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Thrombi of Different Pathologies: Implications for Diagnosis and Treatment

  • Carlos G. Santos-Gallego
  • Jeremías Bayón
  • Juan José Badimón
Cerebrovascular Disease and Stroke

Opinion statement

Stroke is the second leading cause of cardiovascular mortality in the modern world, accounting for 80% of strokes of ischemic origin. There are two main etiologies of ischemic stroke: 70% to 80% are caused by carotid atherosclerotic plaque rupture and superimposed thrombus formation, whereas 30% are caused by systemic embolism of a cardiac thrombus (mainly in atrial fibrillation [AF] patients). Therefore, antithrombotic therapy is the cornerstone of stroke treatment. In AF patients, thrombotic risk should be assessed by means of the CHADS2 score. Patients with a score of 0 should be treated with aspirin; for those with a score of 1, oral anticoagulation (target international normalized ratio, 2–3) or aspirin is recommended. For patients with a CHADS2 score ≥2, oral anticoagulation with warfarin should be initiated (unless contraindicated). If warfarin is contraindicated, antithrombotic treatment should be prescribed (the combination of aspirin and clopidogrel seems to be superior to aspirin alone). For primary prevention in atherosclerotic patients, low-dose aspirin is useful only in women older than 45 years who are not at risk for intracranial hemorrhage and do not have gastrointestinal intolerance (a very small but significant effect). For secondary prevention in atherosclerotic patients, antithrombotic therapy should be administered. It is recommended that patients who do not require anticoagulation receive clopidogrel or a combination of aspirin and dipyridamole. Alternatively, aspirin alone or triflusal may be used. Within 4.5 h of onset of acute stroke, thrombolytic therapy (recombinant tissue plasminogen activator) must be injected urgently (unless contraindicated). Dabigatran is a new oral anticoagulant (competitive thrombin inhibitor) with a promising role in stroke prevention; at low doses, it is noninferior to warfarin for stroke prevention and is safer, whereas at high doses, it is superior to warfarin in stroke prevention with the same incidence of bleeding. Percutaneous left atrial appendage occluders recently were approved for systemic embolism prevention. The use of warfarin after implantation is still under discussion. Dronedarone, a new antiarrhythmic agent, has been shown to decrease cardiovascular mortality and stroke in patients with AF. Carotid endarterectomy surgery is indicated in symptomatic patients with stenosis greater than 70% and in selected patients with 50% to 70% stenosis. Currently, carotid endarterectomy surgery is superior to carotid angioplasty and stenting.

Keywords

Atrial Fibrillation Warfarin Dabigatran Rivaroxaban Apixaban 
These keywords were added by machine and not by the authors. This process is experimental and the keywords may be updated as the learning algorithm improves.

Notes

Disclosure

No potential conflicts of interest relevant to this article were reported.

References and Recommended Reading

Papers of particular interest, published recently, have been highlighted as: • Of importance •• Of major importance

