardiology, Schulich Heart Centre, Sunnybrook Health Sciences Centre, Toronto, Canada (J.V.T.)
| | - Mohammed Al-Omran
- From the Divisions of Vascular Surgery (M.A.H., Z.K., B.A., M.A.-O.), Neurology (G.S.), and Cardiac Surgery (S.V.) and Li Ka Shing Knowledge Institute, St Michael's Hospital (M.M., G.S., S.V., M.A.-O.), Toronto, Canada; Departments of Surgery (M.A.H., S.V., M.A.-O.) and Medicine (J.V.T., G.S.), University of Toronto, Toronto, Canada; Institute of Health Policy, Management, and Evaluation (M.M., J.V.T., G.S.) and Leslie Dan Faculty of Pharmacy (M.M.), University of Toronto, Canada; King Saud University-Li Ka Shing Collaborative Research Program (M.M., B.A., S.V., M.A.-O.); Department of Surgery, Taibah University, Madinah, Kingdom of Saudi Arabia (Z.K.); Department of Surgery, King Saud University, Riyadh, Kingdom of Saudi Arabia (B.A., M.A.-O.); Institute for Clinical Evaluative Sciences (M.M., J.V.T., G.S.), Toronto, Canada; and Division of Cardiology, Schulich Heart Centre, Sunnybrook Health Sciences Centre, Toronto, Canada (J.V.T.).
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Significant Association of Annual Hospital Volume With the Risk of Inhospital Stroke or Death Following Carotid Endarterectomy but Likely Not After Carotid Stenting. Circ Cardiovasc Interv 2016; 9:CIRCINTERVENTIONS.116.004171. [DOI: 10.1161/circinterventions.116.004171] [Citation(s) in RCA: 35] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/25/2016] [Accepted: 09/21/2016] [Indexed: 11/16/2022]
Abstract
Background—
Associations between hospital volume and the risk of stroke or death following carotid endarterectomy (CEA) and carotid artery stenting (CAS) on a national level in Germany were analyzed.
Methods and Results—
Secondary data analysis using microdata from the nationwide statutory German quality assurance database on all surgical or endovascular carotid interventions on the extracranial carotid artery between 2009 and 2014. Hospitals were categorized into empirically determined quintiles according to the annual case volume. The resulting volume thresholds were 10, 25, 46, and 79 for CEA and 2, 6, 12, and 26 for CAS procedures. The primary outcome was any stroke or death before hospital discharge. For risk-adjusted analyses, a multilevel regression model was applied. The analysis included 161 448 CEA and 17 575 CAS procedures. In CEA patients, the crude risk of stroke or death decreased monotonically from 4.2% (95% confidence interval, 3.6%–4.9%) in low-volume hospitals (first quintile 1–10 CEA per year) to 2.1% (2.0%–2.2%) in hospitals providing ≥80 CEA per year (fifth quintile;
P
<0.001 for trend). The overall risk of any stroke or death in CAS patients was 3.7% (3.5%–4.0%), but no trend on annual volume was seen (
P
=0.304). Risk-adjusted analyses confirmed a significant inverse relationship between hospital volume (categorized or continuous) and the risk of stroke or death after CEA but not CAS procedures.
Conclusions—
An inverse volume–outcome relationship in CEA-treated patients was demonstrated. No significant association between hospital volume and the risk of stroke or death was found for CAS.
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Mariné L. Vigencia de la endarterectomía carotídea para el tratamiento de estenosis asintomática en la era de las estatinas. ANGIOLOGIA 2016. [DOI: 10.1016/j.angio.2016.03.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Jalbert JJ, Nguyen LL, Gerhard-Herman MD, Kumamaru H, Chen CY, Williams LA, Liu J, Rothman AT, Jaff MR, Seeger JD, Benenati JF, Schneider PA, Aronow HD, Johnston JA, Brott TG, Tsai TT, White CJ, Setoguchi S. Comparative Effectiveness of Carotid Artery Stenting Versus Carotid Endarterectomy Among Medicare Beneficiaries. Circ Cardiovasc Qual Outcomes 2016; 9:275-85. [DOI: 10.1161/circoutcomes.115.002336] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/24/2015] [Accepted: 03/21/2016] [Indexed: 11/16/2022]
Affiliation(s)
- Jessica J. Jalbert
- From the Division of Pharmacoepidemiology and Pharmacoeconomics (J.J.J., H.K., C.-Y.C., L.A.W., J.L., A.T.R., J.D.S.), Vascular and Endovascular Surgery (L.L.N.), and Cardiovascular Medicine (M.D.G.-H.), Department of Medicine, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA; LASER Analytica, New York, NY (J.J.J.); Department of Epidemiology, Harvard T.H. Chan School of Public Health, Boston, MA (H.K.); Department of Cardiology, Division of Cardiovascular Medicine, Massachusetts
| | - Louis L. Nguyen
- From the Division of Pharmacoepidemiology and Pharmacoeconomics (J.J.J., H.K., C.-Y.C., L.A.W., J.L., A.T.R., J.D.S.), Vascular and Endovascular Surgery (L.L.N.), and Cardiovascular Medicine (M.D.G.-H.), Department of Medicine, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA; LASER Analytica, New York, NY (J.J.J.); Department of Epidemiology, Harvard T.H. Chan School of Public Health, Boston, MA (H.K.); Department of Cardiology, Division of Cardiovascular Medicine, Massachusetts
| | - Marie D. Gerhard-Herman
- From the Division of Pharmacoepidemiology and Pharmacoeconomics (J.J.J., H.K., C.-Y.C., L.A.W., J.L., A.T.R., J.D.S.), Vascular and Endovascular Surgery (L.L.N.), and Cardiovascular Medicine (M.D.G.-H.), Department of Medicine, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA; LASER Analytica, New York, NY (J.J.J.); Department of Epidemiology, Harvard T.H. Chan School of Public Health, Boston, MA (H.K.); Department of Cardiology, Division of Cardiovascular Medicine, Massachusetts
| | - Hiraku Kumamaru
- From the Division of Pharmacoepidemiology and Pharmacoeconomics (J.J.J., H.K., C.-Y.C., L.A.W., J.L., A.T.R., J.D.S.), Vascular and Endovascular Surgery (L.L.N.), and Cardiovascular Medicine (M.D.G.-H.), Department of Medicine, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA; LASER Analytica, New York, NY (J.J.J.); Department of Epidemiology, Harvard T.H. Chan School of Public Health, Boston, MA (H.K.); Department of Cardiology, Division of Cardiovascular Medicine, Massachusetts
| | - Chih-Ying Chen
- From the Division of Pharmacoepidemiology and Pharmacoeconomics (J.J.J., H.K., C.-Y.C., L.A.W., J.L., A.T.R., J.D.S.), Vascular and Endovascular Surgery (L.L.N.), and Cardiovascular Medicine (M.D.G.-H.), Department of Medicine, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA; LASER Analytica, New York, NY (J.J.J.); Department of Epidemiology, Harvard T.H. Chan School of Public Health, Boston, MA (H.K.); Department of Cardiology, Division of Cardiovascular Medicine, Massachusetts
| | - Lauren A. Williams
- From the Division of Pharmacoepidemiology and Pharmacoeconomics (J.J.J., H.K., C.-Y.C., L.A.W., J.L., A.T.R., J.D.S.), Vascular and Endovascular Surgery (L.L.N.), and Cardiovascular Medicine (M.D.G.-H.), Department of Medicine, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA; LASER Analytica, New York, NY (J.J.J.); Department of Epidemiology, Harvard T.H. Chan School of Public Health, Boston, MA (H.K.); Department of Cardiology, Division of Cardiovascular Medicine, Massachusetts
