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Severity of stenosis in symptomatic patients undergoing carotid interventions may influence perioperative neurologic events

Garg, Karan; Chang, Heepeel; Siracuse, Jeffrey J; Jacobowitz, Glenn R; Torres, Jose; Veith, Frank J; Patel, Virendra I; Maldonado, Thomas S; Sadek, Mikel; Cayne, Neal S; Rockman, Caron B
OBJECTIVE:Carotid artery plaque burden, indirectly measured by the degree of stenosis, quantifies future embolic risk. In natural history studies, patients with moderate degrees of stenosis have a lower stroke risk than those with severe stenosis. However, patients with symptomatic carotid stenosis who have experienced TIA or stroke are found to have both moderate and severe degrees of stenosis. We sought to examine the association carotid artery stenosis severity with outcomes in symptomatic patients undergoing carotid interventions including carotid endarterectomy (CEA), transfemoral carotid artery stenting (CAS) and transcervical carotid artery revascularization (TCAR). METHODS:The Society for Vascular Surgery Quality Initiative database was queried for all patients undergoing CAS, CEA and TCAR between 2003 and 2020. Patients were stratified into two groups based on the severity of stenosis - non-severe (0 - 69%) and severe (≥ 70%). Primary endpoints were periprocedural neurologic events (strokes and transient ischemic attacks (TIAs)). Secondary endpoints were periprocedural death, myocardial infarction (MI) and composite outcomes of stroke/death and stroke/death/MI per reporting standards for carotid interventions. RESULTS:Of 29,614 symptomatic patients included in the analysis, 5,296 (17.9%) patients underwent TCAR, 7,844 (26.5%) underwent CAS, and 16,474 (55.6%) underwent CEA for symptomatic carotid artery stenosis. In the CEA cohort, the neurologic event rate was similarly significantly lower in patients with severe stenosis when compared to those with non-severe stenosis (2.6% vs. 3.2%, P=.024). In the TCAR cohort, the periprocedural neurologic even rate was lower in patients with severe stenosis when compared to those with non-severe stenosis (3% vs. 4.3%, P=.033). There was no similar difference noted in the CAS cohort, with periprocedural neurologic event rates of 3.8% in the severe group versus 3.5% in the non-severe group (P=.518). On multivariable analysis, severe stenosis was associated with significantly decreased odds of post procedural neurologic events in patients undergoing CEA (odds ratio [OR] 0.75, 95% confidence interval [CI], 0.6 - 0.92; P=.007) and TCAR (OR .83; CI, .69 - 0.99; P=.039), but not CAS. CONCLUSION/CONCLUSIONS:Severe carotid stenosis as opposed to more moderate degrees of stenosis was associated with decreased rates of periprocedural stroke and TIAs in symptomatic patients undergoing TCAR and CEA, but not CAS. The finding of increased rates of periprocedural neurologic events in symptomatic patients with lesser degrees of stenosis undergoing TCAR and CEA warrants further evaluation with a particular focus on plaque morphology and brain physiology, and their inherent risks with carotid revascularization procedures.
PMID: 35272001
ISSN: 1097-6809
CID: 5183632

The Presence of a Pathologic Perforator May be Predictive of Central Venous Pathology and Multilevel Disease in Severe Chronic Venous Insufficiency

