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

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.

Completion Arteriogram Following Carotid Endarterectomy Yields Lower Perioperative Stroke Rate

Introduction: Completion imaging following carotid endarterectomy (CEA) remains controversial. We present our experience performing routine completion arteriography (CA). Methods: A retrospective review of our prospectively maintained institutional database was performed for patients undergoing isolated CEA. Results: 1439 isolated CEAs with CA were performed on 1297 patients. CEA was for asymptomatic lesions in 70% (1003) of cases. There were no complications related to arteriography. An abnormal arteriogram documented significant abnormalities in the internal carotid artery (ICA) and prompted revision in 1.7% (24/1439) of cases: 20 unsatisfactory distal endpoints of the endarterectomy (12 residual stenoses, 7 intimal flaps, and 1 dissection), 3 kinks or stenoses within the body of the patch, and 1 thrombus. Of the 20 distal endpoint lesions, stent deployment was used in 17 cases and patch revision in 3 cases. The other 4 cases were treated by patch angioplasty (3) or thrombectomy (1). None suffered a perioperative stroke. The overall 30-day stroke, death, and combined stroke/death rate for the 1439 patients in our series was 1.5% (22), .5% (7), and 1.9% (27), respectively. The combined stroke/death rate for asymptomatic lesions was 1.1% (11/1003) and for symptomatic lesions was 2.5% (11/436). Of the 22 strokes in the entire series (all with normal CA), 15 were non-hemorrhagic strokes ipsilateral to the CEA; 14 were confirmed to have widely patent endarterectomy sites by CT-A (13) or re-exploration and repeat arteriography (1). The occluded site was re-explored and underwent thrombectomy, but no technical problems were identified. The remaining strokes were hemorrhagic (4 reperfusion syndrome and 1 surgical site bleeding) or contralateral to the CEA (2). Conclusion: Although not all patients in this series who underwent intraoperative revision due to abnormal CA might have suffered a stroke, performing this simple and safe study may have halved our overall perioperative stroke rate from 3.2% to 1.5%.

Outcomes of Carotid Revascularization in the Treatment of Restenosis After Prior Carotid Endarterectomy

Background and Purpose: Restenosis after carotid endarterectomy (CEA) is associated with an increased risk of ipsilateral stroke. The optimal procedural modality for this indication has yet to be determined. Here, we evaluate the in-hospital outcomes of transcarotid artery revascularization (TCAR), redo-CEA, and transfemoral carotid artery stenting (TFCAS) in a large contemporary cohort of patients who underwent treatment for restenosis after CEA. Methods: We performed a retrospective analysis of all patients in the vascular quality initiative database who underwent TCAR, redo-CEA, or TFCAS after ipsilateral CEA between September 2016 and April 2020. Patients with prior ipsilateral CAS were excluded from this analysis. In-hospital outcomes following TCAR versus CEA and TCAR versus TFCAS were evaluated using multivariate logistic regression analysis. Results: A total of 4425 patients were available for this analysis. There were 963 (21.8%) redo-CEA, 1786 (40.4%) TFCAS, and 1676 (37.9%) TCAR. TCAR was associated with lower odds of in-hospital stroke/death (odds ratio [OR], 0.41 [95% CI, 0.24–0.70], P =0.021), stroke (OR, 0.46 [95% CI, 0.23–0.93], P =0.03), myocardial infarction (MI; OR, 0.32 [95% CI, 0.14–0.73], P =0.007), stroke/transient ischemic attack (OR, 0.42 [95% CI, 0.24–0.74], P =0.002), and stroke/death/MI (OR, 0.41 [95% CI, 0.24–0.70], P =0.001) when compared with redo-CEA. There was no significant difference in the odds of death between the 2 groups (OR, 0.99 [95% CI, 0.28–3.5], P =0.995). TCAR was also associated with lower odds of stroke/transient ischemic attack (OR, 0.37 [95% CI, 0.18–0.74], P =0.005) when compared with TFCAS. There was no significant difference in the odds of stroke, death, MI, stroke/death, or stroke/death/MI between TCAR and TFCAS. Conclusions: TCAR was associated with significantly lower odds of in-hospital stroke, MI, stroke/transient ischemic attack, stroke/death, and stroke/death/MI when compared with redo-CEA and lower odds of in-hospital stroke/transient ischemic attack when compared with TFCAS. Additional long-term studies are warranted to establish the role of TCAR for the treatment of restenosis after CEA.

