Abstract 2652: Carotid Revascularization Provides Similar Outcomes in Symptomatic and Asymptomatic Patients with <70 Years

Stroke ◽  
2012 ◽  
Vol 43 (suppl_1) ◽  
Author(s):  
Paola De Rango ◽  
Fabio Verzini ◽  
Piergiorgio Cao ◽  
Enrico Cieri ◽  
Giuseppe Giordano ◽  
...  
Keyword(s):  
Stroke Risk ◽  
Young Patients ◽  
The Elderly ◽  
Carotid Stenting ◽  
Stroke Incidence ◽  
Perioperative Stroke ◽  
Carotid Revascularization ◽  
Asymptomatic Patients ◽  
Effect Of Age ◽  
Stroke Death

Absolute stroke risk and perioperative stroke risk during carotid revascularization are higher in patients with symptomatic than in those with asymptomatic carotid stenosis. Age is one of the main risk factors for stroke and trials have shown a significant age interaction after carotid stenting (CAS). This study aims to analyze the effect of age on outcomes of carotid revascularization using the 70-year threshold as suggested by CREST. Methods: From 2001 to 2010 patients receiving carotid revascularization, either by CAS or by endarterectomy (CEA) were reviewed. Perioperative stroke-death rates and 72-month survival and late stroke incidence were compared in symptomatic and asymptomatic patients with less and more than 70years. Results: 2196 procedures, 1080 by CAS 1116 by CEA, were reviewed;684 were performed for carotid referable symptoms. Symptomatic patients showed higher perioperative stroke/death risks (3.5% vs 1.9%, p=0.034) and lower 72-months survival (74% vs 82%, p=0.0001) or freedom from late stroke (93% vs 97%, p=0.002) than asymptomatic patients with similar differences detected within CEA or CAS procedure. When only the group of 949 youngsters (≤70y) was analyzed, symptomatic and asymptomatic patients shared similar low perioperative stroke/death risks: 2.1% vs 1.3%, p=0.39. For young symptomatic patients, perioperative stroke/death risk was comparably low in CAS and CEA: 1.8% vs 1.2%. At 72 months, survival (98% vs 97%, p=0.49) and freedom from stroke (89% vs 89%, p=0.33) rates were similarly high in symptomatic and asymptomatic young patients. Comparable risks between the symptomatic and asymptomatic youngsters were found after each CAS (perioperative stroke/death: p=0.64; survival: p=0.10; late stroke: p=0.50) and CEA (perioperative stroke/death: p=0.49; survival: p=0.91; late stroke: p=0.64) procedure. Higher perioperative and late risks were confirmed for symptomatic patients in the elderly (>70y) subgroup (n=1247) regardless of the procedure. Conclusions: Outcomes following carotid revascularization are related to patient age. For younger ages (≤70years) symptomatic and asymptomatic patients may share similarly low perioperative and late risks of stroke and death after carotid revascularization whichever the procedure applied.

Abstract 5: Early and Long-term Safety of Stenting and Endarterectomy in Symptomatic and Asymptomatic Patients Outside Randomized Trials

Stroke ◽  
2012 ◽  
Vol 43 (suppl_1) ◽  
Author(s):  
Paola De Rango ◽  
Massimo Lenti ◽  
Enrico Cieri ◽  
Piergiorgio Cao ◽  
Giuseppe Giordano ◽  
...  
Keyword(s):  
Randomized Trials ◽  
Carotid Stenting ◽  
Stroke Incidence ◽  
Carotid Revascularization ◽  
Kaplan Meier ◽  
Asymptomatic Patients ◽  
Current Guidelines ◽  
Periprocedural Stroke ◽  
Stroke Death

