Intravascular lithotripsy in peripheral lesions with severe calcification and its use in TAVI procedure - a meta-analysis.

Background: Heavily calcified peripheral artery lesions increase the risk of vascular complications, constituting a severe challenge for the operator during catheter-based cardiovascular interventions. Intravascular Lithotripsy (IVL) technology disrupts subendothelial calcification by using localized pulsative sonic pressure waves and represents a promising technique for plaque modification in patients with severe calcification in peripheral arteries. Purpose: Our aim was to systematically review and summarize available data regarding the safety and efficacy of IVL in preparing severely calcified peripheral arteries and its use in Transcatheter Aortic Valve Implantation (TAVI). Patients and methods: This study was conducted according to the PRISMA guidelines. We systematically searched PubMed, SCOPUS, and Cochrane databases from their inception to February 23, 2023, for studies assessing the characteristics and outcomes of patients undergoing IVL in the peripheral vasculature. The diameter of the vessel lumen before and after IVL was estimated. The occurrence of peri-procedural complications was assessed using a random-effects model. Results: 20 studies with a total of 1,223 patients with heavily calcified peripheral lesions were analysed. The mean age of the cohort was 70.6 ± 17.4 years. Successful IVL delivery achieved in 100% (95% CI: 100%-100%, I2 = 0%), with an increase in the luminal diameter (SMD: 4.66, 95% CI: 3.41-5.92, I2 = 90.8%) and reduction in diameter stenosis (SMD: -4.15, 95% CI: -4.75 to -3.55, I2 = 92.8%), and a concomitant low rate of complications. The procedure was free from dissection in 97% (95% CI: 91%-100%, I2 = 81.4%) while dissections of any type (A, B, C, or D) were observed in 6% (95% CI: 2%-10%, I2 = 85.3%) of the patients. Several rare cases of abrupt closure, no-reflow phenomenon, perforation, thrombus formation, and distal embolization were recorded. Finally, the subgroup analysis of patients who underwent a TAVI with IVL assistance presented successful implantation in 100% (95% CI: 100%-100%, I2 = 0%) of the cases, with only 4% (95% CI: 0%-12%, I2 = 68.96%) presenting dissections of any sort. Conclusions: IVL seems to be an effective and safe technique for modifying severely calcified lesions in peripheral arteries and it is a promising modality in TAVI settings. Future prospective studies are needed to validate our results.

Efficacy of intravascular lithotripsy (IVL) in coronary stenosis with severe calcification: A multicenter systematic review and meta-analysis.

BACKGROUND: With heavily calcified coronary and peripheral artery lesions, lesion preparation is crucial before stent placement to avoid underexpansion, associated with stent thrombosis or restenosis and patency failure in the long-term. Intravascular lithotripsy (IVL) technology disrupts superficial and deep calcium by using localized pulsative sonic pressure waves, making it to a promising tool for patients with severe calcification in coronary bed. AIMS: The aim of the study is to systematically review and summarize available data regarding the safety and efficacy of IVL for lesion preparation in severely calcified coronary arteries before stenting. METHODS: This study was conducted according to the PRISMA guidelines. We systematically searched PubMed, SCOPUS, and Cochrane databases from their inception to February 23, 2023, for studies assessing the characteristics and outcomes of patients undergoing IVL before stent implantation. The diameter of the vessel lumen before and after IVL, as well as stent implantation, were analyzed. The occurrence of major adverse cardiovascular events (MACE) was assessed using a random-effects model. RESULTS: This meta-analysis comprised 38 studies including 2977 patients with heavily calcified coronary lesions. The mean age was 72.2 ± 9.1 years, with an overall IVL clinical success of 93% (95% confidence interval [CI]: 91%-95%, I2 = 0%) and procedural success rate of 97% (95% CI: 95%-98%, I2 = 73.7%), while the in-hospital and 30-days incidence of MACE, myocardial infarction (MI), and death were 8% (95% CI: 6%-11%, I2 = 84.5%), 5% (95% CI: 2%-8%, I2 = 85.6%), and 2% (95% CI: 1%-3%, I2 = 69.3%), respectively. There was a significant increase in the vessel diameter (standardized mean difference [SMD]: 2.47, 95% CI: 1.77-3.17, I2 = 96%) and a decrease in diameter stenosis (SMD: -3.44, 95% CI: -4.36 to -2.52, I2 = 97.5%) immediately after IVL application, while it was observed further reduction in diameter stenosis (SMD: -6.57, 95% CI: -7.43 to -5.72, I2 = 95.8%) and increase in the vessel diameter (SMD: 4.37, 95% CI: 3.63-5.12, I2 = 96.7%) and the calculated lumen area (SMD: 3.23, 95% CI: 2.10-4.37, I2 = 98%), after stent implantation. The mean acute luminal gain following IVL and stent implantation was estimated to be 1.27 ± 0.6 and 1.94 ± 1.1 mm, respectively. Periprocedural complications were rare, with just a few cases of perforations, dissection, or no-reflow phenomena recorded. CONCLUSIONS: IVL seems to be a safe and effective strategy for lesion preparation in severely calcified lesions before stent implantation in coronary arteries. Future prospective studies are now warranted to compare IVL to other lesion preparation strategies.

