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Erben Y, Li Y, Da Rocha-Franco JA, Tawk RG, Barrett KM, Freeman WD, Lin M, Huang JF, Miller D, Farres H, Brott TG, Meschia JF, Hakaim AG. Asymptomatic Females Are at Higher Risk for Perioperative TIA/Stroke and Males Are at Higher Risk for Long-Term Mortality after Carotid Artery Stenting: A Vascular Quality Initiative Analysis. Int J Angiol 2024; 33:36-45. [PMID: 38352638 PMCID: PMC10861297 DOI: 10.1055/s-0040-1712506] [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: 10/23/2022] Open
Abstract
The study aims to review the sex differences with respect to transient ischemic attack (TIA)/stroke and death in the perioperative period and on long-term follow-up among asymptomatic patients treated with carotid stenting (CAS) in the vascular quality initiative (VQI). All cases reported to VQI of asymptomatic CAS (ACAS) patients were reviewed. The primary end point was risk of TIA/stroke and death in the in-hospital perioperative period and in the long-term follow-up. The secondary end point was to evaluate predictors of in-hospital perioperative TIA/stroke and mortality on long-term follow-up after CAS. There were 22,079 CAS procedures captured from January 2005 to April 2019. There were 5,785 (62.7%) patients in the ACAS group. The rate of in-hospital TIA/stroke was higher in female patients (2.7 vs. 1.87%, p = 0.005) and the rate of death was not significant (0.03 vs. 0.07%, p = 0.66). On multivariable logistic regression analysis, prior/current smoking history (odds ratio = 0.58 [95% confidence interval or CI = 0.39-0.87]; p = 0.008) is a predictor of in-hospital TIA/stroke in females. The long-term all-cause mortality is significantly higher in male patients (26.9 vs. 15.7%, p < 0.001). On multivariable Cox-regression analysis, prior/current smoking history (hazard ratio or HR = 1.17 [95% CI = 1.01-1.34]; p = 0.03), coronary artery disease or CAD (HR = 1.15 [95% CI = 1.03-1.28]; p = 0.009), chronic obstructive pulmonary disease or COPD (HR = 1.73 [95% CI = 1.55-1.93]; p < 0.001), threat to life American Society of Anesthesiologists (ASA) class (HR = 2.3 [95% CI = 1.43-3.70]; p = 0.0006), moribund ASA class (HR = 5.66 [95% CI = 2.24-14.29]; p = 0.0003), and low hemoglobin levels (HR = 0.84 [95% CI = 0.82-0.86]; p < 0.001) are the predictors of long-term mortality. In asymptomatic carotid disease patients, women had higher rates of in-hospital perioperative TIA/stroke and a predictor of TIA/stroke is a prior/current history of smoking. Meanwhile, long-term all-cause mortality is higher for male patients compared with their female counterparts. Predictors of long-term mortality are prior/current smoking history, CAD, COPD, higher ASA classification of physical status, and low hemoglobin level. These data should be considered prior to offering CAS to asymptomatic female and male patients and careful risks versus benefits discussion should be offered to each individual patient.
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Affiliation(s)
- Young Erben
- Division of Vascular and Endovascular Surgery, Mayo Clinic, Jacksonville, Florida
| | - Yupeng Li
- Department of Political Science and Economics, Rowan University, Glassboro, New Jersey
| | | | - Rabih G. Tawk
- Department of Neurologic Surgery, Mayo Clinic, Jacksonville, Florida
| | | | - William D. Freeman
- Department of Neurologic Surgery, Mayo Clinic, Jacksonville, Florida
- Department of Neurology, Mayo Clinic, Jacksonville, Florida
| | - Michelle Lin
- Department of Neurology, Mayo Clinic, Jacksonville, Florida
| | | | - David Miller
- Department of Radiology, Mayo Clinic, Jacksonville, Florida
| | - Houssam Farres
- Division of Vascular and Endovascular Surgery, Mayo Clinic, Jacksonville, Florida
| | | | | | - Albert G. Hakaim
- Division of Vascular and Endovascular Surgery, Mayo Clinic, Jacksonville, Florida
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Venermo M, Mani K, Boyle JR, Eldrup N, Setacci C, Jonsson M, Menyhei G, Beiles B, Lattmann T, Cassar K, Altreuther M, Thomson I, Settembre N, Laxdal E, Behrendt CA, deBorst GJ. Editor's Choice - Sex Related Differences in Indication and Procedural Outcomes of Carotid interventions in VASCUNET. Eur J Vasc Endovasc Surg 2023; 66:7-14. [PMID: 37105268 DOI: 10.1016/j.ejvs.2023.04.022] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2022] [Revised: 03/01/2023] [Accepted: 04/19/2023] [Indexed: 04/29/2023]
Abstract
OBJECTIVE It has been suggested that peri-operative complications after carotid surgery may be higher in women than in men. This assumption may affect the treatment patterns, and it is thus possible that carotid endarterectomy (CEA) is provided to women less often. The aim of the current VASCUNET study was to determine sex related differences in operative risk in routine clinical practice among non-selected patients undergoing carotid revascularisation. METHODS Data on CEA and carotid artery stenting (CAS) from 14 vascular registries were collected and amalgamated. Comprehensive data were available for 223 626 carotid artery procedures; these were analysed overall and by country. The primary outcome was any stroke and or death within 30 days of carotid revascularisation. Secondary outcomes were stroke, death, or any major cardiac event or haemorrhage leading to re-operation. RESULTS Of the procedures, 34.8% were done in women. The proportion of CEA for asymptomatic stenosis compared with symptomatic stenosis was significantly higher among women than men (38.4% vs. 36.9%, p < .001). The proportion of octogenarians was higher among women than men who underwent CEA in both asymptomatic (21.2% vs. 19.9%) and symptomatic patients (24.3% vs. 21.4%). In the unadjusted analysis of symptomatic and asymptomatic patients, there were no significant differences between men and women in the rate of post-operative combined stroke and or death, any major cardiac event, or combined death, stroke, and any major cardiac event after CEA. Also, after stenting for asymptomatic or symptomatic carotid stenosis, there were no significant differences between men and women in the rate of post-operative complications. In adjusted analyses, sex was not significantly associated with any of the end points. Higher age and CAS vs. CEA were independently associated with all four end points. CONCLUSION This study confirmed that, in a large registry among non-selected patients, no significant sex related differences were found in peri-operative complication rates after interventions for carotid stenosis.
