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Musialek P, Rosenfield K, Siddiqui AH, Grunwald IQ. Carotid Stenosis and Stroke: Medicines, Stents, Surgery-"Wait-and-See" or Protect? Thromb Haemost 2024; 124:815-827. [PMID: 36170885 PMCID: PMC11349427 DOI: 10.1055/a-1952-1159] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2021] [Accepted: 09/27/2022] [Indexed: 10/14/2022]
Affiliation(s)
- Piotr Musialek
- Department of Cardiac and Vascular Diseases, Jagiellonian University, Krakow, Poland
- John Paul II Hospital Stroke Thrombectomy-Capable Centre, Krakow, Poland
| | - Kenneth Rosenfield
- Division of Cardiology, Vascular Medicine and Intervention Section, Massachusetts General Hospital, Boston, United States
| | - Adnan H. Siddiqui
- Departments of Neurosurgery and Radiology, School of Medicine and Biomedical Sciences, University at Buffalo, State University of New York, Buffalo, New York, United States
- Jacobs Institute, Buffalo, New York, United States
- Department of Neurosurgery, Gates Vascular Institute Kaleida Health, Buffalo, New York, United States
| | - Iris Q. Grunwald
- Department of Radiology, Ninewells Hospital, Chair of Neuroradiology, University of Dundee, Dundee, Scotland, United Kingdom
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2
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Rosen R, Bodnar M, Randolph J, Bailey CJ, Nickel C, Katsoulakis E, Mifsud M. Risk, prevention, screening and management of carotid artery stenosis in head & neck cancer patients-An evidence based review. Oral Oncol 2024; 156:106876. [PMID: 38908097 DOI: 10.1016/j.oraloncology.2024.106876] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2024] [Revised: 05/12/2024] [Accepted: 05/28/2024] [Indexed: 06/24/2024]
Abstract
Our review aims to clarify the incidence of carotid artery stenosis, risks of development, screening, management, and primary prevention strategies documented in the literature after radiation therapy for head and neck cancers. The high prevalence of carotid stenosis after radiation therapy for head and neck cancers has made surveillance and risk stratification critical. In addition to general cardiovascular risk factors such as smoking, diabetes, and dyslipidemia, risk factors for carotid artery stenosis after head and neck radiation included total plaque score, radiotherapy use and dosage, length of time after radiotherapy, and age greater than 50. Cancer subtype, namely nasopharyngeal cancer, may be correlated with increased risk as well, though contrasting results have been found. Interestingly, however, no significant relationship has been found between radiotherapy dose and stroke risk. Surgical management of post-radiation carotid stenosis is similar to that of stenosis unrelated to radiation, with carotid endarterectomy considered to be the gold standard treatment and carotid artery stenting being an acceptable, less-invasive alternative. Medical management of these patients has not been well-studied, but antiplatelet therapy, statins, and blood pressure control may be beneficial. The mainstay of screening for radiation-induced stenosis has been Doppler ultrasound, with measurement of changes in the intima-media thickness being a primary marker of disease development. A literature review was carried out using the MeSH terms "Carotid Artery Stenosis," "Head and Neck Neoplasms," and "Radiotherapy."
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Affiliation(s)
| | | | - Jackson Randolph
- Georgetown University Medical Center, Department of Otolaryngology-Head and Neck Surgery, USA
| | - Charles J Bailey
- University of South Florida Morsani College of Medicine, Division of Vascular & Endovascular Surgery, USA
| | - Christopher Nickel
- University of South Florida Morsani College of Medicine, Department of Otolaryngology-Head and Neck Surgery, USA
| | - Evangelia Katsoulakis
- University of South Florida Morsani College of Medicine, Department of Radiation Oncology, USA
| | - Matthew Mifsud
- University of South Florida Morsani College of Medicine, Department of Otolaryngology-Head and Neck Surgery, USA.
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3
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Tresson P, Lo S, Rivoire E, Cho TH, Millon A, Long A. Long-Term Mortality and Morbidity after Carotid Endarterectomy for Symptomatic and Asymptomatic Carotid Stenosis. Ann Vasc Surg 2024:S0890-5096(24)00463-1. [PMID: 39116939 DOI: 10.1016/j.avsg.2024.07.085] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2024] [Revised: 07/08/2024] [Accepted: 07/17/2024] [Indexed: 08/10/2024]
Abstract
BACKGROUND To investigate whether the occurrence of ischemic stroke due to carotid stenosis is a marker of the severity of atherosclerotic disease and of an excess risk of cardiovascular morbidity and mortality, and of all-cause mortality, after carotid endarterectomy (CEA). METHODS Patients who had undergone a CEA from June 2015 to august 2016 were included. Patients were classified into 2 groups, namely symptomatic and asymptomatic. Neurological event, myocardial infarction, and death during early follow up were monitored. Major adverse cardiovascular events, major limb eventss, and all-cause mortality were compared for patients with a CEA for an asymptomatic carotid stenosis versus those with a symptomatic stenosis. RESULTS Among the 190 patients included, 86 (51%) had a CEA for an asymptomatic stenosis and 84 (49%) for a symptomatic stenosis. During the first 30 days, the rate of all-cause death or ischemic stroke was similar in both groups (1%, P = 0.986). After 30 days, there were a total of 35 major adverse cardiovascular events (21.3%) and 15 major limb events (9.1%) during mean follow up of 53 (22.6) months. Overall cardiovascular morbidity and mortality was 30.4% and did not differ between groups (P = 0.565). New ischemic stroke occurred in 11 patients (9.1%) and was significantly more frequent in the asymptomatic group (9 (14.8%) versus 2 (3.6%) in the symptomatic group, (odds ratio: 4.96; confidence interval 95% [1.04-23.77]; P = 0.013)). Overall all-cause mortality was 24% in both groups (P = 0.93) CONCLUSIONS: The occurrence of ischemic stroke of carotid origin before revascularization does not appear to be associated with an excess risk of cardiovascular morbidity or mortality or all-cause mortality after surgery.
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Affiliation(s)
- Philippe Tresson
- Hospices Civils de Lyon, Hôpital Louis Pradel, Service de Chirurgie Vasculaire et Endovasculaire, Bron, France.
| | - Stéphane Lo
- Hospices Civils de Lyon, Hôpital Edouard Herriot, Service de Médecine Interne et de Médecine Vasculaire, Lyon, France; Université de Lyon, University Claude Bernard Lyon 1, Lyon, France
| | - Emeraude Rivoire
- Hospices Civils de Lyon, Hôpital Edouard Herriot, Service de Médecine Interne et de Médecine Vasculaire, Lyon, France; Université de Lyon, University Claude Bernard Lyon 1, Lyon, France
| | - Tae-Hee Cho
- Department of Vascular Neurology, Hospices Civils de Lyon, Université Lyon 1, Lyon, France; CarMeN, INSERM-U1060, INRA-U1397, INSA-Lyon, Université Lyon 1, Lyon, France
| | - Antoine Millon
- Hospices Civils de Lyon, Hôpital Louis Pradel, Service de Chirurgie Vasculaire et Endovasculaire, Bron, France; Université de Lyon, University Claude Bernard Lyon 1, Lyon, France
| | - Anne Long
- Hospices Civils de Lyon, Hôpital Edouard Herriot, Service de Médecine Interne et de Médecine Vasculaire, Lyon, France; Université de Lyon, University Claude Bernard Lyon 1, Lyon, France
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4
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Ristow AVB, Massière B, Meirelles GV, Casella IB, Morales MM, Moreira RCR, Procópio RJ, Oliveira TF, de Araujo WJB, Joviliano EE, de Oliveira JCP. Brazilian Angiology and Vascular Surgery Society Guidelines for the treatment of extracranial cerebrovascular disease. J Vasc Bras 2024; 23:e20230094. [PMID: 39099701 PMCID: PMC11296686 DOI: 10.1590/1677-5449.202300942] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2023] [Accepted: 10/16/2023] [Indexed: 08/06/2024] Open
Abstract
Extracranial cerebrovascular disease has been the subject of intense research throughout the world, and is of paramount importance for vascular surgeons. This guideline, written by the Brazilian Society of Angiology and Vascular Surgery (SBACV), supersedes the 2015 guideline. Non-atherosclerotic carotid artery diseases were not included in this document. The purpose of this guideline is to bring together the most robust evidence in this area in order to help specialists in the treatment decision-making process. The AGREE II methodology and the European Society of Cardiology system were used for recommendations and levels of evidence. The recommendations were graded from I to III, and levels of evidence were classified as A, B, or C. This guideline is divided into 11 chapters dealing with the various aspects of extracranial cerebrovascular disease: diagnosis, treatments and complications, based on up-to-date knowledge and the recommendations proposed by SBACV.
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Affiliation(s)
- Arno von Buettner Ristow
- Pontifícia Universidade Católica do Rio de Janeiro – PUC-RIO, Disciplina de Cirurgia Vascular e Endovascular, Rio de Janeiro, RJ, Brasil.
- Sociedade Brasileira de Angiologia e de Cirurgia Vascular – SBACV-RJ, Rio de Janeiro, RJ, Brasil.
| | - Bernardo Massière
- Pontifícia Universidade Católica do Rio de Janeiro – PUC-RIO, Disciplina de Cirurgia Vascular e Endovascular, Rio de Janeiro, RJ, Brasil.
- Sociedade Brasileira de Angiologia e de Cirurgia Vascular – SBACV-RJ, Rio de Janeiro, RJ, Brasil.
| | - Guilherme Vieira Meirelles
- Sociedade Brasileira de Angiologia e de Cirurgia Vascular – SBACV-SP, São Paulo, SP, Brasil.
- Universidade Estadual de Campinas – UNICAMP, Hospital das Clínicas, Disciplina de Cirurgia do Trauma, Campinas, SP, Brasil.
| | - Ivan Benaduce Casella
- Sociedade Brasileira de Angiologia e de Cirurgia Vascular – SBACV-SP, São Paulo, SP, Brasil.
- Universidade de São Paulo – USP, Faculdade de Medicina, São Paulo, SP, Brasil.
| | - Marcia Maria Morales
- Sociedade Brasileira de Angiologia e de Cirurgia Vascular – SBACV-SP, São Paulo, SP, Brasil.
- Associação Portuguesa de Beneficência de São José do Rio Preto, Serviço de Cirurgia Vascular, São José do Rio Preto, SP, Brasil.
| | - Ricardo Cesar Rocha Moreira
- Sociedade Brasileira de Angiologia e de Cirurgia Vascular – SBACV-PR, Curitiba, PR, Brasil.
- Pontifícia Universidade Católica do Paraná – PUC-PR, Hospital Cajurú, Serviço de Cirurgia Vascular, Curitiba, PR, Brasil.
| | - Ricardo Jayme Procópio
- Universidade Federal de Minas Gerais – UFMG, Hospital das Clínicas, Setor de Cirurgia Endovascular, Belo Horizonte, MG, Brasil.
- Universidade Federal de Minas Gerais – UFMG, Faculdade de Medicina, Belo Horizonte, MG, Brasil.
- Sociedade Brasileira de Angiologia e de Cirurgia Vascular – SBACV-MG, Belo Horizonte, MG, Brasil.
| | - Tércio Ferreira Oliveira
- Sociedade Brasileira de Angiologia e de Cirurgia Vascular – SBACV-SE, Aracajú, SE, Brasil.
- Universidade de São Paulo – USP, Faculdade de Medicina de Ribeirão Preto – FMRP, Ribeirão Preto, SP, Brasil.
| | - Walter Jr. Boim de Araujo
- Sociedade Brasileira de Angiologia e de Cirurgia Vascular – SBACV-PR, Curitiba, PR, Brasil.
- Universidade Federal do Paraná – UFPR, Hospital das Clínicas – HC, Curitiba, PR, Brasil.
| | - Edwaldo Edner Joviliano
- Sociedade Brasileira de Angiologia e de Cirurgia Vascular – SBACV-SP, São Paulo, SP, Brasil.
- Universidade de São Paulo – USP, Faculdade de Medicina de Ribeirão Preto – FMRP, Ribeirão Preto, SP, Brasil.
| | - Júlio Cesar Peclat de Oliveira
- Sociedade Brasileira de Angiologia e de Cirurgia Vascular – SBACV-SP, São Paulo, SP, Brasil.
- Universidade Federal do Estado do Rio de Janeiro – UNIRIO, Departamento de Cirurgia, Rio de Janeiro, RJ, Brasil.
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Paraskevas KI, Musialek P, Mikhailidis DP, Lip GYH. Optimal Stroke Risk Management in Carotid Atherosclerotic Disease: A Patient-Centered Multidisciplinary Approach. Angiology 2024; 75:5-7. [PMID: 37730239 DOI: 10.1177/00033197231203566] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/22/2023]
Affiliation(s)
| | - Piotr Musialek
- Department of Cardiac and Vascular Diseases, Medical College, Jagiellonian University, Krakow, Poland
- John Paul II Hospital, Krakow, Poland
| | - Dimitri P Mikhailidis
- Department of Surgical Biotechnology, Division of Surgery and Interventional Science, University College London Medical School, London, UK
- Royal Free Hospital Campus, University College London (UCL) and Department of Clinical Biochemistry, London, UK
| | - Gregory Y H Lip
- Liverpool Centre for Cardiovascular Science at University of Liverpool, Liverpool John Moores University and Liverpool Heart & Chest Hospital, Liverpool, UK
- Danish Center for Health Services Research, Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
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6
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Paraskevas KI, Musialek P, Mikhailidis DP, Lip GYH. The Fundamental Role of Medical Treatment in the Prevention of Carotid Related Strokes: Insights from a Multispecialty Consensus Document. Curr Vasc Pharmacol 2024; 22:5-7. [PMID: 37909660 DOI: 10.2174/0115701611282696231101072656] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2023] [Accepted: 10/03/2023] [Indexed: 11/03/2023]
Affiliation(s)
| | - Piotr Musialek
- Department of Cardiac and Vascular Diseases, Jagiellonian University, Medical College, Krakow, Poland
- John Paul II Hospital, Krakow, Poland
| | - Dimitri P Mikhailidis
- Department of Surgical Biotechnology, Division of Surgery and Interventional Science, University College London Medical School, University College London (UCL) and Department of Clinical Biochemistry, Royal Free Hospital Campus, UCL, London, UK
| | - Gregory Y H Lip
- Liverpool Centre for Cardiovascular Science at University of Liverpool, Liverpool John Moores University and Liverpool Heart & Chest Hospital, Liverpool, UK
- Danish Center for Health Services Research, Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
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7
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Mohd AB, Alabdallat Y, Mohd OB, Ghannam RA, Sawaqed S, Hasan H, Ellebedy M, Turkmani K, Al-Ezzi S. Medical and Surgical Management of Symptomatic and Asymptomatic Carotid Artery Stenosis: A Comprehensive Literature Review. Cureus 2023; 15:e43263. [PMID: 37692579 PMCID: PMC10491926 DOI: 10.7759/cureus.43263] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/09/2023] [Indexed: 09/12/2023] Open
Abstract
Carotid artery stenosis is a condition where the carotid artery is blocked by fatty cholesterol deposits called plaque, increasing the risk of stroke. Elderly individuals with high cardiovascular risk are more susceptible, along with smokers, those with high cholesterol, males, and older individuals. Young females may also be affected by fibromuscular dysplasia. Carotid stenosis significantly raises stroke risk, and the severity is closely linked to stroke incidence and other cardiovascular events. Early detection and treatment are essential to prevent complications. Treatment options include medical and surgical interventions, such as carotid endarterectomy (CEA) and carotid artery stenting (CAS). The choice between surgery and medical management varies depending on patient characteristics and risk factors. This review explores carotid artery stenosis pathophysiology, risk factors, the importance of early detection and treatment, and the surgical approaches of CEA and CAS, addressing their roles and controversies. Healthcare professionals must understand these aspects to provide optimal care to patients with this condition.