Li, Chong; Nwachukwu, Chukwuma; Jacobowitz, Glenn R; Kabnick, Lowell S; Maldonado, Thomas S; Rockman, Caron B; Berland, Todd L; Sadek, Mikel
INTRODUCTION/BACKGROUND:The treatment of a refluxing perforator is indicated in the setting of severe chronic venous insufficiency, but there are limited data on the presence of multilevel disease in these patients. This study sought to evaluate whether the presence of a pathologic perforator is predictive of the presence of central venous pathology. METHODS:This study was a retrospective review of the institutional vascular quality initiative (VQI) database. Consecutive patient-limbs were identified who underwent intervention of refluxing perforators. The patients who underwent imaging, including MRI or CT (Group A) were compared to those who did not undergo imaging (Group B). The treated limbs in Group A were also compared to the contralateral limbs as an internal control. Anatomical findings on imaging were analyzed by two independent investigators. The primary outcome was the presence and degree of central venous stenosis as measured by an orthogonal diameter reduction of > 50% by axial imaging. Secondary outcomes included demographic and clinical differences between the two groups, frequency of central venous intervention, and duration of ulcer healing. Standard statistical analysis was performed. RESULTS:Ninety-three patient-limbs underwent treatment of a pathologic perforator, with 30 in Group A and 63 in Group B. The following demographic and clinical variables were higher in Group A compared to Group B: Male gender, BMI, deep venous thrombosis history, recent or active anticoagulation use, perforator diameter, Clinical Etiology Anatomy Pathophysiology class 4, 5 or 6, and Venous Clinical Severity Score. Radiographic analysis of Group A revealed concordance of a treated pathological perforator with an ipsilateral central venous stenosis in 53.3% of patients, and a higher frequency of common iliac vein stenosis (50% vs 21.4%, P = 0.024) and external iliac vein stenosis (20% vs 0%, P = 0.012) compared to the contralateral limbs. When separated by left or right limb, the left limbs exhibited a greater degree of common iliac vein stenosis as compared to the contralateral limbs (50.7±20.9% vs 16.3±16.5%, P < 0.001) as well as a greater frequency of >50% common iliac vein stenosis (46.7% vs 13.3%, P = 0.046). The right limbs exhibited a greater frequency of > 50% external iliac vein stenosis as compared to contralateral limbs (33.3% vs 0%, P = 0.022). CONCLUSIONS:This study suggests that patients with severe chronic venous insufficiency who undergo treatment for a pathologic perforator may have additional ipsilateral central venous pathology, supporting the presence of multilevel disease. Additional axial imaging might unmask central venous pathology and provide another option for treatment.
PMID: 34252577
ISSN: 2213-3348
CID: 4938302

Anticoagulation Therapy is Associated with Increased Access-related Wound Infections after Hemodialysis Access Creation

Kumpfbeck, Andrew; Rockman, Caron B; Jacobowitz, Glenn R; Lugo, Joanelle Z; Barfield, Michael E; Scher, Larry A; Nigalaye, Anjali A; Garg, Karan
BACKGROUND:The effect of anticoagulation therapy (AC) on hemodialysis access patency and related complications is not well defined. Patients on long-term or chronic AC due to their underlying comorbid conditions may be particularly susceptible to access-related bleeding and complications from repetitive cannulation. Our goal is to assess the effect of anticoagulation therapy on outcomes after access creation. METHODS:The Vascular Quality Initiative (VQI) database was queried for patients undergoing arteriovenous fistula (AVF) or graft (AVG) placement, from 2011 to 2019. Only patients with data on post-procedural AC status were included. Anticoagulation use was defined as patients on warfarin, dabigatran, or rivaroxaban after access creation at postoperative follow up. Demographic and procedural details were analyzed. Wound infection and patency rates at six months were assessed. Binomial logistic regression analysis was performed to assess the association of anticoagulation use with these outcomes. RESULTS:A total of 27,757 patients underwent access creation, with the majority undergoing AVF creation (78.8%). The average age was 61.4 years and 55.3% were male. 12.9% of patients were on postoperative AC. The wound infection rate was 2.3- 3.8% in the no AC and AC cohorts, respectively (P < 0.001). At six months follow-up, patency was 85.7- 84.3% in the no AC and AC cohorts, respectively (P = 0.044). Expectedly, grafts had lower patency rates compared to AVF; those within the no AC cohort had a patency of 83.0% compared to 81.2 % in those on AC (P = 0.106). On multivariable analysis, anticoagulation use was associated with a higher risk of wound infections (odds ratio [OR] 1.513, 95% confidence interval [CI] 1.160-1.973, P = 0.002). AC use did not significantly affect access patency. CONCLUSION/CONCLUSIONS:Anticoagulation therapy was associated with a higher rate of wound infections but did not affect short-term access patency within six-months. These patients warrant close surveillance of their access for signs of infection. Furthermore, long-term implications of anticoagulation needs further evaluation.
PMID: 34687891
ISSN: 1615-5947
CID: 5068222

Periprocedural P2Y12 Inhibitors Improve Perioperative Outcomes After Carotid Stenting by Primarily Decreasing Strokes [Meeting Abstract]

