CEA) Or Stenting Research Articles

Loss to 1-year Follow-up After Carotid Revascularization is Associated With Worse Survival

Society for Vascular Surgery practice guidelines recommend surveillance with duplex ultrasound at baseline (within 3 months from discharge), every 6 months for 2 years, and annually afterwards following carotid endarterectomy (CEA) or stenting (CAS). There is a growing concern regarding the significance of postoperative follow-up following several vascular procedures. We sought to determine whether loss to 1-year follow-up (LTF) following carotid revascularization was associated with worse outcomes in the Vascular Quality Initiative (VQI) linked to Vascular Implant Surveillance and Interventional Outcomes Network (VISION) database.

Management of asymptomatic carotid stenosis.

Patients with asymptomatic carotid stenosis (ACS) are at very high risk of coronary events, so they should all receive intensive medical therapy. What is often accepted as “best medical therapy” is usually suboptimal. Truly intensive medical therapy includes lifestyle modification, particularly smoking cessation and a Mediterranean diet. All patients with ACS should receive intensive lipid-lowering therapy, should have their blood pressure well controlled, and should receive B vitamins for lowering of plasma total homocysteine (tHcy) if levels are high; a commonly missed cause of elevated tHcy is metabolic B12 deficiency, which should be diagnosed and treated. Most patients with ACS would be better treated with intensive medical therapy than with either carotid endarterectomy (CEA) or stenting (CAS). A process called “treating arteries instead of treating risk factors” markedly reduced the risk of ACS in an observational study; a randomized trial vs. usual care should be carried out. The few patients with ACS who could benefit (~15%, or perhaps more if recent evidence regarding the risk of intraplaque hemorrhage is borne out) can be identified by a number of features. These include microemboli on transcranial Doppler, intraplaque hemorrhage, reduced cerebrovascular reserve, and echolucency of plaques, particularly “juxtaluminal black plaque”. No patient should be subjected to CAS or CEA without evidence of high-risk features, because in most cases the 1-year risk of stroke or death with intervention is higher with either CEA (~2%) or CAS (~4%) than with intensive medical therapy (~0.5%). Most patients, particularly the elderly, would be better treated with CEA than CAS. Most strokes can be prevented in patients with ACS, but truly intensive medical therapy is required.

Long-term outcomes of open and endovascular treatment of recurrent carotid artery stenosis – a 16-year retrospective single centre case series

Background: The aim of this study is to evaluate perioperative as well as long-term outcomes in patients operated with carotid endarterectomy (CEA) or stenting (CAS) due to symptomatic or asymptomatic high-grade restenosis of the internal carotid artery (ICA). Patients and methods: In a retrospective analysis of our electronic database including 2980 patients who underwent carotid endarterectomy or stenting due to a symptomatic or asymptomatic high-grade stenosis of the ICA, between 2000 and 2016, we enrolled 111 patients with recurrent ICA stenosis. Results: An ipsilateral 2nd time restenosis (>80% in the asymptomatic and >50% in the symptomatic patients according to NASCET criteria) of ICA was detected in 13 patients (12%); 3 of them were symptomatic. These patients were managed with either CEA (n=5/38%) or CAS (n=8/62%) with no perioperative stroke or death. The stroke-free survival rates at 2 and 8years for CEA were 98% and 98% versus 100% and 100% for CAS respectively (P=.271). The type of the initial procedure (patch, CAS or interposition) did not play any significant role for the development of a 2nd time restenosis (P=.841). Conclusions: Redo-CEA/CAS seem to have similar results as primary procedures (as reported in the literature) with favorable periprocedural and long-term outcomes.

Abstract TP351: Comorbid Psychiatric Disease is Associated With Lower Revascularization Rates for Stroke Due to Carotid Stenosis

