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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. [PMID: 36170885 DOI: 10.1055/a-1952-1159] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [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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Stefanini M, Cacioppa LM, Bellini L, Ginanni Corradini L, D'Onofrio A, Simonetti G. Dual-layered micromesh stent technology for embolic prevention in carotid revascularization: technical experience and clinical outcomes from a high-volume interventional radiology center. THE JOURNAL OF CARDIOVASCULAR SURGERY 2024; 65:213-220. [PMID: 38727642 DOI: 10.23736/s0021-9509.24.13033-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 07/16/2024]
Abstract
BACKGROUND Carotid artery stenting (CAS) has become a cornerstone of carotid revascularization for stroke prevention. Despite the advantages of CAS, large-scale randomized trials involving prior (single-layer) first generation stents (FGS) demonstrated a higher risk of periprocedural cerebrovascular events compared to surgery. Dual-layer mesh-covered stents (DLSs) showed promising results in terms of 30-day embolic events in initial studies; larger-scale evidence is accumulating. This study aims to evaluate 30-day clinical efficacy of DLS against a closed-cell stent, based on large-volume data. METHODS The study center is part of the Italian National Outcomes Evaluation Program (PNE). CAS procedures performed between November 2017 and September 2023 were eneterd into a prospectively collected database. Our The primary endpoint was survival free of death, stroke, and myocardial infarction (MI) at 30 days. In addition, technical success and periprocedural major adverse clinical event rate (with a focus on stroke) were also evaluated. RESULTS Over a total of 1101 CAS procedures (745 males; mean age 79±7.8 years), 48.6% were symptomatic. Majority (80.2%) were treated with DLSs. Technical success was achieved in 98.9%. The FGSs group showed a significantly higher peri-procedural stroke rate when compared with CGuard and Roadsaver DLS: 4.59% vs. 1.18% vs. 2.63% (P=0.008); minor stroke rates were 4.13% vs. 0.83% and 0% P=0.01). The cumulative stroke, MI and death - free survival at 30 days was 97.46%. A statistically significant higher cumulative 30-day death/stroke/MI rate occurred in FGSs-treated patients compared to the CGuard and Roadsaver DLS-treated (6.42% vs. 1.42% and 2.63%, P=0.001). CONCLUSIONS The use of DLS in patients undergoing CAS in our large-volume center showed a high technical success rate and minimal cerebral embolic complications by 30 days. High volumes and an experienced interventional team may contribute to these favorable outcomes.
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Affiliation(s)
- Matteo Stefanini
- Department of Diagnostic Imaging and Interventional Radiology, Casilino Hospital, Rome, Italy
| | - Laura Maria Cacioppa
- Department of Clinical, Special and Dental Sciences, Polytechnic University of Marche, Ancona, Italy
- Division of Interventional Radiology, Department of Radiological Sciences, Azienda Ospedaliera Universitaria della Marche University Hospital, Ancona, Italy
| | - Luigi Bellini
- Department of Diagnostic Imaging and Interventional Radiology, Casilino Hospital, Rome, Italy -
| | - Luca Ginanni Corradini
- Department of Diagnostic Imaging and Interventional Radiology, Casilino Hospital, Rome, Italy
| | - Adolfo D'Onofrio
- Department of Diagnostic Imaging and Interventional Radiology, Casilino Hospital, Rome, Italy
| | - Giovanni Simonetti
- Department of Diagnostic Imaging and Interventional Radiology, Casilino Hospital, Rome, Italy
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Trystula M, VAN Herzeele I, Kolvenbach R, Tekieli L, Fonteyne C, Mazurek A, Dzierwa K, Chmiel J, Lindsay J, Kwiatkowski T, Hydzik A, Oplawski M, Bederski K, Musialek P. Next-generation transcarotid artery revascularization: TransCarotid flOw Reversal Cerebral Protection And CGUARD MicroNET-Covered Embolic Prevention Stent System To Reduce Strokes - TOPGUARD Study. THE JOURNAL OF CARDIOVASCULAR SURGERY 2024; 65:181-194. [PMID: 39007552 DOI: 10.23736/s0021-9509.24.13121-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 07/16/2024]
Abstract
BACKGROUND Stent-assisted carotid artery revascularization employing surgical cutdown for transcervical access and dynamic flow reversal (TCAR) is gaining popularity. TCAR, despite maximized intra-procedural cerebral protection, shows a marked excess of 30-day neurologic complications in symptomatic vs. asymptomatic stenoses. The TCAR conventional single-layer stent (free-cell area 5.89mm2) inability to seal embologenic lesions may be particularly relevant after the flow reversal neuroprotection is terminated. METHODS We evaluated peri-procedural and 30-day major adverse cerebral and cardiac events (MACCE) of TCAR (ENROUTE, SilkRoad Medical) paired with MicroNET-covered neuroprotective stent (CGuard, InspireMD) in consecutive patients at elevated risk of complications with transfemoral/transradial filter-protected stenting (increased lesion-related and/or access-related risk). CGuard (MicroNET free cell area ≈0.02-0.03 mm2) has level-1 evidence for reducing intra- and abolishing post-procedural lesion-related cerebral embolism. RESULTS One hundred and six increased-risk patients (age 72 [61-76] years, median [Q1-Q3]; 60.4% symptomatic, 49.1% diabetic, 36.8% women, 61.3% left-sided index lesion) were enrolled in three vascular surgery centers. Angiographic stenosis severity was 81 (75-91)%, lesion length 21 (15-26)mm, increased-risk lesional characteristics 87.7%. Study stent use was 100% (no other stent types). 74.5% lesions were predilated; post-dilatation rate was 90.6%. Flow reversal duration was 8 (5-11)min. One stroke (0.9%) occurred in an asymptomatic patient prior to establishing neuroprotection (index lesion disruption with the sheath insertion wire); there were no other peri-procedural MACCE. No further adverse events occurred by 30-days. 30-day stent patency was 100% with normal velocities and absence of any in-stent material by Duplex Doppler. CONCLUSIONS Despite a high proportion of increased-risk lesions and clinically symptomatic patients in this study, TCAR employing the MicroNET-covered anti-embolic stent showed 30-day MACCE rate <1%. This suggests a clinical role for combining maximized intra-procedural prevention of cerebral embolism by dynamic flow reversal with anti-embolic stent prevention of peri- and post-procedural cerebral embolism (TOPGUARD NCT04547387).
