Carotid Stenting Research Articles

Elucidating the hemodynamic impact of residual stenosis post-carotid artery stenting: A numerical study.

Residual stenosis (RS) and hemodynamics demonstrate a significant correlation with postoperative in-stent restenosis/thrombosis following carotid artery stenting (CAS). This study endeavors to elucidate the potential associations between RS and adverse postoperative hemodynamic factors. This study utilized 46 patient-specific carotid artery models post-stenting, which were categorized into two groups based on the presence of RS: the normal group (N, n=23) and the RS group (RS, n=23). A comparative analysis was conducted to evaluate the discrepancies in geometry and adverse hemodynamic parameters, alongside investigating the potential correlation between hemodynamic and geometric parameters. The results reveal that a higher reflux flow volume is discernible in the RS group during low-velocity phases of the cardiac cycle, concomitant with an augmented extent of areas exposed to oscillatory shear stress and extended particle residence time. Moreover, the adverse hemodynamic parameters exhibit a positive correlation with the degree of stent expansion, stent length in the common carotid artery (CCA), and the distal slope of the RS. The distal slope and tortuosity of RS significantly influence the development of adverse hemodynamic conditions post-stenting, exacerbating the hemodynamic environment near the stenosis. Interestingly, while an extended stent length in the internal carotid artery (ICA) region improves hemodynamics by reducing flow disturbance, a longer stent in the CCA significantly worsens these conditions. Hence, it is prudent to analyze the characteristics of the local lesion regions to optimize the strategy for stent implantation.

Utility of ultrasound in the perioperative phase of carotid endarterectomy and carotid artery stent implantation.

This article reviews the latest research results of the use of ultrasound technology in the perioperative period of carotid endarterectomy and carotid stenting and discusses the role of ultrasound technology in accurately evaluating carotid stenosis and plaque stability, assisting in selecting the most suitable surgical method, and providing optimal perioperative imaging to guide carotid endarterectomy (CEA) and carotid artery stenting (CAS) to reduce the occurrence and progression of stroke. The research published in recent years on the application of ultrasound in the perioperative period of CEA and CAS was reviewed through the databases of CNKI, Pubmed, and Web of Science. Ultrasound has high clinical value in preoperative screening for indications, assessing the degree of carotid artery stenosis and the nature of plaque; monitoring hemodynamic changes intraoperatively to prevent cerebral ischemia or overperfusion; and evaluating surgical outcomes postoperatively and in late follow-up review. Ultrasound is currently widely used perioperatively in CEA and CAS and has even become the preferred choice of clinicians to evaluate the efficacy of surgery and follow-up. The presence of vulnerable plaque is an important risk factor for ischemic stroke. Contrast-enhanced ultrasound is an excellent tool to assess plaque stability. In most studies, ultrasound has been used only in a short follow-up period after CEA and CAS, and data from longer follow-ups are needed to provide more reliable evidence.

The Dual-layer CGuard Stent Is Safe and Effective in Emergent Carotid Artery Stenting and in Tandem Occlusions: aMulti-centric Study.

Dual-layer stents have fallen into disrepute after several studies reported high rates of in-stent occlusions in acute stroke treatments. The CGuard stent is anew-generation hybrid dual-layer stent that has been designed to provide less thrombogenicity and to prevent peri- and postinterventional emboli. The aim of the study is to evaluate the safety and efficacy of the CGuard stent for the acute treatment of occlusion or high-grade stenosis of the extracranial internal carotid artery (ICA) in patients with acute ischemic stroke (AIS) with and without concomitant intracranial large vessel occlusion (LVO). All patients who underwent emergent carotid artery stenting (CAS) with the CGuard stent were identified and analyzed from the stroke registries from four tertiary German stroke centers. Clinical, procedural, and imaging data were evaluated. Stent patency within 72 h, intracranial hemorrhage, and modified Rankin score (mRS) at discharge were the safety and efficacy end points. Overall, ninety-six patients were included (mean age70.2 ± 11.8, 66males (68.8%), median NIHSS score at admission 11 (7-17), IVlysis: n = 44 (45.8%)). Stent placement was successful in all patients. Eighty-three (86.4%) patients had tandem occlusions. In-stent occlusion occurred in 5patients (5.2%) and 3patients developed early in-stent stenosis (3.1%). Median mRS at discharge was 2 (1-4). In this multicenter study, the use of the dual-layer CGuard stent for emergent CAS, particularly in tandem occlusions, was safe and resulted in low rates of in-stent occlusions.

