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(searched for: doi:10.3310/hta21570)
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Vincent N. Nguyen,
Introduction to Vascular Neurosurgery pp 249-265; https://doi.org/10.1007/978-3-030-88196-2_13

The publisher has not yet granted permission to display this abstract.
Essential Interventional Radiology Review pp 245-275; https://doi.org/10.1007/978-3-030-84172-0_25

The publisher has not yet granted permission to display this abstract.
Nidhi Gupta
Essentials of Evidence-Based Practice of Neuroanesthesia and Neurocritical Care pp 287-297; https://doi.org/10.1016/b978-0-12-821776-4.00021-4

The publisher has not yet granted permission to display this abstract.
Andreia Coelho, João Peixoto, Alexandra Canedo, L. Jaap Kappelle, Armando Mansilha,
Published: 25 June 2021
Journal of Vascular Surgery, Volume 75, pp 363-371.e2; https://doi.org/10.1016/j.jvs.2021.05.055

Abstract:
Objective Mechanisms of procedural stroke after carotid endarterectomy (CEA) or carotid artery stenting are surprisingly underresearched. However, understanding the underlying mechanism could (1) assist in balancing the choice for revascularization vs conservative therapy, (2) assist in choosing either open or endovascular techniques, and (3) assist in taking appropriate periprocedural measures to further decrease procedural stroke rate. The purpose of this study was to overview mechanisms of procedural stroke after carotid revascularization and establish reporting standards to facilitate more granular investigation and individual patient data meta-analysis in the future. Methods A systematic review was conducted according to the PRISMA statement. Results The limited evidence in the literature was heterogeneous and of low quality. Thus, no formal data meta-analysis could be performed. Procedural stroke was classified as hemorrhagic or ischemic; the latter was subclassified as hemodynamic, embolic (carotid embolic or cardioembolic) or carotid occlusion derived, using a combination of clinical inference and imaging data. Most events occurred in the first 24 hours after the procedure and were related to hypoperfusion (pooled incidence 10.2% [95% confidence interval (CI), 3.0-17.5] vs 13.9% [95% CI, 0.0-60.9] after CEA vs carotid artery stenting events, respectively) or atheroembolism (28.9% [95% CI, 10.9-47.0]) vs 34.3 [95% CI, 0.0-91.5]). After the first 24 hours, hemorrhagic stroke (11.6 [95% CI, 5.7-17.4] vs 9.0 [95% CI, 1.3-16.7]) or thrombotic occlusion (18.4 [95% CI, 0.9-35.8] vs 14.8 [95% CI, 0.0-30.5]) became more likely. Conclusions Although procedural stroke incidence and etiology may have changed over the last decades owing to technical improvements and improvements in perioperative monitoring and quality control, the lack of literature data limits further statements. To simplify and enhance future reporting, procedural stroke analysis and classification should be documented preemptively in research settings. We propose a standardized form enclosing reporting standards for procedural stroke with a systematic approach to inference of the most likely etiology, for prospective use in registries and randomized controlled trials on carotid revascularization.
Mandy D Müller, Leo H Bonati
Published: 1 January 2021
by MDPI
Clinical and Translational Neuroscience, Volume 5; https://doi.org/10.1177/2514183x211001654

Abstract:
Background: Carotid artery stenosis is an important cause for stroke. Carotid endarterectomy (CEA) reduces the risk of stroke in patients with symptomatic carotid stenosis and to some extent in patients with asymptomatic carotid stenosis. More than 20 years ago, carotid artery stenting (CAS) emerged as an endovascular treatment alternative to CEA. Objective and Methods: This review summarises the available evidence from randomised clinical trials in patients with symptomatic as well as in patients with asymptomatic carotid stenosis. Results: CAS is associated with a higher risk of death or any stroke between randomisation and 30 days after treatment than CEA (odds ratio (OR) = 1.74, 95% CI 1.3 to 2.33, p < 0.0001). In a pre-defined subgroup analysis, the OR for stroke or death within 30 days after treatment was 1.11 (95% CI 0.74 to 1.64) in patients <70 years old and 2.23 (95% CI 1.61 to 3.08) in patients ≥70 years old, resulting in a significant interaction between patient age and treatment modality (interaction p = 0.007). The combination of death or any stroke up to 30 days after treatment or ipsilateral stroke during follow-up also favoured CEA (OR = 1.51, 95% CI 1.24 to 1.85, p < 0.0001). In asymptomatic patients, there is a non-significant increase in death or stroke occurring within 30 days of treatment with CAS compared to CEA (OR = 1.72, 95% CI 1.00 to 2.97, p = 0.05). The risk of peri-procedural death or stroke or ipsilateral stroke during follow-up did not differ significantly between treatments (OR = 1.27, 95% CI 0.87 to 1.84, p = 0.22). Discussion and Conclusion: In symptomatic patients, randomised evidence has consistently shown CAS to be associated with a higher risk of stroke or death within 30 days of treatment than CEA. This extra risk is mostly attributed to an increase in strokes occurring on the day of the procedure in patients ≥70 years. In asymptomatic patients, there may be a small increase in the risk of stroke or death within 30 days of treatment with CAS compared to CEA, but the currently available evidence is insufficient and further data from ongoing randomised trials are needed.
Rebecca Sorber, Michael S. Clemens, Peiqi Wang, Martin A. Makary,
Published: 2 September 2020
Annals of Vascular Surgery, Volume 71, pp 132-144; https://doi.org/10.1016/j.avsg.2020.08.118

