1
|
Bhagawati M, Paul S, Mantella L, Johri AM, Laird JR, Singh IM, Singh R, Garg D, Fouda MM, Khanna NN, Cau R, Abraham A, Al-Maini M, Isenovic ER, Sharma AM, Fernandes JFE, Chaturvedi S, Karla MK, Nicolaides A, Saba L, Suri JS. Deep learning approach for cardiovascular disease risk stratification and survival analysis on a Canadian cohort. Int J Cardiovasc Imaging 2024:10.1007/s10554-024-03100-3. [PMID: 38678144 DOI: 10.1007/s10554-024-03100-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/11/2023] [Accepted: 04/02/2024] [Indexed: 04/29/2024]
Abstract
The quantification of carotid plaque has been routinely used to predict cardiovascular risk in cardiovascular disease (CVD) and coronary artery disease (CAD). To determine how well carotid plaque features predict the likelihood of CAD and cardiovascular (CV) events using deep learning (DL) and compare against the machine learning (ML) paradigm. The participants in this study consisted of 459 individuals who had undergone coronary angiography, contrast-enhanced ultrasonography, and focused carotid B-mode ultrasound. Each patient was tracked for thirty days. The measurements on these patients consisted of maximum plaque height (MPH), total plaque area (TPA), carotid intima-media thickness (cIMT), and intraplaque neovascularization (IPN). CAD risk and CV event stratification were performed by applying eight types of DL-based models. Univariate and multivariate analysis was also conducted to predict the most significant risk predictors. The DL's model effectiveness was evaluated by the area-under-the-curve measurement while the CV event prediction was evaluated using the Cox proportional hazard model (CPHM) and compared against the DL-based concordance index (c-index). IPN showed a substantial ability to predict CV events (p < 0.0001). The best DL system improved by 21% (0.929 vs. 0.762) over the best ML system. DL-based CV event prediction showed a ~ 17% increase in DL-based c-index compared to the CPHM (0.86 vs. 0.73). CAD and CV incidents were linked to IPN and carotid imaging characteristics. For survival analysis and CAD prediction, the DL-based system performs superior to ML-based models.
Collapse
Affiliation(s)
- Mrinalini Bhagawati
- Department of Biomedical Engineering, North-Eastern Hill University, Shillong, India
| | - Sudip Paul
- Department of Biomedical Engineering, North-Eastern Hill University, Shillong, India
| | - Laura Mantella
- Division of Cardiology, Department of Medicine, University of Toronto, Toronto, Canada
| | - Amer M Johri
- Division of Cardiology, Department of Medicine, Queen's University, Kingston, Canada
| | - John R Laird
- Heart and Vascular Institute, Adventist Health St. Helena, St Helena, CA, 94574, USA
| | - Inder M Singh
- Stroke Diagnostic and Monitoring Division, AtheroPoint™, Roseville, CA, 95661, USA
| | - Rajesh Singh
- Division of Research and Innovation, UTI, Uttaranchal University, Dehradun, India
| | - Deepak Garg
- School of Cowereter Science and Artificial Intelligence, SR University, Warangal, Telangana, 506371, India
| | - Mostafa M Fouda
- Department of ECE, Idaho State University, Pocatello, ID, 83209, USA
| | | | - Riccardo Cau
- Department of Radiology, Azienda Ospedaliero Universitaria, 40138, Cagliari, Italy
| | | | - Mostafa Al-Maini
- Allergy, Clinical Immunology and Rheumatology Institute, Toronto, ON, Canada
| | - Esma R Isenovic
- Department of Radiobiology and Molecular Genetics, National Institute of The Republic of Serbia, University of Belgrade, 11001, Belgrade, Serbia
| | - Aditya M Sharma
- Division of Cardiovascular Medicine, University of Virginia, Charlottesville, VA, 22904, USA
| | | | - Seemant Chaturvedi
- Department of Neurology & Stroke Program, University of Maryland, Baltimore, MD, USA
| | - Mannudeep K Karla
- Department of Radiology, Massachusetts General Hospital, Boston, MA, USA
| | - Andrew Nicolaides
- Vascular Screening and Diagnostic Centre, University of Nicosia Medical School, Nicosia, Cyprus
| | - Luca Saba
- Department of Radiology, Azienda Ospedaliero Universitaria, 40138, Cagliari, Italy
| | - Jasjit S Suri
- Stroke Diagnostic and Monitoring Division, AtheroPoint™, Roseville, CA, 95661, USA.
- Department of ECE, Idaho State University, Pocatello, ID, 83209, USA.
- Department of CE, Graphic Era Deemed to be University, 248002, Dehradun, India.
| |
Collapse
|
2
|
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 2024:1-7. [PMID: 38480465 DOI: 10.1080/14779072.2024.2330660] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [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.
Collapse
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
| |
Collapse
|
3
|
Paraskevas KI, Brown MM, Lal BK, Myrcha P, Lyden SP, Schneider PA, Poredos P, Mikhailidis DP, Secemsky EA, Musialek P, Mansilha A, Parikh SA, Silvestrini M, Lavie CJ, Dardik A, Blecha M, Liapis CD, Zeebregts CJ, Nederkoorn PJ, Poredos P, Gurevich V, Jawien A, Lanza G, Gray WA, Gupta A, Svetlikov AV, Fernandes E Fernandes J, Nicolaides AN, White CJ, Meschia JF, Cronenwett JL, Schermerhorn ML, AbuRahma AF. Recent advances and controversial issues in the optimal management of asymptomatic carotid stenosis. J Vasc Surg 2024; 79:695-703. [PMID: 37939746 DOI: 10.1016/j.jvs.2023.11.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2023] [Revised: 10/29/2023] [Accepted: 11/03/2023] [Indexed: 11/10/2023]
Abstract
OBJECTIVE The optimal management of patients with asymptomatic carotid stenosis (AsxCS) is enduringly controversial. We updated our 2021 Expert Review and Position Statement, focusing on recent advances in the diagnosis and management of patients with AsxCS. METHODS A systematic review of the literature was performed up to August 1, 2023, using PubMed/PubMed Central, EMBASE and Scopus. The following keywords were used in various combinations: "asymptomatic carotid stenosis," "carotid endarterectomy" (CEA), "carotid artery stenting" (CAS), and "transcarotid artery revascularization" (TCAR). Areas covered included (i) improvements in best medical treatment (BMT) for patients with AsxCS and declining stroke risk, (ii) technological advances in surgical/endovascular skills/techniques and outcomes, (iii) risk factors, clinical/imaging characteristics and risk prediction models for the identification of high-risk AsxCS patient subgroups, and (iv) the association between cognitive dysfunction and AsxCS. RESULTS BMT is essential for all patients with AsxCS, regardless of whether they will eventually be offered CEA, CAS, or TCAR. Specific patient subgroups at high risk for stroke despite BMT should be considered for a carotid revascularization procedure. These patients include those with severe (≥80%) AsxCS, transcranial Doppler-detected microemboli, plaque echolucency on Duplex ultrasound examination, silent infarcts on brain computed tomography or magnetic resonance angiography scans, decreased cerebrovascular reserve, increased size of juxtaluminal hypoechoic area, AsxCS progression, carotid plaque ulceration, and intraplaque hemorrhage. Treatment of patients with AsxCS should be individualized, taking into consideration individual patient preferences and needs, clinical and imaging characteristics, and cultural, ethnic, and social factors. Solid evidence supporting or refuting an association between AsxCS and cognitive dysfunction is lacking. CONCLUSIONS The optimal management of patients with AsxCS should include BMT for all individuals and a prophylactic carotid revascularization procedure (CEA, CAS, or TCAR) for some asymptomatic patient subgroups, additionally taking into consideration individual patient needs and preference, clinical and imaging characteristics, social and cultural factors, and the available stroke risk prediction models. Future studies should investigate the association between AsxCS with cognitive function and the role of carotid revascularization procedures in the progression or reversal of cognitive dysfunction.
