Carotid Stenting Procedure Research Articles

Sex as a Predictor of Outcomes for Symptomatic Carotid Stenosis: A Comparative Analysis between CAS and CEA.

Reporting gender-related outcomes for symptomatic carotid lesion revascularization after both endarterectomy (CEA) and carotid artery stenting (CAS) procedures in an unselected group of patients treated by Italian Vascular Specialists. A retrospective study was conducted on patients presenting with recently symptomatic carotid stenosis treated by CAS and by CEA. The primary endpoint was the 30 days any stroke occurrence rate; secondary endpoints were technical success, occurrence of transient ischemic attack (TIA), acute myocardial infarction (AMI) and death. Demographic, clinical and procedural data were all noted in order to identify the outcome's determining factor. A total of 265 patients (193 males and 72 females) were enrolled, and of these 134 (50.5%) underwent CEA and 131 CAS (49.5%). At 30 days, the overall new stroke rate was 3.4% (one fatal), and no TIA, AMI or deaths were observed. Among strokes, seven major and two minor strokes were reported, with six after CEA and three after CAS (p = 0.32; OR: 2; CI95%: 0.48-8.17). The timing of revascularization has been found to be slightly associated with new stroke occurrence: seven out nine strokes were observed in patients treated within 14 days from symptom onset (5.5% vs. 1.4%; p = 0.08, OR: 3.8, CI95%: 0.77-18.56). Lastly, female patients presented a significantly higher risk of post-operative stroke compared to male patients: 6.9% vs. 2.1% (p: 0.05; OR: 3.52; CI95%: 0.91-13.52). Our experience seems to suggest that both CEA and CAS provide safe and effective results in treating patients presenting with symptomatic carotid stenosis. Regardless of the type of revascularization, female sex is an independent risk factor for stroke recurrence after treatment.

Association Between Hospital Policy on Local Versus General Anesthesia, and Outcomes of Carotid Endarterectomy

BACKGROUND Carotid endarterectomy (CEA) is an established procedure for the treatment of extracranial internal carotid artery stenosis. However, the type of anesthesia during elective CEA is still under debate. This study analyzes the association between the hospital policy on local anesthesia (LA) versus general anesthesia, and the outcome of elective CEA in German hospitals. METHODS This retrospective analysis is based on the nationwide German statutory carotid quality assurance database for the years 2012 to 2016. Research was funded by Germany's Federal Joint Committee Innovation Fund (funding reference number 01VSF19016). Emergency CEA and carotid stenting procedures were excluded from the analysis. A total of 119 800 patients remained in the analysis. Hospitals were classified on a yearly basis as routine general anesthesia (<10% LA), selective LA (10%–90% LA), or routine LA centers (>90% LA). The primary outcome event was the combined in‐hospital rate of stroke or death. Secondary outcome events were in‐hospital stroke, major stroke or death, death, myocardial infarction, and major adverse cardiovascular events. Univariate and multivariable regression analyses were performed to analyze associations between the primary outcome event and the hospital policy on LA versus general anesthesia as well as clinical or procedural variables. RESULTS Patient characteristics did not differ significantly between the groups (age, degree of stenosis, and rate of symptomatic patients). Raw primary outcome event rates were 1.9%, 2.1%, and 1.6% in routine general anesthesia, selective LA, and routine LA centers, respectively. Multivariable analysis revealed a significant lower rate of the primary outcome event for CEA operated under LA (adjusted odds ratio, 0.47 [95% CI, 0.33–0.67]; P <0.001). Stratified multivariable analysis revealed that the beneficial effect of LA was only present in routine LA centers. CONCLUSION LA is associated with a lower risk of in‐hospital stroke or death after CEA in centers that use LA routinely.

Assessment of Plaque Characteristics by Contrast-Enhanced Ultrasound and Stent Restenosis following Carotid Artery Stenting: A Retrospective Study

Background and objective: carotid artery stenosis contributes significantly to ischemic strokes, with management options including carotid endarterectomy (CEA) and carotid artery stenting (CAS) ischemic stroke risk can be reduced. Controversies persist regarding their efficacy and factors influencing complications, and understanding the relationship between atherosclerotic plaque characteristics and stent restenosis after CAS is crucial. Methods: we conducted a retrospective study involving 221 patients who underwent CAS for symptomatic or asymptomatic carotid artery stenosis. Comprehensive assessments of plaque morphology were performed using contrast-enhanced ultrasound (CEUS) before CAS. Patient demographics, including smoking status and diabetes, were also recorded. Stent restenosis was diagnosed using various imaging modalities, including ultrasound, angiography, and digital subtraction angiography (DSA). Results: plaque analysis using CEUS revealed a significant association between plaque grade and restenosis incidence (p < 0.001), particularly with grade 0 (11.1%) and grade 2 plaques (66.7%). Smoking was notably associated with plaque vascularization and restenosis (p < 0.001), while diabetes did not significantly impact plaque characteristics or restenosis risk (p > 0.05). The mean duration of restenosis was 17.67 months. Stenting was the most frequent treatment modality for restenosis (70.6%). However, no significant relationship was found between restenosis type and plaque morphology (p = 0.268). Furthermore, while no clear relationship was observed between plaque morphology and the type of restenosis, our findings underscored the importance of plaque characterization in predicting post-CAS outcomes. Conclusions: this study highlights the utility of CEUS in predicting stent restenosis following CAS. There was a significant association between stent restenosis within 12–24 months after the carotid stenting procedure and an elevated grade of plaque vascularization. Moreover, one of the main factors possibly determining the grade of plaque vascularization was smoking. Further research is warranted to elucidate the underlying mechanisms and refine risk stratification in this patient population.

