scholarly journals Ten-year risk of stroke in patients with previous cerebral infarction and the impact of carotid surgery in the Asymptomatic Carotid Surgery Trial

2016 ◽  
Vol 11 (9) ◽  
pp. 1020-1027 ◽  
Author(s):  
Jonathan Y Streifler ◽  
Anne G den Hartog ◽  
Samuel Pan ◽  
Hongchao Pan ◽  
Richard Bulbulia ◽  
...  
Keyword(s):  
Cerebral Infarction ◽  
Carotid Endarterectomy ◽  
Carotid Stenosis ◽  
Hazard Ratio ◽  
Carotid Surgery ◽  
Asymptomatic Carotid ◽  
Risk Increase ◽  
Surgery Trial ◽  
The Impact

Background Silent brain infarcts are common in patients at increased risk of stroke and are associated with a poor prognosis. In patients with asymptomatic carotid stenosis, similar adverse associations were claimed, but the impact of previous infarction or symptoms on the beneficial effects of carotid endarterectomy is not clear. Our aim was to evaluate the impact of prior cerebral infarction in patients enrolled in the Asymptomatic Carotid Surgery Trial, a large trial with 10-year follow-up in which participants whose carotid stenosis had not caused symptoms for at least six months were randomly allocated either immediate or deferred carotid endarterectomy. Methods The first Asymptomatic Carotid Surgery Trial included 3120 patients. Of these, 2333 patients with baseline brain imaging were identified and divided into two groups irrespective of treatment assignment, 1331 with evidence of previous cerebral infarction, defined as a history of ischemic stroke or transient ischemic attack > 6 months prior to randomization or radiological evidence of an asymptomatic infarct (group 1) and 1002 with normal imaging and no prior stroke or transient ischemic attack (group 2). Stroke and vascular deaths were compared during follow-up, and the impact of carotid endarterectomy was observed in both groups. Results Baseline characteristics of patients with and without baseline brain imaging were broadly similar. Of those included in the present report, male gender and hypertension were more common in group 1, while mean ipsilateral stenosis was slightly greater in group 2. At 10 years follow-up, stroke was more common among participants with cerebral infarction before randomization (absolute risk increase 5.8% (1.8–9.8), p = 0.004), and the risk of stroke and vascular death was also higher in this group (absolute risk increase 6.9% (1.9–12.0), p = 0.007). On multivariate analysis, prior cerebral infarction was associated with a greater risk of stroke (hazard ratio = 1.51, 95% confidence interval: 1.17–1.95, p = 0.002) and of stroke or other vascular death (hazard ratio = 1.30, 95% confidence interval: 1.11–1.52, p = 0.001). At 10 years, greater absolute benefits from immediate carotid endarterectomy were seen in those patients with prior cerebral infarction (6.7% strokes immediate carotid endarterectomy vs. 14.7% delayed carotid endarterectomy; hazard ratio 0.47 (0.34–0.65), p = 0.003), compared to those lower risk patients without prior cerebral infarction (6.0% vs. 9.9%, respectively; hazard ratio 0.61 (0.39–0.94), p = 0.005), though it must be emphasized that the first Asymptomatic Carotid Surgery Trial was not designed to test this retrospective and non-randomized comparison. Conclusions Asymptomatic carotid stenosis patients with prior cerebral infarction have a higher stroke risk during long-term follow-up than those without prior cerebral infarction. Evidence of prior ischemic events might help identify patients in whom carotid intervention is particularly beneficial.

scholarly journals The Asymptomatic Carotid Surgery Trial-2 (ACST-2): an ongoing randomised controlled trial comparing carotid endarterectomy with carotid artery stenting to prevent stroke

2017 ◽  
Vol 21 (57) ◽  
pp. 1-40 ◽  
Author(s):  
Richard Bulbulia ◽  
Alison Halliday
Keyword(s):  
Carotid Artery ◽  
Carotid Stenosis ◽  
Controlled Trial ◽  
Carotid Stenting ◽  
Carotid Surgery ◽  
Asymptomatic Carotid ◽  
Randomised Controlled ◽  
Surgery Trial

