Asymptomatic Carotid Disease Research Articles

Outcomes of Nonagenarian Patients in Vascular Surgery Service in a Tertiary Institution.

With the world population growing and aging, nonagenarians have become a distinct patient cohort with specific characteristics that render the prediction of outcomes essential. We aimed to investigate the specific characteristics of this patient's cohort in a tertiary vascular center. Retrospective analysis was conducted for all consecutive patients 90 years and above referred or treated in the Department of Vascular Surgery between January 2017 and December 2022 for vascular pathologies. The main endpoint was to analyze the type of vascular services required for nonagenarians. Additional endpoints involved evaluation of treatment outcomes during the study period based on medical records. The analysis was patient-based. A total of 148 nonagenarians were included in the study. In all, 71 (48%) of the patients underwent surgery, whereas 77 (52%) had conservative treatment. Most of the patients were referred for peripheral arterial (PAD; 56, 37.8%) and aortic-related (39, 26.4%) diseases. Other pathologies encountered involved acute limb ischemia (ALI; 25, 16.9%), carotid diseases (12, 8.1%), renal/dialysis-related consultations (8, 5.4%), and referrals from other departments (12, 5.4%). Urgent interventions were performed in 27% of the cases. Indications for surgery included PAD Rutherford Stages IV, V, and VI; symptomatic and ruptured aortic aneurysms; ALI Rutherford Stages I, IIa, and IIb; symptomatic and near total occlusion asymptomatic carotid disease; and dialysis-related procedures for patients with chronic renal failure on regular hemodialysis. Perioperative complications were experienced in 22 patients (14.9%), the 30-day reintervention rate was 7.4%, and 30-day mortality was 4.7%. The overall length of hospital stay for operated patients was a median of 8 nights. The proportion of nonagenarians in the population is growing and so is their referral to vascular surgery. Satisfactory short-term treatment outcomes can be achieved in this highly selected cohort of patients. Thirty-day mortality is higher in patients undergoing urgent procedures. Follow-up mortality was higher in the operated nonagenarians as compared with those who were treated conservatively. Careful patient selection and thorough preparation are crucial to enhance clinical outcomes. Further research on therapy outcomes of nonagenarians will enable physicians to make better evidence-based approaches to individual patients and should be encouraged. The study highlights the growing need to manage vascular diseases in nonagenarians, emphasizing that age alone should not exclude patients from surgical interventions. By demonstrating acceptable short-term outcomes with careful patient selection, this research challenges the traditional bias against operating on the elderly. Clinicians should refine risk assessment and treatment plans, particularly when balancing surgical and conservative options. Comorbidities, rather than age, are key determinants of patient suitability, encouraging more individualized, evidence-based approaches in this expanding demographic.

Evolution of Medical and Surgical Management of Carotid Disease from Carotid Endarterectomy to Transfemoral Carotid Stenting to TCAR

Patients with carotid stenosis can be broadly classified into two categories: symptomatic and asymptomatic. While there is little disagreement about surgical management of symptomatic carotid stenosis, the optimal management strategy for the patients with asymptomatic carotid disease has undergone significant evolution over past five decades. With increasing focus on role of plaque morphology on the etiology of symptoms, there has been an increased focus on optimizing the medical management targeted at plaque stabilization, especially for the patients with asymptomatic carotid disease, while reserving the most aggressive surgical treatment options for the patients with symptomatic carotid stenosis. This review summarizes the scientific evidence based on multiple large clinical studies showing how the modern-day management of carotid stenosis has evolved. Multiple, large randomized clinical trials have established carotid endarterectomy (CEA) as the treatment of choice for symptomatic patients with symptomatic, >50% stenosis of carotid artery or those who have asymptomatic high grade carotid stenosis. With the advancements in endovascular techniques, the technique of Trans Femoral Carotid Artery Stenting (TF-CAS) was popularized, but after multiple, large randomized controlled trials demonstrated superiority of CEA, the indications for TF-CAS as the initial operation of choice for carotid disease for all patients have been reduced. In the past five years, the introduction of the newer technique of Trans Carotid Artery Revascularization (TCAR) has shown promising results with significant reduction in the incidence of perioperative complications as compared to CEA and TF-CAS, however, there have been no randomized controlled trials comparing TCAR to either CEA or TF-CAS. Moreover, with the developments in the medical field with introduction of several new medications which have been demonstrated to successfully change the plaque morphology, there has been a renewed interest in exploring if the indications for surgical management for the asymptomatic carotid disease should be revisited.

