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Surgery Open Science Jun 2023The use of an 'eversion' technique is not unequivocally proven to be superior to carotid endarterectomy with patch angioplasty. An up-to-date systematic review is needed... (Review)
Review
INTRODUCTION
The use of an 'eversion' technique is not unequivocally proven to be superior to carotid endarterectomy with patch angioplasty. An up-to-date systematic review is needed for evaluation of benefits and harms of these two techniques.
METHODS
RCTs comparing eversion technique versus endarterectomy with patch angioplasty in patients with a symptomatic and significant (≥50 %) stenosis of the internal carotid artery were enrolled. Primary outcomes were all-cause mortality rate, health-related quality of life and serious adverse events. Secondary outcomes included 30-day stroke and mortality rate, (a) symptomatic arterial occlusion or restenosis, and adverse events not critical for decision making.
RESULTS
Four RCTs were included with 1272 surgical procedures for carotid stenosis; eversion technique = 643 and carotid endarterectomy with patch closure = 629. Meta-analysis comparing both techniques showed, with a very low certainty of evidence, that eversion technique might decrease the number of patients with serious adverse events (RR 0.47; 95% CI 0.34 to 0.64; ≤ 0.01). However, no difference was found on the other outcomes. TSA demonstrated that the required information sizes were far from being reached for these patient-important outcomes. All patient-relevant outcomes were at low certainty of evidence according to GRADE.
CONCLUSIONS
This systematic review showed no conclusive evidence of any difference between eversion technique and carotid endarterectomy with patch angioplasty in carotid surgery. These conclusions are based on data obtained in trials with very low certainty according to GRADE and should therefore be interpreted cautiously. Until conclusive evidence is obtained, the standard of care according to ESVS guidelines should not be abandoned.
PubMed: 37288439
DOI: 10.1016/j.sopen.2023.05.003 -
Journal of Vascular Research 2022Of the 200 million patients worldwide affected by peripheral arterial disease (PAD), 4% will inevitably require major limb amputation. Previous systematic reviews... (Review)
Review
BACKGROUND
Of the 200 million patients worldwide affected by peripheral arterial disease (PAD), 4% will inevitably require major limb amputation. Previous systematic reviews presented a conflicting body of evidence in terms of vascular endothelial growth factor (VEGF) family member effects upon PAD natural progression. Despite that, modulation of intrinsic angiogenesis mechanisms targeting the VEGF family members still confers an attractive therapeutic target. The aim of the present study was to evaluate current evidence of VEGF modulation in the context of PAD.
METHODS
This is a systematic literature review conducted according to the PRISMA guidelines and registered under PROSPERO database [CRD42021285988]. Independent literature search was performed up to April 1, 2022, on six databases. A total of 22 eligible studies were identified [N: 3, interventional patient studies; N: 19, animal studies]. Animal studies were appraised by the SYRCLE risk of bias tool, while human participant studies were assessed by the Newcastle Ottawa scale. Overall, quality of evidence was deemed fair for both animal and human studies. Main study outcomes were percentage change of injured vessel lumen stenosis and neointimal area formation upon VEGF modulation (inhibition or activation) in comparison with control group.
FINDINGS
Nineteen animal models and three human participant studies were included in the systematic review and assessed separately. Positive modulation of VEGF-A in animal models resulted in a median decrease of 65.58% [95% CI 45.2; 71.87] in lumen stenosis [14 studies]. Furthermore, positive modulation of VEGF-A was found to reduce neointimal area proliferation by a median decrease of 63.41% [95% CI 41.6; 79.59] [14 studies]. Median end of study duration was 28 days [range: 14-84 days]. Data were insufficient to assess these outcomes with respect to VEGF-B or VEGF-C modulation. The limited number of available human studies presented inadequate outcome assessment despite their overall fair NOS grading.
INTERPRETATION
VEGF-A-positive modulation decreases lumen stenosis and neointimal hyperplasia in PAD simulation animal models. Previously identified variability among outcomes was found to strongly stem from the variability of experimental designs. Clinical applicability and safety profile of VEGF-A in the context of PAD remain to be defined by a robust and uniformly designed body of further animal model-based experiments.
Topics: Animals; Humans; Vascular Endothelial Growth Factor A; Constriction, Pathologic; Peripheral Arterial Disease
PubMed: 36380643
DOI: 10.1159/000527079 -
European Journal of Vascular and... Mar 2022The aim was to enhance understanding of the role of platelet biomarkers in the pathogenesis of vascular events and risk stratifying patients with asymptomatic or... (Review)
Review
OBJECTIVE
The aim was to enhance understanding of the role of platelet biomarkers in the pathogenesis of vascular events and risk stratifying patients with asymptomatic or symptomatic atherosclerotic carotid stenosis.
