European Carotid Surgery Trial Research Articles

Local and systemic factors associated with quantitative stiffness of carotid plaque.

Plaque stiffness in carotid artery stenosis is a clinically important factor involved in the development of stroke and surgical complications. The purpose of this study was to clarify which local and systemic factors are associated with the quantitatively measured stiffness of plaque. The subjects were 104 consecutive patients who underwent carotid endarterectomy at our institution. To measure quantitative stiffness of plaque, we used an industrial hard meter in the operating room within 1h after removal of plaque. Local factors related to carotid plaque hardness were evaluated, including maximum intima-media thickness (max IMT), degree of stenosis using the European Carotid Surgery Trial (ECST), presence of ulceration or calcification, and echo brightness on preoperative carotid ultrasound. The degree of stenosis was also evaluated using the North American Symptomatic Carotid Endarterectomy Trial method in digital subtraction angiography. Age, sex, and presence or absence of hypertension, diabetes, and dyslipidemia (low-density lipoprotein cholesterol and triglyceride [TG] levels) served as systemic factors and were compared with the quantitative stiffness of carotid plaque. In multivariate analysis, ECST stenosis degree, calcification, and IMT max as local factors affected plaque stiffness. As a systemic factor, plaque stiffness was statistically significantly negatively correlated with TG values in multivariate analysis (p < 0.05). The quantitative stiffness of the plaque was negatively correlated with TG levels as a systemic factor in addition to local factors. This might suggest that reducing high TG levels is associated with plaque stabilization.

Correlation between Ultrasound Peak Systolic Velocity and Angiography for Grading Internal Carotid Artery Stenosis.

(1) Background: The success of carotid revascularization depends on the accurate grading of carotid stenoses. Therefore, it is important for every vascular center to establish its protocols for the same. In this study, we aimed to determine the peak systolic velocity (PSV) thresholds that can predict moderate and severe internal carotid artery (ICA) stenoses. (2) Methods: To achieve this, we enrolled patients who underwent both duplex ultrasound (DUS) and invasive carotid artery digital subtraction angiography (DSA). The degree of ICA stenosis was assessed using the North American Symptomatic Carotid Endarterectomy Trial (NASCET) and the European Carotid Surgery Trial (ECST) protocols. The PSV thresholds were determined using receiver operating characteristic (ROC) curves. (3) Results: Our study included 47 stenoses, and we found that the PSV cut-off for predicting ≥70% NASCET ICA stenoses was 200 cm/s (sensitivity 90.32%, specificity 93.75%). However, PSV did not correlate significantly with ≥50% NASCET ICA stenoses. On the other hand, the optimal PSV threshold for predicting ≥80% ECST ICA stenoses was 180 cm/s (sensitivity 100%, specificity 81.82%). (4) Conclusions: Based on our findings, we concluded that PSV is a good and simple marker for the identification of severe stenoses. We found that PSV values correlate significantly with severe NASCET and ECST stenoses, with 200 cm/s and 180 cm/s PSV thresholds. However, PSV was not reliable with moderate NASCET stenoses. In such cases, complementary imaging should be used.

When Will We Have What We Need to Advise Patients How to Manage Their Carotid Stenosis?: Lessons From SPACE-2.

The recently published SPACE-2 trial (Stent-Supported Percutaneous Angioplasty of the Carotid Artery Versus Endarterectomy-2) compared 3 treatments to prevent stroke in patients with asymptomatic carotid stenosis ≥70%: (1) carotid endarterectomy plus best medical treatment (BMT), (2) transfemoral carotid artery stenting plus BMT, or (3) BMT alone. Because of low enrollment, the findings of similar safety and efficacy for carotid endarterectomy, carotid artery stenting, or BMT alone were inconclusive. Publication of the CREST (Carotid Revascularization and Medical Management for Asymptomatic Carotid Stenosis Trial)-2 results should provide level A evidence that has been lacking for 2 to 3 decades, to guide treatment of asymptomatic patients with severe carotid stenosis. For symptomatic patients with ≥70% stenosis, no trials are underway to update the degree of benefit reported for carotid endarterectomy by NASCET (North American Carotid Endarterectomy Trial) and ECST (European Carotid Surgery Trial), published in 1991. Subsequently, the use of cigarettes has plummeted, and major improvements in medical treatments and in carotid revascularization have emerged. These advances have coincided with abrupt decline in the clinical end points necessary for treatment comparisons in procedural trials. One of the advances in the invasive management of carotid disease has been transcarotid artery revascularization, already with limited approval by the US Food and Drug Administration. Establishing safety and efficacy of transcarotid artery revascularization compared with carotid endarterectomy, carotid artery stenting, or BMT alone may be challenging because of enrollment, regulatory, and funding barriers to design and complete an adequately powered randomized trial.

