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Mazurek A, Malinowski K, Sirignano P, Kolvenbach R, Capoccia L, DE Donato G, VAN Herzeele I, Siddiqui AH, Castrucci T, Tekieli L, Stefanini M, Wissgott C, Rosenfield K, Metzger DC, Snyder K, Karpenko A, Kuczmik W, Stabile E, Knapik M, Casana R, Pieniazek P, Podlasek A, Taurino M, Schofer J, Cremonesi A, Sievert H, Schmidt A, Grunwald IQ, Speziale F, Setacci C, Musialek P. Carotid artery revascularization using second generation stents versus surgery: a meta-analysis of clinical outcomes. THE JOURNAL OF CARDIOVASCULAR SURGERY 2023; 64:570-582. [PMID: 38385840 DOI: 10.23736/s0021-9509.24.12933-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/23/2024]
Abstract
INTRODUCTION Meta-analyses and emerging randomized data indicate that second-generation ('mesh') carotid stents (SGS) may improve outcomes versus conventional (single-layer) stents but clinically-relevant differences in individual SGS-type performance have been identified. No comparisons exist for SGS versus carotid endarterectomy (CEA). EVIDENCE ACQUISITION Thirty-day death (D), stroke (S), myocardial infarction (M), and 12-month ipsilateral stroke and restenosis in SGS studies were meta-analyzed (random effect model) against CEA outcomes. Eligible studies were identified through PubMed/EMBASE/COCHRANE. Forest plots were formed for absolute adverse evet risk in individual studies and for relative outcomes with each SGS deign versus contemporary CEA outcomes as reference. Meta-regression was performed to identify potential modifiers of treatment modality effect. EVIDENCE SYNTHESIS Data were extracted from 103,642 patients in 25 studies (14 SGS-treated, 41% symptomatic; nine randomized controlled trial (RCT)-CEA-treated, 37% symptomatic; and two Vascular Quality Initiative (VQI)-CEA-treated, 23% symptomatic). Casper/Roadsaver and CGuard significantly reduced DSM versus RCT-CEA (-2.70% and -2.95%, P<0.001 for both) and versus VQI-CEA (-1.11% and -1.36%, P<0.001 for both). Gore stent 30-day DSM was similar to RCT-CEA (P=0.581) but increased against VQI-CEA (+2.38%, P=0.033). At 12 months, Casper/Roadsaver ipsilateral stroke rate was lower than RCT-CEA (-0.75%, P=0.026) and similar to VQI-CEA (P=0.584). Restenosis with Casper/Roadsaver was +4.18% vs. RCT-CEA and +4.83% vs. VQI-CEA (P=0.005, P<0.001). CGuard 12-month ipsilateral stroke rate was similar to VQI-CEA (P=0.850) and reduced versus RCT-CEA (-0.63%, P=0.030); restenosis was reduced respectively by -0.26% and -0.63% (P=0.033, P<0.001). Twelve-month Gore stent outcomes were overall inferior to surgery. CONCLUSIONS Meta-analytic integration of available clinical data indicates: 1) reduction in stroke but increased restenosis rate with Casper/Roadsaver, and 2) reduction in both stroke and restenosis with CGuard MicroNET-covered stent against contemporary CEA outcomes at 30 days and 12 months used as a reference. This may inform clinical practice in anticipation of large-scale randomized trials powered for low clinical event rates (PROSPERO-CRD42022339789).
