Comparison of best medical management with carotid intervention procedures in the prevention of stroke recurrence in patients with symptomatic internal carotid artery stenosis (original) (raw)
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Efficacy and safety of carotid artery stenting for stroke prevention
Background: Extracranial carotid artery stenosis is a leading cause of ischemic stroke. Carotid endarterectomy (CEA) is the gold-standard management for secondary stroke prevention yet carotid artery stenting (CAS) has emerged in the last decade as an alternative for high surgical risk patients. Purpose: To assess the effectiveness, safety and outcomes of CAS in extra-cranial carotid artery stenosis patients in terms of stroke prevention. Methodology: Twenty patients with symptomatic and asymptomatic carotid artery stenosis were enrolled between 2012 and 2014. Symptomatic patients were eligible for CAS if the internal carotid artery stenosis was P50%, while 80% was the threshold in asymptomatic patients. Results: Symptomatic patients enrolled were fifteen (75%) and asymptomatic patients were five (25%). Two patients (10%) were excluded owing to target vessel occlusion. One patient (5%) underwent bilateral CAS. The procedure was successful in eighteen patients (90%) one of them complicated by distal embolization (5%). One patient died secondary to associated chronic liver disease (5%), otherwise no stroke or death was recorded along the follow-up period. Conclusion: Careful patient selection and technique optimization are crucial to improve clinical outcome which make it a safe alternative for surgical revascularization in stroke prevention.
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Background Extracranial carotid artery stenosis has been recognized in 9.2% of ischemic stroke patients by duplex ultrasonography in Thailand. The treatment program of this disease has not been established countrywide. Objective Carotid endarterectomy in our institute was firstly evaluated for safety and long-term efficiency in order to assess the possibility of expanding this treatment throughout the country. Material and Method An observational study with long-term follow-up was carried out in 100 consecutive symptomatic patients with severe stenosis (70-99% diameter stenosis) of extracranial internal carotid artery that underwent carotid endarterectomies. All carotid endarterectomies were performed under general anesthesia, with routine use of intravascular shunts during carotid cross clamps and saphenous vein patches for arteriotomy closures. Perioperative mortality and morbidity were evaluated for the safety of this procedure. The long-term stroke-free survival was assessed to ...
Neurosurgery, 2006
Background and Purpose-Acute ischemic stroke attributable to extracranial internal carotid artery (ICA) occlusion is frequently associated with severe disability or death. In selected cases, revascularization with carotid artery stenting has been reported, but the safety, recanalization rate, and clinical outcomes in consecutive case series are not known. Methods-We retrospectively reviewed all of the cases of ICA occlusions that underwent cerebral angiography with the intent to revascularize over a 38-month period. Two groups were identified: (1) patients who presented with an acute clinical presentation within 6 hours of symptom onset (nϭ15); and (2) patients who presented subacutely with neurologic fluctuations because of the ICA occlusion (nϭ10). Results-Twenty-five patients with a mean age of 62Ϯ11 years and median National Institutes of Health Stroke Scale (NIHSS) of 14 were identified. Twenty-three of the 25 patients (92%) were successfully revascularized with carotid artery stenting. Patients in group 1 were younger and more likely to have a tandem occlusion and higher baseline NIHSS when compared with group 2. Patients in group 2 were more likely to show early clinical improvement defined as a reduction of their NIHSS by Ն4 points and a modified Rankin Score of Յ2 at 30-day follow-up. Two clinically insignificant adverse events were noted: 1 asymptomatic hemorrhage and 1 nonflow-limiting dissection.
Carotid Recurrent Stenosis and Risk of Ipsilateral Stroke : A Systematic Review of the Literature
Stroke, 1998
Background —The main goal of follow-up after carotid endarterectomy is to prevent new strokes caused by recurrent stenosis. To determine the most cost-effective follow-up schedule, it is necessary to know the incidence of recurrent stenosis and the risk of stroke it carries. Methods —A systematic review of the literature was performed using standard meta-analytical techniques. Results —Incidence of recurrent stenosis: The data were very heterogeneous. The risk of recurrent stenosis was 10% in the first year, 3% in the second, and 2% in the third. Long-term risk of recurrent stenosis is about 1% per year. Risk of stroke: The reported relative risks of stroke in patients with recurrent stenosis compared with patients without recurrent stenosis showed extreme heterogeneity and ranged from 10 to 0.10. The random effects summary estimator of relative risk was 1.88. Conclusions —The data were very heterogeneous, and much better data are needed to arrive at truly reliable estimates of thes...
Tạp chí Nghiên cứu Y học
Incidence of transient ischemic attack (TIA) or ischemic stroke has increased in recent years in Viet Nam due to lifestyle changes. Carotid stenosis is a common cause of TIA/ischemic stroke. The purpose of this study was to estimate current prevalence and identify risk factors of ipsilateral internal carotid artery (ICA) stenosis in patients with TIA/ischemic stroke. We recruited patients hospitalized to Bach Mai hospital in the first half of 2021 who suffered from TIA/ischemic stroke. The primary outcome is the presence of significant carotid stenosis, defined as atherosclerotic narrowing of 50 percent or greater, and confirmed by multidisciplinary team (MDT) discussion. In total, 328 consecutive patients with TIA/ischemic stroke were included in this study. Of these, 29 (8.84%, 95% confidence interval (CI): 6.0 -12.45) have 50-99% ipsilateral ICA stenosis. Patients with considerable ICA stenosis are more likely to have type 2 diabetes, ischemic heart disease (IHD) and higher creat...