Optimal Dual Antiplatelet Therapy Duration For Carotid Artery Stenting On the Basis of Angioscopic Findings

Background Dual antiplatelet therapy plays a crucial role in preventing thrombosis in the perioperative period of carotid artery stenting (CAS); however, it has been associated with a risk of hemorrhagic complications. A standard regimen for the duration and combination of antiplatelet therapy is yet to be established. Angioscopy enables direct visualization of neointimal coverage and might help determine the optimal duration of dual antiplatelet therapy through the assessment of post‐CAS neointimal coverage. Methods This prospective study enrolled 20 patients who were scheduled to undergo CAS at the Osaka Police Hospital. A 2‐month post‐CAS period was chosen for angioscopic neointima evaluation on the basis of previous evidence of reliable neointimal coverage 2 months following coronary artety stenting. Furthermore, antiplatelet therapy was initiated 1 week before CAS and continued until angioscopic examination. Angioscopic evaluation categorized the degree of neointimal coverage and was supplemented with carotid ultrasonography and biplane angiography. Results Coincidentally, a dual‐layer stent was used in all cases. The stent lumen was observed in 19 of the 20 cases. One case was difficult to evaluate owing to poor visibility. Angioscopy showed complete neointimal coverage in 18 of 19 cases and partial coverage in 1 case. Ultrasonography could detect neointima in 9 of 20 cases, and angiography showed a radiolucent gap suggestive of neointima in all cases in which neointima was confirmed via angioscopy. No post‐CAS or procedural complications occurred. Conclusion Angioscopy performed 2 months following CAS revealed large neointimal coverage, suggesting that a 2‐month duration of dual antiplatelet therapy is generally sufficient. However, as a limitation, this study was performed using the same dual‐layer stent; thus, additional studies with other stents are required.

Carotid Artery Stenting by Direct Punctures of Cervical Carotid Artery Stenoses Using an Exoscope in a Hybrid Operating Room: A Technical Report.

Carotid artery stenting (CAS) has been established as an effective surgical treatment for internalcarotid artery stenosis and/or common carotid artery stenosis (ICAS/CCAS). Typically, CAS is performed via a transfemoral, transbrachial, or transradial approach. However, direct puncture CAS (DP-CAS) is preferred in cases where conventional access routes are challenging, such as in the presence of cervical vascular tortuosity or thoracic aortic aneurysm. Since 2020, our institution has selectively adopted DP-CAS, utilizing 3D exoscopy through the ZEISS KINEVO 900 microscope (Carl Zeiss AG, Oberkochen, Germany) or the ORBEYE exoscope (Sony Olympus Medical Solutions Inc., Tokyo, Japan) for carotid artery surgical exposure and puncture under high magnification in a hybrid operating room. In the hybrid operating room, exoscopic and angiographic fluoroscopic monitors were positioned side by side, enabling the surgeon to simultaneously visualize both during the puncture procedure. In cases utilizing the ORBEYE exoscope, its compact design minimized interference with the fluoroscopic arm, thereby facilitating improved working angles during CAS. This technical report reveals the current status of DP-CAS at our institution and focuses on the effectiveness of DP-CAS using an exoscope based on our clinical experience.

Best Medical Therapy for Asymptomatic Carotid Stenosis: Imminent or Ineffective?

