Carotid Artery Occlusive Disease Research Articles

Avoiding Complications with Transcarotid Artery Revascularization

Transcarotid artery revascularization (TCAR) for carotid artery stenting offers an innovative method for treating carotid artery occlusive disease. This technique utilizes the ENROUTE Transcarotid Neuroprotection System (Silk Road Medical, Sunnyvale, CA) to temporarily reverse flow in the carotid artery prior to crossing or treating the carotid lesion, reducing the perioperative risk of stroke. Herein we summarize the available literature regarding potential complications that may be encountered when performing TCAR. We also report our group's real-world outcomes of 273 patients undergoing TCAR with median (interquartile range) follow up of 17.4 (4.4 - 38.7) months, including safety and restenosis data.

Transcarotid artery revascularization outperforms transfemoral carotid artery stenting regardless of aortic arch type or degree of atherosclerosis

ObjectiveThe Centers for Medicare and Medicaid Services now approve reimbursement for transfemoral carotid artery stenting (TFCAS) in the treatment of standard-risk patients with carotid artery occlusive disease. TFCAS in patients with complex aortic arch anatomy is known to be challenging with worse outcomes. Transcarotid artery revascularization (TCAR) could be a preferable alternative in these patients owing to avoiding the aortic arch and using flow reversal during stent deployment. We aim to compare the outcomes of TCAR vs TFCAS across all aortic arch types and degrees of arch atherosclerosis. MethodsAll patients undergoing carotid artery stenting between September 2016 and October 2023 were identified in the Vascular Quality Initiative database. Patients were stratified into four groups: Group A (mild atherosclerosis and type I/II arch), Group B (mild atherosclerosis and type III arch), Group C (moderate/severe atherosclerosis and type I/II arch), and Group D (moderate/severe atherosclerosis and type III arch). The primary outcome was in-hospital composite stroke or death. Analysis of variance and χ2 tests analyzed differences for baseline characteristics. Logistic regression models were adjusted for potential confounders, and backward stepwise selection was implemented to identify significant variables for inclusion in the final models. Kaplan-Meier survival estimates, log rank test, and multivariable Cox regression models analyzed hazard ratios for 1-year mortality. ResultsA total of 20,114 patients were included (Group A: 12,980 [64.53%]; Group B: 1175 [5.84%]; Group C: 5124 [25.47%]; and Group D: 835 [4.15%]). TCAR was more commonly performed across the four groups (72.21%, 67.06%, 74.94%, and 69.22%; P < .001). Compared with patients with mild arch atherosclerosis, patients with advanced arch atherosclerosis in Group C and Group D were more likely to be female, hypertensive, smokers, and have chronic kidney disease. Patients with type III arch in Group B and Group D were more likely to present with stroke preoperatively. On multivariable analysis, TCAR had less than one-half the risk of stroke/death and 1-year mortality compared with TFCAS in the patients with the mildest atherosclerosis and simple arch anatomy (Group A) (odds ratio [OR], 0.43; 95% confidence interval [CI], 0.31-0.61; P < .001; hazard ratio, 0.42; 95% CI, 0.32-0.57; P < .001). Group B patients with similar atherosclerosis but more complex arch anatomy had 70% lower odds of stroke/death with TCAR compared with TFCAS (OR, 0.30; 95% CI, 0.12-0.75; P = .01). Similar findings were also evident in patients with more severe atherosclerosis and simple arch anatomy (OR, 0.66; 95% CI, 0.44-0.97; P = .037). There was no significant difference in odds of stroke/death in patients with advanced arch atherosclerosis and complex arch (Group D) (OR, 0.91; 95% CI, 0.39-2.16; P = .834). ConclusionsTCAR is safer than TFCAS in patients with simple and advanced arch anatomy. This could be related to the efficiency of flow reversal vs distal embolic protection. The current Centers for Medicare and Medicaid Services decision will likely increase stroke and death outcomes of carotid stenting nationally if multidisciplinary approach and appropriate patient selection are not implemented.

Reversible sulcal fluid-attenuated inversion recovery hyperintensity after combined bypass surgery for moyamoya disease - A "crevasse" sign.

