22 results on '"Mandy D. Müller"'
Search Results
2. Baseline characteristics and outcome of stroke patients after endovascular therapy according to previous symptomatic vascular disease and sex
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Marieta Peycheva, Giovanna Padlina, Kotryna Genceviciute, Marina P. Krasteva, Anna Boronylo, Martina B. Goeldlin, Madlaine Müller, Elena S. Wenz, Mandy D. Müller, Helly Hammer, Philipp Bücke, Sandra Bigi, Barbara Goeggel Simonetti, Angelika Hoffmann, Roza M. Umarova, Sara Pilgram-Pastor, Jan Gralla, Pasquale Mordasini, Kateryna Antonenko, and Mirjam R. Heldner
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cerebrovascular disease/stroke ,acute stroke therapy ,atherosclerosis ,endovascular treatment ,large vessel occlusion ,Neurology. Diseases of the nervous system ,RC346-429 - Abstract
AimThe aim of this study was to investigate baseline characteristics and outcome of patients after endovascular therapy (EVT) for acute large vessel occlusion (LVO) in relation to their history of symptomatic vascular disease and sex.MethodsConsecutive EVT-eligible patients with LVO in the anterior circulation admitted to our stroke center between 04/2015 and 04/2020 were included in this observational cohort study. All patients were treated according to a standardized acute ischaemic stroke (AIS) protocol. Baseline characteristics and successful reperfusion, recurrent/progressive in-hospital ischaemic stroke, symptomatic in-hospital intracranial hemorrhage, death at discharge and at 3 months, and functional outcome at 3 months were analyzed according to previous symptomatic vascular disease and sex.Results995 patients with LVO in the anterior circulation (49.4% women, median age 76 years, median admission NIHSS score 14) were included. Patients with multiple vs. no previous vascular events showed higher mortality at discharge (20% vs. 9.3%, age/sex − adjustedOR = 1.43, p = 0.030) and less independency at 3 months (28.8% vs. 48.8%, age/sex − adjustedOR = 0.72, p = 0.020). All patients and men alone with one or multiple vs. patients and men with no previous vascular events showed more recurrent/progressive in-hospital ischaemic strokes (19.9% vs. 6.4% in all patients, age/sex − adjustedOR = 1.76, p = 0.028) (16.7% vs. 5.8% in men, age-adjustedOR = 2.20, p = 0.035). Men vs. women showed more in-hospital symptomatic intracranial hemorrhage among patients with one or multiple vs. no previous vascular events (23.7% vs. 6.6% in men and 15.4% vs. 5.5% in women, OR = 2.32, p = 0.035/age − adjustedOR = 2.36, p = 0.035).ConclusionsPrevious vascular events increased the risk of in-hospital complications and poorer outcome in the analyzed patients with EVT-eligible LVO-AIS. Our findings may support risk assessment in these stroke patients and could contribute to the design of future studies.
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- 2024
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3. Natural history of carotid artery free-floating thrombus—A single center, consecutive cohort analysis
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Mandy D. Müller, Nikolaos Raptis, Pasquale Mordasini, Werner Z'Graggen, Andreas Raabe, Philippe Schucht, Mirjam R. Heldner, and David Bervini
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carotid free-floating thrombus ,carotid endarterectomy ,stroke risk ,carotid thromboembolism ,carotid thromboendarterectomy ,Neurology. Diseases of the nervous system ,RC346-429 - Abstract
IntroductionCarotid free-floating thrombus (CFFT) is a rare cause of stroke and is thought to be associated with a high risk of recurrent cerebrovascular ischaemic events. The existing data on the natural history and optimal treatment modalities of CFFT is scanty and no clear recommendations exist.ObjectiveA retrospective analysis, single-center cohort of consecutive patients diagnosed with CFFT was conducted, investigating the risk for recurrent cerebrovascular ischaemic events.MethodsWe performed a single-center retrospective analysis including all patients presenting at our tertiary center between January 2005 and December 2020 with symptoms consistent with ischaemic stroke and/or transient ischaemic attack. Digital subtraction angiography (DSA), computed tomography angiography (CTA) or magnetic resonance angiography (MRA) were used to diagnose CFFT. In all included patients, CFFT was confirmed with a second imaging modality. CFFT was defined on imaging as a defect in contrast filling extending into the carotid lumen. We gathered information on vascular risk factors, diagnosis and follow-up methods, modality of treatment and neurological outcome. A survival analysis was performed, assessing the risk for recurrent cerebrovascular events.ResultsIn total, N = 62 patients presenting with symptomatic CFFT were included. Mean age was 68 years, 69% (43/62) of patients were male, 52% (32/62) current or previous smokers, 76% (47/62) suffered from arterial hypertension, 68% (42/62) from dyslipidaemia, and 31% (19/62) from diabetes mellitus. Overall, 71% (44/62) of patients received any kind of intervention [endovascular or surgical carotid thrombo-endartectomy (CEA)] at any time point during follow-up. Sixteen percent of patients (10/62) received intervention within 48 h after diagnosis of CFFT. The survival analysis and Kaplan-Meier model censoring patients at the time of intervention or last follow-up showed that the risk for any recurrent ischaemic stroke was 19.7% within the first 7 days and 27.4% within 3 months after diagnosis. No patients experienced a new ischaemic stroke beyond 11 days after diagnosis of CFTT (n = 17).ConclusionThe risk of recurrent ischaemic events in patients with CFFT is high, especially in the first week after diagnosis. Prospective studies are needed to further investigate the optimal management of these patients.