The publisher has not yet granted permission to display this abstract.
Andreia Coelho, Tossapol Prassaparo, , Jaap Kappelle, Ross Naylor, Gert J. De Borst
Published: 1 September 2020
Stroke, Volume 51, pp 2863-2871; https://doi.org/10.1161/strokeaha.120.030283

Abstract:
Transcarotid revascularization is an alternative to transfemoral carotid artery stenting, designed to avoid aortic arch manipulation and concomitant periprocedural stroke. This article aims to perform a detailed analysis on the quality of the currently available evidence on safety and efficacy of transcarotid artery revascularization. Although current evidence is promising, independent randomized controlled studies comparing transcarotid artery revascularization with carotid endarterectomy in recently symptomatic patients are lacking and will be necessary to establish the true value of transcarotid artery revascularization in carotid artery revascularization.
, Nicolle Cassola, Carolina Dq Flumignan, Luis Cu Nakano, Virginia Fm Trevisani, Ronald Lg Flumignan
Cochrane Database of Systematic Reviews; https://doi.org/10.1002/14651858.cd013573

The publisher has not yet granted permission to display this abstract.
CONTINUUM: Lifelong Learning in Neurology, Volume 26, pp 457-477; https://doi.org/10.1212/con.0000000000000837

Abstract:
Surgical vascular intervention is an important tool in reducing the risk of stroke. This article examines the evidence for using the available options. Carotid endarterectomy is an effective treatment option for reducing the risk of stroke in appropriately selected patients. Patients should be stratified for future stroke risk based on both the degree of stenosis and the presence of symptoms referable to the culprit lesion. Carotid stenting is also useful in reducing stroke risk, again in carefully selected patients. Because of the publication of significant data regarding both carotid endarterectomy and carotid artery stenting in the last several years, selection can be far more personalized and refined for individual patients based on demographics, sex, patient preference, and medical comorbidities. Routine extracranial-intracranial bypass surgery remains unproven as a therapeutic option for large vessel occlusion in reducing the incidence of ischemic stroke although some carefully screened patient populations remaining at high risk may benefit; procedural risks and pathology related to alterations in blood flow dynamics are challenges to overcome. Indirect revascularization remains an appropriate solution for carefully selected patients with cerebral large vessel steno-occlusive disease, and multiple variations of surgical technique are patient specific. Indirect revascularization may benefit from clinical trials with larger patient populations for validation in specific pathologies and offers the advantages of lower surgical complication rates and reduced risk of pathologic responses to altered cerebral flow dynamics. Surgical solutions to reduce stroke risk provide important alternatives in appropriately selected patients and should be considered in addition to medical management and lifestyle modification for optimizing patient outcomes.
, James F. Meschia, Gary S. Roubin, Brian Jankowitz, Donald Heck, Tudor Jovin, Christopher J. White, Kenneth Rosenfield, Barry Katzen, Guilherme Dabus, et al.
Published: 25 July 2019
Journal of Vascular Surgery, Volume 71, pp 854-861; https://doi.org/10.1016/j.jvs.2019.05.035