Carotid Ultrasound Using Superb Microvascular Imaging to Identify Patients Developing In-Stent Restenosis After CAS

Background and purposeIn-stent restenosis (ISR) caused by in-stent intimal hyperplasia (ISH) may develop after carotid artery stenting (CAS), and often necessitates re-stenting. We investigated whether new ultrasound technique is useful for detecting carotid artery plaques prone to ISR. PurposeSuperb micro-vascular imaging (SMI) is a new color Doppler imaging technique for assessing low velocity blood flow such as neovascularization in carotid artery plaques. In this study, we attempted to identify associations between findings from carotid ultrasonography with SMI performed prior to CAS and in-stent restenosis after 6 months of CAS. MethodsThis study investigated 19 patients (18 men; mean age, 72.4 years). Preoperative plaque evaluation was performed by magnetic resonance imaging, ultrasonography, and carotid angiography. Follow up angiography was performed in all patients at 6 months after CAS. ISR was defined as ISH resulting in >50% stenosis based on European Carotid Surgery Trialists criteria. We investigated whether SMI was useful as a predictor of ISR by chi-square test. ResultsPreoperative mean stenosis rate according to North American Symptomatic Carotid Endarterectomy Trial methods in 19 patients was 61.3%. Neovascularization was observed on SMI in 10 patients (52.6%). Carotid angiography at 6 months after CAS revealed ISR in 4 patients, all of whom had shown neovascularization on SMI. A significant association was seen between findings of neovascularization on SMI and development of ISR (p = 0.033). In predicting ISR, neovascularization findings on SMI offered 100.0% sensitivity and 60.0% specificity. ConclusionsPreprocedural plaque characterization by carotid ultrasound with SMI appears useful for predicting ISR at 6 months after CAS.

Carotid Plaque Characteristics Predict Recurrent Ischemic Stroke and TIA: The PARISK (Plaque At RISK) Study

BackgroundPatients with symptomatic carotid stenosis are at high risk for recurrent stroke. The decision for carotid endarterectomy currently mainly relies on degree of stenosis (cutoff value >50% or 70%). Nevertheless, also, patients with mild-to-moderate stenosis still have a considerable recurrent stroke risk. Increasing evidence suggests that carotid plaque composition rather than degree of stenosis determines plaque vulnerability; however, it remains unclear whether this also provides additional information to improve clinical decision making. ObjectivesThe PARISK (Plaque At RISK) study aimed to improve the identification of patients at increased risk of recurrent ischemic stroke using multimodality carotid imaging. MethodsThe authors included 244 patients (71% men; mean age, 68 years) with a recent symptomatic mild-to-moderate carotid stenosis in a prospective multicenter cohort study. Magnetic resonance imaging (carotid and brain) and computed tomography angiography (carotid) were performed at baseline and after 2 years. The clinical endpoint was a recurrent ipsilateral ischemic stroke or transient ischemic attack (TIA). Cox proportional hazards models were used to assess whether intraplaque hemorrhage (IPH), ulceration, proportion of calcifications, and total plaque volume in ipsilateral carotid plaques were associated with the endpoint. Next, the authors investigated the predictive performance of these imaging biomarkers by adding these markers (separately and simultaneously) to the ECST (European Carotid Surgery Trial) risk score. ResultsDuring 5.1 years follow-up, 37 patients reached the clinical endpoint. IPH presence and total plaque volume were associated with recurrent ipsilateral ischemic stroke or TIA (HR: 2.12 [95% CI: 1.02-4.44] for IPH; HR: 1.07 [95% CI: 1.00-1.15] for total plaque volume per 100 µL increase). Ulcerations and proportion of calcifications were not statistically significant determinants. Addition of IPH and total plaque volume to the ECST risk score improved the model performance (C-statistics increased from 0.67 to 0.75-0.78). ConclusionsIPH and total plaque volume are independent risk factors for recurrent ipsilateral ischemic stroke or TIA in patients with mild-to-moderate carotid stenosis. These plaque characteristics improve current decision making. Validation studies to implement plaque characteristics in clinical scoring tools are needed. (PARISK: Validation of Imaging Techniques [PARISK]; NCT01208025)

The Impact of the First 11 Months of the COVID-19 Pandemic on Vascular Patients’ Care and Hospitalisation Rate in the Vascular Surgery Divisions of Southern Italy

The Impact of the First 11 Months of the COVID-19 Pandemic on Vascular Patients’ Care and Hospitalisation Rate in the Vascular Surgery Divisions of Southern Italy

Emerging Role of Carotid MRI for Personalized Ischemic Stroke Risk Prediction in Patients With Carotid Artery Stenosis.

