Severe Asymptomatic Carotid Artery Stenosis Research Articles

Free-Cell Area Impact on Stroke Prevention in Asymptomatic Patients Undergoing Carotid Artery Stenting: The "Carotid Artery sTenting And CeLl-area Impact on Stroke and Major Adverse events" (CATACLISMA) Multicenter Registry.

The study investigated the association between cell-stent area and cerebrovascular events incidence in asymptomatic patients undergoing carotid artery stenting (CAS). This is an observational, retrospective, multicenter, cohort study. Between 2012 and 2022, all patients undergoing primary CAS for severe asymptomatic carotid artery stenosis were evaluated. Three groups were defined on the basis of the cell area (open cell, OC; closed cell, CC; double layer, DL). Periprocedural primary outcomes were 30-day stroke, mortality, myocardial infarction (MI), and major adverse event (MAE, stroke/mortality composite outcome) rates. Follow-up primary outcomes included overall survival, stroke-free survival (SFS), freedom from ipsilateral stroke (FFiS), and freedom from stroke-related mortality (FF-SRM). Data were analyzed at short-term (1 year) and mid-term (2.5 years) period. A total of 1096 CAS were considered (787 men, 71.8%, median age = 74 years). Technical success was achieved in 99.5% procedures. Periprocedural 30-day stroke rate was 1.5% (OC: 1.1%, CC: 2.3%, DL: 1%, p=0.27), mortality was 0.7% (OC: 1.1%, CC: 0.3%, DL: 0.5%, p=0.35), and no MI was recorded. The MAE rate was 2.1% (OC: 2%, CC: 2.6%, DL: 1.5%, p=0.66). Median follow-up was 46 months. At 1 and 2.5 years, estimated overall survival was 96.1% and 91% (p=0.41), SFS was 99.1% and 98.2% (p=0.007, CC stroke rates 2.9% and 4.2% at timepoints), FFiS was 99.4% and 99% (p=0.014, CC FFiS rates 1.7% and 2.6% at timepoints) and FF-SRM was 99.5% and 99% (p=0.28). During follow-up, no stroke events occurred in DL group. CC design showed higher rates of any (4.2%) and ipsilateral stroke (2.6%) within 2.5 years. In asymptomatic patients undergoing CAS, the contemporary overall stroke incidence is 1.5%. No statistical differences were observed in terms of 30-day stroke incidence among groups. The closed free-cell area showed higher rates of any and ipsilateral stroke within 2.5 years. The DL stents may offer the best available performances in terms of mid-term stroke prevention. The study analyzed the contemporary results of carotid artery stenting (CAS) focusing on the impact of cell-stent area on peri- and post-operative cerebrovascular events in a multicenter real-world experience. In asymptomatic patients undergoing CAS the contemporary overall stroke incidence is 1.5%. No statistical differences were observed in terms of 30-day stroke incidence among groups. The closed free-cell area showed higher rates of any and ipsilateral stroke within 2.5 years. DL stents may offer the best available performances in terms of mid-term stroke prevention.

Optimal medical therapy is lacking in patients undergoing intervention for symptomatic carotid artery stenosis and protects against larger areas of cerebral infarction.

