Multifocal arterial disease: clinical implications and management.

PURPOSE OF REVIEW: Vascular disease often affects more than one territory. Atherosclerosis is a global disease affecting multiple organs/systems. Cardiovascular risk factors are associated with an increased risk for the development of arterial disease in all vascular beds but differ in their individual impacts for each vascular bed. We discuss the various options to identify and manage multifocal arterial disease. RECENT FINDINGS: Coronary artery disease may coexist with carotid artery stenosis, abdominal aortic aneurysms, and/or peripheral artery disease (PAD). Atherosclerotic renal artery stenosis and renal function impairment may complicate PAD. Recent studies have confirmed that patients with multivascular bed disease have higher risk than patients with monovascular disease. In addition to the specific surgical/endovascular therapeutic options available, aggressive medical treatment and vascular disease prevention strategies should be rigorously implemented to best manage the overall atherosclerotic burden. SUMMARY: A holistic approach is essential to reduce the cardiovascular morbidity and mortality rates of vascular patients. Preventive measures should complement surgical/endovascular procedures so as to improve outcomes.

Carotid Stenting Prior to Coronary Bypass Surgery: An Updated Systematic Review and Meta-Analysis.

OBJECTIVES: The aim was to determine 30-day outcomes in patients with concurrent carotid and cardiac disease who underwent carotid artery stenting (CAS) followed by coronary artery bypass grafting (CABG). METHODS: This was a systematic review with searches of PubMed/Medline, Embase, and Cochrane databases. "Same-day" procedures involved CAS + CABG being performed on the same day, and "staged" interventions involved at least 1 day's delay between undergoing CAS and then CABG. RESULTS: There were 31 eligible studies (2727 patients), with 80% being neurologically asymptomatic with unilateral stenoses. Overall, the 30-day death/stroke rate was 7.9% (95% confidence interval [CI] 6.9-9.2), while death/stroke/MI was 8.8% (95% CI 7.3-10.5). Staged CAS + CABG was associated with 30-day death/stroke rate of 8.5% (95% CI 7.3-9.7) compared with 5.9% (95% CI 4.0-8.5) after "same-day" procedures. Outcomes following CAS + CABG in neurologically symptomatic patients were poorer, with procedural stroke rates of 15%. There were five antiplatelet (APRx) strategies: (a) no APRx (death/stroke/MI, 4.2%; no data on bleeding complications); (b) single APRx before CAS and CABG, then dual APRx after CABG (death/stroke/MI, 6.7%; 7.3% bleeding complications); (c) dual APRx pre-CAS down to one APRx pre-CABG (death/stroke/MI, 10.1%; 2.8% bleeding complications); (d) dual APRx pre-CAS, both stopped pre-CABG (death/stroke/MI, 14.4%); (e) dual APRx pre-CAS and continued through CABG (death/stroke/MI, 16%). There were insufficient data on bleeding complication in the last two strategies. CONCLUSIONS: In a cohort of predominantly asymptomatic patients with unilateral carotid stenoses, the 30-day rate of death/stroke was about 8%. Notwithstanding the effect of potential biases, this meta-analysis did not find evidence that outcomes after same-day CAS + CABG were higher than after staged interventions. However, outcomes were poorer in neurologically symptomatic patients. More data are required to establish the optimal antiplatelet strategy in patients undergoing same-day or staged CAS + CABG.

Editor's Choice - Delays to Surgery and Procedural Risks Following Carotid Endarterectomy in the UK National Vascular Registry.

