Carotid Angioplasty With Stenting Research Articles

Prediction of cerebral ischemia during carotid stenting depending on the intensity of the preoperative ultrasound signal from the plaque

Carotid stenting is an effective method for improving cerebral perfusion; risk assessment of cerebral embolism associated with this intervention remains a hot research topic. Objective: to identify predictors of cerebral embolism associated with carotid angioplasty with stenting (CAS). Material and methods. A prospective exploratory research included 46 patients (age from 44 to 81 years, median 65 years) with atherosclerotic stenosis of the internal carotid artery, who underwent CAS and were treated at the Scientific Center of Neurology (Moscow). The study did not include patients with restenosis, stroke with severe disability, contraindications for antiplatelet therapy, statins, and MRI examination. All patients underwent preoperative ultrasonographic (US) examination and postoperative histological examination of particles in carotid stent embolic protection devices. The state of the brain was assessed before and 24 hours after CAS using diffusion-weighted MRI. To identify predictors of the development of cerebral embolism, the clinical characteristics of patients, together with ultrasonographic and morphological data, were examined in a multivariate statistical analysis.Results. Preoperative US signal from an atherosclerotic plaque of high (estimated above 35 dB) intensity was associated with dense matter (in a protective device) of the "fibrosis with calcification" and "calcification" type and with a high probability (80%; 95% confidence interval 71–85% ) predicted intraoperative embolization of cerebral vessels with the acute ischemic lesions (AIL) formation. In a low (not higher than 35 dB) intensity of the preoperative ultrasound signal, the probability of AIL formation was statistically significantly lower (50%). Conclusion. There is a direct correlation between the intensity of the ultrasound signal and the density of the substance in the protective device. A high intensity of the preoperative ultrasound signal (estimated above 35 dB) is an unfavorable predictor of AIL, associated with CAS (with a probability of about 80%).

Carotid endarterectomy in Russia. What if current guidelines do not answer difficult questions?

This literature review covers the publications of Russian vascular surgeons in recent years and deals with debatable issues of carotid surgery, including: 1. What is the best technique for carotid endarterectomy (CEA)? 2. Why does restenosis of the internal carotid artery (ICA) develop and how to eliminate it? 3. How to operate on bilateral ICA stenosis? 4. Should carotid glomus be preserved? 5. Is CEA safe in the acute phase of cerebrovascular accident (CVA)? 6. Is CEA safe in elderly patients? 7. How to operate on patients with combined internal carotid and coronary artery involvement? The evidence presented in this publication makes it possible to draw the following conclusions: 1. When choosing a CEA technique, the classical technique with patch angioplasty should be avoided due to the high risk of ICA restenosis. 2. To eliminate ICA restenosis, carotid angioplasty with stenting (CAS) should be used. When performing primary CEA with ICA transposition over the hypoglossal nerve, reCEA can be used 3. In the absence of contraindications, bilateral ICA stenosis can be operated at the same time using CEA. 4. CEA with carotid glomus preservation is the operation of choice in the treatment of patients with hemodynamically significant ICA stenosis due to the elimination of the risks of postoperative hypertension and the formation of hemorrhagic transformation. 5. If there are indications for cerebral revascularization in the most acute period of stroke, CEA should be abandoned in favor of CAS. 6. In old age, CAS is the safest treatment strategy. 7. In the presence of a combined ICA and coronary involvement, the choice of treatment tactics should be carried out only by a multidisciplinary commission, taking into account the risk stratification of adverse cardiovascular events.

Carotid sinus syndrome in carotid angioplasty with stenting

Introduction. Significant progress has been made in primary stroke prevention, including through the widespread use of carotid angioplasty with stenting (CAS). At the same time, there is a growing number of publications reporting the development of carotid sinus syndrome (CSS) (haemodynamic instability) in the periope- rative period, as well as cerebral and cardiac complications and death, which requires in-depth study to improve the quality of medical care for patients with carotid artery stenosis.
 The aim of the study was to determine the frequency, risk factors, clinical features and outcomes of CSS in patients with carotid artery stenosis undergoing CAS.
 Materials and methods. The study included 120 patients with carotid artery disease, who underwent an elective surgical intervention consisting of transluminal balloon angioplasty. All patients underwent comprehensive clinical and laboratory tests and imaging studies.
 Results. CSS developed in 70% of cases (n = 84) of carotid artery stenosis, and was significantly more common in men than women (71.4% vs. 28.6%, respectively) (p 0.05). The median age of all patients with CSS was 68 (4491) years. Mixed form of CSS was significantly more common than the cardioinhibitory or vasodepressor forms (p 0.05). In more than half of all cases, symptoms developed during balloon dilatation or within an hour afterwards. The duration of CSS was 3040 hours. Contralateral carotid occlusion was detected in 12 (10%) patients, significantly (p 0.05) more often in patients with CSS (13%) compared to patients without CSS (2.8%).
 Conclusion. Regardless of stenosis severity or symptoms, CAS is accompanied by CSS in 2/3 of cases. The CSS is predominantly a mixed type and can be accompanied by loss of consciousness in rare cases. CSS appears both intraoperatively and in the early postoperative period, and its average duration is 1.5 days. A factor that may be associated with CSS development is contralateral carotid artery occlusion (p 0.05).

