Treatment Of Carotid Artery Research Articles

Compensated and non-compensated patient injury claims in internal carotid artery interventions in Finland, 2004-2017.

Analysis of patient injuries offers possibilities for improving quality in patient care. The aim of this study was to identify errors and adverse events leading to patient injuries in the treatment of internal carotid artery stenosis (ICAS). A retrospective analysis was performed on data from Finnish patient injury claims and patient insurance center decisions in the treatment of ICAS, 2004-2017. Contributing factors to injury were identified and evaluated. During the 14-year study period, 42 patient injury claims involving ICAS treatment were closed in Finland. One claim involved carotid artery stenting, and the other operations were carotid artery endarterectomies. Nine of the claims were compensated (seven for operations and two for evaluations). Fully trained vascular surgeons had carried out all the operations and evaluations. Stroke was the most common complaint in the claims (n = 12). Six of the compensated patients were symptomatic prior to the interventions. Injuries were related to errors in decision-making and patient selection in two cases. Four patients received compensation for nerve injury and three for stroke. No deaths were compensated as patient injuries. Most negative claim decisions were related to the injury having been unavoidable. Compensated patient injuries involving the treatment of ICAS are rare but often serious and mostly involve open surgery. Patient injury claims provide a valuable source of information for recognizing errors in care and offer possibilities to improve patient safety.

Scalp-Mounted Electrical Impedance Tomography of Cerebral Hemodynamics.

An Electrical Impedance Tomography (EIT) system has been developed for dynamic three-dimensional imaging of changes in conductivity distribution in the human head, using scalp-mounted electrodes. We attribute these images to changes in cerebral perfusion. At 100 frames per second (fps), voltage measurement is achieved with full-scale signal-to-noise ratio of 105 dB and common-mode rejection ratio > 90 dB. A novel nonlinear method is presented for 3-D imaging of the difference in conductivity distribution in the head, relative to a reference time. The method achieves much reduced modelling error. It successfully localizes conductivity inclusions in experimental and simulation tests, where previous methods fail. For > 50 human volunteers, the rheoencephalography (REG) waveform is observed in EIT voltage measurements for every volunteer, with peak-to-peak amplitudes up to approx. 50 μVrms. Images are presented of the change in conductivity distribution during the REG/cardiac cycle, at 50 fps, showing maximum local conductivity change of approx. 1% in grey/white matter. A total of 17 tests were performed during short (typically 5s) carotid artery occlusions on 5 volunteers, monitored by Transcranial Doppler ultrasound. From EIT measurements averaged over complete REG/cardiac cycles, 13 occlusion tests showed consistently decreased conductivity of cerebral regions on the occluded side, and increased conductivity on the opposite side. The maximum local conductivity change during occlusion was approx. 20%. The simplicity of the carotid artery intervention provides a striking validation of the scalp-mounted measurement system in imaging cerebral hemodynamics, and the REG images indicate its unique combination of sensitivity and temporal resolution.

Anatomical Factors That Impede Using the Radial Artery Approach for Carotid Artery Revascularization

We investigated the anatomical characteristics that complicate utilizing the radial artery approach (RAA) for craniocervical intravascular intervention. The data of 73 lesions in 65 consecutive patients who underwent transradial cervical carotid artery intervention was evaluated. We assessed the success rate of RAA in right-sided and left-sided lesions. The diameters and angles of the left and right common carotid arteries and the aortic, brachiocephalic, and right subclavian arteries, which constitute the paths of the guiding sheath, were assessed for each of the left- and right-sided lesions. It was difficult to apply RAA in 10 cases (13.7%), of which 2 (5.0%) involved right-sided and 8 (24.2%) left-sided lesions. The approach was significantly more difficult to perform in left-sided than in right-sided lesions (P= 0.02). Although the treatments were successfully completed, crossover to the femoral artery approach was required in 4 cases (5.5%, 2 cases for left-sided lesions). Placement of the guiding sheath in the common carotid artery was successful for all right-sided lesions; however, the guiding sheath slipped off to the aorta during stent advancement in 2 cases. When the angle between the brachiocephalic artery and aortic arch was small, the introduction of the guiding sheath to left-sided lesions was difficult in eight cases (P= 0.0001). RAA was difficult to perform in cases involving left-sided lesions and a small angle between the brachiocephalic artery and aortic arch. This study could help delineate the factors associated with difficulty of catheter introduction and instability of RAA.