Ethnic and sex-based differences in outcomes after out-of-hospital cardiac arrest: a glimpse of the largest municipal healthcare system in the United States.

Background: Ethnic and sex-based disparity in outcomes after out-of-hospital cardiac arrest (OHCA) may exist and could be due to social factors and inequality in care. We aimed to study whether ethnic and sex-based differences in out-of-hospital cardiac arrest outcomes occurred in a safety net hospital within the largest municipal healthcare system in the United States. Methods: We conducted a retrospective cohort study of patients successfully resuscitated from an OHCA and brought to New York City Health + Hospitals/Jacobi, from January 2019 to September 2021. Out-of-hospital cardiac arrest characteristics, do not resuscitate and withdrawal of life-sustaining therapy orders, and disposition data were collected and analyzed using regression models. Results: Out of 648 patients screened, 154 were included (48.1% women). On multivariable analysis, sex [odds ratio (OR): 0.84; 95% CI: 0.30-2.4; P=0.74] and ethnic background (OR: 0.80; 95% CI: 0.58-1.12; P=0.196) did not predict discharge survival. No significant sex difference in do not resuscitate (P=0.76) or withdrawal of life-sustaining therapy (P=0.39) orders was found. Younger age (OR: 0.96; P=0.04) and initial shockable rhythm (OR: 7.26; P=0.01) independently predicted survival, both at discharge and at one year. Conclusions: Among patients resuscitated after an out-of-hospital cardiac arrest, neither sex nor ethnic background predicted discharge survival and no sex differences in end-of-life preferences were found. These findings are distinct from those of previously published reports. Given the unique population studied, distinct from those of registry-based studies, socioeconomic factors likely served as bigger drivers of out-of-hospital cardiac arrest outcomes rather than ethnic background or sex.

Hybrid coronary revascularization (HCR) versus coronary artery bypass grafting (CABG) in multivessel coronary artery disease (MVCAD): A meta-analysis of 14 studies comprising 4226 patients.