Opportunities and caution when we approach asymptomatic carotid disease as a flow-related phenomenon

Opportunities and caution when we approach asymptomatic carotid disease as a flow-related phenomenon

Atherosclerotic carotid artery disease Radiomics: A systematic review with meta-analysis and radiomic quality score assessment

BackgroundStroke, a leading global cause of mortality and neurological disability, is often associated with atherosclerotic carotid artery disease. Distinguishing between symptomatic and asymptomatic carotid artery disease is crucial for appropriate treatment decisions. Radiomics, a quantitative image analysis technique, and ML have emerged as promising tools in medical imaging, including neuroradiology. This systematic review and meta-analysis aimed to evaluate the methodological quality of studies employing radiomics for atherosclerotic carotid artery disease analysis and ML algorithms for culprit plaque identification using CT or MRI. Materials and methodsPubmed, WoS and Scopus databases were searched for relevant studies published from January 2005 to May 2023. RQS assessed methodological quality of studies included in the review. QUADAS-2 assessed the risk of bias. A meta-analysis and three meta regressions were conducted on study performance based on model type, imaging modality and segmentation method. ResultsRQS assessed methodological quality, revealing an overall low score and consistent findings with other radiology domains. QUADAS-2 indicated an overall low risk, except for a single study with high bias. The meta-analysis demonstrated that radiomics-based ML models for predicting culprit plaques had a satisfactory performance, with an AUC of 0.85, surpassing clinical models. However, combining radiomics with clinical features yielded the highest AUC of 0.89. Meta-regression analyses confirmed these findings. MRI-based models slightly outperformed CT-based ones, but the difference was not significant. ConclusionIn conclusion, radiomics and ML hold promise for assessing carotid plaque vulnerability, aiding in early cerebrovascular event prediction. Combining radiomics with clinical data enhances predictive performance.

New Ischemic Cerebral Lesions in Postprocedural Magnetic Resonance Imaging in Carotid Artery Stenting Versus Carotid Endarterectomy: A Systematic Review and Meta-Analysis

Recent randomized controlled trials (RCTs) have demonstrated similar outcomes in terms of ischemic stroke incidence after carotid endarterectomy (CEA) or carotid artery stenting (CAS) in asymptomatic carotid disease, while CEA seems to be the first option for symptomatic carotid disease. The aim of this meta-analysis is to assess the incidence of silent cerebral microembolization detected by magnetic resonance imaging (MRI) following these procedures. A systematic search was conducted using PubMed, Scopus, and Cochrane databases, including comparative studies involving symptomatic or asymptomatic patients undergoing either CEA or CAS and reporting on new cerebral ischemic lesions in postoperative MRI. The primary outcome was the newly detected cerebral ischemic lesions. Pooled effect estimates for all outcomes were calculated using the random-effects model. Prespecified random effects metaregression and subgroup analysis were conducted to examine the impact of moderator variables on the presence of new cerebral ischemic lesions. 25 studies reporting on a total of 1827 CEA and 1500 CAS interventions fulfilled the eligibility criteria. The incidence of new cerebral ischemic lesions was significantly lower after CEA compared to CAS, regardless of the time of MRI assessment (first 24hours; OR: 0.33, 95% CI: 0.17-0.64, P<0.001), (the first 72hours, OR: 0.25, 95% CI 0.18-0.36, P<0.001), (generally within a week after the operation; OR: 0.24, 95% CI: 0.17-0.34, P<0.001). Also, the rate of stroke (OR: 0.38, 95% CI: 0.23-0.63, P<0.001) and the presence of contralateral new cerebral ischemic lesions (OR: 0.16, 95% CI 0.08-0.32, P<0.001) were less frequent after CEA. Subgroup analysis based on the study design and the use of embolic protection device during CAS showed consistently lower rates of new lesions after CEA. CEA demonstrates significant lower rates of new silent cerebral microembolization, as detected by MRI in postoperative period compared with CAS.

Comparing Carotid Artery Stenting and Carotid Endarterectomy in Symptomatic and Asymptomatic Carotid Stenosis

Objective: In patients with symptomatic and asymptomatic carotid artery stenosis, this retrospective observational study compared the clinical outcomes and side effects of carotid endarterectomy (CEA) with carotid artery stenting (CAS). The study took patient-specific risk variables into account and concentrated on major adverse cardiovascular events (MACE), such as myocardial infarction (MI), stroke, readmission, and death. Material and Method: This was a retrospective observational study carried out at Vascular Surgery Department and Interventional Radiology department of two tertiary care hospitals in Rawalpindi, from Jan 2022 to March 2023. With a 30-day follow-up, 60 patients from two Pakistani tertiary care centres underwent either carotid end arterectomy and carotid artery stenting were included. Patient having asymptomatic and symptomatic carotid disease were selected for the procedure. The impact of risk factors on procedural success and development of major adverse cardiovascular events (MACE) was examined in the study. Data regarding 30-day postoperative parameters of the procedure were collected and evaluated. p&lt; 0.05 is considered significant. Results: The majority of patients in our series were males 46(77%) compared to 14(23%) females in the study. There were no intraoperative mortalities in our patients. The mortality rate of CAS alone was 1(1.66%). Four patients developed complications. Three in CAS group and 1 in CEA group. Comorbidities were present in 46(77%). Conclusion: Compared to CEA, CAS is linked to a greater risk of stroke or mortality in patients with symptomatic carotid stenosis within 30 days of treatment. Patients' unique characteristics, age, comorbidities, and previous surgical experiences should guide the choice of treatment.