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- 2022
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4. Silent Intracerebral Hemorrhage in Patients Randomized to Stenting or Endarterectomy for Symptomatic Carotid Stenosis
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Mandy D. Müller, Lisa M. Jongen, Aysun Altinbas, Kristine A. Blackham, Paul J. Nederkoorn, Sumaira Macdonald, Rolf Jäger, Thomas Wolff, Philippe A. Lyrer, L. Jaap Kappelle, Stephan G. Wetzel, Toby Richards, Jeroen Hendrikse, Gert J. de Borst, H. Bart van der Worp, Stefan T. Engelter, David J. Werring, Martin M. Brown, and Leo H. Bonati
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Diseases of the circulatory (Cardiovascular) system ,RC666-701 - Published
- 2019
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5. Intravenous Thrombolysis in Patients with Stroke Taking Rivaroxaban Using Drug Specific Plasma Levels: Experience with a Standard Operation Procedure in Clinical Practice
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David J. Seiffge, Christopher Traenka, Alexandros A. Polymeris, Sebastian Thilemann, Benjamin Wagner, Lisa Hert, Mandy D. Müller, Henrik Gensicke, Nils Peters, Christian H. Nickel, Christoph Stippich, Raoul Sutter, Stephan Marsch, Urs Fisch, Raphael Guzman, Gian Marco De Marchis, Philippe A. Lyrer, Leo H. Bonati, Dimitrios A. Tsakiris, and Stefan T. Engelter
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rivaroxaban ,stroke ,plasma levels ,thrombolysis ,Diseases of the circulatory (Cardiovascular) system ,RC666-701 - Abstract
Background and Purpose Standard operating procedures (SOP) incorporating plasma levels of rivaroxaban might be helpful in selecting patients with acute ischemic stroke taking rivaroxaban suitable for IVthrombolysis (IVT) or endovascular treatment (EVT). Methods This was a single-center explorative analysis using data from the Novel-Oral-Anticoagulants-in-Stroke-Patients-registry (clinicaltrials.gov:NCT02353585) including acute stroke patients taking rivaroxaban (September 2012 to November 2016). The SOP included recommendation, consideration, and avoidance of IVT if rivaroxaban plasma levels were 100 ng/mL, respectively, measured with a calibrated anti-factor Xa assay. Patients with intracranial artery occlusion were recommended IVT+EVT or EVT alone if plasma levels were ≤100 ng/mL or >100 ng/mL, respectively. We evaluated the frequency of IVT/EVT, door-to-needle-time (DNT), and symptomatic intracranial or major extracranial hemorrhage. Results Among 114 acute stroke patients taking rivaroxaban, 68 were otherwise eligible for IVT/EVT of whom 63 had plasma levels measured (median age 81 years, median baseline National Institutes of Health Stroke Scale 6). Median rivaroxaban plasma level was 96 ng/mL (inter quartile range [IQR] 18‒259 ng/mL) and time since last intake 11 hours (IQR 4.5‒18.5 hours). Twenty-two patients (35%) received IVT/EVT (IVT n=15, IVT+EVT n=3, EVT n=4) based on SOP. Median DNT was 37 (IQR 30‒60) minutes. None of the 31 patients with plasma levels >100 ng/mL received IVT. Among 14 patients with plasma levels ≤100 ng/mL, the main reason to withhold IVT was minor stroke (n=10). No symptomatic intracranial or major extracranial bleeding occurred after treatment. Conclusions Determination of rivaroxaban plasma levels enabled IVT or EVT in one-third of patients taking rivaroxaban who would otherwise be ineligible for acute treatment. The absence of major bleeding in our pilot series justifies future studies of this approach.
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- 2017
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6. Atherosklerose der intrakraniellen Arterien und der extrakraniellen Karotis
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Sara M Pilgram-Pastor, Mirjam Rachel Heldner, Marina P Krasteva, and Mandy D Müller
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medicine.medical_specialty ,Extracranial carotid artery ,business.industry ,medicine.medical_treatment ,General Medicine ,Carotid endarterectomy ,Lower risk ,Asymptomatic ,medicine.anatomical_structure ,Recurrent stroke ,Internal medicine ,Angioplasty ,medicine ,Cardiology ,medicine.symptom ,business ,Artery ,Endarterectomy - Abstract
Zusammenfassung. Intrakranielle atherosklerotische Stenosen sind die häufigste Ursache von ischämischen Hirnschlägen weltweit. Drei Behandlungsverfahren stehen heutzutage für Patienten mit intrakraniellen atherosklerotischen Stenosen zur Verfügung: Das beste konservative Management (bestehend aus Medikamenten, einer optimalen Einstellung vaskulärer Risikofaktoren und einem gesunden Lebensstil), die endovaskuläre Therapie und die chirurgische Therapie. Bei asymptomatischen intrakraniellen atherosklerotischen Stenosen wird aktuell ein bestes konservatives Management empfohlen, ebenso in der Regel bei Patienten mit symptomatischen intrakraniellen atherosklerotischen Stenosen. Ausgewählte Patienten können aber von einer zusätzlichen endovaskulären Therapie profitieren, bspw. wenn sie trotz bestem konservativen Management wiederholte Hirninfarkte im Gefässterritorium der Stenose zeigen. In seltenen Fällen kann auch ein chirurgisches Vorgehen in Frage kommen. Bei Patienten mit symptomatischer extrakranieller atherosklerotischer Karotisstenose konnte wiederholt gezeigt werden, dass die Behandlung mittels Karotisendarterektomie (CEA) ein tieferes Sterblichkeits- und Hirnschlagrisiko aufweist als die Behandlung mittels endovaskulärer Therapie (CAS). Insbesondere bei Patienten im Alter von über 70 Jahren sollte aktuell in der Regel eine CEA dem CAS vorgezogen werden, da das Risiko innerhalb von 30 Tagen nach Behandlung zu versterben oder einen Hirnschlag zu erleiden bei Patienten, welche mit einem CAS behandelt werden praktisch doppelt so hoch liegt, wie bei Patienten, die mittels CEA behandelt werden. Die Studienergebnisse, welche modernisierte Techniken und Devices verwenden, bleiben abzuwarten. Aktuell bleibt es unklar, ob Patienten mit asymptomatischer extrakranieller atherosklerotischer Karotisstenose unter bester konservativer Therapie überhaupt von einer invasiven Therapie im Sinne einer CEA oder eines CAS profitieren.
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- 2021
7. [Atherosclerosis of the intracranial arteries and of the extracranial carotid artery.]
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Marina P, Krasteva, Mandy D, Müller, Sara M, Pilgram-Pastor, and Mirjam R, Heldner
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Aged, 80 and over ,Stroke ,Endarterectomy, Carotid ,Carotid Arteries ,Treatment Outcome ,Risk Factors ,Angioplasty ,Humans ,Carotid Stenosis ,Stents ,Atherosclerosis ,Aged - Abstract
Atherosclerosis of the intracranial arteries and of the extracranial carotid artery.
