Patches of different types for carotid patch angioplasty.

BACKGROUND: Extracranial carotid artery stenosis is the major cause of stroke, which can lead to disability and mortality. Carotid endarterectomy (CEA) with carotid patch angioplasty is the most popular technique for reducing the risk of stroke. Patch material may be made from an autologous vein, bovine pericardium, or synthetic material including polytetrafluoroethylene (PTFE), Dacron, polyurethane, and polyester. This is an update of a review that was first published in 1996 and was last updated in 2010. OBJECTIVES: To assess the safety and efficacy of different types of patch materials used in carotid patch angioplasty. The primary hypothesis was that a synthetic material was associated with lower risk of patch rupture versus venous patches, but that venous patches were associated with lower risk of perioperative stroke and early or late infection, or both. SEARCH METHODS: We searched the Cochrane Stroke Group trials register (last searched 25 May 2020); the Cochrane Central Register of Controlled Trials (CENTRAL; 2020, Issue 4), in the Cochrane Library; MEDLINE (1966 to 25 May 2020); Embase (1980 to 25 May 2020); the Index to Scientific and Technical Proceedings (1980 to 2019); the Web of Science Core Collection; ClinicalTrials.gov; and the World Health Organization (WHO) International Clinical Trials Registry Platform (ICTRP) portal. We handsearched relevant journals and conference proceedings, checked reference lists, and contacted experts in the field. SELECTION CRITERIA: Randomised and quasi-randomised trials (RCTs) comparing one type of carotid patch with another for CEA. DATA COLLECTION AND ANALYSIS: Two review authors independently assessed eligibility, risk of bias, and trial quality; extracted data; and determined the quality of evidence using the GRADE approach. Outcomes, for example, perioperative ipsilateral stroke and long-term ipsilateral stroke (at least one year), were collected and analysed. MAIN RESULTS: We included 14 trials involving a total of 2278 CEAs with patch closure operations: seven trials compared vein closure with PTFE closure, five compared Dacron grafts with other synthetic materials, and two compared bovine pericardium with other synthetic materials. In most trials, a patient could be randomised twice and could have each carotid artery randomised to different treatment groups. Synthetic patch compared with vein patch angioplasty Vein patch may have little to no difference in effect on perioperative ipsilateral stroke between synthetic versus vein materials, but the evidence is very uncertain (odds ratio (OR) 2.05, 95% confidence interval (CI) 0.66 to 6.38; 5 studies, 797 participants; very low-quality evidence). Vein patch may have little to no difference in effect on long-term ipsilateral stroke between synthetic versus vein materials, but the evidence is very uncertain (OR 1.45, 95% CI 0.69 to 3.07; P = 0.33; 4 studies, 776 participants; very low-quality evidence). Vein patch may increase pseudoaneurysm formation when compared with synthetic patch, but the evidence is very uncertain (OR 0.09, 95% CI 0.02 to 0.49; 4 studies, 776 participants; very low-quality evidence). However, the numbers involved were small. Dacron patch compared with other synthetic patch angioplasty Dacron versus PTFE patch materials  PTFE patch may reduce the risk of perioperative ipsilateral stroke (OR 3.35, 95% CI 0.19 to 59.06; 2 studies, 400 participants; very low-quality evidence). PTFE patch may reduce the risk of long-term ipsilateral stroke (OR 1.52, 95% CI 0.25 to 9.27; 1 study, 200 participants; very low-quality evidence). Dacron may result in an increase in perioperative combined stroke and transient ischaemic attack (TIA) (OR 4.41 95% CI 1.20 to 16.14; 1 study, 200 participants; low-quality evidence) when compared with PTFE. Early arterial re-stenosis or occlusion (within 30 days) was also higher for Dacron patches. During follow-up for longer than one year, more 'any strokes' (OR 10.58, 95% CI 1.34 to 83.43; 2 studies, 304 participants; low-quality evidence) and stroke/death (OR 6.06, 95% CI 1.31 to 28.07; 1 study, 200 participants; low-quality evidence) were reported with Dacron patch closure, although numbers of outcome events were small. Dacron patch may increase the risk of re-stenosis when compared with other synthetic materials (especially with PTFE), but the evidence is very uncertain (OR 3.73, 95% CI 0.71 to 19.65; 3 studies, 490 participants; low-quality evidence). Bovine pericardium patch compared with other synthetic patch angioplasty Bovine pericardium versus PTFE patch materials  Evidence suggests that bovine pericardium patch results in a reduction in long-term ipsilateral stroke (OR 4.17, 95% CI 0.46 to 38.02; 1 study, 195 participants; low-quality evidence). Bovine pericardial patch may reduce the risk of perioperative fatal stroke, death, and infection compared to synthetic material (OR 5.16, 95% CI 0.24 to 108.83; 2 studies, 290 participants; low-quality evidence for PTFE, and low-quality evidence for Dacron; OR 4.39, 95% CI 0.48 to 39.95; 2 studies, 290 participants; low-quality evidence for PTFE, and low-quality evidence for Dacron; OR 7.30, 95% CI 0.37 to 143.16; 1 study, 195 participants; low-quality evidence, respectively), but the numbers of outcomes were small. The evidence is very uncertain about effects of the patch on infection outcomes. AUTHORS' CONCLUSIONS: The number of outcome events is too small to allow conclusions, and more trial data are required to establish whether any differences do exist. Nevertheless, there is little to no difference in effect on perioperative and long-term ipsilateral stroke between vein and any synthetic patch material. Some evidence indicates that other synthetic patches (e.g. PTFE) may be superior to Dacron grafts in terms of perioperative stroke and TIA rates, and both early and late arterial re-stenosis and occlusion. Pseudoaneurysm formation may be more common after use of a vein patch than after use of a synthetic patch. Bovine pericardial patch, which is an acellular xenograft material, may reduce the risk of perioperative fatal stroke, death, and infection compared to other synthetic patches. Further large RCTs are required before definitive conclusions can be reached.

