Bae C, et al. Comparative Review of the Treatment Methodologies of Carotid Stenosis. Int J Angiol. 2015 Sep;24(3):215-22. .
The treatment of carotid stenosis entails three methodologies, namely, medical management, carotid angioplasty and stenting (CAS), as well as carotid endarterectomy (CEA). The North American Symptomatic Carotid Endarterectomy Trial (NASCET) and European Carotid Surgery Trial (ECST) have shown that symptomatic carotid stenosis greater than 70% is best treated with CEA. In asymptomatic patients with carotid stenosis greater than 60%, CEA was more beneficial than treatment with aspirin alone according to the Asymptomatic Carotid Atherosclerosis (ACAS) and Asymptomatic Carotid Stenosis Trial (ACST) trials. When CAS is compared with CEA, the CREST resulted in similar rates of ipsilateral stroke and death rates regardless of symptoms. However, CAS not only increased adverse effects in women, it also amplified stroke rates and death in elderly patients compared with CEA. CAS can maximize its utility in treating focal restenosis after CEA and patients with overwhelming cardiac risk or prior neck irradiation. When performing CEA, using a patch was equated to a more durable result than primary closure, whereas eversion technique is a new methodology deserving a spotlight. Comparing the three major treatment strategies of carotid stenosis has intrinsic drawbacks, as most trials are outdated and they vary in their premises, definitions, and study designs. With the newly codified best medical management including antiplatelet therapies with aspirin and clopidogrel, statin, antihypertensive agents, strict diabetes control, smoking cessation, and life style change, the current trials may demonstrate that asymptomatic carotid stenosis is best treated with best medical therapy. The ongoing trials will illuminate and reshape the treatment paradigm for symptomatic and asymptomatic carotid stenosis.
Maxwell DW, Jajja MR, Ferez-Pinzon A, Pouch SM, Cardona K, Kooby DA, Maithel SK, Russell MC, Sarmiento JM. Bile cultures are poor predictors of antibiotic resistance in postoperative infections following pancreaticoduodenectomy.HPB (Oxford). 2019 Oct 26:S1365-182X(19)30756-7.
Results: Common patient characteristics of 522 included patients were 65-years-old, Caucasian (75.5%), male (54.2%), malignant indication (79.3%), and preoperative biliary stent (59.0%). Overall, 275 (89.6%) BCs matured identifiable isolates with 152 (55.2%) demonstrating polymicrobial growth. Ninety-two (17.6%) SOICs were obtained: 48 and 44 occurred in patients with and without intraoperative BCs. Stents were associated with bacteriobilia (85.7%, K = 0.947, p < 0.001; OR 22.727, p < 0.001), but not postoperative infections (15.2%; K = 0.302, p < 0.001; OR 1.428, p = 0.122). Forty-eight patients demonstrated paired BC/SOICs to evaluate. Pathogenic concordance of this group was 31.1% (K = 0.605, p < 0.001) while SRP concordance of matched pathogens was 46.7% (K = 0.167, p = 0.008).
Conclusion: Bile cultures demonstrate poor concordance with the susceptibility/resistance patterns of postoperative infections following pancreaticoduodenectomy and may lead to inappropriate antibiotic therapies.
Hassold N, et al. Effectiveness and outcome of endovascular therapy for late-onset postpancreatectomy hemorrhage using covered stents and embolization. J Vasc Surg. 2016 Nov;64(5):1373-1383.
RESULTS: Covered stent placement was successful in 14 of 16 patients (88%); embolization was successful in 10 of 11 (91%) patients. For the embolization group, the overall 30-day and 1-year survival rate was 70%, and the 1- and 2-year survival rate was 56%; for the covered stent group, these rates were 81% and 74%, respectively. The 30-day patency of the covered stent was 84%, and 1-year patency was 42%; clinically relevant ischemia was observed in two patients. Infarction distal to the embolized vessel occurred in 6 of 11 patients (55%).
