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PURPOSE OF REVIEW: Carotid endarterectomy (CEA) has been shown to prevent stroke in patients with severe carotid stenosis. Carotid artery stenting (CAS) has emerged as a less invasive alternative technique. Data regarding comparat...
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PURPOSE OF REVIEW: Carotid endarterectomy (CEA) has been shown to prevent stroke in patients with severe carotid stenosis. Carotid artery stenting (CAS) has emerged as a less invasive alternative technique. Data regarding comparative effectiveness of CAS and CEA are now available and merit review. RECENT FINDINGS: Four large randomized controlled trials (RCTs) comparing CAS and CEA have shown a higher rate of stroke in symptomatic patients. The largest and most recent trial reported a lower occurrence of myocardial infarction (MI) following CAS and showed overall comparability of CAS to CEA for both symptomatic and asymptomatic patients. Despite methodological differences, these RCTs are consistent in finding an interaction of patient age with outcomes. In younger patients, CAS appears equivalent or superior to CEA if considering the sum of death, stroke, and MI. In elderly patients, CEA appears to have a lower complication rate. For asymptomatic patients, reduction in event rates with current medical therapy may render previous trial results invalid. SUMMARY: CAS is an alternative to CEA in patients requiring carotid intervention. Comparison of both CAS and CEA with contemporary medical management will also be required before recommendations can be made regarding the optimal treatment of patients with asymptomatic carotid stenoses.
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? 2022 The Author(s)Background: The introduction of carotid stenting (CAS) has led to numerous comparative trials with carotid endarterectomy (CEA). Objective: The objective of the study was to review real-world volumes, outcomes,...
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? 2022 The Author(s)Background: The introduction of carotid stenting (CAS) has led to numerous comparative trials with carotid endarterectomy (CEA). Objective: The objective of the study was to review real-world volumes, outcomes, and complications following CEA versus CAS over an extended period to identify durable changes in practice. Methods: Data were extracted from the National Inpatient Sample. Trends were assessed by annual percent change (APC), and adjusted risk ratios were calculated across the last 5 years of the study period. Results: During 1997–2015, 199,330 symptomatic and 1,995,637 asymptomatic patients underwent carotid revascularization. In symptomatic patients, CEA declined (1997–2004; APC = ?7.68%, P < 0.001) and CAS rose (1997–2008; APC = 15.48%, P < 0.001) during the first decade, subsequently becoming more muted. In asymptomatic patients, CEA decreased, whereas CAS initially increased (1997–2006; APC = 20.27%, P < 0.001) and then decreased (2007–2015; APC = ?4.52%, P < 0.001). Routine discharge after symptomatic revascularization declined in CEA after 2003 and in CAS after 2006 (APC = ?1.72% and ?3.11%, respectively, P < 0.001 for both), corresponding to increasing patient comorbidity; similar trends were seen in asymptomatic patients. Death decreased after CEA (symptomatic and asymptomatic; APC = ?4.85% and ?3.53%, respectively, P < 0.001 for both) and CAS (asymptomatic only, APC = ?2.53%, P = 0.04). CAS remained associated with a higher adjusted risk ratio for death, venous thromboembolism, and seizures in all patients and stroke and nonroutine discharge in symptomatic patients, during the last 5 years of the study period. Conclusions: Mortality has improved, but routine discharge has decreased following both CEA and CAS, congruent with increasing patient comorbidity. Trends in volumes, outcomes, and complication rates continue to favor CEA in real-world practice.
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Atherosclerotic disease of the carotid artery places patients at risk of ischemic stroke and consequently is a target of medical, endovascular and open surgical management. Various imaging modalities are used to characterize anato...
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Atherosclerotic disease of the carotid artery places patients at risk of ischemic stroke and consequently is a target of medical, endovascular and open surgical management. Various imaging modalities are used to characterize anatomy/severity of carotid disease and justify intervention, each having advantages and disadvantages. Carotid revascularization techniques including carotid artery stenting, carotid endarterectomy, and transcarotid artery revascularization vary in invasiveness and are not equally suitable for certain subsets of patients. As such, providing quality care for patients with carotid disease requires a multidisciplinary team of experts in clinical diagnosis, image interpretation, medical management, endovascular intervention, and surgical treatment.