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Affiliation(s)
- Maarit Venermo
- Department of Vascular Surgery, University of Helsinki and Helsinki University Hospital, Helsinki, Finland.
| | - Kevin Mani
- Department of Surgical Sciences, Uppsala University, Sweden
| | - Jonathan R Boyle
- Division of Vascular and Endovascular Surgery, Addenbrooke's Hospital, Cambridge University Hospital Trust, Cambridge, UK
| | - Nikolaj Eldrup
- Department of Vascular Surgery, Rigshospitalet, Copenhagen
| | | | - Magnus Jonsson
- Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden, and Department of Vascular Surgery, Karolinska University Hospital, Stockholm, Sweden
| | - Gabor Menyhei
- Department of Vascular Surgery, Pecs University Medical Centre, Pecs, Hungary
| | - Barry Beiles
- Australasian Vascular Audit, Australasian Society for Vascular Surgery, Melbourne, Australia
| | - Thomas Lattmann
- Clinic of Vascular Surgery, Cantonal Hospital, Winterthur, Switzerland
| | - Kevin Cassar
- Department of Surgery, Faculty of Medicine and Surgery, University of Malta
| | - Martin Altreuther
- Department of Vascular Surgery, St Olavs Hospital, Trondheim, Norway
| | - Ian Thomson
- Department of Surgical Sciences, Otago University, Dunedin, New Zealand
| | - Nicla Settembre
- CHRU-Nancy, Inserm 1116, Virtual Hospital of Lorraine, University of Lorraine, Nancy, France
| | - Elin Laxdal
- Department of Vascular Surgery, Landspitalinn University Hospital, Reykjavik, Iceland
| | - Christian-Alexander Behrendt
- Department of Vascular and Endovascular Surgery, Asklepios Clinic Wandsbek, Asklepios Medical School, Hamburg, Germany
| | - Gert J deBorst
- Department of Vascular Surgery G04.129, University Medical Centre Utrecht, The Netherlands
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Nantakool S, Chuatrakoon B, Orrapin S, Leung R, Howard DPJ, Rerkasem A, Derraik JGB, Rerkasem K. Influences of age and gender on operative risks following carotid endarterectomy: A systematic review and meta-analysis. PLoS One 2023; 18:e0285540. [PMID: 37163559 PMCID: PMC10171679 DOI: 10.1371/journal.pone.0285540] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2022] [Accepted: 04/25/2023] [Indexed: 05/12/2023] Open
Abstract
OBJECTIVES This review aims to undertake a comprehensive review of the literature and investigate associations of age and gender on 30 days post carotid endarterectomy (CEA) and up to 5 years post CEA stroke, death, and combined stroke and death. DESIGN A systematic review and meta-analysis. METHODS Three main electronic databases including the Cochrane Library, MEDLINE, and Embase were searched from their inception to July 2022. Studies examining operative risks (i.e., stroke, death, and combined stroke and death following CEA) linked to age or gender were included. Two independent reviewers were responsible for study selection, quality assessment, and data extraction. Odds ratio (OR) and 95% confidence interval (CI) of all outcomes were calculated. RESULTS 44609 studies were retrieved from the search. There were 127 eligible studies (80 studies of age, 72 studies of gender, 25 studies of age and gender) for pooling in the meta-analysis. With regards to stroke and death risks within 30 days post CEA; patients aged ≥75 had higher death (OR 1.38; 95% CI 1.10-1.75) than patients aged <75. Patients aged ≥80 had higher stroke risk (OR 1.17; 95% CI 1.07-1.27) and death risk (OR 1.85; 95% CI 1.48-2.30) particular in asymptomatic patients (OR 2.4; 95% CI 1.56-3.81). Pooled effect estimates by gender, at 30 days post CEA, showed that female was associated with increased risk of stroke (OR 1.28; 95% CI 1.16-1.40), with more risk in asymptomatic female patients (OR 1.51; 95% CI 1.14-1.99). CONCLUSIONS This meta-analysis highlights that older people is associated with increased stroke risk, particularly asymptomatic octogenarians who had higher likelihood of death within 30 days post CEA. In addition, female especially those with asymptomatic carotid stenosis had greater likelihood of stroke within 30 days post CEA surgery.