Carotid artery disease accounts for approximately 20% of all ischemic strokes, a major cause of morbidity, and the fifth leading cause of death in United States. Landmark trials in the 1990s such as Asymptomatic Carotid Atherosclerosis Study (ACAS) and Asymptomatic Carotid Surgery Trial (ACST) establish carotid endarterectomy (CEA) plus best medical therapy (BMT) as the standard of care for patients with asymptomatic carotid stenosis over 60%. However, advances in medical therapy and the emergence of carotid artery stenting (CAS) have prompted a reevaluation of treatment efficacy. Recent studies have questioned the superiority of CEA over BMT alone in reducing stroke risk, suggesting no significant difference in outcomes with contemporary medical management. Additionally, analysis from the US Department of Veterans Affairs indicated minimal net benefit of CEA over BMT when accounting for all-cause mortality. Comparative studies have found no significant difference in long-term stroke free survival between CEA and CAS. However, procedural risks vary, with higher myocardial infarction rates associated with CEA and higher stroke rates with CAS. Identifying high-risk plaques and patient-specific risk factors remains crucial. Meta-analyses have highlighted features such as neovascularization and lipid rich cores as predictors of stenosis progression and ischemic events. Ongoing research, particularly the CREST-2 trial, aims to provide clear guidance on the optimal treatment of asymptomatic carotid stenosis. This trial emphasizes stringent adherence to modern BMT protocols and includes comprehensive lifestyle modification programs. The evolving landscape of medical and surgical interventions necessitates continuous evaluation to optimize treatment strategies for asymptomatic carotid stenosis, which is the impetus for this review. Future findings from ongoing trials are expected to refine current guidelines and improve patient outcomes.

Long-term Survival and Cerebrovascular Events after Carotid Artery Stenting in Patients with Chronic Kidney Disease

Long-term Survival and Cerebrovascular Events after Carotid Artery Stenting in Patients with Chronic Kidney Disease

The Evolution of Carotid Surgery

This review traces the evolution of carotid surgery from its ancient roots to modern practice. The first significant appreciation of the carotid arteries’ role in cerebral ischemia was made by Johann Jakob Wepfer in his 1658 book on apoplexy, which described the separate blood supply to each cerebral hemisphere by the carotid arteries. The 16th-19th centuries saw initial attempts at carotid ligation, while the 20th century marked significant advancements. The first carotid endarterectomy (CEA) by DeBakey, Cooley, and Eastcott in the 1950s paved the way for a new technique in carotid surgery and many subsequent refinements in surgical techniques related to CEA. The latter half of the 20th century brought innovations such as patch angioplasty, microsurgical techniques, and intraoperative shunting, significantly improving outcomes. Pivotal clinical trials established CEA as the standard treatment for symptomatic carotid stenosis. The emergence of carotid artery stenting (CAS) in the 1980s introduced a less invasive alternative, sparking ongoing debates about optimal treatment strategies. Recent developments include transcarotid artery revascularization (TCAR) and transfemoral CAS, with studies comparing their efficacy to traditional CEA. Current research focuses on plaque morphology and novel diagnostic factors to further personalize treatment strategies for carotid artery stenosis.

Avoiding Complications with Transcarotid Artery Revascularization

Transcarotid artery revascularization (TCAR) for carotid artery stenting offers an innovative method for treating carotid artery occlusive disease.This technique utilizes the ENROUTE Transcarotid Neuroprotection System (Silk Road Medical, Sunnyvale, CA) to temporarily reverse flow in the carotid artery prior to crossing or treating the carotid lesion, reducing the perioperative risk of stroke.This review aims to summarize possible complications associated with the procedure and offer suggestions to address or avoid these issues in practice. A review of the available scientific literature was performed via PubMed database queries.Our institutional experience with TCAR was reviewed from a prospectively maintained database.Outcomes assessed included perioperative complications and overall rates of re-stenosis after TCAR. Potential complications of TCAR were identified and summarized.These are organized based on preoperative, intraoperative, or postoperative timing of the potential complication.Our group's real-world outcomes of 273 patients undergoing TCAR with median (interquartile range) follow up of 17.4 (4.4 -38.7) months, including safety and restenosis data, are presented. Herein we summarize the available literature regarding potential complications that may be encountered when performing TCAR.Safe and effective clinical outcomes, comparable to those of published clinical trial data, can be successfully achieved in the real-world setting.

