1
|
Vellek J, Tarawneh OH, Kazim SF, Owodunni OP, Arbuiso S, Shah S, Dicpinigaitis AJ, Schmidt MH, McKee RG, Miskimins R, Al-Mufti F, Bowers CA. Andexanet alfa therapy showed No increased rate of thromboembolic events in spontaneous intracranial hemorrhage patients: A multicenter electronic health record study. World Neurosurg X 2024; 23:100367. [PMID: 38590738 PMCID: PMC10999854 DOI: 10.1016/j.wnsx.2024.100367] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2022] [Revised: 03/06/2024] [Accepted: 03/20/2024] [Indexed: 04/10/2024] Open
Abstract
•Intracranial hemorrhage accounts for two out of every three major intracranial hemorrhages.•Systemic anticoagulation is routinely prescribed for prevention of cerebrovascular accidents.•The FDA approved Andexanet alfa to treat life-threatening bleeding.•Andexanet alfa relationship to outcomes requires further investigation.
Collapse
Affiliation(s)
- John Vellek
- School of Medicine, New York Medical College, Valhalla, NY, 10595, United States
| | - Omar H. Tarawneh
- School of Medicine, New York Medical College, Valhalla, NY, 10595, United States
| | - Syed Faraz Kazim
- Department of Neurosurgery, University of New Mexico Hospital (UNMH), Albuquerque, NM, 87131, United States
| | - Oluwafemi P. Owodunni
- Department of Neurosurgery, University of New Mexico Hospital (UNMH), Albuquerque, NM, 87131, United States
| | - Sophia Arbuiso
- School of Medicine, New York Medical College, Valhalla, NY, 10595, United States
| | - Smit Shah
- PRISMA Health Richland/University of South Carolina School of Medicine, 1 Medical Park, Suite 230, Columbia, SC, 29203, United States
| | | | - Meic H. Schmidt
- Department of Neurosurgery, University of New Mexico Hospital (UNMH), Albuquerque, NM, 87131, United States
| | - Rohini G. McKee
- Department of Surgery, University of New Mexico, Albuquerque, NM, 87106, United States
| | - Richard Miskimins
- Department of Surgery, University of New Mexico, Albuquerque, NM, 87106, United States
| | - Fawaz Al-Mufti
- Department of Neurosurgery, Westchester Medical Center/New York Medical College, Valhalla, NY, 10595, United States
| | - Christian A. Bowers
- Bowers Neurosurgical Frailty and Outcomes Data Science Lab, Sandy, UT, United States
| |
Collapse
|
2
|
Hsu AC, Williams B, Ding L, Weaver FA, Han SM, Magee GA. Risk Factors for Cerebral Hyperperfusion Syndrome following Carotid Revascularization. Ann Vasc Surg 2023; 97:89-96. [PMID: 37356658 DOI: 10.1016/j.avsg.2023.06.006] [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: 03/23/2023] [Revised: 05/31/2023] [Accepted: 06/04/2023] [Indexed: 06/27/2023]
Abstract
BACKGROUND Cerebral hyperperfusion syndrome (CHS) is a rare but known complication of carotid revascularization that can result in severe postoperative disability and death. CHS is a well-described sequela of carotid endarterectomy (CEA) and, more recently, of transfemoral carotid artery stenting (TFCAS), but its incidence after transcarotid artery revascularization (TCAR) has not been delineated. The aims of this study were to determine the impact of procedure type (CEA versus TCAR versus TFCAS) on the development of CHS as well as to identify perioperative risk factors associated with CHS. METHODS The Society for Vascular Surgery Vascular Quality Initiative was queried for patients aged ≥18 years who underwent CEA, TCAR, or TFCAS from 2015-2021. Emergent procedures were excluded. The primary outcome was postoperative development of CHS, defined as the presence of postoperative seizures, intracerebral hemorrhage due to hyperperfusion, or both. Bivariate and multivariable logistic regression analyses were performed to identify factors associated with CHS. RESULTS 156,003 procedures were included (72.7% CEA, 12.4% TCAR, and 14.9% TFCAS). The incidence of CHS after CEA, TCAR, and TFCAS were 0.15%, 0.18%, and 0.53%, respectively. There was no significant difference in risk of CHS after TFCAS compared to CEA (odds ratio [OR]: 1.21; 95% confidence interval [CI] 0.76-1.92; P = 0.416), nor was there a difference between TCAR and CEA (OR: 0.91; 95% CI 0.57-1.45; P = 0.691). Perioperative risk factors associated with an increased risk of CHS included previous history of transient ischemic attack or stroke (OR: 