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Aoki J, Kimura K. The Body Mass Index as a Determinant of Acute Ischemic Location in Mild Non-cardioembolic Stroke Patients. Intern Med 2024; 63:2613-2620. [PMID: 38432968 DOI: 10.2169/internalmedicine.2926-23] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/05/2024] Open
Abstract
Objective Although the body mass index (BMI) is considered a meaningful parameter for evaluating obesity, the association between the BMI and acute non-cardioembolic stroke remains unclear. We investigated how the BMI was related to patients' background, type of infarction, and infarction location in patients with non-cardioembolic stroke using an acute dual study (ADS) cohort. Methods The ADS trial was conducted between May 2011 and June 2017 in Japan. The BMI classifications were those proposed by the World Health Organization classification: underweight, <18.5 kg/m2; normal weight, 18.5-24.9 kg/m2; overweight, 25-29.9 kg/m2; and obese, ≥30 kg/m2. Results Data from 1,136 patients were analyzed. The median BMI was 23.6 kg/m2 (interquartile range: 21.6-25.8 kg/m2), with a BMI ≥30 kg/m2 in 63 patients (6%), 25-29.9 kg/m2 in 321 (28%), 18.5-24.9 kg/m2 in 692 (61%), and <18.5 kg/m2 in 60 (5%). The group with a BMI ≥30 kg/m2 was the youngest, and the group with a BMI <18.5 kg/m2 was the oldest (p<0.001). The proportion of patients with a history of hypertension (p<0.001), diabetes (p<0.001), dyslipidemia (p<0.001), and statin therapy (p=0.005) increased with increasing BMI. Pontine infarcts were frequent in the following order: obese, overweight, normal weight, and underweight (24%, 18%, 14%, and 13%, respectively; p=0.034). In contrast, cortical infarct were frequent in the order of underweight, normal weight, overweight, and obese at 20%, 19%, 14%, and 3%, respectively (p=0.007). Conclusion Acute stroke patients with a high BMI have more atherosclerosis-related factors in their backgrounds than those with lower BMIs. In addition, the BMI may be a determinant of infarct location in patients with acute stroke.
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Affiliation(s)
- Junya Aoki
- Department of Neurology, Graduate School of Medicine, Nippon Medical School, Japan
| | - Kazumi Kimura
- Department of Neurology, Graduate School of Medicine, Nippon Medical School, Japan
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Li P, Wang R, Liu F, Ma L, Yang H, Qu M, Liu S, Sun M, Liu M, Ma Y, Mi W. High body mass index is associated with elevated risk of perioperative ischemic stroke in patients who underwent noncardiac surgery: A retrospective cohort study. CNS Neurosci Ther 2024; 30:e14838. [PMID: 38987899 PMCID: PMC11236734 DOI: 10.1111/cns.14838] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2023] [Revised: 06/22/2024] [Accepted: 06/23/2024] [Indexed: 07/12/2024] Open
Abstract
BACKGROUND Body mass index (BMI) serves as a global metric for assessing obesity and overall health status. However, the impact of BMI, treated as a continuous variable, on the risk of perioperative stroke remains poorly understood. This retrospective cohort study aimed to elucidate the association between BMI and the risk of perioperative ischemic stroke in patients undergoing non-cardiovascular surgery. METHODS A cohort of 223,415 patients undergoing noncardiac surgery at the First Medical Center of Chinese PLA General Hospital between January 1, 2008 and August 31, 2019 was screened. Preoperative high BMI, defined as BMI >22.64 kg/m2, was the primary exposure, and the outcome of interest was the new diagnosis of perioperative ischemic stroke within 30 days post-surgery. Robust controls for patient and intraoperative factors were implemented to minimize residual confounding. Logistic regression and propensity score matching were employed, and patients were stratified into subgroups for further investigation. RESULTS The overall incidence of perioperative ischemic stroke was 0.23% (n = 525) in the cohort. After adjusting for patient-related variables (OR 1.283; 95% CI, 1.04-1.594; p < 0.05), surgery-related variables (OR 1.484; 95% CI, 1.2-1.849; p < 0.001), and all confounding variables (OR 1.279; 95% CI, 1.025-1.607; p < 0.05), patients with BMI >22.64 kg/m2 exhibited a significantly increased risk of perioperative ischemic stroke. This association persisted in the propensity score matched cohort (OR 1.577; 95% CI, 1.203-2.073; p < 0.01). Subgroup analyses indicated that preoperative BMI >22.64 kg/m2 correlated with an elevated risk of perioperative ischemic stroke in female patients, those with coronary heart disease, peripheral vascular diseases, and individuals undergoing neurosurgery. CONCLUSION We first identified BMI >22.64 kg/m2 as a substantial and independent risk factor for perioperative ischemic stroke in Chinese noncardiac surgery patients. Normal BMI may not suffice as a universal preventive standard. Instead, a more stringent perioperative weight management approach is recommended, particularly for specific subgroups such as female patients, those with coronary heart disease and peripheral vascular disease, and individuals scheduled for neurosurgery.
