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Kirchhoff F, Knappich C, Kallmayer M, Bohmann B, Lohe V, Tsantilas P, Naher S, Eckstein HH, Kühnl A. Determinants of prehospital and in-hospital delay in patients with symptomatic carotid stenosis and their influence on the outcome after elective carotid endarterectomy. Stroke Vasc Neurol 2025; 10:e003098. [PMID: 38969509 DOI: 10.1136/svn-2024-003098] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2024] [Accepted: 05/13/2024] [Indexed: 07/07/2024] Open
Abstract
BACKGROUND This study analyses the determinants of prehospital (index event to admission) and in-hospital delay (admission to carotid endarterectomy (CEA)). In addition, the analysis addresses the association between prehospital or in-hospital delay and outcomes after CEA for symptomatic patients in German hospitals. MATERIALS AND METHODS This retrospective analysis is based on the nationwide German statutory quality assurance database. 55 437 patients were included in the analysis. Prehospital delay was grouped as follows: 180-15, 14-8, 7-3, 2-0 days or 'in-hospital index event'. In-hospital delay was divided into: 0-1, 2-3 and >3 days. The primary outcome event (POE) was in-hospital stroke or death. Univariate and multivariable regression analyses were performed for statistical analysis. The slope of the linear regression line is given as the β-value, and the rate parameter of the logistic regression is given as the adjusted OR (aOR). RESULTS Prehospital delay was 0-2 days in 34.9%, 3-14 days in 29.5% and >14 days in 18.6%. Higher age (β=-1.08, p<0.001) and a more severe index event (transitory ischaemic attack: β=-4.41, p<0.001; stroke: β=-6.05, p<0.001, Ref: amaurosis fugax) were determinants of shorter prehospital delay. Higher age (β=0.28, p<0.001) and female sex (β=0.09, p=0.014) were associated with a longer in-hospital delay. Index event after admission (aOR 1.23, 95% CI: 1.04 to 1.47) and an intermediate in-hospital delay of 2-3 days (aOR 1.15, 95% CI: 1.00 to 1.33) were associated with an increased POE risk. CONCLUSIONS This study revealed that older age, higher American Society of Anesthesiology (ASA) stage, increasing severity of symptoms and ipsilateral moderate stenosis were associated with shorter prehospital delay. Non-specific symptoms were associated with a longer prehospital delay. Regarding in-hospital delay, older age, higher ASA stage, contralateral occlusion, preprocedural examination by a neurologist and admission on Fridays or Saturdays were associated with lagged treatment. A very short (<2 days) prehospital and intermediate in-hospital delay (2-3 days) were associated with increased risk of perioperative stroke or death.
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Affiliation(s)
- Felix Kirchhoff
- Clinic and Policlinic for Vascular and Endovascular Surgery, Hospital Rechts der Isar, Technical University of Munich, Munich, Germany
| | - Christoph Knappich
- Clinic and Policlinic for Vascular and Endovascular Surgery, Hospital Rechts der Isar, Technical University of Munich, Munich, Germany
| | - Michael Kallmayer
- Clinic and Policlinic for Vascular and Endovascular Surgery, Hospital Rechts der Isar, Technical University of Munich, Munich, Germany
| | - Bianca Bohmann
- Clinic and Policlinic for Vascular and Endovascular Surgery, Hospital Rechts der Isar, Technical University of Munich, Munich, Germany
| | - Vanessa Lohe
- Clinic and Policlinic for Vascular and Endovascular Surgery, Hospital Rechts der Isar, Technical University of Munich, Munich, Germany
| | | | - Shamsun Naher
- Clinic and Policlinic for Vascular and Endovascular Surgery, Hospital Rechts der Isar, Technical University of Munich, Munich, Germany
| | - Hans-Henning Eckstein
- Clinic and Policlinic for Vascular and Endovascular Surgery, Hospital Rechts der Isar, Technical University of Munich, Munich, Germany
| | - Andreas Kühnl
- Clinic and Policlinic for Vascular and Endovascular Surgery, Hospital Rechts der Isar, Technical University of Munich, Munich, Germany
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Ding J, Maldonado TS. Timing of Intervention in Symptomatic Carotid Artery Stenosis. Ann Vasc Surg 2025; 113:305-310. [PMID: 39349240 DOI: 10.1016/j.avsg.2024.09.041] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2024] [Revised: 09/05/2024] [Accepted: 09/17/2024] [Indexed: 10/02/2024]
Abstract
Symptomatic carotid artery stenosis is defined as an acute neurologic deficit (transient ischemic attack or stroke) occurring in the last 6 months, that is, ipsilateral to an extracranial carotid artery with at least 50% stenosis. Previous studies have identified the benefit of surgical intervention on symptomatic carotid stenosis, but the ideal timing is less clear. The timing of intervention must balance the risk of perioperative stroke and death (higher during the hyperacute period within 48 hr) and the risk of recurrent stroke while waiting to intervene, particularly if delayed beyond 14 days. Several factors such as acuity of neurologic deficit, degree of stenosis, or contralateral occlusion, and other comorbidities, may contribute to the risk of perioperative stroke or death when intervening within the acute period. The Society for Vascular Surgery recommends carotid endarterectomy as the intervention for symptomatic carotid artery stenosis, but recent studies have shown that transcarotid revascularization may also have similar outcomes.
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Affiliation(s)
- Jessica Ding
- NYU Langone Health Division of Vascular and Endovascular Surgery, New York, NY
| | - Thomas S Maldonado
- NYU Langone Health Division of Vascular and Endovascular Surgery, New York, NY.
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Strömberg S, Holsti M, Persson SE, Nordanstig A, Nordanstig J, Johansson E. Two or More Ischaemic Events Within Seven Days Before Carotid Endarterectomy Increases the Risk of Peri-operative Stroke or Death. Eur J Vasc Endovasc Surg 2024; 68:704-711. [PMID: 39134138 DOI: 10.1016/j.ejvs.2024.08.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2023] [Revised: 07/17/2024] [Accepted: 08/07/2024] [Indexed: 09/09/2024]
Abstract
OBJECTIVE The aim of this study was to determine how many pre-operative ischaemic events occurring within a specific timeframe before carotid endarterectomy (CEA) are needed to increase the peri-operative 30 day risk of stroke or death. METHODS This was a secondary exploratory analysis based on pooled data from three observational studies sourced from a single centre. Patients with recently symptomatic conventional ≥ 50% carotid stenosis were included. The principal analysis was limited to patients presenting with stroke or transient ischaemic attack (TIA). The primary outcome was 30 day risk of peri-operative stroke or death. Whether one, two, three, or four or more ipsilateral pre-operative ischaemic events within three, seven, 14, or 30 days before CEA were associated with the primary outcome was assessed. RESULTS The study included 382 patients who underwent CEA with symptomatic conventional ≥ 50% carotid stenosis with stroke or TIA as the presenting event. Mean patient age ± standard deviation was 72 ± 7 years, 117 (30.6%) were female, and 5% were treated with dual antiplatelet therapy. The primary outcome occurred in 21 patients (5.5%). Two or more events within 7 days before CEA was the most discriminative definition of repeated events, with a 14.3% (8/56) risk of the primary outcome. Those who fell outside this definition of two or more events within seven days before CEA had a 4.0% (13/326; p = .006) risk of experiencing the primary outcome (adjusted odds ratio 4.1, 95% confidence interval 1.6 - 10.5). Several alternative definitions were assessed, but patients with two or more events within seven days before CEA and negative for these alternatives still had a > 10% risk of the primary outcome. CONCLUSION Two or more ipsilateral ischaemic events within seven days before CEA is associated with an increased risk of peri-operative stroke or death in cases with symptomatic conventional ≥ 50% carotid stenosis and TIA or stroke as the presenting event. Studies assessing whether delayed or immediate CEA is preferable for this patient group are warranted.
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Affiliation(s)
- Sofia Strömberg
- Department of Molecular and Clinical Medicine, Institute of Medicine, The Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Mari Holsti
- Department of Surgical and Peri-operative Sciences, Umeå University, Umeå, Sweden
| | - Sven-Erik Persson
- Department of Surgical and Peri-operative Sciences, Umeå University, Umeå, Sweden
| | - Annika Nordanstig
- Institute of Neuroscience and Physiology, The Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Joakim Nordanstig
- Department of Molecular and Clinical Medicine, Institute of Medicine, The Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Elias Johansson
- Institute of Neuroscience and Physiology, The Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden; Department of Clinical Sciences, Umeå University, Umeå, Sweden; Wallenberg Centre for Molecular Medicine, Umeå University, Umeå, Sweden.
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Mazzolai L, Teixido-Tura G, Lanzi S, Boc V, Bossone E, Brodmann M, Bura-Rivière A, De Backer J, Deglise S, Della Corte A, Heiss C, Kałużna-Oleksy M, Kurpas D, McEniery CM, Mirault T, Pasquet AA, Pitcher A, Schaubroeck HAI, Schlager O, Sirnes PA, Sprynger MG, Stabile E, Steinbach F, Thielmann M, van Kimmenade RRJ, Venermo M, Rodriguez-Palomares JF. 2024 ESC Guidelines for the management of peripheral arterial and aortic diseases. Eur Heart J 2024; 45:3538-3700. [PMID: 39210722 DOI: 10.1093/eurheartj/ehae179] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 09/04/2024] Open
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Farah M, Moghaddam M, Zarrintan S, Willie-Permor D, Schermerhorn M, Malas M. The effect of controlled vs uncontrolled hypertension on outcomes of carotid revascularization procedures. J Vasc Surg 2024; 80:765-773. [PMID: 38763456 DOI: 10.1016/j.jvs.2024.05.021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2024] [Revised: 05/08/2024] [Accepted: 05/10/2024] [Indexed: 05/21/2024]
Abstract
BACKGROUND Hypertension (HTN) has been implicated as a strong predictive factor for poorer outcomes in patients undergoing various vascular procedures. However, limited research is available that examines the effect of uncontrolled HTN (uHTN) on outcomes after carotid revascularization. We aimed to determine which carotid revascularization procedure yields the best outcome in this patient population. METHODS We studied patients undergoing carotid endarterectomy (CEA), transfemoral carotid artery stenting (TFCAS), or transcarotid artery revascularization (TCAR) from April 2020 to June 2022 using data from the Vascular Quality Initiative. Patients were stratified into two groups: those with cHTN and those with uHTN. Patients with cHTN were those with HTN treated with medication and a blood pressure of <130/80 mm Hg. Patients with uHTN had a blood pressure of ≥130/80 mm Hg. Our primary outcomes were in-hospital stroke, death, myocardial infarction (MI), and 30-day mortality. Our secondary outcomes were postoperative hypotension or HTN, reperfusion syndrome, prolonged length of stay (LOS) (>1 day), stroke/death, and stroke/death/MI. We used logistic regression models for the multivariate analysis. RESULTS A total of 34,653 CEA (uHTN, 11,347 [32.7%]), 8199 TFCAS (uHTN, 2307 [28.1%]), and 17,309 TCAR (uHTN, 4990 [28.8%]) patients were included in this study. There was no significant difference in age between patients with cHTN and patients with uHTN for each carotid revascularization procedure. However, compared with patients with cHTN, patients with uHTN had significantly more comorbidities. uHTN was associated with an increased risk of combined in-hospital stroke/death/MI after CEA (adjusted odds ratio [aOR], 1.56; 95% confidence interval [CI], 1.30-1.87; P < .001), TFCAS (aOR, 1.59; 95% CI, 1.21-2.08; P < .001), and TCAR (aOR, 1.39; 95% CI, 1.12-1.73; P = .003) compared with cHTN. Additionally, uHTN was associated with a prolonged LOS after all carotid revascularization methods. For the subanalysis of patients with uHTN, TFCAS was associated with an increased risk of stroke (aOR, 1.82; 95% CI, 1.39-2.37; P < .001), in-hospital death (aOR, 3.73; 95% CI, 2.25-6.19; P < .001), reperfusion syndrome (aOR, 6.24; 95% CI, 3.57-10.93; P < .001), and extended LOS (aOR, 1.87; 95% CI, 1.51-2.32; P < .001) compared with CEA. There was no statistically significant difference between the outcomes of TCAR compared with CEA. CONCLUSIONS The results from this study show that patients with uHTN are at a higher risk of stroke and death postoperatively compared with patients with cHTN, highlighting the importance of treating HTN before undergoing elective carotid revascularization. Additionally, in patients with uHTN, TFCAS yields the worst outcomes, whereas CEA and TCAR proved to be safer interventions. Patients with uTHN with symptomatic carotid disease treated with CEA or TCAR have better outcomes compared with those treated with TFCAS.
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Affiliation(s)
- Marc Farah
- Georgetown University School of Medicine, Washington, DC
| | - Marjan Moghaddam
- Center for Learning and Excellence in Vascular and Endovascular Surgery (CLEVER), Department of Surgery, Division of Vascular and Endovascular Surgery, University of California San Diego Health System, San Diego, MA
| | - Sina Zarrintan
- Center for Learning and Excellence in Vascular and Endovascular Surgery (CLEVER), Department of Surgery, Division of Vascular and Endovascular Surgery, University of California San Diego Health System, San Diego, MA
| | - Daniel Willie-Permor
- Center for Learning and Excellence in Vascular and Endovascular Surgery (CLEVER), Department of Surgery, Division of Vascular and Endovascular Surgery, University of California San Diego Health System, San Diego, MA
| | - Marc Schermerhorn
- Department of Surgery, Division of Vascular and Endovascular Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, CA
| | - Mahmoud Malas
- Center for Learning and Excellence in Vascular and Endovascular Surgery (CLEVER), Department of Surgery, Division of Vascular and Endovascular Surgery, University of California San Diego Health System, San Diego, MA.
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Solomon Y, Conroy PD, Rastogi V, Yadavalli SD, Schneider PA, Wang GJ, Malas MB, de Borst GJ, Schermerhorn ML. Outcomes following carotid revascularization for stroke stratified by Modified Rankin Scale and time of intervention. J Vasc Surg 2024; 79:287-296.e1. [PMID: 38179993 DOI: 10.1016/j.jvs.2023.10.041] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2023] [Revised: 10/12/2023] [Accepted: 10/13/2023] [Indexed: 01/06/2024]
Abstract
OBJECTIVES The relationship between baseline Modified Rankin Scale (mRS) in patients with prior stroke and optimal timing of carotid revascularization is unclear. Therefore, we evaluated the timing of transfemoral carotid artery stenting (tfCAS), transcarotid artery revascularization (TCAR), and carotid endarterectomy (CEA) after prior stroke, stratified by preoperative mRS. METHODS We identified patients with recent stroke who underwent tfCAS, TCAR, or CEA between 2012 and 2021. Patients were stratified by preoperative mRS (0-1, 2, 3-4, or 5) and days from symptom onset to intervention (time to intervention; ≤2 days, 3-14 days, 15-90 days, and 91-180 days). First, we performed univariate analyses comparing in-hospital outcomes between separate mRS or time-to-intervention cohorts for all carotid intervention methods. Afterward, multivariable logistic regression was used to adjust for demographics and comorbidities across groups, and outcomes between the various intervention methods were compared. Primary outcome was the in-hospital stroke/death rate. RESULTS We identified 4260 patients who underwent tfCAS, 3130 patients who underwent TCAR, and 20,012 patients who underwent CEA. Patients were most likely to have minimal disability (mRS, 0-1 [61%]) and least likely to have severe disability (mRS, 5 [1.5%]). Patients most often underwent revascularization in 3 to 14 days (45%). Across all intervention methods, increasing preoperative mRS was associated with higher procedural in-hospital stroke/death (all P < .03), whereas increasing time to intervention was associated with lower stroke/death rates (all P < .01). After adjustment for demographics and comorbidities, undergoing tfCAS was associated with higher stroke/death compared with undergoing CEA (adjusted odds ratio, 1.6; 95% confidence interval, 1.3-1.9; P < .01) or undergoing TCAR (adjusted odds ratio, 1.3; 95% confidence interval, 1.0-1.8; P = .03). CONCLUSIONS In patients with preoperative stroke, optimal timing for carotid revascularization varies with stroke severity. Increasing preoperative mRS was associated with higher procedural in-hospital stroke/death rates, whereas increasing time to-intervention was associated with lower stroke/death rates. Overall, patients undergoing CEA were associated with lower in-hospital stroke/deaths. To determine benefit for delayed intervention, these results should be weighed against the risk of recurrent stroke during the interval before intervention.
