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Garcia-Pastor A, Gil-Núñez A, Ramirez-Moreno JM, González-Nafría N, Tejada J, Moniche F, Portilla-Cuenca JC, Martínez-Sánchez P, Fuentes B, Gamero-García MA, de Leciñana MA, Masjuan J, Verge DC, Aladro Y, Parkhutik V, Lago A, de Arce-Borda AM, Usero-Ruiz M, Delgado-Mederos R, Pampliega A, Ximenez-Carrillo Á, Bártulos-Iglesias M, Castro-Reyes E. Endarterectomy, Stenting, or Medical Treatment for Symptomatic Carotid Near-Occlusion: Results from CAOS, a Multicenter Registry Study. AJNR Am J Neuroradiol 2022; 43:1304-1310. [PMID: 35981762 PMCID: PMC9451631 DOI: 10.3174/ajnr.a7617] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2022] [Accepted: 06/17/2022] [Indexed: 01/26/2023]
Abstract
BACKGROUND AND PURPOSE The treatment of symptomatic carotid near-occlusion is controversial. Our aim was to analyze the results of carotid endarterectomy and carotid artery stent placement in patients with symptomatic carotid near-occlusion and to identify factors related to technical failure, periprocedural complications, and restenosis. MATERIALS AND METHODS We conducted a multicenter, prospective nonrandomized study. Patients with angiography-confirmed carotid near-occlusion were included. We assessed the revascularization rate and periprocedural stroke or death. Twenty-four-month clinical and carotid imaging follow-up was performed, and rates of carotid restenosis or occlusion, ipsilateral stroke, and mortality were analyzed. Carotid artery stent placement, carotid endarterectomy, and medical treatment were compared. RESULTS One hundred forty-one patients were included. Forty-four carotid artery stent placement and 23 carotid endarterectomy procedures were performed within 6 months after the event. Complete revascularization was achieved in 83.6%, 81.8% in the carotid artery stent placement group and 87% with carotid endarterectomy (P = .360). Periprocedural stroke or death occurred in 6% (carotid artery stent placement = 2.3%; carotid endarterectomy = 13%; P = .077) and was not related to revascularization failure. The carotid restenosis or occlusion rate was 8.3% (5% restenosis, 3.3% occlusion); with carotid artery stent placement it was 10.5%; and with carotid endarterectomy it was 4.5% (P = .419). The 24-month cumulative rate of ipsilateral stroke was 4.8% in the carotid artery stent placement group, 17.4% for carotid endarterectomy, and 13.1% for medical treatment (P = .223). Mortality was 12%, 4.5%, and 5.6%, respectively (P = .422). Revascularization failure and restenosis occurred more frequently in patients with full collapse compared with patients without full collapse (33.3% versus 5.6%, P = .009; 21.4% versus 2.9%, P = .032, respectively). CONCLUSIONS Carotid artery stent placement and carotid endarterectomy are associated with high rates of failure and periprocedural stroke. Carotid near-occlusion with full collapse appears to be associated with an increased risk of technical failure and restenosis. Carotid near-occlusion revascularization does not seem to reduce the risk of stroke at follow-up compared with medical treatment.
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Affiliation(s)
- A Garcia-Pastor
- From the Department of Neurology (A.G.-P., A.G.-N., E.C.-R.), Hospital General Universitario Gregorio Marañón, Madrid, Spain
| | - A Gil-Núñez
- From the Department of Neurology (A.G.-P., A.G.-N., E.C.-R.), Hospital General Universitario Gregorio Marañón, Madrid, Spain
| | - J M Ramirez-Moreno
- Department of Neurology (J.M.R.-M.), Hospital Universitario Infanta Cristina, Badajoz, Spain
| | - N González-Nafría
- Department of Neurology (N.G.-N., J.T.), Complejo Asistencial Universitario de León, Neurology, Leon, Spain
| | - J Tejada
- Department of Neurology (N.G.-N., J.T.), Complejo Asistencial Universitario de León, Neurology, Leon, Spain
| | - F Moniche
- Department of Neurology (F.M.), Hospital Universitario Virgen del Rocío, Sevilla, Sevilla, Spain
| | - J C Portilla-Cuenca
- Department of Neurology (J.C.P.-C.), Hospital San Pedro Alcántara, Cáceres, Spain
| | - P Martínez-Sánchez
- Department of Neurology (P.M.-S., B.F.), Hospital Universitario La Paz, Madrid, Spain