| | - Jun Liu
- From the Division of Pharmacoepidemiology and Pharmacoeconomics (J.J.J., H.K., C.-Y.C., L.A.W., J.L., A.T.R., J.D.S.), Vascular and Endovascular Surgery (L.L.N.), and Cardiovascular Medicine (M.D.G.-H.), Department of Medicine, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA; LASER Analytica, New York, NY (J.J.J.); Department of Epidemiology, Harvard T.H. Chan School of Public Health, Boston, MA (H.K.); Department of Cardiology, Division of Cardiovascular Medicine, Massachusetts
| | - Andrew T. Rothman
- From the Division of Pharmacoepidemiology and Pharmacoeconomics (J.J.J., H.K., C.-Y.C., L.A.W., J.L., A.T.R., J.D.S.), Vascular and Endovascular Surgery (L.L.N.), and Cardiovascular Medicine (M.D.G.-H.), Department of Medicine, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA; LASER Analytica, New York, NY (J.J.J.); Department of Epidemiology, Harvard T.H. Chan School of Public Health, Boston, MA (H.K.); Department of Cardiology, Division of Cardiovascular Medicine, Massachusetts
| | - Michael R. Jaff
- From the Division of Pharmacoepidemiology and Pharmacoeconomics (J.J.J., H.K., C.-Y.C., L.A.W., J.L., A.T.R., J.D.S.), Vascular and Endovascular Surgery (L.L.N.), and Cardiovascular Medicine (M.D.G.-H.), Department of Medicine, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA; LASER Analytica, New York, NY (J.J.J.); Department of Epidemiology, Harvard T.H. Chan School of Public Health, Boston, MA (H.K.); Department of Cardiology, Division of Cardiovascular Medicine, Massachusetts
| | - John D. Seeger
- From the Division of Pharmacoepidemiology and Pharmacoeconomics (J.J.J., H.K., C.-Y.C., L.A.W., J.L., A.T.R., J.D.S.), Vascular and Endovascular Surgery (L.L.N.), and Cardiovascular Medicine (M.D.G.-H.), Department of Medicine, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA; LASER Analytica, New York, NY (J.J.J.); Department of Epidemiology, Harvard T.H. Chan School of Public Health, Boston, MA (H.K.); Department of Cardiology, Division of Cardiovascular Medicine, Massachusetts
| | - James F. Benenati
- From the Division of Pharmacoepidemiology and Pharmacoeconomics (J.J.J., H.K., C.-Y.C., L.A.W., J.L., A.T.R., J.D.S.), Vascular and Endovascular Surgery (L.L.N.), and Cardiovascular Medicine (M.D.G.-H.), Department of Medicine, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA; LASER Analytica, New York, NY (J.J.J.); Department of Epidemiology, Harvard T.H. Chan School of Public Health, Boston, MA (H.K.); Department of Cardiology, Division of Cardiovascular Medicine, Massachusetts
| | - Peter A. Schneider
- From the Division of Pharmacoepidemiology and Pharmacoeconomics (J.J.J., H.K., C.-Y.C., L.A.W., J.L., A.T.R., J.D.S.), Vascular and Endovascular Surgery (L.L.N.), and Cardiovascular Medicine (M.D.G.-H.), Department of Medicine, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA; LASER Analytica, New York, NY (J.J.J.); Department of Epidemiology, Harvard T.H. Chan School of Public Health, Boston, MA (H.K.); Department of Cardiology, Division of Cardiovascular Medicine, Massachusetts
| | - Herbert D. Aronow
- From the Division of Pharmacoepidemiology and Pharmacoeconomics (J.J.J., H.K., C.-Y.C., L.A.W., J.L., A.T.R., J.D.S.), Vascular and Endovascular Surgery (L.L.N.), and Cardiovascular Medicine (M.D.G.-H.), Department of Medicine, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA; LASER Analytica, New York, NY (J.J.J.); Department of Epidemiology, Harvard T.H. Chan School of Public Health, Boston, MA (H.K.); Department of Cardiology, Division of Cardiovascular Medicine, Massachusetts
| | - Joseph A. Johnston
- From the Division of Pharmacoepidemiology and Pharmacoeconomics (J.J.J., H.K., C.-Y.C., L.A.W., J.L., A.T.R., J.D.S.), Vascular and Endovascular Surgery (L.L.N.), and Cardiovascular Medicine (M.D.G.-H.), Department of Medicine, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA; LASER Analytica, New York, NY (J.J.J.); Department of Epidemiology, Harvard T.H. Chan School of Public Health, Boston, MA (H.K.); Department of Cardiology, Division of Cardiovascular Medicine, Massachusetts
| | - Thomas G. Brott
- From the Division of Pharmacoepidemiology and Pharmacoeconomics (J.J.J., H.K., C.-Y.C., L.A.W., J.L., A.T.R., J.D.S.), Vascular and Endovascular Surgery (L.L.N.), and Cardiovascular Medicine (M.D.G.-H.), Department of Medicine, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA; LASER Analytica, New York, NY (J.J.J.); Department of Epidemiology, Harvard T.H. Chan School of Public Health, Boston, MA (H.K.); Department of Cardiology, Division of Cardiovascular Medicine, Massachusetts
| | - Thomas T. Tsai
- From the Division of Pharmacoepidemiology and Pharmacoeconomics (J.J.J., H.K., C.-Y.C., L.A.W., J.L., A.T.R., J.D.S.), Vascular and Endovascular Surgery (L.L.N.), and Cardiovascular Medicine (M.D.G.-H.), Department of Medicine, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA; LASER Analytica, New York, NY (J.J.J.); Department of Epidemiology, Harvard T.H. Chan School of Public Health, Boston, MA (H.K.); Department of Cardiology, Division of Cardiovascular Medicine, Massachusetts
| | - Christopher J. White
- From the Division of Pharmacoepidemiology and Pharmacoeconomics (J.J.J., H.K., C.-Y.C., L.A.W., J.L., A.T.R., J.D.S.), Vascular and Endovascular Surgery (L.L.N.), and Cardiovascular Medicine (M.D.G.-H.), Department of Medicine, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA; LASER Analytica, New York, NY (J.J.J.); Department of Epidemiology, Harvard T.H. Chan School of Public Health, Boston, MA (H.K.); Department of Cardiology, Division of Cardiovascular Medicine, Massachusetts
| | - Soko Setoguchi
- From the Division of Pharmacoepidemiology and Pharmacoeconomics (J.J.J., H.K., C.-Y.C., L.A.W., J.L., A.T.R., J.D.S.), Vascular and Endovascular Surgery (L.L.N.), and Cardiovascular Medicine (M.D.G.-H.), Department of Medicine, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA; LASER Analytica, New York, NY (J.J.J.); Department of Epidemiology, Harvard T.H. Chan School of Public Health, Boston, MA (H.K.); Department of Cardiology, Division of Cardiovascular Medicine, Massachusetts
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African Americans Have Better Outcomes for Five Common Gastrointestinal Diagnoses in Hospitals With More Racially Diverse Patients. Am J Gastroenterol 2016; 111:649-57. [PMID: 27002802 DOI: 10.1038/ajg.2016.64] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/02/2015] [Accepted: 02/01/2016] [Indexed: 12/11/2022]
Abstract
