Carotid Angioplasty And Stenting Research Articles

Assessment of Biomarker Profile in Patients Post Carotid Angioplasty and Stenting

Introduction. Cardiovascular diseases are predominantly caused by atherosclerosis as a multifactorial chronic condition. Alterations in the hematological system and the blood vessel wall are considered as highly significant for onset and development of cerebrovascular disorders associated with atherosclerosis. Biomarkers as measurable indicators are to verify abnormal activity.
 Objective: to assess atherogenesis biomarkers in patients after carotid angioplasty and stenting (CAS) as associated with development of cerebrovascular disease.
 Materials and methods. We evaluated 50 individuals (50% men, 50% women; average age 65.4 6.4 years) with established cerebrovascular disease associated with brain atherosclerosis. All of them had hemodynamically significant abnormalities in the internal carotid artery (ICA) with both symptomatic (stenosis 60% and more) and asymptomatic (stenosis 70% and more) stenoses confirmed by duplex scanning of the brachiocephalic arteries. All patients underwent CAS as indicated. Before and 1 year after the intervention, we performed clinical and neurological examinations, brain magnetic resonance imaging, and laboratory tests of atherogenesis biomarkers.
 Results. At baseline, all the individuals demonstrated a pro-atherogenic shift in the assessed indicators, predominantly markers of extracellular matrix degradation, inflammation and atherogenesis (including osteoprotegerin and chromogranin А). Additionally, we established a direct correlation between osteoprotegerin levels and the characteristics of mostly hyperechoic atherosclerotic plaques (r = 0.29; p 0.05). A year later, no signs of restenosis were shown in follow-up ultrasound assessment of stented arteries in any patient.
 In 1 year post CAS, we found significant changes in the levels of osteoprotegerin (decrease to 1.765 pg/mL [1.592; 1.937]; p 0.05) and chromogranin А (elevation to 31.3 g/L [13.9; 90.7]; p 0.05). Re-assessment demonstrated association between changes in the pattern of the nitrogen oxide system, which tends to improve (NO elevation to 38.23 mol/L [32.95; 43.51]; p 0.001), and atheroprotective shift in the morphology of atherosclerotic plaques and biomarker profile.
 Conclusion. Prospective, 1-year long observation for patients who underwent CAS for symptomatic/asymptomatic hemodynamically significant ICA stenoses revealed favourable atheroprotective shift in both ultrasound and hematological atherogenesis biomarker ratio. This shift contributed to the absence of cerebral atherosclerosis progression during the follow-up. The process may be mediated by chromogranin А and osteoprotegerin, and their further research is needed from perspective of atherogenesis.

Variation of Shear Stresses and Flow Dynamics in Stented Patient Specific Carotid Bifurcation Model using Numerical Investigation

The carotid artery is a clinically important site in the human circulatory system as the consequences of its disease results in adverse outcomes like ischemic strokes, or death for too prolonged ischemia. Understanding the hemodynamics of this artery and its bifurcation are important. A method of treating the stenosis of this artery is Carotid Angioplasty and Stenting (CAS). This procedure results in a heavily modified hemodynamics or state of flow. To understand and predict this flow field modification Computational Fluid Dynamics (CFD) is an important computational tool. Further, the presence of a stent would affect hemodynamics. The aim of this work is to study these effects in patient-specific cases. The reconstructed patient-specific models will form the basis of the construction of the post-stenting carotid bifurcation models. A transient analysis was carried out to estimate the time-varying parameters in the fluid domains over a cardiac cycle as well as to gauge time average values over a cardiac cycle. Results are obtained for hemodynamic parameters, like wall shear stress, velocity, pressure, vorticity, and helicity, in both the prepared stenosed and stented geometries. It is seen that the stenting procedure leads to the renewal of the CCA to ICA flow path. But simultaneously the region in which the stent is present becomes a region of low TAWSS and contains areas of high OSI. These areas of low TAWSS and high OSI within the stented portions of the carotid bifurcations are indications for regions of possible restenosis. Therefore, the investigation demonstrates the likely region for future plaque growth. Further, the effects of widening of the lumen are also noted in comparison to the pre-stent cases

The Three Most Discussed Questions in Carotid Artery Surgery. Review of Russian and Foreign Studies in the Last Five Years

