Periprocedural Death Research Articles

Gender differences in patients with carotid stenosis.

This overview analyses gender differences in prevalence, epidemiology, risk factors and therapy in patients with carotid stenosis in a systematic review. Ischemic stroke is a leading cause of death in Western society, where about 20% of cases are triggered by a carotid stenosis or occlusion, which occurs more frequently in men than in women. The stroke-protective effect of carotid endarterectomy is greater in men. Men have lower peri-procedural stroke and death rates. Particularly men with carotid stenosis and a life expectancy of at least 5 years benefit from surgical treatment. Also, the recurrence rate of ipsilateral stroke 5 years after initial surgery is lower in men than in women. It is not yet fully clarified whether there are significant gender differences regarding the outcome after endovascular versus surgical treatment. Gender differences in the outcome of carotid artery repair may be caused by biological, anatomical (smaller vessel diameter in women) or hormonal differences as well as a protracted development of atherosclerotic changes in women and different plaque morphology. Moreover, women are on average older at the time of surgery and their surgical treatment is often delayed. To reduce the risk of stroke and to improve treatment outcome especially for women, further research on gender differences and their causes is mandatory and promising.

Abstract TP131: Degree of Stenosis by Angiography Does not Influence Risk of Endarterectomy or Stenting in Patients With Severe Asymptomatic Carotid Stenosis

Introduction: Increasing stenosis has been questioned as a factor increasing risk of carotid endarterectomy (CEA) or carotid stenting (CAS) in patients with severe asymptomatic carotid stenosis. Hypothesis: Greater severity of carotid stenosis is associated with higher rates of periprocedural stroke and death following revascularization for asymptomatic patients. Methods: Asymptomatic patients with carotid stenosis ≥ 70% by ultrasound or ≥ 60% by angiogram were eligible for the Carotid Revascularization Endarterectomy vs Stenting Trial (CREST). Patients who had a catheter-angiogram were divided into tertiles based on the degree of stenosis. Outcomes were the occurrence of any stroke or death at 30 days. Proportional hazards models adjusting for age and treatment were used to assess risk of 30 day stroke or death by tertile of stenosis. Results: Among 1181 asymptomatic patients, qualifying angiograms were done for 662 patients who had assigned procedure performed within 30 days of randomization. Median % stenosis was 62.6, 73.4, and 83.0 for the tertiles that otherwise differed only for female sex (40% female in tertile 1, 36% in tertile 2, 29% in tertile 3, p=0.01). The 30-day stroke and death rates did not differ significantly by severity of stenosis (Table), but the number of stroke and deaths was only 14 across the tertiles (Table). Similarly meaningful comparison of CEA vs CAS was not possible. Conclusion: This is the largest contemporary study of carotid angiograms performed in patients with severe asymptomatic carotid stenosis. No relationship was detected between severity of stenosis and 30-day stroke and death. The safety of CEA and CAS in asymptomatic patients limits detection of other factors that may increase risk because so few events complicate these procedures.

Abstract 19: Multicenter Prospective Trial of Intracranial Stent Placement in Patients With Symptomatic High-grade Intracranial Stenosis

Purpose: Based on the results of SAMMPRIS trial, modifications in patient selection and procedural aspects for intracranial stent placement have been recommended. We performed a multicenter prospective single arm trial to determine if such modifications will result in lower rates of peri-procedural stroke and/or death. Materials and Methods: The study enrolled patients with recent transient ischemic attack or ischemic stroke (excluding lacunar ischemic events) related to high-grade (70-99% in severity) stenosis of a major intracranial artery. Patients were treated using angioplasty and self-expanding stent after 3 weeks of index ischemic event at one of the 10 high volume centers in China. An independent neurologist ascertained the occurrence of any stroke and/or death within one month after the procedure. Results: A total of 100 consecutive patients were recruited. The target lesions were located in middle cerebral artery [M1] (n=38, 38%), intracranial internal carotid artery (n=17, 17%), intradural vertebral artery (n=18, 18%), and basilar artery (n=27, 27%). The technical success rate of stent deployment with residual stenosis <50% was 100%. The overall one-month stroke and/or death rate was 2% (95% confidence interval 0.7% - 4.7%). Two ischemic strokes occurred in pontine region (perforator distribution) in patients following angioplasty and stent placement for basilar artery stenosis. Conclusion: The results of this prospective multi-center study demonstrated that modifications in patient selection and procedural aspects can substantially reduce the one-month stroke and/or death rate following intracranial stent placement.