Microplastics and Nanoplastics in Atheromas and Cardiovascular Events

BackgroundMicroplastics and nanoplastics (MNPs) are emerging as a potential risk factor for cardiovascular disease in preclinical studies. Direct evidence that this risk extends to humans is lacking.MethodsWe conducted a prospective, multicenter, observational study involving patients who were undergoing carotid endarterectomy for asymptomatic carotid artery disease. The excised carotid plaque specimens were analyzed for the presence of MNPs with the use of pyrolysis–gas chromatography–mass spectrometry, stable isotope analysis, and electron microscopy. Inflammatory biomarkers were assessed with enzyme-linked immunosorbent assay and immunohistochemical assay. The primary end point was a composite of myocardial infarction, stroke, or death from any cause among patients who had evidence of MNPs in plaque as compared with patients with plaque that showed no evidence of MNPs.ResultsA total of 304 patients were enrolled in the study, and 257 completed a mean (±SD) follow-up of 33.7±6.9 months. Polyethylene was detected in carotid artery plaque of 150 patients (58.4%), with a mean level of 21.7±24.5 μg per milligram of plaque; 31 patients (12.1%) also had measurable amounts of polyvinyl chloride, with a mean level of 5.2±2.4 μg per milligram of plaque. Electron microscopy revealed visible, jagged-edged foreign particles among plaque macrophages and scattered in the external debris. Radiographic examination showed that some of these particles included chlorine. Patients in whom MNPs were detected within the atheroma were at higher risk for a primary end-point event than those in whom these substances were not detected (hazard ratio, 4.53; 95% confidence interval, 2.00 to 10.27; P<0.001).ConclusionsIn this study, patients with carotid artery plaque in which MNPs were detected had a higher risk of a composite of myocardial infarction, stroke, or death from any cause at 34 months of follow-up than those in whom MNPs were not detected. (Funded by Programmi di Ricerca Scientifica di Rilevante Interesse Nazionale and others; ClinicalTrials.gov number, NCT05900947.)

Preoperative Risk Factors Impacting Length of Stay After Transcarotid Artery Revascularization

Transcarotid artery revascularization (TCAR), using interoperative flow reversal is a unique, hybrid operation utilized in treating critical carotid artery stenosis. Over the past decade, TCAR has been increasingly used to treat asymptomatic carotid artery disease and has a similar risk profile to traditional carotid endarterectomy. Postoperative length of stay (LOS) has a significant impact on cost-effectiveness and quality outcomes in this expanded setting. The objective of this study is to develop a multivariate regression model to identify key preoperative variables and their impact factor on LOS after TCAR for asymptomatic carotid artery stenosis. We hypothesized that high-risk preoperative patient factors historically identified in carotid endarterectomy would similarly impact LOS after TCAR. A multi-institution, retrospective study of all adult patients undergoing TCAR with flow-reversal for intraoperative neuroprotection was performed using the Society for Vascular Surgery Vascular Quality Initiative (VQI) from January 2016 to August 2021. Patients with prolonged preoperative hospitalization (preoperative LOS ≥1day) were excluded to enhance the capture of carotid artery stenosis as the index admission. Univariate analysis was done on preoperative factors against LOS using nonparametric statistical tests. A multivariate model was then constructed using a negative binomial regression. The study population was split into 80% "training" data for model formulation and 20% "test" data for model validation. Thirteen thousand four hundred eighty-three patients undergoing TCAR for asymptomatic carotid stenosis met the study's inclusion criteria with a median postoperative LOS of 1.82days. Factors in VQI found to have a significant effect on LOS and retained in the multivariate model were lesion type (restenosis versus atherosclerotic), age, gender, chronic obstructive pulmonary disease, preoperative beta blocker, calcific lesion burden, hypertension status, and race (P<0.05). The model accurately predicted LOS after TCAR within 1day for 86.04% and within 2days for 94.51% of patients in the test population. This large-scale analysis from 2016 to 2021 spans a considerable expansion in the practice of TCAR for asymptomatic carotid disease. All preoperative variables shown to significantly increase the postoperative LOS were derived from the VQI data set. As LOS is a measure of health-care efficiency and cost-effectiveness, this model can be used to identify patients at risk for increased postoperative LOS. It has the potential to be incorporated into a patient/physician decision support tool to optimize resource planning and patient selection for elective TCAR.

