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Hahn M, Gröschel S, Othman A, Brockstedt L, Civelek A, Brockmann MA, Gröschel K, Uphaus T. Real world data in mechanical thrombectomy: who are we losing to follow-up? J Neurointerv Surg 2024; 16:471-477. [PMID: 37460214 PMCID: PMC11041564 DOI: 10.1136/jnis-2023-020435] [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: 04/17/2023] [Accepted: 06/07/2023] [Indexed: 04/25/2024]
Abstract
BACKGROUND Missing outcome data (MOD) is a common problem in clinical trials and registries, and a potential bias when drawing conclusions from these data. Identifying factors associated with MOD may help to increase follow-up rates and assess the need for imputation strategies. We investigated MOD in a multicenter, prospective registry study of mechanical thrombectomy (MT) in large vessel occlusion ischemic stroke. METHODS 13 082 patients enrolled in the German Stroke Registry-Endovascular Treatment from May 2015 to December 2021 were analyzed with regard to MOD (90 day modified Rankin Scale, mRS). Univariate logistic regression analyses identified factors unbalanced between patients with and without MOD. Subgroup analyses were performed to identify patients for whom increased efforts to perform clinical follow-up after hospital discharge are needed. RESULTS We identified 19.7% (2580/13 082) of patients with MOD at the 90 day follow-up. MOD was more common with higher pre-stroke disability (mRS 3-5, 32.2% vs mRS 0-2, 13.7%; P<0.001), absence of bridging intravenous thrombolysis, longer time to treatment, and in patients with high post-stroke disability at discharge (mRS 3-5 vs 0-2: OR 1.234 (95% CI 1.107 to 1.375); P<0.001). In contrast, MOD was less common with futile recanalization (thrombolysis in cerebral infarction (TICI) score of 0-2a, 12.4% vs TICI 2b-3, 15.0%; P=0.001). In patients discharged alive with well documented baseline characteristics, shorter hospital stay (OR 0.992 (95% CI 0.985 to 0.998); P=0.010) and discharge to institutional care or hospital (OR 1.754 (95% CI 1.558 to 1.976); P<0.001) were associated with MOD. CONCLUSION MOD in routine care MT registry data was not random. Increased efforts to perform clinical follow-up are needed, especially in the case of higher pre-stroke and post-stroke disability and discharge to hospital or institutional care. TRIAL REGISTRATION NCT03356392.
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Affiliation(s)
- Marianne Hahn
- Department of Neurology and Focus Program Translational Neuroscience (FTN), Rhine main Neuroscience Network (rmn2), University Medical Center of the Johannes Gutenberg University Mainz, Mainz, Germany
| | - Sonja Gröschel
- Department of Neurology and Focus Program Translational Neuroscience (FTN), Rhine main Neuroscience Network (rmn2), University Medical Center of the Johannes Gutenberg University Mainz, Mainz, Germany
| | - Ahmed Othman
- Department of Neuroradiology, University Medical Center of the Johannes Gutenberg University Mainz, Mainz, Germany
| | - Lavinia Brockstedt
- Department of Neuroradiology, University Medical Center of the Johannes Gutenberg University Mainz, Mainz, Germany
| | - Arda Civelek
- Department of Neurology and Focus Program Translational Neuroscience (FTN), Rhine main Neuroscience Network (rmn2), University Medical Center of the Johannes Gutenberg University Mainz, Mainz, Germany
| | - Marc A Brockmann
- Department of Neuroradiology, University Medical Center of the Johannes Gutenberg University Mainz, Mainz, Germany
| | - Klaus Gröschel
- Department of Neurology and Focus Program Translational Neuroscience (FTN), Rhine main Neuroscience Network (rmn2), University Medical Center of the Johannes Gutenberg University Mainz, Mainz, Germany
| | - Timo Uphaus