Transplant renal artery stenosis: The impact of endovascular management and their outcomes.

Introduction:Transplant renal artery stenosis (TRAS) is a well-known vascular complication of renal transplantation. The aim of this analysis was to assess the short and midterm outcomes of endovascular therapy to salvage transplant kidney.Methods:We retrospectively analyzed our transplant database from 2000 to 2015. Percutaneous transluminal angioplasty/stenting was done in 24 patients (22 men and two women) with significant TRAS. The mean age was 59 ± 12 years. The parameters analyzed were: Technical success, pre- and post-treatment serum creatinine and number of antihypertensive drugs before and after treatment and vessel patency on Doppler ultrasonography at 3 and 6 months.Results:Overall incidence of TRAS in this study was 5.06%. Incidence of TRAS following live donor transplantation was 4.68% while that in deceased donors was 11.5%. Technical success was 100%. There were no periprocedural deaths. Renal function was improved from 2.32 ± 0.5 mg/dL to 1.72 ± 0.3 mg/dL (P < 0.001) and number of antihypertensive medications after the procedure was reduced from 2.9 ± 0.7 to 2 ± 0.6 (P < 0.001) at 6 months follow-up. One patient developed restenosis within 5 months (4.2%). Clinical success at 6 months follow-up was 79.2%.Conclusions:Endovascular treatment of TRAS has high technical success with minimal complications. It also provides satisfactory clinical success with improvement in overall transplant renal function and renovascular hypertension in early follow-up.

0374: Seven-year outcome after TAVI

TAVI is increasingly used but few data exist on long-term outcome. We analyzed 7-year outcome after TAVI and its predictive factors. Between 2006 and 2011, 289 consecutive high-risk patients (EuroScore 23±14%) underwent TAVI in our institution. Mean age was 82±9 years and 85% were in NYHA class III–IV. Procedural success was achieved in 265 pts (92%). At 30 days, 34 patients died (congestive heart failure in 14, peri-procedural death in 10 and septic shock in 10). We focused on the 255 patients discharged alive after TAVI to analyze long-term outcome. Follow-up was complete in 100% of patients. During a mean follow-up of 4.1±0.2 years, 139 patients died, half of deaths being non-cardiac. Overall 7-year survival rate was 26±9%. We identified 5 preprocedural predictive factors of late mortality in multivariate analysis: cancer (p=0.001), diabetes under insulin therapy (p=0.02), NYHA class III-IV (p=0.03), atrial fibrillation (p=0.04), higher creatinin level (p<0.0001) and 2 post-procedural factors: higher systolic PAP (p=0.02) and arrhythmias (p=0.02). Whereas conduction disorders are more frequent after TAVI (29% of cases in this series) and may often lead to pace-maker implantation, only post-TAVI arrhythmias (supraventricular in 32 patients or ventricular in 4) were predictive of late mortality. Finally, in the 116 survivors, 70% were in NYHA class I-II at last follow-up. At 7-year follow-up after TAVI, the survival rate was 27% and most patients have few or no symptoms. The predictive factors of late mortality emphasized the weight of comorbidities. Particular awareness is needed toward the occurrence of post-TAVI arrhythmias which identifies high-risk patients.

17th Interventional Cardiology Workshop New Frontiers in Interventional Cardiology: December 8th, 2016, Krakow, Poland.