OBJECTIVES We sought to characterize the relationship between hospital inpatient racial diversity and outcomes for African-American patients including rates of major complications or mortality during hospitalization for five common gastrointestinal diagnoses. METHODS Using the 2012 National Inpatient Sample database, hospital inpatient racial diversity was defined as the percentage of African-American patients discharged from each hospital. Logistic regression was used to predict major complication rates or death, long length of stay, and high total charges. Control variables included age, gender, payer type, patient location, area-associated income quartile, hospital characteristics including size, urban vs. rural, teaching vs. nonteaching, region, and the interaction of the percentage of African Americans with patient race. RESULTS There were 848,395 discharges across 3,392 hospitals. The patient population was on average 27% minority (s.d.±21%) with African Americans accounting for 14% of all patients. Overall, African-American patients had higher rates of major complications or death relative to white patients (adjusted odds ratio (aOR) 1.19; 95% confidence interval (CI) 1.16-1.23). However, when treated in hospitals with higher patient racial diversity, African-American patients experienced significantly lower rates of major complications or mortality (aOR 0.80; 95% CI 0.74-0.86). CONCLUSIONS African Americans have better outcomes for five common gastrointestinal diagnoses when treated in hospitals with higher inpatient racial diversity. This has major ramifications on total hospital charges.
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Hybrid approach in a difficult case of pseudoaneurysm of right common carotid artery. Indian Heart J 2016; 67 Suppl 3:S57-9. [PMID: 26995434 PMCID: PMC4799024 DOI: 10.1016/j.ihj.2015.12.023] [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: 10/09/2015] [Revised: 12/15/2015] [Accepted: 12/27/2015] [Indexed: 11/22/2022] Open
Abstract
We present the case of a 65-year-old gentleman, who presented with a symptomatic pseudoaneurysm of the right common carotid artery. Because of high surgical risk, endovascular approach was decided upon. However, taking hardware across the lesion via the aortic arch provided us with insurmountable difficulties. Therefore, a hybrid approach was resorted to, in which an arteriotomy was done in the carotid artery followed by direct implantation of the stent. We were thus able to create a favorable trade-off between the high surgical risk of a full surgical procedure and the peri-operative benefit of an endovascular approach.
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Abbott A. Critical Issues That Need to Be Addressed to Improve Outcomes for Patients With Carotid Stenosis. Angiology 2016; 67:420-6. [PMID: 26922085 DOI: 10.1177/0003319716631266] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Significant improvement in outcomes for patients with carotid stenosis requires liberation from the historic fixation with randomization and a procedurally based, late-stage, reactive approach to medical care. We require a multipronged and multidisciplinary approach that includes all of the following: (i) removal of overreliance on, and biased use of, randomized trial data; (ii) using accurate ways to rank evidence quality and relevance; (iii) improved research reporting standards; (iv) building quality assurance and other research capability into routine practice; (v) producing evidence-true rather than evidence-based guidelines; (vi) bringing current optimal medical treatment to the community and measuring its effectiveness; (vii) funding only interventions known to help patients when and where they are treated and use the savings to fund vital research, including quality assurance in routine practice; and (viii) recognize that making the indication for carotid procedures obsolete is a good thing.
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Affiliation(s)
- Anne Abbott
- Department of Epidemiology and Preventive Medicine, School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia Neurology Department, The Alfred Hospital, Melbourne, Victoria, Australia Faculty Advocating Collaborative and Thoughtful Carotid Artery Treatments (FACTCATS), FACTCATS.org
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Veith FJ, Bell PRF. How Many of You Can Read But Still Not See? A Comment on a Recent Review of Carotid Guidelines. Eur J Vasc Endovasc Surg 2015; 51:471-2. [PMID: 26701193 DOI: 10.1016/j.ejvs.2015.10.017] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2015] [Accepted: 10/26/2015] [Indexed: 10/22/2022]
Affiliation(s)
- F J Veith
- Department of Surgery, New York University Medical Center, New York, NY, USA; Cleveland Clinic, Cleveland, OH, USA.
| | - P R F Bell
- Department of Surgery, University of Leicester, UK
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Abbott AL, Paraskevas KI, Kakkos SK, Golledge J, Eckstein HH, Diaz-Sandoval LJ, Cao L, Fu Q, Wijeratne T, Leung TW, Montero-Baker M, Lee BC, Pircher S, Bosch M, Dennekamp M, Ringleb P. Systematic Review of Guidelines for the Management of Asymptomatic and Symptomatic Carotid Stenosis. Stroke 2015; 46:3288-301. [PMID: 26451020 DOI: 10.1161/strokeaha.115.003390] [Citation(s) in RCA: 196] [Impact Index Per Article: 21.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2015] [Accepted: 08/31/2015] [Indexed: 12/12/2022]
Abstract
BACKGROUND AND PURPOSE We systematically compared and appraised contemporary guidelines on management of asymptomatic and symptomatic carotid artery stenosis. METHODS We systematically searched for guideline recommendations on carotid endarterectomy (CEA) or carotid angioplasty/stenting (CAS) published in any language between January 1, 2008, and January 28, 2015. Only the latest guideline per writing group was selected. Each guideline was analyzed independently by 2 to 6 authors to determine clinical scenarios covered, recommendations given, and scientific evidence used. RESULTS Thirty-four eligible guidelines were identified from 23 different regions/countries in 6 languages. Of 28 guidelines with asymptomatic carotid artery stenosis procedural recommendations, 24 (86%) endorsed CEA (recommended it should or may be provided) for ≈50% to 99% average-surgical-risk asymptomatic carotid artery stenosis, 17 (61%) endorsed CAS, 8 (29%) opposed CAS, and 1 (4%) endorsed medical treatment alone. For asymptomatic carotid artery stenosis patients considered high-CEA-risk because of comorbidities, vascular anatomy, or undefined reasons, CAS was endorsed in 13 guidelines (46%). Thirty-one of 33 guidelines (94%) with symptomatic carotid artery stenosis procedural recommendations endorsed CEA for patients with ≈50% to 99% average-CEA-risk symptomatic carotid artery stenosis, 19 (58%) endorsed CAS and 9 (27%) opposed CAS. For high-CEA-risk symptomatic carotid artery stenosis because of comorbidities, vascular anatomy, or undefined reasons, CAS was endorsed in 27 guidelines (82%). Guideline procedural recommendations were based only on results of trials in which patients were randomized 12 to 34 years ago, rarely reflected medical treatment improvements and often understated potential CAS hazards. Qualifying terminology summarizing recommendations or evidence lacked standardization, impeding guideline interpretation, and comparison. CONCLUSIONS This systematic review has identified many opportunities to modernize and otherwise improve carotid stenosis management guidelines.