690 Residual In-stent Carotid Stenosis and Cigarette Smoking are Predictors of Restenosis After Stenting (CAS)

INTRODUCTION: Atherosclerosis of the internal carotid artery remains a significant contributor to stroke morbidity and mortality. While patient risk factors have been identified to be associated with carotid restenosis after carotid stenting (CAS), conflicting theroies exist on whether residual stenosis is an independent risk factor. METHODS: A single-center, prospectively maintained database was retrospectively reviewed for CAS procedures over a 12-year period. Patient demographic, procedural characteristics, radiographic and clinical details were noted. Comparison of baseline characteristics of patients with and without carotid restenosis were performed using chi-squared test for categorical variables and student t-test for continuous variables. Univariate and multivariate analyses were performed to determine risk factors associated with restenosis, defined as >70% on digital subtraction angiography. RESULTS: 1017 consecutive carotid artery stenting (CAS) procedures were performed in 905 patients over the 12-year period, with 738 CAS procedures in 632 patients included after exclusion criteria. Overall restenosis rate was 17%, with a 14% restenosis rate at 2 years-time. Multivariable analysis demonstrated former/current smoking status (OR=2.1 [95%CI 1.2-3.9]), moderate contralateral stenosis (OR 3.0 [95%CI 1.4-6.7]), severe contralateral stenosis (OR3.0 [1.4-6.3]), and residual stenosis (OR 454 [95% 85-2413]) were associated with restenosis. AUC for the multivariable model was 0.78. Cut-point degree for residual stenosis was ∼30%, where there was a 9% and 35% rate of restenosis in those less than, and greater than, 30% residual stenosis, respectively. CONCLUSIONS: We present the largest single-center data in the US to date on carotid artery stenosis treated with CAS, and factors associated with restenosis. Residual in-stent carotid stenosis and smoking history were independent predictors. Maximizing treatment of initial stenosis within stent for carefully selected patients and aggressive smoking cessation education are important steps in preventing future carotid restenosis.

Abstract TP50: Ensuring Safe Post-Procedure Throughput for CEA and CAS Patients

Background: A new policy was implemented in November 2021 to reduce the length of post-anesthesia-care-unit (PACU) stay from 6 hours to 4 hours to reduce the nursing care burden and decrease the length of stay, yet how it affected patients’ events after PACU discharge needed close evaluation. Thus, the QI project aimed to retrospectively examine unexpected or safety events of patients who underwent carotid artery stenting or carotid endarterectomy procedures before versus after implementing the new policy. Objective: To compare and examine the rates of unexpected or safety events that occurred before (5/1/2021 - 10/31/2021; PRE) vs. after (2/1/2022 - 7/31/2022; POST) adoption of the new policy. Methods: A determination of IRB review was granted for the retrospective QI project. The unexpected or safety events included patient issues (rapid response calls, STAT calls to service, or bounce back to a higher level of care) and issues with VS or neuro assessment variability. For group comparison, Fisher’s Exact tests were used for dichotomous information, and the Mann-Whitney U tests were performed for continuous data. Results: A total of 145 patients were identified during the study period composing 75 (51.7%) PRE and 70 (48.3%) POST patients. The rates of VS or neuro assessment variability were similar in both groups (PRE: 1.3% vs. POST: 1.3%, p =1.000). Though we saw a lower rate of patient issues within 24 hours on the floor in POST (4.3%), the difference was not statistically significant (PRE: 8.0%, p =0.496). Conclusion: Inefficient patient throughput can impact currently strained hospital resources. Findings of the QI project confirmed that the new policy did not incur a higher rate of instability on the nursing unit. This data lends confidence to Vascular Surgery and Stroke programs as they seek to streamline patient care and manage hospital resources.

Residual In-Stent Carotid Stenosis and Cigarette Smoking are Independent Predictors of Carotid Restenosis After Carotid Artery Stenting—Results from 738 Carotid Artery Stenting Procedures at a Single Center

BACKGROUND AND OBJECTIVES: Carotid artery stenting (CAS) has become a viable alternative to carotid endarterectomy for the management of carotid stenosis. Our aim was to determine the rate of radiographic restenosis after CAS and clinical, radiographic, and procedural predictors of in-stent restenosis. METHODS: Our single-center, prospectively maintained database was retrospectively reviewed for CAS procedures performed in symptomatic and asymptomatic patients over 12 years (2010-2022). Baseline demographic data, procedural characteristics, and preprocedural and postprocedural radiographic and clinical details were noted. Baseline characteristics of patients with and without carotid restenosis were compared using the χ2 test for categorical variables and the Student t-test for continuous variables. Univariate and multivariate analyses were performed to determine risk factors associated with restenosis, defined as >70% on digital subtraction angiography. RESULTS: A total of 1017 consecutive CAS procedures were performed in 905 patients during the 12-year period, with 738 in 632 patients included in our study. Our cohort's overall restenosis rate was 17%, with a 14% restenosis rate at 2 years. On multivariate regression analysis, former or current smoking status (odds ratio [OR] = 2.3, 95% CI 1.2-4.1), plaque irregularity (OR 0.55, 95% CI 0.33-0.91), moderate (50.1%-75%) contralateral stenosis (OR 3.2, 95% CI 1.4-7.2), severe (75.1%-99.9%) contralateral stenosis (OR 2.8, 95% CI 1.3-6.0), and residual (>70%) in-stent stenosis after initial stenting (OR 433, 95% CI 80-2346) were significantly associated with carotid restenosis. Area under the curve for the multivariate regression model analysis was 0.78. Patients with <28.6% initial (residual) in-stent stenosis (45/517 cases) had a 9% restenosis rate, whereas those with >28.6% initial in-stent stenosis (77/221 cases) had a 35% restenosis rate. CONCLUSION: In this large, single-center study of carotid artery stenosis treated with CAS, residual in-stent carotid stenosis of approximately 30% and smoking status were independent predictors for restenosis. Maximizing treatment of initial stenosis and smoking cessation education are important steps in preventing future carotid restenosis.