Evolution of Medical and Surgical Management of Carotid Disease from Carotid Endarterectomy to Transfemoral Carotid Stenting to TCAR

Patients with carotid stenosis can be broadly classified into two categories: symptomatic and asymptomatic. While there is little disagreement about surgical management of symptomatic carotid stenosis, the optimal management strategy for the patients with asymptomatic carotid disease has undergone significant evolution over past five decades. With increasing focus on role of plaque morphology on the etiology of symptoms, there has been an increased focus on optimizing the medical management targeted at plaque stabilization, especially for the patients with asymptomatic carotid disease, while reserving the most aggressive surgical treatment options for the patients with symptomatic carotid stenosis. This review summarizes the scientific evidence based on multiple large clinical studies showing how the modern-day management of carotid stenosis has evolved. Multiple, large randomized clinical trials have established carotid endarterectomy (CEA) as the treatment of choice for symptomatic patients with symptomatic, >50% stenosis of carotid artery or those who have asymptomatic high grade carotid stenosis. With the advancements in endovascular techniques, the technique of Trans Femoral Carotid Artery Stenting (TF-CAS) was popularized, but after multiple, large randomized controlled trials demonstrated superiority of CEA, the indications for TF-CAS as the initial operation of choice for carotid disease for all patients have been reduced. In the past five years, the introduction of the newer technique of Trans Carotid Artery Revascularization (TCAR) has shown promising results with significant reduction in the incidence of perioperative complications as compared to CEA and TF-CAS, however, there have been no randomized controlled trials comparing TCAR to either CEA or TF-CAS. Moreover, with the developments in the medical field with introduction of several new medications which have been demonstrated to successfully change the plaque morphology, there has been a renewed interest in exploring if the indications for surgical management for the asymptomatic carotid disease should be revisited.

CASSH Registry: Rationale and Study Design

Background Carotid artery disease, a major cause of strokes, often results from carotid atherosclerotic stenosis. Although carotid endarterectomy has long been the standard treatment, carotid artery stenting (CAS) emerged as an alternative for high‐risk surgical patients. Operator experience plays a crucial role in reducing complications, with neurointerventional specialists demonstrating proficiency in CAS. However, they are often underrepresented in CAS studies. The CASSH (Carotid Artery Stenting Outcomes in Comprehensive Stroke Hospitals) registry aims to provide comprehensive insights into CAS outcomes, particularly when performed by neurointerventionalists at comprehensive stroke centers. Methods The CASSH is a multicenter, prospective, observational study currently enrolling patients with carotid artery stenosis undergoing CAS performed by neurointerventional physicians. All the participating sites will screen and report cases that meet inclusion criteria, on a monthly basis. The decision of whether to use CAS is at the discretion of the interventionalist. Results We will collect patients’ baseline clinical, demographic, and radiographic data. In addition, we plan to collect procedure variables and postoperative clinical and imaging data. Outcomes include the rate of postoperative symptomatic stroke (hemorrhagic/ischemic), access site complications, in‐stent thrombosis, and mortality. Conclusion Current literature underrepresents neurointerventionalists in CAS studies, especially as it pertains to procedural expertise and outcomes. CASSH is a prospective observational study that will enhance our understanding of CAS management and outcomes, emphasizing the benefits of neurointerventional expertise within comprehensive stroke centers.

Anatomical navigational difficulties in transradial right carotid artery stenting with 7-F Optimo balloon guide catheter.

Carotid artery stenting (CAS) using a 7-F Optimo balloon guide catheter (BGC) via the right radial artery (RA) was performed for stenosis of the right carotid artery. The factors affecting the difficulty in navigating the BGC from the right RA to the right common carotid artery (CCA) were investigated. For 40 cases of stenosis of the right carotid artery, CAS using a 7-F Optimo BGC via the right RA was performed. Pre-operative anatomical length and angle of the access route were retrospectively examined. The 7-F Optimo BGC successfully reached all lesions; however, navigational difficulties were encountered in seven out of 40 cases (17.5%). One case in the difficult group experienced an ischemic complication. The height from the topmost point of the subclavian artery (SA) to the origin of the SA (SA height) was 44.4 mm versus 28.1 mm (p < 0.01), and the angle between the SA and the CCA (SA-CCA angle) was 21.6° versus 47.9° (p < 0.01) in the difficult and easy groups, respectively. For lesions with difficult navigation, the sensitivity and specificity of the SA height >34 mm were 100% and 82%, and the sensitivity and specificity of the SA-CCA angle <30° were 100% and 82%. For stenosis of the right carotid artery, transradial-CAS using a 7-F Optimo BGC is a safe procedure. However, navigating the BGC becomes difficult when the SA height is >34 mm and the SA-CCA angle is <30°.