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Affiliation(s)
- Ahmed B Mohd
- Faculty of Medicine, Hashemite University, Zarqa, JOR
| | | | - Omar B Mohd
- Faculty of Medicine, Hashemite University, Zarqa, JOR
| | | | - Seri Sawaqed
- Infectious Disease, Faculty of Medicine, Hashemite University, Zarqa, JOR
| | - Hanan Hasan
- Medical Laboratory, The Lab Medical Laboratories, Amman, JOR
| | | | | | - Shakir Al-Ezzi
- Internal Medicine, Hospital Corporation of America (HCA) Medical City Arlington, Dallas, USA
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8
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Paraskevas KI. Mind the young patients undergoing carotid endarterectomy! J Vasc Surg 2023; 78:131. [PMID: 37349008 DOI: 10.1016/j.jvs.2023.02.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2023] [Accepted: 02/23/2023] [Indexed: 06/24/2023]
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9
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Petrovic J, Ilijevski N, Sagic D, Antonic Z, Tanaskovic S. Risk Factors for Carotid Restenosis in Patients After Eversion Endarterectomy vs Stenting: A Single-Center Experience. Angiology 2023; 74:317-324. [PMID: 35968755 DOI: 10.1177/00033197221121005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
The primary aim of the presented study is to analyze and compare the rate of carotid restenosis in patients after eversion carotid endarterectomy (eCEA), primary carotid angioplasty and stenting (CASp), and stenting for carotid artery restenosis after previous eCEA (CASr). The secondary aim is to compare clinical outcomes in patients with carotid restenosis. The total number of patients with evident carotid restenosis was 223 (24.8%). In patients with eCEA, significant carotid restenosis rate was 12.7%, in the CASp group 18.7%, and CASr 6.7%. Patients with carotid restenosis were asymptomatic in 95.1% of cases. Patients in the CASp group experienced transient ischemic attack more than patients with eCEA (P = .007), while no difference was observed regarding cerebrovascular insult (CVI). The incidence of carotid restenosis was higher in CASp patients, and increased during the follow-up. The majority of patients are asymptomatic post-procedural and the degree of carotid restenosis does not correlate with the occurrence of postoperative symptoms. High low-density lipoprotein cholesterol (LDL-C) levels, low high-density lipoprotein cholesterol (HDL-C) levels, smoking, and a history of vascular surgery correlate with higher degrees of carotid restenosis. The most important factor in the prevention of carotid restenosis is risk factor control as well as adequate pharmacological therapy.
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Affiliation(s)
- Jovan Petrovic
- Faculty of Medicine, 54801University of Belgrade, Beograd, Serbia
| | - Nenad Ilijevski
- Faculty of Medicine, 54801University of Belgrade, Beograd, Serbia.,Vascular Surgery Clinic, Dedinje Cardiovascular Institute, Belgrade, Serbia
| | - Dragan Sagic
- Faculty of Medicine, 54801University of Belgrade, Beograd, Serbia.,Clinic for Radiology, Dedinje Cardiovascular Institute, Belgrade, Serbia
| | - Zelimir Antonic
- Clinic for Radiology, Dedinje Cardiovascular Institute, Belgrade, Serbia
| | - Slobodan Tanaskovic
- Faculty of Medicine, 54801University of Belgrade, Beograd, Serbia.,Vascular Surgery Clinic, Dedinje Cardiovascular Institute, Belgrade, Serbia
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10
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Paraskevas KI, Spence JD, Mikhailidis DP, Antignani PL, Gloviczki P, Eckstein HH, Spinelli F, Stilo F, Saba L, Poredos P, Dardik A, Liapis CD, Mansilha A, Faggioli G, Pini R, Jezovnik MK, Sultan S, Musiałek P, Goudot G, Lavenson GS, Jawien A, Blinc A, Myrcha P, Fernandes E Fernandes J, Geroulakos G, Kakkos SK, Knoflach M, Proczka RM, Capoccia L, Rundek T, Svetlikov AS, Silvestrini M, Ricco JB, Davies AH, Di Lazzaro V, Suri JS, Lanza G, Fraedrich G, Zeebregts CJ, Nicolaides AN. Why do guidelines recommend screening for abdominal aortic aneurysms, but not for asymptomatic carotid stenosis? A plea for a randomized controlled trial. Int J Cardiol 2023; 371:406-412. [PMID: 36162523 DOI: 10.1016/j.ijcard.2022.09.045] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/13/2022] [Revised: 09/18/2022] [Accepted: 09/20/2022] [Indexed: 12/14/2022]
Abstract
BACKGROUND Current guidelines do not recommend screening for asymptomatic carotid artery stenosis (AsxCS). The rationale behind this recommendation is that detection of AsxCS may lead to an unnecessary carotid intervention. In contrast, screening for abdominal aortic aneurysms is strongly recommended. METHODS A critical analysis of the literature was performed to evaluate the implications of detecting AsxCS. RESULTS Patients with AsxCS are at high risk for future stroke, myocardial infarction and vascular death. Population-wide screening for AsxCS should not be recommended. Additionally, screening of high-risk individuals for AsxCS with the purpose of identifying candidates for a carotid intervention is inappropriate. Instead, selective screening for AsxCS should be considered and should be viewed as an opportunity to identify individuals at high risk for atherosclerotic cardiovascular disease and future cardiovascular events for the timely initiation of intensive medical therapy and risk factor modification. CONCLUSIONS Although mass screening should not be recommended, there are several arguments suggesting that selective screening for AsxCS should be considered. The rationale supporting such selective screening is to optimize risk factor control and to initiate intensive medical therapy for prevention of future cardiovascular events, rather than to identify candidates for an intervention.
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Affiliation(s)
| | - J David Spence
- Stroke Prevention and Atherosclerosis Research Centre, Robarts Research Institute, Western University, London, ON, Canada
| | - Dimitri P Mikhailidis
- Department of Clinical Biochemistry, Royal Free Hospital Campus, University College London Medical School, University College London (UCL), London, UK
| | | | - Peter Gloviczki
- Division of Vascular and Endovascular Surgery, Mayo Clinic, Rochester, MN, USA
| | - Hans-Henning Eckstein
- Department for Vascular and Endovascular Surgery, Klinikum rechts der Isar, Technical University of Munich, Munich, Germany
| | - Francesco Spinelli
- Vascular Surgery Division, Campus Bio-Medico University of Rome, Rome, Italy
| | - Francesco Stilo
- Vascular Surgery Division, Campus Bio-Medico University of Rome, Rome, Italy
| | - Luca Saba
- Department of Radiology, Azienda Ospedaliera Universitaria Di Cagliari, Cagliari, Italy
| | - Pavel Poredos
- Department of Vascular Disease, University Medical Centre Ljubljana, Slovenia
| | - Alan Dardik
- Division of Vascular and Endovascular Surgery, Yale University School of Medicine, New Haven, CT, USA
| | | | - Armando Mansilha
- Faculty of Medicine of the University of Porto, Porto, Portugal; Department of Angiology and Vascular Surgery, Hospital de S. Joao, Porto, Portugal
| | - Gianluca Faggioli
- Vascular Surgery, University of Bologna "Alma Mater Studiorum", Policlinico S. Orsola Malpighi, Bologna, Italy
| | - Rodolfo Pini
- Vascular Surgery, University of Bologna "Alma Mater Studiorum", Policlinico S. Orsola Malpighi, Bologna, Italy
| | - Mateja K Jezovnik
- Department of Advanced Cardiopulmonary Therapies and Transplantation, The University of Texas Health Science Centre at Houston, Houston, TX, USA
| | - Sherif Sultan
- Western Vascular Institute, Department of Vascular and Endovascular Surgery, University Hospital Galway, National University of Ireland, Galway, Ireland
| | - Piotr Musiałek
- Jagiellonian University Department of Cardiac and Vascular Diseases, John Paul II Hospital, Krakow, Poland
| | - Guillaume Goudot
- Vascular medicine department, Georges Pompidou European hospital, APHP, Université de Paris Cité, Paris, France
| | - George S Lavenson
- Department of Surgery, Uniformed Services University, Bethesda, MD, USA
| | - Arkadiusz Jawien
- Department of Vascular Surgery and Angiology, Collegium Medicum, Nicolaus Copernicus University, Bydgoszcz, Poland
| | - Aleš Blinc
- Department of Vascular Diseases, Division of Internal Medicine, University Medical Centre Ljubljana, Ljubljana, Slovenia
| | - Piotr Myrcha
- Department of General and Vascular Surgery, Faculty of Medicine, Medical University of Warsaw, Warsaw, Poland
| | | | - George Geroulakos
- Department of Vascular Surgery, "Attikon" University Hospital, National and Kapodistrian University of Athens, Athens, Greece
| | - Stavros K Kakkos
- Department of Vascular Surgery, University Hospital of Patras, Patras, Greece
| | - Michael Knoflach
- Department of Neurology, Medical University of Innsbruck, Innsbruck, Austria
| | - Robert M Proczka
- 1(st) Department of Vascular Surgery, Medicover Hospital, Warsaw, Poland
| | - Laura Capoccia
- Department of Surgery "Paride Stefanini", Policlinico Umberto I, "Sapienza" University of Rome, Rome, Italy
| | - Tatjana Rundek
- Department of Neurology, Miller School of Medicine, University of Miami, Miami, FL, USA
| | - Alexei S Svetlikov
- Division of Vascular and Endovascular Surgery, North-Western Scientific Clinical Center of Federal Medical Biological Agency of Russia, St. Petersburg, Russia
| | - Mauro Silvestrini
- Neurological Clinic, Department of Experimental and Clinical Medicine, Marche Polytechnic University, Ancona, Italy
| | - Jean-Baptiste Ricco
- Department of Clinical Research, University of Poitiers, CHU de Poitiers, Poitiers, France
| | - Alun H Davies
- Department of Surgery and Cancer, Section of Vascular Surgery, Imperial College London, Charing Cross Hospital, London, UK
| | - Vincenzo Di Lazzaro
- Neurology, Neurophysiology and Neurobiology Unit, Department of Medicine, Universita Campus Bio-Medico di Roma, Rome, Italy
| | - Jasjit S Suri
- Stroke Diagnostic and Monitoring Division, Atheropoint™, Roseville, CA, USA
| | - Gaetano Lanza
- Vascular Surgery Department, IRCSS Multimedica Hospital, Castellanza, Italy
| | - Gustav Fraedrich
- Department of Vascular Surgery, Medical University of Innsbruck, Innsbruck, Austria
| | - Clark J Zeebregts
- Department of Surgery (Division of Vascular Surgery), University Medical Center Groningen, University of Groningen, Groningen, the Netherlands
| | - Andrew N Nicolaides
- Department of Surgery, University of Nicosia Medical School, Nicosia, Cyprus
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11
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Paraskevas KI, Mikhailidis DP, Antignani PL, Ascher E, Baradaran H, Bokkers RPH, Cambria RP, Comerota AJ, Dardik A, Davies AH, Eckstein HH, Faggioli G, Fernandes E Fernandes J, Fraedrich G, Geroulakos G, Gloviczki P, Golledge J, Gupta A, Jezovnik MK, Kakkos SK, Katsiki N, Knoflach M, Eline Kooi M, Lanza G, Lavenson GS, Liapis CD, Loftus IM, Mansilha A, Millon A, Nicolaides AN, Pini R, Poredos P, Proczka RM, Ricco JB, Riles TS, Ringleb PA, Rundek T, Saba L, Schlachetzki F, Silvestrini M, Spinelli F, Stilo F, Sultan S, Suri JS, Svetlikov AV, Zeebregts CJ, Chaturvedi S. Comparison of Recent Practice Guidelines for the Management of Patients With Asymptomatic Carotid Stenosis. Angiology 2022; 73:903-910. [PMID: 35412377 DOI: 10.1177/00033197221081914] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
Abstract
Despite the publication of several national/international guidelines, the optimal management of patients with asymptomatic carotid stenosis (AsxCS) remains controversial. This article compares 3 recently released guidelines (the 2020 German-Austrian, the 2021 European Stroke Organization [ESO], and the 2021 Society for Vascular Surgery [SVS] guidelines) vs the 2017 European Society for Vascular Surgery (ESVS) guidelines regarding the optimal management of AsxCS patients.The 2017 ESVS guidelines defined specific imaging/clinical parameters that may identify patient subgroups at high future stroke risk and recommended that carotid endarterectomy (CEA) should or carotid artery stenting (CAS) may be considered for these individuals. The 2020 German-Austrian guidelines provided similar recommendations with the 2017 ESVS Guidelines. The 2021 ESO Guidelines also recommended CEA for AsxCS patients at high risk for stroke on best medical treatment (BMT), but recommended against routine use of CAS in these patients. Finally, the SVS guidelines provided a strong recommendation for CEA+BMT vs BMT alone for low-surgical risk patients with >70% AsxCS. Thus, the ESVS, German-Austrian, and ESO guidelines concurred that all AsxCS patients should receive risk factor modification and BMT, but CEA should or CAS may also be considered for certain AsxCS patient subgroups at high risk for future ipsilateral ischemic stroke.
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Affiliation(s)
| | - Dimitri P Mikhailidis
- Department of Clinical Biochemistry, Royal Free Hospital Campus, University College London Medical School, University College London (UCL), London, UK
| | | | - Enrico Ascher
- Division of Vascular Surgery, 12297Vascular Institute of New York, Brooklyn, NY, USA
| | - Hediyeh Baradaran
- Department of Radiology, 14434University of Utah, Salt Lake City, UT, USA
| | - Reinoud P H Bokkers
- Department of Radiology, Medical Imaging Center, 10173University Medical Center Groningen, Groningen, The Netherlands
| | - Richard P Cambria
- Division of Vascular and Endovascular Surgery, St Elizabeth's Medical Center, Boston, MA, USA
| | - Anthony J Comerota
- Inova Heart and Vascular Institute, Inova Alexandria Hospital, Alexandria, VA, USA
| | - Alan Dardik
- Division of Vascular and Endovascular Surgery, Yale University School of Medicine, New Haven, CT, USA
| | - Alun H Davies
- Section of Vascular Surgery, Imperial College and Imperial Healthcare NHS Trust, London, UK
| | - Hans-Henning Eckstein
- Department for Vascular and Endovascular Surgery, Klinikum Rechts der Isar, Technical University of Munich, Munich, Germany
| | - Gianluca Faggioli
- Vascular Surgery, University of Bologna "Alma Mater Studiorum", Policlinico S. Orsola Malpighi, Bologna, Italy
| | | | - Gustav Fraedrich
- Department of Vascular Surgery, Medical University of Innsbruck, Innsbruck, Austria
| | - George Geroulakos
- Department of Vascular Surgery, 69038"Attikon" University Hospital, National and Kapodistrian University of Athens, Athens, Greece
| | - Peter Gloviczki
- Division of Vascular and Endovascular Surgery, 6915Mayo Clinic, Rochester, MN, USA
| | - Jonathan Golledge
- Queensland Research Centre for Peripheral Vascular Disease, James Cook University and Townsville University Hospital, Townsville, Queensland, Australia
| | - Ajay Gupta
- Department of Radiology, 466371Weill Cornell Medicine, New York, NY, USA
| | - Mateja K Jezovnik
- Department of Advanced Cardiopulmonary Therapies and Transplantation, The University of Texas Health Science Centre at Houston, Houston, TX, U.S.A
| | - Stavros K Kakkos
- Department of Vascular Surgery, 37795University of Patras Medical School, Patras, Greece
| | - Niki Katsiki
- First Department of Internal Medicine, 37782AHEPA University Hospital, Thessaloniki, Greece
| | - Michael Knoflach
- Department of Neurology, 27280Medical University of Innsbruck, Innsbruck, Austria
| | - M Eline Kooi
- CARIM School for Cardiovascular Disease, 46837Maastricht University, Maaastricht, The Netherlands.,Department of Radiology and Nuclear Medicine, 46837Maastricht University Medical Center, Maastricht, The Netherlands
| | - Gaetano Lanza
- Vascular Surgery Department, 46837IRCSS MultiMedica Hospital, Castellanza, Italy
| | - George S Lavenson
- Department of Surgery, 1685Uniformed Services University, Bethesda, MD, USA
| | | | - Ian M Loftus
- St George's Vascular Institute, St George's University London, London, UK
| | - Armando Mansilha
- Faculty of Medicine of the University of Porto, Porto, Portugal.,Department of Angiology and Vascular Surgery, Hospital de S. Joao, Porto, Portugal
| | - Antoine Millon
- Department of Vascular and Endovascular Surgery, 26899Louis Pradel Hospital, Hospices Civils de Lyon, France
| | - Andrew N Nicolaides
- Department of Surgery, 121343University of Nicosia Medical School, Nicosia, Cyprus
| | - Rodolfo Pini
- Vascular Surgery, University of Bologna "Alma Mater Studiorum", Policlinico S. Orsola Malpighi, Bologna, Italy
| | - Pavel Poredos
- Department of Vascular Disease, University Medical Centre Ljubljana, Slovenia
| | - Robert M Proczka
- 1stDepartment of Vascular Surgery, Medicover Hospital, Warsaw, Poland
| | - Jean-Baptiste Ricco
- Department of Clinical Research, University of Poitiers, CHU de Poitiers, Poitiers, France
| | - Thomas S Riles
- Department of Surgery, Division of Vascular Surgery, 12297New York University Langone Medical Centre, New York, NY, USA
| | | | - Tatjana Rundek
- Department of Neurology, Miller School of Medicine, 12235University of Miami, Miami, FL, USA
| | - Luca Saba
- Department of Radiology, 97863Azienda Ospedaliera Universitaria Di Cagliari, Cagliari, Italy
| | - Felix Schlachetzki
- Department of Neurology, 210419University of Regensburg, Regensburg, Germany
| | - Mauro Silvestrini
- Neurological Clinic, Department of Experimental and Clinical Medicine, 9294Marche Polytechnic University, Ancona, Italy
| | - Francesco Spinelli
- Vascular Surgery Division, 9311Campus Bio-Medico University of Rome, Rome, Italy
| | - Francesco Stilo
- Vascular Surgery Division, 9311Campus Bio-Medico University of Rome, Rome, Italy
| | - Sherif Sultan
- Western Vascular Institute, Department of Vascular and Endovascular Surgery, University Hospital Galway, National University of Ireland, Galway, Ireland
| | - Jasjit S Suri
- Stroke Diagnosis and Monitoring Division, AtheroPointTM, Roseville, USA
| | - Alexei V Svetlikov
- Division of Vascular and Endovascular Surgery, North-Western Scientific Clinical Center of Federal Medical Biological Agency of Russia, St Petersburgh, Russia
| | - Clark J Zeebregts
- Division of Vascular Surgery, Department of Surgery, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Seemant Chaturvedi
- Department of Neurology & Stroke Program, 12264University of Maryland School of Medicine, Baltimore, MD, USA
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12
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Cheng X, Li Z, Yang M, Liu Y, Wang S, Huang M, Gao S, Yang R, Li L, Yu C. Association of HbA1c with carotid artery plaques in patients with coronary heart disease: a retrospective clinical study. Acta Cardiol 2022; 78:442-450. [PMID: 35356852 DOI: 10.1080/00015385.2022.2040822] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022]
Abstract
BACKGROUND AND AIMS Haemoglobin A1c (HbA1c) levels have been shown to be related to carotid artery plaques. However, studies on the relationship between HbA1c levels and carotid artery plaques in patients with coronary heart disease (CHD) are limited and inconsistent. Our objective was to examine the correlation between HbA1c levels and carotid artery plaques in patients with CHD. METHODS The study comprised 9275 Chinese adults with CHD from January 1, 2014, to September 30, 2020. HbA1c levels were assessed, and colour Doppler ultrasound was used to evaluate the carotid artery, including plaque presence, intima-media thickness, and plaque echo properties, to investigate the association between HbA1c and carotid plaque. A logistic regression model was used to assess the association between carotid artery plaques, carotid plaque echogenicity, and HbA1c. RESULTS The HbA1c level of the plaque-present group was higher than that of the plaque-absent group [6.1 (5.6-7.2) vs. 5.8 (5.5-6.5), p < 0.001]. In multiple linear regression analysis, intima-media thickness was associated with HbA1c (p < 0.001). Logistic regression showed that a higher HbA1c level was associated with plaque incidence as well as hyperechoic and heterogeneous plaques (p < 0.001). These associations persist after adjusting for age, sex, blood pressure, lipid profiles, alcohol consumption, and tobacco exposure. CONCLUSION HbA1c levels are notably associated with carotid artery plaque incidence, intima-media thickness, and plaque echogenicity in patients with CHD. These findings show that different levels of HbA1c may be an indicator for carotid artery plaques and thus, should be observed in patients with CHD.
