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Paraskevas KI, Dardik A, Schermerhorn ML, Liapis CD, Mansilha A, Lal BK, Gray WA, Brown MM, Myrcha P, Lavie CJ, Zeebregts CJ, Secemsky EA, Saba L, Blecha M, Gurevich V, Silvestrini M, Blinc A, Svetlikov A, Fernandes E Fernandes J, Schneider PA, Gloviczki P, White CJ, AbuRahma AF. Why selective screening for asymptomatic carotid stenosis is currently appropriate: a special report. Expert Rev Cardiovasc Ther 2024; 22:159-165. [PMID: 38480465 DOI: 10.1080/14779072.2024.2330660] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/08/2023] [Accepted: 03/11/2024] [Indexed: 03/19/2024]
Abstract
INTRODUCTION Two of the main reasons recent guidelines do not recommend routine population-wide screening programs for asymptomatic carotid artery stenosis (AsxCS) is that screening could lead to an increase of carotid revascularization procedures and that such mass screening programs may not be cost-effective. Nevertheless, selective screening for AsxCS could have several benefits. This article presents the rationale for such a program. AREAS COVERED The benefits of selective screening for AsxCS include early recognition of AsxCS allowing timely initiation of preventive measures to reduce future myocardial infarction (MI), stroke, cardiac death and cardiovascular (CV) event rates. EXPERT OPINION Mass screening programs for AsxCS are neither clinically effective nor cost-effective. Nevertheless, targeted screening of populations at high risk for AsxCS provides an opportunity to identify these individuals earlier rather than later and to initiate a number of lifestyle measures, risk factor modifications, and intensive medical therapy in order to prevent future strokes and CV events. For patients at 'higher risk of stroke' on best medical treatment, a prophylactic carotid intervention may be considered.
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Affiliation(s)
| | - Alan Dardik
- Department of Surgery, Yale School of Medicine, New Haven, CT, USA
- Department of Surgery, VA Connecticut Healthcare System, West Haven, CT, USA
| | - Marc L Schermerhorn
- Department of Surgery, Division of Vascular and Endovascular Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
| | - Christos D Liapis
- Department of Vascular Surgery, Athens Vascular Research Center, Athens, Greece
| | - Armando Mansilha
- Faculty of Medicine of the University of Porto, Porto, Portugal
- Department of Angiology and Vascular Surgery, Hospital de S. Joao, Porto, Portugal
| | - Brajesh K Lal
- Department of Vascular Surgery, University of Maryland School of Medicine, Baltimore, USA
- Department of Vascular Surgery, Baltimore VA Medical Center, Baltimore, USA
- Department of Neurology, Mayo Clinic, Rochester, MN, USA
| | | | - Martin M Brown
- Stroke Research Centre, UCL Institute of Neurology, University College London, London, UK
| | - Piotr Myrcha
- Department of General and Vascular Surgery, Faculty of Medicine, Medical University of Warsaw, Warsaw, Poland
| | - Carl J Lavie
- John Ochsner Heart and Vascular Institute, Ochsner Clinical School, The University of Queensland School of Medicine, New Orleans, LA, USA
| | - Clark J Zeebregts
- Department of Surgery (Division of Vascular Surgery), University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Eric A Secemsky
- Smith Center for Outcomes Research, Division of Cardiology, Department of Medicine, Beth Israel Deaconess Medical Center, Boston, MA, USA
- Harvard Medical School, Boston, MA, USA
| | - Luca Saba
- Department of Radiology, Azienda Ospedaliera Universitaria Di Cagliari, Cagliari, Italy
| | - Matthew Blecha
- Division of Vascular Surgery, Stritch School of Medicine, Loyola University Chicago, Chicago, IL, USA
| | - Victor Gurevich
- Center of Atherosclerosis and Lipid Disorders, Lab of Microangiopathic Mechanisms of Atherogenesis, Saint-Petersburg State University, Mechnikov, Saint-Petersburgh, Russia
| | - Mauro Silvestrini
- Neurological Clinic, Department of Experimental and Clinical Medicine, Marche Polytechnic University, Ancona, Italy
| | - Ales Blinc
- Department of Vascular Diseases, Division of Internal Medicine, University Medical Centre Ljubljana, Ljubljana, Slovenia
- Faculty of Medicine, University of Ljubljana, Ljubljana, Slovenia
| | - Alexei Svetlikov
- Division of Vascular & Endovascular Surgery, North-Western Scientific Clinical Center of Federal Medical Biological Agency, Department of Hospital Surgery, Saint-Petersburg State University, Saint-Petersburg, Russia
| | - Jose Fernandes E Fernandes
- Cardiovascular Center (CCUL), Faculty of Medicine University of Lisbon, Lisbon, Portugal
- Department of Vascular Surgery, Hospital da Luz Torres de Lisboa, Lisbon, Portugal
| | - Peter A Schneider
- Division of Vascular and Endovascular Surgery, University of California, San Francisco, CA, USA
| | - Peter Gloviczki
- Division of Vascular and Endovascular Surgery, Mayo Clinic, Rochester, MN, USA
| | - Christopher J White
- John Ochsner Heart and Vascular Institute, Ochsner Clinical School, The University of Queensland School of Medicine, New Orleans, LA, USA
| | - Ali F AbuRahma
- Department of Surgery, Division of Vascular and Endovascular Surgery, Charleston Area Medical Center/West Virginia University Health Sciences Center, Charleston, WV, USA
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Penton A, Driscoll M, Li R, DeJong M, Blecha M. Carotid Endarterectomy for Asymptomatic Stenosis Based on Duplex Ultrasound Alone Achieves Equivalent Perioperative and Long-Term Outcomes Relative to Advanced Imaging Based Endarterectomy. Ann Vasc Surg 2024; 98:44-57. [PMID: 37454891 DOI: 10.1016/j.avsg.2023.07.093] [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: 12/22/2022] [Revised: 05/08/2023] [Accepted: 07/03/2023] [Indexed: 07/18/2023]
Abstract
BACKGROUND The purpose of this study is to compare both perioperative as well as long-term outcomes of patients undergoing carotid endarterectomy (CEA) for asymptomatic carotid bifurcation stenosis based on duplex ultrasound in isolation relative to a combination of duplex and more advanced imaging. METHODS All CEA in the VQI between January 2003 and May 2022 were queried. We identified 171,816 CEAs in the database. Exclusions were symptomatic carotid lesion (57,742), lack of imaging documentation (908), lack of advanced imaging status (1,816), simultaneous additional arterial intervention in the carotid, coronary, or peripheral arterial system (n = 4,118), and anatomic high-risk status for CEA (n = 4,071). Included patients were then placed into 1 of 2 cohorts: patients undergoing CEA based on duplex imaging alone (n = 33,437) and those undergoing CEA based on advanced imaging (CTA, MRA, or invasive angiography) with or without duplex (n = 69,715). We performed multivariable analysis for the following outcomes utilizing CEA based on duplex in isolation as 1 of the variables: perioperative neurological ischemic event utilizing binary logistic regression; combined 90-day mortality and neurological ischemic event utilizing binary logistic regression; neurological event in long-term follow-up with date of surgery serving as time zero; time dependent Cox regression analysis; mortality in long-term follow-up utilizing time-dependent Cox regression. RESULTS Carotid endarterectomy based on duplex alone and CEA based on advanced imaging had essentially equivalent rates of 90-day mortality (0.9% vs. 1.0%, P = 0.108); combined perioperative neurological event and 90-day mortality (2.0% vs. 2.2%, P = 0.042); and, return to the operating room (1.6% vs. 1.7%, P = 0.154). On multivariable analysis CEA based on advanced imaging was noted to have a slightly higher absolute rate of perioperative neurological event without achieving multivariable significance (1.3% vs. 1.2%, adjusted odds ratio 1.11 (0.98-1.25), P = 0.092. CEA based on advanced imaging had a higher rate of neurological event after index hospital admission relative to duplex in isolation (hazard ratio (HR) 1.44 (1.31-1.60), P < 0.001). However, the absolute percentage difference was just 0.5% (1.6% vs. 2.1%). CEA based on duplex alone was associated with a slightly increased risk of mortality in LTFU (HR 1.16 (1.11-1.21), P < 0.001). At 5 years the absolute risk of mortality was less than 1% different between the cohorts. CONCLUSIONS Performing CEA for asymptomatic bifurcation stenosis based on duplex ultrasound alone is a safe practice which achieves clinically equivalent perioperative and long-term freedom from cerebral ischemia and mortality relative to CEA based on advanced imaging. This has potential implications for health care cost saving as well as avoidance of radiation and iodinated contrast.
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Affiliation(s)
- Ashley Penton
- Loyola University Medical Center Department of Sugery, Maywood, IL
| | - Matthew Driscoll
- Loyola University Chicago Stritch School of Medicine, Maywood, IL
| | - Ruojia Li
- Division of Vascular Surgery and Endovascular Therapy, Maywood, IL
| | - Matthew DeJong
- Loyola University Medical Center Department of Sugery, Maywood, IL
| | - Matthew Blecha
- Division of Vascular Surgery and Endovascular Therapy, Maywood, IL.
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Tekieli L, Kablak-Ziembicka A, Dabrowski W, Dzierwa K, Moczulski Z, Urbanczyk-Zawadzka M, Mazurek A, Stefaniak J, Paluszek P, Krupinski M, Przewlocki T, Pieniazek P, Musialek P. Imaging modality-dependent carotid stenosis severity variations against intravascular ultrasound as a reference: Carotid Artery intravasculaR Ultrasound Study (CARUS). Int J Cardiovasc Imaging 2023; 39:1909-1920. [PMID: 37603155 PMCID: PMC10589130 DOI: 10.1007/s10554-023-02875-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/26/2022] [Accepted: 05/14/2023] [Indexed: 08/22/2023]
Abstract
PURPOSE Different non-invasive and invasive imaging modalities are used to determine carotid artery stenosis severity that remains a principal parameter in clinical decision-making. We compared stenosis degree obtained with different modalities against vascular imaging gold standard, intravascular ultrasound, IVUS. METHODS 300 consecutive patients (age 47-83 years, 192 men, 64% asymptomatic) with carotid artery stenosis of " ≥ 50%" referred for potential revascularization received as per study protocol (i) duplex ultrasound (DUS), (ii) computed tomography angiography (CTA), (iii) intraarterial quantitative angiography (iQA) and (iv) and (iv) IVUS. Correlation of measurements with IVUS (r), proportion of those concordant (within 10%) and proportion of under/overestimated were calculated along with recipient-operating-characteristics (ROC). RESULTS For IVUS area stenosis (AS) and IVUS minimal lumen area (MLA), there was only a moderate correlation with DUS velocities (peak-systolic, PSV; end-diastolic, EDV; r values of 0.42-0.51, p < 0.001 for all). CTA systematically underestimated both reference area and MLA (80.4% and 92.3% cases) but CTA error was lesser for AS (proportion concordant-57.4%; CTA under/overestimation-12.5%/30.1%). iQA diameter stenosis (DS) was found concordant with IVUS in 41.1% measurements (iQA under/overestimation 7.9%/51.0%). By univariate model, PSV (ROC area-under-the-curve, AUC, 0.77, cutoff 2.6 m/s), EDV (AUC 0.72, cutoff 0.71 m/s) and CTA-DS (AUC 0.83, cutoff 59.6%) were predictors of ≥ 50% DS by IVUS (p < 0.001 for all). Best predictor, however, of ≥ 50% DS by IVUS was stenosis severity evaluation by automated contrast column density measurement on iQA (AUC 0.87, cutoff 68%, p < 0.001). Regarding non-invasive techniques, CTA was the only independent diagnostic modality against IVUS on multivariate model (p = 0.008). CONCLUSION IVUS validation shows significant imaging modality-dependent variations in carotid stenosis severity determination.
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Affiliation(s)
- Lukasz Tekieli
- Department of Cardiac and Vascular Diseases, Institute of Cardiology, Jagiellonian University Medical College, Krakow, Poland.
- Department of Interventional Cardiology, Institute of Cardiology, Jagiellonian University Medical College, Krakow, Poland.
- John Paul II Hospital, Krakow, Poland.
| | - Anna Kablak-Ziembicka
- Department of Interventional Cardiology, Institute of Cardiology, Jagiellonian University Medical College, Krakow, Poland
- John Paul II Hospital, Krakow, Poland
- Noninvasive Cardiovascular Laboratory, John Paul II Hospital, Krakow, Poland
| | - Wladyslaw Dabrowski
- Department of Interventional Cardiology, Institute of Cardiology, Jagiellonian University Medical College, Krakow, Poland
- John Paul II Hospital, Krakow, Poland
- KCRI Angiographic and IVUS Core Laboratory, Krakow, Poland
| | - Karolina Dzierwa
- John Paul II Hospital, Krakow, Poland
- Noninvasive Cardiovascular Laboratory, John Paul II Hospital, Krakow, Poland
| | - Zbigniew Moczulski
- Department of Radiology and Diagnostic Imaging, John Paul II Hospital, Krakow, Poland
| | | | - Adam Mazurek
- Department of Cardiac and Vascular Diseases, Institute of Cardiology, Jagiellonian University Medical College, Krakow, Poland
- John Paul II Hospital, Krakow, Poland
| | - Justyna Stefaniak
- Data Management and Statistical Analysis (DMSA), Krakow, Poland
- Department of Bioinformatic and Telemedicine, Jagiellonian University, Krakow, Poland
| | - Piotr Paluszek
- Department of Vascular Surgery and Endovascular Interventions, John Paul II Hospital, Krakow, Poland
| | - Maciej Krupinski
- Department of Radiology and Diagnostic Imaging, John Paul II Hospital, Krakow, Poland
| | - Tadeusz Przewlocki
- Department of Interventional Cardiology, Institute of Cardiology, Jagiellonian University Medical College, Krakow, Poland
- John Paul II Hospital, Krakow, Poland
- Department of Vascular Surgery and Endovascular Interventions, John Paul II Hospital, Krakow, Poland
| | - Piotr Pieniazek
- Department of Cardiac and Vascular Diseases, Institute of Cardiology, Jagiellonian University Medical College, Krakow, Poland
- Department of Interventional Cardiology, Institute of Cardiology, Jagiellonian University Medical College, Krakow, Poland
- John Paul II Hospital, Krakow, Poland
- Department of Vascular Surgery and Endovascular Interventions, John Paul II Hospital, Krakow, Poland
| | - Piotr Musialek
- Department of Cardiac and Vascular Diseases, Institute of Cardiology, Jagiellonian University Medical College, Krakow, Poland.