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The objective of the study was to describe immediate and long-term results of carotid endarterectomy (CEA) versus carotid stenting (CAS) with embolic protection in patients with severe carotid artery stenosis in clinical practice....
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The objective of the study was to describe immediate and long-term results of carotid endarterectomy (CEA) versus carotid stenting (CAS) with embolic protection in patients with severe carotid artery stenosis in clinical practice. Materials and Methods: This is a retrospective cohort study, conducted between 2009 and 2017. During the analyzed period, 2132 operations (2006 patients) were performed: 1215 (57%) CEA and 917 (43%) CAS. 278 patients (13.8% of 2006) were not contactable during the follow-up period (>30 days) leaving 1791 cases (1728 patients) for inclusion in the analysis. Propensity score matching was used to compare the treatment results of groups (561 cases were matched out of 1791). The results of 615 CEA (316 eversion, 299 "classic" with patch) and 615 CAS (using a variety of carotid stents) were compared. Results: In the asymptomatic subgroup (n = 455), the 30-day rate of stroke was not significantly different between the CEA group and the CAS group (1.5% versus 2.4%, P = .48). The 5-year rate of stroke was not significantly higher for CAS than for CEA (4.6% versus 3.3%, P = .3). In the symptomatic subgroup (n = 160), the 30-day rate of stroke was significantly higher in the CAS group than in the CEA group (7.5% versus 2.5%, P = .04). The 5-year rate of stroke was 13% for CAS and 8.7% for CEA (P = .2). Conclusions: In the symptomatic subgroup, the 30-day rate of stroke was significantly higher in the CAS group than in the CEA group, therefore the use of CAS for symptomatic patients in routine practice should be limited. Our study demonstrates that the rates of stroke and survival after CEA and CAS in patients aged 80 years or younger with asymptomatic or symptomatic severe carotid stenosis did not differ significantly over a period of 5 years.
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Every year, about 800,000 people develop either a new or recurrent stroke and about 135,000 die of the disease. About 20% of strokes are attributed to extracranial carotid artery stenosis. Carotid ultrasound has long been establis...
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Every year, about 800,000 people develop either a new or recurrent stroke and about 135,000 die of the disease. About 20% of strokes are attributed to extracranial carotid artery stenosis. Carotid ultrasound has long been established as a useful screening study for evaluation of extracranial carotid disease. Three meta-analyses reviewing published data concluded that the sensitivity range of the technique is 86% to 94% and the specificity range is 87% to 94%. Although these published carotid ultrasound results are high, the accuracy in general laboratories may be lower. A meta-analysis reviewing both published and private data found lower results: sensitivity 83%, specificity 54%. Investigators attributed the lower accuracy rates to less publication bias and introduction of data that reflect everyday clinical practice.
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Objectives To examine the association between a contralateral carotid artery occlusion (CCO) and the rates of subsequent target-lesion restenosis and revascularization after carotid artery stenting (CAS). Background Patients with ...
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Objectives To examine the association between a contralateral carotid artery occlusion (CCO) and the rates of subsequent target-lesion restenosis and revascularization after carotid artery stenting (CAS). Background Patients with carotid artery disease undergoing revascularization often have a CCO. The association of a CCO with long-term outcomes after CAS is uncertain. Methods At two institutions, 267 CAS procedures were performed from 2006 to 2016 including 47 (18%) with a CCO. Regular follow-up with duplex carotid ultrasound was performed to assess for restenosis. Univariate Cox regression analysis was performed to evaluate the association between the presence of a CCO and repeat revascularization. Results The mean patient age was 70 years. There was no significant difference (P > 0.05) in procedural indication (asymptomatic vs ischemic symptoms) or medical comorbidities between groups. During 5-year follow up, the rate of duplex-derived >80% stenosis was 6% in the non-CCO group and 9% in the CCO group (P = 0.45). Despite similar rates of >80% restenosis, there was a significant association between CCO and subsequent target-lesion revascularization (TLR), with rates of 6.4% vs 0.9% at 5 years (HR 7.2, confidence interval (CI) 1.2-43, P = 0.04). There were no significant differences between groups in the 5-year rates of stroke (4.3% in CCO group vs 4.5% in non-CCO group, HR 0.53, CI 0.07-4.22, P = 1.0) or MACCE (15% vs 18%, HR 0.55, CI 0.2-1.55, P = 0.68). Conclusions Patients undergoing CAS with a CCO were more likely to undergo TLR during long-term follow up, but they did not have any differences in procedural success or short- and long-term outcomes.
