Deans' stroke musings: Registry: More Options for Blocked Carotids Mean Better Outcomes

Changing stroke rehab and research worldwide now.Time is Brain! trillions and trillions of neurons that DIE each day because there are NO effective hyperacute therapies besides tPA(only 12% effective). I have 523 posts on hyperacute therapy, enough for researchers to spend decades proving them out. These are my personal ideas and blog on stroke rehabilitation and stroke research. Do not attempt any of these without checking with your medical provider. Unless you join me in agitating, when you need these therapies they won't be there.

What this blog is for:

My blog is not to help survivors recover, it is to have the 10 million yearly stroke survivors light fires underneath their doctors, stroke hospitals and stroke researchers to get stroke solved. 100% recovery. The stroke medical world is completely failing at that goal, they don't even have it as a goal. Shortly after getting out of the hospital and getting NO information on the process or protocols of stroke rehabilitation and recovery I started searching on the internet and found that no other survivor received useful information. This is an attempt to cover all stroke rehabilitation information that should be readily available to survivors so they can talk with informed knowledge to their medical staff. It lays out what needs to be done to get stroke survivors closer to 100% recovery. It's quite disgusting that this information is not available from every stroke association and doctors group.

Tuesday, February 23, 2021

Registry: More Options for Blocked Carotids Mean Better Outcomes

In my opinion being not medically trained they missed the most important option.

Determine if the Circle of Willis is complete.
If yes, then completely close up the offending artery.
Your other three arteries supplying the Circle of Willis provide enough blood for you to function just fine.
This is why I would never consider a carotid endarterectomy as long as the Circle of Willis is complete.
Cognitive Dysfunction and Mortality After Carotid Endarterectomy
Risks of TCAR are here: Transcarotid Artery Revascularization, you don't want them to happen and they put a stent in besides.
And this problem tied to stents:Plaque Protrusion Tied to Stroke in Carotid Stenting 3% rate

The latest here:

Registry: More Options for Blocked Carotids Mean Better Outcomes

Adoption of TCAR may be good for carotid revascularization in general

by Nicole Lou, Staff Writer, MedPage Today February 22, 2021

A computer rendering of the transcarotid artery revascularization procedure

Centers adding transcarotid artery revascularization (TCAR) to their treatment options had improved perioperative outcomes for patients with carotid artery stenosis, according to the Vascular Quality Initiative (VQI) registry.

Major adverse cardiovascular event (MACE) rates -- counting in-hospital stroke, MI, and death at 30 days -- were similar between patients undergoing TCAR and those getting surgical carotid endarterectomy (CEA; 2.3% vs 2.4%, P=0.91), reported a group led by Jesse Columbo, MD, MS, of Dartmouth-Hitchcock Medical Center in Lebanon, New Hampshire.

Despite such similar results, VQI centers had 10% less MACE in their overall carotid revascularization programs in the year after adopting TCAR than if they had stuck with the surgical option alone (OR 0.90, 95% CI 0.81-0.99), according to a difference-in-difference analysis by Columbo's group, published online in JAMA Open Network.

"This finding suggests that this new technology may have allowed proceduralists to select patients for whom TCAR may be superior to CEA, while still performing CEA on patients for whom that procedure was appropriate," study authors said.

"Overall, while observational in nature, these data imply that both TCAR and CEA may be reasonable treatment choices for patients undergoing carotid revascularization and providers may be able to choose the modality they feel best aligns with the patient's clinical presentation and anatomy," they concluded.

Moreover, the observed 10% MACE reduction, already "impressive," may in fact be an underestimation of the benefits of TCAR adoption, because the study included only VQI hospitals, which record only 10% of the CEAs performed in the U.S., commented Peter Groeneveld, MD, of the University of Pennsylvania in Philadelphia, in an invited commentary.

In contrast, device sales records indicate that the registry captures more than 95% of TCAR procedures.

TCAR was introduced to the U.S. market with the 2015 FDA approval of the Enroute stent system from Silk Road Medical.

The carotid procedure is designed to be a lower-risk alternative to surgery for patients at high risk due to anatomic or medical challenges. It is also designed with no need to traverse the aortic arch and carotid lesion prior to embolic protection, unlike transfemoral carotid stenting.

Whether TCAR is truly noninferior to CEA has not been proven in a randomized controlled trial. Transfemoral carotid stenting has been linked to more periprocedural events but no difference in outcomes at 10 years compared with surgery.

"An ongoing challenge for cardiovascular surgeons and interventionalists is to ascertain whether new therapeutic options for patients with a severe cardiovascular disease improve clinical outcomes across the full spectrum of patients with the disease. There are no guarantees that new therapies will produce net benefits across broad populations," Groeneveld cautioned.

He cited the examples of percutaneous coronary intervention, which may have "inappropriately shifted numerous patients away from the better treatment option" of coronary artery bypass grafting, and transcatheter aortic valve replacement, which conversely increased the accessibility of treatment while "potentially improving outcomes across the full spectrum of patients with aortic valve disease."

In general, better clinical outcomes for heart procedure recipients will require a "collective learning process" that harnesses data collection and judicious interpretation of statistical analyses, according to Groeneveld.

The study was a retrospective analysis of a national quality improvement registry maintained by the Society for Vascular Surgery. Included were people who underwent carotid procedures in 2015-2019. Those who got transfemoral carotid stenting were excluded.

A total of 86,027 patients at 469 participating VQI centers constituted the study cohort. Although only 8.9% got TCAR, TCAR procedures had jumped from 0.7% of all carotid procedures in 2015 to 17.0% in 2019. Accordingly, adoption of TCAR rose from 15 VQI centers in 2015 to 247 in 2019.

The TCAR group was significantly older on average (73.1 vs 70.6 years) and included fewer women (36.4% vs 39.5%) than the CEA group.

Unobserved confounding was a major potential limitation to the study.

"The primary threat to this study's validity is whether TCAR adoption by a hospital was associated with other concurrent quality-of-care initiatives that were the actual effectors of lower MACE rates. For example, it would not be surprising if TCAR-adopting hospitals were on a different trajectory for surgical quality than hospitals that did not adopt TCAR or did so slowly," according to Groeneveld.

A randomized trial "is likely the only way to dispel any lingering doubts regarding TCAR's comparative effectiveness" against surgery, but the "preponderance of existing observational data and evidence from single-group trials certainly supports TCAR's noninferiority to CEA," the editorialist acknowledged.