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Loufopoulos G, Manaki V, Tasoudis P, Meintanopoulos AS, Kouvelos G, Ntaios G, Spanos K. New Ischemic Cerebral Lesions in Postprocedural Magnetic Resonance Imaging in Carotid Artery Stenting Versus Carotid Endarterectomy: A Systematic Review and Meta-Analysis. Ann Vasc Surg 2024; 106:297-311. [PMID: 38825067 DOI: 10.1016/j.avsg.2024.05.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2024] [Revised: 05/12/2024] [Accepted: 05/15/2024] [Indexed: 06/04/2024]
Abstract
BACKGROUND Recent randomized controlled trials (RCTs) have demonstrated similar outcomes in terms of ischemic stroke incidence after carotid endarterectomy (CEA) or carotid artery stenting (CAS) in asymptomatic carotid disease, while CEA seems to be the first option for symptomatic carotid disease. The aim of this meta-analysis is to assess the incidence of silent cerebral microembolization detected by magnetic resonance imaging (MRI) following these procedures. METHODS A systematic search was conducted using PubMed, Scopus, and Cochrane databases, including comparative studies involving symptomatic or asymptomatic patients undergoing either CEA or CAS and reporting on new cerebral ischemic lesions in postoperative MRI. The primary outcome was the newly detected cerebral ischemic lesions. Pooled effect estimates for all outcomes were calculated using the random-effects model. Prespecified random effects metaregression and subgroup analysis were conducted to examine the impact of moderator variables on the presence of new cerebral ischemic lesions. RESULTS 25 studies reporting on a total of 1827 CEA and 1500 CAS interventions fulfilled the eligibility criteria. The incidence of new cerebral ischemic lesions was significantly lower after CEA compared to CAS, regardless of the time of MRI assessment (first 24 hours; OR: 0.33, 95% CI: 0.17-0.64, P < 0.001), (the first 72 hours, OR: 0.25, 95% CI 0.18-0.36, P < 0.001), (generally within a week after the operation; OR: 0.24, 95% CI: 0.17-0.34, P < 0.001). Also, the rate of stroke (OR: 0.38, 95% CI: 0.23-0.63, P < 0.001) and the presence of contralateral new cerebral ischemic lesions (OR: 0.16, 95% CI 0.08-0.32, P < 0.001) were less frequent after CEA. Subgroup analysis based on the study design and the use of embolic protection device during CAS showed consistently lower rates of new lesions after CEA. CONCLUSIONS CEA demonstrates significant lower rates of new silent cerebral microembolization, as detected by MRI in postoperative period compared with CAS.
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Affiliation(s)
- Georgios Loufopoulos
- Cardiothoracic and Vascular Surgery Working Group, Society of Junior Doctors, Athens, Greece; Department of Surgery, Saint Imier Hospital, Saint Imier, Switzerland.
| | - Vasiliki Manaki
- Cardiothoracic and Vascular Surgery Working Group, Society of Junior Doctors, Athens, Greece; Department of Vascular Surgery, Aristotle University of Thessaloniki, AHEPA University General Hospital, Thessaloniki, Greece
| | - Panagiotis Tasoudis
- Cardiothoracic and Vascular Surgery Working Group, Society of Junior Doctors, Athens, Greece; Division of Cardiothoracic Surgery, Department of Surgery, School of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, NC
| | | | - George Kouvelos
- Faculty of Medicine, Department of Vascular Surgery, University Hospital of Larissa, School of Health Sciences, University of Thessaly, Larissa, Greece
| | - George Ntaios
- Faculty of Medicine, Department of Internal Medicine, University Hospital of Larissa, School of Health Sciences, University of Thessaly, Larissa, Greece
| | - Konstantinos Spanos
- Faculty of Medicine, Department of Vascular Surgery, University Hospital of Larissa, School of Health Sciences, University of Thessaly, Larissa, Greece
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Pryamikov AD, Mironkov AB, Loluev RY, Khripun AI. [Carotid endarterectomy and carotid artery stenting in advanced age patients]. ZHURNAL VOPROSY NEĬROKHIRURGII IMENI N. N. BURDENKO 2021; 85:113-117. [PMID: 33560627 DOI: 10.17116/neiro202185011113] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
The manuscript is devoted to world experience of carotid endarterectomy and carotid artery stenting in advanced age patients. Some authors report the advantages of endovascular surgery in elderly patients while the others prefer carotid endarterectomy. Senile patients (75-80 years old) with asymptomatic internal carotid artery stenosis is one of the most difficult group for the management. This is due to a more complex assessment of perioperative surgical risk, high incidence of complicated atherosclerotic plaques in carotid arteries and dubious benefits of surgery considering short life expectancy and severe comorbidities. Accumulation of experience in the management of advanced age patients should be valuable for either optimizing or individualizing surgical strategy.