Objective. Due to the different stroke risk exposure, advisability of carotid revascularization by carotid stenting (CAS) or endarterectomy (CEA) strictly depends on patients’ symptomatic status. Periprocedural and 5-year data of 2196 consecutive procedures (1080 CAS, 1116 CEA) based on physician-guided indication for CEA vs CAS and performed after training outside randomized trials, were reviewed for safety. Methods. 684 symptomatic and 1512 asymptomatic patients were analyzed for periprocedural stroke/death and 5-year death or stroke incidence. Kaplan-Meier survival curves with type-of-procedure interaction were employed. Results. Symptomatic patients were older (71.9y vs 71.04y), less frequently females (25.3% vs 30.8%) and treated more by CEA (60.8%) than by CAS (p<0.001). Asymptomatic patients were more likely affected by cardiac disease, peripheral disease and hyperlipidemia. Periprocedural stroke/death was higher in symptomatic than in asymptomatic patients (3.5% vs 1.9%;OR 1.8, 95%CI1.07-3.2) without significant differences between CAS and CEA in both symptomatic (4.5%CAS vs 2.9%CEA) and asymptomatic (2.2% CAS vs 1.6% CEA) groups. Symptomatic patients showed higher 5-year mortality and stroke incidence: survival rate was 78.4% in symptomatic and 85.5% in asymptomatic (p<0.0001). Late stroke freedom was 93.5% in symptomatic and 97.7% in asymptomatic (p=0.001). There were no differences, according to the procedure (CAS vs CEA) for treatment, in survival (Symptomatic: 85% vs 75%; Asymptomatic: 83% vs 83%) or late stroke incidence (Symptomatic: 93% vs 93%; Asymptomatic: 97% vs 97%). Conclusions. Symptomatic patients show higher risks after carotid revascularization and 5-year outcomes are inferior to those of asymptomatic patients regardless of the surgical procedure. Periprocedural stroke/death rates, either by CAS or CEA, are within the complication threshold rates suggested in current guidelines for both symptomatic and asymptomatic patients.

Neurological Outcomes after Carotid Stenting Protected with the NeuroShield Filter Compared to Unprotected Stenting

2002 ◽  
Vol 9 (6) ◽  
pp. 777-785 ◽  
Author(s):  
Sumaira Macdonald ◽  
Fiona McKevitt ◽  
Graham S. Venables ◽  
Trevor J. Cleveland ◽  
Peter A. Gaines
Keyword(s):  
Artery Bypass ◽  
Carotid Stenting ◽  
Death Rates ◽  
Neurological Outcomes ◽  
Protected Group ◽  
Asymptomatic Patients ◽  
Bilateral Carotid ◽  
Before And After ◽  
Carotid Stenoses ◽  
Stroke Death

Purpose: To compare outcomes for two nonrandomized cohorts of patients with high-grade carotid disease who underwent either unprotected carotid stenting or stent implantation protected by the NeuroShield filter. Methods: Under this protocol, symptomatic patients with carotid stenoses >70% or asymptomatic patients with bilateral carotid stenoses who were being evaluated for coronary artery bypass grafting were eligible for carotid stenting. Between December 1998 and November 2001, 75 consecutive patients (57 men; median age 67 years range 45–85) underwent carotid stenting without cerebral protection; concurrently, 75 carotid stent procedures protected with the NeuroShield filter were performed in 73 patients (51 men; median age 66 years, range 47–83). A neurologist reviewed all patients before and after treatment. The groups were comparable for age, sex, and symptoms, but the protected group had a higher proportion of postsurgical restenoses (14.7% versus 1.3%; p=0.003). Outcome measures included death and neurological events at 24 hours and 30 days. Results: There were minor technical difficulties in 12 of the protected group, but none were clinically relevant. The procedural all-stroke/death rates in the unprotected versus protected groups, respectively, were 5.3% (4/75) and 2.7% (2/75; p=0.681), while the disabling stroke/death rates were 4% (3/75) and 1.3% (1/75; p=0.620). At 30 days, the all-stroke/death rates were 10.7% (8/75) in the unprotected group and 4.0% (3/75) in the protected group (p=0.117); the death/major-disability-from-stroke rates were 6.7% (5/75) and 2.7% (2/75), respectively (p=0.442). Conclusions: Filter-related complications are well tolerated. Neuroprotection devices have the potential to reduce the procedural neurological event rate. Larger series and/or randomized trials are required for further evaluation.

scholarly journals Carotid Revascularization: Current Practice and Future Directions

2020 ◽  
Vol 37 (02) ◽  
pp. 132-139 ◽  
Author(s):  
Jacob H. Bagley ◽  
Ryan Priest
Keyword(s):  
Carotid Stenosis ◽  
Current Practice ◽  
Stroke Risk ◽  
Carotid Stenting ◽  
First Line ◽  
Future Directions ◽  
Carotid Revascularization ◽  
Randomized Controlled ◽  
First Line Therapy ◽  
Current State

AbstractCarotid stenosis is responsible for approximately 15% of ischemic strokes. Carotid revascularization significantly decreases patients' stroke risk. Carotid endarterectomy has first-line therapy for moderate-to-severe carotid stenosis after a series of pivotal randomized controlled trials were published almost 30 years ago. Revascularization with carotid stenting has become a popular and effective alternative in a select subpopulation of patients. We review the current state of the literature regarding revascularization indications, patient selection, advantages of each revascularization approach, timing of intervention, and emerging interventional techniques, such as transcarotid artery revascularization.