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Affiliation(s)
- Sothida Nantakool
- Research Institute for Health Sciences, Environmental-Occupational Health Sciences and Non Communicable Diseases Research Group (EOHS and NCD Research Group), Chiang Mai University, Chiang Mai, Thailand
| | - Busaba Chuatrakoon
- Faculty of Associated Medical Sciences, Department of Physical Therapy, Chiang Mai University, Chiang Mai, Thailand
| | - Saritphat Orrapin
- Faculty of Medicine, Department of Surgery, Division of Vascular Surgery, Thammasat University (Rangsit Campus), Pathum Thani, Thailand
| | - Rachel Leung
- Nuffield Department of Clinical Neurosciences, Centre for Prevention of Stroke and Dementia, University of Oxford, Oxford, United Kingdom
| | - Dominic P J Howard
- Nuffield Department of Clinical Neurosciences, Centre for Prevention of Stroke and Dementia, University of Oxford, Oxford, United Kingdom
| | - Amaraporn Rerkasem
- Research Institute for Health Sciences, Environmental-Occupational Health Sciences and Non Communicable Diseases Research Group (EOHS and NCD Research Group), Chiang Mai University, Chiang Mai, Thailand
| | - José G B Derraik
- Research Institute for Health Sciences, Environmental-Occupational Health Sciences and Non Communicable Diseases Research Group (EOHS and NCD Research Group), Chiang Mai University, Chiang Mai, Thailand
- Liggins Institute, University of Auckland, Auckland, New Zealand
- Department of Women's and Children's Health, Uppsala University, Uppsala, Sweden
- Faculty of Medical and Health Sciences, Department of Paediatrics, Child and Youth Health, University of Auckland, Auckland, New Zealand
| | - Kittipan Rerkasem
- Research Institute for Health Sciences, Environmental-Occupational Health Sciences and Non Communicable Diseases Research Group (EOHS and NCD Research Group), Chiang Mai University, Chiang Mai, Thailand
- Faculty of Medicine, Department of Surgery, Chiang Mai University, Chiang Mai, Thailand
- Faculty of Medicine, Clinical Surgical Research Center, Chiang Mai University, Chiang Mai, Thailand
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Carcel C, Caso V, Aguiar de Sousa D, Sandset EC. Sex differences in neurovascular disorders. INTERNATIONAL REVIEW OF NEUROBIOLOGY 2022; 164:69-99. [PMID: 36038210 DOI: 10.1016/bs.irn.2022.07.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/15/2023]
Abstract
Neurovascular disorders is a heterogenous group of diseases, including one of the most time critical disorders in emergency medicine; stroke. Sex differences are extensively described in neurovascular disorders, ranging from differences in symptom presentation, risk factors, treatment and outcomes. For example, women with stroke, more often present with generalized weakness, reduced consciousness and headache than men. Furthermore, there are differences in risk factors, outcomes and in the effect of secondary prevention. Women have a higher risk of cerebral venous thrombosis and developing cerebral aneurysms. In general, women have been underrepresented in trials on neurovascular disorders. This chapter provides an extensive overview of sex differences in stroke in general and in the differences specially seen in ischemic stroke, intracerebral hemorrhage, subarachnoid hemorrhage and in cerebral venous thrombosis.
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Affiliation(s)
- Cheryl Carcel
- The George Institute for Global Health, Faculty of Medicine, University of New South Wales, Sydney, NSW, Australia; Sydney School of Public Health, Sydney Medical School, The University of Sydney, Sydney, NSW, Australia
| | - Valeria Caso
- Stroke Unit, Santa Maria della Misericordia Hospital University of Perugia, Perugia, Italy
| | - Diana Aguiar de Sousa
- Stroke Center, Lisbon Central University Hospital, Lisbon, Portugal; CEEM and Institute of Anatomy, Faculty of Medicine, University of Lisbon, Lisbon, Portugal
| | - Else Charlotte Sandset
- Department of Neurology, Oslo University Hospital, Oslo, Norway; The Norwegian Air Ambulance Foundation, Oslo, Norway.
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Deery SE, Holscher CM, Nejim B, Zettervall SL, Aranson NJ, Zarkowsky DS, Abularrage CJ, Hicks CW. In-hospital and one-year outcomes are similar for women and men following transcarotid artery revascularization in symptomatic and asymptomatic patients. J Vasc Surg 2022; 75:572-580.e3. [PMID: 34560217 PMCID: PMC8792188 DOI: 10.1016/j.jvs.2021.08.081] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2021] [Accepted: 08/21/2021] [Indexed: 02/03/2023]
Abstract
OBJECTIVE In randomized controlled trials and retrospective series, women have higher rates of periprocedural stroke and death following carotid endarterectomy and transfemoral carotid artery stenting compared with men. We sought to compare outcomes by sex following transcarotid artery revascularization (TCAR) among patients in the Vascular Quality Initiative (VQI). METHODS We reviewed all patients in the VQI who underwent TCAR from 2017 to 2020. We stratified the analysis by symptom status. The primary outcome was in-hospital stroke/death, and secondary outcomes were in-hospital stroke and death and 1-year stroke/death, stroke, and death. We used multivariable logistic and Cox regression models to assess the association of sex with in-hospital and 1-year outcomes after adjusting for preoperative and intraoperative characteristics. RESULTS We identified 15,851 patients who underwent TCAR, of whom 7391 (47%) were symptomatic (2708 or 37% female) and 8460 (53%) were asymptomatic (3097 or 37% female). Women were less frequently considered anatomic high risk than men in both groups (symptomatic: 43% vs 46%; P = .004; asymptomatic: 44% vs 48%; P = .004). Among symptomatic patients, women more often had severe ≥70% stenosis (89% vs 87%; P = .02). There were no differences in in-hospital death, stroke, or stroke/death for women vs men following TCAR among symptomatic or asymptomatic patients (all P > .05). After adjusting for baseline differences between groups, female sex was not associated with in-hospital stroke/death in either symptomatic (odds ratio, 1.05; 95% confidence interval, 0.72-1.56) or asymptomatic (odds ratio, 0.93; 95% confidence interval, 0.53-1.63) patients undergoing TCAR. There were also no differences in 1-year stroke, death, or stroke/death risk for women compared with men with and without symptoms on unadjusted or adjusted analyses (P > .05). CONCLUSIONS We found no sex differences in in-hospital or 1-year stroke/death following TCAR, regardless of symptom status. TCAR appears to be as safe of a surgical procedure for women as for men in patients with both symptomatic and asymptomatic carotid artery disease.
