Endarterectomy In Patients Research Articles

Early carotid endarterectomy in patients with symptomatic carotid stenosis in the acute period of ischemic stroke

To identify the optimal timing of CEA in patients with hemodynamic significant stenosis of carotid arteries in the acute period of ischemic stroke (IS). 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. 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.

Outcomes after early and delayed carotid endarterectomy in patients with symptomatic carotid artery stenosis

ObjectiveThe objective of this study was to define outcomes after carotid endarterectomy (CEA) in patients with symptomatic carotid artery stenosis (CAS) when patients are operated on within 14 days after onset of symptoms. MethodsClinical data of consecutive patients who underwent CEA between 2003 and 2012 for symptomatic CAS were reviewed. Patients were classified into group 1, CEA ≤14 days of minor stroke or transient ischemic attack, and group 2, CEA >14 days. Primary end point was stroke/death; secondary end points were stroke, death, and myocardial infarction. ResultsThere were 233 patients (32% female; mean age, 72 ± 9.1 years) who underwent 238 CEAs. Group 1 included 57 CEAs in 56 patients; 11 CEAs were performed at 0 to 2 days, 23 at 3 to 7 days, and 23 at 8 to 14 days. Group 2 included 181 CEAs in 177 patients. One death (group 2) and five strokes (group 1, four; group 2, one) occurred at 30 days (stroke/death, 2.6%), more in group 1 vs group 2 (7.1% vs 1.1%; P = .03). In group 1, three strokes occurred when the patients were operated on within 2 days (27% [3/11]), more than at 3 to 7 days (0% [0/22]) or 8 to 14 days (4.3% [1/23]; P = .008). Patients operated on between days 3 and 14 had similar stroke/death rate to those operated on after 14 days (2.2% vs 1.1%; P = .49). Myocardial infarction occurred in six patients (2.5%; group 1, 0% [0/57]; group 2, 3.3% [6/177]; P = .34). Median follow-up was 7.0 years (interquartile range, 4.6-9.9 years). Freedoms from stroke/death were similar between groups (hazard ratio [HR], 1.22; 95% confidence interval [CI], 0.75-1.99; P = .42), 69% for group 1 and 76% for group 2 at 5 years. Age ≥80 years, high surgical risk, and no preoperative P2Y12 antagonist use predicted stroke/death. Freedoms from any stroke were similar in groups (HR, 2.46; 95% CI, 0.95-6.41; P = .06); survivals were also similar (HR, 1.12; 95% CI, 0.67-1.87; P = .67) at 5 years. ConclusionsIn this single-center study, CEA in symptomatic patients had a 30-day stroke/death rate of 2.6%. Age ≥80 years and high surgical risk predicted late stroke or death; taking P2Y12 antagonists was associated with late stroke. High stroke rates when patients were operated on immediately support CEA after 2 days in symptomatic patients with CAS.

Risk-adjusted hospital outcomes in elective carotid artery surgery in patients with Medicare

BackgroundThe risk-adjusted outcomes by hospital of elective carotid endarterectomy that is inclusive of inpatient and 90-day postdischarge adverse outcomes have not been studied. MethodsWe studied Medicare inpatients to identify hospitals with 25 or more qualifying carotid endarterectomy cases between 2012–2014. Risk-adjusted prediction models were designed for adverse outcomes of inpatient deaths, 3-sigma prolonged duration-of-stay outliers, 90-day postdischarge deaths without readmission, and 90-day postdischarge associated readmissions. Standard deviations of predicted overall adverse outcomes were computed for each hospital. Hospital-specific z scores and risk-adjusted adverse outcomes were calculated. ResultsThere were 77,086 carotid endarterectomy patients from 960 hospitals complicated by 191 inpatient deaths (0.25%), 4,436 prolonged duration of stay (5.8%), 457 90-day postdischarge deaths (0.6%), and 7,956 90-day postdischarge associated readmissions (10.3%). In the 90-day postdischarge associated readmission patients, an additional 561 patients died after readmission, for total deaths of 1,209 (1.6%) for the study period, and 11,928 (15.5%) patients had one or more adverse outcomes. There were 29 best-performing hospitals (3.0%) with z scores of −2.0 or less (P < .05) with a median rate of risk-adjusted adverse outcomes of 7.1%. A total of 61 suboptimal performers (6.3%) had z scores of +2.0 or greater (P < .05) with a median rate of risk-adjusted adverse outcome rate of 26.4%. ConclusionHospital risk-adjusted adverse outcome rates for carotid endarterectomy are highly variable. Comparisons of hospital performance define the opportunity for improvement.