Abstract WMP106: Increased Carotid Stenting For Nonspecific Symptoms In The Post-crest Era

Stroke ◽  
2013 ◽  
Vol 44 (suppl_1) ◽  
Author(s):  
Mahmoud Rayes ◽  
Pratik Bhattacharya ◽  
Rahul Damani ◽  
Seemant Chaturvedi
Keyword(s):  
Primary Care Physicians ◽  
Medical Center ◽  
Carotid Stenting ◽  
Posterior Circulation ◽  
Complication Rates ◽  
Carotid Revascularization ◽  
Carotid Circulation ◽  
Revascularization Procedures ◽  
Specific Symptoms ◽  
Stroke Death

Background: Nonspecific symptoms such as dizziness and syncope may prompt evaluation of the carotid circulation and detection of carotid stenosis. The Carotid Revascularization Endarterectomy Versus Stenting Trial (CREST) demonstrated equivalent outcomes from Endarterectomy (CEA) and Stenting (CAS) in asymptomatic stenosis. We reviewed the trends in selection and outcomes from revascularization procedures for nonspecific symptoms in the light of CREST results. Methods: We performed a retrospective review of carotid revascularization procedures at a large volume urban medical center, between June 2009 (8 months pre-CREST) and April 2012. Demographics, surgical risk features and in-hospital outcomes of stroke/death/MI were reviewed. Patients were labeled as having nonspecific symptoms when they presented with posterior circulation symptoms or with non-focal symptoms i.e. Dizziness, syncope, etc. To evaluate the effect of CREST, we compared pre CREST (up to Jan 2010) and post CREST cases (Feb 2010 to Apr 2012). Results: 701 procedures (36.1% CEA, 63.9% CAS) were performed and mean age was 70 ±10 years. Non-specific indications accounted for 13% of CEA and 15.9% of CAS. Procedures for nonspecific symptoms did not increase post CREST in the CEA group (12.1% VS 13.3%). They increased significantly in the CAS group (6.3% pre and 18.5% post CREST). Among CAS, the rise was insignificant in the first 8 months (Feb 2010-Sep 2010) post CREST: 7.5%. This rose to 21.2% from Oct 2010 to May 2011: p=0.0017; and 23.8% from June 2011 to April 2012: p=0.0004. The rise in CAS was noted among elderly patients (>70 years), a group in which CREST demonstrated higher complication rates. The rise was noted among both men and women and they did not have surgical high-risk criteria. In-hospital complication rates of stroke/death/MI were 5.6% in this group. Most complications occurred in patients >70 years. Conclusion: CAS for nonspecific symptoms has increased following CREST, and the complication rates associated with these procedures is significant. This raises concern about the value of this procedure. Primary care physicians evaluating non-specific symptoms should obtain neurological expertise prior to revascularization procedures, to allow appropriate patient selection.

In-Hospital Outcomes of Urgent, Early, or Late Revascularization for Symptomatic Carotid Artery Stenosis

Stroke ◽  
2021 ◽  
Author(s):  
Christina L. Cui ◽  
Hanaa Dakour-Aridi ◽  
Jinny J. Lu ◽  
Kevin S. Yei ◽  
Marc L. Schermerhorn ◽  
...  
Keyword(s):  
Carotid Artery ◽  
Carotid Artery Stenosis ◽  
Carotid Stenting ◽  
Artery Stenosis ◽  
Optimal Timing ◽  
Hospital Outcomes ◽  
Carotid Revascularization ◽  
Symptomatic Carotid ◽  
Revascularization Procedures ◽  
Stroke Death