Rupture of a vulnerable carotid plaque is an important cause of ischemic stroke. Prediction models can support medical decision-making by estimating individual probabilities of future events, while magnetic resonance imaging (MRI) can provide detailed information on plaque vulnerability. In this review, prediction models for medium to long-term (>90 days) prediction of recurrent ischemic stroke among patients on best medical treatment for carotid stenosis are evaluated, and the emerging role of MRI of the carotid plaque for personalized ischemic stroke prediction is discussed. A systematic search identified two models; the European Carotid Surgery Trial (ECST) medical model, and the Symptomatic Carotid Atheroma Inflammation Lumen stenosis (SCAIL) score. We critically appraised these models by means of criteria derived from the CHARMS (CHecklist for critical Appraisal and data extraction for systematic Reviews of prediction Modeling Studies) and PROBAST (Prediction model Risk Of Bias ASsessment Tool). We found both models to be at high risk of bias. The ECST model, the most widely used model, was derived from data of large but relatively old trials (1980s and 1990s), not reflecting lower risks of ischemic stroke resulting from improvements in drug treatment (e.g., statins and anti-platelet therapy). The SCAIL model, based on the degree of stenosis and positron emission tomography/computed tomography (PET/CT)-based plaque inflammation, was derived and externally validated in limited samples. Clinical implementation of the SCAIL model can be challenging due to high costs and low accessibility of PET/CT. MRI is a more readily available, lower-cost modality that has been extensively validated to visualize all the hallmarks of plaque vulnerability. The MRI methods to identify the different plaque features are described. Intraplaque hemorrhage (IPH), a lipid-rich necrotic core (LRNC), and a thin or ruptured fibrous cap (TRFC) on MRI have shown to strongly predict stroke in meta-analyses. To improve personalized risk prediction, carotid plaque features should be included in prediction models. Prediction of stroke in patients with carotid stenosis needs modernization, and carotid MRI has potential in providing strong predictors for that goal.

Gradient of luminal narrowing of internal carotid artery on atherosclerotic plaque as risk factor for cerebral ischemic damage

Aim. To study the clinical significance of the gradient of narrowing of arterial lumen (GNL) for atherosclerotic stenosis of the internal carotid artery (ICA) as a risk factor for ischemic brain damage.Material and methods. We proposed a new parameter of hemodynamic severity of ICA atherosclerotic stenosis — GNL. It calculated as ratio of the difference in the ICA cross section areas on the stenotic lesion and the near non-stenotic region to the distance between them: Snorm — Sstenosis)/Dnorm — stenosis, mm2 /mm. We examined 25 patients with advanced atherosclerosis and with uni(n=22) or bilateral (n=3) ICA stenosis &gt;50% according to European Carotid Surgery Trial, and 11 individuals without ICA stenosis. Each participant underwent magnetic resonance angiography (MRA) of the carotid arteries with reconstruction of the arteries from C6-C7 level to the parietal bones, and the GNL was calculated. The thickness of the baseline slice was 0,8-1 mm. Each subject also underwent cerebral magnetic resonance imaging (MRI) in T1-, T2-, PD-, flair-weighted protocols. Results. Patients were divided into groups: group 1 (n=12) — without ischemic injury in the ICA system, and group 2 (n=13) — with MRI signs ischemic injury history. The groups did not differ in proportion of stenosis (74,9±4,25% and 77,8±3,8%, p&lt;0,05), ICA lumen area on the stenotic lesion (1,05±0,18 mm2 and 1,14±0,17 mm2 , p&lt;0,05) and the ICA diameter at the non-stenotic region (4,30±0,32 mm and 4,9±0,29 mm, p&lt;0,05). In control group, GNL was &lt;0,75 mm2 /mm. Groups 1 and 2 significantly differed (2,47±0,41 mm2 /mm and 4,60±0,51 mm2 /mm, p&lt;0,02). In group 2, 12 out of 13 patients had GNL &gt;3,35 mm2 /mm, and, in group 1, 9 out of 12 — less than 3,35 mm2 /mm. GNL did not correlate significantly with other parameters of ICA stenosis. Two patients with the highest GNL in each group (5,5 and 8,6 mm2 /mm) had a fatal ischemic stroke within six monthsConclusion. Firstly, proposed parameter of stenosis hemodynamic severity GNL is independent, informative and prognostically important indicator for carotid artery atherosclerotic lesion.

