Carotid Endarterectomy Group Research Articles

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.

METHODS OF SURGICAL PREVENTION OF THE ISCHEMIC STROKE

Objective: to estimate the clinical safety of open and endovascular interventions in the carotid arteries in the treatment and prevention of ischemic stroke. Material and methods: 317 patients (61 women and 256 men) aged 41 to 82 were examined. Carotid endarterectomy (CEA) (Group 1) was performed in 246 patients. Carotid transluminal balloon angioplasty with stenting (CAS) (Group 2) was performed in 71 patients. Symptomatic stenosis of the internal carotid artery (ICA) was detected in 85 patients (in Group1 in 53 patients, in Group2 in 32 patients). Asymptomatic stenosis of the ICA was detected in 232 patients (in Group1 in 193 patients, in Group2 in 39 patients). Results: in the immediate postoperative period in Group 1 of patients 15 complications (6,1%) developed. Ischemic stroke was stated in 8 cases (3,3%), 3 of which were lethal (1,2%). Transient ischemic attack was observed in 2 patients (0,8%). Myocardial infarction developed in 5 cases (2,0%). In the immediate postoperative period in the Group 2 of patients 4 complications (5,6%) was observed. Complications were demonstrated as an ischemic stroke in 2 cases (2,8%), myocardial infarction - in 1 observation (1,4%), a transient ischemic attack - in 1 patient (1,4%). In 1 observation (1,4%) there was a fatal outcome due to myocardial infarction in the background of hemorrhagic shock because of bleeding from an unidentified source. In the late postoperative period 12 complications developed in Group 1 of patients (6,0%). Th e restenosis of the operatedICA was observed in 8 cases (4,0%). An ipsilateral ischemic stroke was registered in 2 cases (1%). A myocardial infarction was stated in 2 cases (1%). A fatal outcome occurred in 3 cases (1,5%). In the late postoperative period 4 complications (6,8%) developed in Group 2 of patients. The restenosis of the operated ICA was stated in 1 observation (1,7%). A contralateral ischemic stroke was observed in 2 patients (3,4%). A myocardial infarction was registered in 1 observation (1,7%). A fatal outcome resulted from a myocardial infarction occurred in 1 case (1,7%). Conclusions : CEA and CAS of carotid arteries have the same effi cacy and safety in the immediate and late postoperative periods.

Three-year follow-up of blood pressure after treating hypertensive patients with symptomatic carotid artery stenosis.

Blood pressure (BP) was reported to decrease significantly after carotid endarterectomy (CEA) or carotid stenting (CAS) up to the 1-year follow-up. We evaluated changes in BP for 3years after treating hypertensive patients with symptomatic carotid artery stenosis by either CEA or CAS and determined predisposing factors for normotensive BP at the 3-year follow-up. A total of 123 hypertensive patients with at least 3years of clinical and radiographic follow-up after treatment were included in this study and placed in the CEA (n = 65) or CAS group (n = 58). BP changes for 3years, the number of patients with a normotensive BP (≤120/80mmHg), and the percentage decrease in BP were evaluated and compared between groups. Compared to pretreatment BP, the CEA group had significantly decreased BP at the 1- and 2-year follow-up (p < 0.05), but not the 3-year follow-up. The CAS group had significantly decreased BP at the 1-, 2-, and 3-year follow-up (p < 0.05). Stenosis location (body lesions over apical lesions; OR = 1.526, 95% CI, 1.341 to 6.224; p = 0.034) was an independent predisposing factor for normotensive BP at the 3-year follow-up. For hypertensive patients with symptomatic carotid artery stenosis, BP was lowered at 3years after both CEA and CAS compared to pretreatment BP. CAS might lower BP better over the long term than did CEA, and hypertensive patients with stenosis at body lesions might be normotensive at 3years after CEA or CAS.