  1. 1.
    Lopez AD, Mathers CD, Ezzati M, et al.: Global and regional burden of disease and risk factors, 2001: systematic analysis of population health data. Lancet 2006, 367:1747–1757.CrossRefPubMedGoogle Scholar
  2. 2.
    • Badimon JJ, Ibanez B, Cimmino G: Genesis and dynamics of atherosclerotic lesions: implications for early detection. Cerebrovasc Dis 2009, 27(Suppl 1):38–47.CrossRefPubMedGoogle Scholar
  3. 3.
    Macleod MR, Amarenco P, Davis SM, Donnan GA: Atheroma of the aortic arch: an important and poorly recognised factor in the aetiology of stroke. Lancet Neurol 2004, 3:408–414.CrossRefPubMedGoogle Scholar
  4. 4.
    Marder VJ, Chute DJ, Starkman S, et al.: Analysis of thrombi retrieved from cerebral arteries of patients with acute ischemic stroke. Stroke 2006, 37:2086–2093.CrossRefPubMedGoogle Scholar
  5. 5.
    Mohr JP, Thompson JL, Lazar RM, et al.: A comparison of warfarin and aspirin for the prevention of recurrent ischemic stroke. N Engl J Med 2001, 345:1444–1451.CrossRefPubMedGoogle Scholar
  6. 6.
    Chimowitz MI, Lynn MJ, Howlett-Smith H, et al.: Comparison of warfarin and aspirin for symptomatic intracranial arterial stenosis. N Engl J Med 2005, 352:1305–1316.CrossRefPubMedGoogle Scholar
  7. 7.
    Molina CA, Montaner J, Arenillas JF, et al.: Differential pattern of tissue plasminogen activator-induced proximal middle cerebral artery recanalization among stroke subtypes. Stroke 2004, 35:486–490.CrossRefPubMedGoogle Scholar
  8. 8.
    Cho KH, Kim JS, Kwon SU, et al.: Significance of susceptibility vessel sign on T2*-weighted gradient echo imaging for identification of stroke subtypes. Stroke 2005, 36:2379–2383.CrossRefPubMedGoogle Scholar
  9. 9.
    Kurth T, Moore SC, Gaziano JM, et al.: Healthy lifestyle and the risk of stroke in women. Arch Intern Med 2006, 166:1403–1409.CrossRefPubMedGoogle Scholar
  10. 10.
    Kurth T, Gaziano JM, Rexrode KM, et al.: Prospective study of body mass index and risk of stroke in apparently healthy women. Circulation 2005, 111:1992–1998.CrossRefPubMedGoogle Scholar
  11. 11.
    Lee CD, Folsom AR, Blair SN: Physical activity and stroke risk: a meta-analysis. Stroke 2003, 34:2475–2481.CrossRefPubMedGoogle Scholar
  12. 12.
    Reynolds K, Lewis B, Nolen JD, et al.: Alcohol consumption and risk of stroke: a meta-analysis. JAMA 2003, 289:579–588.CrossRefPubMedGoogle Scholar
  13. 13.
    Shinton R, Beevers G: Meta-analysis of relation between cigarette smoking and stroke. BMJ 1989, 298:789–794.CrossRefPubMedGoogle Scholar
  14. 14.
    Qureshi AI, Suri MF, Kirmani JF, Divani AA: Cigarette smoking among spouses: another risk factor for stroke in women. Stroke 2005, 36:e74–e76.CrossRefPubMedGoogle Scholar
  15. 15.
    Joshipura KJ, Ascherio A, Manson JE, et al.: Fruit and vegetable intake in relation to risk of ischemic stroke. JAMA 1999, 282:1233–1239.CrossRefPubMedGoogle Scholar
  16. 16.
    He K, Song Y, Daviglus ML, et al.: Fish consumption and incidence of stroke: a meta-analysis of cohort studies. Stroke 2004, 35:1538–1542.CrossRefPubMedGoogle Scholar
  17. 17.
    • Hsia J, Heiss G, Ren H, et al.: Calcium/vitamin D supplementation and cardiovascular events. Circulation 2007, 115:846–854.CrossRefPubMedGoogle Scholar
  18. 18.
    Tornwall ME, Virtamo J, Korhonen PA, et al.: Postintervention effect of alpha tocopherol and beta carotene on different strokes: a 6-year follow-up of the Alpha Tocopherol, Beta Carotene Cancer Prevention Study. Stroke 2004, 35:1908–1913.CrossRefPubMedGoogle Scholar
  19. 19.
    Miller 3rd ER, Pastor-Barriuso R, Dalal D, et al.: Meta-analysis: high-dosage vitamin E supplementation may increase all-cause mortality. Ann Intern Med 2005, 142:37–46.PubMedGoogle Scholar
  20. 20.
