Safety of Carotid Revascularization in Patients With a History of Coronary Heart Disease

Volkers, Eline J.; Algra, Ale; Kappelle, L. Jaap; Jp, Becquemin; Borst, Gert J. de; Brown, Martin M.; Calvet, D.; Eckstein, H.‐H.; Fraedrich, Gustav; Gregson, John; Halliday, Alison; Hendrikse, Jeroen; Howard, George; Jansen, Olav; Roubin, Gary S.; Bonati, Leo H.; Brott, Thomas G.; Jl, Mas; Ringleb, Peter A.; Greving, Jacoba P.

doi:10.1161/strokeaha.118.023085

Cited by 10 publications

(10 citation statements)

References 16 publications

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“…The incidence of MI observed in our study (1.9%) was lower than in the CREST trial (2.4%) [18]. Several even most recent studies did not examine preoperative MI as a risk variable and analysed a combination of risk factors containing MI or used non-standard definitions of MI even within the endpoint, different from our CREST conform definitions [29][30][31][32][33]. Similar to our results they showed contralateral occlusion, diabetes and symptomatic status to be relevant predictors for their differently defined endpoints.…”

Section: Discussioncontrasting

confidence: 77%

The SAPPHIRE criteria, history of myocardial infarction and diabetes predict adverse outcomes following carotid endarterectomy similar to stenting

et al. 2019

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Aims Identifying factors associated with worse outcome following carotid endarterectomy (CEA) is important to improve prevention of major adverse cardiovascular and cerebrovascular events (MACCE), yet rarely used for registries. We intended to identify predictors of MACCE following CEA as recently analysed for stenting. Methods and results Patients undergoing CEA at 2 centers over 13 years were entered into a database. Baseline clinical characteristics, procedural factors and a panel of clinical and lesion-related high-risk features (SHR) and exclusion criteria (SE), empirically compiled for stratification in the SAPPHIRE trial, were differentially analysed using Cox regressions. The analysis included 748 operations; 262 (35%) asymptomatic, 208 (28%) with previous strokes, and 278 (37%) with transient ischemic attacks (TIA). The overall 30-day MACCE rate was 6.7%, 5.0% in asymptomatic and 7.6% in symptomatic patients. Previous MI (HR 2.045, p = 0.022), diabetes (HR 2.111, p = 0.011) and symptomatic patients (HR 2.045, p = 0.044) were independently associated with MACCE. SE patients (n = 81) had a MACCE rate of 13.6%; the MACCE rate of the remainder dropped to 5.8% (4.7% in asymptomatic and 6.5% in symptomatic patients). Hazard ratio for SHR patients was 2.069 (CI 1.087–3.941) and 2.389 for SE (CI 1.223–4.666), each compared to all patients with lower risk and adjusted for symptomatic status. Among SHR and SE criteria NYHA 3–4, contralateral occlusions and intraluminal thrombus were significant determinants and MI < 4 weeks before CEA showed a strong trend (p = 0.05). Conclusion Patients identified by SHR and SE criteria, prior MI and diabetes warrant increased attention to prevent MACCE following CEA. Graphic abstract

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Section: Discussioncontrasting

confidence: 77%

The SAPPHIRE criteria, history of myocardial infarction and diabetes predict adverse outcomes following carotid endarterectomy similar to stenting

et al. 2019

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“…CSTC reported the timing of peri-operative stroke in 4797 patients. 123 The risk of "immediate" stroke (day of procedure) was 4.7% after CAS vs. 1.9% after CEA (OR 2.6, 95% CI 1.9e3.8). Delayed stroke (days 1e30) was 2.5% after CAS vs. 2% after CEA (OR 1.3, 95% CI 0.9e1.9).…”

Section: Peri-operative Morbidity and Mortalitymentioning

confidence: 93%

“…Eight RCTs reported the vascular territory in 330 strokes. 2,12,22,48,78,101,104,106,123 After CEA, 93% were ipsilateral, with 7% contralateral or vertebrobasilar. After CAS, 91% were ipsilateral, with 9% contralateral/vertebrobasilar (FET p ¼ .537).…”