Prevalence and the Risk Factors for Asymptomatic Carotid Artery Stenosis Among Type II Diabetes Mellitus Patients

Prevalence and the Risk Factors for Asymptomatic Carotid Artery Stenosis Among Type II Diabetes Mellitus Patients

Critical Stenosis of the Internal Carotid Artery: Variability in Vertebral Artery Diameters and Areas of Cerebral Chronic Infarction in Computed Tomography

We investigated unilateral and bilateral cervical internal carotid artery (ICA) stenosis according to the North American Symptomatic Carotid Endarterectomy Trial (NASCET) and the European Carotid Surgery Trial (ECST). We retrospectively investigated ICA stenosis on Head&Neck Computed Tomography Angiography (CTA); and their simultaneous brain computed tomography images were also evaluated. In unilateral ICA stenosis group (n=36), 17 of them had right ICA stenosis and 19 left ICA stenosis. In bilateral stenosis group, there were 24 patients. ICA stenosis was evaluated according to NASCET and ECST methods. We also evaluated vertebral artery dimension, plaque density and cerebral infarct (Cerebral kortex, white matter, basal ganglion-thalamus). Unilateral ICA stenosis according to the NASCET was 70.64% to 73.68% (right-left) and according to the ECTS was 65.52% to 71.15% (right-left). For bilateral stenosis, ICA stenosis according to the NASCET was 67.70 to 67.91 (right-left); according to the ECTS was 62.45% to 62.15% (right-left). Vertebral artery dimensions were 3.26 to 3.72 mm (right-left) in unilateral ICA stenosis; and 3.52 to 3.71 mm (right-left) in bilateral ICA stenosis. In bilateral stenosis group, mixt plaque; and in unilateral stenosis group, hard plaque was detected. In unilateral stenosis, white matter and basal ganglion-thalamus infarcts; in bilateral ICA stenosis, cerebral cortical infarct was detected. Left-vertebral artery diameter increased in higher L-ECTS ICA stenosis (unilateral) group. Increase in left vertebral artery diameter in unilateral L-ECTS ICA stenosis may be related to increase of the collateral flow by vertebral arteries to support brain blood-flow.

Angioplasty in asymptomatic carotid artery stenosis vs. endarterectomy compared to best medical treatment: One-year interim results of SPACE-2.

BackgroundTreatment of individuals with asymptomatic carotid artery stenosis is still handled controversially. Recommendations for treatment of asymptomatic carotid stenosis with carotid endarterectomy (CEA) are based on trials having recruited patients more than 15 years ago. Registry data indicate that advances in best medical treatment (BMT) may lead to a markedly decreasing risk of stroke in asymptomatic carotid stenosis. The aim of the SPACE-2 trial (ISRCTN78592017) was to compare the stroke preventive effects of BMT alone with that of BMT in combination with CEA or carotid artery stenting (CAS), respectively, in patients with asymptomatic carotid artery stenosis of ≥70% European Carotid Surgery Trial (ECST) criteria.MethodsSPACE-2 is a randomized, controlled, multicenter, open study. A major secondary endpoint was the cumulative rate of any stroke (ischemic or hemorrhagic) or death from any cause within 30 days plus an ipsilateral ischemic stroke within one year of follow-up. Safety was assessed as the rate of any stroke and death from any cause within 30 days after CEA or CAS. Protocol changes had to be implemented. The results on the one-year period after treatment are reported.FindingsIt was planned to enroll 3550 patients. Due to low recruitment, the enrollment of patients was stopped prematurely after randomization of 513 patients in 36 centers to CEA (n = 203), CAS (n = 197), or BMT (n = 113). The one-year rate of the major secondary endpoint did not significantly differ between groups (CEA 2.5%, CAS 3.0%, BMT 0.9%; p = 0.530) as well as rates of any stroke (CEA 3.9%, CAS 4.1%, BMT 0.9%; p = 0.256) and all-cause mortality (CEA 2.5%, CAS 1.0%, BMT 3.5%; p = 0.304). About half of all strokes occurred in the peri-interventional period. Higher albeit statistically non-significant rates of restenosis occurred in the stenting group (CEA 2.0% vs. CAS 5.6%; p = 0.068) without evidence of increased stroke rates.InterpretationThe low sample size of this prematurely stopped trial of 513 patients implies that its power is not sufficient to show that CEA or CAS is superior to a modern medical therapy (BMT) in the primary prevention of ischemic stroke in patients with an asymptomatic carotid stenosis up to one year after treatment. Also, no evidence for differences in safety between CAS and CEA during the first year after treatment could be derived. Follow-up will be performed up to five years. Data may be used for pooled analysis with ongoing trials.