Clinical results of carotid artery stenting versus carotid endarterectomy

Objective:To review our results of carotid artery stenting (CAS) and carotid endarterectomy (CEA).Methods:We evaluated the medical records of patients undergoing carotid artery revascularization procedure, between 2001 and 2013 in Baskent University Hospital, Ankara, Turkey. Carotid artery stenting or CEA procedures were performed in patients with asymptomatic carotid stenosis (≥70%) or symptomatic stenosis (≥50%). Demographic data, procedural details, and clinical outcomes were recorded. Primary outcome measures were in 30-day stroke/transient ischemic attacks (TIA)/amaurosis fugax or death. Secondary outcome measures were nerve injury, bleeding complications, length of stay in hospital, stroke, restenosis (ICA patency), and all-cause death during long-term follow-up.Results:One hundred ninety-four CEA and 115 CAS procedures were performed for symptomatic and/or asymptomatic carotid artery stenosis. There is no significant differences 30-day mortality and neurologic morbidity between CAS (13%) and CEA procedures (7.7%). Length of stay in hospital were significantly longer in CEA group (p=0.001). In the post-procedural follow up, only in symptomatic patients, restenosis rate was higher in the CEA group (p=.045). The other endpoints did not differ significantly.Conclusions:Endovascular stent treatment of carotid artery atherosclerotic disease is an alternative for vascular surgery, especially for patients that are high risk for standard CEA. The increasing experience, development of cerebral protection systems and new treatment protocols increases CAS feasibility.

Resultados a corto y medio plazo en el tratamiento de estenosis carotídea sintomática mediante «stenting» versus endarterectomía carotídea

IntroductionAtherothrombotic stenosis of the internal carotid artery is a common cause of stroke. Carotid endarterectomy (CEA) is the most common treatment for secondary stroke prevention. Carotid artery stenting is an alternative treatment. ObjectiveTo describe our experience of treating symptomatic carotid artery stenosis with CEA or carotid artery stenting. The primary outcomes were: 30-day stroke, myocardial infarction, or death. The secondary outcomes were severe restenosis (>70%), re-intervention, and death during mid-term follow-up. MethodsRetrospective cohort study including patients treated between 2008 and 2012. A total of 86 patients were included, of which 61.6% (n=53) received CEA, and a CAS technique in the remaining 38.4% (n=33). Diagnosis was established by echo-Doppler, and confirmed with selective arteriography in the carotid artery stenting group. ResultsTwo strokes were recorded in the CEA group, and 4 cases in the carotid artery stenting group (3.21 vs. 12.12%). There was one case of non-lethal myocardial infarction in the CEA group. The 30-day mortality rate was 1.9% (n=1) in the CEA group, and 3.0% (n=1) in the carotid artery stenting group. There were 7 cases of severe restenosis in the carotid artery stenting group, with no cases being reported in the CEA group (p=.006). The median follow-up was 38.5 months in the CEA group and 37.5 months in the carotid artery stenting group. ConclusionOur study reports better results in the early and mid-term after CEA. Thus, it is concluded that CEA should remain the reference-standard treatment in symptomatic patients.

Long-Term Outcome After Carotid Artery Stenting: A Population-Based Matched Cohort Study.

Long-term outcome after carotid artery stenting (CAS), a less invasive technique than carotid endarterectomy (CEA), for prevention of stroke, is unclear. The aim was to assess long-term outcomes after CAS, compared with CEA, in a nationwide cohort study. All patients registered in the national Swedish Vascular Registry (Swedvasc) treated with primary CAS between 2005 and 2012 were identified. For every CAS, 2 CEA controls, matched for sex, age, procedure year, and indication (symtomatic/asymtomatic), were chosen. Postoperative stroke was identified by cross-matching the cohort with the InPatient Registry and charts review. Primary end point was ipsilateral stroke or death >30 days postoperatively. A total of 1157 patients were included, 409 CAS and 748 CEA; 73% men with mean age 70 years and 69% were symptomatic. Risk factor profile was similar between the 2 groups. Median follow-up time was 4.1 years. Ipsilateral stroke or death of >30 days postoperatively occurred in 95 of 394 in the CAS group versus 120 of 724 in the CEA group (adjusted hazard ratio, 1.59; 95% confidence interval, 1.15-2.18). The corresponding adjusted rates for death, ipsilateral stroke of >30 days, and any stroke or death of >30 days were 25.7% versus 18.6% (hazard ratio, 1.20; 95% confidence interval, 0.84-1.72), 9.4% versus 2.9% (hazard ratio, 3.40; 95% confidence interval, 1.53-7.53), 34.2% versus 23.6% (hazard ratio, 1.49; 95% confidence interval, 1.10-2.00) for the CAS group versus CEA group, respectively. In this nationwide cohort study, CAS was associated with an increased long-term risk of ipsilateral stroke and death during after the perioperative phase when compared with CEA.