2.50; 95% CI 1.69-3.68; P < 0.0001), necessity for urgent intervention within 48 hr (OR: 2.03; 95% CI 1.43-2.89; P < 0.0001), treatment of a total occlusion (OR: 3.80; 95% CI 1.16-12.47; P = 0.028), and need for postoperative intravenous blood pressure medication (OR: 5.45; 95% CI 3.97-7.48; P < 0.0001). Age, preoperative hypertension, degree of ipsilateral stenosis less than or equal to 99%, and history of prior carotid procedures were not statistically associated with an increased risk of CHS. Discharging patients on an angiotensin-converting enzyme inhibitor or angiotensin II receptor blocker was associated with a decreased risk of developing CHS (OR: 0.47; 95% CI 0.34-0.65; P < 0.0001). CONCLUSIONS Compared with CEA, TCAR and TFCAS were not statistically associated with an increased risk of postoperative CHS. Patients with a previous history of transient ischemic attack or stroke, who require urgent intervention or postoperative intravenous blood pressure medication, or who are treated for a total occlusion are at a higher risk of developing CHS. Using an angiotensin-converting enzyme inhibitor/angiotensin II receptor blocker on discharge appears to be protective against CHS and should be considered for the highest risk patients.
Collapse
Affiliation(s)
- Ashley C Hsu
- Division of Vascular Surgery and Endovascular Therapy, Keck Medicine of USC, Los Angeles, CA
| | - Brian Williams
- Department of Surgery, University of Southern California, Los Angeles, CA
| | - Li Ding
- Department of Population and Public Health Sciences, University of Southern California, Los Angeles, CA
| | - Fred A Weaver
- Division of Vascular Surgery and Endovascular Therapy, Keck Medicine of USC, Los Angeles, CA
| | - Sukgu M Han
- Division of Vascular Surgery and Endovascular Therapy, Keck Medicine of USC, Los Angeles, CA
| | - Gregory A Magee
- Division of Vascular Surgery and Endovascular Therapy, Keck Medicine of USC, Los Angeles, CA.
| |
Collapse
|
3
|
Marutani T, Kashiwazaki D, Yamamoto S, Akioka N, Hori E, Kuroda S. Therapeutic strategy of severe circular calcified carotid plaque with hemodynamic impairment: A patient treated by carotid endarterectomy following balloon angioplasty to prevent hyperperfusion. Surg Neurol Int 2022; 13:360. [PMID: 36128112 PMCID: PMC9479608 DOI: 10.25259/sni_417_2022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2022] [Accepted: 07/29/2022] [Indexed: 11/12/2022] Open
Abstract
Background: Cerebral hyperperfusion syndrome (HPS) is a serious complication. Recently, staged angioplasty has been reported as an effective strategy to avoid HPS. Severe calcification has been reported as contraindication of carotid artery stenting (CAS). In these cases, carotid endarterectomy (CEA) might be an alternative second stage treatment. We present a case of severe circular calcified plaque with hemodynamic impairments, treated with CEA following percutaneous transluminal angioplasty (PTA) to prevent HPS. Case Description: A 77-year-old woman presented with severe stenosis at the proximal left internal carotid artery. A CT scan of the neck demonstrated circular calcification. 123I-iodoamphetamine single-photon emission computed tomography (123I-IMP SPECT) showed reductions in cerebral blood flow (CBF) and cerebral vascular reserve in the left hemisphere. Staged therapy was subsequently performed as this patient had a high risk of HPS after conventional CAS or CEA. In the first stage, PTA was performed under local anesthesia. Two days after the procedure, 123I-IMP SPECT revealed improvements in CBF. There were no neurological morbidities. CEA was then performed under general anesthesia 7 days later, for the second stage. We found a calcified plaque with a large thrombus at its proximal end. A hematoxylin-eosin stain of the thrombus showed mostly intact and partially lytic blood cells. Postoperative 123I-IMP SPECT revealed CBF was improved, with no hyperperfusion immediately and 2 days after CEA. The patient was discharged with no neurological deficits. Conclusion: CEA following PTA for severe circular calcified plaque can be an alternative treatment strategy to prevent HPS. A disadvantage is the formation of thrombi. Early CEA should be considered if thrombus formation is suspected.