Collapse
Affiliation(s)
| | - Martin M Brown
- Stroke Research Centre, Department of Brain Repair and Rehabilitation, UCL Queen Square Institute of Neurology, University College London, London, UK
| | - Brajesh K Lal
- Department of Vascular Surgery, University of Maryland School of Medicine, Baltimore, MD; Department of Vascular Surgery, Baltimore VA Medical Center, Baltimore, MD; Department of Neurology, Mayo Clinic, Rochester, MN
| | - Piotr Myrcha
- Department of General and Vascular Surgery, Faculty of Medicine, Medical University of Warsaw, Warsaw, Poland
| | - Sean P Lyden
- Department of Vascular Surgery, The Cleveland Clinic, Cleveland, OH
| | - Peter A Schneider
- Division of Vascular and Endovascular Surgery, University of California, San Francisco, CA
| | - Pavel Poredos
- Department of Vascular Diseases, University Medical Centre Ljubljana, Ljubljana, Slovenia
| | - Dimitri P Mikhailidis
- Department of Clinical Biochemistry, Royal Free Hospital Campus, University College London Medical School, University College London (UCL), London, UK
| | - Eric A Secemsky
- Smith Center for Outcomes Research in Cardiology, Division of Cardiology, Department of Medicine, Beth Israel Deaconess Medical Center, Boston, MA
| | - Piotr Musialek
- Jagiellonian University Department of Cardiac and Vascular Diseases, John Paul II Hospital, Krakow, Poland
| | - Armando Mansilha
- Faculty of Medicine of the University of Porto, Porto, Portugal; Department of Angiology and Vascular Surgery, Hospital de S. Joao, Porto, Portugal
| | - Sahil A Parikh
- Division of Cardiology, Department of Medicine, New York-Presbyterian Hospital/Columbia University Irving Medical Center, New York, NY; Center for Interventional Cardiovascular Care and Division of Cardiology, Department of Medicine, Columbia University Irving Medical Center, New York, NY
| | - Mauro Silvestrini
- Neurological Clinic, Department of Experimental and Clinical Medicine, Marche Polytechnic University, Ancona, Italy
| | - Carl J Lavie
- John Ochsner Heart and Vascular Institute, Ochsner Clinical School, The University of Queensland School of Medicine, New Orleans, LA
| | - Alan Dardik
- Department of Surgery, Yale School of Medicine, New Haven, CT
| | - Matthew Blecha
- Division of Vascular Surgery and Endovascular Therapy, Loyola University Chicago, Stritch School of Medicine, Loyola University Health System, Chicago, IL
| | - Christos D Liapis
- Department of Vascular & Endovascular Surgery, Athens Medical Center, Athens, Greece
| | - Clark J Zeebregts
- Department of Surgery, Division of Vascular Surgery, University Medical Center Groningen, University of Groningen, Amsterdam, the Netherlands
| | - Paul J Nederkoorn
- Department of Neurology, Amsterdam UMC, University of Amsterdam, Amsterdam, the Netherlands
| | - Peter Poredos
- Department of Anaesthesiology and Surgical Intensive Care, University Medical Centre Ljubljana, Ljubljana, Slovenia
| | - Victor Gurevich
- Center of Atherosclerosis, Lab of Microangiopathic Mechanisms of Atherogenesis, Saint-Petersburg State University, North-Western State Medical University n.a. I.I. Mechnikov, Saint Petersburg, Russia
| | - Arkadiusz Jawien
- Department of Vascular Surgery and Angiology, Collegium Medicum in Bydgoszcz, Nicolaus Copernicus University in Torun, Torun, Poland
| | - Gaetano Lanza
- Department of Surgery, IRCCS Multimedica Hospital, Castellanza, Italy
| | | | - Ajay Gupta
- Department of Radiology, Weill Cornell Medicine, New York, NY
| | - Alexei V 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
| | | | - Andrew N Nicolaides
- Vascular Screening and Diagnostic Center, Nicosia, Cyprus; University of Nicosia Medical School, Nicosia, Cyprus; Department of Vascular Surgery, Imperial College, London, UK
| | - Christopher J White
- Department of Cardiology, Ochsner Clinical School, University of Queensland and Ochsner Health System, New Orleans, LA
| | | | - Jack L Cronenwett
- Section of Vascular Surgery, Dartmouth-Hitchcock Medical Center, Lebanon, NH
| | - Marc L Schermerhorn
- Department of Surgery, Division of Vascular and Endovascular Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA
| | - Ali F AbuRahma
- Department of Surgery, Division of Vascular and Endovascular Surgery, Charleston Area Medical Center/West Virginia University Health Sciences Center, Charleston, WV
| |
Collapse
|
4
|
Paraskevas KI, Mikhailidis DP, Ringleb PA, Brown MM, Dardik A, Poredos P, Gray WA, Nicolaides AN, Lal BK, Mansilha A, Antignani PL, de Borst GJ, Cambria RP, Loftus IM, Lavie CJ, Blinc A, Lyden SP, Matsumura JS, Jezovnik MK, Bacharach JM, Meschia JF, Clair DG, Zeebregts CJ, Lanza G, Capoccia L, Spinelli F, Liapis CD, Jawien A, Parikh SA, Svetlikov A, Menyhei G, Davies AH, Musialek P, Roubin G, Stilo F, Sultan S, Proczka RM, Faggioli G, Geroulakos G, Fernandes E Fernandes J, Ricco JB, Saba L, Secemsky EA, Pini R, Myrcha P, Rundek T, Martinelli O, Kakkos SK, Sachar R, Goudot G, Schlachetzki F, Lavenson GS, Ricci S, Topakian R, Millon A, Di Lazzaro V, Silvestrini M, Chaturvedi S, Eckstein HH, Gloviczki P, White CJ. An international, multispecialty, expert-based Delphi Consensus document on controversial issues in the management of patients with asymptomatic and symptomatic carotid stenosis. J Vasc Surg 2024; 79:420-435.e1. [PMID: 37944771 DOI: 10.1016/j.jvs.2023.09.031] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2023] [Revised: 09/25/2023] [Accepted: 09/25/2023] [Indexed: 11/12/2023]
Abstract
OBJECTIVE Despite the publication of various national/international guidelines, several questions concerning the management of patients with asymptomatic (AsxCS) and symptomatic (SxCS) carotid stenosis remain unanswered. The aim of this international, multi-specialty, expert-based Delphi Consensus document was to address these issues to help clinicians make decisions when guidelines are unclear. METHODS Fourteen controversial topics were identified. A three-round Delphi Consensus process was performed including 61 experts. The aim of Round 1 was to investigate the differing views and opinions regarding these unresolved topics. In Round 2, clarifications were asked from each participant. In Round 3, the questionnaire was resent to all participants for their final vote. Consensus was reached when ≥75% of experts agreed on a specific response. RESULTS Most experts agreed that: (1) the current periprocedural/in-hospital stroke/death thresholds for performing a carotid intervention should be lowered from 6% to 4% in patients with SxCS and from 3% to 2% in patients with AsxCS; (2) the time threshold for a patient being considered "recently symptomatic" should be reduced from the current definition of "6 months" to 3 months or less; (3) 80% to 99% AsxCS carries a higher risk of stroke compared with 60% to 79% AsxCS; (4) factors beyond the grade of stenosis and symptoms should be added to the indications for revascularization in AsxCS patients (eg, plaque features of vulnerability and silent infarctions on brain computed tomography scans); and (5) shunting should be used selectively, rather than always or never. Consensus could not be reached on the remaining topics due to conflicting, inadequate, or controversial evidence. CONCLUSIONS The present international, multi-specialty expert-based Delphi Consensus document attempted to provide responses to several unanswered/unresolved issues. However, consensus could not be achieved on some topics, highlighting areas requiring future research.
Collapse
Affiliation(s)
| | - Dimitri P Mikhailidis
- Division of Surgery and Interventional Science, Department of Surgical Biotechnology, University College London Medical School, University College London (UCL) and Department of Clinical Biochemistry, Royal Free Hospital Campus, UCL, London, United Kingdom
| | | | - Martin M Brown
- Department of Brain Repair and Rehabilitation, Stroke Research Centre, UCL Queen Square Institute of Neurology, University College London, London, United Kingdom
| | - Alan Dardik
- Department of Surgery, Yale School of Medicine, New Haven, CT
| | - Pavel Poredos
- Department of Vascular Diseases, University Medical Centre Ljubljana, Ljubljana, Slovenia
| | | | - Andrew N Nicolaides
- Vascular Screening and Diagnostic Center, Nicosia, Cyprus; University of Nicosia Medical School, Nicosia, Cyprus; Department of Vascular Surgery, Imperial College, London, United Kingdom
| | - Brajesh K Lal
- Department of Vascular Surgery, University of Maryland School of Medicine, Baltimore, MD; Department of Vascular Surgery, Baltimore VA Medical Center, Baltimore, MD; Department of Neurology, Mayo Clinic, Rochester, MN
| | - Armando Mansilha
- Faculty of Medicine of the University of Porto, Porto, Portugal; Department of Angiology and Vascular Surgery, Hospital de S. Joao, Porto, Portugal
| | | | - Gert J de Borst
- Department of Vascular Surgery, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Richard P Cambria
- Division of Vascular and Endovascular Surgery, St. Elizabeth's Medical Center, Boston, MA
| | - Ian M Loftus
- St George's Vascular Institute, St George's University London, London, United Kingdom
| | - Carl J Lavie
- John Ochsner Heart and Vascular Institute, Ochsner Clinical School, The University of Queensland School of Medicine, New Orleans, LA
| | - Ales Blinc
- Division of Internal Medicine, Department of Vascular Diseases, University Medical Centre Ljubljana, Ljubljana, Slovenia; Faculty of Medicine, University of Ljubljana, Ljubljana, Slovenia
| | - Sean P Lyden
- Department of Vascular Surgery, The Cleveland Clinic, Cleveland, OH
| | - Jon S Matsumura
- Department of Surgery, University of Wisconsin School of Medicine and Public Health, Madison, WI
| | - Mateja K Jezovnik
- Department of Advanced Cardiopulmonary Therapies and Transplantation, The University of Texas Health Science Centre at Houston, Houston, TX
| | - J Michael Bacharach
- Department of Vascular Medicine and Endovascular Intervention, North Central Heart Institute and the Avera Heart Hospital, Sioux Falls, SD
| | | | - Daniel G Clair
- Department of Vascular Surgery, Vanderbilt University Medical Center, Nashville, TN
| | - Clark J Zeebregts
- Department of Surgery (Division of Vascular Surgery), University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Gaetano Lanza
- Vascular Surgery Department, IRCSS Multimedica Hospital, Castellanza, Italy
| | - Laura Capoccia
- Vascular Surgery Division, Department of Surgery, SS. Filippo e Nicola Hospital, Avezzano, Italy
| | - Francesco Spinelli
- Vascular Surgery Division, Department of Medicine and Surgery, Campus Bio-Medico University of Rome, Rome, Italy
| | | | - Arkadiusz Jawien
- Department of Vascular Surgery and Angiology, Collegium Medicum, Nicolaus Copernicus University, Bydgoszcz, Poland
| | - Sahil A Parikh
- Division of Cardiology, Department of Medicine, New York-Presbyterian Hospital/ Columbia University Irving Medical Center, New York, NY; Center for Interventional Cardiovascular Care and Division of Cardiology, Department of Medicine, Columbia University Irving Medical Center, New York, NY
| | - Alexei Svetlikov
- Division of Vascular and Endovascular Surgery, North-Western Scientific Clinical Center of Federal Medical Biological Agency of Russia, St Petersburg, Russia
