Carotid artery stenting in clinical practice results from the Carotid Artery Stenting (CAS)-registry of the Arbeitsgemeinschaft Leitende Kardiologische Krankenhausarzte (ALKK)

Summary Background Carotid artery stenting (CAS) for symptomatic and asymptomatic carotid stenosis seems to be on the doorstep of more widespread use. However, its feasibility and safety in clinical practice at a broad spectrum of hospitals needs to be determined. Methods We analyzed data of the prospective multi-centre Carotid Artery Stenting (CAS) Registry of the German Arbeitsgemeinschaft Leitende Kardiologische Krankenhausärzte (ALKK). Results From 7/1996 to 5/2004 1888 patients from 28 hospitals were included in the CAS Registry. The median hospital stay from CAS until hospital discharge was 3 days (quartiles: 2–6 days). Median patients age was 70 years (quartiles: 64–76 years) with 72.1% males. CAS for symptomatic stenosis was performed in 55% of cases. Patients treated with CAS suffered from coronary artery disease in 66.5%, had arterial hypertension in 91.7%, hyperlipidemia in 86.3% and 34.2% were diabetics. The intended CAS procedure was completed in 98.1% of cases. A stent was implanted in 97.3% of completed cases. The median intervention time was 43 min (quartiles: 30–60 min). During the hospital stay death rate was 0.3% (5/1888) and the rate of ipsilateral stroke 3.2% (58/1840). A contralateral ischemic event occurred in 1.4% (26/ 1840) of patients. The combined rate of all death or strokes was 3.8% (70/1841). Between 1996 and 2004 there was a steady increase in the use of protection devices during CAS (0% in 1996 and 97.9% in 2004; p for trend <0.0001). There was also an increase in the proportion of patients treated for asymptomatic stenoses (p for trend <0.0001). We observed a decrease of the combined endpoint of death or stroke from 6.3% in 1996 to 1.9% in 2004 (p for trend=0.021). Conclusion The multi-centre ALKK CAS Registry data confirm the feasibility and shot-term safety of CAS even in daily clinical practice. There was a rapid penetration of the use of embolic protection devices, an increase in treatment of asymptomatic carotid stenoses and a decrease in acute complication rates from 1996 to 2004.For the Arbeitsgemeinschaft Leitende Kardiologische Krankenhausärzte (ALKK)     

Carotid artery stenting in octogenarians using a proximal endovascular occlusion cerebral protection device: A multicenter registry

Background : Carotid stenting (CAS) has been proposed as an alternative to carotid endoarterectomy also in elderly patients with discrepant results. However, the use of proximal neuroprotection devices have not been evaluated in octogenarians. Purpose : The aim of this multicenter prospective registry was to demonstrate that CAS in octogenarians is safe and effective if performed in high‐volume centers by experienced operators. Methods : From July 2005 to May 2009, a total of 198 octogenarians patients, in three different institutions, were included in this registry. All patients underwent CAS using proximal endovascular occlusion device (Mo.Ma. device Invatec, Roncadelle, Italy). An independent neurologist evaluated all patients. The primary endpoint was death and stroke rate at 30 days. Results : 198 octogenarians (135 men; mean age: 83.2 years) were included in the registry. 39.4% of the patients were symptomatic. Procedural success was 100%. In‐hospital complications: Two minor and two major strokes (2.02%) occurred. No device‐related complications and no serious access site complication were noted. Between discharge and 30‐day follow‐up, one patient died due to a cardiac arrest. The overall 30‐day combined stroke/death rate was 2.52%, resulting in 1.61% event incidence in asymptomatic and 3.9% in symptomatic patients (P = ns). Logistic regression did not identify independent predictor of neurological events, except in the female gender. Conclusion : This multicenter prospective registry shows that CAS performed with proximal flow blockage is safe and feasible also in octogenarians. Thirty days death/stroke rates are similar to those of the overall population and within the International guidelines. © 2010 Wiley‐Liss, Inc.     

