Stefanos Giannopoulos

Revascularization of radiation-induced carotid artery stenosis with carotid endarterectomy vs. carotid artery stenting: A systematic review and meta-analysis

OBJECTIVEnThe incidence of carotid artery stenosis after head and neck radiation is anticipated to rise due to the increasing survival of patients with head and neck malignancies. It remains unclear whether carotid artery stenting (CAS) or endarterectomy (CEA) is the best treatment strategy for radiation-induced carotid artery stenosis.nnnMATERIALS & METHODSnThis study was performed according to the PRISMA and MOOSE guidelines. Eligible studies were identified through a comprehensive search of PubMed, Scopus and Cochrane Central until July 20, 2017. A meta-analysis of random effects model was conducted. The I-square statistic was used to assess for heterogeneity.nnnRESULTSnFive studies and 143 patients were included. Periprocedural stroke, myocardial infarction (MI) and death rates were similar between the two revascularization approaches. However, the risk for cranial nerve (CN) injury was higher in the CEA group (OR: 7.09; 95% CI: 1.17-42.88; I2u202f=u202f0%). CEA was associated with lower mortality rates after a mean follow-up of 50u202fmonths (OR: 0.29; 95% CI: 0.09-0.97; I2u202f=u202f0%). No difference was identified in long-term restenosis rates between CEA and CAS.nnnCONCLUSIONSnPatients with radiation-induced carotid artery stenosis can safely undergo both CAS and CEA with similar risks of periprocedural stroke, MI and death. However, patients treated with CEA have a higher risk for periprocedural CN injuries and a lower risk for long-term mortality.

Carotid Artery Endarterectomy versus Carotid Artery Stenting for Restenosis After Carotid Artery Endarterectomy: A Systematic Review and Meta-Analysis

OBJECTIVEnCarotid artery restenosis may occur after ipsilateral carotid endarterectomy (CEA). The aim of this study was to determine whether carotid artery stenting (CAS) or redo CEA is the optimal treatment for postendarterectomy carotid restenosis.nnnMETHODSnEligible studies for meta-analysis were identified through a search of PubMed, Scopus, and Cochrane up to July 20, 2017. A meta-analysis was conducted with the use of random effects modeling. I2 was used to assess for heterogeneity.nnnRESULTSnThirteen studies comprising 4163 patients were included. Risk for any type of cranial nerve injury was higher in the redo CEA group (odds ratioxa0= 13.61; 95% confidence interval, 5.43-34.16; I2xa0= 3.3%). Periprocedural and/or short-term (within 30 days) stroke, transient ischemic attack, myocardial infarction, temporary cranial nerve injury, and death rates were similar between the 2 revascularization approaches. During median follow-up of 28 months, CAS was associated with significantly lower risk for long-term recurrent carotid artery restenosis when defined as stenosis >60% (odds ratioxa0= 2.16; 95% confidence interval, 1.13-4.12; I2xa0= 0%) or >70% (odds ratioxa0= 2.31; 95% confidence interval, 1.13-4.72; I2xa0= 0%). No difference was identified in long-term target lesion revascularization rates between redo CEA and CAS.nnnCONCLUSIONSnPatients with carotid restenosis after CEA can safely undergo both CAS and CEA with similar risks of periprocedural stroke, transient ischemic attack, myocardial infarction, and death. However, patients treated with CAS have a lower risk for a new restenosis and periprocedural cranial nerve injury.

Carotid Artery Endarterectomy Versus Carotid Artery Stenting for Patients with Contralateral Carotid Occlusion: A Systematic Review and Meta-Analysis

BACKGROUNDnResults from studies investigating the effect of contralateral carotid occlusion (CCO) in patients with carotid artery stenosis undergoing carotid artery endarterectomy (CEA) or carotid artery stenting (CAS) are variable in the literature. We sought to determine whether CEA or CAS is the optimal revascularization approach for patients with CCO.nnnMETHODSnThis meta-analysis was performed according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. A random effects model meta-analysis was conducted, and the I2 statistic was used to assess for heterogeneity. Subgroup and sensitivity analyses were performed as needed.nnnRESULTSnFive retrospective observational cohort studies comprising 6346 patients were included. Patients in the CEA group had a significantly lower risk of 30-day periprocedural mortality (odds ratio, 0.46; 95% confidence interval, 0.30-0.71; I2xa0= 0%). However, no significant differences were identified in terms of stroke, myocardial infarction (MI), and major adverse cardiovascular events (MACEs) between the 2 groups. Subgroup analyses of symptomatic and asymptomatic patients did not yield significant differences for stroke, MI, and death.nnnCONCLUSIONSnPatients with CCO can safely undergo both CAS and CEA with similar risks of stroke, MI, and MACE. However, patients treated with CEA have a lower risk of 30-day periprocedural mortality. Future studies can help further clarify the ideal approach for these patients.