A physician-led initiative to improve clinical documentation results in improved health care documentation, case mix index, and increased contribution margin.

INTRODUCTION: Clinical documentation is the key determinant of inpatient acuity of illness and payer reimbursement. Every inpatient hospitalization is placed into a diagnosis related group with a relative value based on documented procedures, conditions, comorbidities and complications. The Case Mix Index (CMI) is an average of these diagnosis related groups and directly impacts physician profiling, medical center profiling, reimbursement, and quality reporting. We hypothesize that a focused, physician-led initiative to improve clinical documentation of vascular surgery inpatients results in increased CMI and contribution margin. METHODS: A physician-led coding initiative to educate physicians on the documentation of comorbidities and conditions was initiated with concurrent chart review sessions with coding specialists for 3 months, and then as needed, after the creation of a vascular surgery documentation guide. Clinical documentation and billing for all carotid endarterectomy (CEA) and open infrainguinal procedures (OIPs) performed between January 2013 and July 2016 were stratified into precoding and postcoding initiative groups. Age, duration of stay, direct costs, actual reimbursements, contribution margin (CM), CMI, rate of complication or comorbidity, major complication or comorbidity, severity of illness, and risk of mortality assigned to each discharge were abstracted. Data were compared over time by standardizing Centers for Medicare and Medicaid Services (CMS) values for each diagnosis related group and using a CMS base rate reimbursement. RESULTS: Among 458 CEA admissions, postcoding initiative CEA patients (n = 253) had a significantly higher CMI (1.36 vs 1.25; P = .03), CM ($7859 vs $6650; P = .048), and CMS base rate reimbursement ($8955 vs $8258; P = .03) than precoding initiative CEA patients (n = 205). The proportion of admissions with a documented major complication or comorbidity and complication or comorbidity was significantly higher after the coding initiative (43% vs 27%; P < .01). Among 504 OIPs, postcoding initiative patients (n = 227) had a significantly higher CMI (2.23 vs 2.05; P < .01), actual reimbursement ($23,203 vs $19,909; P < .01), CM ($12,165 vs $8840; P < .01), and CMS base rate reimbursement ($14,649 vs $13,496; P < .01) than precoding initiative patients (n = 277). The proportion of admissions with a documented major complication or comorbidity and complication or comorbidity was significantly higher after the coding initiative (61% vs 43%; P < .01). For both CEA and OIPs, there were no differences in age, duration of stay, total direct costs, or primary insurance status between the precoding and postcoding patient groups. CONCLUSIONS: Accurate and detailed clinical documentation is required for key stakeholders to characterize the acuity of inpatient admissions and ensure appropriate reimbursement; it is also a key component of risk-adjustment methods for assessing quality of care. A physician-led documentation initiative significantly increased CMI and CM.