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Affiliation(s)
- A D Pryamikov
- Pirogov Russian National Research Medical University, Moscow, Russia.,Buyanov Clinical Hospital, Moscow, Russia
| | - A B Mironkov
- Pirogov Russian National Research Medical University, Moscow, Russia.,Buyanov Clinical Hospital, Moscow, Russia
| | - R Yu Loluev
- Pirogov Russian National Research Medical University, Moscow, Russia
| | - A I Khripun
- Pirogov Russian National Research Medical University, Moscow, Russia
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Feng Y, Bai X, Wang T, Wang Y, Chen Y, Li M, Hua Y, Ling F, Ma Y, Jiao L. Thirty-day outcomes of carotid endarterectomy in the elderly: A 17-year single-center study. J Clin Neurosci 2020; 78:86-90. [PMID: 32622649 DOI: 10.1016/j.jocn.2020.06.007] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2020] [Accepted: 06/06/2020] [Indexed: 12/25/2022]
Abstract
INTRODUCTION Carotid endarterectomy (CEA) has been supported as a durable procedure for treating patients with carotid artery stenosis by many randomized controlled trials (RCTs). The aim of this study was to evaluate the 30-day outcomes and risk factors for CEA in elderly patients with a retrospective single-center study. METHODS Our study sample consisted of patients from 2001 to 2017 CEA-targeted Xuanwu Hospital, Capital Medical University data set. The primary outcome was 30-day postoperative incidence of major adverse clinical events (MACEs; death, myocardial infarction (MI) and ipsilateral stroke). Univariable and multivariable analyses were performed to identify high-risk patients and procedural characteristics associated with MACEs. RESULTS A total of 348 elderly patients undergoing CEA for carotid artery stenosis were identified and analyzed. The incidence of postoperative MACEs was 4.6% (16 cases, included 1 death, 14 S, and 1 MI respectively) for elderly patients. Univariate analysis indicated symptomatic lesion (81.3% vs 55.7%, p = 0.044), diabetes mellitus (56.3% vs 26.8%, p = 0.011) and DBP (85.56 ± 11.26 mmHg vs 76.53 ± 9.51 mmHg, p < 0.001) were statistically significant with MACEs. On multivariable analysis, independent predictors of MACEs included diabetes mellitus (DM) (OR = 2.882; 95% CI = 1.005-8.266; P = 0.049) and higher diastolic blood pressure (DBP) (OR = 1.079; 95% CI = 1.025-1.136; P = 0.004). Symptomatic lesion was not an independent risk factor (OR = 2.805; 95% CI = 0.759-10.361; P = 0.122). CONCLUSIONS According to our single-center experience, CEA could be safely performed in elderly patients. Risk factors identified for MACEs in this special group patients were DM and higher DBP.
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Affiliation(s)
- Yao Feng
- Interventional Radiology Diagnosis and Treatment Center, Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Xuesong Bai
- Interventional Radiology Diagnosis and Treatment Center, Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Tao Wang
- Interventional Radiology Diagnosis and Treatment Center, Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Yabing Wang
- Interventional Radiology Diagnosis and Treatment Center, Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Yanfei Chen
- Interventional Radiology Diagnosis and Treatment Center, Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Meng Li
- Interventional Radiology Diagnosis and Treatment Center, Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Yang Hua
- Department of Vascular Ultrasonography, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Feng Ling
- Interventional Radiology Diagnosis and Treatment Center, Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Yan Ma
- Interventional Radiology Diagnosis and Treatment Center, Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Liqun Jiao
- Interventional Radiology Diagnosis and Treatment Center, Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, Beijing, China.
