Search

Background: The impact of carotid artery stent fractures on the incidence of adverse clinical events remains unclear. The objective of this study is to report the stent fracture rate and its association with in-stent restenosis and adverse outcomes in the ACT-1 trial (Carotid Angioplasty and Stenting Versus Endarterectomy in Asymptomatic Subjects Who Are at Standard Risk for Carotid Endarterectomy With Significant Extracranial Carotid Stenotic Disease).Methods: ACT-1 is a prospective multicenter trial of patients who have standard surgical risk with severe asymptomatic carotid artery stenosis randomly assigned to carotid artery stenting or carotid endarterectomy (Abbott Vascular). The primary end point was a composite of death, stroke, or myocardial infarction during the 30 days after the procedure or ipsilateral stroke during the 365 days after the procedure. After 771 patients were enrolled, successively randomly assigned patients were required to undergo annual radiographic (x-ray) analysis for stent fracture. Images were independently adjudicated by a core laboratory.Results: Of 1021 patients treated with carotid artery stenting during a mean follow-up of 3.1±1.6 years, 939 had at least 1 x-ray during the follow-up period. Stent fracture was reported in 51 (5.4%) patients. With a maximum follow-up period of 5 years, adverse clinical outcomes occurred in 39 patients with at least 1 x-ray during the follow-up. Of 826 (80.9%) subjects who underwent both duplex ultrasound and x-ray, 822 (99.5%) were interpretable. There was no association between stent fracture and the primary end point (P=0.86) or with restenosis (P=0.53).Conclusions: In this large, independently adjudicated, multicenter study, the stent fracture rate was low and not associated with major adverse clinical events or in-stent restenosis.Clinical Trial Registration: URL: https://www.clinicaltrials.gov. Unique identifier: NCT00106938. [ABSTRACT FROM AUTHOR]

Importance: Carotid endarterectomy and carotid artery stenting are the leading approaches to revascularization for carotid stenosis, yet contemporary data on trends in rates and outcomes are limited.Objective: To describe US national trends in performance and outcomes of carotid endarterectomy and stenting among Medicare beneficiaries from 1999 to 2014.Design, Setting, and Participants: Serial cross-sectional analysis of Medicare fee-for-service beneficiaries aged 65 years or older from 1999 to 2014 using the Medicare Inpatient and Denominator files. Spatial mixed models adjusted for age, sex, and race were fit to calculate county-specific risk-standardized revascularization rates. Mixed models were fit to assess trends in outcomes after adjustment for demographics, comorbidities, and symptomatic status.Exposures: Carotid endarterectomy and carotid artery stenting.Main Outcomes and Measures: Revascularization rates per 100 000 beneficiary-years of fee-for-service enrollment, in-hospital mortality, 30-day stroke or death, 30-day stroke, myocardial infarction, or death, 30-day all-cause mortality, and 1-year stroke.Results: During the study, 937 111 unique patients underwent carotid endarterectomy (mean age, 75.8 years; 43% women) and 231 077 underwent carotid artery stenting (mean age, 75.4 years; 49% women). There were 81 306 patients who underwent endarterectomy in 1999 and 36 325 in 2014; national rates per 100 000 beneficiary-years decreased from 298 in 1999-2000 to 128 in 2013-2014 (P < .001). The number of patients who underwent stenting ranged from 10 416 in 1999 to 22 865 in 2006 (an increase per 100 000 beneficiary-years from 40 in 1999-2000 to 75 in 2005-2006; P < .001); by 2014, there were 10 208 patients who underwent stenting and the rate decreased to 38 per 100 000 beneficiary-years (P < .001). Outcomes improved over time despite increases in vascular risk factors (eg, hypertension prevalence increased from 67% to 81% among patients who underwent endarterectomy and from 61% to 70% among patients who underwent stenting) and the proportion of symptomatic patients (all P < .001). There were adjusted annual decreases in 30-day ischemic stroke or death of 2.90% (95% CI, 2.63% to 3.18%) among patients who underwent endarterectomy and 1.13% (95% CI, 0.71% to 1.54%) among patients who underwent stenting; an absolute decrease from 1999 to 2014 was observed for endarterectomy (1.4%; 95% CI, 1.2% to 1.5%) but not stenting (-0.1%; 95% CI, -0.5% to 0.4%). Rates for 1-year ischemic stroke decreased after endarterectomy (absolute decrease, 3.5% [95% CI, 3.2% to 3.7%]; adjusted annual decrease, 2.17% [95% CI, 2.00% to 2.34%]) and stenting (absolute decrease, 1.6% [95% CI, 1.2% to 2.1%]; adjusted annual decrease, 1.86% [95% CI, 1.45%-2.26%]). Additional improvements were noted for in-hospital mortality, 30-day stroke, myocardial infarction, or death, and 30-day all-cause mortality as well as within demographic subgroups.Conclusions and Relevance: Among fee-for-service Medicare beneficiaries, the performance of carotid endarterectomy declined from 1999 to 2014, whereas the performance of carotid artery stenting increased until 2006 and then declined from 2007 to 2014. Outcomes improved despite increases in vascular risk factors. [ABSTRACT FROM AUTHOR]