- John Paul II Hospital, Krakow, Poland.
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Clezar CN, Flumignan CD, Cassola N, Nakano LC, Trevisani VF, Flumignan RL. Pharmacological interventions for asymptomatic carotid stenosis. Cochrane Database Syst Rev 2023; 8:CD013573. [PMID: 37565307 PMCID: PMC10401652 DOI: 10.1002/14651858.cd013573.pub2] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 08/12/2023]
Abstract
BACKGROUND Carotid artery stenosis is narrowing of the carotid arteries. Asymptomatic carotid stenosis is when this narrowing occurs in people without a history or symptoms of this disease. It is caused by atherosclerosis; that is, the build-up of fats, cholesterol, and other substances in and on the artery walls. Atherosclerosis is more likely to occur in people with several risk factors, such as diabetes, hypertension, hyperlipidaemia, and smoking. As this damage can develop without symptoms, the first symptom can be a fatal or disabling stroke, known as ischaemic stroke. Carotid stenosis leading to ischaemic stroke is most common in men older than 70 years. Ischaemic stroke is a worldwide public health problem. OBJECTIVES To assess the effects of pharmacological interventions for the treatment of asymptomatic carotid stenosis in preventing neurological impairment, ipsilateral major or disabling stroke, death, major bleeding, and other outcomes. SEARCH METHODS We searched the Cochrane Stroke Group trials register, CENTRAL, MEDLINE, Embase, two other databases, and three trials registers from their inception to 9 August 2022. We also checked the reference lists of any relevant systematic reviews identified and contacted specialists in the field for additional references to trials. SELECTION CRITERIA We included all randomised controlled trials (RCTs), irrespective of publication status and language, comparing a pharmacological intervention to placebo, no treatment, or another pharmacological intervention for asymptomatic carotid stenosis. DATA COLLECTION AND ANALYSIS We used standard Cochrane methodological procedures. Two review authors independently extracted the data and assessed the risk of bias of the trials. A third author resolved disagreements when necessary. We assessed the evidence certainty for key outcomes using GRADE. MAIN RESULTS We included 34 RCTs with 11,571 participants. Data for meta-analysis were available from only 22 studies with 6887 participants. The mean follow-up period was 2.5 years. None of the 34 included studies assessed neurological impairment and quality of life. Antiplatelet agent (acetylsalicylic acid) versus placebo Acetylsalicylic acid (1 study, 372 participants) may result in little to no difference in ipsilateral major or disabling stroke (risk ratio (RR) 1.08, 95% confidence interval (CI) 0.47 to 2.47), stroke-related mortality (RR 1.40, 95% CI 0.54 to 3.59), progression of carotid stenosis (RR 1.16, 95% CI 0.79 to 1.71), and adverse events (RR 0.81, 95% CI 0.41 to 1.59), compared to placebo (all low-certainty evidence). The effect of acetylsalicylic acid on major bleeding is very uncertain (RR 0.98, 95% CI 0.06 to 15.53; very low-certainty evidence). The study did not measure neurological impairment or quality of life. Antihypertensive agents (metoprolol and chlorthalidone) versus placebo The antihypertensive agent, metoprolol, may result in no difference in ipsilateral major or disabling stroke (RR 0.14, 95% CI 0.02 to1.16; 1 study, 793 participants) and stroke-related mortality (RR 0.57, 95% CI 0.17 to 1.94; 1 study, 793 participants) compared to placebo (both low-certainty evidence). However, chlorthalidone may slow the progression of carotid stenosis (RR 0.45, 95% CI 0.23 to 0.91; 1 study, 129 participants; low-certainty evidence) compared to placebo. Neither study measured neurological impairment, major bleeding, adverse events, or quality of life. Anticoagulant agent (warfarin) versus placebo The evidence is very uncertain about the effects of warfarin (1 study, 919 participants) on major bleeding (RR 1.19, 95% CI 0.97 to 1.46; very low-certainty evidence), but it may reduce adverse events (RR 0.89, 95% CI 0.81 to 0.99; low-certainty evidence) compared to placebo. The study did not measure neurological impairment, ipsilateral major or disabling stroke, stroke-related mortality, progression of carotid stenosis, or quality of life. Lipid-lowering agents (atorvastatin, fluvastatin, lovastatin, pravastatin, probucol, and rosuvastatin) versus placebo or no treatment Lipid-lowering agents may result in little to no difference in ipsilateral major or disabling stroke (atorvastatin, lovastatin, pravastatin, and rosuvastatin; RR 0.36, 95% CI 0.09 to 1.53; 5 studies, 2235 participants) stroke-related mortality (lovastatin and pravastatin; RR 0.25, 95% CI 0.03 to 2.29; 2 studies, 1366 participants), and adverse events (fluvastatin, lovastatin, pravastatin, probucol, and rosuvastatin; RR 0.76, 95% CI 0.53 to1.10; 7 studies, 3726 participants) compared to placebo or no treatment (all low-certainty evidence). The studies did not measure neurological impairment, major bleeding, progression of carotid stenosis, or quality of life. AUTHORS' CONCLUSIONS Although there is no high-certainty evidence to support pharmacological intervention, this does not mean that pharmacological treatments are ineffective in preventing ischaemic cerebral events, morbidity, and mortality. High-quality RCTs are needed to better inform the best medical treatment that may reduce the burden of carotid stenosis. In the interim, clinicians will have to use other sources of information.
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Affiliation(s)
- Caroline Nb Clezar
- Department of Surgery, Division of Vascular and Endovascular Surgery, Universidade Federal de São Paulo, São Paulo, Brazil
| | - Carolina Dq Flumignan
- Department of Surgery, Division of Vascular and Endovascular Surgery, Universidade Federal de São Paulo, São Paulo, Brazil
| | - Nicolle Cassola
- Department of Surgery, Division of Vascular and Endovascular Surgery, Universidade Federal de São Paulo, São Paulo, Brazil
| | - Luis Cu Nakano
- Department of Surgery, Division of Vascular and Endovascular Surgery, Universidade Federal de São Paulo, São Paulo, Brazil
| | - Virginia Fm Trevisani
- Medicina de Urgência and Rheumatology, Escola Paulista de Medicina, Universidade Federal de São Paulo and Universidade de Santo Amaro, São Paulo, Brazil
| | - Ronald Lg Flumignan
- Department of Surgery, Division of Vascular and Endovascular Surgery, Universidade Federal de São Paulo, São Paulo, Brazil
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Naylor R, Rantner B, Ancetti S, de Borst GJ, De Carlo M, Halliday A, Kakkos SK, Markus HS, McCabe DJH, Sillesen H, van den Berg JC, Vega de Ceniga M, Venermo MA, Vermassen FEG, Esvs Guidelines Committee, Antoniou GA, Bastos Goncalves F, Bjorck M, Chakfe N, Coscas R, Dias NV, Dick F, Hinchliffe RJ, Kolh P, Koncar IB, Lindholt JS, Mees BME, Resch TA, Trimarchi S, Tulamo R, Twine CP, Wanhainen A, Document Reviewers, Bellmunt-Montoya S, Bulbulia R, Darling RC, Eckstein HH, Giannoukas A, Koelemay MJW, Lindström D, Schermerhorn M, Stone DH. Editor's Choice - European Society for Vascular Surgery (ESVS) 2023 Clinical Practice Guidelines on the Management of Atherosclerotic Carotid and Vertebral Artery Disease. Eur J Vasc Endovasc Surg 2023; 65:7-111. [PMID: 35598721 DOI: 10.1016/j.ejvs.2022.04.011] [Citation(s) in RCA: 205] [Impact Index Per Article: 205.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2022] [Accepted: 04/20/2022] [Indexed: 01/17/2023]
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6
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Montorsi P, Mancini E, Galli S, Teruzzi G, Caputi L, Ferrari C, Troiano S, Olivares P, Ravagnani PM, Trabattoni D. Intolerance to occlusion during carotid artery stenting with proximal protection: causes, mechanisms, treatment and prevention. Minerva Cardiol Angiol 2022; 70:751-764. [PMID: 36700670 DOI: 10.23736/s2724-5683.22.06246-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Abstract
Periprocedural cerebral microembolization is the most important complication of carotid artery stenting. Among several variables that play a role to reduce this risk, brain protection (proximal vs. distal) plays a pivot role. Data are accumulating in favor of a better performance of proximal vs. distal especially in symptomatic patients and high-risk carotid plaques. A prerequisite for the technique to be safe and effective is the presence of a valid intracranial collateral circulation to compensate for the target vessel hemisphere avoiding patient intolerance. This complication may occur either soon after the common carotid balloon occlusion or slowly developing during the procedure peaking at the stent post-dilation step. While Willis' circle anatomic variants are the most frequent cause of acute intolerance, a mix of anatomic, hemodynamic and patient cerebral condition play a role for the late developing form. Prevention is the best treatment of intolerance through a pre- and procedural imaging with different techniques (CT angiography, NMR angiography, transcranial Doppler assessment, digital subtraction angiography and back pressure monitoring).
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Affiliation(s)
- Piero Montorsi
- Department of Clinical Sciences and Community Health, University of Milan, Milan, Italy - .,Centro Cardiologico Monzino IRCCS, Milan, Italy -
| | | | | | | | - Luigi Caputi
- Division of Neurology, ASST Crema, Crema, Cremona, Italy
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7
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Tsai CH, Huang CC, Hsiao HM, Hung MY, Su GJ, Lin LH, Chen YH, Lin MS, Yeh CF, Hung CS, Kao HL. Detection of Carotid Artery Stenosis Based on Video Motion Analysis for Fast Screening. J Am Heart Assoc 2022; 11:e025702. [PMID: 35975739 PMCID: PMC9496434 DOI: 10.1161/jaha.122.025702] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
Background Carotid artery stenosis (CAS) is a common cause of ischemic stroke, and the early detection of CAS may improve patient outcomes. Carotid Doppler ultrasound is commonly used to diagnose CAS. However, it is costly and may not be practical for regular screening practice. This article presents a novel noninvasive and noncontact detection technique using video‐based motion analysis (VMA) to extract useful information from subtle pulses on the skin surface to screen for CAS. Methods and Results We prospectively enrolled 202 patients with prior carotid Doppler ultrasound data. A short 30‐second video clip of the neck was taken using a commercial mobile device and analyzed by VMA with mathematical quantification of the amplitude of skin motion changes in a blinded manner. The first 40 subjects were used to set up the VMA protocol and define cutoff values, and the following 162 subjects were used for validation. Overall, 54% of the 202 subjects had ultrasound‐confirmed CAS. Using receiver operating characteristic curve analysis, the area under the curve of VMA‐derived discrepancy values to differentiate patients with and without CAS was excellent (area under the curve, 0.914 [95% CI, 0.874–0.954]; P<0.01). The best cutoff value of VMA‐derived discrepancy values to screen for CAS was 5.1, with a sensitivity of 87% and a specificity of 87%. The diagnostic accuracy was consistently high in different subject subgroups. Conclusions A simple and accurate screening technique to quickly screen for CAS using a VMA system is feasible, with acceptable sensitivity and specificity.
