Treatment of the extracranial carotid artery in tandem lesions during endovascular treatment of acute ischemic stroke:a systematic review and meta-analysis

Endovascular treatment (EVT) is the standard treatment for patients with an acute ischemic stroke due to occlusion of large vessel occlusion (LVO). In 20% of patients, concomitant extracranial internal carotid artery (EICA) lesion is present. These tandem lesions (TL) offer a technical challenge. The treatment strategy for the treatment of the ipsilateral EICA is unclear. The aim of this review is to compare two treatment strategies for TL during EVT: balloon angioplasty (BA) only and immediate carotid artery stenting (iCAS). A systematic review and meta-analysis was performed. Data for each included study was extracted. For comparative studies a meta-analysis was performed. Functional outcome was expressed with the modified Rankin scale and safety endpoints were mortality and symptomatic intracranial hemorrhage (sICH). A total of 72 full text articles evaluating treatment of TL during EVT were screened. Sixteen iCAS and five comparative studies were included for meta-analysis. 53% of patients undergoing iCAS during EVT had good functional outcome in comparison to 45% of patients who underwent only BA. Mortality was comparable at 16% for both groups. The incidences of sICH were 8% and 4% for iCAS and BA respectively. In the meta-analysis, iCAS was associated with good functional outcome, with no significant differences in mortality and sICH with compared to BA. This study shows that treatment with iCAS of a simultaneously ipsilateral EICA lesion during EVT is associated with a favorable functional outcome compared to BA only with no significant difference in mortality or sICH. No conclusion could be drawn about the intracranial or extracranial first approach due to scarce of data. More studies are needed to determine long-term neurological outcomes, the necessity of re-interventions and optimal technical approach (intracranial or extracranial first)

Optimizing Treatment of Significant Carotid Artery Stenosis in Times of Logistic Restraints as a Result of COVID-19 Pandemic

BACKGROUND: COVID-19 confronted medical care with many challenges. During the pandemic, several resources were limited resulting in renouncing or postponing medical care like carotid endarterectomy (CEA) for patients with significant carotid artery stenosis. Although according to international guidelines CEA is the first choice, carotid artery stenting (CAS) could potentially be a reasonable alternative especially during logistical restraints.PURPOSE: To evaluate outcomes of CAS versus CEA before, during and after the COVID-19 pandemic. Our hypothesis was that a CAS first approach yielded comparable outcomes compared to a CEA first approach.METHODS: Retrospective analysis of consecutive patients with significant carotid artery stenosis treated with CEA or CAS between September 2018 and March 2023. Each consecutive period of 1.5 year marked a new (treatment) period: pre-COVID (CEA first strategy), during COVID (CAS first strategy) and post-COVID (patient-tailored approach). Primary outcome was the composite endpoint of stroke, transient ischemic attack or death within 30 days. Secondary outcome consisted of the rate of technical success, cerebral hyperperfusion syndrome, myocardial infarction or other cardiac complications needing intervention, bleeding of the surgical site needing intervention, nerve palsy, unintended IC admission, pseudoaneurysm, restenosis, or occlusion.RESULTS: A total of 318 patients were included. Out of 137 patients treated with CEA, 55, 36 and 46 were treated pre-COVID, during COVID and post-COVID, respectively. Out of 181 CAS procedures, 38, 59 and 84, respectively, were performed in each time period. Primary outcome occurred in 5.5%, 0% and 2.2% in the CEA group and 0%, 1.7% and 3.6% in the CAS group (P = 0.27; P = 1.00; P = 1.00, respectively). Overall technical success was 100% for CEA and 99.4% for CAS (P = 1.00). Rate of restenosis was the only secondary outcome measure which was significantly better after CAS compared to CEA in the pre- and post-COVID period (CEA vs. CAS, 12.7% vs. 7.9%, and 23.9% vs. 4.8% with a P-value of 0.03 and 0.03, respectively). Hospital presentation to treatment interval did not differ significantly during the pandemic.CONCLUSIONS: Outcomes were comparable between CAS versus CEA in patients with significant carotid artery stenosis before, during and after the COVID-19 pandemic. CAS showed better results in terms of other complications (i.e., restenosis rate) in the pre- and post-COVID period compared to CEA. Our results may support a CAS first approach when no relevant contra-indications exist without exposing the patient to complications associated with an open surgical approach. Discussion in a multidisciplinary team is advised.</p

Vascular Reconstructions in Kidney Transplantation

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Causes of death in intensive care patients with a low APACHE II score