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Affiliation(s)
- Yoel Solomon
- Department of Surgery, Division of Vascular and Endovascular Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA; Department of Vascular Surgery, University Medical Center, Utrecht, the Netherlands
| | - Patrick D Conroy
- Department of Surgery, Division of Vascular and Endovascular Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA
| | - Vinamr Rastogi
- Department of Surgery, Division of Vascular and Endovascular Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA
| | - Sai Divya Yadavalli
- Department of Surgery, Division of Vascular and Endovascular Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA
| | - Peter A Schneider
- Division of Vascular and Endovascular Surgery, University of California San Francisco, San Francisco, CA
| | - Grace J Wang
- Division of Vascular Surgery and Endovascular Therapy, Department of Surgery, Hospital of the University of Pennsylvania, Philadelphia, PA
| | - Mahmoud B Malas
- Division of Vascular and Endovascular Surgery, Department of Surgery, University of California San Diego Health System, San Diego, CA
| | - Gert J de Borst
- Department of Vascular Surgery, University Medical Center, Utrecht, the Netherlands
| | - Marc L Schermerhorn
- Department of Surgery, Division of Vascular and Endovascular Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA.
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Marcaccio CL, AbuRahma AF, Eldrup-Jorgensen J, Brooke BS, Schermerhorn ML. Vascular Quality Initiative assessment of compliance with Society for Vascular Surgery clinical practice guidelines on the management of extracranial cerebrovascular disease. J Vasc Surg 2023; 78:111-121.e2. [PMID: 36948279 DOI: 10.1016/j.jvs.2023.03.026] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2023] [Revised: 02/28/2023] [Accepted: 03/07/2023] [Indexed: 03/24/2023]
Abstract
OBJECTIVES Compliance with Society for Vascular Surgery (SVS) clinical practice guidelines (CPGs) is associated with improved outcomes for the treatment of abdominal aortic aneurysm, but this has not been assessed for carotid artery disease. The Vascular Quality Initiative (VQI) registry was used to examine compliance with the SVS CPGs for the management of extracranial cerebrovascular disease and its impact on outcomes. METHODS The 2021 SVS extracranial cerebrovascular disease CPGs were reviewed for evaluation by VQI data. Compliance rates by the center and provider were calculated, and the impact of compliance on outcomes was assessed using logistic regression with inverse probability-weighted risk adjustment for each CPG recommendation, allowing for clustering by the center. Our primary outcome was a composite end point of in-hospital stroke/death. As a secondary analysis, compliance with the 2021 SVS carotid implementation document recommendations and associated outcomes were also assessed. RESULTS Of the 11 carotid CPG recommendations, 4 (36%) could be evaluated using VQI registry data. Median center-specific CPG compliance ranged from 38% to 95%, and median provider-specific compliance ranged from 36% to 100%. After adjustment, compliance with 2 of the recommendations was associated with lower rates of in-hospital stroke/death: first, the use of best medical therapy (antiplatelet and statin therapy) in low/standard surgical risk patients undergoing carotid endarterectomy for >70% asymptomatic stenosis (event rate in compliant vs noncompliant cases 0.59% vs 1.3%; adjusted odds ratio: 0.44, 95% confidence interval: 0.29-0.66); and second, carotid endarterectomy over transfemoral carotid artery stenting in low/standard surgical risk patients with >50% symptomatic stenosis (1.9% vs 3.4%; adjusted odds ratio: 0.55, 95% confidence interval: 0.43-0.71). Of the 132 implementation document recommendations, only 10 (7.6%) could be assessed using VQI data, with median center- and provider-specific compliance rates ranging from 67% to 100%. The impact of compliance on outcomes could only be assessed for 6 (4.5%) of these recommendations, and compliance with all 6 recommendations was associated with lower stroke/death. CONCLUSIONS Few SVS recommendations could be assessed in the VQI because of incongruity between the recommendations and the VQI data variables collected. Although guideline compliance was extremely variable among VQI centers and providers, compliance with most of these recommendations was associated with improved outcomes after carotid revascularization. This finding confirms the value of guideline compliance, which should be encouraged for centers and providers. Optimization of VQI data to promote evaluation of guideline compliance and distribution of these findings to VQI centers and providers will help facilitate quality improvement efforts in the care of vascular patients.
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Affiliation(s)
- Christina L Marcaccio
- 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, West Virginia University-Charleston Division, Charleston, WV
| | - Jens Eldrup-Jorgensen
- Department of Surgery, Division of Vascular Surgery, Maine Medical Center, Portland, ME
| | - Benjamin S Brooke
- Department of Surgery, Division of Vascular Surgery, University of Utah, School of Medicine, Salt Lake City, UT
| | - Marc L Schermerhorn
- Department of Surgery, Division of Vascular and Endovascular Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA.
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De Blasis S, Pulli R, Di Domenico R, Nesi M, Nencini P, Fargion AT, Pratesi C, Dorigo W. Elective or Urgent Carotid Endarterectomy in Symptomatic Patients: Analysis Based on the Type and Timing of Neurological Symptoms. Ann Vasc Surg 2023; 90:7-16. [PMID: 36503019 DOI: 10.1016/j.avsg.2022.10.023] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2022] [Revised: 09/23/2022] [Accepted: 10/23/2022] [Indexed: 12/13/2022]
Abstract
BACKGROUND The aim of this study was to retrospectively analyse perioperative and long-term outcomes of carotid endarterectomy (CEA) performed in symptomatic patients in a high-volume academic vascular centre, stratifying them according to the type of preoperative symptoms and the timing of surgery with respect to the indexed neurological event. METHODS From January 2014 to December 2020, 1,369 consecutive CEAs were performed at our institution. Data concerning these interventions were prospectively collected in a dedicated database including data concerning preoperative assessment, surgical details, perioperative (<30 days) outcomes, and long-term outcomes. A retrospective analysis of the database was performed, and 213 interventions performed in symptomatic patients were found. We identified 2 subgroups of patients: patients with stable neurological symptoms (not recent transient ischemic attack (TIA) or stable major disabling stroke, stable group, and 157 patients) and patients with unstable neurological symptoms (recent TIA, crescendo TIAs, stroke in evolution, acute/recent minor stroke, unstable group, and 56 patients). Perioperative outcomes were analysed in terms of mortality, major neurological events, and local or systemic complications The results were compared using the χ2 test; these were also analysed on the basis of the presenting symptom (isolated TIA, crescendo TIA, stroke in evolution, acute/recent minor stroke, stabilized stroke) and the timing of the intervention relative to the onset of the symptom. Long term results were analysed using the life-table analysis and Kaplan-Meier curves in terms of survival, stroke-free survival, absence of neurological symptoms, and absence of significant restenosis. RESULTS Overall, 30-day stroke and death rate were 4.2%. (3.1% vs. 7%, P = 0.2). Two deaths occurred at 30 days, both in the stable group (mortality 1.2%, P = 0.4 compared to the unstable group), but no fatal strokes were recorded in the overall sample. No differences were found in terms of new perioperative neurological events and local complications between the 2 groups. We found a trend toward poorer perioperative results in patients operated on within 48 hr from the indexed event and in patients operated on for stroke in evolution or acute/recent stroke, whereas we found a trend toward better results in favour of patients operated on between 8 and 14 days (P = 0.08). The median duration of follow-up was 24.8 months (range 1-78); at 5 years we did not find significant differences in terms of survival and stroke-free survival rates between 2 groups. CONCLUSIONS In our experience, carotid surgery in symptomatic patients provided satisfactory results, particularly in patients with stable neurological status. Among unstable patients, the rate of complications significantly increases, mainly among treated in the very early (<48 hr) period for stroke in evolution or acute/recent stroke. Once the perioperative risk is overcome, the results in the long-term setting are similarly good, both in stable and in unstable patients.
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Affiliation(s)
- Serena De Blasis
- Department of Vascular Surgery, Careggi University Hospital, Florence, Italy.
| | - Raffaele Pulli
- Department of Vascular Surgery, Careggi University Hospital, Florence, Italy
| | | | - Mascia Nesi
- Stroke Unit, Careggi University Hospital, Florence, Italy
| | | | | | - Carlo Pratesi
- Department of Vascular Surgery, Careggi University Hospital, Florence, Italy
| | - Walter Dorigo
- Department of Vascular Surgery, Careggi University Hospital, Florence, Italy
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Solomon Y, Marcaccio CL, Rastogi V, Lu JJ, Malas MB, Wang GJ, Schneider PA, de Borst GJ, Schermerhorn ML. In-hospital outcomes after carotid endarterectomy for stroke stratified by modified Rankin scale score and time of intervention. J Vasc Surg 2023; 77:529-537.e1. [PMID: 36395901 DOI: 10.1016/j.jvs.2022.09.018] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2022] [Revised: 09/09/2022] [Accepted: 09/19/2022] [Indexed: 11/16/2022]
Abstract
OBJECTIVE Although the benefits of carotid endarterectomy (CEA) for treating symptomatic carotid stenosis are well known, the optimal timing of intervention after acute stroke and whether the optimal timing will vary with preoperative stroke severity has remained unclear. Therefore, we assessed the effect of stroke severity and timing of the intervention on the postoperative outcomes for patients who had undergone CEA for stroke. METHODS We identified all patients in the Vascular Quality Initiative who had undergone CEA from 2012 to 2020 for prior stroke. The patients were stratified using the preoperative modified Rankin scale score (mRS score, 0-5) and time to CEA after stroke onset (≤2 days, 3-14 days, 15-90 days, 91-180 days). After univariate comparisons, the patients were stratified into the following mRS cohorts for further analysis: 0 to 1, 2, 3 to 4, and 5. The primary outcome was in-hospital stroke/death. RESULTS We identified 15,601 patients, of whom 30% had had an mRS score of 0, 34% an mRS score of 1, 17% an mRS score of 2, 11% an mRS score of 3, 8% an mRS score of 4, and 1% an mRS score of 5. Overall, 9.3% of the patients had undergone CEA within ≤2 days, 46% within 3 to 14 days, 36% in 15 to 90 days, and 8.4% within 90 to 180 days. A decreasing mRS score and an increasing time to CEA were associated with lower rates of perioperative stroke/death (Ptrend < .01). After risk adjustment, with CEA at 3 to 14 days as the comparator group, the mRS score 0 to 1 group had had a higher incidence of stroke/death after CEA within ≤2 days (3.6% vs 2.0%; odds ratio [OR], 1.8; 95% confidence interval [CI], 1.2-2.7). The mRS score 2 group had had a similar incidence of stroke/death after CEA within ≤2 days (4.4% vs 3.9%; OR, 1.2; 95% CI, 0.6-2.3) but a lower incidence after CEA at 15 to 90 days (2.1% vs 3.9%; OR 0.5; 95% CI, 0.3-0.96). The mRS score 3 to 4 group had had a higher incidence of stroke/death after CEA within ≤2 days (8.0% vs 3.8%; OR, 2.4; 95% CI, 1.5-3.9) but a similar incidence of stroke/death after CEA at 15 to 90 days (3.0% vs 3.8%; OR, 0.8; 95% CI, 0.5-1.3). For the mRS score 5 group, the stroke/death rates were ≥6.5% across all the time to CEA groups. However, the low sample size limited meaningful comparisons. CONCLUSIONS Patients with minimal disability after stroke (mRS score, 0-1) seemed to benefit from CEA within 3 to 14 days. However, those with severe disability (mRS score 5) have a very high risk from CEA at any time point given the poor outcomes. In contrast to the current guidelines, patients with mild disability (mRS score 2) could benefit from delaying CEA to 15 to 90 days, and those with moderate disability (mRS score 3-4) might benefit from CEA within 3 to 90 days given the acceptable in-hospital outcomes. These data should be considered within the context of the clinical situation in the weeks after index event to determine the net benefit of delayed CEA.
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Affiliation(s)
- Yoel Solomon
- Division of Vascular and Endovascular Surgery, Department of Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA; Department of Vascular Surgery, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Christina L Marcaccio
- Division of Vascular and Endovascular Surgery, Department of Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA
| | - Vinamr Rastogi
- Division of Vascular and Endovascular Surgery, Department of Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA
| | - Jinny J Lu
- Division of Vascular and Endovascular Surgery, Department of Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA
| | - Mahmoud B Malas
- Division of Vascular and Endovascular Surgery, Department of Surgery, University of California San Diego Health System, San Diego, CA
| | - Grace J Wang
- Division of Vascular Surgery and Endovascular Therapy, Department of Surgery, Hospital of the University of Pennsylvania, Philadelphia, PA
| | - Peter A Schneider
- Division of Vascular and Endovascular Surgery, University of California, San Francisco, San Francisco, CA
| | - Gert J de Borst
- Department of Vascular Surgery, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Marc L Schermerhorn
- Division of Vascular and Endovascular Surgery, Department of Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA.
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Naylor R, Rantner B, Ancetti S, de Borst GJ, De Carlo M, Halliday A, Kakkos SK, Markus HS, McCabe DJH, Sillesen H, van den Berg JC, Vega de Ceniga M, Venermo MA, Vermassen FEG, Esvs Guidelines Committee, Antoniou GA, Bastos Goncalves F, Bjorck M, Chakfe N, Coscas R, Dias NV, Dick F, Hinchliffe RJ, Kolh P, Koncar IB, Lindholt JS, Mees BME, Resch TA, Trimarchi S, Tulamo R, Twine CP, Wanhainen A, Document Reviewers, Bellmunt-Montoya S, Bulbulia R, Darling RC, Eckstein HH, Giannoukas A, Koelemay MJW, Lindström D, Schermerhorn M, Stone DH. Editor's Choice - European Society for Vascular Surgery (ESVS) 2023 Clinical Practice Guidelines on the Management of Atherosclerotic Carotid and Vertebral Artery Disease. Eur J Vasc Endovasc Surg 2023; 65:7-111. [PMID: 35598721 DOI: 10.1016/j.ejvs.2022.04.011] [Citation(s) in RCA: 355] [Impact Index Per Article: 177.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2022] [Accepted: 04/20/2022] [Indexed: 01/17/2023]
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11
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Marcaccio CL, Anjorin A, Patel PB, Rastogi V, Jones DW, Lo RC, Wyers MC, Schermerhorn ML. In-hospital outcomes after upper extremity versus transfemoral and transcarotid access for carotid stenting in the Vascular Quality Initiative. J Vasc Surg 2022; 76:1603-1614.e7. [PMID: 35840075 PMCID: PMC9691591 DOI: 10.1016/j.jvs.2022.05.030] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2022] [Revised: 05/13/2022] [Accepted: 05/23/2022] [Indexed: 10/17/2022]
Abstract
OBJECTIVE Carotid artery stenting (CAS) is frequently used for patients at high risk for carotid endarterectomy. However, there are limited data comparing transradial or transbrachial (tr/tbCAS) access with more established CAS approaches. Therefore, we examined the effect of a tr/tbCAS approach versus a transfemoral (tfCAS) or transcarotid (TCAR) approach on outcomes after CAS. METHODS We identified all patients undergoing CAS in the Vascular Quality Initiative registry from January 2016 to December 2021. We compared outcomes across 1:3 propensity score-matched cohorts of patients who underwent tr/tbCAS versus tfCAS or tr/tbCAS versus TCAR. As a secondary analysis, we assessed outcomes stratified by carotid symptom status. Our primary outcome was a composite end point of in-hospital stroke/death. RESULTS Among 40,835 CAS patients, 962 (2.4%) underwent tr/tbCAS, 18,840 (46%) underwent tfCAS, and 21,033 (52%) underwent TCAR. Among matched patients who underwent tr/tbCAS versus tfCAS, there was no significant difference in the risk of stroke/death (4.1% vs 2.9%; relative risk [RR] 1.4; 95% confidence interval [CI], 0.95-2.1), but tr/tbCAS was associated with a higher risk of death (2.4% vs 1.3%; RR, 1.8; 95% CI, 1.1-3.1). In the symptomatic subgroup, tr/tbCAS was associated with a higher risk of stroke/death (6.1% vs 3.9%; RR, 1.6; 95% CI, 1.0-2.4) and death (3.6% vs 1.7%; RR, 2.1; 95% CI, 1.2-3.7), but there were no differences in asymptomatic patients. After adjustment for mRS in patients with preoperative stroke, there were no significant differences in stroke/death (RR, 1.1; 95% CI, 0.66-1.9) or death (RR, 1.6; 95% CI, 0.81-3.3) between groups. In matched patients who underwent tr/tbCAS versus TCAR, tr/tbCAS was associated with a higher risk of stroke/death (4.2% vs 2.3%; RR, 1.8; 95% CI, 1.2-2.7) and death (2.4% vs 0.5%; RR, 4.8; 95% CI, 2.4-9.5). In the symptomatic subgroup, tr/tbCAS remained associated with a higher risk of stroke/death (6.2% vs 2.4%; RR, 2.6; 95% CI, 1.6-4.2) and death (3.7% vs 0.7%; RR, 5.6; 95% CI, 2.6-12), but there were no differences in asymptomatic patients. After adjustment for Modified Rankin Scale in patients with preoperative stroke, there were no significant differences in stroke/death (RR, 1.4; 95% CI, 0.79-2.6) or death (RR, 2.3; 95% CI, 0.95-5.7) between groups. CONCLUSIONS Compared with tfCAS or TCAR, tr/tbCAS was associated with a higher risk of in-hospital stroke/death in symptomatic patients, which was driven primarily by a higher risk of death. These inferior outcomes were partly attributable to more severe preoperative neurologic disability in tr/tbCAS patients. In contrast, there were no differences in outcomes in asymptomatic patients. Overall, our findings highlight the importance of guideline-directed patient selection in tr/tbCAS.