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Affiliation(s)
- Xufeng Cheng
- Graduate School, Tianjin University of Traditional Chinese Medicine, Tianjin, China
| | - Zhu Li
- Graduate School, Tianjin University of Traditional Chinese Medicine, Tianjin, China
| | - Mingjie Yang
- Graduate School, Tianjin University of Traditional Chinese Medicine, Tianjin, China
| | - Yijia Liu
- Graduate School, Tianjin University of Traditional Chinese Medicine, Tianjin, China
| | - Shuo Wang
- Graduate School, Tianjin University of Traditional Chinese Medicine, Tianjin, China
| | - Mengnan Huang
- Graduate School, Tianjin University of Traditional Chinese Medicine, Tianjin, China
| | - Shan Gao
- Institute of Traditional Chinese Medicine, Tianjin University of Traditional Chinese Medicine, Tianjin, China
| | - Rongrong Yang
- School of Health Science and Engineering, Tianjin University of Traditional Chinese Medicine, Tianjin, China
| | - Lin Li
- Institute of Traditional Chinese Medicine, Tianjin University of Traditional Chinese Medicine, Tianjin, China
| | - Chunquan Yu
- Institute of Traditional Chinese Medicine, Tianjin University of Traditional Chinese Medicine, Tianjin, China
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13
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Sudheer P, Vibha D, Misra S. Asymptomatic Carotid Stenosis: Several Guidelines with Unclear Answers. Ann Indian Acad Neurol 2022; 25:171-176. [PMID: 35693653 PMCID: PMC9175419 DOI: 10.4103/aian.aian_566_21] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2021] [Revised: 08/30/2021] [Accepted: 09/01/2021] [Indexed: 12/24/2022] Open
Affiliation(s)
- Pachipala Sudheer
- Department of Neurology, All India Institute of Medical Sciences, New Delhi, India
| | - Deepti Vibha
- Department of Neurology, All India Institute of Medical Sciences, New Delhi, India
| | - Shubham Misra
- Department of Neurology, All India Institute of Medical Sciences, New Delhi, India
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14
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Meng Q, Li X, Zhao M, Lin S, Yu X, Dong G. Study on the Mechanism of Platelet-Released Clusterins Inducing Restenosis after Carotid Endarterectomy by Activating TLR3/NF- κb p65 Signaling Pathway. JOURNAL OF HEALTHCARE ENGINEERING 2022; 2022:7631126. [PMID: 35047156 PMCID: PMC8763522 DOI: 10.1155/2022/7631126] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/23/2021] [Revised: 12/08/2021] [Accepted: 12/18/2021] [Indexed: 11/18/2022]
Abstract
This study aimed to explore the role of clusterin released by platelet aggregation in restenosis after carotid endarterectomy. 35 patients who underwent carotid endarterectomy due to carotid artery stenosis were enrolled in this study. They were admitted to the Third Affiliated Hospital of Qiqihar Medical University from January 2018 to January 2019. All the patients were divided into two groups: the restenosis group and the nonrestenosis group, according to the follow-up results within 12 months. Peripheral blood was collected on the first day, 6 months, and 12 months after operation. The expression of CLU in serum of plasma and platelet culture medium was detected by an ELISA experiment. The vascular endothelial cells were cultured in vitro with 100 ng/mL of human recombinant CLU added to the medium. Cell proliferation, migration, and invasion were detected by CCK8, scratch, and Transwell invasion tests. The expression level of TLR3 and NF-κb p65 proteins in cells was detected by western blot. TLR3 knockout plasmids in vascular endothelial cell lines were transfected. Cell proliferation and migration were detected by CCK8 and the scratch assay. The CLU content in peripheral blood plasma and supernatant of platelet culture medium was significantly higher in the restenosis group than that of the control group (p=0.003) 6 months after operation (p=0.047) and 12 months after operation (p=0.011). When CLU was added to vascular endothelial cell culture medium, the proliferation and migration were significantly enhanced. The TLR3/NF-κb p65 protein expression level in cells also significantly increased. After the transfection of TLR3 knockout plasmids into vascular endothelial cell lines, CLU cannot promote the proliferation and migration of vascular endothelial cells. Platelet-released clusterin can induce vascular endothelial cell proliferation and migration by activating the TLR3/NF-kb p65 signaling pathway, leading to carotid artery restenosis after carotid endarterectomy.
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Affiliation(s)
- Qingyu Meng
- Vascular Surgery Department, The Third Affiliated Hospital of Qiqihar Medical University, Qiqihar 161000, China
| | - Xichun Li
- Vascular Surgery Department, The Third Affiliated Hospital of Qiqihar Medical University, Qiqihar 161000, China
| | - Mingyu Zhao
- Vascular Surgery Department, The Third Affiliated Hospital of Qiqihar Medical University, Qiqihar 161000, China
| | - Shusen Lin
- Vascular Surgery Department, The Third Affiliated Hospital of Qiqihar Medical University, Qiqihar 161000, China
| | - Xiangwen Yu
- Vascular Surgery Department, The Third Affiliated Hospital of Qiqihar Medical University, Qiqihar 161000, China
| | - Guanglong Dong
- Vascular Surgery Department, The Third Affiliated Hospital of Qiqihar Medical University, Qiqihar 161000, China
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15
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A systematic review of cognitive function after carotid endarterectomy in asymptomatic patients. J Vasc Surg 2022; 75:2074-2085. [PMID: 34995717 DOI: 10.1016/j.jvs.2021.12.059] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2021] [Accepted: 12/04/2021] [Indexed: 11/21/2022]
Abstract
OBJECTIVE Asymptomatic carotid stenosis has been associated with a progressive decline in neurocognitive function. However, the effect of carotid endarterectomy on this process is poorly understood. We aimed to evaluate pre and post-operative cognitive function changes in asymptomatic patients after carotid endarterectomy METHODS: A systematic review of the existing reports in PubMed/MEDLINE, Embase, and Cochran databases was conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-analysis statement recommendations. All original retrospective or prospective studies (including cohort, cross-sectional, case-control, pilot studies, etc.) and clinical trials that compared pre and post-operative neurocognitive function in asymptomatic patients with carotid stenosis after CEA, which were published from January 2000 to April 2021 were identified and considered eligible for inclusion in the study. RESULTS Thirteen studies (502 CEAs) comparing cognitive function changes before and after CEA were identified. In seven studies with a total number of 272 patients, a mean age range of 67.3 ± 4.8 to 76.35 years old and after follow-up ranging between 1 and 12 months, overall cognitive function improved after CEA. However, in six studies with a total sample of 230, a mean age range of 68.6 ± 6.9 to 74.4±6.1 years, and follow-up ranged from 24 hours to 3 years, showed no change or decline in overall cognitive function after procedures. CONCLUSIONS The lack of standardization of specific cognitive tests and cognitive function assessment timing after CEA does not allow for definite conclusions to be made. However, improving the brain perfusion with combination of CEA and statin therapy may be a protective strategy against cognitive function decline.
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16
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Paraskevas KI, Mikhailidis DP, Antignani PL, Baradaran H, Bokkers RP, Cambria RP, Dardik A, Davies AH, Eckstein HH, Faggioli G, Fernandes E Fernandes J, Fraedrich G, Geroulakos G, Gloviczki P, Golledge J, Gupta A, Jezovnik MK, Kakkos SK, Katsiki N, Knoflach M, Kooi ME, Lanza G, Liapis CD, Loftus IM, Mansilha A, Millon A, Nicolaides AN, Pini R, Poredos P, Ricco JB, Riles TS, Ringleb PA, Rundek T, Saba L, Schlachetzki F, Silvestrini M, Spinelli F, Stilo F, Sultan S, Suri JS, Zeebregts CJ, Chaturvedi S. Optimal management of asymptomatic carotid stenosis in 2021: the jury is still out. An International, multispecialty, expert review and position statement. INT ANGIOL 2021; 41:158-169. [PMID: 34913633 DOI: 10.23736/s0392-9590.21.04825-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
OBJECTIVES The recommendations of international guidelines for the management of asymptomatic carotid stenosis (ACS) often vary considerably and extend from a conservative approach with risk factor modification and best medical treatment (BMT) alone, to a more aggressive approach with a carotid intervention plus BMT. The aim of the current multispecialty position statement is to reconcile the conflicting views on the topic. MATERIALS AND METHODS A literature review was performed with a focus on data from recent studies. RESULTS Several clinical and imaging high-risk features have been identified that are associated with an increased long-term ipsilateral ischemic stroke risk in patients with ACS. Such high-risk clinical/imaging features include intraplaque hemorrhage, impaired cerebrovascular reserve, carotid plaque echolucency/ulceration/ neovascularization, a lipid-rich necrotic core, a thin or ruptured fibrous cap, silent brain infarction, a contralateral transient ischemic attack/stroke episode, male patients <75 years and microembolic signals on transcranial Doppler. There is growing evidence that 80-99% ACS indicate a higher stroke risk than 50-79% stenoses. CONCLUSIONS Although aggressive risk factor control and BMT should be implemented in all ACS patients, several high-risk features that may increase the risk of a future cerebrovascular event are now documented. Consequently, some guidelines recommend a prophylactic carotid intervention in high-risk patients to prevent future cerebrovascular events. Until the results of the much-anticipated randomized controlled trials emerge, the jury is still out regarding the optimal management of ACS patients.