Long-Term Outcome After Carotid Endarterectomy in Patients with Ischemic Heart Disease.

The long-term outcome after carotid endarterectomy (CEA) is determined by many confounding factors. Ischemic heart disease (IHD) is linked to atherosclerotic stroke, and it is an important cause of death during the perioperative and follow-up periods after CEA. We aimed to investigate mortality and long-term major adverse cardiovascular events (MACEs) in patients with IHD compared with patients who do not have IHD. We consecutively enrolled 229 patients who underwent CEA procedures from 2000 to 2011. Of these patients, 45 had known or probable IHD defined by history or medical record of myocardial infarction, stable/unstable angina, previous coronary revascularization such as percutaneous coronary intervention or coronary artery bypass graft, or positive stress test. Long-term outcome was identified by using death certificates from the Korean National Statistical Office and telephone interviews by June 2013. We investigated predictors of early (≤30 days) and long-term mortality and MACEs (stroke, myocardial infarction, and death). Mean follow-up period was 49 months. Cox proportional analysis adjusted for potent predictors revealed symptomatic stenosis (hazard ratio, 1.72; 95% confidence interval, 1.02-2.88; P= 0.042) and presence of IHD (hazard ratio, 1.93; 95% confidence interval, 1.09-3.42; P= 0.025) as significant predictors of long-term MACEs. Kaplan-Meier analysis showed a significantly lower rate of survival (P= 0.030) and MACE-free survival (P= 0.003) in the IHD group. In this study, a poor long-term outcome was observed in patients with IHD and symptomatic stenosis but not in patients with conventional high-risk factors for surgery. Therefore, appropriate evaluation and treatment of IHD before and after CEA might be helpful for better outcome.

Is carotid revascularization worthwhile in patients waiting for kidney transplantation?

Renal failure and haemodialysis are associated with an increased risk of cardiovascular disease. Patients undergoing renal transplantation undergo rigorous pre-operative vascular assessment, including optimisation of risk factors for stroke. The indication for carotid intervention and the threshold for carotid endarterectomy in asymptomatic patients with incidental carotid disease has not been clarified in the context chronic kidney disease (CKD). This review aims to analyse outcomes following carotid endarterectomy in patients with CKD, in order to ascertain whether general guidelines for carotid artery revascularisation apply to this specific cohort. The current literature suggests that outcomes following internal carotid artery (ICA) revascularisation are worse in symptomatic and asymptomatic CKD patients compared to the non-CKD population. Consequently, asymptomatic patients with renal failure should be managed conservatively prior to renal transplantation, whilst those with symptomatic disease should be treated according to general guidelines but be informed of higher associated risk of stroke and death. Multidisciplinary optimisation remains essential in all patients waiting for potential renal transplantation.

Prediction models for clinical outcome after a carotid revascularisation procedure: A systematic review.