Transient fluid-attenuated inversion recovery (FLAIR) hyperintensity is often observed on the operated brain surface after direct or combined bypass surgery for moyamoya disease, but its pathophysiology and clinical significance are still obscure. This study was aimed to clarify the underlying mechanism and clinical significance. This prospective study included 106 hemispheres of 61 patients with moyamoya disease and analyzed their radiological findings before and after combined bypass surgery. This study also included 11 patients who underwent superficial temporal artery to middle cerebral artery anastomosis for occlusive carotid artery diseases as the controls. Magnetic resonance imaging examination was serially repeated, and cerebral blood flow was measured before and after surgery. Signal intensity ratio (SIR) in the cortical sulci and cortex to the adjacent white matter on FLAIR images was calculated, and the postoperative SIR changes were semi-quantitatively evaluated to assess the temporal profile of postoperative FLAIR hyperintensity. Postoperative FLAIR hyperintensity occurred within the cortical sulci on the operated hemispheres in all moyamoya patients but not in patients with occlusive carotid artery diseases. SIR values started to increase immediately after surgery, peaked at about 4-fold at 4-13 days post-surgery, then declined, and recovered to baseline values over 28 days or later. The magnitude of this phenomenon was proportional to the severity of cerebral ischemia but not to postoperative hyperperfusion. Reversible sulcal FLAIR hyperintensity specifically occurs in the operated hemispheres after direct bypass surgery for moyamoya disease. This "crevasse sign" may represent the mixture of the extensive leakage of oxygen and proteins from the pial arteries into the CSF.

Ocular ischemic syndrome – case report and literature analysis

Abstract Introduction Ocular ischemic syndrome (OIS) is a rare condition associated with ocular hypoperfusion caused by carotid artery occlusive disease. This article describes the case of a patient who was admitted to the Department of Ophthalmology at UCK in Katowice, Poland, due to significant loss of visual acuity and pain in the right eye. Materials and Methods Retrosopective case report. Results Patient showed up in the ophthalmological emergency department complaining of significant loss of visual acuity and pain in the right eye persisting for 2 weeks. The patient had a history of type II diabetes mellitus, hypertension, status post ACS and PCI, and long-term nicotinism. Examination of the right eye revealed ocular irritation, mixed conjunctival injection, hyphema in the anterior chamber, iris neovascularization, and discrete central retinal fading. Additional examinations were performed, including an angioCT, which showed a long-standing obstruction of the right internal carotid artery, a ballooning thrombus in the lumen of the brachiocephalic trunk, and suspected critical stenosis of the left vertebral artery. A neurologist and vascular surgeon were consulted, and treatment was instituted to limit further complications from the underlying disease. The patient remains under close supervision of the vascular surgeon and neurologist. Conslusions OIS is a rare but potentially blinding condition and should be considered in the differential diagnosis of transient visual acuity reduction or vision loss.

Effects of superficial temporal artery to middle cerebral artery (STA-MCA) anastomosis on the cerebrospinal fluid gas tensions and pH in hemodynamically compromised patients.

This study was aimed to directly measure cerebrospinal fluid (CSF) gas tensions and pH before and after STA-MCA anastomosis for occlusive carotid artery diseases to investigate its direct effects on the ischemic brain. This study included 9 patients who underwent STA-MCA anastomosis on the basis of CBF studies. About 1mL of CSF was collected before and after bypass procedures, and CSF pH, CSF PO2, and CSF PCO2 were measured with a blood gas analyzer. As the controls, the CSF was collected from 6 patients during surgery for unruptured cerebral aneurysm. CSF PO2 and CSF PCO2 were expressed as the ratio to PaO2 and PaCO2, respectively. Before bypass procedure, CSF PO2/PaO2 was 0.88 ± 0.16, being lower than the controls (1.10 ± 0.09; P = 0.005). CSF PCO2/PaCO2 was 0.93 ± 0.13, being higher than the controls (0.84 ± 0.06; P = 0.039). Ipsilateral-to-contralateral CBF ratio had a positive correlation with CSF PO2/PaO2 (P = 0.0028) but a negative correlation with the CSF PCO2/PaCO2 (P = 0.0045). STA-MCA anastomosis increased CSF pH from 7.402 ± 0.133 to 7.504 ± 0.126 (P = 0.0011) and CSF PO2/PaO2 from 0.88 ± 0.16 to 1.05 ± 0.26 (P = 0.018) but decreased CSF PCO2/PaCO2 from 0.93 ± 0.13 to 0.70 ± 0.17 (P = 0.0006). The severity of cerebral ischemia before surgery is intensely reflected in the gas tensions and pH of the CSF. STA-MCA anastomosis carries dramatic effects on CSF gas tensions and pH in hemodynamically compromised patients. CSF would be a valuable surrogate biomarker to monitor the severity of cerebral ischemia.