High-grade carotid artery stenosis: A forgotten area in cardiovascular risk management.

Patients with high-grade (≥70%) carotid artery stenosis (CAS) rank in the highest risk category for future cardiovascular (CV) events, but the quality of cardiovascular risk management in this patient group is unknown. Cross-sectional retrospective study. Data were collected for all patients diagnosed with high-grade CAS in Östergötland county, Sweden between 1 January 2009 and 31 July 2012 regarding the quality of cardiovascular risk management, co-morbidity and outcomes during the 2-year follow-up period after a diagnosis of CAS with a carotid ultrasound scan. Patients were included regardless of whether they underwent carotid endarterectomy (CEA). A total of 393 patients with CAS were included in the study; 133 (33.8%) underwent CEA and 260 (66.2%) were assigned to a conservative management (CM) group. In both groups of patients the prescription of platelet inhibitors, statins and antihypertensive drugs increased significantly (p < 0.001) after diagnosis. However treatment targets were not met in the majority of patients and the low-density lipoprotein level was on target in only 13.5% of patients. During follow-up, low-density lipoprotein levels were not measured in 19.8% of patients who underwent CEA and 44.2% of patients in the CM group (p < 0.001); HbA1c was not measured in 24.4% of patients with diabetes in the CEA group and in 18.8% of patients in the CM group (p = 0.560). There was no documentation of counselling on diet, exercise, smoking cessation or adherence to medication. The combined clinical event rate (all-cause mortality, cardiovascular mortality and non-fatal cardiovascular events) was high in both groups (CEA 36.8% and CM 36.9%; p = 1.00) with no difference in the occurrence of ipsilateral ischaemic stroke. The clinical event rate was high in patients with high-grade CAS and the management of cardiovascular risk was deficient in all aspects.

Temporary Transvenous Pacemaker Implantation during Carotid Endarterectomy in Patients with Trifascicular Block

The risk of severe perioperative bradyarrhythmias in patients with chronic left bundle branch, or bifascicular block, and an additional first-degree atrioventricular block undergoing carotid endarterectomy (CEA) has never been specifically addressed. In this study, we aimed to investigate whether these conduction abnormalities entail an increased risk of hemodynamic compromise during CEA and the role of temporary transvenous pacemaker (TTVPM) implantation as a prophylactic measure in this subgroup of patients. Between June 2006 and June 2013, 37 CEAs were performed in 31 patients (29 men, mean age 76±6years), in whom a TTVPM was implanted for a trifascicular block. Thirty-seven concurrent, consecutive patients operated for other vascular pathologies also with a prophylactic TTVPM for an asymptomatic trifascicular block served as controls. Adverse events were considered: pacemaker activation, block progression, bradycardia ≤40 beats/min, and asystole. Study and control groups were overall comparable. No perioperative mortality was recorded. All patients undergoing CEA were asymptomatic for syncope preoperatively. Among them, in 34 cases, indication for TTVPM was based on preoperative EKG, and in 4, a pacemaker activation was recorded. Three additional patients were also included in the study group in whom TTVPM was implanted due to the occurrence of adverse advents, and not prophylactically. In 2 of these, severe bradycardia with eventual asystole occurred intraoperatively. In both cases, the procedure was discontinued and rescheduled for the following day after a TTVPM was implanted. In the last additional case, the patient had a block progression on day 1 after an uneventful CEA and was emergently treated with a TTVPM. Overall, 7 adverse events were recorded in the study group, and none in the control group (P<0.011). Morbidity in the CEA group also included 1 myocardial infarction, 1 minor stroke, 1 surgical revision for cervical hematoma, 1 new-onset atrial fibrillation, and 1 femoral artery pseudoaneurysm. In our experience, TTVPM implantation was a clinically useful adjunct in patients with trifascicular block submitted to CEA, as compared with other vascular surgical procedures. However, the risks inherent to CEA in this subgroup of patients suggest that surgical treatment may not be warranted for those with asymptomatic carotid disease.