Background and Purpose: Advancements in carotid revascularization have produced promising outcomes in patients with symptomatic carotid artery stenosis. However, the optimal timing of revascularization procedures after symptomatic presentation remains unclear. The purpose of this study is to compare in-hospital outcomes of transcarotid artery revascularization (TCAR), transfemoral carotid stenting (TFCAS), or carotid endarterectomy (CEA) performed within different time intervals after most recent symptoms. Methods: This is a retrospective cohort study of United States patients in the vascular quality initiative. All carotid revascularizations performed for symptomatic carotid artery stenosis between September 2016 and November 2019 were included. Procedures were categorized as urgent (0–2 days after most recent symptom), early (3–14 days), or late (15–180 days). The primary outcome of interest was in-hospital stroke and death. Secondary outcomes include in-hospital stroke, death, and transient ischemic attacks. Multivariable logistic regression was used to compare outcomes. Results: A total of 18 643 revascularizations were included: 2006 (10.8%) urgent, 7423 (39.8%) early, and 9214 (49.42%) late. Patients with TFCAS had the highest rates of stroke/death at all timing cohorts (urgent: 4.0% CEA, 6.9% TFCAS, 6.5% TCAR, P =0.018; early: 2.5% CEA, 3.8% TFCAS, 2.9% TCAR, P =0.054; late: 1.6% CEA, 2.8% TFCAS, 2.3% TCAR, P =0.003). TFCAS also had increased odds of in-hospital stroke/death compared with CEA in all 3 groups (urgent adjusted odds ratio [aOR], 1.7 [95% CI, 1.0–2.9] P =0.03; early aOR, 1.6 [95% CI, 1.1–2.4] P =0.01; and late aOR, 1.9 [95% CI, 1.2–3.0] P =0.01). TCAR and CEA had comparable odds of in-hospital stroke/death in all 3 groups (urgent aOR, 1.9 [95% CI, 0.9–4], P =0.10), (early aOR, 1.1 [95% CI, 0.7–1.7], P =0.66), (late aOR, 1.5 [95% CI, 0.9–2.3], P =0.08). Conclusions: CEA remains the safest method of revascularization within the urgent period. Among revascularization performed outside of the 48 hours, TCAR and CEA have comparable outcomes.

Abstract TMP105: High Utilization Of CAS Procedures Among The Elderly In The Post Crest Era

Stroke ◽  
2013 ◽  
Vol 44 (suppl_1) ◽  
Author(s):  
Mahmoud Rayes ◽  
Pratik Bhattacharya ◽  
Rahul Damani ◽  
Seemant Chaturvedi
Keyword(s):  
High Risk ◽  
Elderly Patients ◽  
Medical Center ◽  
Significant Proportion ◽  
The Elderly ◽  
Carotid Revascularization ◽  
Choice Of Procedure ◽  
Asymptomatic Patients ◽  
Risk Criterion ◽  
Specific Symptoms

Background: An important interaction of age with outcome was revealed in Carotid Revascularization Endarterectomy Versus Stenting Trial (CREST) where elderly patients ≥70 years had worse outcomes with Carotid stenting (CAS) than with Endarterectomy (CEA). Our hypothesis was that following the CREST study, the proportion of CAS procedures in the elderly would decrease. Methods: We performed a retrospective review of carotid revascularization procedures between June 2009 and April 2012 at a large volume urban medical center. Demographics, indications, surgical high-risk criteria and outcomes of in-hospital stroke/death/MI were collected. Data analysis was performed in subjects over 70 years. Time trends were examined in the post-CREST period. Results: A total of 701 procedures (CEA 36%, CAS 64%) were performed during the study period, of which 360 (51.4%) were in patients ≥70 years (CEA 33%, CAS 67%). A significant proportion (22.1%) was in those ≥80 years. The choice of procedure did not change following CREST. The majority of CAS procedures in elderly (90.8%) were performed by cardiologists. Asymptomatic patients (47.3%) and patients with non-specific symptoms (18.7%) comprised a large proportion of this subgroup. A third of elderly patients with asymptomatic and nonspecific symptoms did not have any surgical high-risk criterion. The proportion of elderly patients receiving CAS for non-specific symptoms increased progressively over time post CREST (27.9% in the most recent months). A similar rise in non-specific indications was noted in the subgroup of patient ≥80 years receiving CAS. About half of this subgroup did not have any surgical high-risk criterion. Conclusion: Two years after CREST results, CAS continues to be performed among the elderly, often for non-specific symptoms or in asymptomatic patients. The lack of a decrease in CAS procedures in the elderly raises questions about whether evidence-based carotid revascularization occurs in the real world.