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Affiliation(s)
- Peng Li
- Department of AnesthesiologyThe Sixth Medical Center of Chinese PLA General HospitalBeijingChina
- Department of AnesthesiologyThe First Medical Center of Chinese PLA General HospitalBeijingChina
- Nation Clinical Research Center for Geriatric DiseasesChinese PLA General HospitalBeijingChina
| | - Rui Wang
- Department of AnesthesiologyThe First Medical Center of Chinese PLA General HospitalBeijingChina
- Nation Clinical Research Center for Geriatric DiseasesChinese PLA General HospitalBeijingChina
| | - Fengjin Liu
- Department of EmergencyYantai Yuhuangding HospitalShandongChina
| | - Libin Ma
- Nation Clinical Research Center for Geriatric DiseasesChinese PLA General HospitalBeijingChina
| | - Huikai Yang
- Department of AnesthesiologyThe First Medical Center of Chinese PLA General HospitalBeijingChina
| | - Mengyao Qu
- Department of AnesthesiologyThe First Medical Center of Chinese PLA General HospitalBeijingChina
| | - Siyuan Liu
- Department of AnesthesiologyThe First Medical Center of Chinese PLA General HospitalBeijingChina
- Nation Clinical Research Center for Geriatric DiseasesChinese PLA General HospitalBeijingChina
| | - Miao Sun
- Department of AnesthesiologyThe First Medical Center of Chinese PLA General HospitalBeijingChina
| | - Min Liu
- Department of Anesthesiology, Beijing Tongren HospitalCapital Medical UniversityBeijingChina
| | - Yulong Ma
- Department of AnesthesiologyThe First Medical Center of Chinese PLA General HospitalBeijingChina
- Nation Clinical Research Center for Geriatric DiseasesChinese PLA General HospitalBeijingChina
| | - Weidong Mi
- Department of AnesthesiologyThe First Medical Center of Chinese PLA General HospitalBeijingChina
- Nation Clinical Research Center for Geriatric DiseasesChinese PLA General HospitalBeijingChina
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Dakour-Aridi H, Tanaka A, Mirza AK, Motaganahalli RL, Leckie KE, Keyhani A, Keyhani K, Wang SK. Transcarotid revascularization in obese patients. Vascular 2023; 31:1180-1186. [PMID: 35653693 DOI: 10.1177/17085381221106326] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
OBJECTIVE Transcarotid revascularization (TCAR) is a minimally invasive hybrid surgical carotid stenting technique which utilizes cerebral flow reversal as embolic protection during carotid lesion manipulation. This investigation was performed to define the perioperative risks associated with this operation in the obese patient. METHODS A retrospective review of tandem carotid revascularization databases maintained at two high-volume health systems was performed to capture all TCARs performed between 2015 and 2022. A threshold of body mass index of 35 kg/m2 defined the "obese" patient. Demographics, intraoperative, perioperative, and follow-up characteristics were compared using univariate analysis. RESULTS We performed 793 TCAR procedures that qualified for study inclusion within the prespecified time. After applying our obesity definition, 129 patients qualified as obese and were compared to the remainder. There were no significant differences in baseline demographics as comparable Charlson Comorbidity Indices were noted between groups; however, obese patients had a significantly higher prevalence of hypertension, hyperlipidemia, and diabetes. Intraoperative, case complexity in the obese patients did not seem to be increased, as measured by operative time (68.4 ± 23.0 vs 64.2 ± 25.8 min, p = 0.09), fluoroscopic time (4.9 ± 3.2 vs 4.6 ± 3.6 min, p = 0.38), and estimated blood loss (40.6 ± 49.0 vs 46.6 ± 49.4 min, p = 0.22). Similarly, no disparities were observed with respect to ipsilateral stroke (3.1 vs. 1.7%, p = 0.29), contralateral stroke (0 vs. 0.2%, p > 0.99), death (0 vs. 1.1%, p = 0.61), and stroke/death (3.1 vs. 3.0%, p > 0.99) in the 30-day perioperative period. Both cohorts were followed for approximately 1 year (12.0 ± 13.4 vs 11.6 ± 13.4 months, p = 0.76). During this period, rates of ipsilateral stroke (3.1% vs. 2.7%, p > 0.99), contralateral stroke (1.1 vs. 0.8%, p > 0.99), and death (4.7 vs. 6.2%, p = 0.68) were similar. CONCLUSIONS TCAR performed in the obese population was not more challenging by intraoperative characteristics and did not result in a statistically higher incidence of adverse events in the perioperative phase.
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Affiliation(s)
- Hanaa Dakour-Aridi
- Department of Surgery, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Akiko Tanaka
- Department of Cardiothoracic and Vascular Surgery, McGovern Medical School at The University of Texas Health Science Center at Houston (UTHealth), Houston, TX, USA
| | - Aleem K Mirza
- Department of Surgery, Indiana University School of Medicine, Indianapolis, IN, USA
| | | | - Katherin E Leckie
- Department of Surgery, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Arash Keyhani
- Department of Cardiothoracic and Vascular Surgery, McGovern Medical School at The University of Texas Health Science Center at Houston (UTHealth), Houston, TX, USA
| | - Kourosh Keyhani
- Department of Cardiothoracic and Vascular Surgery, McGovern Medical School at The University of Texas Health Science Center at Houston (UTHealth), Houston, TX, USA
| | - S Keisin Wang
- Department of Cardiothoracic and Vascular Surgery, McGovern Medical School at The University of Texas Health Science Center at Houston (UTHealth), Houston, TX, USA
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Vukašinović D, Maksimović M, Tanasković S, Marinković JM, Radak Đ, Maksimović J, Vujčić I, Prijović N, Vlajinac H. Body Mass Index and Late Adverse Outcomes after a Carotid Endarterectomy. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2023; 20:2692. [PMID: 36768056 PMCID: PMC9916381 DOI: 10.3390/ijerph20032692] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/19/2022] [Revised: 01/14/2023] [Accepted: 01/31/2023] [Indexed: 06/18/2023]
Abstract
A cohort study was conducted to examine the association of an increased body mass index (BMI) with late adverse outcomes after a carotid endarterectomy (CEA). It comprised 1597 CEAs, performed in 1533 patients at the Vascular Surgery Clinic in Belgrade, from 1 January 2012 to 31 December 2017. The follow-up lasted four years after CEA. Data for late myocardial infarction and stroke were available for 1223 CEAs, data for death for 1305 CEAs, and data for restenosis for 1162 CEAs. Logistic and Cox regressions were used in the analysis. The CEAs in patients who were overweight and obese were separately compared with the CEAs in patients with a normal weight. Out of 1223 CEAs, 413 (33.8%) were performed in patients with a normal weight, 583 (47.7%) in patients who were overweight, and 220 (18.0%) in patients who were obese. According to the logistic regression analysis, the compared groups did not significantly differ in the frequency of myocardial infarction, stroke, and death, as late major adverse outcomes (MAOs), or in the frequency of restenosis. According to the Cox and logistic regression analyses, BMI was neither a predictor for late MAOs, analyzed separately or all together, nor for restenosis. In conclusion, being overweight and being obese were not related to the occurrence of late adverse outcomes after a carotid endarterectomy.