IntroductionPrediction models for clinical outcome after carotid artery stenting or carotid endarterectomy could aid physicians in estimating peri- and postprocedural risks in individual patients. We aimed to identify existing prediction models for short- and long-term outcome after carotid artery stenting or carotid endarterectomy in patients with symptomatic or asymptomatic carotid stenosis, and to summarise their most important predictors and predictive performance.Patients and methodsWe performed a systematic literature search for studies that developed a prediction model or risk score published until 22 December 2016. Eligible prediction models had to predict the risk of vascular events with at least one patient characteristic.ResultsWe identified 37 studies that developed 46 prediction models. Thirty-four (74%) models were developed in carotid endarterectomy patients; 27 of these (59%) predicted short-term (in-hospital or within 30 days) risk. Most commonly predicted outcome was stroke or death (n = 12; 26%). Age (n = 31; 67%), diabetes mellitus (n = 21; 46%), heart failure (n = 16; 35%), and contralateral carotid stenosis ≥50% or occlusion (n = 16; 35%) were most commonly used as predictors. For 25 models (54%), it was unclear how missing data were handled; a complete case analysis was performed in 15 (33%) of the remaining 21 models. Twenty-eight (61%) models reported the full regression formula or risk score with risk classification. Twenty-one (46%) models were validated internally and 12 (26%) externally. Discriminative performance (c-statistic) ranged from 0.66 to 0.94 for models after carotid artery stenting and from 0.58 to 0.74 for models after carotid endarterectomy. The c-statistic ranged from 0.55 to 0.72 for the external validations.DiscussionAge, diabetes mellitus, heart failure, and contralateral carotid stenosis ≥50% or occlusion were most often used as predictors in all models. Discriminative performance (c-statistic) was higher for prediction models after carotid artery stenting than after carotid endarterectomy.ConclusionThe clinical usefulness of most prediction models for short- or long-term outcome after carotid artery stenting or carotid endarterectomy remains unclear because of incomplete reporting, methodological limitations, and lack of external validation.

Immediate results of carotid endarterectomy in patients receiving statin therapy

Given the retrospective analysis of the immediate result of carotid endarterectomy in patients with atherosclerotic hemodynamically significant unilateral lesion of the internal carotid artery on statins therapy. 262 carotid endarterectomy in 262 patients are executed. The postoperative period averaged 7.8 days, survival after surgical treatment of 98.86%. The initial condition of the carotid arteries was determined data by duplex scanning, the presence of risk factors and level of lipid profile that have a statistically significant influence on the development of complications in patients receiving statins therapy (p&lt;0.05). Each risk factor did not have a statistically significant impact, however the presence of three or more factors reliably more often aggravated the course of atherosclerosis and increased the incidence of complications (p=0.04). Defined the reliable interrelation of dependence of a lipid profile level (a cholesterol and low density lipoproteins (LDL)) and weight of a course of initial atherosclerotic changes. The maximal values of cholesterol level 5.39±1.13 mmol/l were determined in patients with stenosis of internal carotid artery from 70 to 89% (р=0.05). In all cases of a stenosis of 90% there was increase in level of triglycerides to 1.75±1.05 mmol/l (р=0.05). LDL in all patients registered above the recommended values of 3.45±1.19 mmol/l. However, it is worth noting against the background of statin therapy, the level of high density lipoproteins in the average values did not decrease below 1.46±0.46 mmol/l (p=0.05). Statin therapy has a different degree of influence on the achievement of recommended values of lipid metabolism and the development of complications. In one case (0.38%) there were recorded stroke, transient ischemic attack and myocardial infarction. So effective is the use of synthetic statins III and IV generations: atorvastatin and rosuvastatin. Statin therapy in the preoperative period and continued after surgical important for achieve the surgery to prevent complications. Correction risk factors, such as hypertension, diabetes, smoking, dyslipidemia and other, helps to improve treatment outcomes.