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Affiliation(s)
- Christina L Marcaccio
- Department of Surgery, Division of Vascular and Endovascular Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA
| | - Aderike Anjorin
- Department of Surgery, Division of Vascular and Endovascular Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA
| | - Priya B Patel
- Department of Surgery, Division of Vascular and Endovascular Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA
| | - Vinamr Rastogi
- Department of Surgery, Division of Vascular and Endovascular Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA; Department of Vascular Surgery, Erasmus University Medical Centre, Rotterdam, the Netherlands
| | - Douglas W Jones
- Division of Vascular and Endovascular Surgery, UMass Memorial Medical Center, University of Massachusetts Medical School Worcester, Worcester, MA
| | - Ruby C Lo
- Department of Surgery, Division of Vascular Surgery, Rhode Island Hospital, Alpert Medical School of Brown University, Providence, RI
| | - Mark C Wyers
- Department of Surgery, Division of Vascular and Endovascular Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA
| | - Marc L Schermerhorn
- Department of Surgery, Division of Vascular and Endovascular Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA.
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12
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Cui CL, Yei KS, Ramachandran M, Mwinyogle A, Malas MB. In-Hospital Complications and Long-Term Outcomes Associated with Timing of Carotid Endarterectomy. J Vasc Surg 2022; 76:222-231.e1. [PMID: 35276267 DOI: 10.1016/j.jvs.2022.02.040] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2021] [Accepted: 02/28/2022] [Indexed: 01/22/2023]
Abstract
OBJECTIVE To perform a comprehensive analysis of in-hospital and long-term outcomes of carotid endarterectomy (CEA) performed within different time intervals after most recent symptoms. INTRODUCTION Carotid revascularization performed within two weeks of symptoms has proven to reduce risk of recurrent stroke in patients with symptomatic carotid artery stenosis. However, the optimal timing of revascularization within the two-week window has yet to be determined. METHODS We analyzed 2003-2016 data from the Vascular Quality Initiative (VQI) Vascular Implant Surveillance and Interventional Outcomes Network (VISION). Only revascularizations performed for symptomatic carotid artery stenosis were included. Procedures were categorized as urgent (0-2 days from latest symptom), early (3-14 days) or late (15-180 days). The primary in-hospital outcome was stroke/death. The primary long-term outcomes of interest were 5-year recurrent ipsilateral stroke/death. Multivariable logistic regression, Kaplan-Meier analysis, and Cox-regression were utilized to compare outcomes. RESULTS A total of 18,970 revascularizations were included: 1,130 (6.0%) urgent, 4,643 (24.5%) early, and 13,197 (69.6%) late. Earlier CEA had increased odds of in-hospital stroke/death compared to late CEA [urgent, aOR:1.9, 95%CI:1.3-2.8, p=0.001], [early, aOR:1.7, 95%CI:1.3-2.2, p<0.001]. No differences were seen in 5-year risk of stroke/death [urgent, aHR:0.95, 95%CI:0.79-1.15, p=0.592], [early, aHR:0.97, 95%CI:0.87-1.07, p=0.928]. CONCLUSIONS Urgent and early CEA were associated with increased perioperative risk without difference in 5-year outcomes compared to late CEA. Short-term recurrent stroke prevention could not be assessed. Updated population-based studies comparing recurrent stroke prevention with urgent or early revascularization versus best medical management are warranted.
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Affiliation(s)
- Christina L Cui
- Division of Vascular and Endovascular Surgery, University of California San Diego, La Jolla, CA
| | - Kevin S Yei
- Division of Vascular and Endovascular Surgery, University of California San Diego, La Jolla, CA
| | - Mokhshan Ramachandran
- Division of Vascular and Endovascular Surgery, University of California San Diego, La Jolla, CA
| | | | - Mahmoud B Malas
- Division of Vascular and Endovascular Surgery, University of California San Diego, La Jolla, CA.
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13
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Management of atherosclerotic extracranial carotid artery stenosis. Lancet Neurol 2022; 21:273-283. [DOI: 10.1016/s1474-4422(21)00359-8] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2020] [Revised: 09/30/2021] [Accepted: 10/08/2021] [Indexed: 02/05/2023]
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Angle N, Loja M, Angle A, Alam DABNM M, Gerstch JH. Outcomes of Preferential Early Carotid Endarterectomy Following Recent Stroke. Ann Vasc Surg 2022; 83:26-34. [DOI: 10.1016/j.avsg.2022.02.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2021] [Revised: 02/02/2022] [Accepted: 02/14/2022] [Indexed: 11/25/2022]
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Coelho A, Peixoto J, Mansilha A, Naylor AR, de Borst GJ. Timing of Carotid Intervention in Symptomatic Carotid Artery Stenosis: A Systematic Review and Meta-Analysis. Eur J Vasc Endovasc Surg 2021; 63:3-23. [PMID: 34953681 DOI: 10.1016/j.ejvs.2021.08.021] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2021] [Revised: 07/05/2021] [Accepted: 08/13/2021] [Indexed: 12/29/2022]
Abstract
OBJECTIVE This review aimed to analyse the timing of carotid endarterectomy (CEA) and carotid artery stenting (CAS) after the index event as well as 30 day outcomes at varying time periods within 14 days of symptom onset. METHODS A systematic review was performed according to the Preferred Reporting Items for Systematic reviews and Meta-analysis statement, comprising an online search of the Medline and Cochrane databases. Methodical quality assessment of the included studies was performed. Endpoints included procedural stroke and/or death stratified by delay from the index event and surgical technique (CEA/CAS). RESULTS Seventy-one studies with 232 952 symptomatic patients were included. Overall, 34 retrospective analyses of prospective databases, nine prospective, three RCT, three case control, and 22 retrospective studies were included. Compared with CEA, CAS was associated with higher 30 day stroke (OR 0.70; 95% CI 0.58 - 0.85) and mortality rates (OR 0.41; 95% CI 0.31 - 0.53) when performed ≤ 2 days of symptom onset. Patients undergoing CEA/CAS were analysed in different time frames (≤ 2 vs. 3 - 14 and ≤ 7 vs. 8 - 14 days). Expedited CEA (vs. 3 - 14 days) presented a sampled 30 day stroke rate of 1.4%; 95% CI 0.9 - 1.8 vs. 1.8%; 95% CI 1.8 - 2.0, with no statistically significant difference. Expedited CAS (vs. 3 - 14 days) was associated with no difference in stroke rate but statistically significantly higher mortality rate (OR 2.76; 95% CI 1.39 - 5.50). CONCLUSION At present, CEA is safer than transfemoral CAS within 2/7 days of symptom onset. Also, considering absolute rates, expedited CEA complies with the accepted thresholds in international guidelines. The ideal timing for performing CAS (when indicated against CEA) is not yet defined. Additional granular data and standard reporting of timing of intervention will facilitate future monitoring.
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Affiliation(s)
- Andreia Coelho
- Department of Angiology and Vascular Surgery, Centro Hospitalar Universitário do Porto, Portugal; Department of Surgery and Physiology, Faculdade Medicina da Universidade do Porto, Portugal
| | - João Peixoto
- Department of Surgery and Physiology, Faculdade Medicina da Universidade do Porto, Portugal; Department of Angiology and Vascular Surgery, Centro Hospitalar Vila Nova de Gaia/Espinho, Portugal
| | - Armando Mansilha
- Department of Surgery and Physiology, Faculdade Medicina da Universidade do Porto, Portugal
| | | | - Gert J de Borst
- Department of Vascular Surgery, University Medical Centre Utrecht, the Netherlands.
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Taurino M, Dezi T, Aloisi F, Stella N, Pranteda C, Sirignano P, Rizzo L, Del Porto F, Romano A, Bozzao A. FACTORS AFFECTING THE OUTCOME OF SYMPTOMATIC CAROTID STENOSIS SURGICAL TREATMENT IN A SINGLE CENTER SERIES. Ann Vasc Surg 2021; 83:258-264. [PMID: 34954043 DOI: 10.1016/j.avsg.2021.12.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2021] [Revised: 11/29/2021] [Accepted: 12/04/2021] [Indexed: 11/01/2022]
Abstract
OBJECTIVES The aim of this study is to evaluate the role of preoperative ischemic brain lesion (IBL) volume, assessed by Diffusion-weighted magnetic resonance brain imaging (DW-MRI) with RAPID® processing, and surgery timing in predicting post-operative neurological outcomes in symptomatic carotid stenosis (SCS) patients treated with carotid endarterectomy (CEA). MATERIALS AND METHODS All patients with SCS who underwent CEA between January 2010 and June 2020 were considered. IBLs ipsilateral to the stenosis were identified in the preoperative magnetic resonance brain (MRI). The volume was quantified in mL and correlated with 30-day rates of stroke and stroke/death by χ2 and receiver operating characteristic (ROC) curve. RESULTS 134 patients were surgically treated for SCS during the entire study period. CEA procedures were defined as emergent, urgent, or elective if performed within 48 hours, between 48 hours and 14 days, or after 14 days from symptoms onset, respectively. Cumulative new ipsilateral stroke rate was 4,5%, with a statistically higher neurological complications in emergent patients compared to urgent and elective patients (10,6%, 1,47% and 0% respectively, p 0,039). ROC curve analysis showed a volume of 10 mL was predictive of postoperative stroke with 100% sensitivity and 80% specificity. A IBL volume >10mL was an independent risk factor for postoperative stroke. Infact, the perioperative neurological complication rate was significantly different in high-IBL volume patients (>10 mL) compared with low-IBL volume patients (<10 mL) (p 0,003) CONCLUSIONS: : The present study suggest that the optimal timing for CEA is between 48 hours and 14 days. Furthermore, the present study suggests that the presence of the IBL, by itself, is not definitively related with an unsatisfactory neurological outcome. However, an IBL higher than 10 mL should be as a reliable threshold value adverse neurological result in SCS patients.
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Affiliation(s)
- Maurizio Taurino
- Vascular and Endovascular Surgery Unit, Department of Clinical and Molecular Medicine, Sant'Andrea Hospital, Medical and Psychology School, La Sapienza University, Rome, Italy
| | - Tommaso Dezi
- Vascular and Endovascular Surgery Unit, Department of Clinical and Molecular Medicine, Sant'Andrea Hospital, Medical and Psychology School, La Sapienza University, Rome, Italy.
| | - Francesco Aloisi
- Vascular and Endovascular Surgery Unit, Department of Clinical and Molecular Medicine, Sant'Andrea Hospital, Medical and Psychology School, La Sapienza University, Rome, Italy
| | - Nazzareno Stella
- Vascular and Endovascular Surgery Unit, Department of Clinical and Molecular Medicine, Sant'Andrea Hospital, Medical and Psychology School, La Sapienza University, Rome, Italy
| | - Chiara Pranteda
- Vascular and Endovascular Surgery Unit, Department of Clinical and Molecular Medicine, Sant'Andrea Hospital, Medical and Psychology School, La Sapienza University, Rome, Italy
| | - Pasqualino Sirignano
- Vascular and Endovascular Surgery Unit, Department of Clinical and Molecular Medicine, Sant'Andrea Hospital, Medical and Psychology School, La Sapienza University, Rome, Italy
| | - Luigi Rizzo
- Vascular and Endovascular Surgery Unit, Department of Clinical and Molecular Medicine, Sant'Andrea Hospital, Medical and Psychology School, La Sapienza University, Rome, Italy
| | - Flavia Del Porto
- Internal Medicine Unit, Department of Clinical and Molecular Medicine, Sant'Andrea Hospital, Medical and Psychology School, La Sapienza University, Rome, Italy
| | - Andrea Romano
- Neuroradiology Unit, NESMOS Department (Neuroscience, Mental Health, Sense Organs), Sant'Andrea Hospital, Medical and Psychology School, La Sapienza University, Rome, Italy
| | - Alessandro Bozzao
- Neuroradiology Unit, NESMOS Department (Neuroscience, Mental Health, Sense Organs), Sant'Andrea Hospital, Medical and Psychology School, La Sapienza University, Rome, Italy
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Chisci E, Lazzeri E, Masciello F, Troisi N, Turini F, Sapio PL, Tramacere L, Cincotta M, Fortini A, Baruffi C, Michelagnoli S. "Timing to carotid endarterectomy affects early and long term outcomes of symptomatic carotid stenosis.". Ann Vasc Surg 2021; 82:314-324. [PMID: 34902463 DOI: 10.1016/j.avsg.2021.10.071] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2021] [Revised: 10/26/2021] [Accepted: 10/26/2021] [Indexed: 11/18/2022]
Abstract
OBJECTIVE The aim of this study is to evaluate early and long-term outcomes according to the timing to carotid endarterectomy (CEA) of symptomatic carotid stenosis. METHODS Consecutive CEAs with selective shunting for symptomatic carotid stenosis ≥50% performed between 2009 and 2020. Patients had acute neurological impairment on presentation, defined as <5 points on the National Institutes of Health Stroke Scale(NIHSS). We grouped patients according to time between index event and CEA: the first group was operated between 0-2 days, the second group between 3 and 7 days, the third group between 8 and 14 days and the last group after 15 days. Thirty-day neurological status improvement was defined as a decrease (≥1) in the 30-day NIHSS score vs. NIHSS score immediately before surgery. RESULTS 500 CEAs were performed. The perioperative combined stroke and mortality rate was 3.6% (18/500), representing a perioperative mortality rate of .2 (n=1) and stroke rate of 3.4% (n=17). Overall freedom from stroke was 95% at 1 year, 89 % at 6 years, and 88% at 10 years. Annual stroke rate was 0.6% after the 30-day period. Thirty-day improvement in neurologic status occurred in 103 patients (20.6%), while in 380 (76%) neurologic status was unchanged, and 17 (3.4%) experienced worsening of their neurologic status. Patients treated within 7 days from the index event had significant benefit (OR=2.6) in the 30-day neurological improvement vs. those treated after 7 days from the index event. Timing to CEA <2 days increased significantly the risk of late stroke (OR=9.7). CONCLUSIONS The ideal timing for performing CEA is between 3 and 7 days from the index event if NIHSS <5 as it is associated with the best rates of improvement in neurological status and durability in the long term. Very early CEA (<48 hours) was associated with increased late stroke occurrence.