Carotid interventions are indicated for both patients with symptomatic and a subset of patients with severe asymptomatic carotid artery stenosis (CAS). Symptomatic CAS accounts for up to 12%-25% of overall carotid interventions, but predictors of symptomatic presentation remain poorly defined. The aim of this study was to identify factors associated with symptomatic CAS in our patient population. Between January 2015 and February 2022, an institutional retrospective cohort study of prospectively collected data on patients undergoing interventions for CAS was performed. Procedures included carotid endarterectomy (CEA), transcarotid artery revascularization (TCAR), and transfemoral carotid artery stenting (TF-CAS). Demographic data, comorbidities, procedural details, and anatomic features from various imaging modalities were collected. Comparisons were made between symptomatic (symptoms within the prior 6 months) and asymptomatic patients. During the study period, 279 patients who underwent intervention for symptomatic CAS were paired with a randomly selected cohort of 300 patients who underwent intervention for asymptomatic CAS from a total patient cohort of 1143 patients undergoing interventions for asymptomatic CAS. Demographic data did not differ between groups. Patients with symptomatic CAS more frequently had prior TIA/stroke (>6 months remote to the current event), but less frequently had coronary artery disease or chronic kidney disease and were less likely to receive adequate medical management including antihypertensive agents, lipid-lowering agents, and anti-platelet therapy. On multivariate analysis, remote prior TIA/stroke and lack of anti-platelet therapy remained significant. Among symptomatic patients presenting with stroke, lack of anti-platelet therapy was associated with an overall larger area of parenchymal involvement. No difference was observed with single versus dual anti-platelet therapy. Furthermore, symptomatic patients were more likely to have ulcerated plaques (30.9% vs 18%, p < .001), and symptomatic patients with ulcerated plaques more frequently had less than 50% compared to moderate/severe CAS. Nine patients who presented with symptoms had mild CAS and underwent intervention. Symptomatic CAS was associated with a history of remote prior symptoms and lack of anti-platelet therapy at time of presentation. Furthermore, symptomatic patients not on anti-platelet agents were more likely to have a greater area of parenchymal involvement when presenting with stroke and symptomatic patients with ulcerated plaques were more likely to have mild CAS, suggesting the role of plaque instability in symptomatic presentation. These findings underscore the importance of appropriate medical management and adherence in all patients with CAS and perhaps a role for more frequent surveillance in those with potentially unstable plaque morphology.

Population-based Assessment of Outcome in the Management of Asymptomatic Severe Carotid Artery Stenosis

Population-based Assessment of Outcome in the Management of Asymptomatic Severe Carotid Artery Stenosis

Study of cognitive function in patients with severe asymptomatic carotid artery stenosis by a computerized neuropsychological assessment device.

Carotid stenosis can lead to stroke and cognitive impairment. Moreover, the cognitive function was assessed mostly by paper and pencil cognitive tests. This study aimed to evaluate the impact of severe asymptomatic carotid artery stenosis (SACAS) on cognitive function by a computerized neuropsychological assessment device (CNAD). The diagnostic value of screening SACAS of the CNAD was analyzed. There were 48 patients with ≥70% asymptomatic carotid stenosis and 52 controls without carotid stenosis. Duplex ultrasound defined the degree of stenosis. The differences of cognitive function were analyzed between patients and controls. The relationship of scores of cognitive tests and age were analyzed in the linear regression equation. The diagnostic value of CNAD was evaluated by the receiver operating characteristic (ROC) curve. Stenosis and control subjects had no statistically significant differences in baseline characteristics. Stenosis patients had worse scores for Stroop color-word test (p = 0.002), one back test (p = 0.013), and identification test (p = 0.006) corresponding to attention and executive ability. The analysis of linear regression equation indicated that cognitive scores of stenosis patients declined faster with age, especially for digit span test, Stroop color-word test, one back test and identification test. In analysis of ROC curve, the Stroop color-word test (p = 0.002), one back test (p = 0.013), and identification test (p = 0.006), and comprehensive index of the three tests (p = 0.001) had the diagnostic value. The CNAD has evaluation value and screening value for patients with cognitive impairment and SACAS. But it is necessary to update the CNAD and conduct a study with a bigger sample.

Incidence of Ischemic Stroke in Patients With Asymptomatic Severe Carotid Stenosis Without Surgical Intervention