Frequency of Coronary Endarterectomy in Patients Undergoing Coronary Artery Bypass Grafting at a Single Tertiary Texas Hospital 2010 to 2016 With Morphologic Studies of the Operatively Excised Specimens

This study examines the frequency of coronary endarterectomy (CE) procedures during coronary artery bypass grafting (CABG), and determines the quantity of plaque in the specimens. Of the 2,268 CABG operations performed from January 2010 to June 2016, 35 patients had CE during CABG. The specimens were incised into 5-mm cross sections, stained by the Movat method, and examined. The number of CEs performed ranged from 0.21% to 4.01%. A total of 140 cm of specimens were examined, and all 140 cm contained considerable quantities of atherosclerotic plaque and narrowed lumens. The quantity of plaque present was similar to or greater than that observed in previously studied patients with fatal coronary artery disease. The frequency of CE during CABG varies greatly in surgeons. The quantity of plaque is enormous, and the lumens are severely narrowed.

Differential Expression of microRNAs in Severely Calcified Carotid Plaques

We investigated whether microRNA (miRNA) alteration is related to the presence of calcification in carotid plaques. We classified 10 plaques from carotid endarterectomy patients into high- and low-calcified plaques based on Agatston calcium scores. A microarray analysis for miRNA profiles was performed, with validation by a miRNA quantitative real-time polymerase chain reaction (qRT-PCR). The miRNA microarray identified 697 probes; 657 of them were downregulated. We selected the genes that satisfied total gene signal (TGS) >50, |Log2 ratio| > 1 and ≥1 of the following: (1) false discovery rate (FDR) <.05 in the comparison of mean values of logarithmic transformed signals between the groups; (2) .05 ≤ FDR < .1 and showing either high or median for context score+ in miRSearch among the 72 carefully selected genes related to angiogenesis or calcification; and (3) FDR<.1 in the comparison of 10 individual sets of high- and low-calcified plaques. The expression of miRNA validated by qRT-PCR revealed a significant downregulation of hsa-miR-4530, hsa-miR133b, and hsa-miR-1-3p. A Spearman's rank correlation analysis revealed that the logarithmic TGSs for the microarray of hsa-miR-4530 and hsa-miR-133b were significantly inversely correlated with the carotid plaques' calcium scores, and the delta Cq values for the qRT-PCR showed a direct association. In high-calcified carotid plaques, a specific profile for miRNA may be identified, and the expressions of hsa-miR-4530 and hsa-miR-133b had inverse correlations with the calcium score in the plaques, suggesting that miRNAs may play a modulating role in calcified plaques and plaque stability.

Combined Stump Pressure and Oximetry for Shunt Use During Carotid Endarterectomy.

Cross-clamp ischemia during carotid endarterectomy can be prevented with carotid bypass shunts in vulnerable patients identified by cerebral monitoring for ischemia. We compared transcranial cerebral oximetry (TCO) with carotid stump pressure measurements for selective shunt use. We prospectively collected data on 300 consecutive patients operated on under general anesthesia between 2009 and 2016. Shunts were inserted for a 10% or greater drop in cerebral saturations and/or a mean stump pressure less than 40 mmHg. Seventy-five patients, 25% of the study population, were shunted. The indication was a combined desaturation and stump pressure in 38 (50% of the shunted group), desaturation alone in 11 patients (15%), and a low stump pressure alone in 26 patients (35%). There were no significant differences in baseline characteristics between those patients who were or were not shunted, except angiographic collateral blood supply, which was more commonly identified in patients who were not shunted. A watershed infarct occurred in just one patient with borderline TCO and stump pressure measurements in whom a shunt was not used. There was poor concordance between TCO and stump pressures, but using both in determining the need for shunt use almost eliminated cross-clamp ischemia in this series of 300 carotid endarterectomy patients.