Abstract:
The Carotid Revascularization and Medical Management for Asymptomatic Carotid Stenosis Trial (CREST-2) is a pair of randomized trials assessing the relative efficacy of carotid revascularization in the setting of intensive medical management (IMM) in patients with asymptomatic high-grade atherosclerotic stenosis. One of the trials assesses IMM with or without carotid artery stenting (CAS). Given the low risk of stroke in nonrevascularized patients receiving IMM, it is essential that there be low periprocedural risk of stroke for CAS if it is to show incremental benefit. Thus, credentialing of interventionists to ensure excellence is vital. This analysis describes the protocol-driven approach to credentialing of CAS interventionists for CREST-2 and its outcomes. To be eligible to perform stenting in CREST-2, interventionists needed to be credentialed on the basis of a detailed Interventional Management Committee (IMC) review of data from their last 25 consecutive cases during the past 24 months along with self-reported lifetime experience case numbers. When necessary, additional prospective cases performed in a companion registry were requested after webinar training. Here we review the IMC experience from the first formal meeting on March 21, 2014 through October 14, 2017. The IMC had 102 meetings, and 8311 cases submitted by 334 interventionists were evaluated. Most were either cardiologists or vascular surgeons, although no single specialty made up the majority of applicants. The median total experience was 130 cases (interquartile range [IQR], 75-266; range, 25-2500). Only 9% (30/334) of interventionists were approved at initial review; approval increased to 46% (153/334) after submission of new cases with added training and re-review. The median self-reported lifetime case experience for those approved was 211.5 (IQR, 100-350), and the median number of cases submitted for review was 30 (IQR, 27-35). The number of CAS procedures performed per month (case rate) was the only factor associated with approval during the initial cycle of review (P< .00001). Identification of interventionists who were deemed sufficiently skilled for CREST-2 has required substantial oversight and a controlled system to judge current skill level that controls for specialty-based practice variability, procedural experience, and periprocedural outcomes. High-volume interventionists, particularly those with more recent experience, were more likely to be approved to participate in CREST-2. Primary approval was not affected by operator specialty.
Mirza Jusufovic, Karolina Skagen, Kirsten Krohg-Sørensen, Mona Skjelland
Current Neurovascular Research, Volume 16, pp 96-103; https://doi.org/10.2174/1567202616666190131162811

Abstract:
Carotid Artery Stenosis (CAS) is a marker of systemic atherosclerosis and patients with CAS are at high risk of vascular events in multiple vascular locations, including ipsilateral ischemic stroke. Both medical and surgical therapies have been demonstrated effective in reducing this risk. The optimal management for patients with asymptomatic carotid artery stenosis remains controversial. In patients with symptomatic CAS ≥70%, CEA has been demonstrated to reduce the risk of stroke. With the risk of recurrent stroke being particularly high in the first 2 weeks after the first event, Carotid Endarterectomy (CEA) or carotid angioplasty with stenting provides maximal benefits to patients with symptomatic CAS ≥70% if performed within this «2-week» target. Several large ongoing trials are currently comparing the risks and benefits of carotid revascularization versus medical therapy alone.
Edward Y Woo, Joshua Dearing
Vascular and Endovascular Review, Volume 2, pp 40-44; https://doi.org/10.15420/ver.2018.14.2

Abstract:
Stroke is one of the leading causes of death in the world and carotid artery stenosis is a major cause of ischaemic strokes. Symptomatic patients are often treated with either carotid endarterectomy (CEA) or carotid artery stenting (CAS). Asymptomatic patients can be treated with best medical therapy, CEA or CAS. While guidelines exist for the management of carotid artery stenosis, the results of recent studies are controversial regarding the safety of CAS compared with CEA. This review aims to outline the current guidelines while reviewing up-to- date studies and analyses. Future studies and emerging technologies are outlined in an attempt to provide an evaluation of the current data and management of this complex problem.
Junichiro Satomi
Japanese Journal of Neurosurgery, Volume 28, pp 777-782; https://doi.org/10.7887/jcns.28.777

Abstract:
頚動脈ステント留置術 (CAS) は, CEA高危険群のみならず標準危険群に対してもCEAと同等の治療効果が得られることが示されているが, それぞれの治療における合併症内訳が異なり, 特にCASにおける周術期脳卒中の発生, 高齢者に対する成績不良が今後克服すべき問題点として挙げられる. 近年の治療の発展に従いCEA, CAS, 内科治療とも成績が向上してきているが, 周術期塞栓性合併症を克服するデバイスの洗練化, 新規開発が進むCASの治療成績に注目していく必要がある. 一方, 無症候性病変, 高齢者への治療介入は慎重に検討しなければならず, 各治療を比較した新たなエビデンスの創出が必要な時期に差し掛かっている.
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