Carotid Stenting Procedure Research Articles

Abstract 125: Intravascular Ultrasound: A Clinically Useful Tool for Carotid Plaque Characterization

OBJECTIVE: Virtual Histology Intravascular Ultrasound (VH™ IVUS) is valuable for estimating minimal lumen diameter (MLD) and plaque characterization. The clinical use of IVUS in the carotid arteries is not well characterized. To evaluate carotid plaque morphology, we performed VH™ IVUS in patients with known carotid artery stenosis. METHODS: From July 2010, patients were prospectively enrolled in an IRB approved study to undergo IVUS prior to an elective carotid stenting procedure. Hospital records were reviewed for co-morbidities, carotid/arch anatomy, preoperative carotid duplex velocity measurements, and incidence of postoperative microemboli. Comparison of pre- and postoperative diffusion-weighted MR images was used to identify microemboli. IVUS-derived MLD and vessel wall plaque characteristics were collected. Spearman correlation was performed between MLD and duplex estimated stenosis, and between plaque characteristics and frequency of postoperative microemboli. RESULTS: 14 patients were enrolled during the study period with carotid artery stenosis (average ICA/CCA ratio 5.5, 64.3% asymptomatic). Major co-morbidities included hyperlipidemia (79%), diabetes (71%), and angina (43%). 57% of patients had type 1 arches, and 50% of patients had heavily calcified irregular carotid plaques. MLD correlated with preoperative duplex ICA/CCA ratio (R2=-0.56,p=0.05), and carotid plaque area correlated with peak systolic and diastolic velocities (R2=-0.55,p=0.05). Although microembolic frequency did not correlate with preoperative patient characteristics, it correlated with IVUS-derived plaque necrotic core area (R2=0.53,p=0.05). CONCLUSION: We demonstrate that periprocedural carotid IVUS is clinically feasible and useful. Preoperative duplex measurements correlated with IVUS MLD confirming the fidelity of the technique. Moreover carotid IVUS demonstrates that patients with necrotic plaque cores have a higher frequency of postoperative microemboli. These findings suggest that carotid IVUS may be helpful to identify patients who are at higher risk of microemboli during carotid artery stenting.

COMPARATIVE EFFECTIVENESS OF COMMONLY USED DEVICES FOR CAROTID ARTERY STENTING

A variety of different stents and embolic protection devices (EPD) are used for carotid artery stenting (CAS). Little is known about current usage patterns and differences in outcomes with these devices. We analyzed 9863 consecutive carotid stent procedures in the NCDRR CARER registry performed

Headache in Carotid Artery Stenting and Angiography

Carotid angioplasty headache and diagnostic criteria are based on scarce data and small series. Here, we aimed to determine presence, frequency, and characteristics of headache after carotid artery stenting and angiography headache and speculate on possible mechanisms of head and neck pain emerging during or after the carotid artery stenting procedure. The total of 64 patients who were admitted to our Neuroradiology Division of Radiology Department for primary percutaneous transluminal carotid interna stenting were included in the study. They had symptomatic or asymptomatic carotid artery disease with stenosis more than 70%. All patients were questioned by a neurologist regarding the presence, side, location, quality, severity, duration, and timing of headache after both angiography and stenting procedures. Frequency of headache after carotid interna stenting was 39.1%, it commonly arose in a short period after the procedure and relieved in 10 minutes. This type of headache was mild, ipsilateral, frontotemporal in location, pressing in nature, and arose frequently within 10 minutes after the procedure, whereas angiography headache had a frequency of 21.9% and it was ipsilateral, mild, burning-like headache. Angiography headache also relieved within 10 minutes. Both types of headache were related to severe stenosis. Our study clearly demonstrates that headache is seen after carotid artery stenting (39.1%) and angiography (21.9%). Although both types of headache have similar characteristics, they differ in that it is mostly pressing in the group of carotid artery stenting and burning in angiography group.