Association between operator specialty and outcomes after carotid artery revascularization

ObjectiveTo examine the association between operator specialty and 30-day outcomes among patients undergoing carotid endarterectomy and carotid artery stenting. MethodsWe conducted a population-based, observational cohort study of all individuals who underwent carotid endarterectomy or stenting in Ontario, Canada (population, 13.6 million) between April 1, 2002, and March 1, 2015, using administrative claims databases. We stratified endarterectomy and stenting patients according to operator specialty, and followed them for 30 days after the procedure. For carotid endarterectomy, we compared outcomes between vascular surgeons and nonvascular surgeons. For carotid artery stenting, we compared outcomes between radiologists and neurosurgeons. We built multilevel multivariable logistic regression models adjusted for patient demographics, comorbidities, carotid artery symptom status, and annual institutional and operator volume to examine rates of 30-day stroke or death. ResultsA total of 16,544 patients were studied (n = 14,301 endarterectomy and n = 2243 stenting). Vascular surgeons performed the majority (55.7%) of carotid endarterectomy procedures, followed by neurosurgeons (21.0%), general surgeons (15.3%), and cardiac surgeons (7.9%). Radiologists (82.5%) and neurosurgeons (17.5%) performed carotid artery stenting. In the endarterectomy group, the risk of stroke or death was higher among patients treated by nonvascular surgeons (4.0%) compared with vascular surgeons (2.9%; adjusted odds ratio [OR], 1.32; 95% confidence interval [CI], 1.08-1.62; P = .008). This difference was driven by a higher rate of stroke among nonvascular surgery-treated patients (3.6%) compared with vascular surgery-treated patients (2.5%; adjusted OR, 1.38; 95% CI, 1.11-1.71). The risk of death was similar between the two groups. With respect to specific nonvascular surgery specialties, the rate of 30-day stroke or death was higher in endarterectomy patients treated by neurosurgeons (4.1%; adjusted OR, 1.27; 95% CI, 1.00-1.61) and cardiac surgeons (4.4%; adjusted OR, 1.54; 95% CI, 1.04-2.30) compared with vascular surgeons (2.9%). Patients who underwent carotid artery stenting by radiologists vs neurosurgeons experienced 30-day stroke or death at similar rates (8.0% vs 7.9%, respectively; adjusted OR, 1.07; 95% CI, 0.66-1.74; P = .79). ConclusionsThe risk for periprocedural stroke or death was significantly higher among carotid endarterectomy patients treated by nonvascular surgeons (neurosurgeons and cardiac surgeons) compared with vascular surgeons. Operator specialty did not seem to have a significant effect on periprocedural outcomes among patients who underwent carotid artery stenting. These results can have implications for physician referral practices and local policies.

Quantification of carotid plaque lipid content with magnetic resonance T2 mapping in patients undergoing carotid endarterectomy.

Background and purposeTechniques to stratify subgroups of patients with asymptomatic carotid artery disease are urgently needed to guide decisions on optimal treatment. Reliance on estimates of % luminal stenosis has not been effective, perhaps because that approach entirely disregards potentially important information on the pathological process in the wall of the artery.MethodsSince plaque lipid is a key determinant of plaque behaviour we used a newly validated, high-sensitivity T2-mapping MR technique for a systematic survey of the quantity and distribution of plaque lipid in patients undergoing endarterectomy. Lipid percentage was quantified in 50 carotid endarterectomy patients. Lipid distribution was tested, using two imaging indices (contribution of the largest lipid deposit towards total lipid (LLD %) and a newly-developed LAI ‘lipid aggregation index’).ResultsThe bifurcation contained maximal lipid volume. Lipid percentage was higher in symptomatic vs. asymptomatic patients with degree of stenosis (DS ≥ 50%) and in the total cohort (P = 0.013 and P = 0.005, respectively). Both LLD % and LAI was higher in symptomatic patients (P = 0.028 and P = 0.018, respectively), suggesting that for a given plaque lipid volume, coalesced deposits were more likely to be associated with symptomatic events. There was no correlation between plaque volume or lipid content and degree of luminal stenosis measured on ultrasound duplex (r = -0.09, P = 0.53 and r = -0.05, P = 0.75), respectively. However, there was a strong correlation in lipid between left and right carotid arteries (r = 0.5, P <0.0001, respectively).ConclusionsPlaque lipid content and distribution is associated with symptomatic status of the carotid plaque. Importantly, plaque lipid content was not related to the degree of luminal stenosis assessed by ultrasound. Determination of plaque lipid content may prove useful for stratification of asymptomatic patients, including selection of optimal invasive treatments.