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Affiliation(s)
- Mariusz Trystula
- Department of Vascular Surgery, St. John Paul II Hospital, Krakow, Poland
| | - Isabelle VAN Herzeele
- Department of Thoracic and Vascular Surgery, Ghent University Hospital, Ghent, Belgium
| | - Ralf Kolvenbach
- Department of Vascular Surgery, Sana Kliniken, Düsseldorf, Germany
| | - Lukasz Tekieli
- Department of Cardiac and Vascular Diseases, Jagiellonian University Medical College, Krakow, Poland
- Stroke Thrombectomy-Capable Center, St. John Paul II Hospital, Krakow, Poland
| | - Charlotte Fonteyne
- Department of Thoracic and Vascular Surgery, University of Ghent, Ghent, Belgium
| | - Adam Mazurek
- Department of Cardiac and Vascular Diseases, Jagiellonian University Medical College, Krakow, Poland
- Stroke Thrombectomy-Capable Center, St. John Paul II Hospital, Krakow, Poland
| | - Karolina Dzierwa
- Cardiovascular Imaging Laboratory, St. John Paul II Hospital, Krakow, Poland
| | - Jakub Chmiel
- Department of Cardiac and Vascular Diseases, Jagiellonian University Medical College, Krakow, Poland
- Stroke Thrombectomy-Capable Center, St. John Paul II Hospital, Krakow, Poland
| | | | - Tomasz Kwiatkowski
- Department of Vascular Surgery, St. John Paul II Hospital, Krakow, Poland
| | - Adam Hydzik
- Department of Vascular Surgery, St. John Paul II Hospital, Krakow, Poland
| | | | - Krzysztof Bederski
- Department of Thoracic Surgery, St. John Paul II Hospital, Krakow, Poland
| | - Piotr Musialek
- Department of Cardiac and Vascular Diseases, Jagiellonian University Medical College, Krakow, Poland -
- Stroke Thrombectomy-Capable Center, St. John Paul II Hospital, Krakow, Poland
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4
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Tekieli L, Dzierwa K, Grunwald IQ, Mazurek A, Urbanczyk-Zawadzka M, Wiewiorka L, Banys RP, Dabrowski W, Podlasek A, Weglarz E, Stefaniak J, Nizankowski RT, Musialek P. Outcomes in acute carotid-related stroke eligible for mechanical reperfusion: SAFEGUARD-STROKE Registry. THE JOURNAL OF CARDIOVASCULAR SURGERY 2024; 65:231-248. [PMID: 39007556 DOI: 10.23736/s0021-9509.24.13093-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 07/16/2024]
Abstract
BACKGROUND Carotid-related strokes (CRS) are largely unresponsive to intravenous thrombolysis and are often large and disabling. Little is known about contemporary CRS referral pathways and proportion of eligible patients who receive emergency mechanical reperfusion (EMR). METHODS Referral pathways, serial imaging, treatment data, and neurologic outcomes were evaluated in consecutive CRS patients presenting over 18 months in catchment area of a major carotid disease referral center with proximal-protected CAS expertise, on-site neurology, and stroke thrombectomy capability (Acute Stroke of CArotid Artery Bifurcation Origin Treated With Use oF the MicronEt-covered CGUARD Stent - SAFEGUARD-STROKE Registry; companion to SAFEGUARD-STROKE Study NCT05195658). RESULTS Of 101 EMR-eligible patients (31% i.v.-thrombolyzed, 39.5% women, age 39-89 years, 94.1% ASPECTS 9-10, 90.1% pre-stroke mRS 0-1), 57 (56.4%) were EMR-referred. Referrals were either endovascular (Comprehensive Stroke Centre, CSC, 21.0%; Stroke Thrombectomy-Capable CAS Centre, STCC, 70.2%) or to vascular surgery (VS, 1.8%), with >1 referral attempt in 7.0% patients (CSC/VS or VS/CSC or CSC/VS/STCC). Baseline clinical and imaging characteristics were not different between EMR-treated and EMR-untreated patients. EMR was delivered to 42.6% eligible patients (emergency carotid surgery 0%; STCC rejections 0%). On multivariable analysis, non-tandem CRS was a predictor of not getting referred for EMR (OR 0.36; 95%CI 0.14-0.93, P=0.03). Ninety-day neurologic status was profoundly better in EMR-treated patients; mRS 0-2 (83.7% vs. 34.5%); mRS 3-5 (11.6% vs. 53.4%), mRS 6 (4.6% vs. 12.1%); P<0.001 for all. CONCLUSIONS EMR-treatment substantially improves CRS neurologic outcomes but only a minority of EMR-eligible patients receive EMR. To increase the likelihood of brain-saving treatment, EMR-eligible stroke referral and management pathways, including those for CSC/VS-rejected patients, should involve stroke thrombectomy-capable centres with endovascular carotid treatment expertise.
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Affiliation(s)
- Lukasz Tekieli
- Stroke Thrombectomy-Capable Center, St. John Paul II Hospital, Krakow, Poland -
- Department of Cardiac and Vascular Diseases, Jagiellonian University Medical College, Krakow, Poland -
- Department of Interventional Cardiology, Jagiellonian University Medical College, Krakow, Poland -
| | - Karolina Dzierwa
- Cardiovascular Imaging Laboratory, St. John Paul II Hospital, Krakow, Poland
| | - Iris Q Grunwald
- Division of Imaging Science and Technology, School of Medicine, University of Dundee, Dundee, UK
- Department of Radiology, University of Dundee Ninewells Hospital, Dundee, UK
| | - Adam Mazurek
- Stroke Thrombectomy-Capable Center, St. John Paul II Hospital, Krakow, Poland
- Department of Cardiac and Vascular Diseases, Jagiellonian University Medical College, Krakow, Poland
| | | | - Lukasz Wiewiorka
- Department of Radiology, St. John Paul II Hospital, Krakow, Poland
| | - R Pawel Banys
- Department of Radiology, St. John Paul II Hospital, Krakow, Poland
| | - Wladyslaw Dabrowski
- Department of Interventional Cardiology, Jagiellonian University Medical College, Krakow, Poland
| | - Anna Podlasek
- Tayside Innovation MedTech Ecosystem (TIME), University of Dundee, Dundee, UK
- Precison Imaging Beacon, Radiological Sciences, University of Nottingham, Nottingham, UK
| | - Ewa Weglarz
- Department of Interventional Cardiology, Jagiellonian University Medical College, Krakow, Poland
- Department of Nursing, Faculty of Health Sciences, Jagiellonian University Medical College, Krakow, Poland
| | - Justyna Stefaniak
- Department of Bioinformatics and Telemedicine, Jagiellonian University Medical College, Krakow, Poland
| | - Rafal T Nizankowski
- Quality Promotion in Healthcare, Sano Center for Computational Medicine, Krakow, Poland
| | - Piotr Musialek
- Stroke Thrombectomy-Capable Center, St. John Paul II Hospital, Krakow, Poland
- Department of Cardiac and Vascular Diseases, Jagiellonian University Medical College, Krakow, Poland
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Musialek P, Paraskevas KI, Roubin GS. Improving carotid artery stenting to match carotid endarterectomy: a task accomplished. EUROINTERVENTION 2024; 20:e402-e404. [PMID: 38562074 PMCID: PMC10979383 DOI: 10.4244/eij-e-24-00012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 04/04/2024]
Affiliation(s)
- Piotr Musialek
- Department of Cardiac & Vascular Diseases, Jagiellonian University, Krakow, Poland
- St. John Paul II Hospital, Krakow, Poland
| | | | - Gary S Roubin
- CREST2 Trial Interventional Management Committee, Jackson, WY, USA
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Mazurek A, Malinowski K, Sirignano P, Kolvenbach R, Capoccia L, DE Donato G, VAN Herzeele I, Siddiqui AH, Castrucci T, Tekieli L, Stefanini M, Wissgott C, Rosenfield K, Metzger DC, Snyder K, Karpenko A, Kuczmik W, Stabile E, Knapik M, Casana R, Pieniazek P, Podlasek A, Taurino M, Schofer J, Cremonesi A, Sievert H, Schmidt A, Grunwald IQ, Speziale F, Setacci C, Musialek P. Carotid artery revascularization using second generation stents versus surgery: a meta-analysis of clinical outcomes. THE JOURNAL OF CARDIOVASCULAR SURGERY 2023; 64:570-582. [PMID: 38385840 DOI: 10.23736/s0021-9509.24.12933-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/23/2024]
Abstract
INTRODUCTION Meta-analyses and emerging randomized data indicate that second-generation ('mesh') carotid stents (SGS) may improve outcomes versus conventional (single-layer) stents but clinically-relevant differences in individual SGS-type performance have been identified. No comparisons exist for SGS versus carotid endarterectomy (CEA). EVIDENCE ACQUISITION Thirty-day death (D), stroke (S), myocardial infarction (M), and 12-month ipsilateral stroke and restenosis in SGS studies were meta-analyzed (random effect model) against CEA outcomes. Eligible studies were identified through PubMed/EMBASE/COCHRANE. Forest plots were formed for absolute adverse evet risk in individual studies and for relative outcomes with each SGS deign versus contemporary CEA outcomes as reference. Meta-regression was performed to identify potential modifiers of treatment modality effect. EVIDENCE SYNTHESIS Data were extracted from 103,642 patients in 25 studies (14 SGS-treated, 41% symptomatic; nine randomized controlled trial (RCT)-CEA-treated, 37% symptomatic; and two Vascular Quality Initiative (VQI)-CEA-treated, 23% symptomatic). Casper/Roadsaver and CGuard significantly reduced DSM versus RCT-CEA (-2.70% and -2.95%, P<0.001 for both) and versus VQI-CEA (-1.11% and -1.36%, P<0.001 for both). Gore stent 30-day DSM was similar to RCT-CEA (P=0.581) but increased against VQI-CEA (+2.38%, P=0.033). At 12 months, Casper/Roadsaver ipsilateral stroke rate was lower than RCT-CEA (-0.75%, P=0.026) and similar to VQI-CEA (P=0.584). Restenosis with Casper/Roadsaver was +4.18% vs. RCT-CEA and +4.83% vs. VQI-CEA (P=0.005, P<0.001). CGuard 12-month ipsilateral stroke rate was similar to VQI-CEA (P=0.850) and reduced versus RCT-CEA (-0.63%, P=0.030); restenosis was reduced respectively by -0.26% and -0.63% (P=0.033, P<0.001). Twelve-month Gore stent outcomes were overall inferior to surgery. CONCLUSIONS Meta-analytic integration of available clinical data indicates: 1) reduction in stroke but increased restenosis rate with Casper/Roadsaver, and 2) reduction in both stroke and restenosis with CGuard MicroNET-covered stent against contemporary CEA outcomes at 30 days and 12 months used as a reference. This may inform clinical practice in anticipation of large-scale randomized trials powered for low clinical event rates (PROSPERO-CRD42022339789).