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Affiliation(s)
- Adam Mazurek
- Department of Cardiac and Vascular Diseases, Jagiellonian University Medical College, Krakow, Poland -
- St. John Paul II Hospital Stroke Thrombectomy-Capable Center, Krakow, Poland -
| | - Krzysztof Malinowski
- Department of Bioinformatics and Telemedicine, Faculty of Medicine, Jagiellonian University Medical College, Krakow, Poland
- KCRI, Krakow, Poland
| | - Pasqualino Sirignano
- Department of Vascular and Endovascular Surgery, Sant'Andrea Hospital, La Sapienza University, Rome, Italy
| | - Ralf Kolvenbach
- Department of Vascular Surgery in Sana Kliniken, Düsseldorf Gerresheim, Germany
| | - Laura Capoccia
- Department of Vascular Surgery "Paride Stefanini", Policlinico Umberto I, La Sapienza University, Rome, Italy
| | | | | | - Adnan H Siddiqui
- Department of Radiology, Jacobs School of Medicine and Biomedical Sciences, and Canon Stroke and Vascular Research Center, University at Buffalo, Buffalo, NY, USA
- Jacobs Institute, Buffalo, NY, USA
| | - Tomaso Castrucci
- Department of Vascular Surgery, Sant' Eugenio Hospital, University of Rome Tor Vergata, Rome, Italy
| | - Lukasz Tekieli
- Department of Cardiac and Vascular Diseases, Jagiellonian University Medical College, Krakow, Poland
- St. John Paul II Hospital Stroke Thrombectomy-Capable Center, Krakow, Poland
- Department of Interventional Cardiology, Jagiellonian University Medical College, Krakow, Poland
| | - Matteo Stefanini
- Department of Radiology and Interventional Radiology, Casilino Hospital, Rome, Italy
| | - Christian Wissgott
- Institut für Diagnostische und Interventionelle Radiologie/Neuroradiologie, Imland Klinik Rendsburg, Rendsburg, Germany
| | - Kenneth Rosenfield
- Section of Vascular Medicine and Intervention, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | | | - Kenneth Snyder
- Department of Neurosurgery, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, Buffalo, NY, USA
| | - Andrey Karpenko
- Center of Vascular and Hybrid Surgery, E.N. Meshalkin National Medical Research Center, Novosibirsk, Russia
| | - Waclaw Kuczmik
- Department of General, Vascular Surgery, Angiology and Phlebology, Medical University of Silesia, Katowice, Poland
| | - Eugenio Stabile
- Dipartimento Cardiovascolare, Azienda Ospedaliera Regionale "San Carlo", Potenza, Italy
| | - Magdalena Knapik
- Department of Radiology, Podhalanski Multispecialty Regional Hospital, Nowy Targ, Poland
| | - Renato Casana
- Vascular Surgery Unit, IRCCS Istituto Auxologico Italiano, Milan, Italy
| | - Piotr Pieniazek
- Department of Cardiac and Vascular Diseases, Jagiellonian University Medical College, Krakow, Poland
- Department of Interventional Cardiology, Jagiellonian University Medical College, Krakow, Poland
| | - Anna Podlasek
- Tayside Innovation MedTech Ecosystem (TIME), University of Dundee, Dundee, UK
- Precison Imaging Beacon, Radiological Sciences, University of Nottingham, Nottingham, UK
| | - Maurizio Taurino
- Department of Vascular and Endovascular Surgery, Sant'Andrea Hospital, La Sapienza University, Rome, Italy
| | - Joachim Schofer
- MVZ-Department Structural Heart Disease, Asklepios Clinic St Georg, Hamburg, Germany
| | - Alberto Cremonesi
- Department of Cardiology, Humanitas Gavazzeni, Bergamo, Italy
- Department of Biomedical Sciences, Humanitas University, Milan, Italy
| | - Horst Sievert
- Department of Cardiology and Vascular Medicine, Cardiovascular Center, Frankfurt, Germany
| | - Andrej Schmidt
- Department of Angiology, University Hospital Leipzig, Leipzig, Germany
| | - Iris Q Grunwald
- Tayside Innovation MedTech Ecosystem (TIME), University of Dundee, Dundee, UK
- Department of Radiology Ninewells Hospital, University of Dundee, Dundee, UK
| | - Francesco Speziale
- Department of Vascular Surgery "Paride Stefanini", Policlinico Umberto I, La Sapienza University, Rome, Italy
| | - Carlo Setacci
- Department of Vascular Surgery, University of Siena, Siena, Italy
| | - Piotr Musialek