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Affiliation(s)
- Cheng-Hsuan Tsai
- Graduate Institute of Clinical Medicine National Taiwan University College of Medicine Taipei Taiwan.,Division of Cardiology, Department of Internal Medicine and Cardiovascular Center National Taiwan University Hospital Taipei Taiwan
| | - Ching-Chang Huang
- Division of Cardiology, Department of Internal Medicine and Cardiovascular Center National Taiwan University Hospital Taipei Taiwan
| | - Hao-Ming Hsiao
- Department of Mechanical Engineering National Taiwan University Taipei Taiwan
| | - Ming-Ya Hung
- Department of Mechanical Engineering National Taiwan University Taipei Taiwan
| | - Guan-Jie Su
- Department of Mechanical Engineering National Taiwan University Taipei Taiwan
| | - Li-Han Lin
- Department of Mechanical Engineering National Taiwan University Taipei Taiwan
| | - Ying-Hsien Chen
- Division of Cardiology, Department of Internal Medicine and Cardiovascular Center National Taiwan University Hospital Taipei Taiwan
| | - Mao-Shin Lin
- Division of Cardiology, Department of Internal Medicine and Cardiovascular Center National Taiwan University Hospital Taipei Taiwan
| | - Chih-Fan Yeh
- Division of Cardiology, Department of Internal Medicine and Cardiovascular Center National Taiwan University Hospital Taipei Taiwan
| | - Chi-Sheng Hung
- Division of Cardiology, Department of Internal Medicine and Cardiovascular Center National Taiwan University Hospital Taipei Taiwan
| | - Hsien-Li Kao
- Division of Cardiology, Department of Internal Medicine and Cardiovascular Center National Taiwan University Hospital Taipei Taiwan
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8
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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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Cassola N, Baptista-Silva JC, Nakano LC, Flumignan CD, Sesso R, Vasconcelos V, Carvas Junior N, Flumignan RL. Duplex ultrasound for diagnosing symptomatic carotid stenosis in the extracranial segments. Cochrane Database Syst Rev 2022; 7:CD013172. [PMID: 35815652 PMCID: PMC9272405 DOI: 10.1002/14651858.cd013172.pub2] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Abstract
BACKGROUND Carotid artery stenosis is an important cause of stroke and transient ischemic attack. Correctly and rapidly identifying patients with symptomatic carotid artery stenosis is essential for adequate treatment with early cerebral revascularization. Doubts about the diagnostic value regarding the accuracy of duplex ultrasound (DUS) and the possibility of using DUS as the single diagnostic test before carotid revascularization are still debated. OBJECTIVES To estimate the accuracy of DUS in individuals with symptomatic carotid stenosis verified by either digital subtraction angiography (DSA), computed tomography angiography (CTA), or magnetic resonance angiography (MRA). SEARCH METHODS We searched CRDTAS, CENTRAL, MEDLINE (Ovid), Embase (Ovid), ISI Web of Science, HTA, DARE, and LILACS up to 15 February 2021. We handsearched the reference lists of all included studies and other relevant publications and contacted experts in the field to identify additional studies or unpublished data. SELECTION CRITERIA We included studies assessing DUS accuracy against an acceptable reference standard (DSA, MRA, or CTA) in symptomatic patients. We considered the classification of carotid stenosis with DUS defined with validated duplex velocity criteria, and the NASCET criteria for carotid stenosis measures on DSA, MRA, and CTA. We excluded studies that included < 70% of symptomatic patients; the time between the index test and the reference standard was longer than four weeks or not described, or that presented no objective criteria to estimate carotid stenosis. DATA COLLECTION AND ANALYSIS The review authors independently screened articles, extracted data, and assessed the risk of bias and applicability concerns using the QUADAS-2 domain list. We extracted data with an effort to complete a 2 × 2 table (true positives, true negatives, false positives, and false negatives) for each of the different categories of carotid stenosis and reference standards. We produced forest plots and summary receiver operating characteristic (ROC) plots to summarize the data. Where meta-analysis was possible, we used a bivariate meta-analysis model. MAIN RESULTS We identified 25,087 unique studies, of which 22 were deemed eligible for inclusion (4957 carotid arteries). The risk of bias varied considerably across the studies, and studies were generally of moderate to low quality. We narratively described the results without meta-analysis in seven studies in which the criteria used to determine stenosis were too different from the duplex velocity criteria proposed in our protocol or studies that provided insufficient data to complete a 2 × 2 table for at least in one category of stenosis. Nine studies (2770 carotid arteries) presented DUS versus DSA results for 70% to 99% carotid artery stenosis, and two (685 carotid arteries) presented results from DUS versus CTA in this category. Seven studies presented results for occlusion with DSA as the reference standard and three with CTA as the reference standard. Five studies compared DUS versus DSA for 50% to 99% carotid artery stenosis. Only one study presented results from 50% to 69% carotid artery stenosis. For DUS versus DSA, for < 50% carotid artery stenosis, the summary sensitivity was 0.63 (95% confidence interval [CI] 0.48 to 0.76) and the summary specificity was 0.99 (95% CI 0.96 to 0.99); for the 50% to 69% range, only one study was included and meta-analysis not performed; for the 50% to 99% range, the summary sensitivity was 0.97 (95% CI 0.95 to 0.98) and the summary specificity was 0.70 (95% CI 0.67 to 0.73); for the 70% to 99% range, the summary sensitivity was 0.85 (95% CI 0.77 to 0.91) and the summary specificity was 0.98 (95% CI 0.74 to 0.90); for occlusion, the summary sensitivity was 0.91 (95% CI 0.81 to 0.97) and the summary specificity was 0.95 (95% CI 0.76 to 0.99). For sensitivity analyses, excluding studies in which participants were selected based on the presence of occlusion on DUS had an impact on specificity: 0.98 (95% CI 0.97 to 0.99). For DUS versus CTA, we found two studies in the range of 70% to 99%; the sensitivity varied from 0.57 to 0.94 and the specificity varied from 0.87 to 0.98. For occlusion, the summary sensitivity was 0.95 (95% CI 0.80 to 0.99) and the summary specificity was 0.91 (95% CI 0.09 to 0.99). For DUS versus MRA, there was one study with results for 50% to 99% carotid artery stenosis, with a sensitivity of 0.88 (95% CI 0.70 to 0.98) and specificity of 0.60 (95% CI 0.15 to 0.95); in the 70% to 99% range, two studies were included, with sensitivity that varied from 0.54 to 0.99 and specificity that varied from 0.78 to 0.89. We could perform only a few of the proposed sensitivity analyses because of the small number of studies included. AUTHORS' CONCLUSIONS This review provides evidence that the diagnostic accuracy of DUS is high, especially at discriminating between the presence or absence of significant carotid artery stenosis (< 50% or 50% to 99%). This evidence, plus its less invasive nature, supports the early use of DUS for the detection of carotid artery stenosis. The accuracy for 70% to 99% carotid artery stenosis and occlusion is high. Clinicians should exercise caution when using DUS as the single preoperative diagnostic method, and the limitations should be considered. There was little evidence of the accuracy of DUS when compared with CTA or MRA. The results of this review should be interpreted with caution because they are based on studies of low methodological quality, mainly due to the patient selection method. Methodological problems in participant inclusion criteria from the studies discussed above apparently influenced an overestimated estimate of prevalence values. Most of the studies included failed to precisely describe inclusion criteria and previous testing. Future diagnostic accuracy studies should include direct comparisons of the various modalities of diagnostic tests (mainly DUS, CTA, and MRA) for carotid artery stenosis since DSA is no longer considered to be the best method for diagnosing carotid stenosis and less invasive tests are now used as reference standards in clinical practice. Also, for future studies, the participant inclusion criteria require careful attention.
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Affiliation(s)
- Nicolle Cassola
- Department of Surgery, Division of Vascular and Endovascular Surgery, Universidade Federal de São Paulo, São Paulo, Brazil
| | - Jose Cc Baptista-Silva
- Evidence Based Medicine, Cochrane Brazil, Universidade Federal de São Paulo, São Paulo, Brazil
| | - Luis Cu Nakano
- Department of Surgery, Division of Vascular and Endovascular Surgery, Universidade Federal de São Paulo, São Paulo, Brazil
| | - Carolina Dq Flumignan
- Department of Surgery, Division of Vascular and Endovascular Surgery, Universidade Federal de São Paulo, São Paulo, Brazil
| | - Ricardo Sesso
- Department of Medicine, Division of Nefrology, Universidade Federal de São Paulo, São Paulo, Brazil
| | - Vladimir Vasconcelos
- Department of Surgery, Division of Vascular and Endovascular Surgery, Universidade Federal de São Paulo, São Paulo, Brazil
| | - Nelson Carvas Junior
- Evidence-Based Health Post-Graduation Program, Universidade Federal de São Paulo; Cochrane Brazil; Department of Physiotherapy, Universidade Paulista, São Paulo, Brazil
| | - Ronald Lg Flumignan
- Department of Surgery, Division of Vascular and Endovascular Surgery, Universidade Federal de São Paulo, São Paulo, Brazil
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10
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Heyes A, Crichton A, Rajagopalan S. Carotid artery disease: knowing the numbers. Br J Hosp Med (Lond) 2022; 83:1-6. [DOI: 10.12968/hmed.2022.0184] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
Ischaemic stroke and transient ischaemic attack are of particular interest to the vascular surgeon as over one-third of all strokes are caused by thromboembolism from a stenotic carotid artery, making carotid artery stenosis the leading cause of stroke. If detected early, stenosis can be managed medically, surgically or endovascularly. However, treatment decisions depend on the timing of the transient ischaemic attack and the degree of stenosis, and must be balanced against procedural risk. This article discusses the evidence outlining the epidemiology, measurement and surgical management of carotid artery stenosis that inform national guidelines. Vascular and non-vascular trainees should understand these guidelines because of the potentially debilitating or fatal consequences of untreated carotid stenosis.
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Affiliation(s)
- Adam Heyes
- Department of General Surgery, Great Western Hospital, Great Western Hospitals NHS Foundation Trust, Swindon, UK
| | - Alexander Crichton
- Department of Vascular Surgery, Russells Hall Hospital, The Dudley Group NHS Foundation Trust, Dudley, UK
| | - Sriram Rajagopalan
- Department of Vascular Surgery, Royal Stoke University Hospital, University Hospitals of North Midlands NHS Trust, Stoke-on-Trent, UK
- Department of Undergraduate Medical Education, Keele University School of Medicine, Keele, UK
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11
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Nies KPH, Smits LJM, Kassem M, Nederkoorn PJ, van Oostenbrugge RJ, Kooi ME. Emerging Role of Carotid MRI for Personalized Ischemic Stroke Risk Prediction in Patients With Carotid Artery Stenosis. Front Neurol 2021; 12:718438. [PMID: 34413828 PMCID: PMC8370465 DOI: 10.3389/fneur.2021.718438] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2021] [Accepted: 07/09/2021] [Indexed: 01/04/2023] Open
Abstract
Rupture of a vulnerable carotid plaque is an important cause of ischemic stroke. Prediction models can support medical decision-making by estimating individual probabilities of future events, while magnetic resonance imaging (MRI) can provide detailed information on plaque vulnerability. In this review, prediction models for medium to long-term (>90 days) prediction of recurrent ischemic stroke among patients on best medical treatment for carotid stenosis are evaluated, and the emerging role of MRI of the carotid plaque for personalized ischemic stroke prediction is discussed. A systematic search identified two models; the European Carotid Surgery Trial (ECST) medical model, and the Symptomatic Carotid Atheroma Inflammation Lumen stenosis (SCAIL) score. We critically appraised these models by means of criteria derived from the CHARMS (CHecklist for critical Appraisal and data extraction for systematic Reviews of prediction Modeling Studies) and PROBAST (Prediction model Risk Of Bias ASsessment Tool). We found both models to be at high risk of bias. The ECST model, the most widely used model, was derived from data of large but relatively old trials (1980s and 1990s), not reflecting lower risks of ischemic stroke resulting from improvements in drug treatment (e.g., statins and anti-platelet therapy). The SCAIL model, based on the degree of stenosis and positron emission tomography/computed tomography (PET/CT)-based plaque inflammation, was derived and externally validated in limited samples. Clinical implementation of the SCAIL model can be challenging due to high costs and low accessibility of PET/CT. MRI is a more readily available, lower-cost modality that has been extensively validated to visualize all the hallmarks of plaque vulnerability. The MRI methods to identify the different plaque features are described. Intraplaque hemorrhage (IPH), a lipid-rich necrotic core (LRNC), and a thin or ruptured fibrous cap (TRFC) on MRI have shown to strongly predict stroke in meta-analyses. To improve personalized risk prediction, carotid plaque features should be included in prediction models. Prediction of stroke in patients with carotid stenosis needs modernization, and carotid MRI has potential in providing strong predictors for that goal.
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Affiliation(s)
- Kelly P H Nies
- Department of Radiology, CARIM School for Cardiovascular Diseases, Maastricht University, Maastricht, Netherlands.,Department of Radiology and Nuclear Medicine, Maastricht University Medical Center, Maastricht, Netherlands
| | - Luc J M Smits
- Department of Epidemiology, Maastricht University, Maastricht, Netherlands
| | - Mohamed Kassem
- Department of Radiology, CARIM School for Cardiovascular Diseases, Maastricht University, Maastricht, Netherlands.,Department of Radiology and Nuclear Medicine, Maastricht University Medical Center, Maastricht, Netherlands
| | - Paul J Nederkoorn
- Department of Neurology, Amsterdam University Medical Center, Amsterdam, Netherlands
| | - Robert J van Oostenbrugge
- Department of Radiology, CARIM School for Cardiovascular Diseases, Maastricht University, Maastricht, Netherlands.,Department of Neurology, Maastricht University Medical Center, Maastricht, Netherlands
| | - M Eline Kooi
- Department of Radiology, CARIM School for Cardiovascular Diseases, Maastricht University, Maastricht, Netherlands.,Department of Radiology and Nuclear Medicine, Maastricht University Medical Center, Maastricht, Netherlands
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12
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AbuRahma AF, Avgerinos ED, Chang RW, Darling RC, Duncan AA, Forbes TL, Malas MB, Perler BA, Powell RJ, Rockman CB, Zhou W. The Society for Vascular Surgery implementation document for management of extracranial cerebrovascular disease. J Vasc Surg 2021; 75:26S-98S. [PMID: 34153349 DOI: 10.1016/j.jvs.2021.04.074] [Citation(s) in RCA: 60] [Impact Index Per Article: 20.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2021] [Accepted: 04/28/2021] [Indexed: 12/24/2022]
Affiliation(s)
- Ali F AbuRahma
- Department of Surgery, West Virginia University-Charleston Division, Charleston, WV.