This literature review analyzes Russian and foreign publications over the past five years on the three most discussed issues related to carotid artery surgery: 1.Which is more effective: eversion carotid endarterectomy or conventional carotid endarterectomy with patch closure? 2. Which is better: carotid endarterectomy (CEE) or carotid angioplasty and stenting (CAS)? 3. How soon after the development of ischemic stroke should cerebral revascularization be performed? The authors of the article came to the following conclusions: 1. According to the majority of large studies and meta-analyses, conventional CEE with patch closure is associated with a higher risk of internal carotid artery restenosis compared to eversion carotid endarterectomy. Single-center trials with small samples of patients do not find statistical differences between the outcomes of applying both surgical techniques. 2. Large multicenter randomized trials are required to address the effectiveness of CEA and CAS in symptomatic and asymptomatic patients. To date, there has been no consensus on this matter. 3. CEE and CAS can be equally effective and safe in the most acute and acute periods of ischemic stroke when performed in the presence of a mild neurological deficit and the ischemic brain lesion not exceeding 2.5 cm in diameter. Nevertheless, the choice of treatment strategy should be made strictly personalized by a multidisciplinary council based on the experience of the institution and current recommendations.

From surgical clamping to endovascular flow arrest/reversal: the concept behind the system.

Carotid artery lesions are frequently composed of friable, thrombotic, ulcerated and/or hemorrhagic materials which can embolize during surgical or endovascular interventions. The use of embolic protection devices (EPD) during carotid angioplasty and stenting (CAS) has been proven to be associated with a reduction of the embolic load. Many studies indicate that the clinical results of CAS are comparable with the best surgical series, when EPD are routinely applied. The proximal EPD work by interrupting or reversing the blood flow in the common carotid artery/internal carotid artery (CCA/ICA). Once established the endovascular flow arrest/reversal, these systems have the advantages of promoting a protected crossing of the lesion and blocking both macro-emboli and micro-emboli. Moreover, proximal neuroprotection implies no manipulation of the device in the distal ICA, neither during device deployment nor during device retrieval, and reduces the risk of arterial spasm, dissection, or intimal damage. The choice between transfemoral and transcervical proximal EPD should account for different factors: local availability, operator expertise, and patient characteristics including anatomical features precluding flow arrest/reversal (e.g., incomplete circle of Willis), femoral access (e.g., unfavorable aortic arch anatomy), or transcervical access (e.g., diseased CCA).

A novel integrated angioscope-laser system for atherosclerotic carotid artery occlusion: Feasibility and techniques.

IntroductionAtherosclerotic extracranial carotid artery stenosis accounts for about 20%–30% of all strokes, which is one of the leading causes of adult morbidity and mortality. Although carotid endarterectomy (CEA) is still the mainly operational manner for atherosclerotic carotid artery stenosis/occlusion (ACAS/ACAO), and carotid angioplasty and stenting (CAS) have been used as an alternative, both CEA and CAS have limitations of their own, such as extensive invasiveness and in-stent restenosis.MethodsIn this study we established a novel interventional system in vitro to take advantage of both CEA and CAS. Twenty consecutive carotid atherosclerotic plaques were harvested from the patients who underwent CEA. The plaques were randomized into two groups and inserted into the pruned and sutured descending aortas of the swine in vitro. The ZebraScope™ was modified with a protective device on its flexible tip, so that the plaque could be dissected from the wall of parent carotid artery and ablated completely without damage to the carotid artery. The holmium:YAG (Ho:YAG) and thulium fiber laser (TFL) generators were alternately used when needed.ResultsAll the carotid atherosclerotic plaques were completely ablated by Ho:YAG laser and/or TFL. The Ho:YAG laser was more effective for the atherosclerotic plaques with severe calcification, while the TFL was more suitable for those with moderate calcification. There were still some thermal injury spots on the inner wall of the parent carotid artery caused by the laser in the non-protected group B. In the protected group A, on the contrary, there was no even a thermal injury spot was found on the relevant location except for one sample. The difference of ablating duration was statistically significant between group A (36.5 ± 4.79 min) and group B (63.4 ± 6.55 min) (P < 0.01).ConclusionAccording to our knowledge, this is the first attempt to ablate carotid atherosclerotic plaques assisted by the ZebraScope™ in vitro. The protective and dissecting device on the tip of the angioscope makes it safe and visible when the ablation is performed to carotid atherosclerotic plaques. The Ho:YAG laser and TFL are effective and safe for ablating the plaque in vitro.

Early and mid-term outcomes of carotid angioplasty and stent placement in 579 patients.

