Endarterectomy For Treatment Research Articles

Percutaneous intervention versus surgery in the treatment of common femoral artery lesions: study protocol for the prospective, multi-center, randomized PESTO-CFA trial

BackgroundEndovascular therapy has become established as a first-line therapy in most arterial regions. However, open vascular surgery (endarterectomy) remains the treatment of choice for common femoral artery (CFA) lesions. The aim of this study is to investigate the acute and mid-term results of directional atherectomy plus drug-coated balloon (DCB) in comparison to endarterectomy in treatment of de novo arteriosclerotic CFA lesions.MethodsThis prospective, randomized, multicenter non-inferiority study will enroll 306 participants with symptomatic (Rutherford category 1 to 5) de novo stenosis of the CFA including the bifurcation. Patients eligible for both treatment groups could be included in this 1:1 randomized trial. Primary efficacy endpoint is patency of the target lesion at 12 months defined as restenosis < 50% without the need of clinically driven target lesion revascularization (cdTLR). Primary safety endpoint is a combined endpoint including death, myocardial infarction, major or minor amputation of the target limb, and peri-procedural complications at 30 days. Secondary endpoints include primary patency of the target lesion at 6 and 24 months, secondary patency, cdTLR 6, 12, and 24 months, change in ankle-brachial index, and Rutherford-Becker class at 6, 12, and 24 months. Limb salvage, change in quality of life measured by Walking Impairment Questionnaire, and major adverse events including death, myocardial infarction, and minor or major amputation of the target limb will be determined at 6, 12, 24, and 36 months.DiscussionEndovascular treatment of CFA lesions is still a matter of debate. Few studies compared modern endovascular therapy methods against the so-called gold standard surgical endarterectomy so far. Based on recent positive results, this study aims to confirm non-inferiority of a “leaving nothing behind” endovascular approach combining directional atherectomy and DCB compared to surgical therapy.Trial registrationClinicalTrials.gov NCT02517827.

Carotid Angioplasty and Stenting for Atherosclerotic Stenosis: Case Series

AbstractBackground: Carotid artery stenting is an alternative to endarterectomy in treatment of carotid artery stenosis. Com-parative studies have shown different results regarding the outcome of both techniques.Aim of Study: The aim of our study is to present our experience in carotid artery stenting and compare our results with the literature.Patients and Methods: A retrospective analysis of our series of patients who underwent carotid artery angioplasty/ stenting, between January 2011 and April 2018, in Kasr Al-Ainy University Hospital and Sheikh Zayed Specialized Hospital was performed. Peri-procedural and delayed, minor and major complications rates as well as the rate of restenosis over the follow-up period were analyzed.Results: A total of 106 patients who underwent 109 procedures of carotid artery angioplasty/stenting were included for analysis. Average age of patients was 63±7 years, with 71 male (67%). Symptomatic stenosis was seen in 81 cases (74.3%) and asymptomatic stenosis was seen in 28 cases (25.7%). Filter protection device was used in 69 cases (63.3%) and 40 cases (36.7%) were done without protective device. Pre-stent dilatation was performed in 21 cases (19.2%). Post-stent dilatation was performed in 75 cases (68.8%). Both pre and post-stent dilatations were done in 9 cases (8.2%). No balloon dilatation was done in 3 cases (2.7%). In one case (0.9%) angioplasty was done without stenting. Minor compli-cations occurred in 4 cases (3.7%) in the form of 3 cases of intra-procedural and 1 case of post-procedural transient ischemic attack. Two major complications (1.8%) occurred in the form of distal showering with middle cerebral artery occlusion in 1 case, and retroperitoneal hematoma in another case. Two cases (1.8%) of intraprocedural adverse events occurred in the form of dissection without clinical sequelae. Two cases of insignificant restenosis were encountered in the follow-up.Conclusion: Carotid artery stenting is an effective and relatively safe alternative to carotid endarterectomy. Further studies assessing the value of embolic protective devices and the best type of stent should be conducted.