Collapse
|
4
|
Kwon DH, Jang SH, Park H, Sohn SI, Hong JH. Emergency Cervical Carotid Artery Stenting After Intravenous Thrombolysis in Patients With Hyperacute Ischemic Stroke. J Korean Med Sci 2022; 37:e156. [PMID: 35578588 PMCID: PMC9110268 DOI: 10.3346/jkms.2022.37.e156] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/04/2022] [Accepted: 04/15/2022] [Indexed: 12/03/2022] Open
Abstract
BACKGROUND Intravenous recombinant tissue plasminogen activator (IV rtPA) is the mainstay of treatment for acute ischemic stroke to recanalize thrombosed intracranial vessels within 4.5 hours. Emergency carotid artery stenting for the treatment of acute stroke due to steno-occlusion of the proximal internal carotid artery (ICA) can improve symptoms, prevent neurological deterioration, and reduce recurrent stroke risk. The feasibility and safety of the combination therapy of IV rtPA and urgent carotid artery stenting have not been established. METHODS From November 2005 to October 2020, we retrospectively assessed patients who had undergone emergent carotid artery stenting after IV rtPA for hyperacute ischemic stroke due to steno-occlusive proximal ICA lesion. Hemorrhagic transformation, successful recanalization, modified Rankin Scale (mRS) score at 90 days, and stent patency at 3 and 12 months or longer were evaluated. Favorable outcome was defined as a 90-days mRS score of ≤ 2. RESULTS Nineteen patients with hyperacute stroke had undergone emergent carotid artery stenting after IV rtPA therapy. Their median age was 70 (67.5-73.5) years (94.7% men). Among 15 patients with an additional intracranial occlusion after flow restoration in the proximal ICA, a modified TICI grade ≥ 2b was achieved in 11 patients (73.3%). Hemorrhagic transformation occurred in five patients (26.3%); mortality rate was 5.7%. Eleven patients (57.9%) had favorable outcomes at 90 days. Stent patients (94.1%) maintained stent patency for ≥ 12 months. CONCLUSION We showed that emergent carotid artery stenting after IV rtPA therapy for hyperacute stroke caused by atherosclerotic proximal ICA steno-occlusion was feasible and safe.
Collapse
Affiliation(s)
- Doo Hyuk Kwon
- Department of Neurology, Yeungnam University College of Medicine, Daegu, Korea
- Department of Neurology, Keimyung University School of Medicine, Daegu, Korea
| | - Seong Hwa Jang
- Department of Neurology, Keimyung University School of Medicine, Daegu, Korea
| | - Hyungjong Park
- Department of Neurology, Keimyung University School of Medicine, Daegu, Korea
| | - Sung-Il Sohn
- Department of Neurology, Keimyung University School of Medicine, Daegu, Korea
| | - Jeong-Ho Hong
- Department of Neurology, Keimyung University School of Medicine, Daegu, Korea.
| |
Collapse
|
5
|
Zheng L, Li J, Liu H, Guo H, Zhao L, Bai H, Yan Z, Qu Y. Perioperative Blood Pressure Control in Carotid Artery Stenosis Patients With Carotid Angioplasty Stenting: A Retrospective Analysis of 173 Cases. Front Neurol 2020; 11:567623. [PMID: 33193006 PMCID: PMC7661555 DOI: 10.3389/fneur.2020.567623] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2020] [Accepted: 09/30/2020] [Indexed: 01/03/2023] Open
Abstract
Background: Carotid angioplasty stenting (CAS) is a currently widely used surgical treatment of carotid artery stenosis. However, the influences of the perioperative blood pressure (BP) on patients' prognosis remain unclear. Objective: The present study was designed to explore the effects of different perioperative BP control strategies on CAS patients' prognosis. Methods: One hundred seventy-three consecutive patients admitted between January 2016 and April 2019 were reviewed retrospectively. The outcomes of patients with different systolic BP (<120, 120–130, and >130 mmHg) before CAS and within 24 h after CAS were compared. The primary outcomes were the incidence of secondary cerebral infarction (CI) and intracranial hemorrhage (ICH) after CAS. The secondary outcome was the incidence of unfavorable discharge and in-hospital death. The unfavorable discharge was defined as modified Rankin Scale (mRS) score 3–5 at discharge. Results: There was no significant difference between the incidences of ICH (P = 0.803) and CI (P = 0.410) in patients with different BP before CAS. The patients with post-CAS BP values of >130 mmHg had a 37.67-fold increased risk (95% CI: 6.79–209.01) of ICH compared with others, while no significant difference was observed on the incidence of CI (P = 0.174) among patients with different post-CAS BP values. The patients with post-CAS BP values of >130 mmHg also had a significantly higher incidence of unfavorable discharge (P = 0.002) and in-hospital death (P = 0.001) compared with others. Conclusion: High BP (>130 mmHg) within 24 h after CAS significantly increases the risks of secondary cerebral hemorrhage, unfavorable discharge, and in-hospital death. Thus, the BP should be controlled below 130 mmHg in the first 24 h after CAS.
