Predictors of Neurological Events Associated With Carotid Artery Stenting in High-Surgical-Risk Patients

Aronow, Herbert D.; Gray, William A.; Ramee, Stephen R.; Mishkel, Gregory; Schreiber, Theodore; Wang, Hong

doi:10.1161/circinterventions.110.950097

Cited by 38 publications

(18 citation statements)

References 28 publications

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“…In a pooled analysis of 2,104 patients, the rate of 30-day stroke and/or death in asymptomatic and symptomatic patients was 3.8 and 5.3%, respectively [10]. The absence of this difference in our study can be explained by the paucity of asymptomatic patients.…”

Section: Discussioncontrasting

confidence: 51%

Demographic and Technical Risk Factors of 30-Day Stroke, Myocardial Infarction, and/or Death in Standard- and High-Risk Patients Who Underwent Carotid Angioplasty and Stenting

et al. 2014

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Background: Carotid angioplasty and stenting (CAS) is an accepted treatment to prevent stroke in patients with carotid artery stenosis. The purpose of this study is to identify risk factors for major complications after CAS. Materials and Methods: This is a prospective study that was conducted at Shiraz University of Medical Sciences in southern Iran from March 2011 to June 2014. Consecutive patients undergoing CAS were enrolled. Both standard- and high-risk patients for endarterectomy were enrolled. Demographic data, atherosclerotic risk factors, site of stenosis, degree of stenosis, and data regarding technical factors were recorded. Thirty-day stroke, myocardial infarction, and/or death were considered as the composite primary outcomes of the study. Results: A total of 251 patients were recruited (mean age: 71.1 ± 9.6 years; male: 65.3%). Of these, 178 (70.9%) were symptomatic, 73 (29.1%) were diabetic, 129 (51.4%) were hyperlipidemic, 165 (65.7%) were hypertensive, and 62 (24.7%) patients were smokers. CAS was performed for left internal carotid artery (ICA) in 113 (45.4%) patients. Fourteen (5.6%) patients had sequential bilateral stenting. Mean stenosis of operated ICA was 80.2 ± 13.8%. An embolic protection device was used in 203 (96.2%) patients. Pre- and postdilation were performed in 39 (18.5%) and 182 (86.3%) patients, respectively. Composite outcomes were observed in 3.6% of patients (3.2% stroke, 0% myocardial infarction, and 1.2% death). Left-sided lesions and the presence of diabetes mellitus were significantly associated with poor short-term outcome (p = 0.025 and p = 0.020, respectively). Conclusion: There was a higher risk of short-term major complications in diabetic patients and for left carotid artery intervention.

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Section: Discussioncontrasting

confidence: 51%

Demographic and Technical Risk Factors of 30-Day Stroke, Myocardial Infarction, and/or Death in Standard- and High-Risk Patients Who Underwent Carotid Angioplasty and Stenting

et al. 2014

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“…Cerebral hypoxia and ischaemia are important causes of death and disability, particularly during surgical procedures. Patients undergoing surgical procedures such as endarterectomies and cardiopulmonary bypass surgery have a much greater risk of stroke in the peri‐operative period due to thrombus formation and/or microemboli (Shaw et al 1985; Wolman et al 1999; Aronow et al 2010). Recent studies have found that short, non‐damaging ischaemic episodes before a longer ischaemic episode prevent the damage that would normally occur after the longer ischaemia (Gidday, 2006; Malhotra et al 2006; Roth et al 2006).…”

Section: Introductionmentioning

confidence: 99%

Metabotropic actions of the volatile anaesthetic sevoflurane increase protein kinase Mζ synthesis and induce immediate preconditioning protection of rat hippocampal slices

