Background and Purpose— Even in patients with high-grade carotid stenosis, cardiovascular morbidity causes more deaths than strokes do. Despite successful low-density lipoprotein (LDL) cholesterol lowering, a significant risk of atherosclerotic cardiovascular disease remains, eventually rendering other lipid or lipoprotein ratios more efficient treatment targets. This study aimed to investigate the predictive value of the ratio of serum apolipoprotein A-II/B for overall mortality (primary outcome) of carotid surgery patients. Methods— This single-center, nonrandomized, prospective cohort study comprised 327 consecutive patients undergoing carotid endarterectomy for high-grade internal carotid artery stenosis. Baseline lipoprotein concentrations were measured, and patients were observed for the occurrence of the primary outcome until the census date (January, 2003 to January, 2012; median follow-up, 102.3 months). Results— The ratio of apolipoprotein A-II/B (hazard ratio, 0.74 per SD; confidence interval, 0.60–0.91; P =0.004) showed the highest association with the primary outcome compared with other lipid-risk parameters, significantly improving a prognostic model based on major cardiovascular risk factors, including LDL, high-density lipoprotein, and triglycerides in terms of overall performance, calibration, and discrimination. This led to a significantly improved reclassification of 8.9% of all patients (net reclassification improvement, 0.137; P =0.006 and integrated discrimination improvement, 0.041; P <0.001) and of 13.6% of patients with a serum baseline concentration of <100 mg/dL LDL (net reclassification improvement, 0.270; P =0.030 and integrated discrimination improvement, 0.061; P =0.002). Conclusions— Apolipoprotein A-II/B significantly improves risk prediction of overall survival, also in carotid surgery patients with lower LDL levels. Consequently, this ratio might provide an efficient diagnostic tool and eventually a treatment target for actual lipid-lowering therapies, which has to be addressed in future randomized controlled trials.
was associated with re-establishment of the endothelial lining, suspension of proteolysis, and reconstitution of a new aortic wall with smooth muscle cells and extra cellular matrix. ECs exerted their healing properties through paracrine mechanisms involving up-regulation of endothelium-derived stabilizing factors and recruitment of resident vascular cells. They did not appear to directly participate in aortic wall repair. Transplantation of outgrowth ECs (n ¼ seven) reduced by 30% progression of AAAs and restored abluminal endothelium at 28 days compared with controls (n ¼ nine).Comment: The authors demonstrate that it is possible using EC seeding techniques to institute recovery of the luminal endothelial lining in an animal model of AAA. In addition, this new endothelial lining through paracrine effects appears to result in stabilization of the AAA. It has been previously known that re-endothelialization of denuded arteries can modulate the vascular smooth muscle cell phenotype in neointimal hyperplasia. This study, however, is the first to extend this concept to stabilization of AAAs. It is a unique contribution and perhaps sheds new light on AAA pathophysiology and, from the clinical perspective, suggests ultimately a new mechanism of potentially arresting the growth of AAAs.
Surgery was standardized by performing only eversion endarterectomy under local anesthesia with the systemic administration of Background and Purpose-A limited life expectancy reduces the benefit from carotid endarterectomy (CEA) for treatment of asymptomatic internal carotid artery stenosis. The aim of this study was to assess homocysteine as stratifying biomarker to improve prediction of postoperative survival. Methods-This was a single-center cohort study 2003 to 2012. Two hundred and fourteen consecutive patients (<75 years, n=130; ≥75 years, n=84) undergoing CEA for their asymptomatic internal carotid artery stenosis were observed for 8.5 years for the occurrence of death after CEA as primary end point (EC-nr: 04-067-0604). Homocysteine and major cardiovascular risk factors were used for computation of prognostic indices. Cumulative survival of prognostic indicesbased quintiles was estimated by Kaplan-Meier curves. Results-Total homocysteine had a significant effect on postoperative survival (P<0.0001). Total homocysteine-based quintiles of prognostic indices showed a better prediction of the survival of the patients than age alone. This caused reclassification of 17 patients (20.2%) >75 years as fit for surgery, but also indicated a high risk for 19 patients (14.6%) <75 years. In the majority (79.8%) of patients aged >75 years, statistically, CEA could not be advised because of a significantly reduced 5-year survival rate. Conclusions-High plasma homocysteine levels suggest that older patients with asymptomatic carotid stenosis might rather benefit from intensive medical therapy than from CEA. (Stroke. 2013;44:2311-2314.)
Objectives: Efficacy of carotid surgery (CEA) in asymptomatic patients is subject of intense debate. Biomarkers are required to select those who will most likely benefit from CEA for their asymptomatic carotid stenosis (ICAS) despite advanced age.Aim: In this study we assessed plasma total homocysteine (thcy), a widely acknowledged cardiovascular risk factor, as stratifying biomarker to improve prediction of postoperative survival beyond the age of 75 years.Methods: Single centered, non-randomized, openlabeled prospective cohort-study from 2003 to 2012. 214 consecutive patients (88 female, 126 male, mean age 71 years) undergoing carotid surgery for their asymptomatic high-grade stenosis of their internal carotid stenosis (ICAS) were observed (mean observation period 8.5 years) for the occurrence of death after CEA as primary end point. (Local Ethics Committee nr: 04-067-0604) Statistics: Mann-Whitney-U Test was used for comparison of medians, Cox-Regression for estimating thcy-associated hazard ratios. Classic cardiovascular risk factors were used for computation of prognostic indices (PI). Cumulative survival probability of PI-based quintiles was estimated by Kaplan-Meier Curves. The effect of the prognostic model was evaluated by the actual percental distribution of age groups age (>75 years) over PIbased quintiles.Results: Thcy had a significant effect on postoperative survival. Thcy-based quintiles of prognostic indices showed a better prediction of the patients' 5-year (60 months) survival than age alone. This caused reclassification of 17 patients (20.2%) older than 75 years as fit for surgery, but also indicated a high risk for 19 patients (14.6%) younger than 75 years. In 79.8% of over 75 year old patients, statistically, CEA could not be advised due to significantly reduced survival.Conclusions: Homocysteine levels, along with other major CVRF, allow a better risk stratification of elderly patients undergoing CEA for their asymptomatic ICAS than an age cut-off of 75 years.Objectives: To evaluate operative results and shortterm outcomes in early vs late experience after fenestrated endovascular aortic repair (f-EVAR) in two tertiary European referral centers.Methods: All patients treated in (A) Malmö, Sweden and in (B) Lille, France with f-EVAR for abdominal aortic aneurysm (AAA) were prospectively enrolled in a computerized database. Early experience was defined as the first 50 patients treated at each center. Data from early and late experience was retrospectively analyzed and compared for differences in operative results and oneyear outcomes.Results: Early experience covered 4.7 years in A and 4.5 years in B with late experience covering 5.6 years in A and 3.7 years in B. A total of 288 patients were included without significant differences in comorbidities, gender (male, 88%), age (72 6 7 years) and preoperative AAA diameter (59 6 10 mm) between the groups. In the later phase, stent graft configuration was more complex due to increased number of fenestrations/scallops incorporated in the graft desig...
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