Abstract 2652: Carotid Revascularization Provides Similar Outcomes in Symptomatic and Asymptomatic Patients with <70 Years

Absolute stroke risk and perioperative stroke risk during carotid revascularization are higher in patients with symptomatic than in those with asymptomatic carotid stenosis. Age is one of the main risk factors for stroke and trials have shown a significant age interaction after carotid stenting (CAS). This study aims to analyze the effect of age on outcomes of carotid revascularization using the 70-year threshold as suggested by CREST. Methods: From 2001 to 2010 patients receiving carotid revascularization, either by CAS or by endarterectomy (CEA) were reviewed. Perioperative stroke-death rates and 72-month survival and late stroke incidence were compared in symptomatic and asymptomatic patients with less and more than 70years. Results: 2196 procedures, 1080 by CAS 1116 by CEA, were reviewed;684 were performed for carotid referable symptoms. Symptomatic patients showed higher perioperative stroke/death risks (3.5% vs 1.9%, p=0.034) and lower 72-months survival (74% vs 82%, p=0.0001) or freedom from late stroke (93% vs 97%, p=0.002) than asymptomatic patients with similar differences detected within CEA or CAS procedure. When only the group of 949 youngsters (≤70y) was analyzed, symptomatic and asymptomatic patients shared similar low perioperative stroke/death risks: 2.1% vs 1.3%, p=0.39. For young symptomatic patients, perioperative stroke/death risk was comparably low in CAS and CEA: 1.8% vs 1.2%. At 72 months, survival (98% vs 97%, p=0.49) and freedom from stroke (89% vs 89%, p=0.33) rates were similarly high in symptomatic and asymptomatic young patients. Comparable risks between the symptomatic and asymptomatic youngsters were found after each CAS (perioperative stroke/death: p=0.64; survival: p=0.10; late stroke: p=0.50) and CEA (perioperative stroke/death: p=0.49; survival: p=0.91; late stroke: p=0.64) procedure. Higher perioperative and late risks were confirmed for symptomatic patients in the elderly (>70y) subgroup (n=1247) regardless of the procedure. Conclusions: Outcomes following carotid revascularization are related to patient age. For younger ages (≤70years) symptomatic and asymptomatic patients may share similarly low perioperative and late risks of stroke and death after carotid revascularization whichever the procedure applied.

Creating accountable care for carotid angioplasty and stenting: A multidisciplinary carotid revascularization board

Background:We tested the feasibility of a mandated multidisciplinary carotid revascularization board (MDCB) to review, approve and monitor all carotid artery and stenting (CAS) procedures and outcomes at our institution.Methods:The board was composed of vascular surgeons, cardiologists, interventional neuroradiologists, neurosurgeons, and neurologists, who met weekly to facilitate an evidence-based, consensus recommendation to ensure appropriate CAS referral.Results:The board successfully reviewed and continues to review and approve all CAS procedures at our center. Of the 69 patients considered high risk for standard surgical treatment, 42 patients were symptomatic and 27 patients were asymptomatic. Their mean age was 70.5-year-old and the median degree of stenosis was 79%. In the 74 procedures, periprocedural complications occurred at the following rates: 2.7% death, 2.7% major stroke, 2.7% minor stroke, and 2.7% myocardial infarction (MI) within 30 days of the procedure. At 1 year the primary endpoints of ipsilateral stroke and neurovascular-related death were observed in 8.1% and 2.7% of the patients, respectively. At mean follow-up of 21 months, 18.8% of the patients (13/69) had died (including all causes), and 14.5% (10/69) experienced stroke (including nontarget strokes). Target vessel revascularization was needed in 2.9% patients.Conclusions:A mandated multidisciplinary carotid revascularization board MDCB is feasible and potentially advantageous in real clinical practice. It establishes a model for accountable care by providing a mechanism for institutional oversight, credentialing operators, quality review, standardizing care, cost containment and eliminating the “subspecialty silo mentality.”

