Atherosclerotic Carotid Artery Disease Research Articles

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.

The Natural Course of the Carotid Artery Atherosclerotic Disease in the Contralateral Carotid Artery After Carotid Endarterectomy

The Natural Course of the Carotid Artery Atherosclerotic Disease in the Contralateral Carotid Artery After Carotid Endarterectomy

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.

Another cause of treatable dementia: rapid cognitive improvement after carotid endarterectomy. Illustrative case.

Revascularization techniques in cervical internal carotid artery (ICA) stenosis are indicated to prevent the onset or recurrence of ischemic events in the setting of atherosclerotic carotid artery disease. Recent reports, case series, and comparative studies have suggested that revascularization techniques may also improve cognitive outcome in both symptomatic and asymptomatic patients, thus raising the question of whether another surgically treatable dementia has presented itself. A 70-year-old right-handed female with a history of hypertension, diabetes, and bilateral silent cerebral infarcts was evaluated for progressive cognitive impairment over a 1-year period, which was associated with a severe left cervical ICA stenosis. Carotid endarterectomy (CEA) was indicated as a revascularization technique, and the patient showed significant neurocognitive improvement as early as one month postoperatively, consistent with blood flow restoration to the left hemisphere on control imaging. This case serves as a reminder that CEA may improve the cognitive outcome of patients previously impaired by uncomplicated severe cervical ICA atherosclerotic disease, which can be another cause of treatable dementia. Further prospective studies may help to assess this potential benefit.

Correlation Between Optical Coherence Tomography Angiography Findings at 3 to 6 Weeks and Functional Outcome at 3 Months Following Acute Ischaemic Stroke Due to Extracranial Carotid Artery Atherosclerotic Disease

ABSTRACT We wanted to evaluate if optical coherence tomography angiography OCTA findings could predict the functional outcome in extracranial carotid artery atherosclerotic disease (ECAD) associated stroke. This exploratory study was performed on adults with acute ischaemic stroke due to ECAD at 3–6 weeks following stroke onset with risk factor matched controls without carotid artery stenosis. Twenty-three stroke patients (cases) and 23 controls were enrolled. There was significant difference between cases and controls in deep vessel density at the macula (p = .0007) and in radial peripapillary capillary perfusion density (RPCPD) at the optic nerve head (ONH) (p = .0007). Statistically significant difference was noted in the total superficial vessel density (SVD) at the macula (SVD within 1 standard deviation [SD] versus SVD beyond 1 SD of control data) in the ipsilateral eye and functional outcome at 3 months (poor versus very good outcome, modified Rankin scale [mRS] 0–1 versus mRS 2–6, respectively; p = .0361). There was statistically insignificant correlation between the RPCPD at the ONH and the National Institutes of Health Stroke Scale score at admission, mRS at discharge, and mRS at 3 months following stroke onset (r = .33, r = .35, r = .39; p = .11, p = .09, p = .06, respectively). The findings of this exploratory study suggested that OCTA findings may predict 3 month outcomes in cases of ECAD-related stroke and could be useful in decision making in future intervention studies as to whether intervene or not in patients having critical or non-critical ECAD for preventing stroke.

Abstract 13981: Computed Tomography Angiography Measures of Carotid Artery Plaque Burden in Patients With Atherosclerotic Carotid Artery Disease Stratified by Status of Chronic Kidney Disease

Introduction: Atherosclerotic carotid artery disease (ACAD) is associated with an increased risk of cerebrovascular mortality and morbidity. We have analyzed associations of computed tomography angiography (CTA) measures of carotid artery (CA) plaque burden with chronic kidney disease (CKD). Hypothesis: CTA-based measures of CA plaque burden in patients with ACAD differ across stages of CKD. Methods: A total of 63 ACAD patients (13 without CKD, 50 with CKD), who completed CTA imaging and had demographic data were included in a retrospective analysis of patients from the Michael E. DeBakey Veterans Affairs Medical Center (MEDVAMC), Houston, Texas. CA plaque burden measures include the normalized wall index (NWI), wall area (WA), and lumen area (LA) at three distinct CA locations: CA bifurcation (BF), maximum total vessel cross-sectional area (MTVA) of the internal CA (ICA), and ICA peak stenosis (PS). CTA measures and patient demographics were compared across three CKD classes (no disease: n=13; CKD stages 1 and 2: n=31; and CKD stage 3 and above; n=19). Results: Baseline characteristics differed among CKD groups for the estimated glomerular filtration rate (p=<0.0001) and the body mass index (p=0.046). Inter-observer variability, assessed by intraclass correlation (ICC) analysis, was excellent for CA lumen area and wall area (0.964 (confidence interval [CI]: 0.946, 0.976); 0.865 (CI: 0.804, 0.908): n=100 CTA slices, both). The mean NWI differed significantly among the CKD groups for two of the three CA locations (BF: p=0.018, MTVA: p=0.01; PS: p=0.057). Similarly, lumen area significantly differed between CKD categories (BF: p=0.045, MTVA: p=0.013; PS: p=0.017) but not the wall area. Conclusion: CTA-based measures of carotid plaque burden in ACAD patients are highly reproducible and differed across CKD groups. Imaging-based measures of CA plaque burden may be of interest in stratifying risk assessment of ACAD patients with concomitant CKD.