Background/purpose: Carotid artery stenting (CAS) and carotid artery endarterectomy (CEA) are complementary techniques for management of patients with carotid artery stenosis. This study investigates the impact of chronic kidney disease (CKD) and age on outcomes after carotid artery revascularization.Methods/materials: National Inpatient Sample was surveyed for CAS and CEA among stage 3 and 4 CKD and stage 5/end stage renal disease (ESRD) patients from 2004 to 2012. Primary endpoint was in-hospital major adverse cardiovascular and cerebrovascular events (MACCE) stratified by kidney function and age. Regression analysis and propensity score matching were utilized.Results: There were 3299 patients that underwent CEA and 652 underwent CAS with stage 3 and 4 CKD. Whereas, 1630 patients underwent CEA and 511 patients underwent CAS with stage 5 CKD/ESRD. Patients undergoing CAS had more in-hospital MACCE. Coronary artery disease (OR1.35, 95%CI:1.07-1.70) and CAS (OR1.35, 95%CI:1.02-1.77) were independently associated with MACCE for stage 3 and 4 CKD patients. For the stage 5 CKD/ESRD cohort, CAS (OR1.75, 95%CI:1.29-2.37) was independently associated with MACCE. Stratifying by age, showed no difference in event rates except for higher MACCE among patients <60years old with stage 5 CKD/ESRD undergoing CAS (p<0.001). Propensity score matching showed that treatment type had no significant effect on MACCE rates.Conclusions: Among CKD cohorts studied nationally, in-hospital MACCE were higher for patients that underwent CAS. Overall, age group analyses showed that there was no difference in MACCE rates between CAS and CEA. Although CAS was independently associated with MACCE, propensity score matching showed no risk difference of MACCE between CAS and CEA for either CKD cohort. [ABSTRACT FROM AUTHOR]

Objective: We have previously demonstrated an adverse impact of black race and Hispanic ethnicity on the outcomes of carotid endarterectomy (CEA) and carotid artery stenting (CAS). The current study was undertaken to examine the influence of race and ethnicity on the cost of CEA and CAS. Methods: The Nationwide Inpatient Sample (2005–2009) was queried using ICD-9 codes for CEA and CAS in patients with carotid artery stenosis. The primary outcome was total hospital charges. Multivariate analysis was performed using a generalized linear model adjusting for age, sex, race, comorbidities (Charlson index), high-risk status, procedure type, symptomatic status, year, insurance type, and surgeon and hospital operative volumes and characteristics. Results: Hispanic and black patients were more likely to have a symptomatic presentation, and were more likely to undergo either CEA or CAS by low-volume surgeons at low-volume hospitals (P < 0.05, all). They were also less likely to have private insurance or Medicare (P < 0.001). Overall, CEA was less expensive than CAS over the 4-y study period ($29,502 ± $104 versus $46,713 ± $409, P < 0.001). Total hospital charges after CEA were increased in both blacks ($39,562 ± $843) and Hispanics ($45,325 ± $735) compared with whites on univariate analysis ($28,403 ± $101, P < 0.001). After CAS, total hospital charges were similarly increased in both blacks ($51,770 ± $2085) and Hispanics ($63,637 ± $2766) compared with whites on univariate analysis ($45,550 ± $412, P < 0.001). On multivariable analysis, however, only Hispanic ethnicity remained independently associated with increased charges after both CEA (exponentiated coefficient 1.18; 95% CI [1.15–1.20]; P < 0.001) and CAS (exponentiated coefficient 1.17; 95% CI [1.09–1.24]; P < 0.001). Conclusion: Hispanic ethnicity was independently associated with increased hospital charges after both CEA and CAS. The increased charges seen in black patients were explained, in part, by decreased surgeon operative volume and increased postoperative complications. Further efforts are warranted to contain costs in minorities undergoing carotid revascularization. [ABSTRACT FROM AUTHOR]