Carotid stenting improves cognitive function in asymptomatic cerebral ischemia

ObjectivesAsymptomatic critical internal carotid artery (ICA) stenosis may lead to cognitive impairment. Carotid stenting (CS) may improve cerebral perfusion, but its impact on neuro-cognitive function has been controversial. MethodsWe prospectively enrolled 34 asymptomatic patients with unilateral ICA stenosis or occlusion, in whom CS was attempted. Computed tomography cerebral perfusion (CTP), and functional assessments including National Institutes of Health Stoke Scale (NIHSS), Bathel Index (BI), and a battery of neuropsychological tests including Mini-Mental State Examination (MMSE), Alzheimer Disease Assessment Scale-Cognitive Subtest (ADAS-Cog), verbal fluency, and Color Trail Making A and B, were done prior to and 3months after the procedure. ResultsSuccessful CS was achieved in 28 of 34 patients (82%). Based on the baseline CTP finding and intervention result, patients were divided into three groups: group I (n=6) as ipsilateral cerebral ischemia with failed CS procedure, group II (n=17) as ipsilateral cerebral ischemia with successful CS procedure, and group III (n=11) as normal baseline CTP with successful CS procedure. The demographics and baseline cognitive performances were similar among the three groups. In group II, there were significant improvement in Alzheimer Disease Assessment Scale (pre 6.8±4.3 vs post 4.9±2.8, p=0.033), Mini-Mental State Examination Score (pre 25.8±3.8 vs post 27.4±3.5, p=0.007), and Color Trail test A (pre 120.4±73.9s vs post 95.8±57.6s, p=0.004) after CS. In groups I and III, however, no significant difference was observed in any of the cognitive tests. ConclusionsSuccessful CS improves neurocognitive function in asymptomatic ICA stenosis or occlusion with objective ipsilateral ischemia.

657 Carotid artery stenting: Cerebral lesions risk and serological markers levels

Microembolization during the carotid artery stenting (CAS) procedure may cause cerebral lesions. Elevated C-Reactive Protein (hsCRP), Vascular endothelial growth factor (VEGF) and serum amyloid A protein (SAA) exert inflammatory activities thus promoting carotid plaque instability. Neuron specific enolase (NSE) is considered a marker of cerebral injury. However their clinical significance on the outcome of revascularization is unknown. This study aims to establish the correlation between embolization and serological markers. Serum hsCRP, SAA and VEGF pre-operatory levels were evaluated in patients with symptomatic carotid stenosis who underwent filter-protected CAS procedure. Patients with hsPCR<5mg/l, SAA<10mg/L and VEGF<500pg/ml were classified in class I or in class II for higher values. Plaques were characterized by grey scale median and classified as homogenous or dishomogenous. Cerebral embolization was evaluated by diffusion weight resonance magnetic imaging (DWI-MR) and through microscopical and ultrastructural analysis of filters, based on percentage of surface involvement (SI) and occluded pore (OP) by embolic material. Results were compared by Fisher's, Student T test and Mann-Whitney U test. Mean hsCRP, SAA and VEGF in 26 patients was respectively 13.43 mg/l, 42.24 mg/l e 509.85 pg/ml. In class I patients, with hsCR P < 5 mg/l, SAA<10mg/L and VEGF<500pg/ml, mean OP was 21.5% versus 35.3% for patients in class II (P < 0.05). In either group, embolic material captured by the filter was identified as atherosclerotic plaque fragments and platelets aggregates. Volume and number of cerebral lesions increased significantly in all patients with hsCRP > 5mg/l and SAA>10mg/l (16.5 vs 2.8 mean number, 3564.6 vs 417.6 mm3 mean volume). All patients presented an increase of 32% of NSE mRNA level expression after the CAS procedure. Finally, patients with indication to CAS had serological values of hsCRP, SAA and NSE three times greater compared to a group of patients submitted to carotid endarterectomy procedure. High hsCRP, SAA and VEGF levels in symptomatic patients are associated with significantly greater embolization during CAS. Cerebral lesions occurred in the group of patients with higher level of inflammation marker and OP. This preliminary data suggest that CAS might not be indicated as a method of revascularization in this specific group of patients.