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Affiliation(s)
- Adam Mazurek
- Department of Cardiac and Vascular Diseases, Jagiellonian University Medical College, Krakow, Poland -
- St. John Paul II Hospital Stroke Thrombectomy-Capable Center, Krakow, Poland -
| | - Krzysztof Malinowski
- Department of Bioinformatics and Telemedicine, Faculty of Medicine, Jagiellonian University Medical College, Krakow, Poland
- KCRI, Krakow, Poland
| | - Pasqualino Sirignano
- Department of Vascular and Endovascular Surgery, Sant'Andrea Hospital, La Sapienza University, Rome, Italy
| | - Ralf Kolvenbach
- Department of Vascular Surgery in Sana Kliniken, Düsseldorf Gerresheim, Germany
| | - Laura Capoccia
- Department of Vascular Surgery "Paride Stefanini", Policlinico Umberto I, La Sapienza University, Rome, Italy
| | | | | | - Adnan H Siddiqui
- Department of Radiology, Jacobs School of Medicine and Biomedical Sciences, and Canon Stroke and Vascular Research Center, University at Buffalo, Buffalo, NY, USA
- Jacobs Institute, Buffalo, NY, USA
| | - Tomaso Castrucci
- Department of Vascular Surgery, Sant' Eugenio Hospital, University of Rome Tor Vergata, Rome, Italy
| | - Lukasz Tekieli
- Department of Cardiac and Vascular Diseases, Jagiellonian University Medical College, Krakow, Poland
- St. John Paul II Hospital Stroke Thrombectomy-Capable Center, Krakow, Poland
- Department of Interventional Cardiology, Jagiellonian University Medical College, Krakow, Poland
| | - Matteo Stefanini
- Department of Radiology and Interventional Radiology, Casilino Hospital, Rome, Italy
| | - Christian Wissgott
- Institut für Diagnostische und Interventionelle Radiologie/Neuroradiologie, Imland Klinik Rendsburg, Rendsburg, Germany
| | - Kenneth Rosenfield
- Section of Vascular Medicine and Intervention, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | | | - Kenneth Snyder
- Department of Neurosurgery, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, Buffalo, NY, USA
| | - Andrey Karpenko
- Center of Vascular and Hybrid Surgery, E.N. Meshalkin National Medical Research Center, Novosibirsk, Russia
| | - Waclaw Kuczmik
- Department of General, Vascular Surgery, Angiology and Phlebology, Medical University of Silesia, Katowice, Poland
| | - Eugenio Stabile
- Dipartimento Cardiovascolare, Azienda Ospedaliera Regionale "San Carlo", Potenza, Italy
| | - Magdalena Knapik
- Department of Radiology, Podhalanski Multispecialty Regional Hospital, Nowy Targ, Poland
| | - Renato Casana
- Vascular Surgery Unit, IRCCS Istituto Auxologico Italiano, Milan, Italy
| | - Piotr Pieniazek
- Department of Cardiac and Vascular Diseases, Jagiellonian University Medical College, Krakow, Poland
- Department of Interventional Cardiology, Jagiellonian University Medical College, Krakow, Poland
| | - Anna Podlasek
- Tayside Innovation MedTech Ecosystem (TIME), University of Dundee, Dundee, UK
- Precison Imaging Beacon, Radiological Sciences, University of Nottingham, Nottingham, UK
| | - Maurizio Taurino
- Department of Vascular and Endovascular Surgery, Sant'Andrea Hospital, La Sapienza University, Rome, Italy
| | - Joachim Schofer
- MVZ-Department Structural Heart Disease, Asklepios Clinic St Georg, Hamburg, Germany
| | - Alberto Cremonesi
- Department of Cardiology, Humanitas Gavazzeni, Bergamo, Italy
- Department of Biomedical Sciences, Humanitas University, Milan, Italy
| | - Horst Sievert
- Department of Cardiology and Vascular Medicine, Cardiovascular Center, Frankfurt, Germany
| | - Andrej Schmidt
- Department of Angiology, University Hospital Leipzig, Leipzig, Germany
| | - Iris Q Grunwald
- Tayside Innovation MedTech Ecosystem (TIME), University of Dundee, Dundee, UK
- Department of Radiology Ninewells Hospital, University of Dundee, Dundee, UK
| | - Francesco Speziale
- Department of Vascular Surgery "Paride Stefanini", Policlinico Umberto I, La Sapienza University, Rome, Italy
| | - Carlo Setacci
- Department of Vascular Surgery, University of Siena, Siena, Italy
| | - Piotr Musialek
- Department of Cardiac and Vascular Diseases, Jagiellonian University Medical College, Krakow, Poland
- St. John Paul II Hospital Stroke Thrombectomy-Capable Center, Krakow, Poland
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Szkolka L, Lyko-Morawska D, Balocco S, Bedkowski L, Buczek M, Medon E, Wolkowski M, Dryjski M, Kuczmik W. Vascular surgery study of the CGuard MicroNet-covered stent in patients with indication to carotid revascularization: POLGUARD. THE JOURNAL OF CARDIOVASCULAR SURGERY 2023; 64:615-623. [PMID: 37947755 DOI: 10.23736/s0021-9509.23.12891-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/12/2023]
Abstract
BACKGROUND In a recent randomized study, MicroNet-covered stent (CGuard) significantly reduced procedural and post-procedural cerebral embolism in relation to a single-layer CREST study carotid stent, but real-life clinical practice data are limited. The aim is to prospectively assess clinical outcomes of CGuard as a routine revascularization tool for patients with indication to carotid revascularization. METHODS From April 2019 to November 2021, 204 elective patients (age 71.0±7.1years, 69.6% males, 21.7% symptomatic) were enrolled. RESULTS Mean basal peak-systolic velocity was 251.41±91.85 cm/s with angiographic diameter stenosis 89.7±8.46%. About 34.4% lesions were severely calcified, 6.8% were angulated, and 4.4% showed significant access tortuosity. Access was femoral, with 100% protection device (filter) use. Two hundred and three lesions in 203 patients were treated (1 cross-over to surgery for lack of effective access, no cross-over to other devices); in most cases (66.9%) the stent was placed directly. For pre-dilated lesions, mean balloon diameter was 3.36±0.34mm. Mean nominal stent diameter was 7.64±0.5 mm; length was 37.19±4.5 mm. All stents were post-dilated (balloon diameter 5.2±0.25 mm). Residual stenosis was <30% in all (3.77±6.91%). By discharge, there were 2 minor strokes (0.9%) and one transient ischemic attack. By 30-days, one other minor stroke occurred in relation to de-novo atrial fibrillation. With no deaths or myocardial infarctions, 30-day total death/stroke/myocardial infarction rate was 1.48%. No in-stent thrombosis or patency loss occurred by 30-days. In-stent peak-systolic velocity was 55.49±22.73 cm/s. CONCLUSIONS Thirty-day results from POLGUARD study indicate safety and a low complication rate of the MicroNet-covered carotid stent use in every-day vascular surgery practice of carotid revascularization. Long-term observation is underway.