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Affiliation(s)
- Sarah E Deery
- Division of Vascular Surgery and Endovascular Therapy, Johns Hopkins University School of Medicine, Baltimore, Md; Division of Vascular and Endovascular Therapy, Maine Medical Center, Portland, Me
| | - Courtenay M Holscher
- Division of Vascular Surgery and Endovascular Therapy, Johns Hopkins University School of Medicine, Baltimore, Md
| | - Besma Nejim
- Division of Vascular Surgery, Penn State Health Milton S. Hershey Medical Center, Hershey, Pa
| | - Sara L Zettervall
- Division of Vascular Surgery, University of Washington School of Medicine, Seattle, Wash
| | - Nathan J Aranson
- Division of Vascular and Endovascular Therapy, Maine Medical Center, Portland, Me
| | - Devin S Zarkowsky
- Division of Vascular Surgery and Endovascular Therapy, University of Colorado School of Medicine, Aurora, Colo
| | - Christopher J Abularrage
- Division of Vascular Surgery and Endovascular Therapy, Johns Hopkins University School of Medicine, Baltimore, Md
| | - Caitlin W Hicks
- Division of Vascular Surgery and Endovascular Therapy, Johns Hopkins University School of Medicine, Baltimore, Md.
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Abstract
The goal of the current review is to examine the hazards and benefits of carotid interventions in women and to provide recommendations for the indications for carotid intervention in female patients. Stroke and cerebrovascular disease are prevalent in women. There are inherent biological and other differences in men and women, which affect the manifestations and outcome of stroke, with women experiencing worse disability and higher mortality following ischemic stroke than men. Due to the underrepresentation of female patients in most clinical trials, the ability to make firm but alternative recommendations for women specifically on the management of carotid stenosis is challenging. Although some data suggest that women might have worse periprocedural outcomes as compared to men following all carotid revascularization procedures, there is also an abundance of data to support a similar risk for carotid procedures in men and women, especially with carotid endarterectomy and transcarotid artery revascularization. Therefore, the indications for carotid revascularization are the same in women as they are in men. The choice of a carotid revascularization procedure in women is based upon the same factors as in men and requires careful evaluation of a particular patient's risk profile, anatomic criteria, plaque morphology, and medical comorbidities that might favor one technique over the other. When performing carotid revascularization procedures in women, tailored techniques and procedures to address the small diameter of the female artery are warranted.
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Affiliation(s)
- Caron Rockman
- Division of Vascular Surgery, NYU Grossman School of Medicine, New York, NY (C.R.)
| | - Valeria Caso
- Department of Cardiovascular Medicine, Santa Maria Della Misericordia Hospital, University of Perugia, Italy (V.C.)
| | - Peter A Schneider
- Division of Vascular and Endovascular Surgery, University of California San Francisco (P.A.S.)
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7
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Cui CL, Zarrintan S, Marmor RA, Nichols J, Cajas-Monson L, Malas M. Performance of Carotid Revascularization Procedures as Modified by Sex. Ann Vasc Surg 2021; 81:171-182. [PMID: 34752853 DOI: 10.1016/j.avsg.2021.08.051] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2021] [Revised: 08/27/2021] [Accepted: 08/31/2021] [Indexed: 11/25/2022]
Abstract
BACKGROUND Current recommendations on carotid revascularization postulate that women have both increased perioperative risks, such as stroke and death, as well as reduced benefit from intervention. These recommendations do not include data on transcarotid artery revascularization (TCAR). This study strives to compare safety and benefits of TCAR, TFCAS (Transfemoral Carotid Artery Stenting), and CEA (Carotid Endarterectomy) with regard to patient sex. METHODS We performed retrospective analysis of the Society for Vascular Surgery (SVS) Vascular Quality Initiative (VQI) CEA and stenting registries, as well as TCAR Surveillance Project data. We compared outcomes after TCAR, TFCAS, and CEA based on sex. The primary outcome was the rate of in-hospital stroke or death. Secondary outcomes included in-hospital stroke, death, transient ischemic attack (TIA), myocardial infarction (MI), stroke/death/MI, stroke/TIA, and recurrent ipsilateral stroke and/or death at 1-year of follow-up. RESULTS A total of 75,538 patients were included, of which 28,960 (38.3%) were female and 46,578 (61.7%) were male. TFCAS females had more than 2 times higher odds of stroke/death (OR:2.85, 95%CI: 2.21-3.67, P < 0.001) and stroke/death/MI (OR:2.23, 95%CI:1.75-2.83, P < 0.001) when compared to CEA females. Odds of TIA were also higher in both TFCAS females (OR:2.01, 95%CI:1.19-3.42, P = 0.010) and TCAR females (OR:1.91, 95%CI:1.09-3.35, P = .023) when compared to CEA females. However, only TFCAS females experienced increased odds of stroke/TIA (OR:1.96, 95%CI:1.45-2.65, P < 0.001) when compared to CEA females. TFCAS males had almost twice the odds of stroke/death (OR:1.74, 95%CI:1.39-2.16, P < 0.001) and 44% higher odds of stroke/death/MI (OR:1.44, 95%CI:1.19-1.75, P < 0.001), and more than 3-times increased odds of death (OR:3.45, 95%CI:2.53-4.71, P < 0.001) when compared to CEA males. Odds of in-hospital stroke were comparable between TFCAS and CEA after adjusting for covariates. TCAR males have half the odds of MI when compared to CEA males (OR:0.52, 95%CI:0.34-0.80, P = 0.003). At 1-year TCAR had comparable risk of stroke/death while TFCAS had increased risk of stroke/death when compared to CEA among both males and females. CONCLUSION TCAR performed similarly to CEA in both sexes regardless of symptomatic status. Stroke/death and stroke/death/MI rates were similar in symptomatic and asymptomatic males and females treated by CEA or TCAR. The 1-year outcomes of TCAR were also comparable to CEA in both sexes. It seems that TCAR may be a safe alternative to CEA particularly in women when surgical risk prohibits CEA and while TFCAS is associated with substantial adverse outcomes.
