Surgical and Endovascular Treatment of Extracranial Carotid Stenosis

Identification of patient characteristics that may improve procedure selection for the treatment of carotid stenosis

BACKGROUND

Carotid endarterectomy and carotid artery stenting are common procedures for the treatment of carotid artery stenosis. The aim of this study was to identify factors that modify the effect between type of treatment and outcome, and could thus be used to refine the selection of treatment procedure.

METHODS

All patients who underwent either carotid endarterectomy or carotid artery stenting between 2012 and 2018 in German hospitals were included. The analysis of effect modification was focused on baseline patient characteristics. The outcome was a composite of any stroke or death until discharge from hospital. For multivariable analyses, a generalized linear mixed regression model was used.

RESULTS

Some 221 282 patients were included, of whom 68% were male. In patients who underwent carotid endarterectomy or carotid artery stenting, the risk of any stroke or death was 2.3% and 3.7% respectively. Patient age was statistically significantly associated with a higher risk of a composite outcome of any stroke or death (main effect of age: adjusted OR 1.21 (95% c.i. 1.17 to 1.26), P < 0.001). The age effect was stronger in patients treated with carotid artery stenting (interaction effect: adjusted OR 1.29 (95% c.i. 1.20 to 1.38), P < 0.001). Statistically significant interaction effects were identified for side of treatment, ASA grade, contralateral degree of stenosis, and the time interval between the index event and treatment.

CONCLUSION

This analysis shows that carotid artery stenting may be particularly disadvantageous in older patients, in patients with right-sided stenosis, and in symptomatic patients treated within the first 2 days after the index event. In patients with contralateral occlusion, carotid artery stenting appears equivalent to carotid endarterectomy.

Association between hospital ownership and patient selection, management, and outcomes after carotid endarterectomy or carotid artery stenting : - Secondary data analysis of the Bavarian statutory quality assurance database

BACKGROUND

This study analyses the association between hospital ownership and patient selection, treatment, and outcome of carotid endarterectomy (CEA) or carotid artery stenting (CAS).

METHODS

The analysis is based on the Bavarian subset of the nationwide German statutory quality assurance database. All patients receiving CEA or CAS for carotid artery stenosis between 2014 and 2018 were included. Hospitals were subdivided into four groups: university hospitals, public hospitals, hospitals owned by charitable organizations, and private hospitals. The primary outcome was any stroke or death until discharge from hospital. Research was funded by Germany's Federal Joint Committee Innovation Fund (01VSF19016 ISAR-IQ).

RESULTS

In total, 22,446 patients were included. The majority of patients were treated in public hospitals (62%), followed by private hospitals (17%), university hospitals (16%), and hospitals under charitable ownership (6%). Two thirds of patients were male (68%), and the median age was 72 years. CAS was most often applied in university hospitals (25%) and most rarely used in private hospitals (9%). Compared to university hospitals, patients in private hospitals were more likely asymptomatic (65% vs. 49%). In asymptomatic patients, the risk of stroke or death was 1.3% in university hospitals, 1.5% in public hospitals, 1.0% in hospitals of charitable owners, and 1.2% in private hospitals. In symptomatic patients, these figures were 3.0%, 2.5%, 3.4%, and 1.2% respectively. Univariate analysis revealed no statistically significant differences between hospital groups. In the multivariable analysis, compared to university hospitals, the odds ratio of stroke or death in asymptomatic patients treated by CEA was significantly lower in charitable hospitals (OR 0.19 [95%-CI 0.07-0.56, p = 0.002]) and private hospitals (OR 0.47 [95%-CI 0.23-0.98, p = 0.043]). In symptomatic patients (elective treatment, CEA), patients treated in private or public hospitals showed a significantly lower odds ratio compared to university hospitals (0.36 [95%-CI 0.17-0.72, p = 0.004] and 0.65 [95%-CI 0.42-1.00, p = 0.048], respectively).

CONCLUSIONS

Hospital ownership was related to patient selection and treatment, but not generally to outcomes. The lower risk of stroke or death in the subgroup of electively treated patients in private hospitals might be due to the right timing, the choice of treatment modality or actually to better structural and process quality.