Background: Carotid endarterectomy (CEA) or stenting (CAS) decrease future stroke risk in patients with stroke due to carotid stenosis. Mental illness is pervasive in the U.S., and patients with psychiatric comorbidities experience inequities in treatment for a range of conditions, including stroke. We investigated whether comorbid psychiatric disease is associated with lower rates of CEA/CAS after stroke due to carotid stenosis. Methods: Ischemic stroke cases due to carotid artery disease were identified using ICD9-CM codes in the 2007-2011 Nationwide Inpatient Sample. Psychiatric disease was defined by ICD9-CM codes for secondary diagnoses of schizophrenia, bipolar disorder, depression, anxiety, or substance use disorders. Using logistic regression, we tested the association between psychiatric disease and CEA/CAS, controlling for demographic, clinical, and hospital factors. Results: In the 22,178 included stroke cases, CEA/CAS was used in 18.8% of those with, and 20.6% of those without, psychiatric disease ( p =0.02). The presence of any psychiatric disease was associated with significantly lower odds of CEA/CAS (OR 0.84, 95% CI 0.76-0.94; Table 1). When diagnoses were analyzed separately, schizophrenia (OR 0.60, 95% CI 0.41-0.88) and substance use disorders (OR 0.76, 95% CI 0.63-0.91) were each associated with significantly lower odds of CEA/CAS. Moreover, the odds of CEA/CAS decreased as the number of psychiatric comorbidities increased: the presence of one comorbidity was associated with 13% lower odds of CEA/CAS (OR 0.87, 95% CI 0.78-0.98), while more than one comorbidity was associated with nearly 40% lower odds of CEA/CAS (OR 0.61, 95% CI 0.46-0.81), compared to those without any psychiatric disease. Conclusions: The odds of carotid revascularization after stroke due to carotid stenosis is lower in patients with psychiatric comorbidities, particularly in those with schizophrenia, substance use disorders, or multiple psychiatric diagnoses.

Does metabolic syndrome influence short and long term durability of carotid endarterectomy and stenting?

The metabolic syndrome (MetS) is composed of a cluster of related cardiovascular risk factors. The aim of the present study was to determine how MetS contributes to short- (30-day) and long-term complications and restenosis after carotid endarterectomy (CEA) or stenting (CAS). A consecutive cohort of 752 patients undergoing CEA (n=314) and CAS (n=438) in a single institution was examined, of which 296 (39.4%) were identified as having MetS. All patients were followed-up with carotid duplex ultrasound scan of the supraaortic vessels and a neurological assessment of symptoms status at 30-day postprocedure and at 3, 6, and 12months, with annual follow-up thereafter for 3years. Patients with MetS had a significant increased risk in their 30-day death, major adverse events (MAE), and restenosis rates, both after CEA and after CAS (death: 0.7% vs 0.0%; MAE: 5.3% vs 2.7%; and restenosis: 1.7% vs 0.2%; p<0.05). The MAE and restenosis rates remained statistically different at 36months, with both procedures (29.2% vs 24.2% and 9.5% vs 3.3%, p<0.05, for patients with and without MetS, respectively). Among the components of MetS, high fasting serum glucose, low high-density lipoprotein cholesterol, and elevated body mass index were associated with increased risk of complications at 30days and within 36months. The current study suggested that the presence of MetS is an important risk factor for morbidity and restenosis after CEA and CAS.

Effect of More Expedited Carotid Intervention on Recurrent Ischaemic Event Rate: A National Audit

The benefit of carotid endarterectomy (CEA) or stenting (CAS) for symptomatic stenosis depends on the timing in relation to the presenting event. As the risk of recurrent events is highest in the early phase, guidelines recommend a short delay. The purpose of this national audit was to study the effects of more expedient carotid intervention on the risk of recurrent ischaemic events. Data on all CEA and CAS for symptomatic stenosis, including both recurrent ischaemic events during the waiting time to carotid intervention and peri-operative 30 day complication rates, were obtained from the Swedish Vascular Registry between May 2008 and December 2015. The National Prescribed Drug Registry provided data on preventive medication prior to hospitalisation with the presenting event. The primary endpoint was a recurrent cerebral ischaemic event occurring after the presenting event up to 30 days of post-operative follow up. A total of 6814 procedures for symptomatic carotid stenosis were studied. The proportion of recurrent ischaemic events, meaning all secondary events occurring after the presenting event up to 30 days follow up with inclusion of all pre- and post-intervention recurrences was recorded. These recurrent events decreased over time, from 31% in 2008–2009 to 21% in 2014–2015 (p < .01, chi-square test). In parallel, the median waiting time for carotid intervention decreased from 13 (IQR 6–27) to 7 days (IQR 4–12). Baseline demographic variables and comorbidities were similar during the study period. The proportion of pre-operative recurrences were reduced from 25% to 18% (p < .01, chi-square test) while the peri-operative stroke and/or death rate was 3.6%, and improved slightly during the study. A substantial reduction in the secondary ischaemic event rate was observed when the median waiting time for CEA/CAS was reduced, and this was not counterbalanced by any increase in the peri-operative complication rate.