Proximal Versus Distal Embolic Protection for Carotid Artery Stenting: A National Cardiovascular Data Registry Analysis

ObjectivesThe aim of this study was to compare the stroke/death rates between proximal embolic protection devices (P-EPDs) and distal filter embolic protection devices (F-EPDs) in elective carotid artery stenting (CAS).BackgroundP-EPDs have theoretical advantages that may make them superior to F-EPDs for stroke prevention during CAS.MethodsWe examined 10,246 consecutive elective CAS procedures performed with embolic protection in the NCDR CARE registry between January 2009 and March 2013. We analyzed crude and propensity-matched rates of in-hospital combined death/stroke in patients treated with P-EPDs versus F-EPDs. Secondary analyses included 30-day adverse event rates and stroke rates by the involved cerebrovascular territory.ResultsP-EPDs were used in 590 of 10,246 cases (5.8%). Patients treated with P-EPDs had higher rates of symptomatic lesion status (46.8% vs. 39.7%, p < 0.001), atrial fibrillation/flutter (16.1% vs. 13.0%, p = 0.03), and history of a neurological event (51.2% vs. 46.6%, p = 0.03). In unadjusted and propensity-matched analyses, differences in in-hospital stroke/death between P-EPD and F-EPD cohorts were nonsignificant (1.5% vs. 2.4%, p = 0.16 and 1.6% vs. 2.0%, p = 0.56, respectively). For patients with available data (n = 7,693, 75.1%), 30-day adverse events rates were similar for P-EPDs and F-EPDs before (2.5% vs. 4.2%, p = 0.07) and after (2.7% vs. 4.0%, p = 0.22) propensity matching.ConclusionsUse of a P-EPD during CAS was associated with low rates of in-hospital stroke/death similar to those with an F-EPD in the first comparative effectiveness study of the devices. An adequately powered randomized trial comparing clinical outcomes between these devices is unlikely to be feasible.     

Carotid artery stenting with patient- and lesion-tailored selection of the neuroprotection system and stent type: early and 5-year results from a prospective academic registry of 535 consecutive procedures (TARGET-CAS).

PURPOSE: To develop and prospectively evaluate the safety and efficacy of an algorithm for tailoring neuroprotection devices (NPD) and stent types to the patient/lesion in carotid artery stenting (CAS). METHODS: From November 2002 to October 2007, 499 patients (360 men; mean age 65.2+/-8.4 years, range 36-88) were prospectively enrolled in a safety and efficacy study of tailored CAS using proximal (flow blockade or reversal) or distal (filters or occlusion) NPDs and closed- or open-cell self-expanding stents. Of the 535 lesions treated in the study, 175 (32.7%) were "high risk" by morphology. Half (50.1%) the patients were symptomatic. RESULTS: A quarter (137, 25.6%) of the procedures were performed under proximal protection and the remainder (398, 74.4%) with distal NPDs; the direct stenting rate was 66.9%. High-risk lesions were treated predominantly with a proximal NPD and closed-cell stent (77.1% and 82.9%, respectively) and less frequently by direct stenting (37.1%, p<0.0001 versus non-high-risk lesions). The in-hospital death/stroke rate was 2.0% (95% CI 0.85% to 3.23%), and the death/major stroke rate was 0.7% (95% CI 0.02% to 1.48%). There were no myocardial infarctions, but there was 1 (0.2%) further death within 30 days. With the tailored approach, symptom status and high-risk lesion morphology were not risk factors for an adverse outcome after CAS; only age >75 years (p<0.001) was a predictor of short-term death. Long-term survival (95.4% at 1 and 88.3% at 5 years) was similar for symptomatic versus asymptomatic patients, direct stenting versus predilation, and closed- vs. open-cell stent design; only coronary artery disease adversely impacted survival (p = 0.04). The rates of freedom from death/ipsilateral stroke were 94.9% at 1 year and 85.9% at 5 years. CONCLUSION: Tailored CAS is associated with a low complication rate and high long-term efficacy. CAS operators should have a practical knowledge of different NPDs, including at least one proximal type.     

Carotid Endarterectomy versus Carotid Stenting or Best Medical Treatment in Asymptomatic Patients with Significant Carotid Stenosis: A meta-analysis

