What is the learning curve for carotid artery stenting with neuroprotection? Analysis of 200 consecutive cases at an academic institution

Carotid artery stenting (CAS) has emerged as an acceptable treatment alternative in high-risk patients with carotid stenosis. This study assessed the effect of the learning curve on treatment complications and clinical outcome of CAS. Clinical variables and treatment outcomes of 200 consecutive CAS procedures in 182 patients (mean age, 72 years) with carotid stenosis of 70% or greater during a 40-month period were analyzed. Technical success, periprocedural complications, and treatment outcomes were compared in four sequential groups (group I, II, III, and IV) of 50 consecutive interventions. Treatment indications and relevant risk factors were similar among the four groups. The overall technical success was 98%, and the combined 30-day stroke and death rates was 2.5%. An increase in the technical success rate was noted in the latter three groups compared with group I (P < .05). Total procedural time and contrast volume were significantly higher in group I compared with the latter three groups (P < .05). The intraoperative anticoagulation regimen was changed from an intravenous heparin combination to bivalirudin after the first 54 cases, resulting in reduced bleeding complications in groups III and IV (P = .03) compared with group I. The 30-day stroke and death rate in groups I and II was 8% and 2%, which was reduced significantly to 0% in groups III and IV (P < .05). A Cox regression model identified procedural volume (P = .03) as a predictor of a reduced complication rate. Carotid artery stenting with neuroprotection can provide excellent treatment outcome. Our experience demonstrates a procedural-associated learning curve, as evidenced by the reduced procedural-related complications, fluoroscopic time, and contrast volume that occurred with an increase in physician experience. The procedural success is also enhanced partly by endovascular device refinement and improved anticoagulation regimen. Successful outcome of CAS can be achieved once physicians overcome the initial procedural-related learning curve.     

What is the latest in inventory for carotid stenting and cerebral protection?

Carotid angioplasty is fast being incorporated into the treatment options for patients with carotid occlusive disease. The results of the SAPPHIRE and ARCHER trials have demonstrated that carotid angioplasty and stenting with the use of cerebral protection devices is not inferior to open surgical endarterectomy in high-risk patients. The limiting step for percutaneous carotid interventions was the potential for cerebral embolization during the intervention. However, the ready availability of several embolic protection devices has placed this technology into the hands of many endovascular specialists. A brief outline of the basic inventory necessary for a carotid stent program is presented.     

Corticospinal tract asymmetries at the level of the internal capsule: is there an association with handedness?

The functional integrity of the corticospinal tract (CST) is of crucial importance for fine and independent finger movement. Therefore, it has been frequently speculated that interhemispheric asymmetries in this tract might be associated with handedness. The objective of the present study was to examine this proposed relationship, by studying the effects of handedness on macro- and microstructural properties of the CST. For this purpose, 30 consistently left and 30 consistently right-handed participants of either sex were examined applying a combination of anatomical T1-weighted and diffusion-tensor (DTI) MR imaging. In an automated procedure and based on white matter probability maps as well as on DTI fibre direction information, the left and right hemispheric CST was segmented in the individual brain. Focussing the analysis on the posterior limb of the internal capsule, the size as well as two DTI parameters (mean diffusion and fractional anisotropy) was determined. Although the statistical analysis revealed substantial CST asymmetries regarding size, mean diffusion, and anisotropy, neither of these metrics showed a significant hemisphere-by-handedness interaction. From this it was concluded that handedness might be related to motorcortical asymmetries which seem not to be directly reflected in the corticospinal fibre tract characteristics.     

Effect of an immune-enhancing diet on lymphocyte in head-injured rats: What is the role of arginine?

Objective

The benefit of immune-enhancing diets (IEDs) in the intensive care unit remains controversial. Considering their complexity, the role of each component, in particular arginine (Arg), in their properties is largely unknown. The aim of this study was to determine the role of arginine in the immunomodulatory effects of an IED (Crucial^®) in head-injured rats.

Design

Thirty-four rats were randomized into five groups: AL (ad libitum), HI (head-injured), HI-STD (HI + standard enteral nutrition, EN), HI-STD-Arg (HI + standard EN + Arg in equimolar concentration to Arg in IED), and HI-IED (HI + IED). These isocaloric and isonitrogenous diets were administered over 4?days. After death, the thymus was removed and weighed. The density of CD25, CD4 and CD8 on lymphocytes from blood and from Peyer patches was evaluated. Mesenteric lymph nodes, liver and spleen were cultured for analysis of enterobacterial translocation and dissemination.

Measurements and results

HI induced an atrophy of the thymus which was not corrected by the standard diet (HI 0.27?±?0.03, HI-STD 0.35?±?0.03 vs. AL 0.49?±?0.02?g; p?p?p?Conclusions In this rat HI model, arginine appears to be safe, contributes to a large extent to the immunomodulatory effects of the IED, and seems to limit enterobacterial translocation and dissemination more efficiently alone than in an IED.     

What is wrong with the 30-year-old practice of scalp cooling for the prevention of chemotherapy-induced hair loss?