Carotid Endarterectomy or Stenting in Octogenarians in a Monocentric Experience

Carotid artery stenting (CAS) has emerged as an alternative to carotid endarterectomy (CEA) in patients at high risk for complications from surgery. The very elderly (≥80-year-old) are 1 subgroup of patients identified as being at increased risk for carotid surgery. However, there is concern that the very elderly are also at increased risk for complications of CAS. A stroke and death rate of 12% were reported in very elderly patients during the roll-in phase of Carotid Revascularization Endarterectomy versus Stent Trial. We are reporting on a clinical series of CAS and CEA with independent neurologic assessment in the very elderly. The aim of this article is to evaluate early and mild-term results obtained in the treatment of the carotid artery stenosis in symptomatic and asymptomatic octogenarians, comparing the data of CEA and CAS in academic hospital. Between 2002 and 2013, a consecutive series of 129 CAS and 45 CEA patients (≥80-year-old) were treated in our academic hospital, a center with extensive carotid revascularization experience. Independent neurologic assessment was performed before and after procedures. Exclusion criteria were cerebral hemorrhage diagnosed within 6 months, cerebral tumors and dementia. Hostile aortic arches were nevertheless treated with alternative approaches like cervical or radial access. All the procedures have been performed by the senior authors. The average age was 86.9years. Most patients were male (56%), and the target lesion carotid stenosis was asymptomatic in 80% of patients. No significant differences were obtained regarding gender, symptoms, risk factors or comorbidities, and evident CT lesions among the 2 groups of different treatments. Embolic protection devices were used in all cases with the CAS procedure. The overall 30-day incidence of stroke and death was 2.3% (3 of 129) in CAS group and 4.4% (2 of 45) in CEA group. Exclusion of high-risk patients from CAS, based on age alone, seems to be unjustified. Octogenarians are not at increased risk of periprocedural adverse events after CAS compared with younger patients. The key to obtain satisfactory results is CAS to be performed by an experienced team able to use not only standard filter protected CAS but also familiar with all the other types of access and protection techniques.

Association between age and risk of stroke or death from carotid endarterectomy and carotid stenting: a meta-analysis of pooled patient data from four randomised trials

Age was reported to be an effect-modifier in four randomised controlled trials comparing carotid artery stenting (CAS) and carotid endarterectomy (CEA), with better CEA outcomes than CAS outcomes noted in the more elderly patients. We aimed to describe the association of age with treatment differences in symptomatic patients and provide age-specific estimates of the risk of stroke and death within narrow (5 year) age groups. In this meta-analysis, we analysed individual patient-level data from four randomised controlled trials within the Carotid Stenosis Trialists' Collaboration (CSTC) involving patients with symptomatic carotid stenosis. We included only trials that randomly assigned patients to CAS or CEA and only patients with symptomatic stenosis. We assessed rates of stroke or death in 5-year age groups in the periprocedural period (between randomisation and 120 days) and ipsilateral stroke during long-term follow-up for patients assigned to CAS or CEA. We also assessed differences between CAS and CEA. All analyses were done on an intention-to-treat basis. Collectively, 4754 patients were randomly assigned to either CEA or CAS treatment in the four studies. 433 events occurred over a median follow-up of 2·7 years. For patients assigned to CAS, the periprocedural hazard ratio (HR) for stroke and death in patients aged 65-69 years compared with patients younger than 60 years was 2·16 (95% CI 1·13-4·13), with HRs of roughly 4·0 for patients aged 70 years or older. We noted no evidence of an increased periprocedural risk by age group in the CEA group (p=0·34). These changes underpinned a CAS-versus CEA periprocedural HR of 1·61 (95% CI 0·90-2·88) for patients aged 65-69 years and an HR of 2·09 (1·32-3·32) for patients aged 70-74 years. Age was not associated with the postprocedural stroke risk either within treatment group (p≥0·09 for CAS and 0·83 for CEA), or between treatment groups (p=0·84). In these RCTs, CEA was clearly superior to CAS in patients aged 70-74 years and older. The difference in older patients was almost wholly attributable to increasing periprocedural stroke risk in patients treated with CAS. Age had little effect on CEA periprocedural risk or on postprocedural risk after either procedure. None.

