Changes in CBF After Carotid Endarterectomy: Follow-up in Neurologically Asymptomatic Patients

1992 ◽  
pp. 232-236
Author(s):  
J. A. Rem ◽  
O. Gratzl ◽  
H. R. Müller ◽  
J. Müller-Brand ◽  
E. W. Radü
Keyword(s):  
Carotid Endarterectomy ◽  
Asymptomatic Patients

Carotid Endarterectomy for Asymptomatic Carotid Stenosis

2017 ◽  
Author(s):  
Michael E. Hochman
Keyword(s):  
Vascular Surgery ◽  
Carotid Endarterectomy ◽  
Carotid Stenosis ◽  
Study Design ◽  
Clinical Case ◽  
Asymptomatic Carotid Stenosis ◽  
Asymptomatic Carotid ◽  
Asymptomatic Patients ◽  
Study Intervention

This chapter provides a summary of the landmark surgical study known as the ACST trial, which compared surgical versus nonsurgical treatment for asymptomatic carotid stenosis. Is carotid endarterectomy (CEA) beneficial in asymptomatic patients with severe carotid stenosis? Starting with that question, the chapter describes the basics of the study, including funding, year study began, year study was published, study location, who was studied, who was excluded, how many patients, study design, study intervention, follow-up, endpoints, results, and criticism and limitations. The chapter briefly reviews other relevant studies and information, gives a summary and discusses implications, and concludes with a relevant clinical case involving vascular surgery.

scholarly journals Carotid Stenting in Asymptomatic Carotid Stenosis: The Calgary Experience

2010 ◽  
Vol 37 (5) ◽  
pp. 568-573 ◽  
Author(s):  
N. Shobha ◽  
M. A. Almekhlafi ◽  
A. Pandya ◽  
P. L. Couillard ◽  
W. F. Morrish ◽  
...  
Keyword(s):  
Carotid Endarterectomy ◽  
Carotid Stenosis ◽  
Medical Center ◽  
Carotid Stenting ◽  
Minor Stroke ◽  
Safe Procedure ◽  
Asymptomatic Group ◽  
Symptomatic Group ◽  
Asymptomatic Patients

Background:Although carotid endarterectomy is considered the ‘gold standard’ for standard risk symptomatic patients, the treatment of choice for asymptomatic patients remains controversial. Carotid stenting has demonstrated real-world outcomes consistent with established guidelines for carotid endarterectomy in asymptomatic high-surgical risk patients in recent prospective multicenter trials. We describe our experience with asymptomatic patients who underwent carotid stenting at our center in a routine clinical setting.Methods:This is a retrospective, longitudinal cohort study of patients who underwent carotid angioplasty and stenting at the Foothills Medical Center, Calgary, Canada between 1997 and 2007. The qualifying events were categorized as symptomatic and asymptomatic. The procedures were performed by four experienced neurointerventionists. The primary outcome was stroke or death at 30-day follow- up.Results:243 patients underwent 255 carotid stenting procedures. Their ages ranged from 50 to 83 years; the mean age was 72.0 ± 9.3 years; 67(26.3%) were women. Forty one patients (16.1%) were asymptomatic; 214 patients (83.9%) were symptomatic. The patients in the asymptomatic group were significantly younger - 66.0 ± 8.8 years compared to patients in the symptomatic group 73.2 ± 8.9 years (p<0.0001). Intraprocedurally one minor stroke (2.4%) occurred in the asymptomatic group. At 30-day follow-up, no deaths or further strokes were noted in the asymptomatic group; while eight deaths, six major and seven minor strokes occurred in the symptomatic group (p=0.22).Conclusion:Carotid stenting appears to be a safe procedure in asymptomatic patients with severe carotid stenosis in routine clinical settings as witnessed in this single center study.

Abstract 155: Comparative Effectiveness of Carotid Endarterectomy Compared to Medical Therapy Among Patients With Asymptomatic Carotid Stenosis

Stroke ◽  
2020 ◽  
Vol 51 (Suppl_1) ◽  
Author(s):  
Salomeh Keyhani ◽  
Eric Cheng ◽  
Katherine Hoggatt ◽  
Peter Austin ◽  
Paul Hebert ◽  
...  
Keyword(s):  
Carotid Endarterectomy ◽  
Carotid Stenosis ◽  
Medical Therapy ◽  
Community Sample ◽  
Asymptomatic Carotid Stenosis ◽  
Asymptomatic Carotid ◽  
Immortal Time Bias ◽  
Asymptomatic Patients ◽  
Stroke Death