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- 2021
8. Arterial collateral anatomy predicts the risk for intra-operative changes in somatosensory evoked potentials in patients undergoing carotid endarterectomy: a prospective cohort study
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Kathleen Seidel, Eike I. Piechowiak, Giovanni Peschi, Pascal J. Mosimann, David Bervini, Andreas Raabe, Mandy D Müller, and Philippe Schucht
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Male ,medicine.medical_specialty ,medicine.medical_treatment ,Surgical morbidity ,Collateral Circulation ,610 Medicine & health ,Carotid endarterectomy ,030204 cardiovascular system & hematology ,Neuromonitoring ,03 medical and health sciences ,0302 clinical medicine ,Original Article - Vascular Neurosurgery - Other ,Risk Factors ,Internal medicine ,medicine.artery ,Evoked Potentials, Somatosensory ,medicine ,Humans ,Posterior communicating artery ,Prospective Studies ,Prospective cohort study ,Cerebrovascular disease ,Stroke ,Aged ,Retrospective Studies ,Endarterectomy, Carotid ,Vascular anatomy ,business.industry ,medicine.disease ,Risks assessment ,Anterior communicating artery ,Stenosis ,Somatosensory evoked potential ,Multivariate Analysis ,Cardiology ,Circle of Willis ,Surgery ,Female ,Neurology (clinical) ,business ,030217 neurology & neurosurgery ,Carotid Artery, Internal - Abstract
Background During carotid endarterectomy (CEA), significant amplitude decrement of somatosensory evoked potentials (SEPs) is associated with post-operative neurological deficits. Objective To investigate the association between an incomplete circle of Willis and/or contralateral ICA occlusion and subsequent changes in intra-operatively monitored SEPs. Methods We performed a retrospective analysis of a single center, prospective cohort of consecutive patients undergoing CEA over a 42-month period after reviewing the collateral arterial anatomy on pre-operative radiological imaging. The primary endpoint was an intra-operative decline in SEPs > 50% compared to the baseline value during arterial cross-clamping. Univariate and multivariate logistic regression analyses were performed to investigate a potential association between contralateral ICA occlusion, incomplete circle of Willis, and subsequent alteration in SEPs. Results A total of 140 consecutive patients were included, of which 116 patients (82.9%) had symptomatic carotid stenosis of at least 50% according to the classification used in the North American Carotid Surgery Trial (NASCET) (Stroke 22:711–720, 1991). Six patients (4.3%) showed contralateral ICA occlusion, 22 patients (16%) a missing/hypoplastic anterior communicating artery (Acom) or A1 segment, and 79 patients (56%) a missing ipsilateral posterior communicating artery (Pcom) or P1 segment. ICA occlusion and missing segments of the anterior circulation (missing A1 and/or missing Acom) were associated with the primary endpoint (p = 0.003 and p = 0.022, respectively). Conclusion Contralateral ICA occlusion and missing anterior collaterals of the circle of Willis increase the risk of intra-operative SEP changes during CEA. Pre-operative assessment of collateral arterial anatomy might help identifying patients with an increased intra-operative risk.
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- 2021
9. Outcome of endovascular therapy in stroke with large vessel occlusion and mild symptoms
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Timo Kahles, Henrik Gensicke, Leo H. Bonati, Mandy D. Müller, Marcel Arnold, Georg Kägi, Stefania Nannoni, Giulio Disanto, Urs Fischer, Alessandro Cianfoni, Claudio Staedler, Krassen Nedeltchev, Carlo W. Cereda, Giovanni Bianco, Sebastian Thilemann, Emmanuel Carrera, Andreas R. Luft, Mirjam Rachel Heldner, Johannes Kaesmacher, Simon Jung, Patrik Michel, Concetta Manno, University of Zurich, and Cereda, Carlo W
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Male ,medicine.medical_specialty ,Stroke/epidemiology/surgery ,610 Medicine & health ,Endovascular therapy ,Severity of Illness Index ,Brain Ischemia ,Disability Evaluation ,03 medical and health sciences ,0302 clinical medicine ,Modified Rankin Scale ,Internal medicine ,Severity of illness ,Clinical endpoint ,Humans ,Medicine ,cardiovascular diseases ,Registries ,030212 general & internal medicine ,Stroke ,Aged ,Retrospective Studies ,Brain Ischemia/epidemiology/surgery ,business.industry ,Endovascular Procedures ,Retrospective cohort study ,Odds ratio ,Middle Aged ,medicine.disease ,Confidence interval ,10040 Clinic for Neurology ,ddc:616.8 ,2728 Neurology (clinical) ,Mild symptoms ,Treatment Outcome ,cardiovascular system ,Cardiology ,Female ,Neurology (clinical) ,business ,030217 neurology & neurosurgery ,Large vessel occlusion - Abstract
ObjectiveTo compare outcomes after endovascular therapy (EVT) and IV thrombolysis (IVT) in patients with stroke with emergent large vessel occlusion (LVO) and mild neurologic deficits.MethodsThis was a retrospective analysis of patients from the Swiss Stroke Registry with admission NIH Stroke Scale score ≤5 and LVO treated by EVT (± IVT) vs IVT alone. The primary endpoint was favorable functional outcome (modified Rankin Scale [mRS] score 0–1) at 3 months. Secondary outcomes were independence (mRS score 0–2), mRS score (ordinal shift analysis), and survival with high disability (mRS score 4–5). Safety endpoints were mortality and symptomatic hemorrhage.ResultsOf 11,356 patients, 312 met the criteria and propensity score method matched 108 in each group. A comparably large proportion of patients with EVT and IVT had favorable outcome (63% vs 65.7% respectively; odds ratio 0.94, 95% confidence interval 0.51–1.72; p = 0.840). Patients with EVT showed a nonsignificant trend toward higher mRS score at 3 months (p = 0.717), while the proportion of surviving patients with high disability was comparably very low in both groups (p = 0.419). Mortality was slightly higher among those with EVT (9.3% vs 2.8%; p = 0.06), and symptomatic intracranial hemorrhage was a rare event in both groups (2.8% vs 0%; p = 0.997).ConclusionsIn acute ischemic stroke, EVT and IVT appear similarly effective in achieving favorable outcome at 3 months for patients with LVO and mild neurologic symptoms. EVT might be marginally inferior to IVT regarding outcome across all levels of disability and mortality. Further studies are required to determine whether certain subgroups of patients with LVO and mild symptoms benefit from EVT.Classification of evidenceThis study provides Class III evidence that patients with LVO and mild symptoms receiving either EVT or IVT had similar favorable functional outcomes at 3 months.