OBJECTIVE: Guidelines recommend that patients suffering an ischaemic transient ischaemic attack (TIA) or stroke caused by carotid artery stenosis should undergo carotid endarterectomy (CEA) within 14 days. METHOD: The degree to which UK vascular units met this standard was examined and whether rapid interventions were associated with procedural risks. The study analysed patients undergoing CEA between January 2009 and December 2014 from 100 UK NHS hospitals. Data were collected on patient characteristics, intervals of time from symptoms to surgery, and 30-day postoperative outcomes. The relationship between outcomes and time from symptom to surgery was evaluated using multilevel multivariable logistic regression. RESULTS: In 23,235 patients, the median time from TIA/stroke to CEA decreased over time, from 22 days (IQR 10-56) in 2009 to 12 days (IQR 7-26) in 2014. The proportion of patients treated within 14 days increased from 37% to 58%. This improvement was produced by shorter times across the care pathway: symptoms to referral, from medical review to being seen by a vascular surgeon, and then to surgery. The spread of the median time from symptom to surgery among NHS hospitals shrank between 2009 and 2013 but then grew slightly. Low-, medium-, and high-volume NHS hospitals all improved their performance similarly. Performing CEA within 48 h of symptom onset was associated with a small increase in the 30-day stroke and death rate: 3.1% (0-2 days) compared with 2.0% (3-7 days); adjusted odds ratio 1.64 (95% CI 1.04-2.59) but not with longer delays. CONCLUSIONS: The delay from symptom to CEA in symptomatic patients with ipsilateral 50-99% carotid stenoses has reduced substantially, although 42% of patients underwent CEA after the recommended 14 days. The risk of stroke after CEA was low, but there may be a small increase in risk during the first 48 h after symptoms.

Fate of Distal False Aneurysms Complicating Internal Carotid Artery Dissection: A Systematic Review.

BACKGROUND: False aneurysm formation occurs in 13-49% of internal carotid artery dissections (ICADs). In light of the uncertainty regarding the clinical course, expansion rates and optimal treatment of post-ICAD false aneurysms, a systematic review of the literature was undertaken to establish the fate of the nonoperated distal ICA false aneurysm after ICAD. METHODS: PubMed/MEDLINE, Embase, and Cochrane databases were systematically searched up to 13 August 2015 for studies reporting clinical outcomes and imaging surveillance in patients who were found to have developed a false aneurysm associated with ICAD, with specific emphasis on the fate of the nonoperated false aneurysm. RESULTS: Eight studies reported on the course/clinical outcome of ICAD-associated false aneurysms in 166 patients. Of these, five of 166 false aneurysms (3%) increased in size; 86 of 166 (52%) remained unchanged in diameter; 35 of 166 (21%) diminished in size; 32 of 166 (19%) resolved completely; three of 166 (2%) thrombosed; and five 166 (3%) were repaired surgically. Another four of 166 (2%) underwent late surgery (0.5-5.0 years later). During the course of surveillance, none of the nonoperated false aneurysms associated with spontaneous ICAD gave rise to any new neurological or compressive symptoms. CONCLUSIONS: In this systematic review, >95% of nonoperated false aneurysms affecting the distal internal carotid artery that developed after an ICAD did not increase in size and were not associated with any delayed neurological symptoms suggesting that conservative management and serial surveillance is the optimal mode of treatment. As nearly all studies suffered from serious bias, reporting standards for diagnosis and follow-up are needed in order to better define their natural history.

Stroke/Death Rates Following Carotid Artery Stenting and Carotid Endarterectomy in Contemporary Administrative Dataset Registries: A Systematic Review.

BACKGROUND: Randomised trials have reported higher stroke/death rates after carotid artery stenting (CAS) versus carotid endarterectomy (CEA). Despite this, the 2011 American Heart Association (AHA) guidelines expanded CAS indications, partly because of the Carotid Revascularization Endarterectomy versus Stenting Trial, but also because of improving outcomes in industry sponsored CAS Registries. The aim of this systematic review was: (i) to compare stroke/death rates after CAS/CEA in contemporary dataset registries, (ii) to examine whether published stroke/death rates after CAS fall within AHA thresholds, and, (iii) to see if there had been a decline (over time) in procedural risk after CAS/CEA. METHODS: PubMed/Medline, Embase, and Cochrane databases were systematically searched according to the recommendations of the PRISMA statement from January 1, 2008 until February 23, 2015 for administrative dataset registries reporting outcomes after both CEA and CAS. RESULTS: Twenty-one registries reported outcomes involving more than 1,500,000 procedures. Stroke/death after CAS was significantly higher than after CEA in 11/21 registries (52%) involving "average risk for CEA" asymptomatic patients and in 11/18 registries (61%) involving "average risk for CEA" symptomatic patients. In another five registries, CAS was associated with higher stroke/death rates than CEA for both symptomatic and asymptomatic patients, but formal statistical comparison was not reported. CAS was associated with stroke/death rates that exceeded risk thresholds recommended by the AHA in 9/21 registries (43%) involving "average risk for CEA" asymptomatic patients and in 13/18 registries (72%) involving "average risk for CEA" symptomatic patients. In 5/18 registries (28%), the procedural risk after CAS in "average risk" symptomatic patients exceeded 10%. CONCLUSIONS: Data from contemporary administrative dataset registries suggest that stroke/death rates following CAS remain significantly higher than after CEA and often exceed accepted AHA thresholds. There was no evidence of a sustained decline in procedural risk after CAS.