Transcranial Doppler Emboli Identifies Asymptomatic Carotid Patients at High Stroke Risk: Why This Technique Should be Used More Widely

Angiology ◽  
2016 ◽  
Vol 68 (8) ◽  
pp. 657-660 ◽  
Author(s):  
J. David Spence
Keyword(s):  
Medical Therapy ◽  
Transcranial Doppler ◽  
Stroke Risk ◽  
Carotid Stenting ◽  
The United States ◽  
Asymptomatic Carotid ◽  
Carotid Revascularization ◽  
The Cost ◽  
And Training ◽  
Annual Risk

With modern intensive medical therapy, the annual risk of ipsilateral stroke in asymptomatic carotid stenosis (ACS) is now ∼0.5%. Therefore, even the relative low risks reported from the Carotid Revascularization Endarterectomy versus Stenting Trial (CREST) trial do not justify routine intervention in most (90%) of the patients with ACS. It is therefore necessary to identify the ∼10% to15% of patients with ACS who have a stroke risk high enough to justify intervention. Transcranial Doppler (TCD) embolus detection has been shown in 2 prospective studies (one with 468 patients and the other with 467 patients) to identify patients at high risk and distinguish them from those who would be better served by medical therapy. There is no valid reason why carotid intervention should be carried out in ACS without first identifying that the patient’s risk of stroke is higher than the risk of intervention. The best validated way to do this is by TCD embolus detection, and the cost of TCD equipment and training is approximately the same as the cost of 2 carotid stenting procedures in the United States. This procedure should be used more widely.

Risks, Subtypes, and Hospitalization Costs of Stroke Among Patients with Systemic Lupus Erythematosus: A Retrospective Cohort Study in Taiwan

2012 ◽  
Vol 39 (8) ◽  
pp. 1611-1618 ◽  
Author(s):  
I-KUAN WANG ◽  
CHIH-HSIN MUO ◽  
YI-CHIH CHANG ◽  
CHIH-CHIA LIANG ◽  
SHIH-YI LIN ◽  
...  
Keyword(s):  
Systemic Lupus Erythematosus ◽  
Lupus Erythematosus ◽  
Stroke Risk ◽  
Young Patients ◽  
Systemic Lupus ◽  
Stroke Incidence ◽  
Hospitalization Costs ◽  
Insurance Claims Data ◽  
Health Insurance Claims Data ◽  
The Cost

Objective.To compare risks, subtypes, and hospitalization costs of stroke between cohorts with and without systemic lupus erythematosus (SLE).Methods.From the catastrophic illnesses registry of Taiwan’s universal health insurance claims data, we identified 13,689 patients with SLE diagnosed in 1997–2008 and selected 54,756 non-SLE controls, frequency-matched with age (every 5 years), sex, and index year. Age-specific and type-specific stroke incidence, hazard, and cost of stroke were compared between the 2 cohorts to the end of 2008.Results.Compared with the non-SLE cohort, the risk of stroke was 3.2-fold higher in the SLE cohort (5.53 vs 1.74 per 1000 person-years) with an overall adjusted HR of 2.90 (95% CI 2.52–3.33). The age-specific risk was the highest in patients 1–17 years old (HR 163, 95% CI 22.2–1197) and decreased as age increased (p = 0.004). Hypertension and renal disease were the most important comorbidities in the SLE cohort predicting stroke risk (HR 1.75, 95% CI 1.28–2.39 and HR 1.66, 95% CI 1.32–2.10, respectively). There were more hemorrhagic strokes in the SLE cohort than in the non-SLE cohort, but not significantly (28.0% vs 23.4%; p = 0.10). The hospitalization cost for stroke patients was more than twice the cost for those with SLE than for those without (p < 0.0001).Conclusion.Stroke risk and hospital care costs are considerably greater for patients with SLE than without. The relative risk of stroke is the highest in young patients with SLE.

scholarly journals Epidemiology and Etiology of Young Stroke

2011 ◽  
Vol 2011 ◽  
pp. 1-9 ◽  
Author(s):  
Dayna Griffiths ◽  
Jonathan Sturm
Keyword(s):  
Young Patients ◽  
Case Series ◽  
The Elderly ◽  
Population Based ◽  
Stroke Incidence ◽  
Young Stroke ◽  
Underlying Causes ◽  
Stroke In The Young ◽  
The Individual ◽  
Older Populations

Introduction. Stroke in people under 45 years of age is less frequent than in older populations but has a major impact on the individual and society. In this article we provide an overview of the epidemiology and etiology of young stroke.Methods. This paper is based on a review of population-based studies on stroke incidence that have included subgroup analyses for patients under 45 years of age, as well as smaller community-based studies and case-series specifically examining the incidence of stroke in the young. Trends are discussed along with the relative frequencies of various etiologies.Discussion. Stroke in the young requires a different approach to investigation and management than stroke in the elderly given differences in the relative frequencies of possible underlying causes. It remains the case, however, that atherosclerosis contributes to a large proportion of stroke in young patients, thus, conventional risk factors must be targeted aggressively.

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