DATA SOURCES
Systematic review conducted in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement.
REVIEW METHODS
A systematic review collated data from 1975 to 2020 on ex vivo platelet activation and platelet function/reactivity in patients with atherosclerotic carotid stenosis.
RESULTS
Forty-three studies met the inclusion criteria; the majority included patients on antiplatelet therapy. Five studies showed increased platelet biomarkers in patients with ≥ 30% asymptomatic carotid stenosis (ACS) vs. controls, with one neutral study. Preliminary data from one study suggested that quantification of "coated platelets" in combination with stenosis severity may aid risk stratification in patients with ≥ 50% - 99% ACS. Platelets were excessively activated in patients with ≥ 30% symptomatic carotid stenosis (SCS) vs. controls (≥ 11 positive studies and one neutral study). Antiplatelet-High on Treatment Platelet Reactivity (HTPR), previously called "antiplatelet resistance", was observed in 23% - 57% of patients on aspirin, with clopidogrel-HTPR in 25% - 100% of patients with ≥ 50% - 99% ACS. Aspirin-HTPR was noted in 9.5% - 64% and clopidogrel-HTPR in 0 - 83% of patients with ≥ 50% SCS. However, the data do not currently support the use of ex vivo platelet function/reactivity testing to tailor antiplatelet therapy outside of a research setting. Platelets are excessively activated (n = 5), with increased platelet counts (n = 3) in recently symptomatic vs. asymptomatic patients, including those without micro-emboli on transcranial Doppler (TCD) monitoring (n = 2). Most available studies (n = 7) showed that platelets become more reactive or activated following carotid endarterectomy or stenting, either as an acute phase response to intervention or peri-procedural treatment.
CONCLUSION
Platelets are excessively activated in patients with carotid stenosis vs. controls, in recently symptomatic vs. asymptomatic patients, and may become activated/hyper-reactive following carotid interventions despite commonly prescribed antiplatelet regimens. Further prospective multicentre studies are required to determine whether models combining clinical, neurovascular imaging, and platelet biomarker data can facilitate optimised antiplatelet therapy in individual patients with carotid stenosis.
Topics: Aspirin; Biomarkers; Blood Platelets; Carotid Stenosis; Humans; Platelet Aggregation Inhibitors; Stroke
PubMed: 35181225
DOI: 10.1016/j.ejvs.2021.10.045 -
Journal of Cardiothoracic Surgery Jul 2023Valve-sparing aortic root replacement (VSARR) is a safe and effective surgical procedure to treat aortic root aneurysm. This meta-analysis aimed to investigate how this... (Meta-Analysis)
Meta-Analysis Review
BACKGROUND
Valve-sparing aortic root replacement (VSARR) is a safe and effective surgical procedure to treat aortic root aneurysm. This meta-analysis aimed to investigate how this procedure might differ in patients with bicuspid aortic valve (BAV) and tricuspid aortic valve (TAV).
DESIGN
Meta-analysis with meta-regression and systematic review.
SETTING
Systematic search in the following databases: PubMed, Cochrane Central Register of Controlled Trials, and Embase.
INTERVENTIONS
All observational studies of VSARR in patients with BAV or TAV were included in our study. Studies were included without any restrictions on language or publication date. A trial sequential analysis and a post-hoc meta-regression was performed on the main outcomes.
RESULT
Eleven articles met the inclusion criteria. A total of 1138 patients in BAV group, and 2125 patients in TAV group. No significant differences in gender and age were observed between BAV and TAV patients. BAV and TAV patients showed no differences in in-hospital mortality rate [0.00% vs. 1.93%; RR (95% CI) 0.33 (0.09, 1.26), I = 0%, P = 0.11] and the rate of in-hospital reoperation [5.64% vs. 5.99%; RR (95% CI) 1.01(0.59, 1.73), I = 33%, P = 0.98]. The overall long-term mortality rate of BAV patients was better than that of TAV patients [1.63% vs. 8.15%; RR (95% CI) 0.34 (0.13, 0.86), I = 0%, P = 0.02]. During the follow-up observation period, patients in TAV group showed small but no statistic advantage in 3-year, 5-year, and over 10-year incidences of reintervention. Regarding the secondary endpoints, the two groups showed similar aortic cross-clamping time and total cardiopulmonary bypass time.