Veld JV, et al. Changes in Management of Left-Sided Obstructive Colon Cancer: National Practice and Guideline Implementation. J Natl Compr Canc Netw. 2019 Dec;17(12):1512-1520.
Results: A total of 2,587 patients were included (2,013 ER, 345 DS, and 229 SEMS). A trend was observed in reversal of ER (decrease from 86.2% to 69.6%) and SEMS (increase from 1.3% to 7.8%) after 2014, with an ongoing increase in DS (from 5.2% in 2009 to 22.7% in 2016). DS after 2014 was associated with more laparoscopic resections (66.0% vs 35.5%; P<.001) and more 2-stage procedures (41.5% vs 28.6%; P=.01) with fewer permanent stomas (14.7% vs 29.5%; P=.005). Overall, more laparoscopic resections (25.4% vs 13.2%; P<.001) and shorter total hospital stays (14 vs 15 days; P<.001) were observed after 2014. However, similar rates of primary anastomosis (48.7% vs 48.6%; P=.961), 90-day complications (40.4% vs 37.9%; P=.254), and 90-day mortality (6.5% vs 7.0%; P=.635) were observed.
CONCLUSIONS: Guideline revision resulted in a notable change from ER to BTS for LSOCC. This was accompanied by an increased rate of laparoscopic resections, more 2-stage procedures with a decreased permanent stoma rate in patients receiving DS as BTS, and a shorter total hospital stay. However, overall 90-day complication and mortality rates remained relatively high.
Razavi MK, Razavi MD. Stent-graft treatment of mycotic aneurysms: a review of the current literature. J Vasc Interv Radiol. 2008;19(6 Suppl):S51–S56.
Full-text for Emory users.
“Mycotic aneurysms are rare but are associated with a high risk of rupture if not treated promptly. The early mortality rate associated with traditional surgery depends on patients’ condition and can be as high as 43%. The use of stent-grafts is less invasive but the outcome is unproven in the setting of infected aneurysms. In an attempt to better elucidate the role of stent-grafts in this setting, a literature search was performed to examine 52 articles describing 91 patients with mycotic aneurysms who were treated with stent-grafts. The early mortality rate was 5.6%. Incidences of late aneurysm-related mortality and complications were 12.2% and 7.8%, respectively. The most consistent predictor of poor outcome was development of aortoenteric fistula. Although the 30-day mortality rate associated with the use of stent-grafts appears to be lower than that associated with surgery, late aneurysm-related events are frequent and warrant a more vigilant follow-up regimen than used with noninfected aneurysms.”
One discussion this week involved the Carotid Revascularization Endarterectomy vs. Stenting Trial (CREST).
Reference: Brott TG, et al. Stenting versus endarterectomy for treatment of carotid-artery stenosis. New England Journal of Medicine. 2010 Jul 1;363(1):11-23. doi:10.1056/NEJMoa0912321.
Summary: CREST is an RCT with blinded end-point adjudication whose aim was “to compare the outcomes of carotid-artery stenting with those of carotid endarterectomy among patients with symptomatic or asymptomatic extracranial carotid stenosis” (p.12).
Between December 2000 through July 2008, 2522 patients were enrolled in 108 centers in the US and 9 in Canada. Of those, 1271 patients were randomly assigned to undergo carotid-artery stenting.
Primary findings include (p.18):
- Carotid revascularization performed by highly qualified surgeons and interventionists is effective and safe.
- Stroke was more likely after carotid-artery stenting.
- Myocardial infarction was more likely after carotid endarterectomy, but the effect on the quality of life was less than the effect of stroke.
- Younger patients had slightly fewer events after carotid-artery stenting than after carotid endarterectomy.
- Older patients had few events after carotid endarterectomy.
- Low absolute risk of recurrent stroke suggests that both carotid-artery stenting and carotid endarterectomy are clinically durable and reflect advances in medical therapy.