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Penton A, Lin J, Kolde G, DeJong M, Blecha M. Investigation of Combined Carotid Endarterectomy and Coronary Artery Bypass Graft Surgery Outcomes and Adverse Event Risk Factors in the Vascular Quality Initiative. Vasc Endovascular Surg 2023; 57:884-900. [PMID: 37303074 PMCID: PMC10756645 DOI: 10.1177/15385744231183741] [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] [Indexed: 06/13/2023]
Abstract
OBJECTIVE The purpose of this study was to investigate outcomes of simultaneous CEA and CABG utilizing the Vascular Quality Initiative (VQI). Additionally, we seek to investigate risks for both perioperative and long-term mortality and adverse neurological outcomes. METHODS All carotid endarterectomies in the VQI between January 2003 and May 2022 were queried. We identified 171,816 CEA in the database. We extracted 2 cohorts from these CEA. The first group was patients who underwent simultaneous carotid endarterectomy (CEA) and coronary artery bypass (CABG) (N = 3137). The second group encompassed patients who underwent CABG or percutaneous coronary artery angioplasty/stent within 5 years of ultimately undergoing CEA (N = 27,387). We investigated the following outcomes in a multivariable fashion: 1. Risks for mortality in long term follow-up for both cohorts combined; 2. Risks for ischemic event in the cerebral hemisphere ipsilateral to the CEA site after index hospital admission in follow up for both cohorts combined. Tertiary outcomes are also investigated in the manuscript. RESULTS On multivariable analysis, patients undergoing simultaneous combined CEA and CABG had equivalent long-term survival to patients who underwent coronary revascularization within 5 years of ultimately undergoing CEA. Five-year survival is noted to be 84.5% vs 86% with a Cox regression non-significant P-value (.203). Significant multivariable risks for reduced long term survival (P < .03 for all) included: advancing age (HR 2.48/year); smoking history (HR 1.26); Diabetes (HR 1.33); history of CHF (HR 1.66); history of COPD (HR 1.54); baseline renal insufficiency at the time of surgery (HR 1.30); anemia (HR1.64); lack of preoperative aspirin (HR 1.12); and lack of preoperative statin (HR 1.32); lack of patch placement at CEA site (HR 1.16); perioperative MI (HR 2.04); perioperative CHF (1.66); perioperative dysrhythmia (HR 1.36); cerebral reperfusion injury (HR 2.23); perioperative ischemic neurological event (HR 2.48); and lack of statin at discharge (HR 2.04). Amongst patients with documented neurological status in follow up, combined CEA and CABG had over 99% freedom from ischemic cerebral event ipsilateral to the CEA site after discharge. CONCLUSIONS Combined CEA and CABG provides excellent long-term mortality prevention in patients with co-existing severe coronary and carotid atherosclerosis. Simultaneous CEA and CABG provides equivalent stroke prevention and long-term survival to both a cohort of patients undergoing coronary revascularization within 5 years of CEA and patients undergoing isolated CEA or CABG in the literature. The two most impactful modifiable risk factors towards long-term stroke and mortality prevention for patients undergoing simultaneous CEA-CABG are patch placement at CEA site and adherence to statin medication therapy.