The Diagnostic Value of Trace Metal Concentrations in Hair in Carotid Artery Disease.

Several studies showed the role of trace elements in the increase in human susceptibility to cardiovascular diseases. Carotid artery stenosis is a leading cause of ischemic neurological events. We aimed to analyze the potential role of trace elements in hair as biomarkers of atherosclerotic carotid artery disease. Materials and Methods: Fifty-seven (n = 31 (54%) men and n = 26 (46%) women) individuals with a mean age of 67.7 ± 7.7 years who were white, European, non-Hispanic, and non-Latino were diagnosed and treated in hypertensiology/internal medicine and surgical departments over three consecutive months. Of these patients, forty were diagnosed with advanced carotid artery disease, and seventeen comprised a group of healthy controls. Inflammatory and oncological diseases were exclusion criteria. Hair samples were collected, and 14 trace elements were analyzed. Clinical and laboratory data were compared and revealed differences in the co-existence of diabetes (p = 0.036) and smoking history (p = 0.041). In the multivariable analysis, zinc, chrome, and copper revealed predictive value for the occurrence of carotid artery disease, and their combined receiver operating curve showed area under the curve of 0.935, with a sensitivity of 95% and a specificity of 82.4%. Conclusion: Our report shows the significance of trace elements analyses in patients with advanced carotid artery disease. We revealed that zinc, copper, and chrome concentrations are of particular importance in differentiating atherosclerotic disease and may serve as biomarkers of carotid atherosclerosis. Hair samples represent an easily obtained and beneficial biomatrix for the assessment of biomarkers.

10-channel phased-array coil for carotid wall MRI at 3T.

Accurate assessment of plaque accumulation near the carotid bifurcation is important for the effective prevention and treatment of stroke. However, vessel and plaque delineation using MRI can be limited by low contrast-to-noise ratio (CNR) and long acquisition times. In this work, a 10-channel phased-array receive coil design for bilateral imaging of the carotid bifurcation using 3T MRI is proposed. The proposed 10-channel receive coil was compared to a commercial 4-channel receive coil configuration using data acquired from phantoms and healthy volunteers (N = 9). The relative performance of the coils was assessed, by comparing signal-to-noise ratio (SNR), noise correlation, g-factor noise amplification, and the CNR between vessel wall and lumen using black-blood sequences. Patient data were acquired from 12 atherosclerotic carotid artery disease patients. The 10-channel coil consistently provided substantially increased SNR in phantoms (+77 ± 27%) and improved CNR in healthy carotid arteries (+62 ± 11%), or reduced g-factor noise amplification. Patient data showed excellent delineation of atherosclerotic plaque along the length of the carotid bifurcation using the 10-channel coil. The proposed 10-channel coil design allows for improved visualization of the carotid arteries and the carotid bifurcation and increased parallel imaging acceleration factors relative to a commercial 4-channel coil design.

Systematic review and meta-analysis of the treatment strategies for coronary artery bypass graft patients with concomitant carotid artery atherosclerotic disease