BackgroundThis meta-analysis aimed to evaluate randomized trials (RTs) that compare outcomes among asymptomatic patients with significant carotid stenosis undergoing carotid endarterectomy (CEA) versus carotid stenting (CAS) or best medical treatment (BMT).Material and methodsThe Pubmed, Embase, Scopus and Cochrane Library databases were systematically searched to identify eligible studies. Data were analyzed by using the StatsDirect Statistical software (Version 2.8.0, StatsDirect Ltd). Odds ratios (OR) were used to determine effect size, along with 95% confidence interval (CI). PRISMA guidelines for conducting meta-analyses were utilized.ResultsOverall, 10 RTs including 8771 asymptomatic patients were evaluated. Compared to CAS, 30-day all stroke risk was found to be lower after CEA (pooled OR = 0.56; CI 95% [0.312–0.989]; P = 0.046). However, other early and late outcomes were not different between CEA and CAS. Furthermore, 30-day all stroke (pooled OR = 3.43; CI 95% [1.810–6.510]; P = 0.0002), death (pooled OR = 4.75; CI 95% [1.548–14.581]; P = 0.007) and myocardial infarction (MI) (pooled OR = 9.18; CI 95% [1.668–50.524]; P = 0.011) risks were higher after CEA compared to BMT, as expected. Additionally, 30-day all stroke/death and all stroke/death/MI risks were higher after CEA compared to BMT as well. Regarding long-term results, ipsilateral stroke risk was lower after CEA compared to BMT (pooled OR = 0.46; CI 95% [0.361–0.596]; P < 0.0001) although death due to stroke risk was not different (pooled OR = 0.57; CI 95% [0.223–1.457]; P = 0.240). Unfortunately, no study comparing CAS to BMT was found.ConclusionsCEA is associated with a lower early all stroke risk compared to CAS although other early or late outcomes did not show any difference between the two methods. Additionally, CEA seems to have a benefit over BMT against long-term ipsilateral stroke, although early outcomes are worse after CEA. No studies are available comparing CAS to BMT alone.     

Influence of patient age on acute and late clinical outcomes following Palmaz-Schatz coronary stent implantation

Procedural success may be lower and complication rates higher after balloon angioplasty in older patients. Elective stent implantation improves procedural outcome in younger patients; however, few series have specifically analyzed the octogenarian population. Therefore, we studied 2,534 consecutive patients (3,965 native coronary artery stenoses) who were treated electively with Palmaz-Schatz stents and divided them into 3 groups: (1) < or = 70 years old (n = 1,805), (2) 71 to 80 years old (elderly, n = 607), and (3) > 80 years old (octogenarian, n = 122). Major in-hospital complications (death, myocardial infarction, and urgent bypass surgery) were significantly higher in the octogenarians than in the elderly and patients < or = 70 years of age (4.5% vs 2.0% and 1.5%; p = 0.001). At 1-year follow-up, cardiac events (death, nonfatal myocardial infarction, and need for any revascularization) did not differ among groups; however, there was a stepwise increase in late death in octogenarians (5%) compared with elderly patients (2%) and patients aged < or = 70 years (1%) (p = 0.001). Target lesion revascularization was similar among the groups (11% in octogenarian vs 14% in elderly and 15% in patients < or = 70 years, p = 0.791). By multivariate logistic regression analysis, age was an independent predictor of late mortality (odds ratio 1.05, p = 0.0001), but not a predictor of target lesion revascularization. Stent implantation in octogenarians is associated with (1) more acute complications, (2) a higher in-hospital mortality, (3) a higher late mortality, and (4) a target lesion revascularization similar to younger patients.     

Carotid artery stenting in asymptomatic and surgically high-risk patients: single-centre, single-operator results

BACKGROUND:

Stroke represents the third leading cause of death in developed countries and the leading cause of disability in the elderly. Because asymptomatic, surgically high-risk patients have been systematically excluded from randomized trials of carotid endarterectomy and medical therapy, the management of this group of patients is still controversial. A single-centre, single-operator registry was analyzed to evaluate feasibility and safety of carotid artery stenting (CAS) with distal protection devices in consecutive, asymptomatic, surgically high-risk patients who were scheduled for endovascular treatment of significant carotid stenoses.

METHODS:

A total of 122 consecutive, surgically high-risk, asymptomatic patients (150 carotid arteries, 59% men, mean [± SD] age 69±9 years) with severe carotid stenosis and one or more high-risk features for carotid endarterectomy were scheduled for CAS. All procedures were performed in a single centre by a single operator. All patients were prospectively asked to undergo a clinical 30-day follow-up.

RESULTS:

A total of 154 stents were implanted in 150 carotid arteries. The primary success rate was 98.7%. The rates of stenosis before and after direct CAS were 81%±9% and 10%±13%, respectively. The median of fluoroscopic time of direct CAS was 6 min (range 2.5 min to 31.5 min). At 30 days, data were available in all patients. The combined 30-day mortality and stroke rate was 1.3%.

CONCLUSIONS:

Short-term outcomes of CAS in asymptomatic, surgically high-risk patients treated by a single operator suggest a low periprocedural complication rate.     

Safety of carotid artery stenting for symptomatic carotid artery disease: a meta-analysis.