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Affiliation(s)
- Danka Vukašinović
- Institute of Hygiene and Medical Ecology, Faculty of Medicine, University of Belgrade, 11000 Belgrade, Serbia
| | - Miloš Maksimović
- Institute of Hygiene and Medical Ecology, Faculty of Medicine, University of Belgrade, 11000 Belgrade, Serbia
| | - Slobodan Tanasković
- Vascular Surgery Clinic, “Dedinje” Cardiovascular Institute, 11000 Belgrade, Serbia
- Faculty of Medicine, University of Belgrade, 11000 Belgrade, Serbia
| | - Jelena M. Marinković
- Institute of Medical Statistics and Informatics, Faculty of Medicine, University of Belgrade, 11000 Belgrade, Serbia
| | - Đorđe Radak
- Vascular Surgery Clinic, “Dedinje” Cardiovascular Institute, 11000 Belgrade, Serbia
- Faculty of Medicine, University of Belgrade, 11000 Belgrade, Serbia
| | - Jadranka Maksimović
- Institute of Epidemiology, Faculty of Medicine, University of Belgrade, 11000 Belgrade, Serbia
| | - Isidora Vujčić
- Institute of Epidemiology, Faculty of Medicine, University of Belgrade, 11000 Belgrade, Serbia
| | - Nebojša Prijović
- Clinic of Urology, University Clinical Center of Serbia, 11000 Belgrade, Serbia
| | - Hristina Vlajinac
- Institute of Epidemiology, Faculty of Medicine, University of Belgrade, 11000 Belgrade, Serbia
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Vukašinović D, Maksimović M, Tanasković S, Marinković J, Gajin P, Ilijevski N, Vasiljević N, Radak Đ, Vlajinac H. Body mass index and early outcomes after carotid endarterectomy. PLoS One 2022; 17:e0278298. [PMID: 36538553 PMCID: PMC9767338 DOI: 10.1371/journal.pone.0278298] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2022] [Accepted: 11/14/2022] [Indexed: 12/24/2022] Open
Abstract
As the existing data on the correlation of adiposity with adverse outcomes of carotid endarterectomy (CEA) are inconsistent, the aim of the present study is to examine the correlation of an increased body mass index with 30-day complications after carotid endarterectomy. The cohort study comprises 1586 CEAs, performed at the Clinic for Vascular Surgery in Belgrade, from 2012-2017. Out of them, 550 CEAs were performed in patients with normal body mass index (18.5-24.9), 750 in overweight (25.0-29.9), and 286 in obese (≥30) patients. The association of overweight and obesity with early outcomes of carotid endarterectomy was assessed using univariate and multivariate logistic regression analysis. Overweight patients, in whom CEAs were performed, were significantly more frequently males, compared to normal weight patients-Odds Ratio (OR) 1.51 (95% confidence interval- 1.19-1.89). Moreover, overweight patients significantly more frequently had non-insulin-dependent diabetes mellitus-OR 1.44 (1.09-1.90), and more frequently used ACEI in hospital discharge therapy-OR 1.41 (1.07-1.84) than normal weight patients. Additionally, the CEAs in them were less frequently followed by bleedings-OR 0.37 (0.16-0.83). Compared to normal weight patients, obese patients were significantly younger-OR 0.98 (0.96-0.99), and with insulin-dependent and non-insulin-dependent diabetes mellitus-OR 1.83 (1.09-3.06) and OR 2.13 (1.50-3.01) respectively. They also more frequently had increased triglyceride levels-OR 1.36 (1.01-1.83), and more frequently used oral anticoagulants in therapy before the surgery-OR 2.16 (1.11-4.19). According to the results obtained, overweight and obesity were not associated with an increased death rate, transient ischemic attack (TIA), stroke, myocardial infarction, or with minor complications, and the need for reoperation after carotid endarterectomy. The only exception was bleeding, which was significantly less frequent after CEA in overweight compared to normal weight patients.
