Reporting standards for carotid interventions from the Society for Vascular Surgery
2011; Elsevier BV; Volume: 53; Issue: 6 Linguagem: Inglês
10.1016/j.jvs.2010.11.122
ISSN1097-6809
AutoresCarlos H. Timaran, James F. McKinsey, Peter A. Schneider, Fred N. Littooy,
Tópico(s)Cardiovascular Health and Disease Prevention
ResumoSince the North American Symptomatic Carotid Endarterectomy Trial (NASCET) established the role of carotid endarterectomy in the treatment of symptomatic carotid stenosis,1North American Symptomatic Carotid Endarterectomy Trial CollaboratorsBeneficial effect of carotid endarterectomy in symptomatic patients with high-grade carotid stenosis.N Engl J Med. 1991; 325: 445-453Crossref PubMed Scopus (7401) Google Scholar multiple randomized clinical trials, registries, and observational studies have assessed the safety and efficacy of several medical, interventional, and surgical treatments of extracranial carotid disease.2Hobson R.W. Mackey W.C. Ascher E. Murad M.H. Calligaro K.D. Comerota A.J. et al.Management of atherosclerotic carotid artery disease: clinical practice guidelines of the Society for Vascular Surgery.J Vasc Surg. 2008; 48: 480-486Abstract Full Text Full Text PDF PubMed Scopus (174) Google Scholar Standard methods of reporting the presenting symptomatology, comorbidities, lesion characteristics, and techniques of interventions have become imperative to assess specific outcomes. Because major adverse events and complications after carotid interventions are infrequent, multicenter trials, registries, or meta-analyses of multiple individual studies are often necessary to obtain adequate power to evaluate safety and efficacy of carotid interventions. The complexity of the carotid lesions, adjacent anatomy, and patient comorbidities should be accounted for during the reporting of carotid interventions in order to accurately compare outcomes. As new therapeutic techniques such as carotid artery stenting (CAS) and advances in best medical treatment for vascular disease have become available, it is equally important to develop reporting standards that will allow accurate comparisons among the different trials and various treatment modalities. In 1988, the Ad Hoc Committee on Reporting Standards of the Society for Vascular Surgery/International Society for Cardiovascular Surgery published suggested reporting standards for studies dealing with extracranial carotid disease.3Baker J.D. Rutherford R.B. Bernstein E.F. Courbier R. Ernst C.B. Kempczinski R.F. et al.Suggested standards for reports dealing with cerebrovascular disease Subcommittee on Reporting Standards for Cerebrovascular Disease, Ad Hoc Committee on Reporting Standards, Society for Vascular Surgery/North American chapter, International Society for Cardiovascular Surgery.J Vasc Surg. 1988; 8: 721-729PubMed Google Scholar Because of the recent and rapid advancements in the treatment of carotid artery disease, a revised version of the recommended standards is warranted. This is particularly true as many uncertainties and controversies about the management of carotid artery disease exist and should be addressed in future randomized clinical trials and observational studies. As new data are generated from ongoing and future trials, it is imperative to have uniform reporting standards that will allow meaningful meta-analyses according to different patient, lesion, and procedural characteristics. Postmarket surveillance registries will likely be mandated for conventional risk patients undergoing carotid interventions, as has been the case for patients at high risk for carotid endarterectomy (CEA). Established reporting standards for these registries are also needed. A revised and recommended set of reported standards is presented for the comparative analyses of data and outcomes related to the treatment of carotid artery disease. These reporting standards were developed by a reporting committee appointed by the Society for Vascular Surgery and represent a consensus reached by this group. The American Heart Association published guidelines for the treatment of symptomatic carotid stenosis with CEA in 1995.4Moore W.S. Barnett H.J. Beebe H.G. Bernstein E.F. Brener B.J. Brott T. et al.Guidelines for carotid endarterectomy A multidisciplinary consensus statement from the Ad Hoc Committee, American Heart Association.Circulation. 