Optimal management of patients with asymptomatic severe carotid stenosis is uncertain, due to advances in medical care and a lack of contemporary data comparing medical and surgical treatment. To estimate stroke outcomes among patients with medically treated asymptomatic severe carotid stenosis who did not undergo surgical intervention. Retrospective cohort study that included 3737 adult participants with asymptomatic severe (70%-99%) carotid stenosis diagnosed between 2008 and 2012 and no prior intervention or ipsilateral neurologic event in the prior 6 months. Participants received follow-up through 2019, and all were members of an integrated US regional health system serving 4.5 million members. Imaging diagnosis of asymptomatic carotid stenosis of 70% to 99%. Occurrence of ipsilateral carotid-related acute ischemic stroke. Censoring occurred with death, disenrollment, or ipsilateral intervention. Among 94 822 patients with qualifying imaging studies, 4230 arteries in 3737 (mean age, 73.8 [SD 9.5 years]; 57.4% male) patients met selection criteria including 2539 arteries in 2314 patients who never received intervention. The mean follow-up in this cohort was 4.1 years (SD 3.6 years). Prior to any intervention, there were 133 ipsilateral strokes with a mean annual stroke rate of 0.9% (95% confidence interval [CI], 0.7%-1.2%). The Kaplan-Meier estimate of ipsilateral stroke by 5 years was 4.7% (95% CI, 3.9%-5.7%). In a community-based cohort of patients with asymptomatic severe carotid stenosis who did not undergo surgical intervention, the estimated rate of ipsilateral carotid-related acute ischemic stroke was 4.7% over 5 years. These findings may inform decision-making regarding surgical and medical treatment for patients with asymptomatic severe carotid artery stenosis.

Management of asymptomatic severe carotid artery stenosis in patients undergoing coronary artery bypass surgery: Clinical analysis

Amaç: Koroner arter hastalığı nedeni ile ameliyat yapılacak olan hastalarda semptomatik karotis arter darlığının tedavisi hakkında kılavuzlarda görüş birliği sağlanmış, asemptomatik hastalarda ise kesin görüş birliği sağlanamamıştır. Bu hastalara yaklaşım şeklimizi ve sonuçlarımızı paylaşmak istedik.&#x0D; Gereç ve Yöntemler: Ocak 2016-Ocak 2021 tarihleri arasında koroner arter baypas cerrahisi uyguladığımız tek taraflı %70’ten yüksek karotis arter darlığı bulunan asemptomatik 40 hasta (Grup 1) ile koroner arter baypas cerrahisi uygulanan fakat karotis arter darlığı olmayan 40 hasta (Grup 2) serebrovasküler komplikasyonlar ve cerrahinin sonuçları yönünden karşılaştırıldı. Tüm hastalara koroner arter baypas cerrahisi uygulandı ve karotis arter darlığına müdahale edilmedi.&#x0D; Bulgular: Preoperatif hipertansiyon görülme oranı Grup 1’de daha fazlaydı (%65 ve %32,5, p=0,007). Grup 1 hastalarda koroner arter baypas ameliyatı baypas greft sayısı Grup 2 hastalara göre daha fazla idi (3,250,58 ve 2,870,68, p=0,010). Hiçbir hastada majör serebrovasküler olaya rastlanmadı ve mortalite gelişmedi. &#x0D; Sonuç: Asemptomatik tek taraflı karotis darlığının eşlik ettiği koroner arter hastalarında koroner arter cerrahisinin güvenli olduğu sonucuna vardık. Bu konu ile ilgili kesin görüş birliğine ulaşabilmek için çok merkezli prospektif araştırmaların yapılmasının faydalı olacaktır.

Impact of nutritional assessment on long‐term outcomes in patients with carotid artery stenting

Malnutrition is associated with poor clinical outcomes in many diseases. The Controlling Nutritional Status (CONUT) is an objective index used for evaluating nutritional status of hospitalised patients. The aim of this study was to investigate the relationship between malnutrition assessed by CONUT score and the prognosis in patients undergoing carotid artery stenting (CAS). The study included 170 patients who underwent CAS because of symptomatic or asymptomatic severe carotid artery stenosis. Median follow-up period was 50 (interquartile range [IQR], 41-60) months. Patients were divided into two groups according to the CONUT score as normal CONUT (score <2) and mild-severe CONUT (score ≥2). Primary endpoint was accepted as MACE (major adverse cardiac events) including all-cause death and ischaemic stroke. The prevalence of MACE was significantly higher in the mild-severe CONUT score group (P=.001). Kaplan Meier analysis showed lower survival rates in the mild-severe CONUT score group (log rank=9.36, P=.002; Figure 5). The Cox regression analysis showed that, the CONUT score was associated with increased risk of MACE for both unadjusted model and age- and gender- adjusted model, while in a full adjusted model the best predictor was age. Higher CONUT scores were associated with adverse outcomes in patients with CAS. Malnutrition assessed by the CONUT score is preferable with regards to the detection ofMACE in patients with CAS. Larger studies are warranted to investigate if our preliminary findings translate into clinical outcomes in patients with CAS.