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Ansuategui M, Ibarra G, Romero C, Comanges A, Gonzalez-Fajardo JA. Carotid artery stenting has similar outcomes in men and women. J Vasc Bras 2021; 20:e20200169. [PMID: 34104132 PMCID: PMC8166161 DOI: 10.1590/1677-5449.200169] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
Background The aim of carotid interventions is to prevent cerebrovascular events. Endovascular treatment (carotid-artery-stenting/CAS) has become established as an alternative to open surgery in some cases. Historically, female sex has been considered as a perioperative risk factor, however, there are few studies regarding this hypothesis when it comes to CAS. Objectives To analyze the CAS results in our center adjusted by sex. Methods A retrospective cohort study was designed, including patients with carotid atheromatosis operated at a single center from January 2016 to June 2019. Our objective was to compare cardiovascular risk, including myocardial infarction, stroke, and mortality, by sex. Follow-up rates of stent patency, restenosis, stroke, myocardial infarction, and death were reported. Results 71 interventions were performed in 50 men (70.42%) and 21 women (29.57%). Mean age was 70.50 ± 10.72 years for men and 73.62 ± 11.78 years for women. Cardiovascular risk factors did not differ significantly between sexes. Mean follow-up was 11.28 ± 11.28 months. There were no significant differences in neurological events during follow-up. No adverse cardiological events were detected at any time. Regarding the mortality rate, during medium-term follow up there were 2 neurological related deaths with no significant differences between sexes (p=0.8432). Neither sex had higher rated of restenosis during long term follow-up (5.63% vs. 1.41%, p = 0.9693) or reoperation (1.41% vs. 1.41%, p = 0.4971). All procedures remained patent (<50% restenosis). Conclusions Despite the limitations of our study, CAS is a therapeutic option that is as effective and safe in women as in men. No sex differences were observed.
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Higher Long-Term Mortality with Carotid Artery Stenting in Asymptomatic Male Compared with Female Patients in the Southeastern Vascular Study Group. Ann Vasc Surg 2020; 66:390-399. [DOI: 10.1016/j.avsg.2020.01.090] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2019] [Revised: 01/13/2020] [Accepted: 01/14/2020] [Indexed: 12/26/2022]
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10
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Bereznyakova O, Dewar B, Dowlatshahi D, Howard V, Hamel C, Gocan S, Fedyk M, Shamy M. Benefit of carotid revascularisation for women with symptomatic carotid stenosis: protocol for a systematic review. BMJ Open 2019; 9:e032140. [PMID: 31719088 PMCID: PMC6858193 DOI: 10.1136/bmjopen-2019-032140] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/07/2019] [Revised: 08/29/2019] [Accepted: 10/11/2019] [Indexed: 02/06/2023] Open
Abstract
INTRODUCTION Carotid intervention in the form of endarterectomy or stenting is the current standard of care for the majority of patients with symptomatic high-grade carotid stenosis. However, some randomised controlled trials (RCT) have demonstrated that women benefited significantly less from intervention than men. It is unclear if this is a true phenomenon or a study sampling artefact, as women were severely under-represented in all RCTs of carotid revascularisation. A systematic review is needed to summarise the existing data and to answer the question of whether a women-only trial for symptomatic patients with ipsilateral carotid stenosis is scientifically necessary and ethically permissible. METHODS AND ANALYSIS We will systematically search Medline, Embase, PubMed and the Cochrane libraries for all studies with data from RCTs that included women and compared either endarterectomy with stenting or revascularisation (by means of endarterectomy or stenting) with medical therapy in patients with symptomatic carotid stenosis. Search dates will be restricted to 1991-2018. Two reviewers will conduct screening search results, study selection, data extraction and quality assessment. We will include all studies reporting outcomes of interest. Planned subgroup analysis based on revascularisation technique, degree of stenosis and timing of intervention from the index event will be conducted with enough data. ETHICS AND DISSEMINATION This research is exempt of ethics approval as no primary data will be collected. The results will be published in peer-reviewed journals and disseminated through national and international-level conferences and scientific meetings. The result of this comprehensive review will provide useful information on whether further RCTs are required to study a women-only population with symptomatic carotid disease. PROSPERO REGISTRATION NUMBER CRD42019134967.
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Affiliation(s)
| | - Brian Dewar
- Neurology, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
| | | | - Virginia Howard
- University of Alabama at Birmingham School of Public Health, Birmingham, Alabama, USA
| | - Candyce Hamel
- Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
| | - Sophia Gocan
- Neurology, Ottawa Hospital, Ottawa, Ontario, Canada
| | - Mark Fedyk
- Mount Allison University, Sackville, New Brunswick, Canada
| | - Michel Shamy
- Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
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Eslami MH, Saadeddin Z, Farber A, Fish L, Avgerinos ED, Makaroun MS. External validation of the Vascular Study Group of New England carotid endarterectomy risk predictive model using an independent U.S. national surgical database. J Vasc Surg 2019; 71:1954-1963. [PMID: 31676184 DOI: 10.1016/j.jvs.2019.04.495] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2018] [Accepted: 04/11/2019] [Indexed: 11/15/2022]
Abstract
OBJECTIVE Previously, we described a Vascular Study Group of New England (VSGNE) risk predictive model to predict composite adverse outcomes (postoperative death, stroke, myocardial infarction, or discharge to extended care facilities) after carotid endarterectomy (CEA). The goal of this study was to externally validate this model using an independent database. METHODS The American College of Surgeons National Surgical Quality Improvement Program (NSQIP) CEA-targeted database (2010-2014) was used to externally validate the risk predictor model of adverse outcomes after CEA previously created using the VSGNE carotid database. Emergent cases and those in which CEA was combined with another operation were excluded. Cases in which a discharge destination cannot be determined were also excluded. To assess the predictive power of our VSGNE prediction score within this sample, a receiver operating characteristic curve was constructed. Risk scores for each NSQIP patient were also computed using beta weights from the VSGNE CEA model. To further assess the construct validity of our VSGNE prediction score, the observed proportion of adverse outcomes was examined at each level of our prediction scale and within five roughly equally sized risk groups formed on the basis of our VSGNE prediction scores. RESULTS In this database, 10,889 cases met our inclusion criteria and were used in this analysis. The overall rate of adverse outcomes in this cohort was 8.5%. External validation of the VSGNE model on this sample showed moderately good predictive ability (area under the curve = 0.745). Patients in progressively higher risk groups, based on their VSGNE model scores, exhibited progressively higher rates of observed adverse outcomes, as predicted. CONCLUSIONS The VSGNE CEA risk predictive model was externally validated on an NSQIP CEA-targeted sample and showed a fairly accurate global predictive ability for adverse outcomes after CEA. Although this model has a good population concordance, the lack of cut point indicates that individual risk prediction requires more evaluation. Further studies should be geared toward identification of variables that make this risk predictive model more robust.