Clinical utility of intravascular ultrasound (IVUS) in carotid artery interventions - a systematic review and meat-analysis

IVUS and its extension VH (Virtual Histology) IVUS evaluate plaque characteristics in real time and guide decision making during stenting. To date there is no consensus about indications of IVUS and its validated methods. This systematic review and meta-analysis aims to evaluate the clinical utility of IVUS in carotid artery stenting and develop a future consensus for research and practice parameters.

Neuroprotective Benefit of Renin-Angiotensin System Blocking Agents in Carotid Artery Surgery

Renin-angiotensin system blocking (RASB) agents such as angiotensin-converting enzyme inhibitors and angiotensin receptor blockers are considered first-line antihypertensive agents. However, their role in the perioperative period of carotid artery interventions is unclear. We examined the relationship between the use of RASB agents for patients undergoing carotid endarterectomy (CEA), transfemoral carotid artery stenting (CAS), and transcervical carotid artery revascularization (TCAR). The Vascular Quality Initiative database was queried for all patients who had undergone CEA, TCAR, and CAS. The baseline and procedural characteristics and postoperative outcomes were compared between the RASB agent users and nonusers. The primary outcome was postoperative neurologic events (stroke and transient ischemic attack). The secondary outcomes included postoperative mortality, cardiac events, and postoperative complications. Multivariate logistic regression was used to determine the independent predictors of postoperative neurologic events. More than 150,000 patients were analyzed, including13,666 patients who had undergone TCAR, 13,811 who had undergone CAS, and 125,429 who had undergone CEA (Fig). On univariate analysis, RASB agent use was associated with lower postoperative neurologic events after CEA (1.7% vs 2.0%; P = .001). No difference was detected in the TCAR (2.0% vs 2.4%; P = .162) and CAS (3.4% vs 3.2%; P = .234) cohorts. However, RASB agent use was associated with lower mortality after CAS (1.2% vs 1.7%; P = .001). RASB agent use did not influence the overall rates of cardiac events, including myocardial infarction, dysrhythmia, and congestive heart failure for all intervention types or mortality in the CEA and TCAR groups. On multivariable analysis, RASB agent use was independently and significantly associated with lower rates of postoperative neurologic events for the patients who had undergone CEA (odds ratio [OR], 0.819; 95% confidence interval [CI], 0.747-0.898; P = .01) or TCAR (OR, 0.869; 95% CI, 0.768-0.984; P = .026), but not after CAS (OR, 0.967; 95% CI, 0.884-1.057; P = .461; Table). RASB agent use was associated with decreased neurologic events in the patients who had undergone CEA or TCAR but not for those who had undergone CAS. Because all carotid artery interventions warrant absolute minimization of perioperative complications to be efficacious, the neuroprotective effect associated with RASB agent use during CEA and TCAR warrants further examination.TableMultivariable analysis resultsOR95% CI1.1471.083-1.2151.0621.030-1.0951.0301.009-1.0521.0260.978-1.0761.0191.003-1.0340.9990.964-1.0360.8950.790-1.0150.8880.782-1.0080.8190.747-0.8980.7690.698-38471.2301.020-1.4831.0551.003-1.1081.0471.002-1.0940.9620.844-1.0961.2080.914-1.5950.9890.911-1.0731.1540.752-1.7731.0260.813-1.2950.8690.768-0.9840.8630.812-0.916CI, Confidence interval; OR, odds ratio.Boldface values represent statistical significance. Open table in a new tab

Perioperative outcomes of carotid endarterectomy and transfemoral and transcervical carotid artery stenting in radiation-induced carotid lesions

