Meta-analysis of the outcomes of treatment of internal carotid artery near occlusion.

BACKGROUND: Guidelines recommend treating patients with an internal carotid artery near occlusion (ICANO) with best medical therapy (BMT) based on weak evidence. Consequently, patients with ICANO were excluded from randomized trials. The aim of this individual-patient data (IPD) meta-analysis was to determine the optimal treatment approach. METHODS: A systematic search was performed in MEDLINE, EMBASE and the Cochrane Library databases in January 2018. The primary outcome was the occurrence of any stroke or death within the first 30 days of treatment, analysed by multivariable mixed-effect logistic regression. The secondary outcome was the occurrence of any stroke or death beyond 30 days up to 1 year after treatment, evaluated by Kaplan-Meier survival analysis. RESULTS: The search yielded 1526 articles, of which 61 were retrieved for full-text review. Some 32 studies met the inclusion criteria and pooled IPD were available from 11 studies, including some 703 patients with ICANO. Within 30 days, any stroke or death was reported in six patients (1·8 per cent) in the carotid endarterectomy (CEA) group, five (2·2 per cent) in the carotid artery stenting (CAS) group and seven (4·9 per cent) in the BMT group. This resulted in a higher 30-day stroke or death rate after BMT than after CEA (odds ratio 5·63, 95 per cent c.i. 1·30 to 24·45; P = 0·021). No differences were found between CEA and CAS. The 1-year any stroke- or death-free survival rate was 96·1 per cent for CEA, 94·4 per cent for CAS and 81·2 per cent for BMT. CONCLUSION: These data suggest that BMT alone is not superior to CEA or CAS with respect to 30-day or 1-year stroke or death prevention in patients with ICANO. These patients do not appear to constitute a high-risk group for surgery, and consideration should made to including them in future RCTs of internal carotid artery interventions.

Meta-analysis of the costs of carotid artery stenting and carotid endarterectomy.

BACKGROUND: Carotid artery stenting (CAS) is currently associated with an increased risk of 30-day stroke compared with carotid endarterectomy (CEA), whereas both interventions seem equally durable beyond the periprocedural period. Although the clinical outcomes continue to be scrutinized, there are few data summarizing the costs of both techniques. METHODS: A systematic search was conducted in MEDLINE, Embase and Cochrane databases in August 2016 identifying articles comparing the costs or cost-effectiveness of CAS and CEA in patients with carotid artery stenosis. Combined overall effect sizes were calculated using random-effects models. The in-hospital costs were specified to gain insight into the main heads of expenditure associated with both procedures. RESULTS: The literature search identified 617 unique articles, of which five RCTs and 12 cohort studies were eligible for analysis. Costs of the index hospital admission were similar for CAS and CEA. Costs of the procedure itself were 51 per cent higher for CAS, mainly driven by the higher costs of devices and supplies, but were balanced by higher postprocedural costs of CEA. Long-term cost analysis revealed no difference in costs or quality of life after 1 year of follow-up. CONCLUSION: Hospitalization and long-term costs of CAS and CEA appear similar. Economic considerations should not influence the choice of stenting or surgery in patients with carotid artery stenosis being considered for revascularization.

Renovascular resistance of machine-perfused DCD kidneys is associated with primary nonfunction.

Donation after cardiac death (DCD) has shown to be a valuable extension of the donor pool despite a higher percentage of primary nonfunction (PNF). Limiting the incidence of PNF is of vital importance. Renovascular resistance is believed to predict graft outcome; however the literature is inconsistent. Therefore, we studied whether renovascular resistance is associated with PNF and whether this parameter should be used to discard donor kidneys. All transplanted DCD kidneys preserved by machine perfusion at our center between 1993 and 2007 were analyzed (n = 440). The effects of renovascular resistance on PNF, delayed graft function (DGF), and graft and patient survival were examined using multivariable analyses; predictive quality by calculating the area under the curve (AUC). We showed that renovascular resistance at the start of machine perfusion was significantly and independently associated with PNF (OR 2.040, 95% CI 1.362-3.056; p = 0.001), and DGF (OR 2.345, 95% CI 1.110-4.955; p = 0.025). Predictive quality was moderate (0.609, 95% CI 0.538-0.681). Graft and patient survival were not associated with renovascular resistance. We conclude that renovascular resistance in DCD kidneys is an independent risk factor for PNF; however, the predictive value is relatively low.