| | - Gabor Menyhei
- Department of Vascular Surgery, University of Pecs, Pecs, Hungary
| | - Alun H Davies
- Department of Surgery and Cancer, Section of Vascular Surgery, Imperial College London, Charing Cross Hospital, London, United Kingdom
| | - Piotr Musialek
- Jagiellonian University Department of Cardiac and Vascular Diseases, John Paul II Hospital, Krakow, Poland
| | - Gary Roubin
- Department of Cardiology, Cardiovascular Associates of the Southeast/ Brookwood, Baptist Medical Center, Birmingham, AL
| | - Francesco Stilo
- Vascular Surgery Division, Department of Medicine and Surgery, Campus Bio-Medico University of Rome, Rome, Italy
| | - Sherif Sultan
- Department of Vascular and Endovascular Surgery, Western Vascular Institute, University Hospital Galway, University of Galway, Galway, Ireland
| | - Robert M Proczka
- First Department of Vascular Surgery, Medicover Hospital, Warsaw, Poland, Lazarski University Faculty of Medicine, Warsaw, Poland
| | - Gianluca Faggioli
- Vascular Surgery, University of Bologna "Alma Mater Studiorum", Policlinico S. Orsola Malpighi, Bologna, Italy
| | - George Geroulakos
- Department of Vascular Surgery, "Attikon" University Hospital, National and Kapodistrian University of Athens, Athens, Greece
| | - Jose Fernandes E Fernandes
- Faculty of Medicine, Lisbon Academic Medical Center, University of Lisbon, Portugal, Hospital da Luz Torres de Lisboa, Lisbon, Portugal
| | - Jean-Baptiste Ricco
- Department of Vascular Surgery, University Hospital of Toulouse, Toulouse, France
| | - Luca Saba
- Department of Radiology, Azienda Ospedaliera Universitaria Di Cagliari, Cagliari, Italy
| | - Eric A Secemsky
- Division of Cardiology, Department of Medicine, Smith Center for Outcomes Research, Beth Israel Deaconess Medical Center, Boston, MA; Harvard Medical School, Boston, MA
| | - Rodolfo Pini
- Vascular Surgery, University of Bologna "Alma Mater Studiorum", Policlinico S. Orsola Malpighi, Bologna, Italy
| | - Piotr Myrcha
- Department of General and Vascular Surgery, Faculty of Medicine, Medical University of Warsaw, Warsaw, Poland
| | - Tatjana Rundek
- Department of Neurology, Miller School of Medicine, University of Miami, Miami, FL
| | - Ombretta Martinelli
- Faculty of Medicine, Sapienza University of Rome, Rome, Italy; Vascular Surgery Unit, "Umberto I." Hospital, Rome, Italy
| | - Stavros K Kakkos
- Department of Vascular Surgery, University of Patras Medical School, Patras, Greece
| | - Ravish Sachar
- North Carolina Heart and Vascular Hospital, UNC-REX Healthcare, University of North Carolina, Raleigh, NC
| | - Guillaume Goudot
- Vascular Medicine Department, Georges Pompidou European Hospital, APHP, Université Paris Cité, Paris, France
| | - Felix Schlachetzki
- Department of Neurology, University Hospital of Regensburg, Regensburg, Germany
| | | | - Stefano Ricci
- Neurology Department-Stroke Unit, Gubbio-Gualdo Tadino and Citta di Castello Hospitals, USL Umbria 1, Perugia, Italy
| | - Raffi Topakian
- Department of Neurology, Academic Teaching Hospital Wels-Grieskirchen, Wels, Austria
| | - Antoine Millon
- Department of Vascular and Endovascular Surgery, Louis Pradel Hospital, Hospices Civil de Lyon, Bron, France
| | - Vincenzo Di Lazzaro
- Department of Medicine and Surgery, Unit of Neurology, Neurophysiology, Neurobiology and Psychiatry, Universita Campus Bio-Medico di Roma, Roma, Italy; Fondazione Policlinico Universitario Campus Bio-Medico, Roma, Italy
| | - Mauro Silvestrini
- Department of Experimental and Clinical Medicine, Neurological Clinic, Marche Polytechnic University, Ancona, Italy
| | - Seemant Chaturvedi
- Department of Neurology, University of Maryland School of Medicine, Baltimore, MD
| | - Hans-Henning Eckstein
- Department for Vascular and Endovascular Surgery, Klinikum Rechts der Isar, Technical University of Munich, Munich, Germany
| | - Peter Gloviczki
- Division of Vascular and Endovascular Surgery, Mayo Clinic, Rochester, MN
| | - Christopher J White
- Department of Medicine and Cardiology, Ochsner Clinical School, University of Queensland, Brisbane, Australia; Department of Cardiology, The John Ochsner Heart and Vascular Institute, New Orleans, LA
| |
Collapse
|
5
|
Khanna NN, Singh M, Maindarkar M, Kumar A, Johri AM, Mentella L, Laird JR, Paraskevas KI, Ruzsa Z, Singh N, Kalra MK, Fernandes JFE, Chaturvedi S, Nicolaides A, Rathore V, Singh I, Teji JS, Al-Maini M, Isenovic ER, Viswanathan V, Khanna P, Fouda MM, Saba L, Suri JS. Polygenic Risk Score for Cardiovascular Diseases in Artificial Intelligence Paradigm: A Review. J Korean Med Sci 2023; 38:e395. [PMID: 38013648 PMCID: PMC10681845 DOI: 10.3346/jkms.2023.38.e395] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/31/2023] [Accepted: 10/15/2023] [Indexed: 11/29/2023] Open
Abstract
Cardiovascular disease (CVD) related mortality and morbidity heavily strain society. The relationship between external risk factors and our genetics have not been well established. It is widely acknowledged that environmental influence and individual behaviours play a significant role in CVD vulnerability, leading to the development of polygenic risk scores (PRS). We employed the PRISMA search method to locate pertinent research and literature to extensively review artificial intelligence (AI)-based PRS models for CVD risk prediction. Furthermore, we analyzed and compared conventional vs. AI-based solutions for PRS. We summarized the recent advances in our understanding of the use of AI-based PRS for risk prediction of CVD. Our study proposes three hypotheses: i) Multiple genetic variations and risk factors can be incorporated into AI-based PRS to improve the accuracy of CVD risk predicting. ii) AI-based PRS for CVD circumvents the drawbacks of conventional PRS calculators by incorporating a larger variety of genetic and non-genetic components, allowing for more precise and individualised risk estimations. iii) Using AI approaches, it is possible to significantly reduce the dimensionality of huge genomic datasets, resulting in more accurate and effective disease risk prediction models. Our study highlighted that the AI-PRS model outperformed traditional PRS calculators in predicting CVD risk. Furthermore, using AI-based methods to calculate PRS may increase the precision of risk predictions for CVD and have significant ramifications for individualized prevention and treatment plans.
Collapse
Affiliation(s)
- Narendra N Khanna
- Department of Cardiology, Indraprastha APOLLO Hospitals, New Delhi, India
- Asia Pacific Vascular Society, New Delhi, India
| | - Manasvi Singh
- Stroke Monitoring and Diagnostic Division, AtheroPoint™, Roseville, CA, USA
- Bennett University, Greater Noida, India
| | - Mahesh Maindarkar
- Asia Pacific Vascular Society, New Delhi, India
- Stroke Monitoring and Diagnostic Division, AtheroPoint™, Roseville, CA, USA
- School of Bioengineering Sciences and Research, Maharashtra Institute of Technology's Art, Design and Technology University, Pune, India
| | | | - Amer M Johri
- Department of Medicine, Division of Cardiology, Queen's University, Kingston, Canada
| | - Laura Mentella
- Department of Medicine, Division of Cardiology, University of Toronto, Toronto, Canada
| | - John R Laird
- Heart and Vascular Institute, Adventist Health St. Helena, St. Helena, CA, USA
| | | | - Zoltan Ruzsa
- Invasive Cardiology Division, University of Szeged, Szeged, Hungary
| | - Narpinder Singh
- Department of Food Science and Technology, Graphic Era Deemed to be University, Dehradun, Uttarakhand, India
| | | | | | - Seemant Chaturvedi
- Department of Neurology & Stroke Program, University of Maryland, Baltimore, MD, USA
| | - Andrew Nicolaides
- Vascular Screening and Diagnostic Centre and University of Nicosia Medical School, Cyprus
| | - Vijay Rathore
- Nephrology Department, Kaiser Permanente, Sacramento, CA, USA
| | - Inder Singh
- Stroke Monitoring and Diagnostic Division, AtheroPoint™, Roseville, CA, USA
| | - Jagjit S Teji
- Ann and Robert H. Lurie Children's Hospital of Chicago, Chicago, IL, USA
| | - Mostafa Al-Maini
- Allergy, Clinical Immunology and Rheumatology Institute, Toronto, ON, Canada
| | - Esma R Isenovic
- Department of Radiobiology and Molecular Genetics, National Institute of The Republic of Serbia, University of Belgrade, Beograd, Serbia
| | | | - Puneet Khanna
- Department of Anaesthesiology, AIIMS, New Delhi, India
| | - Mostafa M Fouda
- Department of Electrical and Computer Engineering, Idaho State University, Pocatello, ID, USA
| | - Luca Saba
- Department of Radiology, Azienda Ospedaliero Universitaria, Cagliari, Italy
| | - Jasjit S Suri
- Asia Pacific Vascular Society, New Delhi, India
- Stroke Monitoring and Diagnostic Division, AtheroPoint™, Roseville, CA, USA
- Department of Computer Engineering, Graphic Era Deemed to be University, Dehradun, India.
| |
Collapse
|
6
|
Saba L, Maindarkar M, Khanna NN, Johri AM, Mantella L, Laird JR, Paraskevas KI, Ruzsa Z, Kalra MK, Fernandes JFE, Chaturvedi S, Nicolaides A, Rathore V, Singh N, Fouda MM, Isenovic ER, Al-Maini M, Viswanathan V, Suri JS. A Pharmaceutical Paradigm for Cardiovascular Composite Risk Assessment Using Novel Radiogenomics Risk Predictors in Precision Explainable Artificial Intelligence Framework: Clinical Trial Tool. FRONT BIOSCI-LANDMRK 2023; 28:248. [PMID: 37919080 DOI: 10.31083/j.fbl2810248] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2023] [Revised: 08/02/2023] [Accepted: 08/28/2023] [Indexed: 11/04/2023]
Abstract
BACKGROUND Cardiovascular disease (CVD) is challenging to diagnose and treat since symptoms appear late during the progression of atherosclerosis. Conventional risk factors alone are not always sufficient to properly categorize at-risk patients, and clinical risk scores are inadequate in predicting cardiac events. Integrating genomic-based biomarkers (GBBM) found in plasma/serum samples with novel non-invasive radiomics-based biomarkers (RBBM) such as plaque area, plaque burden, and maximum plaque height can improve composite CVD risk prediction in the pharmaceutical paradigm. These biomarkers consider several pathways involved in the pathophysiology of atherosclerosis disease leading to CVD. OBJECTIVE This review proposes two hypotheses: (i) The composite biomarkers are strongly correlated and can be used to detect the severity of CVD/Stroke precisely, and (ii) an explainable artificial intelligence (XAI)-based composite risk CVD/Stroke model with survival analysis using deep learning (DL) can predict in preventive, precision, and personalized (aiP3) framework benefiting the pharmaceutical paradigm. METHOD The PRISMA search technique resulted in 214 studies assessing composite biomarkers using radiogenomics for CVD/Stroke. The study presents a XAI model using AtheroEdgeTM 4.0 to determine the risk of CVD/Stroke in the pharmaceutical framework using the radiogenomics biomarkers. CONCLUSIONS Our observations suggest that the composite CVD risk biomarkers using radiogenomics provide a new dimension to CVD/Stroke risk assessment. The proposed review suggests a unique, unbiased, and XAI model based on AtheroEdgeTM 4.0 that can predict the composite risk of CVD/Stroke using radiogenomics in the pharmaceutical paradigm.
