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)

Treatment of patch infection after carotid endarterectomy:a systematic review

Carotid endarterectomy (CEA) with patch angioplasty is a widely used method for treating carotid artery stenosis. Patch infections are extremely rare, but the consequences may be serious. The current gold standard for treatment is patch excision and reconstruction with autologous material. However, no consensus has been reached and other options may be valuable as well in certain cases. The objective of this study was to evaluate the various treatment options for carotid patch infection after CEA with patch angioplasty on the basis of their outcomes (reinfection, ischemic stroke, and infection-related mortality). This systematic review was conducted in accordance with the PRISMA statement. The electronic bibliographic databases PubMed, Cochrane, and EMBASE were searched. Case series and case reports were included. Studies in languages other than English were excluded. Patients who developed a post-operative patch infection of CEA with patch angioplasty were included. Angioplasty could be performed with any type of patch. Patch infection needed to be confirmed by clinical presentation in combination with imaging, culture, or during the operation. The primary outcome measures were reinfection, ischemic stroke, and infection-related mortality. Eleven retrospective case series, two prospective case series, and seventeen case reports were included. The study size was 165 patients (mean age 69.7 years, M/F ratio 1.75:1). One hundred and seventy-one patches developed a patch infection after CEA with patch angioplasty and needed treatment. Treatment strategies included conservative treatment (14.0%), endovascular treatment (4.7%), and open surgery (81.4%). Mean follow-up was 34.8 months and extended up to 180 months. Reinfection rate was 4.7%, ischemic stroke rate 5.8%, and infection-related mortality rate 2.3%. No statistical comparison between treatment options could be performed, because of the heterogeneity of the included studies. Autologous material should be the primary choice of treatment if patch infection is diagnosed after CEA with patch angioplasty. In emergency situations, endovascular treatment, carotid ligation, or abscess drainage could be considered. Endovascular treatment and abscess drainage are temporary solutions. After the patient has recovered sufficiently, a more durable treatment i.e., open surgery is advised. Endo vacuum assisted closure (EndoVAC) seems to be promising. Further research is needed to determine the applicability of each treatment option.</p

Clinical importance of testing for clopidogrel resistance in patients undergoing carotid artery stenting-a systematic review

Dual antiplatelet therapy is frequently prescribed for patients undergoing carotid artery stenting (CAS), however clopidogrel resistance might cause thromboembolic complications. The role of testing for clopidogrel resistance in patients undergoing CAS is unclear. In this study, we aimed to review the periprocedural thromboembolic outcomes in clopidogrel resistant patients who underwent CAS. We conducted a review of PubMed, EMBASE, and the Cochrane Library up to October 7, 2020. Studies were included that investigated at least ten patients aged 18 years or older with a symptomatic carotid artery stenosis requiring CAS. Studies were excluded that investigated patients with a carotid artery dissection, case reports, case series of less than ten patients, reviews, commentaries, letters to the editors, and conference abstracts. The primary endpoint was the incidence of thromboembolic events. One hundred seventy-seven unique articles were identified of which three studies were included in our systematic review. The sample sizes ranged from 76 to 449 patients and the follow-up duration from 24 hours to 2 years postprocedural. Two retrospective observational studies determined clopidogrel resistance using measurement of P2Y12 reaction units, and one historical cohort study used genetic testing. Two studies concluded that clopidogrel resistance was a risk factor for thromboembolic complications, the other found higher values of P2Y12 reaction units in patients with thromboembolic events compared to those without. In conclusion, current literature supports a possible relationship between clopidogrel resistance and thromboembolic complications in patients who underwent CAS. Preprocedural testing for clopidogrel resistance might therefore be of additional value. Randomized studies using a valid, reliable clopidogrel resistance test and clinical endpoints, are however required to make a definitive statement and to determine the impact of the thromboembolic complications. This study was registered within PROSPERO (CRD42020197318)

Functional Status and Out-of-Hospital Outcomes in Different Types of Vascular Surgery Patients

Background: We aimed to determine the correlation between the functional status at discharge in non-cardiac vascular surgery patients and the out-of-hospital mortality. Methods: We performed a retrospective cohort study including adult non-cardiac vascular surgery patients (open, endovascular and venous procedures) surviving hospitalization in Boston, Massachusetts, USA. The exposure of interest was functional status determined by a licensed physical therapist at hospital discharge and rated based on qualitative categories adapted from the Functional Independence Measure. The primary outcome was all cause 90 day mortality after hospital discharge. The secondary outcome was readmission within 30days. Adjusted odds ratios were estimated by multivariable logistic regression models. Results: This cohort included 2318 patients (male 51%; mean age 61 +/- 17.7). After evaluation by a physiotherapist, 425 patients scored the lowest functional status, 631 scored moderately low, 681 moderately high and 581 scored the highest functional status. The lowest functional status was associated with a 3.41-fold increased adjusted odds for 90-day mortality (95%CI, 1.70- 6.84) compared to patients with the highest functional status. When excluding venous intervention patients, the adjusted odds ratio was 6.76 (95%CI, 2.53-18.12) for the 90-day mortality post discharge. The adjusted odds for readmission within 30-days was 1.5-fold increase in patients with the lowest functional status (95%CI, 1.04-2.20). Conclusions: In vascular surgery patients surviving hospitalization, functional status is strongly associated with out-of-hospital mortality and readmission rate. Future trials could provide evidence if improvement of functional status could prevent adverse outcomes in the postoperative setting