- Department of Neurology and Focus Program Translational Neuroscience (FTN), Rhine main Neuroscience Network (rmn2), University Medical Center of the Johannes Gutenberg University Mainz, Mainz, Germany
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Sheffet AJ, Howard G, Sam A, Jamil Z, Weaver F, Chiu D, Voeks JH, Howard VJ, Hughes SE, Flaxman L, Longbottom ME, Brott TG. Challenge and Yield of Enrolling Racially and Ethnically Diverse Patient Populations in Low Event Rate Clinical Trials. Stroke 2017; 49:84-89. [PMID: 29191852 DOI: 10.1161/strokeaha.117.018063] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2017] [Revised: 09/28/2017] [Accepted: 10/12/2017] [Indexed: 11/16/2022]
Abstract
BACKGROUND AND PURPOSE We report patient enrollment and retention by race and ethnicity in the CREST (Carotid Revascularization Endarterectomy Versus Stent Trial) and assess potential effect modification by race/ethnicity. In addition, we discuss the challenge of detecting differences in study outcomes when subgroups are small and the event rate is low. METHODS We compared 2502 patients by race, ethnicity, baseline characteristics, and primary outcome (any periprocedural stroke, death, or myocardial infarction and subsequent ipsilateral stroke up to 10 years). RESULTS Two hundred forty (9.7%) patients were minority by race (6.1%) or ethnicity (3.6%); 109 patients (4.4%) were black, 32 (1.3%) Asian, 2332 (93.4%) white, 11 (0.4%) other, and 18 (0.7%) unknown. Ninety (3.6%) were Hispanic, 2377 (95%) non-Hispanic, and 35 (1.4%) unknown. The rate of the primary end point for all patients was 10.9%±0.9% at 10 years and did not differ by race or ethnicity (Pinter>0.24). CONCLUSIONS The proportion of minorities recruited to CREST was below their representation in the general population, and retention of minority patients was lower than for whites. Primary outcomes did not differ by race or ethnicity. However, in CREST (like other studies), the lack of evidence of a racial/ethnic difference in the treatment effect should be interpreted with caution because of low statistical power to detect such a difference. CLINICAL TRIAL REGISTRATION URL: http://www.clinicaltrials.gov. Unique identifier: NCT00004732.
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Affiliation(s)
- Alice J Sheffet
- From the Department of Surgery, Rutgers, the State University of New Jersey, Newark (A.J.S., S.E.H., L.F., T.G.B.); Departments of Biostatistics (G.H.) and Epidemiology, School of Public Health (V.J.H.), University of Alabama at Birmingham; Division of Vascular Surgery, Southern Connecticut Vascular Center, Middletown Hospital (A.S.); Section of Vascular Surgery, St. Michael's Medical Center, Newark, NJ (Z.J.); Division of Vascular Surgery and Endovascular Therapy, Keck Medical Center, University of Southern California, Los Angeles (F.W.); Department of Neurology, Houston Methodist Neurological Institute, TX (D.C); Department of Neurology, Medical University of South Carolina, Charleston (J.H.V.); and Mayo Clinic Florida, Jacksonville (M.E.L., T.G.B.)
| | - George Howard
- From the Department of Surgery, Rutgers, the State University of New Jersey, Newark (A.J.S., S.E.H., L.F., T.G.B.); Departments of Biostatistics (G.H.) and Epidemiology, School of Public Health (V.J.H.), University of Alabama at Birmingham; Division of Vascular Surgery, Southern Connecticut Vascular Center, Middletown Hospital (A.S.); Section of Vascular Surgery, St. Michael's Medical Center, Newark, NJ (Z.J.); Division of Vascular Surgery and Endovascular Therapy, Keck Medical Center, University of Southern California, Los Angeles (F.W.); Department of Neurology, Houston Methodist Neurological Institute, TX (D.C); Department of Neurology, Medical University of South Carolina, Charleston (J.H.V.); and Mayo Clinic Florida, Jacksonville (M.E.L., T.G.B.)