Outcome of Carotid Artery Endarterectomy in Statin Users versus Statin-Naïve Patients: A Systematic Review and Meta-Analysis

BACKGROUNDnCarotid artery endarterectomy (CEA) remains the most common surgical intervention for the treatment of symptomatic and asymptomatic carotid artery stenosis. Several studies have shown a lower risk of periprocedural adverse events in statin users who undergo coronary interventions or carotid artery stenting. The aim of this meta-analysis was to determine whether the use of statins is beneficial in patients undergoing CEA.nnnMETHODSnThis study was performed according to the Preferred Reporting Items for Systematic reviews and Meta-Analyses (PRISMA) guidelines. Eligible studies were identified through a search of PubMed, Scopus, and Cochrane until August 2017. A random effects model meta-analysis was conducted and the I2 statistic was used to assess for heterogeneity.nnnRESULTSnSix studies and 7053 patients overall were included. Thirty days after CEA, 157 (2.2%) patients had a stroke (1.4% in the statin-user group vs. 3% in the statin-naïve group). Despite the difference in the absolute rate of stroke, there was no statistically significant difference in the 30-day stroke rate (odds ratio [OR] 0.40; 95% confidence interval [CI] 0.15-1.09; I2xa0= 75.6%). Overall, 141 (2%) patients suffered 30-day myocardial infarction, with no significant difference between the 2 groups (OR 0.77; 95% CI 0.26-2.24; I2xa0= 77%). Patients who received statins before CEA were at a significantly lower risk for 30-day death (OR 0.26; 95% CI 0.10-0.61; I2xa0= 17.7%).nnnCONCLUSIONSnStatin users undergoing CEA were at a significantly lower risk for periprocedural death compared with statin-naïve patients. Despite an absolute difference in the stroke rate, the current meta-analysis did not detect a statistically significant difference in the 30-day stroke rate between statin-user and statin-naïve patients undergoing CEA.

CAROTID ARTERY ENDARTERECTOMY VERSUS CAROTID ARTERY STENTING FOR RESTENOSIS AFTER CAROTID ARTERY ENDARTERECTOMY: A SYSTEMATIC REVIEW AND META-ANALYSIS

Carotid artery restenosis may occur after ipsilateral carotid endarterectomy (CEA). It remains unclear whether carotid artery stenting (CAS) or a repeat CEA (redoCEA) is the best treatment strategy for carotid artery restenosis.nnThis study was performed according to the PRISMA and MOOSE guidelines

A meta-analysis of randomized trials comparing bovine pericardium and other patch materials for carotid endarterectomy

Objective: Patch angioplasty during carotid endarterectomy is commonly used to treat symptomatic and asymptomatic carotid artery stenosis. The objective of the present study was to compare the different patch materials that are currently available (synthetic vs venous vs bovine pericardium) in terms of short‐ and long‐term outcomes. Methods: This study was performed according to the Preferred Reporting Items for Systematic reviews and Meta‐Analyses (PRISMA) guidelines and eligible randomized control trials were identified through a comprehensive search of PubMed, Scopus, and Cochrane Central published until September 2017. A meta‐analysis was conducted with the use of a random effects model. The I2 statistic was used to assess for heterogeneity. The primary study end point was the incidence of long‐term restenosis. Secondary study end points were 30‐day stroke, transient ischemic attack (TIA), myocardial infarction, neck wound infection, local hematoma, carotid artery thrombosis, cranial nerve injury, long‐term stroke incidence, and death. Results: Eighteen studies and 3234 patients were included. The risk of 30‐day stroke (relative risk [RR], 1.00; 95% confidence interval [CI], 0.45‐2.19; I2 = 0%), TIA (RR, 1.14; 95% CI, 0.41‐3.19; I2 = 0%), myocardial infarction (odds ratio, 0.75; 95% CI, 0.14‐3.97; I2 = 0%), death (RR, 0.53; 95% CI, 0.21‐1.34; I2 = 0%), wound infection (RR, 1.84; 95% CI, 0.43‐7.81; I2 = 0%), carotid artery thrombosis (RR, 1.47; 95% CI, 0.44‐4.97; I2 = 0%), cranial nerve palsy (RR, 1.21; 95% CI, 0.53‐2.77; I2 = 0%), and long‐term stroke (RR, 2.33; 95% CI, 0.76‐7.10; I2 = 0%), death (RR, 1.09; 95% CI, 0.65‐1.83; I2 = 0%) and restenosis of greater than 50% (RR, 0.48; 95% CI, 0.19‐1.20; I2 = 0%) were similar between the synthetic vs venous patch groups. Also, no differences in terms of 30‐day stroke (RR, 0.31; 95% CI, 0.02‐5.16; I2 = 63.1%), TIA (RR, 0.49; 95% CI, 0.14‐1.76; I2 = 0%), death (RR, 0.74; 95% CI, 0.05‐10.51; I2 = 31.7%), carotid artery thrombosis (RR, 0.13; 95% CI, 0.02‐1.07; I2 = 0%), and long‐term restenosis of greater than 70% (RR, 0.15; 95% CI, 0.01‐2.29; I2 = 70.9%) were detected between the synthetic polytetrafluoroethylene and Dacron patch groups. The comparison between the bovine pericardium vs synthetic patch did not yield any statistically significant results in terms of 30‐day stroke (RR, 1.44; 95% CI, 0.19‐10.79; I2 = 12.7%), TIA (RR, 1.05; 95% CI, 0.11‐10.27; I2 = 0%), local neck hematoma (RR, 4.01; 95% CI, 0.46‐34.85; I2 = 0%), and death (RR, 4.01; 95% CI, 0.46‐34.85; I2 = 0%). Conclusions: Closure of the carotid arteriotomy with any of the studied patch materials seems to be similar in terms of short‐ and long‐term end points. However, additional randomized trials with adequate follow‐up periods are needed to compare bovine pericardium patches with other patch materials.