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Affiliation(s)
| | - Dimitri P Mikhailidis
- Department of Clinical Biochemistry, Royal Free Hospital Campus, University College London Medical School, University College London (UCL), London, UK
| | | | - Hediyeh Baradaran
- Department of Radiology, University of Utah, Salt Lake City, UT, USA
| | - Reinoud P Bokkers
- Department of Radiology, Medical Imaging Center, University Medical Center Groningen, Groningen, The Netherlands
| | - Richard P Cambria
- Division of Vascular and Endovascular Surgery, St. Elizabeth's Medical Center, Brighton, MA, USA
| | - Alan Dardik
- Division of Vascular and Endovascular Surgery, Yale University School of Medicine, New Haven, CT, USA
| | - Alun H Davies
- Section of Vascular Surgery, Imperial College & Imperial Healthcare NHS Trust, London, UK
| | - Hans-Henning Eckstein
- Department for Vascular and Endovascular Surgery, Klinikum rechts der Isar, Technical University of Munich, Munich, Germany
| | - Gianluca Faggioli
- Vascular Surgery, Policlinico S. Orsola Malpighi, University of Bologna Alma Mater Studiorum, Bologna, Italy
| | | | - Gustav Fraedrich
- Department of Vascular Surgery, Medical University of Innsbruck, Innsbruck, Austria
| | - George Geroulakos
- Department of Vascular Surgery, Attikon University Hospital, National and Kapodistrian University of Athens, Athens, Greece
| | - Peter Gloviczki
- Division of Vascular and Endovascular Surgery, Mayo Clinic, Rochester, MN, USA
| | - Jonathan Golledge
- Queensland Research Centre for Peripheral Vascular Disease, James Cook University and Townsville University Hospital, Townsville, Australia
| | - Ajay Gupta
- Department of Radiology, Weill Cornell Medicine, New York, NY, USA
| | - Mateja K Jezovnik
- Department of Advanced Cardiopulmonary Therapies and Transplantation, The University of Texas Health Science Centre at Houston, Houston, Texas, USA
| | - Stavros K Kakkos
- Department of Vascular Surgery, University of Patras Medical School, Patras, Greece
| | - Niki Katsiki
- First Department of Internal Medicine, AHEPA University Hospital, Thessaloniki, Greece
| | - Michael Knoflach
- Department of Neurology, Medical University of Innsbruck, Innsbruck, Austria
| | - M Eline Kooi
- CARIM School for Cardiovascular Diseases, Maastricht University, Maastricht, The Netherlands.,Department of Radiology and Nuclear Medicine, Maastricht University Medical Center, Maastricht, The Netherlands
| | - Gaetano Lanza
- Vascular Surgery Department, IRCSS MultiMedica Hospital, Castellanza, Varese, Italy
| | | | - Ian M Loftus
- St. George's Vascular Institute, St. George's University London, London, UK
| | - Armando Mansilha
- Faculty of Medicine of the University of Porto, Porto, Portugal.,Department of Angiology and Vascular Surgery, Hospital de S. Joao, Porto, Portugal
| | - Antoine Millon
- Department of Vascular and Endovascular Surgery, Louis Pradel Hospital, Hospices Civils de Lyon, Lyon, France
| | - Andrew N Nicolaides
- Department of Surgery, University of Nicosia Medical School, Nicosia, Cyprus
| | - Rodolfo Pini
- Vascular Surgery, Policlinico S. Orsola Malpighi, University of Bologna Alma Mater Studiorum, Bologna, Italy
| | - Pavel Poredos
- Department of Vascular Disease, University Medical Centre Ljubljana, Ljubljana, Slovenia
| | - Jean-Baptiste Ricco
- Department of Clinical Research, University of Poitiers, CHU de Poitiers, Poitiers, France
| | - Thomas S Riles
- Department of Surgery, Division of Vascular Surgery, New York University Langone Medical Centre, New York, NY, USA
| | | | - Tatjana Rundek
- Department of Neurology, Miller School of Medicine, University of Miami, Miami, FL, USA
| | - Luca Saba
- Department of Radiology, Azienda Ospedaliera Universitaria di Cagliari, Cagliari, Italy
| | | | - Mauro Silvestrini
- Neurological Clinic, Department of Experimental and Clinical Medicine, Marche Polytechnic University, Ancona, Italy
| | - Francesco Spinelli
- Vascular Surgery Division, Campus Bio-Medico University of Rome, Rome, Italy
| | - Francesco Stilo
- Vascular Surgery Division, Campus Bio-Medico University of Rome, Rome, Italy
| | - Sherif Sultan
- Western Vascular Institute, Department of Vascular and Endovascular Surgery, University Hospital Galway, National University of Ireland, Galway, Ireland
| | - Jasjit S Suri
- Stroke Diagnosis and Monitoring Division, AtheroPointTM, Roseville, CA, USA
| | - Clark J Zeebregts
- Division of Vascular Surgery, Department of Surgery, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Seemant Chaturvedi
- Department of Neurology & Stroke Program, University of Maryland School of Medicine, Baltimore, MD, USA
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17
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Paraskevas KI, Mikhailidis DP, Antignani PL, Baradaran H, Bokkers RPH, Cambria RP, Dardik A, Davies AH, Eckstein HH, Faggioli G, E Fernandes JF, Fraedrich G, Geroulakos G, Gloviczki P, Golledge J, Gupta A, Jezovnik MK, Kakkos SK, Katsiki N, Knoflach M, Kooi ME, Lanza G, Liapis CD, Loftus IM, Mansilha A, Millon A, Nicolaides AN, Pini R, Poredos P, Ricco JB, Riles TS, Ringleb PA, Rundek T, Saba L, Schlachetzki F, Silvestrini M, Spinelli F, Stilo F, Sultan S, Suri JS, Zeebregts CJ, Chaturvedi S. Optimal Management of Asymptomatic Carotid Stenosis in 2021: The Jury is Still Out. An International, Multispecialty, Expert Review and Position Statement. J Stroke Cerebrovasc Dis 2021; 31:106182. [PMID: 34735900 DOI: 10.1016/j.jstrokecerebrovasdis.2021.106182] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2021] [Revised: 10/14/2021] [Accepted: 10/17/2021] [Indexed: 01/19/2023] Open
Abstract
OBJECTIVES The recommendations of international guidelines for the management of asymptomatic carotid stenosis (ACS) often vary considerably and extend from a conservative approach with risk factor modification and best medical treatment (BMT) alone, to a more aggressive approach with a carotid intervention plus BMT. The aim of the current multispecialty position statement is to reconcile the conflicting views on the topic. MATERIALS AND METHODS A literature review was performed with a focus on data from recent studies. RESULTS Several clinical and imaging high-risk features have been identified that are associated with an increased long-term ipsilateral ischemic stroke risk in patients with ACS. Such high-risk clinical/imaging features include intraplaque hemorrhage, impaired cerebrovascular reserve, carotid plaque echolucency/ulceration/ neovascularization, a lipid-rich necrotic core, a thin or ruptured fibrous cap, silent brain infarction, a contralateral transient ischemic attack/stroke episode, male patients < 75 years and microembolic signals on transcranial Doppler. There is growing evidence that 80-99% ACS indicate a higher stroke risk than 50-79% stenoses. CONCLUSIONS Although aggressive risk factor control and BMT should be implemented in all ACS patients, several high-risk features that may increase the risk of a future cerebrovascular event are now documented. Consequently, some guidelines recommend a prophylactic carotid intervention in high-risk patients to prevent future cerebrovascular events. Until the results of the much-anticipated randomized controlled trials emerge, the jury is still out regarding the optimal management of ACS patients.
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Affiliation(s)
- Kosmas I Paraskevas
- Department of Vascular Surgery, Central Clinic of Athens, 24, Alexander Papagou street, N. Iraklio, Athens 14122, Greece.
| | - Dimitri P Mikhailidis
- Department of Clinical Biochemistry, Royal Free Hospital Campus, University College London Medical School, University College London (UCL), London, UK
| | | | - Hediyeh Baradaran
- Department of Radiology, University of Utah, Salt Lake City, UT, United States
| | - Reinoud P H Bokkers
- Department of Radiology, Medical Imaging Center, University Medical Center Groningen, Groningen, the Netherland
| | - Richard P Cambria
- Division of Vascular and Endovascular Surgery, St. Elizabeth's Medical Center, Brighton, MA, United States
| | - Alan Dardik
- Division of Vascular and Endovascular Surgery, Yale University School of Medicine, New Haven, CT, United States
| | - Alun H Davies
- Section of Vascular Surgery, Imperial College and Imperial Healthcare NHS Trust, London, UK
| | - Hans-Henning Eckstein
- Department for Vascular and Endovascular Surgery, Klinikum rechts der Isar, Technical University of Munich, Munich, Germany
| | - Gianluca Faggioli
- Vascular Surgery, University of Bologna "Alma Mater Studiorum", Policlinico S. Orsola Malpighi, Bologna, Italy
| | | | - Gustav Fraedrich
- Department of Vascular Surgery, Medical University of Innsbruck, Innsbruck, Austria
| | - George Geroulakos
- Department of Vascular Surgery, Attikon University Hospital, National and Kapodistrian University of Athens, Athens, Greece
| | - Peter Gloviczki
- Division of Vascular and Endovascular Surgery, Mayo Clinic, Rochester, MN, United States
| | - Jonathan Golledge
- Queensland Research Center for Peripheral Vascular Disease, James Cook University, Townsville University Hospital, Townsville, Queensland, Australia
| | - Ajay Gupta
- Department of Radiology, Weill Cornell Medicine, New York, United States
| | - Mateja K Jezovnik
- Department of Advanced Cardiopulmonary Therapies and Transplantation, The University of Texas Health Science Center, Houston, TX, United States
| | - Stavros K Kakkos
- Department of Vascular Surgery, University of Patras Medical School, Patras, Greece
| | - Niki Katsiki
- First Department of Internal Medicine, AHEPA University Hospital, Thessaloniki, Greece
| | - Michael Knoflach
- Department of Neurology, Medical University of Innsbruck, Innsbruck, Austria
| | - M Eline Kooi
- CARIM School for Cardiovascular Diseases, Maastricht University, Maastricht, the Netherland; Department of Radiology and Nuclear Medicine, Maastricht University Medical Center, Maastricht, the Netherland
| | - Gaetano Lanza
- Vascular Surgery Department, IRCSS MultiMedica Hospital, Castellanza, Italy
| | | | - Ian M Loftus
- St. George's Vascular Institute, St. George's University of London, London, UK
| | - Armando Mansilha
- Faculty of Medicine of the University of Porto, Porto, Portugal; Department of Angiology and Vascular Surgery, Hospital de S. Joao, Porto, Portugal
| | - Antoine Millon
- Department of Vascular and Endovascular Surgery, Louis Pradel Hospital, Hospices Civils de Lyon, France
| | - Andrew N Nicolaides
- Department of Surgery, University of Nicosia Medical School, Nicosia, Cyprus
| | - Rodolfo Pini
- Vascular Surgery, University of Bologna "Alma Mater Studiorum", Policlinico S. Orsola Malpighi, Bologna, Italy
| | - Pavel Poredos
- Department of Vascular Disease, University Medical Center, Ljubljana, Slovenia
| | - Jean-Baptiste Ricco
- Department of Clinical Research, University of Poitiers, CHU de Poitiers, Poitiers, France
| | - Thomas S Riles
- Department of Surgery, Division of Vascular Surgery, New York University, Langone Medical Center, New York, United States
| | | | - Tatjana Rundek
- Department of Neurology, Miller School of Medicine, University of Miami, Miami, FL, United States
| | - Luca Saba
- Department of Radiology, Azienda Ospedaliera Universitaria Di Cagliari, Cagliari, Italy
| | | | - Mauro Silvestrini
- Neurological Clinic, Department of Experimental and Clinical Medicine, Marche Polytechnic University, Ancona, Italy
| | - Francesco Spinelli
- Vascular Surgery Division, Campus Bio-Medico University of Rome, Rome, Italy
| | - Francesco Stilo
- Vascular Surgery Division, Campus Bio-Medico University of Rome, Rome, Italy
| | - Sherif Sultan
- Department of Vascular and Endovascular Surgery, Western Vascular Institute, University Hospital Galway, National University of Ireland, Galway, Ireland
| | - Jasjit S Suri
- Stroke Diagnosis and Monitoring Division, AtheroPointTM, Roseville, United States
| | - Clark J Zeebregts
- Division of Vascular Surgery, Department of Surgery, University Medical Center Groningen, University of Groningen, Groningen, the Netherland
| | - Seemant Chaturvedi
- Department of Neurology and Stroke Program, University of Maryland School of Medicine, Baltimore, MD, United States
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Reiff T, Eckstein HH, Mansmann U, Jansen O, Fraedrich G, Mudra H, Hacke W, Ringleb PA. Successful implementation of best medical treatment for patients with asymptomatic carotid artery stenosis within a randomized controlled trial (SPACE-2). Neurol Res Pract 2021; 3:62. [PMID: 34666833 PMCID: PMC8524978 DOI: 10.1186/s42466-021-00153-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2021] [Accepted: 08/24/2021] [Indexed: 11/11/2022] Open
Abstract
Background Asymptomatic carotid artery stenosis (ACS) can be treated with carotid endarterectomy (CEA), carotid artery stenting (CAS), or best medical treatment (BMT) only. For all treatment options, optimization of vascular risk factors such as arterial hypertension, hyperlipidemia, smoking, obesity, and insufficient physical activity is essential. Data on adherence to BMT and lifestyle modification in patients with ACS are sparse. The subject of this investigation is the implementation and quality of risk factor adjustment in the context of a randomized controlled trial. Methods A total of 513 patients in the prematurely terminated, randomized, controlled, multicenter SPACE-2 trial (ISRCTN 78592017) were analyzed within one year after randomization into 3 groups (CEA, CAS, and BMT only) for implementation of prespecified BMT recommendations and lifestyle modifications. Measurement time points were the screening visit and visits after one month (D30), 6 months (M6), and one year (A1). Differences between groups and follow-up visits (FUVs) relative to the screening visit were investigated. Findings For all FUVs, a significant increase in statin medication (91% at A1; p < 0.0001) was demonstrated to be associated with a significant decrease (p < 0.01) in cholesterol levels (median 167 mg/dl at A1) and LDL cholesterol levels (median 93 mg/dl at A1). The lowest cholesterol levels were achieved by patients in the BMT group. Seventy-eight percent of all patients reached predefined target cholesterol levels (< 200 mg/dl), with significantly better rates in the BMT group (p = 0.036 at D30). Furthermore, a significant decrease in arterial blood pressure at all FUVs (p < 0.05) was associated with a significant increase in antihypertensive medication (96% at A1, p < 0.0001). However, only 28% of patients achieved the predefined treatment goal of a systolic blood pressure of ≤ 130 mmHg. Forty-two of a total of 100 smokers at the screening visit quit smoking within one year, resulting in a significant increase in nonsmokers at all FUVs (p < 0.0001). Recommended HbA1c levels (< 7%) were achieved in 82% without significant changes after one year. Only 7% of obese (BMI > 25) patients achieved sufficient weight reduction after one year without significant changes at all FUVs (median BMI 27 at A1; p = 0.1201). The BMT group showed significantly (p = 0.024) higher rates of adequate physical activity than the intervention groups. Furthermore, after one year, the BMT group showed a comparatively significantly better implementation of risk factor modification (77%; p = 0.027) according to the treating physician. Interpretation SPACE-2 demonstrated sustained improvement in the noninterventional management of vascular risk factors in patients treated in a clinical trial by general practitioners, internists and neurologists. The best implemented treatment targets were a reduction in cholesterol and HbA1c levels. In this context, a significant increase in statin use was demonstrated. Blood pressure control missed its target but was significantly reduced by intensification of antihypertensive medication. Patients on BMT only had better adjusted lipid parameters and were more physically active. However, all groups failed to achieve sufficient weight reduction. Due to insufficient patient recruitment, the results must be interpreted cautiously. Trial registration: ISRCTN Registry, ISRCTN78592017, Registered 16 June 2007, https://www.isrctn.com/search?q=78592017. Supplementary Information The online version contains supplementary material available at 10.1186/s42466-021-00153-w.
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Affiliation(s)
- Tilman Reiff
- Department of Neurology, University Hospital of Heidelberg, Im Neuenheimer Feld 400, 69120, Heidelberg, Germany.
| | - Hans-Henning Eckstein
- Department for Vascular and Endovascular Surgery, Klinikum Rechts Der Isar, Technical University of Munich, Munich, Germany
| | - Ulrich Mansmann
- Institute of Medical Informatics, Biometry and Epidemiology, Ludwig-Maximilians-Universität München, Munich, Germany
| | - Olav Jansen
- Department of Radiology and Neuroradiology, UKSH Campus Kiel, Kiel, Germany
| | - Gustav Fraedrich
- Department of Vascular Surgery, University Hospital of Innsbruck, Innsbruck, Austria
| | - Harald Mudra
- Department of Cardiology, Klinikum Neuperlach, München KlinikMunich, Germany
| | - Werner Hacke
- Department of Neurology, University Hospital of Heidelberg, Im Neuenheimer Feld 400, 69120, Heidelberg, Germany
| | - Peter Arthur Ringleb
- Department of Neurology, University Hospital of Heidelberg, Im Neuenheimer Feld 400, 69120, Heidelberg, Germany
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19
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Çakmak EÖ, Öcal L, Erdoğan E, Cerşit S, Efe SÇ, Karagöz A, Yılmaz F, Fidan S, Alizade E, Zehir R, Kırma C. Prognostic Value of 3 Nutritional Screening Tools to Predict 30-Day Outcome in Patients Undergoing Carotid Artery Stenting. Angiology 2021; 73:225-233. [PMID: 34463144 DOI: 10.1177/00033197211040365] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
The effect of malnutrition on outcomes after carotid artery stenting (CAS) is not well known. This study reports the relationship between malnutrition and post-procedure 30-day major adverse events (MAEs). A total of 978 patients hospitalized for CAS were enrolled in the study. Controlling nutritional status (CONUT) score, the nutritional risk index (NRI), and the prognostic nutritional index (PNI) were calculated. MAEs (myocardial infarction, stroke/transient ischemic attack and mortality) were compared. According to the CONUT score, NRI, and PNI, 9.4%, 41%, and 11.4% patients were moderately or severely malnourished, respectively; 74.8% were at least mildly malnourished by at least 1 score. Forty-seven patients (4.8%) had a post-procedure 30-day MAE. Continuous classifications of the indexes were independently associated with higher MAE. CONUT showed the highest predictive ability, whereas NRI had the lowest (C-index: CONUT, 0.701; NRI, 0.681; PNI, 0.688). According to categorical classification of indexes, only CONUT and PNI showed predictive ability for MAE. Malnutrition assessment could identify patients with CAS at elevated risk for MAE. CONUT, NRI, and PNI continuous scores were independent prognostic factors for the post-procedure 30-day MAE. According to our study, CONUT showed the highest predictive ability.