Symptomatic Renal Artery Stenosis and Infra-renal AAA.

OBJECTIVES: To identify evidence to guide the vascular surgeon as to the relevance of renal artery stenting in a patient with symptomatic renal artery stenosis undergoing elective endovascular aortic aneurysm repair (EVAR). METHODS: A comprehensive literature search of MEDLINE was performed without time limits. The following terms were used in the first instance: renal artery stenting and renal artery stenosis, and any other analogous terms identified during the search. Selection criteria were set to randomised control trials. RESULTS: Despite several large, randomised controlled trials investigating renal artery stenting against medical treatment alone in symptomatic renal artery stenosis, there has been no significant benefit identified in terms of improvement in renal function, control of blood pressure, or need for dialysis. The stented populations were also more likely to suffer from complications caused by the procedure such as bleeding, cholesterol embolisation and flash pulmonary oedema. CONCLUSION: There is no evidence for the use of renal artery stenting over optimal medical management in the treatment of patients with symptomatic atherosclerotic renal artery stenosis, irrelevant of the degree of stenosis. In the setting of EVAR, prevention of deterioration of renal function should be with involvement of the renal physicians, adequate hydration, and use of minimal contrast agent. Repair should be undertaken in centres with access to 24-hour haemofiltration services.

Carotid artery stenting: high-risk interventionist versus high-risk center.

Carotid artery stenting (CAS) is a less invasive alternative to carotid endarterectomy (CEA) for the management of carotid artery stenosis. Although early multicenter randomized controlled trials reported inferior results for CAS compared with CEA, recent advances in technology and increasing CAS operator expertise have lead to improved results. As with any procedure, a high caseload translates into increased experience and better outcomes. This article discusses the current shortfalls of CAS, as well as the various options available to improve CAS results. The majority of studies suggest that there is an inverse relationship between caseload volume and CAS outcomes that defines high-risk interventionists and high-risk centers. Centralizing CAS procedures to high-volume centers is essential for optimization of CAS outcomes.

Comparison of cognitive function after carotid artery stenting versus carotid endarterectomy.

The effect of carotid artery stenting (CAS) and carotid endarterectomy (CEA) on cognitive function is unclear. Both cognitive improvement and decline have been reported after CAS and CEA. We aimed to compare the changes in postprocedural cognitive function after CAS versus CEA. A systematic qualitative review of the literature was conducted according to the recommendations of the Preferred Reporting Items for Systematic Reviews and Meta-analysis statement for studies evaluating the changes in cognitive function after CAS compared with CEA. Thirteen studies (403 CEAs; 368 CAS procedures) comparing the changes in cognitive function after CEA versus CAS were identified. Most studies did not show significant differences in overall cognitive function or only showed a difference in a single cognitive test between the two procedures. A definitive conclusion regarding the effect of CAS versus CEA on cognitive function was not possible owing to heterogeneity in definition, method, timing of assessment, and type of cognitive tests. For the same reasons, performing a meta-analysis was not feasible. The lack of standardization of specific cognitive tests and timing of assessment of cognitive function after CAS and CEA do not allow for definite conclusions to be drawn. Larger, adequately-powered and appropriately designed studies are required to accurately evaluate the effect of CAS versus CEA on postprocedural cognitive function.

Critique of the Carotid Revascularization Endarterectomy versus Stenting Trial (CREST): flaws in CREST and its interpretation.