Single-stage procedure of carotid artery stenting and transcatheter aortic valve implantation.

Single-stage procedure of carotid artery stenting and transcatheter aortic valve implantation.

Using Machine Learning to Predict Outcomes Following Transfemoral Carotid Artery Stenting.

Transfemoral carotid artery stenting (TFCAS) carries important perioperative risks. Outcome prediction tools may help guide clinical decision-making but remain limited. We developed machine learning algorithms that predict 1-year stroke or death following TFCAS. The VQI (Vascular Quality Initiative) database was used to identify patients who underwent TFCAS for carotid artery stenosis between 2005 and 2024. We identified 112 features from the index hospitalization (82 preoperative [demographic/clinical], 13 intraoperative [procedural], and 17 postoperative [in-hospital course/complications]). The primary outcome was 1-year postprocedural stroke or death. The data were divided into training (70%) and test (30%) sets. Six machine learning models were trained using preoperative features with 10-fold cross-validation. The primary model evaluation metric was area under the receiver operating characteristic curve. The algorithm with the best performance was further trained using intra- and postoperative features. Model robustness was assessed using calibration plots and Brier scores. Overall, 35 214 patients underwent TFCAS during the study period and 3257 (9.2%) developed 1-year stroke or death. The best preoperative prediction model was extreme gradient boosting, achieving an area under the receiver operating characteristic curve of 0.94 (95% CI, 0.93-0.95). In comparison, logistic regression had an AUROC of 0.65 (95% CI, 0.63-0.67). The extreme gradient boosting model maintained excellent performance at the intra- and postoperative stages, with area under the receiver operating characteristic curve values of 0.94 (95% CI, 0.93-0.95) and 0.98 (95% CI, 0.97-0.99), respectively. Calibration plots showed good agreement between predicted/observed event probabilities with Brier scores of 0.11 (preoperative), 0.11 (intraoperative), and 0.09 (postoperative). Machine learning can accurately predict 1-year stroke or death following TFCAS, performing better than logistic regression.

Management of Severe Bilateral Symptomatic Internal Carotid Artery Stenosis: Case Report and Literature Review.

Multiple strategies for tandem severe carotid artery stenosis are reported: bilateral carotid artery endarterectomy (CEA), bilateral carotid artery stenting (CAS), and hybrid procedures (CEA and CAS). The management is controversial, considering the reported high risk of periprocedural stroke, hemodynamic distress, and cerebral hyperperfusion syndrome. We present the case of a 64-year-old patient with severe symptomatic bilateral internal carotid artery stenosis (95% stenosis on the left internal carotid artery with recent ipsilateral watershed anterior cerebral artery-medial cerebral artery (ACA-MCA) and medial cerebral artery-posterior cerebral artery (MCA-PCA) ischemic strokes and 90% stenosis on the right internal carotid artery with chronic ipsilateral frontal ischemic stroke) managed successfully with staged CEA within a 3-day interval. The patient had a history of coronary angioplasty and stenting. Strategies for brain protection included shunt placement after the evaluation of carotid stump pressure, internal carotid backflow, and near-infrared spectroscopy. A collagen and silver-coated polyester patch was used to complete the endarterectomy using a 6.0 polypropylene continuous suture in both instances. Management also included neurological consults after extubation, dual antiplatelet therapy, head CT between the two surgeries, myocardial ischemia monitoring, and general anesthesia. Staged CEA with a small time interval between surgeries can be an option to treat tandem symptomatic carotid artery stenosis in highly selected patients. The decision should be tailored according to the patient's characteristics and should also be made by a cardiology specialist, a neurology specialist, and an anesthesia and intensive care physician.