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Affiliation(s)
- Lukasz Szkolka
- Department of Vascular Surgery, General Surgery, Angiology and Phlebology, Silesian Medical University, Katowice, Poland -
| | - Dorota Lyko-Morawska
- Department of Vascular Surgery, General Surgery, Angiology and Phlebology, Silesian Medical University, Katowice, Poland
| | - Simone Balocco
- Department of Mathematics and Computer Science, University of Barcelona, Barcelona, Spain
| | - Lukasz Bedkowski
- Department of Vascular Surgery, General Surgery, Angiology and Phlebology, Silesian Medical University, Katowice, Poland
| | - Michal Buczek
- Department of Vascular Surgery, General Surgery, Angiology and Phlebology, Silesian Medical University, Katowice, Poland
| | - Ewa Medon
- Department of Vascular Surgery, General Surgery, Angiology and Phlebology, Silesian Medical University, Katowice, Poland
| | - Maciej Wolkowski
- Department of Vascular Surgery, General Surgery, Angiology and Phlebology, Silesian Medical University, Katowice, Poland
| | - Maciej Dryjski
- Department of Surgery at the University at Buffalo, Buffalo, NY, USA
| | - Waclaw Kuczmik
- Department of Vascular Surgery, General Surgery, Angiology and Phlebology, Silesian Medical University, Katowice, Poland
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8
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Musialek P, Langhoff R, Stefanini M, Gray WA. Carotid stent as cerebral protector: the arrival of Godot. THE JOURNAL OF CARDIOVASCULAR SURGERY 2023; 64:555-560. [PMID: 38385839 DOI: 10.23736/s0021-9509.23.12956-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/23/2024]
Affiliation(s)
- Piotr Musialek
- Department of Cardiac and Vascular Diseases, Jagiellonian University, Krakow, Poland -
- St. John Paul II Hospital, Stroke Thrombectomy-Capable Center, Krakow, Poland -
| | - Ralf Langhoff
- Department of Angiology, Sankt-Gertrauden Hospital, Academic Teaching Hospital of Charité University, Berlin, Germany
| | - Matteo Stefanini
- Department of Radiology and Interventional Radiology, Casilino Hospital, Rome, Italy
| | - William A Gray
- Main Line Health, Wynnewood, PA, USA
- Sidney Kimmel School of Medicine, Thomas Jefferson University, Philadelphia, PA, USA
- Lankenau Heart Institute, Wynnewood, PA, USA
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Yamaguchi Y, Takada T, Uchida K, Miyata K, Kurisu K, Okuyama T, Tomeoka F, Ajiki M, Hokari M, Asaoka K. Carotid Artery Stenting Using Stent-in-Stent Technique with a Closed-Cell Stent and a Dual-Layer Micromesh Stent: A Case Report. JOURNAL OF NEUROENDOVASCULAR THERAPY 2023; 17:101-106. [PMID: 37546544 PMCID: PMC10400896 DOI: 10.5797/jnet.cr.2023-0003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/02/2023] [Accepted: 03/31/2023] [Indexed: 08/08/2023]
Abstract
Objective Recent studies evaluating plaque protrusion at carotid artery stenting (CAS) using optical coherence tomography showed not a few cases of plaque protrusion when using double-layer micromesh stents. We report a case of symptomatic internal carotid artery (ICA) stenosis with at-risk unstable plaques in which CAS was successfully performed using a stent-in-stent technique by the combined use of a closed-cell stent and a dual-layer micromesh stent. Case Presentation An 87-year-old Japanese man with dysarthria and right hemiparesis was diagnosed with atheromatous cerebral embolism caused by severe left ICA stenosis on MRI and DSA. MRI with T1-weighted black blood methods showed high intensities in the plaques of the left ICA, suggesting unstable plaque characteristics with intraplaque hemorrhage components. On day 20, CAS was performed. After the pre-stent dilation under proximal and distal protection, a Carotid WALLSTENT was placed to cover the stenotic lesion. Then, a CASPER Rx was placed from the proximal left ICA to the common carotid artery to cover the Carotid WALLSTENT. Although visible plaque debris was recognized in the aspirated blood, the debris became invisible after aspiration of 1300 mL. Postoperative angiography showed enough dilation of the left ICA, with no plaque protrusion or acute stent thrombosis. The patient had an uneventful postoperative course and was discharged without any neurological sequelae. Conclusion The present case suggests that the combined stent-in-stent technique using a closed-cell stent and a micromesh stent can be considered as one of the treatment strategies for preventing plaque protrusion and procedural ischemic complications in patients with high-risk carotid plaques.
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Affiliation(s)
- Yoshitaka Yamaguchi
- Department of Cerebrovascular Medicine, Teine Keijinkai Hospital, Sapporo, Hokkaido, Japan
| | - Tatsuro Takada
- Department of Cerebrovascular Medicine, Teine Keijinkai Hospital, Sapporo, Hokkaido, Japan
| | - Kazuki Uchida
- Department of Neurosurgery, Teine Keijinkai Hospital, Sapporo, Hokkaido, Japan
| | - Kei Miyata
- Department of Neurosurgery, Teine Keijinkai Hospital, Sapporo, Hokkaido, Japan
| | - Kota Kurisu
- Department of Neurosurgery, Teine Keijinkai Hospital, Sapporo, Hokkaido, Japan
| | - Tomohiro Okuyama
- Department of Neurosurgery, Teine Keijinkai Hospital, Sapporo, Hokkaido, Japan
| | - Fumiki Tomeoka
- Department of Cerebrovascular Medicine, Teine Keijinkai Hospital, Sapporo, Hokkaido, Japan
| | - Minoru Ajiki
- Department of Cerebrovascular Medicine, Teine Keijinkai Hospital, Sapporo, Hokkaido, Japan
| | - Masaaki Hokari
- Department of Neurosurgery, Teine Keijinkai Hospital, Sapporo, Hokkaido, Japan
| | - Katsuyuki Asaoka
- Department of Neurosurgery, Teine Keijinkai Hospital, Sapporo, Hokkaido, Japan
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10
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Reddy VPK, Mulimani NM. Comparison of the Outcome and Efficacy of Single-Layer versus Dual-Layer Mesh Stent among Carotid Stenosis Patients Attending a Tertiary Care Setting—A Prospective Observational Study. JOURNAL OF CLINICAL INTERVENTIONAL RADIOLOGY ISVIR 2022. [DOI: 10.1055/s-0042-1759799] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022] Open
Abstract
Abstract
Introduction The effect of stent design whether single-layer or double-layer on long-term durability of carotid artery stenting (CAS) is unknown. The aim of this article was to compare the clinical outcome and efficacy of single-layer versus dual-layer mesh stent for CAS among carotid stenosis patients.