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Thirty-Day Outcome of Carotid Artery Stenting in Elderly Patients: A Single-Center Experience. World Neurosurg 2020; 138:e311-e316. [PMID: 32112939 DOI: 10.1016/j.wneu.2020.02.093] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2020] [Revised: 02/14/2020] [Accepted: 02/17/2020] [Indexed: 11/22/2022]
Abstract
BACKGROUND The safety of carotid artery stenting (CAS) in elderly patients is controversial. The aims of this study were to evaluate 30-day outcomes after CAS in elderly patients (≥70 years old) and to investigate risk factors for postoperative incidence of major adverse clinical events (MACE) to improve CAS safety based on clinical evidence in this specific subgroup of patients. METHODS The data set included patients who underwent CAS between 2001 and 2017 at Xuanwu Hospital, Capital Medical University. The primary outcome variable was 30-day postoperative incidence of the following MACE: death, myocardial infarction, and ipsilateral stroke. Univariate and multivariate analyses were performed to identify high-risk patients and procedural characteristics associated with MACE. RESULTS A total of 1029 elderly patients who underwent CAS for carotid artery stenosis were identified and analyzed. The incidence of postoperative MACE was 3.01% (n = 31 cases [5 deaths, 24 strokes, and 2 myocardial infarctions]). After multivariate analysis, independent predictors of MACE included a family history of stroke (odds ratio [OR] = 3.817; 95% confidence interval [CI], 1.227-11.876; P = 0.021), symptomatic status (OR = 2.650; 95% CI, 1.210-5.806; P = 0.015), and modified Rankin Scale score ≥3 (OR = 4.594; 95% CI, 1.708-12.352; P = 0.003). Hyperlipidemia was not an independent risk factor (OR = 1.597; 95% CI, 0.745-3.425; P = 0.229). CONCLUSIONS At our center, CAS was safely performed in elderly patients. A family history of stroke, symptomatic status, and modified Rankin Scale score ≥3 indicating a neurologic deficit increased the risk of 30-day postoperative MACE.
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Texakalidis P, Chaitidis N, Giannopoulos S, Giannopoulos S, Machinis T, Jabbour P, Rivet D, Reavey-Cantwell J, Rangel-Castilla L. Carotid Revascularization in Older Adults: A Systematic Review and Meta-Analysis. World Neurosurg 2019; 126:656-663.e1. [DOI: 10.1016/j.wneu.2019.02.030] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2018] [Revised: 02/04/2019] [Accepted: 02/06/2019] [Indexed: 11/24/2022]
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Long-Term Outcome After Carotid Endarterectomy in Patients with Ischemic Heart Disease. World Neurosurg 2017; 110:e806-e814. [PMID: 29180080 DOI: 10.1016/j.wneu.2017.11.092] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2017] [Revised: 11/16/2017] [Accepted: 11/18/2017] [Indexed: 12/17/2022]
Abstract
BACKGROUND The long-term outcome after carotid endarterectomy (CEA) is determined by many confounding factors. Ischemic heart disease (IHD) is linked to atherosclerotic stroke, and it is an important cause of death during the perioperative and follow-up periods after CEA. We aimed to investigate mortality and long-term major adverse cardiovascular events (MACEs) in patients with IHD compared with patients who do not have IHD. METHODS We consecutively enrolled 229 patients who underwent CEA procedures from 2000 to 2011. Of these patients, 45 had known or probable IHD defined by history or medical record of myocardial infarction, stable/unstable angina, previous coronary revascularization such as percutaneous coronary intervention or coronary artery bypass graft, or positive stress test. Long-term outcome was identified by using death certificates from the Korean National Statistical Office and telephone interviews by June 2013. We investigated predictors of early (≤30 days) and long-term mortality and MACEs (stroke, myocardial infarction, and death). RESULTS Mean follow-up period was 49 months. Cox proportional analysis adjusted for potent predictors revealed symptomatic stenosis (hazard ratio, 1.72; 95% confidence interval, 1.02-2.88; P = 0.042) and presence of IHD (hazard ratio, 1.93; 95% confidence interval, 1.09-3.42; P = 0.025) as significant predictors of long-term MACEs. Kaplan-Meier analysis showed a significantly lower rate of survival (P = 0.030) and MACE-free survival (P = 0.003) in the IHD group. CONCLUSIONS In this study, a poor long-term outcome was observed in patients with IHD and symptomatic stenosis but not in patients with conventional high-risk factors for surgery. Therefore, appropriate evaluation and treatment of IHD before and after CEA might be helpful for better outcome.