Resultados a corto y medio plazo en el tratamiento de estenosis carotídea sintomática mediante «stenting» versus endarterectomía carotídea / Early and mid-term results after stenting and endarterectomy in the treatment of symptomatic carotid stenosis

INTRODUCCIÓN: La estenosis de la arteria carótida interna de origen aterosclerótico es una de las principales causas de los ictus isquémicos. La tromboendarterectomía (TEA) carotídea es el tratamiento clásico para disminuir el riesgo de recurrencia de un nuevo ictus. Las técnicas endovasculares, como el stenting carotídeo están en auge. OBJETIVO: Describir nuestra experiencia en el tratamiento de estenosis carotídea sintomática mediante TEA carotídea y el implante de stent carotídeo. Nuestros objetivos principales son comparar: eventos neurológicos, infarto de miocardio y muerte a los 30 días postintervención. El objetivo secundario es reportar la incidencia de reestenosis severa (≥70%), reintervencion carotídea y mortalidad durante el seguimiento. MÉTODOS: Realizamos un estudio descriptivo de pacientes tratados entre los años 2008 y 2012. Analizamos un total de 86 pacientes, 61,6% (n = 53) recibieron TEA carotídea y 38,4% (n = 33) stent carotídeo. El diagnóstico de estenosis carotídea fue con ecografía-doppler, confirmado mediante arteriografía en el grupo con stent. RESULTADOS: Se registraron 2 casos de ictus en el grupo TEA carotídea frente a 4 en el grupo con stent (3,2 versus 12,1%, respectivamente). Aconteció un solo caso de infarto agudo de miocardio, no letal, en el grupo de TEA carotídea. La mortalidad a los 30 días fue de 1,9% (n = 1) en el grupo TEA carotídea en comparación con 3,0% (n = 1) en el grupo stent. Se registraron 7 casos de reestenosis crítica en el grupo de stent carotídeo, ninguno en el de TEA (p = 0,006). La mediana de seguimiento fue de 38,5 meses en el grupo TEA y 37,5 meses en grupo endovascular. CONCLUSIONES: Nuestra experiencia reporta mejores resultados en el corto y medio plazo, a favor de la TEA carotídea. Así, pensamos que la TEA carotídea debería seguir siendo el tratamiento de elección en pacientes con estenosis carotídea sintomáticos

INTRODUCTION: Atherothrombotic stenosis of the internal carotid artery is a common cause of stroke. Carotid endarterectomy (CEA) is the most common treatment for secondary stroke prevention. Carotid artery stenting is an alternative treatment. OBJECTIVE: To describe our experience of treating symptomatic carotid artery stenosis with CEA or carotid artery stenting. The primary outcomes were: 30-day stroke, myocardial infarction, or death. The secondary outcomes were severe restenosis (>70%), re-intervention, and death during mid-term follow-up. METHODS: Retrospective cohort study including patients treated between 2008 and 2012. A total of 86 patients were included, of which 61.6% (n = 53) received CEA, and a CAS technique in the remaining 38.4% (n = 33). Diagnosis was established by echo-Doppler, and confirmed with selective arteriography in the carotid artery stenting group. RESULTS: Two strokes were recorded in the CEA group, and 4 cases in the carotid artery stenting group (3.21 vs. 12.12%). There was one case of non-lethal myocardial infarction in the CEA group. The 30-day mortality rate was 1.9% (n = 1) in the CEA group, and 3.0% (n = 1) in the carotid artery stenting group. There were 7 cases of severe restenosis in the carotid artery stenting group, with no cases being reported in the CEA group (p=.006). The median follow-up was 38.5 months in the CEA group and 37.5 months in the carotid artery stenting group. CONCLUSION: Our study reports better results in the early and mid-term after CEA. Thus, it is concluded that CEA should remain the reference-standard treatment in symptomatic patients

Vigencia de la endarterectomía carotídea para el tratamiento de estenosis asintomática en la era de las estatinas / Effectiveness of carotid endarterectomy for asymptomatic carotid stenosis in the statins era

