Timing of carotid intervention

Meershoek, Armelle J.A.; Borst, Gert J. de

doi:10.1002/bjs.10950

Cited by 15 publications

(10 citation statements)

References 26 publications

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“…In fact, the mean delay in all RCTs was over 14 days and even over 1 month in all RCTs except two. 89 The lack of robust data investigating the safety and efficacy of CAS in the acute/peri-stroke period is particularly significant given the routine use of ECR for stroke.…”

Section: Acute Stroke and Tandem Lesionsmentioning

confidence: 99%

Carotid artery stenting: Current state of evidence and future directions

et al. 2019

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Both carotid endarterectomy (CEA) and carotid artery stenting (CAS) are common treatments for carotid artery stenosis. Several randomized controlled trials (RCTs) have compared CEA to CAS in the treatment of carotid artery stenosis. These studies have suggested that CAS is more strongly associated with periprocedural stroke; however, CEA is more strongly associated with myocardial infarction. Published longterm outcomes report that CAS and CEA are similar. A reduction in complications associated with CAS has also been demonstrated over time. The symptomatic status of the patient and history of previous CEA or cervical radiotherapy are significant factors when deciding between CEA or CAS. Numerous carotid artery stents are available, varying in material, shape and design but with minimal evidence comparing stent types. The role of cerebral protection devices is unclear. Dual antiplatelet therapy is typically prescribed to prevent in-stent thrombosis, and however, evidence comparing periprocedural and postprocedural antiplatelet therapy is scarce, resulting in inconsistent guidelines. Several RCTs are underway that will aim to clarify some of these uncertainties. In this review, we summarize the development of varying techniques of CAS and studies comparing CAS to CEA as treatment options for carotid artery stenosis. K E Y W O R D Scarotid artery atherosclerosis, carotid artery stenosis, carotid artery stenting, carotid endarterectomy, stroke, stroke prevention | 319 LAMANNA et AL.

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Section: Acute Stroke and Tandem Lesionsmentioning

confidence: 99%

Carotid artery stenting: Current state of evidence and future directions

et al. 2019

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“…3 As a result of this initially high recurrence risk, international guidelines recommend performing carotid revascularisation within 14 days of the first event. 4 In practice, this guideline is often not met, 5 although earlier CEA reduces the recurrent ischaemic event rate. 6 Therefore in recent years, multiple studies have investigated factors associated with this delay.…”

Section: Introductionmentioning

confidence: 99%

Factors Associated with Hospital Dependent Delay to Carotid Endarterectomy in the Dutch Audit for Carotid Interventions

Kuhrij

Meershoek

Karthaus

et al. 2019

European Journal of Vascular and Endovascular Surgery

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WHAT THIS PAPER ADDS This paper identifies factors that are associated with hospital dependent delay to carotid endarterectomy (CEA) using data from a nationwide mandatory clinical audit in the Netherlands. By establishing these factors, other hospitals can learn which patients are at risk of a longer waiting time for CEA and can evaluate their own protocol accordingly. Objectives: As the risk of a recurrent neurological event in patients with symptomatic carotid stenosis requiring carotid endarterectomy (CEA) is highest in the early phase after the first neurological event, guidelines recommend operating on these patients as soon as possible or at least within 14 days of their initial event. However, in real world practice this is often not met. The aim of this study is to identify factors that cause hospital dependent delay to CEA. Methods: All consecutive patients with symptomatic carotid stenosis undergoing CEA registered in the mandatory Dutch Audit for Carotid Interventions from January 2014 up to and including December 2017 were included in the current analysis. Univariable followed by multivariable logistic regression was used to identify independent factors associated with hospital dependent waiting time, defined as time from the first consultation at any hospital to CEA of more than 14 days. Results: A total of 8620 patients were included. The median time to CEA was 11 days (IQR 8e14). Seventy-eight per cent of patients underwent CEA within 14 days of first hospital consultation. Factors associated with a hospital dependent waiting time longer than 14 days were age (OR 0.99 per year, 95% CI 0.98e0.99), any previous CEA (OR 1.67, 95% CI 1.32e2.09), ocular symptoms as index event (OR 1.31, 95% CI 1.15e1.50), and indirect referral (OR 1.53, 95% CI 1.34e1.73). Hospital surgical volume was not identified as a factor for delay, except for the delay of indirectly referred patients where high volume hospitals reported the shortest delay. Conclusion: This cohort derived from a validated nationwide prospective audit identified younger age, previous CEA, ocular symptoms, and indirect referral as hospital dependent factors for delay. High volume hospitals had a similar hospital dependent waiting time to middle and low volume hospitals. However, high volume hospitals had more indirect referrals, implying that their logistics are more efficiently organised.