Early results following synchronous coronary artery bypass grafting and carotid endarterectomy: a propensity score matched comparison with solely carotid endarterectomy

Background: The optimal management for patients with concomitant severe coronary artery disease (CAD) and carotid artery stenosis (CAS) remains controversial. Methods: One hundred and two solely carotid endarterectomy (CEA) patients were matched to 34 synchronous CEA and coronary artery bypass grafting (CABG) patients according to the propensity score during 7 years. We retrospectively analyzed the baseline characteristics and 30-day results of both groups. Results: The two groups were similar with regard to age, sex, the degree of CAS, the incidence of hypertension, diabetes mellitus (DM), smoking, hyperlipidemia and symptomatic CAS. Higher incidence of contralateral >70% CAS occurred in synchronous CEA/CABG group (29.4% vs . 13.7%, P=0.038). More CAD was present in synchronous CEA/CABG group (12.7% vs . 100%, P vs . 0.55±0.09, P vs . 1.98±1.67, P Conclusions: Our study suggested that the 30-day mortality and morbidity rate of synchronous CEA/CABG was comparable to solely CEA. Our results add to the controversy of the outcomes of synchronous CEA/CABG procedure. Further prospective randomized controlled trial is needed to definitely evaluate the results of synchronous CEA/CABG.

The Nerve of it all! Improving Compliance for Periprocedural Neurological Assessments for Carotid Endarterectomy (CEA) and Carotid Artery Stent (CAS) Patients

Stroke is a major comorbidity for CEA/CAS patients (3%-6%) periprocedural. Patients require stringent monitoring post procedure (vital signs & neurological checks) to assess for neurological decline, initiate expedited treatment as necessary for improved patient outcomes. Post assessment auditing demonstrated 37% compliance with documentation of neurological assessments.

Routine Shunting During Carotid Endarterectomy in Patients With Acute Watershed Stroke.

To evaluate the protective role of routine shunting in patients with acute watershed stroke (WS) undergoing carotid endarterectomy (CEA). A total of 138 patients with symptomatic carotid stenosis (SCS) who underwent CEA after acute ischemic stroke from March 2008 to March 2015 were included in this study. Transient ischemic attacks were excluded. These patients were divided into 2 groups according to the topographic pattern of the stroke on magnetic resonance imaging: group 1, territorial strokes (TS) caused by emboli of carotid origin, and group 2, WS caused by a hemodynamic mechanism related to an SCS. Primary end points were 30-day mortality and postoperative neurological morbidity. The insertion of a Pruitt carotid shunt was performed systematically. Ninety (65.2%) patients presented a TS of carotid origin and were included in group 1, and 48 (34.8%) of the 138 patients had a WS related to an SCS and were included in group 2. The median time between clinical onset of the cerebral ischemic event and surgery was 9 days (range: 0-89 days). Postoperative mortality was 0%. Seven (5.1%) patients had an aggravation of the neurological status during the postoperative period, of whom 2 presented a complete regression of the symptoms in less than 1 hour (definitive postoperative neurologic morbidity: 3.6%). Postoperative neurologic morbidity rate was significantly higher in the TS group (7 of 90; 7.8%) compared to the WS group (0 of 48; P = .04). No other independent predictive factor of neurologic morbidity after CEA for an SCS was found. Our results suggest that routine shunting should be considered in case of acute WS since it may play a protective role. Further studies are eagerly awaited to better define the timing and the best treatment option for both acute WS and TS related to an SCS in order to reduce postoperative neurologic morbidity.