Measurement of Cortical Atrophy and Its Correlation to Memory Impairment in Patients With Asymptomatic Carotid Artery Stenosis Based on VBM-DARTEL.

ObjectiveSevere carotid artery stenosis (CAS) can lead to atrophy of gray matter (GM) and memory impairment; however, the underlying mechanism is unknown. Thus, we aimed to identify memory impairment and GM atrophy and explore the possible correlation between them in patients with asymptomatic severe CAS.MethodsTwenty-four patients with asymptomatic severe CAS and 10 healthy controls completed the mini-mental state examination (MMSE) and clinical memory scale (CMS) and underwent 7T magnetic resonance imaging (MRI) scan. Field intensity inhomogeneities were corrected. Images were processed using VBM8, and GM images were flipped. First, 11 flipped and 10 non-flipped images of patients with unilateral CAS and 5 flipped and 5 non-flipped images of controls were pre-processed using DARTEL algorithm and analyzed using an analysis of variance (ANOVA). Second, flipped and non-flipped images of unilateral patients were similarly pre-processed and analyzed using the paired t-test. Third, pre-processed non-flipped GM images and CMS scores of 24 patients were analyzed by multiple regression analysis. Nuisance variables were corrected accordingly.ResultsBasic information was well matched between patients and controls. MMSE scores of patients were in the normal range; however, memory function was significantly reduced (all P < 0.05). GM volumes of patients were significantly reduced in the anterior circulation regions. The stenosis-side hemispheres showed greater atrophy. GM volumes of the left pars opercularis, pars triangularis, and middle frontal gyrus were strongly positively correlated with the total scores of CMS (all r > 0.7, P = 0.001). Additionally, the left middle frontal gyrus was strongly positively correlated with associative memory (r = 0.853, P = 0.001). The left pars opercularis was moderately positively correlated with semantic memory (r = 0.695, P = 0.001).ConclusionPatients with asymptomatic CAS suffer from memory impairment. Bilateral anterior circulation regions showed extensive atrophy. The hemisphere with stenosis showed severer atrophy. Memory impairment in patients may be related to atrophy of the left frontal gyrus and atrophy of different regions may result in different memory impairments.

Selective Non-Operative and Delayed Management of Severe Asymptomatic Carotid Artery Stenosis

Selective Non-Operative and Delayed Management of Severe Asymptomatic Carotid Artery Stenosis

Selective Nonoperative and Delayed Management of Severe Asymptomatic Carotid Artery Stenosis

Although intervention is generally the standard of care for severe (80-99%) asymptomatic carotid stenosis, conservative management may be appropriate for a subset of patients. Our goal was to assess reasons for and outcomes of nonoperative/delayed operative management of asymptomatic severe carotid stenosis. Institutional vascular laboratory data from 2010 to 2018 was queried for all patients who underwent a carotid duplex ultrasonography. Patients with severe asymptomatic carotid stenosis (80-99%) were included. Such stenosis was defined by an end diastolic velocity >140cm/sec on duplex ultrasound in patients without transient ischemic attacks (TIA)/strokes ≤6months prior to imaging. Nonoperative/delayed operative management was defined as not undergone carotid endarterectomy (CEA) or carotid artery stent (CAS) ≤6months after imaging. Reasons for nonoperative management or delayed intervention as well as subsequent TIA/stroke and survival were determined. Kaplan-Meier analysis was performed to evaluate survival. Among 211 patients with severe carotid stenosis, 35 (16.6%) were managed nonoperatively or with delayed operation. Mean age in this subset was 72.6±11.4years and the majority were female (57.1%), had a smoking history (74.3%), and were on statins (91.4%) at the time of index duplex ultrasound. Reasons for no/delayed intervention were classified as severe medical comorbidities (37.1%), advanced age (17.1%), no referral for intervention (14.3%), patient refusal (14.3%), other severe concomitant cerebrovascular disease (11.4%), and active/advanced cancer (5.7%). Over a median follow-up of 35.2months, no patients experienced TIAs/strokes attributable to carotid stenosis. One patient had a multifocal bilateral stroke after a cardiac arrest and prolonged resuscitation. A subset of patients underwent delayed CEA (8.6%) or CAS (2.9%). Four-year survival after initial imaging was 79%. Reasons for nonoperative and delayed operative management in our cohort of asymptomatic carotid stenosis were commonly due to comorbidities and advanced age. However, a subset of patients was never referred to vascular surgeons/interventionalists. Adverse neurologic events due to carotid stenosis were not observed during follow-up and patients had relatively high long-term survival.

