Predictors of poor outcome after carotid intervention

Dua, Anahita; Romanelli, Michael; Upchurch, Gilbert R.; Pan, James; Hood, Douglas B.; Hodgson, Kim J.; Desai, Sapan S.

doi:10.1016/j.jvs.2016.03.428

Cited by 38 publications

(27 citation statements)

References 22 publications

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“…In a very recent study utilizing the Agency for Healthcare Research and Quality National Inpatient Sample and State Ambulatory Services Databases, 1.7 million patients who underwent CAS or CEA over a 14-year time frame were analyzed. 92 A major finding was that for risk-matched patients, with both asymptomatic and symptomatic carotid disease undergoing CAS, female sex was an important variable associated with worse outcomes including higher stroke risk and inpatient mortality. Conversely, women, as well as men, undergoing CEA in this study had superior outcomes.…”

Section: Treatment Modalitiesmentioning

confidence: 99%

Sex differences in stroke: Review of current knowledge and evidence

2016

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Stroke is a leading cause of death among women in the United States, and women are more affected by stroke than men. With women living longer than men, women experience not only a higher incidence of stroke but also more negative outcomes. Despite its lethal impact and high morbidity rate, the road from innovative bench research to improved clinical outcomes has been slow. This review explores the differential physiology, epidemiology, and clinical presentation of stroke between men and women, as well as the current status of laboratory and clinical data.

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Section: Treatment Modalitiesmentioning

confidence: 99%

Sex differences in stroke: Review of current knowledge and evidence

2016

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“…Univariable and multivariable Cox proportional hazards regression models were used to analyze 1-year outcomes and identify their predictors. The variables included in the multivariable model were based on prior literature 20,21 and the univariable analysis. Interaction terms were included to test for effect modification.…”

Section: Discussionmentioning

confidence: 99%

Risks Associated With Primary and Redo Carotid Endarterectomy in the Endovascular Era

et al. 2018

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IMPORTANCE Clinical experience suggests worse outcomes for redo carotid endarterectomy (CEA) relative to primary CEA. Objective quantification of the excess risk attributable to redo CEA in this era of proliferating endovascular therapy remains to be determined. OBJECTIVE To evaluate the risks of redo CEA relative to primary CEA. DESIGN, SETTING, AND PARTICIPANTSThis study was a retrospective analysis of a prospective cohort of patients maintained by the Society for Vascular Surgery in the Vascular Quality Initiative between January 1, 2003, and April 30, 2016. The setting was consecutive patients from academic and community hospitals across the United States. Participants were patients who underwent primary CEA or redo CEA for symptomatic or asymptomatic carotid stenosis.EXPOSURES Primary CEA and redo CEA.MAIN OUTCOMES AND MEASURES Stroke, death, myocardial infarction, stroke or death, and stroke, death, or myocardial infarction at 30 days and 1 year. RESULTS There were 64 118 CEAs recorded, including 62 749 primary CEAs (97.9%) (median age, 71 years; 39.5% female) and 1369 redo CEAs (2.1%) (median age, 71 years; 42.2% female). Comparing primary CEA vs redo CEA, the incidence of 30-day stroke was 0.7% vs 1.9% (P < .001) for asymptomatic patients and 1.5% vs 1.4% (P = .77) for symptomatic patients for an overall 0.9% vs 1.8% (P = .002). Incidences were 0.8% vs 1.3% (P = .09) for perioperative myocardial infarction, 0.6% vs 1.4% (P = .003) for death, and 1.5% vs 2.6% (P = .001) for stroke or death. Risk-adjusted 30-day stroke (odds ratio [OR], 2.82; 95% CI, 1.69-4.71; P < .001), death (OR, 2.15; 95% CI, 1.21-3.79; P = .009), and stroke or death (OR, 2.06; 95% CI, 1.32-3.23; P = .002) were higher for redo CEA compared with primary CEA among asymptomatic patients but were similar among symptomatic patients for stroke (OR, 0.79; 95% CI, 0.33-1.95; P = .62), death (OR, 1.32; 95% CI, 0.53-3.26; P = .55), and stroke or death (OR, 0.85; 95% CI, 0.39-1.82; P = .68). Stroke or death at 1 year among asymptomatic patients was higher for redo CEA (hazard ratio [HR], 1.36; 95% CI, 1.08-1.69; P = .009) but was similar among symptomatic patients (HR, 0.94; 95% CI, 0.67-1.31; P = .71). CONCLUSIONS AND RELEVANCEThe outcomes of redo CEA and primary CEA fall within the professional guidelines for carotid revascularization. However, redo CEA is associated with a 2.8 times increase in the risk of stroke and a 2.2 times increase in the risk of death compared with primary CEA among asymptomatic patients. There is no significant difference in outcomes among symptomatic patients. These redo CEA and primary CEA results should inform patient and clinician expectations at the point of care.