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Affiliation(s)
- Mohammad H Eslami
- Division of Vascular Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pa.
| | - Zein Saadeddin
- Division of Vascular Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pa
| | - Alik Farber
- Division of Vascular and Endovascular Surgery, Boston University School of Medicine, Boston, Mass
| | - Larry Fish
- Division of Vascular Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pa
| | - Efthymios D Avgerinos
- Division of Vascular Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pa
| | - Michel S Makaroun
- Division of Vascular Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pa
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12
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Yanes JA, McKinnell ZE, Reid MA, Busler JN, Michel JS, Pangelinan MM, Sutherland MT, Younger JW, Gonzalez R, Robinson JL. Effects of cannabinoid administration for pain: A meta-analysis and meta-regression. Exp Clin Psychopharmacol 2019; 27:370-382. [PMID: 31120281 PMCID: PMC6663642 DOI: 10.1037/pha0000281] [Citation(s) in RCA: 29] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
Chronic pain states have resulted in an overreliance on opioid pain relievers, which can carry significant risks when used long term. As such, alternative pain treatments are increasingly desired. Although emerging research suggests that cannabinoids have therapeutic potential regarding pain, results from studies across pain populations have been inconsistent. To provide meta-analytic clarification regarding cannabis's impact on subjective pain, we identified studies that assessed drug-induced pain modulations under cannabinoid and corresponding placebo conditions. A literature search yielded 25 peer-reviewed records that underwent data extraction. Baseline and end-point data were used to compute standardized effect size estimates (Cohen's d) across cannabinoid administrations (k = 39) and placebo administrations (k = 26). Standardized effects were inverse-variance weighted and pooled across studies for meta-analytic comparison. Results revealed that cannabinoid administration produced a medium-to-large effect across included studies, Cohen's d = -0.58, 95% confidence interval (CI) [-0.74, -0.43], while placebo administration produced a small-to-medium effect, Cohen's d = -0.39, 95% CI [-0.52, -0.26]. Meta-regression revealed that cannabinoids, β = -0.43, 95% CI [-0.62, -0.24], p < .05, synthetic cannabinoids, β = -0.39, 95% CI [-0.65, -0.14], p < .05, and sample size, β = 0.01, 95% CI [0.00, 0.01], p < .05, were associated with marked pain reduction. These outcomes suggest that cannabinoid-based pharmacotherapies may serve as effective replacement/adjunctive options regarding pain, however, additional research is warranted. Additionally, given demonstrated neurocognitive side effects associated with some constituent cannabinoids (i.e., THC), subsequent work may consider developing novel therapeutic agents that capitalize on cannabis's analgesic properties without producing adverse effects. (PsycINFO Database Record (c) 2019 APA, all rights reserved).
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Affiliation(s)
- Julio A. Yanes
- Department of Psychology, Auburn University, Auburn, AL, USA,Auburn University Magnetic Resonance Imaging Research Center, Auburn University, Auburn, AL, USA,Center for Neuroscience, Auburn University, Auburn, AL, USA,Alabama Advanced Imaging Consortium, AL, USA
| | - Zach E. McKinnell
- Department of Psychology, Auburn University, Auburn, AL, USA,Auburn University Magnetic Resonance Imaging Research Center, Auburn University, Auburn, AL, USA,Center for Neuroscience, Auburn University, Auburn, AL, USA,Alabama Advanced Imaging Consortium, AL, USA
| | - Meredith A. Reid
- Department of Psychology, Auburn University, Auburn, AL, USA,Auburn University Magnetic Resonance Imaging Research Center, Auburn University, Auburn, AL, USA,Center for Neuroscience, Auburn University, Auburn, AL, USA,Alabama Advanced Imaging Consortium, AL, USA
| | - Jessica N. Busler
- Department of Psychology, Auburn University, Auburn, AL, USA,Auburn University Magnetic Resonance Imaging Research Center, Auburn University, Auburn, AL, USA,Center for Neuroscience, Auburn University, Auburn, AL, USA,Alabama Advanced Imaging Consortium, AL, USA
| | - Jesse S. Michel
- Department of Psychology, Auburn University, Auburn, AL, USA
| | | | | | - Jared W. Younger
- Department of Psychology, University of Alabama Birmingham, Birmingham, AL, USA
| | - Raul Gonzalez
- Department of Psychology, Florida International University, Miami, FL, USA
| | - Jennifer L. Robinson
- Department of Psychology, Auburn University, Auburn, AL, USA,Auburn University Magnetic Resonance Imaging Research Center, Auburn University, Auburn, AL, USA,Center for Neuroscience, Auburn University, Auburn, AL, USA,Alabama Advanced Imaging Consortium, AL, USA
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13