El beneficio de la endarterectomía carotídea en pacientes asintomáticos es actualmente cuestionado por la reducción observada en la tasa de infarto cerebral con tratamiento médico actual. Se realiza una revisión de la evidencia disponible. El uso perioperatorio de estatinas, mejor estandarización de técnica quirúrgica, concentración de endarterectomías en cirujanos de mayor volumen quirúrgico e identificación de pacientes de mayor riesgo han permitido una disminución paralela de los infartos postendarterectomía. Se ha identificado una subpoblación asintomática con mayor riesgo de desarrollar eventos neurológicos: estenosis carotídeas severas, rápida progresión de estenosis, presencia de infartos hemisféricos silentes, microembolias en doppler transcraneal, menor reserva cerebrovascular y placas inestables. El futuro de la endarterectomía carotídea radica en la identificación de lesiones de mayor riesgo de infarto y realizar cirugía con mínima morbimortalidad. Los estudios de imágenes han mostrado un rápido avance, pero se requiere de mejor validación antes de cambiar las guías de manejo vigentes

The benefit of carotid endarterectomy in asymptomatic patients is currently questioned, due to an observed reduction in stroke rate with current medical treatment. A review is carried out on the available evidence. The perioperative use of statins, better standardisation of surgical techniques, concentration of endarterectomy by surgeons with a higher surgical volume, and identification of high-risk patients, have led to a parallel decrease in post-endarterectomy stroke. An asymptomatic subpopulation has been identified with an increased risk of developing neurological events: severe carotid stenosis, rapid progression of stenosis, presence of silent hemispherical infarcts, micro-emboli in transcranial doppler, lower cerebrovascular reserve, and unstable plaques. The future of carotid endarterectomy in asymptomatic patients lies in the identification of lesions with increased risk of stroke and performing surgery with minimal morbidity and mortality. Imaging studies have rapidly progress, but better validation is required before changing current management guidelines

Trends in the in-hospital stroke rate following carotid endarterectomy in California and Maryland.

OBJECTIVE: We examined the outcome of carotid endarterectomy (CEA) in the state of Maryland during the last decade to identify any trends in the incidence of in-hospital stroke and mortality and compared these results with the outcome of the operation throughout the state of California as a control population. METHOD: We performed a retrospective analysis of 10 years (1994 to 2003) of the Maryland and 5 years (1999 to 2003) of the California hospital discharge databases. The following patients were included in the analysis: (1) International Classification of Diseases, 9th Revision, Clinical Modification (ICD-9-CM) procedure code 38.12 (endarterectomy of the vessels of the head and neck other than intracranial vessels) in the primary coding position but not in any secondary position, or (2) the diagnosis code 433.00 to 433.91 (occlusion/stenosis, precerebral artery), or (3) the diagnosis-related group (DRG) 5 (extracranial vascular procedure). Symptomatic patients were identified by history of previous stroke (ICD-9 codes 342 or 438), transient ischemic attack (435 or 781.4), or amaurosis fugax (362.34 or 368.12). In-hospital strokes were identified by ICD-9 codes 997.0, 997.00, 997.01, and 997.09. Low-, moderate-, and high-volume surgeons were defined as performing <15, 15 to 74 and >or=75 CEAs annually. Hospital volumes were similarly classified as low for those performing 100 annually. RESULTS: In the Maryland data, 23,237 CEA cases were identified with 169 in-hospital strokes over 10 years (0.73%), whereas the 51,331 California CEAs had 232 in-hospital strokes over 5 years (0.45%). The stroke rate in Maryland was 2.12% in 1994, 1.47% in 1995, and 0.29% to 0.65% from 1996 to 2003. The decrease in strokes was more pronounced among symptomatic patients, where the rate was 3.82% in 1994, 4.44% in 1995, and 0.90% to 2.29% from 1996 to 2003. A similar decrease was identified in the asymptomatic patient population but was less pronounced: 1.64% in 1994, 0.81% in 1995, and 0.15% to 0.44% from 1996 to 2003. The low recent stroke rates were confirmed by the California data (0.44% to 0.48% from 1999 to 2003). Changes in the death rate for CEA during this time frame have not been as pronounced, from 0.33% to 0.58% for Maryland and 0.78% to 0.91% for California. CONCLUSIONS: A dramatic decrease in the in-hospital stroke rates in Maryland occurred around 1995. The stroke rates in Maryland in the past 5 years are similar to those in California during the same period. An analysis of data from the two states shows that the in-hospital stroke rate now for carotid endarterectomy is approximately 0.54%.