Editor's Choice – Effect of More Expedited Carotid Intervention on Recurrent Ischaemic Event Rate: A National Audit

The benefit of carotid endarterectomy (CEA) or stenting (CAS) for symptomatic stenosis depends on the timing in relation to the presenting event. As the risk of recurrent events is highest in the early phase, guidelines recommend a short delay. The purpose of this national audit was to study the effects of more expedient carotid intervention on the risk of recurrent ischaemic events. Data on all CEA and CAS for symptomatic stenosis, including both recurrent ischaemic events during the waiting time to carotid intervention and peri-operative 30 day complication rates, were obtained from the Swedish Vascular Registry between May 2008 and December 2015. The National Prescribed Drug Registry provided data on preventive medication prior to hospitalisation with the presenting event. The primary endpoint was a recurrent cerebral ischaemic event occurring after the presenting event up to 30 days of post-operative follow up. A total of 6814 procedures for symptomatic carotid stenosis were studied. The proportion of recurrent ischaemic events, meaning all secondary events occurring after the presenting event up to 30 days follow up with inclusion of all pre- and post-intervention recurrences was recorded. These recurrent events decreased over time, from 31% in 2008-2009 to 21% in 2014-2015 (p<.01, chi-square test). In parallel, the median waiting time for carotid intervention decreased from 13 (IQR 6-27) to 7 days (IQR 4-12). Baseline demographic variables and comorbidities were similar during the study period. The proportion of pre-operative recurrences were reduced from 25% to 18% (p<.01, chi-square test) while the peri-operative stroke and/or death rate was 3.6%, and improved slightly during the study. A substantial reduction in the secondary ischaemic event rate was observed when the median waiting time for CEA/CAS was reduced, and this was not counterbalanced by any increase in the peri-operative complication rate.

SS25. Impact of Acute Cerebral Ischemic Lesions and Their Volume on the Revascularization Outcome of Symptomatic Carotid Stenosis

The influence of acute ischemic cerebral lesion (CIL) on the revascularization outcome of symptomatic carotid stenosis has been scarcely investigated in the literature. This study evaluated the possible influence of CIL on symptomatic carotid revascularization outcome. All patients with symptomatic carotid artery stenosis who underwent to carotid endarterectomy (CEA) or stenting (CAS) between 2005 and 2014, were considered. CILs ipsilateral to the stenosis were identified in the preoperative cerebral computed tomography, quantified in mm3 and correlated with 30-day stroke and stroke/death by χ2, multivariate analysis, Pearson correlation, and ROC curve. A total of 489 symptomatic patients were treated by CEA (327-67%) or CAS (162-33%), 186 (38%) ≤2 weeks and 303 (62%) >2 weeks from symptoms onset. The stroke and stroke/death rate were not statistically different in CEA and CAS (3.3% vs 5.5%; P = .27; 3.8% vs 5.9%; P = .22). CILs were identified in 251 patients(53%) and were associated with similar stroke and stroke/death rate compared with no CIL patients (4.8% vs 3.5% [P = .46] and 5.6% v s3.5% [P = .26], respectively). However at the Pearson analysis, CIL volume significantly correlates with stroke (r = 0.15, P = .02) and stroke/death (r = 0.14, P = .04), and with stroke independently from the timing of revascularization (< 2 weeks: r = 0.16, P = .03; and >2 weeks: r = 0.21, P = .04). CIL volume correlates with stroke and stroke/death in CAS (r = .27, P = .005 and r = .24, P = .01) but not in CEA (r = 0.05, P = .55 and r = 0.03, P = .65). By the ROC curve analysis, a volume of 4000 mm3 is predictive of postoperative stroke with 75% sensitivity and 63% specificity. CIL volume >4000 mm3 was an independent risk factor for postoperative stroke (OR, 4.6; 95% CI, 1.1-19.1; P = .03). CIL volume in symptomatic carotid stenosis seems to influence the 30-day outcome independently from the timing of carotid revascularization. A CIL volume >4000 mm3 could be considered a significant predictor for postoperative stroke after carotid revascularization.

New cerebral lesions at magnetic resonance imaging after carotid artery stenting versus endarterectomy: an updated meta-analysis.

