In this long-term follow-up of a randomized trial comparing endarterectomy with stenting for carotid-artery stenosis, the risks of periprocedural stroke, myocardial infarction, or death and ...subsequent ipsilateral stroke did not differ between groups over a 10-year period.
We previously reported the outcomes up to 4 years in the Carotid Revascularization Endarterectomy versus Stenting Trial (CREST).
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No significant difference was shown between patients assigned to stenting and those assigned to endarterectomy with respect to the composite primary end point of periprocedural stroke, myocardial infarction, or death and subsequent ipsilateral stroke. At baseline, the mean age of the patients was 69 years, and at that age the average life expectancy is 15 years for men and 17 years for women.
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As such, long-term treatment differences should be central to treatment decisions. We now report whether the outcomes after stenting . . .
Carotid artery stenosis causes up to 10% of all ischemic strokes. Carotid endarterectomy (CEA) was introduced as a treatment to prevent stroke in the early 1950s. Carotid stenting (CAS) was ...introduced as a treatment to prevent stroke in 1994.
The Carotid Revascularization Endarterectomy versus Stenting Trial (CREST) is a randomized trial with blinded end point adjudication. Symptomatic and asymptomatic patients were randomized to CAS or CEA. The primary end point was the composite of any stroke, myocardial infarction, or death during the periprocedural period and ipsilateral stroke thereafter, up to 4 years.
There was no significant difference in the rates of the primary end point between CAS and CEA (7.2% versus 6.8%; hazard ratio, 1.11; 95% CI, 0.81 to 1.51; P=0.51). Symptomatic status and sex did not modify the treatment effect, but an interaction with age and treatment was detected (P=0.02). Outcomes were slightly better after CAS for patients aged <70 years and better after CEA for patients aged >70 years. The periprocedural end point did not differ for CAS and CEA, but there were differences in the components, CAS versus CEA (stroke 4.1% versus 2.3%, P=0.012; and myocardial infarction 1.1% versus 2.3%, P=0.032).
In CREST, CAS and CEA had similar short- and longer-term outcomes. During the periprocedural period, there was higher risk of stroke with CAS and higher risk of myocardial infarction with CEA. Clinical Trial Registration-www.clinicaltrials.gov. Unique identifier: NCT00004732.
Objective Outcomes in the Carotid Revascularization Endarterectomy versus Stenting Trial (CREST) did not differ between carotid artery stenting (CAS) and carotid endarterectomy (CEA) for the ...composite primary end point of stroke, myocardial infarction (MI), or death during the periprocedural period or ipsilateral stroke within 4 years. Rigorous credentialing and training of interventionists, including vascular surgeons, were required for the randomization phase of CREST. Because the lead-in phase of CREST had suggested higher perioperative risks after CAS performed by vascular surgeons, the purpose of this analysis was to examine differences in outcomes after randomization between CAS and CEA performed by vascular surgeons. Methods CREST is a prospective randomized controlled trial with blinded end point adjudication. Vascular surgeons performed 237 (21%) of the CAS procedures and 765 (65%) of the CEA procedures among 2320 patients who received their assigned treatment. Proportional hazards analyses were used to estimate the relative efficacy of CAS vs CEA for the composite primary end point and also for stroke and death. Results Among 2502 randomized patients, 1321 (53%) were symptomatic and 1181 (47%) were asymptomatic. For procedures performed exclusively by vascular surgeons, the primary end point did not differ between CAS and CEA at 4-year follow-up (6.2% vs 5.6%, respectively; hazard ratio HR, 1.30; 95% confidence interval CI, 0.70-2.41; P = .41) In this subgroup, the periprocedural stroke and death rates were higher after CAS than CEA for symptomatic patients (6.1% vs 1.3%; P = .01). Asymptomatic patients also had slightly higher stroke and death rates after CAS (2.6% vs 1.1%; P = .20), although this difference did not reach statistical significance. Conversely, cranial nerve injuries (0.0% vs 5.0%; P < .001) were less frequent after CAS than CEA. The MI rates were slightly lower after CAS (1.3% vs 2.6%; P = .24). In performing CAS, vascular surgeons had outcomes for the periprocedural primary end point comparable to the outcomes of all interventionists (HR, 0.99; 95% CI, 0.50-2.00) after adjusting for age, sex, and symptomatic status. Vascular surgeons also had similar results after CEA for the periprocedural primary end point compared with other surgeons (HR, 0.73; 95% CI, 0.42-1.27). Conclusions When performed by surgeons, CAS and CEA have similar net outcomes, although the periprocedural risks vary (lower stroke with CEA and lower MI with CAS). These data suggest that appropriately trained vascular surgeons may safely offer both CEA and CAS for the prevention of stroke. The remarkably low stroke and death rates after CEA performed by vascular surgeons in CREST, particularly among symptomatic patients, represent the best outcomes ever reported after carotid interventions from a randomized controlled trial. ClinicalTrials.gov identifier: NCT0000473.