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Affiliation(s)
- Danka Vukašinović
- Faculty of Medicine, Institute of Hygiene and Medical Ecology, University of Belgrade, Belgrade, Serbia
| | - Miloš Maksimović
- Faculty of Medicine, Institute of Hygiene and Medical Ecology, University of Belgrade, Belgrade, Serbia
| | - Slobodan Tanasković
- Vascular Surgery Clinic, “Dedinje” Cardiovascular Institute, Belgrade, Serbia
- Faculty of Medicine, University of Belgrade, Belgrade, Serbia
| | - Jelena Marinković
- Faculty of Medicine, Institute of Medical Statistics and Informatics, University of Belgrade, Belgrade, Serbia
| | - Predrag Gajin
- Vascular Surgery Clinic, “Dedinje” Cardiovascular Institute, Belgrade, Serbia
- Faculty of Medicine, University of Belgrade, Belgrade, Serbia
| | - Nenad Ilijevski
- Vascular Surgery Clinic, “Dedinje” Cardiovascular Institute, Belgrade, Serbia
- Faculty of Medicine, University of Belgrade, Belgrade, Serbia
| | - Nađa Vasiljević
- Faculty of Medicine, Institute of Hygiene and Medical Ecology, University of Belgrade, Belgrade, Serbia
| | - Đorđe Radak
- Vascular Surgery Clinic, “Dedinje” Cardiovascular Institute, Belgrade, Serbia
- Faculty of Medicine, University of Belgrade, Belgrade, Serbia
| | - Hristina Vlajinac
- Faculty of Medicine, Institute of Epidemiology, University of Belgrade, Belgrade, Serbia
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Lanza G, Orso M, Alba G, Bevilacqua S, Capoccia L, Cappelli A, Carrafiello G, Cernetti C, Diomedi M, Dorigo W, Faggioli G, Giannace V, Giannandrea D, Giannetta M, Lanza J, Lessiani G, Marone EM, Mazzaccaro D, Migliacci R, Nano G, Pagliariccio G, Petruzzellis M, Plutino A, Pomatto S, Pulli R, Reale N, Santalucia P, Sirignano P, Ticozzelli G, Vacirca A, Visco E. Guideline on carotid surgery for stroke prevention: updates from the Italian Society of Vascular and Endovascular Surgery. A trend towards personalized medicine. THE JOURNAL OF CARDIOVASCULAR SURGERY 2022; 63:471-491. [PMID: 35848869 DOI: 10.23736/s0021-9509.22.12368-2] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/15/2023]
Abstract
BACKGROUND This guideline (GL) on carotid surgery as updating of "Stroke: Italian guidelines for Prevention and Treatment" of the ISO-SPREAD Italian Stroke Organization-Group, has recently been published in the National Guideline System and shared with the Italian Society of Vascular and Endovascular Surgery (SICVE) and other Scientific Societies and Patient's Association. METHODS GRADE-SIGN version, AGREE quality of reporting checklist. Clinical questions formulated according to the PICO model. Recommendations developed based on clinical questions by a multidisciplinary experts' panel and patients' representatives. Systematic reviews performed for each PICO question. Considered judgements filled by assessing the evidence level, direction, and strength of the recommendations. RESULTS The panel provided indications and recommendations for appropriate, comprehensive, and individualized management of patients with carotid stenosis. Diagnostic and therapeutic processes of the best medical therapy, carotid endarterectomy (CEA), carotid stenting (CAS) according to the evidences and the judged opinions were included. Symptomatic carotid stenosis in elective and emergency, asymptomatic carotid stenosis, association with ischemic heart disease, preoperative diagnostics, types of anesthesia, monitoring in case of CEA, CEA techniques, comparison between CEA and CAS, post-surgical carotid restenosis, and medical therapy are the main topics, even with analysis of uncertainty areas for risk-benefit assessments in the individual patient (personalized medicine [PM]). CONCLUSIONS This GL updates on the main recommendations for the most appropriate diagnostic and medical-surgical management of patients with atherosclerotic carotid artery stenosis to prevent ischemic stroke. This GL also provides useful elements for the application of PM in good clinical practice.
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Affiliation(s)
- Gaetano Lanza
- Department of Vascular Surgery, IRCCS MultiMedica, Castellanza Hospital, Castellanza, Varese, Italy
| | - Massimiliano Orso
- Experimental Zooprophylactic Institute of Umbria and Marche, Perugia, Italy
| | - Giuseppe Alba
- Unit of Vascular Surgery, Department of Medicine, Surgery and Neuroscience, University of Siena, Siena, Italy
| | - Sergio Bevilacqua
- Department of Cardiac Anesthesia and Resuscitation, Careggi University Hospital, Florence, Italy
| | - Laura Capoccia
- Department of Vascular and Endovascular Surgery, Umberto I Polyclinic Hospital, Sapienza University, Rome, Italy
| | - Alessandro Cappelli
- Unit of Vascular Surgery, Department of Medicine, Surgery and Neuroscience, University of Siena, Siena, Italy
| | - Giampaolo Carrafiello
- Department of Radiology, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, University of Milan, Milan, Italy
| | - Carlo Cernetti
- Department of Cardiology and Hemodynamics, San Giacomo Apostolo Hospital, Castelfranco Veneto, Treviso, Italy
- Cardiology and Hemodynamics Unit, Ca' Foncello Hospital, Treviso, Italy
| | - Marina Diomedi
- Stroke Unit, Tor Vergata Polyclinic Hospital, Tor Vergata University, Rome, Italy
| | - Walter Dorigo
- Department of Vascular Surgery, Careggi Polyclinic Hospital, University of Florence, Florence, Italy
| | - Gianluca Faggioli
- Department of Vascular Surgery, Alma Mater Studiorum University, Bologna, Italy
| | - Vanni Giannace
- Unit of Vascular Surgery, Department of Medicine, Surgery and Neuroscience, University of Siena, Siena, Italy
| | - David Giannandrea
- Department of Neurology, USL Umbria 1, Hospitals of Gubbio, Gualdo Tadino and Città di Castello, Perugia, Italy
| | - Matteo Giannetta
- Department of Vascular Surgery, IRCCS San Donato Hospitals, San Donato Polyclinic Hospital, Milan, Italy
| | - Jessica Lanza
- Department of Vascular Surgery, IRCCS San Martino Polyclinic Hospital, University of Genoa, Genoa, Italy -
| | - Gianfranco Lessiani
- Unit of Vascular Medicine and Diagnostics, Department of Internal Medicine, Villa Serena Hospital, Città Sant'Angelo, Pesaro, Italy
| | - Enrico M Marone
- Vascular Surgery, Department of Clinical-Surgical, Diagnostic and Pediatric Sciences, University of Pavia, Pavia, Italy
| | - Daniela Mazzaccaro