Collapse
Affiliation(s)
- Longlong Zheng
- Department of Neurosurgery, Tangdu Hospital, The Fourth Military Medical University, Xi'an, China
| | - Jiang Li
- Department of Neurosurgery, Tangdu Hospital, The Fourth Military Medical University, Xi'an, China
| | - Haixiao Liu
- Department of Neurosurgery, Tangdu Hospital, The Fourth Military Medical University, Xi'an, China
| | - Hao Guo
- Department of Neurosurgery, Tangdu Hospital, The Fourth Military Medical University, Xi'an, China
| | - Lei Zhao
- Department of Neurosurgery, Tangdu Hospital, The Fourth Military Medical University, Xi'an, China
| | - Hao Bai
- Department of Neurosurgery, Tangdu Hospital, The Fourth Military Medical University, Xi'an, China
| | - Zhongjun Yan
- Department of Neurosurgery, Tangdu Hospital, The Fourth Military Medical University, Xi'an, China
| | - Yan Qu
- Department of Neurosurgery, Tangdu Hospital, The Fourth Military Medical University, Xi'an, China
| |
Collapse
|
6
|
Mo D, Jia B, Shi H, Sun Y, Liu Q, Fan C, Deng J, Yuan J, Wu W, Jiang C, Zhang G, Du H, Ma N, Gao F, Sun X, Song L, Liu L, Peng G, Wang Y, Wang Y, Miao Z. Staged angioplasty versus regular carotid artery stenting in patients with carotid artery stenosis at high risk of hyperperfusion: a randomised clinical trial. Stroke Vasc Neurol 2020; 6:95-102. [PMID: 32973113 PMCID: PMC8005890 DOI: 10.1136/svn-2020-000391] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2020] [Revised: 07/29/2020] [Accepted: 08/03/2020] [Indexed: 11/13/2022] Open
Abstract
Background and purpose Hyperperfusion (HP) is a devastating complication associated with carotid artery stenting (CAS) or endarterectomy. The efficacy and safety of staged angioplasty (SAP) in patients with CAS at high risk of HP remains unclear. We sought to determine whether SAP is superior to regular CAS in patients with high risk of HP. Methods A randomised, multicentre open-label clinical trial with blinded outcome assessment (STEP) was conducted. Patients with severe carotid stenosis at high risk of HP were randomly assigned (1:1) to the SAP or regular CAS group. The primary endpoint was hyperperfusion syndrome (HPS) and intracerebral haemorrhage (ICH) within 30 days after the procedure. Results From November 2014 to January 2017, a total of 64 patients were enrolled in 11 centres. 33 patients were allocated to the SAP group and 31 to the regular CAS group. At 30 days, the rate of primary endpoint was 0.0% (0/33) in the SAP group and 9.7% (3/31) in the regular CAS group (absolute risk reduction (ARR), 9.7%; 95% CI −20.1% to 0.7%; p=0.11). As one of the secondary endpoints, the incidence of HP phenomenon (HPP) was lower in the SAP group than the regular CAS group (0.0% vs 22.6%, ARR,−22.6%; 95% CI −36.8% to −10.2%; p=0.04). Conclusion The rate of HPS and ICH was not significantly lower in SAP group; the extended secondary endpoint of HPP, however, significantly reduced, which suggested that SAP may be a safe and effective carotid revascularisation procedure to prevent HP. Trial registration number NCT02224209.