- Department of Cardiac and Vascular Diseases, Jagiellonian University Medical College, Krakow, Poland
- St. John Paul II Hospital Stroke Thrombectomy-Capable Center, Krakow, Poland
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Dzierwa K, Kedziora A, Tekieli L, Mazurek A, Musial R, Dobrowolska E, Stefaniak J, Pieniazek P, Paluszek P, Konstanty-Kalandyk J, Sobczynski R, Kapelak B, Kleczynski P, Brzychczy A, Kwiatkowski T, Trystula M, Piatek J, Musialek P. Endovascular carotid revascularization under open-chest extracorporeal circulation combined with cardiac surgery in unstable patients at increased risk of carotid-related stroke: SIMultaneous urgent cardiac surgery and MicroNet-covered stent carotid revascularization in extreme-risk patients-SIMGUARD Study. THE JOURNAL OF CARDIOVASCULAR SURGERY 2023; 64:591-607. [PMID: 38078710 DOI: 10.23736/s0021-9509.23.12896-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/23/2024]
Abstract
BACKGROUND In patients at urgent need for cardiac surgery coexisting with increased-stroke-risk carotid stenosis, any staged intervention increases the risk of complications from the primarily unaddressed pathology. In this challenging cohort, we assessed safety and feasibility of endovascular carotid revascularization under open-chest extracorporeal circulation (ECC) combined with cardiac surgery (hybrid-room true simultaneous treatment). METHODS Per-protocol (PP), after general anesthesia induction, chest-opening and ECC stand-by installation, carotid stenting (CAS) was performed (femoral/radial or direct carotid access) with ad-hoc/on-hand switch to ECC cardiac surgery. RESULTS Over 78 months, 60 patients (70.7±6.9years, 85% male, all American Society of Anesthesiology grade IV) were enrolled. All were at increased carotid-related stroke risk (ipsilateral recent stroke/transient ischemick attack, asymptomatic cerebral infarct, increased-risk lesion morphology, bilateral severe stenosis). Majority of study procedures involved CAS+coronary bypass surgery or CAS+valve replacement±coronary bypass. 45 (75%) patients were PP- and 15 (25%) not-PP (NPP-) managed (context therapy). CAS was 100% neuroprotected (transient flow reversal-64.4%, filters-35.6%) and employed micronet-covered plaque-sequestrating stents with routine post-dilatation optimization/embedding. 4 deaths (6.7%) and 7 strokes (11.7%) occurred by 30-days. Despite CAS+surgery performed on aspirin and unfractionated heparin-only (delayed clopidogrel-loading), no thrombosis occurred in the stented arteries, and 30-days stent patency was 100%. NPP-management significantly increased the risk of death/ipsilateral stroke (OR 38.5; P<0.001) and death/any stroke (OR 12.3; P=0.002) by 30-days. CONCLUSIONS In cardiac unstable patients at increased carotid-related stroke risk who require urgent cardiac surgery, simultaneous cardiac surgery and CAS with micronet-covered stent lesion sequestration is feasible and safe and shows efficacy in minimizing stroke risk. Larger-scale, multicentric evaluation is warranted. (SIMGUARD NCT04973579).
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Affiliation(s)
- Karolina Dzierwa
- Cardiovascular Imaging Laboratory, St. John Paul II Hospital, Krakow, Poland -
| | - Anna Kedziora
- Department of Cardiac Surgery and Transplantation, Jagiellonian University Medical College, Krakow, Poland
- St. John Paul II Hospital in Krakow Clinical Medicine Departments, Krakow, Poland
| | - Lukasz Tekieli
- St. John Paul II Hospital in Krakow Clinical Medicine Departments, Krakow, Poland
- Department of Cardiac and Vascular Diseases, Jagiellonian University Medical College, Krakow, Poland
- Stroke Thrombectomy-Capable Center, St. John Paul II Hospital, Krakow, Poland
- Department of Interventional Cardiology, Jagiellonian University Medical College, Krakow, Poland
| | - Adam Mazurek
- St. John Paul II Hospital in Krakow Clinical Medicine Departments, Krakow, Poland
- Department of Cardiac and Vascular Diseases, Jagiellonian University Medical College, Krakow, Poland
- Department of Interventional Cardiology, Jagiellonian University Medical College, Krakow, Poland