    Bartolucci AA, Howard G: Meta-analysis of data from the six primary prevention trials of cardiovascular events using aspirin. Am J Cardiol 2006, 98:746–750.CrossRefPubMedGoogle Scholar
  21. 21.
    Ridker PM, Cook NR, Lee IM, et al.: A randomized trial of low-dose aspirin in the primary prevention of cardiovascular disease in women. N Engl J Med 2005, 352:1293–1304.CrossRefPubMedGoogle Scholar
  22. 22.
    Berger JS, Roncaglioni MC, Avanzini F, et al.: Aspirin for the primary prevention of cardiovascular events in women and men: a sex-specific meta-analysis of randomized controlled trials. JAMA 2006, 295:306–313.CrossRefPubMedGoogle Scholar
  23. 23.
    Hobson 2nd RW, Krupski WC, Weiss DG: Influence of aspirin in the management of asymptomatic carotid artery stenosis. VA Cooperative Study Group on Asymptomatic Carotid Stenosis. J Vasc Surg 1993, 17:257–263. discussion 263–265.CrossRefPubMedGoogle Scholar
  24. 24.
    Engelter S, Lyrer P: Antiplatelet therapy for preventing stroke and other vascular events after carotid endarterectomy. Cochrane Database Syst Rev 2003, CD001458.Google Scholar
  25. 25.
    Weimar C, Weber R, Diener HC: Antithrombotic medication for stroke prevention. Expert Rev Cardiovasc Ther 2009, 7:1245–1254.CrossRefPubMedGoogle Scholar
  26. 26.
    • Hart RG, Pearce LA, Aguilar MI: Meta-analysis: antithrombotic therapy to prevent stroke in patients who have nonvalvular atrial fibrillation. Ann Intern Med 2007, 146:857–867.PubMedGoogle Scholar
  27. 27.
    Fuster V, Rydén LE, Asinger RW, et al.: American College of Cardiology/American Heart Association Task Force on Practice Guidelines; European Society of Cardiology Committee for Practice Guidelines and Policy Conferences (Committee to Develop Guidelines for the Management of Patients With Atrial Fibrillation); North American Society of Pacing and Electrophysiology: ACC/AHA/ESC Guidelines for the Management of Patients With Atrial Fibrillation: Executive Summary A Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines and the European Society of Cardiology Committee for Practice Guidelines and Policy Conferences (Committee to Develop Guidelines for the Management of Patients With Atrial Fibrillation) Developed in Collaboration With the North American Society of Pacing and Electrophysiology. Circulation 2001, 104:2118–2150.PubMedGoogle Scholar
  28. 28.
    Bhatt DL, Fox KA, Hacke W, et al.: Clopidogrel and aspirin versus aspirin alone for the prevention of atherothrombotic events. N Engl J Med 2006, 354:1706–1717.CrossRefPubMedGoogle Scholar
  29. 29.
    CAPRIE Steering Committee: A randomised, blinded, trial of clopidogrel versus aspirin in patients at risk of ischaemic events (CAPRIE). Lancet 1996, 348:1329–1339.CrossRefGoogle Scholar
  30. 30.
    • Hankey GJ, Eikelboom JW: Antithrombotic drugs for patients with ischaemic stroke and transient ischaemic attack to prevent recurrent major vascular events. Lancet Neurol 2010, 9:273–284.CrossRefPubMedGoogle Scholar
  31. 31.
    Diener HC, Bogousslavsky J, Brass LM, et al.: Aspirin and clopidogrel compared with clopidogrel alone after recent ischemic stroke or transient ischemic attack in high-risk patients (MATCH): randomised, double-blind, placebo-controlled trial. Lancet 2004, 364:331–337.CrossRefPubMedGoogle Scholar
  32. 32.
    Yusuf S, Zhao F, Mehta SR, et al.: Effects of clopidogrel in addition to aspirin in patients with acute coronary syndromes without ST-segment elevation. N Engl J Med 2001, 345:494–502.CrossRefPubMedGoogle Scholar
  33. 33.
    Connolly S, Pogue J, Hart R, et al.: Clopidogrel plus aspirin versus oral anticoagulation for atrial fibrillation in the Atrial fibrillation Clopidogrel Trial with Irbesartan for prevention of Vascular Events (ACTIVE W): a randomised controlled trial. Lancet 2006, 367:1903–1912.CrossRefPubMedGoogle Scholar