OBJECTIVES: To compare the outcomes of hybrid coronary revascularization (HCR) with traditional coronary artery bypass grafting (CABG) in multivessel coronary artery disease (MVCAD). BACKGROUND: HCR has emerged as an alternative to CABG in patients with MVCAD. Through minimally invasive surgical techniques, HCR carries the potential for faster recovery postoperatively, fewer complications, and lower utilization of resources. METHODS: Systematic search of electronic databases was conducted up to December 2021 and studies comparing HCR with CABG in the treatment of MVCAD were included in this meta-analysis. Primary outcomes of interest were incidence of 5-year mortality and major adverse cardiac and cerebral event (MACCE). RESULTS: Fourteen studies (12 observational studies and 2 randomized controlled trials) comprising 4226 patients were included. The rates of 5-year mortality (odds ratios [OR]: 1.55; 95% confidence interval [CI]: 0.92-2.62; I2 = 83.0%) and long-term MACCE (OR: 0.97; 95% CI: 0.47-2.01; I2 = 74.7%) were comparable between HCR and CABG groups. HCR was associated with a significantly lower likelihood of perioperative blood transfusion (OR: 0.36; 95% CI: 0.25-0.51; I2 = 55.9%), shorter mean hospital stay (weighted mean difference: -2.04; 95% CI: -2.60 to -1.47; I2 = 54%), and risk of postoperative acute kidney injury (OR: 0.45; 95% CI: 0.23-0.88; p = 0.02). CABG demonstrated a lower likelihood of requiring long-term repeat revascularization (OR: 1.51; 95% CI: 1.03-2.20; I2 = 18%) over a follow-up duration of 29.14 ± 21.75 months. CONCLUSION: This meta-analysis suggests that HCR is feasible and safe for the treatment of MVCAD. However, benefits of HCR should be carefully weighed against the increased long-term risk of repeat-revascularization when selecting patients, and further studies evaluating differences in long-term mortality between HCR and CABG are required.

Embolic protection devices for carotid artery stenting: A network meta-analysis.

OBJECTIVES: Carotid artery stenting (CAS) is an alternative treatment option for patients at high risk for carotid endarterectomy (CEA) but has been correlated with increased risk for distal embolization and periprocedural stroke despite the use of adjunctive embolic protection devices (EPD). This study compared four types of EPDs and their intra and periprocedural related complications. METHODS: A systematic review of the literature was conducted in PubMed/Medline to identify studies that investigated the outcomes of CAS with adjuvant use of EPDs, including Proximal Balloon (PB), Distal Filter (DF), and Distal Balloon (DB) strategy. Continuous flow reversal performed via transcarotid approach by a commercially available device as an embolic protection strategy was intentionally excluded based on its distinct procedural characteristics and lack of availability outside of the United States. This network meta-analysis was performed according to the PRISMA (Preferred Reporting Items for Systematic reviews and Meta-Analyses) guidelines. RESULTS: Overall, 45 studies, consisting of 7600 participants satisfied the predetermined search criteria and were included in this network meta-analysis. Overall, 13 studies provided data regarding the number of patients with new ischemic lesions detected in the DW-MRI. DF (OR: 3.15; 95% CI: 1.54-6.44; p = 0.002) and DB (OR: 2.28; 95% CI: 1.58-3.29; p < 0.001) were associated with higher odds of new ischemic lesions compared to PB on DW-MRI imaging. No statistical difference was identified between DB versus DF groups (OR: 1.48; 95% CI: 0.73-2.59; p = 0.317). 36 and 27 studies reported on periprocedural stroke and transient ischemic attack (TIA) rates, respectively, showing similar odds of neurologic adverse events between all three groups. CONCLUSIONS: PB deployment during CAS is superior to DF and DB in preventing distal embolization phenomena. However, no statistically significant difference in TIA and stroke rate was found among any of the analyzed EPD groups. Further research is warranted to investigate the association of embolic phenomena on imaging after CAS with clinically significant neurologic deficits.

Percutaneous coronary intervention versus coronary artery bypass graft surgery in dialysis-dependent patients: A pooled meta-analysis of reconstructed time-to-event data.