1995; 91: 566-579Crossref PubMed Scopus (298) Google Scholar Guidelines to clarify the indications of surgery for asymptomatic carotid stenosis were published in 1998.5Biller J. Feinberg W.M. Castaldo J.E. Whittemore A.D. Harbaugh R.E. Dempsey R.J. et al.Guidelines for carotid endarterectomy: a statement for healthcare professionals from a Special Writing Group of the Stroke Council, American Heart Association.Circulation. 1998; 97: 501-509Crossref PubMed Scopus (426) Google Scholar Both these documents were based on level I evidence provided by the largest clinical trials comparing carotid endarterectomy versus best medical management. These trials included the NASCET study,1North American Symptomatic Carotid Endarterectomy Trial CollaboratorsBeneficial effect of carotid endarterectomy in symptomatic patients with high-grade carotid stenosis.N Engl J Med. 1991; 325: 445-453Crossref PubMed Scopus (7401) Google Scholar the European Carotid Surgery Trial (ECST),6Randomised trial of endarterectomy for recently symptomatic carotid stenosis: final results of the MRC European Carotid Surgery Trial (ECST).Lancet. 1998; 351: 1379-1387Abstract Full Text Full Text PDF PubMed Scopus (2733) Google Scholar the Veterans Affairs Symptomatic study,7Mayberg M.R. Wilson S.E. Yatsu F. Weiss D.G. Messina L. Hershey L.A. et al.Carotid endarterectomy and prevention of cerebral ischemia in symptomatic carotid stenosis Veterans Affairs Cooperative Studies Program 309 Trialist Group.JAMA. 1991; 266: 3289-3294Crossref PubMed Scopus (786) Google Scholar and the Asymptomatic Carotid Atherosclerosis Study.8Executive Committee for the Asymptomatic Carotid Atherosclerosis StudyEndarterectomy for asymptomatic carotid artery stenosis.JAMA. 1995; 273: 1421-1428Crossref PubMed Scopus (4852) Google Scholar One major contribution of these trials was the reporting of the perioperative stroke and death rates based on whether the patient was symptomatic or asymptomatic. The resultant stroke and death rates following carotid endarterectomy became the standard of care to which other carotid interventions were compared. Future reports assessing outcomes of carotid interventions should therefore provide outcomes based on symptomatic status, which needs to be clearly established. Patients with carotid stenosis should be considered symptomatic if they present with a history of stroke, amaurosis fugax, or transient ischemic attacks (TIA) involving the ipsilateral carotid territory that occurred within 180 days of the initial assessment. A complete definition and discussion of these terms can be found in the outcomes section.9Adams Jr, H.P. del Zoppo G. Alberts M.J. Bhatt D.L. Brass L. Furlan A. et al.Guidelines for the early management of adults with ischemic stroke: a guideline from the American Heart Association/American Stroke Association Stroke Council, Clinical Cardiology Council, Cardiovascular Radiology and Intervention Council, and the Atherosclerotic Peripheral Vascular Disease and Quality of Care Outcomes in Research Interdisciplinary Working Groups: the American Academy of Neurology affirms the value of this guideline as an educational tool for neurologists.Stroke. 2007; 38: 1655-1711Crossref PubMed Scopus (1844) Google Scholar, 10Easton J.D. Saver J.L. Albers G.W. Alberts M.J. Chaturvedi S. Feldmann E. et al.Definition and Evaluation of transient ischemic attack: a scientific statement for healthcare professionals from the American Heart Association/American Stroke Association Stroke Council; Council on Cardiovascular Surgery and Anesthesia; Council on Cardiovascular Radiology and Intervention; Council on Cardiovascular Nursing; and the Interdisciplinary Council on Peripheral Vascular Disease: the American Academy of Neurology affirms the value of this statement as an educational tool for neurologists.Stroke. 