Female and male patients have similar outcomes after transcarotid artery revascularization in prospective trials

ObjectiveSex disparities in outcomes after carotid revascularization have long been a concern, with several studies demonstrating increased postoperative death and stroke for female patients after either carotid endarterectomy or transfemoral stenting. Adverse events after transfemoral stenting are higher in female patients, particularly in symptomatic cases. Our objective was to investigate outcomes after transcarotid artery revascularization (TCAR) stratified by patient sex hypothesizing that the results would be similar between males and females. MethodsWe analyzed prospectively collected data from the Safety and Efficacy Study for Reverse Flow Used During Carotid Artery Stenting Procedure (ROADSTER)1 (pivotal), ROADSTER2 (US Food and Drug Administration indicated postmarket), and ROADSTER Extended Access TCAR trials. All patients had verified carotid stenosis meeting criteria for intervention (≥80% for asymptomatic patients and ≥50% in patient with symptomatic disease), and were included based on anatomical or clinical high-risk criteria for carotid stenting. Neurological assessments (National Institutes of Health Stroke Scale, Modified Rankin Scale) were obtained before and within 24 hours from procedure end by an independent neurologist or National Institutes of Health Stroke Scale-certified nurse. Patients were stratified by sex (male vs female). Baseline demographics were compared using χ2 and Fisher's exact tests where appropriate; primary outcomes were combination stroke/death (S/D) and S/D/myocardial infarction (S/D/M) at 30 days, and secondary outcomes were the individual components of S/D/M. Univariate logistic regression was conducted. ResultsWe included 910 patients for analysis (306 female [33.6%], 604 male [66.4%]). Female patients were more often <65 years old (20.6% vs 15%) or ≥80 years old (22.6% vs 20.2%) compared with males, and were more often of Black/African American ethnicity (7.5% vs 4.3%). There were no differences by sex in term of comorbidities, current or prior smoking status, prior stroke, symptomatic status, or prevalence of anatomical and/or clinical high-risk criteria. General anesthetic use, stent brands used, and procedure times did not differ by sex, although flow reversal times were longer in female patients (10.9 minutes male vs 12.4 minutes female; P = .01), as was more contrast used in procedures for female patients (43 mL male vs 48.9 mL female; P = .049). The 30-day S/D and S/D/M rates were similar between male and female patients (S/D, 2.7% male vs 1.6% female [P = .34]; S/D/M, 3.6% male vs 2.6% female [P = .41]), which did not differ when stratified by symptom status. Secondary outcomes did not differ by sex, including stroke rates at 30 days (2.2% male vs 1.6% female; P = .80), nor were differences seen with stratification by symptom status. Univariate analysis demonstrated that history of a prior ipsilateral stroke was associated with increased odds of S/D (odds ratio [OR], 4.19; P = .001) and S/D/M (OR, 2.78; P = .01), as was symptomatic presentation with increased odds for S/D (OR, 2.78; P = .02). ConclusionsProspective TCAR trial data demonstrate exceptionally low rates of S/D/MI, which do not differ by patient sex.

Natural history of antiplatelet nonresponders undergoing carotid artery stenting.

Routine antiplatelet responsiveness testing for patients undergoing carotid artery stenting procedures is not performed at most endovascular centers and remains a topic of controversy within the neurointerventional community. The objective of this study was to determine if nonresponsiveness to acetylsalicylic acid or clopidogrel was associated with the development of symptomatic thromboembolic events in patients undergoing carotid stenting procedures. A prospective study was conducted at the Foothills Medical Centre in Calgary, Alberta, Canada, from August 2019 to July 2021. Patients undergoing carotid artery stenting procedures and who were receiving dual antiplatelet therapy were enrolled in the study. Responsiveness to the antiplatelet medications was determined through whole blood impedance aggregometry. The primary outcome was development of a symptomatic thromboembolic event within 90 days after the procedure. The treating physicians were blinded to the aggregometry results for the duration of the study. One hundred two procedures were performed in 100 patients. Eight thromboembolic events (8%) occurred during the study. Age (p = 0.03) and nonresponsiveness to clopidogrel (p = 0.003) were associated with the development of thromboembolic events. The multivariable model showed that clopidogrel nonresponsiveness was independently associated with the development of a thromboembolic event (adjusted OR 6.14, 95% CI 1.25-30.11, p = 0.03). This study demonstrated that patients who were identified as clopidogrel nonresponders, using whole blood impedance aggregometry, were at an increased risk of developing thromboembolic events. Larger studies are needed to assess the utility of routine platelet function testing prior to carotid artery stenting procedures.