Lesion patterns and mechanism analysis of acute contralateral ischemic stroke accompanyingstenosis of unilateral extracranial internal carotid artery.

Previous studies on unilateral internal carotid artery occlusive disease have focused on the mechanisms of ipsilateral hemispheric stroke, and contralateral stroke is considered to be an accidental phenomenon. Little is known about the relationship between severe stenosis (including occlusion) of the unilateral extracranial segment of the internal carotid artery and contralateral cerebral stroke, and the infarct patterns and pathogenesis require further study. The purpose of this study was to investigate the clinical characteristics and pathogenesis of contralateral acute stroke with unilateral extracranial internal carotid artery stenosis (including occlusion). Thirty-four patients were enrolled in this study, and all patients underwent routine clinical evaluation, including medical history, physical examination, laboratory tests, and various imaging evaluations. The morphological characteristics of diffusion-weighted magnetic resonance imaging were applied to determine infarct patterns. The etiological classification was confirmed according to the TOAST classification. There were six distinctive lesion patterns: small subcortical infarcts (six patients), large subcortical infarcts (one patient), diffuse infarcts (eight patients), multiple anterior circulation infarcts (eight patients), multiple posterior circulation infarcts (two patients), and multiple anterior and posterior circulation infarcts (nine patients). Diffuse and multiple infarcts were the most common topographic patterns in ischemic stroke contralateral to internal carotid artery stenosis or occlusion. Hemodynamic impairment of the contralateral hemisphere due to hypoperfusion and blood theft is regarded as the basis of stroke occurrence. Low ischemic tolerance and embolism are the maincauses of acuteischemicstroke.

Hemodynamic instability in the immediate postoperative setting after transcarotid artery revascularization.

Transcarotid artery revascularization (TCAR) is a relatively recent development in the management of carotid artery occlusive disease, the utilization of which is becoming more prevalent. This study aims to evaluate the timing, prevalence, and types of hemodynamic instability after TCAR. We performed a retrospective review of all TCAR procedures performed at two tertiary care academic medical centers within a single hospital system from 2017 through 2019. Demographics, comorbidities, preoperative patient factors, procedural details, and postoperative data were collected. Patients were assessed over 24hours postoperatively for stroke, death, myocardial infarction (MI), and hemodynamic instability at 3, 6, 9, 12, and 24hour intervals. Hemodynamic instability was defined as any vital sign abnormality which required pharmacological intervention with antihypertensive, vasopressor, and/or anti-arrhythmic agents. The incidence and timing of postoperative complications and hemodynamic instability were recorded. During the study period, 76 patients 80 TCAR procedures. Out of 80 procedures, 64 (80.0%) were receiving home antihypertensive medication and 28 (35.0%) were symptomatic lesions preoperatively. Intraoperatively, one patient (1.3%) received atropine, 26 (32.5%) received glycopyrrolate, 76 (95%) underwent predilatation, and 16 (20.0%) underwent postdilatation. Postoperatively, a total of 22 cases (27.5%) required medication for acute control of blood pressure or heart rate, which reached a peak of 19 patients (23.8%) within the first 3hours, and tapered to nine patients (11.3%) by the 24hour mark. A total of three patients (3.75%) required initiation of pharmacological management after the three-hour mark. Six patients (7.5%) underwent stroke code workup, 4 (5.0%) of whom were confirmed to have stroke on CT. Average time to neurologic event was 3.9hours. No patients experienced MI or death. Median ICU and hospital days for unstable patients were two and three, respectively, compared to one and one for stable patients. Hemodynamic instability is common after TCAR and reliably presents at or before postoperative hour 3. Hypo- followed by hyper-tension were the most common manifestations of hemodynamic instability. Regardless, unstable patients and stroke patients were more likely to require longer periods of time in the ICU and in the hospital overall. This may have implications for postoperative ICU resource management when deciding to transfer patients out of a monitored setting. Further study is required to establish relationships between pre- and intra-operative risk factors and outcomes such as hemodynamic instability and/or stroke. At present, one should proceed with careful evaluation of preoperative medications, strict management of postoperative hemodynamics, and clear communication among team members should all be employed to optimize outcomes.