Collapse
Affiliation(s)
- Luca Saba
- Department of Radiology, Azienda Ospedaliero Universitaria, 40138 Cagliari, Italy
| | - Mahesh Maindarkar
- Stroke Monitoring and Diagnostic Division, AtheroPoint™, Roseville, CA 95661, USA
- School of Bioengineering Research and Sciences, Maharashtra Institute of Technology's Art, Design and Technology University, 412021 Pune, India
| | - Narendra N Khanna
- Department of Cardiology, Indraprastha APOLLO Hospitals, 110001 New Delhi, India
| | - Amer M Johri
- Department of Medicine, Division of Cardiology, Queen's University, Kingston, ON K7L 1C2, Canada
| | - Laura Mantella
- Department of Medicine, Division of Cardiology, University of Toronto, Toronto, ON M5S 1A1, Canada
| | - John R Laird
- Heart and Vascular Institute, Adventist Health St. Helena, St Helena, CA 94574, USA
| | - Kosmas I Paraskevas
- Department of Vascular Surgery, Central Clinic of Athens, 11526 Athens, Greece
| | - Zoltan Ruzsa
- Invasive Cardiology Division, University of Szeged, 6725 Szeged, Hungary
| | - Manudeep K Kalra
- Department of Radiology, Harvard Medical School, Boston, MA 02118, USA
| | | | - Seemant Chaturvedi
- Department of Neurology & Stroke Program, University of Maryland, Baltimore, MD 21201, USA
| | - Andrew Nicolaides
- Vascular Screening and Diagnostic Centre and University of Nicosia Medical School, 2368 Agios Dometios, Cyprus
| | - Vijay Rathore
- Nephrology Department, Kaiser Permanente, Sacramento, CA 95823, USA
| | - Narpinder Singh
- Department of Food Science and Technology, Graphic Era Deemed to be University, Dehradun, 248002 Uttarakhand, India
| | - Mostafa M Fouda
- Department of Electrical and Computer Engineering, Idaho State University, Pocatello, ID 83209, USA
| | - Esma R Isenovic
- Department of Radiobiology and Molecular Genetics, National Institute of The Republic of Serbia, University of Belgrade, 11001 Belgrade, Serbia
| | - Mustafa Al-Maini
- Allergy, Clinical Immunology and Rheumatology Institute, Toronto, ON L4Z 4C4, Canada
| | | | - Jasjit S Suri
- Stroke Monitoring and Diagnostic Division, AtheroPoint™, Roseville, CA 95661, USA
- Department of Computer Engineering, Graphic Era Deemed to be University, 248002 Dehradun, India
| |
Collapse
|
7
|
Paraskevas KI, Eckstein HH, Mansilha A, Ricco JB, Geroulakos G, Di Lazzaro V, Rundek T, Lanza G, Fraedrich G, Svetlikov AS, Suri JS, Zeebregts CJ, Davies AH, Capoccia L, Proczka RM, Myrcha P, Antignani PL, Fernandes E Fernandes J, Spence JD, Dardik A, Jezovnik MK, Knoflach M, Lavenson GS, Kakkos SK, Jawien A, Silvestrini M, Blinc A, Spinelli F, Stilo F, Musiałek P, Sultan S, Goudot G, Liapis CD, Saba L, Faggioli G, Pini R, Poredos P, Mikhailidis DP, Gloviczki P, Nicolaides AN. Screening for asymptomatic carotid stenosis in patients with non-valvular atrial fibrillation. Int J Cardiol 2023; 372:120-121. [PMID: 36435330 DOI: 10.1016/j.ijcard.2022.11.037] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/05/2022] [Accepted: 11/21/2022] [Indexed: 11/24/2022]
Affiliation(s)
| | - Hans-Henning Eckstein
- Department for Vascular and Endovascular Surgery, Klinikum rechts der Isar, Technical University of Munich, Munich, Germany
| | - Armando Mansilha
- Faculty of Medicine of the University of Porto, Porto, Portugal; Department of Angiology and Vascular Surgery, Hospital de S. Joao, Porto, Portugal
| | - Jean-Baptiste Ricco
- Department of Clinical Research, University of Poitiers, CHU de Poitiers, Poitiers, France
| | - George Geroulakos
- Department of Vascular Surgery, "Attikon" University Hospital, National and Kapodistrian University of Athens, Athens, Greece
| | - Vincenzo Di Lazzaro
- Neurology, Neurophysiology and Neurobiology Unit, Department of Medicine, Universita Campus Bio-Medico di Roma, Rome, Italy
| | - Tatjana Rundek
- Department of Neurology, Miller School of Medicine, University of Miami, Miami, FL, USA
| | - Gaetano Lanza
- Vascular Surgery Department, IRCSS Multimedica Hospital, Castellanza, Italy
| | - Gustav Fraedrich
- Department of Vascular Surgery, Medical University of Innsbruck, Innsbruck, Austria
| | - Alexei S Svetlikov
- Division of Vascular and Endovascular Surgery, North-Western Scientific Clinical Center of Federal Medical Biological Agency of Russia, St. Petersburg, Russia
| | - Jasjit S Suri
- Stroke Diagnostic and Monitoring Division, Atheropoint™, Roseville, CA, USA
| | - Clark J Zeebregts
- Department of Surgery (Division of Vascular Surgery), University Medical Center Groningen, University of Groningen, Groningen, the Netherlands
| | - Alun H Davies
- Department of Surgery and Cancer, Section of Vascular Surgery, Imperial College London, Charing Cross Hospital, London, UK
| | - Laura Capoccia
- Department of Surgery "Paride Stefanini", Policlinico Umberto I, "Sapienza" University of Rome, Rome, Italy
| | - Robert M Proczka
- 1st Department of Vascular Surgery, Medicover Hospital, Warsaw, Poland
| | - Piotr Myrcha
- Department of General and Vascular Surgery, Faculty of Medicine, Medical University of Warsaw, Warsaw, Poland
| | | | | | - J David Spence
- Stroke Prevention and Atherosclerosis Research Centre, Robarts Research Institute, Western University, London, ON, Canada
| | - Alan Dardik
- Division of Vascular Surgery and Endovascular Therapy, Yale University School of Medicine, New Haven, CT, USA
| | - Mateja K Jezovnik
- Department of Advanced Cardiopulmonary Therapies and Transplantation, The University of Texas Health Science Centre at Houston, Houston, TX, USA
| | - Michael Knoflach
- Department of Neurology, Medical University of Innsbruck, Innsbruck, Austria
| | - George S Lavenson
- Department of Surgery, Uniformed Services University, Bethesda, MD, USA
| | - Stavros K Kakkos
- Department of Vascular Surgery, University Hospital of Patras, Patras, Greece
| | - Arkadiusz Jawien
- Department of Vascular Surgery and Angiology, Collegium Medicum, Nicolaus Copernicus University, Bydgoszcz, Poland
| | - Mauro Silvestrini
- Neurological Clinic, Department of Experimental and Clinical Medicine, Marche Polytechnic University, Ancona, Italy
| | - Aleš Blinc
- Department of Vascular Diseases, Division of Internal Medicine, University Medical Centre Ljubljana, Ljubljana, Slovenia
| | - Francesco Spinelli
- Vascular Surgery Division, Campus Bio-Medico University of Rome, Rome, Italy
| | - Francesco Stilo
- Vascular Surgery Division, Campus Bio-Medico University of Rome, Rome, Italy
| | - Piotr Musiałek
- Jagiellonian University Department of Cardiac and Vascular Diseases, John Paul II Hospital, Krakow, Poland
| | - Sherif Sultan
- Western Vascular Institute, Department of Vascular and Endovascular Surgery, University Hospital Galway, National University of Ireland, Galway, Ireland
| | - Guillaume Goudot
- Vascular Medicine Department, Georges Pompidou European hospital, APHP, Université de Paris Cité, Paris, France
| | | | - Luca Saba
- Department of Radiology, Azienda Ospedaliera Universitaria Di Cagliari, Cagliari, Italy
| | - Gianluca Faggioli
- Vascular Surgery, University of Bologna "Alma Mater Studiorum", Policlinico S. Orsola Malpighi, Bologna, Italy
| | - Rodolfo Pini
- Vascular Surgery, University of Bologna "Alma Mater Studiorum", Policlinico S. Orsola Malpighi, Bologna, Italy
| | - Pavel Poredos
- Department of Vascular Diseases, University Medical Centre Ljubljana, Slovenia
| | - Dimitri P Mikhailidis
- Department of Clinical Biochemistry, Royal Free Hospital Campus, University College London Medical School, University College London (UCL), London, UK
| | - Peter Gloviczki
- Division of Vascular and Endovascular Surgery, Mayo Clinic, Rochester, MN, USA
| | - Andrew N Nicolaides
- Department of Surgery, University of Nicosia Medical School, Nicosia, Cyprus
| |
Collapse
|
8
|
Paraskevas KI, Spence JD, Mikhailidis DP, Antignani PL, Gloviczki P, Eckstein HH, Spinelli F, Stilo F, Saba L, Poredos P, Dardik A, Liapis CD, Mansilha A, Faggioli G, Pini R, Jezovnik MK, Sultan S, Musiałek P, Goudot G, Lavenson GS, Jawien A, Blinc A, Myrcha P, Fernandes E Fernandes J, Geroulakos G, Kakkos SK, Knoflach M, Proczka RM, Capoccia L, Rundek T, Svetlikov AS, Silvestrini M, Ricco JB, Davies AH, Di Lazzaro V, Suri JS, Lanza G, Fraedrich G, Zeebregts CJ, Nicolaides AN. Why do guidelines recommend screening for abdominal aortic aneurysms, but not for asymptomatic carotid stenosis? A plea for a randomized controlled trial. Int J Cardiol 2023; 371:406-412. [PMID: 36162523 DOI: 10.1016/j.ijcard.2022.09.045] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/13/2022] [Revised: 09/18/2022] [Accepted: 09/20/2022] [Indexed: 12/14/2022]
Abstract
BACKGROUND Current guidelines do not recommend screening for asymptomatic carotid artery stenosis (AsxCS). The rationale behind this recommendation is that detection of AsxCS may lead to an unnecessary carotid intervention. In contrast, screening for abdominal aortic aneurysms is strongly recommended. METHODS A critical analysis of the literature was performed to evaluate the implications of detecting AsxCS. RESULTS Patients with AsxCS are at high risk for future stroke, myocardial infarction and vascular death. Population-wide screening for AsxCS should not be recommended. Additionally, screening of high-risk individuals for AsxCS with the purpose of identifying candidates for a carotid intervention is inappropriate. Instead, selective screening for AsxCS should be considered and should be viewed as an opportunity to identify individuals at high risk for atherosclerotic cardiovascular disease and future cardiovascular events for the timely initiation of intensive medical therapy and risk factor modification. CONCLUSIONS Although mass screening should not be recommended, there are several arguments suggesting that selective screening for AsxCS should be considered. The rationale supporting such selective screening is to optimize risk factor control and to initiate intensive medical therapy for prevention of future cardiovascular events, rather than to identify candidates for an intervention.