Carotid angioplasty and stenting (CAS) could be considered for preventing stroke in patients with carotid artery stenosis. This study aimed to determine the incidence and the risk factors of the early and mid-term complications associated with CAS. This is a retrospective cohort study conducted at Shiraz University of Medical Sciences from March 2011 to March 2019. Patients at high risk and standard risk for carotid endarterectomy were included. The primary composite outcome was defined as stroke, myocardial infarction (MI), and death in the first 30days after CAS. All-cause mortality, vascular mortality, and stroke were investigated during mid-term follow-up. A total of 579 patients (618 CAS) were recruited (mean age: 71.52years). Overall, 394 (68.40%), 211 (36.63%), 179 (31.07%), and 96 (16.72%) patients had hypertension, dyslipidemia, diabetes mellitus, or were cigarette smokers, respectively. Primary composite outcomes were observed in 2.59% of patients (1.55% stroke, 0.69% MI, and 1.72% death). Atrial fibrillation was a predictor of primary composite outcome in multivariate logistic regression (p=.048). The presence of total occlusion in the contralateral carotid artery was significantly associated with the risk of stroke in univariate logistic regression (p=.041). The patients were followed for a period ranging from 1 to 83 months. The overall survival rate for all-cause mortality was 93.48% at 1year, 77.24% at 5years, and 52.92% at 8years. All-cause mortality was significantly higher among patients with symptomatic carotid stenosis (p=.014). CAS provides acceptable short-term and mid-term outcomes in a unique population of high- and standard-surgical-risk, symptomatic and asymptomatic, octogenarian, and nonoctogenarian patients.

Relationship between annular calcification of plaques in the carotid sinus and perioperative hemodynamic disorder in carotid angioplasty and stenting

Objective: To investigate the correlation between annular plaque calcification in the carotid sinus and perioperative hemodynamic disorder (HD) in carotid angioplasty and stenting (CAS). MethodsThe clinical data of 49 patients undergoing CAS due to narrowing of the carotid sinus were retrospectively analyzed. All patients had preoperative carotid computed tomography angiography (CTA) and were divided into HD and non-HD groups based on the occurrence of HD in the perioperative period of CAS. HD was defined as persistent bradycardia (heart rate < 60 beats per min) or persistent hypotension (systolic blood pressure < 90 mmHg) in the perioperative period and lasting for at least 1 h. The baseline data, including the degree of carotid artery stenosis, plaque length, plaque thickness, calcified plaque morphologies (i.e., plaque circumferential angle: < 90° defined as dotted calcification; 90°–180° defined as arcuate calcification; > 180° defined as annular calcification), contralateral carotid artery conditions, balloon diameter, and stent types, were compared between the two groups. Binary logistic regression was used to analyze the risk factors for the occurrence of HD. ResultsAmong the 49 patients undergoing CAS, 14 (28.57%) developed perioperative HD, and 35 did not. Annular calcification was more common in the patients in the HD group than in the non-HD group. No significant differences in the probabilities of dotted and arcuate calcifications were found between the two groups (p > 0.05). The duration of continuous dopamine consumption in the HD group was 9–71 h. The average hospital stay of the HD group (10.14 ± 4.17 days) was significantly longer than that of the non-HD group (6.57 ± 1.9 days; p < 0.001). Patients in the HD group had significantly more pronounced lumen stenosis (p = 0.033) and longer plaque length (p = 0.034) than those in the non-HD group. After adjusting for age and sex, multivariate regression analysis showed that the presence of annular plaque calcification was an independent predictor of HD (odds ratio: 7.68, 95% confidence interval: 1.46–40.37, p = 0.016). ConclusionsThe occurrence of annular plaque calcification in the carotid sinus was an independent risk factor for perioperative HD in CAS. Preoperative carotid CTA assists with the early identification of high-risk patients who may develop HD.

Thirty-Day Stroke and Mortality After Carotid Revascularization Among Octogenarians with Symptomatic Carotid Stenosis: Real-World Evidence from a National Surgical Quality Registry