Retinal Claudication: A Rare Case of Light-Induced Amaurosis Fugax Secondary to Occlusive Carotid Artery Disease. (P2-10.010)

Retinal Claudication: A Rare Case of Light-Induced Amaurosis Fugax Secondary to Occlusive Carotid Artery Disease. (P2-10.010)

Abstract 290: Ccr2 Expression Is Increased In Patients With Symptomatic Carotid Arterial Occlusive Disease

Objectives: Chemokines and their receptors play critical roles in the progression of atherosclerosis. The chemokine receptor, C-C chemokine receptor type 2 (CCR2), mediates an essential role in the differentiation of pro-inflammatory monocytes into macrophages. Recent studies suggest that proinflamatory macrophages in plaques predict plaque progression. While there is no clinical consensus on which patient with asymptomatic carotid artery stenosis would benefit from carotid endarterectomy (CEA), we hypothesized that CCR2 plaque content may predict plaque progression. Methods: Carotid plaque of ten patients undergoing elective CEA were harvested from the operating room, paraffin-embedded, sectioned into 5μm segments, immuno-stained for CCR2 and CD68, and imaged. Three 200х500μm regions-of-interest (ROIs) were randomly selected within 200μm of the lumen (superficial intima), outside 200μm of the lumen (deep intima), and the arterial media. Two independent observers evaluated the number of CCR2 and/or CD68 positive cells. Counts in each ROI were averaged and analyzed with Student’s t-test. Results: Patients with symptomatic carotid artery stenosis (6/10) demonstrated higher CCR2 and CCR2-CD68 double positive cells within the superficial intima of carotid artery plaques (A, p&lt;0.05, n=10). Similarly, patients with symptomatic disease also showed increased CCR2 in the plaque media (B, p&lt;0.05, n=10). Interestingly, we also observed a higher number of CCR2 positive cells in the media layer of smokers (6/10) compared to non-smokers (C, p&lt;0.05, n=10). Conclusions: Our study demonstrates the close association between CCR2 cellular content and the incidence of symptomatic carotid artery disease. Additionally, CCR2 plaque content appears to correlate with risk-factors such as smoking. These studies have important implications regarding the impact of immune modulation on carotid plaque vulnerability in patients with asymptomatic carotid artery stenosis.

Factors Influencing Long-Term Blood Flow in Extracranial-to-Intracranial Bypass for Symptomatic Internal Carotid Artery Occlusive Disease: A Quantitative Study.

Maintaining the patency of extracranial-to-intracranial (EC-IC) bypass is critical for long-term stroke prevention. However, reports on the factors influencing long-term bypass patency and quantitative assessments of bypass patency are limited. To quantitatively evaluate blood flow in EC-IC bypass using four-dimensional (4D) flow magnetic resonance imaging (MRI) and investigate factors influencing the long-term patency of EC-IC bypass. Thirty-six adult Japanese patients who underwent EC-IC bypass for symptomatic internal carotid or middle cerebral artery occlusive disease were included. We examined the relationships between decreased superficial temporal artery (STA) blood flow volume and perioperative complications, long-term ischemic complications, patient background, and postoperative antithrombotic medications in patients for whom STA flow could be quantitatively assessed for at least 5 months using 4D flow MRI. The mean follow-up time was 54.7 ± 6.1 months. One patient presented with a stroke during the acute postoperative period that affected postoperative outcomes. No recurrent strokes were recorded during long-term follow-up. Two patients died of malignant disease. Seven cases of reduced flow occurred in the STA, which were correlated with single bypass (P = .0294) and nonuse of cilostazol (P = .0294). STA occlusion was observed in 1 patient during the follow-up period. Hypertension, age, smoking, dyslipidemia, and diabetes mellitus were not correlated with reduced blood flow in the STA. Double anastomoses and cilostazol resulted in long-term STA blood flow preservation. No recurrence of cerebral infarction was noted in either STA hypoperfusion or occlusion cases.

Ischemic Stroke Revascularization.