| | - Albert Sam
- From the Department of Surgery, Rutgers, the State University of New Jersey, Newark (A.J.S., S.E.H., L.F., T.G.B.); Departments of Biostatistics (G.H.) and Epidemiology, School of Public Health (V.J.H.), University of Alabama at Birmingham; Division of Vascular Surgery, Southern Connecticut Vascular Center, Middletown Hospital (A.S.); Section of Vascular Surgery, St. Michael's Medical Center, Newark, NJ (Z.J.); Division of Vascular Surgery and Endovascular Therapy, Keck Medical Center, University of Southern California, Los Angeles (F.W.); Department of Neurology, Houston Methodist Neurological Institute, TX (D.C); Department of Neurology, Medical University of South Carolina, Charleston (J.H.V.); and Mayo Clinic Florida, Jacksonville (M.E.L., T.G.B.)
| | - Zafar Jamil
- From the Department of Surgery, Rutgers, the State University of New Jersey, Newark (A.J.S., S.E.H., L.F., T.G.B.); Departments of Biostatistics (G.H.) and Epidemiology, School of Public Health (V.J.H.), University of Alabama at Birmingham; Division of Vascular Surgery, Southern Connecticut Vascular Center, Middletown Hospital (A.S.); Section of Vascular Surgery, St. Michael's Medical Center, Newark, NJ (Z.J.); Division of Vascular Surgery and Endovascular Therapy, Keck Medical Center, University of Southern California, Los Angeles (F.W.); Department of Neurology, Houston Methodist Neurological Institute, TX (D.C); Department of Neurology, Medical University of South Carolina, Charleston (J.H.V.); and Mayo Clinic Florida, Jacksonville (M.E.L., T.G.B.)
| | - Fred Weaver
- From the Department of Surgery, Rutgers, the State University of New Jersey, Newark (A.J.S., S.E.H., L.F., T.G.B.); Departments of Biostatistics (G.H.) and Epidemiology, School of Public Health (V.J.H.), University of Alabama at Birmingham; Division of Vascular Surgery, Southern Connecticut Vascular Center, Middletown Hospital (A.S.); Section of Vascular Surgery, St. Michael's Medical Center, Newark, NJ (Z.J.); Division of Vascular Surgery and Endovascular Therapy, Keck Medical Center, University of Southern California, Los Angeles (F.W.); Department of Neurology, Houston Methodist Neurological Institute, TX (D.C); Department of Neurology, Medical University of South Carolina, Charleston (J.H.V.); and Mayo Clinic Florida, Jacksonville (M.E.L., T.G.B.)
| | - David Chiu
- From the Department of Surgery, Rutgers, the State University of New Jersey, Newark (A.J.S., S.E.H., L.F., T.G.B.); Departments of Biostatistics (G.H.) and Epidemiology, School of Public Health (V.J.H.), University of Alabama at Birmingham; Division of Vascular Surgery, Southern Connecticut Vascular Center, Middletown Hospital (A.S.); Section of Vascular Surgery, St. Michael's Medical Center, Newark, NJ (Z.J.); Division of Vascular Surgery and Endovascular Therapy, Keck Medical Center, University of Southern California, Los Angeles (F.W.); Department of Neurology, Houston Methodist Neurological Institute, TX (D.C); Department of Neurology, Medical University of South Carolina, Charleston (J.H.V.); and Mayo Clinic Florida, Jacksonville (M.E.L., T.G.B.)
| | - Jenifer H Voeks
- From the Department of Surgery, Rutgers, the State University of New Jersey, Newark (A.J.S., S.E.H., L.F., T.G.B.); Departments of Biostatistics (G.H.) and Epidemiology, School of Public Health (V.J.H.), University of Alabama at Birmingham; Division of Vascular Surgery, Southern Connecticut Vascular Center, Middletown Hospital (A.S.); Section of Vascular Surgery, St. Michael's Medical Center, Newark, NJ (Z.J.); Division of Vascular Surgery and Endovascular Therapy, Keck Medical Center, University of Southern California, Los Angeles (F.W.); Department of Neurology, Houston Methodist Neurological Institute, TX (D.C); Department of Neurology, Medical University of South Carolina, Charleston (J.H.V.); and Mayo Clinic Florida, Jacksonville (M.E.L., T.G.B.)