Cilostazol-based dual antiplatelet treatment in ischemic stroke or transient ischemic attack patients with asymptomatic carotid artery disease: a propensity score matching analysis.

The optimal treatment for asymptomatic atherosclerotic carotid artery disease remains controversial. Data on the efficacy of antiplatelet agents and stroke outcomes are limited. This study aimed to examine the efficacy and safety of cilostazol-based dual antiplatelet therapy in patients with ischemic stroke or transient ischemic attack and asymptomatic carotid artery disease. This retrospective cohort study was conducted in a tertiary-care setting and included baseline characteristics and clinical outcomes of participants. The study included patients who had experienced first-ever ischemic stroke or transient ischemic attack and asymptomatic atherosclerotic carotid artery stenosis, with a minimum follow-up period of 1 year. Asymptomatic carotid artery stenosis refers to stenosis in patients without neurological symptoms referable to the carotid arteries. Propensity scores were estimated using a logistic regression model based on participants' baseline characteristics. The efficacy outcome was the composite outcome of recurrent ischemic events and vascular-related death in patients with ischemic stroke or transient ischemic attack and asymptomatic carotid artery stenosis. The safety outcome was the occurrence of hemorrhagic complications such as intracranial hemorrhages or extracranial hemorrhages. The effectiveness of dual therapy compared to monotherapy was evaluated at various time points following the initiation of antiplatelet treatment. This study included 516 patients with a 1-year follow-up period. At 1 year, composite events occurred in 10 (6.3%) patients in the dual antiplatelet group compared with 12 (7.6%) in the single antiplatelet group (HR, 0.74; 95% CI, 0.61-0.90; p = 0.024). Extracranial hemorrhage occurred in 12 (7.6%) patients in the dual antiplatelet group compared with nine (5.7%) in the single antiplatelet group (HR, 1.35; 95% CI, 1.13-1.48; p = 0.017). No intracranial hemorrhages were observed in this cohort. Patients with asymptomatic carotid artery stenosis who received cilostazol-based dual antiplatelet therapy had a lower risk of composite events but a higher risk of minor extracranial hemorrhage than those who received a single antiplatelet agent.

Abstract 49: 15-Year Trends in Age and Sex-Specific Utilization of Carotid Revascularization Procedures in the United States

Background: In July 2023, the Center for Medicare and Medicaid Services (CMS) proposed broader coverage for carotid artery stenting (CAS) for patients with symptomatic (Sx) and asymptomatic carotid disease (Asx) in the United States (US) Objectives: This study provides a 15-year snapshot of current CAS and carotid endarterectomy (CEA) use in various age and sex groups of the US. Methods: We identified all Sx and Asx CAS and CEA admissions in adults (≥18 years) from the 2006-2020 National Inpatient Sample using International Classification of Diseases codes. We calculated the age and sex-specific proportions of revascularizations that were CAS and combined annual CAS/CEA counts with census data to determine annual utilization rate per 100,000 population. We used Joinpoint regression to estimate annualized percentage change (APC) in usage over time. Results: Of 1,591,651 weighted procedures over the study period, 30% were done in 60-69 year olds and 20% in ≥80 year olds. This age distribution was constant over time. 15.1% of all procedures were CAS but this proportion doubled over time such that in 2020, 29.6% of all procedures were CAS. CAS proportion increased in all age groups including those &gt;70 years and in women, even after excluding patients with tandem occlusions (Figure 1). 22.5% of CAS and 11.7% of CEA were done in Sx patients but this proportion increased over time in both CAS and CEA (p-trend &lt;0.001). Annual usage of CEA declined from 51.6 to 22.5 cases/100,000 population in both sexes combined (APC -5.4%, 95%CI -6.0 to -4.8), while CAS use declined from 2006-2016 but increased significantly over 2016-2020 in both men (APC 16.5%, 95%CI 10.0 to 23.3) and women (APC 15.2%, 95%CI 10.2 to 20.4) (Figure 1). Conclusion: Despite uncertain benefit in selected age and sex groups including those &gt; 70years, CAS use has continued to increase in all age and sex groups and now accounts for one-third of carotid revascularizations . With the CMS change CAS use could increase further.