BackgroundCarotid endarterectomy (CEA) or stenting (CAS) are associated with a relatively low rate of clinical events, but diffusion-weighted imaging (DWI) is increasingly being used to compare the incidence of new ischemic lesions. Therefore, we conducted an updated meta-analysis on the occurrence of post-procedural new DWI lesions after CAS versus CEA.Methods and ResultsMEDLINE, Cochrane, ISI Web of Science and SCOPUS databases were searched and 20 studies (2 randomized and 18 non-randomized) with a total of 2104 procedures (CAS = 989; CEA = 1115) were included. The incidence of new DWI cerebral lesions was significantly greater after CAS than CEA (40.3% vs 12.2%; 20 studies; 2104 patients; odds ratio [OR] 5.17; 95% confidence interval [CI], 3.31-8.06; p<0.00001). Also peri-procedural stroke (17 studies; 1833 patients; OR 2.01; 95% CI, 1.14-3.55; p=0.02) and stroke or TIA (17 studies; 1833 patients; OR 2.40; 95% CI, 1.42-4.08; p=0.001) were significantly increased after CAS. This latter clinical advantage in the CEA group over CAS was tempered when CEA procedures were performed with shunting in all instead of selective shunting or when CAS was performed with only closed cell stents instead of both closed and open cell stents, however, no significant differences between subgroups emerged.ConclusionsCAS is associated with an increased incidence of post-procedural brain DWI lesions. This greater amount of ischemic burden may also reflect a higher rate of cerebral events after CAS. However, whether recent technical advances mainly for CAS could potentially reduce these ischemic events still remains to be evaluated.

Should patients with concomitant coronary and carotid artery disease undergo simultaneous carotid endarterectomy or stenting for severe asymptomatic carotid artery stenosis? A review of the literature

Objectives: The incidence of significant carotid artery disease in patients undergoing coronary artery bypass grafting (CABG) ranges from 2.8 – 22%. Whether simultaneous or delayed carotid endarterectomy (CEA) or stenting (CAS) is recommended for asymptomatic severe carotid disease in patients requiring CABG remains controversial. Current guidelines recommendations were based on previous meta-analyses, that documented no significant differences in outcomes for delayed or simultaneous approaches, while acknowledging the requirement for randomized controlled trials (RCTs).

The Impact of Gender on In-hospital Outcomes after Carotid Endarterectomy or Stenting

Aim: We sought to better define the impact of sex on ‘in-hospital outcomes’ after carotid endarterectomy (CEA) or stenting (CAS). Methods: Hospital discharge databases for all carotid interventions obtained from the New York State (NYS) Department of Health, Statewide Planning and Research Cooperative System between 2000 and 2009 (29,917 women, 39,771 men) were analysed. Mortality, stroke and composite event (stroke/death) were compared between procedures after matching of patients by propensity score. Acute myocardial infarction (AMI) was our secondary ‘end’ point. Results: More than 90% of patients in both sexes were asymptomatic (27,439 women and 36,295 men). Compared to men, asymptomatic women experienced more strokes after CEA (women: 1.38%, men: 1.16%, P = 0.03) and higher AMI rates after both procedures (CEA; women: 0.75%, men: 0.51%, P = 0.0009, CAS; women: 0.96%, men: 0.28%, P = 0.01). Between procedures, symptomatic women undergoing CAS showed higher rates of mortality (CAS: 4.19%, CEA: 0.47%, P = 0.01) and combined (stroke/mortality) events (CAS: 12.09%, CEA: 6.05%, P = 0.02). In all other cohorts, no statistically significant difference was found between the procedures. Conclusions: Compared to CEA, CAS led to inferior in-hospital outcomes only in symptomatic women in the last decade in NYS. Men and asymptomatic women showed comparable outcomes after both procedures, whereas asymptomatic females were more prone to AMI after both interventions. These sex-associated differences should be taken into account for the treatment of carotid artery disease.

The Impact of Gender on In-hospital Outcomes after Carotid Endarterectomy or Stenting

AimWe sought to better define the impact of sex on ‘in-hospital outcomes’ after carotid endarterectomy (CEA) or stenting (CAS). MethodsHospital discharge databases for all carotid interventions obtained from the New York State (NYS) Department of Health, Statewide Planning and Research Cooperative System between 2000 and 2009 (29,917 women, 39,771 men) were analysed. Mortality, stroke and composite event (stroke/death) were compared between procedures after matching of patients by propensity score. Acute myocardial infarction (AMI) was our secondary ‘end’ point. ResultsMore than 90% of patients in both sexes were asymptomatic (27,439 women and 36,295 men). Compared to men, asymptomatic women experienced more strokes after CEA (women: 1.38%, men: 1.16%, P = 0.03) and higher AMI rates after both procedures (CEA; women: 0.75%, men: 0.51%, P = 0.0009, CAS; women: 0.96%, men: 0.28%, P = 0.01). Between procedures, symptomatic women undergoing CAS showed higher rates of mortality (CAS: 4.19%, CEA: 0.47%, P = 0.01) and combined (stroke/mortality) events (CAS: 12.09%, CEA: 6.05%, P = 0.02). In all other cohorts, no statistically significant difference was found between the procedures. ConclusionsCompared to CEA, CAS led to inferior in-hospital outcomes only in symptomatic women in the last decade in NYS. Men and asymptomatic women showed comparable outcomes after both procedures, whereas asymptomatic females were more prone to AMI after both interventions. These sex-associated differences should be taken into account for the treatment of carotid artery disease.