Medium-long-term results of carotid stenting in asymptomic stenosis of the carotid arteries

The article describes the experience of carotid stenting use in asymptomatic cerebral atherosclerosis. The study included 147 patients with unilateral asymptomatic carotid artery disease. The evaluation of mid-longterm results of carotid stenting in patients with asymptomatic stenosis was carried out in comparison with the use of conservative treatment in this category of patients (“optimal drug treatment”). In the course of the work, no significant intergroup difference was revealed in the incidence of adverse outcomes (TIA/stroke, death from stroke,) within a year from the moment of surgical treatment or the beginning of complex correction of risk factors.

Abstract P91: Excess Cerebrovascular Mortality in the U.S. During the Covid-19 Pandemic

Introduction: The magnitude and drivers of excess cerebrovascular-specific mortality during the coronavirus-19 (COVID-19) pandemic are unknown. We aim to quantify excess stroke-related death and characterize its association with psychosocial factors and emerging COVID-19 related mortality. Methods: U.S. and state-level excess cerebrovascular deaths from January-May 2020 were quantified by Poisson regression models built using National Center for Health Statistic (NCHS) data. Weekly excess cerebrovascular deaths in the U.S. were analyzed as functions of time-varying, weekly stroke-related EMS calls and weekly COVID-19 deaths by univariable linear regression. A state-level negative binomial regression analysis was performed to determine the association between excess cerebrovascular deaths and social distancing (degree of change in mobility per Google COVID-19 Community Mobility Reports) during the height of the pandemic after the first COVID-19 death (February 29, 2020), adjusting for cumulative COVID-19 related deaths and completeness of deaths attributable to COVID-19 in NCHS. Findings: There were 918 more cerebrovascular deaths than expected from January 1-May 16 th , 2020 in the U.S. Excess cerebrovascular mortality occurred during every week between March 28-May 2 nd , 2020, up to 7.8% during the week of April 18 th . Decreased stroke-related EMS calls were associated with excess stroke deaths one (β -0.06, 95% CI -0.11, -0.02) and two weeks (β -0.08, 95% CI -0.12, -0.04) later. There was no significant association between weekly excess stroke death and COVID-19 death. Twenty-three states and NYC experienced excess cerebrovascular mortality during the pandemic height. At the state level, a 10% increase in social distancing was associated with a 4.3% increase in stroke deaths (IRR 1.043, 95% CI 1.001–1.085) after adjusting for COVID-19 mortality. Conclusions: Excess U.S. cerebrovascular deaths during the COVID-19 pandemic were observed with decreases in stroke-related EMS calls nationally and less mobility at the state level. Public health measures are needed to identify and counter the reticence to seeking medical care for acute stroke during the COVID-19 pandemic.

Progress Toward Achieving National Targets for Reducing Coronary Heart Disease and Stroke Mortality: A County‐Level Perspective

Background The American Heart Association and Healthy People 2020 established objectives to reduce coronary heart disease (CHD) and stroke death rates by 20% by the year 2020, with 2007 as the baseline year. We examined county‐level achievement of the targeted reduction in CHD and stroke death rates from 2007 to 2017. Methods and Results Applying a hierarchical Bayesian model to National Vital Statistics data, we estimated annual age‐standardized county‐level death rates and the corresponding percentage change during 2007 to 2017 for those aged 35 to 64 and ≥65 years and by urban‐rural classification. For those aged ≥35 years, 56.1% (95% credible interval [CI], 54.1%–57.7%) and 39.8% (95% CI, 36.9%–42.7%) of counties achieved a 20% reduction in CHD and stroke death rates, respectively. For both CHD and stroke, the proportions of counties achieving a 20% reduction were lower for those aged 35 to 64 years than for those aged ≥65 years (CHD: 32.2% [95% CI, 29.4%–35.6%] and 64.1% [95% CI, 62.3%–65.7%]), respectively; stroke: 17.9% [95% CI, 13.9%–22.2%] and 45.6% [95% CI, 42.8%–48.3%]). Counties achieving a 20% reduction in death rates were more commonly urban counties (except stroke death rates for those aged ≥65 years). Conclusions Our analysis found substantial, but uneven, achievement of the targeted 20% reduction in CHD and stroke death rates, defined by the American Heart Association and Healthy People. The large proportion of counties not achieving the targeted reduction suggests a renewed focus on CHD and stroke prevention and treatment, especially among younger adults living outside of urban centers. These county‐level patterns provide a foundation for robust responses by clinicians, public health professionals, and communities.