2009; 40: 2276-2293Crossref PubMed Scopus (1183) Google Scholar Although some controversy exists regarding the duration of current ipsilateral carotid symptoms to define symptomatic status, the 180-day cutoff has been used in most recent clinical trials dealing with carotid artery disease, including the International Carotid Stenting Study (ICSS),11Featherstone R.L. Brown M.M. Coward L.J. International carotid stenting study: protocol for a randomised clinical trial comparing carotid stenting with endarterectomy in symptomatic carotid artery stenosis.Cerebrovasc Dis. 2004; 18: 69-74Crossref PubMed Scopus (195) Google Scholar Stent-Supported Percutaneous Angioplasty of the Carotid Artery versus Endarterectomy (SPACE),12Ringleb P.A. Allenberg J. Bruckmann H. Eckstein H.H. Fraedrich G. Hartmann M. et al.Thirty-day results from the SPACE trial of stent-protected angioplasty versus carotid endarterectomy in symptomatic patients: a randomised noninferiority trial.Lancet. 2006; 368: 1239-1247Abstract Full Text Full Text PDF PubMed Scopus (1242) Google Scholar Angioplasty in Patients with Symptomatic Severe Carotid Stenosis (EVA-3S),13Mas J.L. Chatellier G. Beyssen B. Branchereau A. Moulin T. Becquemin J.P. et al.Endarterectomy versus stenting in patients with symptomatic severe carotid stenosis.N Engl J Med. 2006; 355: 1660-1671Crossref PubMed Scopus (1328) Google Scholar and Carotid Revascularization Endarterectomy versus Stent Trial (CREST),14Crest H.R.W. Carotid revascularization endarterectomy versus stent trial: background, design, and current status.Semin Vasc Surg. 2000; 13: 139-143PubMed Google Scholar, 15Brott T.G. Hobson R.W. Howard G. Roubin G.S. Clark W.M. Brooks W. et al.Stenting versus endarterectomy for treatment of carotid-artery stenosis.N Engl J Med. 2010; 363: 11-23Crossref PubMed Scopus (2091) Google Scholar in line with the definitions used in NASCET1North American Symptomatic Carotid Endarterectomy Trial CollaboratorsBeneficial effect of carotid endarterectomy in symptomatic patients with high-grade carotid stenosis.N Engl J Med. 1991; 325: 445-453Crossref PubMed Scopus (7401) Google Scholar and ECST.6Randomised trial of endarterectomy for recently symptomatic carotid stenosis: final results of the MRC European Carotid Surgery Trial (ECST).Lancet. 1998; 351: 1379-1387Abstract Full Text Full Text PDF PubMed Scopus (2733) Google Scholar Therefore, use of other time intervals to define symptomatic status is discouraged to gain uniformity in reporting. Patients with carotid stenosis that do not meet the definition for symptomatic carotid stenosis are considered asymptomatic. This includes patients with no neurologic symptoms referable to the cerebral hemisphere ipsilateral to the carotid stenosis or a history of previous neurologic events without subsequent event within 180 days. Patients with prior symptoms referable only to the hemisphere contralateral to the target vessel or symptoms in either hemisphere occurring 180 days or longer prior to the initial evaluation should also be considered asymptomatic. Moreover, patients with atypical or nonfocal neurologic symptoms (ie, dizziness, confusion) or vertebrobasilar symptoms should also be defined as asymptomatic from the carotid artery standpoint. Clinical studies that evaluate carotid interventions, particularly those that compare different treatment modalities, may be difficult to interpret when differences in demographics, comorbid conditions, and perioperative risk factors are not identified and characterized.16Moore W.S. Extracranial cerebrovascular disease: the carotid artery.in: Moore W.S. Vascular and endovascular surgery: a comprehensive review. 7th ed. Saunders Elsevier, Philadelphia2006: 617-658Google Scholar, 17Ohki T. Timaran C.H. Yadav J.S. Technique of carotid angioplasty and stenting.in: Moore W.S. Vascular and endovascular surgery: a comprehensive review. 7th ed. Saunders Elsevier, Philadelphia2006: 355-382Google Scholar Grading risk factors in severity with uniform definitions, such as the Society for Vascular Surgery (SVS) 0 to 3 scoring scale, allows severity indexes to be calculated for subgroup comparison.18Rutherford R.B. Baker J.D. Ernst C. Johnston K.W. Porter J.M. Ahn S. et al.Recommended standards for reports dealing with lower extremity ischemia: revised version.J Vasc Surg. 1997; 26: 517-538Abstract Full Text Full Text PDF PubMed Scopus (2496) Google Scholar The following simplified grading system is adopted from the comorbid scoring system currently used for reports dealing with lower extremity ischemia (Table I).Table ISVS medical comorbidity grading systemCategories/GradeDiabetes 0None 1Adult onset, controlled by