Background Among asymptomatic patients with severe carotid artery stenosis but no recent stroke or transient cerebral ischaemia, either carotid artery stenting (CAS) or carotid endarterectomy (CEA) can restore patency and reduce long-term stroke risks. However, from recent national registry data, each option causes about 1% procedural risk of disabling stroke or death. Comparison of their long-term protective effects requires large-scale randomised evidence.Methods ACST-2 is an international multicentre randomised trial of CAS versus CEA among asymptomatic patients with severe stenosis thought to require intervention, interpreted with all other relevant trials. Patients were eligible if they had severe unilateral or bilateral carotid artery stenosis and both doctor and patient agreed that a carotid procedure should be undertaken, but they were substantially uncertain which one to choose. Patients were randomly allocated to CAS or CEA and followed up at 1 month and then annually, for a mean 5 years. Procedural events were those within 30 days of the intervention. Intention-to-treat analyses are provided. Analyses including procedural hazards use tabular methods. Analyses and meta-analyses of non-procedural strokes use Kaplan-Meier and log-rank methods. The trial is registered with the ISRCTN registry, ISRCTN21144362.
Fibromuscular dysplasia (FMD) is an uncommon angiopathy that occurs mainly in young to middle-aged female individuals. It is an idiopathic, segmental, non-inflammatory and non-atherosclerotic vascular disease leading to stenosis of small- and medium-sized arteries. Clinical manifestations are determined by the artery involved, most commonly hypertension (renal artery) and stroke (carotid artery). When FMD affects multiple vascular beds, it may mimic a systemic vasculitis. Here, we present the case of a young female patient with FMD. The patient had a clinical history of bilateral internal carotid artery dissection that required surgical repair. Since a systemic vascular disease was suspected, abdominal angiography was done, showing evidence of a "string of beads" appearance involving the distal two-thirds of the right renal artery. This lesion is considered to be pathognomonic of the medial FMD that accounts for 70-95% of all cases of FMD. Two years later, a new magnetic resonance angiography confirmed the "string of beads" appearance of the middle to distal part of the right renal artery, with significant hemodynamic stenosis that was successfully dilated with percutaneous transluminal angioplasty.
The recent article by Randall et al 1 is of great interest and involves a large number of patients undergoing carotid artery stent (CAS) and staged myocardial revascularization with a low incidence of periprocedural neurological complication. However, we have some comments and report our own experience.Regarding the AHA guidelines, we do not feel it appropriate to perform carotid/coronary surgery, as Naylor pointed out, with a staged procedure. 2 Data on staged procedures taken from his meta-analysis are biased in that the authors do not indicate the number of patients initially enrolled and then submitted to the first procedure (carotid endarterectomy), and the number of patients who leave the study because of neurological or cardiac complications that would contraindicate the programmed staged heart surgery. Furthermore, any procedure, programmed or not, that leaves up to 6 months between the 2 operations was considered staged. By neurologic point of view, the comparison between staged and combined without any cerebral monitoring method is not correct. This is why, even though statistically correct, a postoperative stroke risk of 5.4 for a combined and 3.2% for a staged procedure and a mortality risk of 9.5 versus 6.6% would not seem comparable. Moreover there is no mention of which surgical team performs the combined operations.In Randall's study, no adverse events occurred in the first 30 days, but before myocardial revascularization, there were 3 cardiac death (5.7%) and an overall mortality rate at the end of the 2 procedures of 19.2%. We think that these results are too poor to suggest performing the hybrid carotid artery stent/ coronary artery bypass graft (CABG), which necessarily requires staging, both for technical (interventional vascular radiology room) as well as medical necessity. We agree with Dalainas and Nano 3 on antiplatelet therapy before and after carotid artery stent. The staged procedure makes it necessary to either suspend systemic antiaggregation with an increase in neurological risk or increasing surgical bleeding.It would have been useful to understand the level of clinical involvement of Randall's study patients undergoing this hybrid staged procedure by means of an improved characterization in severity rate of the heart disease (number of vessels involved, symptomatic cardiopathy, emergency) and the degree of carotid desease (controlateral carotid occlusion or neurologic symptoms). The presence of 7.7% symptomatic patients was limited. Furthermore, follow-up was performed only with neurological assessment and no mention was made of Duplex evaluation to reveal any eventual occlusion or intrastent restenosis.In our institution between 1998 and May 2006, 152 combined carotid thromboendarterectomy/CABG (same anesthesiologic setting) were performed. Preoperative symptoms were TIA in 7.8% and stroke in 5.2%. According to AHA guidelines, stenosis was Ͼ80% in 53% of operated cases, and 8.5% had concomitant contralateral carotid occlusion. Three underwent coronary artery bypass; 22 patients ...
An innovative hybrid approach to the supraaortic vessels in a porcelain aorta and severe fibrotic tissue reaction at the neck is described. The technique is demonstrated in an 80-year-old woman with previous several carotid operations but still experiencing recurrent transient ischemic attacks. Clinical success was achieved at midterm follow-up, demonstrating the efficacy of hybrid treatment for this high-risk patient. Novel prosthetic vascular grafts that can be applied without cross-clamping may also provide a solution to approaching a porcelain aorta and difficult anatomies.
scite is a Brooklyn-based organization that helps researchers better discover and understand research articles through Smart Citations–citations that display the context of the citation and describe whether the article provides supporting or contrasting evidence. scite is used by students and researchers from around the world and is funded in part by the National Science Foundation and the National Institute on Drug Abuse of the National Institutes of Health.