Primary mechanism of stroke reduction in transcarotid artery revascularization is dynamic flow reversal
| Autor: | Mahmoud B. Malas, Nadin Elsayed, Isaac Naazie, Hanaa Dakour-Aridi, Gregory A. Magee, Asma Mathlouthi |
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| Rok vydání: | 2021 |
| Předmět: |
Male
Aortic arch medicine.medical_specialty Time Factors medicine.medical_treatment Myocardial Infarction 030204 cardiovascular system & hematology Revascularization Lower risk Risk Assessment Embolic Protection Devices 03 medical and health sciences 0302 clinical medicine Risk Factors medicine.artery Internal medicine medicine Humans Carotid Stenosis Hospital Mortality Registries 030212 general & internal medicine Myocardial infarction Stroke Aged Retrospective Studies Aged 80 and over business.industry Endovascular Procedures Odds ratio Perioperative Middle Aged Protective Factors medicine.disease Treatment Outcome Regional Blood Flow Relative risk Cardiology Female Stents Surgery Cardiology and Cardiovascular Medicine business |
| Zdroj: | Journal of Vascular Surgery. 74:187-194 |
| ISSN: | 0741-5214 |
| DOI: | 10.1016/j.jvs.2020.10.082 |
| Popis: | Objective Recent studies have suggested that the low risk of stroke and death associated with transcarotid artery revascularization (TCAR) is partially attributable to a robust dynamic flow reversal system and the avoidance of the atherosclerotic aortic arch during stenting. However, the benefits of flow reversal compared with distal embolic protection (DEP) in reducing stroke or death in TCAR have not been studied. Methods All patients undergoing carotid artery stenting (CAS) via the transcarotid route with either dynamic flow reversal (TCAR) or DEP (TCAS-DEP) in the Vascular Quality Initiative from September 2016 to November 2019 were analyzed. Both multivariable logistic regression and nearest neighbor propensity score-matched analysis were performed to explore the differences in outcomes between the two procedures. The primary outcome was in-hospital stroke or death. The secondary outcomes were stroke, death, myocardial infarction (MI), and the composite of stroke, death, and MI. A secondary analysis was performed to compare transcarotid stenting with DEP vs transfemoral CAS with DEP to evaluate the effects of crossing the aortic arch. Results A total of 8426 patients were identified (TCAS-DEP, n = 287; 3.4%). TCAR was associated with a lower risk of in-hospital stroke or death (1.6% vs 5.2%; odds ratio [OR], 0.35; 95% confidence interval [CI], 0.20-0.64; P = .001), stroke (1.4% vs 4.2%; OR, 0.37; 95% CI, 0.20-0.68; P = .002), and stroke/death/MI (2.0% vs 5.2%; OR, 0.41; 95% CI, 0.23-0.71; P = .001) compared with TCAS-DEP. Among the 274 pairs of patients identified with propensity score matching, TCAR was associated with a lower risk of stroke/death (1.1% vs 4.7%; risk ratio [RR], 0.23; 95% CI, 0.06-0.81; P = .021) and stroke (0.4% vs 4.0%; RR, 0.09; 95% CI, 0.01-0.70; P = .006) compared with TCAS-DEP but no differences in stroke/death/MI (1.8% vs 4.7%; RR, 0.38; 95% CI, 0.15-1.02; P = .077). The secondary analysis found no differences in stroke between TCAS-DEP and transfemoral CAS with DEP (4.9% vs 3.7%; RR, 1.3; 95% CI, 0.36-1.63; P = .65). Conclusions Compared with TCAS-DEP, TCAR was associated with a lower risk of perioperative stroke or death and stroke. This finding implies that dynamic flow reversal might provide better neuroprotection than does a distal embolic filter in reducing the perioperative risk of stroke. Avoiding the aortic arch did not confer any reduction in the stroke rate. The present findings serve to separate the clinical benefit of dynamic flow reversal from that of avoiding the aortic arch during TCAR. |
| Databáze: | OpenAIRE |
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