The Carotid Revascularization Endarterectomy versus Stenting Trial (CREST) has been used to support the equivalence of carotid artery stenting (CAS) and carotid endarterectomy (CEA) in the treatment of carotid stenosis in both symptomatic and asymptomatic patients. This inclusion of two different forms of the disease decreased the power and significance of the CREST results and weakened the trial. Other flaws in CREST were the equal weighting of mostly minor myocardial infarctions (MIs) with strokes and death in the peri-procedural, composite 'end' point, but not in the 4-year, long-term 'end' point. Although CAS was associated with 50% fewer peri-procedural MIs compared with CEA, there were >2.5-fold more MIs after CAS than CEA at 4 years. The 4-year MI rate, however, was not a component of the primary 'end' point. Additionally, although the initial CREST report indicated that there was no difference in the outcomes of CAS and CEA according to symptomatic status or sex, subsequent subgroup analyses showed that CAS was associated with significantly higher stroke and death rates than CEA in symptomatic patients, in females and in individuals ≥ 65 years of age. The present article will examine these and other flaws and the details of CREST's results derived from the trial's preplanned subanalyses to show why the claims that CREST demonstrates equivalence of the two therapeutic procedures are unjustified.

EVAR for aortoiliac aneurysms, including iliac branched grafts.

For aortoiliac aneurysms involving the common iliac arteries several treatment options have been developed. In the early stages of the endovascular era the internal iliac artery was usually overstented with or without embolization. Thereafter relocation or bypass techniques were used in an attempt to preserve the internal iliac artery. Then endovascular techniques were used that involved the need for a femoro-femoral cross-over bypass. The development of iliac branched devices made it possible to preserve the internal iliac artery by endovascular means only. A first version of the iliac bifurcated graft needed to be pulled into the internal iliac artery but this technique proved too difficult. Newer versions including straight side-branches or helical side-branches for the internal iliac artery require a cross-over catheterization and introduction of a stent-graft to bridge the gap between the internal iliac artery and the iliac branch. Anatomical criteria including sufficient length of the common iliac artery and a normal calibre internal iliac artery should be taken into account, but also the health status of the patient, before one decides to use an iliac branched device for a patient with an aortoiliac aneurysm. Additional costs and technical challenges need to be balanced with the potential benefits for active patients who would be at risk for buttock claudication.

Duration of aortic cross-clamping during elective open abdominal aortic aneurysm repair operations and postoperative cardiac/renal function.

AIM: To determine the effect of the duration of aortic cross-clamping during elective infrarenal abdominal aortic aneurysm (AAA) repair operations on postoperative cardiac and renal function. METHODS: Fifty patients scheduled for open infrarenal AAA repair underwent pre- and postoperative evaluation of serum creatinine and troponin levels. The patients were divided into 2 groups according to the duration of aortic cross-clamping (Group A: <50 min; Group B: >50 min). RESULTS: A prolonged (>50 min) duration of aortic cross-clamping was associated with an increase in post-operative serum troponin (P<0.001) and serum creatinine values (P<0.001). A prolonged duration of aortic cross-clamping was the only independent predictor of postoperative renal (r=0.534; P<0.001) and cardiac dysfunction (r=0.578; P<0.001). CONCLUSION: Elective open infrarenal AAA repair procedures may be associated with mild/moderate cardiac and/or renal dysfunction, especially when aortic cross-clamping time is prolonged. Measuring serum troponin and creatinine levels before and after such operations may reveal an often clinically-silent post-operative cardiac and/or renal dysfunction.

Periodontitis and abdominal aortic aneurysms: a random association or a pathogenetic link?

A number of micro-organisms have been implicated in the development/progression of abdominal aortic aneurysms (AAAs), thus suggesting an infective theory of AAA pathogenesis. Periodontitis may be involved in the development of AAAs by means of introduction of subgingival plaque periodontal bacteria into the bloodstream and degeneration of the aortic wall. A different theory supports that the findings of periodontal pathogens in AAA biopsies are a secondary phenomenon with transient bacteremia leading to invasion of already formed AAAs. It is not yet clear whether the periodontopathic bacteria accelerate the growth/weakening of the aortic wall or whether they are secondary colonizers of AAAs. Clarification of the association between periodontal disease and AAAs in large-scale studies holds implications for a role for chemoprophylaxis/antibiotic treatment in the management of AAAs.