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Affiliation(s)
- Anne L Abbott
- From the Department of Epidemiology and Preventive Medicine, School of Public Health and Preventive Medicine (A.L.A, M.D.), Department of Surgery, Central Clinical School (M.B.), Monash University, Melbourne, Victoria, Australia; Neurology Department, The Alfred Hospital, Prahran, Victoria, Australia (A.L.A.); Department of Cardiovascular Sciences, St. George'sVascular Institute, St George's Hospital, London, United Kingdom (K.I.P.); Department of Vascular Surgery, University of Patras, Patras, Greece (S.K.K.); Queensland Research Centre for Peripheral Vascular Disease, College of Medicine and Dentistry, James Cook University, Townsville, Queensland, Australia (J.G.); Department of Vascular and Endovascular Surgery, The Townsville Hospital, Townsville, Queensland, Australia (J.G.); Department for Vascular and Endovascular Surgery, Klinikum Rechts der Isar, Technical University Munich, Munich, Germany (H.-H.E.); Department of Medicine, Michigan State University, Metro Health Hospital, Grand Rapids, MI (L.J.D.-S.); Cardiology Department, Xiamen Cardiovascular Hospital, Xiamen, Fujian, China (L.C.); Center for Cardiology Intervention Treatment, Department of Cardiology, Zhujiang Hospital, Southern Medical University, Guangzhou, Guangdong, China (Q.F.); Stroke Unit, Department of Neurology, Western Hospital, University of Melbourne, Footscray, Melbourne, Victoria, Australia (T.W.); Department of Medicine and Therapeutics, The Chinese University of Hong Kong, Hong Kong, China (T.W.L.); Department of Vascular Surgery, University of Arizona and Pima Vascular Group, Tucson (M.M.-B.); Department of Neurology, Hallym Neurological Institute, Hallym University, Sacred Heart Hospital, Seoul, South Korea (B.-C.L.); Centre for Health and Social Research, Faculty of Health Sciences, Australian Catholic University, Melbourne, Victoria, Australia (S.P.); and Department of Neurology, University Hospital Heidelberg, Heidelberg, Germany (P.R.).
| | - Kosmas I Paraskevas
- From the Department of Epidemiology and Preventive Medicine, School of Public Health and Preventive Medicine (A.L.A, M.D.), Department of Surgery, Central Clinical School (M.B.), Monash University, Melbourne, Victoria, Australia; Neurology Department, The Alfred Hospital, Prahran, Victoria, Australia (A.L.A.); Department of Cardiovascular Sciences, St. George'sVascular Institute, St George's Hospital, London, United Kingdom (K.I.P.); Department of Vascular Surgery, University of Patras, Patras, Greece (S.K.K.); Queensland Research Centre for Peripheral Vascular Disease, College of Medicine and Dentistry, James Cook University, Townsville, Queensland, Australia (J.G.); Department of Vascular and Endovascular Surgery, The Townsville Hospital, Townsville, Queensland, Australia (J.G.); Department for Vascular and Endovascular Surgery, Klinikum Rechts der Isar, Technical University Munich, Munich, Germany (H.-H.E.); Department of Medicine, Michigan State University, Metro Health Hospital, Grand Rapids, MI (L.J.D.-S.); Cardiology Department, Xiamen Cardiovascular Hospital, Xiamen, Fujian, China (L.C.); Center for Cardiology Intervention Treatment, Department of Cardiology, Zhujiang Hospital, Southern Medical University, Guangzhou, Guangdong, China (Q.F.); Stroke Unit, Department of Neurology, Western Hospital, University of Melbourne, Footscray, Melbourne, Victoria, Australia (T.W.); Department of Medicine and Therapeutics, The Chinese University of Hong Kong, Hong Kong, China (T.W.L.); Department of Vascular Surgery, University of Arizona and Pima Vascular Group, Tucson (M.M.-B.); Department of Neurology, Hallym Neurological Institute, Hallym University, Sacred Heart Hospital, Seoul, South Korea (B.-C.L.); Centre for Health and Social Research, Faculty of Health Sciences, Australian Catholic University, Melbourne, Victoria, Australia (S.P.); and Department of Neurology, University Hospital Heidelberg, Heidelberg, Germany (P.R.)
| | - Stavros K Kakkos
- From the Department of Epidemiology and Preventive Medicine, School of Public Health and Preventive Medicine (A.L.A, M.D.), Department of Surgery, Central Clinical School (M.B.), Monash University, Melbourne, Victoria, Australia; Neurology Department, The Alfred Hospital, Prahran, Victoria, Australia (A.L.A.); Department of Cardiovascular Sciences, St. George'sVascular Institute, St George's Hospital, London, United Kingdom (K.I.P.); Department of Vascular Surgery, University of Patras, Patras, Greece (S.K.K.); Queensland Research Centre for Peripheral Vascular Disease, College of Medicine and Dentistry, James Cook University, Townsville, Queensland, Australia (J.G.); Department of Vascular and Endovascular Surgery, The Townsville Hospital, Townsville, Queensland, Australia (J.G.); Department for Vascular and Endovascular Surgery, Klinikum Rechts der Isar, Technical University Munich, Munich, Germany (H.-H.E.); Department of Medicine, Michigan State University, Metro Health Hospital, Grand Rapids, MI (L.J.D.-S.); Cardiology Department, Xiamen Cardiovascular Hospital, Xiamen, Fujian, China (L.C.); Center for Cardiology Intervention Treatment, Department of Cardiology, Zhujiang Hospital, Southern Medical University, Guangzhou, Guangdong, China (Q.F.); Stroke Unit, Department of Neurology, Western Hospital, University of Melbourne, Footscray, Melbourne, Victoria, Australia (T.W.); Department of Medicine and Therapeutics, The Chinese University of Hong Kong, Hong Kong, China (T.W.L.); Department of Vascular Surgery, University of Arizona and Pima Vascular Group, Tucson (M.M.-B.); Department of Neurology, Hallym Neurological Institute, Hallym University, Sacred Heart Hospital, Seoul, South Korea (B.-C.L.); Centre for Health and Social Research, Faculty of Health Sciences, Australian Catholic University, Melbourne, Victoria, Australia (S.P.); and Department of Neurology, University Hospital Heidelberg, Heidelberg, Germany (P.R.)