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Heo SH, Bushnell CD. Factors Influencing Decision Making for Carotid Endarterectomy versus Stenting in the Very Elderly. Front Neurol 2017; 8:220. [PMID: 28603515 PMCID: PMC5445117 DOI: 10.3389/fneur.2017.00220] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2017] [Accepted: 05/08/2017] [Indexed: 12/29/2022] Open
Abstract
As the population ages worldwide, the number of elderly patients with carotid stenosis is also increasing. There have been many large clinical trials comparing carotid endarterectomy (CAE) versus stenting, but the inclusion criteria (i.e., symptomatic or asymptomatic), stenting methods (i.e., protection device), and primary end point (i.e., the definition of myocardial infarction and follow-up period) were different between trials. Therefore, the interpretation of those results is difficult and requires attention. When it comes to age, the patients older than 80 years were excluded or stratified to a high risk group in previous landmark trials. However, a recent guideline recommended that endarterectomy may be associated with lower stroke risk compared with carotid artery stenting in patients older than 70 years with symptomatic carotid disease. The annual risk of stroke in individuals with asymptomatic carotid stenosis is about 1-3% but the risk is about 4-12% with symptomatic stenosis without carotid intervention. Although the outcome of CAE is better than that of carotid stenting in patients older than 70 years, the perioperative risk is higher in older patients. Therefore, it is important to classify high risk patients and consider underlying disability and life expectancy of very elderly patients before deciding whether to undergo a carotid intervention. In addition, we should also consider that the stroke rate with intensive medical treatment is unknown and is currently being investigated in randomized controlled trials. Intensive medical treatment includes high intensity statins, diabetes and blood pressure control, and aggressive antiplatelet treatment. The aim of this review is to report the factors that may be responsible for the variability in the treatment of carotid stenosis, particularly in the elderly population. This will allow the readers to integrate the current available evidence to individualize the treatment of carotid stenosis in this challenging population.
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Affiliation(s)
- Sung Hyuk Heo
- Department of Neurology, School of Medicine, Kyung Hee University, Seoul, South Korea
| | - Cheryl D. Bushnell
- Department of Neurology, Wake Forest School of Medicine, Winston-Salem, NC, United States
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Petr O, Brinjikji W, Murad MH, Glodny B, Lanzino G. Selective-versus-Standard Poststent Dilation for Carotid Artery Disease: A Systematic Review and Meta-Analysis. AJNR Am J Neuroradiol 2017; 38:999-1005. [PMID: 28302610 DOI: 10.3174/ajnr.a5103] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2016] [Accepted: 12/12/2016] [Indexed: 11/07/2022]
Abstract
BACKROUND The safety and efficacy of standard poststent angioplasty in patients undergoing carotid artery stent placement have not been well-established. PURPOSE We conducted a systematic review of the literature to evaluate the safety and efficacy of carotid artery stent placement and analyzed outcomes of standard-versus-selective poststent angioplasty. DATA SOURCES A systematic search of MEDLINE, EMBASE, Scopus, and the Web of Science was performed for studies published between January 2000 and January 2015. STUDY SELECTION We included studies with >30 patients describing standard or selective poststent angioplasty during carotid artery stent placement. DATA ANALYSIS A random-effects meta-analysis was used to pool the following outcomes: periprocedural stroke/TIA, procedure-related neurologic/cardiovascular morbidity/mortality, bradycardia/hypotension, long-term stroke at last follow-up, long-term primary patency, and technical success. DATA SYNTHESIS We included 87 studies with 19,684 patients with 20,378 carotid artery stenoses. There was no difference in clinical (P = .49) or angiographic outcomes (P = .93) in carotid artery stent placement treatment with selective or standard poststent balloon angioplasty. Both selective and standard poststent angioplasty groups had a very high technical success of >98% and a low procedure-related mortality of 0.9%. There were no significant differences between both groups in the incidence of restenosis (P = .93) or procedure-related complications (P = .37). LIMITATIONS No comparison to a patient group without poststent dilation could be performed. CONCLUSIONS Our meta-analysis demonstrated no significant difference in angiographic and clinical outcomes among series that performed standard poststent angioplasty and those that performed poststent angioplasty in only select patients.
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Affiliation(s)
- O Petr
- From the Departments of Neurologic Surgery (O.P., G.L.) .,Neurosurgery (O.P.), Medical University Innsbruck, Innsbruck, Austria
| | | | - M H Murad
- Division of Preventive Medicine (M.H.M.), Mayo Clinic, Rochester, Minnesota
| | | | - G Lanzino
- From the Departments of Neurologic Surgery (O.P., G.L.).,Radiology (W.B., G.L.)
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