Abstract 119: Can CREST Procedural Results be Reproduced in General Practice in Post CREST Era?: Analysis of National Surgical Quality Improvement Program (NSQIP) Registry

Background: The Carotid revascularization for primary prevention of stroke assessed in CREST trial (year 2010) revealed risk of the composite outcome of stroke, myocardial infarction, or death were almost similar in carotid artery stenting (CAS) and carotid artery endarterectomy (CEA) group. This study analyzed such current clinical practice and outcome (year 2011 to 2013) from multicenter national registry described below. Methods: Cohort of non-high risk patients who underwent targeted CAS or CEA were collected from American College of Surgeons (ACS) National Surgical Quality Improvement Program (NSQIP) Registry in post CREST era. This registry prospectively collects around more than 300 variables across the nation pertaining to patient characteristics, co-morbid conditions, operative details, and 30-day postoperative outcomes. Frequency analysis of such outcome was performed to assess the re-validation of CREST trial in current clinical practice. Results: In Post CREST NSQIP Registry we identified 142 (CAS) and 7834 (CEA) patients. In Post CREST era (current clinical practice) the rates of any stroke among CEA patients (1.9%, 95% CI 1.57-2.17, CREST Ref 2.3%) (p=0.25) and CAS patients (2.1%, 95% CI 0.54-5.75, CREST Ref 4.1%) (p=0.25) observed in clinical practice were comparable to those observed in CREST trial. The rates of MI/arrhythmia among CEA patients (1.7%, 95% CI 1.47-2.06, CREST Ref 2.3%) (p=0.22) and CAS patients (2.8%, 95% CI 0.89-6.79, CREST Ref 1.1%) (p=0.13) are comparable from CREST trial. The rates of 1 month mortality among CEA patients (0.6%, 95% CI 0.42-0.76, CREST Ref 0.3%) (p=0.27) and CAS patients (0.7%, 95% CI 0.04-3.47, CREST Ref 0.7%) (p=0.92) were also similar. The rate of cranial nerve injury in CEA patients has declined (2.1%, CI 1.83-2.47, CREST Ref 4.7 %) (p&lt;0.0001).The combined primary endpoint for CEA patients (3.7%, 95% CI 3.32-4.17, CREST Ref 4.5%) (p=0.19) and CAS patients (5.6%, 95% CI 2.62-10.7, CREST Ref 5.2%) (p=0.81) was similar to CREST trial. Conclusions: Our results support reproducibility of CREST procedural outcomes for both CEA and CAS in general practice in post-trial period.

Carotid Endarterectomy and Carotid Artery Stenting Lead to Improved Cognitive Performance in Patients with Severe Carotid Artery Stenosis.

In patients with severe carotid artery stenosis, the effects of carotid artery reopening, achieved either by carotid endarterectomy (CEA) or carotid artery stenting (CAS), on cognitive functions remain elusive. Herein, we conducted a prospective study to determine whether and to what extent CEA and CAS affected cognitive performance. Patients admitted to the Department of Neurology or Vascular Surgery in Nanjing First Hospital from December 2012 to March 2015 with a diagnosis of severe carotid artery stenosis (>70%) were included in the study. Among them, 77 patients underwent CEA, 81 patients underwent CAS, and 77 patients who refused to receive aforementioned interventions were enrolled in control group. Of note, all patients in this study received basic pharmacological treatment according to the American Heart Association/American Stroke Association guidelines. Cognitive functions were evaluated by a broad spectrum of neuropsychological tests including the Mini-mental State Examination (MMSE), the Montreal Cognitive Assessment (MoCA) and event related potential P300 on the day prior to and at 3 months after indicated intervention. When compared with basic pharmacological treatment, both CEA and CAS significantly increased the scores of MMSE and MoCA at 3 months following procedures. Meanwhile, a significant reduction of P300 score was also observed in patients underwent CEA or CAS. In addition, the changes in MMSE, MoCA and P300 scores over time between CEA and CAS groups were not statistically significant. Taken together, our findings suggest an improvement of cognitive functions following carotid artery reopening. Meanwhile, the beneficial effects of CEA and CAS on cognitive performance seem to be equivalent.

Perioperative time course of matrix metalloproteinase-9 (MMP-9), its tissue inhibitor TIMP-1 & S100B protein in carotid surgery.