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Affiliation(s)
- Ender Ö Çakmak
- Department of Cardiology, 111350University of Medical Sciences, Kartal Kosuyolu High Specialty Training and Research Hospital, Istanbul, Turkey
| | - Lütfi Öcal
- Department of Cardiology, 111350University of Medical Sciences, Kartal Kosuyolu High Specialty Training and Research Hospital, Istanbul, Turkey
| | - Emrah Erdoğan
- Department of Cardiology, 53000Van Yüzüncü Yıl University, Van, Turkey
| | - Sinan Cerşit
- Department of Cardiology, 111350University of Medical Sciences, Kartal Kosuyolu High Specialty Training and Research Hospital, Istanbul, Turkey
| | - Süleyman Çağan Efe
- Department of Cardiology, 111350University of Medical Sciences, Kartal Kosuyolu High Specialty Training and Research Hospital, Istanbul, Turkey
| | - Ali Karagöz
- Department of Cardiology, 111350University of Medical Sciences, Kartal Kosuyolu High Specialty Training and Research Hospital, Istanbul, Turkey
| | - Fatih Yılmaz
- Department of Cardiology, 111350University of Medical Sciences, Kartal Kosuyolu High Specialty Training and Research Hospital, Istanbul, Turkey
| | - Serdar Fidan
- Department of Cardiology, 111350University of Medical Sciences, Kartal Kosuyolu High Specialty Training and Research Hospital, Istanbul, Turkey
| | - Elnur Alizade
- Department of Cardiology, 111350University of Medical Sciences, Kartal Kosuyolu High Specialty Training and Research Hospital, Istanbul, Turkey
| | - Regayip Zehir
- Department of Cardiology, 111350University of Medical Sciences, Kartal Kosuyolu High Specialty Training and Research Hospital, Istanbul, Turkey
| | - Cevat Kırma
- Department of Cardiology, 111350University of Medical Sciences, Kartal Kosuyolu High Specialty Training and Research Hospital, Istanbul, Turkey
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20
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Dominguez D, Levin SR, Cheng TW, Farber A, Jones DW, Eberhard RT, Kalish JA, Eslami MH, Siracuse JJ. Selective Nonoperative and Delayed Management of Severe Asymptomatic Carotid Artery Stenosis. Ann Vasc Surg 2020; 72:159-165. [PMID: 33346124 DOI: 10.1016/j.avsg.2020.10.045] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2019] [Revised: 10/18/2020] [Accepted: 10/28/2020] [Indexed: 11/16/2022]
Abstract
OBJECTIVES Although intervention is generally the standard of care for severe (80-99%) asymptomatic carotid stenosis, conservative management may be appropriate for a subset of patients. Our goal was to assess reasons for and outcomes of nonoperative/delayed operative management of asymptomatic severe carotid stenosis. METHODS Institutional vascular laboratory data from 2010 to 2018 was queried for all patients who underwent a carotid duplex ultrasonography. Patients with severe asymptomatic carotid stenosis (80-99%) were included. Such stenosis was defined by an end diastolic velocity >140 cm/sec on duplex ultrasound in patients without transient ischemic attacks (TIA)/strokes ≤6 months prior to imaging. Nonoperative/delayed operative management was defined as not undergone carotid endarterectomy (CEA) or carotid artery stent (CAS) ≤6 months after imaging. Reasons for nonoperative management or delayed intervention as well as subsequent TIA/stroke and survival were determined. Kaplan-Meier analysis was performed to evaluate survival. RESULTS Among 211 patients with severe carotid stenosis, 35 (16.6%) were managed nonoperatively or with delayed operation. Mean age in this subset was 72.6 ± 11.4 years and the majority were female (57.1%), had a smoking history (74.3%), and were on statins (91.4%) at the time of index duplex ultrasound. Reasons for no/delayed intervention were classified as severe medical comorbidities (37.1%), advanced age (17.1%), no referral for intervention (14.3%), patient refusal (14.3%), other severe concomitant cerebrovascular disease (11.4%), and active/advanced cancer (5.7%). Over a median follow-up of 35.2 months, no patients experienced TIAs/strokes attributable to carotid stenosis. One patient had a multifocal bilateral stroke after a cardiac arrest and prolonged resuscitation. A subset of patients underwent delayed CEA (8.6%) or CAS (2.9%). Four-year survival after initial imaging was 79%. CONCLUSIONS Reasons for nonoperative and delayed operative management in our cohort of asymptomatic carotid stenosis were commonly due to comorbidities and advanced age. However, a subset of patients was never referred to vascular surgeons/interventionalists. Adverse neurologic events due to carotid stenosis were not observed during follow-up and patients had relatively high long-term survival.
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Affiliation(s)
- Dylan Dominguez
- Division of Vascular and Endovascular Surgery, Boston Medical Center, Boston University School of Medicine, Boston, MA
| | - Scott R Levin
- Division of Vascular and Endovascular Surgery, Boston Medical Center, Boston University School of Medicine, Boston, MA
| | - Thomas W Cheng
- Division of Vascular and Endovascular Surgery, Boston Medical Center, Boston University School of Medicine, Boston, MA
| | - Alik Farber
- Division of Vascular and Endovascular Surgery, Boston Medical Center, Boston University School of Medicine, Boston, MA
| | - Douglas W Jones
- Division of Vascular and Endovascular Surgery, Boston Medical Center, Boston University School of Medicine, Boston, MA
| | - Robert T Eberhard
- Division of Cardiovascular Medicine, Boston Medical Center, Boston University School of Medicine, Boston, MA
| | - Jeffrey A Kalish
- Division of Vascular and Endovascular Surgery, Boston Medical Center, Boston University School of Medicine, Boston, MA
| | - Mohammad H Eslami
- Division of Vascular and Endovascular Surgery, University of Pittsburgh, School of Medicine, Pittsburgh, PA
| | - Jeffrey J Siracuse
- Division of Vascular and Endovascular Surgery, Boston Medical Center, Boston University School of Medicine, Boston, MA.
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21
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Paraskevas KI, Veith FJ, Eckstein HH, Ricco JB, Mikhailidis DP. Cholesterol, carotid artery disease and stroke: what the vascular specialist needs to know. ANNALS OF TRANSLATIONAL MEDICINE 2020; 8:1265. [PMID: 33178797 PMCID: PMC7607102 DOI: 10.21037/atm.2020.02.176] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
Hypercholesterolemia is a risk factor for carotid artery stenosis and stroke. Statins are the main drugs for the management of hypercholesterolemia and they are strongly recommended by international guidelines for the management of vascular patients. The present review will focus on the associations between cholesterol, carotid artery stenosis and stroke and will cover several topics, including the conservative and perioperative/periprocedural management of carotid patients, the effect of statins on contrast-induced nephropathy developing after endovascular carotid interventions, the role of statin loading prior to endovascular procedures, as well as the indirect beneficial effects of statin treatment on renal function. It will also discuss the topics of statin intolerance and alternative cholesterol-lowering options for statin-intolerant vascular patients. Cholesterol levels play a prognostic role in carotid patients with regards to both short- and long-term stroke and mortality rates. Physicians should keep in mind the pivotal role of cholesterol levels in determining cardiovascular outcomes and the pleiotropic beneficial effects associated with statin use and should not miss the opportunity for cardiovascular risk reduction with aggressive statin treatment.
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Affiliation(s)
- Kosmas I Paraskevas
- Department of General and Vascular Surgery, Central Clinic of Athens, Athens, Greece
| | - Frank J Veith
- Division of Vascular Surgery, New York University Langone Medical Center, NY, USA.,Division of Vascular Surgery, The Cleveland Clinic, Cleveland, OH, USA
| | - Hans-Henning Eckstein
- Department of Vascular and Endovascular Surgery, Klinikum rechts der Isar, Technical University of Munich, Munich, Germany
| | - Jean-Baptiste Ricco
- Department of Clinical Research, University of Poitiers, CHU de Poitiers, Poitiers, France
| | - Dimitri P Mikhailidis
- Department of Clinical Biochemistry, Royal Free Hospital Campus, University College London Medical School, University College London (UCL), London, UK
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22
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Poredos P, Gregoric ID, Jezovnik MK. Inflammation of carotid plaques and risk of cerebrovascular events. ANNALS OF TRANSLATIONAL MEDICINE 2020; 8:1281. [PMID: 33178813 PMCID: PMC7607075 DOI: 10.21037/atm-2020-cass-15] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
Carotid atherosclerotic plaques represent a risk for ischemic stroke. The data indicate that the risk for distal embolization from atherosclerotic lesions in internal carotid arteries is not related only to the degree of stenosis but also to the composition of plaques. The stability of atherosclerotic plaque depends on the thickness of the fibrous cap and plaque hemorrhage. Recent research indicated that the inflammatory activity of atherosclerotic lesions is pivotal in the progression of atherosclerotic plaques. It also promotes the development of unstable atherosclerotic lesions and is related to thromboembolic cerebrovascular complications. Inflammation destabilizes atherosclerotic plaques through the degradation of their fibrotic structure. Inflammation of atherosclerotic plaques was confirmed by histopathologic findings and levels of circulating inflammatory markers which were correlated to the intensity of the inflammation in atherosclerotic lesions. Recently, new techniques like fluorodeoxyglucose positron emission tomography (18-FDG PET) were developed for the identification of inflammation of atherosclerotic lesions in the vessel wall in vivo. Systemic inflammatory markers, particularly interleukins, tumor necrosis factor-alpha and metalloproteinases were shown to be related to the intensity of the inflammatory process in atherosclerotic lesions and the cerebrovascular events. Identification of inflamed atherosclerotic plaques may help to identify unstable atherosclerotic lesions and subjects at high risk for cerebrovascular incidents who need intensive preventive measures including anti-inflammatory medication.
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Affiliation(s)
- Pavel Poredos
- Department of Vascular Disease, University Medical Centre Ljubljana, Ljubljana, Slovenia.,Department of Advanced Cardiopulmonary Therapies and Transplantation, The University of Texas Health Science Centre at Houston, Houston, TX, USA
| | - Igor D Gregoric
- Department of Advanced Cardiopulmonary Therapies and Transplantation, The University of Texas Health Science Centre at Houston, Houston, TX, USA
| | - Mateja K Jezovnik
- Department of Advanced Cardiopulmonary Therapies and Transplantation, The University of Texas Health Science Centre at Houston, Houston, TX, USA
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23
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BMI, high-sensitivity C-reactive protein and the conversion from metabolically healthy to unhealthy phenotype in Chinese adults: a cohort study. Public Health Nutr 2020; 24:4124-4131. [PMID: 32840191 DOI: 10.1017/s136898002000289x] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
OBJECTIVE We performed the cohort study to evaluate the association between BMI, high-sensitivity C-reactive protein (hs-CRP) and the conversion from metabolically healthy to unhealthy phenotype in Chinese adults. DESIGN Metabolically healthy was defined as participants without history of metabolic diseases and with normal fasting blood glucose level, glycated Hb A1c level, blood pressure, lipid profile, serum uric acid level and liver ultrasonographic findings at baseline. Participants were either classified into normal weight (18·5 ≤ BMI < 24·0 kg/m2) and overweight (BMI ≥ 24·0 kg/m2) based on baseline BMI, or low (<1 mg/l) and high (≥1 mg/l) groups based on baseline hs-CRP. The conversion from metabolically healthy to unhealthy phenotype was deemed if any of the metabolic abnormalities had been confirmed twice or more during 5 years of follow-up. RESULTS Included were 4855 (1942 men and 2913 women, aged 36·0 ± 8·9 years) metabolically healthy Chinese adults. We identified 1692 participants who converted to metabolically unhealthy phenotype during the follow-up. Compared with their counterparts, the adjusted hazards ratio of the conversion was 1·19 (95 % CI 1·07, 1·33) for participants with overweight, while it was 1·15 (95 % CI 1·03, 1·29) for those with high hs-CRP level (≥1 mg/l). Further adjustment of hs-CRP did not materially change the association between BMI and the conversion. However, the association between hs-CRP and the conversion was not significant after further adjustment of BMI. The sensitivity analysis generated similar results to main analysis. CONCLUSION BMI was associated with the risk of the conversion from metabolically healthy to unhealthy status in Chinese adults.
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24
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O'Brien AJ, Donlan J, Vrazas JI. Prevalence of internal carotid artery stenosis in ambulatory patients presenting for non-emergent percutaneous coronary angiogram in a single Australian centre. Australas J Ultrasound Med 2020; 24:31-36. [PMID: 34760609 DOI: 10.1002/ajum.12220] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2019] [Revised: 06/12/2020] [Accepted: 06/22/2020] [Indexed: 11/06/2022] Open
Abstract
Introduction Association between coronary artery disease (CAD) and internal carotid artery stenosis (ICAS) could prove clinically relevant. However, evidence defining this association is currently inconclusive. Our study investigates the prevalence of ICAS in non-emergent, ambulatory patients presenting for PCA with suspected CAD in an Australian context. Methods Between February 2019 and June 2019, 121 consecutive participants were verbally consented and enrolled in our study. The data were analysed retrospectively. PCA and CUS were performed within 24 h of each other. Multinomial logistic regression assessed independent predictors for ICAS, with statistical significance set at P value < 0.05. Linear regression analysis correlated CAD and ICAS severity, with significance of a P-value < 0.05. Analysis was conducted using IBM SPSS 26 software (Chicago, Illinois). Results The final study included 121 patients (age 73 ± 9 years, 76.9% male). ICAS on CUS was present in 55.4% of participants for PCA. CAD was an independent risk factor for ICAS on multinomial logistic regression odds ratio 3.87 (P = 0.023). CAD severity (multi vessel disease) showed significant correlation with ICAS r = 0.22 (P = 0.014) using linear regression analysis. Conclusion CAD is an independent predictor of ICAS, and severity of ICAS is correlated with CAD disease. However, most participants had only minor ICAS (16-49% diameter stenosis). Our findings are consistent with internationally published studies, suggesting their data are generalisable to the Australian population. Larger studies are needed to address the applicability of CUS screening in patients with advanced CAD.
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Affiliation(s)
- Andrew J O'Brien
- Department of Medicine University of Melbourne Parkville Victoria 3010 Australia.,St. Vincent's Private Hospital 59-61 Victoria Parade Fitzroy Victoria 3065 Australia.,Melbourne Institute of Vascular and Interventional Radiology 59-61 Victoria Parade Fitzroy Victoria 3065 Australia
| | - John Donlan
- St. Vincent's Private Hospital 59-61 Victoria Parade Fitzroy Victoria 3065 Australia.,Melbourne Institute of Vascular and Interventional Radiology 59-61 Victoria Parade Fitzroy Victoria 3065 Australia
| | - John I Vrazas
- Department of Medicine University of Melbourne Parkville Victoria 3010 Australia.,St. Vincent's Private Hospital 59-61 Victoria Parade Fitzroy Victoria 3065 Australia.,Melbourne Institute of Vascular and Interventional Radiology 59-61 Victoria Parade Fitzroy Victoria 3065 Australia
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25
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Lv W, Zhang T, Zhao H, He S, Li B, Gao Y, Pan W. Diagnostic value of miR-186-5p for carotid artery stenosis and its predictive significance for future cerebral ischemic event. Diagn Pathol 2020; 15:101. [PMID: 32731869 PMCID: PMC7392647 DOI: 10.1186/s13000-020-01007-w] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2020] [Accepted: 07/14/2020] [Indexed: 12/27/2022] Open
Abstract
BACKGROUND MicroRNAs (miRNAs) serve as novel promising biomarkers for the diagnosis and prognosis of many human diseases. This study investigated the diagnostic value of miR-186-5p for asymptomatic carotid artery stenosis (CAS), and its predictive value for future cerebral ischemic events (CIEs). METHODS Sixty-seven cases with asymptomatic CAS and 60 healthy individuals were recruited. Serum levels of miR-186-5p were tested by using qRT-PCR. Receiving-operator characteristic (ROC) curve was drawn based on sensitivity and specificity analyses. All asymptomatic CAS cases were followed up for 5 years. Kaplan-Meier method was applied for the evaluation of the predictive value of miR-186-5p for the occurrence of CIE. RESULTS The serum level of miR-186-5p was increased significantly in asymptomatic CAS patients. MiR-186-5p was the most significant factor associated with the high degree of carotid stenosis in asymptomatic CAS patients. In the ROC curve analysis, the AUC was 0.919, with the sensitivity of 89.6% and specificity of 81.7% at the cutoff value of 1.221. Kaplan-Meier method results revealed that high miR-186-5p level was associated with the occurrence of CIEs. High miR-186-5p level and high degree of carotid stenosis were independent factors for the occurrence of CIEs. CONCLUSION MiR-186-5p serves as a potential diagnostic biomarker for patients with asymptomatic CAS, and predicts the occurrence of future CIEs.