| | - Robert Musial
- Department of Anesthesia and Intensive Therapy, St. John Paul II Hospital, Krakow, Poland
| | - Elzbieta Dobrowolska
- Department of Anesthesia and Intensive Therapy, St. John Paul II Hospital, Krakow, Poland
| | - Justyna Stefaniak
- Department of Bioinformatics and Telemedicine, Jagiellonian University Medical College, Krakow, Poland
| | - Piotr Pieniazek
- St. John Paul II Hospital in Krakow Clinical Medicine Departments, Krakow, Poland
- Department of Cardiac and Vascular Diseases, Jagiellonian University Medical College, Krakow, Poland
- Department of Vascular Surgery and Endovascular Interventions, St. John Paul II Hospital, Krakow, Poland
| | - Piotr Paluszek
- Department of Vascular Surgery and Endovascular Interventions, St. John Paul II Hospital, Krakow, Poland
| | - Janusz Konstanty-Kalandyk
- Department of Cardiac Surgery and Transplantation, Jagiellonian University Medical College, Krakow, Poland
- St. John Paul II Hospital in Krakow Clinical Medicine Departments, Krakow, Poland
| | - Robert Sobczynski
- Department of Cardiac Surgery and Transplantation, Jagiellonian University Medical College, Krakow, Poland
- St. John Paul II Hospital in Krakow Clinical Medicine Departments, Krakow, Poland
| | - Boguslaw Kapelak
- Department of Cardiac Surgery and Transplantation, Jagiellonian University Medical College, Krakow, Poland
- St. John Paul II Hospital in Krakow Clinical Medicine Departments, Krakow, Poland
| | - Pawel Kleczynski
- St. John Paul II Hospital in Krakow Clinical Medicine Departments, Krakow, Poland
- Department of Interventional Cardiology, Jagiellonian University Medical College, Krakow, Poland
| | - Andrzej Brzychczy
- Department of Vascular Surgery and Endovascular Interventions, St. John Paul II Hospital, Krakow, Poland
| | - Tomasz Kwiatkowski
- Department of Vascular Surgery and Endovascular Interventions, St. John Paul II Hospital, Krakow, Poland
| | - Mariusz Trystula
- Department of Vascular Surgery and Endovascular Interventions, St. John Paul II Hospital, Krakow, Poland
| | - Jacek Piatek
- Department of Cardiac Surgery and Transplantation, Jagiellonian University Medical College, Krakow, Poland
- St. John Paul II Hospital in Krakow Clinical Medicine Departments, Krakow, Poland
| | - Piotr Musialek
- St. John Paul II Hospital in Krakow Clinical Medicine Departments, Krakow, Poland
- Department of Cardiac and Vascular Diseases, Jagiellonian University Medical College, Krakow, Poland
- Stroke Thrombectomy-Capable Center, St. John Paul II Hospital, Krakow, Poland
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Musialek P, Langhoff R, Stefanini M, Gray WA. Carotid stent as cerebral protector: the arrival of Godot. THE JOURNAL OF CARDIOVASCULAR SURGERY 2023; 64:555-560. [PMID: 38385839 DOI: 10.23736/s0021-9509.23.12956-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/23/2024]
Affiliation(s)
- Piotr Musialek
- Department of Cardiac and Vascular Diseases, Jagiellonian University, Krakow, Poland -
- St. John Paul II Hospital, Stroke Thrombectomy-Capable Center, Krakow, Poland -
| | - Ralf Langhoff
- Department of Angiology, Sankt-Gertrauden Hospital, Academic Teaching Hospital of Charité University, Berlin, Germany
| | - Matteo Stefanini
- Department of Radiology and Interventional Radiology, Casilino Hospital, Rome, Italy
| | - William A Gray
- Main Line Health, Wynnewood, PA, USA
- Sidney Kimmel School of Medicine, Thomas Jefferson University, Philadelphia, PA, USA
- Lankenau Heart Institute, Wynnewood, PA, USA
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Lehmann MF, Musialek P. MicroNET-covered stent use to seal carotid artery perforation. ADVANCES IN INTERVENTIONAL CARDIOLOGY 2023; 19:284-288. [PMID: 37854974 PMCID: PMC10580846 DOI: 10.5114/aic.2023.131483] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2023] [Accepted: 09/19/2023] [Indexed: 10/20/2023] Open
Affiliation(s)
- Márcio Francisco Lehmann
- Neurosurgery Service of the University Hospital, State University of Londrina, Londrina, Paraná, Brazil