Physician Specialty and Carotid Stenting Among Elderly Medicare Beneficiaries in the United States

The use of carotid stenting is rising across the United States. How physician specialty relates to its utilization rates or outcomes is uncertain. We performed an observational analysis of fee-for-service Medicare beneficiaries 65 years or older undergoing carotid stenting between 2005 and 2007 in 306 hospital referral regions (HRRs). We first determined how frequently carotid stenting was performed by different specialists within each HRR and then used multivariable regression models to compare population-based utilization rates and 30-day outcomes for this procedure across HRRs based on the proportion performed by cardiologists, surgeons, radiologists, or a mix of specialists. In 272 HRRs where at least 15 procedures were performed during the study period, we identified 28700 carotid stenting procedures performed by 2588 operators. While cardiologists made up approximately one-third of these operators, they were responsible for 14919 (52.0%) procedures. Significant differences were noted in the characteristics of patients treated by cardiologists compared with other specialties, including higher rates of invasive cardiac procedures and lower rates of acute stroke or transient ischemic attacks in the 180 days prior to carotid stenting. Population-based utilization rates were significantly higher in HRRs where cardiologists performed most procedures relative to HRRs where most were done by other specialists or a mix of specialists (P<.001). In contrast, risk-standardized outcomes did not differ across HRRs based on physician specialty. Carotid stenting is being performed by operators from diverse specialties. Hospital referral regions where cardiologists perform most procedures have higher population-based utilization rates with similar outcomes.

Ischemic Stroke and Transient Ischemic Attack After Head and Neck Radiotherapy

Cerebrovascular disease can complicate head and neck radiotherapy and result in transient ischemic attack and ischemic stroke. Although the incidence of radiation vasculopathy is predicted to rise with improvements in median cancer survival, the pathogenesis, natural history, and management of the disease are ill defined. We examined studies on the epidemiology, imaging, pathogenesis, and management of medium- and large-artery intra- and extra-cranial disease after head and neck radiotherapy. Controlled prospective trials and larger retrospective trials from the last 30 years were prioritized. The relative risk of transient ischemic attack or ischemic stroke is at least doubled by head and neck radiotherapy. Chronic radiation vasculopathy affecting medium and large intra- and extra-cranial arteries is characterized by increasing rates of hemodynamically significant stenosis with time from radiotherapy. Disease expression is the likely consequence of the combined radiation insult to the intima-media (accelerating atherosclerosis) and to the adventitia (injuring the vasa vasorum). Optimal medical treatment is not established. Carotid endarterectomy is confounded by the need to operate across scarred tissue planes, whereas carotid stenting procedures have resulted in high restenosis rates. Head and neck radiotherapy significantly increases the risk of transient ischemic attack and ischemic stroke. Evidence-based guidelines for the management of asymptomatic and symptomatic (medium- and large-artery) radiation vasculopathy are lacking. Long-term prospective studies remain a priority, as the incidence of the problem is anticipated to rise with improvements in postradiotherapy patient survival.

Efficient Implementation of Patient-specific Simulated Rehearsal for the Carotid Artery Stenting Procedure: Part-task Rehearsal

Objective(s) Patient-specific simulated rehearsal (PsR) is a technological advance within the domain of endovascular virtual reality (VR) simulation. It allows incorporation of patient-specific computed tomography Digital Imaging and Communications in Medicine (CT DICOM) data into the simulation and subsequent rehearsal of real patient cases. This study aimed to evaluate whether a part-task rehearsal (PTr) of a carotid artery stenting procedure (CAS) on a VR simulator is as effective as a full-task (FTr) preoperative run through. Methods Medical trainees were trained in the CAS procedure and randomised to a PTr or FTr of a challenging CAS case (Type-II arch). PTr consisted of 30 min of repeated catheterisations of the common carotid artery (CCA). Thereafter, both groups performed the CAS procedure in a fully functional simulated operating suite (SOS) with an interventional team. Technical performances were assessed using simulator-based metrics and expert ratings. Other aspects of performance were assessed using the Non-Technical Skills for Surgeons (NOTSS) scoring. Results Twenty trainees were evenly randomised to either PTr or FTr. No differences in performance were seen except for the total time the embolic protection device (EPD) was deployed (9.4 min for the PT vs. 8.1 min for the FT, p = 0.02). Total time (26.3 vs. 25.5 min, p = 0.94), fluoroscopy time (15.8 vs. 14.4 min, p = 0.68), number of roadmaps (10.5 vs. 11.0, p = 0.54), amount of contrast (53.5 vs. 58.0 ml, p = 0.33), time to deploy the EPD (0.9 vs. 0.8 min, p = 0.31) and time to catheterise the CCA (9.2 vs. 8.9 min, p = 0.94) were similar. Qualitative performances as measured by expert ratings (score 24 vs. 24, p = 0.49) and NOTSS ( p > 0.05 for all categories) were also comparable. Conclusions Part- and full-task rehearsals are equally effective with respect to the operative performance of a simulated CAS intervention. This finding makes a patient-specific rehearsal more efficient and may increase the feasibility of implementation of this technology into medical practice.

