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.
Aim. To analyze inhospital outcomes of carotid endarterectomy (CE) in the acute period (within 3 days from the onset) of ischemic stroke.Material and methods. This retrospective multicenter study for the period from January 2008 to August 2020 included 357 patients who underwent CE in the acute period of stroke. An interdisciplinary commission defined the revascularization timing. There were following inclusion criteria: 1. Mild neurological disorders: NIHSS stroke of 3-8; modified Rankin Scale score <2; Bartel index >61; 2. Indications for CE according to the current national guidelines; 3. Brain ischemic focus <2,5 cm in diameter. There were following exclusion criteria: 1. Presence of contraindications to CE. The endpoints were such unfavorable cardiovascular events as death, myocardial infarction (MI), stroke/transient ischemic attack (TIA), silent stroke, silent hemorrhagic transformations, Bleeding Academic Research Consortium (BARC) type >3b bleeding, internal carotid artery thrombosis, composite endpoint (death + all strokes/TIA + MI). Silent strokes were those strokes, established according to control multi-slice computed tomography angiography, without symptoms.Results. During the in-hospital follow-up period, 8 deaths (2,24%), 5 MIs (1,4%), 6 strokes/TIAs (1,7%), 15 silent ischemic strokes (4,2%), 13 hemorrhagic transformations (3,6%), 26 silent hemorrhagic transformations (7,3%), and 6 BARC type >3b bleeding (1,7%) were recorded. Thus, the combined endpoint was 20,4% (n=73).Conclusion. Due to the high incidence of cardiovascular events, CE is not a safe operation for patients in the acute period of ischemic stroke. The stroke + mortality rate exceeding 3% demonstrates the ineffectiveness of this method of treatment.
<p><strong>Aim</strong>. To assess the results of carotid angioplasty with stenting (CAS) performed in the first 3 h after the onset of ischaemic stroke (the most acute period of acute cerebrovascular accident).</p><p><strong>Methods</strong>. This retrospective study included 312 patients from January 2008 to August 2020 with hemodynamically significant stenosis of the internal carotid arteries (ICA) who underwent CAS within 3 h of stroke onset. After a patient was hospitalised in our emergency department, stroke development was assessed by a neurologist. The level of neurological deficit was determined according to the National Institutes of Health Stroke Scale (NIHSS), the modified Rankin scale, the Barthel scale and the Rivermead Mobility Index. Multispiral computed tomography (MSCT) of the brain was then performed. On condition of visualisation of the ischaemic focus, the patient was sent for screening colour duplex scanning of the brachiocephalic arteries (BCA), arteries of the lower extremities, aortic arch and heart. If hemodynamically significant stenosis in the ICA was visualised, the patient underwent MSCT angiography of the BCA. The degree of stenosis was determined using the North American Symptomatic Trial Collaborators (NASCET) classifications. The on-duty ultidisciplinary council determined the tactics of the patient's treatment. Decisions regarding surgical correction and the choice of revascularisation strategy (CAS or carotid endarterectomy) were made based on stratification of the risk of postoperative complications according to the EuroSCORE II scale and the severity of coronary lesions according to the SYNTAX Score (in the presence of a history of coronary angiography). The time between admission to the emergency department and admission to the operating room was 84.5 ± 9.3 minutes. The inclusion criteria were 1. mild neurological disorders from 3 to 8 points on the NIHSS scale, no more than 2 points on the Rankin modification scale and more than 61 points on the Barthel scale; 2. Indication for CAS according to the current national recommendations; 3. Ischaemic focus in the brain no more than 2.5 cm in diameter according to MSCT; 4. Absence of pronounced calcification of the ICA. The exclusion criteria were: 1. Contraindications for CAS; 2. The presence of thrombosis of the ICA requiring the introduction of fibrinolytics (Alteplase), thromboextraction and thromboaspiration.</p><p><strong>Results</strong>. In the hospital postoperative period, 6 (1.92%) patients had lethal outcomes, 5 (1.6%) had myocardial infarctions, 5 (1.6%) had nonfatal stroke, 7 (2.2%) had asymptomatic ‘silent’ stroke, 2 (0.64%) had haemorrhagic transformations and 1 (0.32%) had ICA thrombosis. The combined endpoint (death + stroke + myocardial infarction) was reached in 7.05% of patients (n = 22).</p><p><strong>Conclusion</strong>. CAS is a safe and effective method of brain revascularisation in the first hours after the onset of ischaemic stroke. Interventional correction of hemodynamically significant stenoses of the ICA had permissible levels of ‘stroke + mortality from stroke’ and lethal outcomes, which reached 3.84% and 1.92%, respectively. Urgent implementation of CAS allows a significant regression of neurological deficit which is stable throughout the entire postoperative period.</p><p>Received 21 September 2020. Revised 1 October 2020. Accepted 10 October 2020.</p><p><strong>Funding:</strong> The study did not have sponsorship.</p><p><strong>Conflict of interest:</strong> Authors declare no conflict of interest.</p><p><strong>Author contributions</strong><br />Conception and design: R.A. Vinogradov, M.A. Chernyavsky, V.A. Porkhanov, E.Yu. Kachesov, G.G. Khubulava<br />Data collection and analysis: V.V. Matusevich, K.P. Chernykh, A.B. Zakeryaev. Drafting the article: A.N. Kazantsev<br />Statistical analysis: G.Sh. Bagdavadze, R.Yu. Leader. Critical revision of the article: <br />Final approval of the version to be published: A.N. Kazantsev, R.A. Vinogradov, M.A. Chernyavsky, V.V. Matusevich, <br />K.P. Chernykh, A.B. Zakeryaev, G.Sh. Bagdavadze, R.Yu. Leader, E.Yu. Kachesov, V.A. Porkhanov, G.G. Khubulava</p>
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