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Affiliation(s)
- Weibo Lv
- Department of Neurosurgery, Binzhou Medical University Hospital, Binzhou, 256603, Shandong, China
| | - Tao Zhang
- Department of Neurosurgery, Binzhou Medical University Hospital, Binzhou, 256603, Shandong, China
| | - Hongwei Zhao
- Department of Neurosurgery, Binzhou Medical University Hospital, Binzhou, 256603, Shandong, China
| | - Shuang He
- Department of Neurology, Affiliated Hospital of Nantong University, Nantong, 226001, Jiangsu, China
| | - Bingwei Li
- Department of Neurosurgery, Binzhou Medical University Hospital, Binzhou, 256603, Shandong, China
| | - Yang Gao
- Department of Neurosurgery, Binzhou Medical University Hospital, Binzhou, 256603, Shandong, China
| | - Wenying Pan
- Department of Obstetrics & Gynecology, Binzhou Medical University Hospital, No. 661, Huanghe 2nd Road, Binzhou, 256603, Shandong, China.
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Natural History of Non-operative Management in Asymptomatic Patients with 70%-80% Internal Carotid Artery Stenosis by Duplex Criteria. Eur J Vasc Endovasc Surg 2020; 60:339-346. [PMID: 32660806 DOI: 10.1016/j.ejvs.2020.05.039] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2019] [Revised: 05/04/2020] [Accepted: 05/27/2020] [Indexed: 11/20/2022]
Abstract
OBJECTIVE Treatment of asymptomatic internal carotid artery (ICA) stenosis, particularly for moderate to severe (70%-80%) disease, is controversial. The goal was to assess the clinical course of patients with moderate to severe carotid stenosis. METHODS A single institution retrospective analysis of patients with asymptomatic ICA stenosis identified on duplex ultrasound as moderate to severe (70%-80%) from 2003 to 2018 were analysed. Duplex criteria for 70%-80% stenosis was a systolic velocity of ≥325 cm/s or an ICA:common carotid artery ratio of ≥4, and an end diastolic velocity of <140 cm/s. Asymptomatic status was defined as no stroke/transient ischaemic attack (TIA) within six months of index duplex. Primary outcomes were progression of stenosis to >80%, ipsilateral stroke/TIA without documented progression, and death. RESULTS In total, 206 carotid arteries were identified in 182 patients meeting the inclusion criteria. Mean patient age was 71.5 years, 57.7% were male, and 67% were white. There were 19 stenoses removed from analysis except for survival analysis as they initially underwent carotid endarterectomy or carotid artery stent based on surgeon/patient preference. Documented progression occurred in 24.1% of stenoses. There were 5.3% of stenoses associated with an ipsilateral stroke/TIA without documented progression, which occurred at a mean of 26.4 months. Kaplan-Meier analysis demonstrated a 60.3% five year freedom from stenosis progression, 92.5% five year freedom from stroke/TIA without documented progression, and 83.7% five year survival. Risk factors associated with stroke/TIA without documented progression at five years were atrial fibrillation (hazard ratio [HR] 14.87, 95% confidence interval [CI] 2.72-81.16; p = .002) and clopidogrel use at index duplex (HR 6.19, 95% CI 1.33-28.83; p = .020). Risk factors associated with death at five years were end stage renal disease (HR 9.67, 95% CI 2.05-45.6; p = .004), atrial fibrillation (HR 7.55, 95% CI 2.48-23; p < .001), prior head/neck radiation (HR 6.37, 95% CI 1.39-29.31; p = .017), non-obese patients (HR 5.49, 95% CI 1.52-20; p = .009), and non-aspirin use at index duplex (HR 3.05, 95% CI 1.12-8.33; p = .030). CONCLUSION Patients with asymptomatic moderate to severe carotid stenosis had a low rate of stroke/TIA without documented progression. However, there was a high rate of stenosis progression reinforcing the need to follow these patients closely.
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Paraskevas KI, Eckstein HH, Mikhailidis DP, Veith FJ, Spence JD. Rationale for screening selected patients for asymptomatic carotid artery stenosis. Curr Med Res Opin 2020; 36:361-365. [PMID: 31910676 DOI: 10.1080/03007995.2020.1713075] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
Stroke is a leading cause of death and disability worldwide. Approximately 15% of all first-ever strokes occur due to atheroembolism from a previously undetected/untreated asymptomatic carotid stenosis (ACS). Despite that, international guidelines do not recommend screening for ACS. The rationale for not recommending screening include: (a) the harm associated with screening, (b) the questionable clinical benefit associated with surgery, (c) the lack of proven reduction in the risk of stroke, (d) the large number of false positive/false negative tests, and (e) the cost-effectiveness of such screening programs. A critical analysis of each of these arguments is presented. Patients with ACS have a very high risk of all-cause and cardiac mortality. Detection of ACS should not be viewed as an indication for surgery, but rather as an opportunity to implement best medical treatment (BMT) and lifestyle changes to prevent not only strokes, but also cardiac events. The implementation of screening programs for abdominal aortic aneurysms (AAAs) has led to a considerable reduction in the number of ruptured AAAs and AAA-related deaths. Similarly, screening high-risk individuals for ACS would enable timely identification of patients with ACS and implementation of BMT and lifestyle measures to prevent future strokes and cardiac events.
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Affiliation(s)
- Kosmas I Paraskevas
- Department of Vascular Surgery, "Attikon" University Hospital, Athens, Greece
| | - Hans-Henning Eckstein
- Department for Vascular and Endovascular Surgery, Klinikum rechts der Isar, Technical University of Munich, Munich, Germany
| | - Dimitri P Mikhailidis
- Department of Clinical Biochemistry, Royal Free Hospital Campus, University College London, London, UK
| | - Frank J Veith
- Departments of Vascular Surgery, Langone Medical Center, New York University, New York, NY, USA
- The Cleveland Clinic, Cleveland, OH, USA
| | - J David Spence
- Stroke Prevention & Atherosclerosis Research Centre, Robarts Research Institute, Western University, London, Canada
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Xu R, Zhang T, Wan Y, Fan Z, Gao X. Prospective study of hemoglobin A1c and incident carotid artery plaque in Chinese adults without diabetes. Cardiovasc Diabetol 2019; 18:153. [PMID: 31727070 PMCID: PMC6857319 DOI: 10.1186/s12933-019-0963-5] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/18/2019] [Accepted: 11/05/2019] [Indexed: 12/16/2022] Open
Abstract
Background Diabetes has been reported to be associated with carotid artery plaque (CAP). However, it remains unclear whether hemoglobin A1c (HbA1c) level, a marker for long-term glycemic status, is associated with altered CAP risk in individuals with fasting blood glucose (FBG) concentrations below the current cutoff for diabetes. Methods Included were 16,863 Chinese adults (aged 18 years or more; 9855 men and 7008 women) with fasting blood glucose < 7.0 mmol/L at baseline (2013). Both HbA1c level and CAP (assessed via ultrasound B-mode imaging) were annually assessed during 2014–2018. All the participants were further classified into three groups based on baseline HbA1c level: ≤ 5.6%, 5.7–6.4%, and ≥ 6.5%. We used Cox proportional-hazards model to evaluate the association between HbA1c level and incident CAP, adjusting for a series of potential confounders. Results During 5 years of follow up, 3942 incident CAP cases were identified. Individuals with higher baseline HbA1c had higher future risk of CAP (p-trend < 0.001). In the full-adjusted model, each percent increase of HbA1c was associated with a 56% (HR = 1.56, 95% CI 1.37, 1.78) higher risk of CAP. Excluding participants with chronic inflammation, as assessed by high-sensitivity C-reactive protein and white blood cell, and those with FBG ≥ 5.6 mmol/L at baseline generated similar results. Conclusions Elevated HbA1c level was associated with high risk of developing CAP in Chinese adults without FBG defined diabetes.
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Affiliation(s)
- Renying Xu
- Department of Clinical Nutrition, Ren Ji Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, 200127, China.
| | - Ting Zhang
- Vascular Surgery Department, Ren Ji Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China
| | - Yanping Wan
- Department of Clinical Nutrition, Ren Ji Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, 200127, China
| | - Zhuping Fan
- Department of Digestion, Ren Ji Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China
| | - Xiang Gao
- Department of Nutritional Sciences, The Pennsylvania State University, University Park, PA, 16802, USA.
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Abstract
PURPOSE OF REVIEW The effects of statin loading before, during or after vascular interventions on cardiovascular and renal outcomes are discussed. Furthermore, the selection of optimal statin type and dose, according to current evidence or guidelines, is considered. The importance of treating statin intolerance and avoiding statin discontinuation is also discussed. RECENT FINDINGS Statin loading has been shown to beneficially affect cardiovascular outcomes, total mortality and/or contrast-induced acute kidney injury, in patients undergoing vascular procedures such as percutaneous coronary intervention (PCI), coronary artery bypass grafting (CABG), carotid endarterectomy (CEA), carotid artery stenting, endovascular aneurysm repair, open abdominal aortic aneurysms (AAA) repair and lower extremities vascular interventions. High-dose statin pretreatment is recommended for PCI and CABG according to current guidelines. Statin discontinuation should be avoided during acute cardiovascular events and vascular interventions; adequate measures should be implemented to overcome statin intolerance. SUMMARY Statin loading is an important clinical issue in patients with cardiac and noncardiac vascular diseases, including carotid artery disease, peripheral artery disease and AAA, undergoing vascular interventions. Cardiologists and vascular surgeons should be aware of current evidence and implement guidelines in relation to statin loading, discontinuation and intolerance.
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Alves-Ferreira J, Rocha-Neves J, Dias-Neto M, Braga SF. Poor long-term outcomes after carotid endarterectomy: a retrospective analysis of two portuguese centers. SCAND CARDIOVASC J 2019; 53:266-273. [PMID: 31251084 DOI: 10.1080/14017431.2019.1638518] [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] [Indexed: 01/09/2023]
Abstract
Objetives. Carotid endarterectomy (CEA) is an established treatment for carotid stenosis (CS). However, this procedure is not risk-free and it is insufficient to control disseminated atherosclerosis. Our aim was to determine long-term cardiovascular morbidity and mortality after CEA and identify associated risk predictors. Design. Consecutive cohorts of CEAs performed between 2010 and 2018 in two Portuguese hospitals were retrospectively analysed. The major end-points were acute myocardial infarction (AMI), stroke, all-cause death and major adverse cardiovascular events (MACE). Results. 248 patients (mean age 69 years; 79% male) were enrolled in the study. 24% had postoperative complications. At 52 months median follow-up, 9 ± 2.0% (mean ± standard error) of patients experienced an acute myocardial infarction (AMI), 12 ± 2.4% a stroke and 26 ± 3.2% a MACE. All-cause mortality rate was 21 ± 3.0%. Multivariate analysis identified coronary artery disease (CAD) as significant predictor of AMI (p < .001; Hazard Ratio (HR):9.628; 95% Confidence Interval (95%CI):2.805-33.046), whereas no statistically significant risk factor of stroke was found. Predictors of death included left sided CS (p = .042; HR:1.886; 95%CI:1.024-3.475), chronic kidney disease (CKD) (p = .007; HR:2.352; 95%CI:1.266-4.372) and anticoagulant medication (p = .015; HR:2.107; 95%CI:1.216-6.026), while statin use was significantly protective (p = .049; HR:0.482; 95%CI:0.233-0.998). Concerning MACE, male gender (p = .040; HR:1.709; 95%CI:1.025-2.849), tobacco use (p = .004; HR:2.181; 95%CI:1.277-3.726), CAD (p = .002; HR:2.235; 95%CI:1.340-3.727) and CKD (p < .001; HR:3.029; 95%CI:1.745-5.258) were risk predictors. Conclusions. Patients continue to have high rates of AMI, MACE and death after CEA. Prior CAD is a risk factor for future AMI, whereas CKD is a significant predictor of MACE and death. Aggressive best medical treatment and risk factors modification should be advised in all patients with systemic atherosclerosis.
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Affiliation(s)
| | - João Rocha-Neves
- Department of Biomedicine - Unit of Anatomy, Faculty of Medicine, University of Porto , Porto , Portugal.,Department of Physiology and Surgery - Cardiovascular Research Unit, Faculty of Medicine, University of Porto , Porto , Portugal.,Department of Angiology and Vascular Surgery, São João Hospital Center , Porto , Portugal
| | - Marina Dias-Neto
- Department of Physiology and Surgery - Cardiovascular Research Unit, Faculty of Medicine, University of Porto , Porto , Portugal.,Department of Angiology and Vascular Surgery, São João Hospital Center , Porto , Portugal
| | - Sandrina F Braga
- Department of Angiology and Vascular Surgery, Senhora de Oliveira Hospital Center , Guimarães , Portugal
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Machalińska A, Kawa MP, Babiak K, Sobuś A, Grabowicz A, Lejkowska R, Kazimierczak A, Rynio P, Safranow K, Wilk G, Gutowski P, Machaliński B. Retinal vessel dynamic functionality in the eyes of asymptomatic patients with significant internal carotid artery stenosis. INT ANGIOL 2019; 38:230-238. [PMID: 31112024 DOI: 10.23736/s0392-9590.19.04112-9] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
BACKGROUND The goal of this study was to assess the retinal microvascular function in asymptomatic patients with hemodynamically significant internal carotid artery stenosis (ICAS) and to assess the potential efficacy of carotid endarterectomy (CEA) for the improvement of vessel functionality. METHODS Retinal vessel caliber and reactions to flicker stimulation were assessed in both eyes of 65 asymptomatic patients with unilateral hemodynamically significant ICAS and 34 healthy subjects. Subsequently, the recruited ICAS patients were referred for standard unilateral CEA procedure. The full ophthalmologic examination of both eyes and vessel analysis were performed 1 day before and 3 months after CEA. RESULTS The venous responses to flicker stimulation were significantly lower in the EIS (eyes ipsilateral to stenosis) and ECS (eyes contralateral to stenosis) compared with those in the controls (P<0.0001 and P<0.0001, respectively). No changes were identified in retinal vascular flicker responses after CEA in both groups of eyes compared with the baseline values. We observed a decrease in CRVE (central retinal venular equivalent) after the CEA both in eyes ipsilateral (P=0.01) and contralateral (P=0.04) to CEA. Likewise, a decrease in CRAE (central retinal arteriolar equivalent) was identified in the eyes ipsilateral to CEA (P<0.001). CONCLUSIONS This outcome strongly indicates that microvascular dysfunction is long-lasting despite the recovery of the flow in the carotid artery.
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Affiliation(s)
- Anna Machalińska
- First Department of Ophthalmology, Pomeranian Medical University, Szczecin, Poland -
| | - Miłosz P Kawa
- Department of General Pathology, Pomeranian Medical University, Szczecin, Poland
| | - Katarzyna Babiak
- First Department of Ophthalmology, Pomeranian Medical University, Szczecin, Poland
| | - Anna Sobuś
- Department of General Pathology, Pomeranian Medical University, Szczecin, Poland
| | - Aleksandra Grabowicz
- First Department of Ophthalmology, Pomeranian Medical University, Szczecin, Poland
| | - Renata Lejkowska
- Department of General Pathology, Pomeranian Medical University, Szczecin, Poland
| | - Arkadiusz Kazimierczak
- Department of Vascular Surgery and Angiology, Pomeranian Medical University, Szczecin, Poland
| | - Paweł Rynio
- Department of Vascular Surgery and Angiology, Pomeranian Medical University, Szczecin, Poland
| | - Krzysztof Safranow
- Department of Biochemistry and Medical Chemistry, Pomeranian Medical University, Szczecin, Poland
| | - Grażyna Wilk
- Department of General and Dental Radiology, Pomeranian Medical University, Szczecin, Poland
| | - Piotr Gutowski
- Department of Vascular Surgery and Angiology, Pomeranian Medical University, Szczecin, Poland
| | - Bogusław Machaliński
- Department of General Pathology, Pomeranian Medical University, Szczecin, Poland
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Gaba K, Bulbulia R. Identifying asymptomatic patients at high-risk for stroke. THE JOURNAL OF CARDIOVASCULAR SURGERY 2019; 60:332-344. [PMID: 30785251 DOI: 10.23736/s0021-9509.19.10912-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
Carotid endarterectomy and carotid artery stenting, in addition to good medical therapy, halve long-term stroke risk in asymptomatic patients with carotid artery stenosis. Since the absolute benefits following successful intervention are moderate, identification of asymptomatic patients at high-risk of future stroke could maximize the effectiveness of carotid interventions. The aim of this paper is to summarize the evidence for high-risk features associated with increased long-term stroke risk in asymptomatic patients. There is a paucity of reliable data describing the effect of clinical features, imaging findings and plaque characteristics on increased long-term stroke risk. Clinical and imaging features such as contralateral symptoms, silent brain infarcts/embolic signals, progression of stenosis and impaired cerebrovascular reactivity may be associated with increased future risk of stroke. Plaque characteristics such as echolucency, large plaque size (≥80 mm), intra-plaque hemorrhage, lipid-rich necrotic core and thinned/ruptured fibrous cap may also increase future risk of stroke. Whilst these form the basis for European guidelines targeting carotid intervention in asymptomatic patients with tight stenosis, conclusive evidence of their utility is lacking. Results from ongoing large, multicenter randomized clinical trials comparing carotid endarterectomy and carotid artery stenting with good medical therapy may be consistent with earlier trials, showing a halving of the long-term risk of stroke following successful carotid revascularization. However, they may well lack sufficient statistical power to identify higher-risk subgroups in whom the absolute gains of treatment are significantly higher. Large contemporary cohort studies are needed to provide further clarity regarding high-risk features associated with increased long-term stroke risk in asymptomatic patients with carotid artery stenosis.