Non-operative and Delayed Operative Management Of Severe Asymptomatic Carotid Artery Stenosis

Although intervention is generally the standard of care for severe asymptomatic carotid artery stenosis, conservative management may be appropriate in a subset of patients. Our goal was to assess reasons for and outcomes of non-operative/delayed operative management of asymptomatic severe carotid stenosis.

Application research on carotid arterial shunting during simultaneous coronary artery bypass grafting and carotid endarterectomy

Objective: The optimal operative strategy in patients with asymptomatic severe carotid artery stenosis undergoing coronary artery bypass grafting (CABG) is unknown. We sought to investigate the safety of carotid arterial shunting during simultaneous CABG and carotid endarterectomy (CEA). Methods: The clinical data of patients undergoing synchronous combined CEA and CABG in the First Hospital of China Medical University between March 2017 and July 2019 was retrospectively studied. Patients with asymptomatic severe carotid artery stenosis ≥70% according to NASCET (North American Symptomatic Carotid Endarterectomy Trial) were required CABG surgery. During conventional CEA, carotid arterial shunting was used in all cases. Results: Ten patients were recruited. The average clamping time of carotid artery was 5 minutes. The average follow-up time was 10 months. We did not observe stroke, cerebral hyper perfusion syndrome, death and carotid restenosis. Conclusions: Carotid arterial shunting during synchronous combined CEA and CABG was helpful for obtaining good curative effect.

Changes in retinal flow density measured by optical coherence tomography angiography in patients with carotid artery stenosis after carotid endarterectomy

The aim of the study presented here was to evaluate retinal and optic nerve head (ONH) perfusion in patients with severe asymptomatic carotid artery stenosis (CAS) compared with healthy controls and to analyze the impact of carotid endarterectomy using optical coherence tomography angiography (OCT-A). 25 eyes of 25 patients with CAS (study group) and 25 eyes of 25 healthy controls (control group) were prospectively included in this study. OCT-A was performed using RTVue XR Avanti (Optovue, Inc, Fremont, California, USA). The flow density data in the superficial and deep retinal OCT-angiogram of the macula and in the radial peripapillary capillary network (RPC) of the ONH were extracted and analyzed. The flow density in the superficial retinal OCT angiogram of the macula and in the ONH were significantly lower in the study group compared with the control group (macula: p = 0.003) (ONH: p = 0.013). The flow density in the ONH improved significantly after carotid endarterectomy (p = 0.004). A reduced flow density was observed in patients with CAS when compared with healthy controls. The flow density also improved after carotid endarterectomy. Quantitative changes in the microvascular density, as measured using OCT-A, could well be useful in the diagnosis of CAS and the evaluation of therapy success.

The Impact of Carotid Artery Stenting on Cerebral Perfusion, Functional Connectivity, and Cognition in Severe Asymptomatic Carotid Stenosis Patients.