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Affiliation(s)
- Ashley Penton
- Department of Sugery, Loyola University Medical Center, Maywood, IL, USA
| | - Jonathan Lin
- Loyola University Chicago Stritch School of Medicine, Maywood, IL, USA
| | - Grant Kolde
- Loyola University Chicago Stritch School of Medicine, Maywood, IL, USA
| | - Matthew DeJong
- Department of Sugery, Loyola University Medical Center, Maywood, IL, USA
| | - Matthew Blecha
- Division of Vascular Surgery and Endovascular Therapy, Maywood, IL, USA
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Meng Q, Li X, Zhao M, Lin S, Yu X, Dong G. Study on the Mechanism of Platelet-Released Clusterins Inducing Restenosis after Carotid Endarterectomy by Activating TLR3/NF- κb p65 Signaling Pathway. JOURNAL OF HEALTHCARE ENGINEERING 2022; 2022:7631126. [PMID: 35047156 PMCID: PMC8763522 DOI: 10.1155/2022/7631126] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/23/2021] [Revised: 12/08/2021] [Accepted: 12/18/2021] [Indexed: 11/18/2022]
Abstract
This study aimed to explore the role of clusterin released by platelet aggregation in restenosis after carotid endarterectomy. 35 patients who underwent carotid endarterectomy due to carotid artery stenosis were enrolled in this study. They were admitted to the Third Affiliated Hospital of Qiqihar Medical University from January 2018 to January 2019. All the patients were divided into two groups: the restenosis group and the nonrestenosis group, according to the follow-up results within 12 months. Peripheral blood was collected on the first day, 6 months, and 12 months after operation. The expression of CLU in serum of plasma and platelet culture medium was detected by an ELISA experiment. The vascular endothelial cells were cultured in vitro with 100 ng/mL of human recombinant CLU added to the medium. Cell proliferation, migration, and invasion were detected by CCK8, scratch, and Transwell invasion tests. The expression level of TLR3 and NF-κb p65 proteins in cells was detected by western blot. TLR3 knockout plasmids in vascular endothelial cell lines were transfected. Cell proliferation and migration were detected by CCK8 and the scratch assay. The CLU content in peripheral blood plasma and supernatant of platelet culture medium was significantly higher in the restenosis group than that of the control group (p=0.003) 6 months after operation (p=0.047) and 12 months after operation (p=0.011). When CLU was added to vascular endothelial cell culture medium, the proliferation and migration were significantly enhanced. The TLR3/NF-κb p65 protein expression level in cells also significantly increased. After the transfection of TLR3 knockout plasmids into vascular endothelial cell lines, CLU cannot promote the proliferation and migration of vascular endothelial cells. Platelet-released clusterin can induce vascular endothelial cell proliferation and migration by activating the TLR3/NF-kb p65 signaling pathway, leading to carotid artery restenosis after carotid endarterectomy.
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Affiliation(s)
- Qingyu Meng
- Vascular Surgery Department, The Third Affiliated Hospital of Qiqihar Medical University, Qiqihar 161000, China
| | - Xichun Li
- Vascular Surgery Department, The Third Affiliated Hospital of Qiqihar Medical University, Qiqihar 161000, China
| | - Mingyu Zhao
- Vascular Surgery Department, The Third Affiliated Hospital of Qiqihar Medical University, Qiqihar 161000, China
| | - Shusen Lin
- Vascular Surgery Department, The Third Affiliated Hospital of Qiqihar Medical University, Qiqihar 161000, China
| | - Xiangwen Yu
- Vascular Surgery Department, The Third Affiliated Hospital of Qiqihar Medical University, Qiqihar 161000, China
| | - Guanglong Dong
- Vascular Surgery Department, The Third Affiliated Hospital of Qiqihar Medical University, Qiqihar 161000, China
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Che F, Liu Y, Gong X, Wang A, Bai X, Ju Y, Sui B, Jing J, Geng X, Zhao X. Extracranial Carotid Plaque Hemorrhage Is Independently Associated With Poor 3-month Functional Outcome After Acute Ischemic Stroke-A Prospective Cohort Study. Front Neurol 2022; 12:780436. [PMID: 34970212 PMCID: PMC8712340 DOI: 10.3389/fneur.2021.780436] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2021] [Accepted: 11/15/2021] [Indexed: 11/14/2022] Open
Abstract
Background and Purpose: Carotid plaque hemorrhage (IPH) is a critical plaque vulnerable feature. We aim to elucidate the association between symptomatic extracranial carotid atherosclerotic IPH and poor 3-month functional outcome after acute ischemic stroke by high-resolution vessel wall MRI (HRVMRI). Methods: We prospectively studied consecutive patients with a recent stroke or transient ischemic attack (TIA) of carotid atherosclerotic origin. All patients underwent a High-Resolution (HR) VWMRI scan of ipsilateral extracranial carotid within 1 week after admission. The patients recruited were interviewed by telephone after 3 months after stroke onset. The primary outcome was a 3-month functional prognosis of stroke, expressed as a modified Rankin Scale (mRS) score. A poor prognosis was defined as a 3-month modified Rankin Scale (mRS) score ≥ of 3. Univariate analysis was used to analyze the correlation between risk factors and IPH. The relation between IPH and 3-month functional outcome was analyzed by Logistic regression analysis. Results: A total of 156 patients (mean age, 61.18 ± 10.12 years; 108 males) were included in the final analysis. There were significant differences in the age, gender, smoking history, national institutes of health stroke scale (NIHSS) on admission, and diastolic blood pressure (DBP) on admission between the IPH group and the non-IPH group (all p < 0.05). During the follow-up, 32 patients (20.5%) had a poor functional outcome. According to the prognosis analysis of poor functional recovery, there was a significant difference between the two groups [36.7 vs. 16.7%; unadjusted odds ratio (OR), 2.32, 95% confidence interval (CI), 1.12–4.81, p = 0.024). Even after adjusting for confounding factors [such as age, gender, smoking history, National Institutes of Health Stroke Scale (NIHSS) on admission, DBP on admission, stenosis rate of carotid artery (CA), calcification, loose matrix, lipo-rich necrotic core (LRNC), and statins accepted at 3 months], IPH was still a strong predictor of poor 3-month outcome, and the adjusted OR was 3.66 (95% CI 1.68–7.94, p = 0.001). Conclusions: Extracranial carotid IPH is significantly associated with poor 3-month outcome after acute ischemic stroke and can predict the poor 3-month functional prognosis.