The outcomes of carotid revascularization among octogenarians are not well studied. We present analyses of 30-day stroke and mortality of patients aged ≥80 years using real-world data from a national surgical quality registry. The National Surgical Quality Improvement Program targeted data set for carotid endarterectomy (CEA) and carotid angioplasty and stenting (CAS) was queried for patients aged ≥80 years undergoing CEA and CAS between 2012 and2019. A total of 122 and 3013 patients aged ≥80 years with symptomatic carotid stenosis undergoing CAS and CEA, respectively, were identified. Patients with CAS were more likely to be older than 90 years (P= 0.006) and have diabetes (P= 0.036), were more likely to have high-risk anatomy (P < 0.001), but had lower American Society of Anesthesiologists score (P < 0.001). An ipsilateral stroke had been experienced by 43.6% of patients with CAS and 44.7% of patients with CEA. The rate of 30-day composite outcome was 6.4% in the CAS group and 4.5% in the CEA group (P= 0.326). The f 30-day mortality was significantly higher for CAS (5.6% vs. 1.7%, P= 0.001); however, the difference between the cohorts was not significant (CAS, 2.4% vs. CEA, 3.4%, P= 0.555). On multivariable analysis, CEA was associated with significantly lower odds of mortality (odds ratio [OR], 0.32; P= 0.0145). Symptom presentation other than ipsilateral stroke was associated with significantly decreased odds of 30-day outcome (amaurosis fugax/transient monocular blindness, OR, 0.39, P= 0.004; transient ischemic attack, OR, 0.57, P= 0.003), whereas higher age had significantly increased odds (OR, 1.95; P= 0.0172). Real-world analyses from a surgical quality registry show that CEA may be associated with lower odds of mortality compared with CAS among octogenarians.

Angioplasty and Stenting for Carotid Artery Near-Occlusion

Carotid near-occlusion (CNO) is the type of severe atherosclerotic stenosis of the internal carotid artery (ICA) with or without collapse of the vessel distally to the narrow part. According to the North American Symptomatic Carotid Endarterectomy Trial (NASCET), severity of ICA stenosis highly correlates with the risk of stroke, except for cases of extremely critical stenosis &gt; 94%, where the risk is lower, and, according to recent guidelines, conservative treatment is preferable. This consideration is questionable due to the recent data about early stroke recurrence and worldwide practice. Rapid improvement of endovascular technique during the last decade makes carotid angioplasty and stenting (CAS) a feasible option for the treatment of patients with CNO and is widely reported in the literature. However, in uncertain circumstances, more scientific data are necessary to fulfill the gap in indications, terms and risks of CAS for CNO.&#x0D; The aim. To evaluate the results of the treatment of patients with CNO after CAS.&#x0D; Materials and methods. Three hundred and fifteen patients were surgically treated at Scientific-Practical Center of Endovascular Neuroradiology of the National Academy of Medical Sciences of Ukraine due to ICA stenosis between 2010 and 2020. Among them, 39 (12.4%) patients (11 woman / 28 men (age 57.9±2.1 years) had CNO and underwent CAS at our Center. Patient population, clinical and radiological investigations, procedure compli-cations were investigated. Procedure complications (stroke, hemodynamic depression [HD] and hyperperfusion syndrome [HPS]) were meticulously studied. All the patients had routine ultrasound and clinical check 30 days after the procedure.&#x0D; Results. All the patients with CNO were successfully stented with the improvement of the site of stenosis after CAS, with only minimal residual stenosis in cases of severe HD. We observed two procedural vascular accidents, first patient had transient ischemic attack (TIA) and one had stroke due to middle cerebral artery occlusion after stent placement and further urgent mechanical thrombectomy. The patient had no neurologic decline and was discharged home. We didn’t observe any cases of myocardial infarction (MI) or death in our series during the hospital stay. HD was seen in 13 (33.3%) patients, and mostly resolved after the procedure except for 3 casesthat required prolonged intensive care unit stay. HPS was diagnosed in 2 (5.1%) patients and also didn’t have anyneurologic consequences after supportive care. During 30 days of follow-up, one (2.6%) patient had TIA because of anti-platelets cessation and 1 (2.6%) patient had MI after 1 week since discharge. All control images revealedstents patency without the evidence of critical residual stenosis.&#x0D; Conclusions. CNO remains important diagnostic and therapeutic challenge. Recent data showed high risk ofrecurrent stroke in case of CNO on best medical therapy, especially at an early stage, but it remains a preferred option according to guidelines. Considering worldwide improvement of stroke rates after CAS in patients with symptomatic ICA stenosis, further studies are warranted to evaluate its risk-benefit in case of CNO, especially with full collapse. Our data shows that CAS with careful preoperative diagnosis and planning is an effective procedure for selected patients with CNO.

Effect of Reconstructive Procedures of the Extracranial Segment of the Carotid Arteries on Damage to the Blood-Brain Barrier.