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Affiliation(s)
- Kamran Gaba
- Medical Research Council Population Health Research Unit, Nuffield Department of Population Health, University of Oxford, Oxford, UK.,Clinical Trial Service Unit and Epidemiological Studies Unit, Nuffield Department of Population Health, University of Oxford, Oxford, UK
| | - Richard Bulbulia
- Medical Research Council Population Health Research Unit, Nuffield Department of Population Health, University of Oxford, Oxford, UK - .,Clinical Trial Service Unit and Epidemiological Studies Unit, Nuffield Department of Population Health, University of Oxford, Oxford, UK
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33
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Katsiki N, Mikhailidis DP. Lipids: a personal view of the past decade. Hormones (Athens) 2018; 17:461-478. [PMID: 30229482 DOI: 10.1007/s42000-018-0058-9] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/17/2018] [Accepted: 08/31/2018] [Indexed: 12/27/2022]
Abstract
The past decade has witnessed considerable progress in the field of lipids. New drugs have been "rapidly" developed and some of these drugs have already been evaluated in event-based large trials. This evidence has led to the guidelines recommending new, more aggressive treatment goals for low-density lipoprotein cholesterol (LDL-C) levels. Although LDL-C remains the principal goal for cardiovascular disease (CVD) risk reduction, there has also been considerable interest in other lipid variables, such as high-density lipoprotein cholesterol, triglycerides, and lipoprotein(a). Statin intolerance is now considered a very important topic in daily clinical practice. This has resulted in more attention focusing on non-statin drugs [e.g., ezetimibe and proprotein convertase subtilisin/kexin 9 (PCSK9) inhibitors] and statin-related side effects. The latter mainly involve muscles, but there is also a need to consider other adverse effects associated with statin use (e.g., new onset diabetes). New specific areas of statin use have attracted interest. For example, statin-loading before procedures (e.g., coronary stenting), the prevention of stroke, and the treatment of non-alcoholic fatty liver disease (NAFLD). Statins will remain the most widely used drugs to treat dyslipidaemia and decrease CVD risk. However, we also need to briefly consider some other lipid-lowering drugs, including those that may become available in the future.
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Affiliation(s)
- Niki Katsiki
- Second Department of Propaedeutic Internal Medicine, Medical School, Aristotle University of Thessaloniki, Hippocration Hospital, Thessaloniki, Greece
| | - Dimitri P Mikhailidis
- Department of Clinical Biochemistry, Royal Free Hospital Campus, University College London Medical School, University College London (UCL), Pond Street, London, NW3 2QG, UK.
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Abstract
PURPOSE OF REVIEW Provide a current overview regarding the optimal strategy for managing patients with asymptomatic carotid artery stenosis. RECENT FINDINGS Carotid endarterectomy (CEA) and carotid artery stenting (CAS) reduce long-term stroke risk in asymptomatic patients. However, CAS is associated with a higher risk of peri-procedural stroke. Improvements in best medical therapy (BMT) have renewed uncertainty regarding the extent to which results from older randomised controlled trials (RCTs) comparing outcomes following carotid intervention can be generalised to modern medical practise. 'Average surgical risk' patients with an asymptomatic carotid artery stenosis of 60-99% and increased risk of late stroke should be considered for either CEA or CAS. In patients deemed 'high risk' for surgery, CAS is indicated. Use of an anti-platelet, anti-hypertensive and statin, with strict glycaemic control, is recommended. Results from ongoing large, multicentre RCTs comparing CEA, CAS and BMT will provide clarity regarding the optimal management of patients with asymptomatic carotid artery stenosis.
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Ideal Cardiovascular Health Metrics Associated with Reductions in the Risk of Extracranial Carotid Artery Stenosis: a Population-based Cohort Study. Sci Rep 2018; 8:12277. [PMID: 30115933 PMCID: PMC6095842 DOI: 10.1038/s41598-018-29754-3] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2017] [Accepted: 07/17/2018] [Indexed: 01/08/2023] Open
Abstract
The cardiovascular health (CVH) metrics are closely related to the risk of stroke. Extracranial carotid artery stenosis (ECAS) represents an important risk factor for ischemic stroke. The present study aims to explore the longitudinal effect of the baseline CVH metrics on the development of ECAS. Totally 5,440 participants were randomly enrolled in the Asymptomatic Polyvascular Abnormalities Community study from 2010 to 2011. Information regarding the seven CVH metrics was collected at baseline. ECAS was assessed by performing carotid duplex sonography at baseline (2010-2011) and during the follow-up (2012-2013). Finally 3,487 subjects were included, and 976 participants developed ECAS during the 2-year follow-up. The optimum CVH status was associated with a 42% (95% confidence interval: 0.40-0.85) decreased risk of the incidence of ECAS after adjusting for age, sex, weight, education, income, alcohol use, waist-hip ratio, triglycerides, low-density lipoprotein cholesterol, high-density lipoprotein cholesterol, uric acid, homocysteine, and C-reactive protein. Ideal physical activity, total cholesterol and fasting blood glucose were independent protective factors of ECAS. In this cohort study, the ideal baseline CVH status was negatively associated with the occurrence of ECAS during the follow-up. This study provides practical insight for further developing effective screening strategies or implementing the best medical treatment.
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Maskanakis A, Patelis N, Karaolanis G, Davakis S, Schizas D, Perrea D, Klonaris C, Georgopoulos S, Liakakos T, Bakoyiannis C. Apolipoprotein J as a predictive biomarker for restenosis after carotid endarterectomy: a retrospective study. Acta Pharmacol Sin 2018; 39:1237-1242. [PMID: 29417939 DOI: 10.1038/aps.2017.146] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2017] [Accepted: 10/31/2017] [Indexed: 12/22/2022] Open
Abstract
Carotid endarterectomy (CEA) is an effective surgical option for stroke prophylaxis in most patients. Restenosis after CEA can lead to re-intervention and adverse events, but the factors predicting restenosis are poorly understood. Apolipoprotein J (ApoJ) is considered to be a novel predictive factor of vascular restenosis and is associated with a large number of processes related to atherosclerosis and cell-cycle phases. The aim of this study was to elucidate the predictive value of Apo J in internal carotid artery (ICA) restenosis following CEA. This retrospective study examined all prospectively collected data for patients who underwent CEA at our surgical department over a 2-year period. The serum ApoJ levels of 100 patients were examined; 56 patients who underwent CEA comprised the vascular group (VG), and 44 patients who underwent minor surgery comprised the control group (CG). ApoJ samples were obtained preoperatively, 24 h after the surgical procedure and at 1, 6 and 12 months thereafter during the follow-up. The preoperative difference in ApoJ levels between the CG and VG was statistically signifcant; the mean values were 39.11±14.16 and 83.03±35.35 μg/mL, respectively. In the VG, the serum ApoJ levels were 112.09±54.40, 71.20±23.70, 69.92±25.76 and 62.25±19.17 μg/mL at postoperative day 1 and at 1, 6 and 12 months post-operatively, respectively, while the ApoJ concentrations of patients in the CG remained unchanged. Further subdivision of the VG into patients with or without restenosis revealed that restenosis patients presented signifcantly higher mean ApoJ values than non-restenosis VG patients. In summary, ApoJ seems to be an important predictor for carotid restenosis at 6 and 12 months postoperatively.
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37
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Dai Z, Li R, Zhao N, Han Y, Wang M, Zhang S, Bai Y, Li Z, Liang M, Xiao L, Ma M, Liu X, Xu G. Neutrophil to Lymphocyte Ratio as a Predictor of Restenosis After Angioplasty and Stenting for Asymptomatic Carotid Stenosis. Angiology 2018; 70:160-165. [PMID: 29940783 DOI: 10.1177/0003319718784805] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
The inflammatory response plays a vital role in the development of in-stent restenosis (ISR) after carotid angioplasty and stenting (CAS). The neutrophil to lymphocyte ratio (NLR) has been suggested as a sensitive inflammatory marker. We explored the association between NLR and ISR in CAS patients. A total of 427 patients who underwent CAS were enrolled. Neutrophil to lymphocyte ratio was measured before the procedure. Clinical examination and radiographic evaluation were performed at 6 months and annually after the procedure. In-stent restenosis was defined as ≥50% stenosis in the treated lesion. Cox regression was used to identify predictors of ISR after CAS. Of the 459 arteries (in 427 patients) with CAS, 72 (15.7%) were identified with ISR during a mean follow-up of 14.6 (19.1) months (range, 0.7-120.7 months). Increased NLR (≥2.13) was significantly related to ISR in patients with asymptomatic stenosis ( P = .001). However, significance was not observed in symptomatic stenosis. On multivariate analysis, baseline NLR ≥ 2.13 (hazard ratio [HR], 2.74; 95% confidence interval [CI], 1.46-5.14), smoking (HR, 1.99; 95% CI, 1.11-3.58), residual stenosis (HR, 1.12; 95% CI, 1.09-1.15), and baseline glucose level (HR, 1.01; 95% CI, 1.01-1.02) were associated with ISR. Elevated NLR may be a predictor of ISR after CAS for asymptomatic stenosis.
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Affiliation(s)
- Zhengze Dai
- Department of Neurology, Jinling Clinical College of Nanjing Medical University, Nanjing, Jiangsu, China
- Department of Neurology, Nanjing Pukou Hospital, Nanjing, Jiangsu, China
| | - Rongrong Li
- Department of Neurology, Jinling Hospital, Medical School of Nanjing University, Nanjing, Jiangsu, China
| | - Nan Zhao
- Department of Neurology, Jinling Hospital, Medical School of Nanjing University, Nanjing, Jiangsu, China
| | - Yunfei Han
- Department of Neurology, Jinling Hospital, Medical School of Nanjing University, Nanjing, Jiangsu, China
| | - Mengmeng Wang
- Department of Neurology, Jinling Hospital, Medical School of Nanjing University, Nanjing, Jiangsu, China
| | - Shuai Zhang
- Department of Neurology, Jinling Clinical College of Nanjing Medical University, Nanjing, Jiangsu, China
- Department of Neurology, The Affiliated Hospital of Yangzhou University, Yangzhou University, Yangzhou, Jiangsu, China
| | - Yongjie Bai
- Department of Neurology, Jinling Clinical College of Nanjing Medical University, Nanjing, Jiangsu, China
- Department of Neurology, First Affiliated Hospital, College of Clinical Medicine of Henan University of Science and Technology, Luoyang, Henan, China
| | - Zibao Li
- Department of Neurology, Jinling Clinical College of Nanjing Medical University, Nanjing, Jiangsu, China
| | - Meng Liang
- Department of Neurology, Jinling Hospital, Second Military Medical University, Nanjing, Jiangsu, China
| | - Lulu Xiao
- Department of Neurology, Jinling Clinical College of Nanjing Medical University, Nanjing, Jiangsu, China
- Department of Neurology, Jinling Hospital, Medical School of Nanjing University, Nanjing, Jiangsu, China
| | - Minmin Ma
- Department of Neurology, Jinling Clinical College of Nanjing Medical University, Nanjing, Jiangsu, China
- Department of Neurology, Jinling Hospital, Medical School of Nanjing University, Nanjing, Jiangsu, China
| | - Xinfeng Liu
- Department of Neurology, Jinling Clinical College of Nanjing Medical University, Nanjing, Jiangsu, China
- Department of Neurology, Jinling Hospital, Medical School of Nanjing University, Nanjing, Jiangsu, China
| | - Gelin Xu
- Department of Neurology, Jinling Clinical College of Nanjing Medical University, Nanjing, Jiangsu, China
- Department of Neurology, Jinling Hospital, Medical School of Nanjing University, Nanjing, Jiangsu, China
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Tzovaras AA, Gentimi F, Nikolaou M. Tumor Protein p53 Gene and Cardiovascular Disease. Angiology 2018; 69:736-737. [DOI: 10.1177/0003319718772412] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Affiliation(s)
| | - Fotini Gentimi
- Department of Pediatric Surgery, “Mitera” Pediatric Hospital, Athens, Greece
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Paraskevas KI, Cambria RP. Best Medical Treatment for Patients with Carotid Stenosis: Evidence-Based Medicine or Wishful Thinking? Angiology 2018; 69:97-99. [DOI: 10.1177/0003319717709860] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/30/2023]
Affiliation(s)
- Kosmas I. Paraskevas
- Liverpool Vascular and Endovascular Services, Royal Liverpool University Hospital, Liverpool, UK
| | - Richard P. Cambria
- Division of Vascular and Endovascular Surgery, Thoracic Aortic Centre, Massachusetts General Hospital, Boston, MA, USA
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40
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Lareyre F, Nguyen E, Raffort J, Carboni J, Doyen J, Hassen-Khodja R, Gastaud P, Chofflet J, Jean-Baptiste E. Changes in Ocular Subfoveal Choroidal Thickness After Carotid Endarterectomy Using Enhanced Depth Imaging Optical Coherence Tomography: A Pilot Study. Angiology 2017; 69:574-581. [PMID: 29082746 DOI: 10.1177/0003319717737223] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
The influence of both severe chronic carotid stenosis and carotid endarterectomy (CEA) on ocular tissue has been poorly evaluated. The goal of this study was to measure subfoveal choroidal thickness (SFCT), before and after CEA, in patients with severe carotid stenosis. Consecutive patients (n = 36) with severe carotid stenosis were prospectively included. Patients (n = 19) were followed up at 1 and 3 months after CEA. The SFCT was measured bilaterally using enhanced depth imaging optical coherence tomography (EDI-OCT). Preoperatively, the median SFCT of the ipsilateral eye did not differ significantly from the contralateral eye (223 vs 236 µm; P = .75). In the ipsilateral eye, the mean SFCT was significantly higher at 1 month postsurgery and the effect was maintained at 3 months (226.3 ± 17.1 at 3 months vs 210.8 ± 16.5 µm at baseline; P < .001). For the contralateral eye, the increase in SFCT reached statistical significance at 3 months (220.1 ± 11.3 at 3 months vs 214.8 ± 11.5 µm at baseline; P = .04). The mean SFCT significantly increased bilaterally after CEA, with a more noticeable effect in the ipsilateral eye. Further studies are required to determine whether EDI-OCT could be useful as a potential marker of ophthalmologic outcomes.