Asymptomatic carotid artery stenosis can lead to not only stroke but also cognition impairment. Although it has been proven that carotid artery stenting (CAS) can reduce the risk of future strokes, the effect of CAS on cognition is conflicting. In recent years, pulsed arterial spin labeling (pASL) MRI and resting-state functional MRI (R-fMRI) have been employed in cognitive impairment studies. For the present study, cognition is evaluated in severe asymptomatic carotid artery stenosis patients undergoing CAS, and the mechanisms underlying the cognitive change are explored by pASL MRI and R-fMRI. We prospectively enrolled 24 asymptomatic, severe (≥70%), unilateral internal carotid artery stenosis patients, who were expecting the intervention of CAS. Cognition assessment (including the Montreal Cognitive Assessment Beijing Version, the Minimum Mental State Examination, the Digit Symbol Test, the Rey Auditory Verbal Learning Test, and the Verbal Memory Test) and an integrated MRI program (pASL MRI, and R-fMRI) were administered 7 days before and 3 months after CAS. 16 subjects completed the follow-up study. After stenting, significant improvement in the scores of the MMSE, the Verbal Memory test, and the delayed recall was found. No significant difference was found in the scores of the Montreal Cognitive Assessment Beijing Version, the Digit Symbol Test, and the immediate recall. After CAS treatment, asymptomatic carotid artery stenosis patients showed increased perfusion in the left frontal gyrus, increased amplitude of low-frequency fluctuation (ALFF) in the right precentral gyrus, and increased connectivity to the posterior cingulate cortex (PCC) in the right supra frontal gyrus. However, no significant correlations were found between these imaging changes and cognition assessments. Successful CAS can partly improve cognition in asymptomatic carotid artery stenosis patients. The cognition improvement may be partly attributed to the increased perfusion in the left frontal gyrus, increased ALFF in the right precentral gyrus, and increased connectivity to the PCC in the right supra frontal gyrus.

Modern medical treatment with or without carotid endarterectomy for severe asymptomatic carotid atherosclerosis

This study assessed the value of modern medical treatment (MMT) with and without carotid endarterectomy (CEA) in patients with asymptomatic severe carotid artery stenosis. We conducted a randomized trial involving 55 patients with 70% to 79% carotid stenosis at three Russian centers. Between 2009 and 2013, 31 patients were randomized to undergo CEA with MMT (CEA group) and 24 to receive MMT alone. The primary end point was nonfatal ipsilateral stroke or death from any cause during a follow-up period of 5.0 years. The secondary end point was any nonfatal stroke, carotid revascularization, or death from any cause during follow-up. The trial was stopped after a median follow-up of 3.3 years (maximum, 5.0 years). There were two primary events in the CEA group and nine events in the MMT group. The 3.3-year cumulative primary event rates were 6.5% in the CEA group and 37.5% in the MMT group (hazard ratio for the MMT group, 5.06; 95% confidence interval, 1.53-16.79; P = .008). The 3.3-year cumulative secondary end point was 12.9% in the CEA group and 50.0% in the MMT group (hazard ratio for the MMT group, 4.23; 95% confidence interval, 1.55-11.53; P = .0048). CEA as an initial management strategy could reduce the risk of death and major cerebrovascular events when added to MMT.

Abstract T MP26: Progression Of Asymptomatic Carotid Stenosis: Incidence Of Symptoms And Predictive Factors

Background: Given the uncertainty regarding clinical applicability of early treatment trials and lack of data on long-term disease progression, we evaluated the progression of stenosis and development of symptoms on patients with asymptomatic carotid artery stenosis (ACAS) treated with contemporary medical therapy over a prolonged follow up. Methods: Retrospective review of bilateral carotid arteries from consecutive patients diagnosed with moderate or severe ACAS, at our institution between 2000 and 2001. Patient vascular risk factors and treatments, cerebrovascular imaging, ipsilateral symptoms, and revascularization were recorded. Progression of stenosis was defined by change category of stenosis. Factors associated with symptomatic carotid disease were sought using univariate and multivariate logistic regression analysis. Results: We identified 214 patients (58.8% men; median age 70 years) and collected data on 349 vessels. Severe stenosis (&gt;70%) upon diagnosis was present in 92(26.4%) vessels. All patients were on antithrombotics, 97% on antihypertensives, and 95% on statins. Median length of follow up was 13 years (range 5-14) and the mean number of time points with follow-up imaging was 8.1±3.9. Progression of stenosis was observed in 237(67.9%) vessels. 72(20.6%) patients developed symptomatic carotid stenosis (TIA in 14.4%, non-disabling stroke in 4%, and disabling stroke in 2.2%). Median time to appearance of first symptom was 6 years (range 1-13). Revascularization procedures were performed in 118(33.8%) vessels, including 73(61.9%) vessels which had become symptomatic. On multivariate analysis, baseline stenosis (OR 1.65, 95%CI 1.12-2.44), intracranial stenosis &gt; 50% (OR 2.87, 95%CI 1.46-5.62), plaque ulceration (OR 3.41, 95%CI 1.34-8.69), silent infarction (OR 4.25, 95%CI 2.30-7.83), and previous history of TIA/stroke (OR 2.73, 95%CI 1.14-6.54) were associated with development of TIA/stroke ipsilateral to the carotid stenosis. Conclusions: There is a substantial rate of progression of stenosis in patients with asymptomatic carotid atherosclerosis over time despite adequate medical therapy. Over long-term follow up, one in five patients with ACAS developed ipsilateral TIA/stroke.