Medication error during nonoperating room anesthesia—a case report

Despite a lot has already been done in the field of safety improvement during anesthesia, medication errors still occur during everyday practice. Syringe or ampule swaps are usually the most frequent type of medication error. Recent studies prove that nearly 80% of these errors are preventable. In our case, 30 mg (3 ml) of dopamine (Dopamin Fresenius 10 mg/ml) was injected to the patient’s intravenous line instead of 3 mg (3 ml) midazolam (Midazolam Accord 1 mg/ml) during the preparation for the carotid artery stenting procedure in nonoperating room environment. The error was realized immediately after the application. Besides temporary fulminant hypertensive reaction, tachycardia, restlessness, skin rush, troponin leak, and temporary ST-segment depression, there were no permanent consequences to the patient's health. The team was able to perform the planned procedure 30 min after the event. This medication error of ampule swap, packages of which were stored in the medication cupboard one above the other, was caused by alignment of the latent vulnerable layers of the safety system (Swiss Cheese Model of System Error and Hot Cheese Model) plus the influence of the environmental factors and active failures done by the anesthesia staff. After this event, new safety measures were established by introducing color-coded ISO 26825:2020 syringe labeling, new anesthesia trolleys with color-coded medication compartments, and color-coded medication storage cupboards. Besides this safety committee was formed for the promotion of medication safety education programs.

Protamine Sulfate Following Carotid Artery Stenting: Does the Patient’s Gender Matter?

Protamine sulfate can be administrated to decrease the risk of bleeding after the carotid artery stenting (CAS) procedure. Although a few studies reported data regarding the efficacy and safety of protamine, the existing literature assessing its impact under more personalized patient circumstances is limited. Therefore, in this study, we aimed to identify the potential factors where the patients are more likely to benefit from protamine sulfate after CAS procedures. A retrospective review of Vascular Quality Initiative data between 2016 and 2022 to identify all patients who underwent CAS procedures was performed. The patients were divided into two groups based on the surgical approach: transfemoral CAS (TF-CAS) and transcarotid artery revascularization (TCAR). A multivariate model was conducted to identify the perioperative predictors of bleeding complications in each cohort. In addition, a propensity score matching was performed to compare the rates of thrombotic events between protamine vs no protamine groups in both cohorts. A total of 61,686 patients were identified; 36.6% were female. Approximately 53% of the patients underwent TCAR (protamine: 85.6%; no protamine: 14.4%), whereas TF-CAS was performed in 46.8% (protamine: 18.9%; no protamine: 81.1%). Protamine use was associated with a decreased risk of bleeding complications after TCAR (0.26 [0.2-0.3]; P < .001) but not TF-CAS (1.06 [0.8-1.3]; P = .6164). However, the protamine beneficial impact is more apparent among the female patients regardless of the surgical approach (Table). In addition, no significant increase was noted in the thrombotic complications in both TF-CAS (protamine vs no protamine: death, 7.9% vs 11.5%; myocardial infarction, 0.5% vs 0.9%; stroke/transient ischemic attack, 2.8% vs 2.9%; P > .05 for all, except death P < .001) and TCAR (protamine vs no protamine: death, 7.7% vs 7.3%; myocardial infarction, 0.4% vs 0.3%; stroke/transient ischemic attack, 2.4% vs 2.9%; P > .05 for all) groups. Protamine sulfate appears to be effective in reducing the bleeding complications in patients who undergo TCAR but not TF-CAS, without an increase in the thrombotic complications. However, this beneficial impact is more significant among female patients regardless of the CAS approach.TablePerioperative predictors of bleeding complications after TCAR and TF-CASaCovariatebNo protamineProtamineAdjusted odds ratio (95% CI)P valueAdjusted odds ratio (95% CI)P value(A) TCAR Sex (female)1.45 (1.2-1.9).00501.08 (0.9-1.3).4639 Race (Asian) (Ref: White)4.29 (1.4-13.1).01041.31 (0.6-3.0).5139 Symptomatic CHF1.67 (1.1-2.6).02451.21 (0.8-1.7).3206(B) TF-CAS Sex (female)1.76 (1.4 – 2.2)<.0011.14 (0.8 – 1.7).5277ACEI, Angiotensin-converting enzyme inhibitor; ARB, angiotensin receptor blocker; CHF, congestive heart failure; CI, confidence interval; COPD, chronic obstructive pulmonary disease; TCAR, transcarotid artery revascularization; TF-CAS, transfemoral carotid artery stenting.aOnly the perioperative predictors that were statistically significant on the univariate and multivariate analysis are shown in this table.bOther covariates: age ≥65, Hispanic ethnicity, comorbidities (hypertension, diabetes, dialysis status, smoking, and COPD), perioperative medications (aspirin, antiplatelet, statin, β-blockers, ACEIs/ARBs), and type of anesthesia. Open table in a new tab

Transcarotid Revascularization Outcomes Are Not Affected by the Choice of Antiplatelet with Aspirin