CONCLUSION
The VSARR techniques yielded similar clinical outcomes in both BAV and TAV patients. Although patients with BAV might have a higher incidence of reinterventions after initial VSARR, it is still a safe and effective approach to treat aortic root dilation with or without aortic valve insufficiency. TAV patients showed small but no statistic advantage in long-term (over 10 years) reintervention rate, which means, patients with BAV may face a higher risk of reintervention in the clinic.
Topics: Humans; Aortic Valve; Bicuspid Aortic Valve Disease; Heart Valve Diseases; Aorta; Tricuspid Valve; Transcatheter Aortic Valve Replacement; Aortic Valve Stenosis; Retrospective Studies; Treatment Outcome; Observational Studies as Topic
PubMed: 37400892
DOI: 10.1186/s13019-023-02329-8 -
A systematic review of the association between dementia risk factors and cerebrovascular reactivity.Neuroscience and Biobehavioral Reviews May 2023Cumulative evidence suggests that impaired cerebrovascular reactivity (CVR), a regulatory response critical for maintaining neuronal health, is amongst the earliest... (Review)
Review
Cumulative evidence suggests that impaired cerebrovascular reactivity (CVR), a regulatory response critical for maintaining neuronal health, is amongst the earliest pathological changes in dementia. However, we know little about how CVR is affected by dementia risk, prior to disease onset. Understanding this relationship would improve our knowledge of disease pathways and help inform preventative interventions. This systematic review investigates 59 studies examining how CVR (measured by magnetic resonance imaging) is affected by modifiable, non-modifiable, and clinical risk factors for dementia. We report that non-modifiable risk (older age and apolipoprotein ε4), some modifiable factors (diabetes, traumatic brain injury, hypertension) and some clinical factors (stroke, carotid artery occlusion, stenosis) were consistently associated with reduced CVR. We also note a lack of conclusive evidence on how other behavioural factors such as physical inactivity, obesity, or depression, affect CVR. This review explores the biological mechanisms underpinning these brain-behaviour associations, highlights evident gaps in the literature, and identifies the risk factors that could be managed to preserve CVR in an effort to prevent dementia.
Topics: Humans; Brain; Stroke; Risk Factors; Magnetic Resonance Imaging; Dementia; Cerebrovascular Circulation
PubMed: 36944391
DOI: 10.1016/j.neubiorev.2023.105140 -
Neurology India 2022Carotid endarterectomy (CEA) has been the standard therapy for carotid artery stenosis (CAS). Modified eversion carotid endarterectomy (mECEA) was recently introduced to... (Review)
Review
BACKGROUND
Carotid endarterectomy (CEA) has been the standard therapy for carotid artery stenosis (CAS). Modified eversion carotid endarterectomy (mECEA) was recently introduced to treat CAS. However, the short-term safety and long-term efficacy of mECEA are still controversial among studies. This systematic review aims to summarize the current literatures about safety and efficacy of mECEA in treating CAS.
METHODS
A systematic review of mECEA was conducted in the main bibliographic databases in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) statement. Clinical studies on the safety and efficacy of mECEA in treating CAS with clinical results of transient ischemic attack (TIA), stroke, death, and restenosis were included.
RESULTS
The initial search and screening found 15 references from the main databases, and 7 studies were finally included after full-text article assessment, which consisted of 3 single-arm studies and 4 comparative studies. The risks of postoperative complications including TIA, stroke, myocardial infarction (MI), and death ranged from 1.1% to 2%, 0% to 2.5%, 0% to 4.4%, and 0% to 2.32%, respectively. The mECEA was significantly related to lower risk of carotid artery occlusion, incision numbness, and shorter lengths of stay in hospital and average scar when separately compared with conventional CEA (cCEA), CEA with patch closure (pCEA), and eversion CEA (eCEA).
CONCLUSIONS
The mECEA is a promising surgical option for CAS with acceptable clinical outcomes. In order to prove its safety and efficacy, future practices need to be conducted by more medical workers in more large-scale trials.
Topics: Humans; Endarterectomy, Carotid; Carotid Stenosis; Ischemic Attack, Transient; Stroke; Carotid Artery Diseases; Treatment Outcome; Stents; Risk Factors
PubMed: 36352566
DOI: 10.4103/0028-3886.359282 -
Cureus Apr 2023Wellens' syndrome is well-known for its critical stenosis of the proximal left anterior descending artery (LAD) with characteristic electrocardiographic findings of... (Review)
Review
The Comparative Assessment of Wellens' Syndrome With Proximal Left Anterior Descending Artery (LAD) Stenosis Versus Right Coronary Artery (RCA) or Circumflex Coronary Artery Stenosis and Its Prevalence: A Systematic Review.