Heib, A; Chang, H; Rockman, C; Cayne, N; Jacobowitz, G; Patel, V; Maldonado, T; Garg, K
Objective: The continuation of antiplatelet agents in the periprocedural period around carotid stenting (transfemoral carotid artery stenting [TF-CAS] and transcarotid artery revascularization [TCAR]) procedures is believed to be mandatory to minimize the risk of periprocedural stroke.
Method(s): The Society for Vascular Surgery Vascular Quality Initiative database was queried from 2007 to 2020. All TCAR and TF-CAS procedures were included. The patients were stratified by preoperative use of P2Y12 inhibitors. The primary endpoints were perioperative neurologic events (ie, stroke, transient ischemic attack). The secondary endpoints were mortality and myocardial infarction. The P2Y12 inhibitors included in the analysis were clopidogrel, prasugrel, and ticagrelor.
Result(s): A total of 31,036 carotid stent procedures were included for analysis (49.8% TCAR and 50.2% TF-CAS; 63.8% of the patients were men). Overall, 82.3% of the patients were taking a P2Y12 inhibitor. P2Y12 inhibitor use was significantly more common for men, asymptomatic patients, those aged >70 years, and those with concurrent statin use (Table I). P2Y12 inhibitors were significantly more likely to be used with TCAR cases than with TF-CAS cases (87.3% vs 76.8%; P <.001). The rate of periprocedural neurologic events in the whole cohort was 2.6%. Patients taking P2Y12 inhibitors were significantly less likely to experience a periprocedural neurologic event (2.3% vs 3.9%; P <.001) and periprocedural mortality (0.6% vs 2.1%; P <.001) than were those not taking a P2Y12 inhibitor. No effect was seen on the rates of myocardial infarction. On multivariate analysis, the use of P2Y12 inhibitors demonstrated an independent significant effect in reducing of the rate of perioperative stroke (odds ratio, 0.29; 95% confidence interval, 0.25-0.33; Table II). Finally, additional analysis of the types of P2Y12 inhibitors used revealed that all appeared to be equally effective in reducing the periprocedural neurologic event rate.
Conclusion(s): Continuation of P2Y12 inhibitors in the periprocedural period appears to markedly reduce the perioperative neurologic event rate with TCAR and TF-CAS and should be considered mandatory. Patients with contraindications to P2Y12 inhibitors might not be appropriate candidates for any carotid stenting procedure. Additionally, alternative types of P2Y12 inhibitors appear to be equally effective as clopidogrel. Finally, analysis of the Vascular Quality Initiative demonstrated that even for TCAR cases, only 87.3% of patients were receiving P2Y12 inhibitor therapy in the periprocedural period, leaving room for significant improvement. [Formula presented] [Formula presented]
Copyright
EMBASE:2016861856
ISSN: 1097-6809
CID: 5157932

Natural History of Incidentally Noted Celiac Artery Aneurysms [Meeting Abstract]

Hartwell, C A; Johnson, W; Nwachukwu, C; Garg, K; Sadek, M; Maldonado, T S; Jacobowitz, G R; Kim, D; Rockman, C
Objective: Celiac artery aneurysms (CAAs) are unusual. The reported literature is skewed toward those treated by operative or endovascular intervention. The goal of the present study was to investigate the natural history of untreated CAAs.
Method(s): We performed a single-institution retrospective analysis of patients with CAAs diagnosed by computed tomography from 2015 to 2019. The patients were identified by searching our institutional radiology database. The radiologic, demographic, and follow-up clinical and imaging data were obtained from the electronic medical records.
Result(s): The analyzed cohort consisted of 76 patients (86.8% were men). The mean age was 69.8 years (range, 29-93 years). The medical comorbidities included hypertension (64.5%), diabetes (9.2%), coronary disease (18.4%), and hypercholesterolemia (46.1%). Concomitant vascular disease was noted and included AAA in 13.2%, an additional visceral aneurysm in 10.5%, and a visceral artery anomaly in 11.8%. The mean CAA diameter at the index study was 15.4 mm (range, 7-30 mm). Most (97.3%) were believed to be true aneurysms. Additional characteristics included thrombus (9.2%), calcification (26.3%), and dissection (11.8%). Of the 76 patients, 45 (59.2%) had had follow-up imaging data available for analysis. The mean clinical follow-up time was 31.2 months. The follow-up time for only those with subsequent imaging studies available was 25.2 months. During this period, 16 CAAs (21.1%) had enlarged in size and 29 (79.9%) had remained stable. No patient had developed symptoms or rupture. One patient (1.3%) had undergone intervention for an increasing size in the setting of chronic dissection. On univariate analysis, the only factor that was significantly associated with an increased risk of growth was younger age (mean age at diagnosis, 63.4 years vs 74.3 years; P =.005). We could not identify any other factor that was significantly predictive of, or protective against, aneurysm growth. For patients with follow-up imaging studies available, the freedom from aneurysm growth or intervention was 63% at 37 months. For the entire cohort, the freedom from aneurysm rupture or the need for intervention was 90% at 59 months.
Conclusion(s): The results from the present large study of patients with untreated CAAs revealed that very few lesions either enlarged to a clinically meaningful degree, became symptomatic, or required intervention during a 31.2-month follow-up period. Guidelines that suggest repair of CAAs >=2 cm in diameter might be overly aggressive. Close follow-up with serial imaging studies, especially for patients who are younger at diagnosis, might be preferred for most patients with an incidentally noted true CAA.
Copyright
EMBASE:2016861786
ISSN: 1097-6809
CID: 5157942