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Affiliation(s)
- Fengli Che
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China.,Department of Neurology, Beijing Luhe Hospital, Capital Medical University, Beijing, China
| | - Yanfang Liu
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Xiping Gong
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Anxin Wang
- Tiantan Neuroimaging Center for Excellence, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Xiaoyan Bai
- Department of Neuroradiology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Yi Ju
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Binbin Sui
- Tiantan Neuroimaging Center for Excellence, Beijing Tiantan Hospital, Capital Medical University, Beijing, China.,Department of Neuroradiology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Jing Jing
- Tiantan Neuroimaging Center for Excellence, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Xiaokun Geng
- Department of Neurology, Beijing Luhe Hospital, Capital Medical University, Beijing, China.,Department of Neurology, China-America Institute of Neuroscience, Beijing, China
| | - Xingquan Zhao
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China.,Tiantan Neuroimaging Center for Excellence, Beijing Tiantan Hospital, Capital Medical University, Beijing, China.,Research Unit of Artificial Intelligence in Cerebrovascular Disease, Chinese Academy of Medical Sciences, Beijing, China
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Morgenstern LB, Zahuranec DB, Lim J, Shi X, Brown DL, Kerber KA, Meurer WJ, Skolarus LE, Adelman EE, Campbell MS, Case E, Lisabeth LD. Tissue-Based Stroke Definition Impacts Stroke Incidence but not Ethnic Differences. J Stroke Cerebrovasc Dis 2021; 30:105727. [PMID: 33761450 DOI: 10.1016/j.jstrokecerebrovasdis.2021.105727] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2021] [Revised: 02/28/2021] [Accepted: 03/01/2021] [Indexed: 10/21/2022] Open
Abstract
OBJECTIVES We explored how the new, tissue-based stroke definition impacted incidence estimates, including an ethnic comparison, in a population-based study. METHODS Stroke patients, May, 2014-May, 2016 in Nueces County, Texas were ascertained and validated using source documentation. Overall, ethnic-specific and age-specific Poisson regression models were used to compare first-ever ischemic stroke and intracerebral hemorrhage (ICH) incidence between old and new stroke definitions, adjusting for age, ethnicity, sex, and National Institutes of Health Stroke Scale score. RESULTS Among 1308 subjects, 1245 (95%) were defined as stroke by the old definition and 63 additional cases (5%) according to the new. There were 12 cases of parenchymal hematoma (PH1 or PH2) that were reclassified from ischemic stroke to ICH. Overall, incidence of ischemic stroke was slightly higher under the new compared to the old definition (RR 1.07; 95% CI 0.99-1.16); similarly higher in both Mexican Americans (RR 1.06; 95% CI 1.00-1.12) and Non Hispanic whites (RR 1.09, 95% CI 0.97-1.22), p(ethnic difference)=0.36. Overall, incidence of ICH was higher under the new definition compared to old definition (RR 1.16; 95% CI 1.05-1.29), similarly higher among both Mexican Americans (RR 1.14; 95% CI 1.06-1.23) and Non Hispanic whites (RR 1.20, 95% CI 1.03-1.39), p(ethnic difference)=0.25. CONCLUSION Modest increases in ischemic stroke and ICH incidence occurred using the new compared with old stroke definition. There were no differences between Mexican Americans and non Hispanic whites. These estimates provide stroke burden estimates for public health planning.