Comparative Results of Emergency Carotid Endarterectomy and Emergency Carotid Angioplasty With Stenting in the Acute Period of Ischemic Stroke. Multicenter Study Results

AIM OF STUDY Study of hospital results of emergency carotid endarterectomy (CEE) and carotid angioplasty with stenting (CAS) in the acute period of acute cerebrovascular accident (ACVA). MATERIAL AND METHODS From January 2008 to August 2020, the study included 615 patients with hemodynamically significant stenosis of the internal carotid arteries (ICA), operated on in the acute period of ischemic stroke (within 3 days from the onset of stroke). Depending on the type of revascularization implemented, all patients were divided into 2 groups: group 1 — CAS (n=312); 2nd group — CEE (n=357). Inclusion criteria were as follows: 1. Mild neurological disorders: NIHSS score 3–8; Modified Rankin Scale score 2 of less; Barthel Scale > 61; 2. Indications for CEE / CAS according to the current national recommendations; 3. Ischemic focus in the brain not more than 2.5 cm in diameter. Exclusion criteria: 1. Presence of con-traindications to CEE / CAS. Carotid angioplasty with stenting was performed according to the standard technique; in all cases, distal embolism protection systems were used. Carot-id endarterectomy was performed according to the classical and eversion techniques. When the retrograde pressure in the ICA was less than 60% of the systemic pressure, a temporary shunt (TS) was installed. In the postoperative period, all patients underwent multispiral computed tomography (MSCT) of the brain. In the absence of negative dynam-ics in the neurological status, MSCT was performed on the 7th day after the operation, if available, it was performed urgently. The checkpoints were the development of such unfa-vorable cardiovascular events as death, myocardial infarction (MI), stroke / transient is-chemic attack (TIA), “mute” stroke, “mute” hemorrhagic transformations, combined end-point (death + all strokes / TIA + MI). Strokes were mute if diagnosed according to MSCT, without symptoms. RESULTS In 69% of diabetic patients with anterior myocardial infarction and in 63% of patients with posterolateral MI 12 months after PCI, signs of LV inferiority were revealed in the form of an increase in the indices of end-diastolic and systolic volumes of the LV and low ejection fraction (≤45%). In patients without diabetes, these figures were 18% and 31%, respectively. High concentrations of NT-proBNP on the first day of myocardial infarction after PCI were of the greatest value in the diagnosis and prognosis of LV UR after 12 months. RESULTS When analyzing hospital complications, significant differences in the frequency of lethal outcome were not obtained (group 1: n=6 (1.92%); group 2: n=8 (2.24%); p=0.98; OR=0.85; 95% CI 0.29–2.49); MI (group 1: n=5 (1.6%); group 2: n=5 (1.4%); p=0.91; OR=1.14; 95% CI 0.32–3.99 ); ACVA (ischemic type) / TIA (group 1: n=5 (1.6%); group 2: n=6 (1.7%); p=0.82; OR=0.95; 95% CI 0.28–3.15), as well as “mute” ACVA (group 1: n=7 (2.2%); group 2: n=15 (4.2%); p=0.23; OR=0.52; 95% CI 0.21–1.3). However, the vast majority of hemorrhagic transformations (group 1: n=2 (0.64%); group 2: n=13 (3.6%); p=0.018; OR=0.17; 95% CI 0.03–0.76) and all “mute” hemorrhagic transformations (group 1: n=0; group 2: n=26 (7.3%); p=0.001; OR=0.02; 95% CI 0.001–0.33) were observed only in the CEE group, which was reflected in the maximum values of the combined end point: group 1: n=22 (7.05%); group 2: n=73 (20.4%); p<0.0001; OR=0.29; 95% CI 0.17–0.48). Thus, in the CEE group, every 5th patient had a complication. CONCLUSION Carotid angioplasty with stenting is the safest method of revascularization for patients in the acute period of ACVA. This is largely due to the reduction in the risk of reperfusion syndrome and the prevention of embolism due to the use of modern protection systems. Carotid endarterectomy can be performed with comparable efficiency only when a tempo-rary shunt is placed in the internal carotid arteries in the absence of unstable atheroscle-rotic plaque.