Wellens' syndrome is well-known for its critical stenosis of the proximal left anterior descending artery (LAD) with characteristic electrocardiographic findings of biphasic or deeply inverted T waves in V2-V6 under specific diagnostic criteria. Although the syndrome is known as a high-grade LAD lesion, its sequence of events can also be seen with the right coronary artery (RCA) and the left circumflex artery (LCX). This systemic review attempts to expand on these findings while analyzing the prevalence of Wellens' syndrome with the RCA and/or the circumflex artery. This study also comparatively indicated that Wellens' syndrome is seen in RCA and circumflex artery stenoses when present; the indication of the same medical management is warranted for effective treatment and survival. We extracted and analyzed 24 case reports each with an atypical presentation of acute coronary syndrome (ACS) and specific Wellens' syndrome pattern of electrocardiogram (ECG) presentation with critical stenosis in the LAD, RCA, and left circumflex artery. The risk of bias assessment was undertaken using internal risk analysis by utilizing medical libraries and certain search phrases to find research articles with the involvement of the LAD as opposed to the RCA and LCX in Wellens' syndrome. Based on the number of respective primary research articles found, a bias calculation was done on the reported respective coronary artery involvement. The finding of our systemic review confirms that Wellens' syndrome is a precordial lead disease with T wave abnormalities that present with critical stenosis of not only the LAD but also the RCA and circumflex artery. The result of our systemic review affirmed that although most Wellens' syndrome cases reported involve the stenosis of the LAD, the critical occlusion of the RCA and/or the circumflex artery was found with Wellens' syndrome pattern of ECG presentation, meaning that the sequence of events is not limited to the proximal LAD.
PubMed: 37228569
DOI: 10.7759/cureus.37991 -
Journal of Stroke and Cerebrovascular... Oct 2022Carotid web (CaW) is non-atheromatous, shelf-like intraluminal projection, generally affecting the posterolateral wall of the proximal internal carotid artery, and...
BACKGROUND
Carotid web (CaW) is non-atheromatous, shelf-like intraluminal projection, generally affecting the posterolateral wall of the proximal internal carotid artery, and associated with embolic stroke, particularly in younger patients without traditional stroke risk factors. Treatment options for symptomatic CaWs include interventional therapy with carotid endarterectomy or carotid stenting versus medical therapy with antiplatelet or anticoagulants. As safety and efficacy of these approaches have been incompletely delineated in small-to-moderate case series, we performed a systematic review of outcomes with interventional and medical management.
METHODS
Systematic literature search was conducted and data analyzed per PRISMA guidelines (Preferred Reporting Items for Systemic Reviews and Meta-Analyses) from January 2000 to October 2021 using the search strategy: "Carotid web" OR "Carotid shelf" OR "Web vessels" OR "Intraluminal web". Patient-level demographics, stroke risk factors, technical procedure details, medical and interventional management strategies were abstracted across 15 series. All data were analyzed using descriptive statistics.
RESULTS
Among a total of symptomatic 282 CaW patients across 14 series, age was 49.5 (44-55.7) years, 61.7% were women, and 76.6% were black. Traditional stroke risk factors were less frequent than the other stroke causes, including hypertension in 28.6%, hyperlipidemia 14.6%, DM 7.0%, and smoking 19.8%. Thrombus adherent to CaW was detected on initial imaging in 16.2%. Among 289 symptomatic CaWs across 15 series, interventional management was pursued in 151 (52.2%), carotid artery stenting in 87, and carotid endarterectomy in 64; medical management was pursued in 138 (47.8%), including antiplatelet therapy in 80.4% and anticoagulants in 11.6%. Interventional and medical patients were similar in baseline characteristics. The reported time from index stroke to carotid revascularization was median 14 days (IQR 9.5-44). In the interventional group, no periprocedural mortality was noted, major periprocedural complications occurred in 1/151 (0.5%), and no recurrent ischemic events were observed over follow-up range of 3-60 months. In the medical group, over a follow-up of 2-55 months, the recurrence cerebral ischemia rate was 26.8%.
CONCLUSION
Cumulative evidence from multiple series suggests that carotid revascularization is a safe and effective option for preventing recurrent ischemic events in patients with symptomatic carotid webs.
Topics: Anticoagulants; Carotid Artery, Internal; Carotid Stenosis; Endarterectomy, Carotid; Female; Humans; Male; Middle Aged; Platelet Aggregation Inhibitors; Risk Factors; Stents; Stroke; Treatment Outcome
PubMed: 35998383
DOI: 10.1016/j.jstrokecerebrovasdis.2022.106682 -
Journal of Neurointerventional Surgery Sep 2020Despite the recent increase in the number of publications on diagnostic cerebral angiograms using transradial access (TRA), there have been relatively few regarding TRA...