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Affiliation(s)
- Emiliano Chisci
- Department of Surgery, Vascular and Endovascular Surgery Unit "San Giovanni di Dio" Hospital, Florence, Italy.
| | - Elisa Lazzeri
- Department of Surgery, Vascular and Endovascular Surgery Unit "San Giovanni di Dio" Hospital, Florence, Italy
| | - Fabrizio Masciello
- Department of Surgery, Vascular and Endovascular Surgery Unit "San Giovanni di Dio" Hospital, Florence, Italy
| | - Nicola Troisi
- Vascular Surgery Unit, Department of Translational Research and New Technologies in Medicine and Surgery, University of Pisa, Pisa, Italy
| | - Filippo Turini
- Department of Surgery, Vascular and Endovascular Surgery Unit "San Giovanni di Dio" Hospital, Florence, Italy
| | - Patrizia Lo Sapio
- Department of Surgery, Vascular and Endovascular Surgery Unit "San Giovanni di Dio" Hospital, Florence, Italy
| | - Luciana Tramacere
- Department of Medicine, Unit of Neurology of Florence, "San Giovanni di Dio" Hospital, Florence, Italy
| | - Massimo Cincotta
- Department of Medicine, Unit of Neurology of Florence, "San Giovanni di Dio" Hospital, Florence, Italy
| | - Alberto Fortini
- Department of Medicine, Internal Medicine and Stroke Unit, "San Giovanni di Dio" Hospital, Florence, Italy
| | - Cristina Baruffi
- Department of Medicine, Internal Medicine and Stroke Unit, "San Giovanni di Dio" Hospital, Florence, Italy
| | - Stefano Michelagnoli
- Department of Surgery, Vascular and Endovascular Surgery Unit "San Giovanni di Dio" Hospital, Florence, Italy
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Cui CL, Dakour-Aridi H, Lu JJ, Yei KS, Schermerhorn ML, Malas MB. In-Hospital Outcomes of Urgent, Early, or Late Revascularization for Symptomatic Carotid Artery Stenosis. Stroke 2021; 53:100-107. [PMID: 34872337 DOI: 10.1161/strokeaha.120.032410] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND AND PURPOSE Advancements in carotid revascularization have produced promising outcomes in patients with symptomatic carotid artery stenosis. However, the optimal timing of revascularization procedures after symptomatic presentation remains unclear. The purpose of this study is to compare in-hospital outcomes of transcarotid artery revascularization (TCAR), transfemoral carotid stenting (TFCAS), or carotid endarterectomy (CEA) performed within different time intervals after most recent symptoms. METHODS This is a retrospective cohort study of United States patients in the vascular quality initiative. All carotid revascularizations performed for symptomatic carotid artery stenosis between September 2016 and November 2019 were included. Procedures were categorized as urgent (0-2 days after most recent symptom), early (3-14 days), or late (15-180 days). The primary outcome of interest was in-hospital stroke and death. Secondary outcomes include in-hospital stroke, death, and transient ischemic attacks. Multivariable logistic regression was used to compare outcomes. RESULTS A total of 18 643 revascularizations were included: 2006 (10.8%) urgent, 7423 (39.8%) early, and 9214 (49.42%) late. Patients with TFCAS had the highest rates of stroke/death at all timing cohorts (urgent: 4.0% CEA, 6.9% TFCAS, 6.5% TCAR, P=0.018; early: 2.5% CEA, 3.8% TFCAS, 2.9% TCAR, P=0.054; late: 1.6% CEA, 2.8% TFCAS, 2.3% TCAR, P=0.003). TFCAS also had increased odds of in-hospital stroke/death compared with CEA in all 3 groups (urgent adjusted odds ratio [aOR], 1.7 [95% CI, 1.0-2.9] P=0.03; early aOR, 1.6 [95% CI, 1.1-2.4] P=0.01; and late aOR, 1.9 [95% CI, 1.2-3.0] P=0.01). TCAR and CEA had comparable odds of in-hospital stroke/death in all 3 groups (urgent aOR, 1.9 [95% CI, 0.9-4], P=0.10), (early aOR, 1.1 [95% CI, 0.7-1.7], P=0.66), (late aOR, 1.5 [95% CI, 0.9-2.3], P=0.08). CONCLUSIONS CEA remains the safest method of revascularization within the urgent period. Among revascularization performed outside of the 48 hours, TCAR and CEA have comparable outcomes.
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Affiliation(s)
- Christina L Cui
- University of California San Diego (C.L.C., H.D.-A., K.S.Y., M.B.M.)
| | | | - Jinny J Lu
- Beth Israel Deaconess Medical Center, Boston, MA (J.J.L., M.L.S.)
| | - Kevin S Yei
- University of California San Diego (C.L.C., H.D.-A., K.S.Y., M.B.M.)
| | | | - Mahmoud B Malas
- University of California San Diego (C.L.C., H.D.-A., K.S.Y., M.B.M.)
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Gender, racial and ethnic disparities in index hospitalization operations for symptomatic carotid stenosis in Texas hospitals. Ann Vasc Surg 2021; 80:152-157. [PMID: 34687890 DOI: 10.1016/j.avsg.2021.08.039] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2021] [Revised: 08/03/2021] [Accepted: 08/04/2021] [Indexed: 11/24/2022]
Abstract
BACKGROUND Recent literature and societal recommendations support early revascularization of symptomatic carotid patients over the traditional six-week period. Nonetheless, the timing of these interventions can vary widely among populations. The goal of this study is to identify any factors influencing carotid revascularization during the index hospitalization for patients with symptomatic disease. METHODS The Texas Department of State Health Services database was queried to identify all patients > 45 years old admitted to nonfederal Texas Hospitals between 2009 to 2013 with an admission diagnosis of carotid artery stenosis and either transient ischemic attack (TIA), cerebrovascular accident (CVA), or amaurosis fugax. Diagnoses codes and demographic data were also used to adjust for clinical, social, and demographic factors (including area of residence and treatment). Descriptive statistics and multivariable logistic regression were used to identify significant factors for index admission revascularization. RESULTS A total of 29,046 symptomatic patients were identified among the 153,484 patients who had an eligible admission diagnosis. This included 16,244 (55.9%) males and 12,802 (44.1%) females. Only 4,594 (15.8%) patients were revascularized during the index hospitalization. The majority of these patients presented with amaurosis (OR 5.58; 95% CI 4.84-6.44) instead of CVAs (OR 0.48; 95% CI 0.45-0.51) or TIAs . Adjusting for hospital volume, insurance coverage, residence, and other clinical factors, rates of index admission carotid intervention remained significantly lower for women (OR 0.85; 95% CI 0.79-0.91), persons categorized as black (OR 0.60; 95% CI 0.53-0.69), and persons categorized as Hispanic (OR 0.77; 95% CI 0.70-0.86). CONCLUSIONS Gender, race and ethnicity appear to correlate with rates of carotid intervention at index hospitalization despite thorough risk adjustment for clinical, social and demographic factors. Efforts should be directed towards reducing these disparities.
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Hasan B, Farah M, Nayfeh T, Amin M, Malandris K, Abd-Rabu R, Shah S, Rajjoub R, Seisa MO, Saadi S, Hassett L, Prokop LJ, AbuRahma A, Murad MH. A Systematic Review Supporting the Society for Vascular Surgery Guidelines on the Management of Carotid Artery Disease. J Vasc Surg 2021; 75:99S-108S.e42. [PMID: 34153350 DOI: 10.1016/j.jvs.2021.06.001] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2021] [Accepted: 06/01/2021] [Indexed: 12/29/2022]
Abstract
BACKGROUND To support the development of guidelines on the management of carotid disease, a writing committee from the Society for Vascular Surgery has commissioned this systematic review. METHODS We searched multiple data bases for studies addressing 5 questions: medical management vs. carotid revascularization (CEA) in asymptomatic patients, CEA vs. CAS in symptomatic low surgical risk patients, the optimal timing of revascularization after acute stroke, screening high risk patients for carotid disease, and the optimal sequence of interventions in patients with combined coronary and carotid disease. Studies were selected and appraised by pairs of independent reviewers. Meta-analyses were performed when feasible. RESULTS Medical management compared to carotid interventions in asymptomatic patients was associated with better early outcome during the first 30 days. However, CEA was associated with significantly lower long-term rate of stroke/death at 5 years. In symptomatic low risk surgical patients, CEA was associated with lower risk of stroke, but a significant increase in MI compared to CAS during the first 30 days. When the long-term outcome of transfemoral CAS vs. CEA in symptomatic patients were examined using pre-planned pooled analysis of individual patient data from four randomized trials, the risk of death or stroke within 120 days of the index procedure was 5.5% for CEA and 8.7% for CAS, which lends support that over the long-term, CEA has superior outcome than transfemoral CAS. When managing acute stroke, the comparison of CEA during the first 48 hours to that between day 2 and day14 did not reveal a statistically significant difference on outcomes during the first 30 days. Registry data show good results with CEA performed in the first week, but not within the first 48 hours. A single risk factor, aside from PAD, was associated with low carotid screening yield. Multiple risk factors greatly increase the yield of screening. Evidence on the timing of interventions in patients with combined carotid and coronary disease was sparse and imprecise. Patients without carotid symptoms, who had the carotid intervention first, compared to a combined carotid intervention and CABG, had better outcomes. CONCLUSIONS This updated evidence summary will support the SVS clinical practice guidelines for commonly raised clinical scenarios. CEA was superior to medical therapy in long-term prevention of stroke/death over medical therapy. CEA was also superior to transfemoral CAS in minimizing long-term stroke/death for symptomatic low risk surgical patients. CEA should optimally be performed between 2-14 days from the onset of acute stroke. Having multiple risk factors increases the value of carotid screening.
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Affiliation(s)
- Bashar Hasan
- Evidence-Based Practice Research Program, Mayo Clinic, MN, USA; Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, MN, USA
| | - Magdoleen Farah
- Evidence-Based Practice Research Program, Mayo Clinic, MN, USA; Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, MN, USA
| | - Tarek Nayfeh
- Evidence-Based Practice Research Program, Mayo Clinic, MN, USA; Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, MN, USA
| | - Mustapha Amin
- Evidence-Based Practice Research Program, Mayo Clinic, MN, USA; Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, MN, USA
| | - Kostantinos Malandris
- Evidence-Based Practice Research Program, Mayo Clinic, MN, USA; Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, MN, USA
| | - Rami Abd-Rabu
- Evidence-Based Practice Research Program, Mayo Clinic, MN, USA; Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, MN, USA
| | - Sahrish Shah
- Evidence-Based Practice Research Program, Mayo Clinic, MN, USA; Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, MN, USA
| | - Rami Rajjoub
- Evidence-Based Practice Research Program, Mayo Clinic, MN, USA; Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, MN, USA
| | - Mohamed O Seisa
- Evidence-Based Practice Research Program, Mayo Clinic, MN, USA; Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, MN, USA
| | - Samer Saadi
- Evidence-Based Practice Research Program, Mayo Clinic, MN, USA; Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, MN, USA
| | | | | | - Ali AbuRahma
- Department of Surgery, West Virginia University 3110 MacCorkle Ave., SE, Charleston, WV 25304
| | - M Hassan Murad
- Evidence-Based Practice Research Program, Mayo Clinic, MN, USA; Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, MN, USA.
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21
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SOCIETY FOR VASCULAR SURGERY CLINICAL PRACTICE GUIDELINES FOR MANAGEMENT OF EXTRACRANIAL CEREBROVASCULAR DISEASE. J Vasc Surg 2021; 75:4S-22S. [PMID: 34153348 DOI: 10.1016/j.jvs.2021.04.073] [Citation(s) in RCA: 266] [Impact Index Per Article: 66.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2021] [Accepted: 04/20/2021] [Indexed: 11/22/2022]
Abstract
Management of carotid bifurcation stenosis in stroke prevention has been the subject of extensive investigations, including multiple randomized controlled trials. The proper treatment of patients with carotid bifurcation disease is of major interest to vascular surgeons and other vascular specialists. In 2011, the Society for Vascular Surgery published guidelines for treatment of carotid artery disease. At the time, several randomized trials, comparing carotid endarterectomy (CEA) and carotid artery stenting (CAS), were published. Since that publication, several studies and a few systematic reviews comparing CEA and CAS have been published, and the role of medical management has been re-emphasized. The current publication updates and expands the 2011 guidelines with specific emphasis on five areas: is carotid endarterectomy recommended over maximal medical therapy in low risk patients; is carotid endarterectomy recommended over trans-femoral carotid artery stenting in low surgical risk patients with symptomatic carotid artery stenosis of >50%; timing of carotid Intervention in patients presenting with acute stroke; screening for carotid artery stenosis in asymptomatic patients; and optimal sequence for intervention in patients with combined carotid and coronary artery disease. A separate implementation document will address other important clinical issues in extracranial cerebrovascular disease. Recommendations are made using the GRADE (Grades of Recommendation Assessment, Development and Evaluation) approach, as has been done with other Society for Vascular Surgery guidelines. The committee recommends CEA as the first-line treatment for symptomatic low risk surgical patients with stenosis of 50% to 99% and asymptomatic patients with stenosis of 70% to 99%. The perioperative risk of stroke and death in asymptomatic patients must be <3% to ensure benefit for the patient. In patients with recent stable stroke (modified Rankin 0-2), carotid revascularization is considered appropriate in symptomatic patients with greater than 50% stenosis and is recommended and performed as soon as the patient is neurologically stable after 48 hours but definitely before 14 days of onset of symptoms. In the general population, screening for clinically asymptomatic carotid artery stenosis in patients without cerebrovascular symptoms or significant risk factors for carotid artery disease is not recommended. In selected asymptomatic patients who are at increased risk for carotid stenosis, we suggest screening for clinically asymptomatic carotid artery stenosis as long as the patients would potentially be fit for and willing to consider carotid intervention if significant stenosis is discovered. In patients with symptomatic carotid stenosis 50-99%, who require both CEA and CABG, we suggest CEA before or concomitant with CABG to potentially reduce the risk of stroke and stroke/death. The sequencing of the intervention depends on clinical presentation and institutional experience.
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22
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Johal AS, Naylor AR, Pherwani AD, Li Q, Birmpili P, Waton S, O'Neill R, Boyle JR, Cromwell DA. Carotid Endarterectomy Following Intravenous Thrombolysis in the UK. Eur J Vasc Endovasc Surg 2021; 62:9-15. [PMID: 34088616 DOI: 10.1016/j.ejvs.2021.03.033] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2020] [Revised: 03/24/2021] [Accepted: 03/30/2021] [Indexed: 10/21/2022]
Abstract
OBJECTIVE The aim of this study was to evaluate the effect of pre-operative intravenous thrombolytic therapy (ivTT) on short term outcomes after carotid endarterectomy (CEA) among patients who presented with ischaemic stroke. METHODS A retrospective study using a large population based dataset from the National Vascular Registry in the United Kingdom (UK-NVR). The cohort included adult patients who underwent CEA for ischaemic stroke between 1 January 2014 and 31 December 2019. NVR records provided information on patient demographics, Rankin score, medication, time from onset of symptoms to surgery and whether the patient received ivTT prior to surgery. Logistic regression was used to evaluate the relationship between ivTT and rates of any stroke at 30 days after CEA and in hospital complication rates for neck haematoma. Secondary outcomes included in hospital cardiac and respiratory complications, and cranial nerve injury. RESULTS Between 2014 and 2019, 9 030 patients presented with a stroke and underwent CEA, of whom 1 055 (11.7%) had received pre-operative ivTT. Those receiving ivTT were younger (mean 70.6 vs. 72.0 years, p < .001). The median (IQR) time from symptom to CEA was 10 days (6 - 17) for ivTT patients and 11 days (7 - 20) for CEA patients not receiving ivTT. Post-operative rates of 30 day stroke were similar between the no ivTT (2.1%) and ivTT (1.8%) cohorts (p = .48). In hospital neck haematomas were statistically significantly more common in CEA patients receiving ivTT (3.7%) vs. no ivTT (2.3%) (p = .006). There was no statistically significant association between 30 day stroke and neck haematoma complications when stratified for delays from symptom onset to CEA, but the overall cohort contained few adverse events for analysis during the very early time period. CONCLUSION The use of ivTT before CEA in stroke patients was not associated with an increased risk of 30 day stroke, but there was an increase in the risk of neck haematoma.