Collapse
Affiliation(s)
- Dapeng Mo
- Interventional Neuroradiology, Beijing Tiantan Hospital, Beijing, China
| | - Baixue Jia
- Interventional Neuroradiology, Beijing Tiantan Hospital, Beijing, China
| | - Huaizhang Shi
- Neurosurgery, First Affiliated Hospital of Harbin Medical University, Harbin, China
| | - Yaxuan Sun
- Neurology, Shaanxi Provincial People's Hospital, Xi'an, China
| | - Qingan Liu
- Neurosurgery, Harbin Medical University Fourth Hospital, Harbin, China
| | - Chengzhe Fan
- Neurology, Beijing An Zhen Hospital, Beijing, China
| | - Jianping Deng
- Neurosurgery, Tangdu Hospital, The Second Affiliated Hospital, Fourth Military Medical University, Xi'an, China
| | - Jinglin Yuan
- Neurology, Daxing Teaching Hospital, Capital Medical University, Beijing, China
| | - Wei Wu
- Neurology, Shandong University Qilu Hospital, Jinan, China
| | | | - Guilian Zhang
- Neurology, Xi'an Jiaotong University Second Affiliated Hospital, Xi'an, China
| | - Hanjun Du
- Neurology, Peking University Shougang Hospital, Beijing, China
| | - Ning Ma
- Interventional Neuroradiology, Beijing Tiantan Hospital, Beijing, China
| | - Feng Gao
- Interventional Neuroradiology, Beijing Tiantan Hospital, Beijing, China
| | - Xuan Sun
- Interventional Neuroradiology, Beijing Tiantan Hospital, Beijing, China
| | - Ligang Song
- Interventional Neuroradiology, Beijing Tiantan Hospital, Beijing, China
| | - Lian Liu
- Interventional Neuroradiology, Beijing Tiantan Hospital, Beijing, China
| | - Guangge Peng
- Interventional Neuroradiology, Beijing Tiantan Hospital, Beijing, China
| | - Yongjun Wang
- China National Clinical Research Center for Neurological Diseases, Beijing Tiantan Hospital, Beijing, China.,Neurology, Beijing Tiantan Hospital, Beijing, China
| | - Yilong Wang
- China National Clinical Research Center for Neurological Diseases, Beijing Tiantan Hospital, Beijing, China.,Neurology, Beijing Tiantan Hospital, Beijing, China
| | - Zhongrong Miao
- Interventional Neuroradiology, Beijing Tiantan Hospital, Beijing, China
| | | |
Collapse
|
7
|
Singh R, Dekeyzer S, Reich A, Kotelis D, Gombert A, Wiesmann M, Nikoubashman O. Emergency Carotid Endarterectomy Instead of Carotid Artery Stenting Reduces Delayed Hemorrhage in Thrombectomy Stroke Patients. Clin Neuroradiol 2020; 31:737-744. [PMID: 32940724 PMCID: PMC8463364 DOI: 10.1007/s00062-020-00954-7] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2020] [Accepted: 08/13/2020] [Indexed: 11/26/2022]
Abstract
PURPOSE Data in the literature suggest that thrombectomy with emergency carotid artery stenting (CAS) in acute stroke is associated with an increased hemorrhage rate. As we perform thrombectomy with the patient under general anesthesia, we avoid emergency CAS and perform emergency carotid endarterectomy (CEA) as an alternative to CAS in the same anesthesia session in our angiography suite whenever needed and possible. METHODS We compared 27 thrombectomy patients with emergency CEA and 62 thrombectomy patients with emergency CAS and glycoprotein (Gp) IIb/IIIa inhibitors and/or dual antiplatelet therapy (DAPT) in the same time span. RESULTS The symptomatic hemorrhage rate was 0% (0/27) in the CEA group and 8% (5/62) in the CAS group (p = 0.317). The parenchymal hemorrhage rate (PH2) was 7% (2/27) in the CEA group and 16% (10/62) in the CAS group (p = 0.333). Both cases of PH2 in the CEA group occurred during the intervention and were diagnosed on immediate postinterventional imaging, whereas in the CAS group only 2/10 cases of PH2 occurred during the intervention and the remaining 8 PH2 occurred within 3 days after the intervention (p = 0.048). Clinical outcome at 90 days was comparable with 39% of CEA and 51% of CAS patients achieving good clinical outcome (modified Rankin scale, mRS 0-2, p = 0.452). CONCLUSION The use of CEA is a feasible alternative to CAS in acute stroke and has the advantage that DAPT/GpIIb/IIIa inhibitors are not needed. All PH2 in CEA patients occurred during the intervention, implying that hemorrhage in this group is likely to be caused by reperfusion injury, whereas delayed hemorrhage is likely to be caused by DAPT/GpIIb/IIIa inhibitors.