  34. 34.
    • Connolly SJ, Pogue J, Hart RG, et al.: Effect of clopidogrel added to aspirin in patients with atrial fibrillation. N Engl J Med 2009, 360:2066–2078.CrossRefPubMedGoogle Scholar
  35. 35.
    • Gilard M, Arnaud B, Cornily JC, et al.: Influence of omeprazole on the antiplatelet action of clopidogrel associated with aspirin: the randomized, double-blind OCLA (Omeprazole CLopidogrel Aspirin) study. J Am Coll Cardiol 2008, 51:256–260.CrossRefPubMedGoogle Scholar
  36. 36.
    • O’Donoghue ML, Braunwald E, Antman EM, et al.: Pharmacodynamic effect and clinical efficacy of clopidogrel and prasugrel with or without a proton-pump inhibitor: an analysis of two randomised trials. Lancet 2009, 374:989–997.CrossRefPubMedGoogle Scholar
  37. 37.
    •• Bhatt DL: COGENT: a prospective randomized placebo-controlled trial of omeprazole in patients receiving aspirin and clopidogrel. Presented at Transcatheter Cardiovascular Therapeutics. San Francisco, California; 2009. In the COGENT trial (the only prospective, double-blind, randomized clinical trial assessing the effect of proton pump inhibitors on clopidogrel treatment), there was no difference in clinical events (“hard” end points) between clopidogrel plus omeprazole and clopidogrel alone.Google Scholar
  38. 38.
    Diener HC, Cunha L, Forbes C, et al.: European Stroke Prevention Study. 2. Dipyridamole and acetylsalicylic acid in the secondary prevention of stroke. J Neurol Sci 1996, 143:1–13.CrossRefPubMedGoogle Scholar
  39. 39.
    Olsen TS, Langhorne P, Diener HC, et al.: European Stroke Initiative Recommendations for Stroke Management—update 2003. Cerebrovasc Dis 2003, 16:311–337.CrossRefPubMedGoogle Scholar
  40. 40.
    • Halkes PH, van Gijn J, Kappelle LJ, et al.: Medium intensity oral anticoagulants versus aspirin after cerebral ischaemia of arterial origin (ESPRIT): a randomised controlled trial. Lancet Neurol 2007, 6:115–124.CrossRefPubMedGoogle Scholar
  41. 41.
    EAFT (European Atrial Fibrillation Trial) Study Group: Secondary prevention in non-rheumatic atrial fibrillation after transient ischaemic attack or minor stroke. Lancet 1993, 342:1255–1262.Google Scholar
  42. 42.
    Visser CA, Kan G, Meltzer RS, et al.: Long-term follow-up of left ventricular thrombus after acute myocardial infarction. A two-dimensional echocardiographic study in 96 patients. Chest 1984, 86:532–536.CrossRefPubMedGoogle Scholar
  43. 43.
    • Mant J, Hobbs FD, Fletcher K, et al.: Warfarin versus aspirin for stroke prevention in an elderly community population with atrial fibrillation (the Birmingham Atrial Fibrillation Treatment of the Aged Study, BAFTA): a randomised controlled trial. Lancet 2007, 370:493–503.CrossRefPubMedGoogle Scholar
  44. 44.
    Flaker GC, Gruber M, Connolly SJ, et al.: Risks and benefits of combining aspirin with anticoagulant therapy in patients with atrial fibrillation: an exploratory analysis of stroke prevention using an oral thrombin inhibitor in atrial fibrillation (SPORTIF) trials. Am Heart J 2006, 152:967–973.CrossRefPubMedGoogle Scholar
  45. 45.
    Dressler FA, Craig WR, Castello R, Labovitz AJ: Mobile aortic atheroma and systemic emboli: efficacy of anticoagulation and influence of plaque morphology on recurrent stroke. J Am Coll Cardiol 1998, 31:134–138.CrossRefPubMedGoogle Scholar
  46. 46.
    The National Institute of Neurological Disorders and Stroke rt-PA Stroke Study Group: Tissue plasminogen activator for acute ischemic stroke. N Engl J Med 1995, 333:1581–1587.CrossRefGoogle Scholar
  47. 47.
    Wahlgren N, Ahmed N, Davalos A, et al.: Thrombolysis with alteplase 3–4.5 h after acute ischaemic stroke (SITS-ISTR): an observational study. Lancet 2008, 372:1303–1309.CrossRefPubMedGoogle Scholar