| | - B Fuentes
- Department of Neurology (P.M.-S., B.F.), Hospital Universitario La Paz, Madrid, Spain
| | - M A Gamero-García
- Department of Neurology (M.A.G.-G.), Hospital Universitario Virgen Macarena, Sevilla, Spain
| | - M A de Leciñana
- Department of Neurology (M.A.d.L., J.M.), Hospital Universitario Ramón y Cajal, Madrid, Spain
| | - J Masjuan
- Department of Neurology (M.A.d.L., J.M.), Hospital Universitario Ramón y Cajal, Madrid, Spain
| | - D C Verge
- Department of Neurology (D.C.V.), Corporació Sanitaria Parc Taulí, Sabadell, Spain
| | - Y Aladro
- Department of Neurology (Y.A.), Hospital Universitario de Getafe, Getafe, Spain
| | - V Parkhutik
- Department of Neurology (V.P., A.L.), Hospital Universitari La Fe, Valencia, Spain
| | - A Lago
- Department of Neurology (V.P., A.L.), Hospital Universitari La Fe, Valencia, Spain
| | - A M de Arce-Borda
- Department of Neurology (A.M.d.A.-B), Hospital Universitario de Donostia, Donostia, Spain
| | - M Usero-Ruiz
- Department of Neurology (M.U.-R.), Hospital Universitario de Valladolid, Valladolid, Spain
| | - R Delgado-Mederos
- Department of Neurology (R.D.-M.), Hospital de la Santa Creu i Sant Pau, Barcelona, Spain
| | - A Pampliega
- Department of Neurology (A.P.), Hospital General Univeristario de Alicante, Alicante, Spain
| | - Á Ximenez-Carrillo
- Department of Neurology (Á.X.-C.), Hospital Universitario de La Princesa, Madrid, Spain
| | - M Bártulos-Iglesias
- Department of Neurology (M.B.-I.), Hospital Universitario de Burgos, Burgos, Spain
| | - E Castro-Reyes
- From the Department of Neurology (A.G.-P., A.G.-N., E.C.-R.), Hospital General Universitario Gregorio Marañón, Madrid, Spain
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Palacios-Mendoza MA, García-Pastor A, Gil-Núñez A, Ramírez-Moreno JM, González-Nafría N, Moniche F, Portilla-Cuenca JC, Fuentes B, Gamero-García MA, Alonso de Leciñana M, Masjuan J, Canovas-Verge D, Aladro Y, Lago A, de Arce-Borda AM, Usero-Ruiz M, Delgado-Mederos R, Pampliega A, Ximenez-Carrillo Á, Bártulos-Iglesias M, Castro-Reyes E. Ultrasonographic and hemodynamic characteristics of patients with symptomatic carotid near-occlusion: results from a multicenter registry study. Neuroradiology 2020; 63:705-711. [PMID: 33025041 DOI: 10.1007/s00234-020-02567-w] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2020] [Accepted: 09/23/2020] [Indexed: 11/29/2022]
Abstract
PURPOSE The ultrasonographic and hemodynamic features of patients with carotid near-occlusion (CNO) are still not well known. Our aim was to describe the ultrasonographic and hemodynamic characteristics of a cohort of patients with CNO. METHODS A prospective, observational, nationwide, and multicenter study was conducted from January/2010 to May/2016. Patients with digital subtraction angiography (DSA)-confirmed CNO were included. We collected information on clinical and demographic characteristics, carotid and transcranial ultrasonography and DSA findings, presence of full-collapse, collateral circulation, and cerebrovascular reactivity (CVR). RESULTS One hundred thirty-five patients were analyzed. Ultrasonographic and DSA diagnosis of CNO were concordant in only 44%. This disagreement was related to the presence/absence of full-collapse: 45% of patients with CNO with full-collapse were classified as a complete carotid occlusion, and 40% with a CNO without full-collapse were interpreted as severe stenosis (p < 0.001). Mean velocities (mV) and pulsatility indexes (PIs) were significantly lower in the ipsilateral middle cerebral artery compared with the contralateral (43 cm/s vs 58 cm/s, p < 0.001; 0.80 vs 1.00, p < 0.001). Collateral circulation was identified in 92% of patients, with the anterior communicating artery (73%) being the most frequent. CVR was decreased or exhausted in 66% of cases and was more frequent in patients with a poor or absent collateral network compared with patients with ≥ 2 collateral arteries (82% vs 56%, p = 0.051). CONCLUSION The accuracy of carotid ultrasonography in the diagnosis of CNO seems to be limited, with significant discrepancies with DSA. Decreased ipsilateral mV, PI, and CVR suggest a hemodynamic compromise in patients with CNO.