Carotid plaque characteristics in the CREST-2 trial

BackgroundThe modest stroke prevention from surgery for asymptomatic carotid disease has prompted a search for predictors that may improve risk stratification beyond luminal stenosis. Plaque disruption and atheroembolization are associated with unique anatomical and histological changes. The Carotid Revascularization and Medical Management for Asymptomatic Carotid Stenosis Trial (CREST-2) collects information on duplex ultrasound (DUS) plaque biomarkers with the goal of evaluating their relationship to the periprocedural and long-term risks of stroke. In this study, we examine the reliability with which carotid plaque features can be measured from DUS images, and report baseline carotid DUS-derived stenosis and plaque features using semiautomated digital image analysis of patients enrolled in CREST-2. MethodsWe studied the first 503 patients in CREST-2. Patients underwent standardized carotid DUS evaluation pre-enrollment. B-Mode images were scaled linearly to normalize brightness. Plaques were outlined manually. Dedicated software automatically measured the longitudinal sectional area (mm2), grayscale median (GSM), Gray-Weale classification, and tissue composition (mm2) of intraplaque hemorrhage (IPH), lipid, fibrous tissue, muscle, and calcium. We present the mean, standard deviation, median, interquartile range, minimum and maximum range, and proportions of carotid peak systolic velocities (PSVs) and plaque morphological features. We tested for autocorrelation among plaque features and computed the proportion of potentially unstable plaques in the cohort. Reliability of the image analysis techniques was tested in 100 patients using Bland-Altman plots and intraclass and interclass correlation coefficients. ResultsMost patients were male (58.4%), older (mean age of 69.3 years), White (87.5%), and had a PSV of ≥230 cm/s (98.6%); the 1.4% with a PSV of <230 cm/s were enrolled based on catheter angiography. Plaques in this study were large; the mean longitudinal sectional area was 62 ± 37 mm2 (range, 6.2–256.5 mm2). The mean GSM was 58 ± 30 (unitless) (range, 0–168) and Gray-Weale classification was 3.5 ± 0.9 (range, 1–5). The mean areas of tissue types were IPH 5.3 ± 8.9 mm2, lipid 9.3 ± 8.6 mm2, fibrous tissue 10 ± 10 mm2, muscle 17 ± 12 mm2, and calcium 1.6 ± 4.1 mm2. The PSV of patients showed poor correlation with plaque features. The proportion of plaques with a GSM of ≤35 was 22.8%, IPH of ≥5 mm2 was 30.0%, and a lipid-rich necrotic core of ≥40% was 3.0% of the cohort. Plaque measurements could be performed with high reliability with good interobserver and intraobserver correlations. ConclusionsSite-generated, core laboratory-interpreted ultrasound examination provides a reliable way of characterizing carotid plaque morphological features across studies performed at many CREST-2 sites. The initial cohort of patients randomized in CREST-2 had heterogeneity of plaque features despite causing high-grade stenosis. Completion of the trial will provide an opportunity to assess whether plaque heterogeneity interacts with response to revascularization and medical management.

Carotid Endarterectomy Should Not Be Recommended to End-Stage Kidney Disease Patients with Asymptomatic Carotid Artery Disease

Carotid endarterectomy (CEA) for asymptomatic carotid artery disease is advised for patients with low perioperative stroke risk and life expectancy of 3-5years. We sought to explore the role of risk stratification and postoperative medical management in identifying appropriate asymptomatic candidates for CEA in the end-stage kidney disease (ESKD) population. We identified ESKD patients on dialysis from the United States Renal Data System that underwent CEA (2008-2014) for asymptomatic carotid artery disease. We used the Liu comorbidity index as well as a novel risk prediction model based on Cox proportional hazards model to stratify patients. The primary outcome evaluated was 3-year survival, and Kaplan-Meier methods were used to generate survival estimates. We further conducted a subanalysis of patients with Medicare part D data to determine postoperative usage of the following medications: statins, antiplatelets, and antihypertensives. We evaluated the association of medication utilization and 3-year survival using Kaplan-Meier methods and Cox proportional hazards modeling. We analyzed 1,813 patients meeting inclusion criteria. The population was predominantly older (mean age 70.2±9.1), White (84.8%), and had a high prevalence of cardiovascular comorbidities, such as hypertension (90.7%), diabetes (62.5%), and congestive heart failure (35.4%). Among the entire cohort, 23.0% had a Liu comorbidity index ≤8, 35.0% had index 9-12, and 42.0% had index >12. Increasing Liu comorbidity index was associated with worse survival (P<0.01); however, even the group with Liu index ≤8 had poor 3-year survival of 58.8% (53.9-63.4). The Cox proportional hazards model identified variables for inclusion in the risk model such as age >80 (adjusted hazard ratio [aHR]=2.49, 95% confidence interval [CI] [1.87-3.33], P<0.001), congestive heart failure (aHR=1.31, 95% CI [1.14-1.51], P<0.001), and Liu comorbidity index >12(aHR=1.89, 95% CI [1.56-2.28], P<0.001). The risk score generated ranged from 0 to 6.5, and patients were divided into 3 groups: score ≤2 (43.4%), 2-4 (41.2%), and >4 (15.4%). Increasing risk score was associated with worse survival (P<0.01) but even the "low-risk" group had 3-year survival of 58.5% (54.9-61.9). Subanalysis of the 1,249 (68.8% of total) patients with part D data found that statins and calcium channel blocker use was associated with improved survival, although observed rates for patients on drug were still low. The overall long-term survival of ESKD patients undergoing CEA for asymptomatic carotid artery disease is low. Risk stratification and analysis of postoperative medical management did not identify a subgroup of patients with adequate 3-year survival. Hence, the preventive benefits of CEA are not realized in these patients.