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- 2019
10. Carotid and Vertebral Artery Revascularization
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Mandy D. Müller, Martin M Brown, and Leo H. Bonati
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medicine.medical_specialty ,business.industry ,medicine.medical_treatment ,Vertebral artery ,medicine.artery ,Internal medicine ,Cardiology ,Medicine ,business ,Revascularization - Published
- 2020
11. Lipoprotein(a) is associated with large artery atherosclerosis stroke aetiology and stroke recurrence among patients below the age of 60 years: results from the BIOSIGNAL study
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George Ntaios, Alejandro Bustamante, Corinne Inauen, Georg Kägi, Gian Marco De Marchis, Leo H. Bonati, Arnold von Eckardstein, Marcel Arnold, Katharina Spanaus, Juliane Schweizer, Carlo W. Cereda, Thomas Pokorny, Timo Kahles, Alexander Benedikt Leichtle, Valerie Schütz, Markus F. F. Arnold, Christian Foerch, Laura P. Westphal, Mira Katan, Andreas R. Luft, Mandy D. Müller, Krassen Nedeltchev, Joan Montaner, Christos T. Nakas, Urs Fischer, Antonela Bicvic, University of Zurich, Arnold, Markus, and Arnold, Marcel
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medicine.medical_specialty ,610 Medicine & health ,030204 cardiovascular system & hematology ,2705 Cardiology and Cardiovascular Medicine ,Brain Ischemia ,Cohort Studies ,03 medical and health sciences ,0302 clinical medicine ,Recurrence ,Risk Factors ,Internal medicine ,540 Chemistry ,Medicine ,Humans ,Prospective Studies ,Risk factor ,Stroke ,10038 Institute of Clinical Chemistry ,biology ,business.industry ,Hazard ratio ,Atrial fibrillation ,Lipoprotein(a) ,Odds ratio ,Arteries ,Middle Aged ,medicine.disease ,Atherosclerosis ,10040 Clinic for Neurology ,Cohort ,biology.protein ,Cardiology ,10023 Institute of Intensive Care Medicine ,Cardiology and Cardiovascular Medicine ,business ,030217 neurology & neurosurgery ,Cohort study - Abstract
Aims Lipoprotein(a) [Lp(a)] is a recognized causal risk factor for atherosclerotic cardiovascular disease but its role for acute ischaemic stroke (AIS) is controversial. In this study, we evaluated the association of Lp(a) with large artery atherosclerosis (LAA) stroke and risk of recurrent cerebrovascular events in AIS patients. Methods and results For this analysis of the prospective, observational, multicentre BIOSIGNAL cohort study we measured Lp(a) levels in plasma samples of 1733 primarily Caucasian (98.6%) AIS patients, collected within 24 h after symptom onset. Primary outcomes were LAA stroke aetiology and recurrent cerebrovascular events (ischaemic stroke or transient ischaemic attack) within 1 year. We showed that Lp(a) levels are independently associated with LAA stroke aetiology [adjusted odds ratio 1.48, 95% confidence interval (CI) 1.14-1.90, per unit log10Lp(a) increase] and identified age as a potent effect modifier (Pinteraction =0.031) of this association. The adjusted odds ratio for LAA stroke in patients aged Conclusion Elevated Lp(a) was independently associated with LAA stroke aetiology and risk of recurrent cerebrovascular events among primarily Caucasian individuals aged
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- 2020
12. Carotid artery stenting versus endarterectomy for treatment of carotid artery stenosis
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Philippe Lyrer, Mandy D. Müller, Martin M Brown, and Leo H. Bonati
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Atherosclerotic stenosis ,medicine.medical_specialty ,Carotid arteries ,medicine.medical_treatment ,Myocardial Infarction ,Carotid endarterectomy ,law.invention ,03 medical and health sciences ,0302 clinical medicine ,Randomized controlled trial ,law ,medicine.artery ,Angioplasty ,Internal medicine ,Odds Ratio ,medicine ,Humans ,Carotid Stenosis ,Pharmacology (medical) ,Myocardial infarction ,cardiovascular diseases ,030212 general & internal medicine ,610 Medicine & health ,Stroke ,Aged ,Randomized Controlled Trials as Topic ,Endarterectomy ,Advanced and Specialized Nursing ,Endarterectomy, Carotid ,business.industry ,Odds ratio ,medicine.disease ,Stenosis ,Treatment Outcome ,cardiovascular system ,Cardiology ,Surgery ,Stents ,Neurology (clinical) ,Internal carotid artery ,Carotid stenting ,Cardiology and Cardiovascular Medicine ,business ,Vascular Surgical Procedures ,Angioplasty, Balloon ,Carotid Artery, Internal ,030217 neurology & neurosurgery - Abstract
Background Carotid artery stenting is an alternative to carotid endarterectomy for the treatment of atherosclerotic carotid artery stenosis. This review updates a previous version first published in 1997 and subsequently updated in 2004, 2007, and 2012. Objectives To assess the benefits and risks of stenting compared with endarterectomy in people with symptomatic or asymptomatic carotid stenosis. Search methods We searched the Cochrane Stroke Group Trials Register (last searched August 2018) and the following databases: CENTRAL, MEDLINE, Embase, and Science Citation Index to August 2018. We also searched ongoing trials registers (August 2018) and reference lists, and contacted researchers in the field. Selection criteria Randomised controlled trials (RCTs) comparing stenting with endarterectomy for symptomatic or asymptomatic atherosclerotic carotid stenosis. In addition, we included RCTs comparing carotid artery stenting with medical therapy alone. Data collection and analysis One review author selected trials for inclusion, assessed trial quality and risk of bias, and extracted data. A second review author independently validated trial selection and a third review author independently validated data extraction. We calculated treatment effects as odds ratios (OR) and 95% confidence intervals (CI), with endarterectomy as the reference group. We quantified heterogeneity using the I² statistic and used GRADE to assess the overall certainty of evidence. Main results We included 22 trials involving 9753 participants. In participants with symptomatic carotid stenosis, compared with endarterectomy stenting was associated with a higher risk of periprocedural death or stroke (the primary safety outcome; OR 1.70, 95% CI 1.31 to 2.19; P < 0.0001, I² = 5%; 10 trials, 5396 participants; high‐certainty evidence); and periprocedural death, stroke, or myocardial infarction (OR 1.43, 95% CI 1.14 to 1.80; P = 0.002, I² = 0%; 6 trials, 4861 participants; high‐certainty evidence). The OR for the primary safety outcome was 1.11 (95% CI 0.74 to 1.64) in participants under 70 years old and 2.23 (95% CI 1.61 to 3.08) in participants 70 years old or more (interaction P = 0.007). There was a non‐significant increase in periprocedural death or major or disabling stroke with stenting (OR 1.36, 95% CI 0.97 to 1.91; P = 0.08, I² = 0%; 7 trials, 4983 participants; high‐certainty evidence). Compared with endarterectomy, stenting was associated with lower risks of myocardial infarction (OR 0.47, 95% CI 0.24 to 0.94; P = 0.03, I² = 0%), cranial nerve palsy (OR 0.09, 95% CI 0.06 to 0.16; P < 0.00001, I² = 0%), and access site haematoma (OR 0.32, 95% CI 0.15 to 0.68; P = 0.003, I² = 27%). The combination of periprocedural death or stroke or ipsilateral stroke during follow‐up (the primary combined safety and efficacy outcome) favoured endarterectomy (OR 1.51, 95% CI 1.24 to 1.85; P < 0.0001, I² = 0%; 8 trials, 5080 participants; high‐certainty evidence). The rate of ipsilateral stroke after the periprocedural period did not differ between treatments (OR 1.05, 95% CI 0.75 to 1.47; P = 0.77, I² = 0%). In participants with asymptomatic carotid stenosis, there was a non‐significant increase in periprocedural death or stroke with stenting compared with endarterectomy (OR 1.72, 95% CI 1.00 to 2.97; P = 0.05, I² = 0%; 7 trials, 3378 participants; moderate‐certainty evidence). The risk of periprocedural death or stroke or ipsilateral stroke during follow‐up did not differ significantly between treatments (OR 1.27, 95% CI 0.87 to 1.84; P = 0.22, I² = 0%; 6 trials, 3315 participants; moderate‐certainty evidence). Moderate or higher carotid artery restenosis (50% or greater) or occlusion during follow‐up was more common after stenting (OR 2.00, 95% CI 1.12 to 3.60; P = 0.02, I² = 44%), but the difference in risk of severe restenosis was not significant (70% or greater; OR 1.26, 95% CI 0.79 to 2.00; P = 0.33, I² = 58%; low‐certainty evidence). Authors' conclusions Stenting for symptomatic carotid stenosis is associated with a higher risk of periprocedural stroke or death than endarterectomy. This extra risk is mostly attributed to an increase in minor, non‐disabling strokes occurring in people older than 70 years. Beyond the periprocedural period, carotid stenting is as effective in preventing recurrent stroke as endarterectomy. However, combining procedural safety and long‐term efficacy in preventing recurrent stroke still favours endarterectomy. In people with asymptomatic carotid stenosis, there may be a small increase in the risk of periprocedural stroke or death with stenting compared with endarterectomy. However, CIs of treatment effects were wide and further data from randomised trials in people with asymptomatic stenosis are needed.