ObjectiveStroke is one of the devastating complications after coronary artery bypass graft (CABG). Underlying carotid artery atherosclerotic disease is reported to be an independent risk factor. The optimal treatment strategy for these patients remains under debate. MethodsWe aimed to perform a network meta-analysis to evaluate the safety and efficacy of additional carotid interventions for patients with concomitant carotid artery atherosclerotic disease who require CABG by comparing perioperative adverse event rates. All articles through February 2022 were searched using MEDLINE and EMBASE to identify studies that investigated outcomes of CABG only as well as additional staged vs combined carotid interventions by both carotid endarterectomy (CEA) and carotid artery stenting (CAS). ResultsTwo randomized controlled trials and 23 observational studies were included, yielding a total of 32,473 patients who underwent combined CEA and CABG (n = 20,204), CEA and staged CABG (n = 6882), CABG and staged CEA (n = 340), CAS and CABG regardless of timing and sequences (n = 1224), and CABG only (n = 3823). No strategy showed a significant advantage over CABG only in all perioperative outcomes. CEA and staged CABG was associated with the lowest perioperative stroke/transient ischemic attack (TIA) rate, significantly lower compared with CAS and CABG (odds ratio [OR], 0.52; 95% confidence interval [CI], 0.36-0.76) as well as CABG and staged CEA (OR, 0.41; 95% CI, 0.23-0.74), but was also associated with the highest perioperative mortality (OR, 2.50; 95% CI, 1.67-3.85, vs CAS and CABG) and myocardial infarction rate (OR, 3.70 [95% CI, 1.16-12.5] and OR, 2.50 [95% CI, 1.35-4.55] vs CAS and CABG, vs combined CEA and CABG, respectively). ConclusionsCEA and staged CABG are associated with low perioperative stroke/transient ischemic attack rates with a tradeoff of higher mortality and myocardial infarction rate. No strategy showed a significant advantage over the CABG-only strategy in all perioperative outcomes, outlining the importance of a tailored approach and determining proper indications for carotid intervention in these patients.

566 Role of STA-MCA Bypass in Recurrent Ischemic Stroke

INTRODUCTION: In the recurrent scenario of ischemic strokes, clinicians are faced with the options of switching to a new antiplatelet medication or using a combination of antiplatelet medications in the acute setting and for long-term secondary stroke prevention, balancing future protective benefits and increased hemorrhagic risks. METHODS: Patients presenting recurrent ischemic stroke that were surgically treated with STA-MCA bypass at our hospital between 2016 and 2021. Criteria inclusion were patients diagnosed with a minor ischemic stroke or TIA in MCA or ICA territory, submitted or not to thrombolysis, without indication for mechanical thrombectomy, presenting with hypoperfusion > 10% in the affected vascular territory. Were excluded patients presenting malignant ischemic stroke >1/3 of the MCA territory, cardiogenic causes, or atherosclerotic disease in cervical carotid arteries. RESULTS: STA-MCA bypass was performed in 10 patients presenting recurrent ischemic stroke. There were 6 males and 4 female patients with an age ranging from 40 to 75 years and a mean age of 59.6 (SD 10.59). Presented initial etiologies were ICA occlusion (40%), MCA occlusion (30%), TIA (10%), Moyamoya disease (10%), and Vertebral Artery occlusion (10%). Middle Cerebral Artery (MCA) was the most common site affected (90%), and the mean initial NIHSS was 11.1 (SD 4.57). 1 Day after surgery, the NIHSS average was 11.1 (SD 4.57), followed by 8.3 (SD 4.98), and 6.7 (SD 5.92) average on days 3 and 14, respectively. When comparing pre-op NIHSS and post-op NIHSS, a significant improvement after STA-MCA Bypass (p = 0.0085) was found. CONCLUSIONS: STA-MCA Bypass can be a feasible option in recurrent ischemic strokes and can be indicated in some cases.

The ESVS 2023 guidelines on the management of atherosclerotic carotid and vertebral artery disease. What is new and what remains to be answered

The ESVS 2023 guidelines on the management of atherosclerotic carotid and vertebral artery disease. What is new and what remains to be answered

Timing of carotid intervention in symptomatic carotid artery stenosis: a topical review.

Criteria and optimal timing for carotid artery revascularization have been polarizing subjects for investigators and clinicians dedicated to carotid artery atherosclerotic disease. A topical review was performed with the purpose of 1) providing an overview of the evidence on the definition of index event and on the definition of delay of intervention; 2) summarizing the rationale for the current definition for the optimal timing for carotid intervention, and 3) drawing a sketch for future directions implementing the aspect of timing in daily clinical practice. A literature search was performed using the Medline database and the following query ("Endarterectomy, Carotid"[Mesh]) AND ("Stroke" [Mesh] OR Symptomatic) AND "Randomized Controlled Trial"). A comprehensive review of manuscripts addressing timing of intervention was also performed. A total of eleven RCTs were identified and data on index event definition, timing of intervention and BMT were resumed. The definition of the index event can have a significant impact on the delay times but has (surprisingly) received little attention. Different definitions in itself may be correct, but in terms of stroke prevention, it is most important to understand and emphasize that the risk of recurrent stroke. The optimal timing of CEA after stroke remains an important but unresolved question. No prospective, randomized study has ever been undertaken to specifically determine which patients and when they might safely undergo expedited CEA after recent stroke. Collecting data on events during waiting time to intervention and developing reporting standards for these waiting times seem to be the key for unraveling this controversy.