Effect of Open- vs Closed-Cell Stent Design on Periprocedural Outcomes and Restenosis After Carotid Artery Stenting: A Systematic Review and Comprehensive Meta-analysis

Purpose:To compare periprocedural complications and in-stent restenosis rates associated with open- vs closed-cell stent designs used in carotid artery stenting (CAS). Methods: A systematic search was conducted to identify all randomized and observational studies published in English up to October 31, 2017, that compared open- vs closed-cell stent designs in CAS. Identified studies were included if they reported the following outcomes: stroke, transient ischemic attack (TIA), myocardial infarction (MI), hemodynamic depression, new ischemic lesions detected on imaging, and death within 30 days, as well as the incidence of in-stent restenosis. A random-effects model meta-analysis was employed. Model results are reported as the odds ratio (OR) and 95% confidence interval (CI). The I2 statistic was used to assess heterogeneity. Results: Thirty-three studies (2 randomized trials) comprising 20, 291 patients (mean age 71.3±3.0 years; 74.6% men) were included. Patients in the open-cell stent group had a statistically significant lower risk of restenosis ⩾40% (OR 0.42, 95% CI 0.19 to 0.92; I2=0%) and ⩾70% (OR 0.23, 95% CI 0.10 to 0.52; I2=0%) at a mean follow-up of 24 months. No statistically significant differences were identified for periprocedural stroke, TIA, new ischemic lesions, MI, hemodynamic depression, or death within 30 days after CAS. Sensitivity analysis of the 2 randomized controlled trials only did not point to any significant differences either. Conclusion: Use of open-cell stent design in CAS is associated with a decreased risk for restenosis when compared to the closed-cell stent, without significant differences in periprocedural outcomes.

Proximal embolic protection versus distal filter protection versus combined protection in carotid artery stenting: A systematic review and meta-analysis

OBJECTIVEnProximal embolic protection devices (P-EPD) and distal filters (DF) are used to prevent distal cerebral embolizations during carotid artery stenting (CAS). We compared their comparative effectiveness in regards to prevention of intraprocedural and periprocedural adverse events, including ischemic lesions (ipsilateral and contralateral), stroke, transient ischemic attacks (TIA) and death. We also compared the combination of the two neuroprotection strategies vs. a single strategy in regards to ischemic lesions and stroke.nnnMATERIALS & METHODSnThis study was performed according to the PRISMA and MOOSE guidelines and eligible studies were identified through search of PubMed, Scopus and Cochrane Central. A meta-analysis was conducted with the use of a random effects model. The I-square statistic was used to assess for heterogeneity.nnnRESULTSnTwenty-nine studies involving 16,307 patients were included. There was a significant reduction in ischemic lesions with the use of P-EPD among observational studies (RR: 0.66 [0.45-0.97]). There were no statistically significant differences for the other outcomes between the two treatment groups.nnnCONCLUSIONSnThere is a number of studies reporting outcomes on the comparison between P-EPD and DF for CAS. P-EDP can reduce distal embolization phenomena resulting into ischemic lesions when compared to DF based on the results from real-world studies. P-EPD was not superior however, in regards to periprocedural stroke, TIA and death. Further studies are anticipated to provide a clear answer to this debate.