Management of carotid disease in patients undergoing coronary artery bypass surgery

The management of concurrent severe carotid and coronary disease is a subject of ongoing debate in the absence of randomized clinical trials. Amidst the growing controversy, the clinician has to carefully tailor the best strategy for a given patient based on neurologic and cardiac symptoms. This review aims to compile current evidence in this area to help plan strategies for the optimal management of coexisting severe carotid and coronary disease. Carotid revascularization with carotid endarterectomy (CEA) or stenting (CAS) is frequently performed in conjunction with coronary artery bypass surgery (CABG) in the United States for asymptomatic carotid disease. The risk of perioperative stroke with unilateral asymptomatic 70-99% carotid stenosis is likely small based on several observational data. Moreover, the risk associated with both staged and combined CEA-CABG procedures in the asymptomatic population may outweigh any benefit. Carotid artery stenting is an alternative option in patients with severe coronary disease who are considered 'high risk' for CEA. Neurologically symptomatic patients require carotid revascularization prior to or in conjunction with CABG surgery. Ultimately, the choice of carotid revascularization or conservative management will depend on clinical characteristics, anatomy, and local expertise. Severe carotid disease in the CABG population is often unilateral and asymptomatic. Based on the available data, conservative carotid therapy in the low-risk asymptomatic individuals is likely the best treatment option. Carotid revascularization may be justified in symptomatic or high-risk patients such as those with contralateral carotid occlusion or bilateral severe stenosis.

Asymptomatic Carotid Stenosis

See related article, p 702. In this issue of Stroke , Hirt1 reports that substantial progression of carotid stenosis predicted ipsilateral stroke or transient ischemic attack among patients randomized to medical therapy in the Asymptomatic Carotid Surgery Trial (ACST).2 This might be regarded as another justification to perform carotid endarterectomy (CEA) or stenting (CAS) in some patients with asymptomatic carotid stenosis (ACS), and Hirt’s article may help in the selection for invasive treatment of those ACS patients at highest risk of having a stroke. However, the proportion of patients with progression by ≥2 grades (which carried a high enough risk to identify patients who might benefit from invasive intervention) was small. Among the 1469 patients in the study, there were events in only 50 (3.4%), among the 117 (8%) of patients with progression by ≥2 grades of stenosis. It must also be understood that the ACST trial was conducted before the widespread implementation of intensive medical therapy that has diminished the stroke risk picture markedly. The current situation in the United States is deplorable: as many as 95% of CEA and CAS procedures are being performed in patients with asymptomatic stenoses,3 and most of these patients are more likely to be harmed than helped by these interventions. This is being justified on the basis of historical stroke risks in the ACST2 and the Asymptomatic Carotid Surgery Trial.4 These risks …

Asymptomatic Carotid Surgery Trial-2 (ACST-2): Rationale for a Randomised Clinical Trial Comparing Carotid Endarterectomy with Carotid Artery Stenting in Patients with Asymptomatic Carotid Artery Stenosis

To compare carotid endarterectomy with carotid artery stenting in the prevention of stroke in patients with asymptomatic carotid stenosis. A large, simple, pragmatic international trial of at least 5000 patients with asymptomatic carotid stenosis in whom intervention is thought to be needed but where there is substantial uncertainty about the appropriate choice of treatment. The trial is designed to fit in easily with normal clinical practice. A short (approximately 2 min) telephone call is made to randomise patients to either carotid endarterectomy (CEA) or stenting (CAS). Follow-up by the collaborator will be at one month after the procedure (simple 1-page form) and by the ACST office for 5-years post-procedure. Data will be analysed on an intention-to-treat basis; main outcomes will be 30-day myocardial infarction, stroke and death, and 5-year stroke rates. In addition, appropriate subgroup analyses will be undertaken, and health economic evaluation will consider procedural and stroke-related healthcare costs and quality of life. Collaborators who routinely undertake CEA and CAS are encouraged to participate in ACST-2. This trial, now funded and open for randomisation, will provide important evidence comparing the immediate and long-term safety and efficacy of carotid endarterectomy and stenting in patients with asymptomatic carotid stenosis.