Introduction: Endarterectomy and angioplasty of the internal carotid artery are surgical measures for the prevention of ischemic stroke. Perioperative complications are caused by concomitant embolism and reperfusion syndrome leading to damage of the blood–brain barrier. Methods: The study included 88 patients divided into two groups, depending on the surgical technique used: internal carotid artery endarterectomy (CEA), 66 patients, and percutaneous carotid angioplasty and stenting (CAS), 22 patients. Blood was drawn 24 h before surgery, as well as 8, 24, and 48 h post-surgery. The assessment of damage to the blood–brain barrier was based on the evaluation of the concentration of claudin-1 and occludin, aquaporin-4, the measurements of the activity of metalloproteinase-2 (MMP-2) and -9 (MMP-9), and the assessment of central nervous system damage, measured by changes in the blood S100β protein concentration. Results: A significant increase in the concentration of the blood–brain barrier damage markers and increased MMP-2 and MMP-9 activity were found in patient blood. The degree of damage to the blood–brain barrier was higher in the CEA group. Conclusions: The authors’ own research has indicated that revascularization of the internal carotid artery may lead to damage to the central nervous system secondary to damage to the blood–brain barrier.

Carotid Endarterectomy Is the Most Cost-effective Treatment Modality for Nonemergent Significant Carotid Artery Stenosis

Transcervical carotid artery revascularization (TCAR), transfemoral carotid angioplasty and stenting (CAS), and carotid endarterectomy (CEA) are modalities currently used to treat carotid artery stenosis. With increasing costs of new technology, we conducted a study to determine the most cost-effective treatment modality for carotid stenosis comparing Vascular Quality Initiative data for TCAR, CAS, and CEA outcomes and hospital cost data to determine the most cost-effective treatment modality in our hospital system.

Repeat Revascularization over 10 Years Following Carotid Endarterectomy or Carotid Stent Placement: An Analysis of Carotid Revascularization Endarterectomy Versus Stenting Trial

To identify rates of and factors associated with repeat revascularization in a large cohort of patients prospectively followed over 10 years in Carotid Revascularization Endarterectomy versus Stenting Trial. We compared the effect of carotid angioplasty and stenting (CAS) versus carotid endarterectomy (CEA) on risk of repeat revascularization after adjusting for age, sex, symptomatic status, and initial severity of stenosis (≥70% vs. <70%) using Cox proportional hazards analysis. We used Kaplan-Meier analysis to assess repeat revascularization-free survival for the overall cohort. Repeat revascularization was performed in 90 (3.9%, 95% confidence interval [CI] 3.1%-4.8%) of 2318 patients; 6 (6.7%, 95% CI 2.5%-14.0%) patients experienced the composite end point of any stroke, myocardial infarction, ordeath within 30 days after repeat revascularization. Therewas no difference in risk of repeat revascularization in patients who underwent CAS (compared with CEA) as theindex procedure (hazard ratio 0.92, 95% CI 0.69-1.23, P=0.5765). Patient's age (hazard ratio 1.01, 95% CI 1.01-1.02, P < 0.0001) was associated with performance of repeat revascularization. Mean ± SD repeat revascularization-free survival was 8.2 ± 0.1 years and 8.0 ± 0.1 years for CAS and CEA, respectively (log-rank test P= 0.0823). A low rate of repeat revascularization was seen without any significant difference among patients who underwent CEA or CAS over 10 years. The 6.7% rate of composite end point within 30 days after procedure highlights the need for standardizing the indications for repeat revascularization.

Long non-coding RNA cyclin-dependent kinase inhibitor 2B antisense ribonucleic acid 1 is associated with in-stent restenosis and promotes human carotid artery smooth muscle cell proliferation and migration by sponging miR-143-3p.

Carotid angioplasty and stenting (CAS) is an efficient therapeutic approach for carotid stenosis. However, in-stent restenosis (ISR) frequently occurs and seriously affects the therapeutic efficacy of CAS. Certain non-coding (nc)RNAs serve potential roles in ISR development and progression. Thus, the goals of the present study were to investigate novel biomarkers for ISR development and to further uncover the mechanisms underlying the progression of ISR. The expression of long ncRNA cyclin-dependent kinase inhibitor (CDKN)2B-antisense 1 (AS1) and microRNA (miR)-143-3p in patients with ISR and human carotid artery smooth muscle cells (hHCtASMCs) was analyzed using reverse transcription-quantitative PCR. A luciferase reporter assay was performed to examine the interaction between CDKN2B-AS1 and miR-143-3p. The effects of the CDKN2B/miR-143-3p axis on hHCtASMC proliferation and migration were assessed using Cell Counting Kit-8 and Transwell assays. The results indicated that serum CDKN2B-AS1 was increased and miR-143-3p was decreased in patients with ISR as compared with that in patients with no ISR (all P<0.001). CDKN2B-AS1 and miR-143-3p were identified as risk factors for ISR onset (all P<0.05) and knockdown of CDKN2B-AS1 in hHCtASMCs led to inhibited cell proliferation and migration. Furthermore, the luciferase reporter assay and expression analysis indicated that miR-143-3p is a target of CDKN2B-AS1 and may mediate the effects of CDKN2B-AS1 on hHCtASMC proliferation and migration. In conclusion, dysregulation of CDKN2B-AS1 and miR-143-3p may represent risk factors for the occurrence of ISR. The in vitro results suggested that the CDKN2B-AS1/miR-143-3p axis may regulate the proliferation and migration of hHCtASMCs, indicating its potential to be developed as a target for preventative measures and therapies for ISR.