Item does not contain fulltextBackground: Little is known about the actual causes of death of patients with a low APACHE II score, but iatrogenic reasons may play a role. The aim of this study was to evaluate the demographics, course of disease, and causes of death in this specific group of ICU patients. Methods: For this retrospective observational study, adult patients (>18 years) admitted to the ICU were included. Results: During the 47-month study period, 9279 patients were admitted to our ICU, of which 3753 patients had an APACHE II score &#8804;15. Of the latter group of patients, 131 (3.5%) died during their hospital stay. Their median (IQR) APACHE II was 12 (11-14) and their main reason for ICU admission was respiratory insufficiency (47%). Both in patients with and without limited therapy, haemodynamic insufficiency was the main cause of death (50 and 69%, respectively). Three patients died directly related to medical interventions. Conclusion: Most patients with an APACHE II score lower than 15 who died were admitted to the ICU because of respiratory insufficiency. The main cause of death was haemodynamic insufficiency following limited therapy because of an unfavourable prognosis. In less than one out of 1000 cases of this low-risk group of patients death was related to iatrogenic injury

Poor early graft function impairs long-term outcome in living donor kidney transplantation

Contains fulltext : 117447.pdf (publisher's version ) (Open Access)BACKGROUND: Poor early graft function (EGF) after living donor kidney transplantation (LDKT) has been found to decrease rejection-free graft survival rates. However, its influence on long-term graft survival remains inconclusive. METHODS: Data were collected on 472 adult LDKTs performed between July 1996 and February 2010. Poor EGF was defined as the occurrence of delayed or slow graft function. Slow function was defined as serum creatinine above 3.0 mg/dL at postoperative day 5 without dialysis. RESULTS: The incidence of slow and delayed graft function was 9.3 and 4.4%, respectively. Recipient overweight, pretransplant dialysis and warm ischemia were identified as risk factors for the occurrence of poor EGF. The rejection-free survival was worse for poor EGF as compared to immediate graft function with an adjusted hazard ratio (HR) of 6.189 (95% CI 4.075-9.399; p < 0.001). Long-term graft survival was impaired in the poor EGF group with an adjusted HR of 4.206 (95% CI 1.839-9.621; p = 0.001). CONCLUSIONS: Poor EGF occurs in 13.7% of living donor kidney allograft recipients. Both, rejection-free and long-term graft survivals are significantly lower in patients with poor EGF as compared to patients with immediate graft function. These results underline the clinical relevance of poor EGF as phenomenon after LDKT

Causes of death in intensive care patients with a low APACHE II score

Background: Little is known about the actual causes of death of patients with a low APACHE II score, but iatrogenic reasons may play a role. The aim of this study was to evaluate the demographics, course of disease, and causes of death in this specific group of ICU patients. Methods: For this retrospective observational study, adult patients (>18 years) admitted to the ICU were included. Results: During the 47-month study period, 9279 patients were admitted to our ICU, of which 3753 patients had an APACHE II score &#8804;15. Of the latter group of patients, 131 (3.5%) died during their hospital stay. Their median (IQR) APACHE II was 12 (11-14) and their main reason for ICU admission was respiratory insufficiency (47%). Both in patients with and without limited therapy, haemodynamic insufficiency was the main cause of death (50 and 69%, respectively). Three patients died directly related to medical interventions. Conclusion: Most patients with an APACHE II score lower than 15 who died were admitted to the ICU because of respiratory insufficiency. The main cause of death was haemodynamic insufficiency following limited therapy because of an unfavourable prognosis. In less than one out of 1000 cases of this low-risk group of patients death was related to iatrogenic injury

Deleterious influence of prolonged warm ischemia in living donor kidney transplantation.

Contains fulltext : 110809.pdf (publisher's version ) (Closed access)BACKGROUND: Recent studies investigating early graft function (EGF) after living donor kidney transplantation (LDKT) identified prolonged warm ischemia time (WIT) as a risk factor for the occurrence of poor EGF. The latter is associated with long-term graft loss; therefore the question arises whether prolonged WIT affects long-term outcomes in LDKT. METHODS: Data were collected on 472 consecutive adult LDKTs. Patients were divided according to the total WIT into 3 groups with short (45 minutes) WIT. RESULTS: Of all patients, 193 (40.9%) experienced short, 249 (52.8%) intermediate, and 30 (6.4%) prolonged WIT. Prolonged WIT was a significant risk factor for the occurrence of poor EGF with an adjusted odds ratio of 4.252 (95% confidence interval [CI), 1.914 -9.447). Long-term graft survival was impaired in patients with prolonged WIT, with an adjusted hazard ratio of 3.163 (95% CI, 1.202-8.321). Multivariate analysis revealed determinants of prolonged WIT, including laparoscopic procurement, recipient overweight, right donor kidney, and multiple renal arteries. CONCLUSION: Prolonged WIT impairs long-term graft survival in LDKT. This finding underlines the need to develop strategies to avoid the occurrence of prolonged WIT in LDKT.1 juni 201