Cognition After Carotid Endarterectomy or Stenting: A Randomized Comparison

Abstract

CJ, Engstrom BI, et al. J Vasc Interv Radiol 2012;23: 69-74 Conclusion: Covered stent exclusion of intragraft dialysis access graft pseudoaneurysms is correlated with a high rate of eventual graft infection.Summary: Prosthetic arteriovenous (AV) grafts are prone to develop pseudoaneurysms that are thought related to graft material degeneration secondary to repeated cannulation at specific sites. Such pseudoaneurysms may be particularly prone to develop infection in the face of outflow obstruction. Endovascular treatment can be used to treat prosthetic AV graft pseudoaneurysms with reports of high technical success and acceptable patency rates (Vesely TM, J Vasc Interv Radiol 2005;16:1301-7; Najibi S et al, J Surg Res 2002;106:15-19). However, the authors of this report indicated an anecdotal impression that incorporating this technique into their practice resulted in a higher incidence of prosthetic AV graft infection. They therefore sought to study whether stent graft treatment of prosthetic AV graft pseudoaneurysms influenced the incidence of AV graft infection. The authors reviewed their interventional radiology database for prosthetic AV graft interventions involving stent deployment anywhere within the AV graft and found 235 interventions in 174 patients between November 2004 and December 2008. The incidence of AV graft infection was analyzed by stent type (bare metal vs covered), location, and indication for stent deployment on a per-stent, per-procedure, and per-graft basis. Eventually, 16.3% of AV grafts with stents implanted required surgical excision for graft infection. When covered stents were used to treat intragraft pseudoaneurysms, the subsequent rate of graft infection increased compared with bare-metal stents or covered stents deployed within the graft for other reasons (42.1% vs 18.2%, P ϭ .011). When stents were deployed at an intragraft location, there was a higher incidence of graft infection compared with those deployed at a venous anastomosis or in an outflow vein (26.9% vs 6.9%, P Ͻ .001).Comment: Pseudoaneurysms of prosthetic dialysis grafts are usually associated with a history of repeated punctures at the site where the pseudoaneurysm developed. More punctures in a specific site will likely increase the risk of contamination, and the more the risk of contamination the more the risk of infection. It follows, as shown here, that placing an additional prosthetic under such circumstances is not likely to have favorable outcomes. Cognition After Carotid Endarterectomy or Stenting: A Randomized ComparisonAltinbas A, van Zandvoort MJ, van den Berg E, et al. Neurology 2011;77: 1084-90.

Editor's Choice – Overview of Primary and Secondary Analyses From 20 Randomised Controlled Trials Comparing Carotid Artery Stenting With Carotid Endarterectomy

“…In 120 ICSS patients, Altinbas et al observed a significant decrease in cognitive sum score post-operatively after CAS but not after CEA. 33 However, the overall change in cognitive sum score after CAS at six months (0.19) was not significantly different to that seen after CEA (0.02). 33 Seventy-eight ICSS patients underwent pre-operative MRI and serial assessment of cognitive function.…”

“…33 However, the overall change in cognitive sum score after CAS at six months (0.19) was not significantly different to that seen after CEA (0.02). 33 Seventy-eight ICSS patients underwent pre-operative MRI and serial assessment of cognitive function. 36 The hypothesis was that patients with an increasingly severe WML burden (pre-operatively) would have greater post-operative cognitive decline, because of hypoperfusion of cerebral white matter.…”

Comparison of Cognitive Function after Carotid Artery Stenting versus Carotid Endarterectomy

“…13 Other studies showed a significant deterioration in cognitive functions after CAS, but not after CEA. 23,26,28 One study showed a deterioration in one cognitive domain (working memory index) after CEA, but not after CAS. 22 Another study suggested that patients aged !68 years (but not younger individuals) may demonstrate differences in cognitive functions when undergoing CAS or CEA.…”

Muscle Over Mind?

“…Inversely, data from ICSS sub-studies show a three-fold increase in risk of new silent ischemic brain lesions for patients undergoing CAS, which is associated with deterioration in cognitive function 6 months after treatment. 2,3 Such deterioration was not observed after CEA. The significance of these new brain injuries for longterm survival and quality of life is still unclear, as asymptomatic cerebral embolization and cognitive function were never considered as study endpoints in major RCTs.…”