Since about 1970 scalp cooling has been used to prevent chemotherapy-induced hair loss, one of the most common and emotionally distressing side effects of cancer therapy. Generally accepted opinions, uncertainty and controversy, topics to study and recommendations for improving the results of scalp cooling are the subjects of this article which was also presented at the MASCC Symposium, June 2003, Berlin.This work was presented as an invited lecture at the 15th International Symposium Supportive Care in Cancer, Berlin, Germany, 18–21 June 2003     

Carotid artery interventions for restenosis after prior stenting: is it different from interventions of de novo lesions? Results from the carotid artery stent (CAS)—registry of the Arbeitsgemeinschaft Leitende Kardiologische Krankenhausärzte (ALKK)

Objective

To compare characteristics and outcome of patients with re-stenoses after prior carotid artery stenting (CAS) treated with repeat carotid interventions (Re-CI) with CAS for de novo lesions.

Background

The treatment of re-stenosis is a major problem in vascular interventions. Patients with re-stenoses after prior CAS treated with Re-CI are not well defined.

Methods

We analyzed data from the prospective ALKK CAS Registry.

Results

Out of 3,817 CAS procedures 95 were intended in 93 patients (2.5%) for a restenosis after prior CAS and 3,722 CAS in 3,655 patients (97.5%) for a de novo stenosis. There was no difference in age (p = 0.302) or distribution of gender (p = 0.545) between the two groups. Patients treated for a restenosis after CAS were less likely to be treated for a symptomatic lesion (22.7 vs. 40.1%, p = 0.001). Coronary heart disease (p = 0.017), peripheral arterial disease (p < 0.001) as well as diabetes mellitus (p = 0.004) were more prevalent in the restenosis group. Lesions were less complicated in restenosis patients, with less ulcers (7.4 vs. 19.9%, p = 0.003) and less severe calcifications (7.4 vs. 23.6%, p < 0.001). The intended interventions were more often not performed in the Re-CI group (9.5 vs. 3.3%; p = 0.001). In-hospital, the stroke or death rate was 0% in the Re-CI group as compared to 3.1% in the de novo group (p = 0.115).

Conclusions

Patients treated with Re-CI for repeat stenoses after prior CAS represent 2.5% of current CAS patients. Although representing a subgroup with more concomitant diseases, Re-CI seems to be associated with lower event rates as compared to CAS for de novo lesions.     

What is the role of TPE in management of patients at risk or with pressure ulcer as of 2012? Towards development of French guidelines for clinical practice

IntroductionPressure ulcer (PU) is a common complication in chronic affection, especially neurological disorders and diseases commonly diagnosed in the elderly. For a long period of time, the prevention of skin lesions was taught only in an empirical manner. The development of therapeutic patient education (TPE) sheds a new light on care management for patients with chronic pathologies.ObjectivesDetermine the place of TPE in persons at risk of and/or already suffering from pressure ulcer (PU) as of 2012.MethodsThe methodology used is the one promoted by SOFMER, including: a systematic review of the literature with a query of the PASCAL Biomed, PubMed and Cochrane Library databases for data from 2000 through 2010; a compendium of prevailing professional practices and advice from a committee of experts.ResultsThe review of the literature found six studies including four controlled trials in patients with chronic neurological impairments (most of them with spinal cord injury). No studies were found regarding the elderly. The level of evidence for efficacy in persons with spinal cord injury (SCI) is moderate. The clinical practice study focuses on programs currently underway, dedicated to SCI patients or elderly populations.DiscussionThe approach proposed through TPE has its role in a strategy aimed at preventing PU in persons at chronic risk of developing PU. The educational objectives and techniques used must be adapted to the clinical and psychological context and are debated in this review. The co-construction of programs, recommended in the official texts on therapeutic education in France, should help to tailor these programs to the patients’ needs.ConclusionTPE is relevant in care management or prevention of PU in persons at chronic risk, patients with spinal cord injury (Grade B) or elderly subjects (Grade C).     

The prevalence of carotid artery calcification on the panoramic radiographs of end-stage renal disease patients with peritoneal dialysis: do incidental findings provide life-saving information?

This study investigated the presence of carotid artery calcifications (CACs) on panoramic radiographs (PRs) in end-stage renal disease (ESRD) patients treated with peritoneal dialysis (PD), and analysed the relationship between CAC prevalence and PD duration. A random sample of 110 PRs were collected from ESRD patients (15 with questionable CACs were subsequently excluded). CACs were found in 26 (27.4%) patients; 10 males (23.3% of all males) and 16 females (30.8% of all females). The overall mean PD period was 4.0 +/- 3.2 years. There was a significant difference in PD period between patients with and without CACs (5.3 +/- 3.1 years versus 3.5 +/- 3.1 years, respectively). To our knowledge, this study has the highest CAC prevalence, is the first to be carried out in ESRD patients being treated with PD and has the largest sample of ESRD patients (n = 95). We believe dentists should carefully evaluate patients' PRs for evidence of CACs, enabling these incidental findings to provide life-saving information.