| | - Piotr Musialek
- Department of Cardiac and Vascular Diseases, Jagiellonian University, Krakow, Poland
- John Paul II Hospital, Krakow, Poland
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Mazurek A, Borratynska A, Gancarczyk U, Czyz L, Sikorska M, Tekieli L, Sobien B, Jakiel M, Trystula M, Drazkiewicz T, Podolec P, Musialek P. Diabetes Mellitus and Clinical Outcomes in Carotid Artery Revascularization Using Second-Generation, MicroNet-Covered Stents: Analysis from the PARADIGM Study. J Diabetes Res 2022; 2022:8691842. [PMID: 36200003 PMCID: PMC9529505 DOI: 10.1155/2022/8691842] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/15/2022] [Revised: 06/16/2022] [Accepted: 08/12/2022] [Indexed: 11/18/2022] Open
Abstract
INTRODUCTION Carotid artery stenting (CAS) using conventional (single-layer) stents is associated with worse clinical outcomes in diabetes mellitus (DM) vs. non-DM patients: an effect driven largely by lesion-related adverse events. CAS outcomes with MicroNet-covered stents (MCS) in diabetic patients have not been evaluated. AIM To compare short- and long-term clinical outcomes and restenosis rate in DM vs. non-DM patients with carotid stenosis treated using MCS. MATERIALS AND METHODS In a prospective study in all-comer symptomatic and increased-stroke-risk asymptomatic carotid stenosis, 101 consecutive patients (age 51-86 years, 41% diabetics) underwent 106 MCS-CAS. Clinical outcomes and duplex ultrasound velocities were assessed periprocedurally and at 30 days/12 months. RESULTS Baseline characteristics of DM vs. non-DM patients were similar except for a higher prevalence of recent cerebral symptoms in DM. Type 1 and type 1+2 plaques were more prevalent in DM patients (26.7% vs. 9.8%, p = 0.02; 62.2% vs. 37.7%, p = 0.01). Proximal embolic protection was more prevalent in DM (60% vs. 36%; p = 0.015). 30-day clinical complications were limited to a single periprocedural minor stroke in DM (2.4% vs. 0%, p = 0.22). 12-month in-stent velocities and clinical outcomes were not different (death rate 4.8% vs. 3.3%; p = 0.69; no new strokes). Restenosis rate was not different (0% vs. 1.7%, p = 0.22). CONCLUSIONS MCS may offset the adverse impact of DM on periprocedural, 30-day, and 12-month clinical complications of CAS and minimize the risk of in-stent restenosis. In this increased-stroke-risk cohort, adverse event rate was low both in DM and non-DM. Further larger-scale clinical datasets including extended follow-ups are warranted.
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Affiliation(s)
- Adam Mazurek
- Jagiellonian University, Department of Cardiac & Vascular Diseases, John Paul II Hospital, Krakow, Poland
| | - Anna Borratynska
- John Paul II Hospital, Neurology Outpatient Department, Krakow, Poland
| | - Urszula Gancarczyk
- Jagiellonian University, Department of Cardiac & Vascular Diseases, John Paul II Hospital, Krakow, Poland
| | - Lukasz Czyz
- Jagiellonian University, Department of Cardiac & Vascular Diseases, John Paul II Hospital, Krakow, Poland
| | - Martyna Sikorska
- Jagiellonian University, Department of Cardiac & Vascular Diseases, John Paul II Hospital, Krakow, Poland
| | - Lukasz Tekieli
- Jagiellonian University, Department of Cardiac & Vascular Diseases, John Paul II Hospital, Krakow, Poland
- Jagiellonian University, Department of Interventional Cardiology, John Paul II Hospital, Krakow, Poland
| | - Bartosz Sobien
- Jagiellonian University, Department of Cardiac & Vascular Diseases, John Paul II Hospital, Krakow, Poland
| | - Marcin Jakiel
- Jagiellonian University, Department of Cardiac & Vascular Diseases, John Paul II Hospital, Krakow, Poland
| | - Mariusz Trystula
- John Paul II Hospital, Department of Vascular Surgery, Krakow, Poland
| | | | - Piotr Podolec
- Jagiellonian University, Department of Cardiac & Vascular Diseases, John Paul II Hospital, Krakow, Poland
| | - Piotr Musialek
- Jagiellonian University, Department of Cardiac & Vascular Diseases, John Paul II Hospital, Krakow, Poland
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