A Single-Center Experience of Anterior Accessory Saphenous Vein Endothermal Ablation Demonstrates Safety and Efficacy

Charitable, John; Speranza, Giancarlo; Rockman, Caron; Jacobowitz, Glenn; Kabnick, Lowell; Garg, Karan; Maldonado, Thomas; Berland, Todd; Cayne, Neal; Barfield, Michael; Sadek, Mikel
OBJECTIVE:Endothermal ablation is well established for the treatment of the great and small saphenous veins. Data are lacking for treatment of the Anterior Accessory Saphenous Vein (AASV). The purpose of this study is to evaluate the safety and efficacy of AASV treatment using endothermal ablation. METHODS:This was a retrospective review of 314 limbs at a single academic institution from 2016-2018 using the institutional Vascular Quality Initiative database. All limbs had documented AASV reflux. Baseline characteristics were evaluated including age, sex, ethnicity, CEAP (clinical, etiology, anatomy, pathophysiology) classification, Venous Clinical Severity Score (VCSS), and vein diameter. Outcomes relating to procedure safety and efficacy included treatment modality and length, successful ablation on post-operative imaging, post-procedural clinical outcomes, incidence of endothermal heat induced thrombosis (EHIT), and any post-procedural complication. RESULTS:A total of 314 consecutive limbs were identified from 2016-2018. Pre-procedure VCSS scores were available for 312 limbs and averaged 6.13 ± 3.33. History of varicose veins were reported in all limbs with 49.4% (n=155) having previously undergone a procedure. The most common presenting symptom was mild edema in 52.5% (n=165). Vein diameter and assessment of reflux were obtained by venous duplex ultrasound (DUS). The largest AASV diameter was available for 304 limbs, averaging 7.93 ± 2.69 mm. Treatment modalities included radiofrequency ablation (RFA) in 59.2% (n=186), endovenous laser ablation (EVLA) in 37.9% (n=119), and isolated microphlebectomy in 2.9% (n=9). 38.5% (N=121) of limbs underwent concomitant microphlebectomy at the time of EVLA. Total treatment length was obtained in 297 limbs, averaging 23.0 cm ± 12.0. Post-operatively, 94.6% (n=297) of limbs were prescribed compression stockings. Post-operative DUS was performed in 312 limbs, revealing successful ablation in 96.5% (n=303) with 2 limbs (0.6%) developing an EHIT, both treated with therapeutic enoxaparin for one week. Repeat DUS revealed thrombus resolution in one limb, while the other patient was lost to follow-up. VCSS scores post-procedure were available for 145 limbs and averaged 4.45 ± 2.31. This was a statistically significant decrease from pre-procedure VCSS scores (p<0.01). Average duration of follow-up was 2.2 years, with two limbs lost to follow-up. Of the 9 limbs (3.5%) whose initial procedure failed, 5 (56%) were treated using RFA and 4 (44%) were treated using EVLA. There were no other post-operative complications. CONCLUSION/CONCLUSIONS:Our experience over a three-year period for treating the AASV shows it to be safe and effective in a broad range of disease severity with an improvement in VCSS and a low incidence of EHIT. Additionally, RFA and EVLA exhibit similar treatment efficacy. Long-term follow-up data are needed.
PMID: 35218957
ISSN: 2213-3348
CID: 5172682

Risk Factors For and Intra-operative Management of Intolerance to Flow Reversal in TCAR