| | - Efthymios D Avgerinos
- Division of Vascular Surgery, University of Pittsburgh School of Medicine, UPMC Hearrt & Vascular Institute, Pittsburgh, Pa
| | - Robert W Chang
- Vascular Surgery, Permanente Medical Group, San Francisco, Calif
| | | | - Audra A Duncan
- Division of Vascular & Endovascular Surgery, University of Western Ontario, London, Ontario, Canada
| | - Thomas L Forbes
- Division of Vascular & Endovascular Surgery, University of Western Ontario, London, Ontario, Canada
| | - Mahmoud B Malas
- Vascular & Endovascular Surgery, University of California San Diego, La Jolla, Calif
| | - Bruce Alan Perler
- Division of Vascular Surgery & Endovascular Therapy, Johns Hopkins, Baltimore, Md
| | | | - Caron B Rockman
- Division of Vascular Surgery, New York University Langone, New York, NY
| | - Wei Zhou
- Division of Vascular Surgery, University of Arizona, Tucson, Ariz
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13
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SOCIETY FOR VASCULAR SURGERY CLINICAL PRACTICE GUIDELINES FOR MANAGEMENT OF EXTRACRANIAL CEREBROVASCULAR DISEASE. J Vasc Surg 2021; 75:4S-22S. [PMID: 34153348 DOI: 10.1016/j.jvs.2021.04.073] [Citation(s) in RCA: 201] [Impact Index Per Article: 67.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2021] [Accepted: 04/20/2021] [Indexed: 11/22/2022]
Abstract
Management of carotid bifurcation stenosis in stroke prevention has been the subject of extensive investigations, including multiple randomized controlled trials. The proper treatment of patients with carotid bifurcation disease is of major interest to vascular surgeons and other vascular specialists. In 2011, the Society for Vascular Surgery published guidelines for treatment of carotid artery disease. At the time, several randomized trials, comparing carotid endarterectomy (CEA) and carotid artery stenting (CAS), were published. Since that publication, several studies and a few systematic reviews comparing CEA and CAS have been published, and the role of medical management has been re-emphasized. The current publication updates and expands the 2011 guidelines with specific emphasis on five areas: is carotid endarterectomy recommended over maximal medical therapy in low risk patients; is carotid endarterectomy recommended over trans-femoral carotid artery stenting in low surgical risk patients with symptomatic carotid artery stenosis of >50%; timing of carotid Intervention in patients presenting with acute stroke; screening for carotid artery stenosis in asymptomatic patients; and optimal sequence for intervention in patients with combined carotid and coronary artery disease. A separate implementation document will address other important clinical issues in extracranial cerebrovascular disease. Recommendations are made using the GRADE (Grades of Recommendation Assessment, Development and Evaluation) approach, as has been done with other Society for Vascular Surgery guidelines. The committee recommends CEA as the first-line treatment for symptomatic low risk surgical patients with stenosis of 50% to 99% and asymptomatic patients with stenosis of 70% to 99%. The perioperative risk of stroke and death in asymptomatic patients must be <3% to ensure benefit for the patient. In patients with recent stable stroke (modified Rankin 0-2), carotid revascularization is considered appropriate in symptomatic patients with greater than 50% stenosis and is recommended and performed as soon as the patient is neurologically stable after 48 hours but definitely before 14 days of onset of symptoms. In the general population, screening for clinically asymptomatic carotid artery stenosis in patients without cerebrovascular symptoms or significant risk factors for carotid artery disease is not recommended. In selected asymptomatic patients who are at increased risk for carotid stenosis, we suggest screening for clinically asymptomatic carotid artery stenosis as long as the patients would potentially be fit for and willing to consider carotid intervention if significant stenosis is discovered. In patients with symptomatic carotid stenosis 50-99%, who require both CEA and CABG, we suggest CEA before or concomitant with CABG to potentially reduce the risk of stroke and stroke/death. The sequencing of the intervention depends on clinical presentation and institutional experience.
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Near-occlusion is difficult to diagnose with common carotid ultrasound methods. Neuroradiology 2021; 63:721-730. [PMID: 33715027 PMCID: PMC8041670 DOI: 10.1007/s00234-021-02687-x] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2020] [Accepted: 03/03/2021] [Indexed: 01/01/2023]
Abstract
Purpose To assess the sensitivity and specificity of common carotid ultrasound method for carotid near-occlusion diagnosis. Methods Five hundred forty-eight patients examined with both ultrasound and CTA within 30 days of each other were analyzed. CTA graded by near-occlusion experts was used as reference standard. Low flow velocity, unusual findings, and commonly used flow velocity parameters were analyzed. Results One hundred three near-occlusions, 272 conventional ≥50% stenosis, 162 <50% stenosis, and 11 occlusions were included. Carotid ultrasound was 22% (95%CI 14–30%; 23/103) sensitive and 99% (95%CI 99–100%; 442/445) specific for near-occlusion diagnosis. Near-occlusions overlooked on ultrasound were found misdiagnosed as occlusions (n = 13, 13%), conventional ≥50% stenosis (n = 65, 63%) and < 50% stenosis (n = 2, 2%). No velocity parameter or combination of parameters could identify the 65 near-occlusions mistaken for conventional ≥50% stenoses with >75% sensitivity and specificity. Conclusion Near-occlusion is difficult to diagnose with commonly used carotid ultrasound methods. Improved carotid ultrasound methods are needed if ultrasound is to retain its position as sole preoperative modality.
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Boelitz K, Jirka C, Eberhardt RT, Kalish JA, Siracuse JJ, Farber A, Jones DW. Inadequate Adherence to Imaging Surveillance and Medical Management in Patients with Duplex Ultrasound-Detected Carotid Artery Stenosis. Ann Vasc Surg 2021; 74:63-72. [PMID: 33508459 DOI: 10.1016/j.avsg.2020.12.027] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2020] [Revised: 12/08/2020] [Accepted: 12/27/2020] [Indexed: 10/22/2022]
Abstract
BACKGROUND It is recommended that patients with ≥50% carotid artery stenosis undergo surveillance imaging and atherosclerotic risk reduction medical therapies, regardless of whether revascularization is performed. The objective of this study was to determine rates of adherence to these recommended measures and to identify risk factors for nonadherence. METHODS A retrospective analysis was performed of all carotid duplex ultrasound (DUS) from 2016 to 2017 at a single institution. Patients with unilateral or bilateral ≥50% carotid stenosis were included. Primary outcomes were rates and timing of surveillance imaging and medication regimen. Patient and study characteristics were compared using univariate and multivariable analyses. A subgroup analysis of patients with a new finding of carotid stenosis was also performed. RESULTS Carotid stenosis >50% was detected in 340 patients. Overall, 182 patients (54%) had follow-up imaging (median 261 days [IQR 166-366]) and 158 patients (46%) had no imaging follow-up (NIFU). NIFU patients had similar rates of aspirin use (86% vs. 88%, P = 0.6) and tobacco cessation counseling (71% vs. 71%, P = 0.8) but had less statin use (85% vs. 94%, P = 0.01) compared to those with imaging follow-up. Subsequent carotid revascularization was more common in patients with imaging follow-up (18% vs. 3%, P < 0.001). NIFU patients were less likely to have Medicare or commercial insurance (54% vs. 75%, P < 0.001). The indication for DUS in NIFU patients, compared to those in follow up, was less commonly neurologic symptoms (11% vs. 14%), more commonly other clinical findings (35% vs. 16%), and more commonly as work up before nonvascular surgery (25% vs. 4%, P < 0.001), respectively. NIFU rates decreased with increasing degree of carotid stenosis. Prior carotid intervention, prior DUS, or DUS ordered by a vascular surgeon were characteristics associated with imaging follow-up (P < 0.05 for all). In a subgroup of 160 patients with new carotid stenosis, a majority (64%) had NIFU and statin use was lower in these patients (82% vs. 96%, P = 0.007). On multivariable analysis, preop indication was predictive of NIFU (odds ratio [OR] 8.1 [95% confidence interval, CI 2.5-26.4], P < 0.001) whereas protective factors included: 70-80% stenosis (OR 0.33 [95% CI 0.14-0.76], P = 0.01), study ordered by vascular surgeon (OR 0.40 [95% CI 0.19-0.83], P = 0.01), and Medicare/commercial insurance (OR 0.36 [95% CI 0.2-0.66], P = 0.001). CONCLUSIONS Nearly half of patients found to have ≥50% carotid stenosis on DUS had no imaging follow-up; these patients were less likely to be on recommended statin therapy. The benefits of nonrevascularization-based treatments for carotid disease require adherence to therapy. Forgoing surveillance imaging in patients with hemodynamically significant carotid stenosis should be a shared decision between provider and patient and does not obviate the need for medical therapies.
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Affiliation(s)
- Kris Boelitz
- Division of Vascular and Endovascular Surgery, Boston Medical Center, Boston University School of Medicine, Boston MA
| | - Caroline Jirka
- Division of Vascular and Endovascular Surgery, Boston Medical Center, Boston University School of Medicine, Boston MA
| | - Robert T Eberhardt
- Evans Department of Medicine and Whitaker Cardiovascular Institute, Boston University School of Medicine, Boston, MA
| | - Jeffrey A Kalish
- Division of Vascular and Endovascular Surgery, Boston Medical Center, Boston University School of Medicine, Boston MA
| | - Jeffrey J Siracuse
- Division of Vascular and Endovascular Surgery, Boston Medical Center, Boston University School of Medicine, Boston MA
| | - Alik Farber
- Division of Vascular and Endovascular Surgery, Boston Medical Center, Boston University School of Medicine, Boston MA
| | - Douglas W Jones
- Division of Vascular and Endovascular Surgery, Boston Medical Center, Boston University School of Medicine, Boston MA.
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Kim SM, Kim YJ, Kim K, Kim BJ. Usefulness of carotid ultrasonography and treatment of carotid disease. JOURNAL OF THE KOREAN MEDICAL ASSOCIATION 2020. [DOI: 10.5124/jkma.2020.63.6.342] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022] Open
Abstract
Carotid stenosis is an important etiology of ischemic stroke. Most of the strokes associated with carotid stenosis are caused by artery-to-artery embolism. The risk of embolism highly depends on the stenosis degree and the vulnerability of the carotid plaque. Carotid ultrasonography is useful for evaluating the characteristics of carotid plaque. This review aims to provide information on performing and interpreting the result of carotid ultrasonography and the treatment of carotid artery disease based on the current guidelines. The degree of stenosis can be measured by the diameter reduction and flow velocity criteria. The risk of embolism is highest when the stenosis degree is around 70% to 80%. A heterogeneous echolucent plaque with an irregular surface or an ulcer shows a high risk of embolism. Appropriate treatment is important for the patients with carotid stenosis. In symptomatic patients, a potent antiplatelet treatment, especially during the acute stage, is beneficial. Patients with asymptomatic stenosis over 50% can also be considered for antiplatelet treatments. The associated risk factors should be managed according to the targets. Medically intractable cases or patients with high risk of embolism may receive carotid endarterectomy or carotid artery stenting depending on the concomitant disease and the degree of carotid stenosis. Considering the safety of ultrasound imaging, treatment may be followed-up by carotid ultrasonography.
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Volumetric Carotid Flow Characteristics in Doppler Ultrasonography in Healthy Population Over 65 Years Old. J Clin Med 2020; 9:jcm9051375. [PMID: 32392788 PMCID: PMC7291321 DOI: 10.3390/jcm9051375] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2020] [Revised: 05/04/2020] [Accepted: 05/06/2020] [Indexed: 12/03/2022] Open
Abstract
Background: Carotid flow velocity criteria are well established, with age being a factor influencing measurements. However, there are no volumetric standards for the flow in extracranial arteries. The aim of the study was related to volumetric flow assessment of extracranial arteries in a healthy population >65 years old. Methods: Doppler volumetric measurements of internal carotid (ICA), external carotid (ECA) and vertebral arteries (VA) were performed in 123 healthy volunteers >65 years old and compared with 56 healthy volunteers <65 years old. Results: The continuous decline in cerebral blood flow (CBF) volume was observed (p < 0.00001). Volumetric reference values were established in study groups: 1., 65–69 years: 898.5 ± 119.1; 2., 70–74 years: 838.5 ± 148.9; 3., 75–79 years: 805.1 ± 99.3; 4., >80 years: 685.7 ± 112.3 (mL/min). Significant differences were observed between groups: 1 and 3.4, as well as 3 and 4 (p = 0.0295, < 0.000001, 0.00446 respectively). CBF volume decreases gradually with age: 28–64 years—6.2 mL/year (p = 0.0019), 65–75 years—11.4 mL/year (p = 0.0121) and >75 years—14.3 mL/year (p = 0.0074). This is a consequence of flow volume decline in ICA (p = 0.00001) and to lesser extent ECA (p = 0.0011). The decrease of peak systolic (p = 0.002) and end diastolic (p = < 0.00001) velocities in ICA and peak systolic velocity in ECA (p = 0.0017) were observed. Conclusions: CBF decreases with ageing. Volumetric assessment of CBF may play an important additional role in diagnostics of patients with carotid stenosis. Doppler assessment of cerebral flow volume may create an interesting tool for identifying patients with diminished cerebrovascular reserve and higher risk of ischemic symptoms occurrence.