AIMS: Clinical trials comparing carotid artery stenting (CAS) with carotid endarterectomy (CEA) for patients with symptomatic carotid artery disease have produced conflicting results. We performed a meta-analysis to systematically evaluate currently available data by comparing CAS with CEA in patients with symptomatic carotid artery disease. METHODS AND RESULTS: We searched MEDLINE, Embase, ISI Web of Knowledge, Current Contents, International Pharmaceutical Abstracts databases, the Cochrane Central Register of Controlled Trials, and scientific meeting abstracts up to 31 October 2006 and then calculated summary risk ratios (RRs) for mortality, stroke, disabling stroke, and death using random- and fixed-effect models. Data from five trials with 2122 patients were pooled. There was no difference in risk of 30-day mortality (summary RR 0.57, 95% CI 0.22-1.47, P = 0.25), stroke (summary RR 1.64, 95% CI 0.67-4.00, P = 0.34), disabling stroke (summary RR 1.67, 95% CI 0.50-5.62, P = 0.50), death and stroke (summary RR 1.54, 95% CI 0.81-2.92, P = 0.19), or death and disabling stroke (summary RR 1.19, 95% CI 0.57-2.51, P = 0.64) among patients randomized to CAS, compared with CEA. CONCLUSIONS: No significant differences could be identified between CAS and CEA in the treatment of patients with symptomatic carotid artery disease. Larger randomized controlled trials are warranted to compare the two strategies.     

Percutaneous coronary intervention with drug-eluting stents in octogenarians: characteristics, clinical presentation, and outcomes.

OBJECTIVES: We aimed to compare clinical outcomes of octogenarians > or =80 years of age after coronary drug-eluting stent (DES) implantation. BACKGROUND: Although octogenarians constitute a fast-growing portion of cardiovascular patients, they are not adequately represented in current clinical revascularization trials. METHODS: We analyzed the data of 3,166 consecutive patients who underwent percutaneous coronary intervention (PCI) and DES implantation since March 2003. Periprocedural events, 1- and 6-month clinical outcomes were compared between octogenarians (n = 339) and patients <80 years of age (n = 2,827). RESULTS: Baseline characteristics revealed a higher prevalence of females (P < 0.001), Caucasians (P = 0.004), chronic renal failure (P < 0.001), heart failure (P < 0.001), number of diseased vessels (P = 0.009), and lower ejection fraction (P = 0.03) in octogenarians. Patients <80 years showed more positive family history (P < 0.001), hyperlipidemia (P = 0.006), smoking (P < 0.001), and obesity (P < 0.001). Clinical presentation and procedural success were similar in both groups as were death, myocardial infarction (MI), and repeat revascularization in-hospital. At 6 months, restenosis rates were low and comparable. In the subgroup of octogenarians who presented with acute coronary syndrome, mortality (15% vs. 3%, P < 0.001) and Q-wave MI occurred more often. Multivariate analysis revealed age >80 (P = 0.008), cardiogenic shock (P < 0.001), Q-wave MI at presentation (P = 0.003), and length of hospital stay (P = 0.003) to be independent predictors of mortality. CONCLUSIONS: PCI with DES in octogenarians results in a similar reduction of restenosis rates when compared to patients <80 years. Yet in octogenarians who presented with acute coronary syndrome, incidence of mortality and Q-wave MI at 6 months was higher as compared to younger patients.     

性别和年龄对中国人冠状动脉旁路移植术后住院病死率的影响

目的确定中国人冠状动脉旁路移植术后住院病死率是否存在性别差异以及该差异是否与年龄相关.方法回顾性分析1997年1月1日至2001年12月31日阜外心血管病医院外科全部接受冠状动脉旁路移植术的患者共2682例（男性2316例,女性366例）.按照性别和年龄分组调查它们之间的围手术期并发症及手术后住院病死率的差异.结果女性术前合并主要疾病的比例比男性高,术后并发症多,但她们术前的左心室射血分数较男性好,且冠状动脉病变数量少.然而,女性患者的术后住院病死率是男性的3倍（女性3.01%,男性1.12%,P=0.001）,病死率的性别差异在低龄组更有统计学意义（女性2.6%,男性0.5%,P=0.001,ORs：4.844,95%可信区间：1.549～15.142）,在老年患者中则无统计学意义（女性3.7%,男性2.4%,P=0.383）.结论中国女性冠状动脉旁路移植术的住院病死率高于男性,特别是低龄女性.低龄组女性是住院病死率的独立危险因素.死亡率的性别差异随年龄增加而减少.需要进一步的研究来阐明病死率的性别差异在低龄组更显著的原因.     