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Nevidomskyte D, Tang GL, Shin SH, Hatsukami TS, Khor S, Flum DR, Meissner MH, Shalhub S. Comparison of outcomes in women and men following carotid interventions in the Washington state's Vascular Interventional Surgical Care and Outcomes Assessment Program. J Vasc Surg 2019; 69:1121-1128. [DOI: 10.1016/j.jvs.2018.08.152] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2017] [Accepted: 08/08/2018] [Indexed: 12/01/2022]
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14
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Kang FG, Liu PJ, Liang LY, Lin YQ, Xie SL, He Y, Liang BS, Zhang HF, Chen YX, Wang JF. Effect of pocket irrigation with antimicrobial on prevention of pacemaker pocket infection: a meta-analysis. BMC Cardiovasc Disord 2017; 17:256. [PMID: 28964262 PMCID: PMC5622444 DOI: 10.1186/s12872-017-0689-9] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2017] [Accepted: 09/19/2017] [Indexed: 12/30/2022] Open
Abstract
Background The presence of cardiac implantable electronic devices (CIEDs) pocket infection is difficult to treat, causing serious clinical outcomes, but little is known for prevention. Results from some studies suggested that pocket irrigation could reduce infection while others showed conflicting results. We pooled the effects of pocket irrigations on the prevention of pocket infection by meta-analysis methods. Method Relevant studies published before June, 2017 were retrieved mainly by the computer-based search of PubMed, Cochrane, EMBASE, Web of Science, Chinese BioMedical, Global Health and BIOSIS Previews databases. Estimations of relative ratios (RRs) and 95% confidence intervals (95% CIs) were pooled. Subgroup analyses according to potential key factors affecting the effects were conducted, which was confirmed by meta-regression. Sensitivity analysis and test for publication bias were also performed. Results We identified 10 studies providing data of 5467 patients receiving CIEDs implantations. Pooled infection rates were 1.48 and 3.49% respectively for medication and saline irrigation groups. Meta-analysis showed that medication irrigation conferred protection to pocket infection (RR = 0.44, 95% CI: 0.31-0.63). Subgroup analysis showed that antibiotics, rather than non-antibiotics (antiseptics) exerting the protection. The first and second lines antibiotics against staphylococcus aureus, which is the main pathogen for pocket infection, were both effective (RR = 0.42, 95% CI: 0.24-0.75 and RR = 0.34, 95% CI: 0.20-0.58 respectively for first line and second line therapies). Meta-regression revealed that region and class of irrigation medication completely explained the variance among studies and implied that effects of region were masked by medication types. Sensitivity analysis did not showed any significant change of the result and publication bias were not statistical significance. Conclusion Pocket irrigation with antibiotics were effective for reducing pocket infection and should be encouraged in CIEDs implantation.
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Affiliation(s)
- Feng-Guang Kang
- ShunDe Hospital of Guangzhou University of Chinese Medicine, Foshan, Guangdong, 528333, People's Republic of China
| | - Pei-Jian Liu
- ShunDe Hospital of Guangzhou University of Chinese Medicine, Foshan, Guangdong, 528333, People's Republic of China
| | - Li-Yi Liang
- ShunDe Hospital of Guangzhou University of Chinese Medicine, Foshan, Guangdong, 528333, People's Republic of China
| | - Yong-Qing Lin
- Department of Cardiology, Sun Yat-sen Memorial Hospital, Sun Yat-sen University, Guangzhou, Guangdong, 510120, People's Republic of China.,Laboratory of Cardiac Electrophysiology and Arrhythmia in Guangdong Province, Guangzhou, Guangdong, 510120, People's Republic of China
| | - Shuang-Lun Xie
- Department of Cardiology, Sun Yat-sen Memorial Hospital, Sun Yat-sen University, Guangzhou, Guangdong, 510120, People's Republic of China.,Laboratory of Cardiac Electrophysiology and Arrhythmia in Guangdong Province, Guangzhou, Guangdong, 510120, People's Republic of China
| | - Yi He
- ShunDe Hospital of Guangzhou University of Chinese Medicine, Foshan, Guangdong, 528333, People's Republic of China
| | - Bao-Shan Liang
- ShunDe Hospital of Guangzhou University of Chinese Medicine, Foshan, Guangdong, 528333, People's Republic of China
| | - Hai-Feng Zhang
- Department of Cardiology, Sun Yat-sen Memorial Hospital, Sun Yat-sen University, Guangzhou, Guangdong, 510120, People's Republic of China. .,Laboratory of Cardiac Electrophysiology and Arrhythmia in Guangdong Province, Guangzhou, Guangdong, 510120, People's Republic of China.
| | - Yang-Xin Chen
- Department of Cardiology, Sun Yat-sen Memorial Hospital, Sun Yat-sen University, Guangzhou, Guangdong, 510120, People's Republic of China. .,Laboratory of Cardiac Electrophysiology and Arrhythmia in Guangdong Province, Guangzhou, Guangdong, 510120, People's Republic of China.
| | - Jing-Feng Wang
- Department of Cardiology, Sun Yat-sen Memorial Hospital, Sun Yat-sen University, Guangzhou, Guangdong, 510120, People's Republic of China. .,Laboratory of Cardiac Electrophysiology and Arrhythmia in Guangdong Province, Guangzhou, Guangdong, 510120, People's Republic of China.