Urgent intervention of hemodynamically significant stenosis of the internal carotid artery in the acutest period of an ischaemic stroke

Aim. To assess the results of carotid angioplasty with stenting (CAS) performed in the first 3 h after the onset of ischaemic stroke (the most acute period of acute cerebrovascular accident).Methods. This retrospective study included 312 patients from January 2008 to August 2020 with hemodynamically significant stenosis of the internal carotid arteries (ICA) who underwent CAS within 3 h of stroke onset. After a patient was hospitalised in our emergency department, stroke development was assessed by a neurologist. The level of neurological deficit was determined according to the National Institutes of Health Stroke Scale (NIHSS), the modified Rankin scale, the Barthel scale and the Rivermead Mobility Index. Multispiral computed tomography (MSCT) of the brain was then performed. On condition of visualisation of the ischaemic focus, the patient was sent for screening colour duplex scanning of the brachiocephalic arteries (BCA), arteries of the lower extremities, aortic arch and heart. If hemodynamically significant stenosis in the ICA was visualised, the patient underwent MSCT angiography of the BCA. The degree of stenosis was determined using the North American Symptomatic Trial Collaborators (NASCET) classifications. The on-duty ultidisciplinary council determined the tactics of the patient's treatment. Decisions regarding surgical correction and the choice of revascularisation strategy (CAS or carotid endarterectomy) were made based on stratification of the risk of postoperative complications according to the EuroSCORE II scale and the severity of coronary lesions according to the SYNTAX Score (in the presence of a history of coronary angiography). The time between admission to the emergency department and admission to the operating room was 84.5 ± 9.3 minutes. The inclusion criteria were 1. mild neurological disorders from 3 to 8 points on the NIHSS scale, no more than 2 points on the Rankin modification scale and more than 61 points on the Barthel scale; 2. Indication for CAS according to the current national recommendations; 3. Ischaemic focus in the brain no more than 2.5 cm in diameter according to MSCT; 4. Absence of pronounced calcification of the ICA. The exclusion criteria were: 1. Contraindications for CAS; 2. The presence of thrombosis of the ICA requiring the introduction of fibrinolytics (Alteplase), thromboextraction and thromboaspiration.Results. In the hospital postoperative period, 6 (1.92%) patients had lethal outcomes, 5 (1.6%) had myocardial infarctions, 5 (1.6%) had nonfatal stroke, 7 (2.2%) had asymptomatic ‘silent’ stroke, 2 (0.64%) had haemorrhagic transformations and 1 (0.32%) had ICA thrombosis. The combined endpoint (death + stroke + myocardial infarction) was reached in 7.05% of patients (n = 22).Conclusion. CAS is a safe and effective method of brain revascularisation in the first hours after the onset of ischaemic stroke. Interventional correction of hemodynamically significant stenoses of the ICA had permissible levels of ‘stroke + mortality from stroke’ and lethal outcomes, which reached 3.84% and 1.92%, respectively. Urgent implementation of CAS allows a significant regression of neurological deficit which is stable throughout the entire postoperative period. Received 21 September 2020. Revised 1 October 2020. Accepted 10 October 2020. Funding: The study did not have sponsorship. Conflict of interest: Authors declare no conflict of interest. Author contributionsConception and design: R.A. Vinogradov, M.A. Chernyavsky, V.A. Porkhanov, E.Yu. Kachesov, G.G. KhubulavaData collection and analysis: V.V. Matusevich, K.P. Chernykh, A.B. ZakeryaevDrafting the article: A.N. KazantsevStatistical analysis: G.Sh. Bagdavadze, R.Yu. LeaderFinal approval of the version to be published: A.N. Kazantsev, R.A. Vinogradov, M.A. Chernyavsky, V.V. Matusevich, K.P. Chernykh, A.B. Zakeryaev, G.Sh. Bagdavadze, R.Yu. Leader, E.Yu. Kachesov, V.A. Porkhanov, G.G. Khubulava

Cognitive function dynamics in comorbid patients after angioreconstructive interventions

Angioreconstructive interventions are generally known to be of prophylactic value for cerebrovascular diseases (CVD). At the same time, their prognosis in comorbid patients, particularly in those with type 2 diabetes (T2D), have been insufficiently covered.Objective: to study the impact of T2D on cognitive functions after carotid angioplasty with stenting (CAS)Patients and methods. CAS was performed in 99 patients with chronic CVD. Group 1 consisted of 51 patients (median age, 64.5 years) without carbohydrate metabolism disorders. Group 2 included 48 patients (median age, 64 years) with T2D. Over time, all the patients underwent clinical, neurological, and neuropsychological examinations, general clinical and biochemical blood tests, duplex scanning of the brachiocephalic arteries, and magnetic resonance imaging (MRI) of the brain. Blood flow in the middle cerebral artery was monitored to assess the embolic and hemodynamic situation during a CAS procedure.Results and discussion. The baseline frequency of neurocognitive impairment was almost the same (75%) in both groups; however, the impairment was more obvious in patients with T2D. Re-examination in Group 1 patients immediately after intervention revealed slight positive cognitive changes, while the patients with T2D showed a decrease in the indicators of mental functions. The improved ability to abstract and increase the level of generalization of functions appeared in T2D patients only 2 months after intervention. Post-CAS MRI revealed ipsilateral acute ischemic foci (AIF) in the brain substance in 11 (22%) patients of Group 1 and in 24 (50%) with concomitant T2D. Comparison of neuroimaging data with cognitive function assessments for the entire group of the examinees established deterioration in the cognitive status in patients with new ischemic brain changes detected after intervention.Conclusion. CVD concurrent with T2D usually contributes to deterioration in the cognitive status. Angioreconstructive interventions, in particular CAS, are frequently accompanied by the identification of AIF (including «silent» ones) that can cause a transient deterioration in cognitive functions. When planning angioreconstructive interventions in patients with T2D, the question arises of predicting such risks and possible neuroprotective methods.