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Clezar CNB, Cassola N, Flumignan CDQ, Nakano LCU, Trevisani VFM, Flumignan RLG. Pharmacological interventions for asymptomatic carotid stenosis. Hippokratia 2020. [DOI: 10.1002/14651858.cd013573] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Affiliation(s)
- Caroline NB Clezar
- Universidade Federal de São Paulo; Department of Surgery, Division of Vascular and Endovascular Surgery; Rua Borges Lagoa, 754 São Paulo Brazil
| | - Nicolle Cassola
- Universidade Federal de São Paulo; Department of Surgery, Division of Vascular and Endovascular Surgery; Rua Borges Lagoa, 754 São Paulo Brazil
| | - Carolina DQ Flumignan
- Universidade Federal de São Paulo; Department of Surgery, Division of Vascular and Endovascular Surgery; Rua Borges Lagoa, 754 São Paulo Brazil
| | - Luis CU Nakano
- Universidade Federal de São Paulo; Department of Surgery, Division of Vascular and Endovascular Surgery; Rua Borges Lagoa, 754 São Paulo Brazil
| | - Virginia FM Trevisani
- Escola Paulista de Medicina, Universidade Federal de São Paulo and Universidade de Santo Amaro; Medicina de Urgência and Rheumatology; Rua Botucatu, 740 Vila Clementino São Paulo São Paulo Brazil 04023-900
| | - Ronald LG Flumignan
- Universidade Federal de São Paulo; Department of Surgery, Division of Vascular and Endovascular Surgery; Rua Borges Lagoa, 754 São Paulo Brazil
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Hajhosseiny R, Bahaei TS, Prieto C, Botnar RM. Molecular and Nonmolecular Magnetic Resonance Coronary and Carotid Imaging. Arterioscler Thromb Vasc Biol 2020; 39:569-582. [PMID: 30760017 DOI: 10.1161/atvbaha.118.311754] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Atherosclerosis is the leading cause of cardiovascular morbidity and mortality. Over the past 2 decades, increasing research attention is converging on the early detection and monitoring of atherosclerotic plaque. Among several invasive and noninvasive imaging modalities, magnetic resonance imaging (MRI) is emerging as a promising option. Advantages include its versatility, excellent soft tissue contrast for plaque characterization and lack of ionizing radiation. In this review, we will explore the recent advances in multicontrast and multiparametric imaging sequences that are bringing the aspiration of simultaneous arterial lumen, vessel wall, and plaque characterization closer to clinical feasibility. We also discuss the latest advances in molecular magnetic resonance and multimodal atherosclerosis imaging.
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Affiliation(s)
- Reza Hajhosseiny
- From the School of Biomedical Engineering and Imaging Sciences, King's College London, United Kingdom (R.H., T.S.B., C.P., R.M.B.).,National Heart and Lung Institute, Imperial College London, United Kingdom (R.H.)
| | - Tamanna S Bahaei
- From the School of Biomedical Engineering and Imaging Sciences, King's College London, United Kingdom (R.H., T.S.B., C.P., R.M.B.)
| | - Claudia Prieto
- From the School of Biomedical Engineering and Imaging Sciences, King's College London, United Kingdom (R.H., T.S.B., C.P., R.M.B.).,Escuela de Ingeniería, Pontificia Universidad Catolica de Chile, Santiago, Chile (C.P., R.M.B.)
| | - René M Botnar
- From the School of Biomedical Engineering and Imaging Sciences, King's College London, United Kingdom (R.H., T.S.B., C.P., R.M.B.).,Escuela de Ingeniería, Pontificia Universidad Catolica de Chile, Santiago, Chile (C.P., R.M.B.)
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Aboyans V, Ricco JB, Bartelink MLEL, Björck M, Brodmann M, Cohnert T, Collet JP, Czerny M, De Carlo M, Debus S, Espinola-Klein C, Kahan T, Kownator S, Mazzolai L, Naylor AR, Roffi M, Röther J, Sprynger M, Tendera M, Tepe G, Venermo M, Vlachopoulos C, Desormais I. 2017 ESC Guidelines on the Diagnosis and Treatment of Peripheral Arterial Diseases, in collaboration with the European Society for Vascular Surgery (ESVS): Document covering atherosclerotic disease of extracranial carotid and vertebral, mesenteric, renal, upper and lower extremity arteriesEndorsed by: the European Stroke Organization (ESO)The Task Force for the Diagnosis and Treatment of Peripheral Arterial Diseases of the European Society of Cardiology (ESC) and of the European Society for Vascular Surgery (ESVS). Eur Heart J 2019; 39:763-816. [PMID: 28886620 DOI: 10.1093/eurheartj/ehx095] [Citation(s) in RCA: 1951] [Impact Index Per Article: 390.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
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21
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Murray CSG, Nahar T, Kalashyan H, Becher H, Nanda NC. Ultrasound assessment of carotid arteries: Current concepts, methodologies, diagnostic criteria, and technological advancements. Echocardiography 2019; 35:2079-2091. [PMID: 30506607 DOI: 10.1111/echo.14197] [Citation(s) in RCA: 23] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2018] [Revised: 10/31/2018] [Accepted: 10/31/2018] [Indexed: 01/06/2023] Open
Abstract
Following cardiac disease and cancer, stroke continues to be the third leading cause of death and disability due to chronic disease in the developed world. Appropriate screening tools are integral to early detection and prevention of major cardiovascular events. In a carotid artery, the presence of increased intima-media thickness, plaque, or stenosis is associated with increased risk of a transient ischemic attack or a stroke. Carotid artery ultrasound remains a long-standing and reliable tool in the current armamentarium of diagnostic modalities used to assess vascular morbidity at an early stage. The procedure has, over the last two decades, undergone considerable upgrades in technology, approach, and utility. This review examines in detail the current state and usage of this integrally important means of extracranial cerebrovascular assessment.
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Affiliation(s)
- Christopher S G Murray
- Department of Internal Medicine, Harlem Hospital Center/Columbia University, New York, New York
| | - Tamanna Nahar
- Section of Cardiology, Department of Internal Medicine, Harlem Hospital Center/Columbia University, New York, New York
| | - Hayrapet Kalashyan
- Department of Medicine, University of Alberta, Edmonton, Alberta, Canada
| | - Harald Becher
- Department of Medicine, University of Alberta, Edmonton, Alberta, Canada
| | - Navin C Nanda
- Department of Internal Medicine, Division of Cardiovascular Disease, University of Alabama at Birmingham, Birmingham, Alabama
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22
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Forjoe T, Asad Rahi M. Systematic review of preoperative carotid duplex ultrasound compared with computed tomography carotid angiography for carotid endarterectomy. Ann R Coll Surg Engl 2019; 101:141-149. [PMID: 30767557 PMCID: PMC6400905 DOI: 10.1308/rcsann.2019.0010] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/27/2018] [Indexed: 01/12/2023] Open
Abstract
INTRODUCTION We reviewed the literature for preoperative computed tomography carotid angiography and/or carotid duplex to determine their respective sensitivity and specificity in assessing the degree of carotid stenosis. We aimed to identify whether one imaging modality can accurately identify critical stenosis in patients presenting with transient ischaemic attack or symptoms of a cerebrovascular accident requiring carotid endarterectomy. METHODS Systematic search of MEDLINE, Embase, Cochrane database of systematic reviews, all Evidence-Based Medicine Reviews (Cochrane Database of Systematic Reviews, ACP Journal club, Database of Abstracts of Reviews of Effects, Cochrane Clinical Answers, Cochrane Controlled Trials Register, Cochrane Methodology Register, Health Technology Assessment and NHS Economic Evaluation Database) for primary studies relating to computed tomography carotid angiography (CTA) and/or carotid duplex ultrasound (CDU). Studies included were published between 1990 and 2018 and focused on practice in the UK, Europe and North America. RESULTS The sensitivity and specificity of CTA and CDU are comparable. CDU is safe and readily available in the clinical environment hence its use in the initial preoperative assessment of carotid stenosis. CDU is an adequate imaging modality for determining stenosis greater than 70%; sensitivity and specificity are improved when the criteria for determining greater than 70% stenosis are adjusted. Vascular laboratories opting to use duplex as their sole imaging modality should assess the sensitivity and specificity of their own duplex procedure before altering practice to preoperative single imaging for patients. CONCLUSIONS The sensitivity and specificity of CTA (90.6% and 93%, respectively) and CDU (92.3% and 89%, respectively) are comparable. Both are dependent on criteria used in vascular laboratories. CDU sensitivity and specificity was improved to 98.7% and 94.1%, respectively, where peak systolic velocity and end diastolic velocity were assessed. Either modality can be used to determine greater than 70% stenosis, although a secondary imaging modality may be required for cases of greater than 50% stenosis.
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Affiliation(s)
- T Forjoe
- Manchester Medical School, Manchester, UK
| | - M Asad Rahi
- Regional Vascular Centre, Royal Preston Hospital, Preston, UK
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23
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Carotid Stenosis: Utility of Diagnostic Angiography. World Neurosurg 2019; 121:e962-e966. [DOI: 10.1016/j.wneu.2018.10.054] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2018] [Accepted: 10/07/2018] [Indexed: 11/16/2022]
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Cassola N, Baptista-Silva JCC, Flumignan CDQ, Sesso R, Vasconcelos V, Flumignan RLG. Duplex ultrasound for diagnosing symptomatic carotid stenosis in the extracranial segments. Hippokratia 2018. [DOI: 10.1002/14651858.cd013172] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Affiliation(s)
- Nicolle Cassola
- Universidade Federal de São Paulo; Department of Surgery, Division of Vascular and Endovascular Surgery; Rua Borges Lagoa, 754 São Paulo Brazil 04038-001
| | - Jose CC Baptista-Silva
- Universidade Federal de São Paulo; Evidence Based Medicine, Cochrane Brazil; Rua Borges Lagoa, 564, cj 124 São Paulo São Paulo Brazil 04038-000
| | - Carolina DQ Flumignan
- Universidade Federal de São Paulo; Department of Surgery, Division of Vascular and Endovascular Surgery; Rua Borges Lagoa, 754 São Paulo Brazil 04038-001
| | - Ricardo Sesso
- Escola Paulista de Medicina, Universidade Federal de São Paulo; Disciplina de Nefrologia; Rua Botucato 740 São Paulo São Paulo Brazil 04023-900
| | - Vladimir Vasconcelos
- Universidade Federal de São Paulo; Department of Surgery, Division of Vascular and Endovascular Surgery; Rua Borges Lagoa, 754 São Paulo Brazil 04038-001
| | - Ronald LG Flumignan
- Universidade Federal de São Paulo; Department of Surgery, Division of Vascular and Endovascular Surgery; Rua Borges Lagoa, 754 São Paulo Brazil 04038-001
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Miura M, Hirayama A, Oowada S, Nishida A, Saito C, Yamagata K, Ito O, Hirayama Y, Kohzuki M. Effects of electrical stimulation on muscle power and biochemical markers during hemodialysis in elderly patients: a pilot randomized clinical trial. RENAL REPLACEMENT THERAPY 2018. [DOI: 10.1186/s41100-018-0174-7] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022] Open
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Vlachopoulos C, Georgakopoulos C, Koutagiar I, Tousoulis D. Diagnostic modalities in peripheral artery disease. Curr Opin Pharmacol 2018; 39:68-76. [PMID: 29549715 DOI: 10.1016/j.coph.2018.02.010] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2018] [Revised: 01/31/2018] [Accepted: 02/22/2018] [Indexed: 01/27/2023]
Abstract
Peripheral artery disease (PAD) affects approximately one in five persons older than 70 years of age and it is often present in patients with concomitant vascular disease in different body territories (e.g. coronary artery disease). Diagnosis at an early stage is important in order to achieve improvement in patient's symptoms and prognosis. Remarkable improvements in the field of noninvasive and invasive imaging techniques have led to an advanced level the management of patients with PAD. Throughout this review article, the clinically available diagnostic modalities in PAD are presented. Strong and weaker points are stressed out in a manner that elucidates that no perfect diagnostic method exists. Based on the patient's individual profile, as well as on certain aspects of the disease (e.g. morphology of carotid plaque lesions) the attending physician will ultimately decide which diagnostic path will lead to a prompt and correct diagnosis of PAD with the minimum amount of exams and risk for the patient.
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Affiliation(s)
- Charalambos Vlachopoulos
- Hypertension and Cardiometabolic Syndrome Unit, 1st Department of Cardiology, Medical School, National and Kapodistrian University of Athens, Hippokration Hospital, Athens, Greece.
| | - Christos Georgakopoulos
- Hypertension and Cardiometabolic Syndrome Unit, 1st Department of Cardiology, Medical School, National and Kapodistrian University of Athens, Hippokration Hospital, Athens, Greece
| | - Iosif Koutagiar
- Hypertension and Cardiometabolic Syndrome Unit, 1st Department of Cardiology, Medical School, National and Kapodistrian University of Athens, Hippokration Hospital, Athens, Greece
| | - Dimitrios Tousoulis
- Hypertension and Cardiometabolic Syndrome Unit, 1st Department of Cardiology, Medical School, National and Kapodistrian University of Athens, Hippokration Hospital, Athens, Greece
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Park JH, Lee JH. Carotid Artery Stenting. Korean Circ J 2018; 48:97-113. [PMID: 29171201 PMCID: PMC5861011 DOI: 10.4070/kcj.2017.0208] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2017] [Revised: 09/16/2017] [Accepted: 09/19/2017] [Indexed: 01/01/2023] Open
Abstract
Carotid artery stenosis is relatively common and is a significant cause of ischemic stroke, but carotid revascularization can reduce the risk of ischemic stroke in patients with significant symptomatic stenosis. Carotid endarterectomy has been and remains the gold standard treatment to reduce the risk of carotid artery stenosis. Carotid artery stenting (CAS) (or carotid artery stent implantation) is another method of carotid revascularization, which has developed rapidly over the last 30 years. To date, the frequency of use of CAS is increasing, and clinical outcomes are improving with technical advancements. However, the value of CAS remains unclear in patients with significant carotid artery stenosis. This review article discusses the basic concepts and procedural techniques involved in CAS.
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Affiliation(s)
- Jae Hyeong Park
- Department of Cardiology in Internal Medicine, Chungnam National University School of Medicine, Chungnam National University Hospital, Daejeon, Korea
| | - Jae Hwan Lee
- Department of Cardiology in Internal Medicine, Chungnam National University School of Medicine, Chungnam National University Hospital, Daejeon, Korea.