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Affiliation(s)
- Amundeep S Johal
- The Clinical Effectiveness Unit, The Royal College of Surgeons of England, London, UK.
| | - A Ross Naylor
- The Leicester Vascular Institute, Glenfield Hospital, Leicester, UK
| | - Arun D Pherwani
- Royal Stoke Vascular Unit, Royal Stoke University Hospital, Stoke-On-Trent, UK
| | - Qiuju Li
- The Clinical Effectiveness Unit, The Royal College of Surgeons of England, London, UK; Department of Health Services Research & Policy, London School of Hygiene & Tropical Medicine, London, UK
| | - Panagiota Birmpili
- The Clinical Effectiveness Unit, The Royal College of Surgeons of England, London, UK
| | - Sam Waton
- The Clinical Effectiveness Unit, The Royal College of Surgeons of England, London, UK
| | - Richard O'Neill
- Interventional Radiology Department, Queen's Medical Centre, Nottingham University Hospitals NHS Trust, Nottingham, UK
| | - Jonathan R Boyle
- Cambridge Vascular Unit, Cambridge University Hospitals NHS Trust & Department of Surgery, University of Cambridge, Cambridge, UK
| | - David A Cromwell
- The Clinical Effectiveness Unit, The Royal College of Surgeons of England, London, UK; Department of Health Services Research & Policy, London School of Hygiene & Tropical Medicine, London, UK
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Zakirzhanov NR, Komarov RN, Khalilov IG, Baiazova NI, Evseeva VV. [Comparative analysis of safety of carotid endarterectomy performed in acutest and acute periods of ischaemic stroke]. ANGIOLOGII︠A︡ I SOSUDISTAI︠A︡ KHIRURGII︠A︡ = ANGIOLOGY AND VASCULAR SURGERY 2021; 27:97-106. [PMID: 33825735 DOI: 10.33529/angio2021103] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
Surgical revascularization of the carotid basin in the acutest period of ischaemic stroke, i.e., within 72 hours, will make it possible to prevent the development of recurrent stroke by removing an embologenically dangerous atherosclerotic plaque of the symptomatic carotid artery and to improve cerebral blood supply, having eliminated haemodynamic stenosis of the carotid artery. However, the problem of safety of carotid endarterectomy in patients during the acutest period of ischaemic stroke still remains debatable. PURPOSE To comparatively analyse safety of eversion carotid endarterectomy performed in the acutest (0-72 hours) and acute (4-14 days) periods of minor ischaemic stroke. PATIENTS AND METHODS Between January 2015 and December 2019, specialists of the Department of Vascular Surgery of Municipal Clinical Hospital # 7 of Kazan performed a total of 80 eversion carotid reconstructions in the period of minor ischaemic stroke within 14 days. The patients were divided into 2 groups depending on the terms of performing carotid endarterectomy. The first group comprised 32 (40.0%) patients operated on in the acutest period of ischaemic stroke, i.e., within 72 hours from the onset of first symptoms of neurological deficit. The second group included 48 (60.0%) patients subjected to carotid endarterectomy within 4 to 14 days from the onset of first signs of neurological deficit. RESULTS According to the obtained findings, haemorrhagic transformation in the early postoperative period occured in 2 Group Two patients, with one lethal outcome on POD 3. Cerebral ischaemia increased in one patient of each group without enlargement of the ischaemic zone according to brain computed tomography, with residual neurological deficit in Group I in remote period (Rankin scale score 1) and complete restoration in Group II (Rankin scale score 0). Recurrent minor ischaemic stroke on POD 1 developed in Group II with formation of a new lacunar region of ischaemia of the brain in the operated carotid basin and was verified by the findings of cerebral MRI with persisting neurological deficit for 6 months (Rankin scale score 2). The comparative assessment of severity of stroke on the day of operation and at discharge, as well as that of neurological symptomatology during the 1st and 6th months of follow up in both groups proved positive. No events of acute coronary syndrome, recurrent strokes or lethal outcomes were observed during the follow-up period. CONCLUSION According to the findings of our study, patients with acute cerebral circulation impairment caused by embologenically dangerous lesions of internal carotid arteries should be operated on within the first 72 hours, if there are no accompanying changes requiring time for correction thereof.
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Affiliation(s)
- N R Zakirzhanov
- Department of Vascular Surgery, Municipal Clinical Hospital #7 of the Public Health Ministry of the Republic of Tatarstan, Kazan, Russia; Department of Faculty Surgery #1, I.M. Sechenov First Moscow State Medical University of the RF Ministry of Public Health, Moscow, Russia
| | - R N Komarov
- Department of Faculty Surgery #1, I.M. Sechenov First Moscow State Medical University of the RF Ministry of Public Health, Moscow, Russia
| | - I G Khalilov
- Department of Vascular Surgery, Municipal Clinical Hospital #7 of the Public Health Ministry of the Republic of Tatarstan, Kazan, Russia; Chair of Cardiovascular and Endovascular Surgery, Kazan State Medical University of the RF Ministry of Public Health, Kazan, Russia
| | - N I Baiazova
- Department of Vascular Surgery, Municipal Clinical Hospital #7 of the Public Health Ministry of the Republic of Tatarstan, Kazan, Russia
| | - V V Evseeva
- Chair of Cardiovascular and Endovascular Surgery, Kazan State Medical University of the RF Ministry of Public Health, Kazan, Russia
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Limaye K, Quispe-Orozco D, Zevallos CB, Farooqui M, Dandapat S, Mendez-Ruiz A, Ansari S, Abdelkarim S, Dajles A, Derdeyn C, Samaniego EA, Ortega-Gutierrez S. Safety and Feasibility of Symptomatic Carotid Artery Stent-Assisted Revascularization within 48 Hours after Symptoms Onset. J Stroke Cerebrovasc Dis 2021; 30:105743. [PMID: 33765635 DOI: 10.1016/j.jstrokecerebrovasdis.2021.105743] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2021] [Revised: 02/11/2021] [Accepted: 03/06/2021] [Indexed: 10/21/2022] Open
Abstract
OBJECTIVE We aimed to evaluate the safety and feasibility of carotid artery stenting (CAS) performed in the hyperacute period. METHODS We analyzed a retrospective database of CAS patients from our center. We included patients with symptomatic isolated ipsilateral extracranial carotid stenosis and acute tandem occlusions who underwent CAS. Hyperacute CAS (HCAS) and acute CAS (ACAS) groups were defined as CAS within 48 hours and >48 hours to 14 days from symptoms onset, respectively. The primary outcome was a composite of any stroke, myocardial infarction, or death at 3 months of follow-up. Secondary outcomes were periprocedural complications and restenosis or occlusion rates. RESULTS We included 97 patients, 39 with HCAS and 58 with ACAS. There was no significant difference between groups for the primary outcome (HCAS 3.3% vs. ACAS 6.1%; p = 1). There were no differences in the rate of perioperative complications between groups although a trend was observed (HCAS 15.3% vs. ACAS 3.4%; p = .057). The rate of restenosis or occlusion between groups (HCAS 8.1% vs. ACAS 9,1%; log-rank test p = .8) was similar with a median time of follow-up of 13.7 months. CONCLUSION Based on this study, CAS may be feasible in the hyperacute period. However, there are potential higher rates of perioperative complications in the hyperacute group, primarily occurring in MT patients with acute tandem occlusion. A larger multicenter study may be needed to further corroborate our findings.
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Affiliation(s)
- Kaustubh Limaye
- Department of Neurology, University of Iowa Hospitals and Clinics, Iowa City, IA, USA
| | - Darko Quispe-Orozco
- Department of Neurology, University of Iowa Hospitals and Clinics, Iowa City, IA, USA
| | - Cynthia B Zevallos
- Department of Neurology, University of Iowa Hospitals and Clinics, Iowa City, IA, USA
| | - Mudassir Farooqui
- Department of Neurology, University of Iowa Hospitals and Clinics, Iowa City, IA, USA
| | - Sudeepta Dandapat
- Department of Neurology, University of Iowa Hospitals and Clinics, Iowa City, IA, USA; Department of Neurosurgery, University of Iowa Hospitals and Clinics, Iowa City, IA, USA; Department of Radiology, University of Iowa Hospitals and Clinics, Iowa City, IA, USA
| | - Alan Mendez-Ruiz
- Department of Neurology, University of Iowa Hospitals and Clinics, Iowa City, IA, USA
| | - Sameer Ansari
- Department of Neurology, University of Iowa Hospitals and Clinics, Iowa City, IA, USA
| | - Samir Abdelkarim
- Department of Neurology, University of Iowa Hospitals and Clinics, Iowa City, IA, USA
| | - Andres Dajles
- Department of Neurology, University of Iowa Hospitals and Clinics, Iowa City, IA, USA
| | - Colin Derdeyn
- Department of Radiology, University of Iowa Hospitals and Clinics, Iowa City, IA, USA
| | - Edgar A Samaniego
- Department of Neurosurgery, University of Iowa Hospitals and Clinics, Iowa City, IA, USA; Department of Radiology, University of Iowa Hospitals and Clinics, Iowa City, IA, USA
| | - Santiago Ortega-Gutierrez
- Department of Neurology, University of Iowa Hospitals and Clinics, Iowa City, IA, USA; Department of Neurosurgery, University of Iowa Hospitals and Clinics, Iowa City, IA, USA; Department of Radiology, University of Iowa Hospitals and Clinics, Iowa City, IA, USA.
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Yuan Y, Liao SY, Xin WQ. Carotid endarterectomy should be performed early or delayed in patients with symptomatic carotid stenosis? Clin Neurol Neurosurg 2020; 199:106317. [PMID: 33161214 DOI: 10.1016/j.clineuro.2020.106317] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2020] [Revised: 10/12/2020] [Accepted: 10/13/2020] [Indexed: 10/23/2022]
Abstract
BACKGROUND To date, the literature directly comparing early carotid endarterectomy (CEA) and delayed CEA in patients with symptomatic carotid stenosis (CS) is limited. We aimed to evaluate the efficacy and safety of early CEA and delayed CEA in patients with symptomatic CS by performing a meta-analysis. MATERIAL AND METHOD The PubMed, Cochrane Library (last searched in May 2020) and relevant websites such as Web of Science and EMBASE (1990 to May 2020) were searched. All meta-analyses of eligible results were conducted using the STATA version 12.0 (Stata Corporation, College Station, Texas, USA). RESULTS A total of 7 articles were included in the study hailing from the New Scotland, Chicago, Sweden, UK, Italy, and France. In this study, the early CEA meant that the procedure was performed within the first 14 days or first 30 days. And the delayed CEA meant the procedure was performed more than 14 days or 30 days after the symptom occurrence. Referring to the latter early CEA group and delayed CEA group, there were three publications. The results illustrated that the early CEA group was not associated with a higher incidence of stroke (OR = 0.77, 95 % CI: 0.273-2.170; P = 0.620). And no statistic difference was found on the incidence of postoperative 30-day mortality and stroke or mortality. Meanwhile, referring to the former early CEA group and delayed CEA group, there were six articles. The results demonstrated that the early CEA group was associated with a higher rate of postoperative 30-day mortality (RD = 0.010, 95 % CI: 0.002 to 0.019; P = 0.022). CONCLUSION The meta-analysis of these related studies suggests that, compared to the delayed CEA group, the early CEA performed in patients with the acute post stroke phase resulted in a higher risk of postoperative mortality. Therefore, the delayed CEA was safer than early CEA for patients with symptomatic CS.
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Affiliation(s)
- Yan Yuan
- Department of Neurosurgery, Tianjin Medical University General Hospital, Tianjin, 300052, PR China.
| | - Shi-Yao Liao
- Institute of Integrated Medicine, Dalian Medical University, Dalian, Liaoning, 116011, PR China.
| | - Wen-Qiang Xin
- Department of Neurosurgery, Tianjin Medical University General Hospital, Tianjin, 300052, PR China.
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Cui CL, Dakour-Aridi H, Eldrup-Jorgensen J, Schermerhorn ML, Siracuse JJ, Malas MB. Effects of timing on in-hospital and one-year outcomes after transcarotid artery revascularization. J Vasc Surg 2020; 73:1649-1657.e1. [PMID: 33038481 DOI: 10.1016/j.jvs.2020.08.148] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2020] [Accepted: 08/27/2020] [Indexed: 11/28/2022]
Abstract
OBJECTIVE The current recommendations are to perform carotid endarterectomy within 2 weeks of symptoms for maximum long-term stroke prevention, although urgent carotid endarterectomy within 48 hours has been associated with increased perioperative stroke. With the development and rapid adoption of transcarotid artery revascularization (TCAR), we decided to study the effect of timing on the outcomes after TCAR. METHODS The Vascular Quality Initiative database was searched for symptomatic patients who had undergone TCAR from September 2016 to November 2019. These patients were stratified by the interval to TCAR after symptom onset: urgent, within 48 hours; early, 3 to 14 days; and late, >14 days. The primary outcome was the in-hospital rate of combined stroke and death (stroke/death), evaluated using logistic regression analysis. The secondary outcome was the 1-year rate of recurrent ipsilateral stroke and mortality, evaluated using Kaplan-Meier survival analysis. RESULTS A total of 2608 symptomatic patients who had undergone TCAR were included. The timing was urgent for 144 patients (5.52%), early for 928 patients (35.58%), and late for 1536 patients (58.90%). Patients undergoing urgent intervention had an increased risk of in-hospital stroke/death, which was driven primarily by an increased risk of stroke. No differences were seen for in-hospital death. On adjusted analysis, urgent intervention resulted in a threefold increased risk of stroke (odds ratio [OR], 2.8; 95% confidence interval [CI], 1.3-6.2; P = .01) and a threefold increased risk of stroke/death (OR, 2.9; 95% CI, 1.3-6.4; P = .01) compared with late intervention. Patients undergoing early intervention had comparable risks of stroke (OR, 1.3; 95% CI, 0.7-2.3; P = .40) and stroke/death (OR, 1.2; 95% CI, 0.7-2.1; P = .48) compared with late intervention. On subset analysis, the type of presenting symptoms was an effect modifier. Patients presenting with stroke and those presenting with transient ischemic attack or amaurosis fugax both had an increased risk of stroke/death when undergoing urgent compared with late TCAR (OR, 2.7; 95% CI, 1.1-6.6; P = .04; and OR, 4.1; 95% CI, 1.1-15.0; P = .03, respectively). However only patients presenting with transient ischemic attack or amaurosis fugax had experienced an increased risk of stroke with urgent compared with late TCAR (OR, 5.0; 95% CI, 1.4-17.5; P < .01). At 1 year of follow-up, no differences were seen in the incidence of recurrent ipsilateral stroke (urgent, 0.7%; early, 0.2%; late, 0.1%; P = .13) or postdischarge mortality (urgent, 0.7%; early, 1.6%; late, 1.8%; P = .71). CONCLUSIONS We found that TCAR had a reduced incidence of stroke when performed 48 hours after symptom onset. Urgent TCAR within 48 hours of the onset of stroke was associated with a threefold increased risk of in-hospital stroke/death, with no added benefit for ≤1 year after intervention. Further studies are needed on long-term outcomes of TCAR stratified by the timing of the procedure.