BackgroundThe utilization of the radial access (RA) for percutaneous coronary intervention (PCI) has gradually increased. Recent studies suggest an advantage over femoral access (FA) in high-risk patients presenting with ST-segment elevation myocardial infarction (STEMI). The aim was to evaluate bleeding complications and periprocedural outcomes with safety and efficacy of RA compared with FA for PCI with stent implantation in “real-world” patients with STEMI presentation from Polish National Registry.MethodsThe study group consisted of 22,812 consecutive patients with STEMI treated with PCI and stent implantation between January 2014 and June 2015 in 151 tertiary invasive cardiology centers in Poland. All data were stored in electronic database of National PCI Registry (ORPKI). Patients treated with RA and FA were compared using a propensity score analysis to best match between groups. The analysis was done in the “as-treated” manner.ResultsFemoral access and RA were used in 9,334 (40.9%) and 13,478 (59.1%) patients, respectively. After propensity score matching no differences in baseline characteristic between 6,542 matched pairs was found. Significantly higher total amount of contrast (191.8 ±8 ml vs. 174.8 ±68.8 ml, p = 0.0001) and lower radiation doses were used in FA (1279.5 ±1346.3 mGy vs. 1182.6 ±887 mGy, p = 0.02). More bleeding complications at puncture site after both angiography (0.17% vs. 0.02%; p = 0.004) and PCI (0.23% vs. 0.09%, p = 0.049) were reported in FA group. Periprocedural death (1.94% vs. 0.93%, p = 0.0001) and periprocedural cardiac arrest (1.44% vs. 0.96%, p = 0.01) occurred significantly more often after PCI performed with FA.ConclusionsRadial access was associated with lower incidence of periprocedural death in STEMI patients as well as a significant reduction of bleeding complications at access site.

Single-center experience with percutaneous mitral valve repair using the MitraClip in a high-risk series in Turkey.

Mitral valve regurgitation (MR) is the second most common heart valve disease in Europe. Without intervention, prognosis of severe symptomatic MR is poor. Percutaneous edge-to-edge mitral valve repair with MitraClip is a promising mitral regurgitation treatment technique in select, high-surgical-risk patients. The present objective was to describe the experience of a single center with MitraClip use in a high-risk series in Turkey. Between May 2013 and September 2014, 28 high-surgical-risk patients with MR of at least grade 3+ and mean EuroSCORE of 26% underwent MitraClip implantation at our institution. In-hospital and follow-up safety and efficacy results are presented. Mean patient age was 58 years, and 75% were male. Grade 3 or 4 MR was present in all patients, and was primarily the result of restrictive functional mitral regurgitation (in 89% of cases). Mean left ventricular ejection fraction (LVEF) was 27% and New York Heart Association (NYHA) classification was III or IV in 89% of the population. Acute procedural success was 89%, with 47% of patients receiving a single clip, 39% receiving 2 clips, and 14% receiving 3 clips. One periprocedural death occurred, and 2 deaths occurred during follow-up (mean: 13.9 months). After 1 year, more than 75% of patients had MR severity of ≤2+ and NYHA classification of I or II, but no significant change in left ventricular volume or systolic function. Significant improvement in 6-minute walk test and quality of life was also observed. Initial experience with the MitraClip system showed promising results in patients considered high-surgical-risk, particularly in those with end-stage heart failure.

Patient profile and periprocedural outcomes of bioresorbable vascular scaffold implantation in comparison with drug-eluting and bare-metal stent implantation. Experience from ORPKI Polish National Registry 2014-2015.