diet or oral agents 2Adult onset, insulin-controlled 3Juvenile onsetTobacco use 0None or none for last 10 years 1None current, but smoked in last 10 years 2Current (includes abstinence less than 1 years), less than 1 pack/day 3Current, greater than 1 pack/dayHypertension 0None (cutoff point, diastolic pressure usually lower than 90 mm Hg) 1Controlled (cutoff point, diastolic pressure usually lower than 90 mm Hg) with single drug 2Controlled with two drugs 3Requires more than two drugs or is uncontrolled.Hyperlipidemia 0Cholesterol (low-density lipoprotein and total) and triglyceride levels within normal limits for age 1Mild elevation, readily controllable by diet 2Moderate elevation requiring strict dietary control 3Same as 2, but severe enough to require dietary and drug control.Cardiac status 0Asymptomatic, with normal electrocardiogram 1Asymptomatic but with either remote myocardial infarction by history (>6 months), occult myocardial infarction by electrocardiogram, or fixed defect on dipyridamole thallium or similar scan 2Any one of the following: stable angina, no angina but significant reversible perfusion defect on dipyridamole thallium scan, significant silent ischemia (≥1% of time) on Holter monitoring, ejection fraction 25% to 45%, controlled ectopy or asymptomatic arrhythmia, history of congestive heart failure that is now well compensated 3Any one of the following: unstable angina, symptomatic or poorly controlled ectopy/arrhythmia (chronic/recurrent), poorly compensated or recurrent congestive heart failure, ejection fraction less than 25%, myocardial infarction within 6 months.Renal status 0No known renal disease, normal serum creatinine level 1Moderately elevated creatinine level, as high as 2.4 mg/dL 2Creatinine level, 2.5 to 5.9 mg/dL 3Creatinine level greater than 6.0 mg/dL, or on dialysis or with kidney transplant.Pulmonary status 0Asymptomatic, normal chest X-ray film, pulmonary function tests within 20% of predicted 1Asymptomatic or mild dyspnea on exertion, mild chronic parenchymal X-ray changes, pulmonary function tests 65% to 80% of predicted 2Between 1 and 3 3Vital capacity less than 1.85 L, FEV1 less than 1.2 L or less than 35% of predicted, maximal voluntary ventilation less than 50% of predicted, PCO2 greater than 45 mm Hg, supplemental oxygen use medically necessary, or pulmonary hypertension. Open table in a new tab In general, all conditions presumed to affect reported outcomes should be recorded and reported in any study or trial. The comorbidities and scoring systems are mainly intended to represent systemic factors that are likely to affect major morbidity and mortality associated with endovascular or surgical treatment of carotid lesions. Scoring all and each comorbid condition and risk factors affecting outcome may not be necessary in all instances, but in a given report, it is important to specify those conditions and scores that pertain to the outcome measures being investigated and reported, particularly those that affect an outcome for which a significant difference is claimed. Nevertheless, all of the SVS grading scales are included in this report for the advantage of collecting prospective data in a manner that facilitates later analysis (Table I). Although most risk factors are associated with anatomic and lesion characteristics, medical comorbid conditions and the adequacy of their treatment have also been identified as ominous predictors of periprocedural morbidity and mortality after carotid interventions. For instance, octogenarians and uncontrolled diabetes, ie, when HbA1c >7%, have shown to be independent risk factors for neurologic events and/or 30-day operative mortality.19Hobson R.W. Howard V.J. Roubin G.S. Brott T.G. Ferguson R.D. Popma J.J. et al.Carotid artery stenting is associated with increased complications in octogenarians: 30-day stroke and death rates in the CREST lead-in phase.J Vasc Surg. 2004; 40: 1106-1111Abstract Full Text Full Text PDF PubMed Scopus (503) Google Scholar, 20Hofmann R. Niessner A. Kypta A. Steinwender C. Kammler J. Kerschner K. et al.Risk score for peri-interventional complications of carotid artery stenting.Stroke. 