Collapse
Affiliation(s)
- Raveena Singh
- Department of Neuroradiology, University Hospital RWTH Aachen University, Pauwelsstr. 30, 52074, Aachen, Germany
| | - Sven Dekeyzer
- Department of Neuroradiology, University Hospital RWTH Aachen University, Pauwelsstr. 30, 52074, Aachen, Germany
| | - Arno Reich
- Department of Neurology, University Hospital RWTH Aachen University, Pauwelsstr. 30, 52074, Aachen, Germany
| | - Drosos Kotelis
- Department of Vascular Surgery, University Hospital RWTH Aachen University, Pauwelsstr. 30, 52074, Aachen, Germany
| | - Alexander Gombert
- Department of Vascular Surgery, University Hospital RWTH Aachen University, Pauwelsstr. 30, 52074, Aachen, Germany
| | - Martin Wiesmann
- Department of Neuroradiology, University Hospital RWTH Aachen University, Pauwelsstr. 30, 52074, Aachen, Germany
| | - Omid Nikoubashman
- Department of Neuroradiology, University Hospital RWTH Aachen University, Pauwelsstr. 30, 52074, Aachen, Germany.
| |
Collapse
|
8
|
Lin YH, Liu HM. Update on cerebral hyperperfusion syndrome. J Neurointerv Surg 2020; 12:788-793. [PMID: 32414892 PMCID: PMC7402457 DOI: 10.1136/neurintsurg-2019-015621] [Citation(s) in RCA: 65] [Impact Index Per Article: 16.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2019] [Revised: 04/03/2020] [Accepted: 04/04/2020] [Indexed: 02/07/2023]
Abstract
Cerebral hyperperfusion syndrome (CHS) is a clinical syndrome following a revascularization procedure. In the past decade, neurointerventional surgery has become a standard procedure to treat stenotic or occluded cerebral vessels in both acute and chronic settings, as well as endovascular thrombectomy in acute ischemic stroke. This review aims to summarize relevant recent studies regarding the epidemiology, diagnosis, and management of CHS as well as to highlight areas of uncertainty. Extracranial and intracranial cerebrovascular diseases in acute and chronic conditions are considered. The definition and diagnostic criteria of CHS are diverse. Although impaired cerebrovascular autoregulation plays a major role in the pathophysiology of CHS, the underlying mechanism is still not fully understood. Its clinical characteristics vary in different patients. The current findings on clinical and radiological presentation, pathophysiology, incidence, and risk factors are based predominantly on carotid angioplasty and stenting studies. Hemodynamic assessment using imaging modalities is the main form of diagnosis although the criteria are distinct, but it is helpful for patient selection before an elective revascularization procedure is conducted. After endovascular thrombectomy, a diagnosis of CHS is even more complex, and physicians should consider concomitant reperfusion injury. Management and preventative measures, including intensive blood pressure control before, during, and after revascularization procedures and staged angioplasty, are discussed in detail.