Collapse
Affiliation(s)
| | - J David Spence
- Stroke Prevention and Atherosclerosis Research Centre, Robarts Research Institute, Western University, London, ON, Canada
| | - Dimitri P Mikhailidis
- Department of Clinical Biochemistry, Royal Free Hospital Campus, University College London Medical School, University College London (UCL), London, UK
| | | | - Peter Gloviczki
- Division of Vascular and Endovascular Surgery, Mayo Clinic, Rochester, MN, USA
| | - Hans-Henning Eckstein
- Department for Vascular and Endovascular Surgery, Klinikum rechts der Isar, Technical University of Munich, Munich, Germany
| | - Francesco Spinelli
- Vascular Surgery Division, Campus Bio-Medico University of Rome, Rome, Italy
| | - Francesco Stilo
- Vascular Surgery Division, Campus Bio-Medico University of Rome, Rome, Italy
| | - Luca Saba
- Department of Radiology, Azienda Ospedaliera Universitaria Di Cagliari, Cagliari, Italy
| | - Pavel Poredos
- Department of Vascular Disease, University Medical Centre Ljubljana, Slovenia
| | - Alan Dardik
- Division of Vascular and Endovascular Surgery, Yale University School of Medicine, New Haven, CT, USA
| | | | - Armando Mansilha
- Faculty of Medicine of the University of Porto, Porto, Portugal; Department of Angiology and Vascular Surgery, Hospital de S. Joao, Porto, Portugal
| | - Gianluca Faggioli
- Vascular Surgery, University of Bologna "Alma Mater Studiorum", Policlinico S. Orsola Malpighi, Bologna, Italy
| | - Rodolfo Pini
- Vascular Surgery, University of Bologna "Alma Mater Studiorum", Policlinico S. Orsola Malpighi, Bologna, Italy
| | - Mateja K Jezovnik
- Department of Advanced Cardiopulmonary Therapies and Transplantation, The University of Texas Health Science Centre at Houston, Houston, TX, USA
| | - Sherif Sultan
- Western Vascular Institute, Department of Vascular and Endovascular Surgery, University Hospital Galway, National University of Ireland, Galway, Ireland
| | - Piotr Musiałek
- Jagiellonian University Department of Cardiac and Vascular Diseases, John Paul II Hospital, Krakow, Poland
| | - Guillaume Goudot
- Vascular medicine department, Georges Pompidou European hospital, APHP, Université de Paris Cité, Paris, France
| | - George S Lavenson
- Department of Surgery, Uniformed Services University, Bethesda, MD, USA
| | - Arkadiusz Jawien
- Department of Vascular Surgery and Angiology, Collegium Medicum, Nicolaus Copernicus University, Bydgoszcz, Poland
| | - Aleš Blinc
- Department of Vascular Diseases, Division of Internal Medicine, University Medical Centre Ljubljana, Ljubljana, Slovenia
| | - Piotr Myrcha
- Department of General and Vascular Surgery, Faculty of Medicine, Medical University of Warsaw, Warsaw, Poland
| | | | - George Geroulakos
- Department of Vascular Surgery, "Attikon" University Hospital, National and Kapodistrian University of Athens, Athens, Greece
| | - Stavros K Kakkos
- Department of Vascular Surgery, University Hospital of Patras, Patras, Greece
| | - Michael Knoflach
- Department of Neurology, Medical University of Innsbruck, Innsbruck, Austria
| | - Robert M Proczka
- 1(st) Department of Vascular Surgery, Medicover Hospital, Warsaw, Poland
| | - Laura Capoccia
- Department of Surgery "Paride Stefanini", Policlinico Umberto I, "Sapienza" University of Rome, Rome, Italy
| | - Tatjana Rundek
- Department of Neurology, Miller School of Medicine, University of Miami, Miami, FL, USA
| | - Alexei S Svetlikov
- Division of Vascular and Endovascular Surgery, North-Western Scientific Clinical Center of Federal Medical Biological Agency of Russia, St. Petersburg, Russia
| | - Mauro Silvestrini
- Neurological Clinic, Department of Experimental and Clinical Medicine, Marche Polytechnic University, Ancona, Italy
| | - Jean-Baptiste Ricco
- Department of Clinical Research, University of Poitiers, CHU de Poitiers, Poitiers, France
| | - Alun H Davies
- Department of Surgery and Cancer, Section of Vascular Surgery, Imperial College London, Charing Cross Hospital, London, UK
| | - Vincenzo Di Lazzaro
- Neurology, Neurophysiology and Neurobiology Unit, Department of Medicine, Universita Campus Bio-Medico di Roma, Rome, Italy
| | - Jasjit S Suri
- Stroke Diagnostic and Monitoring Division, Atheropoint™, Roseville, CA, USA
| | - Gaetano Lanza
- Vascular Surgery Department, IRCSS Multimedica Hospital, Castellanza, Italy
| | - Gustav Fraedrich
- Department of Vascular Surgery, Medical University of Innsbruck, Innsbruck, Austria
| | - Clark J Zeebregts
- Department of Surgery (Division of Vascular Surgery), University Medical Center Groningen, University of Groningen, Groningen, the Netherlands
| | - Andrew N Nicolaides
- Department of Surgery, University of Nicosia Medical School, Nicosia, Cyprus
| |
Collapse
|
9
|
Paraskevas KI, Mikhailidis DP, Antignani PL, Ascher E, Baradaran H, Bokkers RPH, Cambria RP, Comerota AJ, Dardik A, Davies AH, Eckstein HH, Faggioli G, Fernandes E Fernandes J, Fraedrich G, Geroulakos G, Gloviczki P, Golledge J, Gupta A, Jezovnik MK, Kakkos SK, Katsiki N, Knoflach M, Eline Kooi M, Lanza G, Lavenson GS, Liapis CD, Loftus IM, Mansilha A, Millon A, Nicolaides AN, Pini R, Poredos P, Proczka RM, Ricco JB, Riles TS, Ringleb PA, Rundek T, Saba L, Schlachetzki F, Silvestrini M, Spinelli F, Stilo F, Sultan S, Suri JS, Svetlikov AV, Zeebregts CJ, Chaturvedi S. Comparison of Recent Practice Guidelines for the Management of Patients With Asymptomatic Carotid Stenosis. Angiology 2022; 73:903-910. [PMID: 35412377 DOI: 10.1177/00033197221081914] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
Abstract
Despite the publication of several national/international guidelines, the optimal management of patients with asymptomatic carotid stenosis (AsxCS) remains controversial. This article compares 3 recently released guidelines (the 2020 German-Austrian, the 2021 European Stroke Organization [ESO], and the 2021 Society for Vascular Surgery [SVS] guidelines) vs the 2017 European Society for Vascular Surgery (ESVS) guidelines regarding the optimal management of AsxCS patients.The 2017 ESVS guidelines defined specific imaging/clinical parameters that may identify patient subgroups at high future stroke risk and recommended that carotid endarterectomy (CEA) should or carotid artery stenting (CAS) may be considered for these individuals. The 2020 German-Austrian guidelines provided similar recommendations with the 2017 ESVS Guidelines. The 2021 ESO Guidelines also recommended CEA for AsxCS patients at high risk for stroke on best medical treatment (BMT), but recommended against routine use of CAS in these patients. Finally, the SVS guidelines provided a strong recommendation for CEA+BMT vs BMT alone for low-surgical risk patients with >70% AsxCS. Thus, the ESVS, German-Austrian, and ESO guidelines concurred that all AsxCS patients should receive risk factor modification and BMT, but CEA should or CAS may also be considered for certain AsxCS patient subgroups at high risk for future ipsilateral ischemic stroke.
Collapse
Affiliation(s)
| | - Dimitri P Mikhailidis
- Department of Clinical Biochemistry, Royal Free Hospital Campus, University College London Medical School, University College London (UCL), London, UK
| | | | - Enrico Ascher
- Division of Vascular Surgery, 12297Vascular Institute of New York, Brooklyn, NY, USA
| | - Hediyeh Baradaran
- Department of Radiology, 14434University of Utah, Salt Lake City, UT, USA
| | - Reinoud P H Bokkers
- Department of Radiology, Medical Imaging Center, 10173University Medical Center Groningen, Groningen, The Netherlands
| | - Richard P Cambria
- Division of Vascular and Endovascular Surgery, St Elizabeth's Medical Center, Boston, MA, USA
| | - Anthony J Comerota
- Inova Heart and Vascular Institute, Inova Alexandria Hospital, Alexandria, VA, USA
| | - Alan Dardik
- Division of Vascular and Endovascular Surgery, Yale University School of Medicine, New Haven, CT, USA
| | - Alun H Davies
- Section of Vascular Surgery, Imperial College and Imperial Healthcare NHS Trust, London, UK
| | - Hans-Henning Eckstein
- Department for Vascular and Endovascular Surgery, Klinikum Rechts der Isar, Technical University of Munich, Munich, Germany
| | - Gianluca Faggioli
- Vascular Surgery, University of Bologna "Alma Mater Studiorum", Policlinico S. Orsola Malpighi, Bologna, Italy
| | | | - Gustav Fraedrich
- Department of Vascular Surgery, Medical University of Innsbruck, Innsbruck, Austria
| | - George Geroulakos
- Department of Vascular Surgery, 69038"Attikon" University Hospital, National and Kapodistrian University of Athens, Athens, Greece
| | - Peter Gloviczki
- Division of Vascular and Endovascular Surgery, 6915Mayo Clinic, Rochester, MN, USA
| | - Jonathan Golledge
- Queensland Research Centre for Peripheral Vascular Disease, James Cook University and Townsville University Hospital, Townsville, Queensland, Australia
| | - Ajay Gupta
- Department of Radiology, 466371Weill Cornell Medicine, New York, NY, USA
| | - Mateja K Jezovnik
- Department of Advanced Cardiopulmonary Therapies and Transplantation, The University of Texas Health Science Centre at Houston, Houston, TX, U.S.A
| | - Stavros K Kakkos
- Department of Vascular Surgery, 37795University of Patras Medical School, Patras, Greece
| | - Niki Katsiki
- First Department of Internal Medicine, 37782AHEPA University Hospital, Thessaloniki, Greece
| | - Michael Knoflach
- Department of Neurology, 27280Medical University of Innsbruck, Innsbruck, Austria
| | - M Eline Kooi
- CARIM School for Cardiovascular Disease, 46837Maastricht University, Maaastricht, The Netherlands.,Department of Radiology and Nuclear Medicine, 46837Maastricht University Medical Center, Maastricht, The Netherlands
| | - Gaetano Lanza
- Vascular Surgery Department, 46837IRCSS MultiMedica Hospital, Castellanza, Italy
| | - George S Lavenson