| | - Jonathan Golledge
- From the Department of Epidemiology and Preventive Medicine, School of Public Health and Preventive Medicine (A.L.A, M.D.), Department of Surgery, Central Clinical School (M.B.), Monash University, Melbourne, Victoria, Australia; Neurology Department, The Alfred Hospital, Prahran, Victoria, Australia (A.L.A.); Department of Cardiovascular Sciences, St. George'sVascular Institute, St George's Hospital, London, United Kingdom (K.I.P.); Department of Vascular Surgery, University of Patras, Patras, Greece (S.K.K.); Queensland Research Centre for Peripheral Vascular Disease, College of Medicine and Dentistry, James Cook University, Townsville, Queensland, Australia (J.G.); Department of Vascular and Endovascular Surgery, The Townsville Hospital, Townsville, Queensland, Australia (J.G.); Department for Vascular and Endovascular Surgery, Klinikum Rechts der Isar, Technical University Munich, Munich, Germany (H.-H.E.); Department of Medicine, Michigan State University, Metro Health Hospital, Grand Rapids, MI (L.J.D.-S.); Cardiology Department, Xiamen Cardiovascular Hospital, Xiamen, Fujian, China (L.C.); Center for Cardiology Intervention Treatment, Department of Cardiology, Zhujiang Hospital, Southern Medical University, Guangzhou, Guangdong, China (Q.F.); Stroke Unit, Department of Neurology, Western Hospital, University of Melbourne, Footscray, Melbourne, Victoria, Australia (T.W.); Department of Medicine and Therapeutics, The Chinese University of Hong Kong, Hong Kong, China (T.W.L.); Department of Vascular Surgery, University of Arizona and Pima Vascular Group, Tucson (M.M.-B.); Department of Neurology, Hallym Neurological Institute, Hallym University, Sacred Heart Hospital, Seoul, South Korea (B.-C.L.); Centre for Health and Social Research, Faculty of Health Sciences, Australian Catholic University, Melbourne, Victoria, Australia (S.P.); and Department of Neurology, University Hospital Heidelberg, Heidelberg, Germany (P.R.)
| | - Hans-Henning Eckstein
- From the Department of Epidemiology and Preventive Medicine, School of Public Health and Preventive Medicine (A.L.A, M.D.), Department of Surgery, Central Clinical School (M.B.), Monash University, Melbourne, Victoria, Australia; Neurology Department, The Alfred Hospital, Prahran, Victoria, Australia (A.L.A.); Department of Cardiovascular Sciences, St. George'sVascular Institute, St George's Hospital, London, United Kingdom (K.I.P.); Department of Vascular Surgery, University of Patras, Patras, Greece (S.K.K.); Queensland Research Centre for Peripheral Vascular Disease, College of Medicine and Dentistry, James Cook University, Townsville, Queensland, Australia (J.G.); Department of Vascular and Endovascular Surgery, The Townsville Hospital, Townsville, Queensland, Australia (J.G.); Department for Vascular and Endovascular Surgery, Klinikum Rechts der Isar, Technical University Munich, Munich, Germany (H.-H.E.); Department of Medicine, Michigan State University, Metro Health Hospital, Grand Rapids, MI (L.J.D.-S.); Cardiology Department, Xiamen Cardiovascular Hospital, Xiamen, Fujian, China (L.C.); Center for Cardiology Intervention Treatment, Department of Cardiology, Zhujiang Hospital, Southern Medical University, Guangzhou, Guangdong, China (Q.F.); Stroke Unit, Department of Neurology, Western Hospital, University of Melbourne, Footscray, Melbourne, Victoria, Australia (T.W.); Department of Medicine and Therapeutics, The Chinese University of Hong Kong, Hong Kong, China (T.W.L.); Department of Vascular Surgery, University of Arizona and Pima Vascular Group, Tucson (M.M.-B.); Department of Neurology, Hallym Neurological Institute, Hallym University, Sacred Heart Hospital, Seoul, South Korea (B.-C.L.); Centre for Health and Social Research, Faculty of Health Sciences, Australian Catholic University, Melbourne, Victoria, Australia (S.P.); and Department of Neurology, University Hospital Heidelberg, Heidelberg, Germany (P.R.)
| | - Larry J Diaz-Sandoval
- From the Department of Epidemiology and Preventive Medicine, School of Public Health and Preventive Medicine (A.L.A, M.D.), Department of Surgery, Central Clinical School (M.B.), Monash University, Melbourne, Victoria, Australia; Neurology Department, The Alfred Hospital, Prahran, Victoria, Australia (A.L.A.); Department of Cardiovascular Sciences, St. George'sVascular Institute, St George's Hospital, London, United Kingdom (K.I.P.); Department of Vascular Surgery, University of Patras, Patras, Greece (S.K.K.); Queensland Research Centre for Peripheral Vascular Disease, College of Medicine and Dentistry, James Cook University, Townsville, Queensland, Australia (J.G.); Department of Vascular and Endovascular Surgery, The Townsville Hospital, Townsville, Queensland, Australia (J.G.); Department for Vascular and Endovascular Surgery, Klinikum Rechts der Isar, Technical University Munich, Munich, Germany (H.-H.E.); Department of Medicine, Michigan State University, Metro Health Hospital, Grand Rapids, MI (L.J.D.-S.); Cardiology Department, Xiamen Cardiovascular Hospital, Xiamen, Fujian, China (L.C.); Center for Cardiology Intervention Treatment, Department of Cardiology, Zhujiang Hospital, Southern Medical University, Guangzhou, Guangdong, China (Q.F.); Stroke Unit, Department of Neurology, Western Hospital, University of Melbourne, Footscray, Melbourne, Victoria, Australia (T.W.); Department of Medicine and Therapeutics, The Chinese University of Hong Kong, Hong Kong, China (T.W.L.); Department of Vascular Surgery, University of Arizona and Pima Vascular Group, Tucson (M.M.-B.); Department of Neurology, Hallym Neurological Institute, Hallym University, Sacred Heart Hospital, Seoul, South Korea (B.-C.L.); Centre for Health and Social Research, Faculty of Health Sciences, Australian Catholic University, Melbourne, Victoria, Australia (S.P.); and Department of Neurology, University Hospital Heidelberg, Heidelberg, Germany (P.R.)
| | - Longxing Cao
- From the Department of Epidemiology and Preventive Medicine, School of Public Health and Preventive Medicine (A.L.A, M.D.), Department of Surgery, Central Clinical School (M.B.), Monash University, Melbourne, Victoria, Australia; Neurology Department, The Alfred Hospital, Prahran, Victoria, Australia (A.L.A.); Department of Cardiovascular Sciences, St. George'sVascular Institute, St George's Hospital, London, United Kingdom (K.I.P.); Department of Vascular Surgery, University of Patras, Patras, Greece (S.K.K.); Queensland Research Centre for Peripheral Vascular Disease, College of Medicine and Dentistry, James Cook University, Townsville, Queensland, Australia (J.G.); Department of Vascular and Endovascular Surgery, The Townsville Hospital, Townsville, Queensland, Australia (J.G.); Department for Vascular and Endovascular Surgery, Klinikum Rechts der Isar, Technical University Munich, Munich, Germany (H.-H.E.); Department of Medicine, Michigan State University, Metro Health Hospital, Grand Rapids, MI (L.J.D.-S.); Cardiology Department, Xiamen Cardiovascular Hospital, Xiamen, Fujian, China (L.C.); Center for Cardiology Intervention Treatment, Department of Cardiology, Zhujiang Hospital, Southern Medical University, Guangzhou, Guangdong, China (Q.F.); Stroke Unit, Department of Neurology, Western Hospital, University of Melbourne, Footscray, Melbourne, Victoria, Australia (T.W.); Department of Medicine and Therapeutics, The Chinese University of Hong Kong, Hong Kong, China (T.W.L.); Department of Vascular Surgery, University of Arizona and Pima Vascular Group, Tucson (M.M.-B.); Department of Neurology, Hallym Neurological Institute, Hallym University, Sacred Heart Hospital, Seoul, South Korea (B.-C.L.); Centre for Health and Social Research, Faculty of Health Sciences, Australian Catholic University, Melbourne, Victoria, Australia (S.P.); and Department of Neurology, University Hospital Heidelberg, Heidelberg, Germany (P.R.)