OBJECTIVE: Το perform a systematic review with meta-analysis of published data comparing outcomes between a percutaneous coronary intervention (PCI) and coronary artery bypass grafting (CABG) in dialysis-dependent patients. METHODS: We searched PubMed, Scopus, and Cochrane databases for studies including dialysis-dependent patients who underwent either CABG or PCI. This meta-analysis follows the recommendations of the Preferred Reporting Items for Systematic Reviews and Meta-Analyses statement. We conducted one-stage and two-stage meta-analysis with Kaplan-Meier-derived individual patient data for overall survival and meta-analysis with the random-effects model for the in-hospital mortality and repeat revascularization. RESULTS: Twelve studies met our eligibility criteria, including 13,651 and 28,493 patients were identified in the CABG and PCI arms, respectively. Patients who underwent CABG had overall improved survival compared with those who underwent PCI at the one-stage meta-analysis (hazard ratio [HR]: 1.12, 95% confidence interval [CI]: 1.09-1.16, p < .0001) and the two-stage meta-analysis (HR: 1.15, 95% CI: 1.08-1.23, p < .001, I2 = 30.0%). Landmark analysis suggested that PCI offers better survival before the 8.5 months of follow-up (HR: 0.96, 95% CI: 0.92-0.99, p = .043), while CABG offers an advantage after this timepoint (HR: 1.3, 95% CI: 1.22-1.32, p < .001). CABG was associated with increased odds for in-hospital mortality (odds ratio [OR]: 1.70, 95% CI: 1.50-1.92, p < .001, I2 = 0.0%) and decreased odds for repeat revascularization (OR: 0.22, 95% CI: 0.14-0.34, p < .001, I2 = 58.08%). CONCLUSIONS: In dialysis-dependent patients, CABG was associated with long-term survival but a higher risk for early mortality. The risk for repeat revascularization was higher with PCI.

Epidemiologic and clinical characteristics of infective endocarditis: a single-center retrospective study in the Bronx, New York.

OBJECTIVE: There is paucity of data on the epidemiological, microbiological, and clinical characteristics of patients admitted with infective endocarditis (IE) in the Bronx, New York. PATIENT AND METHODS: We conducted a retrospective study at Jacobi Medical Center, a tertiary care hospital in the Bronx. All adult patients who were hospitalized with a primary diagnosis of new-onset IE between January 1st, 2010 and September 30th, 2020 were included. The primary outcome was in-hospital mortality. A logistic regression model was used to identify baseline variables associated with in-hospital mortality. RESULTS: 182 patients were included in this analysis (female sex: 38.5%, median age: 54 years). 46 patients (25.3%) reported intravenous drug use. 153 patients (84.1%) had positive blood cultures. Staphylococcus aureus (S. aureus) was the most common isolated pathogen (45.1% of monomicrobial IE). Nearly half of the cases secondary to S. aureus were methicillin resistant Staphylococcus aureus (MRSA) (34/69). 164 patients (90.1%) were diagnosed with native valve IE. The mitral valve was involved in 32.4% of patients followed by the aortic valve (19.8%). The in-hospital mortality was 18.1%. The mortality was higher in the cohort 2010-2015 compared to the cohort 2016-2020 (22.1% vs 14.6%). Increasing age, MRSA IE, and active malignancy were the only variables found to have significant association with in-hospital death. CONCLUSION: S. aureus was the most common causative agent and MRSA accounted for about half of the S. aureus IE cases. The incidence of IE in patients with intravenous drug use increased over time, while the median age decreased. The in-hospital death rate was higher in 2010-2015 compared to 2016-2020.

Invasive and Pharmacological Treatment of Deep Vein Thrombosis: A Scoping Review.

The annual occurrence of venous thromboembolism (VTE) is 300,000-600,000 cases in the United States and 700,000 in Europe. VTE includes deep venous thrombosis (DVT) of upper or lower extremities, superior and inferior vena cava thrombosis, and pulmonary embolism (PE) as well. The primary treatment of DVT includes oral anticoagulation to prevent the progression of the thrombus and decrease the risk of pulmonary embolism. Depending on the symptoms, more invasive treatments can be applied to target the iliofemoral thrombus and its removal. However, less emphasis is given to acute symptomatology, early recovery of function, quality of life improvement, and the individualized likelihood of developing post-thrombotic syndrome. While invasive therapy has been used to enhance the acute management of iliofemoral DVT, our knowledge about the overall outcomes associated with the invasive treatment of VTE is still limited. In this review, we illustrate the available data on pharmacological and endovascular management of iliofemoral VTE, including therapies such as catheter-directed thrombolysis (CDT), mechanical thrombectomy (PMT), and pharmacomechanical catheter-directed thrombolysis (PCDT).

Advances in treatment of chronic thromboembolic pulmonary hypertension.