Overestimation of carotid stenosis on CTA – Real world experience

BackgroundSymptomatic carotid stenosis is responsible for 10% of all strokes. Currently, CT angiography (CTA) is the main diagnostic tool for carotid stenosis. It is frequently the only diagnostic test preceding recommendations for carotid angioplasty and stenting (CAS) or carotid endarterectomy (CEA). However, the specificity of CTA, especially in patients with 50–70% stenosis, was previously reported to be relatively low. Most studies testing the diagnostic accuracy of CTA were published more than a decade ago. Therefore, we aimed to test the diagnostic accuracy of CTA, performed with current available technology, compared with digital subtraction angiography (DSA) in patients with carotid stenosis. This study aims to characterize patients who were candidates for CAS/CEA based on CTA, but may not require it based on DSA. MethodsConsecutive candidates for carotid interventions (CAS or CEA) following CTA were identified from prospectively maintained stroke center registries at two large academic centers. As part of our institutional practice all patients had a routine pre-procedural diagnostic DSA. In each patient, degree of carotid stenosis was compared between CTA and DSA. Patients with concordant degree of stenosis on DSA and CTA (true positive group) were compared to patients with a discordant degree of stenosis with less than 50% on DSA (false positive group). ResultsOut of 90 patients with significant stenosis on CTA, only 70 (78%) were found to have a significant stenosis on DSA. Severe plaque calcification was significantly more common in the false-positive group. In those patients whose CTA reported stenosis of ≥90%, we found a strong agreement between CTA and DSA (positive predictive value [PPV] – 0.9) for a significant stenosis (≥50%). Conversely, the correlation between CTA and DSA in patients with CTA reported 50–70% stenosis was poor (PPV – 0.29) (p < 0.001). ConclusionsOur results suggest that despite ongoing radiological progress, the specificity of CTA in accurately assessing carotid stenosis remains relatively low in patients with both moderate stenosis and heavily calcified plaques. Consequently, patients could possibly be referred for unnecessary CEA surgery and may become exposed to associated potential complications.

Carotid artery revascularization: endarterectomy versus endovascular therapy.

Carotid endarterectomy is considered the gold standard for primary and secondary stroke prevention in patients with asymptomatic and symptomatic carotid artery stenosis. The role of CEA has been defined by multiple randomized multicenter trials and CEA is the most studied surgical procedure. In recent years, with advances in endovascular techniques, carotid angioplasty, and stenting (CAS) has been proposed as an alternative to CEA especially in high-risk patients. In this article, we review some of the most important trials on the invasive treatment of carotid artery stenosis and summarized the most recent treatment recommendations based on current evidence. The data overwhelmingly supports revascularization of patients with symptomatic stenosis between 70-90%, with a clear preference for CEA over CAS to be done within 14 days of symptom onset is possible. However, CAS is an acceptable alternative to CEA in certain symptomatic patients such as those with severe medical comorbidities, high riding plaques, contralateral occlusion, restenosis after prior CEA, and radiation-induced stenosis. Treatment of asymptomatic patients remains controversial because of advanced of modern medical therapy and large trials are underway to define the role of invasive revascularization in these patients.

The management of carotid restenosis: a comprehensive review.