IntroductionThere are limited data on the comparison of bioresorbable vascular scaffold (BVS) and drug-eluting stent (DES)/bare-metal stent (BMS) implantation in an unselected population of patients with coronary artery disease.AimTo compare the periprocedural outcomes and patient profile of BVS and DES/BMS implantation in an all-comer population from the ORPKI Polish National Registry.Material and methodsA total of 141,324 consecutive patients from 151 invasive cardiology centers in Poland were included in this prospective registry between January 2014 and June 2015. Periprocedural data on patients with at least one BVS (Absorb, Abbott Vascular, Santa Clara, CA, USA), DES or BMS (all available types) implantation in de novo lesions during index percutaneous coronary intervention for stable angina (SA) or acute coronary syndrome were collected.ResultsBioresorbable vascular scaffold was the most often used in patients with SA, in single-vessel disease and in younger male patients. Bioresorbable vascular scaffold implantation was significantly more often associated with periprocedural administration of ticagrelor/prasugrel (6.8% vs. 3.6%; p = 0.001) and use of intravascular ultrasound and optical coherence tomography in comparison with the DES/BMS group (2.8% vs. 0.6% and 1.8% vs. 0.1%, respectively; p = 0.001 for both). The incidence of periprocedural death was significantly lower in the BVS group than the DES/BMS group (0.04% vs. 0.32%; p = 0.02), but this difference was no longer significant after adjustment for covariates. On the other hand, coronary artery perforation occurred significantly more often during BVS delivery (0.31% vs. 0.12%; p = 0.01), and BVS implantation was identified as an independent predictor of coronary artery perforation in multivariate logistic regression analysis (OR = 6.728, 95% CI: 2.394–18.906; p = 0.001).ConclusionsPatients treated with BVS implantation presented an acceptable safety and efficacy profile in comparison with the DES/BMS group. However, lower risk patients were the most frequent candidates for BVS implantation.

Periprocedural risk of myocardial infarction after carotid endarterectomy and carotid angioplasty and stenting

MOTS CLES Stenose carotidienne ; Endarteriectomie absolute risk of ischaemic stroke by about 50% in patients with symptomatic or asymptomatic carotid stenosis compared with medical treatment [1—3]. Carotid angioplasty and stenting (CAS) has been evaluated as an alternative to CEA for several years. However, randomized controlled trials (RCTs) have established that the 30-day risk of stroke or death is higher after CAS than after CEA in patients with symptomatic and asymptomatic stenosis [4,5]. Thus, although outcomes after CEA and CAS on long-term follow-up are similar, the overall stroke risk with CAS remains higher due to the excess initial periprocedural risk [4—7]. An intriguing observation found in most RCTs comparing CEA with CAS is an excess risk of periprocedural myocardial infarction after CEA (pooled odds ratio 2.23, 95% confidence interval [CI] 1.37—3.63; six studies, 5725 patients; I2 = 0%; Fig. 1 [1,4,8—13]). Until now, this excess of myocardial infarction after CEA has not been well understood, and the clinical importance of these events has been questioned, mainly because some asymptomatic events manifesting as small elevations of cardiac enzymes were counted as outcomes in the Carotid Revascularization Endarterectomy versus Stenting Trial (CREST) study [14]. On the other hand, small elevations of cardiac enzymes after non-cardiac and cardiac procecarotidienne ; Stenting carotidien ; Infarctus du myocarde ; Meta-analyse dures are associated with increased future mortality [4,15—17]. While stroke is correlated with functional impairment, myocardial infarction could be an important cause of periprocedural death. Although the effect size was similar across all trials, the total number of events observed was small (< 100), and risk factors for periprocedural myocardial infarction remain unknown.

Carotid angiographic characteristics in the CREST trial were major contributors to periprocedural stroke and death differences between carotid artery stenting and carotid endarterectomy

The Carotid Revascularization Endarterectomy versus Stenting Trial (CREST) demonstrated a higher periprocedural stroke and death (S+D) rate among patients randomized to carotid artery stenting (CAS) than to carotid endarterectomy (CEA). Herein, we seek factors that affect the CAS-CEA treatment differences and potentially to identify a subgroup of patients for whom CAS and CEA have equivalent periprocedural S+D risk. Patient and arterial characteristics were assessed as effect modifiers of the CAS-CEA treatment difference in 2502 patients by the addition of factor-by-treatment interaction terms to a logistic regression model. Lesion length and lesions that were contiguous or were sequential and noncontiguous extending remote from the bulb were identified as influencing the CAS-to-CEA S+D treatment difference. For those with longer lesion length (≥12.85mm), the risk of CAS was higher than that of CEA (odds ratio [OR], 3.42; 95% confidence interval [CI], 1.19-9.78). Among patients with sequential or remote lesions extending beyond the bulb, the risk for S+D was higher for CAS relative to CEA (OR, 9.01; 95% CI, 1.20-67.8). For the 37% of patients with lesions that were both short and contiguous, the odds of S+D in those treated with CAS was nonsignificantly 28% lower than for CEA (OR, 0.72; 95% CI, 0.21-2.46). The higher S+D risk for those treated with CAS appears to be largely isolated to those with longer lesion length and/or those with sequential and remote lesions. In the absence of those lesion characteristics, CAS appears to be as safe as CEA with regard to periprocedural risk of S+D.