Background: Carotid endarterectomy (CEA) reduces stroke risk compared to medical therapy alone among patients with asymptomatic carotid stenosis. CEA involves a tradeoff between higher perioperative short-term risks in exchange for a lower long-term risk of stroke. However, overall declines in stroke rates raise concerns that CEA may no longer be a preferred treatment. We examined the effectiveness of CEA compared to medical therapy (MT) among asymptomatic patients in preventing stroke and stroke-death within 5 years of follow-up. Methods: We identified Veterans ≥65 years old with carotid stenosis (n=2712 CEA and n=2509 MT patients) who did not have a history of stroke or transient ischemic attack. We propensity score-matched MT patients to CEA patients to control for baseline confounding and used methods to mimic analyses from the Asymptomatic Carotid Stenosis Trial, the last published trial to compare CEA to MT. We accounted for “immortal time” bias by randomizing patients to CEA and MT groups and censoring patients if their actual treatment became inconsistent with the arm in which they were randomized (e.g., patient received CEA, but was randomized to MT). We accounted for the informative censoring by estimating time-dependent inverse probability of censoring weights using measured covariates (demographics and 72 time-varying comorbidities). We computed weighted Kaplan-Meier (KM) curves and estimated the risk of stroke/stroke-death in each group over 5 years of follow-up. Results: The observed stroke or death rate (perioperative complications) within 30 days in the CEA arm was 3%. The 5-year risk were similar among patients randomized to CEA 5.5% (95% CI, 4.3%-6.7%) versus MT 7.6% (95% CI,5.9%-9.2%) (risk difference, -2.1%, 95% CI -4%- 0%) with little difference in the KM curves (logrank p=0.2). Conclusion: CEA was not superior to MT in a community sample of Veterans after 5 years of follow-up, suggesting that CEA may no longer be the preferred treatment strategy.

scholarly journals Clinical Risk Factors and Plaque Characteristics Associated with New Development of Contralateral Stenosis in Patients Undergoing Carotid Endarterectomy

2016 ◽  
Vol 42 (1-2) ◽  
pp. 122-130 ◽  
Author(s):  
Sophie Merckelbach ◽  
Tesse Leunissen ◽  
Joyce Vrijenhoek ◽  
Frans Moll ◽  
Gerard Pasterkamp ◽  
...  
Keyword(s):  
Risk Factors ◽  
Carotid Endarterectomy ◽  
Duplex Ultrasound ◽  
Clinical Risk Factors ◽  
Individual Treatment ◽  
Lipid Core ◽  
Clinical Risk ◽  
Asymptomatic Patients ◽  
New Development

Background: Following carotid endarterectomy (CEA), cerebrovascular hemodynamic may be hampered by ipsilateral restenosis or development of contralateral stenosis. It remains to be clarified if these patients need follow-up for identifying development of contralateral stenosis. Identification of risk factors contributing to development of contralateral stenosis could allow more specific follow-up. In this current study, we assessed clinical risk factors and plaque characteristics of patients undergoing CEA with development of new contralateral stenosis during mid-term follow-up. Methods: Seven hundred and sixty patients undergoing CEA between 2003 and 2011 at UMC Utrecht were included. Atherosclerotic plaques were excised and analyzed for smooth muscle cells (SMCs), collagen, macrophages, lipid core, plaque hemorrhage and vessel density. Patients underwent clinical and duplex ultrasound follow-up at 3 and 12 months and yearly thereafter. Association between plaque- and patient characteristics with development of contralateral stenosis ≥50% was assessed with univariate and multivariate analysis. Clinical outcome during follow-up was associated with development of new contralateral stenosis. Results: After a median follow-up time of 2.5 years, development of contralateral stenosis was observed in 108 patients (20%). Presence of high collagen (p = 0.025) and high SMC (p = 0.027) was associated with development of new contralateral stenosis, whereas large lipid core was negatively associated with new development of contralateral stenosis (p = 0.034). The same plaque characteristics were related to contralateral occlusion. History of coronary artery disease (p = 0.031) and asymptomatic presentation (p = 0.000) were univariably associated with development of contralateral stenosis. Multiple regression analysis indicated that asymptomatic status was independently associated with contralateral stenosis (p = 0.001). Patients with new development of contralateral stenosis more often showed symptoms during follow-up (p = 0.049). Conclusion: Dissection of a lipid-poor, collagen-rich or SMC-rich plaque yielded an association with development of new contralateral stenosis during mid-term follow-up after CEA. Asymptomatic patients had a significantly higher risk for development of contralateral stenosis. New contralateral stenosis was related to the presence of new cerebral symptoms. These findings may help to develop individual treatment algorithms for patients with cerebrovascular atherosclerotic burden.

scholarly journals Restenosis after Carotid Endarterectomy: Incidence and Endovascular Management

2007 ◽  
Vol 13 (4) ◽  
pp. 345-352 ◽  
Author(s):  
G. Oszkinis ◽  
F. Pukacki ◽  
R. Juszkat ◽  
J.B. Weigele ◽  
M. Gabriel ◽  
...  
Keyword(s):  
Carotid Artery ◽  
Endovascular Treatment ◽  
Carotid Endarterectomy ◽  
Perioperative Complications ◽  
Significant Risk ◽  
Neurological Complications ◽  
Duplex Sonography ◽  
Recurrent Stenosis ◽  
Asymptomatic Patients