| | - Qiang Fu
- From the Department of Epidemiology and Preventive Medicine, School of Public Health and Preventive Medicine (A.L.A, M.D.), Department of Surgery, Central Clinical School (M.B.), Monash University, Melbourne, Victoria, Australia; Neurology Department, The Alfred Hospital, Prahran, Victoria, Australia (A.L.A.); Department of Cardiovascular Sciences, St. George'sVascular Institute, St George's Hospital, London, United Kingdom (K.I.P.); Department of Vascular Surgery, University of Patras, Patras, Greece (S.K.K.); Queensland Research Centre for Peripheral Vascular Disease, College of Medicine and Dentistry, James Cook University, Townsville, Queensland, Australia (J.G.); Department of Vascular and Endovascular Surgery, The Townsville Hospital, Townsville, Queensland, Australia (J.G.); Department for Vascular and Endovascular Surgery, Klinikum Rechts der Isar, Technical University Munich, Munich, Germany (H.-H.E.); Department of Medicine, Michigan State University, Metro Health Hospital, Grand Rapids, MI (L.J.D.-S.); Cardiology Department, Xiamen Cardiovascular Hospital, Xiamen, Fujian, China (L.C.); Center for Cardiology Intervention Treatment, Department of Cardiology, Zhujiang Hospital, Southern Medical University, Guangzhou, Guangdong, China (Q.F.); Stroke Unit, Department of Neurology, Western Hospital, University of Melbourne, Footscray, Melbourne, Victoria, Australia (T.W.); Department of Medicine and Therapeutics, The Chinese University of Hong Kong, Hong Kong, China (T.W.L.); Department of Vascular Surgery, University of Arizona and Pima Vascular Group, Tucson (M.M.-B.); Department of Neurology, Hallym Neurological Institute, Hallym University, Sacred Heart Hospital, Seoul, South Korea (B.-C.L.); Centre for Health and Social Research, Faculty of Health Sciences, Australian Catholic University, Melbourne, Victoria, Australia (S.P.); and Department of Neurology, University Hospital Heidelberg, Heidelberg, Germany (P.R.)
| | - Tissa Wijeratne
- From the Department of Epidemiology and Preventive Medicine, School of Public Health and Preventive Medicine (A.L.A, M.D.), Department of Surgery, Central Clinical School (M.B.), Monash University, Melbourne, Victoria, Australia; Neurology Department, The Alfred Hospital, Prahran, Victoria, Australia (A.L.A.); Department of Cardiovascular Sciences, St. George'sVascular Institute, St George's Hospital, London, United Kingdom (K.I.P.); Department of Vascular Surgery, University of Patras, Patras, Greece (S.K.K.); Queensland Research Centre for Peripheral Vascular Disease, College of Medicine and Dentistry, James Cook University, Townsville, Queensland, Australia (J.G.); Department of Vascular and Endovascular Surgery, The Townsville Hospital, Townsville, Queensland, Australia (J.G.); Department for Vascular and Endovascular Surgery, Klinikum Rechts der Isar, Technical University Munich, Munich, Germany (H.-H.E.); Department of Medicine, Michigan State University, Metro Health Hospital, Grand Rapids, MI (L.J.D.-S.); Cardiology Department, Xiamen Cardiovascular Hospital, Xiamen, Fujian, China (L.C.); Center for Cardiology Intervention Treatment, Department of Cardiology, Zhujiang Hospital, Southern Medical University, Guangzhou, Guangdong, China (Q.F.); Stroke Unit, Department of Neurology, Western Hospital, University of Melbourne, Footscray, Melbourne, Victoria, Australia (T.W.); Department of Medicine and Therapeutics, The Chinese University of Hong Kong, Hong Kong, China (T.W.L.); Department of Vascular Surgery, University of Arizona and Pima Vascular Group, Tucson (M.M.-B.); Department of Neurology, Hallym Neurological Institute, Hallym University, Sacred Heart Hospital, Seoul, South Korea (B.-C.L.); Centre for Health and Social Research, Faculty of Health Sciences, Australian Catholic University, Melbourne, Victoria, Australia (S.P.); and Department of Neurology, University Hospital Heidelberg, Heidelberg, Germany (P.R.)
| | - Thomas W Leung
- From the Department of Epidemiology and Preventive Medicine, School of Public Health and Preventive Medicine (A.L.A, M.D.), Department of Surgery, Central Clinical School (M.B.), Monash University, Melbourne, Victoria, Australia; Neurology Department, The Alfred Hospital, Prahran, Victoria, Australia (A.L.A.); Department of Cardiovascular Sciences, St. George'sVascular Institute, St George's Hospital, London, United Kingdom (K.I.P.); Department of Vascular Surgery, University of Patras, Patras, Greece (S.K.K.); Queensland Research Centre for Peripheral Vascular Disease, College of Medicine and Dentistry, James Cook University, Townsville, Queensland, Australia (J.G.); Department of Vascular and Endovascular Surgery, The Townsville Hospital, Townsville, Queensland, Australia (J.G.); Department for Vascular and Endovascular Surgery, Klinikum Rechts der Isar, Technical University Munich, Munich, Germany (H.-H.E.); Department of Medicine, Michigan State University, Metro Health Hospital, Grand Rapids, MI (L.J.D.-S.); Cardiology Department, Xiamen Cardiovascular Hospital, Xiamen, Fujian, China (L.C.); Center for Cardiology Intervention Treatment, Department of Cardiology, Zhujiang Hospital, Southern Medical University, Guangzhou, Guangdong, China (Q.F.); Stroke Unit, Department of Neurology, Western Hospital, University of Melbourne, Footscray, Melbourne, Victoria, Australia (T.W.); Department of Medicine and Therapeutics, The Chinese University of Hong Kong, Hong Kong, China (T.W.L.); Department of Vascular Surgery, University of Arizona and Pima Vascular Group, Tucson (M.M.-B.); Department of Neurology, Hallym Neurological Institute, Hallym University, Sacred Heart Hospital, Seoul, South Korea (B.-C.L.); Centre for Health and Social Research, Faculty of Health Sciences, Australian Catholic University, Melbourne, Victoria, Australia (S.P.); and Department of Neurology, University Hospital Heidelberg, Heidelberg, Germany (P.R.)
