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Published on: January 18, 2018
Extracranial-Intracranial Cerebral Revascularization for Atherosclerotic Vessel Occlusion: An Updated Systematic
Vincent N Nguyen1, Mustafa Motiwala1, Kara Parikh1
1University of Tennessee Health Sciences Center Department of Neurosurgery, Memphis, Tennessee, USA.
Insights
Surgical revascularization for atherosclerotic steno-occlusive disease shows improved outcomes. Modern techniques and patient selection have reduced stroke rates and increased favorable results.
Area of Science:
- Cerebrovascular disease research
- Surgical interventions for atherosclerotic disease
- Systematic review and meta-analysis methodologies
Background:
- Atherosclerotic steno-occlusive cerebrovascular disease encompasses both extracranial carotid and intracranial atherosclerotic conditions.
- Despite historical negative findings, select patient groups may benefit from revascularization surgery.
- This study aims to update the systematic review on revascularization surgery for atherosclerotic steno-occlusive disease in the current era.
Approach:
- A systematic literature search was conducted by five independent reviewers in October 2022, adhering to Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines.
- Included studies focused on adult patients undergoing bypass for atherosclerotic steno-occlusive disease, reporting clinical outcomes.
- Primary endpoints included perioperative and long-term ischemic strokes, intracerebral hemorrhage, bypass patency, and favorable clinical outcomes. Study quality was assessed using Newcastle-Ottawa, JADAD, and Oxford Centre for Evidence-Based Medicine scales.
Key Points:
- The review identified 50 relevant articles from an initial search of 6709, with a notable increase in publications over the last decade.
- Analysis of 6046 patients and 4447 bypasses (1978-2022) revealed significant improvements post-Carotid Occlusion Surgery Study (COSS).
- Post-COSS outcomes showed reduced perioperative stroke (OR, 0.65), long-term ischemia (OR, 0.32), overall ischemia (OR, 0.36), and increased favorable outcomes (OR, 3.63) compared to pre-COSS.
Conclusions:
- The updated systematic review indicates improved long-term stroke rates and favorable outcomes for surgical revascularization in steno-occlusive disease.
- Outcomes have improved over time and are lower than previously reported in the literature.
- Enhanced patient selection, perioperative care, and surgical techniques are likely contributors to these improved results.
Background:
Atherosclerotic steno-occlusive cerebrovascular disease includes extracranial carotid occlusive and intracranial atherosclerotic disease. Despite the negative findings in Carotid Occlusion Surgery Study (COSS), many large centers continue to report favorable results for revascularization surgery in select groups of patients. The aim of our study was to perform an updated systematic review to investigate the role of revascularization surgery for atherosclerotic steno-occlusive patients in the modern era.
Methods:
Five independent reviewers performed Preferred Reporting Items for Systematic Reviews and Meta-Analyses-guided literature searches in October 2022 to identify articles reporting clinical outcomes in adult patients undergoing bypass for atherosclerotic steno-occlusive disease. Primary endpoints used were perioperative and long-term ischemic strokes, intracerebral hemorrhage, bypass patency, and favorable clinical outcomes. Study quality was evaluated with Newcastle-Ottawa, JADAD, and the Oxford Center for Evidence-Based Medicine scales.
Results:
A total of 6709 articles were identified in the initial search. Of these articles, 50 met the inclusion criteria and were included in the systematic review. A notable increase in the proportion of articles published over the past 10 years was observed. There were 6046 total patients with 4447 bypasses performed over the period from 1978 to 2022. The average length of follow-up was 2.75 ± 2.71 years. The average Newcastle-Ottawa was 6.23 out of 9 stars. There was a significant difference in perioperative stroke (odds ratio [OR], 0.65 [0.48-0.87]; P = 0.004), long-term ischemia (OR, 0.32 [0.23-0.44]; P < 0.0001), overall ischemia (OR, 0.36 [0.28-0.44]; P < 0.0001), and favorable outcomes (OR, 3.63 [2.84-4.64]; P < 0.0001) when comparing pre-COSS to post-COSS time frames in favor of post-COSS.
Conclusions:
Based on a systematic review of 50 articles, the existing literature indicates that long-term stroke rates and favorable outcomes for surgical revascularization for steno-occlusive disease have improved over time and are lower than previously reported. Improved patient selection, perioperative care, and surgical techniques may contribute to improved outcomes.
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