Mortality risk stratification in patients with asymptomatic carotid stenosis

AIMS: The aim of this analysis was to (a) determine the long-term 5-year all-cause and cardiovascular (CV) mortality in patients with asymptomatic internal carotid artery stenosis (ACS), (b) identify risk factors that could be used in mortality risk stratification, and (c) develop a model for predicting a patient's risk of CV death within 5 years. METHODS: This was a multicenter natural history study involving 1121 patients with ACS undergoing medical intervention alone. Proportional-hazards models were used to calculate all-cause and CV mortality using clinical and plaque texture features. RESULTS: Totally 1121 patients with 50%–99% ICA stenosis (European Carotid Surgery Trial criteria) from the Asymptomatic Carotid Stenosis and Risk of Stroke study were included in this analysis for mortality. Mean follow-up was 48 months (range, 6–96 months). There were 213 (19%) deaths during follow-up. Average annual all-cause mortality was 4.6%. About 68.1% of all deaths were due to CV causes. Independent predictors of all-cause mortality were age, male gender, carotid stenosis >80% (NASCET criteria), diabetes, cardiac failure, left ventricular hypertrophy (LVH) on electrocardiogram (ECG), smoking, absence of antiplatelet therapy, and history of vertebrobasilar symptoms. It was also shown that age, male gender, diabetes, fibrinogen >3.6 g/L, carotid stenosis >80% (NASCET criteria), cardiac failure, absence of antiplatelet therapy, and LVH on ECG were independent risk factors for CV mortality. Receiver operating characteristic curves for the above models were 0.709 (95% confidence interval [CI], 0.659–0.754) and 0.701 (95% CI, 0.656–0.746), respectively. The CV mortality prediction model could identify several subgroups of asymptomatic patients with different risk. The highest 90%–100% predicted 5-year CV mortality carried 25 times the risk of the low-risk subgroup in which the 5-year predicted CV mortality was 4%. CONCLUSION: Mortality risk can be taken into consideration in clinical practice, in order to identify patients with ACS who are unlikely to benefit from carotid endarterectomy. The majority of patients with ACS have a very high risk of myocardial infarction and should not be denied aggressive risk factor modification or a full cardiac investigation according to the current guidelines.

Carotid Consensus Panel duplex criteria can replace modified University of Washington criteria without affecting accuracy.

The decision to intervene for internal carotid stenosis often depends on the degree of stenosis seen on duplex ultrasound (US). The aim of this study is to compare the diagnostic accuracy of two criteria: modified University of Washington (UW) and 2003 Carotid Consensus Panel (CCP). All patients undergoing US in an accredited (IAC) vascular laboratory from January 2010 to June 2015 were reviewed ( n=18,772 US exams). Patients receiving a neck computed tomography angiography (CTA) within 6 months of the US were included in the study ( n=254). The degree of stenosis was determined by UW/CCP criteria and confirmed on CTA images using North American Symptomatic Carotid Endarterectomy Trial (NASCET)/European Carotid Surgery Trial (ECST) schema. Kappa analysis with 95% confidence intervals (CIs) were utilized to determine duplex-CTA agreement. A total of 417 carotid arteries from 221 patients were assessed in this study. The modified UW criteria accurately classified 266 (63.9%, kappa = 0.321, 95% CI 0.255 to 0.386) cases according to NASCET-derived measurements. The sensitivity, specificity, and accuracy at ≥ 60% stenosis were 65.7%, 81.3%, and 81.9%. The CCP criteria resulted in 296 (70.9%) accurate diagnoses (kappa = 0.359, 95% CI 0.280 to 0.437). At ≥ 70% stenosis, the sensitivity, specificity and accuracy were 38.8%, 91.6%, and 87.1% for NASCET. Comparison of the duplex results to ECST-derived CTA measurements revealed a similar trend (UW 53.1%, κ = 0.301 vs CCP 62.1%, κ = 0.315). The CCP criteria demonstrate a higher concordance rate with measurements taken from CTAs. The CCP criteria may be more sensitive in classifying clinically significant degrees of stenosis without a loss in diagnostic accuracy.