Outcomes following carotid revascularization in patients with prior ipsilateral carotid artery stenting in the Vascular Quality Initiative

ObjectiveThe outcomes of carotid revascularization in patients with prior carotid artery stenting (CAS) remain understudied. Prior research has not reported the outcomes after transcarotid artery revascularization (TCAR) in patients with previous CAS. In this study, we compared the peri-operative outcomes of TCAR, transfemoral CAS (tfCAS) and carotid endarterectomy (CEA) in patients with prior ipsilateral CAS using the Vascular Quality Iniatitive. MethodsUsing Vascular Quality Initiative data from 2016 to 2023, we identified patients who underwent TCAR, tfCAS, or CEA after prior ipsilateral CAS. We included covariates such as age, race, sex, body mass index, comorbidities (hypertension, diabetes, prior coronary artery disease, prior coronary artery bypass grafting/percutaneous coronary intervention, congestive heart failure, renal dysfunction, smoking, chronic obstructive pulmonary disease, and anemia), symptom status, urgency, ipsilateral stenosis, and contralateral occlusion into a regression model to compute propensity scores for treatment assignment. We then used the propensity scores for inverse probability weighting and weighted logistic regression to compare in-hospital stroke, in-hospital death, stroke/death, postoperative myocardial infarction (MI), stroke/death/MI, 30-day mortality, and cranial nerve injury (CNI) after TCAR, tfCAS, and CEA. We also analyzed trends in the proportions of patients undergoing the three revascularization procedures over time using Cochrane-Armitage trend testing. ResultsWe identified 2137 patients undergoing revascularization after prior ipsilateral carotid stenting: 668 TCAR patients (31%), 1128 tfCAS patients (53%), and 341 CEA patients (16%). In asymptomatic patients, TCAR was associated with a lower yet not statistically significant in-hospital stroke/death than tfCAS (TCAR vs tfCAS: 0.7% vs 2.0%; adjusted odds ratio [aOR], 0.33; 95% confidence interval [CI], 0.11-1.05; P = .06), and similar odds of stroke/death with CEA (TCAR vs CEA: 0.7% vs 0.9%; aOR, 0.80; 95% CI, 0.16-3.98; P = .8). Compared with CEA, TCAR was associated with lower odds of postoperative MI (0.1% vs 14%; aOR, 0.02; 95% CI, 0.00-0.10; P < .001), stroke/death/MI (0.8% vs 15%; aOR, 0.05; 95% CI, 0.01-0.25; P < .001), and CNI (0.1% vs 3.8%; aOR, 0.04; 95% CI, 0.00-0.30; P = .002) in this patient population. In symptomatic patients, TCAR had an unacceptably elevated in-hospital stroke/death rate of 5.1%, with lower rates of CNI than CEA. We also found an increasing trend in the proportion of patients undergoing TCAR following prior ipsilateral carotid stenting (2016 to 2023: 14% to 41%), with a relative decrease in proportions of tfCAS (61% to 45%) and CEA (25% to 14%) (P < .001). ConclusionsIn asymptomatic patients with prior ipsilateral CAS, TCAR was associated with lower odds of in-hospital stroke/death compared with tfCAS, with comparable stroke/death but lower postoperative MI and CNI rates compared with CEA. In symptomatic patients, TCAR was associated with unacceptably higher in-hospital stroke/death rates. In line with the postprocedure outcomes, there has been a steady increase in the proportion of patients with prior ipsilateral stenting undergoing TCAR over time.