Background & objectives:Ischaemic stroke is a life burdening disease for which carotid endarterectomy (CEA) is considered a gold standard intervention. Pro-inflammatory markers like matrix metalloproteinases (MMPs) and their inhibitors (TIMPs) and S-100 Beta (S100B) may have a role in the early inflammation and cognitive decline following CEA. This study was aimed to describe the perioperative time courses and correlations between of MMP-9, TIMP-1 and S100B following CEA.Methods:Fifty four patients scheduled for CEA were enrolled. Blood samples were collected at four time points, T1: preoperative, T2: 60 min after cross-clamp release, T3: first postoperative morning, T4: third postoperative morning. Twenty atherosclerotic patients were included as controls. Plasma MMP-9, TIMP-1 and S100B levels were estimated by ELISA.Results:TIMP-1 was decreased significantly in the CEA group (P<0.01). Plasma MMP-9 was elevated and remained elevated from T1-4 in the CEA group (P<0.05) with a marked elevation in T3 compared to T1 (P<0.05). MMP-9/TIMP-1 was elevated in the CEA group and increased further by T2 and T3 (P<0.05). S100B was elevated on T2 and decreased on T3-4 compared to T1.Interpretation & conclusions:Our study provides information on the dynamic changes of MMP-9-TIMP-1 system and S100B in the perioperative period. Preoperative reduction of TIMP-1 might be predictive for shunt requirement but future studies are required for verification.

Patients with carotid atherosclerosis who underwent or did not undergo carotid endarterectomy: outcome on mood, cognition and quality of life.

BackgroundTo compare the six-month outcome on mood, cognition and quality of life (QoL) in patients with severe carotid atherosclerosis (CA) who underwent carotid endarterectomy (CEA) with subjects who refused treatment.MethodsCohort study on consecutive inpatients with CA (stenosis ≥ 50 %) (N = 46; age 72.56 ± 7.26; male 65.2 %). Intervention cohort: subjects who decided to undergo CEA (N = 35); Control cohort patients who refused CEA (N = 11). DSM-IV-Psychiatric diagnosis made by clinicians using interviews, QoL measured by Short Form Health Survey (SF-12); cognitive performance by WAIS Intelligent Coefficient (IC).ResultsThe study showed a better improvement during six months in Overall IC, Performance IC and Verbal IC in the group that underwent CEA. QoL in the two cohorts did not reach statistical significance. Percentages of patients who improved in the CEA group were significantly higher with regard to Overall and Verbal IC scores, and at the limits of statistical significance in Performance IC. The differences of subject with improvement in SF-12 score in the two groups did not reach statistical significance. Ages below 68 were found to be determinant of a good outcome in Overall IC score. Limit: study conducted with a small sample size.ConclusionsPatients with severe carotid atherosclerosis who underwent CEA enhanced their cognitive performance.

Modern medical treatment with or without carotid endarterectomy for severe asymptomatic carotid atherosclerosis

This study assessed the value of modern medical treatment (MMT) with and without carotid endarterectomy (CEA) in patients with asymptomatic severe carotid artery stenosis. We conducted a randomized trial involving 55 patients with 70% to 79% carotid stenosis at three Russian centers. Between 2009 and 2013, 31 patients were randomized to undergo CEA with MMT (CEA group) and 24 to receive MMT alone. The primary end point was nonfatal ipsilateral stroke or death from any cause during a follow-up period of 5.0 years. The secondary end point was any nonfatal stroke, carotid revascularization, or death from any cause during follow-up. The trial was stopped after a median follow-up of 3.3 years (maximum, 5.0 years). There were two primary events in the CEA group and nine events in the MMT group. The 3.3-year cumulative primary event rates were 6.5% in the CEA group and 37.5% in the MMT group (hazard ratio for the MMT group, 5.06; 95% confidence interval, 1.53-16.79; P = .008). The 3.3-year cumulative secondary end point was 12.9% in the CEA group and 50.0% in the MMT group (hazard ratio for the MMT group, 4.23; 95% confidence interval, 1.55-11.53; P = .0048). CEA as an initial management strategy could reduce the risk of death and major cerebrovascular events when added to MMT.

Stenting Versus Endarterectomy for Restenosis Following Prior Ipsilateral Carotid Endarterectomy: An Individual Patients' Data Meta-Analysis