Risk Factors Predictive of Carotid Artery Stenting–Associated Subclinical Microemboli

Subclinical microemboli documented on diffusion-weighted magnetic resonance imaging (DWI) are common following carotid artery stenting (CAS) procedures despite absence of neurological symptoms. This study was to evaluate risk factors predictive of microemboli in patients undergoing protected CAS with a distal embolic protection device. All CAS patients who received pre- and postprocedural magnetic resonance imaging (MRI) evaluations for carotid interventions at a single academic institution from July 2004 to December 2008 were examined. Microemboli were defined by new hyperintensities on postoperative DWI with corresponding decreased diffusion. Risk factors including patient demographics, medical comorbidities, clinical symptoms, lesion morphologies, and perioperative information were examined, and logistic regression analyses were utilized to determine predictors of CAS-related microemboli. A total of 204 patients underwent carotid interventions (76 CAS and 128 carotid endarterectomies) during the study period; 167 of them, including 67 CAS patients, received both preoperative and postoperative MRIs. Among those who underwent protected CAS, the incidence of microemboli was 46.3% despite a relative low incidence of associated neurological symptoms (2.9%). Univariate and multivariate regression analyses showed that date of procedure (odds ratio [OR] 30.6 and p = 0.019) and preoperative transient ischemic attack symptoms (OR 9.24 and p = 0.009) were independent predictors of developing postoperative changes on DWI in the ipsilateral hemisphere, and age >76 years was predictive of having new lesions on DWI in the contralateral hemisphere (OR 6.11 and p = 0.026). Our study underscores that certain risk factors are significantly associated with CAS-related microemboli and that physician experience and patient selection are essential in improving outcome of CAS procedures.

Abstract No. 40: Improving results for the carotid artery stenting procedure: Validation of the scoring system for anatomic suitability for CAS with simulated procedure rehearsal

Abstract No. 40: Improving results for the carotid artery stenting procedure: Validation of the scoring system for anatomic suitability for CAS with simulated procedure rehearsal

Patient-specific Endovascular Simulation Influences Interventionalists Performing Carotid Artery Stenting Procedures

Objective The ability to perform patient-specific simulated rehearsal of complex endovascular interventions is a technological advance with potential benefits to patient outcomes. This study aimed to evaluate whether patient-specific rehearsal of a carotid artery stenting (CAS) procedure has an influence on tool selection and the use of fluoroscopy. Methods Following case note and computed tomography (CT) angiographic review of a real patient case, subjects performed the CAS procedure on a virtual reality simulator. Endovascular tool requirements and fluoroscopic angles were evaluated with a pre- and post-case questionnaire. Participants also rated the simulation from 1 (poor) to 5 (excellent). Results Thirty-three endovascular physicians with varying degrees of CAS experience were recruited: inexperienced (5–20 CAS procedures) n = 11, moderately (21–50 CAS procedures) n = 7 or highly experienced (>50 CAS procedures) n = 15. For all participants, 96 of a possible 363 changes (26%) were observed from pre- to post-case questionnaires. This was most notable for optimal fluoroscopy C-arm position 15/33 (46%), choice of selective catheter 13/33 (39%), choice of sheath or guiding catheter 11/33 (33%) and balloon dilatation strategy 10/33 (30%). Experience with the CAS procedure did not influence the degree of change significantly ( p > 0.05), and all groups exhibited a considerable modification in tool and fluoroscopy preference. The model was considered realistic and useful as a tool to practice a real case (median score 4/5). Conclusion Patient-specific simulated rehearsal of a complex endovascular procedure strongly influences tool selection and fluoroscopy preferences for the real case. Further research has to evaluate how this technology may transfer from in vitro to in vivo and if it can reduce the radiation dose and the number of endovascular tools used and improve outcomes for patients in the clinical setting.