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“…5 Asymptomatic progression under surveillance is not unusual, and CEA might be considered for these patients. Baseline velocity criteria and duplex progression are predictive of neurologic events, but the rate of neurologic events is rare, and even the low risk for potential complications with surgical revascularization (ie, stroke, nerve injury) 3,4,47–49 justifies the use of conservative CDUS criteria.…”

Section: Discussionmentioning

confidence: 99%

Carotid endarterectomy should not be based on consensus statement duplex velocity criteria

Columbo

Suckow

Griffin

et al. 2017

Journal of Vascular Surgery

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Objective Randomized trials support carotid endarterectomy (CEA) in asymptomatic patients with ≥60% internal carotid artery (ICA) stenosis. The widely referenced Society for Radiologists in Ultrasound Consensus Statement on carotid duplex ultrasound (CDUS) imaging indicates that an ICA peak systolic velocity (PSV) ≥230 cm/s corresponds to a ≥70% ICA stenosis, leading to the potential conclusion that asymptomatic patients with an ICA PSV ≥230 cm/s would benefit from CEA. Our goal was to determine the natural history stroke risk of asymptomatic patients who might have undergone CEA based on consensus statement PSV of ≥230 cm/s but instead were treated medically based on more conservative CDUS imaging criteria. Methods All patients who underwent CDUS imaging at our institution during 2009 were retrospectively reviewed. The year 2009 was chosen to ensure extended follow-up. Asymptomatic patients were included if their ICA PSV was ≥230 cm/s but less than what our laboratory considers a ≥80% stenosis by CDUS imaging (PSV ≥430 cm/s, end-diastolic velocity ≥151 cm/s, or ICA/common carotid artery PSV ratio ≥7.5). Study end points included freedom from transient ischemic attack (TIA), freedom from any stroke, freedom from carotid-etiology stroke, and freedom from revascularization. Results Criteria for review were met by 327 patients. Mean follow-up was 4.3 years, with 85% of patients having >3-year follow-up. Four unheralded strokes occurred during follow-up at <1, 17, 25, and 30 months that were potentially attributable to the index carotid artery. Ipsilateral TIA occurred in 17 patients. An additional 12 strokes occurred that appeared unrelated to ipsilateral carotid disease, including hemorrhagic events, contralateral, and cerebellar strokes. Revascularization was undertaken in59patients,1 for stroke,12for TIA, and 46 for asymptomatic disease. Actuarial freedom from carotid etiology stroke was 99.7%, 98.4%, and 98.4% at 1, 3, and 5 years, respectively. Freedom from TIA was 98%, 96%, and 95%, freedom from any stroke was 99%, 96%, and 93%, and freedom from revascularization was 95%, 86%, and 81% at 1, 3, and 5 years, respectively. Conclusions Patients with intermediate asymptomatic carotid stenosis (ICA PSV 230-429 cm/s) do well with medical therapy when carefully monitored and intervened upon using conservative CDUS criteria. Furthermore, a substantial number of patients would undergo unnecessary CEA if consensus statement CDUS thresholds are used to recommend surgery. Current velocity threshold recommendations should be re-evaluated, with potentially important implications for upcoming clinical trials.

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Predictors of poor outcome after carotid intervention

Cited by 38 publications

References 22 publications

Sex differences in stroke: Review of current knowledge and evidence

Sex differences in stroke: Review of current knowledge and evidence

Risks Associated With Primary and Redo Carotid Endarterectomy in the Endovascular Era

Carotid endarterectomy should not be based on consensus statement duplex velocity criteria

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