  48. 48.
    Hacke W, Kaste M, Fieschi C, et al.: Intravenous thrombolysis with recombinant tissue plasminogen activator for acute hemispheric stroke. The European Cooperative Acute Stroke Study (ECASS). JAMA 1995, 274:1017–1025.CrossRefPubMedGoogle Scholar
  49. 49.
    Hacke W, Kaste M, Fieschi C, et al.: Randomised double-blind placebo-controlled trial of thrombolytic therapy with intravenous alteplase in acute ischaemic stroke (ECASS II). Second European-Australasian Acute Stroke Study Investigators. Lancet 1998, 352:1245–1251.CrossRefPubMedGoogle Scholar
  50. 50.
    •• Hacke W, Kaste M, Bluhmki E, et al.: Thrombolysis with alteplase 3 to 4.5 hours after acute ischemic stroke. N Engl J Med 2008, 359:1317–1329.CrossRefPubMedGoogle Scholar
  51. 51.
    Alexandrov AV, Molina CA, Grotta JC, et al.: Ultrasound-enhanced systemic thrombolysis for acute ischemic stroke. N Engl J Med 2004, 351:2170–2178.CrossRefPubMedGoogle Scholar
  52. 52.
    Molina CA, Ribo M, Rubiera M, et al.: Microbubble administration accelerates clot lysis during continuous 2-MHz ultrasound monitoring in stroke patients treated with intravenous tissue plasminogen activator. Stroke 2006, 37:425–429.CrossRefPubMedGoogle Scholar
  53. 53.
    • Singh BN, Connolly SJ, Crijns HJ, et al.: Dronedarone for maintenance of sinus rhythm in atrial fibrillation or flutter. N Engl J Med 2007, 357:987–999.CrossRefPubMedGoogle Scholar
  54. 54.
    •• Hohnloser SH, Crijns HJ, van Eickels M, et al.: Effect of dronedarone on cardiovascular events in atrial fibrillation. N Engl J Med 2009, 360:668–678.CrossRefPubMedGoogle Scholar
  55. 55.
    •• Connolly SJ, Crijns HJ, Torp-Pedersen C, et al.: Analysis of stroke in ATHENA: a placebo-controlled, double-blind, parallel-arm trial to assess the efficacy of dronedarone 400 mg BID for the prevention of cardiovascular hospitalization or death from any cause in patients with atrial fibrillation/atrial flutter. Circulation 2009, 120:1174–1180.CrossRefPubMedGoogle Scholar
  56. 56.
    • Kober L, Torp-Pedersen C, McMurray JJ, et al.: Increased mortality after dronedarone therapy for severe heart failure. N Engl J Med 2008, 358:2678–2687.CrossRefPubMedGoogle Scholar
  57. 57.
    Endarterectomy for moderate symptomatic carotid stenosis: interim results from the MRC European Carotid Surgery Trial. Lancet 1996, 347:1591–1593.Google Scholar
  58. 58.
    • Nademanee K, Schwab MC, Kosar EM, et al.: Clinical outcomes of catheter substrate ablation for high-risk patients with atrial fibrillation. J Am Coll Cardiol 2008, 51:843–849.CrossRefPubMedGoogle Scholar
  59. 59.
    • Themistoclakis S, Corrado A, Marchlinski FE, et al.: The risk of thromboembolism and need for oral anticoagulation after successful atrial fibrillation ablation. J Am Coll Cardiol 2010, 55:735–743.CrossRefPubMedGoogle Scholar
  60. 60.
    • Bonow RO, Carabello BA, Chatterjee K, et al.: 2006 Writing Committee Members; American College of Cardiology/American Heart Association Task Force: 2008 Focused update incorporated into the ACC/AHA 2006 guidelines for the management of patients with valvular heart disease: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Writing Committee to Revise the 1998 Guidelines for the Management of Patients With Valvular Heart Disease): endorsed by the Society of Cardiovascular Anesthesiologists, Society for Cardiovascular Angiography and Interventions, and Society of Thoracic Surgeons. Circulation 2008, 118:e523–e661.CrossRefPubMedGoogle Scholar
  61. 61.
    • Block PC, Burstein S, Casale PN, et al.: Percutaneous left atrial appendage occlusion for patients in atrial fibrillation suboptimal for warfarin therapy: 5-year results of the PLAATO (Percutaneous Left Atrial Appendage Transcatheter Occlusion) Study. JACC Cardiovasc Interv 2009, 2:594–600.CrossRefPubMedGoogle Scholar