ObjectiveLimited data are available to guide the choice of intervention for patients with radiation-induced carotid stenosis (RICS), either transcarotid artery revascularization (TCAR), transfemoral carotid artery stenting (TFCAS), or carotid endarterectomy (CEA). The purpose of the present study was to evaluate patients who had undergone these carotid artery interventions for RICS and the associated outcomes. MethodsPatients in the Society for Vascular Surgery (SVS) Vascular Quality Initiative (VQI) carotid artery stenting surveillance project registry and the SVS VQI CEA modules who had undergone carotid artery intervention (TCAR, TFCAS, or CEA) for RICS were included. Those aged >90 years and those with concomitant interventions (eg, coronary bypass) were excluded. A composite of death, myocardial infarction (MI), and stroke was the primary outcome. The secondary outcomes included death, MI, stroke, cranial nerve injury (CNI), and other local and systemic complications. Multivariable logistic regression controlling for presenting symptomatic status and comorbid medical conditions was conducted for the outcome variables, except for death, which was analyzed using Cox regression modeling. ResultsA total of 1927 patients with RICS had undergone CEA (n = 1172), TCAR (n = 253), or TFCAS (n = 502). The CEA group had a higher rate of diabetes (31% vs 25% for TCAR and 25% for TFCAS; P = .01), hypertension (85% vs 82% for TCAR and 79% for TFCAS; P < .01), and peripheral vascular disease (8% vs 4% for TCAR and 4% for TFCAS; P < .01). The TCAR and TFCAS groups had higher rates of coronary artery disease (21% for CEA vs 30% for TCAR and 29% for TFCAS; P < .01). The patients who had undergone TFCAS were more likely to have had symptomatic lesions (57% for TFCAS vs 47% for CEA and 41% for TCAR; P < .01) and prior stroke (55% for TFCAS vs 47% for CEA and 40% for TCAR; P < .001). The composite outcome occurred in 3.2% of TCAR patients, 11.2% of TFCAS patients, and 11.1% of CEA patients (P < .01) with an odds ratio of 0.27 for TCAR, 0.91 for TFCAS, and 1.00 for CEA. However, no differences in the individual outcomes were noted for any procedure. TCAR exhibited the lowest odds ratio for CNI (0.15) compared with TFCAS at 0.9, both relative to CEA (P = .03). ConclusionsRICS patients treated by TCAR in the SVS VQI had the lowest risk of the composite of stroke, death, and MI and CNI. Therefore, TCAR might be the preferred treatment modality. Further comparative studies are needed to evaluate the long-term outcomes in this population and to elucidate the relationship of these procedures to the individual outcomes of stroke, MI, and death.

Impact of iliac arterial calcification on procedure success and long-term outcomes among patients undergoing endovascular intervention.

Vascular calcification is a well-known phenomenon and affects coronary and carotid arteries as well as other arterial beds. Presence of arterial calcification is associated with major adverse events in patients undergoing percutaneous coronary artery or carotid artery intervention. Even though there is a clear association between worse outcome and coronary-carotid calcification, there is no research that interrogated the relationship between iliac arterial calcification and clinical outcomes because of lack of data. Therefore, in this study, we aimed to investigate the impact of iliac arterial calcification on procedure success rates and long-term outcomes among patients undergoing endovascular intervention. The records of 453 consecutive patients who underwent endovascular intervention due to symptomatic peripheral artery disease were analyzed. Patients were divided into two groups based on the presence or absence of heavy calcification of iliac arteries. For each group, technical aspects of procedures and subsequent clinical outcomes were analyzed. According to our study, the rate of restenosis following endovascular intervention at 6 and 12 months were similar between two groups. On the other hand, long-term restenosis was significantly higher in patients with heavy calcification of iliac arteries as compared to patients with low calcification on iliac arteries (32.2% vs. 12.8%, p < 0.05). Our data showed that there was a strong association between heavy calcification of iliac arteries and long-term restenosis in patients undergoing endovascular intervention.

Neurological Complications in High-Risk Patients Undergoing Coronary Artery Bypass Surgery

BackgroundCoronary artery bypass grafting (CABG) without cardiopulmonary bypass and minimal or no aortic manipulation may be associated with a lower risk of neurological complications. We investigated this issue in patients with a high risk of perioperative stroke. MethodsData on 7352 patients who underwent isolated CABG from January 2015 to May 2017 were included in the multicenter study E-CABG (European Coronary Artery Bypass Grafting) registry. Of these, 684 patients had an increased risk of neurological complications, ie, previous stroke or transient ischemic attack, severe carotid artery stenosis or occlusion, or previous carotid artery intervention. In this subgroup, we analyzed the rates of the combined primary endpoint comprising any postoperative stroke or transient ischemic attack. A comparative analysis between CABG with and without aortic cross-clamping was performed. ResultsThe primary endpoint was more often reached when aortic cross-clamping was used (propensity score matching, without vs with aortic cross-clamp: 0.9% vs 7.2%; P = .016). In comparison with all other revascularization techniques, off-pump CABG with avoidance of aortic manipulation was associated with the lowest rate of neurological complications (0.7%). ConclusionsIn patients with increased risk of perioperative stroke, aortic manipulation including the use of cardiopulmonary bypass or partial clamping for central anastomoses is associated with higher rates of postoperative neurological complications. These patients may benefit from off-pump surgery without aortic manipulation if complete revascularization can be ensured.