Over one-third of transcarotid revascularization (TCAR) patients demonstrate mild to severe resistance to clopidogrel resulting in an increase in hematologic testing and potential healthcare costs. This investigation was completed to determine if the choice of the second antiplatelet in addition to aspirin affected perioperative outcomes. Consecutive carotid stenting procedures identified from the Vascular Quality Initiative (VQI) from January 2016 to September 2016 were captured. We excluded patients with nonatherosclerotic disease, intracranial disease, and tandem lesions. Two cohorts of patients maintained on dual antiplatelet therapy were compared consisting of aspirin + clopidogrel (AC) and aspirin + prasugrel/ticagrelor (APT). A 1:1 propensity score match including procedure characteristics, age, gender, race, symptomatic status, diabetes, coronary artery disease, prior coronary artery bypass grafting/percutaneous coronary intervention, congestive heart failure, chronic obstructive pulmonary disease, dialysis, smoking status, prior ipsilateral or contralateral coronary artery stenting/carotid endarterectomy, contralateral occlusion, preoperative anticoagulation, urgency, protamine use, and physician case volume was completed to compare perioperative results. Within the specified study period, we captured 38,813 carotid stenting patients on AC and 2346 patients maintained on APT (Table I). Of the AC patients, 25,293 received TCAR while the remaining 13,520 underwent transfemoral stenting. Similarly, 1308 APT patients underwent TCAR and 1038 received transfemoral stenting. Before propensity matching, the crude results noted that APT patients were more likely to experience in-hospital mortality (0.5% vs 1.1%; P < .01), but there was no difference in ipsilateral stroke (1.2% vs 1.1%; P = .62), any stroke (1.5% vs 1.4%; P = .84), or myocardial infarction (MI) (0.5% vs 0.7%; P = .31). After adjustment with our propensity match (Table II), 2047 unique subject pairs were generated. There was no statistical difference with respect to in-hospital mortality (0.6% vs 0.9%; P = .30), ipsilateral stroke (1.4% vs 1.0%; P = .41), any stroke (1.5% vs 1.3%; P = .85), MI (0.8% vs 0.8%; P = .84), or stent thrombosis (0.1% vs 0.3%; P = .18). Additionally, there was no difference in the combined outcomes of stroke/death (1.9% vs 2.0%; P = .63) or stroke/death/MI (2.6% vs 2.7%; P = .74). As testing for antiplatelet resistance has become more prominent in the last several years, we evaluated and noted no variability between study groups before or after a procedure date in 2019. No difference in perioperative stroke, death, and/or stent occlusion are noted after TCAR in patients maintained on AC compared to APT. Therefore, routine testing for clopidogrel resistance is an unnecessary healthcare cost which can be eliminated.Table IACAPTP valuen = 38,813 (94.3)2346 (5.7)Prasugrel346 (14.75)Ticagrelor2000 (85.2)Procedure<.001 Transcarotid artery revascularization25,293 (65.2)1308 (55.7) Transfemoral carotid artery stenting13,520 (34.8)1038 (44.3)Surgery year<.001 2016706 (1.8)37 (1.6) 20173044 (7.8)139 (5.9) 20184666 (12.0)199 (9.5) 20197066 (18.2)379 (16.2) 20207560 (19.5)457 (19.5) 20219836 (25.3)716 (30.5) September 20225935 (15.3)419 (17.9)AC, Aspirin + clopidogrel; APT, aspirin + prasugrel/ticagrelor. Open table in a new tab Table IIBefore PSM (crude outcomes)1:1 PSM (adjusted outcomes)aACAPTP valueACAPTOR (95% CI)bP valuen = 38,813 (94.3)2346 (5.7)n = 2047n = 2047In-hospital outcomes Death204 (0.5)25 (1.1)<0.0113 (0.6)19 (0.9)1.49 (0.70-3.18).30 Ipsilateral stroke457 (1.2)25 (1.1)0.6229 (1.4)21 (1.0)0.77 (0.42-1.43).41 Stroke549 (1.45)32 (1.40)0.8430 (1.5)27 (1.3)0.94 (0.53-1.67).85 MI204 (0.5)16 (0.7)0.3117 (0.8)16 (0.8)0.93 (0.45-1.91).84 Stroke/death680 (1.8)50 (2.1)0.1838 (1.9)41 (2.0)1.13 (0.69-1.83).63 Stroke/death/MI844 (2.2)65 (2.8)0.0653 (2.6)56 (2.7)1.08 (0.70-1.65).74 Bleeding requiring intervention229 (0.6)15 (0.6)0.7611 (0.5)14 (0.7)1.28 (0.56-2.84).54 Immediate restenosis/occlusion63 (0.2)7 (0.3)0.122 (0.1)6 (0.3)3.0 (0.60-14.8).18AC, Aspirin + clopidogrel; APT, aspirin + prasugrel/ticagrelor; CI, confidence interval; MI, myocardial infarction; OR, odds ratio; PSM, propensity score matching.Values are number (%) unless otherwise stated.aNo interaction between antiplatelet regimen and type of procedure in predicting outcome and between antiplatelet regimen and surgeries performed before or after 2019 (P > .10). Open table in a new tab

Young patients undergoing carotid stenting procedures have an increased rate of procedural failure at 1-year follow-up

ObjectiveThe outcomes of patients with premature cerebrovascular disease (age ≤55 years) who undergo carotid artery stenting are not well-defined. Our study objective was to analyze the outcomes of younger patients undergoing carotid stenting. MethodsThe Society for Vascular Surgery Vascular Quality Initiative was queried for transfemoral carotid artery stenting (TF-CAS) and transcarotid artery revascularization (TCAR) procedures between 2016 and 2020. Patients were stratified based on age ≤55 or >55 years. Primary endpoints were periprocedural stroke, death, myocardial infarction (MI), and composite outcomes. Secondary endpoints included procedural failure (defined as ipsilateral restenosis ≥80% or occlusion) and reintervention rates. ResultsOf the 35,802 patients who underwent either TF-CAS or TCAR, 2912 (6.1%) were ≤55 years. Younger patients were less likely than older patients to have coronary disease (30.5% vs 50.2%; P < .001), diabetes (31.5% vs 37.9%; P < .001), and hypertension (71.8% vs 89.8%; P < .001), but were more likely to be female (45% vs 35.4%; P < .001) and active smokers (50.9% vs 24.0%; P < .001) Younger patients were also more likely to have had a prior transient ischemic attack or stroke than older patients (70.7% vs 56.9%; P < .001). TF-CAS was more frequently performed in younger patients (79.7% vs 55.4%; P < .001). In the periprocedural period, younger patients were less likely to have a MI than older patients (0.3% vs 0.7%; P < .001), but there was no significant difference in the rates of periprocedural stroke (1.5% vs 2.0%; P = .173) and composite outcomes of stroke/death (2.6% vs 2.7%; P = .686) and stroke/death/MI (2.9% vs 3.2%; P = .353) between our two cohorts. The mean follow-up was 12 months regardless of age. During follow-up, younger patients were significantly more likely to experience significant (≥80%) restenosis or occlusion (4.7% vs 2.3%; P = .001) and to undergo reintervention (3.3% vs 1.7%; P < .001). However, there was no statistical difference in the frequency of late strokes between younger and older patients (3.8% vs 3.2%; P = .129). ConclusionsPatients with premature cerebrovascular disease undergoing carotid artery stenting are more likely to be African American, female, and active smokers than their older counterparts. Young patients are also more likely to present symptomatically. Although periprocedural outcomes are similar, younger patients have higher rates of procedural failure (significant restenosis or occlusion) and reintervention at 1-year follow-up. However, the clinical implication of late procedural failure is unknown, given that we found no significant difference in the rate of stroke at follow-up. Until further longitudinal studies are completed, clinicians should carefully consider the indications for carotid stenting in patients with premature cerebrovascular disease, and those who do undergo stenting may require close follow-up.

