Carotid endarterectomy in patients with recurrent symptoms associated with an ipsilateral carotid artery near occlusion with full collapse

Meershoek, Armelle J.A.; Vonken, Evert-Jan P.A.; Nederkoorn, Paul J.; Kappelle, L. Jaap; Borst, Gert J. de

doi:10.1007/s00415-018-8939-z

Cited by 18 publications

(20 citation statements)

References 28 publications

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“…Many of the high-risk near-occlusion with full collapse cases were mistaken for occlusions in routine practice imaging (but correctly diagnosed by experts in retrospect), an issue likely not limited to our center, warranting improvements in diagnostics. Also, many of the high-risk near-occlusions were deemed technically unfeasible to treat and had a high risk of stroke when treated; similar risk has been suggested elsewhere [16]-pathophysiological work might reveal other treatment options than revascularization.…”

Section: Discussionmentioning

confidence: 77%

Symptomatic carotid near-occlusion causes a high risk of recurrent ipsilateral ischemic stroke

Aviv

Fox

et al. 2019

J Neurol

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Objective To assess the risk of recurrent ipsilateral ischemic stroke in patients with symptomatic near-occlusion with and without full collapse. Methods Included were consecutive patients eligible for revascularization, grouped into symptomatic conventional ≥ 50% carotid stenosis (n = 266), near-occlusion without full collapse (n = 57) and near-occlusion with full collapse (n = 42). The risk of preoperative recurrent ipsilateral ischemic stroke was analyzed, or, for cases not revascularized within 90 days, 90day risk was analyzed. Results The risk of a preoperative recurrent ipsilateral ischemic stroke or ipsilateral retinal artery occlusion was 15% (95% CI 9-20%) for conventional ≥ 50% stenosis, 22% (95% CI 6-38%) among near-occlusion without full collapse and 30% (95% CI 16-44%) among near-occlusion with full collapse (p = 0.01, log rank test). In multivariate analysis, near-occlusion with full collapse had a higher risk of recurrent ipsilateral ischemic stroke (adjusted HR 2.6, 95% CI 1.3-5.3) and near-occlusion without full collapse tended to have a higher risk (adjusted HR 2.0, 95% CI 0.9-4.5) than conventional ≥ 50% stenosis. Only 24% of near-occlusion with full collapse underwent revascularization, common causes for abstaining were misdiagnosis as occlusion (31%), deemed surgically unfeasible (21%) and low perceived benefit (10%). Conclusions Symptomatic carotid near-occlusion has a high short-term risk of recurrent ipsilateral ischemic stroke, especially near-occlusion with full collapse.

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Section: Discussionmentioning

confidence: 77%

Symptomatic carotid near-occlusion causes a high risk of recurrent ipsilateral ischemic stroke

Aviv

Fox

et al. 2019

J Neurol

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“…Eleven studies with IPD available were included in the meta‐analysis ( Fig . ), including an observational study from University Medical Centre Utrecht. Of the remaining 21 studies, IPD could not be retrieved because the authors did not respond (7; response rate 78 per cent), IPD were not available (12), or the study was an RCT (2).…”

Section: Resultsmentioning

confidence: 99%

Meta-analysis of the outcomes of treatment of internal carotid artery near occlusion

Meershoek¹,

Vries²,

Veen

et al. 2019

British Journal of Surgery

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Background Guidelines recommend treating patients with an internal carotid artery near occlusion (ICANO) with best medical therapy (BMT) based on weak evidence. Consequently, patients with ICANO were excluded from randomized trials. The aim of this individual‐patient data (IPD) meta‐analysis was to determine the optimal treatment approach. Methods A systematic search was performed in MEDLINE, EMBASE and the Cochrane Library databases in January 2018. The primary outcome was the occurrence of any stroke or death within the first 30 days of treatment, analysed by multivariable mixed‐effect logistic regression. The secondary outcome was the occurrence of any stroke or death beyond 30 days up to 1 year after treatment, evaluated by Kaplan–Meier survival analysis. Results The search yielded 1526 articles, of which 61 were retrieved for full‐text review. Some 32 studies met the inclusion criteria and pooled IPD were available from 11 studies, including some 703 patients with ICANO. Within 30 days, any stroke or death was reported in six patients (1·8 per cent) in the carotid endarterectomy (CEA) group, five (2·2 per cent) in the carotid artery stenting (CAS) group and seven (4·9 per cent) in the BMT group. This resulted in a higher 30‐day stroke or death rate after BMT than after CEA (odds ratio 5·63, 95 per cent c.i. 1·30 to 24·45; P = 0·021). No differences were found between CEA and CAS. The 1‐year any stroke‐ or death‐free survival rate was 96·1 per cent for CEA, 94·4 per cent for CAS and 81·2 per cent for BMT. Conclusion These data suggest that BMT alone is not superior to CEA or CAS with respect to 30‐day or 1‐year stroke or death prevention in patients with ICANO. These patients do not appear to constitute a high‐risk group for surgery, and consideration should made to including them in future RCTs of internal carotid artery interventions.

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“…Since the mechanism of CoW appearance (pathological versus congenital) is very difficult to determine with CTA, CoW appearance is likely of limited value when distinguishing between these causes if ICA asymmetry; rather, a systematic approach of several extracranial features seems reasonable [1,8]. Given that ICA size can change with changes in flow [1,9], the small distal ICA in congenital cases is reasonable by CoW variants; however, it cannot be excluded that a small distal ICA congenitally result in CoW variation, why we described this as an association.…”

Section: Discussionmentioning

confidence: 99%

Atherosclerotic ICA stenosis coinciding with ICA asymmetry associated with Circle of Willis variations can mimic near-occlusion

2019

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Differentiating carotid near-occlusion (tight atherosclerotic stenosis causing distal artery size reduction) from conventional stenosis is the first step when grading carotid stenoses with NASCET method. The internal carotid artery (ICA) can be asymmetrically associated with Circle of Willis variations. When such ICA asymmetry coincides with stenosis, it may mimic nearocclusion. We studied ICA anatomical variant prevalence in 4042 consecutive CTA exams from all indications, 53 excluded due to carotid occlusion, 814 with any ≥ 50% steno-occlusive disease intra-or extracranially, 3228 without. Of the 3989 included cases, 568 (14%) had ICA asymmetry, of which 335 (59%) were from associated with Circle of Willis variations. Of 3228 patients without ≥ 50% stenosis or other steno-occlusive disease intra-and extracranially; 257 (8.0%) demonstrated ICA asymmetry associated with Circle of Willis variations, equally common among sexes and age unrelated and most frequently attributed to an ipsilateral A1 hypoplasia/aplasia, less often attributed to large contralateral posterior communicating artery. As ICA asymmetry associated with Circle of Willis variations are common, caution should be exercised diagnosing near-occlusion on asymmetry alone.

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Carotid endarterectomy in patients with recurrent symptoms associated with an ipsilateral carotid artery near occlusion with full collapse

Cited by 18 publications

References 28 publications

Symptomatic carotid near-occlusion causes a high risk of recurrent ipsilateral ischemic stroke

Symptomatic carotid near-occlusion causes a high risk of recurrent ipsilateral ischemic stroke

Meta-analysis of the outcomes of treatment of internal carotid artery near occlusion

Atherosclerotic ICA stenosis coinciding with ICA asymmetry associated with Circle of Willis variations can mimic near-occlusion

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