The article highlights a study which examined the use of carotid stenting among elderly Medicare beneficiaries in the U.S. between 2005 and 2007. The results of the study revealed that carotid stenting is being performed by diverse specialists within hospital referral regions (HRRs). The study also showed that the population-based utilization rates are higher in HRRs where cardiologists perform most of the procedure with similar outcomes.

The article discusses a study on outcomes of carotid stenting based on operator experience in the U.S. from 2005 to 2007. The study evaluated the link between outcomes and two variables of operator experience, namely, annual volume and experience at the time of the procedure among new operators who performed carotid stenting for the first time following a national coverage decision by the Centers for Medicare & Medicaid Services (CMS). Administrative data collected from fee-for-service Medicare beneficiaries aged 65 years old and above was used under the study. Higher 30-day mortality was observed among patients treated by operators with lower annual volumes and patients treated early during a new operator's experience.

Examines the use of patch angioplasty after carotid endarterectomy with primary closure in the United States. Reduction of postoperative recurrent stenosis and ipsilateral stroke; Conduction of carotid duplex ultrasound and magnetic resonance angiography; Application of operative technique and surveillance protocol.

Examines the use of carotid-to-subclavian transposition for treating a patient with coronary-subclavian steal syndrome in Danville, Pennsylvania. Advantages of the transposition over other forms of subclavian revascularization; Symptoms of coronary-subclavian steal syndrome; Details on the surgical morbidity and mortality of carotid transposition.

Objective: To determine whether carotid endarterectomy provides protection against subsequent cerebral ischemia in men with ischemic symptoms in the distribution of significant (greater than 50%) ipsilateral internal carotid artery stenosis.Design: Prospective, randomized, multicenter trial.Setting: Sixteen university-affiliated Veterans Affairs medical centers.Patients: Men who presented within 120 days of onset of symptoms that were consistent with transient ischemic attacks, transient monocular blindness, or recent small completed strokes between July 1988 and February 1991. Among 5000 patients screened, 189 individuals were randomized with angiographic internal carotid artery stenosis greater than 50% ipsilateral to the presenting symptoms. Forty-eight eligible patients who refused entry were followed up outside of the trial.Outcome Measures: Cerebral infarction or crescendo transient ischemic attacks in the vascular distribution of the original symptoms or death within 30 days of randomization.Intervention: Carotid endarterectomy plus the best medical care (n = 91) vs the best medical care alone (n = 98).Results: At a mean follow-up of 11.9 months, there was a significant reduction in stroke or crescendo transient ischemic attacks in patients who received carotid endarterectomy (7.7%) compared with nonsurgical patients (19.4%), or an absolute risk reduction of 11.7% (P = .011). The benefit of surgery was more profound in patients with internal carotid artery stenosis greater than 70% (absolute risk reduction, 17.7%; P = .004). The benefit of surgery was apparent within 2 months after randomization, and only one stroke was noted in the surgical group beyond the 30-day perioperative period.Conclusions: For a selected cohort of men with symptoms of cerebral or retinal ischemia in the distribution of a high-grade internal carotid artery stenosis, carotid endarterectomy can effectively reduce the risk of subsequent ipsilateral cerebral ischemia. The risk of cerebral ischemia in this subgroup of patients is considerably higher than previously estimated. [ABSTRACT FROM AUTHOR]