Morphometric Study and Branching Patterns of External Carotid Artery Using Computed Tomography Angiography Among the South Indian Population: A Retrospective Study.

The prime source of vascularization to the head and neck region is through the carotid arteries. The terminal branches of common carotid arteries, such asexternal carotid artery (ECA) and internal carotid artery (ICA), and their branches are crucial due to the wide area of distribution and variations in their branching pattern. The branching pattern and morphometry are essential for surgeons in the planning and execution of head and neck surgeries. Therefore, this study was conducted to observe the branching patterns of ECA and analyze them morphometrically. This retrospective study includes 100 CT images, inclusive of 32 females and 68 males. The branching pattern and luminal diameter of CCA and ECA were measured and analyzed statistically. The luminal diameter of CCA in males were as follows: 7.4 ± 1.01 (R), 7.1 ± 0.8 (L), and in females: 7.3 ± 0.9 (R), 7 ± 0.9mm (L); and the luminal diameter of ECA in males: 5.2 ± 1.0mm (R), 5.2 ± 0.9mm (L), and in females: 5.0 ± 0.9mm (R), 5.1 ± 1.0mm (L). The level of the carotid bifurcation and ECA branching pattern was observed, and variations were commonly seen in the superior thyroid artery (STA), lingual artery (LA), and facial artery (FA). Conclusion: The findings of the present study with regard to the external carotid artery and its branching pattern correlate with previous studies. The most common variations were observed in the superior thyroid and lingual and facial arteries. Knowledge about the morphology and branching pattern of the carotid artery is essential for procedures such as intra-arterial chemotherapy, carotid artery stenting, endarterectomy, and extra-intra cranial bypass revascularization procedure where it is harvested as a donor's vessel.

Evaluation of the self-expanding effect of carotid stents in the early postoperative period.

To evaluate the expansion effect of self-expandable stents during the first week after carotid artery stenting (CAS) procedure and to examine the variation of the effect according to the carotid plaque type. Seventy stenotic carotid arteries of 69 patients were stented by using self-expanding Wallstents with diameters of 7 and 9mm, after detection of stenosis and plaque type by Doppler ultrasonography. Post-stent aggressive ballooning was avoided and residual stenosis rates were measured with digital subtraction angiography. After the stenting procedure, the caudal, narrowest, and cranial diameters of stents were measured with ultrasonography at 30min, first day and first week. Stent diameter increase and change according to plaque type were evaluated. Two-way repeated measure ANOVA test was used for statistical analysis. A significant increase was observed in the mean stent diameter in the three stent regions (caudal, narrow, and cranial) from the 30th minute to the first and seventh days (p < 0.001). The most prominent stent expansion occurred in the cranial and narrow segments within the first day. In the narrow stent region; Stent diameter increase between 30th minute-first day, 30th minute-first week, and first day-first week were all significant (p < 0.001). At 30min, first day, and first week, no significant difference was detected between plaque type and stent expansion in caudal, narrow, and cranial regions (p = 0.286). We think that keeping the lumen patency limited to 30% residual stenosis after CAS procedure by applying minimal post-stenting balloon dilatation and leaving the remaining lumen expansion to the self-expanding feature of the Wallstent might be a sensible approach in order to avoid embolic events and excessive carotid sinus reactions (CSR).

Evaluation of the association between silent ischemic lesions and stent design in carotid stenting applications

Minor ischemic events and silent ischemic lesions are more common in carotid stenting than in endarterectomy. These silent ischemic lesions are also associated with stroke risk and cognitive impairment, so it is important to understand the factors that increase the risk and develop strategies to reduce the risk. We aimed to evaluate the association between carotid stent design and silent ischemic lesion development. The files of the patients who underwent carotid stenting between January 2020 and April 2022 were scanned. Patients with diffusion MR images taken within the postoperative 24 h were included in the study, while those undergoing acute stent placement were excluded. The patients were divided into two groups: those with open-cell stents and those with closed-cell stents. A total of 65 patients, including 39 patients undergoing open-cell stenting and 26 patients undergoing closed-cell stenting, were included in the study. There was no significant difference in demographic data and vascular risk factors between the groups. New ischemic lesions were detected in 29 (74.4%) patients in the open-cell stent group and 10 (38.4%) patients in the closed-cell stent group and were significantly higher in the open-cell group. There was no significant difference between the two groups in terms of major and minor ischemic events and stent restenosis at the 3-month follow-up. The rate of new ischemic lesion development was found to be significantly higher in carotid stent procedures performed with an open-cell Protégé stent than in those performed with a closed-cell Wallstent stent.