Carotid artery stenosis (CS) is a major medical problem affecting approximately 10% of the general population 80 years or older and causes stroke in approximately 10% of all ischemic events. In patients with symptomatic, moderate-to-severe CS, carotid endarterectomy (CEA) and carotid angioplasty and stenting (CAS), has been used to lower the risk of stroke. In primary CS, CEA was found to be superior to best medical therapy (BMT) according to 3 large randomized controlled trials (RCT). Following CEA and CAS, restenosis remains an unsolved problem involving a large number of patients as the current treatment recommendations are not as clear as those for primary stenosis. Several studies have evaluated the risk of restenosis, reporting an incidence ranging from 5% to 22% after CEA and an in-stent restenosis (ISR) rate ranging from 2.7% to 33%. Treatment and optimal management of this disease process, however, is a matter of ongoing debate, and, given the dearth of level 1evidence for the management of these conditions, the relevant guidelines lack clarity. Moreover, the incidence rates of stroke and complications in patients with carotid stenosis are derived from studies that did not use contemporary techniques and materials. Rapidly changing guidelines, updated techniques, and materials, and modern medical treatments make actual incidence rates barely comparable to previous ones. For these reasons, RCTs are critical for determining whether these patients should be treated with more aggressive treatments additional to BMT and identifying those patients indicated for surgical or endovascular treatments. This review summarizes the current evidence and controversies concerning the risks, causes, current treatment options, and prognoses in patients with restenosis after CEA or CAS.

Long-term imaging follow-up to evaluate restenosis in patients with carotid stenosis after angioplasty and stenting.

Stent patency after carotid angioplasty and stenting (CAS) correlates not only with stroke prevention but also with improvements in cognition and quality of life by positively influencing cerebral perfusion. The long-term outcomes of CAS after more than 5 years have still not been well described. This retrospective study was designed to evaluate the stent patency and significant restenosis (SR) after CAS with more than 5 years of follow-up. Between 2006 and 2012, 118 patients with carotid stenosis who underwent 131 CAS procedures with regular annual imaging follow-up for more than 5 years were enrolled. We evaluated their demographic characteristics and the risk factors related to stent restenosis. Patients with SR (restenosis ≥ 50%) were compared with those with no significant restenosis (NSR, patency or restenosis < 50%) to identify the restenosis predictors and restenosis-free survival. Of the 131 CAS procedures, 16.0% (21/131) had SR. A history of head and neck radiotherapy (HNRT) was a predictor for SR (HR, 6.352; 95% CI, 2.504-16.112; p < 0.001) and was associated with shorter restenosis-free survival (log-rank test p value < 0.001, median time of restenosis-free survival was 38 months). Left-sided stenting was an associated factor for SR (HR, 3.007; 95% CI, 1.068-8.467; p = 0.037) with a trend of less restenosis-free survival (log-rank test p value 0.067). Both HNRT and left-sided carotid stenosis were predictors of SR after CAS in more than 5 years of long-term follow-up. Restenosis-free survival was significantly shorter in patients with prior HNRT than in patients without previous irradiation treatment. We suggest close follow-up and aggressive medical treatment for patients with prior HNRT and left-sided carotid stenosis undergoing CAS.

Clinical outcomes of radiation-induced carotid stenosis: A systematic review and meta-analysis

ObjectivesClinical outcomes of radiation-induced carotid stenosis are still unclear. Therefore, a systematic review and meta-analysis is needed to evaluate the short- and long-term outcomes after interventions to treat radiation-induced carotid stenosis. MethodsPubMed, EMBASE, the Cochrane Library and Web of Science were searched from 1 January 2000 for relevant RCTs and observational studies which reported outcomes after carotid endarterectomy (CEA) and carotid angioplasty and stenting (CAS) for carotid stenosis induced by radiation. Risk of bias were assessed through different scales according to study design. I2 statistic were used to evaluate the heterogeneity, and meta-regression were performed to investigate the source of heterogeneity. Visual inspection of funnel plots was used to judge publication bias. ResultsA total of 26 studies with 1002 patients were included. CEA was performed in 364 patients and CAS in 638 patients. The overall estimated rate of short-term stroke was 0.19% (95% CI: 0–0.90%), and the rate of long-term stroke was 2.68 % (95% CI: 1.19–4.57%). The rate of cranial nerve injury in CEA group was significantly higher than that in CAS group [risk ratio (RR): 6.03, 95% CI: 1.63–22.22, P = .007]. The univariate regression analysis showed that the risk of stroke in CAS group were significantly higher than CEA group in both short- and long-term [incidence rate ratio (IRR): 3.62, 95% CI: 1.21–10.85, P = 0.22; IRR: 2.95, 95% CI: 1.02–8.59, P = .046, respectively]. ConclusionsThis systematic review provided the worldwide profile of outcome of treatment for radiation-induced carotid stenosis, and also found that CEA can yield better results for these patients than CAS. Nonetheless, as large-scale studies have not yet been conducted, and there is a definite need for further studies in the future.