Extracranial-intracranial (EC-IC) bypass is one of the most fundamental techniques for ischemic cerebrovascular disease (CVD). We describe the standard surgical strategies, advanced techniques, and controversies concerning revascularization of ischemic stroke. The standard surgical strategies and techniques emphasize how to determine surgical indication, which should be decided for symptomatic internal carotid artery or middle cerebral artery (MCA) occlusive disease with misery perfusion detected by quantitative single photon emission computed tomography. Advanced techniques are available for complex situations such as posterior circulation revascularization, Bonnet bypass for common carotid artery obstruction, and various EC-IC bypasses for ischemia in the MCA and/or anterior cerebral artery territories using inter-grafts such as femoral veins and radial arteries, illustrated by our surgical results and experiences. Controversies include endovascular treatment complementary to EC-IC bypass. Finally, we advocate emergent EC-IC bypass for progressive ischemic CVD, particularly for contraindication or unsuccessful treatment after intravenous tissue plasminogen activator administration and/or endovascular thrombolysis. EC-IC bypass surgery can be reliable for ischemic CVD under strict optimal surgical indications using safe and reliable surgical techniques.

The relationship of carotid artery disease with mental and neurocognitive disorders

Carotid stenosis constitutes a common vascular disease that significantly affects cerebral blood flow and thus is associated with patients' cognitive functions. Carotid revascularization techniques [carotid endarterectomy (CEA) and carotid artery stenting (CAS)] may benefit cognition, though there are opposing findings, reporting an apparent decrement in cognitive function, no effect, or an apparent improvement after revascularization. A great number of studies are trying to evaluate the effect of carotid revascularization (CEA, CAS) on patients' cognitive functions, as well as on their psychological condition and quality of life through a baseline and follow-up neuropsychological examination. Recent reviews refer only to the narrow limits of cognitive deficits that may be attributed to carotid stenosis, rather than elucidating the outfit of all aspects of mental and cognitive correlations. Most of those findings depict controversy in current literature as far as the neuropsychological effects of carotid revascularization techniques are concerned, while clinical entities of "vascular dementia" and "vascular depression", as well as intercurrent vascular risk factors are also addressed. This might be taken into consideration, when determining the optimal therapeutic strategy for tackling carotid artery occlusive disease, while best practice clinical decisions should be still focused on stroke prevention and symptoms alleviation, until further research on the field of neuroangiology presents undisputable conclusions regarding the underlying effects of revascularization on mood and cognition. Τhe neurovascular interface, as far as mental and neurocognitive impact of carotid stenosis is concerned, also, comprises, the conceptual pathophysiological entity of "atheroinflammation", underscoring the association of vascular lesions with cognitive impairment, major depressive disorder and bipolar disorder. Chronic recurrent ischemia and chronic low perfusion are also addressed from neurocognitive aspect, regarding therapeutic strategies that might be preferred so as to reduce the burden of chronic cerebrovascular disease in both symptomatic and asymptomatic patients, given the fact that inflammatory processes of vascular complexion underlie both neuroinflammation and atherosclerosis, affecting cerebral perfusion as well as cortical blood flow.

Ccr2 Expression Is Increased in Patients with Symptomatic Carotid Arterial Occlusive Disease

Ccr2 Expression Is Increased in Patients with Symptomatic Carotid Arterial Occlusive Disease

Monitoring of Hemodynamics Associated With Carotid Surgery

Transcarotid artery revascularization (TCAR) is an increasingly accepted approach to the management of carotid artery occlusive disease. We aimed to demonstrate that postoperative hemodynamic control is key to improved outcomes.

English

BACKGROUND Central retinal artery occlusion (CRAO) was first described by Van Graefe in 1859 as an embolic event to the central retinal artery in a patient with endocarditis. CRAO has various causes, but patients typically present with sudden, severe, and painless loss of vision. Retinal arterial occlusions are a cause for profound visual loss in the population. Carotid atherosclerosis is common in elderly people. Dyslipidaemia, hypertension, and diabetes mellitus are factors which accelerate the development of carotid atheromatous plaques. Embolism from the carotid bifurcation is the most common cause of retinal artery occlusions. In retinal arterial occlusion carotid arterial occlusion is usually assessed using radiological techniques. The purpose of this study was to evaluate carotid atherosclerotic disease in patients with arterial occlusions in the eye and determine the relation between arterial occlusions in the eye &amp; carotid artery occlusive disease. METHODS This retrospective study included patients aged thirty and above, who had come with symptoms suggestive of arterial occlusions in the eye and carotid doppler was done. The inclusion criteria included patients diagnosed with the following conditions CRAO, branch retinal artery occlusion (BRAO), ophthalmic artery occlusion, anterior ischaemic optic neuropathy (AION) and cilioretinal artery occlusion. Patients usually present with sudden loss of vision in one eye. After taking a detailed history, all patients were subjected to a thorough ocular examination. Patient’s vision is assessed using Snellen’s visual acuity chart, pupillary assessment done, and fundus examination to look for retinal arterial occlusion is also done. Fundus imaging is also done. Carotid doppler was done to rule out carotid artery occlusive disease. RESULTS Patients presenting with retinal arterial occlusion should be investigated thoroughly for both systemic and local causes of CRAO. The risk of developing arterial occlusions were 1.7 - 9.15 times more in patients with carotid artery occlusion than in patients with normal carotids. Arterial occlusion was more found in patients with 70 % occlusion of the carotid artery. CONCLUSIONS There was a strong association between retinal arterial occlusions and carotid artery occlusion. KEYWORDS Central Retinal Artery Occlusion (CRAO), Carotid Artery Occlusive Disease, Carotid Doppler