OBJECTIVE: To study perioperative results and restenosis during follow-up of carotid artery stenting (CAS) versus carotid endarterectomy (CEA) for restenosis after prior ipsilateral CEA in an individual patient data (IPD) meta-analysis. BACKGROUND: The optimal treatment strategy for patients with restenosis after CEA remains unknown. METHODS: A comprehensive search of electronic databases (Medline, Embase) until July 1, 2013, was performed, supplemented by a review of references. Studies were considered for inclusion if they reported procedural outcome of CAS or CEA after prior ipsilateral CEA of a minimum of 5 patients. IPD were combined into 1 data set and an IPD meta-analysis was performed. The primary endpoint was perioperative stroke or death and the secondary endpoint was restenosis greater than 50% during follow-up, comparing CAS and CEA. RESULTS: In total, 13 studies were included, contributing to 1132 unique patients treated by CAS (10 studies, n = 653) or CEA (7 studies; n = 479). Among CAS and CEA patients, 30% versus 40% were symptomatic, respectively (P < 0.01). After adjusting for potential confounders, the primary endpoint did not differ between CAS and CEA groups (2.3% vs 2.7%, adjusted odds ratio 0.8, 95% confidence interval (CI): 0.4-1.8). Also, the risk of restenosis during a median follow-up of 13 months was similar for both groups (hazard ratio 1.4, 95% (CI): 0.9-2.2). Cranial nerve injury (CNI) was 5.5% in the CEA group, while CAS was in 5% associated with other procedural related complications. CONCLUSIONS: In patients with restenosis after CEA, CAS and CEA showed similar low rates of stroke, death, and restenosis at short-term follow-up. Still, the risk of CNI and other procedure-related complications should be taken into account.

Expression of the NLRP3 Inflammasome in Carotid Atherosclerosis

The aim of the present study was to investigate NLRP3 inflammasome expression in human carotid atherosclerotic plaques and its relationship to plaque vulnerability. Carotid atherosclerotic plaques collected from 30 patients scheduled for carotid endarterectomy (CEA) were subjected to immunohistochemical, mRNA, and protein expression studies. Ten mesenteric arteries from intestinal cancer patients served as controls for the immunohistochemical studies. Twenty individuals who had no carotid stenosis or coronary artery stenosis served as controls for analyzing atherosclerotic risk factors and for enzyme-linked immunosorbent assay (ELISA) studies. Serum samples were collected from all patients to determine interleukin-1β (IL-1β) and IL-18 levels. The NLRP3 inflammasome signaling pathway components NLRP3, ASC, caspase-1, IL-1β, and IL-18 were strongly expressed in carotid atherosclerotic plaques, but not in healthy mesenteric arteries. Immunohistochemical, mRNA, and protein expression studies revealed higher expression levels of NLRP3, ASC, caspase-1, IL-1β, and IL-18 in unstable compared to stable plaques. The NLRP3 inflammasome was localized in the cytoplasm of macrophages and foam cells and was associated with cholesterol crystal clefts inside and outside of cells. ELISA showed that the serum levels of the cytokines IL-1β and IL-18 were higher in the CEA group compared to controls. These results demonstrated for the first time the close relationship between the expression of NLRP3 signaling pathway and human carotid atherosclerotic plaques. NLRP3, ASC, caspase-1, IL-1β, and IL-18 were associated with plaque vulnerability and atherogenesis. The serum levels of IL-1β and IL-18 may be useful predictors of atherosclerosis.

A Nationwide Comparison of Early Outcomes After Carotid Endarterectomy and Carotid Artery Stenting

To compare short term outcomes of carotid endarterectomy (CEA) and carotid artery stenting (CAS) in the Nationwide Inpatient Sample (NIS) database of the Healthcare Cost and Utilization Project (HCUP). An analysis of approximately 8 million hospital admissions per year from 2008 to 2012 was obtained from the HCUP NIS database. Using International Classification of Diseases, Ninth Revision, Clinical Modification codes, we selected patients with the diagnosis of carotid artery stenosis and then created a subset of patients that underwent either CEA or CAS. The study focused on early outcomes including stroke, perioperative myocardial infarction (MI), postoperative hematoma, and in-hospital mortality. Statistical analysis was done with IBM SPSS version 21. We used multivariate analysis to study the independent effect of type of procedure on the outcomes. After weighted adjustment, a total of 520,444 (22.4%) patients underwent CEA, and 78,337 (3.4%) patients underwent CAS. Average age of CEA and CAS patients was 71.0 + 9.5 years and 70.7 + 10.0 years, respectively (P = 0). The difference in percentage of octogenarians in both groups was not significant (20.1% vs 20.6%; P = .15). There were 58% males in the CEA group and 61% in the CAS group (P = 0). Postoperative stroke rate for CEA vs CAS was 1.0% vs 2.0% (odds ratio [OR], 2.17; 95% confidence interval [CI], 1.91-2.45; P = 0). In the octogenarian subgroup, this difference increased to 1.0% vs 2.9% (OR, 2.91; 95% CI, 2.28-3.70; P = 0). MI for CEA vs CAS was 1.5% vs 1.9% (OR, 1.26; 95% CI, 1.18-1.43; P = 0). Postoperative hematoma for CEA vs CAS was 2.3% vs 2.1% (OR, 0.92; 95% CI, 0.82-1.03; P = .17), while in-hospital mortality for CEA vs CAS was 0.4% vs 1.0% (OR, 2.53; 95% CI, 2.10-3.04; P = 0). After adjusting for confounders, the differences in postoperative stroke, postoperative hematoma, and death between the two procedures were significant (all P < .05); however, contrary to the unadjusted result, the CAS showed significantly lower risk for MI (OR, 0.82; 95% CI, 0.73-0.97; P = .02). CEA has lower adjusted risk for postoperative stroke and death, while CAS has lower adjusted risk for MI and postoperative hematoma.