Not a trifecta: complementary use of carotid artery revascularization techniques in the era of hybrid neurosurgery.

Carotid stenosis is currently treated by carotid endarterectomy (CEA), carotid artery stenting (CAS), or transcarotid artery revascularization (TCAR). This study sought to add to the literature by providing real-world data comparing the safety and effectiveness associated with the performance of these carotid revascularization techniques by dual-trained neurosurgeons. The authors performed a retrospective review of carotid stenosis databases at two US centers. Patients treated by CEA, transfemoral CAS, or TCAR for atherosclerotic carotid artery disease were included. Clinical outcomes were compared at 30 days after the procedure. Seven hundred eighty patients were included (583 with CAS, 165 with CEA, and 32 with TCAR). Overall, 486 patients (62.3%) were men, and 393 (50.4%) had left-sided carotid stenosis. Most patients (n = 617, 79.1%) had symptomatic disease. Among the three treatment groups, there were no statistically significant differences with respect to 30-day ischemic events (CAS 3.8%, CEA 1.8%, TCAR 6.3%; p = 0.267) or 30-day mortality rates (CAS 3.6%, CEA 2.4%, TCAR 3.1%; p = 0.857). Male sex had significantly lower odds of 30-day transient ischemic attack (TIA) or stroke in both univariable (p = 0.024) and multivariable (p = 0.023) regression models. Increasing age had significantly higher odds of 30-day mortality on univariable (p = 0.006) and multivariable (p = 0.003) regression. Patients with the occurrence of 30-day TIA or stroke also had significantly higher odds of 30-day mortality on univariable (p < 0.001) and multivariable (p < 0.001) regression. This real-world experience reflects the current practice of hybrid neurosurgery at two high-volume tertiary care centers and suggests that all three treatment modalities have comparable safety and effectiveness if patients are properly selected.

Assessment of carotid arteries in stroke patients by ultrasonography and color Doppler

Background: Prevalence and associated mortality and morbidity rates apprehend stroke as a major health concern worldwide. Atherosclerotic disease of carotid arteries is the most common source of stroke. Quick and effective diagnosis, management and treatment of stroke is essential. Conventional diagnostic imaging techniques lacks the efficacy to rapidly and accurately dragonize stroke. Current investigation is focused towards assessing carotid arteries in stroke patients by ultrasonography and color Doppler to study the locate and study the morphology of lesion in carotid artery and to grade severity and extent of stenosis.Methods: A prospective observational study was performed on stroke patients of more than 40 years of age. The study was conducted at the department of radio diagnosis in a tertiary care center for a period of 18 months. Varied color Doppler parameters were studied and optimized to assess the morphology and surface of plaques and to determine stenosisResults: Mean age of the patients with carotid lesion was observed to be 59.7±9.8 years and male patients outnumbered postmenopausal female patients. Hemiparesis was the most common clinical presentation. Majority of patients exhibited raised intimomedial thickness and single or multiple plaques commonly in carotid bulb. Plaques of type II with irregular surface were most commonly observed which exhibited mostly 50-69% stenosis.Conclusions: The carotid artery embolic occlusion stenosis is the primary cause of stroke. Doppler sonography provides a rapid, noninvasive, relatively inexpensive and accurate means of diagnosing carotid stenosis, to determine the degree of cervical carotid stenosis and plaque morphology.

The role of non-stenosing carotid artery plaques in embolic stroke of undetermined source, is it a silent offender? A review of literature.