Surgical procedures designed to restore vascular patency for a recurrent stenosis following carotid endarterectomy (CEA) are burdened with technical difficulties as well as with the possibility of serious neurological complications. An endovascular approach employing transluminal percutaneous angioplasty and stenting (PTAS) is a promising solution to these problems. We aimed to evaluate the incidence of carotid artery restenosis following CEA, and to evaluate the safety and efficacy of treating post-CEA restenosis with an endovascular technique (PTAS). One hundred and two patients who underwent CEA for symptomatic and asymptomatic stenosis were included in the analysis. Clinical and sonographic follow-up examinations identified carotid artery restenosis in 16 patients, who fulfilled our criteria for endovascular treatment. Carotid PTAS was performed on symptomatic patients with a stenosis over 60% of the artery lumen (n=7) and in asymptomatic patients with a stenosis over 80% (n=9). The post-PTAS patients were evaluated by duplex sonography every three months over a 24 month follow-up period for evidence of restenosis. The cumulative incidence of post-CEA carotid restenosis qualifying for PTAS was 9.3% during an average 12-month follow-up interval. The average time from CEA to carotid PTAS was 11 months. All 16 endovascular procedures were technically successful. All of the carotid arteries were widely patent following PTAS. There were no immediate perioperative complications. One patient died two days after carotid PTAS from a cerebral hemorrhage. Thirteen of the 16 patients remained asymptomatic and had no sonographic evidence of significant restenosis during the 24-month post-PTAS follow-up period. One patient developed a symptomatic 80% restenosis proximal to the stent six months after carotid PTAS. Another patient developed an asymptomatic 60% restenosis proximal to the stent at 24 months. One patient was lost to follow-up. Following CEA, there is a significant risk of developing a symptomatic or high-grade carotid artery restenosis requiring correction. Endovascular treatment (PTAS) of a recurrent stenosis after CEA is a safe and effective alternative to repeat carotid surgery.

scholarly journals Moving on unconventional research fields for carotid endarterectomy in asymptomatic patients

2021 ◽  
Vol 73 (5) ◽  
pp. 1834
Author(s):  
Daniele Bissacco ◽  
Maurizio Domanin ◽  
Santi Trimarchi
Keyword(s):  
Carotid Endarterectomy ◽  
Research Fields ◽  
Asymptomatic Patients

Long-term outcomes of symptomatic and asymptomatic patients undergoing carotid endarterectomy in an average-volume community hospital

2020 ◽  
pp. 1-7
Author(s):  
José M. Alvarez Gallesio ◽  
Patricio Gimenez Ruiz ◽  
Michel David ◽  
Martin Devoto ◽  
Alejandro Caride ◽  
...  
Keyword(s):  
Carotid Endarterectomy ◽  
Community Hospital ◽  
Long Term Outcomes ◽  
Average Volume ◽  
Asymptomatic Patients

scholarly journals Carotid artery stenosis – Current evidence and treatment recommendations

2021 ◽  
Vol 5 (1) ◽  
pp. 2514183X2110016
Author(s):  
Mandy D Müller ◽  
Leo H Bonati
Keyword(s):  
Carotid Artery ◽  
Carotid Stenosis ◽  
Carotid Artery Stenosis ◽  
Artery Stenosis ◽  
Current Evidence ◽  
Asymptomatic Carotid Stenosis ◽  
Asymptomatic Carotid ◽  
Risk Of Death ◽  
Asymptomatic Patients

Background: Carotid artery stenosis is an important cause for stroke. Carotid endarterectomy (CEA) reduces the risk of stroke in patients with symptomatic carotid stenosis and to some extent in patients with asymptomatic carotid stenosis. More than 20 years ago, carotid artery stenting (CAS) emerged as an endovascular treatment alternative to CEA. Objective and Methods: This review summarises the available evidence from randomised clinical trials in patients with symptomatic as well as in patients with asymptomatic carotid stenosis. Results: CAS is associated with a higher risk of death or any stroke between randomisation and 30 days after treatment than CEA (odds ratio (OR) = 1.74, 95% CI 1.3 to 2.33, p < 0.0001). In a pre-defined subgroup analysis, the OR for stroke or death within 30 days after treatment was 1.11 (95% CI 0.74 to 1.64) in patients <70 years old and 2.23 (95% CI 1.61 to 3.08) in patients ≥70 years old, resulting in a significant interaction between patient age and treatment modality (interaction p = 0.007). The combination of death or any stroke up to 30 days after treatment or ipsilateral stroke during follow-up also favoured CEA (OR = 1.51, 95% CI 1.24 to 1.85, p < 0.0001). In asymptomatic patients, there is a non-significant increase in death or stroke occurring within 30 days of treatment with CAS compared to CEA (OR = 1.72, 95% CI 1.00 to 2.97, p = 0.05). The risk of peri-procedural death or stroke or ipsilateral stroke during follow-up did not differ significantly between treatments (OR = 1.27, 95% CI 0.87 to 1.84, p = 0.22). Discussion and Conclusion: In symptomatic patients, randomised evidence has consistently shown CAS to be associated with a higher risk of stroke or death within 30 days of treatment than CEA. This extra risk is mostly attributed to an increase in strokes occurring on the day of the procedure in patients ≥70 years. In asymptomatic patients, there may be a small increase in the risk of stroke or death within 30 days of treatment with CAS compared to CEA, but the currently available evidence is insufficient and further data from ongoing randomised trials are needed.

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