Invited commentary

The North American Symptomatic Carotid Endarterectomy Trial (NASCET) concluded that carotid surgery for symptomatic stenosis is better than medical therapy, and the conferred benefit of surgery is proportional to the degree of stenosis.1North American Symptomatic Endarterectomy Trial CollaboratorsBeneficial effect of carotid endarterectomy in symptomatic patients with high-grade carotid stenosis.N Engl J Med. 1991; 325: 445-453Crossref PubMed Scopus (7865) Google Scholar The European Carotid Surgery Trial (ECST) came to a similar conclusion and that “on average, the immediate risk of surgery was worth trading off against the long-term risk of stroke without surgery when the stenosis was greater than 80% diameter.”2European Carotid Surgery Trialists Collaborative GroupRandomised trial of endarterectomy for recently symptomatic carotid stenosis: final results of the MRC European Carotid Surgery Trial (ECST).Lancet. 1998; 351: 1379-1387Abstract Full Text Full Text PDF PubMed Scopus (2966) Google Scholar The preceding and other studies leave little room for doubt that endarterectomy is beneficial to symptomatic patients; what is still being debated is the exact timing of surgery. Most clinicians agree that patients presenting with crescendo transient ischemic attacks or a mobile plaque on imaging deserve to be considered for an emergent endarterectomy to prevent a severe stroke. What is not clear is what type of patient ought to have an urgent (ie, during the same hospitalization and as promptly as possible) carotid endarterectomy. Avgerinos et al attempt to answer the question, When is it optimal to perform endarterectomy for symptomatic patients? They queried the Vascular Study Group of New England database of 14,864 carotid endarterectomies and identified 4076 performed for symptomatic stenosis. Of the latter cases, 989 carotid endarterectomies were performed within a month of symptom onset. They analyzed outcomes based on timing of surgery: same day, <48 hours, 2-5 days, and >6 days. They found that the postoperative stroke rate was highest if surgery was performed <48 hours after presenting stroke or transient ischemic attack, whereas postoperative stroke rates were similar in the other time frames. In a similar analysis from a single center and spanning the same time period, Tsantilas et al found a combined stroke and mortality rate for symptomatic patients of 2.5% and no significant difference in stroke rates in the various time periods of 48 hours, 3-7 days, 8-14 days, and 15-180 days.3Tsantilas P. Kuhnl A. Kallmeyer M. Pelisek J. Poppert H. Schmid S. et al.A short time interval between the neurologic index event and carotid endarterectomy is not a risk factor for carotid surgery.J Vasc Surg. 2017; 65: 12-20Abstract Full Text Full Text PDF PubMed Scopus (24) Google Scholar Other authors have strongly emphasized the need for prompt carotid endarterectomy, provided symptoms are stable, to prevent a recurrent stroke.4Bond R. Rerkasem K. Rothwell P.M. Systematic review of the risks of carotid endarterectomy in relation to the clinical indication for and timing of surgery.Stroke. 2003; 34: 2290-2303Crossref PubMed Scopus (246) Google Scholar In performing an urgent carotid endarterectomy, there are many factors that need to be taken into consideration. By the time the surgeon sees the consult, proper imaging is obtained, and the patient is prepared for surgery, several hours would have passed. Adding to the complexity, a patient admitted on a Friday or Saturday may experience longer delays. This paper concludes that there is no major penalty in waiting a few days. Until we have more sophisticated imaging capabilities to detect which plaques are likely to disintegrate and cause recurrent symptoms, it is a guessing game.5Rothwell P.M. Prediction and prevention of stroke in patients with symptomatic carotid stenosis: the high-risk period and the high-risk patient.Eur J Vasc Endovasc Surg. 2008; 35: 255-263Abstract Full Text Full Text PDF PubMed Scopus (49) Google Scholar The prudent approach, though, is to avoid delays in removing the offending plaque. The opinions or views expressed in this commentary are those of the authors and do not necessarily reflect the opinions or recommendations of the Journal of Vascular Surgery or the Society for Vascular Surgery. Early carotid endarterectomy performed 2 to 5 days after the onset of neurologic symptoms leads to comparable results to carotid endarterectomy performed at later time pointsJournal of Vascular SurgeryVol. 66Issue 6PreviewTiming of carotid endarterectomy (CEA) after onset of neurologic symptoms remains controversial. We assessed the association of CEA timing with postoperative outcomes. Full-Text PDF Open Archive