Symptomatic and silent cerebral ischemia (detected on MRI) in patients with type 2 diabetes mellitus after carotid revascularization procedures

Background: Type 2 diabetes mellitus (T2DM) is a significant independent risk factor for ischaemic stroke. Carotid revascularisation procedures are an effective method of primary and secondary stroke prevention. However, patients developed postoperative acute ischaemic lesions (AILs), which were identified via magnetic resonance imaging (MRI) of the brains. Most of the patients with these AILs lack clinically overt symptoms.
 Aims: To assess the risk of ischaemic brain damage in patients with T2DM in the setting of carotid angioplasty with stenting (CAS) or carotid endarterectomy (CAE).
 Materials and methods: This open prospective study comprised of 164 patients with carotid atherosclerosis, who have undergone either CAS or CAE. Patients with T2DM were included in Group 1: 38 patients and 28 patients with CAE. Group 2 included patients without T2DM: 62 patients with CAS and 36 patients with CAE. All patients underwent a thorough neurological examination and diffusion-weighted brain MRI. In patients with T2DM, plasma glucose levels and glycated haemoglobin (HbA1c) were determined and their relationships to brain damage were evaluated.
 Results: In CAS, there were no statistically significant differences in the AIL frequency in patients with and without T2DM. AILs were found in 15 patients with T2DM (39.8%) and 29 patients without T2DM (46.8%, р = 0.24); three patients without T2DM were diagnosed with stroke. Of the 28 patients with T2DM who underwent CAE, 13 had AIL (46.4%); three had stroke (10.7%). In patients without T2DM, AILs were less prevalent in seven cases (19.4%, р = 0.012) and appeared asymptomatic. Following CAS, the baseline HbA1c levels were higher in patients with T2DM who developed AILs compared to those who did not develop AIL, 7.8% 1.4% vs 7.1 1.1% (р = 0.0469). Negative impact of hyperglycaemia on the risk of cerebral ischaemia was observed in patients who underwent CAE, the baseline fasting plasma glucose level was 8.5 1.9 mmol/l vs 7.0 1.5 mmol/l in patients without AIL (р = 0.014). The baseline HbA1c levels in patients with and without AILs were 8.0% 1.7% and 6.9% 0.9% respectively (р = 0.023).
 Conclusions: Carotid revascularisation procedure for patients with carotid atherosclerosis may be associated with risk of stroke and asymptomatic acute cerebral ischaemic lesions, which are more prevalent in patients with T2DM. Also, increased HbA1c levels is a risk factor for AIL.

Symptomatic and silent cerebral ischemia (detected on MRI) in patients with type 2 diabetes mellitus after carotid revascularization procedures

Background : Type 2 diabetes mellitus (T2DM) is a significant independent risk factor for ischaemic stroke. Carotid revascularisation procedures are an effective method of primary and secondary stroke prevention. However, patients developed postoperative acute ischaemic lesions (AILs), which were identified via magnetic resonance imaging (MRI) of the brains. Most of the patients with these AILs lack clinically overt symptoms. Aims : To assess the risk of ischaemic brain damage in patients with T2DM in the setting of carotid angioplasty with stenting (CAS) or carotid endarterectomy (CAE). Materials and methods : This open prospective study comprised of 164 patients with carotid atherosclerosis, who have undergone either CAS or CAE. Patients with T2DM were included in Group 1: 38 patients and 28 patients with CAE. Group 2 included patients without T2DM: 62 patients with CAS and 36 patients with CAE. All patients underwent a thorough neurological examination and diffusion-weighted brain MRI. In patients with T2DM, plasma glucose levels and glycated haemoglobin (HbA1c) were determined and their relationships to brain damage were evaluated. Results : In CAS, there were no statistically significant differences in the AIL frequency in patients with and without T2DM. AILs were found in 15 patients with T2DM (39.8%) and 29 patients without T2DM (46.8%, р = 0.24); three patients without T2DM were diagnosed with stroke. Of the 28 patients with T2DM who underwent CAE, 13 had AIL (46.4%); three had stroke (10.7%). In patients without T2DM, AILs were less prevalent in seven cases (19.4%, р = 0.012) and appeared asymptomatic. Following CAS, the baseline HbA1c levels were higher in patients with T2DM who developed AILs compared to those who did not develop AIL, 7.8% ± 1.4% vs 7.1 ± 1.1% (р = 0.0469). Negative impact of hyperglycaemia on the risk of cerebral ischaemia was observed in patients who underwent CAE, the baseline fasting plasma glucose level was 8.5 ± 1.9 mmol/l vs 7.0 ± 1.5 mmol/l in patients without AIL (р = 0.014). The baseline HbA1c levels in patients with and without AILs were 8.0% ± 1.7% and 6.9% ± 0.9% respectively (р = 0.023). Conclusions : Carotid revascularisation procedure for patients with carotid atherosclerosis may be associated with risk of stroke and asymptomatic acute cerebral ischaemic lesions, which are more prevalent in patients with T2DM. Also, increased HbA1c levels is a risk factor for AIL.