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Leithner D, Mahmoudi S, Wichmann JL, Martin SS, Lenga L, Albrecht MH, Booz C, Arendt CT, Beeres M, D'Angelo T, Bodelle B, Vogl TJ, Scholtz JE. Evaluation of virtual monoenergetic imaging algorithms for dual-energy carotid and intracerebral CT angiography: Effects on image quality, artefacts and diagnostic performance for the detection of stenosis. Eur J Radiol 2018; 99:111-117. [DOI: 10.1016/j.ejrad.2017.12.024] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2017] [Revised: 12/01/2017] [Accepted: 12/29/2017] [Indexed: 10/18/2022]
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Naylor AR, Ricco JB, de Borst GJ, Debus S, de Haro J, Halliday A, Hamilton G, Kakisis J, Kakkos S, Lepidi S, Markus HS, McCabe DJ, Roy J, Sillesen H, van den Berg JC, Vermassen F, Kolh P, Chakfe N, Hinchliffe RJ, Koncar I, Lindholt JS, Vega de Ceniga M, Verzini F, Archie J, Bellmunt S, Chaudhuri A, Koelemay M, Lindahl AK, Padberg F, Venermo M. Editor's Choice - Management of Atherosclerotic Carotid and Vertebral Artery Disease: 2017 Clinical Practice Guidelines of the European Society for Vascular Surgery (ESVS). Eur J Vasc Endovasc Surg 2018; 55:3-81. [PMID: 28851594 DOI: 10.1016/j.ejvs.2017.06.021] [Citation(s) in RCA: 797] [Impact Index Per Article: 132.8] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
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Lechtman E, Balki I, Thomas K, Chen K, Moody AR, Tyrrell PN. Cost-effectiveness of magnetic resonance carotid plaque imaging for primary stroke prevention in Canada. Br J Radiol 2017; 91:20170518. [PMID: 29076745 DOI: 10.1259/bjr.20170518] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
OBJECTIVE Magnetic resonance of the carotid arteries provides important insight into plaque composition and vulnerability in addition to the traditional measure of stenosis. The purpose of this study was to evaluate the cost-effectiveness of MR imaging as a first-line modality to assess carotid disease and guide management for high-risk patients with <50% stenosis. METHODS Using TreeAge Pro, a cost-effectiveness simulation was conducted comparing two strategies: (a) standard of care first-line carotid duplex ultrasound (DUS) with regular follow-up, vs (b) first-line MR assessment of stenosis and intraplaque haemorrhage (MRIPH) in which patients with IPH received annual DUS surveillance and immediate carotid endarterectomy in case of plaque progression. RESULTS For patients aged 70 years old, using a first-line MRIPH strategy resulted in a 16.8% relative risk reduction in strokes compared to DUS (0.080 vs 0.097 strokes per patient per lifetime), and an increased quality-adjusted-life years (12.23 vs 12.20) at an increased cost of $897.33 over a patient's lifetime ($5784.53 vs $4887.20 average total cost per patient per lifetime). The incremental cost-effectiveness ratio was $29,744 per quality-adjusted-life years. MRIPH remained cost-effective below a willingness-to-pay threshold of $50,000 for 91.8% of sensitivity analyses. CONCLUSION MRIPH was found to be a cost-effective first-line tool to identify asymptomatic patients at high risk for stroke requiring annual surveillance and prompt management. Advances in Knowledge: Using MR imaging as a fist-line method to detect the presence of IPH provides clinically useful and cost-effective information that allows for enhanced risk evaluation and primary stroke prevention.
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Affiliation(s)
- Eli Lechtman
- 1 Department of Medical Imaging,University of Toronto , University of Toronto , Toronto, ON , Canada
| | - Indranil Balki
- 1 Department of Medical Imaging,University of Toronto , University of Toronto , Toronto, ON , Canada
| | - Kiersten Thomas
- 1 Department of Medical Imaging,University of Toronto , University of Toronto , Toronto, ON , Canada
| | - Kevin Chen
- 1 Department of Medical Imaging,University of Toronto , University of Toronto , Toronto, ON , Canada
| | - Alan R Moody
- 1 Department of Medical Imaging,University of Toronto , University of Toronto , Toronto, ON , Canada
| | - Pascal N Tyrrell
- 1 Department of Medical Imaging,University of Toronto , University of Toronto , Toronto, ON , Canada.,2 Department of Statistical Sciences,University of Toronto , University of Toronto , Toronto, ON , Canada
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Editor's Choice - 2017 ESC Guidelines on the Diagnosis and Treatment of Peripheral Arterial Diseases, in collaboration with the European Society for Vascular Surgery (ESVS). Eur J Vasc Endovasc Surg 2017; 55:305-368. [PMID: 28851596 DOI: 10.1016/j.ejvs.2017.07.018] [Citation(s) in RCA: 662] [Impact Index Per Article: 94.6] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
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Ammar CP, Helmer SD, Ammar AD. Carotid Duplex Ultrasonography: Additional Imaging is Rarely Necessary for Appropriate Treatment Planning for Carotid Artery Disease. Am Surg 2017. [DOI: 10.1177/000313481708300425] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
This study was conducted to determine the utility of multiple imaging studies (CT angiography, magnetic resonance angiography, and/or conventional angiography), in addition to duplex ultrasonography (DU), in evaluating patients with carotid stenosis. A retrospective case series was conducted of patients with carotid stenosis who underwent DU alone or DU plus additional imaging. Concordance between DU and additional imaging and the effect on treatment plan was evaluated. Two hundred patients with carotid stenosis were evaluated. Sixty-four had DU plus additional imaging. Sixty-two of the patients (96.9%) had no change in treatment due to additional imaging. Only 2 of the 64 patients (3.1%) with additional imaging had a change in treatment plan. In conclusion, additional imaging, beyond DU, is rarely necessary for treatment planning in patients with carotid disease.
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Affiliation(s)
- Chad P. Ammar
- Department of Surgery, The University of Kansas School of Medicine–Wichita, Wichita, Kansas
| | - Stephen D. Helmer
- Department of Surgery, The University of Kansas School of Medicine–Wichita, Wichita, Kansas
| | - Alex D. Ammar
- Department of Surgery, The University of Kansas School of Medicine–Wichita, Wichita, Kansas
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Guthrie S, Bienkowska-Gibbs T, Manville C, Pollitt A, Kirtley A, Wooding S. The impact of the National Institute for Health Research Health Technology Assessment programme, 2003-13: a multimethod evaluation. Health Technol Assess 2016; 19:1-291. [PMID: 26307643 DOI: 10.3310/hta19670] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
BACKGROUND The National Institute for Health Research (NIHR) Health Technology Assessment (HTA) programme supports research tailored to the needs of NHS decision-makers, patients and clinicians. This study reviewed the impact of the programme, from 2003 to 2013, on health, clinical practice, health policy, the economy and academia. It also considered how HTA could maintain and increase its impact. METHODS Interviews (n = 20): senior stakeholders from academia, policy-making organisations and the HTA programme. Bibliometric analysis: citation analysis of publications arising from HTA programme-funded research. Researchfish survey: electronic survey of all HTA grant holders. Payback case studies (n = 12): in-depth case studies of HTA programme-funded research. RESULTS We make the following observations about the impact, and routes to impact, of the HTA programme: it has had an impact on patients, primarily through changes in guidelines, but also directly (e.g. changing clinical practice); it has had an impact on UK health policy, through providing high-quality scientific evidence - its close relationships with the National Institute for Health and Care Excellence (NICE) and the National Screening Committee (NSC) contributed to the observed impact on health policy, although in some instances other organisations may better facilitate impact; HTA research is used outside the UK by other HTA organisations and systematic reviewers - the programme has an impact on HTA practice internationally as a leader in HTA research methods and the funding of HTA research; the work of the programme is of high academic quality - the Health Technology Assessment journal ensures that the vast majority of HTA programme-funded research is published in full, while the HTA programme still encourages publication in other peer-reviewed journals; academics agree that the programme has played an important role in building and retaining HTA research capacity in the UK; the HTA programme has played a role in increasing the focus on effectiveness and cost-effectiveness in medicine - it has also contributed to increasingly positive attitudes towards HTA research both within the research community and the NHS; and the HTA focuses resources on research that is of value to patients and the UK NHS, which would not otherwise be funded (e.g. where there is no commercial incentive to undertake research). The programme should consider the following to maintain and increase its impact: providing targeted support for dissemination, focusing resources when important results are unlikely to be implemented by other stakeholders, particularly when findings challenge vested interests; maintaining close relationships with NICE and the NSC, but also considering other potential users of HTA research; maintaining flexibility and good relationships with researchers, giving particular consideration to the Technology Assessment Report (TAR) programme and the potential for learning between TAR centres; maintaining the academic quality of the work and the focus on NHS need; considering funding research on the short-term costs of the implementation of new health technologies; improving the monitoring and evaluation of whether or not patient and public involvement influences research; improve the transparency of the priority-setting process; and continuing to monitor the impact and value of the programme to inform its future scientific and administrative development.
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Sharma P, Scotland G, Cruickshank M, Tassie E, Fraser C, Burton C, Croal B, Ramsay CR, Brazzelli M. The clinical effectiveness and cost-effectiveness of point-of-care tests (CoaguChek system, INRatio2 PT/INR monitor and ProTime Microcoagulation system) for the self-monitoring of the coagulation status of people receiving long-term vitamin K antagonist therapy, compared with standard UK practice: systematic review and economic evaluation. Health Technol Assess 2016; 19:1-172. [PMID: 26138549 DOI: 10.3310/hta19480] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023] Open
Abstract
BACKGROUND Self-monitoring (self-testing and self-management) could be a valid option for oral anticoagulation therapy monitoring in the NHS, but current evidence on its clinical effectiveness or cost-effectiveness is limited. OBJECTIVES We investigated the clinical effectiveness and cost-effectiveness of point-of-care coagulometers for the self-monitoring of coagulation status in people receiving long-term vitamin K antagonist therapy, compared with standard clinic monitoring. DATA SOURCES We searched major electronic databases (e.g. MEDLINE, MEDLINE In Process & Other Non-Indexed Citations, EMBASE, Bioscience Information Service, Science Citation Index and Cochrane Central Register of Controlled Trials) from 2007 to May 2013. Reports published before 2007 were identified from the existing Cochrane review (major databases searched from inception to 2007). The economic model parameters were derived from the clinical effectiveness review, other relevant reviews, routine sources of cost data and clinical experts' advice. REVIEW METHODS We assessed randomised controlled trials (RCTs) evaluating self-monitoring in people with atrial fibrillation or heart valve disease requiring long-term anticoagulation therapy. CoaguChek(®) XS and S models (Roche Diagnostics, Basel, Switzerland), INRatio2(®) PT/INR monitor (Alere Inc., San Diego, CA USA), and ProTime Microcoagulation system(®) (International Technidyne Corporation, Nexus Dx, Edison, NJ, USA) coagulometers were compared with standard monitoring. Where possible, we combined data from included trials using standard inverse variance methods. Risk of bias assessment was performed using the Cochrane risk of bias tool. A de novo economic model was developed to assess the cost-effectiveness over a 10-year period. RESULTS We identified 26 RCTs (published in 45 papers) with a total of 8763 participants. CoaguChek was used in 85% of the trials. Primary analyses were based on data from 21 out of 26 trials. Only four trials were at low risk of bias. Major clinical events: self-monitoring was significantly better than standard monitoring in preventing thromboembolic events [relative risk (RR) 0.58, 95% confidence interval (CI) 0.40 to 0.84; p = 0.004]. In people with artificial heart valves (AHVs), self-monitoring almost halved the risk of thromboembolic events (RR 0.56, 95% CI 0.38 to 0.82; p = 0.003) and all-cause mortality (RR 0.54, 95% CI 0.32 to 0.92; p = 0.02). There was greater reduction in thromboembolic events and all-cause mortality through self-management but not through self-testing. Intermediate outcomes: self-testing, but not self-management, showed a modest but significantly higher percentage of time in therapeutic range, compared with standard care (weighted mean difference 4.44, 95% CI 1.71 to 7.18; p = 0.02). Patient-reported outcomes: improvements in patients' quality of life related to self-monitoring were observed in six out of nine trials. High preference rates were reported for self-monitoring (77% to 98% in four trials). Net health and social care costs over 10 years were £7295 (self-monitoring with INRatio2); £7324 (standard care monitoring); £7333 (self-monitoring with CoaguChek XS) and £8609 (self-monitoring with ProTime). The estimated quality-adjusted life-year (QALY) gain associated with self-monitoring was 0.03. Self-monitoring with INRatio2 or CoaguChek XS was found to have ≈ 80% chance of being cost-effective, compared with standard monitoring at a willingness-to-pay threshold of £20,000 per QALY gained. CONCLUSIONS Compared with standard monitoring, self-monitoring appears to be safe and effective, especially for people with AHVs. Self-monitoring, and in particular self-management, of anticoagulation status appeared cost-effective when pooled estimates of clinical effectiveness were applied. However, if self-monitoring does not result in significant reductions in thromboembolic events, it is unlikely to be cost-effective, based on a comparison of annual monitoring costs alone. Trials investigating the longer-term outcomes of self-management are needed, as well as direct comparisons of the various point-of-care coagulometers. STUDY REGISTRATION This study is registered as PROSPERO CRD42013004944. FUNDING The National Institute for Health Research Health Technology Assessment programme.