- Department of Vascular Surgery, IRCCS San Donato Hospitals, San Donato Polyclinic Hospital, Milan, Italy
| | - Rino Migliacci
- Department of Internal Medicine, Valdichiana S. Margherita Hospital, USL Toscana Sud-Est, Cortona, Arezzo, Italy
| | - Giovanni Nano
- Department of Vascular Surgery, IRCCS San Donato Hospitals, San Donato Polyclinic Hospital, Milan, Italy
| | - Gabriele Pagliariccio
- Department of Emergency Vascular Surgery, Ospedali Riuniti University of Ancona, Ancona, Italy
| | | | - Andrea Plutino
- Stroke Unit, Ospedali Riuniti Marche Nord, Ancona, Italy
| | - Sara Pomatto
- Department of Vascular Surgery, Sant'Orsola Malpighi Polyclinic Hospital, University of Bologna, Bologna, Italy
| | - Raffaele Pulli
- Department of Vascular Surgery, University of Bari, Bari, Italy
| | | | | | - Pasqualino Sirignano
- Department of Vascular and Endovascular Surgery, Umberto I Polyclinic Hospital, Sapienza University, Rome, Italy
| | - Giulia Ticozzelli
- First Department of Anesthesia and Resuscitation, IRCCS Policlinico San Matteo Foundation, Pavia, Italy
| | - Andrea Vacirca
- Unit of Vascular Surgery, Department of Experimental, Diagnostic and Specialty Medicine (DIMES), IRCSS Sant'Orsola Polyclinic Hospital, University of Bologna, Bologna, Italy
| | - Emanuele Visco
- Department of Cardiology and Hemodynamics, San Giacomo Apostolo Hospital, Castelfranco Veneto, Treviso, Italy
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7
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Pertsch NJ, Garcia CM, Daniel Y, Phillips RK, Sagaityte E, Hagan MJ, Toms SA, Weil RJ. Outcomes for Adults with Metabolic Syndrome Undergoing Elective Carotid Endarterectomy. World Neurosurg 2022; 163:e146-e155. [PMID: 35338016 DOI: 10.1016/j.wneu.2022.03.082] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2022] [Revised: 03/16/2022] [Accepted: 03/17/2022] [Indexed: 10/18/2022]
Abstract
BACKGROUND Metabolic syndrome (MetS) is a disorder characterized by a constellation of cardiometabolic risk factors including abdominal obesity, dyslipidemia, hypertension, and glucose intolerance that has been associated with adverse perioperative outcomes. We evaluated outcomes for patients with MetS after carotid endarterectomy (CEA) in the largest population to date. METHODS We performed a matched cohort analysis using clinical data from 2012 to 2018 in the American College of Surgeons National Surgical Quality Improvement Program. We used propensity scores to match patients to attain covariate balance and used logistic regression to assess odds of unfavorable outcomes, including a predefined primary outcome of composite cardiovascular incident. RESULTS We identified 50,423 eligible adult patients, of whom 14.2% qualified for MetS (n = 7156). Patients with MetS tended to have CEA at an earlier age, more functional dependence, and longer operative durations. After matching, MetS remained associated with the primary outcome of combined cardiovascular incident (odds ratio [OR], 1.42; 95% confidence interval [CI], 1.18-1.72; P < 0.001), stroke (OR, 1.44; 95% CI, 1.12-1.85; P = 0.004), prolonged length of stay (OR, 1.31; 95% CI, 1.18-1.44; P < 0.001), and discharge to facility (OR, 1.32; 95% CI, 1.08-1.61; P = 0.007). We also found that obesity alone is protective against combined cardiovascular incident, whereas hypertension with diabetes and MetS increase odds of a cardiovascular complication. CONCLUSIONS Metabolic syndrome is associated with adverse outcomes for adult patients undergoing elective CEA.
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Affiliation(s)
- Nathan J Pertsch
- The Warren Alpert School of Medicine, Brown University, Providence, Rhode Island, USA.
| | - Catherine M Garcia
- The Warren Alpert School of Medicine, Brown University, Providence, Rhode Island, USA
| | - Yonathan Daniel
- The Warren Alpert School of Medicine, Brown University, Providence, Rhode Island, USA
| | - Ronald K Phillips
- The Warren Alpert School of Medicine, Brown University, Providence, Rhode Island, USA
| | - Emilija Sagaityte
- The Warren Alpert School of Medicine, Brown University, Providence, Rhode Island, USA
| | - Matthew J Hagan
- The Warren Alpert School of Medicine, Brown University, Providence, Rhode Island, USA
| | - Steven A Toms
- The Warren Alpert School of Medicine, Brown University, Providence, Rhode Island, USA; Department of Neurosurgery, Rhode Island Hospital, Providence, Rhode Island, USA
| | - Robert J Weil
- Department of Neurosurgery, Southcoast Health, North Dartmouth, Massachusetts, USA
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8
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Liu X, Chu H, Ji Y, Bosnjak Z, Ao H, Li T. Which BMI for Diabetes Patients is Better? From the View of the Adipose Tissue Macrophage-Derived Exosome. Diabetes Metab Syndr Obes 2022; 15:141-153. [PMID: 35046685 PMCID: PMC8763208 DOI: 10.2147/dmso.s345890] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/07/2021] [Accepted: 12/24/2021] [Indexed: 12/13/2022] Open
Abstract
PURPOSE Diabetes, as a group of metabolic diseases, can elevate blood glucose, thus leading to the development of life-threatening complications. It is difficult to define the outcome for diabetics with different BMI. This review will illustrate the adipose tissue macrophage-derived exosome in the diabetics with different BMI. PATIENTS AND METHODS Insulin resistance in peripheral tissues can cause diabetes. The peripheral tissues include liver, muscle, or the adipose depots. Communication between these organs is fatal to the maintenance of glucose homeostasis. This review will illustrate this communication. Obesity is closely linked with diabetes. There are different changes in fat distribution in diabetic patients. Adipose tissue macrophages can secrete various hormones, including adiponectin, leptin, resistin and other classical cytokines, such as TNF-α and IL-6. Studies illustrated that exosomes from the adipose tissue, can modulate inter-organ cross-talk by regulating gene expression in other tissues. RESULTS Adipose tissue macrophages exosomes links thin and fat individuals in the development of diabetes. CONCLUSION The molecular pathways initiated by exosomes such as miRNA in the situations of metabolic stress could help us gain a deeper knowledge of the pathophysiology of diabetes.