The timing and surgical choice of surgical treatment for carotid stenosis after radiotherapy

Objective: To evaluate the safety and efficacy of carotid endarterectomy (CEA) and carotid angioplasty with stenting(CAS) for carotid artery stenosis after radiotherapy. Methods: The clinical data of 73 cases with carotid artery stenosis after radiotherapy from October 2007 to September 2017 were analyzed retrospectively. Among them, 36 cases underwent CEA and 37 cases underwent CAS. Results: No complications occurred during the perioperative period in both groups. During the follow-up period, transient cerebral ischemia occurred in 1 case in the CEA group. There was no in-stent restenosis or adverse events such as stroke or myocardial infarction. In the CAS group, transient cerebral ischemia occurred in 2 cases, postoperative restenosis occurred in 2 cases, and myocardial infarction occurred in 1 case. The restenosis rate and incidence of adverse events were lower in the CEA group. Conclusions: Both surgical methods are safe and effective in the treatment of carotid artery stenosis after radiotherapy. CEA surgery can be more beneficial to long-term outcome, and it is supposed to be the preferred surgical method.

Abstract WP123: Timing and Risk Factors for Restenosis Following Carotid Endarterectomy and Angioplasty With Stenting

Background: We sought to determine the incidence of restenosis following carotid endarterectomy (CEA) and carotid angioplasty with stenting (CAS), analyze temporal trends to identify an optimal follow-up schedule, and identify covariates associated with restenosis. Methods: Patients undergoing CEA or CAS at our institution between 2009 and 2016 were assessed retrospectively. Temporal trends in peak systolic velocity (PSV) were examined qualitatively. Restenosis was defined as an increase in PSV to >250 cm/s, or as >70% stenosis on CTA or catheter angiography. Rates of restenosis were calculated using the Kaplan-Meier method. Cox proportional hazards regression was used to evaluate for an association between selected covariates and time to restenosis. Results: We analyzed 204 CEA and 113 CAS cases, of which 85% had symptomatic disease. Cumulative restenosis rates were 9% at one year and 14% at four years (Figure 1). There was no difference between CEA and CAS procedures (hazard ratio 1.285, p=0.58). Interestingly, there was a trend toward higher risk of restenosis for left-sided procedures, which did not reach statistical significance (hazard ratio 2.401, p=.051). Restenosis was asymptomatic in 96% of occurrences. Univariate regression identified no covariates associated with restenosis at a threshold of p<0.05 . Conclusions: The restenosis rate was overall low after CEA and CAS, with the highest risk seen in the first year, and significantly reduced later on. Most restenoses were asymptomatic. We did not identify specific covariates associated with restenosis. Close follow-up with imaging is recommended during the first year after treatment. Due to relatively low incidence of delayed stenosis, follow-up beyond 1 year should be tailored based on individual risk factors.

Visual Aids for Improving Patient Decision Making in Severe Symptomatic Carotid Stenosis

Because of the large amount of information to process and the limited time of a clinical consult, choosing between carotid endarterectomy (CEA) and carotid angioplasty with stenting (CAS) can be confusing for patients with severe symptomatic internal carotid stenosis (ICA). We aim to develop a visual aid tool to help clinicians and patients in the decision-making process of selecting between CEA and CAS. Based on pooled analysis from randomized controlled trials including patients with symptomatic and severe ICA (SSICA), we generated visual plots comparing CEA with CAS for 3 prespecified postprocedural time points: (1) any stroke or death at 4 months, and (2) any stroke or death in the first 30 days and ipsilateral stroke thereafter at 5 years and (3) at 10 years. A total of 4574 participants (2393 assigned to CAS, and 2361 to CEA) were included in the analyses. For every 100 patients with SSICA, 6 would develop any stroke or death in the CEA group compared with 9 undergoing CAS at 4 months (hazard ratio [HR] 1.53; 95%CI 1.20-1.95). At 5 years, 7 patients in the CEA group would develop any periprocedural stroke or death and ipsilateral stroke thereafter versus 12 undergoing CAS (HR 1.72; 95%CI 1.24-2.39), compared with 10 patients in the CEA and 13 in the CAS groups at 10 years (HR 1.17; 95%CI 0.82-1.66). Visual aids presented in this study could potentially help patients with severe symptomatic internal carotid stenosis to better weigh the risks and benefits of CEA versus CAS as a function of time, allowing for the prioritization of personal preferences, and should be prospectively assessed.