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Affiliation(s)
- Christina L Cui
- Division of Vascular and Endovascular Surgery, Department of Surgery, University of California, San Diego, La Jolla, Calif
| | - Hanaa Dakour-Aridi
- Division of Vascular and Endovascular Surgery, Department of Surgery, University of California, San Diego, La Jolla, Calif
| | - Jens Eldrup-Jorgensen
- Division of Vascular and Endovascular Therapy, Department of Surgery, Maine Medical Center, Portland, Me
| | - Marc L Schermerhorn
- Division of Vascular and Endovascular Surgery, Department of Surgery, Beth Israel Deaconess Medical Center, Boston, Mass
| | - Jeffrey J Siracuse
- Division of Vascular and Endovascular Surgery, Department of Surgery, Boston University, Boston Medical Center, Boston, Mass
| | - Mahmoud B Malas
- Division of Vascular and Endovascular Surgery, Department of Surgery, University of California, San Diego, La Jolla, Calif.
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Soenens G, Moreels N, Vermassen F, De Herdt V, Hemelsoet D, Van Herzeele I. Evolution of surgical treatment of carotid artery stenosis: a single center observational study. Acta Chir Belg 2020; 120:301-309. [PMID: 30995167 DOI: 10.1080/00015458.2019.1607489] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
Background: In 2009 and 2011 respectively ESVS and AHA/ASA guidelines recommended to operate patients with a symptomatic carotid artery stenosis within 14 days. This study aimed primarily to determine if an academic hospital has implemented these international guidelines about indication and timing of surgical treatment of carotid stenosis. Second, the influence of referral from another hospital on time from symptoms to surgery and the influence of time between neurological event and surgery on 30-day complication rate was studied. Third, the number of asymptomatic carotid artery lesions treated surgically was also evaluated in both periods.Methods: Retrospective study to compare patients with significant atherosclerotic carotid stenosis who underwent carotid endarterectomy (CEA) or carotid artery stenting (CAS) in 2005-2006 versus patients treated in 2014-2016. Demographic data, treatment characteristics, interval between symptom and surgery and 30-day outcomes were collected.Results: In 2005-2006 38.1% (59/155) of the patients were treated for symptomatic carotid artery stenosis, in 2014-2016 this increased to 66.5% (121/182) (p < .001, 95% CI: 0.179-0.383). Median time from neurological symptom to surgery in symptomatic patients decreased from 30 to 13 d (p <.001, 95% CI: 1.476-2.763). Early surgery did not increase the 30-day postoperative complications (p = .19, 95% CI: 0.987-1.003). Referral from another hospital almost doubled the time interval between symptoms and surgery in 2014-2016 (p <.001, 95% CI: 1.386-2.827).Conclusions: Since the publication of the international guidelines, patients with symptomatic carotid artery stenosis were preferably surgically treated within 2 weeks at an academic institution. The number of treated asymptomatic carotid stenoses was drastically reduced.
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Affiliation(s)
- Gilles Soenens
- Department of Thoracic and Vascular Surgery, Ghent University Hospital, Ghent, Belgium
| | - Nathalie Moreels
- Department of Thoracic and Vascular Surgery, Ghent University Hospital, Ghent, Belgium
| | - Frank Vermassen
- Department of Thoracic and Vascular Surgery, Ghent University Hospital, Ghent, Belgium
| | - Veerle De Herdt
- Department of Neurology, Ghent University Hospital, Ghent, Belgium
| | | | - Isabelle Van Herzeele
- Department of Thoracic and Vascular Surgery, Ghent University Hospital, Ghent, Belgium
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Fereydooni A, Gorecka J, Xu J, Schindler J, Dardik A. Carotid Endarterectomy and Carotid Artery Stenting for Patients With Crescendo Transient Ischemic Attacks: A Systematic Review. JAMA Surg 2020; 154:1055-1063. [PMID: 31483458 DOI: 10.1001/jamasurg.2019.2952] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
Importance Thromboembolic stroke attributable to an ipsilateral carotid artery plaque is a leading cause of disability in the United States and a major source of morbidity. Randomized clinical trials have demonstrated the efficacy of carotid endarterectomy and carotid stenting at minimizing stroke risk in patients with minor stroke and transient ischemic attack. However, there is no consensus on guidelines for medical management and the timing of revascularization in patients with multiple recurrent episodes of transient ischemic attack over hours or days, an acute neurological event known as crescendo transient ischemic attack. Objective To review the management of and timing of intervention in patients presenting with crescendo transient ischemic attack. Evidence Review This systematic review included all English-language articles published from January 1, 1985, to January 1, 2019, available from PubMed (MEDLINE) and Google Scholar. Articles were excluded if they did not include analysis of patients with symptoms, did not report the timing of intervention after crescendo transient ischemic attack, or mixed analysis of patients with stroke in evolution with patients with crescendo transient ischemic attack. The quality of the evidence was assessed with the modified rating from the Oxford Centre for Evidence-based Medicine. Observations Patients with crescendo transient ischemic attack were found to have a higher risk of stroke or death after carotid endarterectomy compared with patients with a single transient ischemic attack or stable stroke. With medical therapy alone, a considerable number of patients with crescendo transient ischemic attack experience a completed stroke within several months and have a poor prognosis without intervention. Urgent carotid endarterectomy, typically performed within 48 hours of initial presentation, is beneficial in carefully selected patients. There have been several reports of operative treatment within the first 24 hours of presentation; however, review of these reports does not show any additional benefit from emergency treatment. Carotid artery stenting is reserved only for selected patients with prohibitive surgical risk for endarterectomy. The literature does not clearly support any additional benefit of intravenous heparin therapy over mono or dual antiplatelet therapy prior to carotid endarterectomy. Conclusions and Relevance Crescendo transient ischemic attack is best managed with optimal medical management as well as urgent carotid endarterectomy within 2 days of presentation. Surgical endarterectomy appears to be preferred because of the increased embolic potential of bifurcation plaque, whereas stenting is an option for patients with contraindications for surgery. With ongoing advances in cerebrovascular imaging and medical treatment of stroke, there is a need for better evidence to determine the optimal timing and preoperative medical management of patients with crescendo transient ischemic attack.
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Affiliation(s)
- Arash Fereydooni
- Department of Surgery, Yale School of Medicine, Yale University, New Haven, Connecticut
| | - Jolanta Gorecka
- Department of Surgery, Yale School of Medicine, Yale University, New Haven, Connecticut
| | - Jianbiao Xu
- Department of Surgery, Yale School of Medicine, Yale University, New Haven, Connecticut
| | - Joseph Schindler
- Department of Neurology, Yale School of Medicine, Yale University, New Haven, Connecticut
| | - Alan Dardik
- Department of Surgery, Yale School of Medicine, Yale University, New Haven, Connecticut
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Brinster CJ, Sternbergh WC. Safety of urgent carotid endarterectomy following thrombolysis. THE JOURNAL OF CARDIOVASCULAR SURGERY 2020; 61:149-158. [PMID: 32225134 DOI: 10.23736/s0021-9509.20.11179-0] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
INTRODUCTION Acute ischemic stroke is a leading cause of morbidity and mortality worldwide, and the incidence of ischemic stroke is predicted to increase in coming years. Carotid atherosclerotic occlusive disease accounts for up to 20% of all ischemic strokes, and mounting evidence suggests that, in the setting of an acute ischemic stroke due to carotid disease, earlier treatment with carotid intervention results in better outcomes. In patients with acute ischemic stroke, systemic or intravenous thrombolysis (IVT) has revolutionized ischemic stroke therapy, and intravenous tissue plasminogen activator (tPA) has become the principal treatment for acute ischemic stroke when administered within 3 to 4.5 hours of neurologic symptom onset. Given these trends in acute ischemic stroke therapy, vascular specialists are increasingly asked to perform carotid intervention following IVT, but reports in the literature examining outcomes in this circumstance are scarce, and the data regarding the appropriate interval from IVT to carotid endarterectomy (CEA) remains controversial. EVIDENCE ACQUISITION Literature searches were performed in PubMed (MEDLINE) and Ovid examining journal articles published between January 1st, 1998 and September 30th, 2019. The search terms used were: "urgent carotid endarterectomy," "carotid endarterectomy" AND "thrombolysis," "acute stroke and thrombolysis," "timing of carotid endarterectomy," and various combinations of these terms. EVIDENCE SYTNHESIS A total of 21 published reports detailing outcomes in 1165 patients have been published to date, with an average interval from IVT to CEA of 7.1 days, a cumulative 30-day stroke and death rate of 4.1% (0-18%) and a mean frequency of intracranial hemorrhage of 2.6% (0-18%). The aggregate data from the 21 reported series suggest that CEA can be performed safely within the first 14 days after the onset of neurologic symptoms in patients receiving antecedent IVT, however, data regarding the safety of urgent CEA within 48 to 72 hours of thrombolysis is conflicting, with some series reporting excellent results and others showing an increased risk of ICH, stroke, and/or death in these select patients. CONCLUSIONS Given the trend toward expedited treatment of acute ischemic stroke with subsequent transfer to regional referral centers, vascular specialists will be confronted with an increasing number of patients who may require urgent CEA after antecedent IVT. Further study is warranted to clearly delineate the appropriate interval from IVT to CEA and, specifically, to establish the safety of CEA with 72 hours of tPA administration.
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Affiliation(s)
- Clayton J Brinster
- Section of Vascular Surgery, Department of Surgery, Ochsner Clinic Foundation, New Orleans, LA, USA -
| | - W Charles Sternbergh
- Section of Vascular Surgery, Department of Surgery, Ochsner Clinic Foundation, New Orleans, LA, USA
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Editor's Choice – Prognostic Role of Pre-Operative Symptom Status in Carotid Endarterectomy: A Systematic Review and Meta-Analysis. Eur J Vasc Endovasc Surg 2020; 59:516-524. [DOI: 10.1016/j.ejvs.2020.01.022] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2019] [Revised: 12/16/2019] [Accepted: 01/16/2020] [Indexed: 01/10/2023]
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Zakirzhanov NR, Komarov RN, Khalilov IG. [Carotid endarterectomy in acute period of ischemic stroke]. Khirurgiia (Mosk) 2020:74-78. [PMID: 32105259 DOI: 10.17116/hirurgia202002174] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
A review is devoted to carotid endarterectomy for symptomatic carotid stenosis in acute period of ischemic stroke. Patient selection criteria, dates of surgical intervention and perioperative risk were analyzed.
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Affiliation(s)
- N R Zakirzhanov
- Kazan Clinical Hospital No. 7 of the Ministry of Health of the Republic of Tatarstan, Kazan, Russia; Sechenov First Moscow State Medical University of the Ministry of Health of Russia, Moscow, Russia
| | - R N Komarov
- Sechenov First Moscow State Medical University of the Ministry of Health of Russia, Moscow, Russia; Sechenov First Moscow State Medical University of the Ministry of Health of Russia, Moscow, Russia
| | - I G Khalilov
- Kazan Clinical Hospital No. 7 of the Ministry of Health of the Republic of Tatarstan, Kazan, Russia
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Darling RC. Timing of urgent carotid endarterectomy for stroke: how to optimize outcomes for patients. THE JOURNAL OF CARDIOVASCULAR SURGERY 2020; 61:131-132. [PMID: 32077674 DOI: 10.23736/s0021-9509.20.11278-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Affiliation(s)
- R Clement Darling
- Division of Vascular Surgery, Albany Medical Center Hospital, Albany Medical College, Albany, NY, USA -
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Aboyans V, Ricco JB, Bartelink MLEL, Björck M, Brodmann M, Cohnert T, Collet JP, Czerny M, De Carlo M, Debus S, Espinola-Klein C, Kahan T, Kownator S, Mazzolai L, Naylor AR, Roffi M, Röther J, Sprynger M, Tendera M, Tepe G, Venermo M, Vlachopoulos C, Desormais I. 2017 ESC Guidelines on the Diagnosis and Treatment of Peripheral Arterial Diseases, in collaboration with the European Society for Vascular Surgery (ESVS): Document covering atherosclerotic disease of extracranial carotid and vertebral, mesenteric, renal, upper and lower extremity arteriesEndorsed by: the European Stroke Organization (ESO)The Task Force for the Diagnosis and Treatment of Peripheral Arterial Diseases of the European Society of Cardiology (ESC) and of the European Society for Vascular Surgery (ESVS). Eur Heart J 2019; 39:763-816. [PMID: 28886620 DOI: 10.1093/eurheartj/ehx095] [Citation(s) in RCA: 2229] [Impact Index Per Article: 371.5] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
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Comment on "Letter to the Editor". Ann Surg 2019; 270:e97-e98. [PMID: 31726628 DOI: 10.1097/sla.0000000000003349] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Magnetic Resonance Imaging Identified Brain Ischaemia in Symptomatic Patients Undergoing Carotid Endarterectomy Is Related to Histologically Apparent Intraplaque Haemorrhage. Eur J Vasc Endovasc Surg 2019; 58:796-804. [PMID: 31631008 DOI: 10.1016/j.ejvs.2019.07.017] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2019] [Revised: 07/11/2019] [Accepted: 07/14/2019] [Indexed: 11/21/2022]
Abstract
OBJECTIVE Intraplaque haemorrhage (IPH) has been independently associated with a higher risk of future ipsilateral stroke in patients with carotid artery stenosis. Evaluation of plaque characteristics may contribute to risk assessment of recurrent (silent) cerebrovascular events in order to prioritise patients for timing of treatment. It is unknown if patients showing histologically apparent IPH also have increased risk of silent ischaemic brain lesions in the waiting period between index event and revascularisation. METHODS A retrospective analysis was performed based on prospectively collected data of patients included simultaneously in the magnetic resonance imaging (MRI) substudy of the International Carotid Stenting Study and Athero-Express biobank. Patients randomised for carotid endarterectomy (CEA) underwent surgery between 2003 and 2008. Brain MRI was performed one to seven days prior to CEA. Plaques were histologically examined for presence of IPH. The primary outcome parameter was presence of silent ipsilateral brain ischaemia on magnetic resonance diffusion weighted imaging (MR-DWI) appearing hypo or isointense on apparent diffusion coefficient. RESULTS Fifty-three patients with symptomatic carotid stenosis meeting the study criteria were identified, of which 13 showed one or more recent ipsilateral DWI lesion on pre-operative scan. The median time between latest ipsilateral neurological event and revascularisation was 45 days (range 6-200) in DWI negative patients vs. 34 days (range 6-74, p = .16) in DWI positive patients. IPH was present in 24/40 (60.0%) DWI negative patients vs. 12/13 (92.3%) DWI positive patients (OR 8.00; 95% CI 0.95-67.7, p = .06). Multivariable logistic regression analysis correcting for age and type of index event revealed that IPH was independently associated with DWI lesions in the waiting period till surgery (OR 10.8; 95% CI 1.17-99.9, p = .04). CONCLUSION Symptomatic patients with ipsilateral carotid stenosis and silent brain ischaemia on pre-operative MR-DWI, more often showed pathological evidence of IPH compared with those without ischaemic lesions. This identifies carotid IPH as a marker for patients at risk of silent brain ischaemia and possibly for future stroke and other arterial disease complications. Such patients may be more likely to benefit from CEA than those without evidence of ipsilateral carotid IPH.