Abstract P566: Identifying Sex-Specific Differences in the Carotid Revascularization Literature: Findings From a Scoping Review

Background and Purpose: No systematic review of the literature has dedicated itself to looking at the management of symptomatic carotid stenosis in women. In this scoping review, we aimed to identify all randomized controlled trials (RCTs) that reported sex-specific outcomes for patients who underwent carotid revascularization, and determine whether sufficient information is reported within these studies to assess women’s short and long-term outcomes. Methods: We systematically searched Medline, Embase, Pubmed, and Cochrane libraries for RCTs published between 1991 and 2020 that included women and compared either endarterectomy with stenting, or any revascularization (endarterectomy or stenting) with medical therapy in patients with symptomatic high grade (greater than 50%) carotid stenosis. Results: From 1,537 references examined, 27 eligible studies were identified. Sex-specific outcomes were reported in 13 studies. Baseline patient characteristics of enrolled women were reported in 2 of those 13 studies. Common outcomes reported included stroke and death, however there was significant heterogeneity in the reporting of both periprocedural and long-term outcomes. Sex-specific differences relating to the degree of stenosis and time from index event to treatment were limited to studies comparing endarterectomy to medical therapy. Adverse events were not reported by sex. Conclusions: Half of the previously published RCTs and systematic reviews report sex-specific outcomes. Detailed analysis on the benefits of carotid artery intervention for women with symptomatic stenosis is limited . Further analysis with individual patient data and a network meta-analysis is the necessary next step to better assess the treatment effects of carotid management in women.

Higher Risk for Reintervention in Patients after Stenting for Radiation-Induced Internal Carotid Artery Stenosis: A Single-Center Analysis and Systematic Review

This study aimed to review short- and long-term outcomes of all carotid artery stenting (CAS) in patients with radiation-induced (RI) internal carotid artery (ICA) stenosis compared with patients with atherosclerotic stenosis (AS). We performed a single-center, multisite case-control study of transfemoral carotid artery intervention in patients stented for RI or AS. Cases of stented RI carotid arteries were identified using a CAS database covering January 2000 to December 2019. These patients were randomly matched 2:1 with stented patients because of AS by age, sex, and year of CAS. A conditional logistic regression model was performed to estimate the odds of reintervention in the RI group. Finally, a systematic review was performed to assess the outcomes of RI stenosis treated with CAS. There were 120 CAS in 113 patients because of RI ICA stenosis. Eighty-nine patients (78.8%) were male, and 68 patients (60.2%) were symptomatic. The reasons for radiation included most commonly treatment for diverse malignancies of the head and neck in 109 patients (96.5%). The mean radiation dose was 58.9±15.6Gy, and the time from radiation to CAS was 175.3±140.4months. Symptoms included 31 transient ischemic attacks (TIAs), 21 strokes (7 acute and 14 subacute), and 17 amaurosis fugax. The mean National Institutes of Health Stroke Scale in acute strokes was 8.7±11.2. In asymptomatic patients, the indication for CAS was high-grade stenosis determined by duplex ultrasound. All CAS were successfully completed. Reinterventions were more frequent in the RI ICA stenosis cohort compared with the AS cohort (10.1% vs. 1.4%). Reinterventions occurred in 14 vessels, and causes for reintervention were restenosis in 12 followed by TIA/stroke in two vessels. On conditional regression modeling, patients with RI ICA stenosis were at a higher risk for reintervention (odds ratio=7.1, 95% confidence interval=2.1-32.8; P=0.004). The mean follow-up was 33.7±36.9months, and the mortality across groups was no different (P=0.12). In our single-center, multisite cohort study, patients who underwent CAS for RI ICA stenosis experienced a higher rate of restenosis and a higher number of reinterventions compared with CAS for AS. Although CAS is safe and effective for this RI ICA stenosis cohort, further data are needed to reduce the risk of restenosis, and close patient surveillance is warranted. In our systematic review, CAS was considered an excellent alternative option for the treatment of patients with RI ICA stenosis. However, careful patient selection is warranted because of the increased risk of restenosis on long-term follow-up.