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Affiliation(s)
- Lewis B Morgenstern
- Stroke Program, Michigan Medicine, Ann Arbor, United States; Department of Epidemiology, University of Michigan School of Public Health, Ann Arbor, United States; Department of Emergency Medicine, Michigan Medicine, Ann Arbor, United States.
| | | | - Jaewon Lim
- Department of Biostatistics, University of Michigan School of Public Health, Ann Arbor, United States
| | - Xu Shi
- Department of Biostatistics, University of Michigan School of Public Health, Ann Arbor, United States
| | - Devin L Brown
- Stroke Program, Michigan Medicine, Ann Arbor, United States
| | - Kevin A Kerber
- Stroke Program, Michigan Medicine, Ann Arbor, United States
| | - William J Meurer
- Stroke Program, Michigan Medicine, Ann Arbor, United States; Department of Emergency Medicine, Michigan Medicine, Ann Arbor, United States
| | | | - Eric E Adelman
- Department of Neurology, University of Wisconsin, Madison, United States
| | | | - Erin Case
- Department of Epidemiology, University of Michigan School of Public Health, Ann Arbor, United States
| | - Lynda D Lisabeth
- Stroke Program, Michigan Medicine, Ann Arbor, United States; Department of Epidemiology, University of Michigan School of Public Health, Ann Arbor, United States
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den Brok MGHE, Kuhrij LS, Roozenbeek B, van der Lugt A, Hilkens PHE, Dippel DWJ, Nederkoorn PJ. Prevalence and risk factors of symptomatic carotid stenosis in patients with recent transient ischaemic attack or ischaemic stroke in the Netherlands. Eur Stroke J 2020; 5:271-277. [DOI: 10.1177/2396987320932065] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2020] [Accepted: 05/13/2020] [Indexed: 11/15/2022] Open
Abstract
Introduction Literature on prevalence of symptomatic internal carotid artery stenosis is scarce and heterogeneous. Prevalence may have decreased in recent years due to improved management of cardiovascular risk factors. We aim to estimate current prevalence and identify risk factors of ipsilateral internal carotid artery stenosis in patients with recent hemispheric transient ischaemic attack or ischaemic stroke in the Netherlands. Patients and methods We included consecutive adult patients admitted to two large hospitals in the Netherlands in 2014 who suffered from amaurosis fugax, retinal ischaemia, transient ischaemic attack or ischaemic stroke in the vessel territory of the internal carotid artery. Primary outcome was presence of ipsilateral internal carotid artery stenosis (degree subdivided following NASCET criteria), as assessed with duplex ultrasonography, computed tomography angiography and/or magnetic resonance angiography. We used univariable and multivariable logistic regression to identify risk factors for the presence of a 50–100% internal carotid artery stenosis. Results We analysed 883 consecutive patients with recent transient ischaemic attack or ischaemic stroke. Of these, 110 (12.5%) had 50–99% ipsilateral internal carotid artery stenosis. Subgroup analyses showed higher prevalence of any degree of internal carotid artery stenosis for male sex and White patients. In adjusted analyses, higher age (odds ratio 1.4/10 years; 95% confidence interval 1.16–1.63), male sex (odds ratio 2.8; 95% confidence interval 1.83–4.19), retinal ischaemia (odds ratio 2.5; 95% confidence interval 1.32–4.76) and current smoking (odds ratio 1.8; 95% confidence interval 1.09–2.79) were statistically significant risk factors for 50–100% internal carotid artery stenosis. Conclusion The prevalence of internal carotid artery stenosis seems to be lower in patients with recent transient ischaemic attack or ischaemic stroke than stated in previous studies. We found that higher age, male sex, White ethnicity, retinal ischaemia and current smoking were important risk factors for symptomatic internal carotid artery stenosis.