Modern advances in endovascular and surgical interventions for patients with carotid artery disease

The article provides an overview of the latest achievements in the treatment of carotid artery disease. For a long time, carotid endarterectomy (CEA) was considered the best option in the treatment of patients with this pathology. However, with the advancement of technology and widespread use of endovascular therapies carotid angioplasty with stenting (CAS) comes to replace the CEA. The largest study comparing the results of CAS with the CEA, was the CREST trial (Carotid Revascularisation Endarterectomy Versus Stenting Trial), which did not show any significant differences in the primary composite endpoint (death, myocardial infarction and stroke in a period of 30 days after procedure) during 10 years of follow up (n=2502) between the stenting group (11.8%; 95% confidence interval - CI 9.1 to 14.8) and carotid endarterectomy group (9.9%; 95% CI, 7.9 to 12.2), (hazard ratio 1.10; 95% CI 0.83 to 1.44). However, there are still many unresolved issues. One of the most important is a high frequency of "small" strokes due to intraprocedural cerebral microembolization. It is hoped by solving these issues CAS will be considered the best option in the treatment of patients with carotid artery disease.

Assessing risk factors for major adverse cardiovascular and cerebrovascular events during the perioperative period of carotid angioplasty with stenting patients.

Carotid atherosclerotic stenosis is a risk factor for ischemic stroke. The rapid development of neuroimaging techniques had led to carotid angioplasty with stenting (CAS) becoming a useful, effective and minimally invasive method for the treatment of extracranial carotid artery stenosis. The aim of the present study was to identify independent risk factors to predict perioperative major adverse cerebral and cardiovascular events for CAS patients and establish a risk evaluation model. Consecutive patients treated with a standardized CAS procedure were enrolled in the present study. The patients included underwent independent neurological evaluation prior to and after the procedure and at 30 days. The rates of transient ischemic attack, stroke, myocardial infarction and mortality were recorded. A relative regression model was established to evaluate risk factors of perioperative major adverse cardiac and cerebrovascular events (MACCE). In total, 403 subjects treated with CAS were enrolled into the study at a baseline MACCE rate of 8.19%, whereas the overall stroke, myocardial infarction and mortality rate at 30 days was 3.97%. The multiple regression analysis revealed that certain factors significantly predicted the 30-day risk of treatment-related MACCE. These factors included age of ≥70 years, ulcerative plaque, severe carotid stenosis, bilateral carotid artery stenting and hemodynamic depression following CAS. The MACCE risk prediction model and risk score system were subsequently established. In conclusion, factors that significantly predicted the 30-day risk of MACCE of CAS included, age of ≥70 years, ulcerative plaque, severe carotid stenosis, bilateral carotid artery stenting and hemodynamic depression, with hemodynamic depression being a controllable factor. The established risk score system is therefore a potentially useful tool that can be employed in the prediction of MACCE after CAS.

Hyperperfusion and intracranial haemorrhage after carotid angioplasty with stenting – latest review

The number of endovascular procedures is constantly increasing. As far as the carotid artery is concerned, carotid angio-plasty with stenting (CAS) is an alternative to surgical treatment (carotid endarterectomy; CEA).Two major devastating complications can occur after both procedures – cerebral hyperperfusion syndrome (CHS) and intracranial haemorrhage (ICH). The incidence of CHS and ICH in CAS is fortunately low but overall morbidity and mortality remains high.This latest review re-evaluates the pathogenesis, clinical features, risk factors and diagnostic procedures as well as mana-gement of these two complications.

Interprocedural Comparison of Changes in Natural Flow Velocity Patterns in the Internal Carotid Artery Following CAS or CEA

Different flow velocities have been reported after carotid angioplasty with stenting (CAS) than after carotid endarterectomy (CEA). We compared blood flow velocities following CAS and CEA in the International Carotid Stenting Study (ICSS; ISRCTN25337470). In total, 254 patients (70% male; 129 CAS and 125 CEA) were included. Mean peak systolic velocities (PSVICA) were assessed at baseline, 30 days, 1 and 2 years. Following both treatments, restenosis ≥ 50% was defined as PSVmean >125 cm s(-1). CAS and CEA resulted in a similar reduction in PSVICA 1 month after treatment. Post-intervention analysis for each treatment separately revealed that PSVICA following CAS increased significantly during follow-up (30 days to 2 years; 22.4 cm s(-1); 95% confidence interval (CI), 14.3 to 30.5). On the contrary, PSVICA following CEA remained relatively stable during follow-up (4.7 cm s(-1); 95% CI, -6.5 to 15.9). When we analysed the increase in PSVICA between both treatments after 2 years of follow-up, no significant interprocedural difference was observed. The internal carotid artery/common carotid artery (ICA/CCA) PSV ratio increased after CAS but not after CEA: 1.2 vs. 1.1 (0.04, 95% CI; -0.16 to 0.25) at 30 days; 1.5 vs. 1.1 (0.39, 95% CI; 0.13 to 0.65) at 1 year; and 1.5 vs. 1.1 (0.36; 95% CI, 0.08 to 0.63) at 2 years. The rate of apparent ipsilateral ICA restenosis >50% was higher following CAS (hazard ratio 2.35; 95% CI, 1.35 to 4.09). Two years after carotid revascularisation, no significant interprocedural difference was observed in the increase of PSVICA between CAS and CEA. However, the ICA/CCA ratio increased more following CAS resulting in an apparent higher rate of restenosis following CAS.