Follow-up after carotid endarterectomy and stenting: What to look for and why

Duplex ultrasound testing after open or endovascular extracranial carotid artery interventions is a clinical practice guideline with a strong recommendation from the Society for Vascular Surgery. Neurologic outcomes are improved by the recognition of repair site stenosis or atherosclerotic disease progression in the unoperated carotid artery. The benefit of surveillance outweighs its risk because duplex testing is free of complications and accurate in the detection of internal carotid artery (ICA) stenosis or occlusion. Surveillance for >70% ICA stenosis is recommended within 30 days of the procedure, then every 6 months for 2 years, and annually thereafter. Repair site and contralateral ICA stenosis classification should be based on angle-corrected pulsed Doppler measurements of peak systolic velocity (PSV), end-diastolic velocity (EDV), and the ratio of PSV at the stenosis to a proximal, nondiseased common carotid artery (CCA) segment (ICA/CCA ratio). Interpretation criteria of PSV >300 cm/s, EDV >125 cm/s, and ICA/CCA ratio >4 predicts >70% repair site stenosis. Endovascular intervention is recommended for a carotid repair site stenosis based on the occurrence of an ipsilateral neurologic event and appropriate anatomy for angioplasty. For asymptomatic restenosis, intervention is based on stenosis progression to elevated PSV and EDV >70% stenosis threshold values and the patient is deemed high risk for stroke due to contralateral ICA occlusion or incomplete functional patency of the circle of Willis.

A deep learning oriented method for automated 3D reconstruction of carotid arterial trees from MR imaging.

The scope of this paper is to present a new carotid vessel segmentation algorithm implementing the U-net based convolutional neural network architecture. With carotid atherosclerosis being the major cause of stroke in Europe, new methods that can provide more accurate image segmentation of the carotid arterial tree and plaque tissue can help improve early diagnosis, prevention and treatment of carotid disease. Herein, we present a novel methodology combining the U-net model and morphological active contours in an iterative framework that accurately segments the carotid lumen and outer wall. The method automatically produces a 3D meshed model of the carotid bifurcation and smaller branches, using multispectral MR image series obtained from two clinical centres of the TAXINOMISIS study. As indicated by a validation study, the algorithm succeeds high accuracy (99.1% for lumen area and 92.6% for the perimeter) for lumen segmentation. The proposed algorithm will be used in the TAXINOMISIS study to obtain more accurate 3D vessel models for improved computational fluid dynamics simulations and the development of models of atherosclerotic plaque progression.

Complexity of Aortic Arch Anatomy Affects the Outcomes of Transcarotid Artery Revascularization Versus Transfemoral Carotid Artery Stenting

Transcarotid artery revascularization (TCAR) has been shown to have half the rates of transient ischemic attack (TIA), stroke, and death compared with transfemoral carotid artery stenting (TFCAS). Successful outcomes of TFCAS require careful patient selection. The aim of this study was to determine the outcomes of TFCAS versus TCAR in both simple (type I) and complex (type II and III) aortic arches. A retrospective cohort study was performed comparing the outcomes of patients undergoing TFCAS versus TCAR with simple and complex aortic arches using the Vascular Quality Initiative registry from August 2011 to May 2019. The primary outcome was a composite of in-hospital TIA/stroke/death. About 6,108 carotid artery interventions were analyzed, including 3,536 (57.9%) patients with type I, 2,013 (33.0%) with type II, and 559 (9.2%) with type III aortic arch. In 3,535 patients with a simple arch, 1,917 underwent TFCAS and 1,619 had TCAR. Mean age was 70.6 (±9.5) years, and 2,382 (67.4%) patients were males. The primary outcome of postoperative TIA/stroke/death was seen significantly less frequently in those undergoing TCAR compared with TFCAS in simple arches (odds ratio [OR], 0.63; 95% confidence interval [95% CI], 0.43-0.94; P=0.0236). Although the individual outcome of death occurred less often in TCAR (P=0.0025), there was no difference in the occurrence of in-hospital stroke (P=0.8836) or TIA (P=0.4608). On multivariable analysis, TCAR was associated with improved outcomes (P=0.0062). A worse outcome was associated with increasing age (P<0.001), a prior stroke (P<0.0001), and increasing number of stents (P=0.0483). In 2,572 patients with a complex arch, 1,416 underwent TFCAS and 1,156 had TCAR. Mean age was 73.0 (±9.1) years, and 1,655 (64.4%) were males. In complex arch anatomy, the primary outcome of in-hospital TIA/stroke/death was seen significantly less frequently in TCAR compared with TFCAS (OR, 0.49; 95% CI, 0.31-0.77; P=0.0022). Again noted was a significant difference in death, with better outcomes in TCAR (P=0.0133). Although the occurrence of in-hospital TIA was no different between the 2 approaches (P=0.6158), there were significantly fewer strokes in those treated with TCAR (P=0.0132). TCAR (P=0.0146) was associated with improved outcomes. A worse outcome was seen with advancing age (P=0.0003), prior strokes (P=0.01), and a left-sided lesion (P=0.0176). TCAR has improved outcomes of TIA/stroke/death compared with TFCAS in both simple and complex aortic arch anatomy. In simple aortic arches, there is no difference in neurologic outcomes between both approaches. In complex arch anatomy, TCAR has fewer strokes.