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Affiliation(s)
- Melina GHE den Brok
- Department of Neurology, Amsterdam University Medical Center, location AMC, Amsterdam, the Netherlands
- Department of Neurology, Radboud University Medical Center, Donders Institute for Brain, Cognition, and Behaviour, Nijmegen, the Netherlands
| | - Laurien S Kuhrij
- Department of Neurology, Amsterdam University Medical Center, location AMC, Amsterdam, the Netherlands
- Dutch Institute for Clinical Auditing, Leiden, the Netherlands
| | - Bob Roozenbeek
- Department of Neurology, Erasmus MC University Medical Center, Rotterdam, the Netherlands
- Department of Radiology & Nuclear Medicine, Erasmus MC University Medical Center, Rotterdam, the Netherlands
| | - Aad van der Lugt
- Department of Radiology & Nuclear Medicine, Erasmus MC University Medical Center, Rotterdam, the Netherlands
| | - Pieter HE Hilkens
- Department of Neurology, St. Antonius Medical Center, Nieuwegein, the Netherlands
| | - Diederik WJ Dippel
- Department of Neurology, Erasmus MC University Medical Center, Rotterdam, the Netherlands
| | - Paul J Nederkoorn
- Department of Neurology, Amsterdam University Medical Center, location AMC, Amsterdam, the Netherlands
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Suttie R, Woo MY, Park L, Nemnom MJ, Stotts G, Perry JJ. Can Emergency Physicians Perform Carotid Artery Point-of-Care Ultrasound to Detect Stenosis in Patients with TIA and Stroke? A Pilot Study. West J Emerg Med 2020; 21:626-632. [PMID: 32421511 PMCID: PMC7234698 DOI: 10.5811/westjem.2020.2.45137] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2019] [Accepted: 02/11/2020] [Indexed: 11/25/2022] Open
Abstract
Introduction Patients with severe, symptomatic carotid stenosis can have their subsequent stroke risk reduced by surgical intervention if performed soon after a transient ischemic attack (TIA) or stroke. Patients presenting to an emergency department (ED) without computed tomography angiography (CTA) with TIA/stroke, may require transfer to another hospital for imaging to rule out carotid artery stenosis. The objective of this study was to determine the test characteristics of carotid artery point-of-care ultrasound (POCUS) in detecting greater than 50% stenosis in patients presenting with TIA/stroke. Methods We conducted a prospective cohort study on a convenience sample of adult patients presenting to a comprehensive stroke centre with TIA or stroke between June–October 2017. Carotid POCUS was performed. Primary outcome measure, stenosis ≥ 50%, was determined by the final radiology report of CTA. A blinded POCUS expert separately reviewed the archived carotid POCUS scans. We calculated sensitivity and specificity for stenosis ≥ 50%. Results We conducted POCUS on 75 patients, of which 70 were included in our analyses. Of those 70, 14.3% were diagnosed with greater than 50% stenosis. Carotid POCUS performed as follows: sensitivity 70.0% (95% confidence interval [CI], 34.8%–93.3%); specificity 86.7% (95% CI, 75.4%–94.1%); positive likelihood ratio (LR +) 5.3 (95% CI, 1.2–9.3); negative likelihood ratio (LR−) 0.4 (95% CI, 0.0–0.7). The inter-rater reliability between POCUS performer interpretation and expert interpretation had moderate agreement (k = 0.68). Scans took a mean 6.2 ± 2.2 minutes to complete. Conclusion Carotid POCUS has low to moderate association with CTA for detection of carotid artery stenosis ≥ 50%. Further research and investigation is needed prior to widespread use of carotid POCUS in patients with acute cerebral ischemia. Additionally, external validity is likely affected by availability of training, maintenance of competency, and experience in more rural centres.
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Affiliation(s)
- Robert Suttie
- University of Ottawa, Department of Emergency Medicine, Ontario, Canada
| | - Michael Y Woo
- University of Ottawa, Department of Emergency Medicine, Ontario, Canada.,The Ottawa Hospital Research Institute, Ontario, Canada
| | - Lily Park
- University of Ottawa, Department of Emergency Medicine, Ontario, Canada
| | | | - Grant Stotts
- The Ottawa Hospital Research Institute, Ontario, Canada.,University of Ottawa, Department of Medicine, Division of Neurology, Ontario, Canada
| | - Jeffrey J Perry
- University of Ottawa, Department of Emergency Medicine, Ontario, Canada.,The Ottawa Hospital Research Institute, Ontario, Canada
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