Search

Both carotid endarterectomy (CEA) and carotid artery stenting (CAS) are common treatments for carotid artery stenosis. Several randomized controlled trials (RCTs) have compared CEA to CAS in the treatment of carotid artery stenosis. These studies have suggested that CAS is more strongly associated with periprocedural stroke; however, CEA is more strongly associated with myocardial infarction. Published long-term outcomes report that CAS and CEA are similar. A reduction in complications associated with CAS has also been demonstrated over time. The symptomatic status of the patient and history of previous CEA or cervical radiotherapy are significant factors when deciding between CEA or CAS. Numerous carotid artery stents are available, varying in material, shape and design but with minimal evidence comparing stent types. The role of cerebral protection devices is unclear. Dual antiplatelet therapy is typically prescribed to prevent in-stent thrombosis, and however, evidence comparing periprocedural and postprocedural antiplatelet therapy is scarce, resulting in inconsistent guidelines. Several RCTs are underway that will aim to clarify some of these uncertainties. In this review, we summarize the development of varying techniques of CAS and studies comparing CAS to CEA as treatment options for carotid artery stenosis.Copyright © 2019 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd

Both carotid endarterectomy (CEA) and carotid artery stenting (CAS) are common treatments for carotid artery stenosis. Several randomized controlled trials (RCTs) have compared CEA to CAS in the treatment of carotid artery stenosis. These studies have suggested that CAS is more strongly associated with periprocedural stroke; however, CEA is more strongly associated with myocardial infarction. Published long-term outcomes report that CAS and CEA are similar. A reduction in complications associated with CAS has also been demonstrated over time. The symptomatic status of the patient and history of previous CEA or cervical radiotherapy are significant factors when deciding between CEA or CAS. Numerous carotid artery stents are available, varying in material, shape and design but with minimal evidence comparing stent types. The role of cerebral protection devices is unclear. Dual antiplatelet therapy is typically prescribed to prevent in-stent thrombosis, and however, evidence comparing periprocedural and postprocedural antiplatelet therapy is scarce, resulting in inconsistent guidelines. Several RCTs are underway that will aim to clarify some of these uncertainties. In this review, we summarize the development of varying techniques of CAS and studies comparing CAS to CEA as treatment options for carotid artery stenosis.Copyright © 2019 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd

Background: The Wells clinical decision rule can risk stratify patients with potential lower limb deep vein thrombosis (DVT). Recently another rule was developed to address the reported lowered sensitivity amongst primary care patients. Objective(s): We evaluated the test characteristics of both the Wells and AMUSE decision rules in a cohort of emergency department (ED) patients with suspected DVT. Method(s): We conducted a prospective cohort study on a sample of adult patients who presented to an academic ED with suspected acute lower limb DVT. Demographic and clinical data were collected and ddimer was measured on all patients, allowing calculation of the Wells and AMUSE scores. The primary outcome was any venous thromboembolism or death at 90 days, as determined by radiology database and medical record review, and structured telephone interview. The sensitivity, specificity, positive and negative likelihood ratios were calculated for patients classified as high-risk for DVT by the rules. Result(s): The 197 study patients had these characteristics: mean age 60 and male sex 46%; 1.0% had congestive heart failure, 2.0% peripheral vascular disease and 0.5% systemic lupus erythematosis. 19.3% were taking antiplatelet agents and 5.6% anticoagulants. 41.2% had elevated d-dimer levels and 32.6% were classified as high-risk by the Wells score and 43.3% by the AMUSE score. 14.2% were positive for the primary outcome and 3.0% died. The Wells score had a sensitivity of 82.1% (95% CI 62.4 - 93.2) and specificity of 76.3%, (95% CI 68.7 - 82.6) whereas the AMUSE score had a sensitivity of 92.9%, (95% CI 75.0 - 98.8) and specificity of 65.8% (95% CI 57.6 - 73.2). (See Table 452) Conclusion(s): The AMUSE score was more sensitive, but the Wells score was more specific for acute lower limb DVT in this cohort. The AMUSE instrument may be more useful for ruling out suspected DVT in ED patients, but this needs confirmation on a larger sample. (Table presented) .

Background: The Wells clinical decision rule can risk stratify patients with potential lower limb deep vein thrombosis (DVT). Recently another rule was developed to address the reported lowered sensitivity amongst primary care patients. Objective(s): We evaluated the test characteristics of both the Wells and AMUSE decision rules in a cohort of emergency department (ED) patients with suspected DVT. Method(s): We conducted a prospective cohort study on a sample of adult patients who presented to an academic ED with suspected acute lower limb DVT. Demographic and clinical data were collected and ddimer was measured on all patients, allowing calculation of the Wells and AMUSE scores. The primary outcome was any venous thromboembolism or death at 90 days, as determined by radiology database and medical record review, and structured telephone interview. The sensitivity, specificity, positive and negative likelihood ratios were calculated for patients classified as high-risk for DVT by the rules. Result(s): The 197 study patients had these characteristics: mean age 60 and male sex 46%; 1.0% had congestive heart failure, 2.0% peripheral vascular disease and 0.5% systemic lupus erythematosis. 19.3% were taking antiplatelet agents and 5.6% anticoagulants. 41.2% had elevated d-dimer levels and 32.6% were classified as high-risk by the Wells score and 43.3% by the AMUSE score. 14.2% were positive for the primary outcome and 3.0% died. The Wells score had a sensitivity of 82.1% (95% CI 62.4 - 93.2) and specificity of 76.3%, (95% CI 68.7 - 82.6) whereas the AMUSE score had a sensitivity of 92.9%, (95% CI 75.0 - 98.8) and specificity of 65.8% (95% CI 57.6 - 73.2). (See Table 452) Conclusion(s): The AMUSE score was more sensitive, but the Wells score was more specific for acute lower limb DVT in this cohort. The AMUSE instrument may be more useful for ruling out suspected DVT in ED patients, but this needs confirmation on a larger sample. (Table presented) .