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15
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de Vries EE, Baldew VGM, den Ruijter HM, de Borst GJ. Meta-analysis of the costs of carotid artery stenting and carotid endarterectomy. Br J Surg 2017; 104:1284-1292. [PMID: 28783225 DOI: 10.1002/bjs.10649] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2017] [Revised: 06/02/2017] [Accepted: 06/19/2017] [Indexed: 11/07/2022]
Abstract
BACKGROUND Carotid artery stenting (CAS) is currently associated with an increased risk of 30-day stroke compared with carotid endarterectomy (CEA), whereas both interventions seem equally durable beyond the periprocedural period. Although the clinical outcomes continue to be scrutinized, there are few data summarizing the costs of both techniques. METHODS A systematic search was conducted in MEDLINE, Embase and Cochrane databases in August 2016 identifying articles comparing the costs or cost-effectiveness of CAS and CEA in patients with carotid artery stenosis. Combined overall effect sizes were calculated using random-effects models. The in-hospital costs were specified to gain insight into the main heads of expenditure associated with both procedures. RESULTS The literature search identified 617 unique articles, of which five RCTs and 12 cohort studies were eligible for analysis. Costs of the index hospital admission were similar for CAS and CEA. Costs of the procedure itself were 51 per cent higher for CAS, mainly driven by the higher costs of devices and supplies, but were balanced by higher postprocedural costs of CEA. Long-term cost analysis revealed no difference in costs or quality of life after 1 year of follow-up. CONCLUSION Hospitalization and long-term costs of CAS and CEA appear similar. Economic considerations should not influence the choice of stenting or surgery in patients with carotid artery stenosis being considered for revascularization.
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Affiliation(s)
- E E de Vries
- Department of Vascular Surgery, University Medical Centre Utrecht, Utrecht, The Netherlands
| | - V G M Baldew
- Department of Vascular Surgery, University Medical Centre Utrecht, Utrecht, The Netherlands
| | - H M den Ruijter
- Experimental Cardiology Laboratory, University Medical Centre Utrecht, Utrecht, The Netherlands
| | - G J de Borst
- Department of Vascular Surgery, University Medical Centre Utrecht, Utrecht, The Netherlands
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Schmid S, Tsantilas P, Knappich C, Kallmayer M, König T, Breitkreuz T, Zimmermann A, Kuehnl A, Eckstein HH. Risk of Inhospital Stroke or Death Is Associated With Age But Not Sex in Patients Treated With Carotid Endarterectomy for Asymptomatic or Symptomatic Stenosis in Routine Practice: Secondary Data Analysis of the Nationwide German Statutory Quality Assurance Database From 2009 to 2014. J Am Heart Assoc 2017; 6:JAHA.116.004764. [PMID: 28288976 PMCID: PMC5524011 DOI: 10.1161/jaha.116.004764] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/02/2022]
Abstract
Background Guideline recommendations on carotid endarterectomy are based predominantly on randomized, controlled trials, in which women or elderly patients are often under‐represented. This study analyzed the association of age and sex with the risk of in‐hospital stroke or death following carotid endarterectomy under routine conditions in Germany. Methods and Results Secondary data analysis using the Statutory German Quality Assurance Database on all carotid endarterectomy procedures (n=142 074) performed between 2009 and 2014. Primary outcome was any stroke or death until discharge; secondary outcomes were any in‐hospital stroke (alone), and death (alone). Descriptive statistics and multilevel multivariable regression analyses were applied. Patients were predominately male (68%), with mean age 71 years. Carotid stenosis was symptomatic in 40%. Primary outcome occurred in 1.8% of women and 1.9% of men. Multivariable regression analysis revealed that more‐advanced age was associated with a higher primary outcome rate (relative risk [RR] per 10‐year increase: 1.19; 95% CI, 1.14–1.24). Risk of death (alone) was associated with age (RR, 1.68; 95% CI, 1.54–1.84). Age was associated with the risk of stroke (alone; RR, 1.05; 95% CI, 1.00–1.11). Sex was not associated with primary outcome rate (1.01; 95% CI, 0.93–1.10), nor did it significantly modify the age effect. Conclusions This study shows that increasing age, but not sex, is associated with a higher risk of in‐hospital stroke or death following carotid endarterectomy under everyday conditions in Germany. Whereas the risk of death (alone) is significantly associated with age, the association between age and the risk of stroke (alone) can be considered of minor importance.
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Affiliation(s)
- Sofie Schmid
- Department of Vascular and Endovascular Surgery, Klinikum rechts der Isar Technical University of Munich, Germany
| | - Pavlos Tsantilas
- Department of Vascular and Endovascular Surgery, Klinikum rechts der Isar Technical University of Munich, Germany
| | - Christoph Knappich
- Department of Vascular and Endovascular Surgery, Klinikum rechts der Isar Technical University of Munich, Germany
| | - Michael Kallmayer
- Department of Vascular and Endovascular Surgery, Klinikum rechts der Isar Technical University of Munich, Germany
| | - Thomas König
- AQUA-Institut für angewandte Qualitätsförderung und Forschung im Gesundheitswesen GmbH, Göttingen, Germany
| | - Thorben Breitkreuz
- AQUA-Institut für angewandte Qualitätsförderung und Forschung im Gesundheitswesen GmbH, Göttingen, Germany
| | - Alexander Zimmermann
- Department of Vascular and Endovascular Surgery, Klinikum rechts der Isar Technical University of Munich, Germany
| | - Andreas Kuehnl
- Department of Vascular and Endovascular Surgery, Klinikum rechts der Isar Technical University of Munich, Germany
| | - Hans-Henning Eckstein
- Department of Vascular and Endovascular Surgery, Klinikum rechts der Isar Technical University of Munich, Germany
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17
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Predictors of poor outcome after carotid intervention. J Vasc Surg 2016; 64:663-70. [DOI: 10.1016/j.jvs.2016.03.428] [Citation(s) in RCA: 34] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2016] [Accepted: 03/14/2016] [Indexed: 01/10/2023]
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18
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Eslami MH, Rybin D, Doros G, Farber A. An externally validated robust risk predictive model of adverse outcomes after carotid endarterectomy. J Vasc Surg 2016; 63:345-54. [DOI: 10.1016/j.jvs.2015.09.003] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2015] [Accepted: 09/14/2015] [Indexed: 01/12/2023]
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