The Mechanism of Procedural Stroke Following Carotid Endarterectomy within the Asymptomatic Carotid Surgery Trial 1

2016 ◽  
Vol 42 (3-4) ◽  
pp. 178-185 ◽  
Author(s):  
Anne Huibers ◽  
Gert Jan de Borst ◽  
Dafydd J. Thomas ◽  
Frans L. Moll ◽  
Richard Bulbulia ◽  
...  
Keyword(s):  
Carotid Artery ◽  
Carotid Endarterectomy ◽  
Pathophysiological Mechanism ◽  
Carotid Surgery ◽  
Asymptomatic Carotid Stenosis ◽  
Asymptomatic Carotid ◽  
Thrombotic Occlusion ◽  
Stroke Type ◽  
Stroke Mechanism ◽  
Surgery Trial

Introduction: Understanding the pathophysiological mechanism of procedural stroke during carotid intervention may help reduce the risk of stroke in those undergoing surgery. We therefore studied the features of procedural strokes within the first Asymptomatic Carotid Surgery Trial-1 (ACST-1) to identify the underlying pathophysiological mechanism. Methods: In ACST-1, 3,120 patients with severe asymptomatic carotid stenosis thought suitable for surgery were randomized to CEA or indefinite deferral of surgery. Information on procedural (within 30 days) stroke type, laterality, severity and timing was collected. Eight possible mechanisms were defined: embolism from the carotid artery, haemodynamic, thrombosis or occlusion of the carotid artery, hyperperfusion syndrome, cardioembolic, either carotid embolic or haemodynamic, either carotid embolic or thrombotic occlusion, or undetermined. Results: Procedural strokes occurred in 53 patients (2.7%). Strokes were predominantly ischaemic (n = 43; 81%), ipsilateral to the treated artery (n = 42; 79%), often occurred on the day of the operation (n = 32; 60%) and in over half the patients, were disabling or fatal (n = 27; 51%). The identified stroke mechanism was carotid embolic (n = 7), haemodynamic (n = 5), thrombosis or occlusion of the carotid artery (n = 9), hyperperfusion (n = 7), cardioembolic (n = 3), ‘probably carotid embolic or haemodynamic' (n = 7), ‘probably carotid embolic or thrombotic occlusion' (n = 3) and undetermined in 12 cases. Conclusion: In ACST-1, the risk of procedural stroke was low. Most strokes (60%) occurred on the day of the procedure and were caused by thrombosis or thrombotic occlusion of the ipsilateral carotid artery. These findings emphasize the importance of immediate assessment of the treated carotid artery when a stroke occurs after CEA.

Second Asymptomatic Carotid Surgery Trial (ACST-2): Randomised Comparison of Carotid Artery Stenting vs Carotid Endarterectomy

2021 ◽  
Author(s):  
Alison Halliday ◽  
Richard Bulbulia ◽  
Leo Bonati ◽  
Johanna Chester ◽  
Andrea Cradduck-Bamford ◽  
...  
Keyword(s):  
Carotid Artery ◽  
Carotid Endarterectomy ◽  
Carotid Artery Stenting ◽  
Carotid Surgery ◽  
Asymptomatic Carotid ◽  
Surgery Trial

Angioplastica carotidea

1998 ◽  
Vol 11 (4) ◽  
pp. 431-442 ◽  
Author(s):  
M. Puglioli ◽  
R. Padolecchia ◽  
P.L. Collavoli ◽  
G. Parenti ◽  
G. Orlandi ◽  
...  
Keyword(s):  
Carotid Endarterectomy ◽  
North American ◽  
Carotid Atherosclerosis ◽  
Sono State ◽  
Carotid Surgery ◽  
Asymptomatic Carotid ◽  
Symptomatic Carotid ◽  
Sono Stati ◽  
Surgery Trial

L'endoarteriectomia, come confermano i risultati degli studi multicentrici NASCET (North American Symptomatic Carotid Endarterectomy Trial), ECST (European Carotid Surgery Trial) ed ACAS (Asymptomatic Carotid Atherosclerosis Study), rappresenta il trattamento di elezione delle stenosi aterosclerotiche interessanti il distretto extracranico dell'arteria carotide, sia nei pazienti sintomatici (stenosi > 70%) che asintomatici (stenosi > 60%). L'intervento chirurgico è gravato da un rischio cumulativo di morbilità-mortalità (stroke/morte) che il NASCET, l'ECST e l'ACAS segnalano, rispettivamente, nel 5,8%, 7,5% e 2,3%, insieme ad altre possibili complicanze: infarto miocardico (0,9%), paralisi di nervi cranici (7,6%), ematoma del collo (5,5%), infezioni (3,4%). Qualora, per ragioni cliniche od anatomiche, il rischio chirurgico sia troppo elevato, come nei pazienti cardiopatici, diabetici, con insufficienza polmonare o renale, con restenosi, con stenosi post-attiniche o fibrodisplastiche, con stenosi carotidee prossimali o distali, con lesioni «tandem», l'angioplastica transluminale percutanea (PTA) e/o lo Stenting carotideo possono rappresentare una valida alternativa terapeutica all'endoarteriectomia. In questo articolo presentiamo la nostra casistica relativa a 41 procedure (36 PTA; 5 Stenting), eseguite su 33 pazienti negli ultimi due anni. I trattamenti sono stati rivolti a 28 arterie carotidi interne, 4 arterie carotidi esterne, 2 arterie carotidi comuni, 2 tronchi anonimi; gli stents sono stati rilasciati in 4 arterie carotidi interne e in 1 arteria carotide comune. Le procedure regolarmente portate a termine sono state 37 (32 PTA; 5 Stents), con un ottimo risultato anatomico in 36 casi. Nei controlli a 6 mesi abbiamo riscontrato una ristenosi (< 60%), asintomatica. In questo articolo illustriamo il nostro protocollo, gli insuccessi tecnici, i risultati e le complicanze.