- Department of Surgery, 1685Uniformed Services University, Bethesda, MD, USA
| | | | - Ian M Loftus
- St George's Vascular Institute, St George's University London, London, UK
| | - Armando Mansilha
- Faculty of Medicine of the University of Porto, Porto, Portugal.,Department of Angiology and Vascular Surgery, Hospital de S. Joao, Porto, Portugal
| | - Antoine Millon
- Department of Vascular and Endovascular Surgery, 26899Louis Pradel Hospital, Hospices Civils de Lyon, France
| | - Andrew N Nicolaides
- Department of Surgery, 121343University of Nicosia Medical School, Nicosia, Cyprus
| | - Rodolfo Pini
- Vascular Surgery, University of Bologna "Alma Mater Studiorum", Policlinico S. Orsola Malpighi, Bologna, Italy
| | - Pavel Poredos
- Department of Vascular Disease, University Medical Centre Ljubljana, Slovenia
| | - Robert M Proczka
- 1stDepartment of Vascular Surgery, Medicover Hospital, Warsaw, Poland
| | - Jean-Baptiste Ricco
- Department of Clinical Research, University of Poitiers, CHU de Poitiers, Poitiers, France
| | - Thomas S Riles
- Department of Surgery, Division of Vascular Surgery, 12297New York University Langone Medical Centre, New York, NY, USA
| | | | - Tatjana Rundek
- Department of Neurology, Miller School of Medicine, 12235University of Miami, Miami, FL, USA
| | - Luca Saba
- Department of Radiology, 97863Azienda Ospedaliera Universitaria Di Cagliari, Cagliari, Italy
| | - Felix Schlachetzki
- Department of Neurology, 210419University of Regensburg, Regensburg, Germany
| | - Mauro Silvestrini
- Neurological Clinic, Department of Experimental and Clinical Medicine, 9294Marche Polytechnic University, Ancona, Italy
| | - Francesco Spinelli
- Vascular Surgery Division, 9311Campus Bio-Medico University of Rome, Rome, Italy
| | - Francesco Stilo
- Vascular Surgery Division, 9311Campus Bio-Medico University of Rome, Rome, Italy
| | - Sherif Sultan
- Western Vascular Institute, Department of Vascular and Endovascular Surgery, University Hospital Galway, National University of Ireland, Galway, Ireland
| | - Jasjit S Suri
- Stroke Diagnosis and Monitoring Division, AtheroPointTM, Roseville, USA
| | - Alexei V Svetlikov
- Division of Vascular and Endovascular Surgery, North-Western Scientific Clinical Center of Federal Medical Biological Agency of Russia, St Petersburgh, Russia
| | - Clark J Zeebregts
- Division of Vascular Surgery, Department of Surgery, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Seemant Chaturvedi
- Department of Neurology & Stroke Program, 12264University of Maryland School of Medicine, Baltimore, MD, USA
| |
Collapse
|
10
|
Paraskevas KI, Mikhailidis DP, Baradaran H, Bokkers RPH, Davies AH, Eckstein HH, Faggioli G, Fernandes E Fernandes J, Gargiulo M, Jawien A, Jezovnik MK, Kakkos SK, Knoflach M, Kooi ME, Lanza G, Liapis CD, Loftus IM, Mansilha A, Mechtouff L, Millon A, Myrcha P, Nicolaides AN, Pini R, Poredos P, Ricco JB, Rundek T, Saba L, Silvestrini M, Spinelli F, Stilo F, Sultan S, Suri JS, Svetlikov AV, Wijeratne T, Zeebregts CJ, Gloviczki P. The burden of carotid-related strokes. Ann Transl Med 2022; 10:159. [PMID: 35284552 PMCID: PMC8904971 DOI: 10.21037/atm-2021-12] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 11/23/2021] [Accepted: 12/24/2021] [Indexed: 11/06/2022]
Affiliation(s)
| | - Dimitri P. Mikhailidis
- Department of Clinical Biochemistry, Royal Free Hospital Campus, University College London Medical School, University College London (UCL), London, UK
| | - Hediyeh Baradaran
- Department of Radiology and Imaging Sciences, Neuroradiology Division, University of Utah Health, Salt Lake City, UT, USA
| | - Reinoud P. H. Bokkers
- Department of Radiology, Medical Imaging Center, University Medical Center Groningen, Groningen, The Netherlands
| | - Alun H. Davies
- Section of Vascular Surgery, Imperial College & Imperial Healthcare NHS Trust, London, UK
| | - Hans-Henning Eckstein
- Department for Vascular and Endovascular Surgery, Klinikum rechts der Isar, Technical University of Munich, Munich, Germany
| | - Gianluca Faggioli
- Vascular Surgery, Department of Experimental, Diagnostic and Specialty Medicine, University of Bologna, IRCSS Policlinico di Sant’Orsola, Bologna, Italy
| | | | - Mauro Gargiulo
- Vascular Surgery, Department of Experimental, Diagnostic and Specialty Medicine, University of Bologna, IRCSS Policlinico di Sant’Orsola, Bologna, Italy
| | - Arkadiusz Jawien
- Department for Vascular Surgery and Angiology, L. Rydygier Collegium Medicum in Bydgoszcz, Nicolaus Copernicus University in Torun, Poland
| | - Mateja K. Jezovnik
- Department of Advanced Cardiopulmonary Therapies and Transplantation, The University of Texas Health Science Centre at Houston, Houston, TX, USA
| | - Stavros K. Kakkos
- Department of Vascular Surgery, University of Patras Medical School, Patras, Greece
| | - Michael Knoflach
- Department of Neurology, Medical University of Innsbruck, Innsbruck, Austria
| | - M. Eline Kooi
- CARIM School for Cardiovascular Diseases, Maastricht University, Maastricht, The Netherlands
- Department of Radiology and Nuclear Medicine, Maastricht University Medical Center, Maastricht, The Netherlands
| | - Gaetano Lanza
- Vascular Surgery Department, IRCSS MultiMedica Hospital, Castellanza, Italy
| | | | - Ian M. Loftus
- St. George’s Vascular Institute, St. George’s University London, London, UK
| | | | | | - Antoine Millon
- Vascular Surgery Department, Hospices Civils de Lyon, Lyon, France
| | - Piotr Myrcha
- First Chair and Department of General and Vascular Surgery, Faculty of Medicine, Medical University of Warsaw, Warsaw, Poland
| | | | - Rodolfo Pini
- Vascular Surgery, Department of Experimental, Diagnostic and Specialty Medicine, University of Bologna, IRCSS Policlinico di Sant’Orsola, Bologna, Italy
| | - Pavel Poredos
- Department of Vascular Disease, University Medical Centre Ljubljana, Slovenia
| | - Jean-Baptiste Ricco
- Department of Clinical Research, University of Poitiers, CHU de Poitiers, Poitiers, France
| | - Tatjana Rundek
- Department of Neurology, Miller School of Medicine, University of Miami, Miami, FL, USA
| | - Luca Saba
- Department of Radiology, Azienda Ospedaliera Universitaria Di Cagliari, Cagliari, Italy
| | - Mauro Silvestrini
- Neurological Clinic, Department of Experimental and Clinical Medicine, Marche Polytechnic University, Ancona, Italy
| | - Francesco Spinelli
- Vascular Surgery Division, Campus Bio-Medico University of Rome, Rome, Italy
| | - Francesco Stilo
- Vascular Surgery Division, Campus Bio-Medico University of Rome, Rome, Italy
| | - Sherif Sultan
- Western Vascular Institute, Department of Vascular and Endovascular Surgery, University Hospital Galway, National University of Ireland, Galway, Ireland
| | - Jasjit S. Suri
- Stroke Diagnosis and Monitoring Division, AtheroPointTM, Roseville, USA
| | - Alexei V. Svetlikov
- Division of Vascular and Endovascular Surgery, North-Western Scientific Clinical Center of Federal Medical Biological Agency of Russia, St. Petersburgh, Russia
| | - Tissa Wijeratne
- Department of Neurology, Sunshine Hospital and Melbourne Medical School, St. Albans, Victoria, Australia
| | - Clark J. Zeebregts
- Division of Vascular Surgery, Department of Surgery, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Peter Gloviczki
- Division of Vascular and Endovascular Surgery, Mayo Clinic, Rochester, MN, USA
| |
Collapse
|
11
|
Paraskevas KI, Mikhailidis DP, Antignani PL, Baradaran H, Bokkers RP, Cambria RP, Dardik A, Davies AH, Eckstein HH, Faggioli G, Fernandes E Fernandes J, Fraedrich G, Geroulakos G, Gloviczki P, Golledge J, Gupta A, Jezovnik MK, Kakkos SK, Katsiki N, Knoflach M, Kooi ME, Lanza G, Liapis CD, Loftus IM, Mansilha A, Millon A, Nicolaides AN, Pini R, Poredos P, Ricco JB, Riles TS, Ringleb PA, Rundek T, Saba L, Schlachetzki F, Silvestrini M, Spinelli F, Stilo F, Sultan S, Suri JS, Zeebregts CJ, Chaturvedi S. Optimal management of asymptomatic carotid stenosis in 2021: the jury is still out. An International, multispecialty, expert review and position statement. INT ANGIOL 2021; 41:158-169. [PMID: 34913633 DOI: 10.23736/s0392-9590.21.04825-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
OBJECTIVES The recommendations of international guidelines for the management of asymptomatic carotid stenosis (ACS) often vary considerably and extend from a conservative approach with risk factor modification and best medical treatment (BMT) alone, to a more aggressive approach with a carotid intervention plus BMT. The aim of the current multispecialty position statement is to reconcile the conflicting views on the topic. MATERIALS AND METHODS A literature review was performed with a focus on data from recent studies. RESULTS Several clinical and imaging high-risk features have been identified that are associated with an increased long-term ipsilateral ischemic stroke risk in patients with ACS. Such high-risk clinical/imaging features include intraplaque hemorrhage, impaired cerebrovascular reserve, carotid plaque echolucency/ulceration/ neovascularization, a lipid-rich necrotic core, a thin or ruptured fibrous cap, silent brain infarction, a contralateral transient ischemic attack/stroke episode, male patients <75 years and microembolic signals on transcranial Doppler. There is growing evidence that 80-99% ACS indicate a higher stroke risk than 50-79% stenoses. CONCLUSIONS Although aggressive risk factor control and BMT should be implemented in all ACS patients, several high-risk features that may increase the risk of a future cerebrovascular event are now documented. Consequently, some guidelines recommend a prophylactic carotid intervention in high-risk patients to prevent future cerebrovascular events. Until the results of the much-anticipated randomized controlled trials emerge, the jury is still out regarding the optimal management of ACS patients.