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Vellimana AK, Washington CW, Yarbrough CK, Pilgram TK, Hoh BL, Derdeyn CP, Zipfel GJ. Thrombolysis is an Independent Risk Factor for Poor Outcome After Carotid Revascularization. Neurosurgery 2019; 83:922-930. [PMID: 29136204 DOI: 10.1093/neuros/nyx551] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2015] [Accepted: 10/02/2017] [Indexed: 12/14/2022] Open
Abstract
BACKGROUND Thrombolysis is the standard of care for acute ischemic stroke patients presenting in the appropriate time window. Studies suggest that the risk of recurrent ischemia is lower if carotid revascularization is performed early after the index event. The safety of early carotid revascularization in this patient population is unclear. OBJECTIVE To evaluate the safety of carotid revascularization in patients who received thrombolysis for acute ischemic stroke. METHODS The Nationwide Inpatient Sample database was queried for patients admitted through the emergency room with a primary diagnosis of carotid stenosis and/or occlusion. Each patient was reviewed for administration of thrombolysis, carotid endarterectomy, (CEA) or carotid angioplasty and stenting (CAS). Primary endpoints were intracerebral hemorrhage (ICH), postprocedural stroke (PPS), poor outcome, and in-hospital mortality. Potential risk factors were examined using univariate and multivariate analyses. RESULTS A total of 310 257 patients were analyzed. Patients who received tissue plasminogen activator (tPA) and underwent either CEA or CAS had a significantly higher risk of developing an ICH or PPS than patients who underwent either CEA or CAS without tPA administration. The increased risk of ICH or PPS in tPA-treated patients who underwent carotid revascularization diminished with time, and became similar to patients who underwent carotid revascularization without tPA administration by 7 d after thrombolysis. Patients who received tPA and underwent CEA or CAS also had higher odds of poor outcome and in-hospital mortality. CONCLUSION Thrombolysis is a strong risk factor for ICH, PPS, poor outcome, and in-hospital mortality in patients with carotid stenosis/occlusion who undergo carotid revascularization. The increased risk of ICH or PPS due to tPA declines with time after thrombolysis. Delaying carotid revascularization in these patients may therefore be appropriate. This delay, however, will expose these patients to the risk of recurrent stroke. Future studies are needed to determine the relative risks of these 2 adverse events.
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Affiliation(s)
- Ananth K Vellimana
- Department of Neurological Surgery, Washington University School of Medi-cine, St. Louis, Missouri
| | - Chad W Washington
- Department of Neurological Surgery, Washington University School of Medi-cine, St. Louis, Missouri
| | - Chester K Yarbrough
- Department of Neurological Surgery, Washington University School of Medi-cine, St. Louis, Missouri
| | - Thomas K Pilgram
- Mallinckrodt Institute of Radiology, Washington University School of Medicine, St. Louis, Missouri
| | - Brian L Hoh
- Department of Neurosurgery, University of Florida, Gainesville, Florida
| | - Colin P Derdeyn
- Department of Neurological Surgery, Washington University School of Medi-cine, St. Louis, Missouri.,Mallinckrodt Institute of Radiology, Washington University School of Medicine, St. Louis, Missouri
| | - Gregory J Zipfel
- Department of Neurological Surgery, Washington University School of Medi-cine, St. Louis, Missouri
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Gunka I, Krajickova D, Lesko M, Renc O, Raupach J, Jiska S, Lojik M, Chovanec V, Hudak A, Maly R. Outcomes of Urgent Carotid Endarterectomy for Crescendo Transient Ischemic Attacks and Stroke in Evolution. Ann Vasc Surg 2019; 61:185-192. [PMID: 31394223 DOI: 10.1016/j.avsg.2019.05.061] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2019] [Revised: 05/27/2019] [Accepted: 05/29/2019] [Indexed: 11/26/2022]
Abstract
BACKGROUND Carotid endarterectomy (CEA) after an unstable neurological presentation is still a controversial issue. The aim of this study was to evaluate outcomes of urgent (≤48 hr) CEA in patients with crescendo transient ischemic attack (cTIA) or stroke in evolution (SIE). METHODS A retrospective analysis was performed using prospectively collected data from all consecutive neurologically unstable patients who underwent urgent CEA during the period from January 2013 to November 2018. End points were 30-day any stroke and death rate, symptomatic intracerebral hemorrhage (ICH), myocardial infarction (MI), surgical site bleeding requiring intervention, National Institutes of Health Stroke Scale (NIHSS) score variation, and functional outcome at 90 days assessed by the modified Rankin scale (mRS). Patients were evaluated according to clinical presentation (cTIA or SIE). RESULTS A total of 46 neurologically unstable patients with cTIA (20 patients; 43.5%) and SIE (26 patients; 56.5%) were included. The 30-day risk of any stroke or death was 10.0% (2 of 20) in the cTIA group and 7.7% (2 of 26) in the SIE group. No symptomatic ICH or MI was detected after surgery in either study group. A total of 2 patients (4.3%; 1 cTIA, 1 SIE) underwent reoperation for surgical site bleeding. In patients with SIE, the mean NIHSS score on admission was 9.85 ± 5.12. Postoperatively, 22 (84.6%) of the 26 patients with SIE had clinical improvement of their neurological deficit, 3 (11.5%) patients had no change, and 1 (3.8%) patient died. On discharge, the mean NIHSS score was 4.31 ± 6.09 points and was significantly improved compared with NIHSS scores at admission (P < 0.001). At 3 months, 21 patients (80.8%) with SIE had a good clinical outcome (mRS ≤ 2). CONCLUSIONS Urgent CEA in neurologically unstable patients can be performed with acceptable perioperative risks. Moreover, in well-selected patients with SIE, urgent CEA may be associated with significantly improved final functional outcomes.
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Affiliation(s)
- Igor Gunka
- Department of Surgery, University Hospital Hradec Kralove, Charles University, Faculty of Medicine in Hradec Kralove, Hradec Kralove, Czech Republic.
| | - Dagmar Krajickova
- Department of Neurology, University Hospital Hradec Kralove, Charles University, Faculty of Medicine in Hradec Kralove, Hradec Kralove, Czech Republic
| | - Michal Lesko
- Department of Surgery, University Hospital Hradec Kralove, Charles University, Faculty of Medicine in Hradec Kralove, Hradec Kralove, Czech Republic
| | - Ondrej Renc
- Department of Radiology, University Hospital Hradec Kralove, Charles University, Faculty of Medicine in Hradec Kralove, Hradec Kralove, Czech Republic
| | - Jan Raupach
- Department of Radiology, University Hospital Hradec Kralove, Charles University, Faculty of Medicine in Hradec Kralove, Hradec Kralove, Czech Republic
| | - Stanislav Jiska
- Department of Surgery, University Hospital Hradec Kralove, Charles University, Faculty of Medicine in Hradec Kralove, Hradec Kralove, Czech Republic
| | - Miroslav Lojik
- Department of Radiology, University Hospital Hradec Kralove, Charles University, Faculty of Medicine in Hradec Kralove, Hradec Kralove, Czech Republic
| | - Vendelin Chovanec
- Department of Radiology, University Hospital Hradec Kralove, Charles University, Faculty of Medicine in Hradec Kralove, Hradec Kralove, Czech Republic
| | - Alexander Hudak
- Department of Surgery, University Hospital Hradec Kralove, Charles University, Faculty of Medicine in Hradec Kralove, Hradec Kralove, Czech Republic
| | - Radovan Maly
- 1st Department of Internal Medicine - Cardioangiology, University Hospital Hradec Kralove, Charles University, Faculty of Medicine in Hradec Kralove, Hradec Kralove, Czech Republic
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Rots ML, Meershoek AJ, Bonati LH, den Ruijter HM, de Borst GJ. Editor's Choice – Predictors of New Ischaemic Brain Lesions on Diffusion Weighted Imaging After Carotid Stenting and Endarterectomy: A Systematic Review. Eur J Vasc Endovasc Surg 2019; 58:163-174. [DOI: 10.1016/j.ejvs.2019.04.016] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2018] [Revised: 04/09/2019] [Accepted: 04/14/2019] [Indexed: 12/16/2022]
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Fisher O, Benson RA, Tian F, Dale NE, Imray CH. Purine nucleoside use as surrogate markers of cerebral ischaemia during local and general anaesthetic carotid endarterectomy. SAGE Open Med 2019; 7:2050312119865120. [PMID: 31367381 PMCID: PMC6643180 DOI: 10.1177/2050312119865120] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2019] [Accepted: 07/01/2019] [Indexed: 12/02/2022] Open
Abstract
Objectives: In periods of cerebral ischaemia, adenosine triphosphate is metabolised,
leading to accumulation of adenosine inosine and hypoxanthine. These can be
measured in real time using peripheral blood samples intraoperatively. The
primary aim of this study was to describe changes in purine concentrations
in a cohort of patients undergoing carotid endarterectomy under general
anaesthetic, and to evaluate correlation between changes in values with
major perioperative steps. The secondary aim was to compare changes in
concentrations with a previous cohort of patients who had undergone carotid
endarterectomy under local anaesthetic. Methods: This was a prospective observational study. Purine concentrations were
determined from arterial line samples and measured via an amperometric
biosensor at specific time points during carotid endarterectomy. Mean
arterial pressure was manipulated to maintain steady cerebral perfusion
pressure throughout the procedure. These results were analysed against data
from a cohort of patients who underwent carotid endarterectomy under local
anaesthetic in previously published work. Results: Valid results were obtained for 37 patients. Purine concentrations at
baseline were 3.02 ± 1.11 µM and 3.16 ± 1.85 µM for the unshunted and
shunted cohorts, respectively. There was no significant change after 30 min
of carotid clamping at 2.07 ± 0.89 and 2.4 ± 3.09 µM, respectively (both p
> 0.05). Peak purine during the clamp phase in the loco-regional
anaesthetic cohort was 6.70 ± 3.4 µM, which was significantly raised
compared to both general anaesthetic cohorts (p = 0.004). There were no
perioperative neurological events in either cohort. Conclusion: This small study does not demonstrate conclusive evidence that purine
nucleosides can be used as a marker of cerebral ischaemia; the comparisons
to the loco-regional anaesthetic data offer information about differences in
the cerebral adenosine triphosphate metabolism between general anaesthetic
and loco-regional anaesthetic. We hypothesise that the lack of a rise in
purine nucleosides under general anaesthetic may be caused by a decrease in
the cerebral metabolic rate and loss of metabolic rate-blood flow coupling
caused by general anaesthetic agents.
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Affiliation(s)
- Owain Fisher
- Department of Vascular Surgery, University Hospitals Coventry and Warwickshire, Coventry, UK.,University of Warwick, Coventry, UK
| | - Ruth A Benson
- Department of Vascular Surgery, University Hospitals Coventry and Warwickshire, Coventry, UK.,University of Birmingham, Birmingham, UK
| | - Faming Tian
- University of Warwick, Coventry, UK.,Sarissa Biomedical Ltd, Coventry, UK
| | - Nicholas E Dale
- University of Warwick, Coventry, UK.,Sarissa Biomedical Ltd, Coventry, UK
| | - Christopher He Imray
- Department of Vascular Surgery, University Hospitals Coventry and Warwickshire, Coventry, UK.,University of Warwick, Coventry, UK
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Ross Naylor A. Reading Beyond the Headlines. Eur J Vasc Endovasc Surg 2019; 58:148. [DOI: 10.1016/j.ejvs.2019.01.032] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2019] [Accepted: 01/13/2019] [Indexed: 10/27/2022]
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Andersen JC, Mannoia KA, Kiang SC, Patel ST, Teruya TH, Bianchi C, Abou-Zamzam AM. Immediate Carotid Endarterectomy Is Associated with Higher Risk in Symptomatic Patients. Ann Vasc Surg 2019; 62:15-20. [PMID: 31201981 DOI: 10.1016/j.avsg.2019.05.008] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2019] [Revised: 04/23/2019] [Accepted: 05/25/2019] [Indexed: 12/01/2022]
Abstract
BACKGROUND Guidelines recommend that patients with carotid artery stenosis ≥50% (Sx-CAS) undergo carotid endarterectomy (CEA) within 14 days of symptoms. However, perioperative risks, especially stroke, may be increased when CEA is performed within 48 hours. This study seeks to more fully evaluate the effect of timing of surgery on outcomes for Sx-CAS. METHODS All CEAs in the Southern California Vascular Outcomes Improvement Collaborative (SoCal VOICe) from 2012 to 18 were reviewed. Ipsilateral cortical or visual symptoms within 6 months defined Sx-CAS. Timing from symptom occurrence to CEA was classified as immediate (0-2 days), early (3-14 days), or delayed (>14 days). Perioperative stroke, myocardial infarction (MI), and 30-day mortality rates were compared by time to surgery. RESULTS Of 2203 CEAs, 436 (20%) were for Sx-CAS (52% stroke, 48% transient ischemic attack). Mean time from symptoms to CEA was 28.3 days (range, 0-172; median, 14 days). Sixty-one cases (14%) were immediate, 166 (38%) early, and 209 (48%) delayed. Perioperative stroke occurred in 2.8% and stroke/MI/30-day mortality in 5.7%. Stroke rate was significantly higher in the immediate group (vs. early and delayed): 8.2%, versus 3.0%, and 0.96%, respectively (P = 0.009). Stroke/MI/30-day mortality was also higher in the immediate group: 13.1%, versus 6.0%, and 3.3%, respectively (P = 0.001). Immediate surgery was associated with greater postoperative events (P = 0.009), and logistic regression confirmed decreased risk of postoperative stroke and stroke/MI/30-day mortality in delayed surgery using immediate surgery as a reference. Wide variability existed among centers in the timing of CEA (immediate-range, 0-50%; delayed-range, 41-83%; P = 0.01). CONCLUSIONS In the SoCal VOICe, 52% of patients undergo CEA within 2 weeks of symptoms. Increased stroke rates occur when CEA is performed within 2 days, whereas stroke and death rates are decreased at 3-14 days and beyond. These data support avoidance of immediate CEA. Opportunity exists to standardize timing of CEA for Sx-CAS among SoCal VOICe participants. Further study is required to define the role of immediate CEA.
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Affiliation(s)
- James C Andersen
- Division of Vascular Surgery, Loma Linda University Medical Center, Loma Linda, CA
| | - Kristyn A Mannoia
- Division of Vascular Surgery, Loma Linda University Medical Center, Loma Linda, CA
| | - Sharon C Kiang
- Division of Vascular Surgery, Loma Linda University Medical Center, Loma Linda, CA
| | - Sheela T Patel
- Division of Vascular Surgery, Loma Linda University Medical Center, Loma Linda, CA
| | - Theodore H Teruya
- Division of Vascular Surgery, Loma Linda University Medical Center, Loma Linda, CA
| | - Christian Bianchi
- Division of Vascular Surgery, Loma Linda University Medical Center, Loma Linda, CA
| | - Ahmed M Abou-Zamzam
- Division of Vascular Surgery, Loma Linda University Medical Center, Loma Linda, CA.
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- Division of Vascular Surgery, Loma Linda University Medical Center, Loma Linda, CA
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Patients with moderate to severe strokes (NIHSS score >10) undergoing urgent carotid interventions within 48 hours have worse functional outcomes. J Vasc Surg 2019; 69:1471-1481. [DOI: 10.1016/j.jvs.2018.07.079] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2018] [Accepted: 07/29/2018] [Indexed: 11/20/2022]
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Trenner M, Eckstein HH, Kallmayer MA, Reutersberg B, Kühnl A. Secondary analysis of statutorily collected routine data. GEFASSCHIRURGIE 2019. [DOI: 10.1007/s00772-019-0524-y] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
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Meershoek AJA, de Borst GJ. Timing of carotid intervention. Br J Surg 2019; 105:1231-1233. [PMID: 30133763 PMCID: PMC6099369 DOI: 10.1002/bjs.10950] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2018] [Accepted: 06/19/2018] [Indexed: 11/11/2022]
Abstract
Flimsy evidence
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Affiliation(s)
- A J A Meershoek
- Department of Vascular Surgery, University Medical Centre Utrecht, Room G04.129, PO Box 85500, 3508, GA, Utrecht, The Netherlands
| | - G J de Borst
- Department of Vascular Surgery, University Medical Centre Utrecht, Room G04.129, PO Box 85500, 3508, GA, Utrecht, The Netherlands
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Savardekar AR, Narayan V, Patra DP, Spetzler RF, Sun H. Timing of Carotid Endarterectomy for Symptomatic Carotid Stenosis: A Snapshot of Current Trends and Systematic Review of Literature on Changing Paradigm towards Early Surgery. Neurosurgery 2019; 85:E214-E225. [DOI: 10.1093/neuros/nyy557] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2018] [Accepted: 01/31/2019] [Indexed: 11/14/2022] Open
Abstract
Abstract
Carotid revascularization has been recommended as the maximally beneficial treatment for stroke prevention in patients with recently symptomatic carotid stenosis (SCS). The appropriate timing for performing carotid endarterectomy (CEA) within the first 14 d after the occurrence of the index event remains controversial. We aim to provide a snapshot of the pertinent current literature related to the timing of CEA for patients with SCS. A systematic review of literature was conducted to study the timing of CEA for SCS. The guidelines of the Preferred Reporting Items for Systematic Reviews and Meta-analysis (PRISMA) were followed. A total of 63 articles were identified as relevant to this topic. A summary of 15 articles favoring urgent CEA (within 48 h) for SCS within 48 h of index event and 9 articles not favoring urgent CEA is presented. A consensus is still to be achieved on the ideal timing of CEA for SCS within the 14-d window presently prescribed. The current literature suggests that patients who undergo urgent CEA (within 48 h) after nondisabling stroke as the index event have an increased periprocedural risk as compared to those who had transient ischemic attack (TIA) as the index event. Further prospective studies and clinical trials studying this question with separate groups classified as per the index event are required to shed more light on the subject. The current literature points to a changing paradigm towards early carotid surgery, specifically targeted within 48 h if the index event is TIA, and within 7 d if the index event is stroke.