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- 2020
13. Intravenous Thrombolysis in Patients with Stroke Taking Rivaroxaban Using Drug Specific Plasma Levels: Experience with a Standard Operation Procedure in Clinical Practice
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Christopher Traenka, Sebastian Thilemann, Stefan T. Engelter, Mandy D. Müller, Stephan Marsch, Christoph Stippich, Alexandros A Polymeris, Philippe Lyrer, Dimitrios A. Tsakiris, Raoul Sutter, Benjamin Wagner, Urs Fisch, Christian H. Nickel, Lisa Hert, Leo H. Bonati, David J. Seiffge, Nils Peters, Henrik Gensicke, Gian Marco De Marchis, and Raphael Guzman
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Drug ,lcsh:Diseases of the circulatory (Cardiovascular) system ,medicine.medical_treatment ,media_common.quotation_subject ,Standard operation procedure ,030204 cardiovascular system & hematology ,03 medical and health sciences ,Plasma levels ,0302 clinical medicine ,Rivaroxaban ,Interquartile range ,Occlusion ,medicine ,Stroke ,media_common ,business.industry ,Thrombolysis ,medicine.disease ,lcsh:RC666-701 ,Anesthesia ,Original Article ,Neurology (clinical) ,Cardiology and Cardiovascular Medicine ,business ,030217 neurology & neurosurgery ,medicine.drug - Abstract
Background and Purpose Standard operating procedures (SOP) incorporating plasma levels of rivaroxaban might be helpful in selecting patients with acute ischemic stroke taking rivaroxaban suitable for IVthrombolysis (IVT) or endovascular treatment (EVT). Methods This was a single-center explorative analysis using data from the Novel-Oral-Anticoagulants-in-Stroke-Patients-registry (clinicaltrials.gov:NCT02353585) including acute stroke patients taking rivaroxaban (September 2012 to November 2016). The SOP included recommendation, consideration, and avoidance of IVT if rivaroxaban plasma levels were 100 ng/mL, respectively, measured with a calibrated anti-factor Xa assay. Patients with intracranial artery occlusion were recommended IVT+EVT or EVT alone if plasma levels were ≤100 ng/mL or >100 ng/mL, respectively. We evaluated the frequency of IVT/EVT, door-to-needle-time (DNT), and symptomatic intracranial or major extracranial hemorrhage. Results Among 114 acute stroke patients taking rivaroxaban, 68 were otherwise eligible for IVT/EVT of whom 63 had plasma levels measured (median age 81 years, median baseline National Institutes of Health Stroke Scale 6). Median rivaroxaban plasma level was 96 ng/mL (inter quartile range [IQR] 18‒259 ng/mL) and time since last intake 11 hours (IQR 4.5‒18.5 hours). Twenty-two patients (35%) received IVT/EVT (IVT n=15, IVT+EVT n=3, EVT n=4) based on SOP. Median DNT was 37 (IQR 30‒60) minutes. None of the 31 patients with plasma levels >100 ng/mL received IVT. Among 14 patients with plasma levels ≤100 ng/mL, the main reason to withhold IVT was minor stroke (n=10). No symptomatic intracranial or major extracranial bleeding occurred after treatment. Conclusions Determination of rivaroxaban plasma levels enabled IVT or EVT in one-third of patients taking rivaroxaban who would otherwise be ineligible for acute treatment. The absence of major bleeding in our pilot series justifies future studies of this approach.