Collapse
Affiliation(s)
| | - Dimitri P Mikhailidis
- Department of Clinical Biochemistry, Royal Free Hospital Campus, University College London Medical School, University College London (UCL), London, UK
| | | | - Hediyeh Baradaran
- Department of Radiology, University of Utah, Salt Lake City, UT, USA
| | - Reinoud P Bokkers
- Department of Radiology, Medical Imaging Center, University Medical Center Groningen, Groningen, The Netherlands
| | - Richard P Cambria
- Division of Vascular and Endovascular Surgery, St. Elizabeth's Medical Center, Brighton, MA, USA
| | - Alan Dardik
- Division of Vascular and Endovascular Surgery, Yale University School of Medicine, New Haven, CT, USA
| | - Alun H Davies
- Section of Vascular Surgery, Imperial College & Imperial Healthcare NHS Trust, London, UK
| | - Hans-Henning Eckstein
- Department for Vascular and Endovascular Surgery, Klinikum rechts der Isar, Technical University of Munich, Munich, Germany
| | - Gianluca Faggioli
- Vascular Surgery, Policlinico S. Orsola Malpighi, University of Bologna Alma Mater Studiorum, Bologna, Italy
| | | | - Gustav Fraedrich
- Department of Vascular Surgery, Medical University of Innsbruck, Innsbruck, Austria
| | - George Geroulakos
- Department of Vascular Surgery, Attikon University Hospital, National and Kapodistrian University of Athens, Athens, Greece
| | - Peter Gloviczki
- Division of Vascular and Endovascular Surgery, Mayo Clinic, Rochester, MN, USA
| | - Jonathan Golledge
- Queensland Research Centre for Peripheral Vascular Disease, James Cook University and Townsville University Hospital, Townsville, Australia
| | - Ajay Gupta
- Department of Radiology, Weill Cornell Medicine, New York, NY, USA
| | - Mateja K Jezovnik
- Department of Advanced Cardiopulmonary Therapies and Transplantation, The University of Texas Health Science Centre at Houston, Houston, Texas, USA
| | - Stavros K Kakkos
- Department of Vascular Surgery, University of Patras Medical School, Patras, Greece
| | - Niki Katsiki
- First Department of Internal Medicine, AHEPA University Hospital, Thessaloniki, Greece
| | - Michael Knoflach
- Department of Neurology, Medical University of Innsbruck, Innsbruck, Austria
| | - M Eline Kooi
- CARIM School for Cardiovascular Diseases, Maastricht University, Maastricht, The Netherlands.,Department of Radiology and Nuclear Medicine, Maastricht University Medical Center, Maastricht, The Netherlands
| | - Gaetano Lanza
- Vascular Surgery Department, IRCSS MultiMedica Hospital, Castellanza, Varese, Italy
| | | | - Ian M Loftus
- St. George's Vascular Institute, St. George's University London, London, UK
| | - Armando Mansilha
- Faculty of Medicine of the University of Porto, Porto, Portugal.,Department of Angiology and Vascular Surgery, Hospital de S. Joao, Porto, Portugal
| | - Antoine Millon
- Department of Vascular and Endovascular Surgery, Louis Pradel Hospital, Hospices Civils de Lyon, Lyon, France
| | - Andrew N Nicolaides
- Department of Surgery, University of Nicosia Medical School, Nicosia, Cyprus
| | - Rodolfo Pini
- Vascular Surgery, Policlinico S. Orsola Malpighi, University of Bologna Alma Mater Studiorum, Bologna, Italy
| | - Pavel Poredos
- Department of Vascular Disease, University Medical Centre Ljubljana, Ljubljana, Slovenia
| | - Jean-Baptiste Ricco
- Department of Clinical Research, University of Poitiers, CHU de Poitiers, Poitiers, France
| | - Thomas S Riles
- Department of Surgery, Division of Vascular Surgery, New York University Langone Medical Centre, New York, NY, USA
| | | | - Tatjana Rundek
- Department of Neurology, Miller School of Medicine, University of Miami, Miami, FL, USA
| | - Luca Saba
- Department of Radiology, Azienda Ospedaliera Universitaria di Cagliari, Cagliari, Italy
| | | | - Mauro Silvestrini
- Neurological Clinic, Department of Experimental and Clinical Medicine, Marche Polytechnic University, Ancona, Italy
| | - Francesco Spinelli
- Vascular Surgery Division, Campus Bio-Medico University of Rome, Rome, Italy
| | - Francesco Stilo
- Vascular Surgery Division, Campus Bio-Medico University of Rome, Rome, Italy
| | - Sherif Sultan
- Western Vascular Institute, Department of Vascular and Endovascular Surgery, University Hospital Galway, National University of Ireland, Galway, Ireland
| | - Jasjit S Suri
- Stroke Diagnosis and Monitoring Division, AtheroPointTM, Roseville, CA, USA
| | - Clark J Zeebregts
- Division of Vascular Surgery, Department of Surgery, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Seemant Chaturvedi
- Department of Neurology & Stroke Program, University of Maryland School of Medicine, Baltimore, MD, USA
| |
Collapse
|
12
|
Paraskevas KI, Mikhailidis DP, Antignani PL, Baradaran H, Bokkers RPH, Cambria RP, Dardik A, Davies AH, Eckstein HH, Faggioli G, E Fernandes JF, Fraedrich G, Geroulakos G, Gloviczki P, Golledge J, Gupta A, Jezovnik MK, Kakkos SK, Katsiki N, Knoflach M, Kooi ME, Lanza G, Liapis CD, Loftus IM, Mansilha A, Millon A, Nicolaides AN, Pini R, Poredos P, Ricco JB, Riles TS, Ringleb PA, Rundek T, Saba L, Schlachetzki F, Silvestrini M, Spinelli F, Stilo F, Sultan S, Suri JS, Zeebregts CJ, Chaturvedi S. Optimal Management of Asymptomatic Carotid Stenosis in 2021: The Jury is Still Out. An International, Multispecialty, Expert Review and Position Statement. J Stroke Cerebrovasc Dis 2021; 31:106182. [PMID: 34735900 DOI: 10.1016/j.jstrokecerebrovasdis.2021.106182] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [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: 08/31/2021] [Revised: 10/14/2021] [Accepted: 10/17/2021] [Indexed: 01/19/2023] Open
Abstract
OBJECTIVES The recommendations of international guidelines for the management of asymptomatic carotid stenosis (ACS) often vary considerably and extend from a conservative approach with risk factor modification and best medical treatment (BMT) alone, to a more aggressive approach with a carotid intervention plus BMT. The aim of the current multispecialty position statement is to reconcile the conflicting views on the topic. MATERIALS AND METHODS A literature review was performed with a focus on data from recent studies. RESULTS Several clinical and imaging high-risk features have been identified that are associated with an increased long-term ipsilateral ischemic stroke risk in patients with ACS. Such high-risk clinical/imaging features include intraplaque hemorrhage, impaired cerebrovascular reserve, carotid plaque echolucency/ulceration/ neovascularization, a lipid-rich necrotic core, a thin or ruptured fibrous cap, silent brain infarction, a contralateral transient ischemic attack/stroke episode, male patients < 75 years and microembolic signals on transcranial Doppler. There is growing evidence that 80-99% ACS indicate a higher stroke risk than 50-79% stenoses. CONCLUSIONS Although aggressive risk factor control and BMT should be implemented in all ACS patients, several high-risk features that may increase the risk of a future cerebrovascular event are now documented. Consequently, some guidelines recommend a prophylactic carotid intervention in high-risk patients to prevent future cerebrovascular events. Until the results of the much-anticipated randomized controlled trials emerge, the jury is still out regarding the optimal management of ACS patients.
Collapse
Affiliation(s)
- Kosmas I Paraskevas
- Department of Vascular Surgery, Central Clinic of Athens, 24, Alexander Papagou street, N. Iraklio, Athens 14122, Greece.
| | - Dimitri P Mikhailidis
- Department of Clinical Biochemistry, Royal Free Hospital Campus, University College London Medical School, University College London (UCL), London, UK
| | | | - Hediyeh Baradaran
- Department of Radiology, University of Utah, Salt Lake City, UT, United States
| | - Reinoud P H Bokkers
- Department of Radiology, Medical Imaging Center, University Medical Center Groningen, Groningen, the Netherland
| | - Richard P Cambria
- Division of Vascular and Endovascular Surgery, St. Elizabeth's Medical Center, Brighton, MA, United States
| | - Alan Dardik
- Division of Vascular and Endovascular Surgery, Yale University School of Medicine, New Haven, CT, United States
| | - Alun H Davies
- Section of Vascular Surgery, Imperial College and Imperial Healthcare NHS Trust, London, UK
| | - Hans-Henning Eckstein
- Department for Vascular and Endovascular Surgery, Klinikum rechts der Isar, Technical University of Munich, Munich, Germany
| | - Gianluca Faggioli
- Vascular Surgery, University of Bologna "Alma Mater Studiorum", Policlinico S. Orsola Malpighi, Bologna, Italy
| | | | - Gustav Fraedrich
- Department of Vascular Surgery, Medical University of Innsbruck, Innsbruck, Austria
| | - George Geroulakos
- Department of Vascular Surgery, Attikon University Hospital, National and Kapodistrian University of Athens, Athens, Greece
| | - Peter Gloviczki
- Division of Vascular and Endovascular Surgery, Mayo Clinic, Rochester, MN, United States
| | - Jonathan Golledge
- Queensland Research Center for Peripheral Vascular Disease, James Cook University, Townsville University Hospital, Townsville, Queensland, Australia
| | - Ajay Gupta
- Department of Radiology, Weill Cornell Medicine, New York, United States
| | - Mateja K Jezovnik
- Department of Advanced Cardiopulmonary Therapies and Transplantation, The University of Texas Health Science Center, Houston, TX, United States
| | - Stavros K Kakkos
- Department of Vascular Surgery, University of Patras Medical School, Patras, Greece
| | - Niki Katsiki
- First Department of Internal Medicine, AHEPA University Hospital, Thessaloniki, Greece
| | - Michael Knoflach
- Department of Neurology, Medical University of Innsbruck, Innsbruck, Austria
| | - M Eline Kooi
- CARIM School for Cardiovascular Diseases, Maastricht University, Maastricht, the Netherland; Department of Radiology and Nuclear Medicine, Maastricht University Medical Center, Maastricht, the Netherland
| | - Gaetano Lanza
- Vascular Surgery Department, IRCSS MultiMedica Hospital, Castellanza, Italy
| | | | - Ian M Loftus
- St. George's Vascular Institute, St. George's University of London, London, UK
| | - Armando Mansilha
- Faculty of Medicine of the University of Porto, Porto, Portugal; Department of Angiology and Vascular Surgery, Hospital de S. Joao, Porto, Portugal
| | - Antoine Millon
- Department of Vascular and Endovascular Surgery, Louis Pradel Hospital, Hospices Civils de Lyon, France
| | - Andrew N Nicolaides
- Department of Surgery, University of Nicosia Medical School, Nicosia, Cyprus
| | - Rodolfo Pini
- Vascular Surgery, University of Bologna "Alma Mater Studiorum", Policlinico S. Orsola Malpighi, Bologna, Italy
| | - Pavel Poredos
- Department of Vascular Disease, University Medical Center, Ljubljana, Slovenia
| | - Jean-Baptiste Ricco
- Department of Clinical Research, University of Poitiers, CHU de Poitiers, Poitiers, France
| | - Thomas S Riles
- Department of Surgery, Division of Vascular Surgery, New York University, Langone Medical Center, New York, United States
| | | | - Tatjana Rundek
- Department of Neurology, Miller School of Medicine, University of Miami, Miami, FL, United States
| | - Luca Saba
- Department of Radiology, Azienda Ospedaliera Universitaria Di Cagliari, Cagliari, Italy
| | | | - Mauro Silvestrini
- Neurological Clinic, Department of Experimental and Clinical Medicine, Marche Polytechnic University, Ancona, Italy
| | - Francesco Spinelli
- Vascular Surgery Division, Campus Bio-Medico University of Rome, Rome, Italy
| | - Francesco Stilo
- Vascular Surgery Division, Campus Bio-Medico University of Rome, Rome, Italy
| | - Sherif Sultan
- Department of Vascular and Endovascular Surgery, Western Vascular Institute, University Hospital Galway, National University of Ireland, Galway, Ireland
| | - Jasjit S Suri
- Stroke Diagnosis and Monitoring Division, AtheroPointTM, Roseville, United States
| | - Clark J Zeebregts
- Division of Vascular Surgery, Department of Surgery, University Medical Center Groningen, University of Groningen, Groningen, the Netherland
| | - Seemant Chaturvedi
- Department of Neurology and Stroke Program, University of Maryland School of Medicine, Baltimore, MD, United States
| |
Collapse
|
13
|
Paraskevas KI, Mikhailidis DP, Baradaran H, Davies AH, Eckstein HH, Faggioli G, Fernandes E Fernandes J, Gupta A, Jezovnik MK, Kakkos SK, Katsiki N, Kooi ME, Lanza G, Liapis CD, Loftus IM, Millon A, Nicolaides AN, Poredos P, Pini R, Ricco JB, Rundek T, Saba L, Spinelli F, Stilo F, Sultan S, Zeebregts CJ, Chaturvedi S. Management of patients with asymptomatic carotid stenosis may need to be individualized: a multidisciplinary call for action. Republication of J Stroke 2021;23:202-212. INT ANGIOL 2021; 40:487-496. [PMID: 34313413 DOI: 10.23736/s0392-9590.21.04751-9] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
The optimal management of patients with asymptomatic carotid stenosis (ACS) is the subject of extensive debate. According to the 2017 European Society for Vascular Surgery guidelines, carotid endarterectomy should (Class IIa; Level of Evidence: B) or carotid artery stenting may be considered (Class IIb; Level of Evidence: B) in the presence of one or more clinical/imaging characteristics that may be associated with an increased risk of late ipsilateral stroke (e.g. silent embolic infarcts on brain computed tomography/magnetic resonance imaging, progression in the severity of ACS, a history of contralateral transient ischemic attack/stroke, microemboli detection on transcranial Doppler, etc.), provided documented perioperative stroke/death rates are <3% and the patient's life expectancy is >5 years. Besides these clinical/imaging characteristics, there are additional individual, ethnic/racial or social factors that should probably be evaluated in the decision process regarding the optimal management of these patients, such as individual patient needs/patient choice, patient compliance with best medical treatment, patient sex, culture, race/ethnicity, age and comorbidities, as well as improvements in imaging/operative techniques/outcomes. The present multispecialty position paper will present the rationale why the management of patients with ACS may need to be individualized.