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Affiliation(s)
- Amey R Savardekar
- Department of Neurosurgery, Louisiana State University Health Sciences Center, Shreveport, Louisiana
| | - Vinayak Narayan
- Department of Neurosurgery, Louisiana State University Health Sciences Center, Shreveport, Louisiana
| | - Devi P Patra
- Department of Neurosurgery, Louisiana State University Health Sciences Center, Shreveport, Louisiana
| | - Robert F Spetzler
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona
| | - Hai Sun
- Department of Neurosurgery, Louisiana State University Health Sciences Center, Shreveport, Louisiana
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Faateh M, Dakour-Aridi H, Kuo PL, Locham S, Rizwan M, Malas MB. Risk of emergent carotid endarterectomy varies by type of presenting symptoms. J Vasc Surg 2019; 70:130-137.e1. [PMID: 30777684 DOI: 10.1016/j.jvs.2018.10.064] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2018] [Accepted: 10/04/2018] [Indexed: 11/16/2022]
Abstract
BACKGROUND The timing of carotid revascularization in symptomatic patients is a matter of ongoing debate. Current evidence indicates that carotid endarterectomy (CEA) within 2 weeks of symptoms is superior to delayed treatment. However, there is little evidence on the outcomes of emergent CEA (eCEA). The purpose of this study was to compare outcomes of emergency eCEA vs nonemergent CEA (non-eCEA), stratified by type of presenting symptoms. METHODS We analyzed the Vascular Targeted-National Surgical Quality Improvement Program dataset from 2011 to 2016. Symptomatic patients were divided into two groups: eCEA and non-eCEA. Univariable and multivariable methods were used to compare patient characteristics and to evaluate stroke, death, myocardial infarction (MI), stroke/death, and stroke/death/MI within 30 days of surgery adjusting for all potential confounders. A further subgroup analysis was done to compare the outcomes of eCEA vs non-eCEA stratified by the type of presenting symptoms (amaurosis, transient ischemic attack [TIA], and stroke). RESULTS A total of 9271 patients were identified, of which 10.7% were eCEA vs 89.3% non-eCEA. Comparing eCEA vs non-eCEA, the two groups were similar in age (70.8 vs 70.5), female gender (36.3% vs 36.9%), diabetes (26.2% vs 28.9%), and smoking status (31.9% vs 28.7%; all P > .05). Patients undergoing eCEA were less likely to be hypertensive (76.2% vs 80.2%; P = .025), but more likely to belong to non-white race (51.5% vs 20.5%; P < .001). The eCEA patients were less likely to be on preprocedural medication vs non-eCEA (antiplatelets, 76.8% vs 89.2%; statins, 74.2% vs 79.9%; beta-blockers, 44.6% vs 50.4%; all P < .05). The 30-day outcomes comparing eCEA vs non-eCEA were: stroke, 6.2% vs 3.1%; death, 2% vs 1%; and stroke/death, 6.9% vs 3.7% (all P < .05). After risk adjustment, perioperative stroke (odds ratio [OR], 2.04; 95% confidence interval [CI], 1.36-3.0), stroke/death (OR, 1.66; 95% CI, 1.13-2.45), and stroke/death/MI (OR, 1.58; 95% CI, 1.18-2.23) were higher after eCEA (all P < .01). When stratified by the type of presenting symptom, eCEA vs non-eCEA stroke outcomes were similar in patients who presented with stroke or amaurosis fugax. However, in the subset of patients presenting with TIA, eCEA had much worse outcomes compared with non-eCEA (stroke, 8.3% vs 2.5%; stroke/death, 8.3% vs 3.2%) and had significantly higher odds of stroke (OR, 3.12; 95% CI, 1.71-5.68) and stroke/death (OR, 2.24; 95% CI, 1.25-4.03) in the adjusted analysis (all P < .05). CONCLUSIONS In patients presenting with stroke, eCEA does not seem to add significant risk compared with non-eCEA. However, patients presenting with TIA might be better served with non-emergent surgery as their risk of stroke is tripled when CEA is performed emergently.
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Affiliation(s)
- Muhammad Faateh
- Johns Hopkins Bayview Vascular and Endovascular Research Center, Baltimore, Md
| | - Hanaa Dakour-Aridi
- Johns Hopkins Bayview Vascular and Endovascular Research Center, Baltimore, Md
| | - Pei-Lun Kuo
- Johns Hopkins Bayview Vascular and Endovascular Research Center, Baltimore, Md
| | - Satinderjit Locham
- Johns Hopkins Bayview Vascular and Endovascular Research Center, Baltimore, Md
| | - Muhammad Rizwan
- Johns Hopkins Bayview Vascular and Endovascular Research Center, Baltimore, Md
| | - Mahmoud B Malas
- Johns Hopkins Bayview Vascular and Endovascular Research Center, Baltimore, Md.
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Blay E, Balogun Y, Nooromid MJ, Eskandari MK. Early Carotid Endarterectomy after Acute Stroke Yields Excellent Outcomes: An Analysis of the Procedure-Targeted ACS-NSQIP. Ann Vasc Surg 2019; 57:194-200. [PMID: 30690159 DOI: 10.1016/j.avsg.2018.10.023] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2018] [Revised: 10/08/2018] [Accepted: 10/15/2018] [Indexed: 11/18/2022]
Abstract
BACKGROUND Recurrent ischemic events have been associated with delayed carotid endarterectomy (CEA) for patients who present with acute strokes. As such, earlier intervention has been advocated to preserve cerebral function and expedient rehabilitation. We sought to determine the differences in 30-day postoperative major adverse clinical events (MACEs) for patients who undergo early (≤7 days) and delayed (>7 days) CEA after acute stroke. METHODS Our sample consisted of patients captured in the CEA-targeted American College of Surgeons National Surgical Quality Improvement Program data set between 2011 and 2015. The primary outcome was 30-day postoperative MACEs (death, stroke, or myocardial infarction [MI]). Differences in postoperative MACEs were determined between early and delayed CEA treatment. In addition, multivariable analyses were done to determine the association between various patient factors and postoperative complications after CEA for patients who presented with acute strokes. RESULTS A total of 3,427 patients were identified who underwent CEA for acute stroke in the CEA-targeted files between 2011 and 2015. Overall, perioperative rates of 30-day death, stroke, or MI were 1.30% (n = 43), 2.74% (n = 94), and 0.96% (n = 33), respectively. There were no differences in 30-day postoperative death, stroke, or MI for early or delayed CEA after acute strokes. On multivariable analysis, independent predictors for postoperative MACEs in patients with acute stroke were age ≥80 years (OR 2.41; 95% CI [1.15-5.06]), preoperative beta-blocker use (OR 2.11; 95% CI [1.13-3.93]), and operative time > 150 min (OR 2.39; 95% CI [0.82-4.98]). CONCLUSIONS There are no differences in postoperative 30-day death, stroke, or MI in early and delayed CEA after an acute stroke. These results substantiate the recommendation for early (<7 days) CEA after acute strokes.
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Affiliation(s)
- Eddie Blay
- Surgical Outcomes and Quality Improvement Center (SOQIC), Department of Surgery and Center for Healthcare Studies, Feinberg School of Medicine, Northwestern University, Chicago, IL; Department of Surgery, Temple University Hospital, Philadelphia, PA.
| | - Yetunde Balogun
- Department of Surgery, Temple University Hospital, Philadelphia, PA
| | - Michael J Nooromid
- Division of Vascular Surgery, Department of Surgery, Northwestern University, Chicago, IL
| | - Mark K Eskandari
- Division of Vascular Surgery, Department of Surgery, Northwestern University, Chicago, IL
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Roussopoulou A, Tsivgoulis G, Krogias C, Lazaris A, Moulakakis K, Georgiadis GS, Mikulik R, Kakisis JD, Zompola C, Faissner S, Chondrogianni M, Liantinioti C, Hummel T, Safouris A, Matsota P, Voumvourakis K, Lazarides M, Geroulakos G, Vasdekis SN. Safety of urgent endarterectomy in acute non-disabling stroke patients with symptomatic carotid artery stenosis: an international multicenter study. Eur J Neurol 2018; 26:673-679. [PMID: 30472766 DOI: 10.1111/ene.13876] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2018] [Accepted: 11/19/2018] [Indexed: 11/28/2022]
Abstract
BACKGROUND AND PURPOSE International recommendations advocate that carotid endarterectomy (CEA) should be performed within 2 weeks from the index event in symptomatic carotid artery stenosis (sCAS) patients. However, there are controversial data regarding the safety of CEA performed during the first 2 days of ictus. The aim of this international, multicenter study was to prospectively evaluate the safety of urgent (0-2 days) in comparison to early (3-14 days) CEA in patients with sCAS. METHODS Consecutive patients with non-disabling (modified Rankin Scale scores ≤2) acute ischaemic stroke or transient ischaemic attack due to sCAS (≥70%) underwent urgent or early CEA at five tertiary-care stroke centers during a 6-year period. The primary outcome events included stroke, myocardial infarction or death during the 30-day follow-up period. RESULTS A total of 311 patients with sCAS underwent urgent (n = 63) or early (n = 248) CEA. The two groups did not differ in baseline characteristics with the exception of crescendo transient ischaemic attacks (21% in urgent vs. 7% in early CEA; P = 0.001). The 30-day rates of stroke did not differ (P = 0.333) between patients with urgent (7.9%; 95% confidence interval 3.1%-17.7%) and early (4.4%; 95% confidence interval 2.4%-7.9%) CEA. The mortality and myocardial infarction rates were similar between the two groups. The median length of hospitalization was shorter in urgent CEA [6 days (interquartile range 4-6) vs. 10 days (interquartile range 7-14); P < 0.001]. CONCLUSIONS Our findings highlight that urgent CEA performed within 2 days from the index event is related to a non-significant increase in the risk of peri-procedural stroke. The safety of urgent CEA requires further evaluation in larger datasets.
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Affiliation(s)
- A Roussopoulou
- Second Department of Neurology, School of Medicine, 'Attikon' Hospital, University of Athens, Athens, Greece
| | - G Tsivgoulis
- Second Department of Neurology, School of Medicine, 'Attikon' Hospital, University of Athens, Athens, Greece
| | - C Krogias
- Department of Neurology, St Josef-Hospital, Ruhr University, Bochum, Germany
| | - A Lazaris
- Department of Vascular Surgery, School of Medicine, 'Attikon' Hospital, University of Athens, Athens, Greece
| | - K Moulakakis
- Department of Vascular Surgery, School of Medicine, 'Attikon' Hospital, University of Athens, Athens, Greece
| | - G S Georgiadis
- Department of Vascular Surgery, School of Medicine, Democritus University of Thrace, Alexandroupolis, Greece
| | - R Mikulik
- Department of Neurology, St Anne's University Hospital in Brno and Masaryk University, Brno, Czech Republic
| | - J D Kakisis
- Department of Vascular Surgery, School of Medicine, 'Attikon' Hospital, University of Athens, Athens, Greece
| | - C Zompola
- Second Department of Neurology, School of Medicine, 'Attikon' Hospital, University of Athens, Athens, Greece
| | - S Faissner
- Department of Neurology, St Josef-Hospital, Ruhr University, Bochum, Germany
| | - M Chondrogianni
- Second Department of Neurology, School of Medicine, 'Attikon' Hospital, University of Athens, Athens, Greece
| | - C Liantinioti
- Second Department of Neurology, School of Medicine, 'Attikon' Hospital, University of Athens, Athens, Greece
| | - T Hummel
- Department of Vascular Surgery, St Josef-Hospital, Ruhr University, Bochum, Germany
| | - A Safouris
- Second Department of Neurology, School of Medicine, 'Attikon' Hospital, University of Athens, Athens, Greece.,Acute Stroke Unit, Metropolitan Hospital, Piraeus, Greece
| | - P Matsota
- Second Department of Anaesthesiology, School of Medicine, 'Attikon' Hospital, University of Athens, Athens, Greece
| | - K Voumvourakis
- Second Department of Neurology, School of Medicine, 'Attikon' Hospital, University of Athens, Athens, Greece
| | - M Lazarides
- Department of Vascular Surgery, School of Medicine, Democritus University of Thrace, Alexandroupolis, Greece
| | - G Geroulakos
- Department of Vascular Surgery, School of Medicine, 'Attikon' Hospital, University of Athens, Athens, Greece
| | - S N Vasdekis
- Department of Vascular Surgery, School of Medicine, 'Attikon' Hospital, University of Athens, Athens, Greece
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Zabirov SS, Chechulov PV, Voznyuk IA, Polyakova AV, Solovyev AV, Haritonova TV. [Early carotid endarterectomy in patients with symptomatic carotid stenosis in the acute period of ischemic stroke]. Zh Nevrol Psikhiatr Im S S Korsakova 2018; 118:49-54. [PMID: 30499560 DOI: 10.17116/jnevro201811809249] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
AIM To identify the optimal timing of CEA in patients with hemodynamic significant stenosis of carotid arteries in the acute period of ischemic stroke (IS). MATERIAL AND METHODS Five samples (n=30 911) based on the search results from January 2008 to April 2016 in Russian and English-language scientific databases were analyzed. The main endpoints of the studies in both groups (repeated stroke, death, cardiac complications, frequency of restenosis) were studied depending on the timing of operative intervention and preoperative selection criteria. Perioperative morbidity and mortality were analyzed within 30 days after disease onset. RESULTS AND CONCLUSION There are heterogeneous and contradictory information on the safety of CEA in patients with symptomatic carotid stenosis in acute period of IS. Fundamentally, a new individual approach is required to select best candidates for timed surgery after disease onset, taking into account the severity of the condition, risk factors, comorbidity and surgical techniques.
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Affiliation(s)
- S Sh Zabirov
- Saint-Petersburg Dzhanelidze Research Institute of Emergency Medicine, St. Petersburg, Russia
| | - P V Chechulov
- Saint-Petersburg Dzhanelidze Research Institute of Emergency Medicine, St. Petersburg, Russia
| | - I A Voznyuk
- Saint-Petersburg Dzhanelidze Research Institute of Emergency Medicine, St. Petersburg, Russia
| | - A V Polyakova
- Saint-Petersburg Dzhanelidze Research Institute of Emergency Medicine, St. Petersburg, Russia
| | - A V Solovyev
- Saint-Petersburg Dzhanelidze Research Institute of Emergency Medicine, St. Petersburg, Russia
| | - T V Haritonova
- Saint-Petersburg Dzhanelidze Research Institute of Emergency Medicine, St. Petersburg, Russia
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Kragsterman B, Nordanstig A, Lindström D, Strömberg S, Thuresson M, Nordanstig J. Editor's Choice – Effect of More Expedited Carotid Intervention on Recurrent Ischaemic Event Rate: A National Audit. Eur J Vasc Endovasc Surg 2018; 56:467-474. [DOI: 10.1016/j.ejvs.2018.06.036] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2017] [Accepted: 06/18/2018] [Indexed: 11/27/2022]
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