Physiologic risk factors increase risk of myocardial infarction with transcarotid artery revascularization in prospective trials

ObjectivePatients can be considered at high risk for carotid endarterectomy (CEA) because of either anatomic or physiologic factors and will often undergo transcarotid artery revascularization (TCAR). Patients with physiologic criteria will be considered to have a higher overall surgical risk because of more significant comorbidities. Our aim was to study the incidence of stroke, myocardial infarction (MI), death, and combined end points for patients who had undergone TCAR stratified by the risk factors (anatomic vs physiologic). MethodsAn analysis of prospectively collected data from the ROADSTER (pivotal; safety and efficacy study for reverse flow used during carotid artery stenting procedure), ROADSTER 2 (Food and Drug Administration indicated postmarket trial; postapproval study of transcarotid artery revascularization in patients with significant carotid artery disease), and ROADSTER extended access TCAR trials was performed. All 851 patients were considered to be at high risk for CEA and were included and stratified using high-risk anatomic criteria (ie, contralateral occlusion, tandem stenosis, high cervical artery stenosis, restenosis after previous endarterectomy, bilateral carotid stenting, hostile neck anatomy with previous neck irradiation, neck dissection, cervical spine immobility) or high-risk physiologic criteria (ie, age >75 years, multivessel coronary artery disease, history of angina, congestive heart failure New York Heart Association class III/IV, left ventricular ejection fraction <30%, recent MI, severe chronic obstructive pulmonary disease, permanent contralateral cranial nerve injury, chronic renal insufficiency). For trial inclusion, asymptomatic patients were required to have had ≥80% carotid stenosis and symptomatic patients to have had ≥50% stenosis. The primary outcome measures were stroke, death, and MI at 30 days. The data were statistically analyzed using the χ2 test, as appropriate. ResultsA total of 851 high surgical risk patients were categorized into two groups: those with anatomic-only risk factors (n = 372) or at least one physiologic risk factor present (n = 479). Of the 851 patients, 74.5% of those in the anatomic subset were asymptomatic, and 76.6% in the physiologic subset were asymptomatic. General anesthesia was used similarly in both groups (67.7% anatomic vs 68.1% physiologic). MI had occurred in eight patients in the physiologic group (1.7%), all of whom had been asymptomatic and in none of the anatomic patients (P = .01). The combined stroke, death, and MI rate was 2.1% in the anatomic cohort and 4.2% in the physiologic cohort (P = .10). Stratification of each group into asymptomatic and symptomatic patients did not yield any further differences. ConclusionsThe patients who had undergone TCAR in the present prospective, neurologically adjudicated trial because of high-risk physiologic factors had had a higher rate of MI compared with the patients who had qualified for TCAR using anatomic criteria only. These patients had experienced comparable rates of combined stroke, death, and MI rates. The anatomic patients represented a healthier and younger subset of patients, with notably low overall event rates.

Periprocedural P2Y12 inhibitors improve perioperative outcomes after carotid stenting by primarily decreasing strokes

ObjectiveThe continuation of antiplatelet agents in the periprocedural period around carotid stenting (CAS) procedures is felt to be mandatory to minimize the risk of periprocedural stroke. However, the optimal antiplatelet regimen is unclear, with some advocating dual antiplatelet therapy, and others supporting the use of P2Y12 inhibitors alone. The objective of this study was to evaluate the periprocedural effect of P2Y12 inhibitors for CAS. MethodsThe Vascular Quality Initiative was used from years 2007 to 2020. All transcarotid artery revascularization (TCAR) and transfemoral carotid artery stenting (TF-CAS) procedures were included. Patients were stratified based on perioperative use of P2Y12 inhibitors as well as symptomatic status. Primary end points were perioperative neurological events (strokes and transient ischemic attacks). Secondary end points were mortality and myocardial infarction. ResultsA total of 31,036 CAS procedures were included for analysis, with 49.8% TCAR and 50.2% TF-CAS cases; 63.8% of patients were male and 82.3% of patients were on a P2Y12 inhibitor. P2Y12 inhibitor use was more common in males, asymptomatic patients, those older than 70 years, and concurrent statin use. P2Y12 inhibitors were more likely to be used in TCAR cases than in TF-CAS cases (87.3% vs 76.8%; P < .001). The rate of periprocedural neurological events in the whole cohort was 2.6%. Patients on P2Y12 inhibitors were significantly less likely to experience a periprocedural neurological event (2.3% vs 3.9%; P < .001) and mortality (0.6% vs 2.1%; P < .001) than those who were not on a P2Y12 inhibitor. There was no effect on the rates of myocardial infarction. On multivariate analysis, both symptomatic and asymptomatic patients on P2Y12 inhibitors were significantly less likely to develop perioperative neurological events. Additionally, the use of P2Y12 inhibitors demonstrated an independent significant effect in reducing of the rate of perioperative stroke (odds ratio, 0.29; 95% confidence interval, 0.25-0.33). Finally, additional analysis of the types of P2Y12 inhibitors used revealed that all seemed to be equally effective in decreasing the periprocedural neurological event rate. ConclusionsThe use of perioperative P2Y12 inhibitors seems to markedly decrease the perioperative neurological event rate with TCAR and TF-CAS in both symptomatic and asymptomatic patients and should be strongly considered. Patients with contraindications to P2Y12 inhibitors may not be appropriate candidates for any CAS procedure. Additionally, alternative types of P2Y12 inhibitors seem to be equally effective as clopidogrel. Finally, an analysis of the Vascular Quality Initiative demonstrates that, even for TCAR cases, only 87.3% of patients seem to be on P2Y12 inhibitors in the periprocedural period, leaving room for significant improvement.