Alcohol consumption in relation to carotid subclinical atherosclerosis and its progression: results from a European longitudinal multicentre study

Background/AimThe association between alcohol consumption and subclinical atherosclerosis is still unclear. Using data from a European multicentre study, we assess subclinical atherosclerosis and its 30-month progression by carotid intima-media thickness (C-IMT) measurements, and correlate this information with self-reported data on alcohol consumption.MethodsBetween 2002–2004, 1772 men and 1931 women aged 54–79 years with at least three risk factors for cardiovascular disease (CVD) were recruited in Italy, France, Netherlands, Sweden, and Finland. Self-reported alcohol consumption, assessed at baseline, was categorized as follows: none (0 g/d), very-low (0 − 5 g/d), low (> 5 to ≤ 10 g/d), moderate (> 10 to ≤ 20 g/d for women, > 10 to ≤ 30 g/d for men) and high (> 20 g/d for women, > 30 g/d for men). C-IMT was measured in millimeters at baseline and after 30 months. Measurements consisted of the mean and maximum values of the common carotids (CC), internal carotid artery (ICA), and bifurcations (Bif) and whole carotid tree. We used quantile regression to describe the associations between C-IMT measures and alcohol consumption categories, adjusting for sex, age, physical activity, education, smoking, diet, and latitude.ResultsAdjusted differences between median C-IMT values in different levels of alcohol consumption (vs. very-low) showed that moderate alcohol consumption was associated with lower C-IMTmax[− 0.17(95%CI − 0.32; − 0.02)], and Bif-IMTmean[− 0.07(95%CI − 0.13; − 0.01)] at baseline and decreasing C-IMTmean[− 0.006 (95%CI − 0.011; − 0.000)], Bif-IMTmean[− 0.016(95%CI − 0.027; − 0.005)], ICA-IMTmean[− 0.009(95% − 0.016; − 0.002)] and ICA-IMTmax[− 0.016(95%: − 0.032; − 0.000)] after 30 months. There was no evidence of departure from linearity in the association between alcohol consumption and C-IMT.ConclusionIn this European population at high risk of CVD, findings show an inverse relation between moderate alcohol consumption and carotid subclinical atherosclerosis and its 30-month progression, independently of several potential confounders.

Reduced Recurrent Ischemic Event Rate for Patients Undergoing Invasive Carotid Artery Intervention

Introduction - Patients with a symptomatic carotid artery stenosis risk a recurrent ischemic event during the waiting time to intervention or in the perioperative period. As the risk of recurrence is highest in the early phase after the presenting event, recent strategies recommend short delay to intervention but there are concerns that the possible benefit from early intervention may be counterbalanced by an increased perioperative complication rate. The aim of this national audit was to study the effects of more expedient carotid intervention on the risk of recurrent ischemic events. Methods - The Swedish Vascular Registry (Swedvasc) covers all centers in the country performing carotid interventions, and all registrations for symptomatic carotid artery stenosis from May 2008 to December 2015 were analyzed, focusing on recurrent ischemic events in the delay to surgical intervention and during the 30-day perioperative follow-up. The National Prescribed Drug Registry provided data on preventive medications prior to hospitalization for the carotid procedure. Results - In Swedvasc 6814 procedures for symptomatic carotid stenosis were registered during the time period. The mean age was 72 (±8) years and 68% were male. The presenting events were TIA in 58%, amaurosis fugax in 22% and stroke in 20%. Baseline demographic variables, comorbidities and secondary prevention pharmacotherapy when admitted for the procedure was similar during study period. The waiting time from the presenting neurological event to carotid intervention decreased from 13 (IQR 6-27) to 7 days (IQR 4-12) during the study period. Importantly, the proportion of recurrent ischemic events decreased over time from 30% (CI 28-33%) in 2008-2009 to 21% (CI 19–23%) in 2014-2015 (p< 0.01, χ2test). The perioperative stroke and/or death rate was 3.6%, with a decreasing trend during study period (5.3% 2008-2009 vs. 3.2% 2014-2015, p=0.05). Conclusion - In this population-based study, the overall risk for a recurrent ischemic event, from the presenting event until the 30-day follow-up, was markedly decreased during the time period. Efforts in reducing the delay to surgery were not counterbalanced by any increase in the perioperative complication rate.