| | - Miguel Montero-Baker
- From the Department of Epidemiology and Preventive Medicine, School of Public Health and Preventive Medicine (A.L.A, M.D.), Department of Surgery, Central Clinical School (M.B.), Monash University, Melbourne, Victoria, Australia; Neurology Department, The Alfred Hospital, Prahran, Victoria, Australia (A.L.A.); Department of Cardiovascular Sciences, St. George'sVascular Institute, St George's Hospital, London, United Kingdom (K.I.P.); Department of Vascular Surgery, University of Patras, Patras, Greece (S.K.K.); Queensland Research Centre for Peripheral Vascular Disease, College of Medicine and Dentistry, James Cook University, Townsville, Queensland, Australia (J.G.); Department of Vascular and Endovascular Surgery, The Townsville Hospital, Townsville, Queensland, Australia (J.G.); Department for Vascular and Endovascular Surgery, Klinikum Rechts der Isar, Technical University Munich, Munich, Germany (H.-H.E.); Department of Medicine, Michigan State University, Metro Health Hospital, Grand Rapids, MI (L.J.D.-S.); Cardiology Department, Xiamen Cardiovascular Hospital, Xiamen, Fujian, China (L.C.); Center for Cardiology Intervention Treatment, Department of Cardiology, Zhujiang Hospital, Southern Medical University, Guangzhou, Guangdong, China (Q.F.); Stroke Unit, Department of Neurology, Western Hospital, University of Melbourne, Footscray, Melbourne, Victoria, Australia (T.W.); Department of Medicine and Therapeutics, The Chinese University of Hong Kong, Hong Kong, China (T.W.L.); Department of Vascular Surgery, University of Arizona and Pima Vascular Group, Tucson (M.M.-B.); Department of Neurology, Hallym Neurological Institute, Hallym University, Sacred Heart Hospital, Seoul, South Korea (B.-C.L.); Centre for Health and Social Research, Faculty of Health Sciences, Australian Catholic University, Melbourne, Victoria, Australia (S.P.); and Department of Neurology, University Hospital Heidelberg, Heidelberg, Germany (P.R.)
| | - Byung-Chul Lee
- From the Department of Epidemiology and Preventive Medicine, School of Public Health and Preventive Medicine (A.L.A, M.D.), Department of Surgery, Central Clinical School (M.B.), Monash University, Melbourne, Victoria, Australia; Neurology Department, The Alfred Hospital, Prahran, Victoria, Australia (A.L.A.); Department of Cardiovascular Sciences, St. George'sVascular Institute, St George's Hospital, London, United Kingdom (K.I.P.); Department of Vascular Surgery, University of Patras, Patras, Greece (S.K.K.); Queensland Research Centre for Peripheral Vascular Disease, College of Medicine and Dentistry, James Cook University, Townsville, Queensland, Australia (J.G.); Department of Vascular and Endovascular Surgery, The Townsville Hospital, Townsville, Queensland, Australia (J.G.); Department for Vascular and Endovascular Surgery, Klinikum Rechts der Isar, Technical University Munich, Munich, Germany (H.-H.E.); Department of Medicine, Michigan State University, Metro Health Hospital, Grand Rapids, MI (L.J.D.-S.); Cardiology Department, Xiamen Cardiovascular Hospital, Xiamen, Fujian, China (L.C.); Center for Cardiology Intervention Treatment, Department of Cardiology, Zhujiang Hospital, Southern Medical University, Guangzhou, Guangdong, China (Q.F.); Stroke Unit, Department of Neurology, Western Hospital, University of Melbourne, Footscray, Melbourne, Victoria, Australia (T.W.); Department of Medicine and Therapeutics, The Chinese University of Hong Kong, Hong Kong, China (T.W.L.); Department of Vascular Surgery, University of Arizona and Pima Vascular Group, Tucson (M.M.-B.); Department of Neurology, Hallym Neurological Institute, Hallym University, Sacred Heart Hospital, Seoul, South Korea (B.-C.L.); Centre for Health and Social Research, Faculty of Health Sciences, Australian Catholic University, Melbourne, Victoria, Australia (S.P.); and Department of Neurology, University Hospital Heidelberg, Heidelberg, Germany (P.R.)
| | - Sabine Pircher
- From the Department of Epidemiology and Preventive Medicine, School of Public Health and Preventive Medicine (A.L.A, M.D.), Department of Surgery, Central Clinical School (M.B.), Monash University, Melbourne, Victoria, Australia; Neurology Department, The Alfred Hospital, Prahran, Victoria, Australia (A.L.A.); Department of Cardiovascular Sciences, St. George'sVascular Institute, St George's Hospital, London, United Kingdom (K.I.P.); Department of Vascular Surgery, University of Patras, Patras, Greece (S.K.K.); Queensland Research Centre for Peripheral Vascular Disease, College of Medicine and Dentistry, James Cook University, Townsville, Queensland, Australia (J.G.); Department of Vascular and Endovascular Surgery, The Townsville Hospital, Townsville, Queensland, Australia (J.G.); Department for Vascular and Endovascular Surgery, Klinikum Rechts der Isar, Technical University Munich, Munich, Germany (H.-H.E.); Department of Medicine, Michigan State University, Metro Health Hospital, Grand Rapids, MI (L.J.D.-S.); Cardiology Department, Xiamen Cardiovascular Hospital, Xiamen, Fujian, China (L.C.); Center for Cardiology Intervention Treatment, Department of Cardiology, Zhujiang Hospital, Southern Medical University, Guangzhou, Guangdong, China (Q.F.); Stroke Unit, Department of Neurology, Western Hospital, University of Melbourne, Footscray, Melbourne, Victoria, Australia (T.W.); Department of Medicine and Therapeutics, The Chinese University of Hong Kong, Hong Kong, China (T.W.L.); Department of Vascular Surgery, University of Arizona and Pima Vascular Group, Tucson (M.M.-B.); Department of Neurology, Hallym Neurological Institute, Hallym University, Sacred Heart Hospital, Seoul, South Korea (B.-C.L.); Centre for Health and Social Research, Faculty of Health Sciences, Australian Catholic University, Melbourne, Victoria, Australia (S.P.); and Department of Neurology, University Hospital Heidelberg, Heidelberg, Germany (P.R.)