Transcatheter aortic valve implantation through a diseased left common carotid artery: Combined approach with endarterectomy and left carotid‐subclavian bypass

We report a case of transcatheter aortic valve implantation (TAVI) with the self-expanding Medtronic CoreValve bioprosthesis (Medtronic, Minneapolis, MI) through a diseased left common carotid (LCC) artery. This 81-year-old male patient presented with heart failure due to a severe degenerative aortic valve stenosis. Comorbidities included diabetes, hypertension, and dyslipidemia as well as peripheral and coronary artery disease, resulting in a logistic EuroScore II of 25.9%. Consequently, he was rejected to undergo surgery and a transcatheter approach was planned. Due to severe peripheral vascular disease with iliofemoral lesions, significant calcifications and unfavourable angulations of the innominate artery as well as prior bypass surgery precluding a direct aortic and subclavian approach, none of the established access sites were suitable. Therefore, we considered a left carotid access, which had to be combined with a surgical endarterectomy for treatment of a significant common carotid bifurcation stenosis and left subclavian-LCC permanent tunnel bypass graft. The procedure was successful without cardiac, cerebrovascular, or access complications. This case illustrates a true heart team approach, establishing a unique access for TAVI for patients without regular access options.

Carotid endarterectomy for treatment of in-stent restenosis after carotid angioplasty and stenting

Carotid endarterectomy for treatment of in-stent restenosis after carotid angioplasty and stenting

Stenting versus Endarterectomy for Treatment of Carotid-Artery Stenosis

Stenting versus Endarterectomy for Treatment of Carotid-Artery Stenosis

Stenting versus Endarterectomy for Treatment of Carotid-Artery Stenosis

Stenting versus Endarterectomy for Treatment of Carotid-Artery Stenosis

Carotid stenting or surgical carotid endarterectomy to prevent strokes?

Evaluation of: Brott TG, Hobson RW 2nd, Howard G et al.; the CREST Investigators. Stenting versus endarterectomy for treatment of carotid-artery stenosis (CREST trial). N. Engl. J. Med. 363(1), 11–23 (2010).Stroke has a high incidence and is associated with a dramatic degree of morbidity and mortality. Carotid stenosis is responsible for approximately 20% of strokes in all patient populations, and is especially prevalent in elderly patients. Therapies to decrease the risk of stroke are urgently warranted. The first established therapy was surgical endarterectomy. Over the last few years, however, carotid artery stenting has evolved as a less invasive approach. Hitherto, the paper under evaluation (the North American Carotid Revascularization Endarterectomy versus Stenting Trial [CREST]) is the largest and most important study comparing these two treatment modalitites. The study demonstrates comparable effectiveness for carotid stenting and carotid artertectomy to reduce the risk for future strokes.

Is Endovascular Stent Therapy or Endarterectomy More Effective for the Treatment of Symptomatic and Asymptomatic Carotid Stenosis?

Several previous trials comparing the efficacy of endovascular stent therapy to endarterectomy for treatment of symptomatic and asymptomatic carotid stenosis have been inconclusive, with a trend toward superiority for endarterectomy. The CREST (Carotid Revascularization Endarterectomy Versus Stenting Trial) is the largest randomized controlled trial comparing these modalities. It has an added advantage that it incorporated new developments in stent technology as the trial progressed so that valid comparisons could be made with the most modern techniques available.

Management of Stenosis of the Extracranial Internal Carotid Artery: Endarterectomy Versus Angioplasty and Stenting

Recent randomized clinical trial data support the safety and efficacy of carotid artery stenting and carotid endarterectomy for treatment of symptomatic and asymptomatic carotid occlusive disease. Endarterectomy is more effective in preventing stroke, but this may be countered by a higher risk of perioperative myocardial infarction. Age is an important determinant in selecting patients for either carotid endarterectomy or stenting. Patients older than 70years achieve better outcomes with endarterectomy, and younger patients achieve better outcomes with stenting. Comparative clinical and anatomic durability of endarterectomy and stenting will require additional follow-up from recently completed trials. The efficacy of carotid revascularization compared with modern medical therapy in asymptomatic patients remains an important and unanswered clinical question.