The Impact of Female Gender on Outcome Following Carotid Revascularisation

Women at any age have a lower risk of stroke than men. However, because women on average live longer than men and the risk of stroke increases with advancing age, the burden of stroke is greater in women than in men.1 The recognition of sex differences has raised awareness of the burden of cardiovascular disease in women in the last decade, giving further rise to analyses on intervention-type-specific outcome differences between sexes.2 In terms of long-term stroke prevention by carotid endarterectomy (CEA), women do not gain equivalent clinical benefit with respect to men for both symptomatic3 and asymptomatic carotid stenosis.4 The lower magnitude of benefit in women is most probably due to a (slightly) higher procedural risk as compared with men,5 combined with the lower natural history risk of stroke in women. Bisdas et al. retrospectively assessed sex-differentiated inhospital outcomes following CAS (Carotid Angioplasty with Stenting) or CEA in mainly asymptomatic patients,6 based on discharge data from the New York state on an impressive nearly 70 000 hospitalisations for carotid intervention over a decade. Asymptomatic men and women showed comparable outcomes after both procedures. Procedural stroke rates were higher after CAS as compared to CEA in all sub-groups (but only significantly different in symptomatic women). There was a twofold increase in stroke/ mortality rate in symptomatic women undergoing CAS compared to those who had CEA, an observation confirmed by others.7 Of relevance, as stroke after CAS may occur for a relevant part in the days following revascularisation, the in-hospital analysis performed might significantly underestimate the event rate, especially in the CAS cohort. Of note, especially in the light of the ongoing CREST (Carotid Revascularisation Endarterectomy Versus Stenting Trial) controversy, myocardial infarction (MI) showed not to be a main driver of the composite ‘end’ point independent of presenting neurological status for both sexes. Asymptomatic womenweremore prone toMI after both revascularisations than men, a finding confirmed in randomised data.8 Unfortunately, no clear definition of MI other than a discharge ‘code 410’ in any position could be provided. Furthermore, and highly surprisingly, no dedicated The International Classification of Diseases, 9th Revision, Clinical Modification

Carotid artery stenting in patients with symptomatic carotid stenosis: A single-center series

Carotid angioplasty with stenting (CAS) in patients with carotid stenosis (CS) has become more restricted in France especially since the disclosure of such studies as EVA-3S and Stent-supported percutaneous angioplasty of the carotid artery versus endarterectomy (SPACE). This report is of a series of CS cases contraindicated for endarterectomy that underwent CAS at a French center of interventional neuroradiology. Fifty-five patients with symptomatic CS more than 60% consecutively submitted to CAS between September 2008 and February 2011. The primary endpoint was either death or stroke within 30 days of the procedure; a secondary goal was to identify any possible factors that might have influenced the success and outcome of the intervention. The overall periprocedural stroke/death rate at 30 days was 5.4% (three out of 55 patients), with three non-disabling strokes and no deaths. Twenty-seven patients (49.1%) were treated with a cerebral protection device (CPD). Stent placement was achieved in all cases. Open- and closed-cell stents were implanted in 40 (72.7%) and 15 procedures (27.3%), respectively. Neither the use of a CPD, the carotid stent cell design nor any anatomical or technical factors were associated with a lower risk of stroke or death within 30 days of CAS. CAS in symptomatic patients with CS contraindicated for endarterectomy in this selected French series proved feasible and safe, with acceptable levels of morbidity. Use of a CPD, type of stent (open- or closed-cell), and anatomical and technical factors had no influence on the success of the procedure or the outcome within 30 days of the operation.

Plasma thrombin-cleaved osteopontin elevation after carotid artery stenting in symptomatic ischemic stroke patients

Atherothrombosis is the primary pathophysiology that underlies ischemic cerebral infarction. Osteopontin (OPN) is produced in atherosclerotic lesions and is cleaved by activated thrombin. We hypothesized that the rupture or damage of an unstable atherosclerotic plaque increases plasma levels of thrombin-cleaved OPN (trOPN). This study included 90 patients who received carotid angioplasty with stenting (CAS), 23 patients with essential hypertension (EHT) and 10 patients who were treated with carotid endarterectomy (CEA). The CAS patient group included 36 patients that had pre- and post-operative blood tests, diffusion-weighted imaging (DWI) using cerebral MRIs and estimated thrombus debris within the protection device. Immunohistochemistry of CEA specimens revealed that trOPN was detected around intra-plaque vessels. The highest tertile of plasma trOPN levels in CAS patients was higher than trOPN levels in EHT patients. Post-operative trOPN levels were significantly higher in symptomatic compared with asymptomatic patients (P=0.003). New ipsilateral DWI-positive patients revealed higher post-operative trOPN levels (P=0.003) and a higher grade of thrombi (P<0.001) than DWI-negative patients. TrOPN may be a novel biomarker that reflects the atherothrombotic status in ischemic stroke.