Carotid intima-media thickness as a marker of cardiovascular risk in hypertensive patients with coronary artery disease

BACKGROUND: The aim of this study was to examine the significance of ultrasound-measured carotid intima-media thickness (CIMT) in high-risk patients with hypertension and coronary artery disease (CAD), as an independent prognostic factor in determining the risk of all-cause death or future cardiovascular events. METHODS: The study included 297 consecutive patients (mean age +/- SD, 57 +/- 9.4 years) with diagnosed hypertension and CAD, referred for coronary angiography. The mean of maximal CIMT in two arterial segments bilaterally was calculated. The primary endpoint was a patient's death from all causes. Death, stroke, or myocardial infarction comprised the secondary, composite endpoint. RESULTS: There was a follow-up of 1 to 79 (mean, 41) months. The predictors of death in a multivariate Cox proportional hazards model were the number of stenosed coronary arteries (P = .007) and CIMT (P = .001). The risk of the secondary, composite endpoint (death, stroke, or myocardial infarction) was determined by diabetes (P = .008) and CIMT (P = .010). Nearly 99% of patients with "low CIMT" (< or =1.13 mm) survived for 5 years, versus 78% with "high CIMT" >1.13 mm (log-rank test; P < .001). For the secondary, composite endpoint (death, stroke, or myocardial infarction), the event-free survival rate was 95% (low CIMT), versus 74% after 5 years (high CIMT) (P < .008). CONCLUSIONS: Intima-media thickness of the carotid arteries is a strong and independent predictor of death and serious cardiovascular events in hypertensive patients with CAD referred for coronary angiography.     

Comparison of in-hospital outcomes of patients with versus without previous carotid endarterectomy undergoing carotid stenting (from the German ALKK CAS Registry)

Repeat carotid endarterectomy (CEA) for recurrent stenosis remains a challenging treatment option associated with high morbidity and mortality. Carotid artery stenting (CAS) is an attractive alternative management option for these patients. However, data about the effectiveness and safety of CAS in a large number of unselected patients are less known. We evaluated 3,070 patients who underwent CAS enrolled in a German registry from 1996 to 2006 at 31 sites. We compared clinical and angiographic features and in-hospital outcomes of patients with and without previous CEA who underwent CAS. Of 3,070 patients in the registry, 223 (7.3%) underwent CAS for restenosis after previous CEA. Median age was similar in patients with and without previous CEA (70 years, interquartile range 64 to 76 vs 71 years, interquartile range 65 to 76). Ipsilateral neurologic symptoms occurred in approximately 1/2 the patients in both groups. Other co-morbid conditions and angiographic or procedural factors did not differ between the 2 groups. In-hospital events including death (0% vs 0.4%), ipsilateral major stroke (1.4% vs 1.5%), death or major ipsilateral stroke (1.4% vs 1.7%), ipsilateral transient ischemic attack (1.9% vs 2.8%), myocardial infarction (0.4% vs 0.1%), and reintervention (0.7% vs 0.4%) were all low and not significantly different between those with and without previous CEA (p >0.05 for all comparisons). In conclusion, our data for a large number of patients who underwent CAS in a recent contemporary community-based practice attests to the low risk of periprocedural events in patients with recurrent stenosis after previous CEA. This low risk along with the less invasive nature of the procedure should make CAS an attractive and perhaps preferred option for the treatment of these patients.     

Carotid angioplasty and stenting in octogenarians: Is it safe?

Purpose: Elderly patients have a higher risk of complications in carotid endarterectomy. The aim of the study was to evaluate whether carotid artery stenting (CAS) performed in octogenarians also increases the procedure related risk. Methods: 870 patients (male 626) mean age 70.9 ± 9.3 years underwent 930 CAS for de novo lesions (n = 851) restenoses (n = 54) post radiation (n = 14) inflammatory arteritis (n = 9) post trauma aneurysms (n = 2). Indications for treatment: symptomatic carotid stenosis ≥ 70% (n = 577) or asymptomatic stenosis ≥ 80%. Patients were separated into two age groups: <80 years (749 patients, 806 CAS) and >80 years (121 patients, 124 CAS). 187 CAS performed without protection (N.P?) 6 patients >80 years, 743 with protection (NP+) (occlusion balloon: 334, filters: 404, reversal flow: 6) 118 patients >80 years. Data analysis included neurological complications, death and myocardial infarction (MI) rate at 30 days, anatomical particularities. Technical points will be described depending on the age of the patient. Results: Technical success 804/806 in patients <80 years, 123/124 in patients >80 years (NS). 30 days outcomes: in the patient group <80 years we observed 9 TIA (1.1%) 3 without NP (1.7%) 6 with NP (0.9%), 5 minor strokes (0.6%) 2 without NP (1.1%) 3 with NP (0.5%), 3 major strokes: 2 without NP (1.1%) 1 with NP (0.2%), 5 deaths (0.6%) 2 without NP (1.1%) 3 with NP (0.5%). Death/stroke/MI: 14 (1.8%) 6 without NP (3.3%), 8 with NP (1.3%). In the group >80 years, we observed 2 TIA (1.7%) 1 without NP 1 with NP (0.92%) 1 minor stroke without NP (17%) no major stroke, no death. Death/stroke/MI 1 without NP (17%). Conclusion: CAS can be performed in elderly patients without higher risk than in younger patients. But good indications, a meticulous technique, protection devices are mandatory and some technical points must be pointed out to avoid neurological complications and failures. © 2008 Wiley‐Liss, Inc.     