Objective: To evaluate therapy with aspirin plus dipyridamole in reducing restenosis after carotid endarterectomy.Patients: A total of 163 patients having 175 surgical carotid endarterectomies.Intervention: Eighty-three patients (90 endarterectomies) were randomly assigned to receive oral aspirin, 325 mg, plus dipyridamole, 75 mg, beginning 12 hours preoperatively, followed by a second dose administered within 8 hours after the operation, and given three times daily thereafter for 1 year. Eighty patients (85 endarterectomies) received placebo medication that was identical in appearance to the study drugs.Measurements: After the adequacy of the surgical procedure was confirmed by intraoperative angiography, restenosis at the endarterectomy sites was evaluated using serial duplex ultrasound studies before hospital discharge and at 3-month intervals postoperatively for 1 year.Results: Based on the time for developing identifiable restenosis and on efficacy analysis, greater than 50% restenosis developed in 11 operated vessels (16%) in the treated group and in 10 arteries (14%) in the placebo group, yielding an observed risk increase of 14% (95% CI, -52% to 167%; P greater than 0.2). By intention-to-treat analysis, greater than 50% restenosis developed in 16 of 90 operated vessels in treated patients and in 10 of 85 arteries in patients receiving placebo (26% for the treated group and 12% for the placebo group; P = 0.18, Mantel-Haenszel statistic), representing an observed risk increase of 110% (CI, -5% to 365%). Similar differences were observed for greater than 20% restenosis and for the comparison of patients rather than operated vessels by either intention-to-treat or efficacy analyses.Conclusions: Because therapy not only failed to reduce carotid restenosis but may have actually increased its frequency, treatment with aspirin plus dipyridamole probably has no clinically important benefit on restenosis in patients having carotid endarterectomy. [ABSTRACT FROM AUTHOR]

The article discusses the roles of carotid endarterectomy (CEA) and carotid artery stenting (CAS) in patients with symptomatic and asymptomatic carotid disease. In 2011, the U.S. Food and Drug Administration (FDA) gave its approval to the RX Acculink® Carotid Stent system for average-risk patients. Included is a list of key observations on CAS and CEA, along with unresolved issues surrounding the use of CAS.

The author examines the trends in carotid endarterectomy (CEA) in the U.S. which is characterized by wide geographic variations for three decades. He presents evidence that CEA is both underused and overused in minorities across the country. He presents a commentary on and an overview of a study which investigated CEA use by examining Medicare claims from 2003 to 2006. He also mentions factors which contributed to the wide geographic variations in CEA trends.

The article discusses research on the safety and effectiveness of carotid artery stenting. It references a study sponsored by the National Institute of Neurological Disorders and Stroke, published in the 2010 issue of "Lancet." The study involved 2,502 individuals with asymptomatic and symptomatic carotid artery stenosis to undergo either an endarterectomy or carotid artery stenting. The economics and insurance coverage implications of the Carotid Revascularization Endarerectomy vs. Stenting Trial (CREST) are also examined.

The article comments on the rapid increase in the use of carotid stenting for preventing cerebrovascular diseases in the U.S. despite nonconclusive data. According to several researchers, 70 to 90 percent of carotid stents are now being implanted in asymptomatic patients. Some studies also show an association between carotid stenting and increased risk of stroke and mortality.

Discusses carotid disease and impaired cognition. Findings of Johnston and colleagues in the prevalence of impaired cognition in patients with high-grade stenosis of the left internal carotid artery but not the right internal carotid; Need for more inclusive studies before accepting this finding as evidence that carotid stenosis causes functionally important cognitive impairment; Example of two clinical trails, in USA and Europe; Alternative to carotid endarterectomy as carotid stenting; Recommendation of medical prophylaxis for most persons with asymptomatic carotid disease.

The article presents several articles related to health and medicine published in various medical journals. These articles focus on different topics such as research conducted to determine whether women after menopause could be treated by boosting the level of hormone leptin in the body, medical follow up conducted on people with fractured forearms and whether one could delay the occurrence of relapse of acute lymphoblastic leukaemia in children by introducing extensive initial treatment.

The article discusses the author's views on the impact of carotid artery stenting (CAS) and carotid endarterectomy (CEA) on the patients with extracranial carotid stenosis. A study called Carotid Revascularization Endarterectomy versus Stenting Trial (CREST) reveals that CAS and CEA do not cause dissimilar results for a composite of stroke, myocardial infarction, and death in patients with carotid stenosis at four years.