Elective carotid stenting fulfills quality standards defined in guidelines

PURPOSE

According to evidence from randomized trials and current guidelines, elective carotid artery stenting (CAS) is still considered second-line therapy compared with carotid endarterectomy (CEA). However, the publication of randomized comparative trials for patients with symptomatic stenoses occurred well over 10 years ago. In view of problems regarding German quality assurance when differentiating elective from emergency interventions and low case numbers for CAS indications, it seemed reasonable to present neurologically controlled CAS results and to investigate whether elective CAS consistently fulfills the strict quality criteria and what differences exist with respect to emergency CAS interventions in acute ischemic stroke.

MATERIALS AND METHODS

Between 01/2012 and 07/2022, 141 elective CAS procedures were performed to treat patients with symptomatic (n = 123) and asymptomatic (n = 18) stenoses. Protection by a filter system was achieved in 134 of these elective procedures (95 %). During the same period, 158 patients underwent carotid stenting for acute stroke. Complication rates were determined using neurologically controlled data. CAS-related complications (stent thrombosis, stent-associated vascular damage, thromboembolism, and symptomatic hemorrhage) were extracted from emergency interventions, and clinical outcome (NIHSS progression) was determined during the inpatient stay.

RESULTS

The rate of stroke and death determined during the inpatient stay for elective symptomatic patients was 0.8 %. Early treatment within the first 7 days after the index event, age > 70 years, and operator experience were not significant risk factors for the occurrence of complications. No complications were observed after CAS of asymptomatic stenoses. The procedure-related complication rate for emergency procedures was 7.8 %, which was significantly higher than after elective CAS, as expected (p < 0.006).

CONCLUSION

Even with limited indications and limited case numbers, compliance with the strict quality criteria of the current S3 Guideline 2022 for elective CAS interventions is possible for both symptomatic and asymptomatic stenoses in an experienced center. Emergency CAS interventions have significantly higher complication rates under other conditions and must be considered separately with regard to quality assurance.

KEY POINTS

· Elective carotid stenting fulfills the strict quality criteria of the current S3 guideline 2022.. · Emergency carotid stenting has significantly higher complication rates than elective procedures.. · Elective and emergency carotid stenting cannot be meaningfully compared..

CITATION FORMAT

· Keil F, Stahn S, Reitz SC et al. Elective carotid stenting fulfills quality standards defined in guidelines. Fortschr Röntgenstr 2024; 196: 471 - 481.

[Important recommendations of the German-Austrian S3 guidelines on management of extracranial carotid artery stenosis]

BACKGROUND

Lesions of the extracranial carotid artery are the cause of 10-15 % of all cases of cerebral ischemia. The aims of the updated S3 guidelines are evidence-based and consensus-based recommendations for action on comprehensive care of patients with extracranial carotid stenosis in Germany and Austria.

METHODS

A systematic literature search (1990-2019) and methodical assessment of existing guidelines and systematic reviews were carried out. Consensus answers to 37 key questions with evidence-based recommendations.

RESULTS

The prevalence of extracranial carotid stenosis is approximately 4% and increases after the age of 65 years. The most important examination method is duplex sonography. Randomized controlled studies (RCT) have shown that carotid endarterectomy (CEA) of an asymptomatic 60-99% carotid artery stenosis reduces the absolute risk of stroke (absolute risk reduction, ARR) within 5 years in comparison to drug treatment alone by 4.1%. Due to an improved pharmaceutical prevention of arteriosclerosis, the S3 guidelines recommend a prophylactic CEA of a 60-99% stenosis only for patients without an increased surgical risk. Additionally, one or more clinical or imaging results should be present, which indicate an increased risk of carotid-related stroke in the follow-up. For medium-grade (50-69 %) and high-grade (70-99 %) symptomatic stenoses the ARRs after 5 years are 4.6% and 15.6%, respectively. Systematic reviews of RCTs have shown that CEA is associated with a ca. 50% lower periprocedural risk of stroke compared to carotid artery stenting (CAS). There are no differences in the long-term course. The CEA is recommended for high-grade asymptomatic, medium-grade and high-grade symptomatic carotid stenosis as a standard procedure, alternatively CAS can be considered. For both procedures the periprocedural stroke rate/mortality during hospitalization should be a maximum of 2% (asymptomatic stenosis) or 4% (symptomatic stenosis).