Prevalence of moderate and severe asymptomatic extracranial carotid disease in patients with peripheral artery disease: systematic review and meta-analysis

Prevalence of moderate and severe asymptomatic extracranial carotid disease in patients with peripheral artery disease: systematic review and meta-analysis

Endoscopically Active Ulcerative Colitis Is Associated With Asymptomatic Atherosclerotic Vascular Disease: A Case-Control Study.

Chronic inflammation in immune-mediated conditions has been associated with an increased risk in atherosclerotic disease. There is paucity of evidence regarding the prevalence of asymptomatic atherosclerosis in patients with ulcerative colitis (UC) and its association with disease activity. We sought to compare the prevalence of asymptomatic atherosclerotic disease between young patients with UC with and without mucosal healing (MH) and healthy control individuals. An observational study was conducted in 2 hospitals in Buenos Aires, Argentina. Patients with UC 18 to 50 years of age with at least 1 previous colonoscopy in the last year were enrolled, along with age- and sex-matched healthy control individuals. Carotid and femoral ultrasound assessments were performed to determine the prevalence of atherosclerotic lesions and abnormal intima-media thickness (IMT). We compared the prevalence of atherosclerotic disease and the prevalence of abnormally increased IMT in at least 1 vascular territory. Sixty patients with UC and 60 healthy control individuals were enrolled. Mean age was 38 years and 53.33% were men. Although the prevalence of atherosclerotic lesions was similar in patients with UC without MH when compared with both patients with UC with MH and control individuals (3.7% vs 0% vs 6.67%; P = .1), we found a significant increase in abnormal IMT in at least 1 vascular territory in UC patients without MH when compared with healthy control individuals (48.15% vs 26.67%; P = .05). Patients with UC with active mucosal inflammation showed a significantly increased odds of asymptomatic femoral or carotid vascular disease when compared with control individuals.

Accelerated Measurement of Carotid Plaque Volume Using Artificial Intelligence Enhanced 3D Ultrasound

Carotid plaque volume (CPV) can be measured by 3D ultrasound and may be a better predictor of stroke than stenosis, but analysis time limits clinical utility. This study tested the accuracy, reproducibility, and time saved of using an artificial intelligence (AI) derived semiautomatic software to measure CPV ("auto-CPV"). Three-dimensional (3D) ultrasound images for 121 individuals were analyzed by 2 blinded operators to measure auto-CPV. Corresponding endarterectomy specimen volumes were calculated by the validated saline suspension technique. Inter-rater and intrarater agreement plus accuracy compared with the volume of the endarterectomized plaque were calculated. Measurement times were compared with previous manual CPV measurement. The mean difference between auto-CPV and surgical volume was small at (±s.d.) [95% confidence interval [CI]] 0.06 (0.24) [-0.41 to 0.54] cm3. The intraclass correlation (ICC) was strong at 0.91; 95% CI 0.86-0.94. Interobserver and intraobserver error was low with mean difference (±s.d.) [95%CI] 0.01 (0.26) [-0.5 to 0.5] cm3 and 0.03 (0.19) [-0.35 to 0.40] cm3 respectively. Both showed excellent ICC with narrow confidence intervals, ICC=0.90; 95% CI (0.85-0.94) and ICC=0.95; 95% CI (0.92-0.96). Auto-CPV measurement took 43% the time of manual planimetry; median (IQR) 05:39 (01:58) minutes compared to 13:05 (04:15) minutes, Wilcoxon rank-sum test, P<0.01. Auto-CPV assessment is accurate, reproducible, and significantly faster than manual planimetry. Improved feasibility means that the utility of CPV can be assessed in large population studies to stratify risk in asymptomatic carotid disease or assess response to medical treatment.

The influence of gender on 30-day adverse clinical outcomes in patients undergoing carotid surgery.