Comparison of Complications and Cost for Transfemoral Versus Transcarotid Stenting of Carotid Artery Stenosis

Options for endovascular treatment of carotid artery disease have been developed to compliment with carotid endarterectomy, transfemoral carotid artery stenting (TFCAS) and a hybrid approach with transcarotid artery revascularization (TCAR). We sought to capture endpoints outside of stroke, myocardial infarction (MI), and death involved with each procedure at our institution as well as evaluate cost. Carotid stent procedures performed from 2014 to 2020 at our institution underwent comparative analysis based upon access site and type of stent procedure performed, TFCAS versus TCAR. Procedural details and outcomes were captured prospectively and included in the National Cardiovascular Data Peripheral Vascular Intervention Registry (NCDR-PVI). Further retrospective review was performed to evaluate endpoints beyond stroke, MI, and death. Total in-hospital cost, including administrative, capital and utilities (fixed cost), and labor and supplies (variable cost) were also evaluated. One hundred thirty-seven patients were reviewed. Seventy-seven were treated with TFCAS and 60 with TCAR. The mean age was 74years, predominantly male (68%) and Caucasian (90%). Patients undergoing TFCAS were more likely to be symptomatic compared to those receiving TCAR (81.8% vs. 50.0%, P = <0.001). There were no statistically significant differences in event rates, including mortality, recurrent cerebrovascular accident / transient ischemic attack, or bleeding. Complications not captured in the NCDR-PVI database were more frequent in the TCAR group (21.7% vs. 5.2%, P=0.004) and included pneumothorax (n=2), neck hematoma (n=8), and common carotid artery stenosis or injury (n=3). Rates of complications in the TFCAS group (n=4) were lower and limited to groin hematoma (n=2), central retinal artery occlusion causing vision loss and a case of postoperative dysphagia. Geographic miss of initial stent placement was identified in 15.0% of TCAR patients and 2.6% (P=0.008) of TFCAS patients. Restenosis rates on duplex ultrasound were similar between the two groups (14.6% of patients) and were not associated with symptoms. The mean follow-up interval was similar for both groups of 31.8months for TCAR and 30.7months for TFCAS (P=0.797). There was a statistically significant difference in total cost with TCAR being more expensive ($22,315 vs. $11,001) driven by direct costs that included devices, imaging, and extended length of stay in the TCAR group (P<0.001). There was no significant difference between stroke free survival (91.1% vs. 88.6%, P=0.69) and mortality (78.1% vs. 85.2%, P=0.677) at 3years follow-up between TCAR and TFCAS, respectively. Both TFCAS and TCAR provide similar 3-year stroke and mortality risk/benefit and are distinctly different procedures. Both should be evaluated independently with analysis of variables beyond stroke, death, and MI. TFCAS is more cost-effective than TCAR in this single institution study.

The safety and efficacy of the Mo.Ma system device for carotid artery stenting: A single-center experience from Taiwan.

BackgroundProximal protection devices, such as the Mo.Ma system provides better neurological outcomes than the distal filter system in the carotid artery stenting (CAS) procedure. This study first evaluated the safety and efficacy of the Mo.Ma system during CAS in a single tertiary referral hospital from Taiwan. The outcomes of distal vs. proximal embolic protection devices were also studied.MethodsA total of 294 patients with carotid artery stenosis who underwent the CAS procedure were retrospectively included and divided into two groups: 152 patients in the distal filter system group and 142 patients in the Mo.Ma system. The outcomes of interest were compared between the two groups. The factors contributing to occlusion intolerance (OI) in the Mo.Ma system were evaluated.ResultsThe procedure success rates were more than 98% in both groups. No major stroke occurred in this study. The minor stroke rates were 2.8% (4/142) and 4.6% (7/152) in the Mo.Ma system and filter system, respectively (p = 0.419). Patients with hypoalbuminemia significantly predicted the risk of stroke with an odds ratio of 0.08 [95% confidence interval (CI), 0.01–0.68, p = 0.020] per 1 g/day of serum albumin in the filter group. A total of 12 patients developed OI in the Mo.Ma system (12/142, 8%). Low occlusion pressure predicted the occurrence of OI in the Mo.Ma group with the hazard ratios of 0.88 (95% CI: 0.82–0.96) and 0.90 (95% CI: 0.84–0.98) per 1 mmHg of occlusion systolic pressure (OSP) and diastolic pressure (ODP), respectively. We further indicated that patients with an OSP of ≥60 mmHg or an ODP of ≥44 mmHg could tolerate the procedure of occlusion time up to 400 s, while patients with an OSP of <49 mmHg or an ODP of <34 mmHg should undergo the procedure of occlusion time less than 300 s to prevent the occurrence of OI.ConclusionWe have demonstrated the safety and effectiveness of the Mo.Ma system during CAS in an Asia population. By reducing the occlusion time, our study indicated a lower risk of OI in the Mo.Ma system and proposed the optimal occlusion time according to occlusion pressure to prevent OI during the CAS procedure. Further large-scale and prospective studies are needed to verify our results.

Stroke Neurologists Question the FDA Expanded Indication for Carotid Stenting Procedure

Stroke Neurologists Question the FDA Expanded Indication for Carotid Stenting Procedure