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- 2017
14. Vascular Anatomy Predicts the Risk of Cerebral Ischemia in Patients Randomized to Carotid Stenting Versus Endarterectomy
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Toby Richards, F.J. Ahlhelm, Aad van der Lugt, Philippe Lyrer, H. Bart van der Worp, Leo H. Bonati, Stefan T. Engelter, Alexander von Hessling, Mandy D. Müller, Martin M. Brown, Jeroen Hendrikse, Sumaira Macdonald, Paul J. Nederkoorn, D Doig, Christoph Stippich, Radiology & Nuclear Medicine, ANS - Neurovascular Disorders, Neurology, ACS - Amsterdam Cardiovascular Sciences, and ACS - Atherosclerosis & ischemic syndromes
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Male ,Risk ,medicine.medical_specialty ,Computed Tomography Angiography ,medicine.medical_treatment ,Ischemia ,Aorta, Thoracic ,030204 cardiovascular system & hematology ,Brain Ischemia ,law.invention ,Brain ischemia ,03 medical and health sciences ,0302 clinical medicine ,Randomized controlled trial ,law ,Internal medicine ,medicine ,Humans ,Carotid Stenosis ,cardiovascular diseases ,Stroke ,Aged ,Endarterectomy ,Aged, 80 and over ,Advanced and Specialized Nursing ,Endarterectomy, Carotid ,medicine.diagnostic_test ,business.industry ,Middle Aged ,medicine.disease ,Magnetic Resonance Imaging ,Cerebral Angiography ,Surgery ,Diffusion Magnetic Resonance Imaging ,Outcome and Process Assessment, Health Care ,Angiography ,Cardiology ,Female ,Stents ,Neurology (clinical) ,Carotid stenting ,Cardiology and Cardiovascular Medicine ,business ,Vascular Surgical Procedures ,Carotid Artery, Internal ,Magnetic Resonance Angiography ,030217 neurology & neurosurgery ,Cerebral angiography - Abstract
Background and Purpose— Complex vascular anatomy might increase the risk of procedural stroke during carotid artery stenting (CAS). Randomized controlled trial evidence that vascular anatomy should inform the choice between CAS and carotid endarterectomy (CEA) has been lacking. Methods— One-hundred eighty-four patients with symptomatic internal carotid artery stenosis who were randomly assigned to CAS or CEA in the ICSS (International Carotid Stenting Study) underwent magnetic resonance (n=126) or computed tomographic angiography (n=58) at baseline and brain magnetic resonance imaging before and after treatment. We investigated the association between aortic arch configuration, angles of supra-aortic arteries, degree, length of stenosis, and plaque ulceration with the presence of ≥1 new ischemic brain lesion on diffusion-weighted magnetic resonance imaging (DWI+) after treatment. Results— Forty-nine of 97 patients in the CAS group (51%) and 14 of 87 in the CEA group (16%) were DWI+ (odds ratio [OR], 6.0; 95% confidence interval [CI], 2.9–12.4; P P =0.027) and the degree of the largest internal carotid artery angle (≥60° versus P =0.002) were both associated with DWI+, also after correction for age. No predictors for DWI+ were identified in the CEA group. The DWI+ risk in CAS increased further over CEA if the largest internal carotid artery angle was ≥60° (OR, 11.8; 95% CI, 4.1–34.1) than if it was P =0.035). Conclusions— Complex configuration of the aortic arch and internal carotid artery tortuosity increase the risk of cerebral ischemia during CAS, but not during CEA. Vascular anatomy should be taken into account when selecting patients for stenting. Clinical Trial Registration— URL: http://www.isrctn.com/ISRCTN25337470 . Unique identifier: ISRCTN25337470.
- Published
- 2017
15. Secular Trends in Procedural Stroke or Death Risks of Stenting Versus Endarterectomy for Symptomatic Carotid Stenosis A Pooled Analysis of Randomized Trials
- Author
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Peter A. Ringleb, Jean-Pierre Becquemin, John Gregson, Richard Bulbulia, Martin M. Brown, David Calvet, Gustav Fraedrich, Alison Halliday, Jeroen Hendrikse, Leo H. Bonati, Ale Algra, Hans-Henning Eckstein, Jean-Louis Mas, Stefanie von Felten, Mandy D. Müller, George Howard, Thomas G. Brott, and Olav Jansen
- Subjects
medicine.medical_specialty ,medicine.medical_treatment ,Carotid endarterectomy ,030204 cardiovascular system & hematology ,Revascularization ,law.invention ,03 medical and health sciences ,0302 clinical medicine ,Randomized controlled trial ,law ,Internal medicine ,medicine ,Journal Article ,risk factors ,cardiovascular diseases ,humans ,Stroke ,Endarterectomy ,endarterectomy ,business.industry ,Odds ratio ,medicine.disease ,Clinical trial ,Stenosis ,stents ,Cardiology ,carotid stenosis ,business ,Cardiology and Cardiovascular Medicine ,030217 neurology & neurosurgery - Abstract
Background: Over the past decades, stroke risk associated with carotid disease has decreased, reflecting improvements in medical therapy and a more rigorous control of vascular risk factors. It is less clear whether the procedural risk of carotid revascularization has declined over time. Methods: We analyzed temporal changes in procedural risks among 4597 patients with symptomatic carotid stenosis treated with carotid artery stenting (n=2326) or carotid endarterectomy (n=2271) in 4 randomized trials between 2000 and 2008, using generalized linear mixed-effects models with a random intercept for each source trial. Models were additionally adjusted for age and other baseline characteristics predicting treatment risk. The primary outcome event was any procedural stroke or death, occurring during or within 30 days after revascularization. Results: The procedural stroke or death risk decreased significantly over time in all patients (unadjusted odds ratio per year, 0.91; 95% CI, 0.85–0.97; P =0.006). This effect was driven by a decrease in the carotid endarterectomy group (unadjusted odds ratio per year, 0.82; 95% CI, 0.73–0.92; P =0.003), whereas no significant decrease was found after carotid artery stenting (unadjusted odds ratio, 0.96; 95% CI, 0.88–1.04; P =0.33). Carotid endarterectomy patients had a lower procedural stroke or death risk compared with carotid artery stenting patients, and the difference significantly increased over time (interaction P =0.031). After adjustment for baseline characteristics, the results remained essentially the same. Conclusions: The risk of stroke or death associated with carotid endarterectomy for symptomatic carotid stenosis decreased over an 8-year period, independent of clinical predictors of procedural risk. No corresponding reduction in procedural risk was seen in patients treated with stenting. Clinical Trial Registration: URL: https://www.clinicaltrials.gov ; http://www.isrctn.com . Unique identifier: NCT00190398 (EVA-3S), NCT00004732 (CREST), ISRCTN57874028 (SPACE), and ISRCTN25337470 (ICSS).