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Affiliation(s)
- Pawana Sharma
- Health Services Research Unit, University of Aberdeen, Aberdeen, UK
| | - Graham Scotland
- Health Services Research Unit, University of Aberdeen, Aberdeen, UK.,Health Economics Research Unit, University of Aberdeen, Aberdeen, UK
| | | | - Emma Tassie
- Health Economics Research Unit, University of Aberdeen, Aberdeen, UK
| | - Cynthia Fraser
- Health Services Research Unit, University of Aberdeen, Aberdeen, UK
| | - Chris Burton
- Centre of Academic Primary Care, University of Aberdeen, Aberdeen, UK
| | - Bernard Croal
- Department of Clinical Biochemistry, University of Aberdeen, Aberdeen, UK
| | - Craig R Ramsay
- Health Services Research Unit, University of Aberdeen, Aberdeen, UK
| | - Miriam Brazzelli
- Health Services Research Unit, University of Aberdeen, Aberdeen, UK
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35
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Windecker S, Kolh P, Alfonso F, Collet JP, Cremer J, Falk V, Filippatos G, Hamm C, Head SJ, Jüni P, Kappetein AP, Kastrati A, Knuuti J, Landmesser U, Laufer G, Neumann FJ, Richter DJ, Schauerte P, Sousa Uva M, Stefanini GG, Taggart DP, Torracca L, Valgimigli M, Wijns W, Witkowski A. 2014 ESC/EACTS guidelines on myocardial revascularization. EUROINTERVENTION 2015; 10:1024-94. [PMID: 25187201 DOI: 10.4244/eijy14m09_01] [Citation(s) in RCA: 211] [Impact Index Per Article: 23.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Affiliation(s)
- Stephan Windecker
- Cardiology, Bern University Hospital, Freiburgstrasse 4, CH-3010 Bern, Switzerland
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36
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Abstract
Four diagnostic modalities are used to image the following internal carotid artery: digital subtraction angiography (DSA), duplex ultrasound (DUS), computed tomography angiography (CTA), and magnetic resonance angiography (MRA). The aim of this article is to describe the potentials of these techniques and to discuss their advantages and disadvantages. Invasive DSA is still considered the gold standard and is an indivisible part of the carotid stenting procedure. DUS is an inexpensive but operator-dependent tool with limited visibility of the carotid artery course. Conversely, CTA and MRA allow assessment of the carotid artery from the aortic arch to intracranial parts. The disadvantages of CTA are radiation and iodine contrast medium administration. MRA is without radiation but contrast-enhanced MRA is more accurate than noncontrast MRA. The choice of methods depends on the clinical indications and the availability of methods in individual centers. However, the general approach to patient with suspected carotid artery stenosis is to first perform DUS and then other noninvasive methods such as CTA, MRA, or transcranial Doppler US.
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Affiliation(s)
- Theodor Adla
- Department of Radiology, 2nd Faculty of Medicine, Charles University in Prague and Motol University Hospital, Prague, Czech Republic
| | - Radka Adlova
- Complex Cardiovascular Centre for Adult Patients, Cardiology Clinic of the 2nd Faculty of Medicine, Charles University in Prague and Motol University Hospital, Prague, Czech Republic
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Abstract
General thinking has previously centered on managing carotid artery stenosis (CAS) by carotid endarterectomy and subsequently, stenting for higher risk patients. However for CAS and other forms of vascular disease, especially when asymptomatic, there is new emphasis on defining underlying mechanisms. Knowledge of these mechanisms can lead to medical treatments that result in possible atherosclerotic plaque stabilization, and even plaque regression, including in the patient with CAS. For now, the key medication class for a medical approach are the statins. Their use is supported by good cardiovascular clinical trial evidence including some directed carotid artery studies, especially with a demonstrated decrease in carotid intima-media thickness. Procedural controversy still exists but the current era in medicine offers significant support for medical management of asymptomatic CAS while techniques to recognize the vulnerable plaque evolve. If CAS converts to a symptomatic status, early referral for endarterectomy or stenting is indicated.
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Affiliation(s)
- Thomas F Whayne
- Division of Cardiovascular Medicine, Gill Heart Institute, University of Kentucky, Lexington, Kentucky
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38
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Pokrovsky AV, Beloyartsev DF. [A role of carotid endarterectomy in prevention of cerebral ischemic damage]. Zh Nevrol Psikhiatr Im S S Korsakova 2015. [PMID: 28635933 DOI: 10.17116/jnevro2015115924-14] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
Authors present a literature review on the prevalence, clinical presentations, diagnosis and outcome of surgical treatment of atherosclerotic stenosis of the internal carotid artery.
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39
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Wardlaw J, Brazzelli M, Miranda H, Chappell F, McNamee P, Scotland G, Quayyum Z, Martin D, Shuler K, Sandercock P, Dennis M. An assessment of the cost-effectiveness of magnetic resonance, including diffusion-weighted imaging, in patients with transient ischaemic attack and minor stroke: a systematic review, meta-analysis and economic evaluation. Health Technol Assess 2014; 18:1-368, v-vi. [PMID: 24791949 DOI: 10.3310/hta18270] [Citation(s) in RCA: 50] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023] Open
Abstract
BACKGROUND Patients with transient ischaemic attack (TIA) or minor stroke need rapid treatment of risk factors to prevent recurrent stroke. ABCD2 score or magnetic resonance diffusion-weighted brain imaging (MR DWI) may help assessment and treatment. OBJECTIVES Is MR with DWI cost-effective in stroke prevention compared with computed tomography (CT) brain scanning in all patients, in specific subgroups or as 'one-stop' brain-carotid imaging? What is the current UK availability of services for stroke prevention? DATA SOURCES Published literature; stroke registries, audit and randomised clinical trials; national databases; survey of UK clinical and imaging services for stroke; expert opinion. REVIEW METHODS Systematic reviews and meta-analyses of published/unpublished data. Decision-analytic model of stroke prevention including on a 20-year time horizon including nine representative imaging scenarios. RESULTS The pooled recurrent stroke rate after TIA (53 studies, 30,558 patients) is 5.2% [95% confidence interval (CI) 3.9% to 5.9%] by 7 days, and 6.7% (5.2% to 8.7%) at 90 days. ABCD2 score does not identify patients with key stroke causes or identify mimics: 66% of specialist-diagnosed true TIAs and 35-41% of mimics had an ABCD2 score of ≥ 4; 20% of true TIAs with ABCD2 score of < 4 had key risk factors. MR DWI (45 studies, 9078 patients) showed an acute ischaemic lesion in 34.3% (95% CI 30.5% to 38.4%) of TIA, 69% of minor stroke patients, i.e. two-thirds of TIA patients are DWI negative. TIA mimics (16 studies, 14,542 patients) make up 40-45% of patients attending clinics. UK survey (45% response) showed most secondary prevention started prior to clinic, 85% of primary brain imaging was same-day CT; 51-54% of patients had MR, mostly additional to CT, on average 1 week later; 55% omitted blood-sensitive MR sequences. Compared with 'CT scan all patients' MR was more expensive and no more cost-effective, except for patients presenting at > 1 week after symptoms to diagnose haemorrhage; strategies that triaged patients with low ABCD2 scores for slow investigation or treated DWI-negative patients as non-TIA/minor stroke prevented fewer strokes and increased costs. 'One-stop' CT/MR angiographic-plus-brain imaging was not cost-effective. LIMITATIONS Data on sensitivity/specificity of MR in TIA/minor stroke, stroke costs, prognosis of TIA mimics and accuracy of ABCD2 score by non-specialists are sparse or absent; all analysis had substantial heterogeneity. CONCLUSIONS Magnetic resonance with DWI is not cost-effective for secondary stroke prevention. MR was most helpful in patients presenting at > 1 week after symptoms if blood-sensitive sequences were used. ABCD2 score is unlikely to facilitate patient triage by non-stroke specialists. Rapid specialist assessment, CT brain scanning and identification of serious underlying stroke causes is the most cost-effective stroke prevention strategy. FUNDING The National Institute for Health Research Health Technology Assessment programme.
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Affiliation(s)
- Joanna Wardlaw
- Centre for Clinical Brain Sciences, University of Edinburgh, Edinburgh, UK
| | - Miriam Brazzelli
- Centre for Clinical Brain Sciences, University of Edinburgh, Edinburgh, UK
| | - Hector Miranda
- Centre for Clinical Brain Sciences, University of Edinburgh, Edinburgh, UK
| | - Francesca Chappell
- Centre for Clinical Brain Sciences, University of Edinburgh, Edinburgh, UK
| | - Paul McNamee
- Health Economics Research Unit, University of Aberdeen, Aberdeen, UK
| | - Graham Scotland
- Health Economics Research Unit, University of Aberdeen, Aberdeen, UK
| | - Zahid Quayyum
- Health Economics Research Unit, University of Aberdeen, Aberdeen, UK
| | - Duncan Martin
- Centre for Clinical Brain Sciences, University of Edinburgh, Edinburgh, UK
| | - Kirsten Shuler
- Centre for Clinical Brain Sciences, University of Edinburgh, Edinburgh, UK
| | - Peter Sandercock
- Centre for Clinical Brain Sciences, University of Edinburgh, Edinburgh, UK
| | - Martin Dennis
- Centre for Clinical Brain Sciences, University of Edinburgh, Edinburgh, UK
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40
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Windecker S, Kolh P, Alfonso F, Collet JP, Cremer J, Falk V, Filippatos G, Hamm C, Head SJ, Jüni P, Kappetein AP, Kastrati A, Knuuti J, Landmesser U, Laufer G, Neumann FJ, Richter DJ, Schauerte P, Sousa Uva M, Stefanini GG, Taggart DP, Torracca L, Valgimigli M, Wijns W, Witkowski A. 2014 ESC/EACTS Guidelines on myocardial revascularization: The Task Force on Myocardial Revascularization of the European Society of Cardiology (ESC) and the European Association for Cardio-Thoracic Surgery (EACTS)Developed with the special contribution of the European Association of Percutaneous Cardiovascular Interventions (EAPCI). Eur Heart J 2014; 35:2541-619. [PMID: 25173339 DOI: 10.1093/eurheartj/ehu278] [Citation(s) in RCA: 3299] [Impact Index Per Article: 329.9] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
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41
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Saba L, Anzidei M, Piga M, Ciolina F, Mannelli L, Catalano C, Suri JS, Raz E. Multi-modal CT scanning in the evaluation of cerebrovascular disease patients. Cardiovasc Diagn Ther 2014; 4:245-62. [PMID: 25009794 DOI: 10.3978/j.issn.2223-3652.2014.06.05] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2014] [Accepted: 05/07/2014] [Indexed: 11/14/2022]
Abstract
Ischemic stroke currently represents one of the leading causes of severe disability and mortality in the Western World. Until now, angiography was the most used imaging technique for the detection of the extra-cranial and intracranial vessel pathology. Currently, however, non-invasive imaging tool like ultrasound (US), magnetic resonance (MR) and computed tomography (CT) have proven capable of offering a detailed analysis of the vascular system. CT in particular represents an advanced system to explore the pathology of carotid arteries and intracranial vessels and also offers tools like CT perfusion (CTP) that provides valuable information of the brain's vascular physiology by increasing the stroke diagnostic. In this review, our purpose is to discuss stroke risk prediction and detection using CT.