We aimed to further evaluate sex differences of perioperative and 30-day complications after carotid surgery in patients with both asymptomatic and symptomatic carotid artery stenosis. This was a single-center prospective cohort study including 2013 consecutive patients, who were treated surgically due to extracranial carotid artery stenosis and prospectively followed. Patients who underwent carotid artery stenting and who were treated conservatively were excluded. The primary endpoints for this study were hospital stroke/transitory ischemic attack (TIA) and overall survival rates. Secondary outcomes included all other hospital adverse events, 30-day stroke/TIA, and 30-day mortality rates. Hospital mortality was higher in female patients with symptomatic carotid stenosis (3% vs. 0.5%, P=0.018). Bleeding requiring re-intervention occurred more often in female patients with both asymptomatic (1.5% vs. 0.4%, P=0.045) and symptomatic carotid stenosis (2.4% vs. 0.2%, P=0.022). 30-day stroke/TIA and mortality rates were higher in female patients with both asymptomatic (stroke/TIA 4.4% vs. 2.5%, P=0.041; mortality 3.3% vs. 1.6%, P=0.046) and symptomatic carotid stenosis (stroke/TIA 8.3% vs. 4.2%, P=0.040; mortality 4.1% vs. 0.7%, P=0.006). After adjusting for all confounding factors, female gender remained an important predicting factor for 30-day stroke/TIA in asymptomatic (OR=1.4, 95%CI 1.0-4.7, P=0.041) and symptomatic patients (OR=1.7, 95%CI 1.1-5.3, P=0.040), as well as for 30-day all-cause mortality in patients with asymptomatic (OR=1.5, 95%CI 1.1-4.1, P=0.030) and symptomatic carotid artery disease (OR=1.2, 95%CI 1.0-5.2, P=0.048). Female gender is important predicting factor for stroke/TIA and all-cause mortality, both perioperative and during the first 30 days after carotid surgery.

A Comparison of Outcomes Between Transfemoral Versus Transradial Access for Carotid Stenting.

The transradial (TR) approach has emerged as an alternative to the transfemoral (TF) approach in carotid artery stenting (CAS) because of its perceived benefits in access site complications and overall patient experience. To assess outcomes of TF vs TR approach for CAS. This is a retrospective single-center review of patients receiving CAS through the TR or TF route between 2017 and 2022. All patients with symptomatic and asymptomatic carotid disease who underwent attempted CAS were included in our study. A total of 342 patients were included in this study: 232 underwent CAS through TF approach vs 110 through the TR route. On univariate analysis, the rate of overall complications was more than double for the TF vs TR cohort; however, this did not achieve statistical significance (6.5% vs 2.7%, odds ratio [OR] = 0.59 P = .36). The rate of cross-over from TR to TF was significantly higher on univariate analysis (14.6 % vs 2.6%, OR = 4.77, P = .005) and on inverse probability treatment weighting analysis (OR = 6.11, P < .001). The rate of in-stent stenosis (TR: 3.6% vs TF: 2.2%, OR = 1.71, P = .43) and strokes at follow-up (TF: 2.2% vs TR: 1.8%, OR = 0.84, P = .84) was not significantly different. Finally, median length of stay was comparable between both cohorts. The TR approach is safe, feasible, and provides similar rates of complications and high rates of successful stent deployment compared with the TF route. Neurointerventionalists adopting the radial first approach should carefully assess the preprocedural computed tomography angiography to identify patients amenable to TR approach for carotid stenting.

Study on asymptomatic carotid artery disease in high-risk population: A hospital-based study in the eastern part of India

Study on asymptomatic carotid artery disease in high-risk population: A hospital-based study in the eastern part of India

Evaluation of Carotid Arteries in Stroke Patients using Colour Doppler Sonography: A Cross-sectional Study

Introduction: Cerebral ischaemic stroke is a neurological condition that can be fatal and debilitating and is one of the leading causes of morbidity and mortality. The major benefit of sonography is its capacity to describe plaque and identify plaques with increased risk of embolisation, in addition, to evaluate the degree of stenosis. Aim: To diagnose and characterise the plaque morphology in extracranial portion of carotid arteries using colour Doppler sonography in patients with stroke. Materials and Methods: A time-bound, hospital-based cross-sectional study was conducted in the Department of Radiodiagnosis, MGM Medical College and MY Hospital, Indore, Madhya Pradesh, India from August 2021 to July 2022. There were 80 stroke patients in the study. Risk factors like smoking, diabetes, hypertension, and family history were recorded. B- mode ultrasonography was used to assess carotid arteries and various Doppler parameters like Peak Systolic Velocity (PSV). Plaque characteristics and morphology like smooth margin, irregular margin, ulceration and haemorrhage were evaluated. Statistical parameters such as Student’s t-test were used for association between ICA PSV and ICA/CCA PSV with degree of stenosis. Results: Hypertension was the most common risk factor 57 (71.1%). A total of 54 (67%) stroke patients were found to have plaque in their carotid vasculature. A total of 21 (38.8%) of patients had type-3 plaque followed by type-1 plaque 14 (25.9%). Out of 67% of patients who had plaque, majority of patients 38 (47.5%) had &lt;50% stenosis and 16 (29.6%) of patients had significant stenosis (&gt;50%). Conclusion: It was shown that carotid Doppler ultrasonography can be used as a screening tool for patients, who have risk factors for stroke to find asymptomatic carotid disease.