Collapse
Affiliation(s)
- Yen-Heng Lin
- Medical Imaging, National Taiwan University Hospital, Taipei, Taiwan
| | - Hon-Man Liu
- Radiology, National Taiwan University, Taipei, Taiwan .,Medical Imaging, Fu Jen Catholic University Hospital, Fu Jen Catholic University, New Taipei City 24352, Taiwan
| |
Collapse
|
9
|
Seo KD, Lee KY, Suh SH. Comparison of Long Term Prognosis between Carotid Endarterectomy versus Stenting; A Korean Population-Based Study Using National Insurance Data. Neurointervention 2019; 14:82-90. [PMID: 31450880 PMCID: PMC6736496 DOI: 10.5469/neuroint.2019.00115] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2019] [Accepted: 08/12/2019] [Indexed: 12/24/2022] Open
Abstract
Purpose Although carotid endarterectomy (CEA) is recommended as a treatment for carotid stenosis rather than carotid artery stenting (CAS), CAS has been preferred in Korea. The aim of this study was to analyze long-term outcomes after CAS compared with CEA using Korean nationwide insurance data.Materials and Methods We obtained all data from the nationwide database of the Health Insurance Review & Assessment Service (HIRA) during the study period using several codes regarding the procedure or operation. We included the HIRA data, which included at least one-year follow-up after the procedures. The outcomes associated with both procedures were death, recurrence of ischemic stroke, and admission for cerebral hemorrhage. Results A total of 16,065 eligible patients who were treated with CAS or CEA between 1 January 2007 and 31 December 2016 were analyzed. The number of patients with CAS and CEA was 12,173 (75.8%) and 3,892 (24.2%), respectively. 8,976 patients (55.9%) were classified as symptomatic patients. CAS was associated with a higher risk of all-cause mortality (adjusted hazard ratio [HR], 1.282; 95% confidence interval [CI], 1.173–1.400). The adjusted rates for recurrent ischemic stroke and cerebral hemorrhage between CAS versus CEA were 24.9% versus 15.9% (HR, 1.474; 95% CI, 1.325–1.639) and 1.5% versus 0.9% (HR, 2.026; 95% CI, 1.322–3.106), respectively. In young symptomatic patients, there was no statistically significant difference in all-cause mortality and cardiovascular death between CAS and CEA. Conclusion Our study using Korean nationwide insurance data demonstrated similar results to previous studies. Until further evidence of CAS is established through prospective studies, CAS should be performed in selected patients according to current guidelines.
Collapse
Affiliation(s)
- Kwon-Duk Seo
- Department of Neurology, National Health Insurance Service Ilsan Hospital, Goyang, Korea
| | - Kyung-Yul Lee
- Department of Neurology, Gangnam Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Sang Hyun Suh
- Department of Radiology, Gangnam Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
- Correspondence to: Sang Hyun Suh, MD, PhD Department of Radiology, Gangnam Severance Hospital, Yonsei University College of Medicine, 211 Eonju-ro, Gangnam-gu, Seoul 06273, Korea Tel: +82-2-2019-3510 Fax: +82-2-3462-5472 E-mail:
| |
Collapse
|
10
|
Salata K, Hussain MA, de Mestral C, Greco E, Aljabri BA, Mamdani M, Forbes TL, Bhatt DL, Verma S, Al-Omran M. Comparison of Outcomes in Elective Endovascular Aortic Repair vs Open Surgical Repair of Abdominal Aortic Aneurysms. JAMA Netw Open 2019; 2:e196578. [PMID: 31290986 PMCID: PMC6624804 DOI: 10.1001/jamanetworkopen.2019.6578] [Citation(s) in RCA: 35] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/07/2023] Open
Abstract
IMPORTANCE Knowledge regarding the long-term outcomes of elective treatment of abdominal aortic aneurysm (AAA) using endovascular aortic repair (EVAR) is increasing. However, data with greater than 10 years' follow-up remain sparse and are lacking from population-based studies. OBJECTIVE To determine the long-term outcomes of EVAR compared with open surgical repair (OSR) for elective treatment of AAA. DESIGN, SETTING, AND PARTICIPANTS This retrospective, population-based cohort study used linked administrative health data from Ontario, Canada, to identify all patients 40 years and older who underwent elective EVAR or OSR for AAA repair from April 1, 2003, to March 31, 2016, with follow-up terminating on March 31, 2017. A total of 17 683 patients were identified using validated procedure and billing codes and were propensity score matched. Analysis was conducted from June 26, 2018, to January 16, 2019. EXPOSURES Elective EVAR or OSR for AAA. MAIN