Collapse
Affiliation(s)
| | - Dimitri P Mikhailidis
- Department of Clinical Biochemistry, Royal Free Hospital Campus, University College London Medical School, University College London (UCL), London, UK
| | - Hediyeh Baradaran
- Department of Radiology, University of Utah, Salt Lake City, UT, USA
| | - Alun H Davies
- Section of Vascular Surgery, Imperial College & Imperial Healthcare NHS Trust, London, UK
| | - Hans-Henning Eckstein
- Department of Vascular and Endovascular Surgery, Klinikum rechts der Isar, Technical University of Munich, Munich, Germany
| | - Gianluca Faggioli
- Vascular Surgery, University of Bologna Alma Mater Studiorum, Policlinico S. Orsola Malpighi, Bologna, Italy
| | | | - Ajay Gupta
- Department of Radiology, Weill Cornell Medicine, New York, NY, USA
| | - Mateja K Jezovnik
- Department of Advanced Cardiopulmonary Therapies and Transplantation, The University of Texas Health Science Centre at Houston, Houston, TX, USA
| | - Stavros K Kakkos
- Department of Vascular Surgery, University of Patras Medical School, Patras, Greece
| | - Niki Katsiki
- First Department of Internal Medicine, AHEPA University Hospital, Thessaloniki, Greece
| | - M Eline Kooi
- CARIM School for Cardiovascular Diseases, Maastricht University, Maastricht, The Netherlands.,Department of Radiology and Nuclear Medicine, Maastricht University Medical Center, Maastricht, The Netherlands
| | - Gaetano Lanza
- Vascular Surgery Department, IRCSS MultiMedica Hospital, Castellanza, Varese, Italy
| | | | - Ian M Loftus
- St. George's Vascular Institute, St. George's University London, London, UK
| | - Antoine Millon
- Department of Vascular and Endovascular Surgery, Louis Pradel Hospital, Hospices Civils de Lyon, Lyon, France
| | - Andrew N Nicolaides
- Department of Surgery, University of Nicosia Medical School, Nicosia, Cyprus
| | - Pavel Poredos
- Department of Vascular Disease, University Medical Centre Ljubljana, Ljubljana, Slovenia
| | - Rodolfo Pini
- Vascular Surgery, University of Bologna Alma Mater Studiorum, Policlinico S. Orsola Malpighi, Bologna, Italy
| | - Jean-Baptiste Ricco
- Department of Clinical Research, University of Poitiers, CHU de Poitiers, Poitiers, France
| | - Tatjana Rundek
- Department of Neurology, Miller School of Medicine, University of Miami, Miami, FL, USA
| | - Luca Saba
- Department of Radiology, Azienda Ospedaliera Universitaria di Cagliari, Cagliari, Italy
| | - Francesco Spinelli
- Vascular Surgery Division, Campus Bio-Medico University of Rome, Rome, Italy
| | - Francesco Stilo
- Vascular Surgery Division, Campus Bio-Medico University of Rome, Rome, Italy
| | - Sherif Sultan
- Western Vascular Institute, Department of Vascular and Endovascular Surgery, University Hospital Galway, National University of Ireland, Galway, Ireland
| | - Clark J Zeebregts
- Division of Vascular Surgery, Department of Surgery, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Seemant Chaturvedi
- Department of Neurology & Stroke Program, University of Maryland School of Medicine, Baltimore, MD, USA
| |
Collapse
|
14
|
Paraskevas KI, Mikhailidis DP, Baradaran H, Davies AH, Eckstein HH, Faggioli G, Fernandes JFE, Gupta A, Jezovnik MK, Kakkos SK, Katsiki N, Kooi ME, Lanza G, Liapis CD, Loftus IM, Millon A, Nicolaides AN, Poredos P, Pini R, Ricco JB, Rundek T, Saba L, Spinelli F, Stilo F, Sultan S, Zeebregts CJ, Chaturvedi S. Management of Patients with Asymptomatic Carotid Stenosis May Need to Be Individualized: A Multidisciplinary Call for Action. J Stroke 2021; 23:202-212. [PMID: 34102755 PMCID: PMC8189852 DOI: 10.5853/jos.2020.04273] [Citation(s) in RCA: 20] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2020] [Accepted: 04/12/2021] [Indexed: 12/15/2022] Open
Abstract
The optimal management of patients with asymptomatic carotid stenosis (ACS) is the subject of extensive debate. According to the 2017 European Society for Vascular Surgery guidelines, carotid endarterectomy should (Class IIa; Level of Evidence: B) or carotid artery stenting may be considered (Class IIb; Level of Evidence: B) in the presence of one or more clinical/imaging characteristics that may be associated with an increased risk of late ipsilateral stroke (e.g., silent embolic infarcts on brain computed tomography/magnetic resonance imaging, progression in the severity of ACS, a history of contralateral transient ischemic attack/stroke, microemboli detection on transcranial Doppler, etc.), provided documented perioperative stroke/death rates are <3% and the patient’s life expectancy is >5 years. Besides these clinical/imaging characteristics, there are additional individual, ethnic/racial or social factors that should probably be evaluated in the decision process regarding the optimal management of these patients, such as individual patient needs/patient choice, patient compliance with best medical treatment, patient sex, culture, race/ethnicity, age and comorbidities, as well as improvements in imaging/operative techniques/outcomes. The present multispecialty position paper will present the rationale why the management of patients with ACS may need to be individualized.
Collapse
Affiliation(s)
| | - Dimitri P Mikhailidis
- Department of Clinical Biochemistry, Royal Free Hospital Campus, University College London Medical School, University College London (UCL), London, UK
| | - Hediyeh Baradaran
- Department of Radiology, University of Utah, Salt Lake City, UT, USA
| | - Alun H Davies
- Section of Vascular Surgery, Imperial College & Imperial Healthcare NHS Trust, London, UK
| | - Hans-Henning Eckstein
- Department of Vascular and Endovascular Surgery, Klinikum rechts der Isar, Technical University of Munich, Munich, Germany
| | - Gianluca Faggioli
- Vascular Surgery, University of Bologna "Alma Mater Studiorum", Policlinico S. Orsola Malpighi, Bologna, Italy
| | | | - Ajay Gupta
- Department of Radiology, Weill Cornell Medicine, New York, NY, USA
| | - Mateja K Jezovnik
- Department of Advanced Cardiopulmonary Therapies and Transplantation, The University of Texas Health Science Centre at Houston, Houston, TX, USA
| | - Stavros K Kakkos
- Department of Vascular Surgery, University of Patras Medical School, Patras, Greece
| | - Niki Katsiki
- First Department of Internal Medicine, AHEPA University Hospital, Thessaloniki, Greece
| | - M Eline Kooi
- CARIM School for Cardiovascular Diseases, Maastricht University, Maastricht, The Netherlands.,Department of Radiology and Nuclear Medicine, Maastricht University Medical Center, Maastricht, The Netherlands
| | - Gaetano Lanza
- Vascular Surgery Department, IRCSS MultiMedica Hospital, Castellanza, Italy
| | | | - Ian M Loftus
- St. George's Vascular Institute, St. George's University London, London, UK
| | - Antoine Millon
- Department of Vascular and Endovascular Surgery, Louis Pradel Hospital, Hospices Civils de Lyon, France
| | - Andrew N Nicolaides
- Department of Surgery, University of Nicosia Medical School, Nicosia, Cyprus
| | - Pavel Poredos
- Department of Vascular Disease, University Medical Centre Ljubljana, Slovenia
| | - Rodolfo Pini
- Vascular Surgery, University of Bologna "Alma Mater Studiorum", Policlinico S. Orsola Malpighi, Bologna, Italy
| | - Jean-Baptiste Ricco
- Department of Clinical Research, University of Poitiers, CHU de Poitiers, Poitiers, France
| | - Tatjana Rundek
- Department of Neurology, Miller School of Medicine, University of Miami, Miami, FL, USA
| | - Luca Saba
- Department of Radiology, Azienda Ospedaliera Universitaria Di Cagliari, Cagliari, Italy
| | - Francesco Spinelli
- Vascular Surgery Division, Campus Bio-Medico University of Rome, Rome, Italy
| | - Francesco Stilo
- Vascular Surgery Division, Campus Bio-Medico University of Rome, Rome, Italy
| | - Sherif Sultan
- Western Vascular Institute, Department of Vascular and Endovascular Surgery, University Hospital Galway, National University of Ireland, Galway, Ireland
| | - Clark J Zeebregts
- Division of Vascular Surgery, Department of Surgery, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Seemant Chaturvedi
- Department of Neurology & Stroke Program, University of Maryland School of Medicine, Baltimore, MD, USA
| |
Collapse
|
15
|
Seabra J, Pedro LM, Fernandes E Fernandes J, Sanches J. Ultrasonographic characterization and identification of symptomatic carotid plaques. Annu Int Conf IEEE Eng Med Biol Soc 2011; 2010:6110-3. [PMID: 21097136 DOI: 10.1109/iembs.2010.5627811] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Carotid plaques are the main cause of neurological symptoms due to distal embolization or flow reduction. An objective classification of such lesions into symptomatic or asymptomatic is crucial for optimal treatment planning.
Collapse
Affiliation(s)
- Jose Seabra
- Institute for Systems and Robotics, Technical Superior Institute, Av. Rovisco Pais, 1049-001 Lisbon, Portugal.
| | | | | | | |
Collapse
|