Recommendations for Low-Grade Carotid Stenosis Follow-up Based on a Single-Institution Database.

The purpose of this study was to determine the incidences and rates of progression of varying degrees of carotid stenosis that do not require intervention according to the Asymptomatic Carotid Atherosclerosis Study, the European Carotid Surgery Trial, and the North American Symptomatic Carotid Endarterectomy Trial, and from this information, to provide evidence-based recommendations for follow-up imaging. A retrospective review was performed of all carotid ultrasound examinations performed at a single institution from January 1995 through April 2015. Examinations following endarterectomy or stenting were excluded. Stenoses were classified by a modification of the criteria of Bluth et al (Radiographics 1988; 8:487-506). A Kaplan-Meier survival analysis was performed for stenosis progression and to provide information for follow-up recommendations. Most of the carotid arteries (91.6%) reviewed for this study showed 1% to 39% stenosis. However, only 6.8% of carotid arteries with 1% to 39% stenosis progressed compared to 38.9% of carotid arteries with 40% to 59% stenosis. A table of evidence-based follow-up recommendations is provided for patients with varying levels of stenosis. We provide evidence-based follow-up recommendations for patients who have low degrees of carotid stenosis. Different degrees of carotid stenosis progress at different rates and therefore should be followed at different intervals. Additionally, the most patients in our database showed 1% to 39% stenosis and did not have any follow-up imaging, suggesting that carotid ultrasound may not be overused for low degrees of stenosis.

Abstract TP415: A Pilot Study on the Effect of Neck Irradiation Treatment for Nasopharyngeal Carcinoma on Carotid Artery Stenosis

Introduction: Extracranial carotid stenosis, a risk factor for ischemic stroke, is thought to be accelerated by irradiation to the neck region. Nasopharyngeal carcinoma (NPC) has a predilection for East Asian with an incidence of 200-300 annually in Singapore. We studied the prevalence and severity of extracranial carotid disease in patients with prior neck irradiation for NPC, who were at different timepoints from the time of irradiation. Hypothesis: The prevalence of extracranial carotid disease is high among patients with prior neck irradiation, and this may justify a screening programme for early detection and primary stroke prevention. Methods: We conducted a pilot study to examine 50 patients (median age 55.2 years) with prior radiation for NPC with intensity-modulated radiation therapy (IMRT): 26 with &lt;5 years after treatment and 24 with &gt;=5 years after treatment. All patients received radiation therapy to the neck. Carotid disease was assessed by duplex sonography for severity of stenosis. The European Carotid Surgery Trial (ECST) criteria was employed for assessment for degree of stenosis. Results: Among patients with IMRT &gt;=5 years ago, 25% (6/24) had carotid stenosis of &gt;=50% compared to only 8% (2/26) of patients with IMRT within 5 years. Of these 8 patients with carotid stenosis &gt;=50%, 5 (63%) had plaques with irregular or ulcerated surfaces, which is known to be associated with stroke risk. Based on these preliminary data, the study would require a larger sample size of 100 in each group to be powered at 90% with an alpha of 0.05. All 8 patients with carotid stenosis &gt;=50% from the screening were referred for further evaluation for symptoms and risk factors, and management for secondary stroke prevention. Conclusions: Based on our findings, there is a rationale for screening for carotid disease among patients with prior neck irradiation and the timing of screening is more optimal after 5 years from IMRT. Patients found to have carotid disease should be counselled about risk factor control, antiplatelet medication and possibly carotid intervention for primary stroke prevention.