CREST-2: Identifying the Best Method of Stroke Prevention for Carotid Artery Stenosis: National Institute of Neurological Disorders and Stroke Organizational Update.

One of the great achievements of modern medicine is the successful prevention of stroke and other cardiovascular diseases. Although the incidence of stroke has substantially declined over the last 30 years, ≈200 000 preventable stroke deaths still occur annually in the United States. According to a recent study based on the Greater Cincinnati/Northern Kentucky Stroke Study, annually ≈41 000 strokes in the United States are attributed to extracranial internal carotid artery stenosis. Early revascularization for symptomatic carotid stenosis—that is, in patients with recent ipsilateral stroke or TIA—is well established as effective at preventing ipsilateral stroke. Carotid stenosis in the absence of symptoms is extremely common, but the best treatment is unclear. While 2 randomized trials showed a benefit of carotid endarterectomy (CEA) over antiplatelet therapy with aspirin, the number needed to treat approaches 200. Does aggressive risk factor control change that balance? Population screening for carotid stenosis followed by revascularization is considered to cause net harm. Are complication rates from endarterectomy and stenting now low enough to justify expanding their indications in asymptomatic patients? The National Institute of Neurological Disorders and Stroke (NINDS)–funded CREST-2 trial (Carotid Revascularization and Medical Management for Asymptomatic Carotid Stenosis Trial) is an ambitious attempt to further refine the treatment of asymptomatic carotid stenosis. As one of the largest randomized stroke prevention trials, the first CREST (Carotid Revascularization Endarterectomy Versus Stenting Trial) was designed to compare the safety and efficacy of 2 stroke prevention procedures for carotid artery narrowing—CEA and carotid artery stenting (CAS)—in symptomatic and asymptomatic individuals. Starting in December 2000, this NINDS-funded trial enrolled >2500 patients at 117 sites in the United States and Canada. Because of slow enrollment, the trial took 9 years to complete. In 2010, the results of CREST indicated that the 2 revascularization procedures were equivalent for …

202 - Targeting the Oncogenic Nexus of SETBP1-Set-PP2A by Structure Guided Small Molecule Design and Fragment Based Chemical Synthesis

Carotid artery stenting remains an effective alternative to carotid endarterectomy for stroke prevention; however, the long-term durability of carotid artery stenting remains poorly defined. We performed a 10-year “real-world” comparative analysis of carotid endarterectomy and carotid artery stenting to help evaluate the success of these procedures in preventing late ischemic stroke events.This was a single-center retrospective review of 996 patients (symptomatic and asymptomatic) treated with carotid endarterectomy or carotid artery stenting from January 2001 through December 2011 at a tertiary academic medical center. All-cause death, stroke, and myocardial infarction event rates were analyzed using log-rank analysis.Among the 996 patients treated with carotid endarterectomy (n = 787) or carotid artery stenting (n = 209), the 30-day, 1-year, 5-year, and 10-year survival rates for carotid endarterectomy patients were 99.1%, 95.3%, 77.9%, and 54.8%; carotid artery stenting rates were 99.5%, 96.2%, 67.8%, and 40.2%, respectively (P = .005, at 10 years). There was no significant difference in early stroke rates or myocardial infarction rates between the groups. Subgroup analysis comparing symptomatic status demonstrated no statistically significant differences in overall survival, stroke, or myocardial infarction rates at 10 years. In addition to reduced long-term overall survival, carotid artery stenting patients had a higher long-term restenosis rate as compared to carotid endarterectomy (6.3% vs 2.8%, P < .0001) and reduced restenosis-free survival (P = .01).Early death, stroke, and myocardial infarction rates are comparable after carotid endarterectomy and carotid artery stenting. Carotid artery stenting is an effective means of preventing stroke among patients with carotid artery stenosis. Symptomatic status does not seem to affect rates of stroke, myocardial infarction, or death. Carotid endarterectomy continues to be the preferred long-term solution for extracranial carotid artery occlusive disease as it is associated with better long-term survival and lower restenosis rates.