Utilization of Artificial Intelligence to Improve Door-In Door-Out Times for Mechanical Thrombectomy-Eligible Patients at a Hub-and-Spoke Community-Based Comprehensive Stroke Center: A Single Case Study Presentation

Background: Delays in the transfer of patients with hyperacute stroke may lead to treatment ineligibility due to the degree of cerebral hypoxic injury suffered. Cloud-based artificial intelligence applications may improve transfer times and expand access to advanced therapies. One case between a community-based comprehensive stroke center (CSC) and a primary stroke center (PSC) using a third-party telemedicine service and shared cloud-based artificial intelligence application may provide insight in opportunities to improve stroke systems of care. Case Presentation: A 62-year-old female with a past medical history of hypertension, current everyday tobacco smoker, and marijuana user presented to an outlying emergency department (ED) with dense left-sided hemiplegia affecting the arm and leg, right-sided gaze preference, and severe dysarthria. Her last known well (LKW) time was 0900 hours. CNS imaging revealed a right middle cerebral artery occlusion, visible to members of the CSC stroke team through the use of a cloud-based artificial intelligence cell phone application. The patient was treated with intravenous thrombolytics at the PSC, and she was transferred to the CSC, where she underwent a diagnostic cerebral arteriogram with carotid artery stenting. Later, Magnetic Resonance Imaging (MRI) of the brain revealed a 3.5 cm x 2.5 cm hemorrhagic lesion in the right frontal lobe and diffusion restriction in the right frontal and right posterior temporal lobes. The patient’s hospital stay was three days and, at the time of discharged, her modified Rankin score and NIHSS were zero. She was discharged on dual antiplatelet therapy, statin therapy, and nicotine replacement. Utilization of Artificial Intelligence: Transfer delays are complicated by organizing care at PSC and CSC and can be lengthy when communication across different facilities and subspecialties. Implementing cloud-based AI image sharing in stroke systems of care has reduced DIDO times by providing rapid imaging interpretation, streamlining communication, and enhancing coordination between PSCs and CSCs. Conclusions: Our case presentation showed how a hub-and-spoke model combined with cloud-based AI utilization can improve DIDO times and enhance stroke systems of care.

Postoperative outcomes in patients with anemia undergoing carotid revascularization

BackgroundPreoperative anemia is associated with worse postoperative morbidity and mortality after major vascular procedures. Limited research has examined the optimal method of carotid revascularization in patients with anemia. Therefore, we aim to compare the postoperative outcomes after carotid endarterectomy (CEA), transfemoral carotid artery stenting (TFCAS), and transcarotid artery revascularization (TCAR) among patients with anemia. Study designThis is a retrospective review of patients with anemia undergoing CEA, TFCAS, and TCAR in the Vascular Quality Initiative database between 2016 and 2023. We defined anemia as a preoperative hemoglobin level of <13 g/dL in men and <12 g/dL in women. The primary outcomes were 30-day mortality and in-hospital major adverse cardiac events (MACE). Logistic regression models were used for multivariate analyses. ResultsOur study included 40,383 CEA (59.3%), 9159 TFCAS (13.5%), and 18,555 TCAR (27.3%) cases in patients with anemia. TCAR patients were older and had more medical comorbidities than CEA and TFCAS patients. TCAR was associated with a decreased 30-day mortality (adjusted odds ratio [aOR], 0.45; 95% confidence interval [CI], 0.37-0.59; P < .001), in-hospital MACE (aOR, 0.58; 95% CI, 0.46-0.75; P < .001) compared with TFCAS. Additionally, TCAR was associated with a 20% decrease in the risk of 30-day mortality (aOR, 0.80; 95% CI, 0.65-0.98; P = .03) and a similar risk of in-hospital MACE (aOR, 0.86; 95% CI, 0.77-1.01; P = .07) compared with CEA. Furthermore, TFCAS was associated with an increased risk of 30-day mortality (aOR, 2; 95% CI, 1.5-2.68; P < .001) and in-hospital MACE (aOR, 1.7; 95% CI, 1.4-2; P < .001) compared with CEA. ConclusionsIn this multi-institutional national retrospective analysis of a prospectively collected database, TFCAS was associated with a high risk of 30-day mortality and in-hospital MACE compared with CEA and TCAR in patients with anemia. TCAR was associated with a lower risk of 30-day mortality compared with CEA. These findings suggest TCAR as the optimal minimally invasive procedure for carotid revascularization in patients with anemia.