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“…In light of evidence suggesting that very urgent intervention may increase procedural risk due to presumed plaque vulnerability, procedural timing has to be planned more carefully. 37,38 In previous studies the advantage of CEA over CAS with respect to prevention of new DWI lesions has already been demonstrated. 2,3 Although a meta-analysis of European RCT data showed that CAS was associated with a significantly higher risk of procedural death/stroke risk after 30 days than CEA, follow up results of these RCTs show that CAS appears to be as durable as CEA after the first 30 days.…”

Section: Discussionmentioning

confidence: 95%

“…35,36,41 Another topic of interest is procedural timing in symptomatic patients. 37 As cerebrovascular events are more likely to occur in patients with unstable plaque, one could rationalise that timing of the procedure in symptomatic patients may influence the chance of dislodgement of plaque debris and therefore new DWI lesions, in line with research suggesting increased stroke risk after very urgent CEA. 38 Future research on intervention timing should incorporate presence of DWI lesions as one of the secondary outcome measures.…”

Section: Discussionmentioning

confidence: 99%

Editor's Choice – Predictors of New Ischaemic Brain Lesions on Diffusion Weighted Imaging After Carotid Stenting and Endarterectomy: A Systematic Review

Rots

Meershoek

Bonati

et al. 2019

European Journal of Vascular and Endovascular Surgery

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WHAT THIS STUDY ADDS This systematic review presents an overview of the available evidence on patient related features associated with an increased susceptibility to the development of new ischaemic brain lesions on magnetic resonance diffusion weighted imaging after carotid endarterectomy and carotid artery stenting. These demographic, radiological, and biochemical predictors may be helpful in decision making on patient selection for medical intervention, carotid stenting, or endarterectomy.Objectives: Peri-procedural ischaemic brain lesions on diffusion weighted imaging (DWI) after carotid endarterectomy (CEA) and carotid artery stenting (CAS) have been related to a higher chance of recurrent cerebrovascular events. This systematic review provides an overview of patient characteristics associated with increased risk of new DWI lesions. Methods: MEDLINE, EMBASE, and Cochrane library databases were systematically searched (update November 2018) for studies reporting post-procedural DWI lesions after CEA or CAS. Data derived from both procedures were analysed separately. Studies reporting predictive features that were present prior to intervention were assigned to 10 categories: age, gender, cardiovascular risk factors, symptomatology, plaque vulnerability, atherosclerotic burden, cerebrovascular haemodynamics, carotid/arch anatomy, inflammatory markers, and markers of coagulation. A semi-quantitative analysis was performed by plotting studies that found an association between the investigated features and DWI lesions against those that did not find an association. Results: Forty-six studies (5018 patients) were included: 10 reported only CEA, 33 CAS, and three both interventions. 68.0% of 1873 CEA patients and 55.9% of 3145 CAS patients were symptomatic. The weighted prevalence of DWI lesions was 18.1% (95% CI 14.0e22.7%) in CEA patients compared with 40.5% (95% CI 35.4e45.7%) in CAS patients. Studies reporting on CEA patients predominantly found an increased risk in symptomatic patients (two of seven studies, including 848/1661 patients), those with impaired haemodynamics (five of five studies), and increased inflammatory markers (two of three studies). Studies reporting on CAS patients often found a positive association with age (10/26 studies), high plaque vulnerability (25/34 studies), or complex carotid/arch anatomy (three out of five studies). Conclusions: For patients undergoing CEA, symptomatic status, impeded cerebral haemodynamics, and increased inflammatory markers are associated with increased susceptibility to peri-operative DWI lesions. In CAS patients, higher age, plaque vulnerability and complex carotid/aortic arch anatomy were identified as risk factors. These clinical predictors may assist with decision making on patient selection for medical treatment, CEA or CAS.

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Timing of carotid intervention

Abstract: Flimsy evidence

Cited by 15 publications

References 26 publications

Carotid artery stenting: Current state of evidence and future directions

Carotid artery stenting: Current state of evidence and future directions

Factors Associated with Hospital Dependent Delay to Carotid Endarterectomy in the Dutch Audit for Carotid Interventions

Editor's Choice – Predictors of New Ischaemic Brain Lesions on Diffusion Weighted Imaging After Carotid Stenting and Endarterectomy: A Systematic Review

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