Abstract 12692: Contemporary Evidence on the Risks of Early Carotid Revascularization After Stroke in Evolution

Introduction: Current stroke guidelines suggest performing carotid endarterectomy (CEA) within 2 weeks after an ischemic stroke or TIA caused by severe carotid stenosis. However, early carotid revascularization in patients in unstable neurological condition after acute stroke (“stroke in evolution”, SIE) is controversial because of the risk of new ischemic stroke, intracerebral hemorrhage (ICH) and death. Published studies have not found a consistent benefit in this cohort. Hypothesis: The aim of this systematic review and meta-analysis was to document outcomes after urgent carotid intervention performed within 2 weeks from SIE. Methods: A systematic review of studies published in the last 8 years (2008-2015) reporting the risk of stroke, death and ICH following carotid intervention performed within 2 weeks from acute stroke in patients with SIE, was undertaken. Pooled proportion of periprocedural stroke, stroke or death and ICH were obtained with proportion meta-analysis and random effects model. Results: Out of 47 published series reporting on 2-week timing of carotid intervention after ischemic neurological event, only 15 separately described periprocedural risks for patients with SIE. In 8 studies patients underwent thrombolysis for acute stroke management of SIE before carotid revascularization. The pooled proportion of periprocedural stroke was 5.0% (95% Confidence Intervals, CI, 3.3 - 7.1), ranging 0 -14.2% among different studies. Figure. The pooled proportion of periprocedural risk for the combined of stroke or death was 4.7% (95% CI 2.9 -7.0) and that of periprocedural ICH, 1.2% (95% CI 0.4-2.4). Conclusions: The current risk of stroke, death and ICH after urgent carotid revascularization performed within 2 weeks for patients with stroke in evolution is lower than that anticipated in previous studies. Nevertheless, due to the heterogeneity in reporting and differential in patient selection, these findings should be interpreted with caution.

Outcomes of middle cerebral artery angioplasty and stenting with Wingspan at a high-volume center.

This study was to investigate the periprocedural stroke rates, safety, and long-term effect of Wingspan stenting for symptomatic severe stenosis of the middle cerebral artery (MCA) at a high-volume center. Between July 2007 and April 2013, 196 consecutive patients with severe MCA atherosclerotic stenosis (≥70%) who were treated with Wingspan stenting were retrospectively studied. All patients had arterial stenosis-related temporary ischemic attack or strokes. The demographic data, cerebral angiography, technical success rate, periprocedural complications, and clinical and imaging follow-up were analyzed. The successful stenting rate was 98.0%, and the stenosis rate was improved from pre-stenting (80.6 ± 8.3 %) to post-stenting (15.5 ± 6.8%). The 30-day periprocedural stroke or death rate was 7.1%, with a disabling or fatal rate of 2.6%. The perioprocedural stroke rate was significantly (P < 0.01) greater in the early learning stage (16.0%) than in the later technical maturation stage (4.1%). The total periprocedural ischemic and perforator stroke rates were greater in patients with the most stenosis in the distal MCA 1/3 segment (6.8 and 5.7%, respectively) than in the proximal and middle 2/3 segments (0.9 and 0%, respectively). The ipsilateral stroke or death rate beyond 30 days (6-69 months, mean 30 ± 16) was 4.8%, with the 1- and 2-year cumulative stroke rates of 9.6 and 12.1%, respectively. Imaging follow-up 6-69 months (mean 10.9 ± 8.5) revealed restenosis in 21 cases (20.4 %). Intracranial stenting of MCA stenoses may have the potential of better clinical outcomes if patients are properly selected and treated by an experienced operator at a high-volume center.

