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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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Pini R, Faggioli G, Muscari A, Rocchi C, Palermo S, Vacirca A, Gallitto E, Gargiulo M. Carotid Endarterectomy is often not Possible after an Unheralded Stroke: Unheralded Stroke in Carotid Artery Stenosis. J Stroke Cerebrovasc Dis 2021; 30:105594. [PMID: 33429239 DOI: 10.1016/j.jstrokecerebrovasdis.2020.105594] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2020] [Revised: 12/16/2020] [Accepted: 12/27/2020] [Indexed: 11/26/2022] Open
Abstract
OBJECTIVES The ongoing literature recommends carotid endarterectomy (CEA) primarily for patients with neurological symptoms, however CEA can be precluded by the onset of a severe stroke or a total carotid occlusion. The present study aims to evaluate the effect of unheralded strokes in patients with a previously asymptomatic carotid stenosis (ACS) possibly considered for CEA. MATERIALS AND METHODS From 2009 to 2019, patients with an unheralded stroke from an ACS were considered. By neurological examination, patients were divided in unfit-for-CEA (uCEA) - either for the severity of the stroke (according to modified Rankin-Scale - mRS) or the onset of a total carotid occlusion - and patients submitted to CEA. Predictors for uCEA and stroke severity were evaluated. RESULTS Over a total of 532 patients with symptomatic carotid stenosis, 277 (52%) with unheralded stroke were included in the study. One hundred and one (36%) were considered uCEA: 64(23%) due to their neurological conditions (mRS:5) and 37 (13%) because of the onset of carotid occlusion. One hundred seventy-six (64%) patients underwent CEA. The preoperative medical therapy was similar in uCEA vs CEA patients. Age≥80 years and female sex were independently associated with uCEA (OR:5.9, 95%CI:3.1-11.4, P<.01; OR:3.9, 95%CI:2.0-7.6, P<.01. respectively). Patients submitted to CEA had mRS: 0-2 in 102(37%) cases and mRS:3-4 in 74 (27%). The contralateral carotid occlusion (CCO) was independently associated with mRS:3-4 (OR:8.4, 95%CI 1.8-79, P=.01). Postoperative stroke rate after CEA was 2.9% (4/167); patients with preoperative mRS:3-4 had a higher risk for postoperative stroke compared to those with mRS:0-2 (5.9% vs. 0%. P=.02). CONCLUSIONS An unheralded stroke in patients with ACS leads to a severe neurological damage in more than half of cases, either precluding CEA (36%) or increasing the risk of postoperative complications (27%). Female sex, age≥80 and CCO are independent predictors of these occurrences and should be considered in ACS patients.
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Affiliation(s)
- Rodolfo Pini
- Division of Vascular Surgery, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Italy.
| | - Gianluca Faggioli
- Division of Vascular Surgery, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Italy
| | - Antonio Muscari
- Department of Medical and Surgical Science, University of Bologna, Italy
| | - Cristina Rocchi
- Division of Vascular Surgery, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Italy
| | - Sergio Palermo
- Division of Vascular Surgery, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Italy
| | - Andrea Vacirca
- Division of Vascular Surgery, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Italy
| | - Enrico Gallitto
- Division of Vascular Surgery, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Italy
| | - Mauro Gargiulo
- Division of Vascular Surgery, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Italy
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Pini R, Vacirca A, Palermo S, Gallitto E, Mascoli C, Gargiulo M, Faggioli G. Impact of cerebral ischemic lesions on the outcome of carotid endarterectomy. ANNALS OF TRANSLATIONAL MEDICINE 2020; 8:1264. [PMID: 33178796 PMCID: PMC7607094 DOI: 10.21037/atm-20-1098] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Patients with carotid artery stenosis (CAS) are commonly defined as asymptomatic or symptomatic according with their neurological conditions, however, emerging evidences suggest stratifying patients according also with the presence of cerebral ischemic lesions (CIL). In asymptomatic patients, the presence of CIL increases the risk of future neurologic event from 1% to 4% per year, leading to a stronger indication to carotid revascularization. In symptomatic patients, the presence of CIL does not seem to influence the outcome of the carotid revascularization if the volume of the lesion is small (<4,000 mm3); the benefit of the revascularization is also more significant if performed within 2 weeks from the index event. However, high volume (>4,000 mm3) CIL are associated in some experiences with a higher risk of carotid revascularization suggesting to delay the carotid revascularization for at least 4 weeks. As a matter of fact, the evaluation of CIL dimensions and characteristics in patients with CAS gives to the physician involved in the treatment a valuable adjunctive tool in the choice of the ideal treatment.
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Affiliation(s)
- Rodolfo Pini
- Vascular Surgery, Department of Experimental, Diagnostic and Specialty Medicine, DIMES, University of Bologna, Bologna, Italy
| | - Andrea Vacirca
- Vascular Surgery, Department of Experimental, Diagnostic and Specialty Medicine, DIMES, University of Bologna, Bologna, Italy
| | - Sergio Palermo
- Vascular Surgery, Department of Experimental, Diagnostic and Specialty Medicine, DIMES, University of Bologna, Bologna, Italy
| | - Enrico Gallitto
- Vascular Surgery, Department of Experimental, Diagnostic and Specialty Medicine, DIMES, University of Bologna, Bologna, Italy
| | - Chiara Mascoli
- Vascular Surgery, Department of Experimental, Diagnostic and Specialty Medicine, DIMES, University of Bologna, Bologna, Italy
| | - Mauro Gargiulo
- Vascular Surgery, Department of Experimental, Diagnostic and Specialty Medicine, DIMES, University of Bologna, Bologna, Italy
| | - Gianluca Faggioli
- Vascular Surgery, Department of Experimental, Diagnostic and Specialty Medicine, DIMES, University of Bologna, Bologna, Italy
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