Teter, Katherine; Rockman, Caron; Lamparello, Patrick; Macdonald, Sumaira; Garg, Karan; Barfield, Michael; Maldonado, Thomas S
OBJECTIVES/OBJECTIVE:In patients deemed high risk for carotid endarterectomy (CEA) who are indicated for treatment of carotid artery stenosis (CAS), transcarotid artery revascularization (TCAR) has been demonstrated as a safe and effective alternative to trans-femoral carotid artery stenting (TF-CAS). Compared to CEA, where approx. 12% of patients undergoing awake intervention do not tolerate internal carotid artery (ICA) clamping, only 1-2% of patients were observed to have intolerance to flow reversal during TCAR based on data from the ROADSTER1/2 trials. This study reviewed awake interventions from those trials to assess factors associated with intolerance to flow reversal and review how those cases were managed. METHODS:This is a retrospective review of prospectively collected data from Reverse Flow Used During Carotid Artery Stenting Procedure (ROADSTER) multicenter trial along with the subsequent post-approval (ROADSTER-2) trial. The subset of patients from both trials undergoing awake TCAR was analyzed to compare demographics, procedural details, and anatomic factors between patients who did and did not experience intolerance to reversal of flow to assess for predisposing factors. Patients were deemed intolerant to flow reversal at the discretion of the operator, often related to changes in completion of neurologic tasks, hemodynamic stability, or patient reported symptoms. RESULTS:103 patients from ROADSTER and 194 patients from ROADSTER-2 underwent TCAR under local/regional anesthesia. Of these, 8 patients had intolerance to flow reversal, though all cases were successfully completed. While intra-operative hemodynamic data was only available for 5 of the 8 intolerant patients, none experienced hypotension. 4 cases were completed under low flow reversal, 3 cases were successfully weaned from low to high flow over several minutes, and 1 case required general anesthesia. No significant association was found between intolerance to flow reversal and comorbidities including diabetes mellitus (DM), hypertension (HTN), hyperlipidemia (HLD), congestive heart failure (CHF), prior MI or angina, pre-op CAS-related symptoms, prior stroke, prior CAS or CEA, prior neck radiation, tandem stenosis, high cervical stenosis, or hostile neck (tables 1, 2). A trend towards significance was seen with chronic obstructive pulmonary disease (COPD) and contralateral carotid artery occlusion (p= 0.086 and 0.139, respectively). CONCLUSIONS:Despite intolerance to flow reversal, TCAR cases were successfully completed by adjusting reversal-of-flow rate and do not typically require conversion to GETA. While factors contributing to intolerance of flow reversal during TCAR remain poorly understood, this study identified a trend towards significance with an association of pre-existing COPD and contralateral carotid artery occlusion. Given the low number of patients who experienced this issue, a larger sample size is required to better elucidate these trends.
PMID: 34688872
ISSN: 1615-5947
CID: 5042142

Outcomes of transfemoral carotid artery stenting and transcarotid artery revascularization for restenosis after prior ipsilateral carotid endarterectomy

Chang, Heepeel; Rockman, Caron B; Veith, Frank J; Kashyap, Vikram S; Jacobowitz, Glenn R; Sadek, Mikel; Garg, Karan; Maldonado, Thomas S
OBJECTIVE:Restenosis after carotid endarterectomy (CEA) poses unique therapeutic challenges, with no specific guidelines available on the operative approach. Traditionally, transfemoral carotid artery stenting (TfCAS) has been regarded as the preferred approach to treating restenosis after CEA. Recently, transcarotid artery revascularization with a flow-reversal neuroprotection system (TCAR) has gained popularity as an effective alternative treatment modality for de novo carotid artery stenosis. The aim of the present study was to compare the contemporary perioperative outcomes of TfCAS and TCAR in patients with prior ipsilateral CEA. METHODS:The Vascular Quality Initiative database was reviewed for patients who had undergone TfCAS and TCAR for restenosis after prior ipsilateral CEA between January 2016 and August 2020. The primary outcome was the 30-day composite outcome of stroke and death. The secondary outcomes included 30-day stroke, transient ischemic attack (TIA), myocardial infarction (MI), death, and composite 30-day outcomes of stroke, death, and TIA, stroke and TIA, and stroke, death, and MI. Multivariable logistic regression models were used to evaluate the outcomes of interest after adjustment for potential confounders and baseline differences between cohorts. RESULTS:Of 3508 patients, 1834 and 1674 had undergone TfCAS and TCAR, respectively. The TCAR cohort was older (mean age, 71.6 years vs 70.2 years; P < .001) and less likely to be symptomatic (27% vs 46%; P < .001), with a greater proportion taking aspirin (92% vs 88%; P = .001), a P2Y12 inhibitor (89% vs 80%; P < .001), and a statin (91% vs 87%; P = .002) compared with the TfCAS cohort. Perioperatively, the TCAR cohort had had lower 30-day composite outcomes of stroke/death (1.6% vs 2.7%; P = .025), stroke/death/TIA (1.8% vs 3.3%; P = .004), and stroke/death/MI (2.1% vs 3.2%; P = .048), primarily driven by lower rates of stroke (1.3% vs 2.3%; P = .031) and TIA (0.2% vs 0.7%; P = .031). Among asymptomatic patients, the incidence of stroke (0.6% vs 1.4%; P = .042) and the composite of stroke/TIA (0.8% vs 1.8%; P = .036) was significantly lower after TCAR than TfCAS, and TCAR was associated with a lower incidence of TIA (0% vs 1%; P = .038) among symptomatic patients. On adjusted analysis, the TCAR cohort had lower odds of TIA (adjusted odds ratio, 0.17; 95% confidence interval, 0.04-0.74; P = .019). CONCLUSIONS:Among patients undergoing carotid revascularization for restenosis after prior ipsilateral CEA, TCAR was associated with decreased odds of 30-day TIA compared with TfCAS. However, the two treatment approaches were similarly safe in terms of the remaining perioperative outcomes, including stroke and death and stroke, death, and MI. Our results support the safety and efficacy of TCAR in this subset of patients deemed at high risk of reintervention.
PMID: 34506900
ISSN: 1097-6809
CID: 5067172