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Affiliation(s)
- Xiaojie Liu
- Department of Anesthesiology, Affiliated Hospital of Qingdao University, Qingdao, Shandong Province, People’s Republic of China
- Departments of Medicine and Physiology, Medical College of Wisconsin, Milwaukee, WI, USA
- Department of Anesthesiology, Fuwai Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, People’s Republic of China
| | - Haichen Chu
- Department of Anesthesiology, Affiliated Hospital of Qingdao University, Qingdao, Shandong Province, People’s Republic of China
| | - Yuzhi Ji
- Obstetrics, Affiliated Hospital of Qingdao University, Qingdao, Shandong Province, People’s Republic of China
| | - Zeljko Bosnjak
- Departments of Medicine and Physiology, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Hushan Ao
- Department of Anesthesiology, Fuwai Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, People’s Republic of China
- Correspondence: Hushan Ao Department of Anesthesiology, Fuwai Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, No.167 North Lishi Road, Xicheng District, Beijing, People’s Republic of ChinaTel/Fax +86-10-68006210 Email
| | - Tianjun Li
- Department of Oncology, Affiliated Hospital of Qingdao University, Qingdao, Shandong Province, People’s Republic of China
- Tianjun Li Department of Oncology, Affiliated Hospital of Qingdao University, No. 59 Haier Road, Laoshan District, Qingdao, Shandong Province, People’s Republic of ChinaTel/Fax +86-10-82913035 Email
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9
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The Association of Body Mass Index with Outcomes after Carotid Endarterectomy. Ann Vasc Surg 2021; 77:7-15. [PMID: 34437970 DOI: 10.1016/j.avsg.2021.05.046] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2021] [Revised: 05/11/2021] [Accepted: 05/14/2021] [Indexed: 12/20/2022]
Abstract
BACKGROUND Patients who are obese or underweight are traditionally at higher risk for perioperative morbidity and mortality. The effect of body mass index (BMI) on outcomes after carotid endarterectomy (CEA) is unclear. Our goal was to analyze the association of BMI with perioperative and long-term outcomes after elective CEA. METHODS The Vascular Quality Initiative (VQI) database was queried from 2003-2018 for patients undergoing elective CEAs. Patients were categorized into 5 BMI cohorts - underweight (UW, BMI < 18.5 kg/m2), normal weight (NW, BMI 18.5-24.9 kg/m2), overweight (OW, BMI 25-29.9 kg/m2), obese (OB, BMI 30-39.9 kg/m2), and morbidly obese (MO, BMI ≥ 40 kg/m2). Perioperative and long-term outcomes were assessed with univariable and multivariable analyses. RESULTS There were 89,079 patients included: 2% UW, 26% NW, 38.4% OW, 29.9% OB, and 3.6% MO. Overall, the mean age was 70.6 years, 60% were male, and 91.8% were of white race. There were significant differences among the BMI cohorts in regards to age, sex, smoking status, and comorbidities (all P < 0.05). For perioperative outcomes, the BMI cohorts differed significantly in reoperation for bleeding and 30-day mortality. On multivariable analysis, BMI was not associated with stroke or perioperative mortality. MO was associated with perioperative cardiac complications (Odds Ratios [OR] 1.26, 95% CI 1-1.57, P = 0.05). UW status was associated with increased return to the operating room (OR 1.89, 95% confidence interval [95% CI] 1.28-2.78, P = 0.001), 30-day mortality (OR 1.68, 95% CI 1-2.86, P =0.05), 1-year mortality (Hazard ratio [HR] 1.37, 95% CI 1.08-1.74, P = 0.01), and 5-year mortality (HR 1.22, 95% CI 1.06-1.41, P =0.005). CONCLUSIONS BMI status was not associated with perioperative stroke, cranial nerve injury, or surgical site infections. Patients with MO had higher perioperative cardiac complications. UW patients have lower short and long-term survival and should be a focus for long-term targeted risk factor stratification and modification.
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10
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Bagley JH, Priest R. Carotid Revascularization: Current Practice and Future Directions. Semin Intervent Radiol 2020; 37:132-139. [PMID: 32419725 DOI: 10.1055/s-0040-1709154] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
Carotid stenosis is responsible for approximately 15% of ischemic strokes. Carotid revascularization significantly decreases patients' stroke risk. Carotid endarterectomy has first-line therapy for moderate-to-severe carotid stenosis after a series of pivotal randomized controlled trials were published almost 30 years ago. Revascularization with carotid stenting has become a popular and effective alternative in a select subpopulation of patients. We review the current state of the literature regarding revascularization indications, patient selection, advantages of each revascularization approach, timing of intervention, and emerging interventional techniques, such as transcarotid artery revascularization.