2006; 37: 2557-2561Crossref PubMed Scopus (68) Google Scholar In this regard, the effects and potential increasing role of the current medical treatment for vascular disease in the management of patients with carotid artery disease needs to be systematically evaluated. Standardization and reporting of medical therapies in light of the patient's comorbidities in future trials will be critical to determining the role of current best medical therapy in preventing stroke in patients with carotid stenosis. Because carotid stenting with cerebral embolic protection is frequently used for the treatment of severe carotid stenosis among high-risk patients, the presence of such high-risk categories,21Gray W.A. Hopkins L.N. Yadav S. Davis T. Wholey M. Atkinson R. et al.Protected carotid stenting in high-surgical-risk patients: the ARCHeR results.J Vasc Surg. 2006; 44: 258-268Abstract Full Text Full Text PDF PubMed Scopus (355) Google Scholar, 22Hopkins L.N. Myla S. Grube E. Wehman J.C. Levy E.I. Bersin R.M. et al.Carotid artery revascularization in high surgical risk patients with the NexStent and the Filterwire EX/EZ: 1-year results in the CABERNET trial.Catheter Cardiovasc Interv. 2008; 71: 950-960Crossref PubMed Scopus (85) Google Scholar, 23Safian R.D. Bresnahan J.F. Jaff M.R. Foster M. Bacharach J.M. Maini B. et al.Protected carotid stenting in high-risk patients with severe carotid artery stenosis.J Am Col Card. 2006; 47: 2384-2389Abstract Full Text Full Text PDF PubMed Scopus (172) Google Scholar, 24Yadav J.S. Wholey M.H. Kuntz R.E. Fayad P. Katzen B.T. Mishkel G.J. et al.Protected carotid-artery stenting versus endarterectomy in high-risk patients.N Engl J Med. 2004; 351: 1493-1501Crossref PubMed Scopus (2427) Google Scholar, 25Iyer S.S. White C.J. Hopkins L.N. Katzen B.T. Safian R. Wholey M.H. et al.Carotid artery revascularization in high-surgical-risk patients using the Carotid WALLSTENT and FilterWire EX/EZ: 1-year outcomes in the Beach Pivotal Group.J Am Coll Cardiol. 2008; 51: 427-434Abstract Full Text Full Text PDF PubMed Scopus (99) Google Scholar particularly those related to concomitant significant comorbidities, should always be specified and reported (Table II). This is particularly important as recent observational studies challenge the adverse outcomes seen after CEA among patients in these “high-risk” categories and demonstrate improved outcomes similar to those of low-risk patients.26Boules T.N.M. Proctor M.C.M. Aref A.B. Upchurch G.R.J. Stanley J.C.M. Henke P.K.M. Carotid endarterectomy remains the standard of care, even in high-risk surgical patients.Ann Surg. 2005; 241: 356-363Crossref PubMed Scopus (61) Google Scholar, 27Mozes G. Sullivan T.M. Torres-Russotto D.R. Bower T.C. Hoskin T.L. Sampaio S.M. et al.Carotid endarterectomy in sapphire-eligible high-risk patients: implications for selecting patients for carotid angioplasty and stenting.J Vasc Surg. 2004; 39: 958-965Abstract Full Text Full Text PDF PubMed Scopus (158) Google Scholar, 28Sidawy A.N. Zwolak R.M. White R.A. Siami F.S. Schermerhorn M.L. Sicard G.A. Risk-adjusted 30-day outcomes of carotid stenting and endarterectomy: results from the SVS Vascular Registry.J Vasc Surg. 2009; 49: 71-79Abstract Full Text Full Text PDF PubMed Scopus (151) Google Scholar Future studies in which further risk stratification based on preintervention anatomy and comorbid conditions is assessed should report results of carotid interventions according to “high-risk” criteria for each procedure.Table IISignificant comorbidities that define high risk for carotid endarterectomyaBased on conditions that were used to determine patients at high risk for carotid endarterectomy in carotid stenting trials and registries, such as ARCHER, CABERNET, CREATE, SAPPHIRE, and BEACH.Clinically significant cardiac disease Congestive heart failure (NYHA class III/IV) Left ventricular ejection fraction 70% stenosis Recent myocardial infarction (>24 hours and <4 weeks) MI within 30 days and need carotid revascularization Abnormal stress test Need open heart surgery within 30 daysSevere pulmonary disease Severe COPD defined as the need for home oxygen or PO2 <60 on room air Forced expiratory volume in 1 s (FEV1) <30% (predicted)Dialysis-dependent renal failureCCS, Canadian Cardiovascular Society; COPD, chronic obstructive pulmonary disease; MI, myocardial infarction; NYHA, New York Heart Association.a Based on conditions that