Methods A prospective observational study was conducted among 41 consecutive patients, who underwent CAS procedures between November 2019 and November 2021. Procedural data and outcomes for patients treated with the single-layer stent (n = 19patients) and double-layer stent (n = 22) were compared. Procedural efficacy and complications were considered as primary outcome variable. SPSS version 22 was used for statistical analysis.
Results Mean age of study population in dual-layer stents group was 63.86 ± 11.08 years and it was 61.47 ± 8.26 years in single-layer stent group. There was no statistically significant difference between two groups with age, stenosis, side of stenosis, prestenting angioplasty, and poststenting angioplasty (p-value >0.05). Out of 22 participants with dual-layer stent, only one (4.5%) participant experienced five episodes of transient ischemic attack in last 1 month. Both clinical and associated complaints were more in dual-layer group compared with single layer. One (5.26%) participant in single-layer group had reclusion/restenosis at 30 days. Majority in single-(57.8%) and double-layer (63.64%) stents group showed modified Rankin Scale score of 0.
Conclusion Restenosis after CAS occurred less frequently in patients treated with double-layer mesh when compared with single-layer stent. However, both stents were equally effective at preventing peri procedural complications.
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Affiliation(s)
| | - Navin M. Mulimani
- Department of Interventional Radiology, Dr KLEs Prabhakar Kore Hospital & MRC, Belagavi, Karnataka, India
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11
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Safety of Carotid Artery Stenting in Elderly Patients by Treatment Selection Based on Plaque Characteristics. Indian J Surg 2022. [DOI: 10.1007/s12262-022-03585-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
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12
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Mazurek A, Malinowski K, Rosenfield K, Capoccia L, Speziale F, de Donato G, Setacci C, Wissgott C, Sirignano P, Tekieli L, Karpenko A, Kuczmik W, Stabile E, Metzger DC, Amor M, Siddiqui AH, Micari A, Pieniążek P, Cremonesi A, Schofer J, Schmidt A, Musialek P. Clinical Outcomes of Second- versus First-Generation Carotid Stents: A Systematic Review and Meta-Analysis. J Clin Med 2022; 11:jcm11164819. [PMID: 36013058 PMCID: PMC9409706 DOI: 10.3390/jcm11164819] [Citation(s) in RCA: 31] [Impact Index Per Article: 15.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2022] [Revised: 07/20/2022] [Accepted: 07/29/2022] [Indexed: 01/10/2023] Open
Abstract
Background: Single-cohort studies suggest that second-generation stents (SGS; “mesh stents”) may improve carotid artery stenting (CAS) outcomes by limiting peri- and postprocedural cerebral embolism. SGS differ in the stent frame construction, mesh material, and design, as well as in mesh-to-frame position (inside/outside). Objectives: To compare clinical outcomes of SGS in relation to first-generation stents (FGSs; single-layer) in CAS. Methods: We performed a systematic review and meta-analysis of clinical studies with FGSs and SGS (PRISMA methodology, 3302 records). Endpoints were 30-day death, stroke, myocardial infarction (DSM), and 12-month ipsilateral stroke (IS) and restenosis (ISR). A random-effect model was applied. Results: Data of 68,422 patients from 112 eligible studies (68.2% men, 44.9% symptomatic) were meta-analyzed. Thirty-day DSM was 1.30% vs. 4.11% (p < 0.01, data for SGS vs. FGS). Among SGS, both Casper/Roadsaver and CGuard reduced 30-day DSM (by 2.78 and 3.03 absolute percent, p = 0.02 and p < 0.001), whereas the Gore stent was neutral. SGSs significantly improved outcomes compared with closed-cell FGS (30-day stroke 0.6% vs. 2.32%, p = 0.014; DSM 1.3% vs. 3.15%, p < 0.01). At 12 months, in relation to FGS, Casper/Roadsaver reduced IS (−3.25%, p < 0.05) but increased ISR (+3.19%, p = 0.04), CGuard showed a reduction in both IS and ISR (−3.13%, −3.63%; p = 0.01, p < 0.01), whereas the Gore stent was neutral. Conclusions: Pooled SGS use was associated with improved short- and long-term clinical results of CAS. Individual SGS types, however, differed significantly in their outcomes, indicating a lack of a “mesh stent” class effect. Findings from this meta-analysis may provide clinically relevant information in anticipation of large-scale randomized trials.
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Affiliation(s)
- Adam Mazurek
- Department of Cardiac and Vascular Diseases, John Paul II Hospital, Jagiellonian University, 31-202 Krakow, Poland
- Correspondence: (A.M.); (P.M.)
| | - Krzysztof Malinowski
- Department of Bioinformatics and Telemedicine, Faculty of Medicine, Jagiellonian University Medical College, 31-008 Krakow, Poland
| | - Kenneth Rosenfield
- Vascular Surgery, Surgery Department, Massachusetts General Hospital, Boston, MA 02114, USA
| | - Laura Capoccia
- Vascular and Endovascular Surgery Unit, Department of Surgery, Sapienza University of Rome, 00185 Rome, Italy
| | - Francesco Speziale
- Vascular and Endovascular Surgery Unit, Department of Surgery, Sapienza University of Rome, 00185 Rome, Italy
| | | | - Carlo Setacci
- Department of Vascular Surgery, University of Siena, 53100 Siena, Italy
| | - Christian Wissgott
- Institut für Diagnostische und Interventionelle Radiologie/Neuroradiologie, Imland Klinik Rendsburg, 24768 Rendsburg, Germany
| | - Pasqualino Sirignano
- Vascular and Endovascular Surgery Unit, Department of Surgery, Sapienza University of Rome, 00185 Rome, Italy
| | - Lukasz Tekieli
- Department of Interventional Cardiology, John Paul II Hospital, Jagiellonian University, 31-202 Krakow, Poland
| | - Andrey Karpenko
- Centre of Vascular and Hybrid Surgery, E.N. Meshalkin National Medical Research Center, 630055 Novosibirsk, Russia
| | - Waclaw Kuczmik
- Department of General, Vascular Surgery, Angiology and Phlebology, Medical University of Silesia, 40-055 Katowice, Poland
| | | | | | - Max Amor
- Department of Interventional Cardiology, U.C.C.I. Polyclinique d’Essey, 54270 Nancy, France
| | - Adnan H. Siddiqui
- Department of Neurosurgery, SUNY University at Buffalo, Buffalo, NY 14203, USA
| | - Antonio Micari
- Department of Biomedical and Dental Sciences and Morphological and Functional Imaging, University of Messina, 98122 Messina, Italy
| | - Piotr Pieniążek
- Department of Cardiac and Vascular Diseases, John Paul II Hospital, Jagiellonian University, 31-202 Krakow, Poland
- Department of Interventional Cardiology, John Paul II Hospital, Jagiellonian University, 31-202 Krakow, Poland
| | - Alberto Cremonesi
- Cardiovascular Department, Humanitas Gavazzeni Hospital, 24125 Bergamo, Italy
| | - Joachim Schofer
- MVZ-Department Structural Heart Disease, Asklepios Clinic St. Georg, 20099 Hamburg, Germany
| | - Andrej Schmidt
- Department of Angiology, University Hospital Leipzig, 04103 Leipzig, Germany
| | - Piotr Musialek
- Department of Cardiac and Vascular Diseases, John Paul II Hospital, Jagiellonian University, 31-202 Krakow, Poland
- Correspondence: (A.M.); (P.M.)