| | - Virginia J Howard
- From the Department of Surgery, Rutgers, the State University of New Jersey, Newark (A.J.S., S.E.H., L.F., T.G.B.); Departments of Biostatistics (G.H.) and Epidemiology, School of Public Health (V.J.H.), University of Alabama at Birmingham; Division of Vascular Surgery, Southern Connecticut Vascular Center, Middletown Hospital (A.S.); Section of Vascular Surgery, St. Michael's Medical Center, Newark, NJ (Z.J.); Division of Vascular Surgery and Endovascular Therapy, Keck Medical Center, University of Southern California, Los Angeles (F.W.); Department of Neurology, Houston Methodist Neurological Institute, TX (D.C); Department of Neurology, Medical University of South Carolina, Charleston (J.H.V.); and Mayo Clinic Florida, Jacksonville (M.E.L., T.G.B.)
| | - Susan E Hughes
- From the Department of Surgery, Rutgers, the State University of New Jersey, Newark (A.J.S., S.E.H., L.F., T.G.B.); Departments of Biostatistics (G.H.) and Epidemiology, School of Public Health (V.J.H.), University of Alabama at Birmingham; Division of Vascular Surgery, Southern Connecticut Vascular Center, Middletown Hospital (A.S.); Section of Vascular Surgery, St. Michael's Medical Center, Newark, NJ (Z.J.); Division of Vascular Surgery and Endovascular Therapy, Keck Medical Center, University of Southern California, Los Angeles (F.W.); Department of Neurology, Houston Methodist Neurological Institute, TX (D.C); Department of Neurology, Medical University of South Carolina, Charleston (J.H.V.); and Mayo Clinic Florida, Jacksonville (M.E.L., T.G.B.)
| | - Linda Flaxman
- From the Department of Surgery, Rutgers, the State University of New Jersey, Newark (A.J.S., S.E.H., L.F., T.G.B.); Departments of Biostatistics (G.H.) and Epidemiology, School of Public Health (V.J.H.), University of Alabama at Birmingham; Division of Vascular Surgery, Southern Connecticut Vascular Center, Middletown Hospital (A.S.); Section of Vascular Surgery, St. Michael's Medical Center, Newark, NJ (Z.J.); Division of Vascular Surgery and Endovascular Therapy, Keck Medical Center, University of Southern California, Los Angeles (F.W.); Department of Neurology, Houston Methodist Neurological Institute, TX (D.C); Department of Neurology, Medical University of South Carolina, Charleston (J.H.V.); and Mayo Clinic Florida, Jacksonville (M.E.L., T.G.B.)
| | - Mary E Longbottom
- From the Department of Surgery, Rutgers, the State University of New Jersey, Newark (A.J.S., S.E.H., L.F., T.G.B.); Departments of Biostatistics (G.H.) and Epidemiology, School of Public Health (V.J.H.), University of Alabama at Birmingham; Division of Vascular Surgery, Southern Connecticut Vascular Center, Middletown Hospital (A.S.); Section of Vascular Surgery, St. Michael's Medical Center, Newark, NJ (Z.J.); Division of Vascular Surgery and Endovascular Therapy, Keck Medical Center, University of Southern California, Los Angeles (F.W.); Department of Neurology, Houston Methodist Neurological Institute, TX (D.C); Department of Neurology, Medical University of South Carolina, Charleston (J.H.V.); and Mayo Clinic Florida, Jacksonville (M.E.L., T.G.B.)
| | - Thomas G Brott
- From the Department of Surgery, Rutgers, the State University of New Jersey, Newark (A.J.S., S.E.H., L.F., T.G.B.); Departments of Biostatistics (G.H.) and Epidemiology, School of Public Health (V.J.H.), University of Alabama at Birmingham; Division of Vascular Surgery, Southern Connecticut Vascular Center, Middletown Hospital (A.S.); Section of Vascular Surgery, St. Michael's Medical Center, Newark, NJ (Z.J.); Division of Vascular Surgery and Endovascular Therapy, Keck Medical Center, University of Southern California, Los Angeles (F.W.); Department of Neurology, Houston Methodist Neurological Institute, TX (D.C); Department of Neurology, Medical University of South Carolina, Charleston (J.H.V.); and Mayo Clinic Florida, Jacksonville (M.E.L., T.G.B.).