Chronic Thromboembolic Pulmonary Hypertension (CTEPH) is a progressive pulmonary vascular disease which can lead to right heart failure and death, if left untreated. CTEPH is caused by persistent obstruction of large, middle-sized, or distal pulmonary arteries due to limited thromboembolic resolution in the pulmonary vascular arterial tree. Every patient with CTEPH should undergo evaluation for Pulmonary Endarterectomy (PEA) after referral to institutions with an experienced multidisciplinary CTEPH team. Although management of distal thromboembolic lesions with PEA remains a challenge due to their difficult accessibility, limited distal CTEPH is not considered an absolute contraindication for PEA, as more expertise surgical teams operate on them successfully. Furthermore, in up to 30-50% of patients who undergo PEA, curative treatment is not achieved due to incomplete thrombi removal or extensive pulmonary microvascular disease. Medical therapies that target the underlying pulmonary microvascular disease can offer symptomatic and hemodynamic benefits, although they do not deal with the core mechanism of the disease which is the removal of thromboembolic material from pulmonary vasculature. Recent research has provided evidence suggesting balloon pulmonary angioplasty (BPA) is a reasonable treatment option for inoperable CTEPH and recurrent/persistent pulmonary hypertension after PEA. Advancements in diagnostic modalities and refinements of BPA technique have decreased the complication rate and increased its beneficial effects in hemodynamics, symptoms, right ventricular function and long-term survival. Ongoing trials and future prospective cohorts will provide evidence regarding the optimal selection of patients and lesions prone to BPA treatment along with hybrid therapeutic strategies combining pharmacological therapy, PEA and BPA, which can potentially change the standard of care in CTEPH.

Diagnostic accuracy of coronary computed tomography angiography in ischemic workup of heart failure: a meta-analysis.

Aim: The role of coronary computed tomography angiography (CCTA) in evaluating the etiology of heart failure with reduced ejection fraction (HFrEF) is unclear. This is a meta-analysis assessing the pooled diagnostic accuracy of CCTA in diagnosing significant coronary artery disease in HFrEF. Materials & methods: Electronic databases were searched for studies comparing CCTA with invasive coronary angiography in HFrEF. A random-effects model meta-analysis was conducted. Results: Five studies comprising 269 patients were included. On patient-based analysis, pooled sensitivity and specificity of CCTA were 0.99 (95% CI: 0.94-1.00) and 0.94 (95% CI: 0.90-0.97), respectively. On segment-based analysis, pooled sensitivity and specificity were 0.74 (95% CI: 0.67-0.80) and 0.99 (95% CI: 0.98-0.99), respectively. Conclusion: CCTA has excellent diagnostic accuracy in diagnosing significant coronary artery disease in newly diagnosed HFrEF.

The role of 'CAT scan,' a computerized series of x-rays, in determining the cause of heart failure with low pumping capacity of the heart is unclear. We conducted a study to assess the accuracy of CAT scan in diagnosing significant blockage of blood vessels supplying the heart muscle. We searched electronic databases for studies comparing the accuracy of CAT scan with another procedure that injects a special dye into blood vessels to visualize blockage of the blood vessels supplying the heart muscle, specifically in patients with heart failure. On statistically analysis, CAT scan was found to be highly accurate in diagnosing significant blockage of these blood vessels in patients with heart failure.

A Systematic Review and Meta-Analysis on the Efficacy and Safety of Direct Oral Anticoagulants in Patients with Peripheral Artery Disease.