American Journal of Neuroradiology, 2011
BACKGROUND AND PURPOSE: The WASID study established the risk of subsequent ischemic stroke at 1 year in subjects with symptomatic intracranial atherosclerotic stenosis (70%-99%) at 18%. The efficacy of different methods of endovascular revascularization in stroke prevention still has not been established. We compared the stroke rate in our registry at 1 year following intervention with the WASID results to identify which method, if any, provides the most benefit in stroke prevention. This result from the BMC-IRR follows a previously published article comparing stent placement and angioplasty outcomes. MATERIALS AND METHODS: We maintained a nonrandomized single-center single-operator registry of consecutive symptomatic patients who underwent endovascular intracranial revascularization. Data were collected prospectively and retrospectively and analyzed retrospectively. Patients were treated with angioplasty, BMS, or self-expanding WS. To make our data comparable with that in the WASID study, we selected patients with a single lesion of 50%-99% stenosis undergoing a single intervention. Data was collected on patients until symptom recurrence, repeat intervention, or 1 year postintervention, whichever occurred first. RESULTS: We found that 115 patients fit the inclusion criteria, with 38 angioplasty, 28 BMS, and 49 WS cases. For patients with 70%-99% stenosis, the overall probability of stroke at 1 year postintervention was 19.3%. The overall stroke probability per device, independent of clinical presentation, was 12.5% for angioplasty, 20.2% for BMS, and 24.1% for WS. CONCLUSIONS: Compared with the WASID data, angioplasty appears to have a lower stroke rate after 1 year than medical therapy alone. However, neither stent-placement arm compared favorably with the WASID results. ABBREVIATIONS: ACA ϭ anterior cerebral artery; BA ϭ basilar artery; BCC-IRR ϭ Borgess Medical Center Intracranial Revascularization Registry; BMS ϭ balloon-mounted stent; BMT ϭ best medical therapy; CI ϭ confidence interval; ICA ϭ internal carotid artery; MCA ϭ middle cerebral artery; mRS ϭ modified Rankin Scale; SAMMPRIS ϭ Stenting and Aggressive Medical Management for Preventing Recurrent Stroke in Intracranial Stenosis; SSYLVIA ϭ Stenting of Symptomatic Atherosclerotic Lesions in the Vertebral or Intracranial Arteries; TIA ϭ transient ischemic attack; VA ϭ vertebral artery; WASID ϭ Warfarin-Aspirin Symptomatic Intracranial Disease; WS ϭ Wingspan stent
Open surgery remains a valid option for the treatment of recurrent carotid stenosis
Journal of Vascular Surgery, 2010
The choice between open surgery (OS) and transluminal carotid angioplasty with stenting (CAS) for the treatment of primary carotid stenosis remains controversial. However, CAS is considered a valid option for selected cases, such as recurrent carotid stenosis (RCS). Tertiary RCS seems to be a concerning issue after CAS but few large reports focused on the durability of CAS and OS. We report our early and long-term results with OS for RCS. Methods: From 1989 to 2006, perioperative data regarding 4245 consecutive surgical carotid reconstructions was prospectively collected. Patients whose indication was RCS were subjected to further analysis. Indications for surgery were symptomatic RCS >50% or asymptomatic RCS >80%. Freedom from neurologic event was defined as the absence of any ipsilateral symptom at any time after the procedure. Kaplan-Meier analysis was used to estimate freedom from reintervention, freedom from restenosis >50% and occlusion, freedom from neurologic event and survival. Results: A total of 119 patients (2.8%) with RCS underwent OS. The average time from the primary OS was 59.4 ؎ 54.5 months (range, 2-204). Forty-nine patients (41%) were symptomatic. In 103 patients (87%), the technique did not differ from a primary approach. Postoperative (<30 days) combined stroke and death rate was 3.3%. Cranial nerve injury occurred in 5 cases (4.2%). With a mean follow-up of 53 ؎ 48 months (range, 1-204), 3 patients had an ipsilateral stroke (including one hemorrhagic stroke) and 7 were diagnosed with a tertiary RCS >50%. At 5 years, Kaplan-Meier estimates of freedom from reintervention, freedom from restenosis and occlusion, freedom from neurologic event, and survival were 99%, 91%, 89%, and 91%, respectively. Conclusion: OS for RCS is not a high-risk procedure and provides excellent long-term results, with low rates of tertiary RCS and reinterventions. The comparison between OS and CAS in this indication suffers from the absence of standardized follow-up paradigms after primary OS and the lack of prospective randomized trial comparing the two techniques. Despite these limitations in the available data, we conclude that OS should remain the first line therapy when treatment of RCS is indicated. ( J Vasc Surg 2010;51:1124-32.)
Background:Carotid endarterectomy (CEA) and carotid artery stenting (CAS) are both options for treating carotid artery stenosis, an important cause of stroke. Aim of the work: to evaluate the different options of treatment of carotid artery stenosis; which is the best one as regard safety and efficacy? Methods: This study was conducted upon 40 patients with carotid artery stenosis from July 2010 to December 2014 at Al Azhar University Hospitals. CEA was done with carotid shunt for 4 patients and without shunt for 14 patients. And CAS was done with primary stenting and balloon dilatation for 14 patients (6 of them with cerebral protection device) and without balloon dilatation with self-expanding stenting for 8 patients. The primary composite end point was stroke, myocardial infarction, or death from any cause during the periprocedural period or any ipsilateral stroke in the first one month. Results: For 45 patients over a period of one month, there was no significant CEA and CAS, after careful patient selection and determine which therapeutic approach is more suitable for everyone. Conclusion: Optimizing medical therapy and using CEA and CAS as complementary therapies rather than competing ones will likely achieve the best patient outcomes.