OUTCOMES AND MEASURES The primary outcome was overall survival. Secondary outcomes were major adverse cardiovascular event-free survival, defined as being free of death, myocardial infarction, or stroke; reintervention; and secondary rupture. RESULTS Among 17 683 patients who received elective AAA repairs (mean [SD] age, 72.6 [7.8] years; 14 286 [80.8%] men), 6100 (34.5%) underwent EVAR and 11 583 (65.5%) underwent OSR. From these patients, 4010 well-balanced propensity score-matched pairs of patients were defined, with a mean (SD) age of 73.0 (7.6) years and 6583 (82.1%) men. In the matched cohort, the mean (SD) follow-up was 4.4 (2.7) years, and maximum follow-up was 13.8 years. The overall median survival was 8.9 years. Compared with OSR, EVAR was associated with a higher survival rate up to 1 year after repair (91.0% [95% CI, 90.1%-91.9%] vs 94.0% [95% CI, 93.3%-94.7%]) and a higher major adverse cardiovascular event-free survival rate up to 4 years after repair (69.9% [95% CI, 68.3%-71.3%] vs 72.9% [95% CI, 71.4%-74.4%]). Cumulative incidence of reintervention was higher among patients who underwent EVAR compared with those who underwent OSR at the 7-year follow-up (45.9% [95% CI, 44.1%-47.8%] vs 42.2% [95% CI, 40.4%-44.0%]). Survival analyses demonstrated no statistically significant differences in long-term survival, reintervention, and secondary rupture for patients who underwent EVAR compared with those who underwent OSR. Kaplan-Meier analysis suggested superior long-term major adverse cardiovascular event-free survival among patients who underwent EVAR compared with those who underwent OSR (32.6% [95% CI, 26.9%-38.4%] vs 14.1% [95% CI, 4.0%-30.4%]; stratified log-rank P < .001) during a maximum follow-up of 13.8 years. CONCLUSIONS AND RELEVANCE Endovascular aortic repair was not associated with a difference in long-term survival during more than 13 years' maximum follow-up. The reasons for these findings will require studies to consider specific graft makes and models, adherence to instructions for use, and types and reasons for reintervention.
Collapse
Affiliation(s)
- Konrad Salata
- Division of Vascular Surgery, University of Toronto, Toronto, Ontario, Canada
- Division of Vascular Surgery, Li Ka Shing Knowledge Institute, St Michael’s Hospital, Toronto, Ontario, Canada
| | - Mohamad A. Hussain
- Division of Vascular Surgery, University of Toronto, Toronto, Ontario, Canada
- Division of Vascular Surgery, Li Ka Shing Knowledge Institute, St Michael’s Hospital, Toronto, Ontario, Canada
| | - Charles de Mestral
- Division of Vascular Surgery, University of Toronto, Toronto, Ontario, Canada
- Division of Vascular Surgery, Li Ka Shing Knowledge Institute, St Michael’s Hospital, Toronto, Ontario, Canada
| | - Elisa Greco
- Division of Vascular Surgery, University of Toronto, Toronto, Ontario, Canada
- Division of Vascular Surgery, Li Ka Shing Knowledge Institute, St Michael’s Hospital, Toronto, Ontario, Canada
| | - Badr A. Aljabri
- Division of Vascular Surgery, University of Toronto, Toronto, Ontario, Canada
- Division of Vascular Surgery, Li Ka Shing Knowledge Institute, St Michael’s Hospital, Toronto, Ontario, Canada
- Department of Surgery, King Saud University, Riyadh, Kingdom of Saudi Arabia
| | - Muhammad Mamdani
- Li Ka Shing Centre for Healthcare Analytics Research and Training (CHART), Li Ka Shing Knowledge Institute, St Michael’s Hospital, Toronto, Ontario, Canada
- Leslie Dan Faculty of Pharmacy, University of Toronto, Toronto, Ontario, Canada
| | - Thomas L. Forbes
- Division of Vascular Surgery, University of Toronto, Toronto, Ontario, Canada
- Division of Vascular Surgery, Peter Munk Cardiac Centre, University Health Network, Toronto, Ontario, Canada
| | - Deepak L. Bhatt
- Brigham and Women’s Hospital Heart and Vascular Center, Boston, Massachusetts
- Harvard Medical School, Boston, Massachusetts
| | - Subodh Verma
- Division of Vascular Surgery, University of Toronto, Toronto, Ontario, Canada
- Division of Cardiac Surgery, Li Ka Shing Knowledge Institute, St Michael’s Hospital, Toronto, Ontario, Canada
- Division of Vascular Surgery, University of Toronto, Toronto, Ontario, Canada
| | - Mohammed Al-Omran
- Division of Vascular Surgery, University of Toronto, Toronto, Ontario, Canada
- Division of Vascular Surgery, Li Ka Shing Knowledge Institute, St Michael’s Hospital, Toronto, Ontario, Canada
- Department of Surgery, King Saud University, Riyadh, Kingdom of Saudi Arabia
| |
Collapse
|