BACKGROUND: PAD is a significant cause of morbidity and mortality affecting over 200 million people worldwide. Current guidelines recommend at least a single antiplatelet or anticoagulant agent in symptomatic PAD and lifelong antithrombotic treatment after a revascularization procedure. The aim of this systematic review and meta-analysis was to investigate the efficacy and safety of direct oral anticoagulants (DOACs) in patients with peripheral artery disease (PAD). PAD is a significant cause of morbidity and mortality affecting over 200 million people worldwide. METHODS: The present systematic review and meta-analysis was performed according to the Preferred Reporting Items for Systematic reviews and Meta-Analyses guidelines. Risk ratios (RR) were calculated using the random effects model. RESULTS: Overall, 10 studies were included in this systematic review and meta-analysis. In 4 studies, 14,257 patients with PAD were enrolled and they were assigned to receive either aspirin (ASA)+/- clopidogrel (N = 5,894) or DOAC+/- anti-platelet (e.g., ASA, clopidogrel) (n = 8,363). Non DOAC users were found to have higher reintervention rates (RR 1.12; 95% CI 1.01-1.24; P = 0.025) compared to DOAC users. No statistically significant difference was observed between the 2 groups, in terms of major bleeding (RR 0.78; 95% CI 0.50-1.23; P = 0.285), all-cause mortality (RR 0.98; 95% CI: 0.83-1.16; P = 0.818) and cardiovascular mortality (RR: 0.99; 95% CI: 0.73-1.333; P = 0.946) mortality. In addition, two real-world studies comparing DOAC with warfarin showed decreased rates of major cardiovascular events in the DOAC group. CONCLUSION: DOAC use alone or combined with an anti-platelet agent could be associated with lower re-intervention rates, without increasing the risk for adverse bleeding events. However, this study failed to detect any difference in terms of all-cause mortality, MACEs and MALEs between DOAC users and DOAC naïve patients. Future studies are needed to better determine the efficacy and safety of DOACs in patients with PAD.

Atrial Fibrillation Following Coronary Artery Bypass Graft: Where Do We Stand?

Atrial fibrillation (AF) is the most common atrial arrhythmia following coronary artery bypass graft (CABG). Its prevalence is 15-45% and is associated with poor long-term prognosis. Risk factors can be patient-related, intraoperative, and/or postoperative. Therapeutic and preventive strategies have been developed to curtail AF burden. Cardioversion is recommended for unstable or symptomatic patients and rate control if asymptomatic. Anticoagulation is challenging with risk of thromboembolism and bleeding. However, patients should be anticoagulated after cardioversion or if AF persists >48 h and risk factors of stroke exist. A minimum of 4 weeks is recommended but longer duration should be considered in patients at high risk of stroke irrespective of recurrence of AF.

Effect of Hydroxychloroquine on QTc in Patients Diagnosed with COVID-19: A Systematic Review and Meta-Analysis.

BACKGROUND: Hydroxychloroquine or chloroquine with or without the concomitant use of azithromycin have been widely used to treat patients with SARS-CoV-2 infection, based on early in vitro studies, despite their potential to prolong the QTc interval of patients. OBJECTIVE: This is a systematic review and metanalysis designed to assess the effect of hydroxychloroquine with or without the addition of azithromycin on the QTc of hospitalized patients with COVID-19. MATERIALS AND METHODS: PubMed, Scopus, Cochrane and MedRxiv databases were reviewed. A random effect model meta-analysis was used, and I-square was used to assess the heterogeneity. The prespecified endpoints were ΔQTc, QTc prolongation > 500 ms and ΔQTc > 60 ms. RESULTS: A total of 18 studies and 7179 patients met the inclusion criteria and were included in this systematic review and meta-analysis. The use of hydroxychloroquine with or without the addition of azithromycin was associated with increased QTc when used as part of the management of patients with SARS-CoV-2 infection. The combination therapy with hydroxychloroquine plus azithromycin was also associated with statistically significant increases in QTc. Moreover, the use of hydroxychloroquine alone, azithromycin alone, or the combination of the two was associated with increased numbers of patients that developed QTc prolongation > 500 ms. CONCLUSION: This systematic review and metanalysis revealed that the use of hydroxychloroquine alone or in conjunction with azithromycin was linked to an increase in the QTc interval of hospitalized patients with SARS-CoV-2 infection that received these agents.

Transcervical carotid artery revascularization: A systematic review and meta-analysis of outcomes.