Clinical Impact of Contralateral Carotid Occlusion in Patients Undergoing Carotid Artery Revascularization

BackgroundThe presence of a contralateral carotid occlusion (CCO) is an established high-risk feature for patients undergoing carotid endarterectomy (CEA) and is traditionally an indication for carotid artery stenting (CAS). Recent observational data have called into question whether CCO remains a high-risk feature for CEA.ObjectivesThe purpose of this study was to determine the clinical impact of CCO among patients undergoing CEA and CAS in a contemporary nationwide registry.MethodsAll patients undergoing CEA or CAS from 2007 to 2019 in the NCDR CARE (National Cardiovascular Data Registry Carotid Artery Revascularization and Endarterectomy) and PVI (Peripheral Vascular Intervention) registries were included. The primary exposure was the presence of CCO. The outcome was a composite of in-hospital death, stroke, and myocardial infarction. Multivariable logistic regression and inverse-probability of treatment weighting were used to compare outcomes.ResultsAmong 58,423 patients who underwent carotid revascularization, 4,624 (7.9%) had a CCO. Of those, 68.9% (n = 3,185) underwent CAS and 31.1% (n = 1,439) underwent CEA. The average age of patients with CCO was 69.5 ± 9.7 years, 32.6% were women, 92.8% were Caucasian, 51.7% had a prior transient ischemic attack or stroke, and 45.4% presented with symptomatic disease. Over the study period, there was a 41.7% decrease in the prevalence of CCO among patients who underwent carotid revascularization (p < 0.001), but CAS remained the primary revascularization strategy. Unadjusted composite outcome rates were lower in patients with CCO after CAS (2.1%) than CEA (3.6%). Following adjustment, CCO was associated with a 71% increase in the odds of an adverse outcome after CEA (95% confidence interval: 1.27 to 2.30; p < 0.001) compared with no increase after CAS (adjusted odds ratio: 0.94; 95% confidence interval: 0.72 to 1.22; p = 0.64).ConclusionsCCO remains an important predictor of increased risk among patients undergoing CEA, but not CAS.     

颈动脉血管成形术和颈动脉内膜切除术治疗颈动脉狭窄近期疗效的Meta分析

目的评价颈动脉血管成形术和颈动脉内膜切除术治疗颈动脉狭窄的近期临床疗效和安全性。方法电子检索中国学术期刊网全文数据库(1996—2006年)、MEDLINE(1996—2006年)和Cochrane图书馆(2006年12月前已发表的文献和已注册但未发表的临床试验),并与研究者取得联系获得更多的相关研究资料。纳入比较颈动脉血管成形术和内膜切除术治疗颈动脉狭窄的随机对照试验,比较两种治疗方法术后30d内卒中发生率和卒中与死亡的联合发生率。以卒中发生率作为疗效评价指标,以卒中和死亡的联合发生率作为安全性评价指标。2名评价员独立检索和提取资料,对纳入试验的方法学质量进行评价,数据采用RevMan4.2.10版软件进行统计分析。结果在术后30d内的卒中发生率方面,共纳入7项临床试验的2747例患者,其中颈动脉血管成形术组1381例,颈动脉内膜切除术组1366例。在术后30d的卒中和死亡的联合发生率方面,纳入8项临床试验,共2966例患者,其中颈动脉血管成形术组1488例,颈动脉内膜切除术组1478例。Meta分析结果显示,在术后30d内的卒中发生率方面,颈动脉血管成形术略高于颈动脉内膜切除术(OR:1.44;95%CI:1.05~1.97,Z=2.28,P=0.02);在术后30d内卒中和死亡的联合发生率方面,颈动脉血管成形术与颈动脉内膜切除术间差异无统计学意义(OR:1.50;95%CI:0.89~2.52,Z=1.51,P=0.13)。结论现有临床研究资料显示,在目前的技术条件下,颈动脉血管成形术在治疗颈动脉狭窄的近期疗效方面未显示优于内膜切除术;而在治疗的安全性方面,两者间差异无统计学意义。     

Is Age of 80 Years a Threshold for Carotid Revascularization?