Brachial and Axillary Artery Vascular Access for Endovascular Interventions

Background: Endovascular access is usually achieved through the common femoral artery due to its large size and accessibility. Access through the upper extremity can however be necessary due to anatomic reasons, obesity, or peripheral arterial disease. The 2 main methods of access are surgical cutdown and percutaneous puncture. In this single-centre retrospective cohort study we compared complication risks for both surgical cutdown and percutaneous puncture of an upper arm approach. Materials and Methods: Data was obtained from patients receiving endovascular access through the brachial or axillary artery between 2005 and 2018. A total of 109 patients were included. Patient demographics including age, sex, medical history, smoking status, and actual medication were registered, as well as postoperative complications including hematoma, thrombosis, dissection, infection, pseudoaneurysm, nerve injury, reoperation, and readmission. Results: Access was achieved through surgical cutdown in 53% (n = 58) and through percutaneous puncture in 47% (n = 51) of patients. Fifty-eight percent (n = 63) received access via the brachial artery (BA) and 42% (n = 46) via the axillary artery. Complication rate was 25.0% (3 of 12) for surgical cutdown via the BA, 29.4% (15 of 51) for percutaneous puncture via the BA, and 10.9% (5 of 46) for surgical cutdown via the axillary artery. Major complication rate was 8.3% (1 of 12) for surgical cutdown via the BA, 13.7% (7 of 51) for percutaneous puncture via the BA, and 4.3% (2 of 46) for surgical cutdown via the axillary artery. There was no association between baseline patient characteristics and complication rate. Conclusions: In this nonrandomized retrospective study, surgical cutdown via the axillary artery was the safest option with fewest complications, but selection of patients may have blurred the results. Surgical cutdown and percutaneous puncture seem equally safe in terms of complication rate in the BA

Systematic Review on the Mid-Term Outcomes of Elective Endovascular Aneurysm Sealing in Comparison to Endovascular Aneurysm Repair

Introduction The Nellix endovascular aneurysm sealing (EVAS) system has been a topic of discussion. Early results were promising but did not deliver on the long-term and the device has been recalled from the market. This study compares literature for EVAS and conventional endovascular aneurysm repair (EVAR). Methods A systematic review and analysis was conducted according to the preferred reporting items for systematic reviews and meta-analyses (PRISMA) guidelines. PubMed, Embase, and Cochrane Library were searched and identified the eligible studies. Proportion rates for the outcomes of interest were extracted. Subgroup analyses were performed for EVAS and EVAR. Results A total of 12 studies were included (EVAS n = 4, EVAR n = 8) including 10,255 patients (EVAS n = 784, EVAR n = 9441). The longest duration of follow-up was 3.4 years for EVAS and 5.0 years for EVAR studies. Throughout follow-up the overall all-cause mortality rates were 6% for EVAS and 13% for EVAR, and endoleak of any type was described in 10% of EVAS and 17% of EVAR patients. The migration rate &gt;10 mm was 8% for EVAS and 0% for EVAR and aneurysm growth &gt;5 mm was found in 11% of EVAS and 3% of EVAR cases. Total reintervention rate was 13% for EVAS and 7% for EVAR patients. For all analyzed outcome parameters heterogeneity was &gt;50%. Conclusion There is a tendency toward lower mortality and overall endoleak rates for EVAS compared to EVAR but with a higher rate of migration, aneurysm growth, and reintervention. Despite lower overall endoleak rates there was a tendency toward less type II and more type I endoleaks after EVAS compared to EVAR. Substantial heterogeneity however limits robust statistical analyses, and is probably caused by significant instructions for use breach in EVAS-treated patients. We call for more high-quality and long-term follow-up studies on both EVAS and EVAR in order to confirm the trends found in this study.</p

Long-Term Survival and Quality of Life After Fenestrated Endovascular Repair for Complex Abdominal Aortic Aneurysms

Objectives: Fenestrated endovascular repair (FEVAR) has become a widely used treatment option for complex abdominal aortic aneurysms (AAA) but long-term survival and quality of life (QoL) outcomes are scarce. This single center cohort study aims to evaluate both long-term survival and QoL after FEVAR.Methods: All juxtarenal and suprarenal AAA patients treated with FEVAR in a single-center between 2002 and 2016 were included. QoL scores, measured by the RAND 36-Item Short Form Survey (SF-36), were compared with baseline data of the SF-36 provided by RAND.Results: A total of 172 patients were included at a median follow-up of 5.9 years (IQR 3.0-8.8). Follow-up at 5 and 10 years post-FEVAR yielded survival rates of 59.9% and 18%, respectively. Younger patient age at surgery had a positive influence on 10-year survival and most patients died due to cardiovascular pathology. Emotional well-being was better in the research group as compared to baseline RAND SF-36 1.0 data (79.2 ± 12.4 vs 70.4 ± 22.0; P &lt; 0.001). Physical functioning (50 (IQR 30–85) vs 70.6 ± 27.4; P = 0.007) and health change (51.6 ± 17.0 vs 59.1 ± 23.1; P = 0.020) were worse in the research group as compared to reference values.Conclusions: Long-term survival was 60% at 5-years follow-up, which is lower than reported in recent literature. An adjusted positive influence of younger age at surgery was found on long-term survival. This could have consequences for future treatment indication in complex AAA surgery but further large-scale validation is necessary.</p