The Journal of cardiovascular surgery
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J Cardiovasc Surg (Torino) · Jun 2019
Meta AnalysisQuality appraisal of systematic reviews, and meta-analysis of the hospital/surgeon-linked volume-outcome relationship of carotid revascularization procedures.
Several systematic reviews and meta-analyses of primary studies have been published on the relationship between annual case load of carotid endarterectomy (CEA) and carotid artery stenting (CAS) performed at hospital level or by individual surgeons, and perioperative outcomes. Many studies on volume-outcome relationship have already been published and high-quality systematic reviews are crucial for further guideline development. ⋯ For CEA, high quality aggregated evidence revealed an inverse relationship between hospital/surgeon CEA volume and periprocedural rate of stroke or death. The same was true for operator linked CAS volume. Regarding hospital linked CAS volume, no unequivocal evidence was found. Additionally, heterogeneity was found regarding volume definition, and time of outcome assessment. Thus, future studies should aim to harmonize volume definitions and outcome time points.
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J Cardiovasc Surg (Torino) · Jun 2019
ReviewTechnical improvements in carotid revascularization based on the mechanism of procedural stroke.
The benefit of carotid revascularization in patients with severe carotid artery stenosis is hampered by the risk of stroke due to the intervention itself. The risk of periprocedural strokes is higher for carotid artery stenting (CAS) as compared to carotid endarterectomy (CEA). Over the past years, the pathophysiological mechanism responsible for periprocedural stroke seems to unfold step by step. ⋯ In addition, TCD is able to adequately identify and exclude patients at risk for CHS. For CAS, the additional value of periprocedural cerebral monitoring to prevent strokes needs urgent attention. In conclusion, this review provides an overview of the pathophysiological mechanism of stroke following carotid revascularization (both CAS and CEA) and of the technical improvements that have contributed to reducing this stroke risk.
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J Cardiovasc Surg (Torino) · Jun 2019
ReviewNew technical approach for type B dissection: from the PETTICOAT to the STABILISE concept.
Endovascular treatment of acute complicated type B aortic dissection (TBD) has recently acquired a primary therapeutic role when anatomically feasible. However, strategies meant to simply close the proximal entry tear leave the risk of persistent perfusion of the false lumen (FL) through additional tears in the thoracoabdominal aorta, and therefore the potential for aneurysmal degeneration remains significant over the years. Thus, additional bare stent implantation in the thoracoabdominal aorta has been proposed to promote true lumen (TL) expansion, malperfusion relief, and intimal lamella stabilization. ⋯ An evolution of PETTICOAT, mainly including aggressive ballooning of the covered stent-graft and of the distal bare stents deployed in the TL, in order to obtain full expansion of the stents in a single channeled aorta, has been proposed in 2012 and named Stent-Assisted Balloon-Induced Intimal Disruption and Relamination in Aortic Dissection Repair (STABILISE) technique. Although this approach produced excellent early results in single-center series, it did not gain immediate acceptance in the community, mainly because of concerns regarding the potential risk of rupturing the aorta during ballooning. In this review, we summarize the current evidence on the results of these strategies, we present a recently modified approach of the STABILISE technique, and report the early results in a cohort of patients treated in the last two years at our institution.