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Affiliation(s)
- Fabien Lareyre
- 1 Department of Vascular Surgery, University Hospital of Nice, Nice, France.,2 Université Côte d'Azur, CNRS, Inserm, IRCAN, Nice, France
| | - Elisabeth Nguyen
- 3 Department of Ophthalmologic Surgery, University Hospital of Nice, Nice, France
| | - Juliette Raffort
- 2 Université Côte d'Azur, CNRS, Inserm, IRCAN, Nice, France.,4 Clinical Chemistry Laboratory, University Hospital of Nice, Nice, France
| | - Joseph Carboni
- 1 Department of Vascular Surgery, University Hospital of Nice, Nice, France.,5 Université Côte d'Azur, Nice, France
| | | | - Réda Hassen-Khodja
- 1 Department of Vascular Surgery, University Hospital of Nice, Nice, France.,5 Université Côte d'Azur, Nice, France
| | - Pierre Gastaud
- 3 Department of Ophthalmologic Surgery, University Hospital of Nice, Nice, France
| | - Jacques Chofflet
- 3 Department of Ophthalmologic Surgery, University Hospital of Nice, Nice, France
| | - Elixène Jean-Baptiste
- 1 Department of Vascular Surgery, University Hospital of Nice, Nice, France.,5 Université Côte d'Azur, Nice, France
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41
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Qualitätsmanagement und klinische Pfade in der Diagnostik und Therapie der Karotisstenose. GEFÄSSCHIRURGIE 2017. [DOI: 10.1007/s00772-017-0319-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
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42
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Paraskevas KI, Naylor AR. External Validation of Randomized Trial Outcomes Following Carotid Interventions in the Modern Era. Angiology 2017; 68:669-674. [DOI: 10.1177/0003319716664267] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/30/2023]
Abstract
An essential prerequisite of randomized controlled trials (RCTs) is “external validation,” that is, results obtained in the “real world” closely replicate those from RCTs. In this respect, contemporary administrative data set registries reporting outcomes after carotid endarterectomy and carotid artery stenting (CAS) have recently reported death/stroke rates that exceed the accepted risk thresholds for intervening. The current article evaluates this controversy and offers reasons why this might continue to happen, namely: (1) difference in interventionists’ competence/experience, (2) patient selection, and (3) advances in CAS technology/technique. As CAS is a continuously evolving technique, the results obtained from patients recruited into the landmark RCTs (as early as the late 1990s) do not reflect contemporary practice. Although RCTs are not always the perfect solution, the process of randomization ensures minimization of selection bias. A possible way forward may be the introduction of prospective, randomized, controlled clinical registries.
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Affiliation(s)
| | - A. Ross Naylor
- Vascular Research Group, Division of Cardiovascular Sciences, Department of Vascular Surgery, Leicester Royal Infirmary, Leicester, UK
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43
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Pini R, Faggioli G, Vacirca A, Cacioppa LM, Gallitto E, Gargiulo M, Stella A. The fate of asymptomatic severe carotid stenosis in the era of best medical therapy. Brain Inj 2017; 31:1711-1717. [DOI: 10.1080/02699052.2017.1346285] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Affiliation(s)
- Rodolfo Pini
- Vascular Surgery Unit, Policlinico S. Orsola-Malpighi, University of Bologna, Bologna, Italy
| | - Gianluca Faggioli
- Vascular Surgery Unit, Policlinico S. Orsola-Malpighi, University of Bologna, Bologna, Italy
| | - Andrea Vacirca
- Vascular Surgery Unit, Policlinico S. Orsola-Malpighi, University of Bologna, Bologna, Italy
| | - Laura Maria Cacioppa
- Vascular Surgery Unit, Policlinico S. Orsola-Malpighi, University of Bologna, Bologna, Italy
| | - Enrico Gallitto
- Vascular Surgery Unit, Policlinico S. Orsola-Malpighi, University of Bologna, Bologna, Italy
| | - Mauro Gargiulo
- Vascular Surgery Unit, Policlinico S. Orsola-Malpighi, University of Bologna, Bologna, Italy
| | - Andrea Stella
- Vascular Surgery Unit, Policlinico S. Orsola-Malpighi, University of Bologna, Bologna, Italy
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Musiałek P, Hopkins LN, Siddiqui AH. One swallow does not a summer make but many swallows do: accumulating clinical evidence for nearly-eliminated peri-procedural and 30-day complications with mesh-covered stents transforms the carotid revascularisation field. ADVANCES IN INTERVENTIONAL CARDIOLOGY 2017; 13:95-106. [PMID: 28798779 PMCID: PMC5545669 DOI: 10.5114/pwki.2017.69012] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2017] [Accepted: 07/10/2017] [Indexed: 02/07/2023] Open
Abstract
Atherosclerotic carotid artery stenosis (CS) continues to be a common cause of acute ischaemic stroke. Optimised medical therapy (OMT), the first-line treatment modality in CS, may reduce or delay - but it does not abolish - CS-related strokes. As per current AHA/ASA and ESC/ESVS/ESO guidelines, carotid artery stenting (CAS) is a less-invasive alternative to carotid endarterectomy (CEA) for CS revascularisation in primary and secondary stroke prevention. Ten-year follow-up from the CREST trial in patients with symptomatic and asymptomatic CS confirmed equipoise of CAS and CEA in the primary endpoint. Nevertheless CAS - using a widely open-cell, first-generation stent and first-generation (distal/filter) neuroprotection - has been criticised for its relative excess of (mostly minor) strokes by 30 days, a significant proportion of which were post-procedural. Atherosclerotic plaque protrusion through conventional carotid stent struts, confirmed on intravascular imaging, has been implicated as a leading mechanism of the relative excess of strokes with CAS vs. CEA, including delayed strokes with CAS. Different designs of mesh-covered carotid stents have been developed to prevent plaque prolapse. Several multi-centre/multi-specialty clinical studies with CGurad MicroNet-Covered Embolic Prevention Stent System (EPS) and RoadSaver/Casper were recently published and included routine DW-MRI cerebral imaging peri-procedurally and at 30 days (CGuard EPS). Data from more than 550 patients in mesh-covered carotid stent clinical studies to-date show an overall 30-day complication rate of ~1% with near-elimination of post-procedural events. While more (and long-term) evidence is still anticipated, these results - taken together with optimised intra-procedural neuroprotection in CAS (increased use of proximal systems including trans-carotid dynamic flow reversal) and the positive 12-month mesh-covered stent data reports in 2017 - are transforming the carotid revascularisation field today. Establishing effective algorithms to identify the asymptomatic subjects at stroke risk despite OMT, and large-scale studies with mesh-covered stents including long-term clinical and duplex ultrasound outcomes, are the next major goals.
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Affiliation(s)
- Piotr Musiałek
- Department of Cardiac and Vascular Diseases, Jagiellonian University, School of Medicine, John Paul II Hospital, Krakow, Poland
| | - L. Nelson Hopkins
- Departments of Neurosurgery and Radiology, School of Medicine and Biomedical Sciences, University at Buffalo, State University of New York, Jacobs Institute, Gates Vascular Institute Kaleida Health, Buffalo, New York, USA
| | - Adnan H. Siddiqui
- Departments of Neurosurgery and Radiology, School of Medicine and Biomedical Sciences, University at Buffalo, State University of New York, Jacobs Institute, Gates Vascular Institute Kaleida Health, Buffalo, New York, USA
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Rich K, Treat-Jacobson D, DeVeaux T, Fitzgerald K, Kirk L, Thomson L, Foley A, Hill D. Society for Vascular Nursing-Carotid endarterectomy (CEA) updated nursing clinical practice guideline. JOURNAL OF VASCULAR NURSING 2017; 35:90-111. [PMID: 28527733 DOI: 10.1016/j.jvn.2017.03.004] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2017] [Accepted: 03/24/2017] [Indexed: 01/22/2023]
Affiliation(s)
| | | | | | | | - Laura Kirk
- University of Minnesota School of Nursing, Minneapolis, Minnesota
| | - Lily Thomson
- Section of Vascular Surgery, Health Sciences Centre, Vascular Research Lab, Winnipeg, Manitoba, Canada
| | - Anne Foley
- Department of Vascular Surgery, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Debbie Hill
- Vascular Health Partners, Community Care Physicians, Albany, New York
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46
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Matsumaru Y, Ishikawa E, Yamamoto T, Matsumura A. Recent Trends in Neuro-endovascular Treatment for Acute Ischemic Stroke, Cerebral Aneurysms, Carotid Stenosis, and Brain Arteriovenous Malformations. Neurol Med Chir (Tokyo) 2017; 57:253-260. [PMID: 28458385 PMCID: PMC5495956 DOI: 10.2176/nmc.ra.2017-0027] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Abstract
The efficacy of mechanical thrombectomy with stent retrievers for emergent large vessel occlusion has been proved by randomized trials. Mechanical thrombectomy is increasingly being adopted in Japan since stent retrievers were first approved in 2014. An urgent clinical task is to offer structured systems of care to provide this treatment in a timely fashion to all patients with emergent large vessel occlusion. Treatment with flow-diverting stents is currently a preferred treatment option worldwide for large and giant unruptured aneurysms. Initial studies reported high rates of complete aneurysm occlusion, even in large and giant aneurysms, without delayed aneurysmal recanalization and/or growth. The Pipeline Embolic Device is a flow diverter recently approved in Japan for the treatment of large and giant wide-neck unruptured aneurysms in the internal carotid artery, from the petrous to superior hypophyseal segments. Carotid artery stenting is the preferred treatment approach for carotid stenosis in Japan, whereas it remains an alternative for carotid endarterectomy in Europe and the United States. Carotid artery stenting with embolic protection and plaque imaging is effective in achieving favorable outcomes. The design and conclusions of a randomized trial of unruptured brain arteriovenous malformations (ARUBA) trial, which compared medical management alone and medical management with interventional therapy in patients with an unruptured arteriovenous brain malformation, are controversial. However, the annual bleeding rate (2.2%) of the medical management group obtained from this study is worthy of consideration when deciding treatment strategy.
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Affiliation(s)
- Yuji Matsumaru
- Division for Stroke, Department of Neurosurgery, Faculty of Medicine, University of Tsukuba
| | - Eiichi Ishikawa
- Department of Neurosurgery, Faculty of Medicine, University of Tsukuba
| | - Tetsuya Yamamoto
- Department of Neurosurgery, Faculty of Medicine, University of Tsukuba
| | - Akira Matsumura
- Department of Neurosurgery, Faculty of Medicine, University of Tsukuba
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47
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Spence JD. Rational Medical Therapy Is the Key to Effective Cardiovascular Disease Prevention. Can J Cardiol 2017; 33:626-634. [DOI: 10.1016/j.cjca.2017.01.003] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2016] [Revised: 12/26/2016] [Accepted: 01/08/2017] [Indexed: 12/14/2022] Open
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Spence JD. Transcranial Doppler monitoring for microemboli: a marker of a high-risk carotid plaque. Semin Vasc Surg 2017; 30:62-66. [PMID: 28818260 DOI: 10.1053/j.semvascsurg.2017.04.011] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/30/2023]
Abstract
In the United States, 90% of carotid intervention is being performed for asymptomatic carotid stenosis, even though 90% of patients would be better treated with intensive medical therapy. This is being justified by comparing risks of stroke or death with medical therapy during clinical trials completed decades ago (approximately 2% per year) with risks of intervention with carotid artery stenting (CAS) versus carotid endarterectomy in recent trials that did not have a medical arm. Such extrapolations are, simply put, invalid. Even though the two most recent papers comparing carotid endarterectomy with CAS reported that the long-term risk (after first deducting periprocedural risks) is similar to that with medical therapy (approximately 0.5% per year), when the periprocedural risks are considered (approximately 3% with stenting v 1.5% with CAS), most patients would be better treated with intensive medical therapy. Furthermore, it must be recognized that the low risks observed in clinical trials with highly selected surgeons and interventionalists are much lower than in real-world practice. It is therefore necessary to have ways to identify, among patients with asymptomatic carotid stenosis, the few (approximately 10% to 15%) who could benefit from intervention. Indicators of vulnerable plaque, such as ulceration, juxtaluminal lucent plaque, intraplaque hemorrhage on magnetic resonance imaging, and plaque inflammation on positron emission tomography/computed tomography are in development for that purpose. The best-validated approach is detection of microemboli on transcranial Doppler. A prospective single-center study of 468 patients showed that microemboli identified high-risk asymptomatic stenosis; this was validated by a prospective multicenter international study in 467 patients. Increased risk with microemboli persisted in the era of lower risks with intensive medical therapy. Patients with asymptomatic carotid stenosis should not be offered CAS or carotid endarterectomy without first being identified as high risk; percent stenosis does not do so. Currently, the best way to improve the risk to benefit ratio for intervention is transcranial Doppler embolus detection.
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Affiliation(s)
- J David Spence
- Stroke Prevention and Atherosclerosis Research Centre, Robarts Research Institute, Western University, 1400 Western Road, London, Ontario, Canada N6G 2V4.
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49
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Morris DR, Ayabe K, Inoue T, Sakai N, Bulbulia R, Halliday A, Goto S. Evidence-Based Carotid Interventions for Stroke Prevention: State-of-the-art Review. J Atheroscler Thromb 2017; 24:373-387. [PMID: 28260723 PMCID: PMC5392474 DOI: 10.5551/jat.38745] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2016] [Accepted: 02/01/2017] [Indexed: 12/28/2022] Open
Abstract
Carotid artery stenosis is responsible for between 10-20% of all ischaemic strokes. Interventions, such as carotid endarterectomy and carotid stenting, effectively reduce the risk of stroke in selected individuals. This review describes the history of carotid interventions, and summarises reliable evidence on the safety and efficacy of these interventions gained from large randomised clinical trials.Early trials comparing carotid endarterectomy to medical therapy alone in symptomatic patients, and asymptomatic patients, demonstrated that endarterectomy halved the risk of stroke and perioperative death in these two unique populations. The absolute risk reduction was smaller in the asymptomatic carotid trials, consistent with their lower absolute stroke risk. More recent trials in symptomatic patients, suggest that carotid stenting has similar long term durability to carotid endarterectomy, but possibly has higher procedural hazards dominated by non-disabling strokes. The Asymptomatic Carotid Surgery Trial-2, along with individual patient data meta-analysis of all asymptomatic trials, will provide reliable evidence for the choice of intervention in asymptomatic patients in whom a decision has been made for carotid revascularisation. Given improvements in effective cardiovascular medical therapy, in particular lipid-lowering medications, there is renewed uncertainty as to whether carotid interventions still provide meaningful net reductions in stroke risk in asymptomatic populations. Four large trials in Europe and the US are currently underway, and are expected to report long-term results in the next decade.It is essential that surgeons, interventionalists, and physicians continue to randomise large numbers of patients from around the world to clarify current uncertainty around the management of asymptomatic carotid stenosis.
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Affiliation(s)
- Dylan R. Morris
- Clinical Trial Service Unit and Epidemiological Studies Unit, University of Oxford, Oxford, UK
| | - Kengo Ayabe
- Department of Medicine (Cardiology), Tokai University School of Medicine, Kanagawa, Japan
| | - Takashi Inoue
- Department of Neurosurgery, Sendai Medical Center, Sendai, Japan
| | - Nobuyuki Sakai
- Department of Neurosurgery, KCGH Comprehensive Stroke Center, Kobe City Medical Center General Hospital, Kobe, Japan
| | - Richard Bulbulia
- Clinical Trial Service Unit and Epidemiological Studies Unit, University of Oxford, Oxford, UK
| | - Alison Halliday
- Nuffield Department of Surgical Sciences, University of Oxford, Oxford, UK
| | - Shinya Goto
- Department of Medicine (Cardiology), Tokai University School of Medicine, Kanagawa, Japan
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50
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Paraskevas KI, Veith FJ, Mikhailidis DP, Liapis CD. Appropriate Patient Selection for Carotid Revascularization Procedures is Urgently Needed. Angiology 2017; 69:12-16. [PMID: 28078914 DOI: 10.1177/0003319716687870] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
The identification/selection of appropriate patient subgroups with asymptomatic carotid artery stenosis and the performance of prophylactic carotid endarterectomy (CEA)/carotid artery stenting (CAS) exclusively on these asymptomatic patient subgroups is currently one of the "hottest" topics in vascular surgery. It is now clear that offering CEA/CAS to asymptomatic carotid patients based only on the degree of carotid stenosis is unjustified and scientifically flawed. On the other hand, offering only best medical therapy to every asymptomatic patient, irrespective of certain high-risk criteria (such as the detection of microemboli by transcranial Doppler, intraplaque hemorrhage, silent embolic infarcts on brain computed tomography/magnetic resonance imaging, elevated biomarkers, family history), is equally wrong. The validation of specific measures to identify those asymptomatic patients at high risk for developing symptoms is crucial to achieve optimal use of carotid interventions and avoid wasting stroke prevention resources.
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Affiliation(s)
- Kosmas I Paraskevas
- 1 Northern Vascular Centre, Freeman Hospital, Newcastle Upon Tyne, NHS Foundation Trust, UK
| | - Frank J Veith
- 2 Divisions of Vascular Surgery, New York University Langone Medical Center and Cleveland Clinic, New York, NY and Cleveland, OH, USA
| | - Dimitri P Mikhailidis
- 3 Department of Clinical Biochemistry, Royal Free Hospital Campus, University College London Medical School, University College London (UCL), London, UK
| | - Christos D Liapis
- 4 Vascular and Endovascular Clinic, Athens Medical Center, Athens, Greece
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