CONCLUSION

Both CEA and CAS necessitate a critical evaluation of the indications and strict quality criteria. Future studies should evaluate even better selection criteria for an individual, optimal, conservative, operative or endovascular treatment.

Diagnosis, Treatment and Follow-up in Extracranial Carotid Stenosis

BACKGROUND

Around 15% of cerebral ischemias are caused by lesions of the extracranial carotid artery. The goal of this guideline is to provide evidence- and consensus-based recommendations for the management of patients with extracranial carotid stenoses throughout Germany and Austria.

METHODS

A systematic literature search (1990-2019) and methodical assessment of existing guidelines and systematic reviews; consensus-based answers to 37 key questions with evidence-based recommendations.

RESULTS

The prevalence of extracranial carotid artery stenoses is around 4% overall, higher from the age of 65 years. The most important examination modality is duplex sonography. Randomized trials have shown that carotid endarterectomy (CEA) significantly reduces the 5-year risk of stroke in patients with 60-99 % asymptomatic stenoses (absolute risk reduction [ARR] 4.1% over 5 years, number needed to treat [NNT] 24) or 50-99% symptomatic stenoses (50-69%: ARR 4.6 % over 5 years, NNT 22; 70-99%: 15.9 % over 5 years, NNT 6). With the aid of intensive conservative treatment, the carotid artery-associated risk of stroke can be reduced to as little as 1% per year. Critical determination of indications and strict quality criteria are therefore necessary for CEA and carotid artery stenting (CAS). Systematic reviews of controlled trials comparing CEA and CAS show that the procedural risk of stroke is higher for CAS (asymptomatic: 2.6% versus 1.3%; symptomatic: 6.2% versus 3.8%). There are no differences in the long term. CEA is recommended as standard procedure for high-grade asymptomatic and moderate to high-grade symptomatic carotid artery stenoses; CAS may be considered as an alternative. For both procedures, the periprocedural combined rate of stroke or death should not exceed 2% for asymptomatic stenoses or 4% for symptomatic stenoses.

CONCLUSION

Future studies should evaluate even better selection criteria for optimal individualized treatment, whether conservative, surgical, or endovascular.

Regional frequency variation of revascularization procedures for carotid stenosis in Germany: Secondary data analysis of DRG data from 2012 to 2014

Background

For Germany, regional variation of procedure rates of carotid endarterectomy (CEA) and carotid artery stenting (CAS) performed for carotid stenosis have so far not been analyzed at a national level. The aim of this study was to assess small area estimates of procedure rates among German regions, and to identify regional characteristics, which are associated with the regional frequency of procedures.

Methods

German diagnosis-related groups (DRG) statistics (2012-2014) were analyzed. Inclusion and exclusion criteria for procedural codes were set according to German quality assurance measures in combination with the diagnosis of carotid stenosis (I65.2). Rates of CEA and CAS were indirectly standardized for sex and age.

Results

In total, 88,182 procedures were performed (73,042 CEA; 15,367 CAS). The overall procedure rate varied between 13.2 per 100,000 (Augsburg) and 89.2 per 100,000 (Wilhelmshaven). Spatial analysis revealed that regional distribution was significantly clustered.

Conclusion

The rates of CEA, and especially of CAS showed high regional variation. The spatial distribution was significantly clustered. In addition to the regional prevalence of diabetes mellitus, smoking and obesity, socioeconomic factors, such as income and debts were correlated with the overall frequency of CEA and CAS. No significant association was found between indicators of health infrastructure (e. g. density of hospital beds, vascular surgeons and angiologists) and the overall procedure rate.