Synchronous carotid artery stenting and open heart surgery

The optimal management of the patients requiring cardiac surgery with concomitant severe carotid disease remains a controversy. The traditional approach involves staged or combined carotid endarterectomy and cardiac surgery. This study evaluated the feasibility and safety of angioplasty and stenting for the treatment of carotid stenoses concomitantly to cardiac operations to reduce the risk of perioperative stroke. All patients scheduled for cardiac surgery were screened preoperatively by color duplex ultrasonography for carotid disease. Carotid stenoses ≥60% in symptomatic patients and ≥70% in asymptomatic patients were treated using carotid artery stenting (CAS) under local anesthesia immediately before the open heart surgery. Cerebral protection devices were used in all cases. Patients did not receive aspirin or clopidogrel before the procedure. In a prospective, nonrandomized study, we analyzed 90 consecutive patients requiring cardiac surgery with concomitant severe carotid artery disease who underwent one stage CAS and cardiac surgery. Despite the high baseline risk profile, our results were encouraging. Carotid stenting was successful in all patients. No neurologic complications occurred during the carotid stenting procedures. The 30-day death/stroke rate was 2.2% (one death, one contralateral stroke). No myocardial infarction occurred. The carotid restenosis rate was zero during the intermediate-term follow-up. In our experience, CAS followed immediately by cardiac surgery is safe and represents a reasonable option for selected patients presenting with severe carotid and coronary disease.

Can experienced physicians with high peripheral interventional volume but low carotid artery stenting (CAS) volume achieve low complication rates during CAS?

It has been stated that experienced physicians with a high volume of carotid artery stent (CAS) procedures have low complication rates, including cerebrovascular accidents (CVA). Complication rates, however, are not known for physicians with a low volume of CAS (<50 CAS/yr) but with a high volume of other peripheral endovascular procedures. Since the techniques used in CAS are similar to those used routinely in other peripheral interventions, we hypothesise that high volume peripheral interventional operators with appropriate training would have low complication rates during CAS procedures. We reviewed all CAS procedures that were performed from 2004-2009 by an experienced physician with a high peripheral interventional volume (>250 interventions/year). Filter-based embolic protection devices were used during each CAS procedure. Each patient was followed for 30 days and data on major adverse cardiac and cerebral events (MACCE) collected. Ninety-two patients with ninety-five lesions were treated with CAS. Recent CVA was the indication in half of the patients and asymptomatic high-grade stenosis was the indication in the other half. Twenty-one (23%) patients had previous history of CEA and six (7%) patients had previous CAS in the contralateral side. All CAS procedures were technically successful. One patient (1.1%) had a TIA with total resolution of symptoms in ten minutes. There were no major strokes. MACCE rate was 1.1% at 30 days. We found a very low complication rate following CAS with embolic protection performed by an experienced physician who has a relatively low CAS volume but a high volume of other peripheral interventions.

Predictors of Neurological Events Associated With Carotid Artery Stenting in High-Surgical-Risk Patients

Background— Comorbid and anatomic characteristics that portend higher procedural risk are well defined for carotid endarterectomy but less so for carotid artery stenting. Methods and Results— We pooled carotid stent data from 4 Cordis-sponsored trials (n=2104) with similar patient cohorts and end point determination to identify predictors of neurological death or stroke within 30 days of the procedure. Median age was 74 years (24% &gt;80 years), 36% were women, and 24.2% were symptomatic in the previous 6 months. There were 88 (4.2%) neurological deaths or strokes at 30 days. Among symptomatic patients, the risk of adverse neurological outcome declined with increasing time between the incident neurological event and carotid stent procedure. In a logistic regression model that included preprocedural and procedural variables, significant multivariable predictors of 30-day neurological death or stroke were older age (continuous), black race, angiographically visible thrombus in symptomatic patients, procedural use of glycoprotein IIb/IIIa inhibitors, procedural transient ischemic attack, final residual stenosis &gt;30%, and periprocedural use of protamine or vasopressors. Conclusions— In this pooled analysis, a number of preprocedural and procedural factors predicted higher risk of stroke and neurological death within 30 days of a carotid stent procedure. Identification of such predictors may help to guide patient selection and further refine procedural technique.