Stroke: high rate of occult atrial fibrillation, effects of insulin on growth of infarction and stenting versus endarterectomy for treatment of carotid-artery stenosis

This month’s Journal Club will focus on three clinically relevant articles in the field of stroke. The first article deals with the frequency of atrial fibrillation in patients with cryptogenic stroke. The frequency of detected paroxysmal atrial fibrillation seems to depend very much on the frequency and duration of looking for it. Looking into the future, it may even turn out that paroxysmal atrial fibrillation is much more relevant than previously assumed. In the current article, paroxysmal atrial fibrillation was examined with so-called transtelephonic EKG monitoring in patients with TIA or stroke. In 9.2% of the examined patients previously undetected paroxysmal atrial fibrillation was found, which, of course, has considerable consequences for the secondary prophylaxis, because warfarin or phenprocoumon are indicated and highly effective in the prophylactic treatment. In the second article, the effects of insulin for acute post-stroke hyperglycemia were evaluated. This lowered blood glucose and attenuated an increase in brain lactate, but did not affect cerebral infarct growth. However, in this study only a small number of patients (n = 40) were included. Therefore, the conclusions may not be fully justified. The third and final article deals with a clinically very important issue: stenting versus endarterectomy for the treatment of carotid-artery stenosis. In this study, 2,502 patients with symptomatic or asymptomatic carotid stenosis were prospectively examined for a median follow-up period of 2.5 years. There was no difference in the risk of composite primary outcome. During the periprocedural period, however, there was a higher risk of stroke with stenting and a higher risk of myocardial infarction with endarterectomy.

Stenting versus Endarterectomy for Treatment of Carotid-Artery Stenosis

Stenting versus Endarterectomy for Treatment of Carotid-Artery Stenosis

Stenting Versus Endarterectomy for Carotid Artery Stenosis: What Are the Trade-Offs?

The use of stenting as an alternative to surgical endarterectomy for treatment of carotid artery stenosis is controversial (JW Cardiol Apr 7 2010). In this North American multicenter trial, 2502 adults with carotid stenosis (baseline age, 69) were randomized to undergo endarterectomy or stenting. Forty-seven percent of patients were asymptomatic, and embolic protection was employed …

Clinical selection of endovascular stenting and carotid endarterectomy in treatment of carotid artery stenosis

To explore reasonable clinical decision in treating carotid artery stenosis under different conditions. The data of 133 carotid artery stenosis patients were retrospectively analyzed. Of the patients, 46 cases were treated with carotid angioplasty and stenting (CAS), 87 patients received carotid endarterectomy (CEA). The length of hospital stay and National Institutes of Health Stroke Scale (NIHSS) grade before and after treatment in both groups were observed; the forward flow were assessed by digital subtraction angiography (DSA) before and after treatment; the degree of carotid artery stenosis were determined by using ultrasound during 3 to 24 months after treatment in both groups; the cumulative incidence of major cardiovascular events was concentrated, including appearance of death, stroke or myocardial infarction during 30 days after CAS and CEA and death or homonymy stroke during 31 days to 2 years. Significant difference was found in hospital stay and when NIHSS exceed 20 after treatment between the two groups (P < 0.05); there was no significant difference in the forward flow before and after treatment in both groups; the carotid artery stenosis had been improved significantly after the operation in both groups; the cumulative incidence of major cardiovascular events in CEA group was significantly higher than in CAS group in 30 days after the operation (P < 0.05), but no statistical difference in 31 days to 2 years after the operation. CAS and CEA has equivalent effects in treating carotid artery stenosis, and should be selected according to the location of stenosis, etiological factors and the condition of opposite carotid artery.