BACKGROUND
Despite the recent increase in the number of publications on diagnostic cerebral angiograms using transradial access (TRA), there have been relatively few regarding TRA for neurointerventional cases. Questions of feasibility and safety may still exist among physicians considering TRA for neurointerventional procedures.
METHODS
A systematic literature review was performed following PRISMA guidelines. Three online databases (MedLine via PubMed, Scopus and Embase) were searched for articles published between January 2000 and December 2019. Search terms included "Transradial access", "Radial Access", "Radial artery" AND "Neurointerventions". The reference lists of selected articles and pertinent available non-systematic analysis were reviewed for other potential citations. Primary outcomes measured were access site complications and crossover rates.
RESULTS
Twenty-one studies (n=1342 patients) were included in this review. Two of the studies were prospective while the remaining 19 were retrospective. Six studies (n=616 patients) included TRA carotid stenting only. The rest of the studies included treatment for cerebral aneurysms (n=423), mechanical thrombectomy (n=127), tumor embolization (n=22), and other indications (n=154) such as angioplasty and stenting for vertebrobasilar stenosis, balloon test occlusion, embolization of dural arteriovenous fistula and arteriovenous malformation, chemotherapeutic drug delivery, intra-arterial thrombolysis, and arterial access during a venous stenting procedure. Two (0.15%) major complications and 37 (2.75%) minor complications were reported. Sixty-four (4.77%) patients crossed over to transfemoral access for completion of the procedure. Seven (0.52%) patients crossed over due to access failure and 57 (4.24%) patients crossed over to TFA due to inability to cannulate the target vessel.
CONCLUSION
This systematic review demonstrates that TRA has a relatively low rate of access site complications and crossovers. With increasing familiarity, development of TRA-specific neuroendovascular devices, and the continued reports of its success in the literature, TRA is expected to become more widely used by neurointerventionalists.
Topics: Angioplasty; Catheterization; Catheterization, Peripheral; Cerebral Angiography; Embolization, Therapeutic; Female; Humans; Intracranial Aneurysm; Male; Neurosurgical Procedures; Prospective Studies; Radial Artery; Randomized Controlled Trials as Topic; Retrospective Studies; Stents
PubMed: 32152185
DOI: 10.1136/neurintsurg-2019-015764 -
Kardiologia Polska 2021Ionizing radiation remains a well-known risk factor of carotid artery stenosis. The survival rates of head and neck cancer patients undergoing radiotherapy have risen... (Meta-Analysis)
Meta-Analysis
BACKGROUND
Ionizing radiation remains a well-known risk factor of carotid artery stenosis. The survival rates of head and neck cancer patients undergoing radiotherapy have risen owing to medical advancements in the field. As a consequence, the incidence of carotid artery stenosis in these high-risk patients has increased.
AIMS
In this study we sought to compare the outcomes of carotid endarterectomy (CEA) vs carotid artery stenting (CAS) for radiation-induced carotid artery stenosis.
METHODS
This study was performed according to the Preferred Reporting Items for Systematic reviews and Meta-Analyses guidelines. Eligible studies were identified through a comprehensive search of PubMed, Scopus and Cochrane Central until July 2020. A random-effects model meta-analysis was conducted, and odds ratios (ORs) were calculated. The I-square statistic was used to assess for heterogeneity.
RESULTS
Seven studies and 201 patients were included. Periprocedural stroke, myocardial infarction (MI), and death rates were similar between the two revascularization approaches. However, the risk for cranial nerve (CN) injury was higher in the CEA group (OR, 7.40; 95% CI, 1.58-34.59; I2 = 0%). Analysis revealed no significant difference in terms of long-term mortality (OR, 0.41; 95% CI, 0.14-1.16; I2 = 0%) and restenosis rates (OR, 0.69; 95% CI, 0.29-1.66; I2 = 0%) between CEA and CAS after a mean follow-up of 40.5 months.
CONCLUSIONS
CAS and CEA appear to have a similar safety and efficacy profile in patients with radiation-induced carotid artery stenosis. Patients treated with CEA have a higher risk for periprocedural CN injuries. Future prospective studies are warranted to validate these results.
Topics: Carotid Stenosis; Endarterectomy, Carotid; Humans; Prospective Studies; Risk Assessment; Risk Factors; Stents; Stroke; Treatment Outcome
PubMed: 33885270
DOI: 10.33963/KP.15956