  62. 62.
    •• Holmes DR, Reddy VY, Turi ZG, et al.: Percutaneous closure of the left atrial appendage versus warfarin therapy for prevention of stroke in patients with atrial fibrillation: a randomised non-inferiority trial. Lancet 2009, 374:534–542.CrossRefPubMedGoogle Scholar
  63. 63.
    •• Connolly SJ, Ezekowitz MD, Yusuf S, et al.: Dabigatran versus warfarin in patients with atrial fibrillation. N Engl J Med 2009, 361:1139–1151.CrossRefPubMedGoogle Scholar
  64. 64.
    •• Garcia D, Libby E, Crowther MA: The new oral anticoagulants. Blood 2010, 115:15–20.CrossRefPubMedGoogle Scholar
  65. 65.
    • Chamorro A: TP receptor antagonism: a new concept in atherothrombosis and stroke prevention. Cerebrovasc Dis 2009, 27(Suppl 3):20–27.CrossRefPubMedGoogle Scholar
  66. 66.
    •• Viles-Gonzalez JF, Fuster V, Corti R, et al.: Atherosclerosis regression and TP receptor inhibition: effect of S18886 on plaque size and composition—a magnetic resonance imaging study. Eur Heart J 2005, 26:1557–1561.CrossRefPubMedGoogle Scholar
  67. 67.
    • Huang Y, Cheng Y, Wu J, et al.: Cilostazol as an alternative to aspirin after ischaemic stroke: a randomised, double-blind, pilot study. Lancet Neurol 2008, 7:494–499.CrossRefPubMedGoogle Scholar
  68. 68.
    Fergusson GG, Eliasziw M, Bar HW, et al.: The North American Symptomatic Carotid Endarterectomy Trial: surgical results in 1415 patients. Stroke 1999, 30:1751–1758.Google Scholar
  69. 69.
    European Carotid Surgery Trialists’ Collaborative Group: MRC European Carotid Surgery Trial: interim results for symptomatic patients with severe (70–99%) or with mild (0–29%) carotid stenosis. Lancet 1991, 337:1235–1243.CrossRefGoogle Scholar
  70. 70.
    Asymptomatic Carotid Atherosclerosis Study Group: Study design for randomized prospective trial of carotid endarterectomy for asymptomatic atherosclerosis. Stroke 1989, 20:844–849.Google Scholar
  71. 71.
    Halliday AW, Thomas D, Mansfield A, et al.: The Asymptomatic Carotid Surgery Trial (ACST). Rationale and design. Steering Committee. Eur J Vasc Surg 1994, 8:703–710.CrossRefPubMedGoogle Scholar
  72. 72.
    Iyer SS, White CJ, Hopkins LN, 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, 51:427–434.CrossRefPubMedGoogle Scholar
  73. 73.
    Registry Study to Evaluate the NeuroShield Bare Wire Cerebral Protection System and X-Act Stent in Patients at High Risk for Carotid Endarterectomy. Available at http://www.strokecenter.org/trials.
  74. 74.
    Endarterectomy Versus Angioplasty in Patients With Severe Symptomatic Carotid Stenosis. Available at http://www.strokecenter.org/trials.
  75. 75.
    Gray WA, Hopkins LN, Yadav S, et al.: Protected carotid stenting in high-surgical-risk patients: the ARCHeR results. J Vasc Surg 2006, 44(2):258–268.CrossRefPubMedGoogle Scholar
  76. 76.
    Gray WA, Yadav JS, Verta P, et al.: The CAPTURE registry: predictors of outcomes in carotid artery stenting with embolic protection for high surgical risk patients in the early post-approval setting. Catheter Cardiovasc Interv 2007, 70:1025–1033.CrossRefPubMedGoogle Scholar
  77. 77.
    Safian RD, Bacharach JM, Ansel GM, et al.: Carotid stenting with a new system for distal embolic protection and stenting in high-risk patients: the carotid revascularization with ev3 arterial technology evolution (CREATE) feasibility trial. Catheter Cardiovasc Interv 2004, 63:1–6.CrossRefPubMedGoogle Scholar
  78. 78.
    Multicenter Registry to Assess the Safety and Efficacy of the MO.MA Cerebral Protection Device During Carotid Stenting. Available at htpp://www.strokecenter.org/trials.
  79. 79.