Carotid Stenting at the Crossroads

STROKE IS A MAJOR CAUSE OF DEATH AND DISABILITY. Approximately 10% to 15% of ischemic strokes are attributable to atherosclerosis of the internal carotid arteries, and there is great interest in surgical and endovascular approaches to stroke prevention. Carotid artery surgery or endarterectomy (CEA) has been the traditional intervention, and carotid angioplasty with stenting (CAS) is the newer percutaneous procedure. Both procedures increase the short-term risk of death or stroke due to the intervention in exchange for a lower long-term risk of stroke. Therefore, the magnitude and balance of the risks and benefits for these procedures are crucial considerations. Patients with symptomatic disease (ie, those who have had a stroke or transient ischemic attack in the past 6-12 months in the distribution of a carotid artery with 50% stenosis) benefit from CEA, which reduces the absolute risk of stroke by 8% per year. Asymptomatic patients (those with carotid occlusive disease without neurological symptoms) have a more modest benefit from CEA (absolute stroke reduction of 0.8%-1% per year). Carotid artery surgery or endarterectomy is considered beneficial only if it can be performed with a 30-day risk of death or stroke of 6% or less among symptomatic patients and 3% or less among those who are asymptomatic. Carotid angioplasty with stenting was originally approved by the US Food and Drug Administration (FDA) in 2004 for patients who were at too high a risk for CEA because of comorbidity or anatomical factors. In October 2004, because of uncertainty about efficacy, Medicare restricted reimbursement for CAS to high-risk symptomatic patients enrolled in postapproval studies. In March 2005, Medicare expanded coverage to allow treatment of high-risk symptomatic patients with carotid stenosis greater than 70% outside of trials using FDAapproved stents and embolic protection devices. The Centers for Medicare & Medicaid Services (CMS) also covers CAS for symptomatic patients with 50% to 70% carotid stenosis and asymptomatic patients with greater than 80% carotid stenosis if the procedure is performed in a postapproval or randomized controlled trial (RCT). Since then, CAS use has increased substantially, with large geographic variations in utilization. The Carotid Revascularization Endarterectomy vs Stenting Trial (CREST) compared CAS with CEA for patients with symptomatic and asymptomatic carotid disease. However, debate persists regarding interpretation of the study findings; CAS was equivalent to CEA for the primary composite end point of periprocedural death, stroke, or myocardial infarction or subsequent ipsilateral stroke. Carotid angioplasty with stenting was associated with worse outcomes than CEA for the combined outcome of periprocedural death or stroke or subsequent stroke, the end point used in trials comparing CEA with medical therapy. In May 2011, based on the CREST results, the FDA expanded the indication for CAS to all patients with carotid disease, not just those at high surgical risk. Against this backdrop, the outcomes and use of CAS in real-world practice is of great importance. In this issue of JAMA, Nallamothu and colleagues examine the relationship between operator experience and 30-day mortality rates following CAS using national Medicare administrative data from 24 701 procedures performed by 2339 physicians between 2005 and 2007. The authors found that patients treated by lowest-volume operators ( 6 CAS procedures per year) had an increased odds of death compared with patients treated by high-volume operators ( 24 procedures per year). Low-volume operators were much less likely to use an embolic protection device, an intervention associated with improved outcomes. They also demonstrated a “learning curve” at the individual physician level among the 1792 “later adopters” who started performing CAS after the 2005 CMS cov-

The Role of Perfusion Computed Tomography in the Prediction of Cerebral Hyperperfusion Syndrome

BackgroundHyperperfusion syndrome (HPS) following carotid angioplasty with stenting (CAS) is associated with significant morbidity and mortality. At present, there are no reliable parameters to predict HPS. The aim of this study was to clarify whether perfusion computed tomography (CT) is a feasible and reliable tool in predicting HPS after CAS.Methodology/Principal FindingsWe performed a retrospective case-control study of 54 patients (11 HPS patients and 43 non-HPS) with unilateral severe stenosis of the carotid artery who underwent CAS. We compared the prevalence of vascular risk factors and perfusion CT parameters including regional cerebral blood volume (rCBV), regional cerebral blood flow (rCBF), and time to peak (TTP) within seven days prior to CAS. Demographic information, risk factors for atherosclerosis, and perfusion CT parameters were evaluated by multivariable logistic regression analysis. The rCBV index was calculated as [(ipsilateral rCBV - contralateral rCBV)/contralateral rCBV], and indices of rCBF and TTP were similarly calculated. We found that eleven patients had HPS, including five with intracranial hemorrhages (ICHs) of whom three died. After a comparison with non-HPS control subjects, independent predictors of HPS included the severity of ipsilateral carotid artery stenosis, 3-hour mean systolic blood pressure (3 h SBP) after CAS, pre-stenting rCBV index >0.15 and TTP index >0.22.Conclusions/SignificanceThe combination of severe ipsilateral carotid stenosis, 3 h SBP after CAS, rCBV index and TTP index provides a potential screening tool for predicting HPS in patients with unilateral carotid stenosis receiving CAS. In addition, adequate management of post-stenting blood pressure is the most important treatable factor in preventing HPS in these high risk patients.