were used to determine patients at high risk for carotid endarterectomy in carotid stenting trials and registries, such as ARCHER, CABERNET, CREATE, SAPPHIRE, and BEACH. Open table in a new tab CCS, Canadian Cardiovascular Society; COPD, chronic obstructive pulmonary disease; MI, myocardial infarction; NYHA, New York Heart Association. Preprocedural evaluation of patients with carotid artery disease should include imaging studies to determine the degree of carotid stenosis and assess morphologic characteristics and location of carotid lesions. Carotid duplex, computed tomography angiography (CTA), magnetic resonance angiography (MRA), and digital subtraction angiography (DSA) are the most frequent current methods of assessing carotid artery lesions. CTA, MRA, and DSA are also imaging studies capable of assessing vascular anatomy from the aortic arch to the intracranial circulation, which is particularly helpful for evaluating carotid and arch morphology of patients with carotid stenosis considered for CAS.29Wyers M.C. Powell R.J. Fillinger M.F. Nolan B.W. Cronenwett J.L. The value of 3D-CT angiographic assessment prior to carotid stenting.J Vasc Surg. 2009; 49: 614-622Abstract Full Text Full Text PDF PubMed Scopus (23) Google Scholar, 30Timaran C.H. Rosero E.B. Valentine R.J. Modrall J.G. Smith S. Clagett G.P. Accuracy and utility of three-dimensional contrast-enhanced magnetic resonance angiography in planning carotid stenting.J Vasc Surg. 2007; 46: 257-263Abstract Full Text Full Text PDF PubMed Scopus (15) Google Scholar The imaging modalities used for preprocedural evaluation and their findings should be reported. Duplex ultrasound is usually the initial diagnostic method used in the evaluation of carotid artery disease. Duplex ultrasound is inexpensive, convenient, and does not require radiation or potentially nephrotoxic contrast medium. It is, however, operator dependent and can be of limited value in severely diseased or calcified vessels. Duplex findings may be interpreted as abnormal when carotid velocities meet previously validated criteria, such as NASCET or the University of Washington modified criteria for nonstented carotid arteries.31Zhou W. Felkai D.D. Evans M. McCoy S.A. Lin P.H. Kougias P. et al.Ultrasound criteria for severe in-stent restenosis following carotid artery stenting.J Vasc Surg. 2008; 47: 74-80Abstract Full Text Full Text PDF PubMed Scopus (70) Google Scholar, 32Stradness D.E. Duplex scanning in vascular disorders. Raven Press, New York1990Google Scholar If different velocity criteria are used to determine the degree of stenosis, these should be validated at each laboratory using digital subtraction angiography as the reference standard. The status of validation and accreditation of the vascular laboratory performing the vascular evaluation should be reported. For the highest degree of objectivity of the duplex evaluation, a standard protocol to perform the study should be developed and reported.33Thiele B.L. Jones A.M. Hobson R.W. Bandyk D.F. Baker W.H. Sumner D.S. et al.Standards in noninvasive cerebrovascular testing Report from the Committee on Standards for Noninvasive Vascular Testing of the Joint Council of the Society for Vascular Surgery and the North American chapter of the International Society for Cardiovascular Surgery.J Vasc Surg. 1992; 15: 495-503Abstract Full Text Full Text PDF PubMed Scopus (68) Google Scholar Peak systolic and end diastolic velocities in the distal common carotid artery (CCA) and internal carotid artery (ICA) should be carefully assessed and recorded. Similar evaluations of treated or stented carotid arteries during follow-up surveillance should be performed, with careful evaluation of velocities and B-mode imaging at the proximal, middle, and distal portions of the stent. In cases of in-stent restenosis, velocity and B-mode measurements at the site of maximum in-stent stenosis need to be determined and reported. If a different methodology for determining the degree of stenosis is used, it should be reported and described in detail. Transcranial Doppler (TCD) is a noninvasive ultrasound-based technique that is increasingly used for periprocedural evaluation and monitoring of blood flow velocities within the cerebral arterial circulation during carotid interventions.34Consensus Committee of the Ninth International Cerebral Hemodynamic SymposiumBasic identification criteria of Doppler microembolic signals.Stroke. 