Impact of the type of anesthesia on adverse events during transcarotid artery revascularization

ObjectiveThe use of local or regional anesthesia (LRA) is encouraged during transcarotid artery revascularization (TCAR) because the procedure is performed through a small incision. LRA permits neurologic evaluation during the procedure and may reduce periprocedural cardiac morbidity compared with general anesthesia (GA). There is limited and conflicting information regarding the preferred anesthesia to use during TCAR. We compared periprocedural clinical and technical complications, and intraprocedural performance metrics of TCAR performed under GA vs LRA. MethodsPatient, lesion, physician, and procedural information was collected in a worldwide quality assurance program of consecutive TCAR procedures. A composite clinical adverse event rate (death, stroke, transient ischemic attack, myocardial infarction) and a composite technical adverse event rate (aborted procedure, conversion to carotid endarterectomy, bleeding, dissection, cranial-nerve injury, device failure) in the periprocedural period were computed. Four intraprocedural performance measures (flow-reversal time, fluoroscopy time, contrast volume, and skin-to-skin time) were recorded. Deidentified data were analyzed independently at the Center for Vascular Research, University of Maryland. Poisson regressions were used to assess the impact of anesthesia type on adverse event rates. Linear regressions were used to compare performance measures. ResultsA total of 27,043 TCARs were performed by 1456 physicians between 2012 and 2021. A majority of patients (83%) received GA, and this proportion increased over time (R2 = 0.74; P < .0001). Some physicians (33.4%) used LRA in some of their procedures; only 2.7% used LRA in all of their procedures. Clinical risk factors were more common in the LRA group (P < .0001) and anatomic risk factors in the GA group (P < .0001); these differences were adjusted for in subsequent analyses. LRA was more likely to be used by vascular surgeons and by physicians with higher prior transfemoral carotid stenting experience (P < .0001). When comparing GA vs LRA, clinical adverse events (1.49%; 95% confidence interval [CI], 1.3-1.8 vs 1.55%; 95% CI, 1.2-2.0; P = .78), technical adverse events (5.6%; 95% CI, 5.2-6.2 vs 5.3%; 95% CI, 4.5-6.3; P = .47), and intraprocedural performance measures did not differ by type of anesthesia. ConclusionsAlmost two-thirds of physicians performed TCAR exclusively under GA, and the overall proportion of procedures performed under GA increased over time. A larger fraction of patients with severe medical risk factors received LRA vs GA, whereas a larger fraction of patients with anatomic risk-factors received GA. Periprocedural clinical and technical adverse events did not differ by type of anesthesia. Intraprocedural performance metrics that drive procedural cost were similar between groups; potential differences in procedural cost driven by anesthetic choice require further study.

Forearm access for carotid artery stenting using the dual protection of flow reversal and distal filter: Trans-forearm dual protection technique.

Although transfemoral carotid artery stenting (CAS) is widely performed for carotid stenosis, serious or even fatal complications such as embolic and access site complications can still occur. We devised a novel dual protection system with continuous flow reversal to the cephalic vein of the forearm in transradial CAS, referred to as the "trans-forearm dual protection" technique. A 75-year-old man with a diagnosis of symptomatic left cervical internal carotid artery (ICA) stenosis underwent CAS using the trans-forearm dual protection technique. A 4F sheath was introduced into the cephalic vein of the right forearm. After an 8F balloon-guiding catheter was navigated into the left common carotid artery (CCA) via right sheathless radial access, a distal filter protection device was advanced into the high cervical ICA. The 8F balloon-guiding catheter was inflated and connected to the 4F sheath with a blood filter interposed. Under the dual protection of flow reversal and distal filter, the CAS procedure was performed. The postprocedural course was uneventful. Diffusion-weighted imaging 2 days after the procedure showed no evidence of ischemic stroke. The patient was discharged home without any complications 1 week after the procedure. Carotid duplex ultrasound performed 9 months after the procedure showed no signs of restenosis. This method allows for CAS under the dual protection of flow reversal and filter device protection via the trans-forearm access, reducing the risk of embolism and access site complications. Therefore, the trans-forearm dual protection technique can be a useful option for CAS.