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Affiliation(s)
| | - A García-Pastor
- Hospital General Universitario Gregorio Marañón, Neurology, C/ Dr Esquerdo 46, 28007, Madrid, Spain
| | - A Gil-Núñez
- Hospital General Universitario Gregorio Marañón, Neurology, C/ Dr Esquerdo 46, 28007, Madrid, Spain
| | | | | | - F Moniche
- Hospital Universitario Virgen del Rocío, Sevilla, Neurology, Sevilla, Spain
| | | | - B Fuentes
- Hospital Universitario La Paz, Neurology, Madrid, Spain
| | | | | | - J Masjuan
- Hospital Universitario Ramón y Cajal, Neurology, Madrid, Spain
| | | | - Y Aladro
- Hospital Universitario de Getafe, Neurology, Getafe, Spain
| | - A Lago
- Hospital Universitari La Fe, Neurology, Valencia, Spain
| | | | - M Usero-Ruiz
- Hospital Universitario de Valladolid, Neurology, Valladolid, Spain
| | | | - A Pampliega
- Hospital General Univeristario de Alicante, Neurology, Alicante, Spain
| | | | | | - E Castro-Reyes
- Hospital General Universitario Gregorio Marañón, Neurology, C/ Dr Esquerdo 46, 28007, Madrid, Spain
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García-Pastor A, Gil-Núñez A, Ramírez-Moreno JM, González-Nafría N, Tejada J, Moniche F, Portilla-Cuenca JC, Martínez-Sánchez P, Fuentes B, Gamero-García MÁ, Alonso de Leciñana M, Masjuán J, Cánovas-Verge D, Aladro Y, Parkhutik V, Lago-Martín A, de Arce-Borda AM, Usero-Ruíz M, Delgado-Mederos R, Pampliega A, Ximenez-Carrillo Á, Bártulos-Iglesias M, Castro-Reyes E. The risk of recurrent stroke at 24 months in patients with symptomatic carotid near-occlusion: results from CAOS, a multicentre registry study. Eur J Neurol 2019; 26:1391-1398. [PMID: 31126001 DOI: 10.1111/ene.14006] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2019] [Accepted: 05/14/2019] [Indexed: 11/28/2022]
Abstract
BACKGROUND AND PURPOSE The risk of recurrent stroke amongst patients with symptomatic carotid near-occlusion (SCNO) has not been clearly established, and its management remains controversial. The aim was to define the 24-month risk of recurrent stroke and to analyse the effect of the different treatment modalities (medical treatment and revascularization) in a population of patients with SCNO. METHODS A multicentre, nationwide, prospective study from January 2010 to May 2016 was performed. Patients with angiography-confirmed SCNO were included. The primary end-point was ipsilateral ischaemic stroke including periprocedural events within 24 months following the presenting event. Revascularization results and periprocedural complications, ipsilateral transient ischaemic attack, disabling or fatal stroke, and mortality were also noted. RESULTS The study population comprised 141 patients from 17 Spanish centres. Seventy patients (49.6%) were treated by revascularization (carotid stenting in 47, endarterectomy in 23). Complete revascularization was achieved in 58 patients (83%). Periprocedural stroke or death occurred in 5.7%. The 24-month cumulative incidence of the primary end-point was 11.1% (95% confidence interval 5.8-16.4; n = 15), 12% in the medical treatment group and 10.2% in the revascularization group, log-rank P = 0.817. The cumulative rates of ipsilateral ischaemic stroke or transient ischaemic attack, disabling or fatal stroke, and mortality, were 17%, 4.5% and 7.5%, respectively. CONCLUSIONS The rate of ipsilateral ischaemic stroke in patients with SCNO seems to be lower than the known rate associated with severe carotid stenosis without near-occlusion. The potential benefit of revascularization in the prevention of stroke in patients with SCNO may be influenced by the effectiveness and safety of the procedure.
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Affiliation(s)
- A García-Pastor
- Hospital General Universitario Gregorio Marañón, Madrid, Spain
| | - A Gil-Núñez
- Hospital General Universitario Gregorio Marañón, Madrid, Spain
| | | | | | - J Tejada
- Complejo Asistencial Universitario de León, León, Spain
| | - F Moniche
- Hospital Universitario Virgen del Rocío, Sevilla, Spain
| | | | | | - B Fuentes
- Hospital Universitario La Paz, Madrid, Spain
| | | | | | - J Masjuán
- Hospital Universitario Ramón y Cajal, Madrid, Spain
| | | | - Y Aladro
- Hospital Universitario de Getafe, Getafe, Spain
| | - V Parkhutik
- Hospital Universitari i Politècnic La Fe, Valencia, Spain
| | - A Lago-Martín
- Hospital Universitari i Politècnic La Fe, Valencia, Spain
| | | | - M Usero-Ruíz
- Hospital Clínico Universitario de Valladolid, Valladolid, Spain
| | | | - A Pampliega
- Hospital General Universitario de Alicante, Alicante, Spain
| | | | | | - E Castro-Reyes
- Hospital General Universitario Gregorio Marañón, Madrid, Spain
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