Clinical Utility of Preoperative Carotid Duplex Ultrasonography Prior to Operation for Peripheral Artery Disease

Carotid duplex ultrasonography (CDUS) is one of useful screening modality for internal carotid artery stenosis (ICAS) associated with vascular disease. We aimed to clinical utility of CDUS for neurological asymptomatic patient prior to operation for peripheral artery disease (PAD). This study had institutional review board approval, and informed consent was waived. From January 2011 to December 2015, 231 consecutive patients (69.5±7.74 years, male 202 patients) who had undergone preoperative CDUS (Phlilips IU 22 , Philps Healthcare, Amsterdam, Netherland) for peripheral artery disease were included in this study and two radiologists assessed degree of ICAS by using European Carotid Surgery Trial (ECST) with consensus and severe (> 70%) ICAS or moderate ICAS (50-69%) ICAS with vulnerable plaque were defined as significant ICAS. To find out risk factors of asymptomatic significant ICAS, we analyzed demographics, co-existing medial conditions, lesion of PAD, and ankle brachial index (ABI) with multiple logistic regression model. For statistical analysis, data were tested by multiple logistic regression analysis and Chi-square test. Among 231 PAD patients, 35 patients had significant ICAS (15.1%). Multi-level lesion revealed significantly higher incidence of significant ICAS than iliac and infrainguinal lesion (22.5% vs. 9.4% vs. 8%: P = 0.016). Age (OR:1.05, 95% CI: 1.00-1.10: P = 0.035), Chronic kidney disease (CKD, OR:6.19, 95% CI: 1.47-26.06: P = 0.013) and cerebral vascular disease (CVD, OR:4.08, 95% CI: 1.09-15.30: P = 0.037) were significant risk factors of significant ICAS in multivariate analysis. Prevalence of significant ICAS according to ABI in PAD was not significant. CDUS can be a useful non-invasive preoperative screening imaging tool for evaluation of significant ICAS in PAD patients with multi-level lesion, age, CKD, and CVA.

Computed angiography for planning carotid surgery

Objective: to evaluate accuracy of computed angiography in preoperative assessment of carotid occlusive disease. Material and Method: During 2013-2016 years 256 patients underwent preoperative examinations, that included ultrasound (study of brachiocephalic arteries (BCA), transcranial Doppler and computed angiography (CTA). Received with computed angiography data were analyzed with criteria NASCET (North American Symptomatic Carotid Endarterectomy Trial) and ECST (European Carotid Surgery Trial). Results: Unilateral occlusive disease was observed in majority of patients, occlusive lesions in carotid arteries was usually accompanied with changes in other vascular territories. In 29 cases (11%) in patients with internal carotid subocclusion (ICA) a distal diff use narrowing of lumen was observed. Comorbid diseases that aff ect management of our patients were: intracranial aneurysms (4%), lesions of larynx and pharynx (1%), lung cancer (1%). Conclusion: Computed angiography is necessary for carotid surgery planning.

Commentary on ‘Risk of Recurrent Stroke in Patients with Symptomatic Mild (20–49% NASCET) Carotid Stenosis’

Commentary on ‘Risk of Recurrent Stroke in Patients with Symptomatic Mild (20–49% NASCET) Carotid Stenosis’

Searching the perfect ultrasonic classification in assessing carotid artery stenosis: comparison and remarks upon the existing ultrasound criteria.

Doppler ultrasound scanning is the first line investigation for quantifying the internal carotid artery stenosis. Nevertheless, the lack of internationally accepted ultrasound criteria for describing the degree of stenosis has contributed to the different and confusing measurements ranges. The use of two different angiographic methods, the North American Symptomatic Carotid Endoarterectomy Study and the European Carotid Surgery Trial was probably the major initial source of confusion in deriving valid and reliable duplex ultrasound criteria worldwide. The consensus proposed in 2003 by the Society of Radiologists in Ultrasound has been a great attempt to create a conformity document, establishing grey scale and Doppler criteria in considering the different degrees of stenosis. According to this attempt, in 2010, the multi-parametric Deutsche Gesellschaft für Ultraschall in der Medizin ultrasound criteria have been proposed with a precise differentiation between main and additional criteria and depicted a different peak systolic velocity (PSV) threshold. In 2012, these criteria have been implemented, focusing on the multi-parametric approach, re-defining the PSV values and clearly introducing the concept of PSV average. Despite these attempts, a wide range of practice patterns still exists, with consistent disparities in patients' care. This paper collects these previous experiences and summarizes their strengths and weaknesses, to give a contribution in the carotid artery stenosis grading standardization using ultrasonic methods. Carotid ultrasound as the only diagnostic tool for the selection of patients for carotid surgery or stenting will be possible only with internationally accepted criteria.