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Mazurek A, Borratynska A, Gancarczyk U, Czyz L, Sikorska M, Tekieli L, Sobien B, Jakiel M, Trystula M, Drazkiewicz T, Podolec P, Musialek P. Diabetes Mellitus and Clinical Outcomes in Carotid Artery Revascularization Using Second-Generation, MicroNet-Covered Stents: Analysis from the PARADIGM Study. J Diabetes Res 2022; 2022:8691842. [PMID: 36200003 PMCID: PMC9529505 DOI: 10.1155/2022/8691842] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/15/2022] [Revised: 06/16/2022] [Accepted: 08/12/2022] [Indexed: 11/18/2022] Open
Abstract
INTRODUCTION Carotid artery stenting (CAS) using conventional (single-layer) stents is associated with worse clinical outcomes in diabetes mellitus (DM) vs. non-DM patients: an effect driven largely by lesion-related adverse events. CAS outcomes with MicroNet-covered stents (MCS) in diabetic patients have not been evaluated. AIM To compare short- and long-term clinical outcomes and restenosis rate in DM vs. non-DM patients with carotid stenosis treated using MCS. MATERIALS AND METHODS In a prospective study in all-comer symptomatic and increased-stroke-risk asymptomatic carotid stenosis, 101 consecutive patients (age 51-86 years, 41% diabetics) underwent 106 MCS-CAS. Clinical outcomes and duplex ultrasound velocities were assessed periprocedurally and at 30 days/12 months. RESULTS Baseline characteristics of DM vs. non-DM patients were similar except for a higher prevalence of recent cerebral symptoms in DM. Type 1 and type 1+2 plaques were more prevalent in DM patients (26.7% vs. 9.8%, p = 0.02; 62.2% vs. 37.7%, p = 0.01). Proximal embolic protection was more prevalent in DM (60% vs. 36%; p = 0.015). 30-day clinical complications were limited to a single periprocedural minor stroke in DM (2.4% vs. 0%, p = 0.22). 12-month in-stent velocities and clinical outcomes were not different (death rate 4.8% vs. 3.3%; p = 0.69; no new strokes). Restenosis rate was not different (0% vs. 1.7%, p = 0.22). CONCLUSIONS MCS may offset the adverse impact of DM on periprocedural, 30-day, and 12-month clinical complications of CAS and minimize the risk of in-stent restenosis. In this increased-stroke-risk cohort, adverse event rate was low both in DM and non-DM. Further larger-scale clinical datasets including extended follow-ups are warranted.
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Affiliation(s)
- Adam Mazurek
- Jagiellonian University, Department of Cardiac & Vascular Diseases, John Paul II Hospital, Krakow, Poland
| | - Anna Borratynska
- John Paul II Hospital, Neurology Outpatient Department, Krakow, Poland
| | - Urszula Gancarczyk
- Jagiellonian University, Department of Cardiac & Vascular Diseases, John Paul II Hospital, Krakow, Poland
| | - Lukasz Czyz
- Jagiellonian University, Department of Cardiac & Vascular Diseases, John Paul II Hospital, Krakow, Poland
| | - Martyna Sikorska
- Jagiellonian University, Department of Cardiac & Vascular Diseases, John Paul II Hospital, Krakow, Poland
| | - Lukasz Tekieli
- Jagiellonian University, Department of Cardiac & Vascular Diseases, John Paul II Hospital, Krakow, Poland
- Jagiellonian University, Department of Interventional Cardiology, John Paul II Hospital, Krakow, Poland
| | - Bartosz Sobien
- Jagiellonian University, Department of Cardiac & Vascular Diseases, John Paul II Hospital, Krakow, Poland
| | - Marcin Jakiel
- Jagiellonian University, Department of Cardiac & Vascular Diseases, John Paul II Hospital, Krakow, Poland
| | - Mariusz Trystula
- John Paul II Hospital, Department of Vascular Surgery, Krakow, Poland
| | | | - Piotr Podolec
- Jagiellonian University, Department of Cardiac & Vascular Diseases, John Paul II Hospital, Krakow, Poland
| | - Piotr Musialek
- Jagiellonian University, Department of Cardiac & Vascular Diseases, John Paul II Hospital, Krakow, Poland
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14
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Tekieli L, Mazurek A, Pieniazek P, Musialek P. Symptomatic atherosclerotic plaque progression in a first-generation carotid stent: management and 5-year clinical and imaging outcome-a case report. Eur Heart J Case Rep 2022; 6:ytab489. [PMID: 35174303 PMCID: PMC8846173 DOI: 10.1093/ehjcr/ytab489] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2021] [Revised: 06/08/2021] [Accepted: 11/15/2021] [Indexed: 11/23/2022]
Abstract
Background Restenosis in first-generation (single-layer) carotid stents (FGS) is believed to represent an exaggerated healing response of (neo)intimal hyperplasia (NIH) formation. Rather than NIH, we describe symptomatic in-FGS unstable plaque (neo)atherosclerosis mandating re-revascularization. To halt continued plaque evolution, we propose a novel treatment strategy involving a microNet-covered stent (MCS, second-generation carotid stent) to sequestrate the plaque from the vessel lumen. A durable long-term result is documented using multi-modal imaging. Case summary With a seemingly optimal result of FGS (Precise) symptomatic carotid lesion revascularization followed by optimal medical therapy, a late (≥3 years) progressive in-stent restenosis (ISR) arose. At Year 11, crescendo ipsilateral transient ischaemic attacks occurred. Angiography showed an ulcerated tight lesion throughout stent length. Intravascular ultrasound (IVUS) virtual histology imaging revealed thin-cap fibroatheroma. Reintervention was performed under distal protection. Undersized balloon predilatation to insert a stent caused symptomatic no-flow, and aspiration catheter was used to reduce the filter load. A MCS (CGuard) was implanted and post-dilated to ensure full lumen gain; IVUS confirmed complete plaque sequestration. The optimal anatomic result remained unchanged throughout 5 years (ultrasound and computed tomography verification); this was accompanied by clinical cure. Discussion This is the first demonstration of in-FGS (neo)atherosclerosis resolution using an MCS to sequestrate and insulate the atherosclerotic plaque. We show that ISR may be underlined by atherosclerotic plaque progression via the FGS single-layer stent struts that may show vulnerable plaque phenotype and may be associated with cerebral ischaemia. The anatomically and clinically effective exclusion of the atherosclerotic plaque by an MCS enabled lasting, optimal endovascular reconstruction and clinical cure.