Time From Symptoms to Carotid Endarterectomy or Stenting and Perioperative Risk

Prior meta-analysis showed that carotid endarterectomy benefits decline with increasing surgical delay following symptoms. For symptomatic patients in the Carotid Revascularization Endarterectomy Versus Stenting Trial (CREST), we assessed if differences in time between symptoms and carotid endarterectomy or carotid artery stenting are associated with differences in risk of periprocedural stroke or death. We analyzed the 1180 symptomatic patients in CREST who received their assigned procedure and had clearly defined timing of symptoms. Patients were classified into 3 groups based on time from symptoms to procedure: <15, 15 to 60, and >60 days. For carotid endarterectomy, risk of periprocedural stroke or death was not significantly different for the 2 later time periods relative to the earliest time period (hazard ratio, 0.74; 95% confidence interval, 0.22-2.49 for 15-60 days and hazard ratio, 0.91; 95% confidence interval, 0.25-3.33 for >60 days; P=0.89). For carotid artery stenting, risk of periprocedural stroke or death was also not significantly different for later time periods relative to the earliest time period (hazard ratio, 1.12; 95% confidence interval, 0.53-2.40 for 15-60 days and hazard ratio, 1.15; 95% confidence interval, 0.48-2.75 for >60 days; P=0.93). Time from symptoms to carotid endarterectomy or carotid artery stenting did not alter periprocedural safety, supporting early revascularization regardless of modality. URL: http://www.clinicaltrials.gov. Unique identifier: NCT00004732.

Stroke : Highlights of Selected Articles

<i>Stroke</i> : Highlights of Selected Articles

Meta-Analysis of Randomized Controlled Trials Comparing the Long-Term Outcomes of Carotid Artery Stenting Versus Endarterectomy.

Stenting is an endovascular alternative to endarterectomy for the management of carotid stenosis, but its long-term safety and efficacy relative to endarterectomy remain unclear. Our objective was to compare the safety and efficacy of stenting with those of endarterectomy, with a particular focus on long-term outcomes, via meta-analysis of randomized controlled trials (RCTs). We systematically searched PubMed, EMBASE, MEDLINE, and the Cochrane Library for RCTs with ≥50 patients that compared stenting with endarterectomy in patients with carotid stenosis. Periprocedural and long-term outcomes were assessed, with data pooled across RCTs using random-effects models. Eight RCTs were included in our meta-analysis (n=7091), with follow-up ranging from 2.0 to 10.0 years. When compared with endarterectomy, stenting was associated with an increased risk of periprocedural stroke (relative risk, 1.49, 95% confidence interval [CI], 1.11 to 2.01; risk difference, 1.7%; 95% CI, 0.3 to 3.0) but a decreased risk of periprocedural myocardial infarction (relative risk, 0.47; 95% CI, 0.29 to 0.78; risk difference, -0.4%; 95% CI, -0.8% to 0.1%). During long-term follow-up, stenting was associated with an increased risk of stroke (relative risk, 1.36; 95% CI, 1.16 to 1.61) and a composite end point of ipsilateral stroke, periprocedural stroke, or periprocedural death (relative risk, 1.45; 95% CI, 1.20 to 1.75). Although stenting has more favorable periprocedural outcomes with respect to myocardial infarction, the observed increased risk of stroke and death throughout follow-up with stenting suggests that endarterectomy remains the treatment of choice for carotid stenosis.

Predictors of Long-Term Survival Following Transvenous Extraction of Defibrillator Leads.

Little data exist on long-term outcomes following extraction of implantable cardioverter defibrillator (ICD) leads, particularly for noninfectious indications. We sought to identify predictors of long-term survival after ICD lead extraction. We retrospectively reviewed ICD lead extractions at our institution (n = 508). Procedural outcomes and long-term survival were ascertained by medical records review. Indication for lead extraction was infection in 32.5% and lead failure in 61.8%. Mean dwell time of the oldest extracted lead was 5.1 ± 5.9 years. Complete procedural success was achieved in 96.5% of cases. Major procedure-related complications occurred in 1.6% with six periprocedural deaths. During a mean follow-up of 866 ± 798 days, survival was significantly worse among patients with infection as the indication for extraction. At 1 year after extraction, survival among those with infection was 88.2%, compared to 95.0% in the lead failure cohort (P < 0.001). Procedural failure was a significant predictor of long-term mortality, even after excluding periprocedural deaths. In multivariate models, the presence of chronic kidney disease, increased number of leads requiring extraction, lower ejection fraction, and procedural failure were predictors of mortality. Despite high rates of procedural success, infectious indication for ICD lead extraction is associated with increased long-term mortality. In contrast, among patients undergoing extraction for lead failure, long-term survival was excellent. The presence of procedural failure was a significant predictor of long-term mortality. Further studies will be necessary to better understand the mechanisms by which procedural failure may adversely impact long-term outcomes.