Stroke death profiles in Brazil between the years 2010 and 2019

Background: In most cases, strokes are events with an abrupt onset characterized by a neurological deficit attributed to a focal vascular cause. Such events can have ischemic or hemorrhagic origin with diagnosis attributed to clinical and imaging exams. In this work, we analyze the profile of deaths by stroke in the Brazilian population, outlining an overview of the disease in Brazil. Objective: Analyze stroke death profiles between the years 2010 and 2019. Methodology: We perform a descriptive documentary study based on the Mortality Information System (SIM) for the years 2010 to 2019, made available by the Brazilian Unified Health System (SUS) Information Department. Our study is delimited by age, starting from 15-year-olds, and considering the ICD-10 I64 pathologies. Results: In the analyzed period, 400.395 stroke deaths were registered. Over the years, these deaths showed a decrease of approximately 24.47% with 2011 being the year with the highest number of registered deaths (n=44 892). The southeast region registered most deaths with 38.18% of the total. The most affected groups were men (50.79%), whites (46.43%), over 80 years-old (41.80%) and with no formal education (27.31%). Conclusion: There is a decrease in stroke cases in Brazil between 2010 and 2019. The high prevalence of deaths from stroke in the elderly highlights the need for greater control of modifiable risk factors to reduce mortality. Thus, the continuous improvement of socioeconomic, educational, and hospital care conditions in Brazil is necessary.

10 years of ARISTOTLE trial: results and lessons

In 2021, the world cardiology community celebrates the anniversary of one of the greatest research in clinical medicine – the Apixaban for Reduction in Stroke and Other Thromboembolic Events in Atrial Fibrillation (ARISTOTLE) study. The study showed that in patients with atrial fibrillation, the use of apixaban was more effective than the use of warfarin in the prevention of stroke or systemic embolism, was accompanied by a lower frequency of bleeding and was associated with lower mortality from all causes. To date, 77 subanalyses of this ambitious study have been published, a brief overview of which is given in the article. As shown by the post-hoc analysis of the ARISTOTLE study, apixaban was equally effective and safe both in patients without comorbidities and in polymorbid patients. The efficacy and safety of apixaban has been demonstrated in atrial fibrillation and in the presence of comorbidities, including diabetes mellitus, chronic kidney disease, obesity, and coronary heart disease. A number of subanalyses of the ARISTOTLE study are devoted to the prognostic assessment of biomarkers such as cardiac troponins, growth differentiation factor-15, pro-B-type N-terminal natriuretic peptide, D-dimer, asymmetric and symmetric dimethylarginine, interleukin-6, C-reactive protein. Based on the study of biomarkers, new, more informative scales for assessing the risk of stroke, death and bleeding were created: the ABC-stroke scale, the ABC-lethal outcome scale and the ABC-bleeding scale. The data of the corresponding sub-analyzes confirmed the greater efficacy and/or safety of apixaban treatment compared with warfarin, regardless of the level of various biomarkers in blood plasma and the degree of risk of stroke, death and bleeding, assessed using both traditional and new scales.

Atrial Fibrillation Ablation: When and Why?

Ablation of Atrial Fibrillation (AF) has quickly become an alternative strategy to impact the adverse symptoms and outcomes associated with or caused by AF. Early reports in 1998 demonstrated spontaneous initiation of AF by ectopic beats originating in the Pulmonary Veins (PVs) followed rapidly by showing that Radio Frequency (RF) circumferential ablation around the orifices of the PVs could “electrically disconnect” the PVs from the Left Atria (LA). This resulted in the explosive growth utilizing this procedure for AF Ablation (AFA) across a wide demographic spectrum of recipients. Foreseeable healthy debates have surfaced as to who best benefits and who may actually suffer complications or harm from AFA utilizing present techniques. Disagreement also persists as to whether AFA fundamentally and universally reduces stroke, death, hospitalization or does it initiate a more nuanced set of outcomes. The present effort asks the simple question: Has AFA matured to the point of requisite explicative review? Is it time now to peel back the layers and identify which cohort will be optimally served by AFA and perhaps which ones need demonstration of benefit? The present brief review suggests that prudent employment of AFA must now identify disparities in the variables reflected in these cohort outcomes. This will enable judgment in the use of AFA and the achievement of optimal outcomes.