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Affiliation(s)
- Lukasz Tekieli
- Department of Interventional Cardiology, Jagiellonian University Institute of Cardiology, John Paul II Hospital, ul. Pradnicka 80, 31-202 Krakow, Poland.,Department of Cardiac and Vascular Diseases, Jagiellonian University Institute of Cardiology, John Paul II Hospital, ul. Pradnicka 80, 31-202 Krakow, Poland
| | - Adam Mazurek
- Department of Cardiac and Vascular Diseases, Jagiellonian University Institute of Cardiology, John Paul II Hospital, ul. Pradnicka 80, 31-202 Krakow, Poland
| | - Piotr Pieniazek
- Department of Interventional Cardiology, Jagiellonian University Institute of Cardiology, John Paul II Hospital, ul. Pradnicka 80, 31-202 Krakow, Poland.,Department of Cardiac and Vascular Diseases, Jagiellonian University Institute of Cardiology, John Paul II Hospital, ul. Pradnicka 80, 31-202 Krakow, Poland.,Department of Vascular Surgery and Endovascular Interventions, John Paul II Hospital, ul. Pradnicka 80, 31-202 Krakow, Poland
| | - Piotr Musialek
- Department of Cardiac and Vascular Diseases, Jagiellonian University Institute of Cardiology, John Paul II Hospital, ul. Pradnicka 80, 31-202 Krakow, Poland
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Karpenko A, Bugurov S, Ignatenko P, Starodubtsev V, Popova I, Malinowski K, Musialek P. Randomized Controlled Trial of Conventional Versus MicroNet-Covered Stent in Carotid Artery Revascularization. JACC Cardiovasc Interv 2021; 14:2377-2387. [PMID: 34736737 DOI: 10.1016/j.jcin.2021.08.005] [Citation(s) in RCA: 27] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/19/2021] [Revised: 07/27/2021] [Accepted: 08/03/2021] [Indexed: 10/19/2022]
Abstract
OBJECTIVES The aim of this study was to compare procedure-related ipsilateral cerebral embolism with a conventional (Acculink, Abbott Vascular) versus a MicroNet-covered (CGuard, InspireMD) stent in carotid artery stenting (CAS). BACKGROUND The MicroNet-covered stent may reduce periprocedural cerebral embolism in CAS, but level 1 evidence is lacking. METHODS A total of 100 consecutive patients were randomized 1:1 to filter-protected CAS using the Acculink or the CGuard device. The study was powered for its primary endpoint of at least 50% reduction in ipsilateral diffusion-weighted magnetic resonance imaging lesion average volume 48 hours postprocedure (blinded external core laboratory analysis). RESULTS The baseline characteristics of the study groups were similar. Eighty-two (total volume = 18,212 mm3) diffusion-weighted magnetic resonance imaging postprocedural cerebral lesions occurred in 26 Acculink-treated patients and 45 lesions (total volume = 3,930 mm3; 78.4% reduction) in 25 CGuard-treated patients. New cerebral lesion average volume was 171 mm3 vs 73 mm3 (P = 0.017) per affected patient and 222 mm3 vs 84 mm3 (P = 0.038) per lesion (Acculink vs CGuard). In lesion-affected patients, the average sum of lesion volumes was 701 mm3 vs 157 mm3 (P = 0.007). The Acculink significantly increased the risk for multiple (≥5) cerebral lesions (relative risk: 7.8; 95% CI: 1.3-14.9; P = 0.021). At 30 days, new permanent (fluid-attenuated inversion recovery) lesion prevalence was 3:1 (P < 0.001), with total permanent lesion volume 7,474 mm3 vs 574 mm3 (92.3% reduction with the CGuard). There were 6 vs 0 new ipsilateral lesions (P = 0.030) and 2 versus 0 strokes. CONCLUSIONS The MicroNet-covered stent significantly reduced periprocedural and abolished postprocedural cerebral embolism in relation to a conventional carotid stent. This is consistent with the MicroNet-covered stent's sustained embolism prevention, translating into cerebral protection not only during but also after CAS. The present findings may influence decision making in carotid revascularization. (The SIBERIA Trial [Acculink™ Versus CGuard™]; NCT03488199).
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Affiliation(s)
- Andrey Karpenko
- Centre of Vascular and Hybrid Surgery, E.N. Meshalkin National Medical Research Center, Novosibirsk, Russia.
| | - Savr Bugurov
- Centre of Vascular and Hybrid Surgery, E.N. Meshalkin National Medical Research Center, Novosibirsk, Russia
| | - Pavel Ignatenko
- Centre of Vascular and Hybrid Surgery, E.N. Meshalkin National Medical Research Center, Novosibirsk, Russia
| | - Vladimir Starodubtsev
- Centre of Vascular and Hybrid Surgery, E.N. Meshalkin National Medical Research Center, Novosibirsk, Russia
| | - Irina Popova
- Centre of Vascular and Hybrid Surgery, E.N. Meshalkin National Medical Research Center, Novosibirsk, Russia
| | | | - Piotr Musialek
- Jagiellonian University, Department of Cardiac and Vascular Diseases, John Paul II Hospital, Krakow, Poland.
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Reiff T, Eckstein HH, Mansmann U, Jansen O, Fraedrich G, Mudra H, Böckler D, Böhm M, Brückmann H, Debus ES, Fiehler J, Mathias K, Ringelstein EB, Schmidli J, Stingele R, Zahn R, Zeller T, Niesen WD, Barlinn K, Binder A, Glahn J, Ringleb PA. Contralateral Stenosis and Echolucent Plaque Morphology are Associated with Elevated Stroke Risk in Patients Treated with Asymptomatic Carotid Artery Stenosis within a Controlled Clinical Trial (SPACE-2). J Stroke Cerebrovasc Dis 2021; 30:105940. [PMID: 34311420 DOI: 10.1016/j.jstrokecerebrovasdis.2021.105940] [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: 03/25/2021] [Revised: 05/30/2021] [Accepted: 06/01/2021] [Indexed: 10/20/2022] Open
Abstract
BACKGROUND Asymptomatic carotid artery stenosis (ACS) has a low risk of stroke. To achieve an advantage over noninterventional best medical treatment (BMT), carotid endarterectomy (CEA) or carotid artery stenting (CAS) must be performed with the lowest possible risk of stroke. Therefore, an analysis of risk-elevating factors is essential. Grade of ipsilateral and contralateral stenosis as well as plaque morphology are known risk factors in ACS. METHODS The randomized, controlled, multicenter SPACE-2 trial had to be stopped prematurely after recruiting 513 patients. 203 patients were randomized to CEA, 197 to CAS, and 113 to BMT. Within one year, risk factors such as grade of stenosis and plaque morphology were analyzed. RESULTS Grade of contralateral stenosis (GCS) was higher in patients with any stroke (50%ECST vs. 20%ECST; p=0.012). Echolucent plaque morphology was associated with any stroke on the day of intervention (OR 5.23; p=0.041). In the periprocedural period, any stroke was correlated with GCS in the CEA group (70%ECST vs. 20%ECST; p=0.026) and with echolucent plaque morphology in the CAS group (6% vs. 1%; p=0.048). In multivariate analysis, occlusion of the contralateral carotid artery (CCO) was associated with risk of any stroke (OR 7.00; p=0.006), without heterogeneity between CEA and CAS. CONCLUSION In patients with asymptomatic carotid artery stenosis, GCS, CCO, as well as echolucent plaque morphology were associated with a higher risk of cerebrovascular events. The risk of stroke in the periprocedural period was increased by GCS in CEA and by echolucent plaque in CAS. Due to small sample size, results must be interpreted carefully.