Background A successful open surgical operation to remove atheromatous carotid artery narrowing that has not yet caused a stroke (asymptomatic carotid stenosis) carries some procedural risk but, if completed successfully, halves patients’ future annual stroke risk for at least 10 years. A newer, less invasive alternative is carotid stenting, which also carries some procedural risk, especially if the carotid lesion has recently given rise to a stroke (symptomatic carotid stenosis). For both surgery and stenting, improvements in technique (and in medication) have reduced risk. Early studies showed that treating carotid narrowing by stenting, particularly for symptomatic lesions, caused more procedural minor strokes than surgery, but more recent trials in symptomatic and in asymptomatic patients found that both procedures might now be equally safe and effective. However, low patient numbers, short follow-up of the long-term effects on stroke rates and wide confidence intervals mean that worldwide uncertainty persists between carotid surgery and carotid stenting, and national and international guidelines remain unclear as to which is generally better. Objectives The second Asymptomatic Carotid Surgery Trial (ACST-2) compares carotid endarterectomy (CEA) with carotid artery stenting (CAS) directly, randomising patients with asymptomatic carotid stenosis for whom a carotid procedure is considered definitely necessary; both procedures seem anatomically feasible, and there is substantial uncertainty as to which of the two would be better for such individuals. Although it will compare procedural risks, the trial’s primary aim is to compare the long-term durability of protection against strokes occurring in the years post procedure due to any remaining or recurrent carotid disease. Design Randomised controlled trial comparing CEA with CAS. Setting Hospitals in the UK and worldwide, in which carotid procedures are common. Participants Men and women with severely stenotic atherosclerotic carotid artery disease, with or without previous stroke but with no recent symptoms from the randomised artery. Interventions CEA and CAS. Outcomes (1) Periprocedural risk defined as myocardial infarction, stroke or death within 30 days after the randomised procedure and (2) long-term rates of disabling or fatal stroke during follow-up of patients. Measurement of costs and outcomes Measurement of intervention costs and stroke costs (periprocedural and during follow-up) and of quality of life [EuroQol-5 Dimensions (EQ-5D®)] for patients in the top six recruiting countries (UK, Italy, Belgium, Germany, Serbia and Sweden), who currently constitute 85% of those randomised. Progress so far By the end of March 2016, ACST-2 had included 2125 patients, nearly two-thirds of the planned recruitment of 3600; 1061 were randomly allocated to CEA and 1064 to CAS. Conclusions Further funding has been secured and recruitment continues, with completion anticipated by the end of 2019. ACST-2 will report initial results in 2021. Trial registration Current Controlled Trials ISRCTN21144362. Funding This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 21, No. 57. See the NIHR Journals Library website for further project information. Funding was also received from BUPA Foundation [BUPAF/33(a)/05].

Angioplastica carotidea

1998 ◽  
Vol 11 (4) ◽  
pp. 431-442 ◽  
Author(s):  
M. Puglioli ◽  
R. Padolecchia ◽  
P.L. Collavoli ◽  
G. Parenti ◽  
G. Orlandi ◽  
...  
Keyword(s):  
Carotid Endarterectomy ◽  
North American ◽  
Carotid Atherosclerosis ◽  
Sono State ◽  
Carotid Surgery ◽  
Asymptomatic Carotid ◽  
Symptomatic Carotid ◽  
Sono Stati ◽  
Surgery Trial

L'endoarteriectomia, come confermano i risultati degli studi multicentrici NASCET (North American Symptomatic Carotid Endarterectomy Trial), ECST (European Carotid Surgery Trial) ed ACAS (Asymptomatic Carotid Atherosclerosis Study), rappresenta il trattamento di elezione delle stenosi aterosclerotiche interessanti il distretto extracranico dell'arteria carotide, sia nei pazienti sintomatici (stenosi > 70%) che asintomatici (stenosi > 60%). L'intervento chirurgico è gravato da un rischio cumulativo di morbilità-mortalità (stroke/morte) che il NASCET, l'ECST e l'ACAS segnalano, rispettivamente, nel 5,8%, 7,5% e 2,3%, insieme ad altre possibili complicanze: infarto miocardico (0,9%), paralisi di nervi cranici (7,6%), ematoma del collo (5,5%), infezioni (3,4%). Qualora, per ragioni cliniche od anatomiche, il rischio chirurgico sia troppo elevato, come nei pazienti cardiopatici, diabetici, con insufficienza polmonare o renale, con restenosi, con stenosi post-attiniche o fibrodisplastiche, con stenosi carotidee prossimali o distali, con lesioni «tandem», l'angioplastica transluminale percutanea (PTA) e/o lo Stenting carotideo possono rappresentare una valida alternativa terapeutica all'endoarteriectomia. In questo articolo presentiamo la nostra casistica relativa a 41 procedure (36 PTA; 5 Stenting), eseguite su 33 pazienti negli ultimi due anni. I trattamenti sono stati rivolti a 28 arterie carotidi interne, 4 arterie carotidi esterne, 2 arterie carotidi comuni, 2 tronchi anonimi; gli stents sono stati rilasciati in 4 arterie carotidi interne e in 1 arteria carotide comune. Le procedure regolarmente portate a termine sono state 37 (32 PTA; 5 Stents), con un ottimo risultato anatomico in 36 casi. Nei controlli a 6 mesi abbiamo riscontrato una ristenosi (< 60%), asintomatica. In questo articolo illustriamo il nostro protocollo, gli insuccessi tecnici, i risultati e le complicanze.

Second Asymptomatic Carotid Surgery Trial (ACST-2): Randomised Comparison of Carotid Artery Stenting vs Carotid Endarterectomy

2021 ◽  
Author(s):  
Alison Halliday ◽  
Richard Bulbulia ◽  
Leo Bonati ◽  
Johanna Chester ◽  
Andrea Cradduck-Bamford ◽  
...  
Keyword(s):  
Carotid Artery ◽  
Carotid Endarterectomy ◽  
Carotid Artery Stenting ◽  
Carotid Surgery ◽  
Asymptomatic Carotid ◽  
Surgery Trial

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.

Sign in / Sign up

Export Citation Format

Share Document