How EVAR Changed the Game: Trends in Patient Characteristics, Surgical Techniques and Outcomes of Non–-ruptured AAA Repair in Germany from 1999 to 2010

2. The number of CEAs under loco-regional anesthesia increased significantly from 10.1% to 28.1% (p < 0.0001). Intraluminal shunting was performed less frequent (48.1% to 43.5%, p < 0.0001), whereas an intraoperative morphological control of the carotid artery was performed more often (44.5% to 68.3%, p < 0.0001). Any neuro-monitoring method was used increasingly (CEA: 49.8% to 61.4%, CAS: 33.7% to 35.8%; p < 0.0001). The portion of patients who were neurologically assessed before or after CEA increased from 61.7% to 69.0% and 36.5% to 57.2% respectively. In CAS 78% of the patients were assessed before and 70% after the procedure. The median time interval between the neurological index event and CEA was reduced from 25 in 2003 to 8 days in 2013 (CAS: 9 days in 2012 and 2013). 3. Combined peri-procedural stroke and death rates decreased significantly in asymptomatic patients after CEA (2.0% to 1.3%, p 1⁄4 <0.001) and remained stable for CAS (1.7%). In symptomatic patients with a 50e99% stenosis peri-operative complication rates decreased significantly (4.6% to 2.7%, p 1⁄4 0.001) whereas CAS was associated with a risk of 3.9% in 2012 and 4.2% in 2013. Conclusion: The analysis of the annual quality reports demonstrates that CEA and CAS were performed within acceptable stroke and death rates. While patient age is increasing the clinical outcomes after CEA have improved significantly over time. Most importantly the time interval between the neurological index event and CEA or CAS could be reduced to 8 to 9 days.

Periprocedural Myocardial Infarction After Carotid Endarterectomy and Stenting

Carotid angioplasty and stenting (CAS) is associated with higher risk of periprocedural stroke and death when compared with carotid endarterectomy (CEA). By contrast, the risk of myocardial infarction (MI) was higher after CEA than after CAS in randomized trials. However, numbers were small, and risk factors are unknown. We performed a systematic review and a meta-analysis of studies published from January 1980 to June 2014 and collected unpublished data. We extracted data on 9 predefined risk factors (age, contralateral carotid occlusion, coronary artery disease, diabetes mellitus, sex, hypertension, peripheral artery disease, type stenosis, and clinical presentation). We selected studies with data available on MI in at least 1 subgroup, calculated absolute and relative risks, and identified differential effects on risks of MI. The 30-day absolute risk of MI was 0.87% (95% confidence interval, 0.69-1.07) after CEA and 0.70% (95% confidence interval, 0.54-0.88) after CAS (Pint=0.38). After CAS, patients with symptomatic stenosis and restenosis were at higher risk of MI, whereas men were at lower risk. After CEA, age, history of coronary artery disease, peripheral artery disease, and restenosis increased the risk of MI. Only the effect of sex differed between CAS and CEA with men being at lower risk of MI than women after CAS, whereas there was no difference between after CEA (Pint=0.01). The risk of MI after CEA and CAS did not significantly differ. Risk factors for MI are overall similar in both techniques except that men are at lower risk of MI after CAS but not after CEA.