Comparison of domain-specific cognitive function after carotid endarterectomy and stenting

Observational data indicate that carotid artery stenting (CAS) is associated with higher incidence of subclinical cerebral microemboli than carotid endarterectomy (CEA). We hypothesized that CEA would be associated with superior performance on detailed domain-specific cognitive testing compared with CAS. Patients with >80% asymptomatic carotid artery stenosis were randomized to CEA or CAS with side of stenosis balanced across condition. A robust battery of tests was used to assess the cognitive domains of attention, memory, mood, visual-spatial skills, motor ability, processing speed, and executive functioning ≤10 days preoperatively and postoperatively at 6 weeks and 6 months. Tests were administered using standardized conditions and were scored by individuals blinded to treatment allocation. Baseline cognitive performance was similar between CAS (n = 29) and CEA (n = 31) groups (P > .05). Relative to baseline, verbal and visual memory and attention functions substantially improved in the CAS and CEA groups at 6 months (multiple cognitive tests achieved statistical significance). Compared with CEA, cognitive processing speed (Stroop Color test: 9.0 vs 7.3, P = .04; and Stroop Word test: 9.0 vs 7.4, P = .05) was superior in the CAS group at 6 weeks. Executive functioning (phonemic verbal fluency: 10.6 vs 8.4, P = .043) and motor function (Grooved Pegboard of nondominant extremity: 45.7 vs 38.9, P = .022) were also superior in the CAS group at 6 months. Tests of attention, memory, and visual-spatial skills were similar between CAS and CEA patients at 6 weeks and 6 months. Carotid revascularization improves memory and attention within the first 6 postoperative months. Compared with CEA, CAS produces improvements in cognitive processing speed, executive functioning, and motor function.

Carotid Bifurcation Resection and Interposition of a Polytetrafluorethylene Graft (BRIG) for Carotid Disease: A Retrospective Study of 153 Consecutive Procedures

Carotid endarterectomy (CEA) is the gold standard for treatment of carotid artery stenosis. CEA can be challenging, even technically impossible. Prosthetic carotid bypass grafting is a proven and safe alternative when CEA is hazardous. An alternative technique that is prosthetic carotid bifurcation resection and interposition of a polytetrafluorethylene graft (BRIG) is described in this article. In our Department of Vascular Surgery, between January 2007 and October 2014, 103 BRIG procedures were performed. The outcome of conventional CEA and patients treated by the BRIG procedure were compared. Within the same period of time 50 CEA procedures (32.7%) were performed. Morbidity, mortality, and postoperative restenosis were compared. The 30-day mortality was 1% for the BRIG group and 0% in the CEA group (P value, 0.4839). The 30-day stroke rate was 1.9% for the BRIG group and 0% in the CEA group (P value, 0.3222). One patient died in the early postoperative period from acute myocardial infarction. A total of 13 (8.5%) patients died during follow-up, none of which were surgery related. Median follow-up was 29.1 months. There was a statistically higher restenosis rate in the CEA group compared with the BRIG group (16.0% vs. 1.9%, P value, 0.0053). Other complications were comparable. Mean operating and clamping time were significantly shorter in the BRIG group. BRIG appears to be a safe and feasible surgical alternative to CEA. The technique allows for shorter operating time, shorter clamping time, and appears to result in lower restenosis rates. Complication rates seem to be comparable to CEA. Prospective, randomized controlled trials on this topic are needed. To perform bilateral procedures, a bifurcation graft should be created to revascularize both the internal and external carotid artery.