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Affiliation(s)
- Luca Saba
- 1 Department of Radiology, Azienda Ospedaliero Universitaria (A.O.U.), di Cagliari - Polo di Monserrato s.s. 554 Monserrato (Cagliari) 09045, Italy ; 2 Departments of Radiological Sciences, University of Rome La Sapienza, Viale Regina Elena 324, 00161 (Rome), Italy ; 3 Department of Radiology, University of Washington, Seattle, Washington, USA ; 4 Fellow AIMBE, CTO, AtheroPoint LLC, Roseville, CA, USA ; 5 Department of Biomedical Engineering, Idaho State University (Aff.), ID, USA ; 6 Department of Radiology, New York University School of Medicine, New York, USA ; 7 Department of Neurology and Psychiatry, Sapienza University of Rome, Viale dell' Università, 30, 00185 Rome, Italy
| | - Michele Anzidei
- 1 Department of Radiology, Azienda Ospedaliero Universitaria (A.O.U.), di Cagliari - Polo di Monserrato s.s. 554 Monserrato (Cagliari) 09045, Italy ; 2 Departments of Radiological Sciences, University of Rome La Sapienza, Viale Regina Elena 324, 00161 (Rome), Italy ; 3 Department of Radiology, University of Washington, Seattle, Washington, USA ; 4 Fellow AIMBE, CTO, AtheroPoint LLC, Roseville, CA, USA ; 5 Department of Biomedical Engineering, Idaho State University (Aff.), ID, USA ; 6 Department of Radiology, New York University School of Medicine, New York, USA ; 7 Department of Neurology and Psychiatry, Sapienza University of Rome, Viale dell' Università, 30, 00185 Rome, Italy
| | - Mario Piga
- 1 Department of Radiology, Azienda Ospedaliero Universitaria (A.O.U.), di Cagliari - Polo di Monserrato s.s. 554 Monserrato (Cagliari) 09045, Italy ; 2 Departments of Radiological Sciences, University of Rome La Sapienza, Viale Regina Elena 324, 00161 (Rome), Italy ; 3 Department of Radiology, University of Washington, Seattle, Washington, USA ; 4 Fellow AIMBE, CTO, AtheroPoint LLC, Roseville, CA, USA ; 5 Department of Biomedical Engineering, Idaho State University (Aff.), ID, USA ; 6 Department of Radiology, New York University School of Medicine, New York, USA ; 7 Department of Neurology and Psychiatry, Sapienza University of Rome, Viale dell' Università, 30, 00185 Rome, Italy
| | - Federica Ciolina
- 1 Department of Radiology, Azienda Ospedaliero Universitaria (A.O.U.), di Cagliari - Polo di Monserrato s.s. 554 Monserrato (Cagliari) 09045, Italy ; 2 Departments of Radiological Sciences, University of Rome La Sapienza, Viale Regina Elena 324, 00161 (Rome), Italy ; 3 Department of Radiology, University of Washington, Seattle, Washington, USA ; 4 Fellow AIMBE, CTO, AtheroPoint LLC, Roseville, CA, USA ; 5 Department of Biomedical Engineering, Idaho State University (Aff.), ID, USA ; 6 Department of Radiology, New York University School of Medicine, New York, USA ; 7 Department of Neurology and Psychiatry, Sapienza University of Rome, Viale dell' Università, 30, 00185 Rome, Italy
| | - Lorenzo Mannelli
- 1 Department of Radiology, Azienda Ospedaliero Universitaria (A.O.U.), di Cagliari - Polo di Monserrato s.s. 554 Monserrato (Cagliari) 09045, Italy ; 2 Departments of Radiological Sciences, University of Rome La Sapienza, Viale Regina Elena 324, 00161 (Rome), Italy ; 3 Department of Radiology, University of Washington, Seattle, Washington, USA ; 4 Fellow AIMBE, CTO, AtheroPoint LLC, Roseville, CA, USA ; 5 Department of Biomedical Engineering, Idaho State University (Aff.), ID, USA ; 6 Department of Radiology, New York University School of Medicine, New York, USA ; 7 Department of Neurology and Psychiatry, Sapienza University of Rome, Viale dell' Università, 30, 00185 Rome, Italy
| | - Carlo Catalano
- 1 Department of Radiology, Azienda Ospedaliero Universitaria (A.O.U.), di Cagliari - Polo di Monserrato s.s. 554 Monserrato (Cagliari) 09045, Italy ; 2 Departments of Radiological Sciences, University of Rome La Sapienza, Viale Regina Elena 324, 00161 (Rome), Italy ; 3 Department of Radiology, University of Washington, Seattle, Washington, USA ; 4 Fellow AIMBE, CTO, AtheroPoint LLC, Roseville, CA, USA ; 5 Department of Biomedical Engineering, Idaho State University (Aff.), ID, USA ; 6 Department of Radiology, New York University School of Medicine, New York, USA ; 7 Department of Neurology and Psychiatry, Sapienza University of Rome, Viale dell' Università, 30, 00185 Rome, Italy
| | - Jasjit S Suri
- 1 Department of Radiology, Azienda Ospedaliero Universitaria (A.O.U.), di Cagliari - Polo di Monserrato s.s. 554 Monserrato (Cagliari) 09045, Italy ; 2 Departments of Radiological Sciences, University of Rome La Sapienza, Viale Regina Elena 324, 00161 (Rome), Italy ; 3 Department of Radiology, University of Washington, Seattle, Washington, USA ; 4 Fellow AIMBE, CTO, AtheroPoint LLC, Roseville, CA, USA ; 5 Department of Biomedical Engineering, Idaho State University (Aff.), ID, USA ; 6 Department of Radiology, New York University School of Medicine, New York, USA ; 7 Department of Neurology and Psychiatry, Sapienza University of Rome, Viale dell' Università, 30, 00185 Rome, Italy
| | - Eytan Raz
- 1 Department of Radiology, Azienda Ospedaliero Universitaria (A.O.U.), di Cagliari - Polo di Monserrato s.s. 554 Monserrato (Cagliari) 09045, Italy ; 2 Departments of Radiological Sciences, University of Rome La Sapienza, Viale Regina Elena 324, 00161 (Rome), Italy ; 3 Department of Radiology, University of Washington, Seattle, Washington, USA ; 4 Fellow AIMBE, CTO, AtheroPoint LLC, Roseville, CA, USA ; 5 Department of Biomedical Engineering, Idaho State University (Aff.), ID, USA ; 6 Department of Radiology, New York University School of Medicine, New York, USA ; 7 Department of Neurology and Psychiatry, Sapienza University of Rome, Viale dell' Università, 30, 00185 Rome, Italy
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Reynolds MR, Lamotte M, Todd D, Khaykin Y, Eggington S, Tsintzos S, Klein G. Cost-effectiveness of cryoballoon ablation for the management of paroxysmal atrial fibrillation. ACTA ACUST UNITED AC 2014; 16:652-9. [DOI: 10.1093/europace/eut380] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
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43
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Saba L, Anzidei M, Marincola BC, Piga M, Raz E, Bassareo PP, Napoli A, Mannelli L, Catalano C, Wintermark M. Imaging of the carotid artery vulnerable plaque. Cardiovasc Intervent Radiol 2013; 37:572-85. [PMID: 23912494 DOI: 10.1007/s00270-013-0711-2] [Citation(s) in RCA: 80] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/04/2013] [Accepted: 07/03/2013] [Indexed: 11/28/2022]
Abstract
Atherosclerosis involving the carotid arteries has a high prevalence in the population worldwide. This condition is significant because accidents of the carotid artery plaque are associated with the development of cerebrovascular events. For this reason, carotid atherosclerotic disease needs to be diagnosed and those determinants that are associated to an increased risk of stroke need to be identified. The degree of stenosis typically has been considered the parameter of choice to determine the therapeutical approach, but several recently published investigations have demonstrated that the degree of luminal stenosis is only an indirect indicator of the atherosclerotic process and that direct assessment of the plaque structure and composition may be key to predict the development of future cerebrovascular ischemic events. The concept of "vulnerable plaque" was born, referring to those plaque's parameters that concur to the instability of the plaque making it more prone to the rupture and distal embolization. The purpose of this review is to describe the imaging characteristics of "vulnerable carotid plaques."
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Affiliation(s)
- Luca Saba
- Department of Radiology, Azienda Ospedaliero Universitaria (A.O.U.), di Cagliari - Polo di Monserrato, s.s. 554, 09045, Monserrato, Cagliari, Italy,
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44
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Thapar A, Garcia Mochon L, Epstein D, Shalhoub J, Davies AH. Modelling the cost-effectiveness of carotid endarterectomy for asymptomatic stenosis5. Br J Surg 2012. [DOI: 10.1002/bjs.8960] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Abstract
Background
The aim of this study was to model the cost-effectiveness of carotid endarterectomy for asymptomatic stenosis versus medical therapy based on 10-year data from the Asymptomatic Carotid Surgery Trial (ACST).
Methods
This was a cost–utility analysis based on clinical effectiveness data from the ACST with UK-specific costs and stroke outcomes. A Markov model was used to calculate the incremental cost-effectiveness ratio (ICER, or cost per additional quality-of-life year) for a strategy of early endarterectomy versus medical therapy for the average patient and published subgroups. An exploratory analysis considered contemporary event rates.
Results
The ICER was £ 7584 per additional quality-adjusted life-year (QALY) for the average patient in the ACST. At thresholds of £ 20 000 and £ 30 000 there was a 74 and 84 per cent chance respectively of early endarterectomy being cost-effective. The ICER for men below 75 years of age was £ 3254, and that for men aged 75 years or above was £ 71 699. For women aged under 75 years endarterectomy was less costly and more effective than medical therapy; for women aged 75 years or more endarterectomy was less effective and more costly than medical therapy. At contemporary perioperative event rates of 2·7 per cent and background any-territory stroke rates of 1·6 per cent, early endarterectomy remained cost-effective.
Conclusion
In the ACST, early endarterectomy was predicted to be cost-effective in those below 75 years of age, using a threshold of £ 20 000 per QALY. If background any-territory stroke rates fell below 1 per cent per annum, early endarterectomy would cease to be cost-effective.
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Affiliation(s)
- A Thapar
- Academic Section of Vascular Surgery, Imperial College London, London, UK
| | - L Garcia Mochon
- Department of Health Management, Andalusian School of Public Health, Granada, Spain
| | - D Epstein
- Centre for Health Economics, University of York, York, UK
- Department of Health Management, Andalusian School of Public Health, Granada, Spain
| | - J Shalhoub
- Academic Section of Vascular Surgery, Imperial College London, London, UK
| | - A H Davies
- Academic Section of Vascular Surgery, Imperial College London, London, UK
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45
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Ringleb P, Görtler M, Nabavi D, Arning C, Sander D, Eckstein HH, Kühnl A, Berkefeld J, Diel R, Dörfler A, Kopp I, Langhoff R, Lawall H, Storck M. S3-Leitlinie Extracranielle Carotisstenose. GEFÄSSCHIRURGIE 2012. [DOI: 10.1007/s00772-012-1052-1] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
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Salem M, Sayers R, Bown M, West K, Moore D, Nicolaides A, Robinson T, Naylor A. Patients with Recurrent Ischaemic Events from Carotid Artery Disease have a Large Lipid Core and Low GSM. Eur J Vasc Endovasc Surg 2012; 43:147-53. [DOI: 10.1016/j.ejvs.2011.11.008] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2011] [Accepted: 11/08/2011] [Indexed: 01/27/2023]
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47
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Mendiz OA, Sposato LA, Fabbro N, Lev GA, Calle A, Valdivieso LR, Fava CM, Klein FR, Torralva T, Gleichgerrcht E, Manes F. Improvement in executive function after unilateral carotid artery stenting for severe asymptomatic stenosis. J Neurosurg 2012; 116:179-84. [DOI: 10.3171/2011.9.jns11532] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Object
Executive functions are crucial for organizing and integrating cognitive processes. While some studies have assessed the effect of carotid artery stenting (CAS) on cognitive functioning, results have been conflicting. The object of this study was to assess the effect of CAS on cognitive status, with special interest on executive functions, among patients with severe asymptomatic internal carotid artery (ICA) stenosis.
Methods
The authors prospectively assessed the neuropsychological status of 20 patients with unilateral asymptomatic extracranial ICA stenosis of 60% or more by using a comprehensive assessment battery focused on executive functions before and after CAS. Individual raw scores on neuropsychological tests were converted into z scores by normalizing for age, sex, and years of education. The authors compared baseline and 3-month postoperative neuropsychological scores by using Wilcoxon signed-rank tests.
Results
The mean preoperative cognitive performance was within normal ranges on all variables. All patients underwent a successful CAS procedure. Executive function scores improved after CAS, relative to baseline performance as follows: set shifting (Trail-Making Test Part B: −0.75 ± 1.43 vs −1.2 ± 1.48, p = 0.003) and processing speed (digit symbol coding: −0.66 ± 0.85 vs −0.97 ± 0.82, p = 0.035; and symbol search: −0.24 ± 1.32 vs −0.56 ± 0.77, p = 0.049). The benefit of CAS for working memory was marginally significant (digit span backward: −0.41 ± 0.61 vs −0.58 ± 0.76, p = 0.052). Both verbal (immediate Rey Auditory Verbal Learning Test: 0.35 ± 1.04 vs −0.22 ± 0.82, p = 0.011) and visual (delayed Rey-Osterrieth Complex Figure: 0.27 ± 1.26 vs −0.22 ± 1.01, p = 0.024) memory improved after CAS.
Conclusions
The authors found a beneficial effect on executive function and memory 3 months after CAS among their prospective cohort of consecutive patients with unilateral and asymptomatic ICA stenosis of 60% or more.
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Affiliation(s)
| | - Luciano A. Sposato
- 2INECO and INECO Foundation, Buenos Aires, Argentina; and
- 3Institute of Neurosciences, Favaloro University Hospital
- 4Laboratory of Neuroscience, Universidad Diego Portales, Santiago, Chile
| | - Nicolás Fabbro
- 3Institute of Neurosciences, Favaloro University Hospital
| | | | - Analía Calle
- 3Institute of Neurosciences, Favaloro University Hospital
| | | | | | | | - Teresa Torralva
- 2INECO and INECO Foundation, Buenos Aires, Argentina; and
- 3Institute of Neurosciences, Favaloro University Hospital
| | - Ezequiel Gleichgerrcht
- 2INECO and INECO Foundation, Buenos Aires, Argentina; and
- 3Institute of Neurosciences, Favaloro University Hospital
| | - Facundo Manes
- 2INECO and INECO Foundation, Buenos Aires, Argentina; and
- 3Institute of Neurosciences, Favaloro University Hospital
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Intraoperative hypotension, new onset atrial fibrillation, and adverse outcome after carotid endarterectomy. J Neurol Sci 2011; 309:5-8. [DOI: 10.1016/j.jns.2011.07.052] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2011] [Accepted: 07/28/2011] [Indexed: 12/11/2022]
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Abstract
In the study of carotid arteries, modern techniques of imaging allow to analyze various alterations beyond simple luminal narrowing, including the morphology of atherosclerotic plaques, the arterial wall and the surrounding structures. By using CTA and MRI it is possible to obtain three-dimensional rendering of anatomic structures with excellent detail for treatment planning. This paper will detail the role of various imaging methods for the assessment of carotid artery pathology with emphasis on the detection, analysis and characterization of carotid atherosclerosis.
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50
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Ricotta JJ, Aburahma A, Ascher E, Eskandari M, Faries P, Lal BK. Updated Society for Vascular Surgery guidelines for management of extracranial carotid disease. J Vasc Surg 2011; 54:e1-31. [PMID: 21889701 DOI: 10.1016/j.jvs.2011.07.031] [Citation(s) in RCA: 439] [Impact Index Per Article: 33.8] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2011] [Revised: 06/21/2011] [Accepted: 07/12/2011] [Indexed: 11/30/2022]
Affiliation(s)
- John J Ricotta
- Washington Hospital Center, Georgetown University School of Medicine, Washington, DC 20010, USA.
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