A Systematic Review for the Design of In Vitro Flow Studies of the Carotid Artery Bifurcation.

PURPOSE: In vitro blood flow studies in carotid artery bifurcation models may contribute to understanding the influence of hemodynamics on carotid artery disease. However, the design of in vitro blood flow studies involves many steps and selection of imaging techniques, model materials, model design, and flow visualization parameters. Therefore, an overview of the possibilities and guidance for the design process is beneficial for researchers with less experience in flow studies. METHODS: A systematic search to in vitro flow studies in carotid artery bifurcation models aiming at quantification and detailed flow visualization of blood flow dynamics results in inclusion of 42 articles. RESULTS: Four categories of imaging techniques are distinguished: MRI, optical particle image velocimetry (PIV), ultrasound and miscellaneous techniques. Parameters for flow visualization are categorized into velocity, flow, shear-related, turbulent/disordered flow and other parameters. Model materials and design characteristics vary between study type. CONCLUSIONS: A simplified three-step design process is proposed for better fitting and adequate match with the pertinent research question at hand and as guidance for less experienced flow study researchers. The three consecutive selection steps are: flow parameters, image modality, and model materials and designs. Model materials depend on the chosen imaging technique, whereas choice of flow parameters is independent from imaging technique and is therefore only determined by the goal of the study.

Volumetric assessment of extracranial carotid artery aneurysms.

The extracranial carotid artery aneurysm (ECAA) is a rare pathology for which clinical treatment guidelines are lacking. In general, symptoms or growth of the aneurysm sac are thought to indicate intervention. ECAAs may present in a large variety of shapes and sizes, and conventional diameter measurements fail to indicate geometrical differences. Therefore, we propose a protocol to measure ECAA size by 3D volumetric assessment. The volumes of 40 ECAAs in computed tomography angiography (CTA) images were measured through manual segmentation, by two independent operators. Volumes of the entire internal carotid artery (ICA) and the ECAA were measured separately. Excellent inter- and intraoperator reliability was found for both ICA and ECAA volumes, with all intraclass correlation coefficients above 0.94. Bland-Altman analysis revealed normal differences for both inter- and intraoperator agreement. For all volumes, similarity of the segmentations was excellent. Outliers were explained by presence of intraluminal ECAA thrombus, which hampered identification of the aneurysm outer wall. These results implicate robustness of our protocol, which is designed as a step-up towards (semi)automatic volumetric measurements to monitor patients with ECAA. Future (semi)automatic volumetric assessments are recommended and such techniques can be developed and validated using the proposed protocol and manual reference segmentations.

Multidrug resistance protein MRP1 protects against the toxicity of the major lipid peroxidation product 4-hydroxynonenal.

4-Hydroxynonenal (4HNE) is the most prevalent toxic lipid peroxidation product formed during oxidative stress. It exerts its cytotoxicity mainly by the modification of intracellular proteins. The detection of 4HNE-modified proteins in several degenerative disorders suggests a role for 4HNE in the onset of these diseases. Efficient protection mechanisms are required to prevent the intracellular accumulation of 4HNE. The toxicity of 4HNE was tested with the small cell lung cancer cell lines GLC(4) and the multidrug-resistance-protein (MRP1)-overexpressing counterpart GLC(4)/Adr. In the presence of the MRP1 inhibitor MK571 or the GSH-depleting agent buthionine sulphoximine, both cell lines became more sensitive and showed decreased survival. Transport experiments were performed with the (3)H-labelled glutathione S-conjugate of 4HNE ([(3)H]GS-4HNE) with membrane vesicles from GLC(4)-derived cell lines with different expression levels of MRP1. [(3)H]GS-4HNE was taken up in an ATP-dependent manner and the transport rate was dependent on the amount of MRP1. The MRP1 inhibitor MK571 decreased [(3)H]GS-4HNE uptake. MRP1-specific [(3)H]GS-4HNE transport was demonstrated with membrane vesicles from High Five insect cells overexpressing recombinant MRP1. Kinetic experiments showed an apparent K(m) of 1.6+/-0.21 microM (mean+/-S.D.) for MRP1-mediated [(3)H]GS-4HNE transport. In conclusion, MRP1 has a role in the protection against 4HNE toxicity and GS-4HNE is a novel MRP1 substrate. MRP1, together with GSH, is hypothesized to have a role in the defence against oxidative stress.