scholarly journals Ten-year risk of stroke in patients with previous cerebral infarction and the impact of carotid surgery in the Asymptomatic Carotid Surgery Trial

2016 ◽  
Vol 11 (9) ◽  
pp. 1020-1027 ◽  
Author(s):  
Jonathan Y Streifler ◽  
Anne G den Hartog ◽  
Samuel Pan ◽  
Hongchao Pan ◽  
Richard Bulbulia ◽  
...  
Keyword(s):  
Cerebral Infarction ◽  
Carotid Endarterectomy ◽  
Carotid Stenosis ◽  
Hazard Ratio ◽  
Carotid Surgery ◽  
Asymptomatic Carotid ◽  
Risk Increase ◽  
Surgery Trial ◽  
The Impact

Background Silent brain infarcts are common in patients at increased risk of stroke and are associated with a poor prognosis. In patients with asymptomatic carotid stenosis, similar adverse associations were claimed, but the impact of previous infarction or symptoms on the beneficial effects of carotid endarterectomy is not clear. Our aim was to evaluate the impact of prior cerebral infarction in patients enrolled in the Asymptomatic Carotid Surgery Trial, a large trial with 10-year follow-up in which participants whose carotid stenosis had not caused symptoms for at least six months were randomly allocated either immediate or deferred carotid endarterectomy. Methods The first Asymptomatic Carotid Surgery Trial included 3120 patients. Of these, 2333 patients with baseline brain imaging were identified and divided into two groups irrespective of treatment assignment, 1331 with evidence of previous cerebral infarction, defined as a history of ischemic stroke or transient ischemic attack > 6 months prior to randomization or radiological evidence of an asymptomatic infarct (group 1) and 1002 with normal imaging and no prior stroke or transient ischemic attack (group 2). Stroke and vascular deaths were compared during follow-up, and the impact of carotid endarterectomy was observed in both groups. Results Baseline characteristics of patients with and without baseline brain imaging were broadly similar. Of those included in the present report, male gender and hypertension were more common in group 1, while mean ipsilateral stenosis was slightly greater in group 2. At 10 years follow-up, stroke was more common among participants with cerebral infarction before randomization (absolute risk increase 5.8% (1.8–9.8), p = 0.004), and the risk of stroke and vascular death was also higher in this group (absolute risk increase 6.9% (1.9–12.0), p = 0.007). On multivariate analysis, prior cerebral infarction was associated with a greater risk of stroke (hazard ratio = 1.51, 95% confidence interval: 1.17–1.95, p = 0.002) and of stroke or other vascular death (hazard ratio = 1.30, 95% confidence interval: 1.11–1.52, p = 0.001). At 10 years, greater absolute benefits from immediate carotid endarterectomy were seen in those patients with prior cerebral infarction (6.7% strokes immediate carotid endarterectomy vs. 14.7% delayed carotid endarterectomy; hazard ratio 0.47 (0.34–0.65), p = 0.003), compared to those lower risk patients without prior cerebral infarction (6.0% vs. 9.9%, respectively; hazard ratio 0.61 (0.39–0.94), p = 0.005), though it must be emphasized that the first Asymptomatic Carotid Surgery Trial was not designed to test this retrospective and non-randomized comparison. Conclusions Asymptomatic carotid stenosis patients with prior cerebral infarction have a higher stroke risk during long-term follow-up than those without prior cerebral infarction. Evidence of prior ischemic events might help identify patients in whom carotid intervention is particularly beneficial.

scholarly journals Carotid endarterectomy: current indications for surgery

1998 ◽  
Vol 5 (6) ◽  
pp. E3 ◽  
Author(s):  
James J. Brennan ◽  
Christopher M. Loftus
Keyword(s):  
Carotid Artery ◽  
Carotid Endarterectomy ◽  
Occlusive Disease ◽  
Veterans Administration ◽  
Asymptomatic Carotid ◽  
Symptomatic Disease ◽  
Symptomatic Carotid ◽  
The North ◽  
Surgery Trial ◽  
Asymptomatic Disease

The study of carotid artery occlusive disease interventions can be divided clinically into the treatment of asymptomatic and symptomatic diseases. Clinical trials that have studied or are currently studying asymptomatic disease include: the Carotid Artery Stenosis with Asymptomatic Narrowing Operation Versus Aspirin study; the Mayo Asymptomatic Carotid Endarterectomy trial; Veterans Administration Cooperative Trial on Asymptomatic Carotid Stenosis; and the Asymptomatic Carotid Atherosclerosis Study. Trials for the treatment of symptomatic disease include: the North American Symptomatic Carotid Endarterectomy Trial; the European Carotid Surgery Trial; and the Veterans Administration Cooperative Study. In the earliest trials conducted to study asymptomatic disease medical therapy was slightly favored; on close scrutiny these studies were flawed and the findings appeared to be equivocal. The more scientific and appropriate trial, which was ended due to ethical concerns, revealed a clear advantage in patients who underwent surgery for greater than 60% stenosis and when the surgical center demonstrated less than 3% surgical risks. All trials studying symptomatic disease found a significant decrease in subsequent stroke when surgical intervention was performed. It is now judged that patients with greater than 50% stenosis receive significant benefit. In this paper the authors review the data from all of these studies. They also review data for special circumstances, such as critical stenosis and patients with symptomatic and asymptomatic Hollenhorst plaques. It is their opinion that these data have allowed surgeons to make much more educated decisions when considering the treatment of patients with carotid artery occlusive disease.

Sign in / Sign up

Export Citation Format

Share Document