Wang¹,

Meng²,

Cottrell³

et al. 2012

The Journal of Physiology

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Key points• Volatile anaesthetics, such as sevoflurane, have been shown to reduce neuronal damage when administered as preconditioning protective agents before hypoxia or ischaemia.• Most rapid onset protective effects of anaesthetics have been thought to be due to direct effects on ion channels in the neurons and do not require the activation of biochemical pathways or protein synthesis • We found that sevoflurane activates the mammalian target of rapamycin (mTOR) biochemical pathway, increasing the rapid synthesis and activation of the protein kinase, PKMζ, a PKC isoform critical for maintaining long-term potentiation and long-term memory storage; this, in turn, increases the activity of K ATP channels, and induces an increased hyperpolarization during hypoxia. This reduces and delays the hypoxic depolarization and improves neuronal recovery from hypoxia.• Thus, it would be advantageous to choose an anaesthetic, such as sevoflurane, that rapidly preconditions and protects neurons from hypoxia and ischaemia for surgeries in which the brain is at risk for damage.Abstract Anaesthetic preconditioning occurs when a volatile anaesthetic, such as sevoflurane, is administered before a hypoxic or ischaemic insult; this has been shown to improve neuronal recovery after the insult. We found that sevoflurane-induced preconditioning in the rat hippocampal slice enhances the hypoxic hyperpolarization of CA1 pyramidal neurons, delays and attenuates their hypoxic depolarization, and increases the number of neurons that recover their resting and action potentials after hypoxia. These altered electrophysiological effects and the improved recovery corresponded with an increase in the amount of a constitutively active, atypical protein kinase C isoform found in brain, protein kinase M zeta (PKMζ). A selective inhibitor of this kinase, zeta inhibitory peptide (ZIP), blocked the increase in the total amount of PKMζprotein and the amount of the activated form of this kinase, phospho-PKMζ(p-PKMζ); it also blocked the altered electrophysiological effects and the improved recovery. We found that both cycloheximide, a general protein synthesis inhibitor, and rapamycin, a selective inhibitor of the mTOR pathway for regulating protein synthesis, blocked the increase in p-PKMζ, the electrophysiological changes, and the improved recovery due to sevoflurane-induced preconditioning. Glibenclamide, a K ATP channel blocker, when present only during the hypoxia, prevented the enhanced hyperpolarization, the delayed and attenuated hypoxic depolarization, and the improved recovery following sevoflurane-induced preconditioning. To examine the function of persistent PKMζ and K ATP channel activity after the preconditioning was established, we administered 4% sevoflurane for 30 min and then discontinued it for 30 min before 10 min of hypoxia. When either tolbutamide, a K ATP channel blocker, or ZIP were administered at least 15 min after the washout of sevoflurane, there was little recovery compared with sevoflurane alone. Thus, continuous K ATP chan...

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“…3 However, only 171 of 1989 patients received protamine in that study. Our study improves on these findings by comparing 555 patients treated with protamine to a control group of patients using propensity score adjustment.…”

Section: Discussionmentioning

confidence: 89%

Protamine Does Not Increase Risk of Stroke in Patients With Elective Carotid Stenting

McDonald

Kallmes

Lanzino

et al. 2013

Stroke

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Background and Purpose-Reversal of anticoagulation with protamine might predispose to a higher risk of stroke in patients with carotid stenting. We evaluated a national, multihospital patient database to examine the risk of stroke in patients with carotid stenting receiving protamine compared with those who did not. Methods-The Premier Perspective database was used to identify patients who were electively hospitalized for carotid stenting from 2006 through 2011. The incidence of in-hospital mortality and morbidity was compared between patients who did and did not receive protamine after propensity score adjustment via 1:1 matching to reduce selection bias. Results-Of 6664 patients with carotid stenting treated at 193 hospitals, 556 (8%) received protamine on the day of the procedure. After matching by propensity score, patients who received protamine had a similar likelihood of stroke or transient ischemic attack (P=0.77), in-hospital mortality (P=0.12), discharge to long-term care (P=0.15), and access site complications (P=0.90) as compared with patients who did not receive protamine. Conclusions-Protamine administration is not associated with additional risk of adverse events after carotid stenting.

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Predictors of Neurological Events Associated With Carotid Artery Stenting in High-Surgical-Risk Patients

Cited by 38 publications

References 28 publications

Demographic and Technical Risk Factors of 30-Day Stroke, Myocardial Infarction, and/or Death in Standard- and High-Risk Patients Who Underwent Carotid Angioplasty and Stenting

Demographic and Technical Risk Factors of 30-Day Stroke, Myocardial Infarction, and/or Death in Standard- and High-Risk Patients Who Underwent Carotid Angioplasty and Stenting

Metabotropic actions of the volatile anaesthetic sevoflurane increase protein kinase Mζ synthesis and induce immediate preconditioning protection of rat hippocampal slices

Protamine Does Not Increase Risk of Stroke in Patients With Elective Carotid Stenting

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