Maybe asymptomatic carotid disease is not as benign as we think.

In this issue of JVS, Turner et al1Turner A.D. Zhu J. Rao A. Ting W. Han D. Tadros R. et al.Carotid stenosis patients with a remote history of cerebrovascular events have increased risk of major adverse events over asymptomatic patients.J Vasc Surg. 2022; 76: 1625-1632Google Scholar provide some additional insight into the impact of a remote history of cerebrovascular events as a marker for increased periprocedural adverse events after carotid stenting. The default definition of “asymptomatic” extracranial carotid disease is the absence of clinical signs and symptoms of a transient ischemic attack or stroke. As this report shows, although most asymptomatic patients are truly asymptomatic, a subset do indeed have a prior history of a neurologic event that occurred more than 180 days before an intervention but are still typically categorized as asymptomatic. This current report demonstrates that at least among patients treated with carotid stenting (transfemoral vs transcarotid), the periprocedural outcomes more closely resemble the symptomatic rather than the asymptomatic patient population. For years, we have tried a variety of imaging techniques to identify the unstable asymptomatic plaque including computed tomographic evaluation, magnetic resonance plaque characterization, ultrasound gray scale median, and transcranial Doppler.2Kakkos S.K. Griffin M.B. Nicolaides A.N. Kyriacou E. Sabetai M.M. Tegos T. et al.Asymptomatic Carotid Stenosis and Risk of Stroke (ACSRS) study group. The size of juxtaluminal hypoechoic area in ultrasound images of asymptomatic carotid plaques predicts the occurrence of stroke.J Vasc Surg. 2013; 57 (discussion: 617-8): 609-618.e1Abstract Full Text Full Text PDF PubMed Scopus (127) Google Scholar,3Saba L. Antignani P.L. Gupta A. Cau R. Paraskevas K.I. Poredos P. et al.International Union of Angiology (IUA) consensus paper on imaging strategies in atherosclerotic carotid artery imaging: from basic strategies to advanced approaches.Atherosclerosis. 2022; 354: 23-40Abstract Full Text Full Text PDF PubMed Scopus (3) Google Scholar Unfortunately, none are broadly recognized as an accurate predictor. In my institution, transcranial Doppler is used quite frequently by the stroke neurologists, yet it has not made a noticeable impact on the current treatment algorithm for most patients. Hopefully, upcoming prospective studies such as the Carotid Artery Multimodality imaging Prognostic study may provide more valuable insight of the unstable asymptomatic plaque with contemporary imaging techniques.4Gargani L. Baldini M. Berchiolli R. Bort I.R. Casolo G. Chiappino D. et al.Detecting the vulnerable carotid plaque: the Carotid Artery Multimodality imaging Prognostic study design.J Cardiovasc Med (Hagerstown). 2022; 23: 466-473Crossref Scopus (1) Google Scholar Although the current report demonstrates improved outcomes among the transcarotid treated patient population vs transfemoral stenting using the Vascular Quality Initiative database, some concerns exist in regard to the data quality and sample size. Important unknowns include adherence and implementation of currently accepted optimal medical therapy, operator expertise, and objective neurologic assessment before and after the procedure. Nevertheless, the important message is that asymptomatic patients with any prior history of a remote neurologic event tend to have less favorable outcomes as compared those with no prior history of a neurologic event, and this information should be taken into consideration as part of the treatment algorithm. The opinions or views expressed in this commentary are those of the authors and do not necessarily reflect the opinions or recommendations of the Journal of Vascular Surgery or the Society for Vascular Surgery. Carotid stenosis patients with a remote history of cerebrovascular events have increased risk of major adverse events over asymptomatic patientsJournal of Vascular SurgeryVol. 76Issue 6PreviewAsymptomatic patients with a remote history of transient ischemic attack (TIA) or stroke are not well studied as a separate population from asymptomatic patients with no prior history of TIA or stroke. We compared in-hospital outcomes after transcarotid artery revascularization (TCAR) and transfemoral carotid artery stenting (TFCAS) among symptomatic patients, patients with a remote history of neurologic symptoms, and asymptomatic patients. Full-Text PDF