Patient-specific simulation in carotid artery stenting

Patient-specific virtual reality (VR) simulation is a technologic advancement that allows planning and practice of the carotid artery stenting (CAS) procedure before it is performed on the patient. The initial findings are reported, using this novel VR technique as a tool to optimize technical and nontechnical aspects of this complex endovascular procedure. In the angiography suite, the same interventional team performed the VR rehearsal and the actual CAS on the patient. All proceedings were recorded to allow for video analysis of team, technical, and nontechnical skills. Analysis of both procedures showed identical use of endovascular tools, similar access strategy, and a high degree of similarity between the angiography images. The total procedure time (24.04 vs 60.44 minutes), fluoroscopy time (11.19 vs 21.04 minutes), and cannulation of the common carotid artery (1.35 vs 9.34) took considerably longer in reality. An extensive questionnaire revealed that all team members found that the rehearsal increased the subjective sense of teamwork (4/5), communication (4/5), and patient safety (4/5). A VR procedure rehearsal is a practical and feasible preparatory tool for CAS and shows a high correlation with the real procedure. It has the potential to enhance the technical, nontechnical, and team performance. Further research is needed to evaluate if this technology can lead to improved outcomes for patients.

Carotid Stenting in Asymptomatic Carotid Stenosis: The Calgary Experience

Although carotid endarterectomy is considered the 'gold standard' for standard risk symptomatic patients, the treatment of choice for asymptomatic patients remains controversial. Carotid stenting has demonstrated real-world outcomes consistent with established guidelines for carotid endarterectomy in asymptomatic high-surgical risk patients in recent prospective multicenter trials. We describe our experience with asymptomatic patients who underwent carotid stenting at our center in a routine clinical setting. This is a retrospective, longitudinal cohort study of patients who underwent carotid angioplasty and stenting at the Foothills Medical Center, Calgary, Canada between 1997 and 2007. The qualifying events were categorized as symptomatic and asymptomatic. The procedures were performed by four experienced neurointerventionists. The primary outcome was stroke or death at 30-day follow- up. 243 patients underwent 255 carotid stenting procedures. Their ages ranged from 50 to 83 years; the mean age was 72.0 ± 9.3 years; 67(26.3%) were women. Forty one patients (16.1%) were asymptomatic; 214 patients (83.9%) were symptomatic. The patients in the asymptomatic group were significantly younger - 66.0 ± 8.8 years compared to patients in the symptomatic group 73.2 ± 8.9 years (p < 0.0001). Intraprocedurally one minor stroke (2.4%) occurred in the asymptomatic group. At 30-day follow-up, no deaths or further strokes were noted in the asymptomatic group; while eight deaths, six major and seven minor strokes occurred in the symptomatic group (p = 0.22). Carotid stenting appears to be a safe procedure in asymptomatic patients with severe carotid stenosis in routine clinical settings as witnessed in this single center study.

Patient-specific rehearsal of a carotid artery stenting procedure results in superior operative performance compared to a preoperative generic warm-up

Patient-specific rehearsal of a carotid artery stenting procedure results in superior operative performance compared to a preoperative generic warm-up

Classification for Carotid Artery Stenting Complications:Manifestation, Management, and Prevention

Carotid artery stenting is a rapidly evolving method for treating carotid artery disease. Various intraprocedural and postprocedural complications have been reported in the literature. However, the absence of a unified classification scheme for these complications makes it difficult, if not impossible, to study their precise incidence, predictors, and management. The aim of this article is to propose the first joint classification of periprocedural complications, to analyze their incidence and etiology, and suggest possible ways to manage and prevent them. This classification is intended to be used as a common platform for prompt recognition, evaluation, treatment, and universal study of the complications during carotid stenting procedures. For this purpose, the opinions of the major experts on carotid interventions worldwide were merged with all the available information reported in the English-language literature to present as accurately as possible the management and prevention of carotid stenting complications according to this proposed classification.