| | - Marije Bosch
- From the Department of Epidemiology and Preventive Medicine, School of Public Health and Preventive Medicine (A.L.A, M.D.), Department of Surgery, Central Clinical School (M.B.), Monash University, Melbourne, Victoria, Australia; Neurology Department, The Alfred Hospital, Prahran, Victoria, Australia (A.L.A.); Department of Cardiovascular Sciences, St. George'sVascular Institute, St George's Hospital, London, United Kingdom (K.I.P.); Department of Vascular Surgery, University of Patras, Patras, Greece (S.K.K.); Queensland Research Centre for Peripheral Vascular Disease, College of Medicine and Dentistry, James Cook University, Townsville, Queensland, Australia (J.G.); Department of Vascular and Endovascular Surgery, The Townsville Hospital, Townsville, Queensland, Australia (J.G.); Department for Vascular and Endovascular Surgery, Klinikum Rechts der Isar, Technical University Munich, Munich, Germany (H.-H.E.); Department of Medicine, Michigan State University, Metro Health Hospital, Grand Rapids, MI (L.J.D.-S.); Cardiology Department, Xiamen Cardiovascular Hospital, Xiamen, Fujian, China (L.C.); Center for Cardiology Intervention Treatment, Department of Cardiology, Zhujiang Hospital, Southern Medical University, Guangzhou, Guangdong, China (Q.F.); Stroke Unit, Department of Neurology, Western Hospital, University of Melbourne, Footscray, Melbourne, Victoria, Australia (T.W.); Department of Medicine and Therapeutics, The Chinese University of Hong Kong, Hong Kong, China (T.W.L.); Department of Vascular Surgery, University of Arizona and Pima Vascular Group, Tucson (M.M.-B.); Department of Neurology, Hallym Neurological Institute, Hallym University, Sacred Heart Hospital, Seoul, South Korea (B.-C.L.); Centre for Health and Social Research, Faculty of Health Sciences, Australian Catholic University, Melbourne, Victoria, Australia (S.P.); and Department of Neurology, University Hospital Heidelberg, Heidelberg, Germany (P.R.)
| | - Martine Dennekamp
- From the Department of Epidemiology and Preventive Medicine, School of Public Health and Preventive Medicine (A.L.A, M.D.), Department of Surgery, Central Clinical School (M.B.), Monash University, Melbourne, Victoria, Australia; Neurology Department, The Alfred Hospital, Prahran, Victoria, Australia (A.L.A.); Department of Cardiovascular Sciences, St. George'sVascular Institute, St George's Hospital, London, United Kingdom (K.I.P.); Department of Vascular Surgery, University of Patras, Patras, Greece (S.K.K.); Queensland Research Centre for Peripheral Vascular Disease, College of Medicine and Dentistry, James Cook University, Townsville, Queensland, Australia (J.G.); Department of Vascular and Endovascular Surgery, The Townsville Hospital, Townsville, Queensland, Australia (J.G.); Department for Vascular and Endovascular Surgery, Klinikum Rechts der Isar, Technical University Munich, Munich, Germany (H.-H.E.); Department of Medicine, Michigan State University, Metro Health Hospital, Grand Rapids, MI (L.J.D.-S.); Cardiology Department, Xiamen Cardiovascular Hospital, Xiamen, Fujian, China (L.C.); Center for Cardiology Intervention Treatment, Department of Cardiology, Zhujiang Hospital, Southern Medical University, Guangzhou, Guangdong, China (Q.F.); Stroke Unit, Department of Neurology, Western Hospital, University of Melbourne, Footscray, Melbourne, Victoria, Australia (T.W.); Department of Medicine and Therapeutics, The Chinese University of Hong Kong, Hong Kong, China (T.W.L.); Department of Vascular Surgery, University of Arizona and Pima Vascular Group, Tucson (M.M.-B.); Department of Neurology, Hallym Neurological Institute, Hallym University, Sacred Heart Hospital, Seoul, South Korea (B.-C.L.); Centre for Health and Social Research, Faculty of Health Sciences, Australian Catholic University, Melbourne, Victoria, Australia (S.P.); and Department of Neurology, University Hospital Heidelberg, Heidelberg, Germany (P.R.)
| | - Peter Ringleb
- From the Department of Epidemiology and Preventive Medicine, School of Public Health and Preventive Medicine (A.L.A, M.D.), Department of Surgery, Central Clinical School (M.B.), Monash University, Melbourne, Victoria, Australia; Neurology Department, The Alfred Hospital, Prahran, Victoria, Australia (A.L.A.); Department of Cardiovascular Sciences, St. George'sVascular Institute, St George's Hospital, London, United Kingdom (K.I.P.); Department of Vascular Surgery, University of Patras, Patras, Greece (S.K.K.); Queensland Research Centre for Peripheral Vascular Disease, College of Medicine and Dentistry, James Cook University, Townsville, Queensland, Australia (J.G.); Department of Vascular and Endovascular Surgery, The Townsville Hospital, Townsville, Queensland, Australia (J.G.); Department for Vascular and Endovascular Surgery, Klinikum Rechts der Isar, Technical University Munich, Munich, Germany (H.-H.E.); Department of Medicine, Michigan State University, Metro Health Hospital, Grand Rapids, MI (L.J.D.-S.); Cardiology Department, Xiamen Cardiovascular Hospital, Xiamen, Fujian, China (L.C.); Center for Cardiology Intervention Treatment, Department of Cardiology, Zhujiang Hospital, Southern Medical University, Guangzhou, Guangdong, China (Q.F.); Stroke Unit, Department of Neurology, Western Hospital, University of Melbourne, Footscray, Melbourne, Victoria, Australia (T.W.); Department of Medicine and Therapeutics, The Chinese University of Hong Kong, Hong Kong, China (T.W.L.); Department of Vascular Surgery, University of Arizona and Pima Vascular Group, Tucson (M.M.-B.); Department of Neurology, Hallym Neurological Institute, Hallym University, Sacred Heart Hospital, Seoul, South Korea (B.-C.L.); Centre for Health and Social Research, Faculty of Health Sciences, Australian Catholic University, Melbourne, Victoria, Australia (S.P.); and Department of Neurology, University Hospital Heidelberg, Heidelberg, Germany (P.R.)
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32
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Abstract
Background Carotid artery procedures, such as surgery and stenting, although associated with significant risks and costs, are often recommended in guidelines which cite12- to 34-year-old randomized trial evidence of benefit; however, these recommendations exist although there is no evidence these procedures benefit patients who receive only current optimal medical treatment (encouragement of a healthy lifestyle and appropriate use of medication). Objective To examine whether bias exists in the use of randomized trial evidence and its impact on guideline recommendations. Material and methods Examples of how bias underpins endorsement of carotid procedures for patients with asymptomatic or symptomatic carotid stenosis were sought from available literature. . Results Many forms of procedural bias were identified involving the need for randomized trials, and their design and interpretation. Fundamental problems included failure to first adequately measure outcomes with non-invasive treatment alone, lack of appreciation of quality non-randomized trial measurements of risk in determining need for randomized trials and their applicability in routine practice, poor randomized trial methods with biased comparisons, inaccurate definitions of target populations, confusion of efficacy and safety outcomes, too much reliance on statistical rather than clinical significance and biased use of terminology to make procedures sound more effective. Conclusion Procedural bias in design and interpretation of randomized trials has resulted in widespread loss of understanding of how to optimize outcomes in patients with carotid artery stenosis. Current guidelines reflect the cumulative impact of this bias and are an excellent starting point for efforts to improve prevention of stroke and other vascular disease complications; however, there is also need for clinicians, policy makers, health service funding bodies, educators and the general public to assist.
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