An Alternative Approach to Carotid Endarterectomy in the High Carotid Bifurcation

Surgical exposure of a high carotid bifurcation (HCB) for carotid endarterectomy (CEA) can be technically challenging due to the presence of bony structures in the most cranial portion of the neck and is associated with significant morbidity making carotid artery stenting (CAS) a common alternative. However, a high transverse neck incision with subplatysmal flaps facilitates CEA in these patients without additional exposure techniques. We present a high transverse neck incision with subplatysmal flaps as an alternative to the standard surgical exposure of the carotid bifurcation to facilitate CEA in patients with HCB. Four patients with carotid bifurcations located cranial to the C3-4 vertebral interspace (identified on preoperative imaging) requiring intervention underwent CEA using a high transverse neck incision through an existing skin crease with subplatysmal flap elevation. CEA was performed in a standard fashion with bovine pericardial patch. Two male and 2 female patients with an average age of 65years successfully underwent CEA using this incision. One patient underwent concurrent carotid body tumor excision. None of the patients required mandibulotomy or hyoid bone resection. Two patients required division of the posterior belly of the digastric muscle. There were no perioperative complications. Primary patency was 100% in the 4 patients with surveillance studies, and mean follow-up of 160days (range 54-369days). There were no significant cranial nerve injuries. No patient required conversion to an endovascular procedure due to inaccessibility of the lesion or subsequent interventions for incomplete endarterectomy. A high transverse incision with subplatysmal flaps is a safe, effective, and cosmetically preferable surgical approach in patients with HCB requiring carotid artery intervention and may be an alternative to CAS.

Simultaneous revascularization of the occluded internal carotid artery using the Solitaire as a workhorse wire during acute ischemic stroke intervention.

Tandem lesions involving a large vessel occlusion intracranially with concomitant cervical carotid critical stenosis or occlusion are a common presentation of acute ischemic stroke. These lesions are both challenging and time-consuming but can be extremely beneficial for patients when successful. We present a technique utilizing the pusher wire of the stent retriever used for intracranial thrombectomy as the workhorse wire for carotid intervention using a monorail system to perform cervical carotid angioplasty. We reviewed four successive patients who presented with a tandem occlusion and underwent thrombectomy and simultaneous carotid artery intervention using this technique. All four patients had radiographically successful intracranial thrombectomy and cervical carotid revascularization. Time from groin puncture to intracranial stent retriever deployment was 63 min on average. Then, using the pusher wire as a monorail workhorse, time from stent retriever deployment to carotid angioplasty was on average 6 min. This technique allows for cervical carotid revascularization to begin during the recommended 5-min wait time after stent retriever deployment, allowing for rapid near-simultaneous revascularization across both lesions. This technique has been reported briefly in the past for management of a cervical dissection. There is continued debate regarding the management of tandem occlusions, as to which lesion should be managed first. As the management paradigms of tandem occlusions continue to evolve, this technique may improve outcomes by expediting endovascular intervention. Using the stent retriever wire provides a method of expediting the management of the proximal lesion after addressing the more distal intracranial occlusion first.

How Can We Treat Asymptomatic Carotid Disease in Patients with a Planned CABG?

Carotid artery intervention to the neurological asymptomatic patients is one of the most controversial issue of vascular surgery throughout the last decades. The decision about how to manage asymptomatic carotid disease in the setting of planned CABG becomes more complex due to surgical treatment of either pathology may be complicated by multiple factors. Current guidelines do not support routine screening for carotid artery stenosis before CABG because of given the low prevalence of stroke after CABG. Optimal surgical intervention and timing for patients having concomitant severe carotid and coronary artery stenosis remains uncertain. In this brief review, we analyze the incidence of significant carotid stenosis in patients undergoing CABG, association of untreated asymptomatic carotid stenosis on postoperative stroke, effects of carotid endarterectomy (CEA) on postoperative incidence of stroke, determination of surgical options and technical variations for CEA, scanning methods for identifying the vulnerable carotid plaque and revealing risk factors and predictors associated with stroke after CABG. Synchronous or staged CEA still remain valuable options in order to diminish postoperative risk of stroke for neurologically asymptomatic patients undergoing to CABG who have bilateral significant carotid artery stenosis or contralateral occlusion.