OBJECTIVE: Carotid artery stenosis is considered a determinant factor for cerebrovascular events, estimated to be the cause of 10% to 20% of all ischemic strokes. Transcervical carotid artery revascularization (TCAR) has been offered as an alternative to transfemoral carotid artery stenting and carotid endarterectomy to treat carotid artery stenosis. METHODS: We performed a systematic review and meta-analysis of prospective and retrospective studies reporting the outcomes of patients who had undergone TCAR for carotid artery stenosis. The incidence of periprocedural adverse events was calculated. RESULTS: A total of 45 studies with 14,588 patients met the predefined eligibility criteria and were included in the present meta-analysis. The technical success rate was 99% (95% confidence interval [CI], 98%-99%). The reasons for technical failure included an inability to cross the lesion and/or failure to deploy the stent. Access site complications occurred in 2% of all cases (95% CI, 1%-2%; 30 studies). Overall, the incidence of cranial nerve (CN) injuries was very rare, with only 33 of 8994 patients experiencing neurologic deficits attributed to CN involvement. Bleeding complications were reported by 20 studies and occurred in 2% (95% CI, 1%-3%) of all cases. The overall periprocedural all-cause mortality and stroke rate was 0.5% and 1.3%, respectively. In-stent restenosis was observed in 4 of 260 patients (1.5%; 7 studies), and early (30-day) reocclusion or acute thrombosis of the target lesion occurred in 12 of 1243 patients (∼1%; 11 studies). CONCLUSIONS: The results from the present study have provided significant evidence that TCAR is a very promising and safe carotid revascularization approach with favorable technical success rates associated with low periprocedural stroke and CN injury rates.

Revascularization approaches in patients with radiation-induced carotid stenosis: an updated systematic review and meta-analysis.

BACKGROUND: Ionizing radiation remains a well-known risk factor of carotid artery stenosis. The survival rates of head and neck cancer patients undergoing radiotherapy have risen owing to medical advancements in the field. As a consequence, the incidence of carotid artery stenosis in these high-risk patients has increased. AIMS: In this study we sought to compare the outcomes of carotid endarterectomy (CEA) vs carotid artery stenting (CAS) for radiation-induced carotid artery stenosis. METHODS: This study was performed according to the Preferred Reporting Items for Systematic reviews and Meta-Analyses guidelines. Eligible studies were identified through a comprehensive search of PubMed, Scopus and Cochrane Central until July 2020. A random-effects model meta-analysis was conducted, and odds ratios (ORs) were calculated. The I-square statistic was used to assess for heterogeneity. RESULTS: Seven studies and 201 patients were included. Periprocedural stroke, myocardial infarction (MI), and death rates were similar between the two revascularization approaches. However, the risk for cranial nerve (CN) injury was higher in the CEA group (OR, 7.40; 95% CI, 1.58-34.59; I2 = 0%). Analysis revealed no significant difference in terms of long-term mortality (OR, 0.41; 95% CI, 0.14-1.16; I2 = 0%) and restenosis rates (OR, 0.69; 95% CI, 0.29-1.66; I2 = 0%) between CEA and CAS after a mean follow-up of 40.5 months. CONCLUSIONS: CAS and CEA appear to have a similar safety and efficacy profile in patients with radiation-induced carotid artery stenosis. Patients treated with CEA have a higher risk for periprocedural CN injuries. Future prospective studies are warranted to validate these results.

Repeat Coronary Artery Bypass Grafting: A Meta-Analysis of Off-Pump versus On-Pump Techniques in a Large Cohort of Patients.

BACKGROUND: Redo coronary artery bypass grafting (CABG) can be performed with either the off-pump (OPCAB) or the on-pump (ONCAB) technique. METHOD: Following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA), this meta-analysis compared the safety and efficacy of OPCAB versus ONCAB redo CABG. RESULTS: Twenty-three (23) eligible studies were included (OPCAB, n=2,085; ONCAB, n=3,245). Off-pump CABG significantly reduced the risk of perioperative death (defined as in-hospital or 30-day death rate), myocardial infarction, atrial fibrillation, and acute kidney injury. The two treatment approaches were comparable regarding 30-day stroke and late all-cause mortality. CONCLUSIONS: Off-pump redo CABG resulted in lower perioperative death and periprocedural complication rates. No difference was observed in perioperative stroke rates and long-term survival between the two techniques.