Hemodynamic events during carotid stenting are associated with significant periprocedural stroke and adverse events

BackgroundThere are limited data on the impact of carotid angioplasty and stenting (CAS)-related changes in blood pressure, heart rate, and preprocedural medications on periprocedural stroke in contemporary, real-world practice. This study evaluates the risk attributable to the CAS-related hemodynamic events and the impact preprocedural medications have on mitigating this risk in a large, population-based cohort. MethodsWe studied all patients in the Vascular Quality Initiative who underwent CAS between January 2006 and December 2016. Kaplan-Meier, multivariable logistic, and Cox regression analyses were used to evaluate the impact of periprocedural hypertension, hypotension, bradycardia, and medication use on immediate periprocedural stroke (IPPS), 30-day, and 1-year stroke. ResultsOf the 13,698 CAS procedures studied, 1239 (9.1%), 1824 (13.3%), and 1333 (9.7%) patients experienced periprocedural hypertension, hypotension, and bradycardia, respectively. IPPS was 3.2% vs 2.1% vs 0.65% (P < .001), comparing patients with periprocedural hypertension vs hypotension vs normotension and 1.4 vs 1.0% (P = .19) for bradycardic vs nonbradycardic patients. Periprocedural hypertension was associated with a four-fold increase in IPPS (adjusted odd ratio [aOR], 3.97; 95% confidence interval [CI], 2.63-5.99; P < .001). periprocedural hypotension and bradycardia were associated with 5.5-fold (aOR, 5.56; 95% CI, 3.24-9.52; P < .001) and 2.3-fold (aOR, 2.31; 95% CI, 1.26-4.25; P = .007) increases in IPPS among patients with carotid symptoms. There was 76% decrease in IPPS for patients who did not experience a periprocedural hemodynamic event (aOR, 0.24; 95% CI, 0.16-0.35; P < .001). Unlike preprocedural beta-blockers and angiotensin-converting enzyme inhibitors, prophylactic antibradyarrhythmic agents conferred a 58% reduction in IPPS among patients with carotid symptoms (aOR, 0.42; 95% CI, 0.23-0.78; P = .006). The periprocedural hemodynamic events were also associated with 7.7-fold increase in myocardial infarction (aOR, 7.70; 95% CI, 4.77-12.45; P < .001), a 2.2-fold increase in 30-day mortality (aOR, 2.24; 95% CI, 1.61-3.12; P < .001), and a 16% increase in length of stay (aOR, 1.16; 95% CI, 0.04-2.28; P = .042). The occurrence of these hemodynamic events is higher in patients with prior cardiac disease and the difference in periprocedural outcomes extended to 1 year. ConclusionsPeriprocedural hemodynamic events are associated with an increase in periprocedural stroke, myocardial infarction, death, and length of stay. Periprocedural hypertension in all patients; hypotension and bradycardia in patients with symptomatic carotid disease are associated with significant increase in IPPS. Prophylactic antibradyarrhythmic agents are associated with decrease in bradycardia and IPPS. These results heighten the need to anticipate and promptly address these CAS-related hemodynamic events, especially in susceptible patients.

Optical Coherence Tomography Angiography Evaluation of Retinal Microvasculature Before and After Carotid Angioplasty and Stenting

The aim of the study was to evaluate the influence of carotid angioplasty and stenting (CAS) on retinal microvasculature using optical coherence tomography angiography (OCTA) in patients with severe carotid stenosis. 20 patients with severe carotid stenosis underwent comprehensive ophthalmic examinations and OCTA before and one month after CAS. Automated algorithms were used to quantify vessel density in the macular superficial vascular complex (SVC), deep vascular complex (DVC), and radial peripapillary capillary (RPC) around the optic disc. Eyes on the operated side constituted the ipsilateral eye group, and the other eye constituted the fellow eye group. In the ipsilateral eye group, the vessel density in the DVC increased significantly after stent implantation (P = 0.010), but the vessel density change in the SVC was not statistically different (P = 0.999). In the fellow eye group, the vessel density in the SVC (P = 0.028) and DVC (P = 0.034) were significantly increased after stent implantation. The vessel density in the RPC did not significantly change in the ipsilateral (P = 0.363) or fellow (P = 0.878) eye groups. This study shows that unilateral CAS for severe carotid stenosis increases macular vessel densities in both eyes.