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Affiliation(s)
- Jacob H Bagley
- Department of Neurological Surgery, Oregon Health and Science University, Portland, Oregon
| | - Ryan Priest
- Dotter Department of Interventional Radiology, Oregon Health and Science University, Portland, Oregon
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11
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The obesity paradox: does it exist in the perioperative period? Int Anesthesiol Clin 2020; 58:14-20. [PMID: 32250998 DOI: 10.1097/aia.0000000000000278] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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12
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Rinaldo L, Rabinstein AA, Lanzino G. Increased Body Mass Index Associated With Reduced Risk of Delayed Cerebral Ischemia and Subsequent Infarction After Aneurysmal Subarachnoid Hemorrhage. Neurosurgery 2020; 84:1035-1042. [PMID: 29659999 DOI: 10.1093/neuros/nyy104] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2017] [Accepted: 03/02/2018] [Indexed: 01/08/2023] Open
Abstract
BACKGROUND Increased body mass index (BMI) may be protective against cerebral ischemia in certain clinical contexts. OBJECTIVE To investigate whether increased BMI was associated with delayed cerebral ischemia (DCI) and subsequent infarction after aneurysmal subarachnoid hemorrhage (aSAH). METHODS We retrospectively reviewed the clinical course of patients presenting to our institution for management of aSAH. Patient were segregated according to BMI< or ≥29.4, a value determined by Classification and Regression Tree analysis. Predictors of DCI and delayed infarction were identified using stepwise multivariate logistic regression analysis. RESULTS There were 161 patients included for analysis. Average BMI within our patient cohort was 28.9, with 67 patients presenting with a BMI of ≥29.4 on admission. DCI occurred in 50 patients (31.1%) and was complicated by delayed infarction in 15 patients (9.3%). On stepwise multivariate analysis, BMI ≥ 29.4 was independently associated with reduced likelihood of DCI (odds ratio [OR] 0.42, 95% confidence interval [CI] 0.18-0.92) and delayed infarction (OR 0.13, 95% CI 0.02-0.61; P = .008). Increasing maximum flow velocity on transcranial Doppler ultrasound was independently associated with increased odds of both DCI (Unit OR 1.19, 95% CI 1.09-1.30; P < .001) and delayed infarction (Unit OR 1.31, 95% CI 1.13-1.56; P < .001), while intracerebral hemorrhage was independently associated with increased odds of delayed infarction (OR 6.99, 95% CI 1.82-30.25; P = .005). CONCLUSION We report an association between elevated BMI and reduced incidence of DCI and delayed infarction, suggesting a protective effect of increasing BMI on the risk of ischemic complications after aSAH.
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Affiliation(s)
- Lorenzo Rinaldo
- Department of Neurosurgery, Mayo Clinic, Rochester, Minnesota
| | | | - Giuseppe Lanzino
- Department of Neurosurgery, Mayo Clinic, Rochester, Minnesota.,Department of Neurointerventional Radiology, Mayo Clinic, Rochester, Minnesota
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13
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High Operator and Hospital Volume Are Associated With a Decreased Risk of Death and Stroke After Carotid Revascularization: A Systematic Review and Meta-analysis. Ann Surg 2020; 269:631-641. [PMID: 30102632 DOI: 10.1097/sla.0000000000002880] [Citation(s) in RCA: 26] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
OBJECTIVE To examine the association between operator or hospital volume and procedural outcomes of carotid revascularization. BACKGROUND Operator and hospital volume have been proposed as determinants of outcome after carotid endarterectomy (CEA) or carotid artery stenting (CAS). The magnitude and clinical relevance of this relationship are debated. METHODS We systematically searched PubMed and EMBASE until August 21, 2017. The primary outcome was procedural (30 days, in-hospital, or perioperative) death or stroke. Obtained or estimated risk estimates were pooled with a generic inverse variance random-effects model. RESULTS We included 87 studies. A decreased risk of death or stroke following CEA was found for high compared to low operator volume with a pooled adjusted odds ratio (OR) of 0.50 (95% confidence interval [CI] 0.28-0.87; 3 cohorts), and a pooled unadjusted relative risk (RR) of 0.59 (95% CI 0.42-0.83; 9 cohorts); for high compared to low hospital volume with a pooled adjusted OR of 0.62 (95% CI 0.42-0.90; 5 cohorts), and a pooled unadjusted RR of 0.68 (95% CI 0.51-0.92; 9 cohorts). A decreased risk of death or stroke after CAS was found for high compared to low operator volume with an adjusted OR of 0.43 (95% CI 0.20-0.95; 1 cohort), and an unadjusted RR of 0.50 (95% CI 0.32-0.79; 1 cohort); for high compared to low hospital volume with an adjusted OR of 0.46 (95% CI 0.26-0.80; 1 cohort), and no significant decreased risk in a pooled unadjusted RR of 0.72 (95% CI 0.49-1.06; 2 cohorts). CONCLUSIONS We found a decreased risk of procedural death and stroke after CEA and CAS for high operator and high hospital volume, indicating that aiming for a high volume may help to reduce procedural complications. REGISTRATION This systematic review has been registered in the international prospective registry of systematic reviews (PROSPERO): CRD42017051491.
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14
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Liu X, Zhang W, Wang L, Wang S, Yu Y, Chen S, Ao H. Male patients with diabetes undergoing coronary artery bypass grafting have increased major adverse cerebral and cardiovascular events. Interact Cardiovasc Thorac Surg 2019; 28:607-612. [PMID: 30325425 DOI: 10.1093/icvts/ivy287] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2018] [Revised: 08/20/2018] [Accepted: 08/29/2018] [Indexed: 11/13/2022] Open
Abstract
OBJECTIVES The role of body mass index (BMI) in the prognosis of patients with diabetes undergoing coronary artery bypass grafting (CABG) has been of great interest for a long time. However, the precise relationship between BMI and major adverse cerebral and cardiovascular events (MACCEs) in these patients is still unclear. The goal of this study was to investigate the outcome of patients with diabetes with different BMIs undergoing CABG and the results from the 5-year follow-up. METHODS This study included 771 patients with diabetes undergoing CABG from 1 January 2003 to 31 December 2009. They were classified based on the Chinese standard for BMI as follows: underweight: <18.5 kg/m2; normal weight: 18.5-23.9 kg/m2; overweight: 24-27.9 kg/m2; and obese: >28 kg/m2. Short-term outcomes and 5-year MACCEs were compared among various BMI groups after surgery. RESULTS Obese and overweight patients with diabetes tended to be younger than normal weight patients [57 years (49-64) vs 62 years (54-68) and 64 years (59-69); P < 0.001]. There were fewer male patients (25.20% vs 17.78% and 16.54%, P = 0.041). More smokers were in the 2 groups (38.8% vs 51.55% and 57.14%, P < 0.001). Glucose concentration was highest in the overweight group [6.40 (5.40-7.80) vs 6.96 (5.69-8.22) and 6.80 (5.90-8.40); P = 0.041)]. Cox regression analysis of the 5-year follow-up data indicated that various BMI groups were not associated with significant differences in 5-year MACCEs; however, male sex was the risk factor for MACCEs (hazard ratio 1.83, 95% confidence interval 1.11-3.04; P = 0.019). CONCLUSIONS The BMI of the patients with diabetes undergoing CABG had no effect on MACCEs. Male sex was the risk factor in these patients.