Background and purpose:

Carotid Angioplasty and Stenting (CAS) has emerged as an alternative to Carotid Endarterectomy (CEA) in treatment of carotid stenotic disease. With increasing life expectancy clinicians are more often confronted with patients of higher age. Octogenarians were often excluded from randomized trials comparing CAS to CEA because they were considered high-risk for revascularization. Conflicting results on the peri-procedural outcome of carotid revascularization in these patients have been reported. In order to objectively evaluate whether age above 80 years should be an upper limit for indicating carotid revascularization we systematically reviewed the currently available literature.

Methods:

Literature was systematically reviewed between January 2000 and June 2010 using Pubmed and Embase, to identify all relevant studies concerning CAS and CEA in octogenarians. Inclusion criteria were 1) reporting outcome on either CEA or CAS; and 2) data subanalysis on treatment outcome by age. The 30-day Major Adverse Event (MAE) rate (disabling stroke, myocardial infarction or death) was extracted as well as demographic features of included patients.

Results:

After exclusion of 23 articles, 46 studies were included in this review, 18 involving CAS and 28 involving CEA. A total of 2.963 CAS patients and 14.365 CEA patients with an age >80 years were reviewed. The MAE rate was 6.9% (range 1.6 - 24.0%) following CAS and 4.2% (range 0 – 8.8%) following CEA.A separate analysis in this review included the results of one major registry 140.376 patients) analyzing CEA in octogenarians only reporting on 30-day mortality and not on neurological or cardiac adverse events. When these data were included the MAE following CEA is 2.4% (range 0 – 8.8%)

Conclusions:

MAE rates after CEA in octogenarians are comparable with the results of large randomized trials in younger patients. Higher complication rates are described for CAS in octogenarians. In general, age > 80 years is not an absolute cut off point to exclude patients from carotid surgery. In our opinion, CEA should remain the golden standard in the treatment of significant carotid artery stenoses, even in the very elderly.     

Stroke and myocardial infarction in Chinese patients: comparison of risk factors and in-hospital outcomes

Although coronary heart disease (CHD) and stroke share important risk factors,some associations differ between these two components of cardiovascular diseases.The objective of this study was to compare vascular risk factor profiles and in-hospital outcomes in acute stroke (AS) and acute myocardial infarction (AMI) patients.Methods We evaluated 383 consecutive patients who were admitted to the 94th Hospital of Chinese PLA and the Third Hospital of Nanchang with diagnoses of AS (ischemic stroke or intracerebral hemorrhage;n = 310) or AMI (n = 73) during a 2-year period.The frequency of risk factors and inhospital mortality rates were assessed in both groups.Results AS patients were significantly older than AMI patients ( 68.9 ± 9.1 years vs.62.8 ±11.7 years;P ＜ 0.01).AMI was significantly more common than AS in patients younger than 65 years;51% of this group had AMI and 26% had AS (P ＜ 0.001).Hypertension was more common in AS patients than in AMI patients (69% vs.58%;P = 0.042).Patients who died did not differ significantly in age between the groups.In-hospital mortality rates were significantly higher in AS than AMI cases (31% vs.12%,P ＜ 0.001 for all patients;37% vs.5%,P ＜ 0.001 for men).Women hospitalized for AMI were more likely to die in hospital than men (28% vs.5%;P = 0.002).Conclusions Patients with stroke and with AMI differ in their risk factor profile.Age at the time of presentation was a significant differentiating factor between patients with AS and AMI.We observed significantly higher in-hospital mortality for patients with AS (when adjusted for age) than for patients with AMI.(J Geriatr Cardiol 2008;5:223-226)     

Bleeding outcomes after non-emergency percutaneous coronary intervention in the very elderly