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Abstract Background To evaluate early and long-term outcomes of symptomatic patients treated for in-stent carotid restenosis (ISR) with carotid bypass (CB). Methods Data were retrospectively collected from a prospectively compiled...
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Abstract Background To evaluate early and long-term outcomes of symptomatic patients treated for in-stent carotid restenosis (ISR) with carotid bypass (CB). Methods Data were retrospectively collected from a prospectively compiled database on patients treated with CB in two high-volume Italian centers between 2008 and 2016, for symptomatic high-grade ISR after CAS. After carotid endarterectomy and stent removal, a greater saphenous vein (GSV) was preferentially employed as the graft; when the GSV was not accessible, a 6mm polytetrafluoroethylene (PTFE) graft was implanted. Standard follow-up protocol included clinical examinations, duplex scans (DUS) and computed tomographic angiography. Measures considered for analysis were perioperative (30-day) and long-term occurrence of new ipsilateral cerebral events, neurological deficits, death from all causes, and needs for reintervention. In addition, peripheral nerve palsy, cervical hematomas, and other local complications after surgery were noted. Results The population of the study comprised 13 patients (11 men and two women; median age was 66.5years (range 56-88)). Mean time s from index CAS to stent explantation were 38.9±18.2months. GSV grafts were used in seven cases (53.8%) and PTFE grafts in the remaining six (46.2%) cases. Intraoperative neurological complications rate was null. One patient presented a transient dysphagia. At 30-day, no new neurological complications, reinterventions or deaths occurred. At mean follow-up of 41.2±18.2months, three patients died in absence of further neurological events. None of the CB patients required reintervention. Conclusions In our experience, CB offers satisfactory results in patients treated for symptomatic ISR with an acceptable risk of cranial nerve injury.
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Both carotid endarterectomy (CEA) and carotid artery stenting (CAS) are common treatments for carotid artery stenosis. Several randomized controlled trials (RCTs) have compared CEA to CAS in the treatment of carotid artery stenosi...
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Both carotid endarterectomy (CEA) and carotid artery stenting (CAS) are common treatments for carotid artery stenosis. Several randomized controlled trials (RCTs) have compared CEA to CAS in the treatment of carotid artery stenosis. These studies have suggested that CAS is more strongly associated with periprocedural stroke; however, CEA is more strongly associated with myocardial infarction. Published long‐term outcomes report that CAS and CEA are similar. A reduction in complications associated with CAS has also been demonstrated over time. The symptomatic status of the patient and history of previous CEA or cervical radiotherapy are significant factors when deciding between CEA or CAS. Numerous carotid artery stents are available, varying in material, shape and design but with minimal evidence comparing stent types. The role of cerebral protection devices is unclear. Dual antiplatelet therapy is typically prescribed to prevent in‐stent thrombosis, and however, evidence comparing periprocedural and postprocedural antiplatelet therapy is scarce, resulting in inconsistent guidelines. Several RCTs are underway that will aim to clarify some of these uncertainties. In this review, we summarize the development of varying techniques of CAS and studies comparing CAS to CEA as treatment options for carotid artery stenosis.
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Background: In the current literature, correlations between a contralateral carotid artery occlusion (CCO) with mortality and major adverse cardiac or cerebrovascular events (MACCE) rates after carotid artery stenting (CAS) are of...
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Background: In the current literature, correlations between a contralateral carotid artery occlusion (CCO) with mortality and major adverse cardiac or cerebrovascular events (MACCE) rates after carotid artery stenting (CAS) are often described with controversial conclusions. Moreover, long-term results of mortality, MACCE and restenosis rate are scarcely reported. This study examined the association between a CCO and the short- and long-term outcomes after CAS.
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