Stenting Versus Aggressive Medical Management for Symptomatic Vertebral Artery Stenosis

Posterior circulation strokes account for 20% of all strokes (2). Traditional studies cite a 5-year stroke rate ranging from 22%e 35% following an initial vertebrobasilar transient ischemic attack (TIA) or stroke (11, 14). Contrary to traditional beliefs, the overall risk of recurrent stroke in the posterior circulation is similar to the risk after an anterior circulation stroke, and likely higher in the acute phase (8). In one pooled analysis of 359 patients experiencing vertebrobasilar territory TIA or stroke, the 90-day risk of stroke after the presenting event was 9.6% in patients with vertebrobasilar stenosis versus 2.8% in those without (OR 3.7, 95% CI 1.2e11.0, P 1⁄4 0.012) (9). The authors noted a trend that this risk was higher with intracranial vertebrobasilar stenosis than extracranial vertebral stenosis (P 1⁄4 0.06). To mitigate this risk, aggressive medical management incorporating diet and lifestyle modification, control of hypertension, and the usage of statins and antiplatelet agents may be used (3, 5, 16). In addition, multiple individual case series have suggested that stenting vertebrobasilar lesions may be associated with a low-risk profile and subsequently low rates of referable TIAs or strokes (1, 10, 12, 13, 15). A systematic review of stenting symptomatic, atherosclerotic vertebrobasilar disease reported periprocedural TIA, stroke, and death rates of 1.6%, 1.3%, and 0.3%, respectively, across 313 cases with proximal vertebral artery disease (6). Over a mean follow-up period of 14.2 months, the post-treatment annual rate of TIA or stroke in the vertebrobasilar territory was 0.6%. Interestingly, for 283 cases of distal vertebrobasilar stenting, the periprocedural TIA, stroke, and death rates were 0.7%, 10.6% and 3.2%, respectively (6). The annual rate of subsequent vertebrobasilar stroke over a mean follow-up of 13 months after treatment was 1.9%. Thus although patients with symptomatic intracranial vertebrobasilar stenosis may have a greater risk of TIA or stroke without treatment (9), the risk of stenting may also be higher in this group (6). However, more specifically, a subgroup analysis from the Stenting and Aggressive Medical Management for Preventing Recurrent Stroke in Intracranial Stenosis (SAMMPRIS) trial demonstrated significantly higher periprocedural ischemic events in patients undergoing stenting of the basilar artery as compared with those undergoing stenting of the intracranial internal carotid, middle cerebral, or vertebral artery (7). Before the Vertebral Artery Stenting Trial (VAST) (3), subgroup analyses of 2 randomized control trials comparing stenting of symptomatic arterial stenosis to best medical management demonstrated no benefit of stenting for patients with vertebral artery stenosis (4, 5). In the Carotid And Vertebral Artery Transluminal Angioplasty Study (CAVATAS), 16 patients with

Safety and efficacy of transarterial chemoembolization in patients with transjugular intrahepatic portosystemic shunts

BackgroundTransarterial chemoembolization (TACE) for the treatment of hepatocellular carcinoma (HCC) is an important option as the majority of patients present with advanced disease. Data regarding treatment outcomes in patients who have undergone transjugular intrahepatic portosystemic shunts (TIPS) are limited. The present study seeks to evaluate the safety and efficacy of TACE in HCC patients with a TIPS. MethodsA retrospective review identifying patients with HCC and concomitant TIPS who were treated with TACE was performed. ResultsFrom 1999 to 2014, 16 patients with HCC underwent a total of 27 TACE procedures; eight patients required multiple treatments. The median patient age at the time of the initial TACE was 60.5 years [interquartile range (IQR) : 52.5–67.5] with the majority being male (n = 12, 75%) and Childs–Pugh Class B (n = 12, 75%). At 6 weeks after TACE, 56.3% of patients achieved an objective response rate (complete and partial response) by mRECIST criteria. Clavien Grade 3 or higher complications occurred in 11.1% of TACE procedures. There were no peri-procedural deaths. The median progression-free (PFS) and overall survival (OS) were 9 and 22 months, respectively, when censored for liver transplantation (median follow-up: 11.5 months). ConclusionTACE is an effective treatment strategy for HCC in TIPS patients; albeit may be associated with higher complication rates.