Atherosclerotic cervical internal carotid artery disease is one of the major causes of ischemic stroke and transient ischemic attacks. The risk of stroke from mild to moderate stenoses (i.e. <50% stenosis) might be underestimated. There is increasing evidence that plaque morphological features reflect plaque instability that may harbor high risk for embolization. In this narrative review, we will review the literature on plaque features that predict vulnerability beyond the degree of stenosis, discuss the clinical association with stroke, and evaluate the evidence that these lesions serve as a source for embolic stroke of unknown source (ESUS). We performed a literature search using PubMed, EMBASE, and Web of Science. The terms "embolic stroke of undetermined source" and "plaque morphology" were used either alone or in combination with "non-flow limiting stenosis," "non-stenosing plaques," "high-risk plaque features" or "internal carotid artery plaque." Data on plaque morphology and ESUS were mainly taken from review articles, observational studies including retrospective cohort and cross-sectional studies, meta-analyses, and systematic reviews. Nonstenosing carotid artery plaques with high-risk features carry a remarkable risk for stroke occurrence and randomized clinical trials are warranted for further evaluation of using carotid artery stenting or carotid endarterectomy to mitigate the risk of stroke.

The role of carotid ultrasound in patients with non-lateralizing neurological complaints

ABSTRACT Objectives In the United States, approximately 18–25% of carotid duplex ultrasound (CUS) studies are ordered to assess patients with non-lateralizing neurological complaints such as syncope, blurry vision, lightheadedness, headache, and altered mental status. The purpose of this study is to evaluate the benefit of CUS in the evaluation of patients presenting with non-lateralizing signs or symptoms. Materials and Methods We conducted a retrospective analysis to assess the degree and laterality of carotid stenosis among patients with non-lateralizing neurological complaints who underwent CUS interpreted by certified vascular neurologists over a period of 3 years. The primary endpoint was to identify the prevalence of moderate-to-severe carotid artery stenosis among 280 patients who met inclusion criteria. Results A total of 17.7% of CUS studies were ordered for non-lateralizing symptoms. Two hundred and sixty-one patients (93.21%) had either normal imaging or mild carotid stenosis of <50%. Nineteen patients (6.79%) were found to have stenosis of ≥50%. In this subgroup, age and known preexisting carotid artery atherosclerotic disease were the only variables found to have a statistically significant association with the level of stenosis found on CUS. Two patients with asymptomatic stenosis of >70% underwent a revascularization procedure. Conclusion At least 17.7% of CUS studies were completed for non-lateralizing symptoms. The study is of low-yield with the prevalence of moderate-to-severe stenosis being comparable to that in the general asymptomatic population. We conclude that there is minimal clinical value in the use of CUS to investigate non-lateralizing neurological complaints, resulting in unnecessary healthcare costs.

Misery Perfusion and Tau Deposition in Atherosclerotic Major Cerebral Artery Disease: A 18F-Florzolotau Positron Emission Tomography Study.

Studies using animal models have shown that cerebral hypoperfusion causes hyperphosphorylation of tau protein, leading to neuronal damage. However, the relationship between hypoperfusion and tau deposition in humans is unclear. Hence, we aimed to determine whether cerebral hypoperfusion leading to decreased blood flow relative to metabolic demand [increased oxygen extraction fraction (OEF), misery perfusion] is associated with increased tau deposition in patients with atherosclerotic internal carotid artery or middle cerebral artery disease. We prospectively evaluated the distribution of tau aggregate deposition using positron emission tomography and 18F-florzolotau (PMPBB3 [1-fluoro-3-((2-((1E,3E)-4-(6-(methylamino)pyridine-3-yl)buta-1,3-dien-1-yl)benzo[d]thiazol-6-yl)oxy)propan-2-ol)]) in 8 patients with atherosclerotic disease of the internal carotid artery or middle cerebral artery. The standardized uptake value ratio of 18F-florzolotau at 100 to 110 minutes after injection was calculated using the cerebellar cortex as a reference region and was correlated with OEF obtained from 15O-gas positron emission tomography in the middle cerebral artery distributions. Significant decreases in cerebral blood flow and cerebral metabolic rate of oxygen and increases in OEF were found in the hemisphere ipsilateral to the arterial lesion. 18F-florzolotau standardized uptake value ratio in this region was also greater than that in the contralateral hemisphere. In the ipsilateral hemisphere, 18F-florzolotau standardized uptake value ratio positively correlated with OEF values. This pilot study with a small sample size suggests that increases in OEF-misery perfusion-may be associated with increased tau aggregates deposition in atherosclerotic internal carotid artery or middle cerebral artery disease.

Atherosclerotic Carotid Artery Disease: Where to from the emergency room? University hospital experience.