Meta-analysis of the outcomes of treatment of internal carotid artery near occlusion.

BackgroundGuidelines recommend treating patients with an internal carotid artery near occlusion (ICANO) with best medical therapy (BMT) based on weak evidence. Consequently, patients with ICANO were excluded from randomized trials. The aim of this individual‐patient data (IPD) meta‐analysis was to determine the optimal treatment approach.MethodsA systematic search was performed in MEDLINE, EMBASE and the Cochrane Library databases in January 2018. The primary outcome was the occurrence of any stroke or death within the first 30 days of treatment, analysed by multivariable mixed‐effect logistic regression. The secondary outcome was the occurrence of any stroke or death beyond 30 days up to 1 year after treatment, evaluated by Kaplan–Meier survival analysis.ResultsThe search yielded 1526 articles, of which 61 were retrieved for full‐text review. Some 32 studies met the inclusion criteria and pooled IPD were available from 11 studies, including some 703 patients with ICANO. Within 30 days, any stroke or death was reported in six patients (1·8 per cent) in the carotid endarterectomy (CEA) group, five (2·2 per cent) in the carotid artery stenting (CAS) group and seven (4·9 per cent) in the BMT group. This resulted in a higher 30‐day stroke or death rate after BMT than after CEA (odds ratio 5·63, 95 per cent c.i. 1·30 to 24·45; P = 0·021). No differences were found between CEA and CAS. The 1‐year any stroke‐ or death‐free survival rate was 96·1 per cent for CEA, 94·4 per cent for CAS and 81·2 per cent for BMT.ConclusionThese data suggest that BMT alone is not superior to CEA or CAS with respect to 30‐day or 1‐year stroke or death prevention in patients with ICANO. These patients do not appear to constitute a high‐risk group for surgery, and consideration should made to including them in future RCTs of internal carotid artery interventions.

Risk of intracranial hemorrhage after carotid artery stenting versus endarterectomy: a population-based study.

OBJECTIVEIntracranial hemorrhage (ICH) associated with cerebral hyperperfusion syndrome is a rare but major complication of carotid artery revascularization. The objective of this study was to compare the rate of ICH after carotid artery stenting (CAS) with that after endarterectomy (CEA).METHODSThe authors performed a retrospective population-based cohort study of patients who underwent carotid artery revascularization in the province of Ontario, Canada, between 2002 and 2015. The primary outcome was the rate of ICH that occurred within 90 days after carotid artery intervention among patients who underwent CAS versus that of those who underwent CEA. The authors used inverse probability of treatment weighting and propensity scores to account for selection bias. In sensitivity analyses, patients who had postprocedure ischemic stroke were excluded, and the following subgroups were examined: patients with symptomatic and asymptomatic carotid artery stenosis, patients treated between 2010 and 2015, and patients aged ≥ 66 years (to account for antiplatelet and anticoagulant use).RESULTSA total of 16,688 patients underwent carotid artery revascularization (14% CAS, 86% CEA). Patients with more comorbid illnesses, symptomatic carotid artery stenosis, or cardiac disease and those who were taking antiplatelet agents or warfarin before surgery were more likely to undergo CAS. Among the overall cohort, 80 (0.48%) patients developed ICH within 90 days (0.85% after CAS, 0.42% after CEA). The 180-day mortality rate after ICH in the overall cohort was 2.7%, whereas the 180-day mortality rate among patients who suffered ICH was 42.5% (40% for CAS-treated patients, 43.3% for CEA-treated patients). In the adjusted analysis, patients who underwent CAS were significantly more likely to have ICH than those who underwent CEA (adjusted OR 1.77; 95% CI 1.32-2.36; p < 0.001). These results were consistent after excluding patients who developed postprocedure ischemic stroke (adjusted OR 1.90; 95% CI 1.41-2.56) and consistent among symptomatic (adjusted OR 1.74; 95% CI 1.16-2.63) and asymptomatic (adjusted OR 1.75; 95% CI 1.16-2.63) patients with carotid artery stenosis, among patients treated between 2010 and 2015 (adjusted OR 2.21; 95% CI 1.45-3.38), and among the subgroup of patients aged ≥ 66 years (adjusted OR 1.53; 95% CI 1.05-2.24) after adjusting for medication use.CONCLUSIONSCAS is associated with a rare but higher risk of ICH relative to CEA. Future research is needed to devise strategies that minimize the risk of this serious complication after carotid artery revascularization.