- Published
- 2019
16. Silent intracerebral hemorrhage in patients randomized to stenting or endarterectomy for symptomatic carotid stenosis
- Author
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Philippe Lyrer, Stefan T. Engelter, Mandy D. Müller, Gert J. de Borst, Stephan G. Wetzel, Toby Richards, Sumaira Macdonald, Rolf Jager, Jeroen Hendrikse, Thomas Wolff, Lisa M. Jongen, Paul J. Nederkoorn, David J. Werring, L. Jaap Kappelle, H. Bart van der Worp, Martin M. Brown, Leo H. Bonati, Aysun Altinbas, Kristine A Blackham, ACS - Atherosclerosis & ischemic syndromes, Amsterdam Neuroscience - Neurovascular Disorders, and Neurology
- Subjects
Intracerebral hemorrhage ,medicine.medical_specialty ,lcsh:Diseases of the circulatory (Cardiovascular) system ,business.industry ,medicine.medical_treatment ,Clinical Neurology ,medicine.disease ,Clinical neurology ,Surgery ,Stenosis ,Text mining ,lcsh:RC666-701 ,medicine ,Journal Article ,In patient ,Neurology (clinical) ,business ,Cardiology and Cardiovascular Medicine ,Letter to the Editor ,Endarterectomy - Published
- 2019
17. Stent Design, Restenosis and Recurrent Stroke After Carotid Artery Stenting in the International Carotid Stenting Study
- Author
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Dominick J. H. McCabe, Stefan T. Engelter, Mandy D. Müller, Gert J. de Borst, Thomas Wolff, Leo H. Bonati, Trevor J. Cleveland, John Gregson, H. Bart van der Worp, Martin M. Brown, Paul J. Nederkoorn, Philippe Lyrer, Neurology, ACS - Atherosclerosis & ischemic syndromes, and ANS - Neurovascular Disorders
- Subjects
Male ,medicine.medical_specialty ,Internationality ,medicine.medical_treatment ,Restenosis ,Recurrence ,medicine.artery ,medicine ,Humans ,Carotid Stenosis ,cardiovascular diseases ,Stroke ,Aged ,Endarterectomy ,Aged, 80 and over ,Advanced and Specialized Nursing ,Endarterectomy, Carotid ,business.industry ,Hazard ratio ,Graft Occlusion, Vascular ,Stent ,Equipment Design ,Middle Aged ,medicine.disease ,equipment and supplies ,Surgery ,Stenosis ,Female ,Stents ,Neurology (clinical) ,Internal carotid artery ,Carotid stenting ,Cardiology and Cardiovascular Medicine ,business ,Carotid Artery, Internal ,Follow-Up Studies - Abstract
Background and Purpose— Open-cell carotid artery stents are associated with a higher peri-procedural stroke risk than closed-cell stents. However, the effect of stent design on long-term durability of carotid artery stenting (CAS) is unknown. We compared the medium- to long-term risk of restenosis and ipsilateral stroke between patients treated with open-cell stents versus closed-cell stents in the ICSS (International Carotid Stenting Study). Methods— Patients with symptomatic carotid stenosis were randomized to CAS or endarterectomy and followed with duplex ultrasound for a median of 4.0 years. We analyzed data from patients with completed CAS procedures, known stent design, and available ultrasound follow-up. The primary outcome, moderate or higher restenosis (≥50%) was defined as a peak systolic velocity of >1.3 m/s on ultrasound or occlusion of the treated internal carotid artery and analyzed with interval-censored models. Results— Eight hundred fifty-five patients were allocated to CAS. Seven hundred fourteen patients with completed CAS and known stent design were included in the current analysis. Of these, 352 were treated with open-cell and 362 with closed-cell stents. Moderate or higher restenosis occurred significantly less frequently in patients treated with open-cell (n=113) than closed-cell stents (n=154; 5-year risks were 35.5% versus 46.0%; unadjusted hazard ratio, 0.68; 95% CI, 0.53–0.88). There was no significant difference in the risk of severe restenosis (≥70%) after open-cell stenting (n=27) versus closed-cell stenting (n=43; 5-year risks, 8.6% versus 12.7%; unadjusted hazard ratio, 0.63; 95% CI, 0.37–1.05). The risk of ipsilateral stroke beyond 30 days after treatment was similar with open-cell and closed-cell stents (hazard ratio, 0.78; 95% CI, 0.35–1.75). Conclusions— Moderate or higher restenosis after CAS occurred less frequently in patients treated with open-cell stents than closed-cell stents. However, both stent designs were equally effective at preventing recurrent stroke during follow-up. Clinical Trial Registration— URL: http://www.isrctn.com/ . Unique identifier: ISRCTN25337470.
- Published
- 2019
18. Carotid artery stenosis – Current evidence and treatment recommendations
- Author
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Mandy D Müller and Leo H. Bonati
- Subjects
medicine.medical_specialty ,business.industry ,Carotid arteries ,medicine.medical_treatment ,Neurosciences. Biological psychiatry. Neuropsychiatry ,610 Medicine & health ,Carotid endarterectomy ,030204 cardiovascular system & hematology ,medicine.disease ,03 medical and health sciences ,Stenosis ,0302 clinical medicine ,Internal medicine ,medicine ,Cardiology ,In patient ,cardiovascular diseases ,business ,Stroke ,030217 neurology & neurosurgery ,RC321-571 - Abstract
Background: Carotid artery stenosis is an important cause for stroke. Carotid endarterectomy (CEA) reduces the risk of stroke in patients with symptomatic carotid stenosis and to some extent in patients with asymptomatic carotid stenosis. More than 20 years ago, carotid artery stenting (CAS) emerged as an endovascular treatment alternative to CEA. Objective and Methods: This review summarises the available evidence from randomised clinical trials in patients with symptomatic as well as in patients with asymptomatic carotid stenosis. Results: CAS is associated with a higher risk of death or any stroke between randomisation and 30 days after treatment than CEA (odds ratio (OR) = 1.74, 95% CI 1.3 to 2.33, p < 0.0001). In a pre-defined subgroup analysis, the OR for stroke or death within 30 days after treatment was 1.11 (95% CI 0.74 to 1.64) in patients Discussion and Conclusion: In symptomatic patients, randomised evidence has consistently shown CAS to be associated with a higher risk of stroke or death within 30 days of treatment than CEA. This extra risk is mostly attributed to an increase in strokes occurring on the day of the procedure in patients ≥70 years. In asymptomatic patients, there may be a small increase in the risk of stroke or death within 30 days of treatment with CAS compared to CEA, but the currently available evidence is insufficient and further data from ongoing randomised trials are needed.