Predictive Value of Neutrophil-to-Lymphocyte, Aspartate-to-Alanine Aminotransferase, Lymphocyte-to-Monocyte and Platelet-to-Lymphocyte Ratios in Severity and Side of Carotid Artery Stenosis: Are Those Significant?

Atherosclerosis is a chronic disease that leads to mortality and morbidity by affecting arterial vascular structures. Carotid artery is one of these arterial structures and occlusive disease of carotid artery may cause stroke or cranial ischemic infarction. Inflammation plays a role in the atherosclerotic process. In this study, we aimed to discuss the relationship between the severity and side of carotid artery occlusion and novel inflammatory parameters include platelet-to-lymphocyte, neutrophil-to- lymphocyte, lymphocyte-to-monocyte, and aspartate-to-alanine aminotransferase ratios. One-hundred-fifteen patients who had carotid artery stenosis between 50%-99% and 115 healthy subjects with no carotid artery stenosis or additional disease were included in the study. The relationship between the side and degree of the lesion and platelet-to-lymphocyte, neutrophil-to-lymphocyte, lymphocyte-to-monocyte, and aspartate-to-alanine aminotransferase ratios were studied in the patient group. The patients with carotid artery stenosis and the healthy subjects were compared, in the terms of same parameters. Data were evaluated statistically. There were no statistically significant differences between the groups, in the terms of platelet-to-lymphocyte, neutrophil-to-lymphocyte, lymphocyte-to-monocyte, and aspartate-to-alanine aminotransferase ratios and the degree of stenosis. There was no statistically significant difference between the sides of the lesions and the parameters above except lymphocyte-to-monocyte ratio. It was statistically significantly higher in left-sided lesions. Aspartate-to- alanine aminotransferase and neutrophil-to-lymphocyte ratios were markedly higher in the patient group, when compared to controls. Platelet-to-lymphocyte, neutrophil-to-lymphocyte, lymphocyte-to-monocyte, and aspartate-to- alanine aminotransferase ratios are inexpensive, easy, fast, and reproducible parameters that can be used in determining the prediction of carotid artery stenosis.

The use of curved sheath technique to facilitate difficult internal carotid artery occlusions

Carotid Artery Occlusive Disease or Carotid Artery Stenosis (CAS), a widely prevalent disease, involves blockage of the arterial wall through atherosclerotic plaques. Due to the high prevalence of carotid artery stenosis, innovative approaches to improve the outcome are required, particularly for more difficult and unique cases. Within this report, we present a particularly difficult case of Type III Aortic Arch – Right Internal Carotid Artery (ICA) stenosis making it a challenging case. We describe a symptomatic 87-year-old male who presented to Cardiology clinic. CT angiogram showed 70% occlusion of right internal carotid artery and patient was deemed high risk for carotid artery surgery; hence, the patient underwent internal carotid artery stenting. After the procedure, angiogram results were excellent, and the patient was transferred to CICU in stable hemodynamic condition. This case demonstrates the significance of innovative new techniques in the development of medical treatment.&#x0D; Keywords: Carotid Artery Stenting, Curve Sheath Technique, Type 3 Aortic Arch, Right Internal Carotid Artery Stenosis