Short- and long-term outcome after carotid artery stenting with neuroprotection: single-center experience within a prospective registry

Carotid artery stenting is an alternative method to surgical endarterectomy for treatment of carotid artery stenosis. Three hundred and seventy-one consecutive patients (71+/-9 years) undergoing 405 carotid artery interventions at a single cardiologic center were studied prospectively within a therapy registry. In general, the interventional procedure was performed using neuroprotective devices to prevent distal embolization. Stents were used routinely whenever possible. Independent neurological assessment took place prior to and after carotid stenting. The neurological event rate was assessed in the early (<30 days) and late post interventional period. In asymptomatic patients, 286 interventions were done with a 30-day stroke rate of 1.3% (ipsilateral 1.0%). In symptomatic patients, strokes occurred in a significantly (p<0.005) higher rate of 5.0% after 119 interventions (all ipsilateral). At long-term follow-up (mean 728+/-548 days) additional strokes occurred ipsilateral to the side of carotid intervention in 0.4% of asymptomatic patients (1.7% of symptomatic patients); contralateral strokes were seen at long-term follow-up in 1.1% of asymptomatic (1.7% of symptomatic) patients. Due to their comorbidities, 1.6% of patients died early, and an additional 11.1% late after carotid stenting. Carotid artery stenting with the general use of neuroprotective devices yields acceptable shortterm results with respect to neurological events. Asymptomatic patients have significantly less periprocedural strokes than symptomatic patients. Neurological events during long-term follow-up are rare, in particular ipsilateral to the side of carotid stenting. Thus, carotid artery stenting with neuroprotection is a safe method for carotid revascularization, with acceptable periprocedural events, particularly in asymptomatic patients, and a good long-term neurologic outcome.

Outcomes of pulmonary endarterectomy for treatment of extreme thromboembolic pulmonary hypertension

Outcomes of pulmonary endarterectomy for treatment of extreme thromboembolic pulmonary hypertension

Comparison of Angioplasty and Stenting With Cerebral Protection Versus Endarterectomy for Treatment of Internal Carotid Artery Stenosis in Elderly Patients

Comparison of Angioplasty and Stenting With Cerebral Protection Versus Endarterectomy for Treatment of Internal Carotid Artery Stenosis in Elderly Patients

Comparison of Angioplasty and Stenting With Cerebral Protection Versus Endarterectomy for Treatment of Internal Carotid Artery Stenosis in Elderly Patients

Comparison of Angioplasty and Stenting With Cerebral Protection Versus Endarterectomy for Treatment of Internal Carotid Artery Stenosis in Elderly Patients

Is carotid artery stenting equivalent or superior to carotid endarterectomy for treatment of carotid artery stenosis?

A best evidence topic in vascular surgery was written according to a structured protocol. The question addressed was whether carotid artery stenting (CAS) is equivalent or even superior to carotid endarterectomy (CEA) for the treatment of significant carotid artery stenosis. Four hundred and ninety-four papers were identified, of which 14 papers including five randomised controlled trials (RCTs) presented the best evidence to answer the clinical question. The author, journal, date and country of publication, patient group studied, study type, relevant outcomes, results and study weaknesses of these papers are tabulated. We conclude that the risk of peri-procedure stroke or death was similar for patients treated with carotid artery angioplasty+/-stenting and those treated with surgery. However, CAS did reduce the risk of minor complications at the site of vascular access, the incidence of cranial nerve injury, and may reduce economic costs due to shorter hospital stays and earlier return to work. Long term follow-up of these patients is, however, lacking. There are currently four large multi-centre RCTs in progress and their results will determine whether CAS will surpass CEA as the gold standard in the future.

Carotid Angioplasty and Stenting Versus Carotid Endarterectomy for Treatment of Asymptomatic Carotid Stenosis: A Randomized Trial in a Community Hospital

The authors conducted a study to determine if carotid artery stenting (CAS) is equivalent to carotid endarterectomy (CEA) in reducing the risk of stroke in asymptomatic patients with carotid stenosis, Patients (n = 85) were randomized to CAS or CEA and followed for 48 months. Both procedures were well-tolerated. No major complications occurred. Hospital stay was similar. Stenosis decreased to an average of 5% after CAS and the patency of the reconstructed artery remained satisfactory regardless of the technique. The authors concluded that an experienced cerebrovascular team may effectively treat CAS with results similar to those achieved with CEA.

Comparison of angioplasty and stenting with cerebral protection versus endarterectomy for treatment of internal carotid artery stenosis in elderly patients

Comparison of angioplasty and stenting with cerebral protection versus endarterectomy for treatment of internal carotid artery stenosis in elderly patients