Objectives Determine the prevalence and clinical significance of deep venous thrombosis (DVT) in the asymptomatic contralateral extremity of patients referred to the vascular laboratory with ...unilateral symptoms and DVT confirmed by duplex scan. Method From December 2003 to October 2006, a total of 4813 patients were referred to our vascular laboratory for unilateral venous duplex scans. We prospectively studied 239 patients who were found to have acute DVT and had unilateral symptoms. Contralateral examinations were performed and demographic data, including risk factors for DVT, were entered into a computerized database. Results Of the 239 patients, 133 (55.6%) had a major DVT (popliteal vein or above) and 106 (44.4%) had a calf vein DVT. The majority were outpatients (195, 81.6%) and the rest were inpatients (44, 18.4%). The contralateral leg was normal in 192 (80.3%) patients, whereas 47 (19.7%) patients had some evidence of venous thrombosis. These thromboses consisted of acute major DVT (18/47, 38.3%), acute calf vein DVT (14/47, 29.8%), and less clinically significant chronic or superficial thrombus (15/47 (31.9%). All 18 patients with major contralateral DVT had underlying risk factor for thrombosis: active malignancy (12/18), recent surgery (4/18), or trauma (2/18). Patients with asymptomatic contralateral calf vein involvement often had thrombotic risk factors (10/14) but occasionally did not (4/14). Patients with an active malignancy were significantly more likely to have DVT in the asymptomatic leg (18/47, 38.3%) than were patients without cancer (23/192, 12%; both P < .0001). Inpatients were much more likely to have contralateral asymptomatic thrombosis (15/44, 34.1%) than outpatients (31/195, 15.9%; both P < .006). If treatment had been based on the findings in the symptomatic leg, all but 2 of the 239 patients would have been adequately treated. These two patients had multiple thrombotic risk factors that should have precluded ordering of a unilateral examination. Conclusions Inpatients have a very high incidence of clinically silent contralateral thrombosis (34%) and should usually undergo bilateral examinations. Patients with active malignancy have a 38% incidence of asymptomatic contralateral clot and should always have a bilateral study. Outpatients with unilateral symptoms and no associated risk factors for thrombosis can safely undergo unilateral examinations and should be adequately treated according to the unilateral findings. Algorithms to select patients for limited studies should include screening data for active malignancy, recent trauma or surgery, pregnancy, hormone therapy, or history of thrombophilia.
A 66-year-old man with an abdominal aortic aneurysm previously repaired with an endovascular stent graft presented to our facility with worsening midabdominal and back pain. Previous postoperative ...surveillance computed tomography scans were unremarkable, showing excellent stent–wall apposition and a shrinking aneurysm sac; however, imaging done on his arrival identified a contained rupture at the level of the celiac artery containing a perforating suprarenal stent. We repaired this rupture with a surgeon-modified fenestrated stent graft. To our knowledge, this is the first reported case of penetration of the native aorta by a suprarenal stent in the absence of infection or trauma.
Cystic Adventitial Disease of the Popliteal Artery Motaganahalli, Raghunandan L., MD, FRCS; Pennell, Richard C., MD, FACS; Mantese, Vito A., MD, FACS ...
Journal of the American College of Surgeons,
10/2009, Letnik:
209, Številka:
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Journal Article
Background
The Carotid Revascularization Endarterectomy Versus Stenting Trial (CREST) is a multicenter randomized trial of stenting versus endarterectomy in patients with symptomatic and asymptomatic ...carotid disease. This study assesses management of vascular risk factors.
Methods and Results
Management was provided by the patient's physician, with biannual monitoring results collected by the local site. Therapeutic targets were low‐density lipoprotein, cholesterol <100 mg/dL, systolic blood pressure <140 mm Hg, fasting blood glucose <126 mg/dL, and nonsmoking status. Optimal control was defined as achieving all 4 goals concurrently. Generalized estimating equations were used to compare risk factors at baseline with those observed in scheduled follow‐up visits for up to 48 months. In the analysis cohort of 2210, significant improvements in risk‐factor control were observed across risk factors for all follow‐up visits compared with baseline. At 48 months, achievement of the low‐density lipoprotein cholesterol goal improved from 59.1% to 73.6% (P<0.001), achievement of the systolic blood pressure goal improved from 51.6% to 65.1% (P<0.001), achievement of the glucose goal improved from 74.9% to 80.7% (P=0.0101), and nonsmoking improved from 74.4% to 80.9% (P<0.0001). The percentage with optimal risk‐factor control also improved significantly, from 16.7% to 36.2% (P<0.001), but nearly 2 of 3 study participants did not achieve optimal control during the study.
Conclusions
Site‐based risk‐factor control improved significantly in the first 6 months and over the long term in CREST but was often suboptimal. Intensive medical management should be considered for future trials of carotid revascularization.
Clinical Trial Registration
URL: ClinicalTrials.gov. Unique identifier: NCT00004732.
Ascending and thoracic aortic dissections progress into thoracoabdominal aneurysms 20-40% of the time, due to the initial aortic injury with associated weakness of the aortic wall. The increased ...firmness of the intimal flap usually results in a collapsed true lumen that does not spontaneously reexpand even with progressive dilatation of the aorta. In an effort to identify a safe and effective treatment path for this complex disease process, we present 4 cases illustrating successful sequential thoracic endovascular aortic repair (TEVAR) and fenestrated endovascular aortic repair (FEVAR). The treatment of these patients with endovascular techniques is less invasive than open conventional operations. However, multiple procedures are required using various complex novel techniques.
Institutional review board approval was obtained to identify 4 cases between January 2010 and May 2015 of patients with pretreatment hypertension, who initially presented with an aortic dissection. All patients subsequently developed a descending aortic aneurysm and were treated by TEVAR and FEVAR. Monthly and yearly outcomes were analyzed.
All procedures concluded with branched visceral vessel patency and no type I endoleaks. One patient required extraction of the retrograde superior mesenteric artery stent placed during the acute phase for visceral reperfusion. Another patient developed acute thromboembolic occlusion of the right common femoral artery requiring emergent revascularization in the immediate postoperative period.
Aortic dissection is the most common cause of death related to aortic pathology. Treatment of type B aortic dissections has traditionally been initially medical therapy unless complications develop. The treatment of subsequent complications has been associated with a high morbidity and mortality rate. However, the advent of evolving endovascular therapies has resulted in the reassessment of how these patients might be handled. This case series illustrates the treatment of expanding chronic thoracoabdominal aortic dissecting aneurysms with a total endovascular approach using various novel techniques.
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