Background Octogenarians constitute an increasing proportion of patients presenting for non-emergency percutaneous coronary intervention (PCI). Methods This study evaluated the in-hospital procedural characteristics and outcomes, including the bleeding events of 293 octogenarians presenting between January 2010 and December 2012 for non-emergency PCI to a single large volume tertiary care Australian center. Comparisons were made with 293 consecutive patients aged less than or equal to 60 years, whose lesions were matched with the octogenarians. Results Non-ST elevation myocardial infarction was the most frequent indication for non-emergency PCI in octogenarians. Compared to the younger cohort, they had a higher prevalence of co-morbidities and more complex coronary disease, comprising more type C and calcified lesions. Peri-procedural use of low molecular weight heparin (LMWH; 1.0% vs. 5.8%; P < 0.001) and glycoprotein IIb/IIIa inhibitors (2.1% vs. 9.6%; P < 0.001) was lower, while femoral arterial access was used more commonly than in younger patients (80.9% vs. 67.6%; P < 0.001). Overall, there was a non-significant trend towards higher incidence of all bleeding events in the elderly (9.2% vs. 5.8%; P = 0.12). There was no significant difference in access site or non-access site bleeding and major or minor bleeding between the two cohorts. Sub-analysis did not reveal any significant influence on bleeding rates by the use of LMWH, glycoprotein IIb/IIIa inhibitors or femoral arterial access. In addition, there were no significant differences in the rates of in-hospital mortality, stroke or acute stent thrombosis between the two groups. Conclusions In this single center study, we did not observe significant increases in adverse in-hospital outcomes including the incidence of bleeding in octogenarians undergoing non-emergency PCI.     

Peri-procedural outcome of series of 104 carotid artery stenting procedures

BackgroundManagement of carotid artery stenosis is considered an important strategy for stroke prevention. Carotid artery stenting (CAS) has been introduced as an acceptable alternative to surgical carotid endarterectomy (CEA) in the treatment of internal carotid artery (ICA) stenosis.ObjectiveAssessment of peri-procedural outcome of CAS in 104 consecutive procedures.MethodsThe study included 104 consecutive CAS procedures. Included patients had ⩾50% ICA stenosis in the symptomatic group and ⩾70% stenosis in the asymptomatic group. Procedures were performed in cath. labs of Catania and Ragusa hospitals-Italy.ResultsIncluded procedures were done in 100 consecutive eligible patients with ICA stenosis. Four patients had undergone CAS procedures in both sides in 2 separate sessions. Patients were 71 males and 29 females, mean age was 71.9 ± 7.85 years, and 21 patients were ⩾80 years old (octogenarians). The majority of patients had asymptomatic ICA stenosis (76%) and was diagnosed accidentally during medical checkup. Twenty-four patients had symptomatic ICA stenosis (ipsilateral TIA or stroke). Technical success was obtained in 103 procedures (99%). Embolic protection devices were used in all succeeded cases. Combined cerebrovascular events had occurred in 5 patients with estimated rate = 4.8%. No cases of amaurosis fugax, MI or death had occurred. Adverse events was 4.1% in the symptomatic group and 1.3% in the asymptomatic group with no significant statistical difference (P = 0.064).ConclusionCAS with EPDs seems a feasible and safe procedure and could be performed with an acceptable rate of periprocedural adverse events.     

Safety and Effectiveness of Transvenous Lead Extraction in Octogenarians

Transvenous Lead Extraction . Introduction: As the population ages, the number of elderly patients with implantable cardiac devices referred for transvenous lead extraction will dramatically increase in Western countries. The safety and effectiveness of lead extraction in elderly patients has not been well evaluated. We report the safety and effectiveness of transvenous lead extraction in octogenarians. Methods and Results: From January 2005 to January 2011, we reviewed data from consecutive patients ≥ 80 years referred to our institutions for transvenous lead extraction because of cardiac device infection or lead malfunction. Clinical characteristics, procedural features, and periprocedural major and minor complications were compared between octogenarians and younger patients. Out of 849 patients undergoing lead extraction in the participating institutions during the study period, 150 (18%) patients were octogenarians (mean age 84 years; range 80–96; 64% males). A significantly higher percentage of octogenarians presented with chronic renal failure (55% vs 26%; P < 0.001), history of malignancy (22% vs 6%; P < 0.001), and chronic obstructive pulmonary disease (46% vs 19%; P < 0.001). Complete lead extraction rates were similar in the 2 age groups (97% in octogenarians vs 96% in patients <80 years; P = 0.39). Periprocedural death occurred in 2 (1.3%) patients ≥80 years and in 5 (0.72%) patients <80 years (P = 0.45 for comparison). No differences in terms of other periprocedural major and minor complications were found between the 2 age groups. Conclusion: Despite presenting with a significantly higher rate of comorbidities, transvenous lead extraction can be performed safely and successfully in octogenarians. (J Cardiovasc Electrophysiol, Vol. 23 pp. 1103‐1108, October 2012)