Andrea Vacirca

Impact of acute cerebral ischemic lesions and their volume on the revascularization outcome of symptomatic carotid stenosis

Background: The influence of acute cerebral ischemic lesions (CILs) on the revascularization outcome of symptomatic carotid stenosis has been scarcely investigated in the literature. This study evaluated the effect of CILs and their volume on the results of carotid revascularization in symptomatic patients. Methods: All patients with symptomatic carotid artery stenosis who underwent carotid endarterectomy (CEA) or carotid artery stenting (CAS) between 2005 and 2014 were considered. CILs ipsilateral to the stenosis were identified in the preoperative cerebral computed tomography. The volume was quantified in mm3 and correlated with 30‐day rates of stroke and stroke/death by χ2, multivariate analysis, Pearson correlation, and receiver operating characteristic curves. Results: A total of 489 symptomatic patients were treated by CEA (327 [67%]) or CAS (162 [33%]), 186 (38%) ≤2 weeks and 303 (62%) >2 weeks from symptom onset. CEA and CAS patients had statistically similar rates of stroke (3.3% vs 5.5%; P = .27) and stroke/death (3.8% vs 5.9%; P = .22). CILs were identified in 251 patients (53%) and were associated with similar stroke and stroke/death rate compared with patients without CIL (12 [4.8%] vs 8 [3.5%], P = .46; and 14 [5.6%] vs 8 [3.5%]; P = .26, respectively). The median CIL volume was 1000 mm3 (interquartile range [IQR], 7000 mm3). Patients with postoperative stroke and stroke/death had a significantly higher preoperative CIL volume of 5100 mm3 (IQR, 31,000 mm3) vs 1000 mm3 (IQR, 7000 mm3; P = .01) and 4500 mm3 (IQR, 17,450 mm3) vs 1000 mm3 (IQR, 7000 mm3; P = .03), respectively. The receiver operating characteristic curve analysis showed a volume of 4000 mm3 was predictive of postoperative stroke with 75% sensitivity and 63% specificity. A CIL volume ≥4000 mm3 was an independent risk factor for postoperative stroke, with a stroke rate of 9.3% (n = 9) vs 1.9% (n = 3) for a CIL volume of <4000 mm3 (odds ratio, 4.6; 95% confidence interval, 1.1‐19.1; P = .03). Conclusions: CIL volume in symptomatic carotid stenosis seems to influence the 30‐day outcome independently from the timing of carotid revascularization. A CIL volume of ≥4000 mm3 could be considered a significant predictor for postoperative stroke after carotid revascularization.

The Assessment of Carbon Dioxide Automated Angiography in Type II Endoleaks Detection: Comparison with Contrast-Enhanced Ultrasound

Introduction Iodinated contrast media completion angiography (ICM-A) may underestimate the presence of type II endoleak (ELII) after endovascular aortic repair (EVAR), particularly if they are at low flow. Contrast-enhanced ultrasound (CEUS) has been proposed as the gold standard in ELII detection during EVAR follow-up. Intraprocedural carbon dioxide (CO2) angiography has been shown to be useful in this setting; however no comparative studies including these three techniques are currently available. Our aim was to investigate the accuracy of a new automated CO2 angiographic (CO2-A) system in the detection of ELII, by comparing it with ICM-A and CEUS. Methods A series of consecutive patients undergoing EVAR for abdominal aortic aneurysm (AAA) were enrolled and submitted to ICM-A and CO2-A during the procedure. The iodinated contrast media were delivered through an automatic injector connected to a pigtail catheter in the suprarenal aorta. CO2 was delivered through a recently available automatic injector connected to a 10 F sheath positioned in the external iliac artery. All patients were blindly evaluated by CEUS within postoperative day 1. The ICM-A and CO2-A ability to detect ELII was compared with that of CEUS through Cohens concordance Index (K). Results Twenty-one patients were enrolled in the study. One (5%), seven (33%), and four (19%) ELII were detected by ICM-A, CO2-A, and CEUS, respectively. The only ELII detected by ICM-A was also detected by CO2-A and CEUS. Three cases of ELII detected by CO2-A were not detected by CEUS. All ELII detected by CEUS were visualized by CO2-A. CEUS and ICM-A showed a poor agreement (Cohens K: 0.35) while CEUS and CO2-A showed a substantial agreement (Cohens K: 0.65) for ELII detection. Conclusion CO2-A is safe and effective method for ELII detection in EVAR, with a significantly higher agreement with CEUS if compared with ICM-A. This trial is registered with 155/2015/U/Oss.