Section: Peri-operative Morbidity and Mortalitymentioning

confidence: 99%

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

Batchelder

Saratzis

Naylor

2019

European Journal of Vascular and Endovascular Surgery

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This paper provides an overview of primary/secondary outcome data from 20 randomised controlled trials comparing carotid endarterectomy (CEA) with carotid artery stenting (CAS) in symptomatic and asymptomatic patients, including meta-analyses for peri-operative risks and late ipsilateral stroke. Secondary analyses include (i) risk factors for stroke after CEA/CAS; (ii) the effect of peri-operative stroke or myocardial infarction on long term survival; (iii) non-stroke complications; (iv) the significance of new white matter lesions on late stroke and cognitive impairment; and (v) whether asymptomatic 70%e99% restenoses increase the risk of ipsilateral stroke after CEA and CAS. Objectives: The aim of this review was to carry out primary and secondary analyses of 20 randomised controlled trials (RCTs) comparing carotid endarterectomy (CEA) with carotid artery stenting (CAS). Methods: A systematic review and meta-analysis of data from 20 RCTs (126 publications) was carried out. Results: Compared with CEA, the 30 day death/stroke rate was significantly higher after CAS in seven RCTs involving 3467 asymptomatic patients (odds ratio [OR] 1.64, 95% confidence interval [CI] 1.02e2.64) and in 10 RCTs involving 5797 symptomatic patients (OR 1.71, 95% CI 1.38e2.11). Excluding procedural risks, late ipsilateral stroke was about 4% at 9 years for both CEA and CAS, i.e., CAS was durable. Reducing procedural death/stroke after CAS may be achieved through better case selection, e.g., performing CEA in (i) symptomatic patients aged > 70 years; (ii) interventions within 14 days of symptom onset; and (iii) situations where stroke risk after CAS is predicted to be higher (segmental/remote plaques, plaque length > 13 mm, heavy burden of white matter lesions [WMLs], where two or more stents might be needed). New WMLs were significantly more common after CAS (52% vs. 17%) and were associated with higher rates of late stroke/transient ischaemic attack (23% vs. 9%), but there was no evidence that new WMLs predisposed towards late cognitive impairment. Restenoses were more common after CAS (10%) but did not increase late ipsilateral stroke. Restenoses (70%e99%) after CEA were associated with a small but significant increase in late ipsilateral stroke (OR 3.87, 95% CI 1.96e7.67; p < .001). Conclusions: CAS confers higher rates of 30 day death/stroke than CEA. After 30 days, ipsilateral stroke is virtually identical for CEA and CAS. Key issues to be resolved include the following: (i) Will newer stent technologies and improved cerebral protection allow CAS to be performed < 14 days after symptom onset with risks similar to CEA? (ii) What is the optimal volume of CAS procedures to maintain competency? (iii) How to deliver better risk factor control and best medical treatment? (iv) Is there a role for CEA/CAS in preventing/reversing cognitive impairment?

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“… 1 About 15% of ischemic strokes are caused by atherosclerotic stenosis of the internal carotid artery. 2 Atherosclerotic disease is a complex, multifactorial process characterized by deposition and accumulation of cholesterol along the arterial wall. 3 …”

Section: Introductionmentioning

confidence: 99%

Effect of Apolipoprotein E ε4 Allele on the Progression of Carotid Atherosclerosis Through Apolipoprotein Levels

Ma¹,

Zhang²,

Li³

et al. 2022

PGPM

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Background The apolipoprotein E (ApoE) genetic variation may be involved in the development of Carotid Atherosclerosis (CAS) disease. So far, few data are available on the role of ApoE isoforms in CAS. The association between this ApoE genotype and CAS remains controversial. The aim of this study was to investigate ApoE gene polymorphism in relation to CAS and the relationships between ApoE gene polymorphism and plasma lipid levels in the ShaanXi Han populations. Patients and methods The study group enrolled 399 CAS participants and 399 non-CAS controls. ApoE gene polymorphisms were determined by Polymerase chain reaction and hybridization. Results The ε3/ε4 genotype and ε4 allele in patients with CAS were significantly higher than control participants. In stratified analyses by age and sex, the elevated risk conferred by ɛ4 allele was evident in adults under 60 years old, but not in adults over 60 years old, females and males. ε4 carriers had significantly elevated ApoB and ApoB/ApoA and decreased ApoE levels than ε2 carriers in CAS patients. After adjusting for confounding factors, hypertension, ApoA-I, low density lipoprotein cholesterol (LDL-C), triglycerides (TG) and ε4 allele were significant independent risk factor for CAS. ApoE-ε4 allele was associated with a nearly 1.5-fold increased risk of CAS. Conclusion This study provides convincing evidence that ε4 allele, hypertension, ApoA-I, LDL-C and TG levels are independent risk factor for CAS in the ShaanXi Han populations. ApoE polymorphism was associated with CAS and this association was partly mediated through blood lipids. Also, the clinical use of genomic data may become useful in optimizing individual preventative and therapeutic strategies.

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Safety of Carotid Revascularization in Patients With a History of Coronary Heart Disease

Abstract: Supplemental Digital Content is available in the text.

Cited by 10 publications

References 16 publications

The SAPPHIRE criteria, history of myocardial infarction and diabetes predict adverse outcomes following carotid endarterectomy similar to stenting

The SAPPHIRE criteria, history of myocardial infarction and diabetes predict adverse outcomes following carotid endarterectomy similar to stenting

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

Effect of Apolipoprotein E ε4 Allele on the Progression of Carotid Atherosclerosis Through Apolipoprotein Levels

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