1995; 26: 1123Crossref PubMed Scopus (283) Google Scholar The middle cerebral artery is the vessel usually insonated with a 2 MHz pulsed signal transmitted through the temporal bone. Gaseous or solid microemboli within the middle cerebral artery can be detected with TCD as high-intensity transient signals (HITS), also known as cerebral microembolic signals (MES).34Consensus Committee of the Ninth International Cerebral Hemodynamic SymposiumBasic identification criteria of Doppler microembolic signals.Stroke. 1995; 26: 1123Crossref PubMed Scopus (283) Google Scholar, 35Smith J.L. Evans D.H. Fan L. Gaunt M.E. London N.J. Bell P.R. et al.Interpretation of embolic phenomena during carotid endarterectomy.Stroke. 1995; 26: 2281-2284Crossref PubMed Scopus (81) Google Scholar When TCD is used for monitoring carotid interventions, the methods to detect microemboli should be reported. In general, MES should be defined as HITS with duration of <300 ms and amplitude that is 3 dB higher than the background blood flow signal.34Consensus Committee of the Ninth International Cerebral Hemodynamic SymposiumBasic identification criteria of Doppler microembolic signals.Stroke. 1995; 26: 1123Crossref PubMed Scopus (283) Google Scholar The total number of HITS detected throughout the entire procedure and during different phases should be reported, as appropriate. Traditionally, TCD has been used during carotid endarterectomy to help assess the need for shunting during the cross clamp phase36Jansen C. Vriens E.M. Eikelboom B.C. Vermeulen F.E. van Gijn J. Ackerstaff R.G. Carotid endarterectomy with transcranial Doppler and electroencephalographic monitoring A prospective study in 130 operations.Stroke. 1993; 24: 665-669Crossref PubMed Scopus (116) Google Scholar More recently, TCD has also been used to measure the intraoperative microembolic events during CEA and CAS.35Smith J.L. Evans D.H. Fan L. Gaunt M.E. London N.J. Bell P.R. et al.Interpretation of embolic phenomena during carotid endarterectomy.Stroke. 1995; 26: 2281-2284Crossref PubMed Scopus (81) Google Scholar, 37Rubartelli P. Brusa G. Arrigo A. Abbadessa F. Giachero C. Vischi M. et al.Transcranial Doppler monitoring during stenting of the carotid bifurcation: evaluation of two different distal protection in preventing embolization.J Endovasc Ther. 2006; 13: 436-442Crossref PubMed Scopus (40) Google Scholar, 38Ackerstaff R.G.A. Suttorp M.J. van den Berg J.C. Overtoom T.T.C. Vos J.A. Bal E.T. et al.Prediction of early cerebral outcome by transcranial Doppler monitoring in carotid bifurcation angioplasty and stenting.J Vasc Surg. 2005; 41: 618-624Abstract Full Text Full Text PDF PubMed Scopus (94) Google Scholar, 39Garami Z.F. Bismuth J. Charlton-Ouw K.M. Davies M.G. Peden E.K. Lumsden A.B. Feasibility of simultaneous pre- and postfilter transcranial Doppler monitoring during carotid artery stenting.J Vasc Surg. 2009; 49: 340-345Abstract Full Text Full Text PDF PubMed Scopus (36) Google Scholar The timing and methods of postprocedural TCD monitoring should be reported, which is particularly important because of the likely temporal variability in embolization during and after carotid interventions. Because adverse neurologic events after CAS and CEA are rare events in high volume practices, TCD monitoring and quantification of microembolization may also be used as a surrogate end point in the evaluation of different techniques and devices on cerebral embolization during carotid interventions. Changes in flow velocities in the cerebral circulation detected with TCD should also be reported, particularly in cases of hyperperfusion and intracranial hemorrhage after carotid interventions. TCD has, in fact, been proven useful in the prediction of these complications.40Powers A.D. Smith R.R. Hyperperfusion syndrome after carotid endarterectomy: a transcranial Doppler evaluation.Neurosurgery. 1990; 26: 56-59Crossref PubMed Scopus (76) Google Scholar, 41Sfyroeras G.S. Karkos C.D. Arsos G. Liasidis C. Dimitriadis A.S. Papazoglou K.O. et al.Cerebral hyperperfusion after carotid stenting: a transcran
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