Demographic And Technical Risk Factors Of 30-Day Stroke, Myocardial Infarction, And/Or Death In Standard And High Risk Patients Who Underwent Carotid Angioplasty And Stenting

Background: Carotid angioplasty and stenting (CAS) is an accepted treatment to prevent stroke in patients with carotid artery stenosis. The purpose of this study is to identify risk factors for major complications after carotid angioplasty and stenting.Methods and Material: This is a prospective study conducted at Shiraz University of Medical Sciences in southern Iran from March 2011 to June 2014. Consecutive patients undergoing carotid angioplasty and stenting were enrolled. Both standard risk and high risk patients for endarterectomy were enrolled. Demographic data, atherosclerotic risk factors, site of stenosis, degree of stenosis, and data regarding technical factors were recorded. 30-day stroke, myocardial infarction, and/or death were considered as the composite primary outcome of the study.Results: two hundred and fifty one patients were recruited (mean age: 71.1+ 9.6 years, male: 65.3%). One hundred and seventy eight (70.9%) patients were symptomatic; 73 (29.1%), 129 (51.4%), 165 (65.7%) and 62 (24.7%) patients were diabetic, hyperlipidemic, hypertensive and smoker respectively. CAS performed for left ICA in 113 (45.4%) patients. 14 (5.6%) patients had Sequential bilateral stenting. Mean stenosis of operated ICA was 80.2 +13.8 %. Embolic protection device was used in 203 (96.2%) patients. Predilation and post-dilation were performed in 39 (18.5%) and 182 (86.3%) patients respectively. Composite outcome was observed in 3.6% (3.2% stroke, 0% myocardial infarction and 1.2% death). Left sided lesions and presence of DM was significantly associated with poor short term outcome. (P value: 0.025 and 0.020, respectively)Conclusion: There was a higher risk of short term major complications in diabetic patients and left carotid artery intervention.

Comparing short and long term survival of patients undergoing off pump coronary artery bypass graft with and without coronary endarterectomy

Background and aimThere is some controversy about survival of coronary endarterectomy (CE) patients, so the current study aims to compare short and long term survival of patients undergoing off pump coronary artery bypass graft (OPCAB) with and without coronary endarterectomy. Patients and methodswe performed a retrospective analysis of data on patients undergoing OPCAB and CE between 2011 and 2012. Preoperative, perioperative and postoperative data collected from data bank. Follow-up information was obtained from telephone contact mean time 37.13±23.82months after surgery. Early and late outcomes were compared by univariate and Kaplan-Meier analysis. ResultOPCAB was performed in 474 patients, which 69 of them had a CE. The mean long term survival was similar between OPCAB (56.28±0.61) and OPCAB+CE (55.54±1.3) groups (p=0.66). Multiple Cox regression shows that age, gender, BMI, EF and angina were significant predictors of mortality. Patients undergoing CE have a long term intensive care unit (ICU) stay (51.31±5.59 vs 37.23±0.88, P=0.015) and blood transfusion was higher in CE group (650.62±110 vs. 324.71±22, P=0.001). ConclusionThe current study demonstrates that results of CE are acceptable with respect to short and long -term survival. Patients undergoing CE required long term ICU stay and higher blood transfusion.

How to Clamp and Bypass if There Is Single Artery Supply to the Head and That Contains Severe Stenosis?

Takayasu arteritis manifests with arterial occlusions and aneurysms. Revascularization is sometimes challenging, especially when carotid arteries are affected. In this report, we present a carotid artery revascularization technique in a patient who was admitted with orthostatic and postprandial transient ischemic attacks, resulting in a diagnosis of bilaterally occluded subclavian and vertebral arteries, occluded left common carotid artery, and severely stenosed right common carotid artery. Clamping of the right carotid artery was a challenge; however, our technique provides a neurologically safe revascularization.