The natural history of asymptomatic severe carotid artery stenosis

Although level 1 evidence supports carotid endarterectomy (CEA) for stroke prevention in patients with asymptomatic severe carotid artery stenosis (ASCAS; >70%), medical therapy alone has been promulgated by some as equally effective. The goal of this study was to determine the natural history of medically treated patients with ASCAS. Patients with ASCAS from 2005 to 2006 were identified in a health network database. Patients were included if the initial therapeutic plan involved medical therapy alone (usually because of comorbidities or patient preference). Study end points included: ipsilateral neurologic symptoms (INS) of transient ischemic attack and/or stroke, death, and INS and/or death. There were 126 carotid arteries identified in 115 patients. Using standard duplex velocity criteria, 88 (70%) had severe (70%-89%) and 38 (30%) had very severe stenoses (VSS; 90%-99%). The average age was 73.5years, demographic characteristics included: 66% hypertension, 64% coronary artery disease, 30% diabetes, 5% chronic kidney disease (CKD), and 86% were taking a statin drug (28% had a low-density lipoprotein level<100mg/dL). There were 31 patients (24.6%) who developed INS during a mean follow-up of 27months; most (23 of 31; 74%) occurred within 12months of the initial duplex ultrasound examination; 14 (45%) were strokes. The 5-year actuarial freedom from INS was 70.1± 5%. Multivariate predictors of INS included: VSS (hazard ratio [HR], 3.23; 95% confidence interval [CI], 1.56-6.76; P= .002), CKD (HR, 6.25; 95% CI, 2.05-19.2; P= .001), and age (HR, 0.94; 95% CI, 0.91-0.98; P= .001). There were 41 patients (33%) who underwent eventual carotid revascularization (32 CEA, nine stent); 23 of 41 (56%) were performed for INS and 18 (44%) for plaque progression. Overall 5-year actuarial survival was 69.8%± 4.1%. Multivariate predictors of death included: age (HR, 1.06; 95% CI, 1.03-1.1; P= .0001), chronic obstructive pulmonary disease (HR, 1.92; 95% CI, 1.08-3.41; P= .03), and diabetes (HR, 5.08; 95% CI, 2.86-9.01; P< .0001). The 5-year actuarial freedom from INS and/or death was 54± 4.4%. Multivariate predictors of INS and/or death were: VSS (HR, 1.98; 95% CI, 1.22-3.23; P= .006), CKD (HR, 5.46; 95% CI, 2.12-14.08; P= .0004), and diabetes (HR, 2.6; 95% CI, 1.59-4.24; P= .0001). Statin use was not protective against INS or death in this cohort. Medically managed patients with ASCAS develop INS early, especially in patients with VSS. Medical therapy with aspirin and statins failed to control ASCAS, thus validating the role of CEA in these patients as promulgated in multiple current treatment guidelines.

Natural History of Asymptomatic Severe Carotid Artery Stenosis

Natural History of Asymptomatic Severe Carotid Artery Stenosis

Shaggy aortaと高度腎機能障害を有する無症候性両側頚部内頚動脈高度狭窄症に対してCABG前に両側CASを施行した1例

Shaggy aortaと高度腎機能障害を有する無症候性両側頚部内頚動脈高度狭窄症に対してCABG前に両側CASを施行した1例

Patients With Severe Asymptomatic Carotid Artery Stenosis Do Not Have a Higher Risk of Stroke and Mortality After Coronary Artery Bypass Surgery

Patients With Severe Asymptomatic Carotid Artery Stenosis Do Not Have a Higher Risk of Stroke and Mortality After Coronary Artery Bypass Surgery