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Kakkos SK, Kakisis I, Tsolakis IA, Geroulakos G. Endarterectomy achieves lower stroke and death rates compared with stenting in patients with asymptomatic carotid stenosis. J Vasc Surg 2017; 66:607-617. [PMID: 28735954 DOI: 10.1016/j.jvs.2017.04.053] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2016] [Accepted: 04/10/2017] [Indexed: 11/28/2022]
Abstract
BACKGROUND It is currently unclear if carotid artery stenting (CAS) is as safe as carotid endarterectomy (CEA) for patients with significant asymptomatic stenosis. The aim of our study was to perform a systematic review and meta-analysis of trials comparing CAS with CEA. METHODS On March 17, 2017, a search for randomized controlled trials was performed in MEDLINE and Scopus databases with no time limits. We performed meta-analyses with Peto odds ratios (ORs) and 95% confidence intervals (CIs). Quality of evidence was assessed with the Grading of Recommendations Assessment, Development, and Evaluation method. The primary safety and efficacy outcome measures were stroke or death rate at 30 days and ipsilateral stroke at 1 year (including ipsilateral stroke and death rate at 30 days), respectively. Perioperative stroke, ipsilateral stroke, myocardial infarction (MI), and cranial nerve injury (CNI) were all secondary outcome measures. RESULTS The systematic review of the literature identified nine randomized controlled trials reporting on 3709 patients allocated into CEA (n = 1479) or CAS (n = 2230). Stroke or death rate at 30 days was significantly higher for CAS (64/2176 [2.94%]) compared with CEA (27/1431 [1.89%]; OR, 1.57; 95% CI, 1.01-2.44; P = .044), with low level of heterogeneity beyond chance (I2 = 0%). Also, stroke rate at 30 days was significantly higher for CAS (63/2176 [2.90%]) than for CEA (26/1431 [1.82%]; OR, 1.63; 95% CI, 1.04-2.54; P = .032; I2 = 0%). MI at 30 days was nonsignificantly lower for CAS (12/1815 [0.66%]) compared with CEA (16/1070 [1.50%]; OR, 0.53; 95% CI, 0.24-1.14; P = .105; I2 = 0%); however, CNI at 30 days was significantly lower for CAS (2/1794 [0.11%]) than for CEA (33/1061 [3.21%]; OR, 0.13; 95% CI, 0.07-0.26; P < .00001; I2 = 0%). Regarding the long-term outcome of stroke or death rate at 30 days plus ipsilateral stroke during follow-up, this was significantly higher for CAS (79/2173 [3.64%]) than for CEA (35/1430 [2.45%]; OR, 1.51; 95% CI, 1.02-2.24; P = .04; I2 = 0%). Quality of evidence for all stroke outcomes was graded moderate. CONCLUSIONS Among patients with asymptomatic stenosis undergoing carotid intervention, there is moderate-quality evidence to suggest that CEA had significantly lower 30-day stroke and also stroke or death rates compared with CAS at the cost of higher CNI and nonsignificantly higher MI rates. The long-term efficacy of CEA in ipsilateral stroke prevention, taking into account perioperative stroke and death, was preserved during follow-up. There is an urgent need for high-quality research before a firm recommendation is made that CAS is inferior or not to CEA.
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Affiliation(s)
- Stavros K Kakkos
- Department of Vascular Surgery, University of Patras Medical School, Patras, Greece; Department of Surgery and Cancer, Imperial College London, London, United Kingdom.
| | - Ioannis Kakisis
- National and Kapodistrian University of Athens, Athens, Greece
| | - Ioannis A Tsolakis
- Department of Vascular Surgery, University of Patras Medical School, Patras, Greece
| | - George Geroulakos
- Department of Surgery and Cancer, Imperial College London, London, United Kingdom; National and Kapodistrian University of Athens, Athens, Greece
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