Alessandra Manzone

Summary of Evidence on Early Carotid Intervention for Recently Symptomatic Stenosis Based on Meta-Analysis of Current Risks

Background and Purpose— This study aimed to assess the evidence on the periprocedural (<30 days) risks of carotid intervention in relation to timing of procedure in patients with recently symptomatic carotid stenosis. Methods— A systematic literature review of studies published in the past 8 years reporting periprocedural stroke/death after carotid endarterectomy (CEA) and carotid stenting (CAS) related to the time between qualifying neurological symptoms and intervention was performed. Pooled estimates of periprocedural risk for patients treated within 0 to 48 hours, 0 to 7 days, and 0 to 15 days were derived with proportional meta-analyses and reported separately for patients with stroke and transient ischemic attack as index events. Results— Of 47 studies included, 35 were on CEA, 7 on CAS, and 5 included both procedures. The pooled risk of periprocedural stroke was 3.4% (95% confidence interval [CI], 2.6–4.3) after CEA and 4.8% (95% CI, 2.5–7.8) after CAS performed <15 days; stroke/death rates were 3.8% and 6.9% after CEA and CAS, respectively. Pooled periprocedural stroke risk was 3.3% (95% CI, 2.1–4.6) after CEA and 4.8% (95% CI, 2.5–7.8) after CAS when performed within 0 to 7 days. In hyperacute surgery (<48 hours), periprocedural stroke risk after CEA was 5.3% (95% CI, 2.8–8.4) but with relevant risk differences among patients treated after transient ischemic attack (2.7%; 95% CI, 0.5–6.9) or stroke (8.0%; 95% CI, 4.6–12.2) as index. Conclusions— CEA within 15 days from stroke/transient ischemic attack can be performed with periprocedural stroke risk <3.5%. CAS within the same period may carry a stroke risk of 4.8%. Similar periprocedural risks occur after CEA and CAS performed earlier, within 0 to 7 days. Carotid revascularization can be safely performed within the first week (0–7 days) after symptom onset.

Safety of Carotid Stenting (CAS) is Based on Institutional Training More than Individual Experience in Large-volume Centres

BACKGROUND Operator training is a key factor for the safety of carotid stenting (CAS). Whether institutional practice is associated with improved individual operator outcomes is debated. OBJECTIVE To evaluate the effect of the institutional experience on outcomes of new trainees with CAS, a retrospective analysis of a prospectively held database was performed. METHODS The overall study period, 2004-2012, was divided into two sequential time frames: 2004-April 2006 (leaders-team phase) and May 2006-2012 (expanded team phase). In the first frame, a single leader-operators team that first approached CAS and passed the original institutional learning curve, performed all the procedures; in the following expanded-team phase, five new trainees joined. Institutional CAS training for new trainees was based on a team-working approach including selection of patients, devices and techniques and collegial meetings with critical review and discussion of all procedural steps and imaging. RESULTS A total of 431 CAS procedures were performed in the leaders-team phase and 1026 in the sequential expanded-team phase. Periprocedural complication rates in the two time frames were similar: stroke/death (3.0% vs. 2.1%; P = 0.35), stroke (2.8% vs. 2.1%; P = 0.45) major stroke (0.9% vs. 0.6%, P = 0.49), death (0.2% vs. 0%; P = 0.29) during the leaders-team and expanded-team phase, respectively. However, rates of CAS failure requiring surgical conversions (3.7% vs. 0.8%; P < 0.0001) and mean contrast use (91.6 vs. 71.1 ml; P = 0.0001) decreased in the expanded phase. In the expanded-team frame (May 2006-2012), there was no mortality, and stroke rates were comparable between the leader and new operator teams: 2.6% vs. 1.2%; P = 0.17. CONCLUSIONS Institutional experience, including instruction on selection of patients and materials best suited for the procedure, is a primary factor driving outcomes of CAS. An effective team-working approach can reliably improve the training of new trainees preserving CAS safety and efficacy.

Percutaneous approach in the maintenance and salvage of dysfunctional autologous vascular access for dialysis

Purpose Endovascular procedures have been increasingly used for salvage of failing vascular access with conflicting results. The aim of this study was to assess the mid-term patency and complication rates of angioplasty procedures performed in a single center for treatment of stenosis compromising vascular accesses. Methods A prospective database of vascular accesses performed in 2006–2010 was investigated. The endovascular approach was applied following a standardized protocol by a dedicated team. A total of 531 consecutive procedures were reviewed (326 men; mean age 70.94 years). Patency rates were estimated using the Kaplan-Meier method. Results There were 199 procedures for failing access: 135 were surgical and 64 angioplasties performed for anastomosis (n=27), venous (n=45) or arterial (n=7) stenosis. Immediate technical success of endovascular procedures was 95.3%(61/64); complication rate was 6.3% (4/64). Primary patency rates were 55% at six months, 49% at 12 months, and 21% at 24 months. In the concurrent group of 135 open procedures, primary patency rates were 80% at six months and 67% at 12 months (P=.002); nevertheless, at 24 months, patency was as low as 49%. Cost estimates for angioplasty revealed additional fees ranging from 411.34 to 446.34 Euro with respect to open surgical procedures. Conclusions Most dysfunctional vascular accesses can be successfully and safely treated by the endovascular route. In spite of poor mid-term durability, the angioplasty balloon might be considered as a bridge, effective, and repeatable solution with reasonable costs to prolong access survival avoiding additional surgery. The failure rate in the mid-term for dysfunctional vascular access may also be high after surgical reintervention.

Effect of statins on survival in patients undergoing dialysis access for end-stage renal disease

The benefit of statin therapy in patients with advanced chronic kidney disease remains uncertain. Randomized trials have questioned the efficacy of the drug in improving outcomes for on-dialysis populations, and many patients with end-stage renal disease are not currently taking statins. This study aimed to investigate the impact of statin use on survival of patients with vascular access performed at a vascular center for chronic dialysis. Consecutive end-stage renal disease patients admitted for vascular access surgery in 2006 to 2013 were reviewed. Information on therapy was retrieved and patients on statins were compared to those who were not on statins. Primary endpoint was 5-year survival. Independent predictors of mortality were assessed with Cox regression analysis adjusting for covariates (ie, age, sex, hyperlipidemia, hypertension, cardiac disease, cerebrovascular disease, chronic obstructive pulmonary disease, obesity, diabetes, and statins). Three hundred fifty-nine patients (230 males; mean age 68.9 ± 13.7 years) receiving 554 vascular accesses were analyzed: 127 (35.4%) were on statins. Use of statins was more frequent in patients with hypertension (89.8% v 81%; P = .034), hyperlipidemia (52.4% v 6.2%; P < .0001), coronary disease (54.1% v 42.6%; P = .043), diabetes (39.4% v 21.6%; P = .001), and obesity (11.6% v 2.0%; P < .0001). Mean follow-up was 35 months. Kaplan-Meier survival rates at 3 and 5 years were 84.4% and 75.9% for patients taking statins and 77.0% and 65.1% for those not taking statins (P = .18). Cox regression analysis selected statins therapy as the only independent negative predictor (odds ratio = 0.55; 95% confidence interval = 0.32-0.95; P = .032) of mortality, while age was an independent positive predictor (odds ratio = 1.05; 95% confidence interval = 1.03-1.08; P < .0001). Vascular access patency was comparable in statin takers and those not taking statins (P = .60). Use of statins might halve the risk of all-cause mortality at 5 years in adult patients with vascular access for chronic dialysis. Statins therapy should be considered in end-stage renal disease populations requiring dialysis access placement.