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Affiliation(s)
- Xiaojie Liu
- Department of Anesthesiology, State Key Laboratory of Cardiovascular Disease, National Clinical Research Center of Cardiovascular Diseases, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences, Peking Union Medical College, Beijing, China
| | - Wenyuan Zhang
- Department of Anesthesiology, The First affiliated Hospital, Nanchang University, Nanchang, China
| | - Lijuan Wang
- Department of Anesthesiology, State Key Laboratory of Cardiovascular Disease, National Clinical Research Center of Cardiovascular Diseases, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences, Peking Union Medical College, Beijing, China
| | - Sudena Wang
- Department of Anesthesiology, State Key Laboratory of Cardiovascular Disease, National Clinical Research Center of Cardiovascular Diseases, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences, Peking Union Medical College, Beijing, China
| | - Yang Yu
- Department of Anesthesiology, State Key Laboratory of Cardiovascular Disease, National Clinical Research Center of Cardiovascular Diseases, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences, Peking Union Medical College, Beijing, China
| | - Sipeng Chen
- The Department of Information Center, State Key Laboratory of Cardiovascular Disease, National Clinical Research Center of Cardiovascular Diseases, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences, Peking Union Medical College, Beijing, China
| | - Hushan Ao
- Department of Anesthesiology, State Key Laboratory of Cardiovascular Disease, National Clinical Research Center of Cardiovascular Diseases, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences, Peking Union Medical College, Beijing, China
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15
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Batchelder AJ, Saratzis A, Ross Naylor A. Editor's Choice - Overview of Primary and Secondary Analyses From 20 Randomised Controlled Trials Comparing Carotid Artery Stenting With Carotid Endarterectomy. Eur J Vasc Endovasc Surg 2019; 58:479-493. [PMID: 31492510 DOI: 10.1016/j.ejvs.2019.06.003] [Citation(s) in RCA: 46] [Impact Index Per Article: 9.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2018] [Revised: 05/30/2019] [Accepted: 06/05/2019] [Indexed: 12/19/2022]
Abstract
OBJECTIVES The aim of this review was to carry out primary and secondary analyses of 20 randomised controlled trials (RCTs) comparing carotid endarterectomy (CEA) with carotid artery stenting (CAS). METHODS A systematic review and meta-analysis of data from 20 RCTs (126 publications) was carried out. RESULTS Compared with CEA, the 30 day death/stroke rate was significantly higher after CAS in seven RCTs involving 3467 asymptomatic patients (odds ratio [OR] 1.64, 95% confidence interval [CI] 1.02-2.64) and in 10 RCTs involving 5797 symptomatic patients (OR 1.71, 95% CI 1.38-2.11). Excluding procedural risks, late ipsilateral stroke was about 4% at 9 years for both CEA and CAS, i.e., CAS was durable. Reducing procedural death/stroke after CAS may be achieved through better case selection, e.g., performing CEA in (i) symptomatic patients aged > 70 years; (ii) interventions within 14 days of symptom onset; and (iii) situations where stroke risk after CAS is predicted to be higher (segmental/remote plaques, plaque length > 13 mm, heavy burden of white matter lesions [WMLs], where two or more stents might be needed). New WMLs were significantly more common after CAS (52% vs. 17%) and were associated with higher rates of late stroke/transient ischaemic attack (23% vs. 9%), but there was no evidence that new WMLs predisposed towards late cognitive impairment. Restenoses were more common after CAS (10%) but did not increase late ipsilateral stroke. Restenoses (70%-99%) after CEA were associated with a small but significant increase in late ipsilateral stroke (OR 3.87, 95% CI 1.96-7.67; p < .001). CONCLUSIONS CAS confers higher rates of 30 day death/stroke than CEA. After 30 days, ipsilateral stroke is virtually identical for CEA and CAS. Key issues to be resolved include the following: (i) Will newer stent technologies and improved cerebral protection allow CAS to be performed < 14 days after symptom onset with risks similar to CEA? (ii) What is the optimal volume of CAS procedures to maintain competency? (iii) How to deliver better risk factor control and best medical treatment? (iv) Is there a role for CEA/CAS in preventing/reversing cognitive impairment?
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Affiliation(s)
| | | | - A Ross Naylor
- The Leicester Vascular Institute, Glenfield Hospital, Leicester, UK.
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16
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Oksala NK, Lindström I, Khan N, Pihlajaniemi VJ, Lyytikäinen LP, Pienimäki JP, Hernesniemi J. Pre-Operative Masseter Area is an Independent Predictor of Long-Term Survival after Carotid Endarterectomy. Eur J Vasc Endovasc Surg 2019; 57:331-338. [DOI: 10.1016/j.ejvs.2018.11.011] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2018] [Accepted: 11/18/2018] [Indexed: 01/09/2023]
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17
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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: 12] [Impact Index Per Article: 1.7] [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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