Stroke is the second leading cause of death worldwide, resulting in 5.5 million deaths in 2016. Vascular interventions, including carotid endarterectomy (CEA) and carotid artery stenting, play a major role in stroke prevention, especially when performed early after onset of symptoms. This study aimed to define the role of vascular surgeons in ischaemic stroke management and hence improve referral patterns by creating an algorithm for the referral process. This could reduce time to intervention and optimise patient benefit from intervention. This retrospective study reviewed symptomatic and asymptomatic patients with atherosclerotic disease of the carotid artery who were referred to the Vascular Surgery Unit of Sultan Qaboos University Hospital, Muscat, Oman, from April 2018 to March 2020 to examine factors influencing recognition of suitable candidates for intervention. Following analysis of the data, algorithms/protocols were created to simplify the referral process of symptomatic and asymptomatic carotid artery disease for surgical intervention. A total of 38 patients with ischaemic stroke were recognised as having carotid artery stenosis and were referred to the vascular surgery service during the study period. Only six met the criteria for CEA, four of which underwent the procedure. Choice of patients for CEA involves multiple steps, with potential for missed opportunities. By involving a multidisciplinary team approach, the recommended protocol aims to lead to early and appropriate referral to a vascular surgeon or an interventional radiologist, resulting in increased and optimised intervention in stroke prevention.

3D-Arterial analysis software and CEUS in the assessment of severity and vulnerability of carotid atherosclerotic plaque: a comparison with CTA and histopathology

PurposeOur purpose is to assess Multiparametric Ultrasound (MPUS) efficacy for evaluation of carotid plaque vulnerability and carotid stenosis degree in comparison with Computed Tomography angiography (CTA) and histology.Material and methods3D-Arterial Analysis is a 3D ultrasound software that automatically provides the degree of carotid stenosis and a colorimetric map of carotid plaque vulnerability.We enrolled 106 patients who were candidates for carotid endarterectomy. Prior to undergoing surgery, all carotid artery plaques were evaluated with Color-Doppler-US (CDUS), Contrast-Enhanced Ultrasound (CEUS), and 3D Arterial analysis (3DAA) US along with Computerized Tomographic Angiography (CTA) to assess the carotid artery stenosis degree. Post-surgery, the carotid specimens were fixed with 10% neutral buffered formalin solution, embedded in paraffin and used for light microscopic examination to assess plaque vulnerability morphological features.ResultsThe results of the CTA examinations revealed 91 patients with severe carotid stenoses with a resultant diagnostic accuracy of 82.3% for CDUS, 94.5% for CEUS, 98.4% for 3DAA, respectively. The histopathological examination showed 71 vulnerable plaques with diagnostic accuracy values of 85.8% for CDUS, 93.4% for CEUS, 90.3% for 3DAA, 92% for CTA, respectively.ConclusionsThe combination of CEUS and 3D Arterial Analysis may provide a powerful new clinical tool to identify and stratify “at-risk” patients with atherosclerotic carotid artery disease, identifying vulnerable plaques. These applications may also help in the postoperative assessment of treatment options to manage cardiovascular risks.

Comparison of primary suturing and dacron patch in carotid endarterectomy

Background: In carotid artery atherosclerotic disease; indications for intervention are accepted to be over 75% stenosis for asymptomatic patients and over 50% for symptomatic patients. Preferred surgical treatment is carotid endarterectomy. In this study, we compared clinical outcomes and ultrasonographic findings in two different surgical techniques of arteriotomy closure. First technique consisted of primary suturing and second is patch angioplasty with dacron patch. In 6 month follow up period clinical examinations and dupplex ultrasonography were performed and analysed statistically. &#x0D; Methods: 60 patients who underwent carotid endarterectomy for carotid artery disease between January 2017 and December 2020 were enrolled in the study. Data was obtained from hospital database and evaluated statistically. 30 arteriotomy incisions were closed primarily and 30 with dacron patch angioplasty. As surgical indication 50% stenosis in symptomatic patients and 70% stenosis in asymptomatic were determined. Postoperative complications were evaluated. After discharge one-week, two-month, six-month clinical examitanions were performed and in six-month follow up dupplex ultrasonography was performed by an independent radiology specialist, and these results were compared statistically. &#x0D; Results: When the patients were evaluated in terms of postoperative complications, clinical follow-up after discharge, and 6-month Doppler ultrasonography, no significant differences were detected.&#x0D; Conclusion: No statistically significant difference was found among techniques primary suturing and dacron patch angioplasty for stroke, occlusion and re-stenosis rates. According to short term results both techniques may be feasible for arteriotomy closure during carotid endarterectomy.