Poor concordance between definitions of type III arch and implications for risk prediction and assessment for carotid artery stenting.

OBJECTIVE: The type III arch configuration has been inconsistently reported as a stroke risk factor during carotid artery stenting. However, at least three different methods for the definition of type III arch can be identified in the literature, related to the level of the origin of the innominate artery (IA). According to Casserly's definition, a type III arch presents with an origin of the IA below the horizontal plane of the inner curvature. According to Madhwal's definition, a type III arch has a distance greater than twice the diameter of the left common carotid artery between the highest point of the arch and the origin of the IA. According to MacDonald's definition, a type III arch presents with a distance of ≥2 cm between the highest point of the arch and the origin of the IA. Our aim was to assess the level of concordance between these different methods. METHODS: Anonymized thoracic computed tomography scans of 100 healthy patients were reviewed. Two of us independently stratified the selected cases as a type I to III arch, according to the three considered definitions. The interobserver level of concordance for each type III arch classification and level of concordance among the three definitions were assessed. RESULTS: The 100 selected patients (64% male) were 76 ± 7 years old. For each definition, the interobserver repeatability was almost perfect for all three (Madhwal, κ = 0.81; 95% confidence interval [CI], 0.71-0.99; MacDonald, κ = 0.82; 95% CI, 0.72-0.92; Casserly, κ = 0.84; 95% CI, 0.74-0.93). The level of concordance among the different definitions was very low (Madhwal vs MacDonald, 85% [P = .002]; 33% for type III arch; Madhwal vs Casserly, 60% [P < .0001]; 12% for type III arch; MacDonald vs Casserly, 75% [P < .0001]; 12% for type III arch). CONCLUSIONS: The three definitions of the type III arch have a very low level of concordance, which might account for the varying clinical relevance of this configuration. Our findings have relevant implications for risk prediction for carotid artery stenting based on the presence of a type III arch, for comparisons of the results from different studies, and for comparisons of different datasets from multicenter trials.

Assessment of long-term survival and stroke after carotid endarterectomy and carotid stenting in patients older than 80 years.

OBJECTIVE: The objective of this study was to analyze preoperative risk factors affecting long-term survival and the occurrence of stroke in patients older than 80 years undergoing either carotid endarterectomy (CEA) or carotid artery stenting (CAS) for carotid stenosis. METHODS: Data of all consecutive patients treated from January 1999 to December 2017 were retrospectively reviewed and outcomes analyzed. Kaplan-Meier analysis was used to estimate long-term survival and the risk of stroke for both groups. Cox proportional hazards analysis was used to assess the relative risk of all-cause mortality and long-term stroke for patients in the presence of selected comorbidities, including preoperative symptoms, coronary artery disease, chronic renal failure, atrial fibrillation (AF), hypertension, diabetes mellitus, and dyslipidemia. A P value <.05 was considered statistically significant. RESULTS: A total of 473 patients older than 80 years (298 men [63%]) underwent either CEA (n = 178) or CAS. At 30 days, one patient died in the CEA group of unrelated causes; no deaths were recorded after CAS (0.6% vs 0%; P = .18). At 5 years, survival was 67.6% ± 4.9% after CEA and 90.2% ± 2.3% after CAS (P < .0001). The main cause of death after CEA and CAS was a neoplasm. Estimated freedom from any stroke at 5 years was 97.3% ± 0.5% after CEA and 93.2% ± 1.2% after CAS (P = .07). The presence of preoperative AF significantly affected long-term mortality after CAS (hazard ratio [HR], 1.56; 95% confidence interval [CI], 1.34-1.98; P = .04) as well as being classified as American Society of Anesthesiologists class 3 at evaluation of the preoperative anesthesiology risk. The presence of preoperative AF was the only factor that significantly affected the occurrence of long-term stroke after both CAS (HR, 2.28; 95% CI, 1.86-5.63; P = .001) and CEA (HR, 3.45; 95% CI, 2.29-8.19; P = .005). CONCLUSIONS: Both CEA and CAS showed low 30-day mortality and any-stroke rates in patients older than 80 years. In the long term, survival was significantly better after CAS; however, deaths after CEA and CAS were mainly unrelated to the procedure. No significant differences were recorded in the occurrence of any stroke in the long term. The presence of preoperative AF significantly affected long-term survival after CAS as well as being classified as American Society of Anesthesiologists class 3 at evaluation of the preoperative anesthesiology risk. The presence of preoperative AF also significantly affected long-term risk of stroke after both CAS and CEA.

Appropriateness of Duplex ultrasound assessment on venous system of the legs: a two-month preliminary analysis.

AIM: The goal of this study is to evaluate the appropriateness to prescribe venous ultrasound of lower limbs. MATERIAL OF STUDY: Over a two months period, 1005 Duplex scans were performed by our Vascular Surgery Unit; out of the total, 225 exams were conducted on venous system of lower limbs. We retrospectively analyzed appropriateness of prescription (according to Lombardy District indications), urgency of prescription, time-lapse between application for the exams and its execution, positive or negative results, National Health System's sustained cost. RESULTS: During the above mentioned period, 87,5% of the exams were conducted as normal screening with no urgency characteristics, 61 exams (27%) were combined with arterial duplex of the same district. General Practitioners' requests accounted for 76,8% while only 9,7% were from vascular surgeons. Following indications of appropriateness, 117 exams (52%) were judged as appropriate. Combining appropriateness and result (χ2 test) we found that if the indication was inappropriate the negative result rate was 90,75%; in the group of exams prescribed with an urgent request the rate of appropriateness raised to 60,7% of whose 94.1% were pathologically positive. DISCUSSION: There is no evidence in Literature about appropriateness of prescription of Duplex ultrasound for vascular districts. While Lombardy District recently published guidelines for prescription, neither vascular surgeon societies nor National Health Service ever provided any indication. CONCLUSION: Nowadays there is increasing demand for appropriateness in healthcare. This study delivered such significant data to make it a pivotal study for an extended analysis during 2016. KEY WORDS: Appropriateness, Vascular Duplex Ultrasound, Venous System.