Statin Use Reduces Mortality in Patients Who Develop Major Complications After Transcarotid Artery Revascularization [Meeting Abstract]

Chang, H; Zeeshan, M; Rockman, C B; Veith, F J; Laskowski, I; Kashyap, V S; Jacobowitz, G R; Garg, K; Sadek, M; Maldonado, T S
INTRODUCTION AND OBJECTIVES: The impact of preoperative statin use in patients undergoing transcarotid artery revascularization (TCAR) is not well established. The aim of this study was to evaluate the effect of statin on postoperative outcomes after TCAR.
METHOD(S): Vascular Quality Initiative registry (2012-2020) was queried for patients undergoing TCAR. Patient demographics, perioperative characteristics and 30-day outcomes were compared between patients treated with and without statins at least 30 days preoperatively. Multivariable logistic regression models were used to estimate the effect of statins on postoperative outcomes. RESULTS: A total of 15,797 patients underwent TCAR, and 10,116 (64%) were males. 14,152 (89.6%) patients were on statin preoperatively (Table). There was higher incidence of both prior ipsilateral stroke (17.2% vs 13.5%; P<.001) and recent ipsilateral stroke (<= 30 days; 7.1% vs 5.6%; P=.02) in the statin group. Perioperative stroke and major adverse cardiac event (MACE; myocardial infarction, congestive heart failure and dysrhythmia) occurred in 1.5% and 2.4% among patients on statins and 1.4% and 2.3% among those not on statins, respectively. After adjusting for potential confounders and baseline differences, statin use was associated with 62% reduction in the odds of mortality (OR 0.38; 95% CI, 0.19-0.99; P=.047) in patients who developed a perioperative stroke or MACE after TCAR (Figure).
CONCLUSION(S): Statin use was associated with a significant reduction in postoperative mortality in patients who develop a stroke or MACE after TCAR. Therefore, strict adherence to statin is strongly recommended, particularly in patients who may be at high risk of major postoperative complications.[Formula presented]
Copyright
EMBASE:2016756291
ISSN: 1615-5947
CID: 5158152

Carotid Interventions for Women: The Hazards and Benefits

Rockman, Caron; Caso, Valeria; Schneider, Peter A
The goal of the current review is to examine the hazards and benefits of carotid interventions in women and to provide recommendations for the indications for carotid intervention in female patients. Stroke and cerebrovascular disease are prevalent in women. There are inherent biological and other differences in men and women, which affect the manifestations and outcome of stroke, with women experiencing worse disability and higher mortality following ischemic stroke than men. Due to the underrepresentation of female patients in most clinical trials, the ability to make firm but alternative recommendations for women specifically on the management of carotid stenosis is challenging. Although some data suggest that women might have worse periprocedural outcomes as compared to men following all carotid revascularization procedures, there is also an abundance of data to support a similar risk for carotid procedures in men and women, especially with carotid endarterectomy and transcarotid artery revascularization. Therefore, the indications for carotid revascularization are the same in women as they are in men. The choice of a carotid revascularization procedure in women is based upon the same factors as in men and requires careful evaluation of a particular patient's risk profile, anatomic criteria, plaque morphology, and medical comorbidities that might favor one technique over the other. When performing carotid revascularization procedures in women, tailored techniques and procedures to address the small diameter of the female artery are warranted.
PMID: 34983240
ISSN: 1524-4628
CID: 5107042