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Affiliation(s)
- Tilman Reiff
- Department of Neurology, University Hospital of Heidelberg, 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, München Klinik, Klinikum Neuperlach, Munich, Germany.
| | - Dittmar Böckler
- Department of Vascular and Endovascular Surgery, University Hospital of Heidelberg, Heidelberg, Germany.
| | - Michael Böhm
- Department of Internal Medicine, University Hospital of Homburg/Saar, Homburg, Germany.
| | - Hartmut Brückmann
- Department of Neuroradiology, Ludwig-Maximilians-Universität München, Munich, Germany.
| | - E Sebastian Debus
- Department of Vascular Surgery, University Hospital of Hamburg, Hamburg, Germany.
| | - Jens Fiehler
- Department of Neuroradiology, University Hospital of Hamburg, Hamburg, Germany.
| | - Klaus Mathias
- Department of Radiology, Klinikum Dortmund, Germany.
| | | | - Jürg Schmidli
- Department of Vascular Surgery, University Hospital of Bern, Bern, Switzerland.
| | - Robert Stingele
- Department of Neurology, DRK-Kliniken Berlin, Berlin, Germany.
| | - Ralf Zahn
- Department of Internal Medicine, Klinikum Ludwigshafen, Ludwigshafen, Germany.
| | - Thomas Zeller
- Department of Angiology, University Heart-Center Freiburg-Bad Krozingen, Bad Krozingen, Germany.
| | - Wolf-Dirk Niesen
- Department of Neurology, University Hospital Freiburg, Freiburg, Germany.
| | - Kristian Barlinn
- Department of Neurology, University Hospital of Dresden, Dresden, Germany.
| | - Andreas Binder
- Department of Neurology, UKSH Campus Kiel, Kiel, Germany.
| | - Jörg Glahn
- Department of Neurology, Johannes Wesling Klinikum, Minden, Germany.
| | - Peter Arthur Ringleb
- Department of Neurology, University Hospital of Heidelberg, Heidelberg, Germany.
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17
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Reiff T, Ringleb PA. [Asymptomatic carotid artery stenosis - treatment recommendations]. Dtsch Med Wochenschr 2021; 146:793-800. [PMID: 34130321 DOI: 10.1055/a-1221-7065] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
For the asymptomatic carotid stenosis, defined as an atherosclerotic carotid stenosis without neurological symptoms for more than 6 months, there are in contrast to a symptomatic carotid stenosis still no reliable treatment recommendations. Possible therapy recommendations based on current data are presented below.
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Ösken A, Akdeniz E, Keskin M, Öz A, Ipek G, Zehir R, Barutça H, Çam N, Şahin S. Estimated Glomerular Filtration Rate as a Predictor of Restenosis After Carotid Stenting Using First-Generation Stents. Angiology 2021; 72:762-769. [PMID: 33966501 DOI: 10.1177/00033197211014684] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
This study evaluated the impact of the baseline estimated glomerular filtration rate (eGFR) on clinical and angiographic outcomes and long-term in-stent restenosis (ISR) rates in patients undergoing elective carotid artery stenting (CAS) procedures. Consecutive patients who underwent CAS were retrospectively enrolled (n = 456). At the end of 3 years of follow-up, patients who had died or were lost follow-up were excluded from the study and a final analysis was performed using data from the remaining 405 patients. The study population (n = 405) was divided into 3 tertiles based on the tertile values of the eGFR level (T1, T2, and T3); then, clinical and procedural characteristics and 3-year ISR rates were compared between the groups. An ISR of 50% was detected in 49 (12%) surviving patients. The 3-year ISR was higher among patients with the lowest eGFR values (T1) by 3.7 times (95% CI: 2.01-11.38) than that among patients with the highest eGFR values (T3). These significant relationships persisted following adjustment for confounders. A lower baseline eGFR level was significantly associated with an increased ISR rate. Decreased renal function may be a predictor of ISR after CAS using first-generation stents.
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Affiliation(s)
- Altuğ Ösken
- Department of Cardiology, 111319Dr Siyami Ersek Thoracic and Cardiovascular Surgery Center, Training and Research Hospital, Istanbul, Turkey
| | - Evliya Akdeniz
- Department of Cardiology, 111319Dr Siyami Ersek Thoracic and Cardiovascular Surgery Center, Training and Research Hospital, Istanbul, Turkey.,Department of Cardiology, Başkent University Faculty of Medicine, Istanbul, Turkey
| | - Muhammed Keskin
- Department of Cardiology, 111319Dr Siyami Ersek Thoracic and Cardiovascular Surgery Center, Training and Research Hospital, Istanbul, Turkey.,Department of Cardiology, Abdulhamid Han Training and Research Hospital, Istanbul, Turkey
| | - Ahmet Öz
- Department of Cardiology, 111319Dr Siyami Ersek Thoracic and Cardiovascular Surgery Center, Training and Research Hospital, Istanbul, Turkey.,Department of Cardiology, Istanbul Training and Research Hospital, Istanbul, Turkey
| | - Göktürk Ipek
- Department of Cardiology, 111319Dr Siyami Ersek Thoracic and Cardiovascular Surgery Center, Training and Research Hospital, Istanbul, Turkey
| | - Regayip Zehir
- Department of Cardiology, 111319Dr Siyami Ersek Thoracic and Cardiovascular Surgery Center, Training and Research Hospital, Istanbul, Turkey.,Department of Cardiology, Kartal Koşuyolu Training and Research Hospital, Istanbul, Turkey
| | - Hakan Barutça
- Department of Radiology, 111319Dr Siyami Ersek Thoracic and Cardiovascular Surgery Center, Training and Research Hospital, Istanbul, Turkey
| | - Neşe Çam
- Department of Cardiology, 111319Dr Siyami Ersek Thoracic and Cardiovascular Surgery Center, Training and Research Hospital, Istanbul, Turkey
| | - Sinan Şahin
- Department of Radiology, 111319Dr Siyami Ersek Thoracic and Cardiovascular Surgery Center, Training and Research Hospital, Istanbul, Turkey
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19
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Transient flow reversal combined with sustained embolic prevention in transcervical revascularization of symptomatic and highly-emboligenic carotid stenoses for optimized endovascular lumen reconstruction and improved peri- and post-procedural outcomes. ADVANCES IN INTERVENTIONAL CARDIOLOGY 2020; 16:495-506. [PMID: 33598027 PMCID: PMC7863838 DOI: 10.5114/aic.2020.102134] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2020] [Accepted: 12/20/2020] [Indexed: 11/24/2022] Open
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20
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Mazurek A, Borratynska A, Malinowski KP, Brozda M, Gancarczyk U, Dluzniewska N, Czyz L, Duplicka M, Sobieraj E, Trystula M, Drazkiewicz T, Podolec P, Musialek P. MicroNET-covered stents for embolic prevention in patients undergoing carotid revascularisation: twelve-month outcomes from the PARADIGM study. EUROINTERVENTION 2020; 16:e950-e952. [PMID: 32482614 DOI: 10.4244/eij-d-19-01014] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Affiliation(s)
- Adam Mazurek
- Jagiellonian University, Department of Cardiac & Vascular Diseases, John Paul II Hospital, Krakow, Poland
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21
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Mazurek A, Bugurov S, Musialek P. Letter by Mazurek et al Regarding Article, "Short-Term Double Layer Mesh Stent Patency for Emergent or Elective Carotid Artery Stenting: A Single Center Experience". Stroke 2019; 50:e433-e434. [PMID: 31679500 DOI: 10.1161/strokeaha.119.027176] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Adam Mazurek
- Department of Cardiac and Vascular Diseases Jagiellonian University, John Paul II Hospital, Krakow, Poland
| | - Savr Bugurov
- Department of Vascular Surgery, E.N. Meshalkin Research Institute, Novosybirsk, Russia
| | - Piotr Musialek
- Department of Cardiac and Vascular Diseases, Jagiellonian University, John Paul II Hospital, Krakow, Poland
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