    Coppi G, Moratto R, Silingardi R, et al.: Proximal flow blockage cerebral protection during carotid stenting: results from a multicenter Italian registry. J Cardiovasc Surg (Torino) 2005, 46:219–227.Google Scholar
  80. 80.
    Katzen BT, Criado FJ, Ramee SR, et al.: Carotid artery stenting with emboli protection surveillance study: thirty-day results of the CASES-PMS study. Catheter Cardiovasc Interv 2007, 70:316–323.CrossRefPubMedGoogle Scholar
  81. 81.
    Hopkins LN, Myla S, Grube E, et al.: Carotid artery revascularization in high risk patients with the Nexstent and the Filterwire EX/EZ: 1 year results of the CABERNET trial. Catheter Cardiovasc Interv 2008, 71:950–960.CrossRefPubMedGoogle Scholar
  82. 82.
    Naylor AR, Bolia A, Abbott RJ, et al.: Randomized study of carotid angioplasty and stenting versus carotid endarterectomy: a stopped trial. J Vasc Surg 1998, 28:326–334.CrossRefPubMedGoogle Scholar
  83. 83.
    CAVATAS Investigators: Endovascular versus surgical treatment in patients with carotid stenosis in the Carotid and Vertebral Artery Transluminal Angioplasty Study (CAVATAS): a randomised trial. Lancet 2001, 357:1729–1737.CrossRefGoogle Scholar
  84. 84.
    Alberts MJ: Results of a multicenter prospective randomized trial of carotid artery stenting vs carotid endarterectomy. Stroke 2001, 32:325.Google Scholar
  85. 85.
    Brooks WH, McClure RR, Jones MR, et al.: Carotid angioplasty and stenting versus carotid endarterectomy: randomized trial in a community hospital. J Am Coll Cardiol 2001, 38:1589–1595.CrossRefPubMedGoogle Scholar
  86. 86.
    Brooks WH, McClure RR, Jones MR, et al.: Carotid angioplasty and stenting versus carotid endarterectomy for treatment of asymptomatic carotid stenosis: a randomized trial in a community hospital. Neurosurgery 2004, 54:318–325.CrossRefPubMedGoogle Scholar
  87. 87.
    CaRESS Steering Committee: Carotid Revascularization Using Endarterectomy or Stenting Systems (CaRESS) phase I clinical trial: 1-year results. J Vasc Surg 2005, 42:213–219.CrossRefGoogle Scholar
  88. 88.
    Yadav JS, Wholey MH, Kuntz RE, et al.: Protected carotid-artery stenting versus endarterectomy in high-risk patients. N Engl J Med 2004, 351:1493–1501.CrossRefPubMedGoogle Scholar
  89. 89.
    SPACE Collaborative Group, Ringleb PA, Allenberg J, Brückmann H, et al.: 30 day results from the SPACE trial of stent-protected angioplasty versus carotid endarterectomy in symptomatic patients: a randomized non-inferiority trial. Lancet 2006, 368:1239–1247.CrossRefPubMedGoogle Scholar
  90. 90.
    Mas JL, Chatellier G, Beyssen B, et al.: Endarterectomy versus stenting in patients with symptomatic severe carotid stenosis. N Engl J Med 2006, 355:1660–1671.CrossRefPubMedGoogle Scholar
  91. 91.
    International Carotid Stenting Study Investigators: Carotid artery stenting compared with endarterectomy in patients with symptomatic carotid stenosis (International Carotid Stenting Study): an interim analysis of a randomized control trial. Lancet 2010, 375:985–997.CrossRefGoogle Scholar
  92. 92.
    Brott TG, Roubin G, Howard G, et al.: The Randomized Carotid Revascularization Endarterectomy vs Stenting Trial (CREST): primary results [abstract 197]. Presented at the 2010 American Stroke Association International Stroke Conference. San Antonio, TX; February 26, 2010.Google Scholar

Copyright information

© Springer Science+Business Media, LLC 2010

Authors and Affiliations

  • Carlos G. Santos-Gallego
    • 1
  • Jeremías Bayón
    • 2
  • Juan José Badimón
    • 1
  1. 1.Atherothrombosis Research Unit, The Zena and Michael A. Wiener Cardiovascular Institute, 1 Gustave Levy Place, Box 1030, Mount Sinai School of MedicineNew YorkUSA
  2. 2.Cardiology Department, Hospital Central de AsturiasOviedoSpain

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