Ct-angiography in assessment of critical occlusive carotid artery disease

Occlusive carotid artery disease is still one of the major causes of ischemic stroke in the world. Progression of severe carotid stenosis may lead to critical stenosis and vascular occlusion. Nevertheless, there is still no pure definition of the concept of critical occlusive carotid artery disease. To define the role of CT-angiography in assessment of critical occlusive carotid artery disease. We analyzed data of 405 patients who underwent preoperative precise assessment of carotid arteries and subsequent surgical treatment for the period from 2016 to 2019. Contrast-enhanced CT-angiography (Philips Ict scanner, 256 slices) was made after previous ultrasound. Contrast agent injection rate was 4-5 ml/sec. CT angiography data were assessed according to a specialized protocol. Critical occlusive carotid artery disease was observed in 128 (31.6%) cases including critical stenosis (24.94%), near-occlusion (5.92%) and local occlusion (0.74%). Critical stenosis was characterized by local narrowing ≥90% and normal diameter of distal arterial segment. In case of near-occlusion, local critical stenosis was accompanied by narrowing of distal arterial segment. In case of local occlusion, distal collateral supply of internal carotid artery occurred through atypically originating ascending pharyngeal artery. Patients with near-occlusion and local occlusion of internal carotid artery had no signs of ICA hypoplasia and intracranial stenoses. All elements of circle of Willis were observed in 70% of patients. State of distal segment of internal carotid artery can be considered as a differential diagnostic criterion for critical occlusive carotid disease variants. CT-angiography provides all necessary data and can be recommended for precise preoperative assessment.

Safety of different carotid artery revascularization strategies in the coronary artery bypass graft population: study protocol for a systematic review and network meta-analysis.

BackgroundConcomitant significant carotid artery occlusive diseases (CAOD) increase the risk of perioperative stroke and death in patients who undergo coronary artery bypass graft (CABG). Although several surgical strategies can be used in the management of such patients, controversy still surrounds which is the best option for CABG patients with accompanying CAOD.MethodsLiterature searches will be conducted covering articles published in PubMed, the Cochrane Central Register of Controlled Trials, Web of Science, and Embase between January 1989 and December 2019. Search results will be limited to articles published in English. Six surgical strategies using carotid endarterectomy (CEA) or carotid artery stenting (CAS) with different timings (i.e., before, after, or combined with CABG) will be evaluated. Randomized controlled trials and non-randomized studies comparing these strategies will be included. The quality of studies will be critically appraised using the Cochrane risk-of-bias tool or ROBINS-I tool. Since CEA and CAS have comparable effectiveness for the treatment of significant CAOD, we will integrate direct and indirect evidence using network meta-analysis (NMA) to create hierarchies of the six surgical strategies based on their perioperative safety. The primary outcomes will be the probability of perioperative stroke and the probability of perioperative death. Additionally, we will analyze the probability of perioperative myocardial infarction (MI) as a secondary outcome. Pairwise meta-analyses and Bayesian network meta-analyses will be performed for all related outcome measures. Subgroup analyses, sensitivity analyses, and network meta-regression will be conducted to assess the robustness of the findings.DiscussionThis NMA will summarize the direct and indirect evidence of perioperative safety with the aim of providing a ranking of the various surgical strategies. The results of this meta-analysis will provide useful information on optimal surgical management of CABG patients with concomitant significant CAOD.Trial registration numberPROSPERO CRD42020162611.

"Modern Endovascular Therapy".

The past 25years have been witness to a revolution in how vascular care is delivered. The majority of arterial and venous interventions have converted from open surgery to minimally invasive percutaneous endovascular procedures. This surgical innovations symposium article reviews current endovascular therapy in multiple vascular beds with a primary focus on carotid artery occlusive disease, aortic pathologies, and lower extremity arterial occlusive disease. Mesenteric arterial occlusive disease and lower extremity venous endovascular therapies are also briefly discussed. Indications for intervention, treatment examples and outcomes analysis are presented. While not reviewed in this article, endovascular therapy has also become first line in the treatment of coronary artery disease, chronic mesenteric arterial occlusive disease, superficial venous reflux, central vein occlusion, and acute venous thrombus intervention when indicated. Endovascular therapies are used in all vascular beds to treat the full spectrum of vascular pathologies. Aneurysm disease, atherosclerotic arterial occlusive disease, acute arterial and venous thrombosis, ongoing hemorrhage, and venous reflux are among the issues which can be addressed by endovascular means. The minimally invasive nature of endovascular treatments in what is largely a very co-morbid patient cohort is an attractive method of avoiding major procedural related morbidity and mortality.