The different scenarios of urgent carotid revascularization for crescendo and single transient ischemic attack

Objective Carotid stenosis with crescendo-transient-ischemic-attack (cTIA) requires a prompt intervention to reduce the stroke risk. Few data are reported in literature about cTIA suggesting a different perioperative risk compared with patients with single TIA (sTIA). This study aimed to compare the outcome of carotid endarterectomy (CEA) in patients with TIA (single/crescendo) and evaluate the outcome risk-factors. Methods Data from two tertiary hospitals for vascular treatment were analyzed from 2007 to 2016. All patients with TIA subjected to CEA were considered, comparing the 30-day postoperative stroke and stroke/death in patients with cTIA and sTIA, particularly in the urgent (≤48 h) setting. Results On a total of 3866 CEA, 888 (23%) were performed in symptomatic patients and 515 for TIA: 365 (71%) patients with sTIA and 150 (29%) with cTIA. When compared with sTIA, cTIA patients were younger and less frequently affected by coronary disease, dyslipidemia, and chronic pulmonary disease; however, contralateral carotid occlusion was more common (20% vs. 10%, P = .004; 56% vs. 46, P = .03; 16% vs. 7%, P = .01; >80 years 26% vs. 16%, P = .01 and 2% vs. 10%, P = .001; respectively). Postoperative stroke and stroke/death were significantly higher in cTIA compared with sTIA (5.3% vs. 1.6%, P = .02 and 6.0% vs. 2.2%, P = .03; respectively). Urgent CEA was performed in 58% (n: 87) cTIA and in 11% (n: 56) sTIA(P<.01). The urgent setting did not influence the stroke and stroke/death rate of CEA for sTIA (3.6% vs. 1.3%, P = .21 and 3.6% vs. 1.9%, P = .44, respectively), but was associated with lower rate of events in cTIA (1.1%vs. 11.1%, P = .01 and 2.3% vs. 11.1%, P = .03, respectively). This beneficial effect in patients with cTIA treated within 48-h was confirmed also by multivariate analysis (OR: 0.09, 95% CI: 0.76–0.01, P=.02). Conclusions cTIA subjected to CEA have a higher stroke and stroke/death risk compared with patients with sTIA. The urgent setting seems to reduce the stroke/death rate cTIA; for sTIA with a stable neurological condition, the timing of CEA did not influence the outcome.

IP043. Predictors of Survival in Malignant Aortic Tumors

Objective: Malignant aortic tumors are exceedingly rare. For that reason, no case series have been published so far in the literature, and a comprehensive review of clinical and therapeutic aspects is lacking. The aim of this study was to analyze all known cases of malignant aortic tumors and to identify predictors of patients’ survival. Methods: All patients with a diagnosis of aortic tumor treated in a single center together with all case reports and reviews available in the literature (through a specific PubMed search with keywords such as malignant and aorta or aortic tumor or sarcoma or angiosarcoma) were analyzed. Tumor primary location, clinical presentation, histologic features, and treatment choice were all examined. Survival at 1 year, 2 years, and 5 years and the possible preoperative and operative predictors of outcome were evaluated by Kaplan-Meier analysis with log-rank test. Results: In addition to the 5 cases treated in our center, 218 other cases of malignant aortic tumor have been reported in the literature from 1873 to 2017. Overall, the mean age of the patients was 60.1 6 11.9 years, and the male to female ratio was 1.59:1. The mean overall survival from diagnosis was 13.6 6 7.7 months; 1-, 3-, and 5-year survival rates were 35.2% 6 3.7%, 10.9% 6 2.6%, and 6.1% 6 2.2%, respectively (Fig). Chronic hypertension (P 1⁄4 .03), fever (P 1⁄4 .03), back pain (P 1⁄4 .01), asthenia (P 1⁄4 .04), and signs of peripheral embolization (P 1⁄4 .007) were significant predictors of patients’ poor outcome. Histologic subtypes had different impacts on

The fate of asymptomatic severe carotid stenosis in the era of best medical therapy

ABSTRACT Background: Medical therapy for asymptomatic carotid artery stenosis (ACAS) may obviate the carotid revascularization, according to recent literature reports, but many studies also considered moderate carotid artery stenosis (50–69% NASCET). This study reviews the most recent series of ACAS focusing on ipsilateral transient ischemic attack (TIA) stroke and annual risk of stroke in patients with ACAS ≥70%, thereby also evaluating the adherence to best medical therapy (BMT). Methods: A systematic review consisting of all the series of patients with ACAS being treated medically was performed, which was published after 2005. The annual pooled risk of ipsilateral TIA-stroke and stroke in patients with ACAS ≥70% was calculated. A subgroup of studies with BMT defined as ≥90% of the patients in antiplatelet and statin therapy was performed. Results: Eleven studies, with the enrolling period from 1996 to 2009, were reviewed. Overall, 2185 patients were considered, with a follow-up from 2 to 13 years, for a total of 6834 patients/year. The pooled risk was 3.4%/year for ipsilateral TIA-stroke and 1.6%/year for stroke. Five studies, published from 2014, had BMT adherence, for a total of 1665 patients/year. The pooled risk was 3.5%/year for ipsilateral TIA-stroke and for stroke. Conclusion: The most recent series of ACAS ≥70% and BMT had an overall stroke rate which is relatively low; however, the risk of developing symptoms is still relevant (3.4%/year).