- Published
- 2021
19. Stent Design, Restenosis and Recurrent Stroke After Carotid Artery Stenting in the International Carotid Stenting Study
- Author
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Dominick J. H. McCabe, G.J. de Borst, H. B. van der Worp, Paul J. Nederkoorn, John Gregson, and Mandy D. Müller
- Subjects
medicine.medical_specialty ,business.industry ,Carotid arteries ,medicine.medical_treatment ,medicine.disease ,Restenosis ,Recurrent stroke ,Internal medicine ,medicine ,Cardiology ,Surgery ,Carotid stenting ,Cardiology and Cardiovascular Medicine ,business ,Stent design - Published
- 2020
20. Restenosis and risk of stroke after stenting or endarterectomy for symptomatic carotid stenosis in the International Carotid Stenting Study (ICSS): secondary analysis of a randomised trial
- Author
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Leo H, Bonati, John, Gregson, Joanna, Dobson, Dominick J H, McCabe, Paul J, Nederkoorn, H Bart, van der Worp, Gert J, de Borst, Toby, Richards, Trevor, Cleveland, Mandy D, Müller, Thomas, Wolff, Stefan T, Engelter, Philippe A, Lyrer, Martin M, Brown, and Bojana, Zvan
- Subjects
Male ,Risk ,Endarterectomy, Carotid ,Graft Occlusion, Vascular ,Kaplan-Meier Estimate ,Middle Aged ,Stroke ,Treatment Outcome ,Risk Factors ,Humans ,Carotid Stenosis ,Female ,Stents ,Aged ,Follow-Up Studies ,Ultrasonography - Abstract
The risk of stroke associated with carotid artery restenosis after stenting or endarterectomy is unclear. We aimed to compare the long-term risk of restenosis after these treatments and to investigate if restenosis causes stroke in a secondary analysis of the International Carotid Stenting Study (ICSS).ICSS is a parallel-group randomised trial at 50 tertiary care centres in Europe, Australia, New Zealand, and Canada. Patients aged 40 years or older with symptomatic carotid stenosis measuring 50% or more were randomly assigned either stenting or endarterectomy in a 1:1 ratio. Randomisation was computer-generated and done centrally, with allocation by telephone or fax, stratified by centre, and with minimisation for sex, age, side of stenosis, and occlusion of the contralateral carotid artery. Patients were followed up both clinically and with carotid duplex ultrasound at baseline, 30 days after treatment, 6 months after randomisation, then annually for up to 10 years. We included patients whose assigned treatment was completed and who had at least one ultrasound examination after treatment. Restenosis was defined as any narrowing of the treated artery measuring 50% or more (at least moderate) or 70% or more (severe), or occlusion of the artery. The degree of restenosis based on ultrasound velocities and clinical outcome events were adjudicated centrally; assessors were masked to treatment assignment. Restenosis was analysed using interval-censored models and its association with later ipsilateral stroke using Cox regression. This trial is registered with the ISRCTN registry, number ISRCTN25337470. This report presents a secondary analysis, and follow-up is complete.Between May, 2001, and October, 2008, 1713 patients were enrolled and randomly allocated treatment (855 were assigned stenting and 858 endarterectomy), of whom 1530 individuals were followed up with ultrasound (737 assigned stenting and 793 endarterectomy) for a median of 4·0 years (IQR 2·3-5·0). At least moderate restenosis (≥50%) occurred in 274 patients after stenting (cumulative 5-year risk 40·7%) and in 217 after endarterectomy (29·6%; unadjusted hazard ratio [HR] 1·43, 95% CI 1·21-1·72; p0·0001). Patients with at least moderate restenosis (≥50%) had a higher risk of ipsilateral stroke than did individuals without restenosis in the overall patient population (HR 3·18, 95% CI 1·52-6·67; p=0·002) and in the endarterectomy group alone (5·75, 1·80-18·33; p=0·003), but no significant increase in stroke risk after restenosis was recorded in the stenting group (2·03, 0·77-5·37; p=0·154; p=0·10 for interaction with treatment). No difference was noted in the risk of severe restenosis (≥70%) or subsequent stroke between the two treatment groups.At least moderate (≥50%) restenosis occurred more frequently after stenting than after endarterectomy and increased the risk for ipsilateral stroke in the overall population. Whether the restenosis-mediated risk of stroke differs between stenting and endarterectomy requires further research.Medical Research Council, the Stroke Association, Sanofi-Synthélabo, and the European Union.
- Published
- 2018
21. Immediate and Delayed Procedural Stroke or Death in Stenting Versus Endarterectomy for Symptomatic Carotid Stenosis
- Author
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S. von Felten, Richard Bulbulia, Jean-Pierre Becquemin, Martin M. Brown, Mandy D. Müller, and A. Algra
- Subjects
medicine.medical_specialty ,Stenosis ,business.industry ,Internal medicine ,medicine.medical_treatment ,medicine ,Cardiology ,Surgery ,Cardiology and Cardiovascular Medicine ,medicine.disease ,business ,Stroke ,Endarterectomy - Published
- 2019
22. Immediate and Delayed Procedural Stroke or Death in Stenting Versus Endarterectomy for Symptomatic Carotid Stenosis
- Author
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Jean-Louis Mas, Stefanie von Felten, Alison Halliday, Richard Bulbulia, Ale Algra, Leo H. Bonati, Thomas G. Brott, John Gregson, George Howard, Hans-Henning Eckstein, Gustav Fraedrich, Martin M. Brown, Mandy D. Müller, Peter A. Ringleb, Jean-Pierre Becquemin, David Calvet, Olav Jansen, Jeroen Hendrikse, and Collaboration, Carotid Stenosis Trialists’
- Subjects
Male ,medicine.medical_specialty ,Time Factors ,medicine.medical_treatment ,Carotid endarterectomy ,030204 cardiovascular system & hematology ,Article ,law.invention ,03 medical and health sciences ,Postoperative Complications ,0302 clinical medicine ,Randomized controlled trial ,Risk Factors ,law ,Internal medicine ,Odds Ratio ,medicine ,Humans ,Carotid Stenosis ,In patient ,Mortality ,Stroke ,Aged ,Endarterectomy ,Advanced and Specialized Nursing ,Endarterectomy, Carotid ,business.industry ,Age Factors ,Odds ratio ,Middle Aged ,medicine.disease ,Clinical trial ,Stenosis ,Treatment Outcome ,Cardiology ,Female ,Stents ,Neurology (clinical) ,Cardiology and Cardiovascular Medicine ,business ,human activities ,030217 neurology & neurosurgery - Abstract
Background and Purpose— Stenting for symptomatic carotid stenosis (carotid artery stenting [CAS]) carries a higher risk of procedural stroke or death than carotid endarterectomy (CEA). It is unclear whether this extra risk is present both on the day of procedure and within 1 to 30 days thereafter and whether clinical risk factors differ between these periods. Methods— We analyzed the risk of stroke or death occurring on the day of procedure (immediate procedural events) and within 1 to 30 days thereafter (delayed procedural events) in 4597 individual patients with symptomatic carotid stenosis who underwent CAS (n=2326) or CEA (n=2271) in 4 randomized trials. Results— Compared with CEA, patients treated with CAS were at greater risk for immediate procedural events (110 versus 42; 4.7% versus 1.9%; odds ratio, 2.6; 95% CI, 1.9–3.8) but not for delayed procedural events (59 versus 46; 2.5% versus 2.0%; odds ratio, 1.3; 95% CI, 0.9–1.9; interaction P =0.006). In patients treated with CAS, age increased the risk for both immediate and delayed events while qualifying event severity only increased the risk of delayed events. In patients treated with CEA, we found no risk factors for immediate events while a higher level of disability at baseline and known history of hypertension were associated with delayed procedural events. Conclusions— The increased procedural stroke or death risk associated with CAS compared with CEA was caused by an excess of events occurring on the day of procedure. This finding demonstrates the need to enhance the procedural safety of CAS by technical improvements of the procedure and increased operator skill. Higher age increased the risk for both immediate and delayed procedural events in CAS, mechanisms of which remain to be elucidated. Clinical Trial Registration— URL: https://clinicaltrials.gov . Unique identifier: NCT00190398. URL: http://www.isrctn.com . Unique identifier: ISRCTN57874028. URL: http://www.isrctn.com . Unique identifier: ISRCTN25337470. URL: https://clinicaltrials.gov . Unique identifier: NCT00004732.
- Published
- 2018
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